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Glossary of Must-Know Gender Identity Terms

Arlin Cuncic, MA, is the author of The Anxiety Workbook and founder of the website About Social Anxiety. She has a Master's degree in clinical psychology.

Daniella Amato is a biomedical scientist and fact-checker with expertise in pharmaceuticals and clinical research.

Verywell / Alex Dos Diaz

A Through E

F through l, m through r, s through z.

Gender identity terms are words that are used to help convey meaning related to how people identify with particular genders regardless of their sex assignment at birth. While it may seem arbitrary to some people, the words that we use are extremely important as they can be used to either exclude or empower. Choosing words carefully when we speak can help to affirm someone’s identity and challenge discrimination against them.

On the other hand, choosing not to use the words someone prefers can be disempowering and demeaning. To help you recognize the words that are best in each situation and be an ally , it helps to familiarize yourself with common terms. Given that terms are also constantly changing, it can be helpful to ask someone how they self-identify to make sure that you are using the language that they prefer and that feels affirming to them.

You may feel awkward or uncomfortable asking someone their pronouns , for example, but rest assured that people are generally happy to educate to ensure they are identified correctly.

In addition, terms may not be standard across cultures, languages, and different groups of people. In particular, if you grew up as part of Gen X or an older generation, chances are that all of these terms feel somewhat new to you. While you may feel that you are at a disadvantage in terms of knowing what to say, there’s no need to worry that you are going to say the wrong thing if you are willing to learn.

While in the past people were accustomed to speaking in binary language (male vs. female gender matching assigned sex only), this terminology ignored people who experience a sense of gender that doesn’t fit into societal norms. This also reflected a limited understanding of gender that doesn’t account for the variations of identities that we know to exist today.

Below is a glossary of terms to help you familiarize yourself with the different words and meanings that you may encounter. Remember that these terms are constantly changing and it's important to stay up-to-date by asking people about their preferred terms.

AFAB: Acronym with the meaning “assigned female at birth.”

AMAB: Acronym with the meaning “assigned male at birth.”

Agender: Referring to a person who does not identify with any gender identities, most people who use agender don't feel that they have a gender at all.

Ally: Ally is a term to describe anyone who actively and fully supports the LGBTQIA+ community.

Androgynous: Referring to a person with a gender identity or presentation that is neutral or has both masculine and feminine parts. Synonyms include null-gender, androgyne, genderless, and neutrosis.

Assigned Sex at Birth: A medical assignment given at birth based on physical characteristics of the body. This can refer to male, female, or also intersex.

Bigender : Referring to a person who identifies with two different genders at the same time.

Body Dysphoria: Discomfort about the body that is related to gender identity and misalignment with physical characteristics such as anatomy, secondary sex characteristics, reproductive organs, etc.

Cisgender or Cisnormativity: A person whose gender identity or subconscious sex aligns with the sex that they were assigned at birth. For example, a person assigned the sex of a male at birth who identifies as male gender would be considered cisgender. Similarly, a person assigned the sex of female at birth and who identifies as female gender would be cisgender .

Most people are cisgender and so this is considered the “norm,” which can lead to systemic and unintentional prejudice against trans people in society. However, cisgender individuals can also be gender non-conforming . The Latin prefix “cis” means “on the same side.”

Cisgender Privilege : Referring to the experience of never having one’s natural sexual identity be questioned by society. This leads to the behavior of taking for granted that everyone has the same life experience and a lack of struggle with their gender identity.

Coming out: The ongoing process of disclosing one's gender identity to oneself and others (e.g., with friends, at work, with family).

Cross-Dresser: A person who wears clothing that is not typical for their gender. Usually, the term is used for men who prefer to dress in women’s clothing. This may be done for self-expression or other reasons. Synonyms include transvestite or drag queen. Being a cross-dresser does not automatically equal being transgender, some people may just do this to express themselves.

Deadname: Name assigned at birth that the individual does not identify with. Deadnames reflect the idea that the name is no longer how the person identifies, hence the word “dead.” Being deadnamed can cause trans people to experience dysphoria.

Demigender/Demiboy/Demigirl: The prefix “demi” indicates a person who has the experience of partially identifying with a particular gender and includes those who may be nonbinary. Other related terms include demienby and demitrans.

Family of choice: The circle of friends, partners, etc. that people who are LGBTQIA+ choose to associate with because they provide validation, support, and a feeling of belonging that they may be missing in their biological family.

Female-to-male (FTM): Referring to people who were assigned female at birth but who identify as male. This may or may not involve changing the body through medical procedures or surgeries.

Feminine-of-center: Referring to a person who identifies with a feminine gender expression regardless of whether they consider themself a woman or were assigned the sex of female at birth.

Feminine-presenting: Referring to a person with an outward gender expression that appears feminine. For example, this could be shown through style, mannerisms, body language, etc.

Femme: Referring to a person with a gender identity or expression that leans toward being feminine in general. A person who is femme does not necessarily identify as a woman and is not necessarily assigned the female sex at birth by a doctor.

Gender Affirmation Surgery: Surgery to affirm an individual’s gender identity that involves changing primary or secondary sex characteristics. This can be necessary to alleviate gender dysphoria.

Gender Apathetic: Referring to a person who does not care about their gender nor how they appear to others in terms of their gender. In other words, they do not identify with any particular gender.

Gender Binary: A binary division of gender into only two types (man or woman) which is expected to match the sex assigned at birth (male, female, or intersex). This system does not allow for people who identify with a gender that does not fit the binary system or people who feel their gender is fluid rather than fixed.

Gender Conforming: Referring to a person who follows the rules of society about how genders should act, behave, and appear to others.

Gender Dysphoria: A medical diagnosis and term to reflect the distress experienced by individuals who have a misalignment between their sex assigned at birth and the gender that they identify with internally. This means that a person doesn’t feel right about their body parts, physical characteristics, or societal interactions in terms of their internal experience of gender.

Gender Expansive: Referring to people who work to make culture more inclusive in terms of gender expression, gender roles, and gender norms in society.

Gender Expression: The way that a person publicly expresses their gender as masculine, feminine, androgynous, etc. For example, gender can be expressed through their clothing, hair and makeup, body language, chosen name, pronouns, mannerisms, interests, etc.

For trans people, they may also physically alter their body through medical interventions to match their internal gender identity such as hormone therapy or surgery. Also known as gender presentation.

Gender Bender: Referring to an attack on stereotypes about gender that questions norms and expectations in society. May also be referred to as a genderf***.

Genderfluid: Referring to a person who shifts between genders or who feels as though their gender changes over time either rapidly or gradually.

Gender Identity: A core sense of the self as being a woman, man, or neither. This does not always align with the sex assigned at birth and can develop and change over time. It also cannot be assumed based on outward physical characteristics.

Gender-Inclusive Pronouns: Pronouns that are neutral and can be used by both transgender and cisgender people. For example, the words they, them, and theirs when used to refer to a single person are gender-neutral pronouns.

Gender Minority: Referring to people who are transgender or gender non-conforming and are in the minority in relation to society as a whole in terms of the binary view of gender.

Gender Non-conforming (gender variant, genderqueer): People whose gender expression does not follow the gender norms or societal expectations for the sex they were given at birth or their perceived sex. This includes people who are androgynous , feminine men, masculine women, etc. This can include trans people but not all people who are gender non-conforming identify as trans. People of any gender can be gender nonconforming (e.g., cis, nonbinary, trans).

Gender Norms: The cultural and social norms assigned to women and men regarding clothing, appearance, roles, and behavior. For example, women are expected to behave more passively than men, while men are expected to be more dominant than women. People who do not fit gender norms may be singled out (e.g., an overly feminine man or a dominant woman).

Gender Queer: Referring to a person who does not align with the gender binary of man vs. woman.

Gender Questioning: Referring to a person who is questioning aspects of their gender such as their gender identity or gender expression.

Gender Roles: Societal norms about what it means to belong to a certain gender. These can change over time and refer to behaviors, interests, etc. They may also differ across cultures.

Gender Outlaw: A person who does not follow the rules of society as far as being defined in a binary way (male vs. female).

Graygender: Referring to a person who does not experience a strong pull toward any particular gender identity or expression.

Intergender: Referring to a person who does not experience one gender, but rather falls between male and female gender identities.

Internalized Transphobia: Feeling uncomfortable with oneself because of having transgender feelings or a gender identity that does not match one’s assigned sex at birth or the gender roles of society.

Intersex: A person born with characteristics that are not easily categorized as male or female (e.g., reproductive organs, chromosomes, hormones). For example, a man could be born with ovaries instead of testes or a woman could be born with XY chromosomes. Intersex occurs at a rate of about one in 1500 births but most people are assigned either male or female sex at birth regardless of being intersex. Intersex people may identify with their assigned sex, identify with the opposite sex, or identify as intersex. They do not usually identify as trans (transgender or transsexual).

LGBTTTIQ: An acronym representing lesbian, gay, bisexual, transsexual, transgender, two-spirit, intersex, and queer.

LGBT: An acronym representing lesbian, gay, bisexual, transgender.

LGBTQIA+: An acronym representing lesbian, gay, bisexual, transgender, queer/questioning, intersex, asexual/ally, etc.

LGBTQ+ : An acronym representing lesbian, gay, bisexual, transgender, queer/questioning, etc. This acronym is internationally recognized.

LGBTQ2: An acronym representing lesbian, gay, bisexual, transgender, queer/questioning, and two-spirit.

LGBTI: An acronym representing lesbian, gay, bisexual, transgender, and intersex.

“Lived” Gender Identity: The combination of an internal gender identity and how it is publicly expressed (gender expression) in daily life such as when shopping, at work, when in the community, etc.

Male-to-female (MTF): Referring to people who were assigned male at birth but who identify as female. This may or may not involve changing the body through medical procedures.

Masculine-of-Center: People who identify as masculine. These individuals may or may not identify as a man. Being masculine-of-center does not indicate a person’s assigned sex at birth.

Masculine-presenting: People with a gender expression that they consider to be masculine. This includes outward expression through such things as body language, mannerisms, physical characteristics, and style.  This term does not indicate anything about assigned sex at birth.

Maverique: A person who experiences their gender identity to be separate from current categories and descriptions.

Misgender: Calling someone by the wrong pronoun or using language that is not inclusive to their gender identity.

Multi-gender: People who identify with more than one gender. This includes people who identify as bigender, trigender, pangender, polygender, and in some cases, genderfluid.

Neutrois: People who have a gender that is neither male nor female. This includes nonbinary, genderless, genderfluid, and agender identities.

Nonbinary: Nonbinary (sometimes called enby or nb) is an umbrella term for anyone who falls outside the gender binary of male or female. Some people simply identify as non-binary and some identify as a specific type of nonbinary identity. Examples include genderqueer, genderfluid, agender, bigender, etc.

Novigender: A gender identity used to describe the experience of people who don’t feel that their gender can be described using existing categories due to its complexity.

Out or Out of the Closet: Being open about one’s gender identity with others.

Outing Someone: Outing someone means telling a person about someone else's gender identity or sexuality when they may not be out yet. Ex. My friend Stacy told her parents I'm trans when I didn't want them to know yet. Outing someone can be very harmful as they might not be in a safe environment to come out on their own.

Omnigender: A person who identifies with all gender identities.

Pangender: A gender identity that involves experiencing many different gender identities simultaneously.

Passing: The experience of “passing” for one’s gender identity. For example, a transgender individual may be accepted by strangers as being the gender that they identify with even when this is different from their assigned sex at birth. This typically involves cues originating from physical characteristics, behaviors, and mannerisms.

Polygender and Pangender: The experience of displaying different parts from multiple gender identities.

Queer: Previously used as a derogatory term for transgender and transsexual individuals, which has since been reclaimed by the community to display their identities with pride .

Questioning: People who are in the process of questioning their gender identity and wish to explore different options.

Sex: A classification system assigned at birth based on a person’s physical characteristics, reproductive systems, chromosomes, hormones, and secondary sex characteristics. Sex is generally classified at birth as male, female, or intersex based on the appearance of the external genitalia. If these are ambiguous, sex is assigned based on internal genitalia, hormones, and chromosomes. Sex is generally recorded on the birth certificate but can sometimes be changed on this document as well as on other legal documents such as a driver’s license.

Sex Assigned at Birth: The sex assigned to a person at birth based on the existing classification system.

Social Dysphoria: A type of gender dysphoria that arises from distress about how other people label, interact with or perceive an individual. It can also be a result of one’s own behavior that is at odds with their gender identity.

Third Gender: The term third gender comes from native and non-Western cultures. It refers to a gender category that does not divide simply into male or female.

Trans Man/Trans Woman: A trans man is someone who was assigned the sex of “female” at birth but who identifies as a man (also known as female-to-male or FTM). A trans woman is someone who was assigned the sex of “male” at birth but who identifies as a woman (also known as male-to-female or MTF).

Transfeminine: Having a feminine gender identity but being assigned a different sex at birth.

Transgender/Trans: Transgender is as an umbrella term for anyone who identifies as a gender other than the one they were assigned at birth. This includes trans men or women and non-binary identities such as genderfluid, genderqueer, and agender.

Transitioning: Activities engaged in by trans individuals to affirm their gender identity such as changing their name, clothing, pronouns, sex designation, etc. This can include medical treatments such as hormone therapy, sex reassignment surgery, etc. This process is different for every person and the time it takes and activities that are engaged in are not universal.

Transmasculine: Having a masculine gender identity but being assigned a different sex at birth.

Transpositive: This term refers to the opposite of transphobia. This type of attitude is validating and accepting of transsexual and transgender individuals and celebrates their rights.

Transsexual: A person whose gender identity is different from the sex that they were assigned at birth. Transsexual generally means the individual has had gender-affirming surgeries and has fully gone through with their transition.

Transphobia: Intolerance, fear, aversion, prejudice, harassment, discrimination, violence, or hatred aimed at trans individuals and trans communities based on stereotypes and misconceptions.

Trigender: The experience of having three gender identities at the same time.

Two-Spirit: Two-Spirit is an important term in many indigenous cultures. It has no set definition but is mainly used to describe a spiritual view of gender or sexuality. It can be used to describe sexual orientation, gender identity, or spiritual identity. It is a term specific to Indigenous cultures and using it as a non-indigenous person would be cultural appropriation.

A Word From Verywell

Remember that terms are constantly changing and that it is important to keep current and ask people what terms they prefer when you are unsure. Although it may feel confusing, using the terms that affirm a person’s gender identity is no different than letting someone know that you care enough to understand things from their perspective.

Those who are cisgender may experience a type of privilege in that they do not understand what it is like to live with a gender identity that is outside the norm. Rather than trying to understand things through your own set of life experiences and views, it’s important to acknowledge that you can’t possibly understand what it might be like to live as a transgender person or someone with a gender identity that goes against the norm.

In these cases, it is best to defer to someone else’s personal experience of what it is like to live their life and what would help them the most. If someone shares their preferred pronouns with you, keep them in mind the same way that you would if they had told you their first name.

Government of Canada. Gender and Sexual Diversity Glossary .

Persad I. Sexual Orientation and Gender Identity Glossary .

Ontario Human Rights Commission. Appendix B. Glossary for Understanding Gender Identity and Expression .

Government of Canada. LGBTQ2 Terminology. Glossary and Common Acronyms .

By Arlin Cuncic, MA Arlin Cuncic, MA, is the author of The Anxiety Workbook and founder of the website About Social Anxiety. She has a Master's degree in clinical psychology.

SEX ASSIGNED AT BIRTH

Jessica a. clarke*.

Transgender rights discussions often turn on the distinction between “gender identity” and “sex assigned at birth.” Gender identity is a person’s own internal sense of whether they are a man, a woman, or nonbinary. “Sex assigned at birth” means the male or female designation that doctors ascribe to infants based on genitalia and is marked on their birth records. Sex assigned at birth is intended to displace the concept of “biological sex.”

This Article provides an account of the origins of the terms “biological sex” and “sex assigned at birth” and assesses the potential of the shift to sex assigned at birth for transgender rights arguments. The debate is not one over mere nomenclature. This Article’s examination reveals that the term “biological sex” rose to prominence to lend a veneer of scientific support to projects denying the validity of transgender identities and that the unquestioned use of that concept continues to underwrite exclusion. By referring instead to sex assigned at birth, transgender rights advocates convey that “biological sex” is not simple, static, or binary and that gender identity also has biological aspects. Furthermore, the phrase “assigned at birth” invokes philosophical arguments against assigning particular social roles to individuals at birth. It taps into the moral intuition that a person’s genitalia and health data are private matters.

