One of the most misunderstood, even feared, aspects of our changing U.S. culture is its increasing gender diversity. For the wellness of all of us, HealthySteps to Wellness hopes to demystify our changing gender landscape and come to a better understanding of every person’s search for identity.

The local context:
Gender and sexual orientation diversity at Stanford

In the 2015 Stanford Campus Climate Survey, 1.5% of students who responded (140 of 9,067) identified themselves as, instead of a woman or a man, one of the listed gender-diverse types (female to male transgender or trans man, male to female transgender or trans woman, genderqueer/gender-nonconforming, “I prefer another term,” and/or selected multiple identities). When asked, additionally, about their sexual orientation, 12% identified as LGBQQA (lesbian, gay, bisexual, queer, questioning, asexual) or something else, versus 88% who identified as straight/heterosexual. In the May 2016 supplement, these same two percentages of those identifying as gender-diverse and/or non-heterosexual were trending higher.

Understanding the science

We’ve all heard that Bruce Jenner is now Caitlyn Jenner. And most know that North Carolina legislators passed a bill, only recently repealed, which banned transgender people from using bathrooms designated for a sex they were not assigned at birth. But to truly understand and accept gender diversity, and the journey a significant number of individuals go on in search of their true gender identity, it is important to first grasp the essential scientific facts concerning gender and sex, and then to delve into the psychology and social ramifications of gender identity.

Sex: Not just black and white

In general terms, “sex” refers to the biological differences between males and females, such as the genitalia and genetic differences. For instance, male and female genitalia, both internal and external, are different; similarly, the levels and types of hormones present in male and female bodies are different. Genetics defines the sex of an individual: women have 46 chromosomes including two Xs and men have 46 including an X and a Y.

Although the male/female split is often seen as binary, this is not scientifically accurate. For instance, some men are born with two or three X chromosomes, just as some women are born with a Y chromosome. In some cases, a child is born with a mix between female and male genitalia; they are sometimes termed intersex, and the parents may decide which gender to assign to the child. While it’s been thought that intersex individuals account for around 1 in 1,500 births, other sources believe the percentage is probably higher: says Inge Hansen, PsyD, Director, Weiland Health Initiative, and Asst. Director of Outreach at Counseling & Psychological Services (CAPS), “intersex individuals are closer to 1% of the population when one accounts for all variations of intersex identity, which is about as common as red hair.”

Thus, although sex is often considered a black and white state of affairs, there is, in fact, a significant amount of middle ground. While this may at first seem confusing, understand that many in the scientific community would say that sex should be considered a continuum as opposed to two mutually exclusive categories. As stated by Gender Spectrum, a featured resource on the website of the Stanford Children’s Health Gender Clinic, “a sex binary fails to capture even the biological aspect of gender.”

Gender: A spectrum

If you now grasp that sex, even based purely on biology, cannot always be seen only as binary, one’s gender is made up of an even more expansive, multi-faceted set of characteristics, because gender factors in social and cultural aspects of how people are perceived, treated, or told to behave.

What is gender? Interestingly, definitions vary, and seem to be evolving. The more “traditional” definition of gender is akin to how the American Psychological Association defines it: “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.” This definition, noticeably, leaves out biology.

However, increasingly, medical professionals and scientists are defining gender in a subtly different way, which incorporates biology. Gender Spectrum states that “A person’s gender is the complex interrelationship between three dimensions: Body, Identity, and Expression.” Similarly, in National Geographic’s article, How Science Helps Us Understand Gender Identity, gender is defined as “an amalgamation of several elements: chromosomes (those X’s and Y’s), anatomy (internal sex organs and external genitals), hormones (relative levels of testosterone and estrogen), psychology (self-defined gender identity), and culture (socially defined gender behaviors).”

Gender identity: Your inner true self

At birth, we tend to use the terms sex and gender interchangeably because a newborn’s sex is “assigned” as either male or female, based on their genitals. Once a sex is assigned, we presume the child’s gender. However, while gender may begin with the assignment of sex, it doesn’t end there. First, the aforementioned societal and cultural factors exert a huge and complex influence. But also, it is increasingly becoming understood that biology continues to be a factor in how one’s gender may develop into and beyond childhood. The science is still “young” in this area, but research in neurology, endocrinology, and cellular biology points to a broader biological basis for an individual’s experience of gender. For example, early (and very preliminary) brain imaging research suggests that our brains may play a key role in how we each experience our gender.

So what exactly is gender identity? Here, again, a few different definitions now circulate. Gender Spectrum states: “Gender identity is our internal experience and naming of our gender.” A Cisgender person has a gender identity consistent with the sex they were assigned at birth. For example, a child whose sex was assigned male on their birth certificate and who identifies as a boy is cisgender (you may hear this term shortened to “cis”). But gender is a spectrum, and not limited to just two possibilities. A Transgender person has a gender identity that does not match the sex they were assigned at birth. So, a child who was assigned male on their birth certificate and who identifies as a girl is transgender (sometimes this term is shortened to “trans”). A child may have a Non-binary gender identity, meaning they do not identify strictly as a boy or a girl; they could identify as both, or neither, or as another gender entirely. Agender people do not identify with any gender, or they do not identify with the concept of gender at all.

