What Does It Mean to Be Transgender?

NewYork-Presbyterian experts help explain the diversity of gender identity.

A person holding a piece of paper with a transgender sign on it

Gender diversity is a topic making headlines as more Americans feel emboldened in affirming their unique gender identity, but many more may be wondering how someone identifies as transgender and what they need to know to better understand the transgender experience.

“There’s been an increased awareness among the public over the last few years around gender identity and gender diversity,” says Dr. Melina Sevlever, a psychologist at NewYork-Presbyterian/Columbia University Irving Medical Center and the lead clinician of the Columbia Gender Identity Program, which was founded in 2018 to provide compassionate, personalized, and expert care to children, adolescents, adults, and families across the gender and sexuality spectrum. “With the increased awareness, people are finding the language to talk about this, parents have heightened awareness with respect to what may be going on with their children, and overall there’s more acceptance around this subject.”

Sexual Orientation vs. Gender Identity

Some people confuse gender identity and sexual orientation, or assume that if someone is transgender, they are also gay.

“I think those two concepts often get confused, but actually they’re completely distinct,” says Dr. Sevlever. “Whether or not someone is transgender, gender nonconforming, or gender nonbinary, that doesn’t tell you anything about their sexual orientation.”

Dr. Sevlever defines sexual orientation as someone’s sense of whom they are attracted to, and that may be somebody of the same gender or a different gender. Gender identity, she says, is a person’s internal sense of the gender with which they identify.

“This could mean they identify as a member of the other sex or somewhere else on the gender spectrum,” says Dr. Sevlever. “For example, people who identify as gender nonconforming or gender nonbinary also have a gender identity that’s distinct or different from the sex they were assigned at birth.”

“When I was coming out, there was a very narrow narrative: If you didn’t feel like you were trapped in the wrong body from the day you were born, you weren’t really transgender,” says Brandon Elgün, an HIV prevention coordinator at NewYork-Presbyterian’s Center for Special Studies who is transgender. That limited understanding of the difference between sexual orientation and gender identity means Elgün came out twice: first as a lesbian and then transgender. “Now we’ve moved beyond that.”

How Does Someone Affirm Their Gender Identity?

Gender identity means different things for different people, and a person may make the choice to affirm their gender identity early or late in life. Some may choose to socially affirm their gender by using new pronouns, while those who want their bodies to align with their gender identity may undergo a process called transitioning. This involves taking hormones and sometimes undergoing surgery to change their sex characteristics.

“I don’t think there’s one way in which a person discovers a sense of incongruence with respect to how they see themselves and their physical body,” says Dr. Sevlever. “Some people develop that awareness at a really young age, for some people the awareness doesn’t start until around puberty, and then for some the awareness doesn’t develop until later in adolescence or adulthood. In my work, I’ve seen all of those different kinds of journeys.”

Elgün echoes Dr. Sevlever’s observation. For him, the ah-ha moment came when he saw Boys Don’t Cry, the 1999 Oscar-winning film that portrayed the real-life story of a transgender person, Brandon Teena.

“I was watching it with my mother,” he recalls. “At the end, we both looked at each other and started crying — no words were exchanged, but we just knew that now there was this word that explained so much: transgender.” His name, Brandon, was inspired in part by the movie.

When Elgün talks to other transgender people who are trying to navigate their own gender identity, he tells them there is no one way or right way to be trans.

“Hormones aren’t for everyone and surgery isn’t for everyone,” he says. “You don’t have to have felt trans since the day you were born.”

Behind the Numbers

The U.S. Census records one’s sex assigned at birth but does not track current gender identity, or whether one’s current sex differs from that given when they were born. That means the size of the transgender population in the U.S. is not officially known.

In 2017, however, the American Journal of Public Health published a study that aggregated data from national surveys to estimate the number of transgender people in the country. It found that transgender adults number 1 in 250, or almost 1 million Americans. The study noted that they are more likely to be younger adults. Additionally, a study that same year by the University of Minnesota found that about three percent of state high school students identify as transgender or gender nonconforming, a higher percentage than any previous study has found.

Despite these numbers, society in many ways is still struggling to be inclusive of this population. And transgender people continue to feel stigmatized.

Elgün can cite several examples of discrimination — and humiliation — he endured as a transgender person in high school, including one in which his gym teacher referred to him as “it” in class.

“But now, a lot has changed,” Elgün, 34, says of the progress in recent years. “My gym-class experience would be completely lawsuit-worthy, but at the time [such a lawsuit] just wasn’t a thing.”

Such discrimination results in high rates of anxiety and depression among this population. In fact, Dr. Sevlever says, according to a study from the Williams Institute at the UCLA School of Law, 40 percent will attempt suicide at some point in their lives.

“People, and this includes adolescents, who are transgender experience higher rates of bullying, higher rates of rejection, and higher rates of discrimination or harassment,” she says. “And with all of that we have higher rates of anxiety, depression, or suicidality.”

Portrait of Dr. Melina Sevlever

Dr. Melina Sevlever

Care and Support for Transgender Patients

There are primary care providers and individual surgeons within NewYork-Presbyterian who have experience helping patients with hormones or offering surgical interventions to affirm their gender, and there are psychotherapy and support services available. In addition, Columbia University Irving Medical Center, through the Gender Identity Program, is in the early stages of creating a comprehensive program focused on working with transgender patients who wish to explore their gender identity and gender expression.

“Part of our mission is to establish a multidisciplinary team that can serve to provide people who are trans with all aspects of the care they need,” says Dr. Sevlever of the Gender Identity Program. She and her colleagues would like to create a single point of entry for patients seeking everything from mental health care to surgery, and they are building relationships with clinicians throughout NewYork-Presbyterian so both patients and their families have easier access to coordinated care.

“Parents and family members who want to support their child or relative may not always know the best way to do that,” says Dr. Sevlever. “It’s incredibly important to provide treatment and support options for not only patients but also family members of those who identify as transgender.”

Elgün agrees with the importance of having multidisciplinary teams work with transgender patients.

“Navigating legal systems and insurance systems to support gender affirmation from name changes to surgical intervention is difficult,” he says, citing his own pursuit of surgery and his invaluable case manager, who helped him traverse all kinds of complexities. “Then there is also the need to address mental health, substance use, and other psychosocial issues that disproportionately affect trans people because of stigma.”

Causes of Transgenderism

You’ve likely heard stories of kids, or know one personally, who from a very early age felt that they were not the gender they had been assigned at birth. It is not known for certain, however, what exactly causes a young person to feel this way.

“There is some evidence from genetic studies and brain imaging studies that it’s something biological, but it’s certainly not something that we have a conclusive understanding of where it comes from,” explains Dr. Sevlever. “While research has increased in the last decade, it’s still a growing area for the medical community.”

While the question remains of what may cause gender dysphoria, which the American Psychiatric Association defines as the conflict between a person’s physical or assigned gender and the gender with which he/she/they identify, Dr. Sevlever says the current trend in research is to get a better understanding of the impact of increased access to individualized treatment.

“Given the political situation that we’re currently in, there’s the reality that access to care may again be threatened,” she says.

“Research can be really influential by documenting the psychological improvements and health benefits that we know can happen when people obtain access to affirming medical care and affirming psychotherapy. The emphasis right now is to develop those studies so we can document the importance of high-quality care.”

For more information on the Columbia Gender Identity Program, click here.