Answers To Your Sex, Language And Transgender Medical Questions

We wrap up our series on living transgender with your questions from our Friday live chat:

Why are so many young people comfortable with the idea of "genderqueer"?
How's sex after sex reassignment surgery?
Which sports team do transgender students play on?

Answers from you and the panelists follow.

Dr. Cecile Unger, OB/GYN who trained at Brigham and Women's and Massachusetss General Hospital and is currently a fellow at the Cleveland Clinic where she is training in Female Pelvic Medicine & Reconstructive Surgery and developing a subspecialty in transgender women's surgery and health.

Bianca, transgender advocate. A former patient at Boston Children’s Hospital, Bianca transitioned from male to female when she was 14. She was the first person in the country to have Medicaid pay for her surgery. Now 26, Bianca is applying to law school.

Jennifer Levi, runs the Transgender Rights Project at GLAD and specializes in transgender legal issues.

Question from Margaret: Is there an age cutoff for surgery? That is, can someone be "too old" for gender-changing surgery? I have a good friend, born male, who has been transitioning to female for about two years now. She's in her mid-50s and has been taking hormones most of that time.

Response from Cecile Unger: Margaret, as someone who sees these patients, I can say that there is absolutely no age of patients discover their identity later in life while some patients choose to wait. Many individuals undergo surgery in late adulthood.

Comment From Kelly: [I ] would love to hear you discuss the concept of "genderqueer" and the generational divide.

I have noticed that many younger people are very comfortable with the notion of being genderqueer and getting away from binary definitions of gender, while older trans people I know have been more focused on passing as the gender they identify with--perhaps for safety and economic reasons--but it seems also because the concept of being able to live without a binary definition of gender was less common 30 or even 20 years ago.
Response from Bianc: Though I am not an expert within this field, I would purport: individuals’ whom express gender plasticity—gender neutrality—are captured within the transgender umbrella. I would assert that those individuals do not reflect that of the traditional transgender person. I abhor the notion of wanting to be male—or floating in a suspended animation between the two genders. I’m a woman; everything about says that. Youth today have the flexibility and choice for gender neutrality; I personally live a life of integration.

Comment from Diane: My transgendered child will not be allowed to play on the sports team of her affirmed gender once she gets to high school. The state athletic governing body has a transgender policy that is more suited to an Olympic athlete.
Response from Jennifer Levi: I am not sure what state you are in. But guidance issued by the Mass Department of Elementary and Secondary Education says transgender youth should be allowed to participate in sports based on their gender identity. The state school non-discrimination law should ensure your child can participate in sports in high school without having to have surgery.
Diane: We live in New Hampshire.
Levi: New Hampshire has a sports policy that no transgender high school student can realistically meet. This is something my organization is trying to work on. Please contact Gay & Lesbian Advocates & Defenders GLAD Answers at 1-800-455-GLAD. WE can try to help.

Question from Guest: My eldest is transgender, born female. There were never any signs growing up that (she) should have been a boy. I just can’t get the pronoun change right. It’s the only thing I can’t do yet. I guess once the transition has been complete, if that is what (she) wants, then it might be easier. But for now she’s still my daughter and not my son. I can’t get past this. Can you give me some advice on how to begin this? Deep in my heart, I do want this to be a phase that (she) grows out of.
Unger responds: This is not an uncommon dilemma so many families and friends of transgender individuals have. It is a complete life-changer to find out that your son or daughter no longer wishes to be their biologic sex. The truth to this though is that it’s not actually a wish… in fact, they probably wish they could identify with their body and be content living that way. Gender dysphoria is debilitating, and it is only first alleviated by having the people closest to that person recognize that he or she is transgender, acknowledge that this is ok, and then make the necessary changes to help them transition successfully, which includes using the correct pronouns. I am not saying this is easy…by any means.

Bianca responds: If you son (daughter) is actively engaging in cross-sex attributions, asking to be called 'he" and "male"; is willing to face the world with this burden 9being transgender), than I would purport this is not something he will grow out of. My advice: listen to what your son is saying, look at the changes he is making--he is serious! Support and acknowledge his decisions. If they change, change with him.

Response from Jen: As a Boston-area clinical social worker who works with families with gender non-conforming children, I can say that it is normal to struggle with a family member's transition. One can experience feelings of grief over the loss of the girl or boy they thought they knew. I really encourage you to reach out to a supportive professional or the PFLAG (Parents and Friends of Lesbians and Gays) for support.

Question from Richard D.: What's the difference between a person’s sex and gender?
Bianca responds: Sex is the person whom you're attracted too. Gender is based upon how you perceive yourself.
Unger responds: A person's sex refers to their genetic identity - the chromosomes they were born with which usually dictates (if development happens normally) their biologic sex and the genitalia they are born with. Gender usually refers socially constructed roles such as what it means to be a "girl" or a "boy".

