gender transition essay

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The Experiences, Challenges and Hopes of Transgender and Nonbinary U.S. Adults

Findings from pew research center focus groups, table of contents, identity and the gender journey, navigating gender day-to-day, seeking medical care for gender transitions , connections with the broader lgbtq+ community, policy and social change.

• Focus groups
• The American Trends Panel survey methodology
• Panel recruitment
• Sample design
• Questionnaire development and testing
• Data collection protocol
• Data quality checks
• Acknowledgments

Introduction

Transgender and nonbinary people have gained visibility in the U.S. in recent years as celebrities from  Laverne Cox  to  Caitlyn Jenner  to  Elliot Page  have spoken openly about their gender transitions. On March 30, 2022, the White House issued a proclamation  recognizing Transgender Day of Visibility , the first time a U.S. president has done so.  

More recently, singer and actor Janelle Monáe  came out as nonbinary , while the U.S. State Department and Social Security Administration announced that Americans  will be allowed to select “X” rather than “male” or “female” for their sex  marker on their passport and Social Security applications. 

At the same time, several states have enacted or are considering legislation that would  limit the rights of transgender and nonbinary people . These include bills requiring people to use public bathrooms that correspond with the sex they were assigned at birth, prohibiting trans athletes from competing on teams that match their gender identity, and restricting the availability of health care to trans youth seeking to medically transition. 

A new Pew Research Center survey finds that 1.6% of U.S. adults are transgender or nonbinary – that is, their gender is different from the sex they were assigned at birth. This includes people who describe themselves as a man, a woman or nonbinary, or who use terms such as gender fluid or agender to describe their gender. While relatively few U.S. adults are transgender, a growing share say they know someone who is (44% today vs.  37% in 2017 ). One-in-five say they know someone who doesn’t identify as a man or woman. 

In order to better understand the experiences of transgender and nonbinary adults at a time when gender identity is at the center of many national debates, Pew Research Center conducted a series of focus groups with trans men, trans women and nonbinary adults on issues ranging from their gender journey, to how they navigate issues of gender in their day-to-day life, to what they see as the most pressing policy issues facing people who are trans or nonbinary. This is part of a larger study that includes a survey of the general public on their attitudes about gender identity and issues related to people who are transgender or nonbinary.

The terms  transgender  and  trans  are used interchangeably throughout this essay to refer to people whose gender is different from the sex they were assigned at birth. This includes, but is not limited to, transgender men (that is, men who were assigned female at birth) and transgender women (women who were assigned male at birth). 

Nonbinary adults  are defined here as those who are neither a man nor a woman or who aren’t strictly one or the other. While some nonbinary focus group participants sometimes use different terms to describe themselves, such as “gender queer,” “gender fluid” or “genderless,” all said the term “nonbinary” describes their gender in the screening questionnaire. Some, but not all, nonbinary participants also consider themselves to be transgender.

References to  gender transitions  relate to the process through which trans and nonbinary people express their gender as different from social expectations associated with the sex they were assigned at birth. This may include social, legal and medical transitions. The social aspect of a gender transition may include going by a new name or using different pronouns, or expressing their gender through their dress, mannerisms, gender roles or other ways. The legal aspect may include legally changing their name or changing their sex or gender designation on legal documents or identification.  Medical care  may include treatments such as hormone therapy, laser hair removal and/or surgery. 

References to  femme  indicate feminine gender expression. This is often in contrast to “masc,” meaning masculine gender expression.

Cisgender  is used to describe people whose gender matches the sex they were assigned at birth and who do not identify as transgender or nonbinary. 

Misgendering  is defined as referring to or addressing a person in ways that do not align with their gender identity, including using incorrect pronouns, titles (such as “sir” or “ma’am”), and other terms (such as “son” or “daughter”) that do not match their gender. 

References to  dysphoria  may include feelings of distress due to the mismatch of one’s gender and sex assigned at birth, as well as a  diagnosis of gender dysphoria , which is sometimes a prerequisite for access to health care and medical transitions.

The acronym  LGBTQ+  refers to lesbian, gay, bisexual, transgender, queer (or, in some cases, questioning), and other sexual orientations or gender identities that are not straight or cisgender, such as intersex, asexual or pansexual. 

Pew Research Center conducted this research to better understand the experiences and views of transgender and nonbinary U.S. adults. Because transgender and nonbinary people make up only about 1.6% of the adult U.S. population, this is a difficult population to reach with a probability-based, nationally representative survey. As an alternative, we conducted a series of focus groups with trans and nonbinary adults covering a variety of topics related to the trans and nonbinary experience. This allows us to go more in-depth on some of these topics than a survey would typically allow, and to share these experiences in the participants’ own words.

For this project, we conducted six online focus groups, with a total of 27 participants (four to five participants in each group), from March 8-10, 2022. Participants were recruited by targeted email outreach among a panel of adults who had previously said on a survey that they were transgender or nonbinary, as well as via connections through professional networks and LGBTQ+ organizations, followed by a screening call. Candidates were eligible if they met the technology requirements to participate in an online focus group and if they either said they consider themselves to be transgender or if they said their gender was nonbinary or another identity other than man or woman (regardless of whether or not they also said they were transgender). For more details, see the  Methodology . 

Participants who qualified were placed in groups as follows: one group of nonbinary adults only (with a nonbinary moderator); one group of trans women only (with a trans woman moderator); one group of trans men only (with a trans man moderator); and three groups with a mix of trans and nonbinary adults (with either a nonbinary moderator or a trans man moderator). All of the moderators had extensive experience facilitating groups, including with transgender and nonbinary participants. 

The participants were a mix of ages, races/ethnicities, and were from all corners of the country. For a detailed breakdown of the participants’ demographic characteristics, see the  Methodology .

The findings are not statistically representative and cannot be extrapolated to wider populations.

Some quotes have been lightly edited for clarity or to remove identifying details. In this essay, participants are identified as trans men, trans women, or nonbinary adults based on their answers to the screening questionnaire. These words don’t necessarily encompass all of the ways in which participants described their gender. Participants’ ages are grouped into the following categories:  late teens; early/mid/late 20s, 30s and 40s; and 50s and 60s (those ages 50 to 69 were grouped into bigger “buckets” to better preserve their anonymity).

These focus groups were not designed to be representative of the entire population of trans and nonbinary U.S. adults, but the participants’ stories provide a glimpse into some of the experiences of people who are transgender and/or nonbinary. The groups included a total of 27 transgender and nonbinary adults from around the U.S. and ranging in age from late teens to mid-60s. Most currently live in an urban area, but about half said they grew up in a suburb. The groups included a mix of White, Black, Hispanic, Asian and multiracial American participants. See  Methodology  for more details.

Most focus group participants said they knew from an early age – many as young as preschool or elementary school – that there was something different about them, even if they didn’t have the words to describe what it was. Some described feeling like they didn’t fit in with other children of their sex but didn’t know exactly why. Others said they felt like they were in the wrong body. 

“I remember preschool, [where] the boys were playing on one side and the girls were playing on the other, and I just had a moment where I realized what side I was supposed to be on and what side people thought I was supposed to be on. … Yeah, I always knew that I was male, since my earliest memories.” – Trans man, late 30s

“As a small child, like around kindergarten [or] first grade … I just was [fascinated] by how some people were small girls, and some people were small boys, and it was on my mind constantly. And I started to feel very uncomfortable, just existing as a young girl.” – Trans man, early 30s

“I was 9 and I was at day camp and I was changing with all the other 9-year-old girls … and I remember looking at everybody’s body around me and at my own body, and even though I was visually seeing the exact shapeless nine-year-old form, I literally thought to myself, ‘oh, maybe I was supposed to be a boy,’ even though I know I wasn’t seeing anything different. … And I remember being so unbothered by the thought, like not a panic, not like, ‘oh man, I’m so different, like everybody here I’m so different and this is terrible,’ I was like, ‘oh, maybe I was supposed to be a boy,’ and for some reason that exact quote really stuck in my memory.” – Nonbinary person, late 30s

“Since I was little, I felt as though I was a man who, when they were passing out bodies, someone made a goof and I got a female body instead of the male body that I should have had. But I was forced by society, especially at that time growing up, to just make my peace with having a female body.” – Nonbinary person, 50s

“I’ve known ever since I was little. I’m not really sure the age, but I just always knew when I put on boy clothes, I just felt so uncomfortable.” – Trans woman, late 30s

“It was probably as early as I can remember that I wasn’t like my brother or my father [and] not exactly like my girl cousins but I was something else, but I didn’t know what it was.” – Nonbinary person, 60s

Many participants were well into adulthood before they found the words to describe their gender. For those focus group participants, the path to self-discovery varied. Some described meeting someone who was transgender and relating to their experience; others described learning about people who are trans or nonbinary in college classes or by doing their own research.  

“I read a Time magazine article … called ‘Homosexuality in America’ … in 1969. … Of course, we didn’t have language like we do now or people were not willing to use it … [but] it was kind of the first word that I had ever heard that resonated with me at all. So, I went to school and I took the magazine, we were doing show-and-tell, and I stood up in front of the class and said, ‘I am a homosexual.’ So that began my journey to figure this stuff out.” – Nonbinary person, 60s

“It wasn’t until maybe I was 20 or so when my friend started his transition where I was like, ‘Wow, that sounds very similar to the emotions and challenges I am going through with my own identity.’ … My whole life from a very young age I was confused, but I didn’t really put a name on it until I was about 20.” – Nonbinary person, late 20s

“I knew about drag queens, but I didn’t know what trans was until I got to college and was exposed to new things, and that was when I had a word for myself for the first time.” – Trans man, early 40s

“I thought that by figuring out that I was interested in women, identifying as lesbian, I thought [my anxiety and sadness] would dissipate in time, and that was me cracking the code. But then, when I got older, I left home for the first time. I started to meet other trans people in the world. That’s when I started to become equipped with the vocabulary. The understanding that this is a concept, and this makes sense. And that’s when I started to understand that I wasn’t cisgender.” – Trans man, early 30s

“When I took a human sexuality class in undergrad and I started learning about gender and different sexualities and things like that, I was like, ‘oh my god. I feel seen.’ So, that’s where I learned about it for the first time and started understanding how I identify.” – Nonbinary person, mid-20s

Focus group participants used a wide range of words to describe how they see their gender. For many nonbinary participants, the term “nonbinary” is more of an umbrella term, but when it comes to how they describe themselves, they tend to use words like “gender queer” or “gender fluid.” The word “queer” came up many times across different groups, often to describe anyone who is not straight or cisgender. Some trans men and women preferred just the terms “man” or “woman,” while some identified strongly with the term “transgender.” The graphic below shows just some of the words the participants used to describe their gender.

The way nonbinary people conceptualize their gender varies. Some said they feel like they’re both a man and a woman – and how much they feel like they are one or the other may change depending on the day or the circumstance. Others said they don’t feel like they are either a man or a woman, or that they don’t have a gender at all. Some, but not all, also identified with the term transgender. 

