THIS SECTION REVIEWS FOUR BASIC CONCEPTS REQUIRED for understanding trans and gender-nonconforming youth. Many times youth or their families confuse or conflate concepts of sex, gender expression, gender identity, and sexual orientation. It is essential to be able to distinguish these concepts so we can understand and support trans youth. This chapter also explores the language trans and gender-nonconforming youth may use to describe themselves and their identities within the context of these basic concepts.
Biological Sex
The first question asked when someone gives birth is, “Is ‘it’ a boy or a girl?” It is almost as if a child isn’t “real” until we know what their sex is. This “sex assigned at birth” is based on our physical bodies. It is a decision the delivery doctor makes based on the appearance of our genitalia. In this sense, sex is about biology; it is about our physical body, our anatomy, or our chromosomal makeup.
For most of us, this biological sex is beyond question. We have a penis or a vagina. We have XX or XY chromosomes. However, this differentiation is not always as clear-cut as we have been taught to believe. One in 2,000 infants (Intersex Society of North America, n.d.) are born with ambiguous genitalia or variant chromosomal combinations that make it impossible for a doctor to clearly determine whether the child is a “girl” or a “boy.” The current language to describe this experience is that the child was born with an “intersex condition.” The older term, no longer used, was “hermaphrodite.”
Historically, when a baby was born with an intersex condition, medical professionals would immediately whisk the infant off and surgically alter their genitals so that they appeared more “normative.” This was thought to be essential. Without this surgery, doctors and mental health professionals believed the child would experience ridicule about their physical appearance and likely be confused about their gender identity. Many times the parents were not even informed about this condition prior to the surgery on their infant. In more recent years, parents have been informed about their child’s intersex condition, but surgery to alter the appearance of the infant’s genitals is still often recommended and considered essential for the child’s emotional well-being.
There are two problems with this surgery being done during infancy. The first is that the doctor makes a decision about sex based on the appearance of the infant’s genitalia. If the infant has a penis but it is considered “too small” to be a “valid” or “functional” penis, the penis is typically removed and the child is classified as a girl. This decision made at birth by a doctor may not match the child’s developing sense of gender identity. As a result, there are intersex adults who were declared girls at birth whose genitals were altered to more closely resemble female genitalia. Yet as they grow up, their gender identity may be male, and the adult man may prefer to have maintained his penis regardless of whether or not it was considered “long enough.”
The second difficulty with surgery performed during infancy is that the way the genitals are altered often diminishes that person’s ability to experience a rich and full adult sexual life. The removal of erotic tissue during surgery can compromise the person’s ability to experience the full sexual pleasure that would have been possible if their genitalia had been left intact.
These factors have led many adults with intersex conditions to advocate that genital surgeries be delayed until a child or adolescent is old enough to make an informed decision for themselves. This allows the child’s gender identity to emerge before any decisions about surgery are made and puts these decisions, which may impact sexual satisfaction, within the control of the individual themselves.
With the awareness that significant numbers of births involve intersex conditions, it is clear that biological sex, typically understood as unequivocal, is not nearly as binary or unambiguous as often assumed. Cultural messages tell us that you (or your child) are either a boy or a girl. These messages tell us that what distinguishes our sex is the genitals we were born with. Intersex conditions make it apparent that biological sex is more complex. While male and female obviously exist, variations are clearly evident along the sex/gender continuum.
For most people, their internal gender identity matches the sex they were assigned at birth. Most infants assigned male at birth grow up and identify as men. Most infants assigned female at birth grow up and identify as women. For these individuals, their gender identity is aligned with their biological sex. When discussing these individuals who constitute the bulk of the human population, we use the term “cisgender,” meaning that their biological sex and their gender identity are aligned (the Latin prefix cis- means to align or line up).
For transgender people, the sex assigned to them at birth differs from their gender identity. There is a mismatch or disconnect between how they were categorized at birth and their emerging gendered sense of themselves. Their gender identity “crosses over” (the meaning of the Latin prefix trans-) their biological sex. Transgender women are individuals assigned male at birth but whose gender identity is female. Transgender men are persons who were assigned female at birth but whose gender identity is male.
