Transgender

Transgender is the state of one's gender identity (self-identification as woman, man, neither or both) not matching one's assigned sex (identification by others as male, female or intersex based on physical/genetic sex). Transgender does not imply any specific form of sexual orientation; transgender people may identify as heterosexual, homosexual, bisexual, pansexual, polysexual, or asexual; some may consider conventional sexual orientation labels inadequate or inapplicable to them. The precise definition for transgender remains in flux, but includes:
 * "Of, relating to, or designating a person whose identity does not conform unambiguously to conventional notions of male or female gender roles, but combines or moves between these."
 * "People who were assigned a sex, usually at birth and based on their genitals, but who feel that this is a false or incomplete description of themselves."
 * "Non-identification with, or non-presentation as, the sex (and assumed gender) one was assigned at birth."

A transgender individual may have characteristics that are normally associated with a particular gender, identify elsewhere on the traditional gender continuum, or exist outside of it as other, agender, genderqueer, or third gender. Transgender people may also identify as bigender, or along several places on either the traditional transgender continuum, or the more encompassing continuums which have been developed in response to the significantly more detailed studies done in recent years. Furthermore, many transgender people go through a period of identity development, marked by increases in understanding of one's self-image, self-reflection, and self-expression. More specifically, the degree to which individuals feel genuine, authentic, and comfortable within their external appearance and accept their genuine identity is referred to as transgender congruence.

Evolution of the term transgender
Writing for health professionals in the second edition of his reference work Sexual Hygiene and Pathology in 1965, psychiatrist John F. Oliven of Columbia University used the lexical compound trans+gender in the Transexualism section of “Primary Transvestism,” noting "'transgenderism' is what is meant, because sexuality is not a major factor in primary transvestism." Crossdressing pioneer Virginia Charles Prince used the compound in the December 1969 issue of Transvestia, a national magazine for cross dressers founded by Prince. In the mid-1970s both trans-gender and trans people were in use as umbrella terms. *In April 1970, TV Guide published an article which referenced a post-operative transsexual movie character as being "transgendered." *In the 1974 edition of Clinical Sexuality: A Manual for the Physician and the Professions, transgender was used as an umbrella term and the Conference Report from the 1974 "National TV.TS Conference" held in Leeds, West Yorkshire, UK used "trans-gender" and "trans.people" as umbrella terms., (2006). The Transgender Phenomenon  *However A Practical Handbook of Psychiatry (1974) references "transgender surgery" noting, "The transvestite rarely seeks transgender surgery, since the core of his perversion is an attempt to realize the fantasy of a phallic woman." 'Transgenderist' was used to describe people who wanted to live cross-gender without sex reassignment surgery. By 1976, transgenderist was abbreviated as TG in educational materials.

In 1979, Christine Jorgensen publicly rejected transsexual and instead identified herself in newsprint as a trans-gender saying, "gender doesn't have to do with bed partners, it has to do with identity.” By 1984, the concept of a "transgender community" had developed, in which transgender was used as an umbrella term. In 1985, Richard Elkins established the "Trans-Gender Archive" at the University of Ulster.  By 1992, the International Conference on Transgender Law and Employment Policy defined transgender as an expansive umbrella term including "transsexuals, transgenderists, cross dressers" and anyone transitioning.

Distinguishing transgender from transsexuality
Transsexual was defined by Harry Benjamin in his seminal book The Transsexual Phenomenon. Benjamin invented a classification system for transsexuals and transvestites; he called his system the Sex Orientation Scale (SOS). In the SOS, Benjamin assigns transsexuals and transvestites to one of six categories based on their reasons for crossdressing, and the relative urgency of their need (if any) for sex reassignment surgery. Many transsexuals believe that to be a true transsexual, a person needs to have a desire for surgery. However, it is notable that Benjamin's moderate intensity "true transsexual" needs either estrogen or testosterone as a "substitute for or preliminary to operation." There are also people who have had sexual reassignment surgery (SRS), but do not meet the definition of a transsexual, while other people do not desire SRS, yet clearly meet Benjamin Scale definition of a "true transsexual", such as Miriam Rivera.

In addition to the larger categories of transgender and transsexual, there is a wide range of gender expressions and identities which are contrary to the mainstream male-female binary. These include cross dressers, drag queens, drag kings, transvestites, genderqueer, etc.

Some people take issue with transsexual because Virginia Charles Prince, who started Transvestia, and built up the cross-dressing organization Tri-Ess, used transgender to distinguish cross-dressers from gay, bisexual and transsexual people. In "Men Who Choose to Be Women," Prince wrote "I, at least, know the difference between sex and gender and have simply elected to change the latter and not the former." There is ample academic literature on the difference between sex and gender, but in pragmatic English this distinction is often ignored, so that "gender" is used to describe the categorical male/female difference and "sex" is used to describe the physical act of sexual intercourse.

