Patient education: Being transgender (The Basics)

What are sex and gender identity? — This can be confusing. The terms do not mean exactly the same thing:

●Your sex refers to your body's biology. It includes all of the things that are related to reproduction: your genitals, reproductive organs, sex chromosomes, sex hormones, and certain genes. The term "birth-recorded sex" is used to mean a person's sex when they are born, based on all of these things.

●Your gender identity is based on how you feel. It is your sense of being a man, woman, a combination, or something else. Many people whose birth-recorded sex is male identify as men, and many people whose birth-recorded sex is female identify as women. This is called being "cisgender." But not everyone's gender identity lines up with their birth-recorded sex in this way.

What does it mean to be transgender? — "Transgender," or "trans," is a word some people use to describe themselves when their gender identity is different from their birth-recorded sex.

●A transgender woman is a person whose birth-recorded sex is male, but who identifies as a woman.

●A transgender man is a person whose birth-recorded sex is female, but who identifies as a man.

●Some people do not identify as being either a man or a woman, or identify as being somewhere between the 2. They might prefer another term like "nonbinary," "genderqueer," or "genderfluid" to describe themselves. There are many other terms people use to describe their gender identity, too.

Many transgender people want their appearance or "gender expression" to match their gender identity, although this is not always the case. Transgender people might choose to take medicines and/or have surgery to change their bodies to better reflect their gender identity. Some people also choose to change the pronouns they use, like "he," "she," or "they."

Gender identity is not the same as sexual orientation. Sexual orientation refers to your physical or sexual attraction to other people. No matter what their gender identity is, a person could be attracted to people of the same sex, different sex, neither, or both.

How do I know if I am transgender? — Transgender people feel that their gender identity does not match their birth-recorded sex. Doctors sometimes use the term "gender incongruence" for this. Some use the term "gender dysphoria" when this feeling causes distress or discomfort.

Many transgender adults felt this way as children, even before they went through puberty. Puberty is the term for the changes the body goes through during the preteen and teen years.

If you think that you might be transgender, a doctor, nurse, or therapist can help you understand what this means. It's a good idea to talk with a doctor or other professional who has experience working with transgender people. They can talk to you about your options and help you get the support you need.

If you are feeling very sad or anxious, tell a doctor or nurse right away. There are treatments that can help.

What if I think that my child might be transgender? — If your child shows signs that their gender identity might not match their birth-recorded sex, you can help by being accepting and supportive. Some children and young teens might express a different gender identity in some ways, or for a short time, but not actually be transgender. Others are indeed transgender. The best thing you can do is make it clear that you support your child no matter how they identify.

Working with doctors and other professionals who understand transgender issues can help both you and your child. Remember that being transgender is not a mental illness and that every person is different. For example, some children might want to change the way they dress or use a new name or pronouns, while others do not.

What is gender-affirming care? — This refers to health care that is meant to help a person align their body with their gender identity in the way that feels best to them. It might include therapy, medicines, or surgery. Different people choose different treatments.

For children or teens, doctors can prescribe medicines that stop or delay puberty. This might be an option if a child is starting puberty and thinks that they might be transgender. Stopping the body changes that happen during puberty can give the child more time to figure out if they are truly transgender. If not, they can stop taking the medicines and go through puberty as usual. If they are indeed transgender, they can instead choose to start hormone treatment. This usually happens around age 16, but can be earlier in some cases. For people who also choose to have surgery, doctors often recommend waiting until age 18.

Gender-affirming care should involve doctors, nurses, and others who have experience working with transgender people. It might include:

●Therapy with a counselor – This involves talking with an expert like a psychiatrist, psychologist, nurse, or social worker. Therapy can help you understand your gender identity and figure out what changes you might want to make. They might also have you speak with other transgender people, so you can talk to someone who has gone through something similar. This can help you get a better idea of what you might experience as your body changes with hormone treatment and with surgery, if you choose these treatments.

●Social transition – This means living according to your gender identity, both at home and in public. This might include wearing clothes or hair styles often associated with this gender identity. It might also include using a name and pronouns (like "he," "she," or "they") that fit with your gender identity. If you or your child wants to try a social transition, talk with a counselor or other expert. They can help you figure out how to do this.