Gender Expression
In contrast to sex as biological, gender expression is about the ways we express our identities as men or women (or both or neither) to ourselves and in the world. Gender expression is about the ways we communicate our gender to those around us. It can include things like our choice of clothing (masculine, feminine, androgynous); the hairstyles we like; our physical mannerisms, such as the way we walk or talk or move our hands; and whether we wear jewelry, and if so, what kind, and on which body part.
We also express our gender through the activities we enjoy, the roles we assume in our day-to-day lives, or the careers we choose. In white Western culture, there are norms about what is considered acceptable masculine or feminine gender expression. There are activities and careers that are considered “masculine” and others considered “feminine.” In some contexts, these expectations about appearance or interests and activities are rigidly enforced, and individuals may be punished for violating the norms.
Gender expression often leads to assumptions about sexual orientation and/or gender identity. A good example of this is the way most children read people. It’s the way children determine whether someone is a girl/woman or a boy/man. Children look for clues like the length of a person’s hair, the kinds of clothes another child wears, or whether an adult is wearing earrings or makeup. For younger children, these gendered expectations tend to be fixed and not easily altered, even in the face of new information. For example, a young child may have internalized a belief that auto mechanics are men and maintain this belief even after meeting a female mechanic. Despite these assumptions, our gender expression is not necessarily a statement about our sexual orientation or gender identity. It can simply be about how we enjoy looking or what we enjoy doing.
Having grown up in a conservative religious environment where male and female gender expectations were distinct and clear, my first understanding of our inability to “read” someone’s identity or orientation by their appearance came during college when I was camping along the coast of Maine. During our first week there, I noticed many women with short haircuts dressed in blue jeans and flannel shirts. I remember thinking, “Wow! There are a lot of lesbians in Maine.” As we continued our vacation, I learned that most of these women, whose gender expression would have been considered more masculine, were actually cisgender (not transgender) straight married women who simply bought their clothes at L. L. Bean. The norm for female gender expression in Maine at that time allowed for more “masculine” gender expression than might have been acceptable in other areas in the United States.
Our gender expression is distinct from our gender identity or sexual orientation. The fact that a woman enjoys carpentry or electrical work does not indicate anything about her gender identity or sexual orientation. The fact that a man might wear pink does not tell you whether he is straight, gay, or bisexual, and it does not indicate that he identifies as a transgender woman or feels more feminine than other men. There are cisgender straight women whose gender expression is very stereotypically feminine; there are cisgender straight women whose gender expression is more masculine; and there are cisgender women with androgynous gender expression. The same is true for men within our culture. There is a wide range and variation in the ways we may express our gender as men, women, both, or neither.
At the same time, Western culture does have expectations about what is considered “acceptable” gender expression for men and women. The norms for girls/women are certainly broader than those for boys/men. Young girls have much more latitude for masculine gender expression than do young boys for female expression. If a young girl likes wearing baggy jeans and T-shirts and playing baseball, we even have a fairly affectionate name for that: tomboy. This expansiveness typically narrows upon reaching adolescence. With the onset of puberty, girls are expected to “femme up,” grow out of their tomboy phase, and become interested in things that are more stereotypically feminine.
There is no “tomboy” counterpart for young boys. Boys (or men) have little room in white Western culture for any hint of feminine gender interests or expression. A young boy or male adolescent with feminine gender expression is likely to be quickly labeled a “sissy”—a word with extremely pejorative and demeaning connotations meant to enforce acceptable “masculine” behavior and punish any deviations from this standard.
This difference in gender expectations and norms for girls/women and boys/men is rooted in patriarchy, sexism, and misogyny. It evolves out of an underlying belief that no man would want to be anything like a woman—because we all “know” that women are inferior to men, that boys are better (smarter, faster, stronger, more capable) than girls. This kind of sexism and misogyny holds that any man or boy with feminine interests or gender expression is “less of a man” or not a “real” man.
