Are you a boy or are you a girl? The notion of gender identity is at the very core of our being and defines who we are, how we’re seen by the world around us, and the way we express ourselves through behaviors, characteristics, and thoughts.

But gender identity is so much more than the sex you’re assigned at birth. “Gender has never been as simple as anatomy,” says Margaret Nichols, PhD, president of Nichols Counseling and Psychotherapy in New Jersey and founder/president emeritus of the Institute for Personal Growth. Many people have ‘mixed’ anatomy in some way. “As many as one in 100 people have an intersex condition, sometimes so mild, it goes undetected,” Nichols says. 

Though they’re often used interchangeably, gender and sex are not the same things. Your sex is a label that goes on your birth certificate that’s given by doctors based on genitalia and chromosomes, but it’s not the whole story of who you are as a human being.

“Gender identity is more than the parts you were born with,” says Georgia-based gender identity therapist Katie Leikam, LCSW, a certified member of the World Professional Association of Transgender Health. “It’s a feeling in your mind and your heart of who you are as a person. It doesn’t have to be a binary identity, meaning it doesn’t have to be all-male or female,” she says.

What Age Does Gender Identity Develop?

For a long time, no one really questioned that gender is based on anatomy—when a baby is born, the gender marker recorded on a birth certificate is typically based on looking at the genitals of the newborn baby. Period.

But in recent history, doctors have begun debating this and some argue gender is not as simple as anatomy. “Doctors can’t tell the gender identity of anyone other than by asking. There is no objective test,” says Joshua D. Safer, MD, FACE, executive director of the Mount Sinai Center for Transgender Medicine and Surgery in New York. “A substantial portion of gender identity is biologically ‘hard-wired’ and present at birth. We don’t know genes or other factors at play,” he says.

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Child Gender Dysphoria Quiz?

Children show different signs than adults and teens when it comes to gender dysphoria.

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Children can understand the concept of sex/gender as early as two and name things correctly in that regard, Dr. Safer says. “However, people develop their understanding of themselves at varying rates depending on interest, language, etc.”

According to the Mayo Clinic, most children typically develop the ability to recognize and label gender groups, such as girl, woman, and feminine, and boy, man, and masculine, between ages 18 and 24 months. Gender identity also develops socially from cues the child is surrounded by, Leikam says. “By the time a child is five-to-six years old, they may have a more rigid gender identity, but socialization and gender cues and norms can be taught and modeled to a child,” she says.

For most people, gender identity becomes fixed in childhood and doesn’t develop in puberty and adulthood, although gender expression and/or gender roles may change and evolve, Nichols says. “For transgender/nonbinary people, puberty is extremely distressing, and may even be the first time it really becomes clear to them that they are trans/nonbinary,” she says.

This is because in advance of puberty, male and female bodies are not that different beyond genitalia. “During puberty, secondary sex characteristics develop, making it overwhelmingly clear to trans people that their internal sense of gender identity does not match their body,” Nichols says.

The majority of transgender people present to clinicians in late adolescence or adulthood, Dr. Safer says. This late presentation may be from an inability to articulate gender identity or recognize gender incongruence, or pressure to conform. Some adolescents may report their gender incongruence in order to avoid the “wrong puberty”.

When Gender Becomes An Internal Struggle

“When someone has a different gender identity from the sex they were assigned at birth, it can create anxiety, frustration, depression, despair, and potentially suicidal thoughts if the person feels like they cannot express who they truly are,” Leikam says.

This is what’s known as gender dysphoria: the conflict between a person’s assigned gender and the gender with which he/she/they identify. People with gender dysphoria are often very uncomfortable in their own skin and with their “assigned” sex. Studies suggest that the prevalence of a self-reported transgender identity in children, adolescents, and adults ranges from 0.5 to 1.3%.

The Diagnostic and Statistical Manual of Mental Disorders categorizes gender dysphoria as a disorder. Many mental health professionals disagree and want it removed altogether. “In the upcoming International Classification of Diseases (ICD-12), gender dysphoria is set to be categorized as an issue of sexual concern instead,” Leikam says.

Not all transgender people have dysphoria, Dr. Safer says. Yet, many US insurance companies require a diagnosis of gender dysphoria for reimbursement of transgender medical and surgical interventions.

What Does It Mean to Be Transgender?

