Gender Transitioning: Expressing and Affirming Gender Identity

Gender transitioning is the process of affirming and expressing an individual’s internal sense of gender rather than the one assigned at birth. How can learning the aspects of gender and gender transitioning help support the LGBTQ+ community?

Gender Transitioning

Gender transitioning or gender affirmation is a process through which transgender and gender-nonconforming individuals align their internal gender identity with their external gender expression. It can be described as a binary – male or female – but can also be non-binary, meaning an individual is neither exclusively male nor female.

• The process can involve aesthetic appearances, changes in social roles, legal recognitions, and/or physical aspects of the body.
• Social affirmation – dressing differently or coming out to friends and family.
• Legal affirmation – changing name and gender on legal documents.
• Medical affirmation – using hormones and/or surgery to change certain physical aspects of their body.
• Transgender individuals can pursue some or all of these.

Barriers

Gender transitioning can be obstructed by various barriers that can include:

• Cost
• Lack of insurance
• Lack of family, friends, or partner support.
• Discrimination
• Stigma

Addressing  All Aspects

The process does not have a specific timeline and is not always linear.

• Many transgender and gender-nonconforming individuals prefer gender affirmation to gender transitioning because transitioning is often taken to mean the process of medically transforming the body.
• An individual does not have to undergo medical treatment to affirm their identity, and some transgender people avoid hormones or gender-affirming surgery.
• Transitioning is a holistic process that addresses all aspects of who a person is inwardly and outwardly.
• Certain aspects of transitioning may be more important than others, like changing one’s name and gender on their birth certificate.
• Reevaluation and revision of gender identity can be continual rather than a step-by-step, one-way process.

Exploring Gender Identity

Gender transitioning often starts in response to gender dysphoria which describes the constant sense of uneasiness that occurs when the gender an individual was assigned at birth does not match how they experience or express their gender internally.

• Some individuals have experienced symptoms of gender dysphoria as early as 3 or 4 years of age. (Selin Gülgöz, et al., 2019)
• Gender dysphoria can be largely informed by the culture that surrounds the individual, specifically in cultures where strict codes determine what is masculine/male and feminine/female.

Unease Expressed in Different Ways

• Dislike of one’s sexual anatomy.
• A preference for clothes typically worn by the other gender.
• Not wanting to wear clothes typically worn by their own gender.
• A preference for cross-gender roles in fantasy play.
• A strong preference for engaging in activities that are typically done by the other gender.

Dysphoria

• Gender dysphoria can fully emerge during puberty when awareness about how an individual’s body defines them creates internal distress.
• Feelings may be amplified when an individual is described as a tomboy, or a sissy, or is criticized and attacked for acting like a girl or acting like a boy.
• During puberty, the physical changes can cause long-standing feelings of not fitting in and may evolve into feelings of not fitting in their own body.
• This is when individuals can undergo a process referred to as internal transitioning and begin to change how they see themselves.

Gender transitioning/affirmation becomes the next step. Transitioning is not about changing or recreating oneself but about expressing their authentic self and asserting who they are socially, legally, and/or medically.

Social

Social transitioning involves how a person publicly expresses their gender. The transition can include:

• Changing pronouns.
• Using chosen name.
• Coming out to friends, family, coworkers, etc.
• Wearing new clothes.
• Cutting or styling hair differently.
• Changing mannerisms like moving, sitting, etc.
• Changing voice.
• Binding – strapping the chest to hide breasts.
• Wearing breast and hip prosthetics to accentuate feminine curvature.
• Packing – wearing a penile prosthesis to create a penile bulge.
• Tucking – tucking the penis to conceal a bulge.
• Playing certain sports
• Pursuing different lines of work.
• Participating in activities that might typically be seen as male or female.

Legal

Legal transitioning involves changing legal documents to reflect the individual’s chosen name, gender, and pronouns. This includes governmental and non-government documents that can include:

• Birth certificates
• Social Security ID
• Driver’s license
• Passport
• Bank records
• Medical and dental records
• Voter registration
• School ID
• Provisions allowing for changes can vary by state.
• Some states only allow changes if bottom surgery – genital reconstruction is performed.
• Others will allow the changes without any form of gender-affirming surgery.
• Other states have begun to offer an X-gender option for non-binary individuals. (Wesley M King, Kristi E Gamarel. 2021)

Medical

Medical transitioning typically involves hormone therapy to develop some of the male or female sex characteristics. It can also involve surgery to change certain physical aspects combined with hormone therapy.