This Article argues that sex assigned at birth is an important concept that clarifies the stakes of disputes over transgender rights. But it cautions that this conceptual shift is not sufficient to secure victories in transgender rights litigation. Ultimately, definitional debates about sex and gender cannot resolve the moral and practical questions at the heart of contemporary controversies over transgender rights. Recent legal victories on transgender rights issues have done more than debate the meanings of sex and gender: They have addressed practical objections to transgender inclusion, cultivated empathy for plaintiffs, and staked claims in the registers of equality, autonomy, and dignity.

The full text of this Article can be found by clicking the PDF link to the left.

* Cornelius Vanderbilt Chair in Law, Vanderbilt University Law School. I am grateful to Anne Alstott, Lisa Bressman, June Carbone, David Cruz, Robin Dembroff, Bill Eskridge, Katie Eyer, Marie-Amélie George, Sasha Gombar, Katrina Karkazis, Ido Katri, Anna Lvovsky, Laura Portuondo, Austin Reagan, Vicki Schultz, Meredith Severtson, Naomi Schoenbaum, Maayan Sudai, Ezra Young, and workshop participants at Boston College Law School, Boston University School of Law, University of Kansas School of Law, Temple University Beasley School of Law, and Vanderbilt University Law School for their feedback on this project. Thanks to Katie Hanschke and Ashli Thomas Wells of the Vanderbilt Law Library for research assistance.

Introduction

In the last few years, the concept of “sex assigned at birth” has appeared with increasing frequency in U.S. case law on discrimination against transgender people. 1 1 See, e.g., Williams v. Kincaid, No. 21-2030, 2022 WL 3364824, at *1 (4th Cir. Aug. 16, 2022) (“Williams is a transgender woman whose gender identity (female) differs from the gender (male) she was assigned at birth.”); Adams ex rel. Kasper v. Sch. Bd. of St. Johns Cnty., 3 F.4th 1299, 1305 (11th Cir. 2021) (“The sex assigned to Mr. Adams at the time of birth was female, but his consistent, internal sense of gender is male.”), vacating and super­seding 968 F.3d 1286 (11th Cir. 2020), vacated and reh’g en banc granted, 9 F.4th 1369 (11th Cir. 2021) (mem.); Whitaker ex rel. Whitaker v. Kenosha Unified Sch. Dist. No. 1 Bd. of Educ., 858 F.3d 1034, 1048 (7th Cir. 2017) (“By definition, a transgender individual does not conform to the sex-based stereotypes of the sex that he or she was assigned at birth.”); A.M. ex rel. E.M. v. Indianapolis Pub. Schs., No. 1:22-cv-01075-JMS-DLP, 2022 WL 2951430, at *1 (S.D. Ind. July 26, 2022) (“Plaintiff A.M. is a ten-year-old transgender girl whose birth-assigned sex was male.”), appeal docketed, No. 22-2232 (7th Cir. July 27, 2022); B.P.J. v. W. Va. State Bd. of Educ., 550 F. Supp. 3d 347, 351 (S.D. W. Va. 2021) (explaining that “B.P.J. is a transgender girl who, while assigned the sex of male at birth, knew from a young age that she is a girl”); Corbitt v. Taylor, 513 F. Supp. 3d 1309, 1313 (M.D. Ala. 2021), appeal docketed, No. 21-10486 (11th Cir. Feb. 21, 2021) (“For individuals born in Alabama or pre­viously licensed here whose gender identity differs from the sex they were assigned at birth, the policy requires surgery, which results in permanent infertility in ‘almost all cases,’ to be able to obtain a license with a sex designation that matches their gender.”); Hecox v. Little, 479 F. Supp. 3d 930, 957 n.11 (D. Idaho 2020) (stating that it was permissible to refer to the plaintiff as “a person whose sex assigned at birth (male) differs from her gender identity (female)”), appeal docketed, Nos. 20-35813, 20-35815 (9th Cir. Sept. 17, 2020); J.A.W. v. Evansville Vanderburgh Sch. Corp., 396 F. Supp. 3d 833, 836 (S.D. Ind. 2019) (“J.A.W. was assigned the gender of female at birth.”); Evancho v. Pine-Richland Sch. Dist., 237 F. Supp. 3d 267, 272 (W.D. Pa. 2017) (using the term “assigned sexes” and explaining that transgender plaintiffs “had ‘male’ listed on their birth certificates when they were born”). ... Close The phrase had been used, at least since the 1960s, to describe an obstetrician’s “casual pronouncement of the newborn as a male or female,” “based upon inspection of the external gen­italia.” 2 2 See, e.g., Edgar Burns, Albert Segaloff & G.M. Carerra, Reassignment of Sex: Report of 3 Cases, 84 J. Urology 126, 126 (1960) (using the phrase “[a]ssignment of sex at birth”). ... Close This pronouncement, then and now, results in a male or female designation on a child’s birth certificate that is sometimes considered the person’s legal sex, unless changed through formal processes. 3 3 See, e.g., Radtke v. Miscellaneous Drivers & Helpers Union Local #638 Health, Welfare, Eye & Dental Fund, 867 F. Supp. 2d 1023, 1034 (D. Minn. 2012) (holding that the sex on a Minnesota birth certificate is an individual’s “legal sex” for all purposes). Although some legal authorities refer to the birth certificate as establishing “legal sex,” see, e.g., id., administrative practices of sex classification are varied, complex, and contradictory, and birth certificate designations do not control in every legal context. See, e.g., Paisley Currah, Sex Is as Sex Does: Governing Transgender Identity 7–10 (2022) [hereinafter Currah, Sex Is as Sex Does]; Dean Spade, Documenting Gender, 59 Hastings L.J. 731, 734 (2008) [hereinafter Spade, Documenting Gender]. ... Close Over the past two decades, the concept of sex assigned at birth has been taken up by transgender rights advocates to replace the troublesome term “biologi­cal sex.” 4 4 See infra section I.C. ... Close Assigned sex is opposed to gender identity—an individual’s own internal sense of whether they are a man, a woman, or nonbinary. 5 5 GLAAD, Glossary of Terms: Transgender, GLAAD Media Reference Guide (11th ed.), https://www.glaad.org/reference/trans-terms [https://perma.cc/99U2-TMLC] (last visited Aug. 13, 2022) (explaining that “infants are assigned a sex at birth, ‘male’ or ‘female,’ based on the appearance of their external anatomy” and defining “gender identity” as “[a] person’s internal, deeply held knowledge of their own gender,” which may or may not “align with the sex they were assigned at birth”). ... Close It is the basis for the legal definition of “transgender”: having a gender identity that does not match the one expected for an individual’s sex assigned at birth. 6 6 See, e.g., Bostock v. Clayton County, 140 S. Ct. 1731, 1756 n.6 (2020) (Alito, J., dissenting) (“The Court does not define what it means by ‘transgender status,’ but the American Psychological Association describes ‘transgender’ as ‘[a]n umbrella term encom­passing those whose gender identities or gender roles differ from those typically associated with the sex they were assigned at birth.’” (quoting A Glossary: Defining Transgender Terms, 49 Monitor on Psych. 32, 32 (2018))); GLAAD, supra note 5. ... Close It appeared in 2016 regulations interpreting the Affordable Care Act 7 7 Nondiscrimination in Health Programs and Activities, 81 Fed. Reg. 31,376, 31,467 (May 18, 2016) (to be codified at 45 C.F.R. pt. 92) (defining “gender identity” as “an individual’s internal sense of gender, which may be male, female, neither, or a combination of male and female, and which may be different from an individual’s sex assigned at birth”). In 2020, the Trump Administration repealed these regulations. Nondiscrimination in Health and Health Education Programs or Activities, Delegation of Authority, 85 Fed. Reg. 37,160, 37,161–62 (June 19, 2020). In 2022, the Biden Administration proposed regulations that would revert to the Obama-era policy. Nondiscrimination in Health Programs and Activities, 87 Fed. Reg. 47,824, 47,828 (Aug. 4, 2022). The proposed regulations also refer to “sex assigned at birth.” Id. at 47,918. ... Close and in a proposed 2021 federal law that would bar discrimination on the basis of LGBTQ status in employment, health care, and housing. 8 8 Equality Act, H.R. 5, 117th Cong. § 1101(a)(2) (2021) (“The term ‘gender identity’ means the gender-related identity, appearance, mannerisms, or other gender-related characteristics of an individual, regardless of the individual’s designated sex at birth.”). ... Close

But courts have been reluctant to embrace the concept. In the Supreme Court’s landmark Bostock v. Clayton County decision, which held that Title VII of the Civil Rights Act forbids discrimination against transgender people, the Court declined to use the term sex assigned at birth. 9 9 Bostock , 140 S. Ct. at 1731. The employees’ briefs in Bostock used the term “sex assigned at birth,” but at oral argument, David Cole, the advocate for Aimee Stephens, a transgender woman, conceded that assigned sex and biological sex were one in the same. Ezra Ishmael Young, What the Supreme Court Could Have Heard in R.G. & G.R. Harris Funeral Homes v. EEOC and Aimee Stephens , 11 Calif. L. Rev. Online 9, 11 (2020) (criticizing Cole’s decision). At one point, Cole resisted Chief Justice John Roberts’s references to “biological sex,” arguing that the issue was discrimination based on “what we think is more accurately referred to as sex assigned at birth,” but he did not press the point. Transcript of Oral Argument at 7, Equal Emp. Opportunity Comm’n v. R.G. & G.R. Harris Funeral Homes, Inc., 139 S. Ct. 1599 (2019) (No. 18-107), 2019 WL 9096155. ... Close Instead, it proceeded on the assumption that “sex” refers “only to biological distinctions between male and female.” 10 10 Bostock , 140 S. Ct. at 1739 (“[B]ecause nothing in our approach to these cases turns on the outcome of the parties’ debate, and because the employees concede the point for argument’s sake, we proceed on the assumption that ‘sex’ signified what the employers sug­gest, referring only to biological distinctions between male and female.”). Bostock assumed that these biological distinctions were synonymous with sex “identified,” not assigned, “at birth.” Id. at 1741. There is a meaningful difference between identification, a term that implies an objective process of classification, and assignment, a term that connotes the imposition of expectations. See infra section II.B. ... Close In this respect, Bostock is representative. Many federal court decisions fail to critically consider the differences between sex assigned at birth and “biological sex” or even conflate the two concepts. 11 11 See, e.g., Adams ex rel. Kasper v. Sch. Bd. of St. Johns Cnty., 3 F.4th 1299, 1304 (11th Cir. 2021) (“Mr. Adams is transgender, meaning when he was born, doctors assessed his sex and wrote ‘female’ on his birth certificate . . . .” (emphasis added)), vacating and superseding 968 F.3d 1286 (11th Cir. 2020), vacated and reh’g en banc granted, 9 F.4th 1369 (11th Cir. 2021) (mem.); Parents for Privacy v. Barr, 949 F.3d 1210, 1217 (9th Cir. 2020) (“This case concerns whether an Oregon public school district may allow transgender students to use school bathrooms, locker rooms, and showers that match their gender iden­tity rather than the biological sex they were assigned at birth.” (emphasis added)); Doe ex rel. Doe v. Boyertown Area Sch. Dist., 897 F.3d 518, 522 (3d Cir. 2018) (“‘Sex’ is defined as the ‘anatomical and physiological processes that lead to or denote male or female.’ Typically, sex is determined at birth based on the appearance of external genitalia.” (emphasis added)); Dodds v. U.S. Dep’t of Educ., 845 F.3d 217, 221 (6th Cir. 2016) (“The crux of this case is whether transgender students are entitled to access restrooms for their identified gender rather than their biological gender at birth.” (emphasis added)); Evancho v. Pine-Richland Sch. Dist., 237 F. Supp. 3d 267, 273 n.3 (W.D. Pa. 2017) (“[T]he Court will use the term ‘assigned sex’ to refer to the physical characteristics of the external sex organs of a person being referenced.”). ... Close

This confusion is dangerous. In the wake of Bostock , there has been an unprecedented onslaught of federal and state legislation aimed at curtail­ing transgender rights, 12 12 See, e.g., Tommy Beer, Latest GOP Trans Ban Fails: Sen. Tuberville’s Effort Is Latest Related to Sports Participation, Forbes (Mar. 6, 2021), https://www.forbes.com/‌sites/‌tommybeer/2021/03/06/latest-gop-trans-ban-fails-sen-tubervilles-effort-is-latest-related-to-sports-participation/?sh=5d76491e67ac (on file with the Columbia Law Review ) (describing a proposed amendment to federal COVID-19 relief legislation in 2021 that would have barred transgender women and girls from women’s and girls’ athletics but was voted down in the Senate 49-50); Matt Lavietes & Elliott Ramos, Nearly 240 Anti-LGBTQ Bills Filed in 2022 So Far, Most of Them Targeting Trans People, NBC News (Mar. 20, 2022), https://‌www.nbcnews.com/nbc-out/out-politics-and-policy/nearly-240-anti-lgbtq-bills-filed-2022-far-targeting-trans-people-rcna20418 [https://perma.cc/8KBX-3V9K] (discussing the rise in state anti-LGBTQ bills in response to Bostock , including 238 in the first three months of 2022 alone). ... Close almost all of it directly invoking the idea of “biological sex.” 13 13 See infra notes 144, 147–149 (quoting recent state laws invoking “biological sex” to restrict transgender rights). ... Close Federal courts will soon be asked to consider the defini­tion of sex as they resolve challenges to new laws in eighteen states barring transgender women and girls from sports, 14 14 See infra note 144 (collecting state laws restricting transgender students from participating in sports). Thus far, federal courts have reached decisions in three cases challenging these laws. A.M. ex rel. E.M. v. Indianapolis Pub. Schs., No. 1:22-cv-01075-JMS-DLP, 2022 WL 2951430, at *14 (S.D. Ind. July 26, 2022) (granting a preliminary injunction against enforcement of an Indiana law that would prohibit a ten-year-old transgender girl from playing softball on the school’s girls’ team), appeal docketed, No. 22-2332 (7th Cir. July 27, 2022); B.P.J. v. W. Va. State Bd. of Educ., 550 F. Supp. 3d 347, 358 (S.D. W. Va. 2021) (granting a preliminary injunction against enforcement of a West Virginia law that would prohibit an eleven-year-old transgender girl from participating in girls’ track and field); Hecox v. Little, 479 F. Supp. 3d 930, 989 (D. Idaho 2020) (granting a preliminary injunction against the enforcement of an Idaho law that would have barred a transgender woman from competing in women’s track and field at Boise State University), appeal docketed, Nos. 20-35813, 20-35815 (9th Cir. Sept. 17, 2020). ... Close two laws banning certain forms of gender-affirming health care for transgender youth, 15 15 See infra note 147 (discussing laws passed by Alabama and Arkansas). Both of these laws have been preliminarily enjoined. Eknes-Tucker v. Marshall, No. 2:22-CV-184-LCB, 2022 WL 1521889, at *1 (M.D. Ala. May 13, 2022), appeal docketed, No. 22-11707 (11th Cir. May 18, 2022); Brandt v. Rutledge, 551 F. Supp. 3d 882, 894 (E.D. Ark. 2021), aff’d, No. 21-2875, 2022 WL 3652745 (8th Cir. Aug. 25, 2022). In February 2022, government officials in Texas invoked biological sex in support of an executive directive to investigate parents of children undergoing certain forms of gender-affirming health care for child abuse. Tex. Att’y Gen., Opinion Letter on Whether Certain Medical Procedures Performed on Children Constitute Child Abuse 2–3 (2022), https://texasattorneygeneral.gov/sites/‌default/files/global/KP-0401.pdf [https://perma.cc/BBM2-GY9P] (“[I]t is important to note that it remains medi­cally impossible to truly change the sex of an individual because this is determined biologically at conception.”). In May 2022, the Texas Supreme Court held that those execu­tive officials did not have statutory authority to require the relevant state agency to conduct child abuse investigations. In re Abbott, 645 S.W.3d 276, 281 (Tex. 2022). At the time of this writing, litigation over the investigations is ongoing. See PFLAG National, Lambda Legal, and ACLU File New Lawsuit to Stop Texas From Persecuting Parents With Transgender Kids, Lambda Legal (June 8, 2022), https://www.lambdalegal.org/blog/‌abbott_tx_20220608_‌pflag-ll-and-aclu-file-new-lawsuit-to-stop-tx-from-persecuting-parents-with-transgender-kids [https://perma.cc/K27V-RSPC]. ... Close three laws limiting restroom access, 16 16 See infra note 148 (discussing laws passed by Alabama, Oklahoma, and Tennessee); cf. Bongo Prods., LLC v. Lawrence, No. 3:21-CV-00490, 2022 WL 1557664, at *1 (M.D. Tenn. May 17, 2022) (granting summary judgment in favor of plaintiffs on their First Amendment challenge to a Tennessee law requiring that entities with transinclusive restroom policies post warning signs). ... Close and three laws restricting a person’s ability to change the sex designation on their identification documents. 17 17 See infra note 149 (discussing laws passed by Idaho, Montana, and Oklahoma). A number of recent court decisions have found problems with such laws and policies. See, e.g., Corbitt v. Taylor, 513 F. Supp. 3d 1309, 1323 (M.D. Ala. 2021), appeal docketed, No. 21-10486 (11th Cir. Feb. 21, 2021) (holding that an Alabama rule that requires genital surgery before an individual can change the sex designation on their driver’s license violated the Equal Protection Clause); F.V. v. Jeppesen, 477 F. Supp. 3d 1144, 1150 (D. Idaho 2020) (pro­hibiting Idaho from categorically refusing to change birth certificate sex designations for transgender individuals); Marquez v. Montana, No. DV 21-873, para. 183 (Mont. 13th Jud. Dist. Ct. Apr. 21, 2022) (granting motion for preliminary injunction against enforcement of the Montana statute, because the plaintiffs made out a prima facie case that the statute vio­lated their rights to due process because it was impermissibly vague with respect to which surgeries might be required). ... Close Although a “growing consensus” of courts agree that it is impermissible discrimi­nation for schools to refuse to allow transgender students to use restrooms consistent with their gender identities, 18 18 Grimm v. Gloucester Cnty. Sch. Bd., 972 F.3d 586, 593 (4th Cir. 2020), cert. denied, 141 S. Ct. 2878 (2021) (mem.). Justices Clarence Thomas and Samuel Alito would have granted the petition for certiorari. Gloucester Cnty. Sch. Bd. v. Grimm, 141 S. Ct. 2878, 2878 (2021) (mem.). ... Close the Eleventh Circuit is currently reconsidering the issue en banc. 19 19 Adams ex rel. Kasper v. Sch. Bd. of St. Johns Cnty., 9 F.4th 1369, 1372 (11th Cir. 2021) (mem.) (vacating and granting en banc review of a panel decision holding that ex­clusion of a transgender boy from the boys’ restroom violated the Equal Protection Clause), vacating and granting reh’g en banc 3 F.4th 1299 (11th Cir. 2021). ... Close Bostock declined to spell out its implications for restrooms, sports, identity documents, or other such controversies, and so transgender rights may end up back in the Supreme Court again soon. 20 20 Bostock v. Clayton County, 140 S. Ct. 1731, 1753 (2020) (“[W]e do not purport to address bathrooms, locker rooms, or anything else of the kind . . . . Whether other policies and practices might or might not qualify as unlawful discrimination or find justifications under other provisions of Title VII are questions for future cases, not these.”); see also Tennessee v. U.S. Dep’t of Educ., No. 3:21-cv-308, 2022 WL 2791450, at *3 (E.D. Tenn. July 15, 2022) (granting motion for preliminary injunction barring federal agencies from en­forcing interpretations of Title IX that would bar discrimination on the basis of LGBTQ status and interpretations of Title VII that would apply Bostock in the contexts of “dress codes, bathrooms, locker rooms, showers, and use of preferred pronouns or names”). ... Close