“’Transgender’ is an umbrella term that is meant to include all people who don’t fit into the gender binary, including people who want to fully transition to the gender opposite of their birth gender, people who are cross-dressers, people who are nonbinary, and/or gender fluid,” Nichols says.

While the term “transsexual” gets thrown around, “it’s an old term, rarely used by professionals today, that refers to someone who fully medically and socially transitions to the ‘other’ gender,” she says.

“The term ‘Transgender’ is used in a more general way for people whether they’ve had surgeries or hormones or no treatment,” Dr. Safer says. “The point is that transgender people are not defined by their medical treatments, which are customized to individual circumstances.”

Transgender population estimates in the US vary. A 2016 report from The Williams Institute puts the percentage of transgender people at approximately 0.6%  or about 1.4 million people. However, an analysis of population-based probability samples collected nationally between 2006 and 2016 and published in the American Journal of Public Health (2017) concluded there about 1 million transgender people but the authors noted future surveys are likely to find higher numbers. Their report also recommended standardized questions be used in future national population surveys “to allow a more accurate population size estimate.”

An increasing number of people identify as lesbian, gay, bisexual, or transgender (LGBT), according to a recent Gallup Poll.  Gallup’s latest data finds 5.6% of US adults identify as LGBT (the majority of whom say they are bisexual)—an increase of 4.5% from Gallup’s previous update based on 2017 data. Perhaps because of growing acceptance, younger generations are more likely to consider themselves to be something other than heterosexual. In the recent poll, one in six adult members of Generation Z (those aged 18 to 23 in 2020) claim to be LGBT.

For those opting to have gender-affirming surgery, there are several categories that are common for transgender people, Dr. Safer says. “Feminizing surgeries include facial feminization surgeries, breast augmentation, and genital surgeries.

The classic genital surgery is vaginoplasty, creating a vagina with the corresponding tissues from the penis. Masculinizing surgeries include masculinizing chest surgery (mastectomy), hysterectomy-oophorectomy, and genital surgeries. The classic genital surgery involves using tissues from elsewhere on the body to make a penis.”

To break it down even further:

Transgender Women: Those Transitioning from Male Bodies to Female

  • Breast augmentation for those who want larger breasts than they get from hormones
  • Genital surgery: These range from orchiotomy (removal of testes) to full vaginoplasty, a surgery where typically, the skin of the penis is inverted to create a vagina as well as a labia and the vagina retains the sexual sensitivity of the penis. Orgasms are still possible.
  • Facial feminization: surgeries that change the facial structure and/or shave the Adam’s apple

Transgender Men: Those Transitioning from Female Bodies to Male

  • Chest reconstruction surgery, which involves the removal of the breasts and sometimes other changes to make the chest resemble a male chest
  • Genital surgery: These range from the removal of the ovaries and/or uterus or a metoidioplasty, a procedure that ‘releases’ the clitoris from the clitoral hood so that the clitoris is larger and longer, resembling a small penis, to a full penis reconstruction, done several different ways. “While no surgery yet can construct a penis capable of erection on its own, there are several methods to do this, including implants and injections. The constructed penis retains sexual sensitivity and orgasms are possible,” Nichols says.

The Politics of Gender

For transgender people, the determination of their gender, while a personal decision, is often deemed a political one by members of society and politicians. Blame it on morality or religious beliefs based on biblical scripture dictating that a woman is a woman and a man is a man.

“It’s not really an anatomical conversation,” Nichols says. “It’s about emerging sex and gender identities and the fact that they all threaten heteronormativity: the idea that there are two genders, male and female, that men and women are only attracted to opposites, and that women are inferior,” she says. “Basically, trans/nonbinary people, like gay people, threaten the institutional structures that uphold the patriarchy.”

The Trump administration enacted a regulation erasing protection for transgender sex discrimination in healthcare—i.e. doctors, hospitals, and health insurance companies. “Decisions as far as military service and rights of the transgender community in healthcare and medical and mental health insurance are being chipped away at an alarming rate,” Leikam says.

Then you have bathroom bills like the one in North Carolina, (which was ultimately repealed) requiring transgender people in government and public buildings to use the bathroom that corresponds with the gender on their birth certificate.

Another issue is privacy. In order to do everything from open a bank account and start a new job to enroll in school and obtain a passport, trans people need accurate and consistent forms of identification. But the name and gender change process are not only complicated and expensive, but many state and federal governments require intrusive requirements—such as proof of surgery or court orders.