“I had days where I would go out and just play with the boys and be one of the boys, and then there would be times that I would play with the girls and be one of the girls. And then I just never really knew what I was. I just knew that I would go back and forth.” – Nonbinary person, mid-20s

“Growing up with more of a masculine side or a feminine side, I just never was a fan of the labelling in terms of, ‘oh, this is a bit too masculine, you don’t wear jewelry, you don’t wear makeup, oh you’re not feminine enough.’ … I used to alternate just based on who I felt I was. So, on a certain day if I felt like wearing a dress, or a skirt versus on a different day, I felt like wearing what was considered men’s pants. … So, for me it’s always been both.” – Nonbinary person, mid-30s

“I feel like my gender is so amorphous and hard to hold and describe even. It’s been important to find words for it, to find the outlines of it, to see the shape of it, but it’s not something that I think about as who I am, because I’m more than just that.” – Nonbinary person, early 30s

“What words would I use to describe me? Genderless, if gender wasn’t a thing. … I guess if pronouns didn’t exist and you just called me [by my name]. That’s what my gender is. … And I do use nonbinary also, just because it feels easier, I guess.” – Nonbinary person, late 20s

Some participants said their gender is one of the most important parts of their identity, while others described it as one of many important parts or a small piece of how they see themselves. For some, the focus on gender can get tiring. Those who said gender isn’t a central – or at least not the most central – part of their identity mentioned race, ethnicity, religion and socioeconomic class as important aspects that shape their identity and experiences.

“It is tough because [gender] does affect every factor of your life. If you are doing medical transitioning then you have appointments, you have to pay for the appointments, you have to be working in a job that supports you to pay for those appointments. So, it is definitely integral, and it has a lot of branches. And it deals with how you act, how you relate to friends, you know, I am sure some of us can relate to having to come out multiple times in our lives. That is why sexuality and gender are very integral and I would definitely say I am proud of it. And I think being able to say that I am proud of it, and my gender, I guess is a very important part of my identity.” – Nonbinary person, late 20s

“Sometimes I get tired of thinking about my gender because I am actively [undergoing my medical transition]. So, it is a lot of things on my mind right now, constantly, and it sometimes gets very tiring. I just want to not have to think about it some days. So, I would say it’s, it’s probably in my top three [most important parts of my identity] – parent, Black, queer nonbinary.” – Nonbinary person, mid-40s

“I live in a town with a large queer and trans population and I don’t have to think about my gender most of the time other than having to come out as trans. But I’m poor and that colors everything. It’s not a chosen part of my identity but that part of my identity is a lot more influential than my gender.” – Trans man, early 40s

“My gender is very important to my identity because I feel that they go hand in hand. Now my identity is also broken down into other factors [like] character, personality and other stuff that make up the recipe for my identity. But my gender plays a big part of it. … It is important because it’s how I live my life every day. When I wake up in the morning, I do things as a woman.” – Trans woman, mid-40s

“I feel more strongly connected to my other identities outside of my gender, and I feel like parts of it’s just a more universal thing, like there’s a lot more people in my socioeconomic class and we have much more shared experiences.” – Trans man, late 30s

Some participants spoke about how their gender interacted with other aspects of their identity, such as their race, culture and religion. For some, being transgender or nonbinary can be at odds with other parts of their identity or background. 

“Culturally I’m Dominican and Puerto Rican, a little bit of the macho machismo culture, in my family, and even now, if I’m going to be a man, I’ve got to be a certain type of man. So, I cannot just be who I’m meant to be or who I want myself to be, the human being that I am.” – Trans man, mid-30s

“[Judaism] is a very binary religion. There is a lot of things like for men to do and a lot of things for women to do. … So, it is hard for me now as a gender queer person, right, to connect on some levels with [my] religion … I have just now been exposed to a bunch of trans Jewish spaces online which is amazing.” – Nonbinary person, mid-40s

“Just being Indian American, I identify and love aspects of my culture and ethnicity, and I find them amazing and I identify with that, but it’s kind of separated. So, I identify with the culture, then I identify here in terms of gender and being who I am, but I kind of feel the necessity to separate the two, unfortunately.” – Nonbinary person, mid-30s

“I think it’s really me being a Black woman or a Black man that can sometimes be difficult. And also, my ethnic background too. It’s really rough for me with my family back home and things of that nature.” – Nonbinary person, mid-20s

For some, deciding how open to be about their gender identity can be a constant calculation. Some participants reported that they choose whether or not to disclose that they are trans or nonbinary in a given situation based on how safe or comfortable they feel and whether it’s necessary for other people to know. This also varies depending on whether the participant can easily pass as a cisgender man or woman (that is, they can blend in so that others assume them to be cisgender and don’t recognize that they are trans or nonbinary).

“It just depends on whether I feel like I have the energy to bring it up, or if it feels worth it to me like with doctors and stuff like that. I always bring it up with my therapists, my primary [care doctor], I feel like she would get it. I guess it does vary on the situation and my capacity level.” – Nonbinary person, late 20s

“I decide based on the person and based on the context, like if I feel comfortable enough to share that piece of myself with them, because I do have the privilege of being able to move through the world and be identified as cis[gender] if I want to. But then it is important to me – if you’re important to me, then you will know who I am and how I identify. Otherwise, if I don’t feel comfortable or safe then I might not.” – Nonbinary person, early 30s

“The expression of my gender doesn’t vary. Who I let in to know that I was formerly female – or formerly perceived as female – is kind of on a need to know basis.” – Trans man, 60s

“It’s important to me that people not see me as cis[gender], so I have to come out a lot when I’m around new people, and sometimes that’s challenging. … It’s not information that comes out in a normal conversation. You have to force it and that’s difficult sometimes.” – Trans man, early 40s

Work is one realm where many participants said they choose not to share that they are trans or nonbinary. In some cases, this is because they want to be recognized for their work rather than the fact that they are trans or nonbinary; in others, especially for nonbinary participants, they fear it will be perceived as unprofessional.

“It’s gotten a lot better recently, but I feel like when you’re nonbinary and you use they/them pronouns, it’s just seen as really unprofessional and has been for a lot of my life.” – Nonbinary person, early 30s

“Whether it’s LinkedIn or profiles [that] have been updated, I’ve noticed people’s resumes have their pronouns now. I don’t go that far because I just feel like it’s a professional environment, it’s nobody’s business.” – Nonbinary person, mid-30s

“I don’t necessarily volunteer the information just to make it public; I want to be recognized for my character, my skill set, in my work in other ways.” – Trans man, early 30s

Some focus group participants said they don’t mind answering questions about what it’s like to be trans or nonbinary but were wary of being seen as the token trans or nonbinary person in their workplace or among acquaintances. Whether or not they are comfortable answering these types of questions sometimes depends on who’s asking, why they want to know, and how personal the questions get.

“I’ve talked to [my cousin about being trans] a lot because she has a daughter, and her daughter wants to transition. So, she always will come to me asking questions.” – Trans woman, early 40s

“It is tough being considered the only resource for these topics, right? In my job, I would hate to call myself the token nonbinary, but I was the first nonbinary person that they hired and they were like, ‘Oh, my gosh, let me ask you all the questions as you are obviously the authority on the subject.’ And it is like, ‘No, that is a part of me, but there are so many other great resources.’” – Nonbinary person, late 20s

“I don’t want to be the token. I’m not going to be no spokesperson. If you have questions, I’m the first person you can ask. Absolutely. I don’t mind discussing. Ask me some of the hardest questions, because if you ask somebody else you might get you know your clock cleaned. So, ask me now … so you can be educated properly. Otherwise, I don’t believe it’s anybody’s business.” – Trans woman, early 40s

Most nonbinary participants said they use “they/them” as their pronouns, but some prefer alternatives. These alternatives include a combination of gendered and gender-neutral pronouns (like she/they) or simply preferring that others use one’s names rather than pronouns. 

“If I could, I would just say my name is my pronoun, which I do in some spaces, but it just is not like a larger view. It feels like I’d rather have less labor on me in that regard, so I just say they/them.” – Nonbinary person, late 20s

“For me personally, I don’t get mad if someone calls me ‘he’ because I see what they’re looking at. They look and they see a guy. So, I don’t get upset. I know a few people who do … and they correct you. Me, I’m a little more fluid. So, that’s how it works for me.” – Nonbinary person, mid-30s

“I use they/she pronouns and I put ‘they’ first because that is what I think is most comfortable and it’s what I want to draw people’s attention to, because I’m 5 feet tall and 100 pounds so it’s not like I scream masculine at first sight, so I like putting ‘they’ first because otherwise people always default to ‘she.’ But I have ‘she’ in there, and I don’t know if I’d have ‘she’ in there if I had not had kids.” – Nonbinary person, late 30s

“Why is it so hard for people to think of me as nonbinary? I choose not to use only they/them pronouns because I do sometimes identify with ‘she.’ But I’m like, ‘Do I need to use they/them pronouns to be respected as nonbinary?’ Sometimes I feel like I should do that. But I don’t want to feel like I should do anything. I just want to be myself and have that be accepted and respected.” – Nonbinary person, early 30s

“I have a lot of patience for people, but [once someone in public used] they/them pronouns and I thanked them and they were like, ‘Yeah, I just figure I’d do it when I don’t know [someone’s] pronouns.’ And I’m like, ‘I love it, thank you.’” – Nonbinary person, early 30s

Transgender and nonbinary participants find affirmation of their gender identity and support in various places. Many cited their friends, chosen families (and, less commonly, their relatives), therapists or other health care providers, religion, or LGBTQ+ spaces as sources of support.

“I’m just not close with my family [of origin], but I have a huge chosen family that I love and that fully respects my identity.” – Nonbinary person, early 30s

“Before the pandemic I used to go out to bars a lot; there’s a queer bar in my town and it was a really nice place just being friends with everybody who went and everybody who worked there, it felt really nice you know, and just hearing everybody use the right pronouns for me it just felt really good.” – Nonbinary person, early 30s

“I don’t necessarily go to a lot of dedicated support groups, but I found that there’s kind of a good amount of support in areas or groups or fandoms for things that have a large LGBT population within them. Like certain shows or video games, where it’s just kind of a joke that all the gay people flock to this.”  – Trans woman, late teens

“Being able to practice my religion in a location with a congregation that is just completely chill about it, or so far has been completely chill about it, has been really amazing.” – Nonbinary person, late 30s

Many participants shared specific moments they said were small in the grand scheme of things but made them feel accepted and affirmed. Examples included going on dates, gestures of acceptance by a friend or social group, or simply participating in everyday activities.