Norms about gender expression vary over time. One hundred years ago in the United States, dresses were the only acceptable clothing for female-bodied people. Women who chose to break this norm were often censured in some way. Yet today women routinely wear pants, even in formal settings. The norms about expressing one’s female gender through clothing have shifted over time. Wearing pants today does not bring a woman’s gender identity or sexual orientation into question. Similarly, a century ago, pink was considered a men’s color. It was considered too strong a color for the “more delicate” sex to wear. While some men wear pink shirts today, pink has overwhelmingly become a “girls’ color.”
Acceptable norms for gender expression also vary across different cultural contexts. In white Western Anglo culture, it is not considered masculine for men to express emotions other than anger. Beyond that, men are expected to be fairly stoic. They are not encouraged to be verbally or physically affectionate, not given much room for feelings of sadness or grief, and not expected to cry—at least in public.
Socialization about normative or acceptable gender expression begins very early with children. While riding the New York City subway, I sat near a two-and-a-half-year-old boy riding with a young man in his early 20s. They were listening to music together. The young boy had one earphone and his caregiver had the other. At one point, the toddler did what all toddlers do: took the earphone out of his ear and put it in his mouth. His caregiver immediately yelled at him and popped him on the head. The young boy burst into tears and began crying loudly. What I heard next was the young adult man admonishing him: “Stop crying! You’re acting like a stupid girl!” Even at two and a half years, this boy was being given the message that boys don’t cry, that it’s not acceptable masculine gender expression to shed tears.
Adult men in Western Anglo cultures are rarely allowed to physically express their affection for another man. Doing so will get them called a sissy or a “faggot” and may even put them at risk of violence. About the closest white Anglo men get to physical affection is a slap on the butt after scoring a touchdown on the football field. Yet in many Mediterranean and Latin cultures, it’s considered perfectly acceptable masculine behavior to be more emotionally demonstrative. In these cultural contexts, men often greet each other with an embrace or even a kiss, and this is considered acceptable masculine gender expression. So our norms about masculine and feminine gender expression, our rules about what is considered acceptable, vary across both different historical time periods and different cultures.
Gender Identity
Gender identity reflects our own internal sense of who we are as a man or woman. For some people, this identity might be both man and woman or neither man nor woman. In contrast to our “sex” assigned at birth, gender identity is our internalized understanding of who we are. Sex is about our bodies, our biology, the secondary sex characteristics that emerge with puberty. Gender identity is about what’s in our mind. It’s about how we think of ourselves as male or female, both or neither.
The term transgender is often used as an umbrella that includes all gender-nonconforming people. It is also used more narrowly for those transgender people who transition from their assigned sex at birth to their identified gender. An older term used for the latter group is transsexual. This word was coined within psychiatric circles and carries a strong connotation of mental illness and psychological deficiency.
Given these origins, transsexual is less often used today. Just as gay and lesbian people rejected the term homosexual because of its psychiatric origins, transgender people have largely rejected the term transsexual and have chosen transgender to describe themselves. The use of transgender reflects the way trans communities are embracing more positive and empowering language to define who they are.
There are some persons who continue to use the word transsexual to describe themselves. This choice often reflects a feeling that their identity as male or female and their choice to transition is at risk of erasure as the transgender umbrella continues to broaden, encompassing both people who transition and those who identify as nonbinary, gender-nonconforming, or gender-fluid.
The transgender umbrella also includes cross-dressers. These are generally cisgender men who value being able to express feminine aspects of themselves. This may mean dressing “as a woman” might, wearing makeup, styling their hair in more traditionally feminine ways, or wearing a wig so that their feminine or female self is visible in different settings in their lives. For them, cross-dressing and presenting as female is distinct from being a gay man or a transgender woman. It is an aspect of their gender expression and not necessarily an indication of their sexual orientation or gender identity. Most men who cross-dress identify as (cisgender) men; they do not identify as female, and they do not generally wish to transition and live as a woman.