This Article attempts to uncover the history of the concept of sex assigned at birth, as well as that of its main competitor, “biological sex,” and to set forth the case in favor of the shift toward sex assigned at birth as an idea that can advance legal protection for transgender, nonbinary, 21 21 This Article uses the term “nonbinary” to refer to a person who does not exclusively identify as a man or a woman. See, e.g., Jessica A. Clarke, They, Them, and Theirs, 132 Harv. L. Rev. 894, 905–14 (2019) [hereinafter Clarke, They, Them, and Theirs] (discussing the diversity of nonbinary gender identities and reasons for bias and discrimination against them). ... Close and gender-nonconforming people. 22 22 This Article uses the term “gender nonconforming” to refer to those who do not reject the gender identity associated with the sex assigned to them at birth but who deviate from the roles, behaviors, and appearances expected of their sex. Cf. Mary Anne Case, Legal Protections for the “Personal Best” of Each Employee: Title VII’s Prohibition on Sex Discrimination, the Legacy of Price Waterhouse v. Hopkins , and the Prospect of ENDA, 66 Stan. L. Rev. 1333, 1335–36 (2014) (discussing “gender benders” such as men who do not claim to be transgender but “nevertheless engage[] in behavior seen as stereotypically feminine”). ... Close

One contribution of this Article is to excavate the histories of the concepts of “biological sex” and “sex assigned at birth.” 23 23 See infra Part I. Other scholars have delved into the meaning of the term “sex” as it is used in the Civil Rights Act of 1964. See, e.g., William N. Eskridge Jr., Brian G. Slocum & Stefan Th. Gries, The Meaning of Sex: Dynamic Words, Novel Applications, and Original Public Meaning, 119 Mich. L. Rev. 1503, 1549 (2021) (explaining that “ [s]ex was a broad, catchall term in 1964, used in circumstances where we would use terms such as gender , sexuality , and sexual orientation ”). But they have not inquired into the origins of “biological sex,” a concept now being deployed by state legislators seeking to restrict transgender rights, or its progressive alternative, “sex assigned at birth.” ... Close In recent years, many courts and legislatures have taken for granted that there is some simple attribute called “biological sex” that is easily separa­ble from gender identity. 24 24 See infra notes 144, 147–149 (collecting statutes). ... Close In litigation over access to sex-segregated restrooms and sports, opponents of transgender rights lean heavily on “biology” as a simple and scientific basis for excluding transgender indi­viduals from the categories of “male” and “female.” 25 25 See, e.g., Adams ex rel. Kasper v. Sch. Bd. of St. Johns Cnty., 3 F.4th 1299, 1322 (11th Cir. 2021) (Pryor, C.J., dissenting) (asserting that a school did not violate the Equal Protection Clause by excluding a transgender boy from the boys’ restroom based on its def­inition of “‘sex’ in its ordinary, traditional sense” as synonymous with “biological sex”), vacated and reh’g en banc granted, 9 F.4th 1369 (11th Cir. 2021) (mem.); Intervenors-Appellants Madison Kenyon and Mary Marshall’s Opening Brief at 4, Hecox v. Little, Nos. 20-35813, 20-35815 (9th Cir. filed Nov. 12, 2020) (“Recently . . . women and girls have become bystanders in their own sports as biologically male athletes who identify as female demand to be able to compete against women and girls.”); id. at 1–64 (using the terms “biological male” or “biologically male” sixty-eight times in a sixty-four page brief). The Hecox litigation pertains to the constitutionality of Idaho’s Fairness in Women’s Sports Act, which defines sex as “biological” and requires that it be verified based on “the student’s reproductive anatomy, genetic makeup, or normal endogenously produced testosterone levels.” Idaho Code § 33-6203 (2021). ... Close But the idea of “biological sex” as distinct from gender identity is not a time-honored scientific or legal category; it is a contested concept from mid-twentieth-century medicine. In the 1970s, “biological sex” found its way into legal doctrine as a result of an outdated understanding of transgender identity as a mental illness caused by early childhood experiences, along with pol­icy concerns about the need to distinguish the sexes for purposes such as avoiding same-sex marriage. 26 26 See infra section I.B. ... Close Lawmakers today are unable to agree on any definition of “biological sex” based in anatomy, genetics, hormones, or other such properties, so they often enact laws that define sex as the male or female designation on an individual’s original birth certificate. 27 27 See infra notes 144–150 and accompanying text (collecting statutes invoking “biological sex” without any consistent definition of that term). ... Close Rather than vindicating any biological standard, these laws endeavor to exclude transgender people. Assigned sex terminology also emerged at midcentury in medical research related to people with intersex variations. “Intersex” is “an umbrella term for differences in sex traits or reproductive anatomy,” such as “differences in genitalia, hormones, internal anatomy, or chromosomes, compared to the usual two ways that human bodies develop.” 28 28 What Is Intersex?, InterACT, https://interactadvocates.org/faq/#definition [https://‌perma.cc/NAK2-93G9] (last updated Jan. 26, 2021). ... Close Transgender theorists borrowed this terminology in the 1990s to describe the process of assigning sexes to all infants, and it began to appear in legal contexts in the early 2000s. 29 29 See infra sections I.B–.C. ... Close It now competes with the term “biological sex” in legal disputes over transgender rights. 30 30 See infra section I.C. ... Close

Another contribution of this Article is to present the full theoretical case in favor of “sex assigned at birth” as an alternative to “biological sex.” 31 31 I do not argue that “sex assigned at birth” should be the definition of “sex” whenever that term appears in the law; as I have argued elsewhere, to the extent that legal sex classifications are justified at all, sex determinations should reflect each law’s particular purposes, as well as the values of autonomy, dignity, and equality. Clarke, They, Them, and Theirs, supra note 21, at 933–36. Rather, sex assigned at birth is useful as an explanatory concept that challenges the idea that every person has one true sex. See infra Part II. ... Close “Sex assigned at birth” is not a euphemism for “biological sex” but a critique of the very concept. It acknowledges that “sex” can be defined in many ways. To speak of assigned sex is to point out that while adminis­trative “M” and “F” classifications might be simple, the biology of sex is not. “Biological sex” is not binary, stable, or uniform. 32 32 See, e.g., Claire Ainsworth, Sex Redefined, 518 Nature 288, 288 (2015) (“[N]ew technologies in DNA sequencing and cell biology are revealing that almost everyone is, to varying degrees, a patchwork of genetically distinct cells, some with a sex that might not match that of the rest of their body.”); see also infra notes 170–179 and accompanying text. ... Close And it is inconsistent with medical research to assert that gender identity has no biological underpinnings. 33 33 See, e.g., Wylie C. Hembree et al., Endocrine Treatment of Gender-Dysphoric/‌Gender-Incongruent Persons: An Endocrine Society Clinical Practice Guideline, 102 J. Clinical Endocrinology & Metabolism 3869, 3874 (2017) (“Results of studies from a variety of biomedical disciplines—genetic, endocrine, and neuroanatomic—support the concept that gender identity and/or gender expression likely reflect a complex interplay of biologi­cal, environmental, and cultural factors.”); Joshua D. Safer & Vin Tangpricha, Care of Transgender Persons, 381 New Eng. J. Med. 2451, 2451 (2019) (collecting sources in sup­port of the claim that “[a]lthough the mechanisms that inform gender identity are unknown, current data suggest a biologic underpinning programmed from birth”); cf. Aditi Bhargava et al., Considering Sex as a Biological Variable in Basic and Clinical Studies: An Endocrine Society Scientific Statement, 42 Endocrine Revs. 219, 227 (2021) (concluding “there is ample but incomplete evidence for biological substrates—neuroanatomic, genetic, and hormonal—for gender orientation, making this an important area of ongoing research”). For a plain-language explanation, see Denise Grady, Anatomy Does Not Determine Gender, Experts Say, N.Y. Times (Oct. 22, 2018), https://www.nytimes.com/‌‌2018/10/22/health/transgender-trump-biology.html (on file with the Columbia Law Review ). ... Close The claim that sex is assigned at birth, rather than being a self-evident biological property that naturally corresponds with certain gender identities and roles, goes beyond the feminist argu­ment against biology as destiny. 34 34 See infra section III.A (discussing the feminist argument that while biology may not be changeable, social norms with respect to the roles of men and women can be contested politically). ... Close Administrative assignments of identities and social roles threaten liberal principles of autonomy that insist that every person should be, at least in part, the author of their own life story, 35 35 Cf. Joseph Raz, The Morality of Freedom 370 (1986) (“The autonomous person is part author of his life.”). ... Close as well as postmodern sensibilities about the role of creativity and play in constructing the self. 36 36 Cf. Julie E. Cohen, Configuring the Networked Self: Law, Code, and the Play of Everyday Practice 133–35 (2012) (discussing a dynamic view of the self that is in some ways culturally determined but also evolves through “[p]lay with texts, artifacts, personae, and social conventions”). ... Close The idea of assignments at birth evokes the egalitar­ian’s umbrage at lotteries of birth in which roles and opportunities are distributed in infancy. 37 37 Cf. John Rawls, A Theory of Justice 74–75 (1971) (criticizing a conception of equality that allows the distribution of resources to be “decided by the outcome of the natural lottery”); Elizabeth S. Anderson, What Is the Point of Equality?, 109 Ethics 287, 289–90 (1999) [hereinafter Anderson, Point of Equality] (discussing theories of “luck egalitar­ianism” that appeal because of “the force of the obviously correct claim that no one deserves their genetic endowments or other accidents of birth, such as who their parents are or where they were born”). ... Close That these assignments subject individuals to in­tersecting social hierarchies—such as those that elevate men over women, gender conformers over nonconformers, and cisgender over transgender people—offends theories of the purpose of antidiscrimination law  as  undermining  systemic  patterns  of  subordination. 38 38 See, e.g., Anderson, Point of Equality, supra note 37, at 312 (explaining how egalitarian political movements oppose hierarchical social relationships that “generate, and were thought to justify, inequalities in the distribution of freedoms, resources, and wel­fare”); cf. Tarunabh Khaitan, A Theory of Discrimination Law 91 (2015) (explaining that the purpose of “discrimination law is to secure an aspect of the well-being of persons by reducing the abiding, pervasive, and substantial relative disadvantage faced by members of protected groups”). ... Close Moreover, by pointing out that sex is assigned at birth, advocates draw attention to the fact that institutions that exclude transgender people are doing so based on what is essentially a medical record of a doctor’s examination of a person’s genitalia in infancy. Yet genitalia and medical records are quintessentially private.

Thus, the idea that sex is assigned at birth has the potential to disrupt legal invocations of “biological sex” as a simple, natural, neutral, and normatively unproblematic basis for classifying individuals. In practice, however, sex assigned at birth has not lived up to its theoretical potential. Another contribution of this Article is to explain why. 39 39 See infra Part III. ... Close Of course, some oppose the concept due to ideological opposition to transgender rights in general. But the idea has encountered resistance even from those without fixed positions in this particular culture war. One reason is that the idea of “biological sex” as a self-evident essence is an entrenched form of common sense that is difficult to dislodge, even though it has been undermined by advances in science and medicine. The concept is reinforced by the insist­ence of many feminists that there is an important difference between biological sex and social gender. 40 40 See infra section III.A. ... Close Another reason for the persistence of biological sex is dissatisfaction with gender identity as an alternative basis for sex or gender classification. Judges and other decisionmakers are often concerned that gender identity is too subjective and easily manipulated to serve as the basis for sorting individuals into male and female categories.

A final contribution of this Article is to discuss ways to overcome these barriers. 41 41 See infra Part IV. ... Close Sex assigned at birth clarifies what is at stake in disputes over restrooms, sports, and identity documents—these are not debates over bi­ology; rather, they are controversies over how to prioritize conflicting values and whether, as an empirical matter, more inclusive policies will have deleterious effects. While sex assigned at birth can clarify what the stakes are, it cannot, on its own, resolve the moral and practical questions at the heart of contemporary transgender rights controversies. This Article cautions against an approach taken by many courts, which is to attempt to evade moral and practical questions by insisting that an individual’s true sex is their gender identity as a man or a woman, if medical experts verify that they live all aspects of their lives consistently with that gender identity. The result of such an approach may be to limit legal protection to only that subset of the transgender community that can prove the bona fides of their gender identities to medical experts and to base the case for protec­tion on a scientific foundation that may not be able to bear its weight. Moreover, this approach is not necessary. A review of recent litigation demonstrates that advocates have won transgender rights cases not just with appeals to scientific authorities on the validity of transgender people’s gender identities but also with arguments that tap into values like equality, autonomy, and dignity, with stories that cultivate empathy, and with evidence debunking practical objections to transgender inclusion.