“I went on a date with a really good-looking, handsome guy. And he didn’t know that I was trans. But I told him, and we kept talking and hanging out. … That’s not the first time that I felt affirmed or felt like somebody is treating me as I present myself. But … he made me feel wanted and beautiful.” – Trans woman, late 30s

“I play [on a men’s rec league] hockey [team]. … I joined the league like right when I first transitioned and I showed up and I was … nervous with locker rooms and stuff, and they just accepted me as male right away.” – Trans man, late 30s

“I ended up going into a barbershop. … The barber was very welcoming, and talked to me as if I was just a casual customer and there was something that clicked within that moment where, figuring out my gender identity, I just wanted to exist in the world to do these natural things like other boys and men would do. So, there was just something exciting about that. It wasn’t a super macho masculine moment, … he just made me feel like I blended in.” – Trans man, early 30s

Participants also talked about negative experiences, such as being misgendered, either intentionally or unintentionally. For example, some shared instances where they were treated or addressed as a gender other than the gender that they identify as, such as people referring to them as “he” when they go by “she,” or where they were deadnamed, meaning they were called by the name they had before they transitioned. 

“I get misgendered on the phone a lot and that’s really annoying. And then, even after I correct them, they keep doing it, sometimes on purpose and sometimes I think they’re just reading a script or something.” – Trans man, late 30s

“The times that I have been out, presenting femme, there is this very subconscious misgendering that people do and it can be very frustrating. [Once, at a restaurant,] I was dressed in makeup and nails and shoes and everything and still everyone was like, ‘Sir, what would you like?’ … Those little things – those microaggressions – they can really eat away at people.” – Nonbinary person, mid-40s

“People not calling me by the right name. My family is a big problem, they just won’t call me by my name, you know? Except for my nephew, who is of the Millennial generation, so at least he gets it.” – Nonbinary person, 60s

“I’m constantly misgendered when I go out places. I accept this – because of the way I look, people are going to perceive me as a woman and it doesn’t cause me huge dysphoria or anything, it’s just nice that the company that I keep does use the right pronouns.” – Nonbinary person, early 30s

Some participants also shared stories of discrimination, bias, humiliation, and even violence. These experiences ranged from employment discrimination to being outed (that is, someone else disclosing the fact that they are transgender or nonbinary without their permission) without their permission to physical attacks.

“I was on a date with this girl and I had to use the bathroom … and the janitor … wouldn’t let me use the men’s room, and he kept refusing to let me use the men’s room, so essentially, I ended up having to use the same bathroom as my date.” – Trans man, late 30s

“I’ve been denied employment due to my gender identity. I walked into a supermarket looking for jobs. … And they flat out didn’t let me apply. They didn’t even let me apply.” – Trans man, mid-30s

“[In high school,] this group of guys said, ‘[name] is gay.’ I ignored them but they literally threw me and tore my shirt from my back and pushed me to the ground and tried to strip me naked. And I had to fight for myself and use my bag to hit him in the face.” – Trans woman, late 20s

“I took a college course [after] I had my name changed legally and the instructor called me out in front of the class and called me a liar and outed me.” – Trans man, late 30s 

Many, but not all, participants said they have received  medical care , such as surgery or hormone therapy, as part of their gender transition. For those who haven’t undergone a medical transition, the reasons ranged from financial barriers to being nervous about medical procedures in general to simply not feeling that it was the right thing for them.

“For me to really to live my truth and live my identity, I had to have the surgery, which is why I went through it. It doesn’t mean [that others] have to, or that it will make you more or less of a woman because you have it. But for me to be comfortable, … that was a big part of it. And so, that’s why I felt I had to get it.” – Trans woman, early 40s

“I’m older and it’s an operation. … I’m just kind of scared, I guess. I’ve never had an operation. I mean, like any kind of operation. I’ve never been to the hospital or anything like that. So, it [is] just kind of scary. But I mean, I want to. I think about all the time. I guess have got to get the courage up to do it.” – Trans woman, early 40s

“I’ve decided that the dysphoria of a second puberty … would just be too much for me and I’m gender fluid enough where I’m happy, I guess.” – Nonbinary person, early 30s

“I’m too old to change anything, I mean I am what I am. [laughs]” – Nonbinary person, 60s

Many focus group participants who have sought medical treatment for their gender transition faced barriers, although some had positive experiences. For those who said there were barriers, the cost and the struggle to find sympathetic doctors were often cited as challenges. 

“I was flat out turned down by the primary care physician who had to give the go-ahead to give me a referral to an endocrinologist; I was just shut down. That was it, end of story.” – Nonbinary person, 50s

“I have not had surgery, because I can’t access surgery. So unless I get breast cancer and have a double mastectomy, surgery is just not going to happen … because my health insurance wouldn’t cover something like that. … It would be an out-of-pocket plastic surgery expense and I can’t afford that at this time.” – Nonbinary person, 50s

“Why do I need the permission of a therapist to say, ‘This person’s identity is valid,’ before I can get the health care that I need to be me, that is vital for myself and for my way of life?” – Nonbinary person, mid-40s

“[My doctor] is basically the first person that actually embraced me and made me accept [who I am].” – Trans woman, late 20s

Many people who transitioned in previous decades described how access has gotten much easier in recent years. Some described relying on underground networks to learn which doctors would help them obtain medical care or where to obtain hormones illegally. 

“It was hard financially because I started so long ago, just didn’t have access like that. Sometimes you have to try to go to Mexico or learn about someone in Mexico that was a pharmacist, I can remember that. That was a big thing, going through the border to Mexico, that was wild. So, it was just hard financially because they would charge so much for testosterone. And there was the whole bodybuilding community. If you were transitioning, you went to bodybuilders, and they would charge you five times what they got it [for], so it was kind of tough.” – Trans man, early 40s

“It was a lot harder to get a surgeon when I started transitioning; insurance was out of the question, there wasn’t really a national discussion around trans people and their particular medical needs. So, it was challenging having to pay everything out of pocket at a young age.” – Trans man, early 30s

“I guess it was hard for me to access hormones initially just because you had to jump through so many hoops, get letters, and then you had to find a provider that was willing to write it. And now it’s like people are getting it from their primary care doctor, which is great, but a very different experience than I had.” – Trans man, early 40s

The discussions also touched on whether the participants feel a connection with a broader lesbian, gay, bisexual, transgender, and queer (LGBTQ+) community or with other people who are LGBTQ+. Views varied, with some saying they feel an immediate connection with other people who are LGBTQ+, even with those who aren’t trans or nonbinary, and others saying they don’t necessarily feel this way. 

“It’s kind of a recurring joke where you can meet another LGBT person and it is like there is an immediate understanding, and you are basically talking and giving each other emotional support, like you have been friends for 10-plus years.” – Trans woman, late teens 

“I don’t think it’s automatic friendship between queer people, there’s like a kinship, but I don’t think there’s automatic friendship or anything. I think it’s just normal, like, how normal people make friends, just based on common interests.” – Nonbinary person, early 30s 

“I do think of myself as part of the LGBT [community] … I use the resources that are put in place for these communities, whether that’s different health care programs, support groups, they have the community centers. … So, I do consider myself to be part of this community, and I’m able to hopefully take when needed, as well as give back.” – Trans man, mid-30s

“I feel like that’s such an important part of being a part of the [LGBTQ+] alphabet soup community, that process of constantly learning and listening to each other and … growing and developing language together … I love that aspect of creating who we are together, learning and unlearning together, and I feel like that’s a part of at least the queer community spaces that I want to be in. That’s something that’s core to me.” – Nonbinary person, early 30s

“I identify as queer. I feel like I’m a part of the LGBT community. That’s more of a part of my identity than being trans. … Before I came out as trans, I identified as a lesbian. That was also a big part of my identity. So, that may be too why I feel like I’m more part of the LGB community.” – Trans man, early 40s

While many trans and nonbinary participants said they felt accepted by others in the LGBTQ+ community, some participants described their gender identity as a barrier to full acceptance. There was a sense among some participants that cisgender people who are lesbian, gay or bisexual don’t always accept people who are transgender or nonbinary.  

“I would really like to be included in the [LGBTQ+] community. But I have seen some people try to separate the T from LGB … I’ve run into a few situations throughout my time navigating the [LGBTQ+] community where I’ve been perceived – and I just want to say that there’s nothing wrong with this – I’ve been perceived as like a more feminine or gay man in a social setting, even though I’m heterosexual. … But the minute that that person found out that I wasn’t a gay man … and that I was actually a transgender person, they became cold and just distancing themselves. And I’ve been in a lot of those types of circumstances where there’s that divide between the rest of the community.” – Trans man, early 30s

“There are some lesbians who see trans men as being traitors to womanhood. Those are not people that I really identify with or want to be close to.” – Trans man, early 40s 

“It’s only in the past maybe dozen or so years, that an identity like gender fluid or gender queer was acceptable even within the LGBTQ+ community. … I tried to go to certain LGBTQ+ events as a trans man and, you know, I was not allowed in because I looked too female. The gay men would not allow me to participate.” – Nonbinary person, 50s 

“Technically based on the letters [in the acronym LGBTQ+] I am part of that community, but I’ve felt discrimination, it’s very heavily exclusive to people who are either gay or lesbian and I think that’s true … for queer or bisexual or asexual, intersex … anybody who’s not like exclusively hardcore gay or lesbian. It’s very exclusive, like excluding to those people. … I feel like the BTQ is a separate group of people…. So, I identify with the second half of the letters as a separate subset.” – Trans man, late 30s

When asked to name the most important policy or political issues facing transgender and nonbinary people in the United States today, many participants named basic needs such as housing, employment, and health care. Others cited recent legislation or policies related to people who are transgender that have made national news.

“Housing is a huge issue. Health care might be good in New York, it might be good in California, but … it’s not a national equality for trans folks. Health care is not equal across the states. Housing is not equal across the states. So, I think that the issues right now that we’re all facing is health care and housing. That’s the top, the most important things.” – Trans woman, early 40s 

“Definitely education. I think that’s very important … Whether you identify as trans or not as a young child, it’s good to understand and know the different things under the umbrella, the queer umbrella. And it is also just a respect thing. And also, the violence that happens against trans and nonbinary people. I feel like educating them very young, that kind of helps – well, it is going to help because once you understand what’s going on and you see somebody that doesn’t identify the same as you, you’ll have that respect, or you’ll have that understanding and you’re less likely to be very violent towards them.” – Nonbinary person, mid-20s 

“Employment is a big one. And I know that some areas, more metropolitan progressive-leaning areas, are really on top of this, but they’re trans people everywhere that are still being discriminated against. I think it’s a personal thing for me that goes back to my military service, but still, it’s just unfortunate. It’s an unfortunate reality.” – Trans man, early 30s

“I think just the strong intersectionality of trans people with mental health issues, or even physical health issues. … So in that way, accessing good health care or having good mental health.” – Trans man, late 30s

“I honestly think that the situation in Texas is the most pressing political and policy situation because it is a direct attack on the trans community. … And it is so insidious because it doesn’t just target bathrooms. This is saying that if you provide medical care to trans youth it is tantamount to child abuse. And it is so enraging because it is a known proven fact that access to gender affirming medical care saves lives. It saves the lives of trans youth. And trans youth have the highest suicide rate in the country.” – Nonbinary person, mid-40s 

Participants had different takes on what gets in the way of progress on issues facing transgender and nonbinary people. Some pointed to the lack of knowledge surrounding the history of these issues or not knowing someone who is transgender or nonbinary. Others mentioned misconceptions people might have about transgender and nonbinary people that influence their political and policy perspectives. 