There is political tension between the identities that fall under the "transgender umbrella." For example, transsexual men and women who can pay for medical treatments (or who have institutional coverage for their treatment) are likely to be concerned with medical privacy and establishing a durable legal status as their gender later in life. Extending insurance coverage for medical care is a coherent issue in the intersection of transsexuality and economic class.

Transgender identities


While people self-identify as transgender, the transgender identity umbrella includes sometimes-overlapping categories. These include transsexual; transvestite or cross-dresser; genderqueer; androgyne; and bigender. Usually not included are transvestic fetishists (because it is considered to be a paraphilia rather than gender identification), and drag kings and drag queens, who are performers who cross-dress for the purpose of entertaining. In an interview, celebrity drag queen RuPaul talked about society's ambivalence to the differences in the people who embody these terms. "A friend of mine recently did the Oprah show about transgender youth," said RuPaul. "It was obvious that we, as a culture, have a hard time trying to understand the difference between a drag queen, transsexual, and a transgender, yet we find it very easy to know the difference between the American baseball league and the National baseball league, when they are both so similar." These terms are explained below.

The current definitions of transgender include all transsexual people, although this has been criticized. (See below.) Intersex people have genitalia or other physical sexual characteristics that do not conform to strict definitions of male and/or female, but intersex people are not necessarily transgender, since they do not all disagree with their assigned sex at birth. Transgender and intersex issues often overlap, however, because they both challenge the notion of rigid definitions of sex and gender.

The term trans man refers to female-to-male (FtM or F2M) transgender people, and trans woman refers to male-to-female (MtF or M2F) transgender people. In the past, it was assumed that there were more trans women than trans men, but a Swedish study estimated a ratio of 1.4:1 in favour of trans women for those requesting sex reassignment surgery and a ratio of 1:1 for those who proceeded.

The term cisgender has been coined as an antonym referring to non-transgender people; i.e. those who identify with their gender assigned at birth.

When referring to a transgender person, it is respectful to always use that person's preferred name and pronoun regardless of their legal gender status (as not all transgender people can afford surgery or other body modifications). Unlike 'transsexual', the word "transgender" should be used as an adjective rather than a noun — for example, "Max is transgender" or "Max is a transgender man" rather than "Max is a transgender." 'Transgendered' is also grammatically incorrect because 'transgender' is simply an adjective.

Transsexual
Transsexual people identify as a member of the sex opposite to that assigned at birth, and desire to live and be accepted as such.

Transsexual people may undergo gender transition, the process of aligning one's gender expression or presentation with their internal gender identity. People who have transitioned may or may not necessarily identify as transgender or transsexual any longer, but simply as a man or a woman. Those who continue identifying as transsexual men or women may not want to ignore their pre-transition life, and may continue strong ties with other trans people and raising social consciousness.

The process of transition may involve some kind of medical gender reassignment therapy and often (but not always) includes hormone replacement therapy and/or sex reassignment surgery. References to "pre-operative", "post-operative" and "non-operative" transsexual people indicate whether they have had, or are planning to have sex reassignment surgery, although some trans people reject these terms as objectifying trans people based on their surgical status and not their mental gender identity.

Transvestite or cross-dresser
A transvestite is a person who cross-dresses, or dresses in clothes of the opposite sex. The term "transvestite" is used as a synonym for the term "cross-dresser", although "cross-dresser" is generally considered the preferred term. The term 'cross-dresser' is not exactly defined in the relevant literature. Michael A. Gilbert, professor at the Department of Philosophy, York University, Toronto, offers this definition: "[A cross-dresser] is a person who has an apparent gender identification with one sex, and who has and certainly has been birth-designated as belonging to [that] sex, but who wears the clothing of the opposite sex because it is the clothing of the opposite sex." This excludes people "who wear opposite sex clothing for other reasons," such as "those female impersonators who look upon dressing as solely connected to their livelihood, actors undertaking roles, individual males and females enjoying a masquerade, and so on. These individuals are cross dressing but are not cross dressers." Cross-dressers may not identify with, or want to be the opposite gender, nor adopt the behaviors or practices of the opposite gender, and generally do not want to change their bodies medically. The majority of cross-dressers identify as heterosexual. People who cross-dress in public can have a desire to pass as the opposite gender, so as not to be detected as a cross-dresser, or may be indifferent.

The term "transvestite" and the associated outdated term "transvestism" are conceptually different from the term "transvestic fetishism", as "transvestic fetishist" describes those who intermittently use clothing of the opposite gender for fetishistic purposes. In medical terms, transvestic fetishism is differentiated from cross-dressing by use of the separate codes 302.3 in the DSM and F65.1 in the ICD.