While theorists and advocates have been deploying the concept of sex assigned at birth for the past two decades, 42 42 See, e.g., Susan Stryker, Transgender History: The Roots of Today’s Revolution 19 (2d ed. 2017) [hereinafter Stryker, Transgender History (2d ed.)] (employing the term “birth-assigned gender”); Paisley Currah, Transgender Rights Without a Theory of Gender?, 52 Tulsa L. Rev. 441, 450 n.36 (2017) [hereinafter Currah, Transgender Rights Without a Theory of Gender?] (discussing the author’s work to pass a 2002 New York City Human Rights Law amendment using the term “legal sex assigned to that person at birth”). ... Close no work of legal scholar­ship has explored the idea’s potential for transgender rights arguments, or unearthed the origins of that term and its main competitor, “biological sex.” 43 43 Much recent legal scholarship has focused on what it means to ban discrimination “because of sex” for purposes of the Civil Rights Act of 1964, the issue in Bostock . See, e.g., Eskridge, supra note 23. The discrimination question is distinct from the less-explored issue of how the law defines who counts as male or female in those contexts in which distinctions might still be permitted. This Article builds on the important insights of Professor Paisley Currah and Professor Dean Spade on this issue. See Currah, Sex Is as Sex Does, supra note 3, at 7–10 (arguing that how the state defines who is recognized as male or female often depends on the work that a particular arm of the state is doing); Spade, Documenting Gender, supra note 3, at 733 (detailing the “rarely discussed” matrix of rules governing gender reclassification in the United States). ... Close Transgender people continue to face uniquely high rates of discrim­ination, harassment, and violence with devastating consequences. 44 44 Sandy E. James, Jody L. Herman, Susan Rankin, Mara Keisling, Lisa Mottet & Ma’ayan Anafi, The Report of the 2015 U.S. Transgender Survey 2, 5 (2016), http://www.transequality.org/sites/default/files/docs/usts/USTS%20Full%20Report%20-%20FINAL%201.6.17.pdf [https://perma.cc/2MKH-MN2C] (surveying 27,715 transgender people and finding they reported “high levels of mistreatment, harassment, and violence in every aspect of life”). The Williams Institute estimates that the number of adults in the United States who identify as transgender is 1.3 million, or 0.5% of the population. Jody L. Herman, Andrew R. Flores & Kathryn K. O’Neill, Williams Inst., How Many Adults and Youth Identify as Transgender in the United States? 4 (2022), https://williamsinstitute.law.ucla.edu/‌wp-content/uploads/Trans-Pop-Update-Jun-2022.pdf [https://perma.cc/KE9F-RBSF]. ... Close Moreover, rules requiring that people conform with expectations for their assigned sex impact individuals who do not necessarily identify as transgender but are gender nonconforming or nonbinary. 45 45 See supra notes 21–22 (defining these terms). ... Close In addition to its contributions to the study of transgender rights litigation, this Article’s account is of relevance to feminist scholarship on biological concepts of sex and gender. 46 46 See, e.g., Katrina Karkazis, The Misuses of “Biological Sex”, 394 Lancet 1898, 1898 (2019) [hereinafter Karkazis, Misuses of “Biological Sex”] (discussing the “long history of using—and misusing—discrete biological criteria to determine sex and thereby include or exclude certain people from categories”); Heather Shattuck-Heidorn & Sarah S. Richardson, Neurogenderings: Sex/Gender and the Biosocial Turn, Scholar & Feminist Online (2019), https://sfonline.barnard.edu/sex-gender-and-the-biosocial-turn/ [https://‌‌perma.cc/3Q8H-84ZC] (discussing feminist criticisms of the concept of “sex as a biological variable”). ... Close

Part I of this Article uncovers the origins of the debate between “biological sex” and “sex assigned at birth” in transgender rights advocacy and public policy. Part II sets out the theoretical argument for the shift to sex assigned at birth and explains why that concept is superior to alterna­tives. It demonstrates that sex assigned at birth does useful work in litigation by disrupting the assumption that sex classifications reflect mere biology and pointing to how those classifications can threaten autonomy, equality, privacy, and dignity. Part III explains why courts have been reluc­tant to abandon biological sex in favor of sex assigned at birth. Part IV offers an analysis of recent transgender rights litigation that concludes that, to overcome this reluctance, the claim that sex is assigned at birth must be accompanied by arguments that speak to values, practicalities, and empathy in particular cases.

• Open access
• Published: 09 February 2022

A review of the essential concepts in diagnosis, therapy, and gender assignment in disorders of sexual development

• Vivek Parameswara Sarma   ORCID: orcid.org/0000-0001-9484-7090 1  

Annals of Pediatric Surgery volume  18 , Article number:  13 ( 2022 ) Cite this article

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The aim of this article is to review the essential concepts, current terminologies and classification, management guidelines and the rationale of gender assignment in different types of differences/disorders of sexual development.

The basics of the present understanding of normal sexual differentiation and psychosexual development were reviewed. The current guidelines, consensus statements along with recommendations in management of DSD were critically analyzed to formulate the review. The classification of DSD that is presently in vogue is presented in detail, with reference to old nomenclature. The individual DSD has been tabulated based on various differential characteristics. Two schemes for analysis of DSD types, based on clinical presentation, karyotype and endocrine profile has been proposed here. The risk of gonadal malignancy in different types of DSD is analyzed. The rationale of gender assignment, therapeutic options, and ethical dimension of treatment in DSD is reviewed in detail.

The optimal management of different types of DSD in the present era requires the following considerations: (1) establishment of a precise diagnosis, employing the advances in genetic and endocrine evaluation. (2) A multidisciplinary team is required for the diagnosis, evaluation, gender assignment and follow-up of these children, and during their transition to adulthood. (3) Deeper understanding of the issues in psychosexual development in DSD is vital for therapy. (4) The patients and their families should be an integral part of the decision-making process. (5) Recommendations for gender assignment should be based upon the specific outcome data. (6) The relative rarity of DSD should prompt constitution of DSD registers, to record and share information, on national/international basis. (7) The formation of peer support groups is equally important. The recognition that each subject with DSD is unique and requires individualized therapy remains the most paramount.

The aim of this article is to review the essential concepts, current terminologies and classification, management guidelines, and the rationale of gender assignment in different types of differences/disorders of sexual development (DSD). The basics of the present understanding of normal sexual differentiation and psychosexual development were reviewed. The current guidelines, consensus statements along with recommendations in management of DSD were critically analyzed to formulate the review. The classification of DSD that is presently in vogue is presented in detail, with reference to old nomenclature. The individual DSD has been tabulated based on various differential characteristics. Two schemes for analysis of DSD types, based on clinical presentation, karyotype, and endocrine profile has been proposed here. The risk of gonadal malignancy in different types of DSD is analyzed. The rationale of gender assignment, therapeutic options, and ethical dimension of treatment in DSD is reviewed in detail.

The normal sexual differentiation

The normal pattern of human sexual development and differentiation that involves specific genetic activity and hormonal mediators [ 1 , 2 ] is explained by the classical Jost’s paradigm; the essence of which is narrated below [ 3 ].

The establishment of chromosomal sex (XX or XY) occurs at the time of fertilization. The variations in sex chromosome include XO, XXY or mosaicism as in XO/XY.

Chromosomal sex influences the determination of the gonadal sex, thus differentiating the bipotential gonadal ridge into testis or ovary. (Variations in gonadal sex include ovotestis and streak gonad.) The SRY gene (referred to as the testis-determining gene) on the short arm of Y chromosome directs the differentiation into testes, with formation of Leydig and Sertoli cells [ 4 , 5 ].

The sex phenotype (internal and external genitalia) is determined by the specific hormones secreted by the testes, which translates the gonadal sex into phenotype. Testosterone secretion by Leydig cells promotes Wolffian duct differentiation into vas deferens, epididymis, and seminal vesicles. The Wolffian ducts regress in the absence of androgenic stimulation. Testosterone is converted to dihydrotestosterone (DHT), by 5-alpha reductase, which results in masculinization of external genitalia, closure of urethral folds, and development of the prostate and scrotum. In the absence of influence of SRY gene, the development of bipotential gonad will evolve along the female pathway. Thus, the Mullerian ducts develop (even without any obvious hormonal input) into the uterus, fallopian tubes, and the proximal 2/3 of vagina. DHT is also important for the suppression of development of the sinovaginal bulb, which gives rise to the distal 1/3 of vagina. The fact that internal duct development reflects the ipsilateral gonad (due to the paracrine effect of sex hormones) is an important consideration in the understanding of specific types of DSD. The anti-Mullerian hormone (AMH) from Sertoli cells of Testis is vital for the regression of Mullerian structures. Therefore, Wolffian structures will develop on one side, along with Mullerian duct regression, only in the presence of a fully functional testis. But, Mullerian duct structures develop on one side even in the presence of an ipsilateral streak gonad. The genital tubercle develops as a clitoris, the urethral folds form the labia minora, and the labioscrotal swellings form the labia majora [ 1 , 2 , 4 , 5 , 6 ].

The concept of psychosexual development was added to the above sequence by Money et al. [ 7 ]. The brain undergoes sexual differentiation consistent with the other characteristics of sex. It is proposed that androgens organize the brain in early development and pubertal steroids activate the same, leading to masculine behavior. The sexual differentiation of genitalia occur in first 2 months of pregnancy, while sexual differentiation of brain occurs in the second half of pregnancy, and hence these processes can be influenced independently. Therefore, the extent of virilization of genitalia may not reflect the extent of masculinization of brain [ 8 , 9 ].

Psychosexual development is a complex and multifactorial process influenced by brain structure, genetics, prenatal and postnatal hormonal factors, environmental, familial, and psychosocial exposure [ 10 , 11 , 12 ]. Psychosexual development is conceptualized as three components: (1) gender identity is defined as the self-representation of a person as male, female or even, neither. (2) Gender role (sex-typical behavior) describes behavior, attitudes and traits that a society identifies as masculine or feminine. (3) Sexual orientation denotes the individual responsiveness to sexual stimuli, which includes behavior, fantasies, and attractions (hetero/bi/homo-sexual).

Psychosexual development is influenced by various factors such as Androgen exposure, sex chromosome genes, brain structure, family dynamics and social structure. With reference to altered psychosexual development, two conditions are important to be recognized and differentiated. (1) Gender dissatisfaction denotes unhappiness with the assigned sex, the etiology of which is poorly understood. (With respect to subjects with DSD, it has to be remembered that homo-sexual orientation or cross-sex interest is not considered an indication of incorrect gender assignment.) (2) Gender dysphoria (GD) is characterized by marked incongruence between the assigned gender and experienced/expressed gender, which is associated with clinically significant functional impairment. (It can occur in the presence or absence of DSD) [ 12 , 13 , 14 ].

The term “disorders/differences of sex development” (DSD) is defined as congenital anomalies in which development of chromosomal, gonadal, or phenotypic sex (including external genitalia/internal ductal structures) is atypical. In a wider perspective, DSD includes all conditions where chromosomal, gonadal, phenotypical, or psychological sex are incongruent. The three components of psychosexual development also may not always be concordant in DSD [ 15 , 16 ].

A greater understanding of underlying genetic and endocrine abnormalities has necessitated refinement in terminologies and classification of DSD. The newer classification of DSD aims to be more precise, specific, flexible, and inclusive of advances in genetic diagnosis, while being sensitive to patient concerns (Table  1 ). Terms such as intersex, hermaphrodite, pseudohermaphrodite, and sex reversal are avoided, to this end, in diagnostic terminologies. Presently, a specific molecular diagnosis is identified only in about 20% of all DSD. The majority of virilized 46 XX infants will have CAH, but only 50% of 46 XY DSD will have a definitive diagnosis [ 16 , 17 ].

For the purpose of understanding of the basic pathology and ease of comprehension, DSD can be classified as follows:

Sex chromosomal DSD: here, the sex chromosome itself is abnormal. This includes XO (Turner syndrome), XXY (Klinefelter’s syndrome), mosaic patterns of XO/XY (Mixed Gonadal Dysgenesis and Partial Gonadal Dysgenesis), XX/XY (Ovotesticular DSD), and even SRY-positive XX in 46 XX testicular DSD (de la Chapelle syndrome). These are essentially genetic anomalies characterized by a varying degrees of gonadal dysgenesis/abnormal gonadal differentiation secondary to the sex chromosome defect and in certain situations, associated systemic abnormalities and increased risk of malignancies. The phenotypic sex (internal ductal structures and external genitalia) reflects the gonadal sex.

Disorders of gonadal development: these are characterized by abnormal gonadal development, in the absence of any obvious sex chromosomal abnormality, i.e., Karyotype is either 46 XX or 46 XY. It includes 46 XY complete gonadal dysgenesis (Swyer syndrome), 46 XY partial gonadal dysgenesis, 46 XY ovotesticular DSD, 46 XX pure gonadal dysgenesis (Finnish syndrome) and 46 XX ovotesticular DSD. Here also, the phenotypic sex reflects the gonadal sex (streak or dysgenetic gonads/ovotestis).

Abnormalities in phenotypic sex secondary to hormonal defects: these are characterized by normal chromosomal sex (46 XX or 46 XY) and gonadal sex (testes/ovaries), but abnormal phenotype (internal ductal and/or external genital) due to defects in hormonal function. In 46 XY DSD, this can be due to defects in synthesis or action of androgens or less commonly, AMH. In 46 XX DSD, this is due to androgen excess, as in Congenital Adrenal Hyperplasia, or less commonly, gestational hyperandrogenism.

Primary endocrine abnormalities: These are characterized by a severe underlying endocrine abnormality, as in congenital hypogonadotropic hypogonadism or pan-hypopitutarism.

Malformation syndromes: these are characterized by the presence of genital abnormalities due to severe congenital anomalies including persistent cloaca, cloacal exstrophy, Mullerian agenesis/MRKH syndrome, or vaginal atresia.

The common pattern of correlation of gonadal sex with internal duct structure development is summarized in Table  2 . The cardinal characteristics of chromosomal, gonadal, and phenotypic sex in the individual types of DSD is summarized in Table  3 .

The genetic testing in DSD

For a sex chromosome DSD, no further genetic analysis is required. However, a DSD with 46 XX or 46 XY karyotype, the underlying etiology may be a monogenic disorder where the candidate gene has to be analyzed. The algorithm of genetic analysis of DSD is defined according to the results of sex chromosome complement (karyotyping/array CGH or SNP array) and presence of regions of Y chromosome (FISH/QFPCR). The next step is to study specific genes involved in gonadal development by techniques including Sanger sequencing combined with MLPA to assess specific genetic defects. Further analysis includes evaluation for causes of monogenic DSD or analysis of copy number variations (CNV) or both. Panels for candidate genes (CYP21A2 in CAH, AR in androgen insensitivity syndrome) provide rapid and reliable results. The evolving use of whole exome sequencing (WES) and whole genome sequencing (WGS) aim to identify previously unrecognized genetic etiology of DSD.

The further characterization of 46 XY DSD

The further characterization of individual types of 46 XY DSD based on endocrine and genetic evaluation is summarized in Table  4 . The selective use of the following investigations is required in 46 XY DSD to arrive at a specific diagnosis of the subtype:

Assay of serum testosterone, LH and FSH.

hCG stimulation test, to assess response in testosterone levels.

Assay of AMH, to detect the presence of functioning testicular tissue.

Testosterone: dihydrotestosterone (DHT) ratio.

Testosterone: androstenedione ratio.

ACTH test, for the diagnosis of testosterone biosynthesis defects.

Specific substrates like progesterone, 17-OHP, and 1-OH pregnenelone, for typing of Androgen biosynthesis defects.

Ultrasound scan/MRI and laparoscopy for the detection of Mullerian structures.

Gonadal biopsy for the diagnosis of ovotesticular DSD and gonadal dysgenesis.

Genetic testing including screening of androgen receptor gene for mutations, Molecular testing for 5-alpha reductase-2 gene mutations, androgen receptor expression, and androgen binding study in genital skin fibroblasts.