Question from Guest: Is being transgender a phase?
Levi responds: No. The scientific evidence that exists shows that being transgender or having a cross gender identity is not a phase. Gender identity – for everyone, not just transgender people, is set at a very young age and does not change and is unaffected by external influences. So, a person’s gender identity does not change and is not changeable. What changes is the extent to which the person is loved and supported for who he or she is and, therefore, able to authentically express his or her true self.
Bianca responds: Most individuals (around 80%) that express gender variance, end up not being truly transgender—they’re in a flux that eventually resolves itself. The remaining 20% stay within said flux, seeking resolve from the cognitive disharmony that grips every fiber of their being. I would assert, most Trans people feel profoundly stricken with the notion that they are trapped—trapped within the confines of a body which inaccurately reflects their internal vision of themself. These individuals will stop at nothing to become that which they see within (Stats from Dr. Norman Spack)

Question from Laura: I am a stealth trans woman who transitioned 20 years ago. I am curious to hear from Bianca on how it is to be open about being trans publicly. I find it somewhat scary to be open about it, or the prospect of being outed; it is hard to even open up to my friends about it. Are things getting better? What is your experience? I consider myself private about it and I worry about things like online privacy.
Bianca responds: Laura, I too find it extraordinarily difficult to come out. Because I started my transition early, I was/am afforded the capacity to pass unnoticed. That said,I still must "out" myself to those whom are within my inner circle. My advice to you: You are a woman; that’s enough. If you deem it necessary to come out, do it. Otherwise, live an integrated life, free from fear.

Comment from Daniel M.: How helpful is the term "gender," as it seems to raise more questions than answers?
Unger responds: The term gender is a confusing one. It refers to social norms - constructs that have been created over time to define what it means to be a boy or a girl. It is an identity. The mistake that is often made is not believing that a spectrum exists for gender - it is not necessarily a constant or concrete in its definition. Additionally, biologic sex does not define gender. So I agree with you, it is not a useful term and confuses a lot of people.

Question from Guest: What happens to a criminal record if a person changes their gender and or name?
Levi responds: The criminal record is maintained based on the name and gender at the time the record was made.

Comment From Unilantern: More younger people are going for genderqueer and none binary identities. But the current system of gender makes it hard for them to live full lives. Laws tend to protect gender identity in the form of a two gender system. Laws tend not to protect gender expression outside the binary.
Levi responds: Actually, the state non-discrimination laws that protect transgender people have been written to include ranges of gender expression and not just the binary. However, it will take time and precedent before the full scope of the law is realized. The guidance from the MA Department of Secondary and Elementary Education does include a statement that teachers should not have policies that exacerbate stereotypes. E.g. schools should NOT require girls to wear pink gowns and boys to wear blue at graduation. No separate lines for boys and girls. Times are changing, but slowly.

Question from a reader: Should we be trying to help transgender people feel more comfortable in the body they were born into rather than helping them make sure a dramatic change?

Levi responds: Whether we help someone feel comfortable in their own body or provide medical assistance to help them transition turns on the individual needs of each person. For some, there is no other way to support their identity than to provide necessary medical treatments – including surgery or hormone therapy. For others, affirmation of their identity and permitting them to live consistent with their internal sense of who they are is sufficient. For others, cross gender hormones is the right level of treatment. There is no “one size fits all” treatment any more than there is for any other medical condition.

Unger responds: This is referring to cognitive-behavioral therapy, a commonly used type of therapy that a lot of mental health professionals use for certain psychiatric and mental health disorders, including depression and anxiety. If a person changes the way they think about certain things, their behavior will eventually fall in line with their new beliefs. In the case of gender dysphoria, we know this type of therapy doesn’t help. These individuals feel a true disconnect between who they are and their bodies, and no therapy can eventually make them comfortable with this. We know that treatment exists on a spectrum for these patients – it includes psychotherapy to make them comfortable with being transgender and to provide support through any transition processes, as well as hormonal and surgical therapy.

Question from a listener: How can doctors be sure that teenagers or adults are ready for surgery?
Unger responds: These patients are (and should be) seen by a multidisciplinary team. What I mean by that is a team of mental health professionals, endocrinologists who manage hormonal therapies, and surgeons who perform reassignment surgeries. For surgery, at least one, if not two, recommendations are necessary from mental health professionals, confirming that surgery is appropriate for a patient.