Historically, individuals who cross-dressed were called “transvestites” (coined by Magnus Hirschfeld in the early 1900s). It was believed these men cross-dressed because of the sexual excitement this generated in them. It represented dysfunctional psychosexual development within childhood or adolescence and was characterized as a mental illness (transvestic fetishism). Given the pejorative psychiatric connotation, the term transvestite is rarely used within trans communities today.
Derogatory views about cross-dressers reflect the earlier discussion about how little room there is for male-bodied people to demonstrate any “feminine” gender interest, expression, or aspects of themselves. Men who cross-dress and wear feminine clothing break these rules and historically have been stigmatized and penalized for these “transgressions” against masculinity.
The penalties for men who express femininity or female selves are much more severe than what women typically encounter today as “tomboys” or “butch” women (though there are settings in which more masculine gender expression among women is prohibited and punished).
Individuals who “cross-dress” for specific purposes, typically entertainment, may refer to themselves as “drag queens” (in the case of men who perform as women entertainers) or “drag kings” (female-bodied persons who perform as male entertainers). In this context, “doing drag” is something anyone might do regardless of their sexual orientation or gender identity. Doing drag has a long history within theater arts and typically is more about performance and art than identity.
People who identify as gender-queer experience their gender identity as more fluid. Their gender identity does not neatly fit into one of the two binary boxes labeled male or female. The word largely originated among younger people in urban areas who reject the assumption that we are only either male or female. They claim a space along, or even beyond or outside, the continuum of maleness and femaleness. Some gender-queer people see themselves as both male and female. Some identify as neither male nor female. Some believe the categories of male and female are not large enough to encapsulate all of who they are. And others believe the boxes of male and female are simply irrelevant to their own sense of themselves. Various words gender-queer people might use to describe themselves include gender-fluid, gender-variant, gender-expansive, or gender-diverse. Bigender is typically used by those who identify as both male and female. The term agender may be used if neither category of male or female fits the individual. Some youth use pangender to indicate their identification with all genders (again, broader than a male/female binary construct).
It is evident that the language trans people use to describe themselves is rapidly evolving. It is also evident that many people in the trans community, and particularly many young people, are moving beyond binary constructs for understanding gender identity and instead embracing more complex and fluid ways of experiencing themselves (Ehrensaft, 2016).
Transgender people who identify as male or female and choose to transition and live in their identified/true gender generally use gendered pronouns, such as he/him or she/her, to refer to themselves. Individuals with a more fluid gender identity or a bigender or agender identity often choose gender-neutral pronouns such as “zie” and “hir.” Individuals may also use the plural pronouns “they” and “them.”
Mental health professionals must respect a client’s choice of name and pronouns. Some young people will disclose their preferred name and pronouns immediately. Whether someone is already out as transgender or comes out during their work with you, their birth name may still be their legal name. Even when this is true, it is considered best practice to ask what name and pronoun they would like you to use. It is also important to be cognizant that the choice of name and pronouns may evolve over time among young people exploring their gender identity and expression and among those whose identity or expression is more fluid.
Continuing to use a young person’s birth-assigned name and associated pronouns when they have requested the use of their “new” name and pronouns is disrespectful and both denies and invalidates that individual’s identity. It communicates that you do not see them for who they are. When someone continues to use male pronouns for a trans woman, it communicates an underlying message that they do not believe she is “really” a woman. It sends a message that in their eyes she is, and always will be, a man.
Sexual Orientation
It is essential to differentiate between gender expression, gender identity, and sexual orientation. Sometimes people conflate sexual orientation and gender identity. They think being gay equals being transgender and being transgender is the same as being gay. In reality, these are two distinct aspects of who we are as human beings. Sexual orientation is about who we are attracted to; it’s about who we think is hot. It’s about our physical and emotional attraction to other people, and whether we tend to be attracted to people of the opposite sex/gender or people of the same sex/gender. All of us—cisgender or transgender—have both a sexual orientation and a gender identity. We have an internal sense of who we are as men/women/both/neither, and we have an understanding of our sexual and emotional attractions. These two concepts reflect different aspects of our being.