“People who don’t know trans people, honestly … that’s the only barrier I can understand because people fear what they don’t know and then react to it a lot of the time.” – Nonbinary person, early 30s

“Sometimes even if they know someone, they still don’t consider them to be a human being, they are an ‘other,’ they are an ‘it,’ they are a ‘not like me,’ ‘not like my family,’ person and so they are put into a place socially where they can be treated badly.” – Nonbinary person, 50s

“Just the ignorance and misinformation and this quick fake social media fodder, where it encourages people who should not be part of the conversation to spread things that are not true.” – Trans man, late 30s

“Also, the political issues that face nonbinary people, it’s that people think nonbinary is some made-up thing to feel cool. It’s not to feel cool. And if someone does do it to feel cool, maybe they’re just doing that because they don’t feel comfortable within themselves.” – Nonbinary person, mid-30s

“There’s so much fear around it, and misunderstanding, and people thinking that if you’re talking to kids about gender and sexuality, that it’s sexual. And it’s like, we really need to break down that our bodies are not inherently sexual. We need to be able to talk with students and children about their bodies so that they can then feel empowered to understand themselves, advocate for themselves.” – Nonbinary person, early 30s

When asked what makes them hopeful for the future for trans and nonbinary people, some participants pointed to the way things in society have already changed and progress that has been made. For example, some mentioned greater representation and visibility of transgender and nonbinary people in entertainment and other industries, while others focused on changing societal views as things that give them hope for the future. 

“I am hopeful about the future because I see so many of us coming out and being visible and representing and showing folks that we are not to stereotype.” – Trans woman, early 40s

“Also, even though celebrity is annoying, it’s still cool when people like Willow [Smith] or Billie Eilish or all these popstars that the kids really love are like, ‘I’m nonbinary, I’m queer,’ like a lot more progressive. … Even just more visibility in TV shows and movies, the more and more that happens the more it’s like, ‘Oh yeah, we are really here, you can’t not see us.’” – Nonbinary person, late 20s

“We shouldn’t have to look to the entertainment industry for role models, we shouldn’t have to, we should be able to look to our leaders, our political leaders, but I think, that’s what gives me hope. Soon, it’s going to become a nonissue, maybe in my lifetime.” – Trans man, 60s

“I have gotten a little bit into stand-up comedy in the last few weeks, and it is like the jokes that people made ten years ago are resurfacing online and people are enraged about it. They are saying like, ‘Oh, this is totally inappropriate.’ But that comes with the recognition that things have changed, and language has changed, and people are becoming more intolerant of allowing these things to occur. So that is why I am hopeful, is being able to see that progression and hopeful continued improvement on that front.” – Nonbinary person, late 20s

“I think because of the shift of what’s happening, how everything has become so normal, and people are being more open, and within the umbrella of queerness so many different things are happening, I think as we get more comfortable and we progress as a society, it’s just going to be better. So, people don’t have to hide who they are. So, that gives me hope.” – Nonbinary person, mid-20s

For many, young people are a source of hope. Several participants talked about younger generations being more accepting of those who are transgender or nonbinary and also being more accepted by their families if they themselves are trans or nonbinary. 

“And then the other portion that gives me hope are the kids, because I work now with so many kids who are coming out as trans earlier and their families are embracing them and everything. … So I really am trusting in the young generation.” – Nonbinary person, 60s

“I mean kids don’t judge you the same way as adults do about gender, and they’re so expansive and have so much creativity. … So it’s just the kids, Gen Z, and it just makes me feel really, really hopeful.” – Nonbinary person, early 30s

“The youth, the youth. They understand almost intrinsically so much more about these things than I feel like my generation did. They give me so much hope for the future.” – Nonbinary person, early 30s

“I think future generations, just seeing this growing amount of support that they have, that it’s just going to keep improving … there’s an increase in visibility but there’s also an increase in support … like resources for parents where they can see that they don’t have to punish their kids. Their kids can grow up feeling like, ‘This is okay to be this way.’ And I feel like that’s not something that can be stopped.” – Trans man, late 30s

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Understanding transgender people, gender identity and gender expression

According to the APA Style guide, the term “transsexual” is largely outdated, but some people identify with it; this term should be used only for an individual who specifically claims it. While the term “transsexual” appears multiple times throughout this document, APA’s Committee on Sexual Orientation and Gender Diversity is undertaking a systematic review of its use along with other terms. In the meantime, please refer to the Guidelines for Psychological Practice with Transgender and Gender Nonconforming People (PDF, 472KB)  for more up-to-date language regarding transgender and gender nonconforming people.

Transgender is an umbrella term for persons whose gender identity, gender expression or behavior does not conform to that typically associated with the sex to which they were assigned at birth. Gender identity refers to a person’s internal sense of being male, female or something else; gender expression refers to the way a person communicates gender identity to others through behavior, clothing, hairstyles, voice or body characteristics. “Trans” is sometimes used as shorthand for “transgender.” While transgender is generally a good term to use, not everyone whose appearance or behavior is gender-nonconforming will identify as a transgender person. The ways that transgender people are talked about in popular culture, academia and science are constantly changing, particularly as individuals’ awareness, knowledge and openness about transgender people and their experiences grow.

What is the difference between sex and gender?

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.

Have transgender people always existed?

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.

What are some categories or types of transgender people?

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  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.

Why are some people transgender?

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.

How prevalent are transgender people?

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.

What is the relationship between gender identity and sexual orientation?

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.

How does someone know that they are transgender?

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.

What should parents do if their child appears to be transgender or gender nonconforming?

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.

How do transgender individuals make a gender transition?

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.

Is being transgender a mental disorder?

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.

According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), people who experience intense, persistent gender incongruence can be given the diagnosis of "gender dysphoria." 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. The International Classification of Diseases (ICD) is under revision and there may be changes to its current classification of intense persistent gender incongruence as "gender identity disorder."

What kinds of discrimination do transgender people face?

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. 

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.

How can I be supportive of transgender family members, friends, or significant others?

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.

Where can I find more information about transgender health, advocacy and human rights?

• American Psychological Association Office on Sexual Orientation and Gender Diversity 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) 476-4172
• 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 Spectrum (510) 788-4412 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 Email

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, D.C.: Author.

American Psychological Association. (2008). Answers to questions: For a better understanding of sexual orientation and homosexuality . Washington, D.C.: Author.

Coleman, E., Bockting, W., Botzer, M., Cohen-Kettenis, P., DeCuypere, G., Feldman, J., ... Zucker, K. (2012). Standards of care for the health of transsexual, transgender, and gender nonconforming people (7th version). International Journal of Transgenderism, 13 , 165-232. doi:10.1080/15532739.2011.700873

National Center for Transgender Equality and the National Gay and Lesbian Task Force. (2011). Injustice at every turn .

World Health Organization. (1990). ICD-10: International classification of diseases and related health problems (10th ed).

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Pamphlets in English and Spanish may be purchased in bundles of 25 for $4.00 plus shipping by calling (800) 374-2721 or by  email .

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This pamphlet also is available in the following languages:

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Related resources

• Sexual orientation and gender diversity
• Transgender Identity Issues in Psychology
• Guidelines for Psychological Practice with Transgender and Gender Nonconforming People (PDF, 472KB)
• APA LGBTQ Resources and Publications

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May 12, 2022

What the Science on Gender-Affirming Care for Transgender Kids Really Shows

Laws that ban gender-affirming treatment ignore the wealth of research demonstrating its benefits for trans people’s health

By Heather Boerner

As attacks against transgender kids increase in the U.S., Minnesotans hold a rally at the state’s capitol in Saint Paul in March 2022 to support trans kids in Minnesota and Texas and around the country.

Michael Siluk/UCG/Universal Images Group via Getty Images

Editor’s Note (3/30/23): This article from May 2022 is being republished to highlight the ways that ongoing anti-trans legislation is harmful and unscientific.

For the first 40 years of their life, Texas resident Kelly Fleming spent a portion of most years in a deep depression. As an adult, Fleming—who uses they/them pronouns and who asked to use a pseudonym to protect their safety—would shave their face in the shower with the lights off so neither they nor their wife would have to confront the reality of their body.

What Fleming was experiencing, although they did not know it at the time, was gender dysphoria : the acute and chronic distress of living in a body that does not reflect one’s gender and the desire to have bodily characteristics of that gender. While in therapy, Fleming discovered research linking access to gender-affirming hormone therapy with reduced depression in transgender people. They started a very low dose of estradiol, and the depression episodes became shorter, less frequent and less intense. Now they look at their body with joy.

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So when Fleming sees what authorities in Texas , Alabama , Florida and other states are doing to bar transgender teens and children from receiving gender-affirming medical care, it infuriates them. And they are worried for their children, ages 12 and 14, both of whom are agender—a identity on the transgender spectrum that is neither masculine nor feminine.

“I’m just so excited to see them being able to present themselves in a way that makes them happy,” Fleming says. “They are living their best life regardless of what others think, and that’s a privilege that I did not get to have as a younger person.”

Laws Based on “Completely Wrong” Information

Currently more than a dozen state legislatures  or administrations are considering—or have already passed—laws banning health care for transgender young people. On April 20 the Florida Department of Health issued guidance to withhold such gender-affirming care. This includes social gender transitioning—acknowledging that a young person is trans, using their correct pronouns and name, and supporting their desire to live publicly as the gender of their experience rather than their sex assigned at birth. This comes nearly two months after Texas Governor Greg Abbott issued an order for the Texas Department of Family and Protective Services to investigate for child abuse parents who allow their transgender preteens and teenagers to receive medical care. Alabama recently passed SB 184 , which would make it a felony to provide gender-affirming medical care to transgender minors. In Alabama, a “minor” is defined as anyone 19 or younger.

If such laws go ahead, 58,200 teens in the U.S. could lose access to or never receive gender-affirming care, according to the Williams Institute at the University of California, Los Angeles. A decade of research shows such treatment reduces depression, suicidality and other devastating consequences of trans preteens and teens being forced to undergo puberty in the sex they were assigned at birth).

The bills are based on “information that’s completely wrong,” says Michelle Forcier, a pediatrician and professor of pediatrics at Brown University. Forcier literally helped write the book on how to provide evidence-based gender care to young people. She is also an assistant dean of admissions at the Warren Alpert Medical School of Brown University. Those laws “are absolutely, absolutely incorrect” about the science of gender-affirming care for young people, she says. “[Inaccurate information] is there to create drama. It’s there to make people take a side.”

The truth is that data from more than a dozen studies of more than 30,000 transgender and gender-diverse young people consistently show that access to gender-affirming care is associated with better mental health outcomes—and that lack of access to such care is associated with higher rates of suicidality, depression and self-harming behavior. (Gender diversity refers to the extent to which a person’s gendered behaviors, appearance and identities are culturally incongruent with the sex they were assigned at birth. Gender-diverse people can identify along the transgender spectrum, but not all do.) Major medical organizations, including the American Academy of Pediatrics (AAP) , the American Academy of Child and Adolescent Psychiatry , the Endocrine Society , the American Medical Association , the American Psychological Association and the American Psychiatric Association , have published policy statements and guidelines on how to provide age-appropriate gender-affirming care. All of those medical societies find such care to be evidence-based and medically necessary.