Genderqueer
Genderqueer is a recent attempt to signify gender experiences that do not fit into binary concepts, and refers to a combination of gender identities and sexual orientations. One example could be a person whose gender presentation is sometimes perceived as male, sometimes female, but whose gender identity is female, gender expression is butch, and sexual orientation is lesbian. It suggests nonconformity or mixing of gender stereotypes, conjoining both gender and sexuality, and challenges existing constructions and identities. In the binary sex/gender system, genderqueerness is unintelligible and abjected.

Androgyne
An androgyne is a person who does not fit cleanly into the typical gender roles of their society. It does not imply any specific form of sexual orientation. Androgynes may identify as beyond gender, between genders, moving across genders, entirely genderless, or any or all of these, exhibiting a variety of male, female, and other characteristics. Androgyne identities include pangender, ambigender, non-gendered, agender, gender fluid or intergender. Androgyny can be either physical or psychological, and it does not depend on birth sex. Occasionally, people who do not define themselves as androgynes adapt their physical appearance to look androgynous. This outward androgyny has been used in fashion, and the milder forms of it (women wearing men's pants or men wearing two earrings, for example) are not seen as transgender behavior.

The term androgyne is also sometimes used as a medical synonym for an intersex individual.

Bigender
A bigender (sometimes rendered as bi-gender, dual gender, or bi+gender) individual is one who moves between masculine and feminine gender roles. Such individuals move between two distinct personalities fluidly depending on context. While an androgynous person retains the same gender-typed behaviour across situations, the bigendered person consciously or unconsciously changes their gender-role behaviour from primarily masculine to primarily feminine, or vice versa.

Drag kings and queens
Drag is a term applied to clothing and make-up worn on special occasions for performing or entertaining. This is in contrast to those who are transgender or who cross-dress for other reasons. Drag performance also includes overall presentation and behavior in addition to clothing and makeup. Drag can be theatrical, comedic, or grotesque. Drag queens have been considered caricatures of women by second-wave feminism. Drag artists have a long tradition in LGBT culture. Generally the terms drag queen covers men doing female drag, drag king covers women doing male drag, and faux queen covers women doing female drag. Nevertheless, there are drag artists of all genders and sexualities who perform for various reasons. Some drag performers, transvestites, and people in the gay community, have embraced the pornographically-derived term tranny to describe drag queens or people who engage in transvestism or cross-dressing, however this term is widely considered offensive if applied to transsexual people.

Transgender people and the LGBT community
The concepts of gender identity and transgender identity differ from that of sexual orientation. Sexual orientation describes an individual's enduring physical, romantic, emotional, and/or spiritual attraction to another person, while gender identity is one's personal sense of being a man or a woman. Transgender people have more or less the same variety of sexual orientations as cisgender people. In the past, the terms homosexual and heterosexual were incorrectly used to label transgender individuals' sexual orientation based on their birth sex. Professional literature now uses terms such as attracted to men (androphilic), attracted to women (gynephilic), attracted to both or attracted to neither to describe a person's sexual orientation without reference to their gender identity. Therapists are coming to understand the necessity of using terms with respect to their clients' gender identities and preferences. For example, a person who is assigned male at birth, transitions to female, and is attracted to men would be identified as heterosexual.

Despite the distinction between sexual orientation and gender, throughout history the gay, lesbian, and bisexual subculture was often the only place where gender-variant people were socially accepted in the gender role they felt they belonged to; especially during the time when legal or medical transitioning was almost impossible. This acceptance has had a complex history. Like the wider world, the gay community in Western societies did not generally distinguish between sex and gender identity until the 1970s, and often perceived gender variant people more as homosexuals who behaved in a gender-variant way than as gender-variant people in their own right. Today, members of the transgender community often continue to struggle to remain part of the same movement as lesbian, gay and bisexual citizens, and to be included in rights protections.

Pride symbols


A common symbol for the transgender community is the transgender pride flag, which was designed by Monica Helms, and was first shown at a pride parade in Phoenix, Arizona, United States in 2000.

The flag consists of five horizontal stripes, two light blue, two pink, with a white stripe in the center.

Monica describes the meaning of the flag as follows: The light blue is the traditional color for baby boys, pink is for girls, and the white in the middle is for those who are transitioning, those who feel they have a neutral gender or no gender, and those who are intersexed. The pattern is such that no matter which way you fly it, it will always be correct. This symbolizes us trying to find correctness in our own lives.

Other transgender symbols include the butterfly (symbolizing transformation or metamorphosis), and a pink/light blue yin and yang symbol.