Gender expression: Not always aligned with gender identity

What may seem most confusing at first is the notion that how you “express” your gender may not even match your gender identity. Gender expression is a part of gender identity, yet some medical professionals caution that it is often “distinct” from identity. As Gender Spectrum explains, “expectations around gender expression are so rigid [that] we frequently assume that what someone wears, or how they move, talk, or express themselves, tells us something about their gender identity. But…we can’t assume a person’s gender identity based on their gender expression. For example, a cisgender boy may like to wear skirts or dresses. His choice in clothing doesn’t change his gender identity; it simply means that he prefers (at least some of the time) to wear clothing that society typically associates with girls.”

Sexual orientation: Distinct from gender

One final distinction to make is the difference between gender and sexual orientation, which are often incorrectly thought to be the same thing. Gender is personal (how we see ourselves), while sexual orientation is interpersonal (who we are physically, emotionally and/or romantically attracted to). Most organizations, such as GLAAD, view sexual orientation as distinctly separate from gender identity, and yet many media sources (notably, the widely read cover story from Time, Beyond He and She) call gender identity a combination of “how one sees themselves as a man or woman … and who they are drawn to physically and romantically.”

Putting it all together:
The gender identity and sexual orientation melting pot

The types of gender identities in our population at its current time are undoubtedly much broader and more diverse than most people realize, although the younger generation seems to be more aware of it. Quoting a GLAAD survey, conducted by Harris Poll, Time reported that an amazingly high 20% of millennials say they are something other than strictly straight and cisgender, compared to 7% of boomers: “Several said they use the pronoun they rather than he or she to refer to themselves. This variety of identities is something that people are seeing reflected in the culture at large. Facebook, with its 1 billion users, has about 60 options for users’ gender. Dating app Tinder has about 40.” Just as significantly, millennials (defined as people age 18-34) who identify as cisgender and straight display far greater acceptance of those who are gender-diverse than do older generations: in the large Jan. 2015 Fusion Survey of Millennials, a whopping 50% of all respondents said they believe that “gender is a spectrum.”

The medical/scientific establishment, increasingly, is agreeing with millennials — that gender is a spectrum, and quite a wide one. When asked about the increase in Stanford’s gender-diverse population, Inge Hansen, PsyD, states: “This number is growing and I believe it will continue to grow — not because there are actually more gender-diverse people all of a sudden, but rather because greater trans visibility and greater trans acceptance allows more people to acknowledge their true gender identity as well as express their gender more authentically. Globally, there are reports of 200+% increases in utilization of gender clinics and similar resources for transition.”

Medical staff at Stanford Children’s Health Gender Clinic, which opened in the summer of 2016 and is one of only about 30 such clinics in the nation, generally concur that an increasing number of children are coming into the clinic questioning what gender they are and how they should proceed to identify their true gender and embrace it fully. As noted by Tandy Aye, MD, an associate professor of pediatric endocrinology and a transgender specialist at the Stanford Gender Clinic, “In the Bay Area, we’ve had an increased need from children who are gender non-conforming.”

Gender expansion is real

Some people may question what’s driving this rise in the number of “gender non-conforming” claimants. How do children, teens, even young adults really “know” that their true identity is different than the sex they were assigned at birth? How do medical professionals, much less parents, or even the child, know if the identity conviction is “true” or just a “passing phase”? Inge Hansen, PsyD, offers up this explanation: “Many young children experiment with gender, but only a few become transgender adolescents or adults. In the words of the gender expert Diane Ehrensaft, the distinction is those kids whose gender-expansive presentation is ‘insistent, persistent, and consistent.’ When assessing adolescents and adults for a letter of support, which is required for hormonal or surgical transition, clinicians often take a gender history to determine that the motivation is in fact gender-based and that the individual fully understands the procedure they are about to undergo. This is in line with guidelines set by the World Professional Association for Transgender Health (WPATH).”

Tandy Aye, MD, at Stanford’s Gender Clinic, similarly states that “we ask the child and the family to talk with a therapist and help the child identify and know what it means to transition.” Amy Valentine, a clinical social worker at the same clinic, adds that clinicians can assess “… kids that feel like they’re born into the wrong body and … from a very young age really persist with that through the years.”

It should be noted that not all trans people seek gender-affirming surgeries or even “transition” per say, but rather increasingly align their gender expression with their gender identity.

The search for identity and gender dysphoria

Mental health professionals would point out that thousands of us will, at one point or more in our lives, struggle to “find our identity”: indeed, this search for identity is at the crux of many a couch session between a therapist and a patient seeking psychological counseling for a host of mental issues, including depression and anxiety. But when the identity struggle includes the search for a different gender identity, the struggle takes on a different level of complication.

Studies show that transgender and gender non-conforming individuals suffer significantly higher rates of depression, anxiety, harmful behaviors and suicide as compared to cisgenders. Lawmakers defending legislation banning transgender people from using bathrooms that do not match the sex on their birth certificates, and other people who generally feel somehow justified in discriminating against transgenders (whether for employment, housing, or in other situations), often point to these mental health “realities” as support for their theories that “people aren’t meant to transition” or embrace different gender types. They will also point to the fact that “gender dysphoria” is actually a medical diagnosis.