The further characterization of 46 XX DSD is summarized in Table  5 . The classification of the major types of DSD based on the different clinical manifestations is summarized in Table  6 .

Gonadal dysgenesis syndromes

There are five common patterns of gonadal dysgenesis syndromes, in addition to the dysgenetic ovotestis which is found in 46 XX or 46 XY ovotesticular DSD.

46 XY complete gonadal dysgenesis (Swyer syndrome)

46 XY partial gonadal dysgenesis (Noonan syndrome)

45 XO/46 XY mixed gonadal dysgenesis

46 XX pure gonadal dysgenesis (Finnish syndrome)

45 XO Turner’s syndrome.

Gender assignment in DSD

The classical “optimal gender policy” involved early sex assignment and surgical correction of genitalia and hormonal therapy, with the objective of an unambiguous gender of rearing, that will influence the future gender identity and gender role [ 7 , 11 ]. The genital phenotype (characteristics of genitalia) has historically been the guide for gender assignment, considering esthetic, sexual, and fertility considerations. This perspective, which assumes psychosexual neutrality at birth, has been challenged now, with the present focus shifting to the importance of prenatal and genetic influences on psychosexual development. In addition to the progress in the diagnostic techniques and therapeutic modalities, there has been greater understanding of the associated psychosocial issues and acceptance of patient advocacy [ 19 , 20 , 21 ].

Factors to be considered for gender assignment in DSD

The most common gender identity outcome, observed incidence of GD, and requirement of gender reassignment in the specific type of DSD from available data.

The most common pattern of psychosexual development in the particular DSD, consistent with established neurological characteristics.

The requirement of genital reconstructive surgery to conform to the assigned sex.

The estimated risk of gonadal malignancy and need for gonadectomy (Table  7 ).

The requirement, possible response, and timing of HRT.

The expected post-pubertal cosmetic and functional outcome of genitalia, after reconstruction where required.

The potential for fertility, even with the presumed aid of assisted reproduction techniques.

Though GD in patients with DSD influences, the choice of gender assignment (and reassignment), sexual orientation, and gender-atypical behavior do not affect the decision-making process in gender assignment of DSD [ 22 ].

Gender assignment in neonates should be done only after expert evaluation. The evaluation, therapy, and long-term follow-up should only be done at a centre with an experienced multidisciplinary team. The multidisciplinary team for management of DSD should include pediatric subspecialists in endocrinology, surgery/urology, genetics, gynecology, and psychiatry along with pediatrician/neonatologist, psychologist, specialist nurse, social worker, and medical ethicist. The core group will vary according to the type of DSD. All individuals with DSD should receive the appropriate gender assignment [ 22 , 23 , 24 , 25 ]. The patient and family should be able to have an open communication and participation in the decision-making process. The concerns of patients and their families should be respected and addressed in strict confidence.

The rationale of gender assignment in different clinical conditions of DSD

The usually recommended gender assignment guidelines in different clinical types of DSD is summarized in Table  8 .

46 XX DSD—congenital adrenal hyperplasia (CAH)

In CAH, female gender identity is the most common outcome despite markedly masculinized gender-related behavior. Patients diagnosed in the neonatal period, particularly with lower degrees of virilization, should be assigned and reared as female gender, with early feminizing surgery. GD is rare when female gender is assigned. Those with delayed diagnosis and severely masculinized genitalia need evaluation by a multidisciplinary team. Evidence supports the current recommendation to rear such infants, even with marked virilization, as females [ 18 , 19 , 22 , 23 , 26 ]. A psychological counseling for children with CAH and their families, focused on gender identity and GD, is recommended.

46 XY complete gonadal dysgenesis

It is recommended to rear these children as female, due to following considerations: (a) these patients have typical female psychosexual development. (b) Reconstructive surgery is not required for the external genitalia to be consistent with female gender. (c) Hormonal replacement therapy (HRT) is required at puberty as streak gonads should be removed in view of high risk of gonadal malignancy. (d) Pregnancy is feasible with implantation of fertilized donor eggs and hormonal therapy [ 19 , 22 , 23 ].

Complete androgen insensitivity syndrome (CAIS)

It is recommended that subjects with CAIS should be reared as female, due to the following considerations: (a) they have well documented female-typical core psychosexual characteristics, with no significant GD, in accordance with the proposed absence of androgenization of the brain. (b) Surgical reconstruction of the genitalia is not required for consistency with female gender, though vaginoplasty may be necessary. (c) HRT is required with estrogens after gonadectomy, but testosterone replacement is untenable due to androgen resistance [ 18 , 19 , 22 , 23 , 26 ].

5-alpha reductase deficiency

Male gender assignment is usually recommended due to the following considerations: (a) the genital tissue is responsive to androgens. (b) The potential for fertility. (c) The reported high incidence of subjects requesting female-to-male gender reassignment after puberty*. (d) HRT is not required at puberty for patients reared as male, if testes are not removed. (e) As the risk of gonadal malignancy is low, testes can potentially be retained. (f) They are very likely to have a male gender identity.*(As most neonates with this disorder have female external genitalia at birth, they are reared as females. Profound virilization occurs at puberty, with a gender role change from female to male during adolescence in up to 63% cases.) About 60% of these patients, assigned female in infancy and virilizing at puberty, and all who are assigned male, live as males. When the diagnosis is made in infancy, the combination of male gender identity in the majority and the potential for fertility, should be considered for gender assignment [ 19 , 22 , 23 ].

17-beta-HSD-3 deficiency

Classical features are that of an undervirilized male. Some of the affected patients with feminine genitalia at birth are reared as females. Virilization occurs at puberty, with gender role change from female to male in up to 64% cases. They are highly likely to identify as males. Male gender assignment is recommended in partial defects. But there is no strong data to support male gender assignment, as in 5-alpha reductase deficiency. The other considerations against male gender assignment are the lack of reported cases of fertility and the intermediate risk of germ cell tumors. Hence, regular testicular surveillance is required for those reared as male, with retained testes. Therefore, gender assignment should be made considering all the above factors [ 18 , 19 , 22 , 23 , 26 ].

Partial androgen insensitivity syndrome (PAIS)

Infants with PAIS are assigned to male/female gender, depending partially on the degree of undervirilization. The virilization at puberty is also variable and incomplete. The response to hCG stimulation test/testosterone therapy can serve as a guide to the possible sex of rearing. The phenotype is highly variable in PAIS, which is correspondingly reflected in the sex of rearing. The gender identity has considerable fluidity in PAIS, though gender identity is usually in line with the gender of rearing. Though fertility is possible if the testes are retained, it should be remembered that there is an intermediate risk of gonadal germ cell tumors. Hence, gender assignment in these patients is a complex, multifactorial process [ 18 , 19 , 22 , 23 , 26 ].

47 XXY Klinefelter’s syndrome and variants

They usually report a male gender identity, but with a putative high incidence of GD, which needs to be elaborated in larger series.

Mixed gonadal dysgenesis

The genital phenotype is highly variable. The prenatal androgen exposure, internal ductal anatomy, testicular function at and after puberty, post-puberty phallic development, and gonadal location have to be considered to decide the sex of rearing.

• Ovotesticular DSD

These entities were previously referred to as “true hermaphroditism”, signifying the presence of both testicular and ovarian tissue, though dysgenetic, in the same subject. The three patterns seen are as follows:

46 XX/XY–33% of ovotesticular DSD, with testis and ovary/ovotestis.

46 XX–33% of ovotesticular DSD, with dysgenetic ovotestis.

46 XY–7% of ovotesticular DSD, with dysgenetic ovotestis.

This is characterized by ambiguity of genitalia or severe hypospadias at birth, with secondary sexual changes at puberty, corresponding to the relative predominance of ovarian/testicular tissue. The management depends on the age at diagnosis and anatomical differentiation. Either sex assignment is appropriate when the diagnosis is made early, prior to definition of gender identity. The sex of rearing should be decided considering the potential for fertility, based on gonadal differentiation and genital development. It should be ensured that the genitalia are, or can be made, consistent with the chosen sex [ 19 , 22 , 23 , 24 , 25 ].

General guidelines for surgery and HRT in DSD

Feminizing genitoplasty.

Surgery for correction of virilization (clitoral recession, with conservation of neurovascular and erectile structures, and labioplasty) should be carried out in conjunction with the repair of the common urogenital sinus (vaginoplasty). The current recommendation is to perform early, single-stage feminizing surgery for female infants with CAH. It is opined that correction in first year of life relieves parental distress related to anatomic concerns, mitigates the risks of stigmatization and gender identity confusion, and improves attachment between the child and parents. The current recommendation is the early separation of vagina and urethra, the rationale of which includes the beneficial effects of estrogen for wound healing in early infancy, limiting the postoperative stricture formation and avoidance of possible complications from the abnormal connection between the urinary tract and peritoneum through the Fallopian tubes. Surgical reconstruction in infancy may require refinement at puberty. Vaginal dilatation should not be undertaken before puberty. An absent or inadequate vagina, requiring a complex reconstruction of at high risk of stricture formation, may be appropriately delayed. But, the need for complete correction of urogenital sinus, prior to the onset of menstruation, is an important consideration [ 19 , 22 , 23 , 24 , 25 , 26 ].

Male genital reconstruction

The standard timing and techniques of operative procedures for correction of ventral curvature and urethral reconstruction, along with selective use of pre-operative testosterone supplementation is advised when male sex of rearing is adopted. The complexity of phallic reconstruction later in life, compared to infancy, is an important consideration in this regard. There is no evidence that prophylactic removal of discordant structures (utriculus/pseudovagina, Mullerian remnants) that are asymptomatic, is required. But symptoms in the future may mandate surgical removal. In patients with symptomatic utriculus, removal can be attempted laparoscopically, though it may not be practically feasible to preserve the continuity of vas deferens [ 19 , 22 , 23 , 24 , 25 ].

Gonadectomy

The gonads at the greatest risk of malignancy are both dysgenetic and intra-abdominal. The streak gonad in a patient with MGD, raised male should be removed by laparoscopy in early childhood. Bilateral gonadectomy (for bilateral streak gonads) is done in early childhood for females with gonadal dysgenesis and Y chromosome material, which should be detected by techniques like FISH and QFPCR. In patients with defects of Androgen biosynthesis raised female, gonadectomy is done before puberty. The testes in patients with CAIS and those with PAIS, raised as females, should be removed to prevent malignancy in adulthood. Immunohistochemical markers (IHM) that can serve to identify gonads at risk of developing malignancy include OCT 3/ 4, PLAP, AFP, beta-Catenin and CD 117. Early removal at the time of diagnosis (along with estrogen replacement therapy) also takes care of the associated hernia, psychological problems associated with the retained testes and risk of malignancy. Parental choice allows deferment until adolescence, in view of the fact that earliest reported malignancy in CAIS is at 14 years of age. A scrotal testis in gonadal dysgenesis is at risk of malignancy. Current recommendations are surveillance with testicular biopsy at puberty to detect premalignant lesions, which if detected, is treated with local low-dose radiotherapy (with preliminary sperm banking). Also, patients with bilateral ovotestes are potentially fertile from the functioning ovarian tissue. Separation of ovarian and testicular tissue, though challenging, is preferably done early in life [ 19 , 22 , 23 , 24 , 25 , 26 ].

Hormonal therapy/sex steroid replacement

Hormonal induction at puberty in hypogonadism should attempt to replicate normal pubertal maturation to induce secondary sexual characteristics, pubertal growth spurt, optimal bone mineral accumulation together with psychosocial support for psychosexual maturation. Treatment is initiated at low doses and progressively increased. Testosterone supplementation in males (initiated at bone age of 12 years) and estrogen supplementation in females (initiated at bone age of 11 years) is given accordingly for established hypogonadism. In males, exogenous testosterone is generally given till about 21 years, while the same in females is variable. Also, in females a progestin is added after breakthrough bleeding occurs, or within 1–2 years of continuous estrogen. No evidence of benefit exists for addition of cyclical progesterone in females without uterus [ 22 , 23 , 24 , 25 ].

The advances in molecular diagnosis of DSD

The advent of advanced tools for genetic diagnosis has enabled specific diagnosis to be made by molecular studies. WES and WGS represent evolving translational research that help to identify novel genetic causes of DSD. The techniques for identification of novel genetic factors in DSD have evolved from the use of CGH and custom array sequencing to the use of next generation sequencing (NGS) which mainly includes polymerase-based and ligase-based techniques. The importance of molecular diagnosis in DSD lies in the guidance of management in relation to possible gender development, assessment of adrenal and gonadal function, evaluation of the risk of gonadal malignancy, assessment of the risk of familial recurrence, and prediction of possible morbidities and long-term outcome. Hence, the advances in molecular diagnosis of DSD constitute a rapidly evolving frontier in the understanding and therapy of DSD.

The ethical dimension in DSD

The predominant ethical considerations in management of DSD are twofold. Firstly, when the components of biological sex (the sexual profile of genome, gonads, phenotype, endocrine and neurological status) align strongly, prediction of gender identity and recommendations for sex assignment can be made accordingly. The more discordant the determinants of biological sex, more variation in subsequent components of psychosexual development. Secondly, irreversible anatomic and physiologic effects of surgical assignment of sex have to be avoided, especially when the components of biological sex do not strongly align. The objective in such situations should be to delay such treatment till the appropriate age [ 24 , 25 , 26 ].

The arguments favoring recognition of DSD as an alternate gender, with delayed sex assignment and deferred surgical therapy has gained ground over the past decades, highlighted by certain judicial interventions across the globe. In this regard, it has to be emphasized that a transgender state, without incongruity of biological sex, has to be clearly distinguished from a DSD. Though differences in psychosexual development can occur in DSD, the vast majority of clinically diagnosed DSD (CAH, MGD, 46 XY DSD) have the anatomic and physiological consequences of altered components of biological sex. The issues in these subjects are not only confined to the genitalia, but also include problems that can include life-threatening cortisol deficiency, features of hypogonadism and urogenital sinus, and even the risk of gonadal malignancy. The early identification and correction of each issue is vital, and the best available window for the same is limited and usually, early in life. It is some of the less frequently encountered types of DSD (ovotesticular DSD, 17-BHSD deficiency, PAIS) that invariably require a more complex decision-making process. The diagnostic and therapeutic approach in the majority of clinically encountered DSD requires a structured scientific approach, with due consideration of the intricacies of psychosexual development.

The optimal management of different types of DSD in the present era requires the following considerations: (1) establishment of a precise diagnosis, employing the advances in genetic testing and endocrine evaluation. (2) A multidisciplinary team is required for the diagnosis, evaluation, gender assignment and follow-up of these children, and during their transition to adulthood. (3) Deeper understanding of the issues in psychosexual development in DSD is vital for therapy. (4) The patients and their families should be an integral part of the decision-making process. (5) Recommendations for gender assignment should be based upon the specific outcome data. (6) The relative rarity of DSD should prompt constitution of DSD registers, to record and share information, on national/international basis. (7) The formation of peer support groups is equally important. The recognition that each subject with DSD is unique and requires individualized therapy remains the most paramount.

Availability of data and materials

Available on request.

Abbreviations

Disorders of sexual differentiation

• Congenital adrenal hyperplasia

Complete androgen insensitivity syndrome

Partial androgen insensitivity syndrome

Follicular stimulating hormone

Leutinizing hormone

Human chorionic gonadotropin

Fluorescence in situ hybridization

Quantitative fluorescence polymerase chain reaction

Comparative genomic hybridization

Multiplex ligand-dependent probe amplification

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The sincere guidance and help provided by Dr. K Sivakumar, Professor and Head, Department of Pediatric Surgery, Government Medical College, Thiruvananthapuram, Kerala, is gratefully acknowledged.

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Sarma, V.P. A review of the essential concepts in diagnosis, therapy, and gender assignment in disorders of sexual development. Ann Pediatr Surg 18 , 13 (2022). https://doi.org/10.1186/s43159-021-00149-w

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DOI : https://doi.org/10.1186/s43159-021-00149-w

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• Disorders of sexual development
• Ambiguous genitalia
• Gonadal dysgenesis
• Psychosexual development
• Gender dysphoria

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• J Clin Res Pediatr Endocrinol
• v.12(4); 2020 Dec

Gender Identity and Assignment Recommendations in Disorders of Sex Development Patients: 20 Years’ Experience and Challenges

Fatih gürbüz.