A young trans woman who likes other women may identify as lesbian; a young trans man who is attracted to other guys may identify as gay; young trans women attracted to guys may identify as straight, as may young trans men who are attracted to women. A youth attracted to people of both genders may identify as bisexual.
Other youth identify as pansexual, an orientation typically broader than simply being “bi” or attracted to either/both men and women. Youth who identify as pansexual are typically attracted to a range or type of gender expression and not necessarily to a specific sex or gender or specific “body parts.” For example, if a young cisgender or transgender woman identifies as pansexual, she may be attracted to people of all or any gender expression. Or she may be attracted to masculine gender expression, and this attraction could include cisgender guys, trans guys, or butch lesbians. What is important to her in this case is another person’s masculine energy, appearance, or gender expression. Their specific body parts (breasts, vagina, penis) are not the primary attraction. The same can be true for transgender men—embracing a pansexual identity can describe an attraction to a particular gender expression (masculine, feminine, both, neither) rather than a desire for intimacy with someone whose physical body reflects normative sex or gender assumptions.
The acronym “LGBT” is often used to abbreviate “lesbian, gay, bisexual, and transgender.” Sometimes the acronym will read “LGBTQ,” where the “Q” stands for “Queer.” In work with youth the “Q” may also stand for youth who are “Questioning” or exploring their gender identity and/or sexual orientation. The acronym is also sometimes written as “LGBTQI” where the “I” stands for “intersex.” Beliefs about the inclusion of intersex vary among people with intersex conditions. Some individuals living with an intersex condition consider this (being intersex) part of their identity and thus include the “I” in “LGBTQI.” Other persons understand their intersex experience as a medical condition (like any other medical condition) and do not view it as part of who they are or their identity.
Many younger lesbian and gay people (especially in urban areas) have incorporated the word Queer into the LGBT acronym (LGBTQ). It is also used on its own to describe someone’s identity. Historically, queer was a derogatory epithet hurled at lesbian and gay people with the goal of demeaning them. Many older lesbian and gay people still find the word offensive because, when they came of age, being called queer was a slur used in the context of verbal harassment or even physical violence.
In recent years, instead of allowing others to disparage them by calling them queer, many young people have reclaimed the word to express their pride in themselves and their community. In this sense, Queer often has an “in-your-face” political edge, as in the slogan “I’m here. I’m Queer. Get used to it.” It reflects the LGBT community’s insistence on being seen and accepted for who they are, rather than being invisible or silent as was often true in the past. Queer is used as part of the LGBTQ acronym and can be used independently as an umbrella term for the whole spectrum of people within LGBT communities. In this sense, it can speak to either sexual orientation or gender identity or expression or both.
Within the context of this book about trans and gender-nonconforming youth, I use the term transgender to describe those youth whose gender identity does not align with their assigned sex and desire to transition so that they can live as the gender they understand themselves to be. I will alternately sometimes shorten transgender to trans. When I discuss these young people who intend to or do transition, I use the language affirmed gender to reflect their understanding of their gender identity (as opposed to the sex they were assigned at birth). Children and adolescents who have transitioned either socially or medically are now living and presenting to the world in their affirmed gender (and not their birth-assigned sex).
The terms gender-variant and gender-nonconforming have been used to describe children and adolescents whose gender expression varies from what is stereotypically expected from boys or girls. Both of these terms imply that the young person’s gender identity or expression is in some way abnormal. In contrast, I use gender-diverse to describe children who express their gender in (diverse) ways that are not reflective of a binary gender construct. These children do not necessarily intend to transition, though at times a child whose initial or present gender expression is more fluid or nonconforming may later come to identify as transgender and transition. These dynamics and varying narratives will be explored more fully within the remainder of the book.