Indeed, the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) does list “gender dysphoria” — when a person experiences “intense, persistent gender incongruence” — as a diagnosis. But, as Inge Hansen, PsyD, points out, “’Gender dysphoria’ is significant as a diagnosis because it no longer contains the word ‘disorder.’ Trans identities are not a disorder, but rather an incongruence between the sex one was assigned at birth and one’s current gender identity. A primary reason to still have a diagnostic category in the DSM-5 is that it allows for insurance coverage for individuals seeking support around their transition process, including letters of support required for medical transition.” She goes on to explain that, “There is no psychological issue inherent to transgender or non-binary identities; however, many individuals struggle with depression, anxiety, suicidality and other emotional challenges due to rejection from their families and community. There is a direct positive correlation between family support and positive psychological outcomes for transgender and non-binary individuals.”

Preliminary research does suggest that transgender kids with supportive parents and a caring community will grow up with much better mental health. A team led by Kristina Olson, PhD, associate professor of psychology at the University of Washington in Seattle, reported in Pediatrics (2016) and Journal of the American Academy of Child & Adolescent Psychiatry (2017) that well-supported transgender kids had similar feelings of self-worth and rates of depression to age-matched control kids, and only slightly higher rates of anxiety. The data suggest that psychological distress is not an inevitable aspect of being transgender.

Societal Challenges

However, beyond a childhood that hopefully includes supportive parents and a progressive, caring school or group of friends, societal (and, in turn, mental) challenges remain for gender non-conforming individuals. As Inge Hansen, PsyD, points out, “transgender and non-binary individuals face legal discrimination, such as bathroom bills, and they experience much higher rates of sexual assault, violence, and murder than their cisgender peers.” These individuals often also have to deal with “family and peer rejection, employment discrimination, and lack of access to appropriate medical care. They deal with the invalidation of their identity and being in the everyday workings of their lives.” The 2015 U.S. Transgender Survey is considered the largest U.S. study documenting discrimination and oppression faced by transgender and nonbinary people.

Even in some medical arenas, gender non-conforming individuals feel harassed and discriminated against. Stanford Medicine, in a 2013 SCOPE article (Study finds ER avoidance in transgender individuals needing care), reported that transgender and non-conforming people have high levels of postponed medical care “owing to experiences including refusal of care, harassment and violence in medical settings, and lack of provider knowledge.” A 2011 committee opinion from the American Colleges of Obstetricians and Gynecologists called the consequences of inadequate treatment among this population “staggering.”

How can the search for gender identity be made “easier”?

It is clearly incumbent upon society at large, and individuals one by one, to create a more supportive, encouraging, inclusive community for gender non-conforming individuals. States Hansen, “As a person transitions socially, medically or otherwise, their community and loved ones will need to adjust to their new gender identity and expression, which may include a new appearance, name, pronouns, and so on. It can be helpful in this situation to do some reading on transgender and non-binary identities or to find a supportive community of others who are in a similar situation.”

Here are just a few of the steps we can all take to progress toward better understanding and support of gender non-conforming individuals:

• Develop your own gender literacy:
  Glossary of Transgender Terms (Stanford Vaden Health Center):
  Redefining Gender: The Glossary (National Geographic)
• Share your own pronouns and ask people for theirs (it’s easy to put your pronouns in your email signature).
  Use people’s correct name and pronouns.
• In the workplace, attend workshops on topics of diversity.
• Initiate a gender inclusivity policy at your work or school, or help to increase transgender inclusivity and belonging in areas where you have influence. Learn more.
• Create a safe space for everyone to use the bathroom by ensuring that All Gender Restrooms are available, or advocating for them if not. Learn more.
• Lobby your medical providers to provide a safe haven for patients and families who are working through gender-identity issues. Gender Spectrum calls this “gender affirmative care”: Learn more.
• Lobby the schools your children attend to ensure they are providing gender inclusivity and safe environments for non-conforming students. The right for every student to attend school in a safe and supportive setting regardless of gender is supported by a vast number of legal protections at the federal, state and local level. Learn more.

Lane McKenna
November 2017

This report would not have been possible without the assistance of Inge Hansen, PsyD, Tandy Aye, MD, the Gender Clinic at Stanford Children’s Health, Weiland Health Initiative, Vaden Health Center and the following publications:

Transgender: Caring for kids making the transition (Stanford Medicine, Erin Digitale, Spring 2017)
A journey of identity: Stanford Children’s gender clinic helps families navigate (Stanford Medicine, Erin Digitale, May 2017)
Stanford Health Opens Clinic for Transgender Children (NBC Bay Area, Ryann Vargas, Oct. 2016)
How Science Is Helping Us Understand Gender (National Geographic, Robin Marantz Heni, April 2016)
Beyond He and She (Time, May 2017)
Born this way? Researchers explore the science of gender identity (Reuters, Daniel Trotta, August 2017)
Intersex Society of North America
Gender Spectrum
2015 U.S. Transgender Survey
Jan. 2015 Fusion Survey of Millennials