1 Çukurova University Faculty of Medicine, Department of Pediatric Endocrinology, Adana, Turkey

Murat Alkan

2 Çukurova University Faculty of Medicine, Department of Pediatric Surgery, Adana, Turkey

Gonca Çelik

3 Çukurova University Faculty of Medicine, Department of Child Psychiatry, Adana, Turkey

Atıl Bişgin

4 Çukurova University Faculty of Medicine, Department of Medical Genetics, Adana, Turkey

Necmi Çekin

5 Çukurova University Faculty of Medicine, Department of Forensic Medicine, Adana, Turkey

İlker Ünal

6 Çukurova University Faculty of Medicine, Department of Biostatistics, Adana, Turkey

Ali Kemal Topaloğlu

Ünal zorludemir, ayşe avcı, bilgin yüksel.

Gender assignment in infants and children with disorders of sex development (DSD) is a stressful situation for both patient/families and medical professionals.

The purpose of this study was to investigate the results of gender assignment recommendations in children with DSD in our clinic from 1999 through 2019.

The mean age of the 226 patients with DSD at the time of first admission were 3.05±4.70 years. 50.9% of patients were 46,XY DSD, 42.9% were 46,XX DSD and 6.2% were sex chromosome DSD. Congenital adrenal hyperplasia (majority of patients had 21-hydroxylase deficiency) was the most common etiological cause of 46,XX DSD. In 46,XX patients, 87 of 99 (89.7%) were recommended to be supported as a female, 6 as a male, and 4 were followed up. In 46,XY patients, 40 of 115 (34.8%) were recommended to be supported as a female, and 70 as male (60.9%), and 5 were followed up. In sex chromosome DSD patients, 3 of 14 were recommended to be supported as a female, 9 as a male. The greatest difficulty in making gender assignment recommendations were in the 46,XY DSD group.

Conclusion:

In DSD gender assignment recommendations, the etiologic diagnosis, psychiatric gender orientation, expectation of the family, phallus length and Prader stage were effective in the gender assignment in DSD cases, especially the first two criteria. It is important to share these experiences among the medical professionals who are routinely charged with this difficult task in multidisciplinary councils.

What is already known on this topic?

Gender assignment in disorders of sex development (DSD) patients is always very difficult, complex and demanding experience in the management for both families and clinicians, particularly in cases where the gender appropriate for the clinical diagnosis is incompatible with the psychological gender of the patient. Gender assignment councils must have an experienced and multidisciplinary approach.

What this study adds?

Here, we present 20 years of experience and challenges in gender assignment, the causes and clinical characteristics of patients with DSD. This study is the longest timeframe, is the most comprehensive and has the largest number of cases in terms of gender assignment recommendation and assessing the factors affecting gender assignment from Turkey.

Introduction

According to Jost’s paradigm, the first sexual development stage begins with the identification of the chromosomal sex at the time of fertilization and is completed as a result of many biological process ( 1 ). Money et al. ( 2 ) added the theory of psychosexual development to this paradigm. This theory is influenced by hormonal and genetic status, environmental and psychosocial experiences, and social and parental behavior ( 3 , 4 , 5 ). Any defect occurring during this complicated process of sexual differentiation may lead to a discordant development of chromosomal, gonadal, and anatomical sex/phenotype and is defined as disorders of sex development (DSD) ( 6 , 7 , 8 ). DSD are a heterogeneous group of rare conditions which include various etiologies and presentations ( 9 , 10 , 11 ). The incidence of DSD is almost 1 in 4,500-5,500 ( 10 , 11 , 12 ).

The long-term physical, social and psychological outcomes of patients with DSD are still unclear. There are increasing concerns regarding early decisions about gender assignment in recent reports ( 13 , 14 , 15 , 16 , 17 , 18 ). Studies have been generally conducted regarding psychosexual and surgical outcomes in this group of patients ( 19 , 20 , 21 , 22 ). Gender assignment of a child with DSD is the most difficult and stressful condition for both the family and the clinician, especially in cases of ambiguous genitalia ( 6 , 23 , 24 ). Families will always want to know the actual gender of their DSD baby as soon as possible and give their baby a gender appropriate name. The primary goal in DSD is for gender identity to be consistent with the gender assigned ( 6 ). In this respect, a multidisciplinary approach is required for the diagnosis and treatment of DSD ( 25 ). Influencing factors to consider when debating gender assignment include medical diagnosis, external genital appearance, potential of fertility and sexuality, therapeutic and/or surgical intervention options, views and desires of the patients and their families, sociocultural factors, and the psychological gender development status of the child ( 26 , 27 , 28 ).

There is a multidisciplinary council to make gender assignment recommendations in DSD patients which, in our clinic, consists of pediatric endocrinology, pediatric surgery, pediatric psychiatry, medical genetics and forensic science specialists. Here, we present 20 years of experience at a single regional referral center in assistance with gender assignment in DSD patients.

The purpose of this study was to investigate the results of gender assignment recommendations in children with DSD and the factors affecting these results in our clinic. In the present study, the file records of the 226 children with DSD admitted to the Department of Pediatric Endocrinology of Çukurova University between the years of 1999 and 2019 were reviewed. The clinical diagnosis of a DSD was supported by anatomical examination findings, gonadal and pelvic ultrasound, cytogenetic studies, determination of serum electrolytes, 17-hydroxyprogesterone levels, the ratio of testosterone-dihydrotestosterone (basal and hCG stimulated) and molecular genetic testing. 21-hydroxylase deficiency (21-OHD) (72 of 88), 11-beta-hydroxylase deficiency (6 of 6), 17-beta-hydroxysteroid dehydrogenase type 3 deficiency (4 of 4), Steroidogenic Acute Regulatory Protein (STAR) gene mutations (5 of 5), complete androgen resistance (8 of 9), incomplete androgen resistance (6 of 6), 5-alpha-reductase deficiency, (19 of 19), Leydig cell aplasia/hypoplasia (2 of 2), 17-alpha-hydroxylase deficiency, (1 of 1), DSS-AHC Region on Human X Chromosome ( DAX1 ; also known as NR0B1 ) (2 of 2), NR5A1 (SF1) (2 of 2), Persistent Mullerian Duct syndrome (1 of 1), and Klinefelter syndrome (2 of 2) were diagnosed by cytogenetic studies and molecular genetic analyses. However, mixed gonadal dysgenesis, gonadal dysgenesis, ovotestis and Sertoli cell only syndrome were diagnosed by laparoscopy with gonadal biopsy, and molecular genetic testing. All the genetic testing was performed for diagnostic purposes after consent from the patients or child’s legal representative.

Laparoscopy and gonadal biopsy were performed in selected DSD patients for determination of gonadal histology. Cystoscopy was performed in order to examine urethra, uterus and uterine remnants.

Our center is the first, and the oldest and largest ‘Gender Evaluation Council’ in the region. This council consists of pediatric endocrinologists, pediatric surgeons, child psychiatrists, specialists in forensic medicine and a medical geneticist. Gender assignment recommendations were made by this council. The role of the council is to evaluate medical data, to conduct expert discussion, and to provide information and medical advice to the patient and/or family. The council ensures that ample time and opportunities are provided to patient and families for their questions, concerns, and counseling needs.

Exclusion criteria for this study were: DSD patients who did not need gender assignment (therefore not discussed in the council) such as Turner syndrome and isolated hypospadias. Written inform consent was obtained after the council from the parents or legal guardians of all the patients before participation. The study protocol was approved by the Ethics Committee of Çukurova University and performed in accordance with the ethical standards of the Declaration of Helsinki (ethical decision no: 452018.77/10).

Background clinical data obtained from medical file records included age at the time of first admission and meeting, reason for admission, genital examination findings, Prader stage, karyotype, diagnosis, psychiatric gender orientations, gender patient was being raised as, parents’ views and requests for the gender, number of council meetings held for each patient, and gender assigned. Although genital phenotype evaluation according to the Sinnecker classification is more appropriate for 46,XY DSD cases ( 29 ), all patients were evaluated via Prader classification in order to avoid confusion ( 30 ).

The patients were classified into three main groups on the basis of the karyotype of the affected individual, according to The Lawson Wilkins Pediatric Endocrine Society and the European Society for Paediatric Endocrinology consensus ( 8 , 9 , 31 ). These groups are: 46,XX DSD; 46,XY DSD; and sex chromosome DSD.

The psychological evaluation for gender orientation was based on psychiatric interview with children and according to Diagnostic and Statistical Manual of Mental Disorders-5 diagnostic criteria ( 32 ).

Statistical Analysis

All analyses were performed using SPSS, version 20.0 statistical software package (IBM Inc., Armonk, NY, USA). Categorical variables were expressed as numbers and percentages, whereas continuous variables were summarized as mean and standard deviation (SD). Chi-square test was used to compare categorical variables between the groups. The normality of distribution for continuous variables was confirmed with the Shapiro-Wilk test. For comparison of continuous variables between two groups, the Student’s t-test or Mann-Whitney U test was used depending on the distribution being normal or non-parametric, respectively. For comparison of continuous variables between more than two groups, Kruskal Wallis test was used. Bonferroni adjusted Mann-Whitney U test was used for pairwise comparisons of groups. The statistical level of significance for all tests was considered to be 0.05.

A total of 226 patients were classified as 46,XY DSD (n=115, 50.9%), 46,XX DSD (n=97, 42.9%) or sex chromosome DSD (n=14, 6.2%) ( Table 1 ). The mean±SD age at first admission of the patients was 3.05±4.70 (range 0-17.58) years.

Of the 226 patients, ambiguous genitalia (n=141, 62.4%) was the most frequent cause of admission for all three groups ( Table 1 ).

When the diagnostic distribution of the patients was examined, congenital adrenal hyperplasia (CAH) was the most common cause of DSD. Among the 46,XX DSD (n=97) patients, 21-OHD was the most common (n=88, 90.7%) ( Table 1 ). The most common cause amongst 46,XY DSD cases (n=115) was 5-alpha reductase deficiency (n=19, 16.5%). This was followed by complete androgen insensitivity syndrome (CAIS) and incomplete androgen resistance (PAIS) (total n=15, 13%). Forty-two (18.6%) of all cases had undetermined causes for DSD. The vast majority of these were 46,XY DSD cases (40/42, 95.2%) ( Table 1 , ​ ,2 2 ).

The psychiatric evaluation of cases showed that only about half of the 46,XX DSD patients had female and one in three of the 46,XY DSD patients had male gender orientation. In the sex chromosome DSD cases, female gender was 4/15 and male gender was 5/14 patients and 5/15 patients had no sexual orientation ( Figure 1 ).

Gender orientations and gender assignment recommendations

DSD: disorders of sex development, F: female, M: male, NSO: no sexual orientation

*Two of the 3 cases with 46,XX related to 21-hydroxylase deficiency were raised as a male and their families insisted on an assignment recommendation as the male gender. The other one case had female gender orientation, but the family wanted to raise as the male gender. The remaining one 46,XX DSD patient had 11-OH deficiency, and raised as the male gender. Moreover, patient’s family wanted to raise as the male gender although the patient had menstrual bleeding.

**For 2 cases with 46,XY DSD diagnosed with 5-alpha reductase deficiency a follow-up recommendation was made, who were raised as female gender instead of male gender by their parents. Families were persistently wanting for a female assignment to be made. The other two 46,XY DSD cases had a diagnosis of gonadal dysgenesis and had not yet developed a gender orientation. The one 46,XY DSD patient had 17-betahydroxysteroid dehydrogenase type 3 deficiency, was raised as a female and the family asked for a male gender assignment.

***The one Klinefelter syndrome case was raised as a female and her family wanted to raise as the female gender. The other one patient was mixed gonadal dysgenesis and had no gender orientation yet.

The median age of all cases was 1.90 (mean: 4.46±4.98, range 0.12-18.63) years at the time of the council meeting. For each of the categories 46,XX DSD, 46,XY DSD and sex chromosome DSD patients these median ages were 1.60 (mean: 3.20±3.92, range 0.12-18.56), 2.98 (mean: 5.49±5.41, range 0.13-18.38) and 1.67 (mean: 4.77±6.15, range 0.21-18.63) years, respectively (p=0.004). While 200 (88.5%) of 226 patients had gender assignment at the first council meeting, 26 patients (11.5%) had more than one council meeting of whom 18/26 were 46,XY DSD, six were 46,XX DSD and two were sex chromosomal DSD patients. It is notable that patients requiring more than one meeting were mostly 46,XY DSD cases.

The mean age intervals of presentation and being considered at the meeting for 46,XX DSD, 46,XY DSD, and sex chromosome DSD were 1.19±2.03 (range 0.06-10.96) years, 1.45±2.12 (range 0.03-11.97) years and 2.73±4.58 (range 0.02-15.08) years, respectively. It was found that, these intervals were not different according to the DSD diagnosis (p=0.113), Prader stage (p=0.949) and decision (p=0.062).

In 46,XY DSD patients, 40 of 115 (34.8%) were recommended to be assigned as a female gender ( Figure 1 ). The female gender assignment recommendation in these cases was made for all of the CAIS, Leydig cell aplasia/hypoplasia, STAR gene mutations, 17-alpha hydroxylase and DAX1 (NR0B1) mutation cases according to the genetic diagnosis ( Table 2 ).

Eleven of 226 cases (4.8%) were followed without a gender assignment ( Figure 1 ). The common characteristic of all these cases who were not assigned a gender was that the family’s gender expectation was not compatible with chromosomal analysis, specific diagnosis, Prader stage and/or psychiatric evaluation.

When the effect of phallus length on the assignment recommendation was examined, it was found that in all three groups, phallus length was significantly higher in male assignments than in female assignments ( Table 3 ).

According to the Prader classification with gender assignments recommendation, lower Prader stages (especially stage 1) were effective in making a female gender assignment in 46,XY DSD and sex chromosomal DSD cases. In addition, as the Prader stage increased, the decision-making ratio was gradually increased in favor of the male gender. However, the higher Prader stages were not associated with making a male gender assignment in 46,XX DSD cases. Moreover, the gender assignment of patients with Prader stage 1-4 was the female gender in a very large number of the 46,XX DSD cases. In general, it was found that a lower Prader stage was more effective in making a female gender assignment recommendation, than making a male gender assignment recommendation with a higher Prader stage ( Table 4 ).

In this study, 20 years of experience in helping gender assignment, the causes and clinical characteristics of patients with DSD in a single referral clinic are presented. Gender assignment is always very difficult, complex and demands experience in the management of patients with DSD for both families and clinicians, particularly in cases where the gender appropriate for the clinical diagnosis is incompatible with the psychological gender of the patient. It should be recognized that every DSD is unique and has to be treated with individualized care. To our knowledge, this study has the longest timeframe, is the most comprehensive and has the largest number of cases in terms of gender assignment recommendation and assessing the factors affecting gender assignment from Turkey.

DSD are a heterogeneous group of conditions, which has an estimated incidence of 1:4500-5500 ( 10 , 11 , 12 , 33 , 34 ). In a recent study from Turkey by Aydin et al ( 35 ), it was found that the DSD newborn with ambiguous genitalia rate was 1.3/1000 newborns. However, this rate may be higher in our region where there is an increase in autosomal recessive forms of DSD due to higher rates of consanguinity, around 20% to 25% ( 35 ). This is in contrast to the consanguineous marriage rate reported by Aydin et al ( 35 ) (3 families of total 18 DSD patients). Nordenvall et al ( 36 ) remarked that the developmental anomalies of the external genitalia may be seen in 1:300 infants. However, not all of these conditions require gender assignment, including relatively common conditions such as isolated undescended testis and/or hypospadias.

Previous studies have reported a higher incidence of 46,XY DSD compared to 46,XX or sex chromosome DSD ( 35 , 37 , 38 , 39 , 40 , 41 , 42 ). In accordance with this the most common DSD group in our cohort was 46,XY DSD (50.9%). In a study with 117 patients from Thailand, it was reported that most of the cases were sex chromosome DSD (53%) ( 43 ). However, the majority of these patients were Turner syndrome. Girls with Turner syndrome were excluded from the present study because there is no necessity for gender assignment. Two Klinefelter syndrome patients were included because of ambiguous genitalia but other patients with Klinefelter syndrome without ambiguous genitalia, and thus without requirement for a gender assignment process were excluded.