AAP and Endocrine Society guidelines call for developmentally appropriate care, and that means no puberty blockers or hormones until young people are already undergoing puberty for their sex assigned at birth. For one thing, “there are no hormonal differences among prepubertal children,” says Joshua Safer, executive director of the Mount Sinai Center for Transgender Medicine and Surgery in New York City and co-author of the Endocrine Society’s guidelines. Those guidelines provide the option of gonadotropin-releasing hormone analogues (GnRHas), which block the release of sex hormones, once young people are already into the second of five puberty stages—marked by breast budding and pubic hair. These are offered only if a teen is not ready to make decisions about puberty. Access to gender-affirming hormones and potential access to gender-affirming surgery is available at age 16—and then, in the case of transmasculine youth, only mastectomy, also known as top surgery. The Endocrine Society does not recommend genital surgery for minors.

Before puberty, gender-affirming care is about supporting the process of gender development rather than directing children through a specific course of gender transition or maintenance of cisgender presentation, says Jason Rafferty, co-author of AAP’s policy statement on gender-affirming care and a pediatrician and psychiatrist at Hasbro Children’s Hospital in Rhode Island. “The current research suggests that, rather than predicting or preventing who a child might become, it’s better to value them for who they are now—even at a young age,” Rafferty says.

A Safe Environment to Explore Gender

A 2021 systematic review of 44 peer-reviewed studies found that parent connectedness, measured by a six-question scale asking about such things as how safe young people feel confiding in their guardians or how cared for they feel in the family, is associated with greater resilience among teens and young adults who are transgender or gender-diverse. Rafferty says he sees his role with regard to prepubertal children as offering a safe environment for the child to explore their gender and for parents to ask questions. “The gender-affirming approach is not some railroad of people to hormones and surgery,” Safer says. “It is talking and watching and being conservative.”

Only once children are older, and if the incongruence between the sex assigned to them at birth and their experienced gender has persisted, does discussion of medical transition occur. First a gender therapist has to diagnose the young person with gender dysphoria .

After a gender dysphoria diagnosis—and only if earlier conversations suggest that hormones are indicated—guidelines call for discussion of fertility, puberty suppression and hormones. Puberty-suppressing medications have been used for decades for cisgender children who start puberty early, but they are not meant to be used indefinitely. The Endocrine Society guidelines recommend a maximum of two years on GnRHa therapy to allow more time for children to form their gender identity before undergoing puberty for their sex assigned at birth, the effects of which are irreversible.

“[Puberty blockers] are part of the process of ‘do no harm,’” Forcier says, referencing a popular phrase that describes the Hippocratic Oath, which many physicians recite a version of before they begin to practice.

Hormone blocker treatment may have side effects. A 2015 longitudinal observational cohort study of 34 transgender young people found that, by the time the participants were 22 years old, trans women experienced a decrease in bone mineral density. A 2020 study of puberty suppression in gender-diverse and transgender young people found that those who started puberty blockers in early puberty had lower bone mineral density before the start of treatment than the public at large. This suggests, the authors wrote, that GnRHa use may not be the cause of low bone mineral density for these young people. Instead they found that lack of exercise was a primary factor in low bone-mineral density, especially among transgender girls.

Other side effects of GnRHa therapy include weight gain, hot flashes and mood swings. But studies have found that these side effects—and puberty delay itself—are reversible , Safer says.

Gender-affirming hormone therapy often involves taking an androgen blocker (a chemical that blocks the release of testosterone and other androgenic hormones) and estrogen in transfeminine teens, and testosterone supplementation in transmasculine teens. Such hormones may be associated with some physiological changes for adult transgender people. For instance, transfeminine people taking estrogen see their so-called “good” cholesterol increase. By contrast, transmasculine people taking testosterone see their good cholesterol decrease. Some studies have hinted at effects on bone mineral density, but these are complicated and also depend on personal, family history, exercise, and many other factors in addition to hormones.”

And while some critics point to decade-old study and older studies suggesting very few young people persist in transgender identity into late adolescence and adulthood, Forcier says the data are “misleading and not accurate.” A recent review detailed methodological problems with some of these studies . New research in 17,151 people who had ever socially transitioned found that 86.9 percent persisted in their gender identity. Of the 2,242 people who reported that they reverted to living as the gender associated with the sex they were assigned at birth, just 15.9 percent said they did so because of internal factors such as questioning their experienced gender but also because of fear, mental health issues and suicide attempts. The rest reported the cause was social, economic and familial stigma and discrimination. A third reported that they ceased living openly as a trans person because doing so was “just too hard for me.”

The Harms of Denying Care

Data suggest the effects of denying that care are worse than whatever side effects result from delaying sex-assigned-at-birth puberty. And medical society guidelines conclude that the benefits of gender-affirming care outweigh the risks. Without gender-affirming hormone therapy, cisgender hormones take over, forcing body changes that can be permanent and distressing.

A 2020 study of 300 gender-incongruent young people found that mental distress—including self-harm, suicidal thoughts and depression— increased as the children were made to proceed with puberty according to their assigned sex. By the time 184 older teens (with a median age of 16) reached the stage in which transgender boys began their periods and grew breasts and transgender girls’ voice dropped and facial hair began to appear, 46 percent had been diagnosed with depression, 40 percent had self-harmed, 52 percent had considered suicide, and 17 percent had attempted it—rates significantly higher than those of gender-incongruent children who were a median of 13.9 years old or of cisgender kids their own age.

Conversely, access to gender-affirming hormones in adolescence appears to have a protective effect. In one study, researchers followed 104 teens and young adults for a year and asked them about their depression, anxiety and suicidality at the time they started receiving hormones or puberty blockers and again at the three-month, six-month and one-year mark. At the beginning of the study, which was published in JAMA Network Open in February 2022, more than half of the respondents reported moderate to severe depression, half reported moderate to severe anxiety, and 43.3 percent reported thoughts of self-harm or suicide in the past two weeks.

But when the researchers analyzed the results based on the kind of gender-affirming care the teens had received, they found that those who had access to puberty blockers or gender-affirming hormones were 60 percent less likely to experience moderate to severe depression. And those with access to the medical treatments were 73 percent less likely to contemplate self-harm or suicide.

“Delays in prescribing puberty blockers and hormones may in fact worsen mental health symptoms for trans youth,” says Diana Tordoff, an epidemiology graduate student at the University of Washington and co-author of the study.

That effect may be lifelong. A 2022 study of more than 21,000 transgender adults showed that just 41 percent of adults who wanted hormone therapy received it, and just 2.3 percent had access to it in adolescence. When researchers looked at rates of suicidal thinking over the past year in these same adults, they found that access to hormone therapy in early adolescence was associated with a 60 percent reduction in suicidality in the past year and that access in late adolescence was associated with a 50 percent reduction.

For Fleming’s kids in Texas, gender-affirming hormones are not currently part of the discussion; not all trans people desire hormones or surgery to feel affirmed in their gender. But Fleming is already looking at jobs in other states to protect their children’s access to such care, should they change their mind. “Getting your body closer to the gender [you] identify with—that is what helps the dysphoria,” Fleming says. “And not giving people the opportunity to do that, making it harder for them to do that, is what has made the suicide rate among transgender people so high. We just—trans people are just trying to survive.”

IF YOU NEED HELP If you or someone you know is struggling or having thoughts of suicide, help is available. Call the National Suicide Prevention Lifeline at 1-800-273-8255 (TALK), use the online Lifeline Chat or contact the Crisis Text Line by texting TALK to 741741.

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Pamela Paul

As Kids, They Thought They Were Trans. They No Longer Do.

By Pamela Paul

Opinion Columnist

Grace Powell was 12 or 13 when she discovered she could be a boy.

Growing up in a relatively conservative community in Grand Rapids, Mich., Powell, like many teenagers, didn’t feel comfortable in her own skin. She was unpopular and frequently bullied. Puberty made everything worse. She suffered from depression and was in and out of therapy.

“I felt so detached from my body, and the way it was developing felt hostile to me,” Powell told me. It was classic gender dysphoria, a feeling of discomfort with your sex.

Reading about transgender people online, Powell believed that the reason she didn’t feel comfortable in her body was that she was in the wrong body. Transitioning seemed like the obvious solution. The narrative she had heard and absorbed was that if you don’t transition, you’ll kill yourself.

At 17, desperate to begin hormone therapy, Powell broke the news to her parents. They sent her to a gender specialist to make sure she was serious. In the fall of her senior year of high school, she started cross-sex hormones. She had a double mastectomy the summer before college, then went off as a transgender man named Grayson to Sarah Lawrence College, where she was paired with a male roommate on a men’s floor. At 5-foot-3, she felt she came across as a very effeminate gay man.

At no point during her medical or surgical transition, Powell says, did anyone ask her about the reasons behind her gender dysphoria or her depression. At no point was she asked about her sexual orientation. And at no point was she asked about any previous trauma, and so neither the therapists nor the doctors ever learned that she’d been sexually abused as a child.

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Gender Transition: Is There a Right to Be Forgotten?

Mónica correia.

Faculty of Medicine of the University of Porto, Alameda Prof. Hernâni Monteiro, 4200-319 Porto, Portugal

Guilhermina Rêgo

The European Union (EU) faced high risks from personal data proliferation to individuals’ privacy. Legislation has emerged that seeks to articulate all interests at stake, balancing the need for data flow from EU countries with protecting personal data: the General Data Protection Regulation . One of the mechanisms established by this new law to strengthen the individual’s control over their data is the so-called “right to be forgotten”, the right to obtain from the controller the erasure of records. In gender transition, this right represents a powerful form of control over personal data, especially health data that may reveal a gender with which they do not identify and reject. Therefore, it is pertinent to discern whether the right to have personal data deleted—in particular, health data—is ethically acceptable in gender transition. Towards addressing the ethical dimensions of the right to be forgotten in this case, this study presents relevant concepts, briefly outlines history, ethics and law of records considering the evolution from paper to electronic format, the main aspects of identity construction and gender identity, and explores the relationship between privacy, data protection/information control and identity projection. Also, it discusses in gender transition the relation between “the right to self-determination”, “the right to delete”, and “the right to identity and individuality”. Conclusions on the ethical admissibility of the ‘right to be forgotten’ to control gender-affirming information are presented.