Transgender people and feminism
Some feminists and feminist groups are supportive of transgender people. Others are not.

Though second-wave feminism argued for the sex and gender distinction, some feminists believed there was a conflict between transgender identity and the feminist cause. These feminists believed, for example, that male-to-female transition abandoned or devalued female identity, and that trangender people embraced traditional gender roles and stereotypes. Many transgender feminists, however, viewed themselves as contributing positively to feminism by questioning and subverting gender norms. Third wave and contemporary feminism have tended to be more accepting of transgender people.

Feminist writer Janice Raymond asserts that sex determines gender, and that there is no practical difference between the two. In her view, genitalia or "birth sex" or chromosomes deeply and permanently determine one's essential identity as a woman or man; trying to violate this divide is impossible, unnatural, and unhealthy. She argues that while transpeople may claim to feel like a certain gender, only a biological female can genuinely feel what it is to occupy a woman's body, including having experiences such as childbirth.

Mental healthcare
Therapy is recommended by most mental health professionals for those who suffer from internal conflicts regarding their gender identity or those who feel discomfort in their assigned gender role, especially if they desire to transition. People who experience discord between their gender and the expectations of others or whose gender identity conflicts with their body may benefit by talking through their feelings in depth with someone who will listen attentively. However, research on gender identity is relatively new to psychology and scientific understanding of it and related issues is still in its infancy.

Transgender people may be eligible for diagnosis of gender identity disorder (GID) "only if [being transgender] causes distress or disability." This distress is referred to as gender dysphoria and may manifest as depression or inability to work and form healthy relationships with others. This diagnosis is often misinterpreted as implying that simply being transgender means a person suffers from GID, which is not the case. This has caused much confusion to transgender people and those who seek to either criticize or affirm them. Transgender people who are comfortable with their gender, whose gender does not directly cause inner frustration or impair their functioning, do not suffer from GID. Moreover, GID is not necessarily permanent, and is often resolved through therapy and/or transitioning. GID does not refer to people who feel oppressed by the negative attitudes and behaviors or others including legal entities in the same way that racist institutions do not create a "race disorder." Neither does GID imply an opinion of immorality; the psychological establishment holds the position that people with any kind of mental or emotional problem should not receive stigma. The solution for GID is whatever will alleviate suffering and restore functionality; this often, but not always, consists of undergoing a gender transition.

The terms "transsexualism", "dual-role transvestism", "gender identity disorder in adolescents or adults" and "gender identity disorder not otherwise specified" are listed as such in the International Statistical Classification of Diseases (ICD) or the American Diagnostic and Statistical Manual of Mental Disorders (DSM) under codes F64.0, F64.1, 302.85 and 302.6 respectively.

In February 2010, France became the first country in the world to remove transgender identity from the list of mental diseases.

The issues around psychological classifications and associated stigma (whether based in paraphilia or not) of cross dressers, transsexual men and women (and for that matter lesbian and gay children who may be difficult to tell apart from trans children early in life) have recently become more complex since it was announced that CAMH colleagues Kenneth Zucker and Ray Blanchard would serve on the DSM-V's Sexual and Gender Identity Disorders Work Group. CAMH aims to 'cure' transgender people of their 'disorder', especially in children. Within the trans community, this has mostly produced shock and outrage with attempts to organize other responses.

One of the reasons there is so much controversy about Kenneth Zucker and Ray Blanchard's work group is that many people believe that gender identity disorders/homosexuality are incurable as they are genetic and/or occur as a result of events occurring before birth (therefore already "solidified" by the time of birth). If this is the case, then trying to 'cure' said condition(s) could lead (and in some individuals already has led  ) to increased confusion, more intense dysphoria later in life, and perhaps even suicide (likely due to the fact that the younger the transgender individual, the greater the effect of hormones). While some cases of individuals partaking in these sessions seem to show success, the long term repercussions (if any) of some of these individuals being 'cured' have not yet been observed, due to an indefinite amount of time before negative reactions could possibly occur.

Transgender issues are both new in the scientific field and affect relatively few people, so many mental healthcare providers know little about transgender issues. People seeking help from these professionals often end up educating the professional rather than receiving help. Among those therapists who profess to know about transgender issues, many believe that transitioning from one sex to another – the standard transsexual model – is the best or only solution. This usually works well for those who are transsexual, but is not the solution for other transgender people, particularly genderqueer people who do not identify as exclusively male or female. Instead, therapists can work with their transgender clients to support them in whatever steps they choose to take to transition, or support their decision to not transition, while also addressing their clients' sense of congruence between gender identity and appearance.