●Hormone therapy – These include both sex hormones and medicines that block sex hormones. They are taken as pills, injections (shots), or gels you rub on your skin.

Sex hormones cause changes in the sexual organs and other parts of the body. Adding certain hormones, or using medicine to block other hormones, can cause changes in the body. Male hormones are called "androgens," and female hormones are called "estrogens."

•Transgender women – Transgender women (whose birth-recorded sex is male) can take medicines that block androgens. They can also take estrogen. Both of these things can help lessen body hair and make the body appear more feminine.

•Transgender men – Transgender men (whose birth-recorded sex is female) can take androgens. The main androgen that people take is testosterone. Testosterone causes hair to grow on the face and increases muscle. It also makes the clitoris grow larger (figure 1). (The clitoris is the structure above the vagina that gives sexual pleasure.) In addition to making the body look more masculine, testosterone also eventually stops monthly periods.

●Surgery – Not all transgender people choose to have surgery. But some do. There are several different surgery options for different parts of the body. These are called "gender confirmation surgeries" or "gender-affirming surgeries." Different people choose different surgeries based on what changes they want.

There are 3 types of surgery that transgender women might consider:

•Surgeries on the face and neck to create a more feminine appearance – Doctors call these "facial feminization" surgeries.

•Surgery to make the breasts larger

•Genital surgery – Doctors call this "vaginoplasty." This is a surgery to create a vagina. The surgeon uses the skin of the penis to line the inside of the new vagina, and tissue from the tip of the penis to serve as the clitoris. The surgeon removes the testicles and uses the skin of the scrotum (figure 2) to create the folds of tissue around the vagina (called "labia").

There are 3 types of surgery that transgender men might consider:

•Surgery to remove breast tissue and make the chest look more masculine. This is often referred to as "top surgery."

•Surgeries to remove the uterus and/or ovaries

•Genital surgery – Some people have surgery to make the clitoris longer (called "metoidioplasty") or to create a penis (called "phalloplasty"). The surgeon might use tissue from the person's arm or leg to create a penis. They can also lengthen the urethra, which is the tube that carries urine from the bladder to outside of the body. This allows the person to urinate standing up if they want to. The labia can be used to create a scrotum. Small plastic balls can be put inside the scrotum to make testicles.

If you are considering surgery, your doctor can talk to you about your options, what to expect with each procedure, and the risks.

Do transgender people need other types of medical care? — Yes, if they take hormone therapy. That's because some hormones might make a person slightly more likely to have certain medical conditions, including dangerous blood clots and heart disease. In general, transgender people who take hormone therapy should expect to see their doctor every 3 months for the first year of treatment, then 1 or 2 times a year after that. The doctor can test the person's hormone levels and check for any medical problems.

Some types of care, like cancer screenings, are based on what body parts you have, no matter what your gender identity is. For example, if you have a prostate, you might need screening for prostate cancer, even if you are a transgender woman. If you have breasts, you might need screening for breast cancer, even if you are a transgender man.

Having a doctor whom you trust is an important part of making sure that you get the health care you need.

Can transgender people have children? — The hormone treatments transgender people get can affect their fertility. "Fertility" means the ability to get pregnant, or get a partner pregnant. If a person has surgery to remove their ovaries, uterus, or testicles, they will not be able to get pregnant or get a partner pregnant.

When deciding about treatment, it's important to think about whether you might want to have children in the future. Some people choose to freeze sperm or eggs in case they want to use them later. For example:

●Transgender women (whose birth-recorded sex is male) can try "sperm banking." This involves collecting sperm before you start hormone treatment. The sperm are frozen and stored until you choose to use them.

●Transgender men (whose birth-recorded sex is female) can try freezing their eggs before starting hormone treatment. The frozen eggs are stored until you choose to use them.

There are other ways to start a family, too. Some people choose to adopt a baby or child. Others use sperm or eggs that came from other people (called "donor" sperm or eggs).

More on this topic

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