Introduction

It is undeniable that the European Union (EU)’s adoption of new legislation concerning personal data protection comes from a technological evolution that has generated a massive collection, conservation, and proliferation of data over the past two decades [ 2 , 7 , 15 , 18 , 65 , 69 , 82 ]. This new legislation has significant implications in foreign to EU countries (third countries), especially the United States of America (USA) and developed countries [ 73 ]. Recently, the EU faced high risks from data proliferation to individuals’ privacy. The use of Facebook profiles by Cambridge Analytica during the 2016 USA presidential election campaign to influence undecided voters for the benefit of candidate Donald Trump is an example of this problem [ 64 ]. Consequently, new legislation emerged that seeks to articulate all interests at stake, balancing the need for data flow from EU countries with protecting personal data: the General Data Protection Regulation (GDPR) [ 78 ]. One of the mechanisms established by this new legal regime to strengthen the individual's control over their personal data is the so-called “right to be forgotten”, the right to obtain from the controller the erasure of records. The literature on this new law is still scarce. From the perspective of medical data—a special category of personal data that is particularly sensitive—scientific literature has a gap that should be filed by discussing the ethical issues associated with this right’s exercise. Although patients do not have a consistent right to delete or modify their health records, this traditional position changes due to technological developments and the effects of data connexion. There are already situations where it is considered legitimate to delete health data [ 21 , 56 ]. For example, in the United Kingdom, “ confidential treatment requests, including end of life plans, where people ask to be allowed to die at home or enter instructions such as “do not resuscitate” [ 16 ], and personal information that is no longer required included in the NHS database (Spine) can be deleted [ 16 ].

In gender transition, the right to be forgotten represents a powerful form of control for the owner over personal data, especially health data that may reveal a gender with which they do not identify and reject. Therefore, it is pertinent to discern whether the right to delete personal data—in particular, health data—is ethically acceptable in gender transition.

At this point, it bears emphasising the complexities of transition because it can take the form of legal, social, and medical, or often some combination of two or three. For instance, some trans people use hormones and change their legal sex but do not have any surgeries. Also, some studies address said complexity mainly because there is scientific evidence of the relationship between stigma and health care vulnerability of transgender and gender-nonconforming people [ 8 , 34 , 39 , 40 , 60 – 62 , 72 , 84 , 86 ]. Therefore, notwithstanding other motives to modify registries, their legal impact, or other significant branches of the topic, this article’s scope is to discuss the ethical admissibility of the right to be forgotten to control gender-affirming health information. Indeed, regardless of transition-related surgery, as long as gender transition has legal recognition in public registries and critical documents, we aim to provide an ethical assessment of possible claims to have gender-affirming health information deleted.

Towards addressing this issue, we will start by defining relevant concepts. Briefly, outline history, ethics and law of records considering the evolution from paper to electronic format, the main aspects of identity construction and gender identity and expression, and explore the relationship between privacy, data protection/information control and identity projection. Also, we will analyse in gender transition the relation between the rights to “self-determination”, “delete”, and “identity and individuality”. We present conclusions on the ethical admissibility of the right to delete to control gender-affirming health information.

Definitions

“Genetic data”—“ personal data relating to the inherited or acquired genetic characteristics of a natural person which give unique information about the physiology or the health of that natural person and which result, in particular, from an analysis of a biological sample from the natural person in question ”—Article 4/13 GDPR [ 78 ];

“Health data” or “Data concerning health”—“ personal data related to the physical or mental health of a natural person, including the provision of health care services, which reveal information about his or her health status ”—Article 4/15 GDPR [ 78 ];

“Right not to know”—right for individuals not to be informed/acknowledged of personal information [ 23 ];

“Right to be forgotten”—“ right for individuals to have personal data erased ” [ 37 ];

“Sex”—“ A person’s biological status (chromosomal, hormonal, gonadal, and genital) as male or female. An individual's sex at birth (birth-assigned sex) is usually determined based on genital appearance, with those present usually assuming that other components of sex are consistent with the newborn’s genital sex. ” [ 84 ]

“Cisgender person”—“ A person who has a gender identity that corresponds with the gender assigned at birth .” [ 41 ]

“Gender”—“ The attitudes, feelings, and behaviours linked to one's biological sex's experience and expression. ” [ 84 ]

“Gender identity”—“ refers to each person's deeply felt internal and individual experience of gender, which may or may not correspond with the sex assigned at birth, including the personal sense of the body (which may involve, if freely chosen, modification of bodily appearance or function by medical, surgical or other means) and other expressions of gender, including dress, speech and mannerisms. ” [ 41 , 85 ]

“Gender expression”—“ The expression of one's gender identity, often through appearance and mode of dress, and also sometimes through behaviour and interests. Gender stereotypes often influence gender expression. ” [ 84 ]

“Gender transition” or “Gender affirmation”—“ refers to the social process of being recognised or affirmed in one's gender identity, expression, and/or role. Although gender affirmation can be theorised as an inherently social process, it must necessarily also be conceptualised as multidimensional with at least four core constructs: social (choice of name and pronoun, interpersonal and institutional acknowledgement and recognition), psychological (internal felt sense of self-actualisation, validation of gendered self, internalised transphobia), medical (pubertal blockers, hormones, surgery, other body modification), and legal (legal name change, legal change of gender marker designation). There is no one single path to gender affirmation—no "one size fits all" approach describes how trans people affirm their felt or expressed gender. Some trans individuals pursue social but not medical gender affirmation; some pursue medical but not legal gender affirmation, and so on. Gender affirmation sometimes, but not always, conforms to binary categories of being female or male. Furthermore, gender affirmation does not require linearly following a discrete series of “transition” events—it is conceptualised as an ongoing process throughout the life course. ” [ 61 ]

“Transgender and gender-nonconforming people (trans or gender minority)”—“ People who have a gender identity that is different from the gender assigned at birth. This includes people who might or might not undergo gender reassignment, as well as those who prefer or choose to present themselves differently from the expectations of the gender assigned to them at birth. ” [ 41 ].

A Brief Outlook of History, Ethics and Law of Identity Records

Birth is a fact of autonomous relevance, regardless of motherhood and fatherhood. It is essential even if it is impossible to identify the mother and the father, as is the registries of abandoned children. However, in history, this has not always been the case. Indeed, as Andrade [ 5 ] points out, in ancient times and most medieval periods of western history, people ruled themselves according to their geographical origin, family lineage, tribal and religious relationships. Personal distinctiveness was diluted in the groups and communities to which they belonged and not according to their characteristics. However, this perspective began to change at the end of the Middle Ages. Indeed, the state-building process that started in the Renaissance required implementing an administrative mechanism capable of individualising. The individuation and differentiation of people were fundamental for the state to oversee law enforcement and tax collection. The solution was to select criteria by which people could be described. Once observed, compiled and recorded on paper by the state, these identification characteristics made it possible to identify individuals and distinguish them from others [ 5 ].

On the other hand, according to Durbach [ 26 ], the history of registers in the United Kingdom, for example, suggests that, although people’s documentation primarily addressed the needs of the state, this technique was also favourable to some social classes that participated in the process to the extent that their economic interests benefited. Interest in identification registration arose primarily to secure inheritance rights for wealthier social classes. However, the registration of actual events, such as birth and marriage, was equally important for those who did not own property. In the UK, since the sixteenth century, people have understood that the registration of vital information could guarantee their property rights and their rights to state support in times of economic deprivation [ 26 ].

Nowadays, registration has become the first step for the state to secure all forms of citizenship, that is, to ensure that they are acknowledged to benefit from the distribution of social state resources, i.e. to ensure that they are protected by society. Registration allows access to widespread personal and economic development tools such as getting a job or a passport. Indeed, besides identity construction, there are other practical reasons for registering one’s identity. For example, people are interested in registering themselves correctly to receive corresponding identity documents necessary for voting or board an aircraft. Undoubtedly, these are some of the reasons for promoting birth registration as a relevant UNICEF activity in the world [ 77 ].

Thus, in contemporary society, facts that have an essential impact on relationships with others, such as birth, parentage, marital status, parental responsibilities, nationality, and gender, are recorded in a mandatory manner. Registration allows safeguarding values and principles of certainty and security as to the effects of the people involved. When registered by the state, these data are compulsory, so there is an obligation to register. Thus, registration has a double role: it is an organisational measure of the state; and is regarded as a means of personal affirmation or self-determination, since individualisation through registration facilitates respect for human dignity. Identity registries represent the person’s affirmation as a unique human being, assisting respect for each individual's human dignity. It should also be acknowledged that identity registries serve other functions, such as surveillance and policing. For instance, allegedly, the REAL ID registration system in the United States has anti-terrorism purposes [ 57 ].

Furthermore, given the technological revolution of the last two decades, the state has advanced with registering and archiving personal identification data and health and genetic information. The ease of dissemination and connection of data has increased the need for health and genetic data protection, raising complex ethical and legal issues in gender transition, which we will discuss onwards.

Gender and Identity Construction

Gender identity substantially relates to human dignity since it plays a vital role in identity construction. Although the right to delete may cover registered realities other than gender, namely, challenges to paternity or maternity established at birth or adoption, gender identity—a personality-related fundamental value—represents an independent scope for ethical analysis given its complexity.

Human beings are usually divided in a binary way, either female or male, based on biological information commonly exemplified and recorded at birth [ 27 ]. Usually, people are registered by the state based on the biological information voluntarily provided or shared by the parents or by someone on their behalf. However, there is a difference between registration and other forms of data collection since data can be gathered by other means. Indeed, the observation of facts (medical records, for instance) or a transaction between its holder and someone else (such as data uploaded in a website visited) can reveal a profile [ 81 ]. These are the so-called observed data. Additionally, there are derived or inferred data that, through the combination of observation and analysis of voluntary data and derivatives, allow one to deduce trends and make behavioural and personality profiles [ 49 ], as is the case of human research.

A significant number of countries continue to address gender through a dualistic classification of biological sex. A pathology-based conception of trans and nonbinary identities still exists, which justifies studies to find the best solutions for altered conditions in genital appearance detected at birth. Thus, the pathology-based literature on this subject addresses the advantages and disadvantages of early surgery. Thomas [ 75 ] found that establishing gender after transition-related surgery during childhood is generally an “ imperfect exercise ” since the documented results revealed insufficient long-term functional and psychological effects of an early approach. Therefore, this perspective suggests the maintenance of the “ male genital phenotype, visibly not corrected in girls , which, however, is inadmissible for most parents. ” [ 75 ]. Also, on this issue, Fallat et al. [ 29 ] argue that this condition should not be hidden from children, as this would likely create a disturbance at an age when “ sexual identity and peer-group identification is important. ” [ 29 ]. We agree with these authors that we should consider both the child’s and future adults’ needs. In this sense, clinical information, especially that related to the child’s body, should not be “forgotten” or deleted.

At this point, it should be acknowledged that the pathology-based approach has been subject to substantial critique because the establishment of gender does not depend on physical characteristics but identity. Gender expression is another concept related to gender identity, and a person’s gender expression may, or may not, follow their gender identity [ 84 ]. For example, some trans individuals who have not transitioned may hold an internal gender identity that they do not externalise via gender expression. Also, a large body of writing, including Articles 5 and 10 of CEDAW—The Convention on the Elimination of All Forms of Discrimination against Women [ 55 ],—seeks to dismantle the idea of stereotyped sex or gender roles [ 84 ].