• Hormone therapy assists individuals to physically look more like the gender they identify as.
• They can be used on their own and can also be used before gender-affirming surgery.

Hormone therapy takes two forms:

Transgender Men

• Testosterone is taken to help deepen the voice, increase muscle mass, promote body and facial hair, and enlarge the clitoris. (M S Irwig, K Childs, A B Hancock. 2017)

Transgender Women

• Estrogen is taken as well as testosterone blockers to redistribute body fat, increase breast size, reduce male-pattern baldness, and reduce testicle size. (Vin Tangpricha 1, Martin den Heijer. 2017)

Surgery

Gender affirmation surgery aligns an individual’s physical appearance to their gender identity. Many hospitals provide gender-affirming surgery through a transgender medicine department. Medical procedures include:

• Facial surgery – Facial feminization surgery.
• Breast augmentation – Increases breast size with implants.
• Chest masculinization – Removes contours of breast tissues.
• Tracheal shaving – Reduces the Adam’s apple.
• Phalloplasty – Construction of a penis.
• Orchiectomy – Removal of the testicles.
• Scrotoplasty – Construction of a scrotum.
• Vaginoplasty – Construction of a vaginal canal.
• Vulvoplasty – Construction of the outer female genitalia.

Roadblocks

• Transgender individuals are protected from public and private insurance discrimination under federal and state laws, including Medicare and Medicaid. (National Center for Transgender Equality. 2021)
• Medicaid programs in nine states do not cover gender-affirming medical treatments, and only Illinois and Maine offer comprehensive standard care recommended by the World Professional Association for Transgender Health/WPATH. (Kaiser Family Foundation. 2022)
• Medicare also has no consistent policy regarding the approval of gender-affirming surgery.
• It relies on precedents in individual states to direct whether a treatment is approved or not. (Center of Medicare and Medicaid Services. 2016)
• In private insurance, most providers have removed restrictions on gender-affirming care.
• Larger insurers like Aetna and Cigna typically cover a more comprehensive array of services, in full or part.
• Smaller insurers might not cover surgeries and only cover things like hormone therapy. (Transgender Legal Defense and Education Fund. 2023)
• Another roadblock is stigma and discrimination.
• Studies show that more than half of transgender individuals report being harassed or bullied in public. (National Center for Transgender Equality and National Gay and Lesbian Task Force. 2011)
• Others report family or partner disapproval as the main reason why they discontinue gender affirmation. (Jack L. Turban, et al., 2021)

If you know someone who is transgender or is considering transitioning, learning about gender and gender transitioning and how to be supportive is a great way to be an ally.

Enhancing Your Lifestyle

References

Gülgöz, S., Glazier, J. J., Enright, E. A., Alonso, D. J., Durwood, L. J., Fast, A. A., Lowe, R., Ji, C., Heer, J., Martin, C. L., & Olson, K. R. (2019). Similarity in transgender and cisgender children’s gender development. Proceedings of the National Academy of Sciences of the United States of America, 116(49), 24480–24485. https://doi.org/10.1073/pnas.1909367116

Irwig, M. S., Childs, K., & Hancock, A. B. (2017). Effects of testosterone on the transgender male voice. Andrology, 5(1), 107–112. https://doi.org/10.1111/andr.12278

Tangpricha, V., & den Heijer, M. (2017). Estrogen and anti-androgen therapy for transgender women. The Lancet. Diabetes & endocrinology, 5(4), 291–300. https://doi.org/10.1016/S2213-8587(16)30319-9

National Center for Transgender Equality. Know Your Rights in Health Care.

Kaiser Family Foundation. Update on Medicaid coverage of gender-affirming health services.

Center of Medicare and Medicaid Services. Gender dysphoria and gender reassignment surgery.

Transgender Legal Defense and Education Fund. Health insurance medical policies.

National Center for Transgender Equality and National Gay and Lesbian Task Force. Injustice at Every Turn: A Report of the National Transgender Discrimination Survey.

Turban, J. L., Loo, S. S., Almazan, A. N., & Keuroghlian, A. S. (2021). Factors Leading to “Detransition” Among Transgender and Gender Diverse People in the United States: A Mixed-Methods Analysis. LGBT health, 8(4), 273–280. https://doi.org/10.1089/lgbt.2020.0437