Because of this, according to the US Transgender Survey, only 11% of respondents reported that all of their IDs had the name and gender they preferred, while more than two-thirds (68%) reported that none of their IDs had the name and gender they preferred.

Conflicting identification, in effect, causes everything from denial of employment and housing to harassment and violence. According to the US Transgender Survey, 32% of respondents who have shown an ID with a name or gender that did not match their gender presentation were verbally harassed, denied benefits or service, asked to leave, or assaulted.

The Cultural Zeitgeist Around Gender

Despite political opposition, discrimination, and governmental mandates, visibility, and acceptance of transgender people in the United States are growing.

  • More than half (60% of respondents of the US Transgender Survey who were out to their immediate family reported that their family was supportive of them as a transgender person.
  • 68% of those who were out to their coworkers reported that their coworkers were supportive.
  • 56% of students who were out to their classmates reported that their classmates supported them as a transgender person.

At large, attitudes, practices, and inclusivity measures seem to be slowly shifting. Governments, institutions, and people in general are realizing that trying to force individuals into two gender boxes doesn’t work for everyone, and culturally, the gender binary is breaking down, Nichols says. “It should be noted that many Asian countries, take for granted the nonbinary nature of gender, and a number of countries have legislated third genders,” she says. In fact, at least 10 countries have issued a third gender marker designation for ID documents, including Australia, Bangladesh, Canada, Germany, India, and New Zealand.

As more Americans are identifying as nonbinary, not strictly male or female, laws for nonbinary gender markers are changing, with a growing number of jurisdictions in the US allowing some form of nonbinary-identification including state IDs, driver’s licenses, and birth certificates.

As of late 2019, at least seven states offer a third gender option for people who don’t identify as male or female. In 2018, United Airlines became the first major airline to offer nonbinary gender options for booking, and several other major airlines including American, Delta, Southwest, Alaska, and JetBlue, have also indicated that they are in the process of adding a nonbinary gender option.

The State Department has updated passport regulations and currently allows a change of sex marker for gender on passports. According to the website, “passports are valid for different lengths of time depending on whether you have completed your transition or are still in the process of transition.” It’s the first legislative effort for a nonbinary gender marker in a federal document.

Then there’s the changing terminology designed to be more inclusive. Take, for example, “Latinx”, a gender-neutral term used in lieu of “Latino” or “Latina” to refer to a person of Latin American descent. Merriam-Webster dictionary even added the word to its repertoire in 2018.

LGBTQ, LGBTQIA, Intersex and Other Gender Terminology

The wide spectrum of acronyms and terms surrounding gender and sexuality can be all kinds of confusing, especially as classifications continue to change and evolve. To help you make sense of it all, here’s a primer on a few of the terms:

  1. LGBTQ: “This stands for Lesbian, Gay, Bisexual, Transgender, Queer, and the abbreviation is used as a way to refer to the community that contains people from these groups,” says Austin Texas-based clinical psychologist Jo Eckler, PsyD, RYT, author of I Can’t Fix You—Because You’re Not Broken, who goes by the pronouns they/them. “Some people add “Questioning” as another part of the letter Q.”
  2. LGBTQIA: This is a newer version of LGBTQ with the addition of “Intersex, Asexual/Agender” to be more inclusive and more accurately describe this community, Eckler says. Some people consider the A to also stand for “Allied.”
  3. Intersex: This is a broad term referring to people born with physical, chromosomal, and/or hormonal characteristics that do not fully fit the commonly perceived ideas of male or female. Sometimes these are visible, but these characteristics also may not be discovered unless/until that person tries to conceive children, Eckler says. In fact, since visibly intersex children may be subjected to surgery soon after birth, some may not even know that they are intersex. “There is a movement advocating to stop these non-consensual surgeries and to wait until children are old enough to make their own decisions about what they want to do with their bodies. Being intersex is often estimated to be as common as having red hair,” Eckler says.
  4. Transgender: Someone who is transgender has a gender identity that is not congruent or the same as the sex they were assigned at birth often by the doctor who delivered them. A person does not have to have medically transitioned to be transgender.
  5. Nonbinary: A nonbinary person is someone who doesn’t identify as strictly male or female and who uses the pronouns “they” and “them.” According to the National Center for Transgender Equality (NCTE), nonbinary individuals are identified as those who don’t neatly fit into the categories of ‘man’ or ‘woman,’ or ‘male’ or “female.’
  6. Gender Fluid: A person whose gender identity fluctuates at some level back and forth between the binary of male and female.
  7. Gender Identity vs Sexual Orientation: Gender identity is who you are as a person in relation to being male, female, transgender, or gender expansive. Sexual orientation is about who you are attracted to on an intimate level or the lack of attraction intimately, for example, someone who is asexual.
  8. Cisgender: This is someone whose sex they were assigned at birth matches with the gender identity they feel in their mind and present as.
  9. Sex Assigned At Birth is the sex someone, usually a doctor, gave you when you were born, usually by observing your genitalia.
  10. Gender expression refers to the ways in which a person communicates their gender identity to others. These can include behavior, outward appearances, such as dress, hair, makeup, body language, and voice. A person’s pronoun and chosen name are also ways of expressing gender.

