Sex is assigned at birth, refers to one’s biological status as either male or female, and is associated primarily with physical attributes such as chromosomes, hormone prevalence, and external and internal anatomy. Gender refers to the socially constructed roles, behaviors, activities, and attributes that a given society considers appropriate for boys and men or girls and women. These influence the ways that people act, interact, and feel about themselves. While aspects of biological sex are similar across different cultures, aspects of gender may differ.

Various conditions that lead to atypical development of physical sex characteristics are collectively referred to as intersex conditions. For information about people with intersex conditions (also known as disorders of sex development), see APA’s brochure Answers to Your Questions About Individuals With Intersex Conditions (PDF, 1MB).

Transgender persons have been documented in many indigenous, Western, and Eastern cultures and societies from antiquity until the present day. However, the meaning of gender nonconformity may vary from culture to culture.

Many identities fall under the transgender umbrella. The term transsexual refers to people whose gender identity is different from their assigned sex. Often, transsexual people alter or wish to alter their bodies through hormones, surgery, and other means to make their bodies as congruent as possible with their gender identities. This process of transition through medical intervention is often referred to as sex or gender reassignment, but more recently is also referred to as gender affirmation. People who were assigned female, but identify and live as male and alter or wish to alter their bodies through medical intervention to more closely resemble their gender identity are known as transsexual men or transmen (also known as female-to-male or FTM). Conversely, people who were assigned male, but identify and live as female and alter or wish to alter their bodies through medical intervention to more closely resemble their gender identity are known as transsexual women or transwomen (also known as male-to-female or MTF). Some individuals who transition from one gender to another prefer to be referred to as a man or a woman, rather than as transgender.

People who cross-dress wear clothing that is traditionally or stereotypically worn by another gender in their culture. They vary in how completely they cross-dress, from one article of clothing to fully cross-dressing. Those who cross-dress are usually comfortable with their assigned sex and do not wish to change it. Cross-dressing is a form of gender expression and is not necessarily tied to erotic activity. Cross-dressing is not indicative of sexual orientation (See Answers to Your Questions: For a Better Understanding of Sexual orientation and Homosexuality (PDF, 1MB) for more information on sexual orientation.). The degree of societal acceptance for cross-dressing varies for males and females. In some cultures, one gender may be given more latitude than another for wearing clothing associated with a different gender.

The term drag queens generally refers to men who dress as women for the purpose of entertaining others at bars, clubs, or other events. The term drag kings refers to women who dress as men for the purpose of entertaining others at bars, clubs, or other events.

Genderqueer is a term that some people use who identify their gender as falling outside the binary constructs of “male” and “female.” They may define their gender as falling somewhere on a continuum between male and female, or they may define it as wholly different from these terms. They may also request that pronouns be used to refer to them that are neither masculine nor feminine, such as “zie” instead of “he” or “she,” or “hir” instead of “his” or “her.” Some genderqueer people do not identify as transgender.

Other categories of transgender people include androgynous, multigendered, gender nonconforming, third gender, and two-spirit people. Exact definitions of these terms vary from person to person and may change over time, but often include a sense of blending or alternating genders. Some people who use these terms to describe themselves see traditional, binary concepts of gender as restrictive.

There is no single explanation for why some people are transgender. The diversity of transgender expression and experiences argues against any simple or unitary explanation. Many experts believe that biological factors such as genetic influences and prenatal hormone levels, early experiences, and experiences later in adolescence or adulthood may all contribute to the development of transgender identities.

It is difficult to accurately estimate the number of transgender people, mostly because there are no population studies that accurately and completely account for the range of gender identity and gender expression.

Gender identity and sexual orientation are not the same. Sexual orientation refers to an individual’s enduring physical, romantic, and/or emotional attraction to another person, whereas gender identity refers to one’s internal sense of being male, female, or something else. Transgender people may be straight, lesbian, gay, bisexual, or asexual, just as nontransgender people can be. Some recent research has shown that a change or a new exploration period in partner attraction may occur during the process of transition. However, transgender people usually remain as attached to loved ones after transition as they were before transition. Transgender people usually label their sexual orientation using their gender as a reference. For example, a transgender woman, or a person who is assigned male at birth and transitions to female, who is attracted to other women would be identified as a lesbian or gay woman. Likewise, a transgender man, or a person who is assigned female at birth and transitions to male, who is attracted to other men would be identified as a gay man.