Physical healthcare
Medical and surgical procedures exist for transsexual and some transgender people. (Most categories of transgender people as described above are not known for seeking the following treatments.) Hormone replacement therapy for trans men induces beard growth and masculinises skin, hair, voice and fat distribution. Hormone replacement therapy for trans women feminises fat distribution and breasts. Laser hair removal or electrolysis removes excess hair for trans women. Surgical procedures for trans women feminise the voice, skin, face, adam's apple, breasts, waist, buttocks and genitals. Surgical procedures for trans men masculinise the chest and genitals and remove the womb and ovaries and fallopian tubes. The acronyms "GRS" and "SRS" refer to genital surgery. The term "sex reassignment therapy" (SRT) is used as an umbrella term for physical procedures required for transition. Use of the term "sex change" has been criticized for its emphasis on surgery, and the term "transition" is preferred. Availability of these procedures depends on degree of gender dysphoria, presence or absence of gender identity disorder, and standards of care in the relevant jurisdiction.

Transgender people and the law


Legal procedures exist in some jurisdictions allowing individuals to change their legal gender, or their name, to reflect their gender identity. Requirements for these procedures vary from an explicit formal diagnosis of transsexualism, to a diagnosis of gender identity disorder, to a letter from a physician attesting to the individual's gender transition, or the fact that one has established a different gender role. In 1994, the DSM IV entry was changed from "Transsexual" to "Gender Identity Disorder." In many places, transgender people are not legally protected from discrimination in the workplace or in public accommodations. A report released in February 2011 found that 90% of transgender people faced discrimination at work, and were unemployed at double the rate of the general population. Over half had been harassed or turned away when attempting to access public services. Members of the transgender community also encounter high levels of discrimination in health care on an everyday basis.

In Canada, a private members bill protecting the rights of freedom of gender expression and gender identity passed in the House of Commons on February 9, 2011. It amends the Canada Human Rights code to help protect gender-variant people from discrimination by including gender identity and expression in the list of prohibited grounds for discrimination, as well as including gender identity and expression in the description of identifiable group, so that offences deliberately against gender-variant people can be punished to a similar extent as a racial-based crime. It is uncertain whether the bill will be passed by the Senate.

In the U.S., a federal bill to protect workers from discrimination based on sexual orientation and gender identity – called the Employment Non-Discrimination Act – has stalled and failed several times over the past two decades. Still, individual states and cities have begun passing their own non-discrimination ordinances. In New York, for example, Governor David Paterson passed the first legislation to include transgender protections in September 2010.

Nicole Maines took a case of whether she is allowed to use her high school's girl's bathroom, as a transgender girl, to Maine's Supreme Court in June, 2013. She claims being denied such access is a violation of Maine's Human Rights Act, though a state judge has already disagreed with her.

Brain-based studies
Several studies have concentrated on whether sexually dimorphic brain structures in transsexuals are more similar to their preferred sex or to their birth sex. Researchers caution that there are known brain differences between homosexual and heterosexual persons and that the brain changes in response to hormone-treatment, which many transsexuals use. In order to know what in the brain is related to what feature of the person, studies of more uniform groups give clearer results than do studies of more mixed groups.

Androphilic MtF transsexuals
Studies have consistently shown that specifically androphilic male-to-female transsexuals (sometimes called homosexual MtF transsexuals in studies) show a shift towards the female direction in brain anatomy. In 2009, the German team of radiologists led by Gizewski compared 12 androphilic transsexuals with 12 biological males and 12 biological females. Using functional magnetic resonance imaging (fMRI), they found that when shown erotica, the biological men responded in several brain regions that the biological women did not, and that the sample of androphilic transsexuals was shifted towards the female direction in brain responses.

Rametti and colleagues used diffusion tensor imaging (DTI) to compare 18 androphilic male-to-female transsexuals with 19 gynephilic males and 19 typical (heterosexual) females. The androphilic transsexuals differed from both control groups in multiple brain areas, including the superior longitudinal fasciculus, the right anterior cingulum, the right forceps minor, and the right corticospinal tract. The study authors concluded that androphilic transsexuals are halfway between the patterns exhibited by male and female controls.

Gynephilic MtF transsexuals
Conversely, gynephilic male-to-female transsexuals also show differences in the brain from non-transsexual males, but in a unique pattern different from being shifted in a female direction. Researchers of the Karolinska Institute of Stockholm used MRI to compare 24 gynephilic male-to-female transsexuals with 24 non-transsexual male and 24 non-transsexual female controls. None of the study participants were on hormone treatment. The researchers found sex-typical differentiation between the MtF transsexuals and non-transsexual males, and the non-transsexual females; but the gynephilic transsexuals "displayed also singular features and differed from both control groups by having reduced thalamus and putamen volumes and elevated GM volumes in the right insular and inferior frontal cortex and an area covering the right angular gyrus."