The comprehensive notion of gender nowadays still encompasses difficulties in choosing sex for registration under different conditions of the morphological sex of the newborn. There is a risk of being arbitrary, and the registered individual may link to a gender with which they might not identify. Besides, problems to transition it later might happen, according to the jurisdictions of the various countries. This difficulty has led to the suggestion that birth registries should admit a third approach, such as a simple procedure for subsequent alteration, or that reference to sex should be omitted. The United Kingdom discussed this idea on a similar issue in 1947. Attempts to allow birth certificate without the father’s name had limited success but were made as a public health measure and in light of the high mortality rates of out of wedlock children [ 26 ]. Recently, critiques of the gender binary view are gaining momentum as a growing number of countries—Belgium, Germany, Greece, Iceland, Malta, The Netherlands—now recognise nonbinary genders in official registries or use no gender markers at all in their official documentation [ 28 ].

Still, in some European countries (e.g., Denmark, Ireland, Norway and Portugal), although gender markers are in use, it is unnecessary to undergo gender-affirming surgery for gender transition legal recognition. Gender identity is based on self-determination [ 41 , 53 ], so people have the right to maintain primary and secondary sexual characteristics even if they chose to transition their gender. The right to self-determine one’s gender identity and gender expression is ensured, namely, through the free development of one’s personality according to identity and gender expression. Denmark evolved to adopt a self-determination policy, but before 2014, it was only after forced sterilisation that a different gender could be legally recognised [ 10 , 66 ]. The state could change the last digit of the identification document number (even for female; odd for male), which reflected an outdated conceptualisation of gender based on a dualistic understanding of biological sex [ 63 ].

Privacy, Data Protection and Identity Projection

The concept of privacy is not consensual, but we believe it is an expression of human dignity. We will try to demonstrate this point by confronting arguments from relevant literature. Whitman [ 83 ], for example, considers privacy very difficult to define because of cultural differences between American and European societies, as so, he argues there is no universal concept of privacy. This author also claims that culture and the law shape the sense of privacy of individuals. Likewise, the foundations of differences in values that the law embodies derive from old social and political dissimilarities. Thus, according to this author, two conceptions of privacy exist, sustained by two main sets of values: in Europe, privacy is an aspect of personal dignity, understood as the right to image, name, reputation, threatened mainly by the media; in the USA privacy is an aspect of freedom, endangered mainly by the government. From this perspective, he claims that it is defenceless to consider human dignity as a universal value, equally felt by any society, regardless of its culture and history.

Despite the outstanding writing style Whitman [ 83 ] uses to develop his central argument, the problem with this view is that it reduces the value of human dignity to a matter of honour/image. Human dignity is more profound in our judgment, as it represents an abstract capacity and potential for self-determination, regardless of the ability or concrete will for it. This ability may not even exist, as it necessarily happens when one recognises the human person’s dignity with a mental disability. Thus, human dignity relies upon considering the human being as an end in itself, never a means, and this perspective goes far beyond image or honour. From this angle, human dignity is imposed on the individual himself and considered a universal value. Freedom is then a condition of dignity. However, for freedom to exist, there is another condition: privacy. Therefore, privacy is a condition of human dignity. Indeed, as noted by Ursin [ 80 ], “ For don’t we assume that there must be a right not to be watched in certain situations and that we should be able to control other peoples’ access to personal information to some degree? The idea that privacy entails being in control of personal information about oneself again links privacy to autonomy, but in this perspective, autonomy is a precondition of dignity. ”

However, in an era of perpetual technological evolution, we are continually facing new instruments, such as combining the physical domain with the virtual one, the so-called “Internet of Things” (IoT).

Furthermore, the means of collecting, preserving and analysing personal information has increased exponentially [ 81 ], since the traditional information registers have added new standards, including robotics associated with artificial intelligence, the use of which allows the control of individuals through the establishment of behavioural patterns. Therefore, the associated ethical issues have grown from concerning a right to privacy and confidentiality (privacy strictu sensu) to protect the facts themselves, which are primarily innocuous but, once interconnected, convey the individual’s essence without himself knowing it [ 22 ]. Technology is why we have gone from protecting intimacy and privacy to protect personal data, a fundamental human right.

At this point, it bears emphasising that ethics and law view rights differently, although they are correlated. Ethics corresponds to a reflection by the society of a mandatory directive’s choice for its members. That is, it concerns an axiological selection of the behaviours desired by a particular human group. The human being is allowed a wide variety of options in the sphere of personal decision, which we call self-determination. However, individual choices result from internal traits, the environment, and interactions with society, resulting in subjective opinions. Thus, it is necessary to find a minimum neutral standard accepted by the conscience of any individual. These standards of conduct taken by any human being, regardless of their ideological or religious principles, constitute the values ​​that shape ethics. The law, in turn, assesses human conduct being permeable to the facts, as it values them in the construction of its norms. However, the law often brings rules and principles impregnated with ethical values, recognised by the political system as essential to its formation. In this way, legal regimes have moral foundations, such as the dignity of the human person.

Notwithstanding, the right to data protection guarantees an individual the right to dispose of all data relating to his personality, health, personal life, political or religious conviction, race, for example. Thus, it serves to sustain privacy protection in a world where collecting, storing, and intersecting large amounts of data is possible [ 38 , 42 , 50 , 74 ]. Under these circumstances, the significance of facts and information previously considered irrelevant increases. Modern technology has created a “remembering-by-default” environment where personal data is recorded and stored indefinitely and shared quickly, resulting in the right to privacy violated, identity itself endangered [ 81 ]. Most individuals have many aspects of their identity that they hide from others and this circumstance is not necessarily circumscribed to the fear of embarrassment. They may not even cause that effect at all but, rather, might be elements of their personality that they do not wish to divulge in a given context. For example, someone who likes to sing sacred music or practice boxing may not want to reveal this fact in his/her work environment. The fact itself may not be embarrassing, but the data subject has the right to protect it regardless. They are only exercising the right to be different according to the circumstance, the interlocutor, the moment, the goal and their history. This choice describes the freedom of projection of the self, according to the data holder’s free will, moreover, when those facts have the potential of creating a profile.

The Right to Be Forgotten and Trans Identity Information

Representing a more robust form of personal data protection, the right to be forgotten has recently emerged. The literature on this subject approaches this new law and its ethical foundation from managerial, legal, and societal perspectives [ 1 , 2 , 9 , 15 , 17 , 18 , 31 , 33 , 52 , 67 , 69 , 70 ]. Regardless of the disciplinary perspective from which the subject is approached, it is stressed the new paradigm created by technology—eradicating one of human memory’s functions—the ability to forget [ 14 , 46 , 71 ]. In general, the “right to be forgotten” is valuable for dealing with outdated, useless or decontextualised information [ 35 , 49 ]. For example, a transgender person who willingly has gender-affirming surgery obtains gender transition recognition in their official documents (as is the case in several European countries). They may wish to delete the confirmatory clinical record of performing, for instance, trans masculine chest/top surgery, which unequivocally relates them with a gender they do not want to project into society.

As enshrined in European culture and legislation, the right to be forgotten raises interesting ethical questions because it does not limit deleting data of any kind. Patients appear to have the right to exclude their health information if the data are no longer required for reference by the purpose for which it was collected or processed, or even if consent is withdrawn. Besides, it seems this right exists when the data subject opposes processing, and there are no legitimate grounds for rejecting this request; also, when the data has been processed unlawfully—all these reasons following Article 17 of the GDPR [ 78 ]. The law has no limits regarding genetic and health data. In this context, any data that can unveil a “self” that the holder does not want to project to society could be subject to the right to be forgotten. Indeed, from a particular perspective, this right, rather than privacy protection, protects identity and self-determination because the right to privacy only deals with protecting private information to prevent it from being divulged in the public sphere. In contrast, the right to identity relates to data transmission into the public sphere: the correct projection and representation. The right to delete associated with the right to personal identity allows reaching information that has already been released to the public [ 6 ].

In another approach, the right to identity and individuality is considered a fundamental human right. It may take varied ethical contours, namely, the subjects’ right to be informed about their biological ancestry. Amzat and Grandi [ 3 ] point out that individuals are characterised, among other attributes, by “historicity”. This perspective also contemplates the right not to be informed of one’s genetic heritage. That is to say, denying the knowledge of information that concerns the individual: the so-called “right not to know”, resulting from informational self-determination [ 20 ], considered the ethical and legal ancestor of data protection [ 36 ]. It could be argued that the right not to know and the right to be forgotten have a shared perspective. Both rights promote autonomy and control [ 4 , 49 ].

Nonetheless, if data exist, even if private and only accessible under limited circumstances, the importance of not knowing can be compromised by unwanted revelations of information [ 4 ]. Given that information is registered, regardless of being under seal, the circumstance is different [ 54 ]. The right not to know is not assured following the availability of information. From an identity perspective, we argue that the right to be forgotten offers more advanced protection to autonomy than the right to privacy.

In this way, some arguments contribute to the admissibility of the right to forget or delete health and genetic data related to gender transition: those we have already mentioned and the ideas that support transgender rights. As emphasised by Powell et al. [ 58 ], these rights are usually based on the circumstance’s congenital nature. That is, they state that gender identity is unalterable and insusceptible of choice. However, human rights-based arguments provide a more challenging foundation for transgender rights. Following this line of thought, we say that human rights give more substantial support for the right to erase gender affirming-related data. Indeed, trans people rights derive from human rights, that is, fundamental rights belonging to all people. People with cisgender or transgender identities are equal in human dignity [ 43 ]. According to the Universal Declaration of Human Rights [ 79 ], “ All human beings are born free and equal in dignity and rights ”.

Nonetheless, when discussing transgender rights as human rights, it is crucial to stress the proportionality principle that is a cornerstone concerning the international human rights system. Indeed, the principle of proportionality consists in assessing the suitability, necessity and balance of state intervention in a specific fundamental right. It is based on moderation and justice logic that should apply to any state intervention in individuals’ rights, even if the restrictive act’s purpose is to avoid harm to another individual right [ 44 ].

The societies that developed after World War-II under the guidance of the abovementioned international instrument sought to translate, through its principles, a plural understanding, encompassing individuals with diverse ethical expectations and different visions of the world. Pluralism of thinking in modern societies leads political systems to respect freedom. That is, citizens have the right to live their lives in the way they understand, being limited only by others’ rights. In this sense, public authorities should only intervene in their citizens’ free choices to avoid harming other individuals [ 24 ]. This idea can be found, for instance, in John Stuart Mill’s so-called harm principle, which he introduces by stating: “ The only purpose for which power can be rightfully exercised over any member of a civilised community, against his will, is to prevent harm to others. His own good, either physical or moral, is not a sufficient warrant. ” [ 48 ]. In other words, society can interfere in any individual’s freedom only to avoid harm to others, but it cannot do so because it is for that person’s good. Thus, it is natural to suppose that Mill’s defence of individual liberty is founded on utilitarianism [ 47 ]. In Mill’s utilitarianism, the right action is to maximise good and utility. The good is, in general, pleasure. Thus, utilitarianism is the ethics of ordinary happiness. Actions are right if they tend to support the greatest global happiness and wrong if not. Individual sacrifice is useless if it does not increase the total amount of happiness. Indeed, the claims of individuals lose importance for the benefit of all [ 47 ]

Similarly, as long as the person does not cause harm to others, his freedom must be guaranteed. This idea is accurate even in the case where such interference could produce significant overall gains in happiness.