Transgender people experience their transgender identity in a variety of ways and may become aware of their transgender identity at any age. Some can trace their transgender identities and feelings back to their earliest memories. They may have vague feelings of “not fitting in” with people of their assigned sex or specific wishes to be something other than their assigned sex. Others become aware of their transgender identities or begin to explore and experience gender-nonconforming attitudes and behaviors during adolescence or much later in life. Some embrace their transgender feelings, while others struggle with feelings of shame or confusion. Those who transition later in life may have struggled to fit in adequately as their assigned sex only to later face dissatisfaction with their lives. Some transgender people, transsexuals in particular, experience intense dissatisfaction with their sex assigned at birth, physical sex characteristics, or the gender role associated with that sex. These individuals often seek gender-affirming treatments.

Parents may be concerned about a child who appears to be gender-nonconforming for a variety of reasons. Some children express a great deal of distress about their assigned sex at birth or the gender roles they are expected to follow. Some children experience difficult social interactions with peers and adults because of their gender expression. Parents may become concerned when what they believed to be a “phase” does not pass. Parents of gender-nonconforming children may need to work with schools and other institutions to address their children’s particular needs and ensure their children’s safety. It is helpful to consult with mental health and medical professionals familiar with gender issues in children to decide how to best address these concerns. It is not helpful to force the child to act in a more gender-conforming way. Peer support from other parents of gender-nonconforming children may also be helpful.

Transitioning from one gender to another is a complex process and may involve transition to a gender that is neither traditionally male nor female. People who transition often start by expressing their preferred gender in situations where they feel safe. They typically work up to living full time as members of their preferred gender by making many changes a little at a time. While there is no “right” way to transition genders, there are some common social changes transgender people experience that may involve one or more of the following: adopting the appearance of the desired sex through changes in clothing and grooming, adopting a new name, changing sex designation on identity documents (if possible), using hormone therapy treatment, and/or undergoing medical procedures that modify their body to conform with their gender identity.

Every transgender person’s process or transition differs. Because of this, many factors may determine how the individual wishes to live and express their gender identity. Finding a qualified mental health professional who is experienced in providing affirmative care for transgender people is an important first step. A qualified professional can provide guidance and referrals to other helping professionals. Connecting with other transgender people through peer support groups and transgender community organizations is also helpful.

The World Professional Association for Transgender Health (WPATH), a professional organization devoted to the treatment of transgender people, publishes The Standards of Care for Gender Identity Disorders, which offers recommendations for the provision of gender affirmation procedures and services.

A psychological state is considered a mental disorder only if it causes significant distress or disability. Many transgender people do not experience their gender as distressing or disabling, which implies that identifying as transgender does not constitute a mental disorder. For these individuals, the significant problem is finding affordable resources, such as counseling, hormone therapy, medical procedures, and the social support necessary to freely express their gender identity and minimize discrimination. Many other obstacles may lead to distress, including a lack of acceptance within society, direct or indirect experiences with discrimination, or assault. These experiences may lead many transgender people to suffer with anxiety, depression, or related disorders at higher rates than nontransgender persons.

In the United States, payment for health care treatment by insurance companies, Medicare, and Medicaid must be for a specific “disorder,” defined as a condition within the International Classification of Diseases (ICD) or the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). According to DSM-IV, people who experience intense, persistent gender incongruence can be given the diagnosis of gender identity disorder. This diagnosis is highly controversial among some mental health professionals and transgender communities. Some contend that the diagnosis inappropriately pathologizes gender noncongruence and should be eliminated. Others argue that it is essential to retain the diagnosis to ensure access to care.

Anti-discrimination laws in most U.S. cities and states do not protect transgender people from discrimination based on gender identity or gender expression. Consequently, transgender people in most cities and states face discrimination in nearly every aspect of their lives. The National Center for Transgender Equality and the National Gay and Lesbian Task Force released a report in 2011 entitled Injustice at Every Turn, which confirmed the pervasive and severe discrimination faced by transgender people. Out of a sample of nearly 6,500 transgender people, the report found that transgender people experience high levels of discrimination in employment, housing, health care, education, legal systems, and even in their families. The report can be found online.

Transgender people may also have additional identities that may affect the types of discrimination they experience. Groups with such additional identities include transgender people of racial, ethnic, or religious minority backgrounds; transgender people of lower socioeconomic statuses; transgender people with disabilities; transgender youth; transgender elderly; and others. Experiencing discrimination may cause significant amounts of psychological stress, often leaving transgender individuals to wonder whether they were discriminated against because of their gender identity or gender expression, another sociocultural identity, or some combination of all of these.