These researchers concluded that

"Contrary to the primary hypothesis, no sex-atypical features with signs of 'feminization' were detected in the transsexual group....The present study does not support the dogma that [male-to-female transsexuals] have atypical sex dimorphism in the brain but confirms the previously reported sex differences. The observed differences between MtF-TR and controls raise the question as to whether gender dysphoria may be associated with changes in multiple structures and involve a network (rather than a single nodal area)."

In Sweden, non-androphilic transsexual women were tested when they were smelling odorous steroids. The results showed that the transsexual women demonstrated "a pattern of activation away from the biological sex, occupying an intermediate position with predominantly female-like features."

Anne Lawrence, a sexologist, physician, and self-identified autogynephilic transsexual, has hypothesized that the desire by persons with autogynephilia, including some cross dressers and some transsexuals, to alter their body can be compared with apotemnophilia (alternately body integrity identity disorder if framed as an identity issue rather than a fetish). Explanations of the desire to transition based on libido, such as this, have been criticized by some transsexuals who argue that they are unscientific or transphobic.

Mixed samples of MtF transsexuals
Several teams of researchers have examined the brains or brain functioning of MtF transsexuals, but without breaking down the samples into androphilic (or homosexual) and gynephilic (or autogynephilic or heterosexual) types. Such studies have yielded contradictory results, with some studies reporting differences between the (mixed groups of) MtF transsexuals and the non-transsexual controls but with other studies finding no differences.

One brain structure that was examined in MtF transsexuals because of having known sex difference is the corpus callosum, which is larger and of a different shape in men than in women. In 1991, a University of Texas team reported comparing the corpora callosa of 10 MtF transsexuals, 10 FtM transsexuals, 20 control males, and 20 control females. No significant differences were found.

In a pair of reports, the Dutch team led by Dick Swaab, examined the volume and neuron count in the bed nucleus of the stria terminalis in six estrogen-treated transsexuals and one pre-treatment transsexual. They found the BSTc to be female-shifted (smaller) among the transsexuals than among the male control subjects. A subsequent study by Swaab found that the BSTc becomes sexually dimorphic only in adulthood, suggesting that differentiation of the BSTc does not cause transsexualism. Rather, the difference in the BSTc might instead be the result of a "failure to develop a male-like gender identity" (p. 1032). The BSTc has also been reported to be smaller in other sexually atypical populations unrelated to transsexualism.

Another team of Dutch researchers examined the effects of cross-gender hormone treatment on the brain in 8 male-to-female transsexuals and in 6 female-to-male transsexuals, finding that the hormones changed the sizes of the hypothalamus in a gender consistent manner. Treatment with male hormones shifted the hypothalamus towards the male direction in the same way as in male controls, and treatment with female hormones shifted the hypothalamus towards the female direction in the same way as female controls.

A 2003 study by Haraldsen and colleagues compared the performance of 52 persons with Gender Identity Disorder (33 from Norway and 19 from the U.S.) with that of 29 control subjects on a series of tests that tap into the functioning of different parts of the brain and on which men and women perform differently. The people in the GID sample "were either homosexually attracted by males or females (n=38), by both (n=3) or by neither (n=9)." No effects of transsexual status were detected.

Johns Hopkins researchers in 2005 reported on another test of brain functioning using test performance. The study subjects included 27 MtF transsexuals and 16 control men, and the authors reported that no female-typical patterns in cerebral lateralization or cognitive performance were found within the transsexual sample.

In 2009, UCLA researchers used MRIs to examine a mixed sample of 24 non-hormone-treated male-to-female transsexuals (6 were androphilic, and 18 were gynephilic), comparing them with 30 non-transsexual males and 30 non-transsexual females. The results "revealed that regional gray matter variation in MTF transsexuals is more similar to the pattern found in men than in women," except for the "right putamen.". They concluded that "These findings provide new evidence that transsexualism is associated with distinct cerebral pattern, which supports the assumption that brain anatomy plays a role in gender identity."

Gynephilic FtM transsexuals
Brain-based research has repeatedly shown that female-to-male transsexuals have several male-like characteristics in neuroanatomy. In 2010, a team of neuroscientists compared 18 female-to-male transsexuals with 24 male and 19 female gynephilic controls, using an MRI technique called diffusion tensor imaging or DTI. DTI is a specialized technique for visualizing white matter of the brain, and white matter structure is one of the differences in neuroanatomy between men and women. The study found that the white matter pattern in female-to-male transsexuals was shifted in the direction of biological males, even before the female-to-male transsexuals started taking male hormones (which can also modify brain structure).