Questions from a reader: Aren't there harmful side effects when you pump a lot of extra estrogen or testosterone into your body?
Unger responds: There are side effects, yes. Which is why a lot of thought goes into which patients are the right candidates for this type of therapy. Most doses are physiologic, however, and are the same as what a biologic man or woman have. For instance, a transgender woman on estrogen therapy should have the same levels measured in her bloodstream as a biologic woman who is not undergoing hormonal therapy for gender transition. Sometimes, the levels are a little higher with therapy, but these are monitored closely. The most important thing is that these patients are monitored closely. When therapy is first initiated, their physician usually checks their levels and other metabolic indices about every 3 months for the first year and then once or twice per year every year the patients are on hormones. In addition, physicians seeing these patients for routine health care should be aware that most of these hormone regimens have a risk of causing metabolic alterations that can lead to diabetes, high cholesterol and liver dysfunction, and therefore, patients should be checked more often than the general population. This speaks to the importance of ensuring patients are not using off-label hormonal therapy, which is a problem is some patient populations. These patients certainly are a high risk of side effects.

Comment from Betty Schwartz: Cross gender hormones are only safe under medical supervision and then any drug can have side effects.

Bianca responds: With any medication, side effects are possible. Because extended-use of hormone therapy is still relatively new, It is unknown what the long-term effects of therapies are. I was certainly initially informed about the potential for increased risk of cancer.

Comment from Pam Popovich: How do the sexual fetishes of transvestism/crossdresser and autogynephilia relate to the concept of transgender? In both cross dressing and autogynephiliamen are sexually aroused by dressing in women's clothing and being seen "as women" in public. How is this different from transgender?

Unger responds: I think the important thing to note is that being transgender refers to one's identity and sense of self. Transvestism is a behavior that some people pursue and enjoy but is not related to who a person is. The terms are often mixed up and muddled.

Comment from Betty Schwartz: That can only be determined in counseling. On the surface it can all look the same. I think part of it is that cross gender behavior tends to be a taboo and because it is, it becomes fetishized. We don't think of Scottish soldiers in Kilts as cross gender cause society has determined it's not feminine.

Question from a listener: Do people still use the term "transsexual?"
Levi responds: The term is certainly used though there are differences in opinion about whether it is an outdated term given the range of ways in which people transition. It is not a legal term of art. Language is evolving as social understandings evolve.

Unger responds: Physicians still use this term. It is used to refer to patients who have fully transitioned (genital surgery completed). A transsexual is a transgender individual who has undergone reassignment surgery.

Bianca responds: Within the scope of the community in which I live, transsexual is used interchangeably with transgender(ism). states transsexual as:"..A medical term applied to individuals who seek hormonal (and often, but not always) surgical treatment to modify their bodies so they may live full time as members of the sex category opposite to their birth-assigned sex (including legal status). Some individuals who have completed their medical transition prefer not to use this term as a self-referent. Avoid using this term as a noun: a person is not "a transsexual"; they may be a transsexual person."

Comment from Jane: I find that one of the biggest challenges for me as a sexuality educator is to help youth and adults understand that "everyone is a story." I try to share stories from transgender folks, information and resources. Because language and identity around gender is fluid, it is hard to be correct all the time. What advice do any of you have for cisgender people like me to do the best we can as educators if our goal is to promote caring, justice and inclusivity?
Levi responds: Dylan Scholinski wrote a wonderful book called, The Last Time I Wore a Dress. In it, he asks readers to engage a thought experiment about having to wear the wrong clothing or being referred to as the wrong gender, not as a lark or as a joke, but for real and for a long time. He suggests, and I agree, that the experience would be disabling and distressing for anyone. I think seriously engaging the thought experiment can be helpful in getting people to understand many transgender peoples' experience.

Bianca responds: Most teens interface with the notion of sexuality—specifically sexual identity. At 11, coming out as gay was the first appropriate step in my transition. Throughout my early transition, I knew I was different; being gay seemed unpalatable and not satisfactory something did not feel quite right. As a young child I sought emotional comfort when entering my mother’s wardrobe, slipping on her white pumps and carefully removing her dresses from the wooden hanger, sliding it gently over my small frame and relishing in the feeling of wholeness—a fleeting sense. For when I was in her closet, I was cloaked in the purest feeling of contentedness: I felt whole, complete—my anxieties subsided for those brief moments. In order to understand / support trans person's, you must take the time and listen to their stories. Use their stories as a platform from which to support and honor their decision. The utilization of appropriate pronouns is integral to making one feel supported and accepted. I remember the day when my mother finally stopped using male pronouns. From that point on, I felt completely and utterly supported.