Most patients with DSD are referred with ambiguous genitalia ( 35 , 37 , 38 , 39 , 43 ). In this study, ambiguous genitalia was the most common cause of admissions for all three DSD classifications ( Table 1 ).

Despite the current advanced genetic analyses, a definitive genetic diagnosis can only be made in about 20% of cases of DSD ( 11 , 12 , 31 , 37 ). Compatible with this information, the rate of patients with undetermined causes of DSD was 18.6% (42/226) in our study. There were only two patients (2%) with undetermined causes in the 46,XX DSD group whereas this was 40/115 (34.7%) amongst the 46,XY DSD cases, thus constituting 40/42 (95%) of the patients without a definitive genetic diagnosis.

The etiologic cause of most of the patients with 46,XX DSD is CAH due to 21-OHD ( 37 , 38 , 39 , 44 ). In this study, CAH was the most common underlying etiological condition of 46,XX DSD ( Table 1 ). CAH due to 21-OHD and 11-OHD accounted for 97.9% of 46,XX DSD in our series. Similarly, Ocal et al ( 39 ) found that 21-OHD and 11-OHD were the most frequent etiology (88.8%) of their 46,XX DSD group. De Paula et al (38) from Brazil with a 408 case series of genital ambiguity, Al-Mutair et al ( 45 ) from Saudi Arabia with a total of 120 DSD patients, and Al-Agha et al ( 46 ) from Australia report that the main etiology of 46,XX DSD was 21-OHD. However, Ganie et al ( 37 ) reported that the main referring cause of 46,XX DSD was ovotesticular in patients from sub-Saharan Africa.

It has been reported that only 50% of patients with 46,XY DSD can be given a definite diagnosis ( 44 ). In our study, the rate of 46,XY DSD patients with diagnosed causes was higher (n=75, 65.2%). The reason for this difference may be due to the further development of genetic understanding over the years. 5-alpha reductase deficiency was the most common etiology followed by CAIS and PAIS in 46,XY DSD ( Table 1 , ​ ,2). 2 ). The etiological distributions of both 46,XX DSD and 46,XY DSD patients were similar to previous studies ( 38 , 39 , 41 , 45 , 46 , 47 ). Contrary to this, Ganie et al ( 37 ) report that the main etiological cause of 46,XY DSD was disorder of androgen synthesis or action.

Mixed gonadal dysgenesis was the most common etiology in the sex chromosome DSD group in our study (85.7%) which excluded Turner syndrome. Jaruratanasirikul and Engchaun ( 43 ) from Thailand reported that the most common sex chromosome DSD was Turner syndrome followed by Klinefelter syndrome and 45,X/46,XY DSD. Similar to this report, Ganie et al ( 37 ) from South Africa, with a total 346 cases diagnosed with DSD, noted that Turner syndrome constituted the largest proportion of the sex chromosome DSD group (61%), followed by mixed gonadal dysgenesis.

Gender identity is a characteristic which is influenced by various prenatal and postnatal variables. Psychosexual development plays an important role in the formation of sexual identity and is the main component of sexual identity, which is influenced by genetic status, pre/postnatal exposure to androgens, sociocultural factors, and family dynamics ( 6 , 39 , 48 , 49 ). Gender assignment is an important problem in DSD patients who have a virilized brain with undervirilized external genitalia ( 13 , 14 , 15 , 39 ).

Eleven of 97 46,XX patients (11.3%) had male gender orientation in the psychological evaluation, and were raised as the male gender by parents (nine were 21-OHD, one was 11-OHD, and one had Sertoli cell only syndrome; mean age of cases was 9.92±4.96 years). At the council meeting, six of these 11 cases were gender assignment recommendation male, two as female and three were not assigned and were recommended to be followed up.

Five of the patients who received a male assignment recommendation were 46,XX 21-OHD CAH and the other one was Sertoli cell only syndrome ( Table 2 ). The mean age at presentation and at the time of the meeting of these five 21-OHD CAH patients was 7.56±5.26 years and 10.66±3.88 years, respectively. It was found that all of these patients were Prader stage 4-5, raised as male and their psychologic gender orientation was male, and all of the parents demanded a male gender assignment. The factors most strongly influencing recommended gender assignment in 46,XX cases included etiological diagnosis, age, psychologic gender and Prader staging ( Table 2 , ​ ,4 4 ).

Similar to our study, Khattab et al ( 13 ) report three 46,XX with 21-OHD CAH patients who were reared as male gender. In another study, of 50 DSD patients, 4/11 cases diagnosed with 46,XX DSD due to CAH had assumed a male social gender ( 15 ). This condition occurs due to prenatal and/or postnatal exposure to high levels of androgens that promote the masculinization of gender behavior ( 16 , 50 ). With the recent implementation of national neonatal CAH screening, it is hoped that late diagnosis of CAH, and therefore ambiguous genitalia, will be prevented.

For our council, the greatest difficulty in making gender assignment recommendations was in the 46,XY DSD group. The mean length of the phallus of patients who received a female assignment was 0.82±0.71 cm and 90% were Prader stage 1-2; etiological causes of these cases is shown in Table 2 . Most of the 46,XY DSD patients who had no etiological diagnosis and had female gender assignment recommendations were Prader stage 1-2. Interestingly, psychological evaluation of these cases showed 8/9 had female gender and 1/9 had no gender orientation.

The majority, 93.7%, of the 46,XY cases with a male gender assignment recommendation and no etiological diagnosis were Prader stage 3-5. Moreover, 62.5% of these patients had no gender orientation yet. These findings suggest that, besides the etiologic diagnosis, the expectation of the family, phallus length and Prader stage were effective in the female assignment recommendations in 46,XY DSD cases. Furthermore, if there is no definite etiologic diagnosis, the most important factors in determining the gender assignment recommendation in 46,XY DSD patients were Prader stage and psychological gender orientation.

Study Limitations

The major limitation of this study was the patients were only considered from presentation until the final decision for each individual by the gender assignment recommendation council. Due to ethical concerns, follow-up of patients after gender assignment recommendation was not included and thus there is no measure of agreement or discordance with the decision of the council reported.

The most difficult aspect of managing a patient with DSD diagnosis who has ambiguous genitalia is the assignment of an appropriate gender. Specific diagnosis and psychological gender are more effective in gender assignment of DSD patients with an etiologic cause. Phallus length and Prader stage are important criteria in the gender assignment of patients with undiagnosed DSD. In this cohort none of the clinical, etiological or genetic features of the patients dominated the gender assignment decision. Gender assignment should be determined by evaluating the patient’s chromosome structure, specific diagnosis, fertility, Prader stage, phallus length, psychological orientation, family wish and the consensus opinion of experienced specialist physicians. Gender assignment becomes more difficult, especially if there is a mismatch of the gender the child is raised as, with the etiologic diagnosis. Gender assignment councils must have an experienced and multidisciplinary approach to the diagnosis, medical and/or surgical treatment, psychosocial support, and genetic counseling of patients with DSD. We hope that by publishing our extensive experience in this challenging clinical area we will help other clinicians and patients facing these difficult choices.

Acknowledgments

The authors would like to thank the patients and their parents who participated in this study.

Ethics Committee Approval: The study protocol was approved by the Ethics Committee of Çukurova University and performed in accordance with the ethical standards of the Declaration of Helsinki (ethical decision no: 452018.77/10).

Informed Consent: Written inform consent was obtained after the council from the parents or legal guardians of all the patients before participation.

Peer-review: Externally peer-reviewed.

Authorship Contributions

Financial Disclosure: The authors declared that this study received no financial support.

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Article contents

Gender identity and gender expression.

• Jama Shelton Jama Shelton Hunter College, City University of New York
• https://doi.org/10.1093/acrefore/9780199975839.013.1324
• Published online: 21 June 2023

Gender identity and gender expression are aspects of personal identity that impact an individual across multiple social dimensions. As such, it is critical that social workers understand the role of gender identity and gender expression in an individual’s life. Many intersecting factors contribute to an individual’s gender identity development and gender expression, as well as their experiences interacting with individuals, communities, and systems. For instance, an individual’s race, geographic location, disability status, cultural background, religious affiliation, age, economic status, and access to gender-affirming healthcare are some of the factors that may impact experiences of gender identity and gender expression. Gender identity and expression are dimensions of diversity that social workers will interact with at all levels of practice. As such, it is important for social work educational institutions to ensure their students are prepared for practice with people of all gender identities and expression, while also understanding the historical context of the social work profession in relation to transgender populations and the ways in which the profession has reinforced the sex and gender binaries.

• gender binary
• gender equity
• gender identity
• gender expression

What Are Gender Identity and Gender Expression?

Every individual has a gender identity, and every individual expresses their gender (see Table 1 ). Gender identity and gender expression are often referenced in relation to transgender, nonbinary, and gender-expansive people, yet one’s gender and the expression of gender are dimensions of identity that every individual possesses. Gender identity can be understood as an individual’s internal sense of self as it relates to gender. One’s gender is a deeply felt, personal sense of self as a girl/woman, boy/man, both a girl/woman and a boy/man, neither a girl/woman nor a boy/man, or a combination of a girl/woman and a boy/man. Additional words people may use to describe their gender include (but are not limited to): nonbinary, gender expansive, agender, multigender, two-spirited, gender-fluid, genderqueer, and muxe. Importantly, there is no external source that can dictate an individual’s gender identity.

Gender expression refers to the ways in which an individual expresses their gender outwardly. Gender expression may include an individual’s dress, hairstyle, mannerisms, and behaviors. These are typically based on stereotypes about gender within a particular cultural context. An individual’s gender expression may or may not conform to social norms that are typically associated with an individual’s gender or with gendered assumptions based on an individual’s assigned sex. Importantly, an individual’s gender presentation may or may not reflect their gender identity. Issues such as personal safety and access to accurately gendered items may impact an individual’s ability to express their gender in a way that aligns with their gender identity.

Table 1. Additional Relevant Terms

The sex and gender binaries.

The terms gender and sex are often used interchangeably. While these terms may be related in some instances, they are not the same. An individual’s sex is connected to their chromosomes, hormones, and anatomy. Typically, an individual is assigned a sex at birth, if not prior to birth. A sex assignment is most often made based on the appearance of a baby’s genitals. The options for sex assignment have historically been either male or female, which is then listed on an individual’s birth certificate. This is still often the case in the United States, even though evidence demonstrates that sex is not a binary construct ( Fausto-Sterling, 2018 ). Some states in the country allow an additional option (X) for the classification of sex on the birth certificate. While it is beyond the scope of this article to examine the category of intersex (discussed in “XXX”), intersex people cannot be overlooked in discussions of sex and gender. The binary construction of sex assumes the existence of only two sexes. This is an inaccurate and limiting construct that ignores human variability. Not only is it inaccurate and limiting, it is also harmful. Intersex babies and children often undergo surgical procedures that they do not consent to, and are required to take hormones in order to make their bodies fit within a binary that their bodies directly challenge.

An individual’s gender is most often presumed based on their sex assignment, and is presumed to fall within the binary gender categories of girl/woman and boy/man. For instance, if a baby is assigned female, the assumption is that the baby is a girl and will grow up to be a woman. With this assumption comes a set of gendered norms and expectations, societally reinforced in myriad ways including options for grooming and dress, presumptions about appropriate behavior and presentation, and even the choice of language used to praise or discipline (“such a pretty girl” or “that’s not ladylike”). However, an individual’s assigned sex does not always predict their gender; gender identity is more strongly linked to an individual’s experience of gender than to assigned sex ( Olson et al., 2015 ). Yet, the connection between an individual’s sex and their gender and the binary constructions of both sex and gender are so widely taught that this misperception is pervasive in the United States and in many Western countries despite the fact that “defining gender as a condition determined strictly by a person’s genitals is based on a notion that doctors and scientists abandoned long ago as oversimplified and often medically meaningless” ( Grady, 2018 ). In addition to the limitations of these binary categories, sex and gender are often viewed as immutable and stable over time. The lived experiences of intersex, nonbinary, transgender, and gender-expansive people demonstrate the inaccuracy of the binary system of sex and gender categorization.

It is important to note that an individual’s identification within the gender binary is not itself problematic. Because many laws and policies in the United States are based on a binary construction of sex and/or gender, it is the classification system itself that is flawed. Binary classifications are problematic when identification with the gender binary and associated gender expressions are required for entry within social and legal systems.

Beyond the Binary: Reconceptualizing Gender Identity and Gender Expression

Some think about gender identity and gender expression as a continuum, with binary classifications marking the endpoints and a range of identities and expressions in between. More contemporary understandings assert that gender identity and gender expression exist more as a “galaxy” rather than a continuum ( Action Canada for Sexual Health and Rights, n.d. ). This thinking is more in alignment with moving beyond binary conceptualizations of gender altogether and situates all gender identities and gender expressions as equally viable, without relying on the containment of binary categories.

Moving beyond the gender binary not only improves the lived experiences of transgender, nonbinary, and gender-expansive people but also opens up possibilities for everyone . The construct of gender carries with it prescribed ways of being ranging from what is “appropriate” physical and behavioral gender expression to what are appropriate fields of study and career choices. Truly moving beyond the gender binary can liberate all people from the constraints inherent in presumptive and prescribed notions of what is deemed socially, culturally, and politically appropriate.

How could moving beyond the gender binary be operationalized within the social work profession? Prior to discussing suggestions for moving beyond the binary in social work education, practice, and research, it is important to first examine the history of the social work profession as it relates to gender identity and gender expression.

Social Work, Gender Identity, and Gender Expression: A Brief History

Historically, the social work profession is rife with demands that nonconforming gender expressions and bodies adapt to mainstream gendered expectations. Examples include the profession’s support for the assimilative Native American Residential Schools, electroconvulsive therapies intended to “cure” homosexuality, and a host of welfare eligibility requirements that serve to police Black families for their deviation from White heteronormative standards ( Bowles & Hopps, 2014 ). Thus, common practices centered around promoting access to resources through acclimating and gaining membership to the status quo. As such, the profession of social work has been complicit in the policing of gender and the maintenance of the gender binary. It is important for the profession to reckon with this disciplinary approach to gender identity and expression in the past, while also developing equitable frameworks for the future.

The primary formal mechanism for the policing of gender and, thus the reification of the gender binary, is the Diagnostic and Statistical Manual of Mental Disorders (DSM). Gender identity disorder was first included in the DSM-III in 1980 , and included the diagnoses “gender identity disorder of childhood” and “transsexualism.” When updated in 1987 , the new DSM-III-R included gender identity disorder of adolescence and adulthood, nontranssexual type ( Drescher, 2009 ). Gender identity disorder of adolescence and adulthood, nontranssexual type, was removed from the DSM-IV and replaced with the category gender identity disorder, a diagnosis encompassing both gender identity disorder of childhood and transsexualism ( Shelton et al., 2019 ). The most recent version of the DSM (the DSM-5) replaced gender identity disorder with gender dysphoria. This shift in diagnostic terminology signifies a change in the understanding of the root causes of the challenges individuals face when their gender identity and gender expression fall outside of the dominant societal norms prescribed to the gender associated with their assigned sex. Namely that societal definitions of and expectations surrounding gender do not accurately reflect people’s lived experience of gender. However, the fact that a mental health diagnosis remains in the DSM is considered problematic by many, as gender related dissonance continues to be constructed as individual pathology.

The DSM solidified the notion of a gendered norm any deviation from which required correction. For decades, the remedy was to fit an individual into a gender that aligned with the expectations associated with their assigned sex. Through modern medicine, a new type of “correction” emerged for those who could gain access, through hormone treatment and affirming surgeries. Though these interventions are medical in nature, the psychiatric diagnoses remain a driving force in accessing these treatments. Further, gender-affirming treatments have reinforced the necessity of binary gender conformity, by supporting an individual in their transition from one gender to the other gender. It is important to note here that these treatments have been and continue to be life-saving for many individuals, and that identifying with the gender binary is not in itself problematic. As already stated, the gender binary is problematic when a binary classification is imposed and/or presumed and is not in alignment with an individual’s stated gender and understanding of their own body ( Ansara & Hegarty, 2012 ), and when identification or categorization within the gender binary is required for entry into and acceptance within social and legal systems ( Shelton et al., 2019 ).