Another team of neuroscientists, led by Nawata in Japan, used a technique called single-photon emission computed tomography (SPECT) compare the regional cerebral blood flow (rCBF) of 11 female-to-male transsexuals (attracted to women) with that of 9 biological females (attracted to men). Although the study did not include a sample of biological males so that a conclusion of "male shift" could be made, the study did reveal that the female-to-male transsexuals showed significant decrease in blood flow in the left anterior cingulate cortex and a significant increase in the right insula, two brain regions known to respond during sexual arousal.

Genetic studies
In 2008, a study was performed to attempt to find a link between genes and transsexuality. The researchers compared 112 male-to-female transsexuals (both androphilic and gynephilic), mostly already undergoing hormone treatment, with 258 cis-gendered male controls. The male-to-female transsexuals were more likely than non-transsexual males to have a longer version of a receptor gene for the sex hormone androgen or testosterone. The research suggests reduced androgen and androgen signaling contributes to the female gender identity of male to female transsexuals. The authors say that it is possible that a decrease in testosterone levels in the brain during development might result in incomplete masculinization of the brain in male to female transsexuals, resulting in a more feminized brain and a female gender identity.

Terms and typology
The use of homosexual transsexual and related terms have been applied to transgender people since the middle of the 20th century, though concerns about the terms have been voiced since then. Harry Benjamin said in 1966: ...it seems evident that the question "Is the transsexual homosexual?" must be answered "yes" and " no." "Yes," if his anatomy is considered; "no" if his psyche is given preference.

What would be the situation after corrective surgery has been performed and the sex anatomy now resembles that of a woman? Is the "new woman" still a homosexual man? "Yes," if pedantry and technicalities prevail. "No" if reason and common sense are applied and if the respective patient is treated as an individual and not as a rubber stamp.

Many sources, including some supporters of the typology, criticize this choice of wording as confusing and degrading. Biologist Bruce Bagemihl writes "..the point of reference for "heterosexual" or "homosexual" orientation in this nomenclature is solely the individual's genetic sex prior to reassignment (see for example, Blanchard et al. 1987[24], Coleman and Bockting, 1988[25], Blanchard, 1989[26]). These labels thereby ignore the individual’s personal sense of gender identity taking precedence over biological sex, rather than the other way around." Bagemihl goes on to take issue with the way this terminology makes it easy to claim transsexuals are really homosexual males seeking to escape from stigma. Leavitt and Berger stated in 1990 that "The homosexual transsexual label is both confusing and controversial among males seeking sex reassignment. Critics argue that the term "homosexual transsexual" is "heterosexist", "archaic", and demeaning because it labels people by sex assigned at birth instead of their gender identity. Benjamin, Leavitt, and Berger have all used the term in their own work.  Sexologist John Bancroft also recently expressed regret for having used this terminology, which was standard when he used it, to refer to transsexual women. He says that he now tries to choose his words more sensitively. Sexologist Charles Allen Moser is likewise critical of the terminology.

Use of androphilia and gynephilia was proposed and popularized by psychologist Ron Langevin in the 1980s. Psychologist Stephen T. Wegener writes, "Langevin makes several concrete suggestions regarding the language used to describe sexual anomalies. For example, he proposes the terms gynephilic and androphilic to indicate the type of partner preferred regardless of an individual's gender identity or dress. Those who are writing and researching in this area would do well to adopt his clear and concise vocabulary."

Psychiatrist Anil Aggrawal explains why the terms are useful in a glossary: "Androphilia – The romantic and/or sexual attraction to adult males. The term, along with gynephilia, is needed to overcome immense difficulties in characterizing the sexual orientation of transmen and transwomen. For instance, it is difficult to decide whether a transman erotically attracted to males is a heterosexual female or a homosexual male; or a transwoman erotically attracted to females is a heterosexual male or a lesbian female. Any attempt to classify them may not only cause confusion but arouse offense among the affected subjects. In such cases, while defining sexual attraction, it is best to focus on the object of their attraction rather than on the sex or gender of the subject."

Psychologist Rachel Ann Heath writes, "The terms homosexual and heterosexual are awkward, especially when the former is used with, or instead of, gay and lesbian. Alternatively, I use gynephilic and androphilic to refer to sexual preference for women and men, respectively. Gynephilic and androphilic derive from the Greek meaning love of a woman and love of a man respectively. So a gynephilic man is a man who likes women, that is, a heterosexual man, whereas an androphilic man is a man who likes men, that is, a gay man. For completeness, a lesbian is a gynephilic woman, a woman who likes other women. Gynephilic transsexed woman refers to a woman of transsexual background whose sexual preference is for women. Unless homosexual and heterosexual are more readily understood terms in a given context, this more precise terminology will be used throughout the book. Since homosexual, gay, and lesbian are often associated with bigotry and exclusion in many societies, the emphasis on sexual affiliation is both appropriate and socially just." Author Helen Boyd agrees, writing, "It would be much more accurate to define sexual orientation as either "androphilic" (loving men) and "gynephilic" (loving women) instead." Sociomedical scientist Rebecca Jordan-Young challenges researchers like Simon LeVay, J. Michael Bailey, and Martin Lalumiere, who she says "have completely failed to appreciate the implications of alternative ways of framing sexual orientation."

