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, Ph.D., 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,” Dr. Nichols says. 

Though they’re often used interchangeably, gender and sex are not the same thing. 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, 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.

When Gender Identity Develops

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 differed on 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, M.D., 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.

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.”

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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, Dr. 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 until 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,” Dr. 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 remoed 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 U.S. insurance companies require a diagnosis of gender dysphoria for reimbursement of transgender medical and surgical interventions.

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, including the current administration. 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,” Dr. 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.”

Recently, the Trump administration moved ahead with a regulation that erases 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 is 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 U.S. 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 U.S. 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 is growing.

  • More than half (60 percent) of respondents of the U.S. Transgender Survey who were out to their immediate family reported that their family was supportive of them as a transgender person.
  • 68 percent of those who were out to their coworkers reported that their coworkers were supportive.
  • 56 percent 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 are 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, Dr. 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 21 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. Last year, 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. Recently, the State Department proposed a bill to offer an “X” as a marker for gender on passports. 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.

Understanding Gender Identity Terminology

To understand gender identity, you need to know the language. Here’s a quick guide to help familiarize yourself with the various terms. For more in-depth explainers, read this.

  1. 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.
  2. 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.’
  3. Gender fluid A person whose gender identity fluctuates at some level back and forth between the binary of male and female.
  4. 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.
  5. Cis gender This is someone whose sex they were assigned at birth matches with the gender identity they feel in their mind and present as.
  6. Sex assigned at birth Sex assigned at birth is the sex someone, usually a doctor, gave you when you were born, usually by observance of your genitalia.
  7. Intersex People who are intersex fall outside the category of binary male or female. This could be by having different chromosomes, different outwardly or inwardly appearing genitalia, or a different level of male and female hormones than expected. Sometimes surgeries are performed on babies who are intersex so they will outwardly match their expected gender, and this has come under opposition because it’s thought children should have the opportunity to have their own gender identity exploration.
  8. Gender expression This refers to the ways in which a person communicates their gender identity to others. These can include behavior, outward appearance, such as dress, hair, makeup, body language, and voice. A person’s pronoun and chosen name are also ways of expressing gender.

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 Trevor Project. 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: Jul 27, 2020