Comment From Mason Dunn (Massachusetts Transgender Political Coalition): Jane, I think you're approaching this topic and education from a fantastic place. One thing that I think is helpful and important in teaching about transgender lives, is having transgender people tell their stories. We have some videos that speak to challenges and triumphs of transgender people in Massachusetts (and beyond):

Question from a reader: Will we eventually get rid of the term "transgender" and just refer to people once they have transitioned as either "male" or "female"?
Unger responds: From a medical standpoint it is useful to have that terminology because transgender individuals have some different health care needs than non-transgender patients due to their hormonal therapies, as well as their anatomical changes. But I agree with you that referring to someone as either male or female regardless of what their biologic sex is makes sense and should be the norm. When I speak to patients, I refer to them as either male or female and leave out the transgender.

Comment From Lynne: My niece is gender variant. Her parents are trying to find support for her. However, her profile is complicated. She was adopted and has a history of trauma due to early developmental deprivation and also has social pragmatic issues. Do you have any resources you can give for parents with adopted children with a history of trauma who also have gender variance? Also- has there been research on the topic of adoption/trauma/and gender variance?
Unger responds: There is literature that shows that many transgender patients have co-morbid psychiatric disorders such as depression, anxiety, PTSD - many patients of course, do not. For those that do - specialized mental health professionals must be able to identify these and determine if there is true gender dysphoria present before any patient can go through a transition. Adoption and trauma can certainly lead to a patient having co-morbid disorders in addition to gender dysphoria - but there are no studies that specifically address this.

Comment From Jenn Burleton (TransActive Gender Center): Lynne, you can certainly contact TransActive for support. We've worked with families of adopted children who are transgender. You can reach us via email at or by calling 503-252-3000

Comment from EJ: Speaking from a feminist perspective... I can't help wondering if supporting the idea that discomfort with one's sex and gender presentation not "matching up" would be better solved by abolishing gender roles, not changing people's sex. People should be able to be whoever they are regardless of what their body looks like. Is transgender politics opposed to this?
Levi responds: These are really two different issues. Abolishing prescriptive gender roles that don't fit everyone's lives would be helpful for transgender and non-transgender people — men and women. However, for some transgender people, no amount of external affirmation can change the disabling effects of gender dysphoria. Only changing one's body can.

Question from Guest: Doesn't surgery — ie removing penis/uterus — make it impossible for a person to ever achieve sexual satisfaction?
Unger responds: Luckily, no. In male-to-female reassignment, the glans of the penis is maintained and serves as the clitoris, and maintains its blood and nerve supply and therefore can maintain the ability to orgasm. In female-to-male patients, the clitoris is often also maintained during the surgery.

Bianca responds: Great question: The basis of this question relies upon the qualifications and expertise of the plastic surgeon. Dr. Sherman Leis who is in practice in Philadelphia, is someone whom I would refer to as an expert in his field. The doctor takes a small section of the penis head, which is still attached to the nerve bundle. After the labia are created, he accordions the nerve bundle and sutures the new clitoris in place. Now some 3-years out from my surgery, I can fully attest to being completely functional--in every way.

Question from Lisa: Why are we encouraging body mutilation rather than encouraging people to be comfortable in their own bodies even if their personalities don't jive with gender stereotypes? What's wrong with being a "masculine" woman or a "feminine" man?
Levi responds: There is nothing wrong with being a masculine woman or a feminine man. However, for some transgender people, the only way to alleviate the serious and disabling effects of gender dysphoria, is to undergo surgery.

Unger responds: Any patient who experiences gender dysphoria undergoes an extremely debilitating process when it comes to trying to reconcile their genitalia with how they actually feel as a person. Gender defines who we are. It is our identity, and if it does not feel right, nothing can change it other than transition - the degree of necessary transition depends on the individual.

Comment from Laura: Gender is not just masculinity and femininity. And as a trans person who went through gender role coercion growing up, I am totally in support of tearing down restrictive roles that only hurt people and keep them from being themselves, both trans and non-trans, this affects everyone. That wouldn't help however relieve dysphoria that pertains to one's sexed anatomy.

Comment From Mason Dunn (Massachusetts Transgender Political Coalition): I wanted to quickly weigh in about transgender access to health care, and the discrimination transgender people face here in Massachusetts. We know that transgender people face significant discrimination in health care: One survey indicates that 19% of transgender people who responded were refused medical care, simply because they were transgender. 28% report harassment while seeking medical care.
People within the transgender community deserve access to quality health care and medical treatment just like anyone else. Right now, we’re working on the Equal Access Bill, which will remedy the public accommodations piece of the non-discrimination laws, ensuring that places like hospitals cannot discriminate against people on the basis of the gender identity. For more information about the bill or about MTPC, you can visit

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Martha Bebinger Reporter
Martha Bebinger covers health care and other general assignments for WBUR.



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