Blanchard's typology
Blanchard's transsexualism typology characterizes trans women as having one of two motivations for transition. Whereas previous descriptions of transgenderism included very many combinations of sexual orientation, gender identity, and the desire to cross-dress, Blanchard interprets his evidence as suggesting that there were only two basic phenomena. One phenomenon was androphilia (male homosexuality), which ranged from typical gay men to, when extreme, androphilic or homosexual transsexualism. The other phenomenon was autogynephilia, which ranged from typical cross-dressers to, when extreme, autogynephilic transsexualism (or non-homosexual transsexualism). Androphilic male-to-female transsexuals are characterized by sexual attraction to males and by overt and obvious femininity since childhood, whereas autogynephilic transsexuals are characterized by sexual attraction to females (or sometimes to females and males, or by asexuality) and whose presentations are internal and typically unremarkable until they choose to disclose them, typically later in life. There are community activists who dislike the theory.

Scientific criticism of the theory includes papers from Veale, Nuttbrock, Moser, and others who argue that the theory is poorly representative of MTF transsexuals, non-instructive, the experiments poorly controlled, or contradicted by other data. Many sources, including some supporters of the theory, criticize Blanchard's choice of wording as confusing or degrading.

Also the DSM V workgroup has been quoted as saying: "'In contemporary clinical practice, sexual orientation per se plays only a minor role in treatment protocols or decisions. Also, changes as to the preferred gender of sex partner occur during or after treatment (DeCuypere, Janes, & Rubens, 2005; Lawrence, 2005; Schroder & Carroll, 1999). It can be difficult to assess sexual orientation in individuals with a GI diagnosis, as they preoperatively might give incorrect information in order to be approved for hormonal and surgical treatment (Lawrence, 1999). Because sexual orientation subtyping is of interest to researchers in the field, it is recommended that reference to it be addressed in the text, but not as a specifier. It should also be assessed as a dimensional construct.'" Blanchard is a member of the DSM V Sexual and Gender Identity Disorders Work Group chaired by Kenneth J. Zucker. Though it has supporters, the transsexual community has for the most part vehemently rejected Blanchard's typology theory.

Asia
In Thailand and Laos, the term kathoey is used to refer to male-to-female transgender people and effeminate gay men. The cultures of the Indian subcontinent include a third gender, referred to as hijra in Hindi. Transgender people have also been documented in Iran, Japan, Nepal, Indonesia, Vietnam, South Korea, Singapore, and the greater Chinese region, including Hong Kong, Taiwan, and the People's Republic of China.

North America
In what is now the United States and Canada, many Native American and First Nations peoples recognised the existence of more than two genders, such as the Zuñi male-bodied Ła'mana, the Lakota male-bodied winkte and the Mohave male-bodied alyhaa and female-bodied hwamee. Such people were previously referred to as berdache but are now referred to as Two-Spirit, and their spouses would not necessarily have been regarded as gender-different. In Mexico, the Zapotec culture includes a third gender in the form of the Muxe.

Other
In early Medina, gender-variant male-to-female Islamic people were acknowledged in the form of the Mukhannathun. In Ancient Rome, the Gallae were castrated followers of the Phrygian goddess Cybele and can be regarded as transgender in today's terms.

Among the ancient Middle Eastern Akkadian people, a salzikrum was a person who appeared biologically female but had distinct male traits. Salzikrum is a compound word meaning male daughter. According to the Code of Hammurabi, salzikrūm had inheritance rights like that of priestesses; they inherited from their fathers, unlike regular daughters. A salzikrum's father could also stipulate that she inherit a certain amount.

Mahu is a traditional status in Polynesian cultures. Also, in Fa'asamoa traditions, the Samoan culture allows a specific role for male to female transgender individuals as Fa'afafine.

Coming out
Transgender people vary greatly in choosing when, if, and how to disclose their transgender status to family, close friends, and others. The prevalence of discrimination and violence against the transgender community can make coming out a risky decision. Fear of retaliatory behavior, such as being removed from the parental home while underage, is a cause for transgender people to not come out to their families until they have reached adulthood. Parental confusion and lack of acceptance of the child's transgenderism may be met with an effort to change their children back to "normal" by utilizing mental health services to alter the child's sexual orientation and what is seen as a "phase".