According to the study, while discrimination is pervasive for the majority of transgender people, the intersection of anti-transgender bias and persistent, structural racism is especially severe. People of color in general fare worse than White transgender people, with African American transgender individuals faring far worse than all other transgender populations examined.

Many transgender people are the targets of hate crimes. They are also the victims of subtle discrimination—which includes everything from glances or glares of disapproval or discomfort to invasive questions about their body parts.

• Educate yourself about transgender issues by reading books, attending conferences, and consulting with transgender experts. Be aware of your attitudes concerning people with gender-nonconforming appearance or behavior.

• Know that transgender people have membership in various sociocultural identity groups (e.g., race, social class, religion, age, disability, etc.) and there is not one universal way to look or be transgender.

• Use names and pronouns that are appropriate to the person’s gender presentation and identity; if in doubt, ask.

• Don’t make assumptions about transgender people’s sexual orientation, desire for hormonal or medical treatment, or other aspects of their identity or transition plans. If you have a reason to know (e.g., you are a physician conducting a necessary physical exam or you are a person who is interested in dating someone that you’ve learned is transgender), ask.

• Don’t confuse gender nonconformity with being transgender. Not all people who appear androgynous or gender nonconforming identify as transgender or desire gender affirmation treatment.

• Keep the lines of communication open with the transgender person in your life.

• Get support in processing your own reactions. It can take some time to adjust to seeing someone you know well transitioning. Having someone close to you transition will be an adjustment and can be challenging, especially for partners, parents, and children.

• Seek support in dealing with your feelings. You are not alone. Mental health professionals and support groups for family, friends, and significant others of transgender people can be useful resources.

• Advocate for transgender rights, including social and economic justice and appropriate psychological care.Familiarize yourself with the local and state or provincial laws that protect transgender people from discrimination.

• American Psychological Association
  Lesbian, Gay, Bisexual and Transgender Concerns
  Programs and Projects
  750 First Street, NE
  Washington, DC 20002
  Email
  
• Children's National Medical Center
  Gender and Sexuality Advocacy and Education
  111 Michigan Avenue, NW
  Washington, DC 20010
  (202) 884-2504
  
• Family Acceptance Project
  San Francisco State University
  3004 16th Street, #301
  San Francisco, CA 94103
  Email
  
• FTMInternational
  (FTM means Female-to-Male)
  601 Van Ness Ave., Suite E327
  San Francisco, CA 94102
  (877) 267-1440
  Email
  
• Gender Education & Advocacy
  
• Gender Spectrum
  539 Glen Drive
  San Leandro, CA 94577
  (520) 567-3977
  Email
  
• National Center for Transgender Equality
  1325 Massachusetts Ave., Suite 700
  Washington, DC 20005
  (202) 903-0112
  (202) 393-2241 (fax)
  Email
  
• Parents, Families, and Friends of Lesbians and Gays (PFLAG) Transgender Network (TNET)
  PFLAG National Office
  1828 L Street, NW, Suite 660
  Washington, DC 20036
  (202) 467-8180
  Email
  
• Sylvia Rivera Law Project
  147 W. 24th Street, 5th Floor
  New York, NY 10011
  (212) 337-8550
  (212) 337-1972 (Fax)
  Email
  
• Transgender Law Center
  870 Market Street Room 400
  San Francisco, CA 94102
  (415) 865-0176
  Email
  
• TransYouth Family Allies
  P.O. Box1471
  Holland, MI 49422-1471
  (888) 462-8932
  
• World Professional Association for Transgender Health
  1300 South Second Street, Suite 180
  Minneapolis, MN 55454
  (612) 624-9397
  (612)624-9541 (Fax)
  Email

• American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (DSM-IV). Washington, DC: American Psychiatric Publishing, Inc.

• American Psychological Association. (2006). Answers to your questions about individuals with intersex conditions (PDF, 1MB). Washington, DC: Author.

• American Psychological Association. (2008). Answers to questions: For a better understanding of sexual orientation and homosexuality (En español).Washington, DC: Author.

• Harry Benjamin International Gender Dysphoria Association. (2001). The standards of care for gender identity disorders, sixth version. Minneapolis, MN: World Professional Association for Transgender Health. Retrieved from http://www.wpath.org/documents2/socv6.pdf

• National Center for Transgender Equality and the National Gay and Lesbian Task Force. (2011). Injustice at every turn. Washington, DC: Author.

• World Health Organization. (1992). ICD-10: International classification of diseases and related health problems. Washington, DC: American Psychiatric Publishing, Inc.