FAQs

What is gender identity?

Gender identity is who you are as a person in relation to being male, female, transgender, or gender expansive. It defines who we are, how we’re seen by the world around us, and the way we express ourselves through behaviors, characteristics, and thoughts. “Gender identity is more than the parts you were born with. It’s a feeling in your mind and your heart of who you are as a person. It doesn’t have to be a binary identity, meaning it doesn’t have to be all male or female,” Leikam says.

How can I figure out my gender identity?

For most people, gender identity becomes fixed in childhood and doesn’t develop in puberty and adulthood, although gender expression and/or gender roles may change and evolve. “For transgender/nonbinary people, puberty is extremely distressing, and may even be the first time it really becomes clear to them that they are trans/nonbinary,” Nichols says. That's because, before the onset of puberty, male and female bodies are not that different beyond genitalia. “During puberty, secondary sex characteristics develop, making it overwhelmingly clear to trans people that their internal sense of gender identity does not match their body,” Nichols says.

What's the difference between gender identity and gender dysphoria?

“When someone has a different gender identity from the sex they were assigned at birth, it can create anxiety, frustration, depression, despair, and potentially suicidal thoughts if the person feels like they cannot express who they truly are,” Leikam says. This is what’s known as gender dysphoria: the conflict between a person’s assigned gender and the gender with which he/she/they identify.

What causes gender dysphoria?

Gender dysphoria happens when gender identity becomes an internal struggle. People with gender dysphoria are often very uncomfortable in their own skin and with their “assigned” sex.

What does transgender mean?

“'Transgender' is an umbrella term that is meant to include all people who don't fit into the gender binary, including people who want to fully transition to the gender opposite from their birth gender, people who are cross-dressers, people who are nonbinary, and/or gender fluid,” Nichols says.

What percentage of the US population is transgender?

Transgender population estimates in the US vary. A 2016 report from The Williams Institute puts the percentage of transgender people at approximately 0.6%  or about 1.4 million people. However, an analysis of population-based probability samples collected nationally between 2006 and 2016 and published in the American Journal of Public Health (2017) concluded there about 1 million transgender people but the authors noted future surveys are likely to find higher numbers. Their report also recommended standardized questions be used in future national population surveys “to allow a more accurate population size estimate.”

What's the difference between transgender and transsexual?

While the term “transsexual” gets thrown around, “it’s an old term, rarely used by professionals today, that refers to someone who fully medically and socially transitions to the 'other' gender,”Nichols says.

How does transgender surgery work?

For those opting to have gender affirming surgery, there are several categories that are common for transgender people. “Feminizing surgeries include facial feminization surgeries, breast augmentation surgeries, and genital surgeries. The classic genital surgery is vaginoplasty, creating a vagina with the corresponding tissues from the penis. Masculinizing surgeries include masculinizing chest surgery (mastectomy), hysterectomy-oophorectomy, and genital surgeries. The classic genital surgery involves using tissues from elsewhere on the body to make a penis,” Dr. Safer says.

Gender Identity Resources

Since gender identity is so central to who you are, allowing the expression of gender identity is incredibly important to self-esteem and well-being. For more support on gender, check out the following resources:

If you need immediate support, please contact Trans Lifeline 877-565-8860, or the Trevor Project Lifeline, 866-488-7386.

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Last Updated: Feb 26, 2021