Notwithstanding the philosophical literature that builds upon Mill’s harm principle [ 51 , 68 , 76 ], some criticise his arguments. It is one of the most debated political philosophy points, e.g. in Rawls’ work [ 30 ]. However, despite the apparent tension between his utilitarianism and liberalism, Mill clarifies that his arguments for individual liberty are, in the long run, dependent on the principle of utility [ 87 ]. We stress that, in utilitarianism, Mill seems to regard the principle of liberty as a moral rule. He adheres to the notion that individual liberty protection would ultimately maximise general happiness in a civilised society. Because of this, he stresses the liberty principle’s adoption, whose purpose is to prevent each person’s freedom from being excessively repressed by society. Mill believes that the cultivation of individuality is indispensable to the human being as a progressive being. Mill argues that we need freedom so that we can develop our individuality. It seems that Mill’s arguments for the principle of liberty are sustained in his utilitarianism. In this sense, a more significant sum of happiness/utility can be a reality in which the exercise of authority occurs without constraint and would tend to maximise utility. Therefore, Mill’s utilitarianism would protect individuals’ vital interests as minimum conditions for promoting happiness, disapproving of well-being through the limitation of individual liberty. In this perspective, Mill would remain a utilitarian, but his defence of liberty would be compatible with his utilitarianism. Mill sophisticated utilitarianism, making it a theory that better accommodates the legitimate concerns of those who seek to solve problems related to well-being, happiness, rights and justice [ 47 , 48 , 87 ].

In Judaeo-Christian culture, a similar moral imperative stems from the Bible: “ Thou shalt love thy neighbour as thyself ” [ 11 ]. In secular terms, this principle reflects a fundamental ethical imperative that requires acting in all circumstances with the responsibility not to affect others’ autonomy and, consequently, of oneself.

At this point, suppose we consider the right to be forgotten as a means to operationalise data protection and privacy, both conditions of identity. In this context, it makes sense to evaluate this legal mechanism for the entire exercise of identity in matters of gender transition. Hence, it is necessary to discuss the limits of the right to be forgotten regarding gender transition information, considering the principle of liberty and the proportionality principle as a foundation in human rights law. Based on these arguments, we argue that the right to be forgotten may raise ethical and legal difficulties in the following circumstances:

• The right to erase health and genetic information related to gender transition makes tracing genetic diseases impossible, especially relevant when dealing with their biological offspring. Thus, direct biological relatives should have access to a collected genetic sample as long as necessary to understand their genetic status better. This difficulty is not potential but of actual relevance because a line of thought gaining momentum is that transgender people should have reproductive rights. The truth is that transgender people may undergo fertility preservation gametes, usually before gender-affirming treatment. Therefore, some scientific literature calls for legal recognition of gender having in mind self-determination. It is stated that the relinquishment of reproductive capacity is no longer a prerequisite for gender transition, recognising that transgender people desire to be parents and are not intrinsically wrong parents merely due to their non-normative gender identities expressions. This perspective is based on equality and human dignity [ 13 , 32 , 45 , 59 ].
• Researchers might have to rely on medical records to study how health issues manifest differently based on biological sex at birth [ 43 ]. Consequently, the right to delete gender-affirming associated information could be the starting point for exposing certain health research types.
• The right to forget gender-affirming health information could harm selection in terms of high-performance sports. It is not the purpose of this analysis to discuss the binary division in high-performance sports. However, it is well known that hormone levels differ by gender and that this influences sports performance. Although we agree with Lau [ 43 ] that basing the selection of athletes on gender markers in identification documents is disproportioned – because it may violate the rights of transgender athletes in terms of the equality principle – the same cannot be said about their health information. To determine if the hormonal level of transgender athletes is equal to that of cisgender athletes is necessary for equity. Thus, deleting this health information would be disproportionate for this purpose.
• The right to be forgotten regarding gender-affirming information might generate ethical conflicts with other circumstances, such as marriage and adoption, whose impediments (depending on the jurisdiction) might be violated by a gender transition. For example, at a marriage, a member of the couple transitions their gender. Different implications might occur as this relationship turns into a same-sex marriage. Depending on the jurisdiction, adoption, and the use of medically-assisted reproduction techniques might be restricted. In contrast, regarding the latter, suppose it is not restricted. The procedure might be endangered if medical history data have been deleted. As abovementioned, the discussion of recognising reproductive rights to transgender people is a matter of equality and human dignity.
• Also, in case of repentance: changing ideas is also an exercise of autonomy, which is why deleting gender-affirming health data can harm the owner, preventing them from exercising the most varied rights if data recovery is not possible;
• The right to be forgotten so far as gender transition is concerned might create the inability to trace the previous identity, and so criminal responsibilities could be avoided, as it would allow identification forgery; moreover, civil responsibilities could be jeopardised, as it might cause contractual and inheritance problems, for example. In this regard, Lau [ 43 ], which defends gender recognition as a human right, acknowledges that past-gender information registries are the proportioned measure to prevent fraud and protect public safety. Instead of relying on ID gender markers, governments could legitimately access previous IDs and link them to current ones during background checks on criminal records [ 43 ]. Thus, we argue the right to delete in the abovementioned cases would not be proportionate regarding necessary information. The same argument is valid when gender-affirming associated information supports public faith regarding facts that rely on documentary evidence with a link to identity (e.g., certifying academic qualifications or issuing a passport).

Consequently, although the right to be forgotten is in line with the right to self-determination, there are ethical and legal doubts to ponder. Indeed, we presented sound arguments to support the non-deletion of health data. Still, there are already practical solutions to better collect health data from trans people and respect their privacy. Solutions are suggested by Deutsch and Buchholz [ 25 ] to improve their health condition, as there is evidence of their vulnerability. Moreover, Cahill and Makadon [ 19 ] recommend recording these situations because these people’s marginalisation is often subjected to unequal health care. Therefore, erasing gender-affirming data can contribute to their health exposure.

Human beings are allowed a wide variety of personal choices influenced by their environment, culture, and psychology. This freedom in the sphere of individual decision-making—or self-determination–is the basis of self-fulfilment. On the one hand, recognising gender identity as a fundamental human right—in the sense of full development of an individual’s personality through self-determination and self-realisation—is accepted as an integral part of respect for human dignity. In contrast, forgetting gender-affirming health data should be regulated at the international level to protect the human person’s inalienable rights and future generations.

Gender identity is intrinsically linked to human existence because it is present from birth, developing at the same time as a personality following the outer and inner worlds of the individual. So naturally, in any debate, there will always be different and complex cultural sensibilities influenced by the environment in which the individuals are inserted, whether it is public opinion influenced by the media and social networks, by political and economic interests, or religious beliefs. In this sense, we agree with Rich and Ashby [ 63 ] assertion that bioethics’ role is to promote thoughtful analysis that applies its principles, as Beauchamp and Childress framed [ 12 ] towards human beings and their fundamental rights. Autonomy, beneficence and justice shall be the starting point of any regulatory action. Thus, bioethics, by analysing values in a neutral way and with no preconceived notions, seems to be the most acceptable way to promote gender identity issues while fully respecting human dignity.

After examining some inter-related and conflicting issues regarding the right to delete personal data, specifically medical and genetic records, in the context of gender transition, we conclude that the admissibility of this right should be limited and regulated. However, sound arguments accepted by fair-minded people supported by the principle of liberty and the proportionality principle should be the basis of such a decision.

We argue that the right to delete should be restricted to data that do not risk the issues developed in this discussion. Indeed, given that it is impossible to forget by complete deletion, but only to hinder access, this problem’s total solution may lie in technology. It is required to invest in technology that guarantees the maintenance of the information necessary to comply with the restrictions indicated. Nevertheless, the fundamental question is the ethics that must be endorsed in the regulation of this matter. As so, data that affect any of the values referred in the hypotheses previously discussed, i.e., those which might affect the right to self-determination of other individuals, whether present or future, cannot be subject to oblivion, not even to definitive obstruction of technological access. Deleting health and genetic data can undoubtedly undermine the rights of direct biological relatives as well as generations to come, so we argue that erasing them might be considered ethically unacceptable. Gender identity is a personality-related fundamental value but should not prevail without considering other values because it should not be regarded as absolute.

Regardless of the future of information about the past, it urges a discussion about specific features associated with the right to delete health and genetic data in gender transition from an ethical perspective. It is an issue that deserves broad and extensive exploration, which, along with other contributions, warrants bioethicists’ prompt attention.

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Analysis finds strong consensus on effectiveness of gender transition treatment

A new analysis conducted by researchers at the What We Know Project (WWKP), an initiative of Cornell University’s Center for the Study of Inequality (CSI), reviewed more than 25 years of scholarship on transgender mental health and found a strong consensus that undergoing gender transition can improve the well-being of transgender people.

The year-long review screened more than 4,000 studies and identified 56 that assessed whether gender transition improves the mental well-being of transgender individuals. The analysis concluded that 93 percent of the studies found positive effects from gender transition, indicating “a robust international consensus in the peer-reviewed literature that gender transition, including medical treatments such as hormone therapy and surgeries, improves the overall well-being of transgender individuals.”

The findings could play a role in a renewed debate about the fitness and health of transgender service members. The Pentagon has moved recently to reinstitute a transgender service ban based on claims of “uncertainty” about the science of treatment for gender dysphoria.

“Among researchers who have studied gender transition, there is little doubt that it improves the well-being of transgender people, often markedly,” said Nathaniel Frank, director of the What We Know Project, and co-lead, with researcher Kellan Baker, of the online study. “A consensus like this is rare in social science.” Their analysis confirms earlier findings that reflect near unanimity of opinion by experts on treatment of gender dysphoria, Frank said. “Just like anyone else,” he said, “with access to adequate health care, transgender people can excel at life and at work.”

Among the findings of the analysis are the following:

• Of 56 peer-reviewed studies, 52 (93 percent) found that gender transition improves the overall well-being of transgender people. The other 7 percent reported mixed or null findings. None of the reviewed studies showed that gender transition harms well-being.
• The positive outcomes of gender transition and related medical treatments include improved quality of life, greater relationship satisfaction, higher self-esteem and confidence, and reductions in anxiety, depression, suicidal tendencies and substance use.
• The positive impact of gender transition has grown considerably in recent years, as surgical techniques and social support have improved.
• Regrets following gender transition are extremely rare and have become increasingly rarer.

WWKP aggregates and summarizes scholarly research on topics relating to social, economic and political inequality. Kim Weeden, chair of the Department of Sociology in the College of Arts and Sciences, serves as faculty director, as well as director of CSI, a research center that supports nonpartisan academic research on the patterns, causes and consequences of social and economic inequality.

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