The National Association of Social Workers released a position statement denouncing the continued inclusion of gender identity related diagnoses in the DSM-5, stating that diagnoses such as gender dysphoria should be approached from a medical model rather than a mental health model. Because of the authority that the DSM holds in social work and related professions, the inclusion of gender dysphoria perpetuates the notion that the variability of gender is a psychiatric condition, reinforcing cisnormativity and the binary gender system. Advocacy organizations argue that until gender related diagnoses are removed from the DSM, transgender and gender-expansive people will continue to suffer from stigma, discrimination, and the invalidation of their identities and experiences.

Social workers may find themselves in a gatekeeping role when working with individuals whose gender identity and/or gender expression expand beyond binary classifications or stretch the boundaries of what is typically considered appropriate gendered behavior based on an individual’s sex assignment. For instance, according to the Standards of Care put forth by the World Professional Association for Transgender Health ( WPATH, 2012 ), in order to access gender-affirming care (such as hormone treatment or surgery), an individual must obtain a letter of recommendation from a qualified mental health professional diagnosing their persistent gender dysphoria and indicating their readiness for care ( Coleman et al, 2022 ). Thus, the notion that individuals whose gender identities expand beyond the binary cisgender norm are not only pathologized but also viewed as incapable of owning their own bodily expertise. The same requirements are not expected from cisgender individuals seeking body altering surgeries, such as breast augmentation, hair implants, or facelifts.

Notably, not every nonbinary, gender-expansive, or transgender individual desires gender-affirming medical procedures. There is no single way to be nonbinary, gender expansive, or transgender, just as there is no single way to be a girl, woman, boy, or man. Each individual person experiences and expresses their gender in their own unique way.

Social Work and Gender Equity

Social workers are charged with confronting injustice; social justice is a core value of the profession. In recognition of the social worker’s responsibility to work toward social justice, the Council on Social Work Education (CSWE) (2015 ) generated accreditation standards requiring social workers to understand diversity and difference in the context of privilege, power, oppression, and marginalization to eliminate biases (Competency 2). Because gender identity and gender expression are included as dimensions of diversity that professionals must understand and value, social workers have an ethical commitment to advance gender equity in all professional practice, education, and research activities. The National Association of Social Workers (NASW) Code of Ethics ( 2017 / 1996 ) includes gender identity and gender expression as specific categories to include when confronting discrimination. The Code of Ethics ( 2017 / 1996 , p. 21) states that “social workers should not practice, condone, facilitate, or collaborate with any form of discrimination on the basis of ... sexual orientation, gender identity or expression.”

In order to meet CSWE’s Competency 2—that social workers must understand diversity and difference in the context of privilege, power, oppression, and marginalization to eliminate biases—it is important that the profession broadens its analysis from individual and interpersonal acts of discrimination to include social systems and institutions that permit individual and interpersonal acts of discrimination. In other words, the role of structural discrimination in the oppression of people based on their gender identity and/or gender expression must be addressed. Structural discrimination can be understood as “the policies of dominant race/ethnic/gender institutions and the behavior of the individuals who implement these policies and control these institutions, which are race/ethnic/gender neutral in intent but which have a differential and/or harmful effect on minority race/ethnic/gender groups” ( Pincus, 1996 , p. 186).

To engage from within a structural framework would require social workers to address the structural conditions that marginalize people on the basis of their gender identity and/or gender expression. For example, rather than working with people to cope with the gender identity and expression based marginalization they face, social workers would also address the systems and structures that produce and reinforce marginalization. This may include challenging policies and practices within institutions of social work practice and education that rely on a binary classification of gender as a way to organize and categorize people. It may include insisting that all gender restrooms are accessible to all clients in one’s agency, or becoming involved in advocacy efforts aimed at removing gender identity based diagnoses from the DSM.

Social workers can begin to move beyond the gender binary by taking an inventory of the policies and practices within their organizations, critically examining the ways in which they may be inadvertently marginalizing clients and communities based on gender identity and gender expression. By centering transgender and nonbinary people in their examinations of policy and practice, social workers can intentionally assess their inclusion of and impact on transgender, nonbinary, and gender-expansive people. Because societal systems and services were built on the premise of binary sex and gender, they are rooted in the presumption that every individual who comes into contact with them can be categorized within these binary constructions. Public restrooms provide a concrete example. Social norms around restroom use necessitate that males and females are separated in different rooms, even with the physical separation of locked and partitioned stalls. In instances when public restrooms are single occupancy, they are most often still labeled male and female. The rationale for this separation is often safety and privacy. As Davis (2014 , p. 53) asserts, “If privacy and safety are the main reasons for sex-segregated restrooms, then might alternative physical designs such as floor-to-ceiling stall partitions do an even better job of meeting that goal than the current design of most American public restrooms?”

With regard to social work education, Shelton and Dodd (2020 ) outline key strategies for challenging cisnormativity and moving beyond the gender binary, including:

Use all gender pronouns (they and them) when speaking and writing rather than only including she and he or his and hers, an example of binarizing ( Blumer et al., 2013 ).

Examine and review course syllabi for implicit cisnormativity. Include your name and pronouns, ensure gender identity and expression are a part of classroom nondiscrimination standards, avoid binarizing language, and identify any all-gender restrooms available in the building.

Examine and review content on course syllabi. Ensure readings by and about transgender people are included. Transgender topics and authors should appear in a unit on gender identity. When planning a session about parenting, for instance, include a reading about transgender, gender-expansive, genderqueer, or nonbinary parents.

Be intentional when planning classroom introductions. Some students may not use the names indicated on your class roster or on school records. Plan introductions in such a way that enables students to introduce themselves first (before reading names from the provided class roster).

Model the sharing of pronouns and give students the option to include their pronouns when introducing themselves. For example, you could say, “Please share your name and your pronouns if you would like to do so.”

When utilizing case examples in the classroom, make sure transgender people are included/represented.

When including transgender people in case examples, make sure they are included in a way that does not perpetuate negative stereotypes and misinformation. For instance, a case example including a transgender person does not need to be focused solely on gender dysphoria and does not need to be related to their transgender identity.

Engage students in nuanced discussions about the history of the pathologization of gender and sexual minorities and the role of social work in this history.

Social work researchers can concretely work toward gender equity throughout the research process, helping to ensure all gender identities and gender expressions are acknowledged as valid. From the design of demographic questions to the reporting of results, researchers can intentionally include participants with a range of gender identities and expressions. Demographic questions can include additional options for sex and gender beyond the binary categorizations of female/male, woman/man, or girl/boy. When analyzing quantitative data, researchers can opt out of collapsing sex and/or gender into a dichotomous variable. Though this may make the process of analysis less simple, making these variables dichotomous erases the lived experiences of participants. When reporting results, researchers can include the experiences of participants across a range of gender identities and gender expressions. In reporting only statistically significant findings, critical data about frequently marginalized and underrepresented populations is lost. Recruitment strategies should include specific outreach to individuals and communities of diverse gender identities and gender expressions. This will require community engaged research and a willingness to extend recruitment timelines to ensure adequate representation. A 2021 study from the Williams Institute reported that 1.2 million adults in the United States are nonbinary ( Wilson & Meyer, 2021 ). Expanding beyond binary conceptualizations of gender within social work research is imperative in order to address the health and well-being of nonbinary individuals and communities.

In summary, gender identity and gender expression are dimensions of identity that are relevant to and impact all people. Thus, it is important for social workers to understand the ways in which gender identity and gender expression impact the individuals and communities with whom they work, as well as the ways that systems and institutions may perpetuate bias and marginalization based on gender identity and gender expression. Although the profession of social work has a fraught history with regard to policing and pathologizing individuals whose gender identities and expressions exist outside of or in between the gender binary, contemporary practice charges social workers with confronting injustice, including dimensions of diversity such as gender identity and gender expression.

Further Reading

• Bilodeau, B. , & Renn, K. (2005). Analysis of LGBT identity development models and implications for practice. New Directions for Student Services , 111 , 25–39.
• Burdge, B. (2007). Bending gender, ending gender: Theoretical foundations for social work practice with the transgender community. Social Work , 52 (3), 243–250.
• Butler, J. (2004). Undoing gender . Routledge.
• James, S. E. , Herman, J. L. , Rankin, S. , Keisling, M. , Mottet, L. , & Anafi, M. (2016). The report of the 2015 U.S. transgender survey . National Center for Transgender Equality.
• Kroehle, K. , Shelton, J. , Clark, E. , & Seelman, K. (2020). Mainstreaming dissidence: Confronting binary gender in social work’s grand challenges. Social Work , 65 (4), 368–377.
• Sanger, T. (2008). Queer(y)ing gender and sexuality: Transgender people’s lived experiences and intimate partnerships. In L. Moon (Ed.), Feeling queer or queer feelings? Radical approaches to counselling sex, sexualities and genders (pp. 72–88). Routledge.
• Action Canada for Sexual Health and Rights . (n.d.). Gender galaxy .
• Ansara, Y. , & Hegarty, P. (2012). Cisgenderism in psychology: Pathologising and misgendering children from 1999 to 2008. Psychology & Sexuality , 3 (2), 137–160.
• Blumer, M. L. C. , Ansara, Y. G. , & Watson, C. M. (2013). Cisgenderism in family therapy: How everyday clinical practices can delegitimize people’s gender self-designations. Special Section: Essays in Family Therapy. Journal of Family Psychotherapy , 24 (4), 267–285.
• Bowles, D. D. , & Hopps, J. G. (2014). The profession’s role in meeting its historical mission to serve vulnerable populations. Advances in Social Work , 15 (1), 1–20.
• Council on Social Work Education . (2015). Educational policy and accreditation standards .
• Coleman, E. , Radix, A. E. , Bouman, W. P. , Brown, G. R. , de Vries, A. L. C. , Deutsch, M. B. , Ettner, R. , Fraser, L. , Goodman, M. , Green, J. , Hancock, A. B. , Johnson, T. W. , Karasic, D. H. , Knudson, G. A. , Leibowitz, S. F. , Meyer-Bahlburg, H. F. L. , Monstrey, S. J. , Motmans, J. , Nahata, L. , Nieder, T. O. , … Arcelus, J. (2022). Standards of Care for the Health of Transgender and Gender Diverse People, Version 8 . International journal of transgender health, 23(Suppl 1), S1–S259.
• Davis, H. (2014). Sex-classification policies as transgender discrimination: An intersectional critique. Perspectives on Politics , 12 (1), 45–60.
• Drescher, J. (2009). Queer diagnoses: Parallels and contrasts in the history of homosexuality, gender variance, and the diagnostic and statistical manual. Archives of Sexual Behavior , 39 , 427–460.
• Fausto-Sterling, A. (2018, October 15). Why sex is not binary. The New York Times .
• Grady, D. (2018, October 2). Anatomy does not determine gender, experts say . The New York Times , 10A.
• National Association of Social Workers . (2017). The NASW code of ethics (Rev. ed.). (Original work published 1996)
• Olson, K. R. , Key, A. C. , & Eaton, N. R. (2015). Gender cognition in transgender children. Psychological Science , 26 (4), 467–474.
• Pincus, F. (1996). Discrimination comes in many forms: Individual, institutional, and structural. The American Behavioral Scientist , 40 (2), 186–194.
• Shelton, J. , & Dodd, S. J. (2020). Beyond the binary: Addressing cisnormativity in the social work classroom. Journal of Social Work Education , 56 (1), 179–185.
• Shelton, J. , Kroehle, K. , & Andia, M. (2019). The trans person is not the problem: Brave spaces and structural competence as educative tools for trans justice in social work. Journal of Sociology and Social Welfare , 46 (4), 97–123.
• World Professional Association for Transgender Health . (2012). Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People [7 th Version].
• Wilson, B. D. M. , & Meyer, I. (2021). Nonbinary LGBTQ adults in the United States . The Williams Institute.

Related Articles

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The Language of Gender Identity

More from our inbox:, power over principle in the g.o.p., upgrading our electric grid, shakespeare’s insights, still relevant today.

To the Editor:

Re “ The Problem With Saying ‘Sex Assigned at Birth, ’” by Alex Byrne and Carole K. Hooven (Opinion guest essay, nytimes.com, April 3):

Mr. Byrne and Ms. Hooven argue that use of “assigned sex” terminology “creates doubt about a biological fact when there shouldn’t be any.” But sex characteristics are not “a biological fact”; they are rather a series of facts — anatomical, hormonal and genetic — that are not always in alignment.

The term “sex assignment” derives from the medical literature of the 1940s and 1950s, in which physicians grappled with what was then called “hermaphroditism” and is now called “intersex” or “D.S.D.,” for disorders or differences of sex development.

To conclude that the words “assigned at birth” are needless is to deny the complexity of biological sex and to erase both the history of intersex conditions and the embodied reality of the people who are born and live with them.

Barbara M. Chubak New York The writer is an associate professor of urology at the Icahn School of Medicine at Mount Sinai.

Transgender people like me do not exist as a topic of rational debate, something to be tossed around in discourse; we are people, and our lives exist far beyond your philosophizing. Articles like this are not only unnecessary, but they are also harmful, patronizing and dehumanizing.

The phrase “sex assigned at birth” is causing no one any harm, and it is not meant to replace “sex.” We are not advocating the end of “male” and “female.”

“Sex assigned at birth” is simply meant to convey the following notion: This individual was born as one sex, but their current body and/or lived experiences may contradict that. It allows trans people the very medical clarity this article claims to strive for. If I, a trans man far into his medical transition, were to walk into a doctor’s office and claim to simply be “female,” utter confusion could follow.

But we should not have to defend ourselves under the guise of rational discourse. We have bigger issues. In Texas, my parents would be possibly liable for child abuse for allowing me to transition as a teenager — so stop treating us as if we do not know what we are talking about.

When people tell you the language that makes them the most comfortable, you use it and move on. You may believe sex to be black and white, as it may be the most convenient reality for you to live in, but for many of us, our bodies are the gray areas.

Max Greenhill New York

I fully agree with this essay: Biological sex is accurately recorded at birth; it is not arbitrarily “assigned.”

The reason activists are pushing the sex-assigned-at-birth terminology is not simply that they want more empathy and inclusiveness for trans persons, but that they want the public to believe that one’s birth sex was, as the authors say, an educated guess at best. If the public accepts that idea, they will be more agreeable to the idea that one’s misassigned sex needs to be corrected later when the individual is old enough to determine their “true, authentic self.”

Most adults don’t care what gender someone declares, but biological sex is a scientific fact. The range of “genders” now being proclaimed is making the whole concept of gender meaningless. Every behavior, feeling, mood, attribute, sexual orientation or social statement does not constitute a gender.

Mark Godburn Norfolk, Conn.

The problem is not that we are confusing the male/female binary; the problem is that the human gender story is bigger than a simple binary, and our language does not reflect that, but it should.

Intersex people exist and have always existed. People whose gender expression doesn’t match their biological presentation exist and have always existed. The authors are correct that language is powerful, but in this case they have the power dynamic exactly backward.

When we adhere to strict binary language, we are asking gender-abundant people to amputate whole parts of themselves. We need to allow people to flourish in the language that fits them.

As my 9-year-old recently explained to my 6-year-old, “You don’t really know what gender a baby is when it’s born, because you know their parts, but you don’t know their heart.”

Meghan Lin St. Paul, Minn.

Thank you, thank you, thank you for publishing this guest essay by Alex Byrne and Carole K. Hooven. In a society inundated with well-meaning absurdities such as “sex assigned at birth” and “pregnant people,” this message desperately needs to be broadcast, received and acted upon.

Mark Featherstone Alameda, Calif.

Re “ Sununu Says Trump ‘Contributed’ to Insurrection, but Still Has His Support ” (news article, nytimes.com, April 14):

Gov. Chris Sununu of New Hampshire now says he will support Donald Trump for president, even as he concedes that Mr. Trump “absolutely contributed” to an attempted insurrection on Jan. 6. Like many of his fellow Republicans, Mr. Sununu has chosen power over principle.

Ethics don’t flash on and off like neon lights. Integrity cannot be situational. And character isn’t a chameleon that shifts to secure political advantage. History will record all the elected officials who embraced Mr. Trump’s mendacity while looking away from the democratic principles they swore an oath to uphold.

Welcome to the club, Governor Sununu.

Maryellen Donnellan Falls Church, Va.

Re “ The U.S. Urgently Needs a Bigger Grid. Scientists Have a Faster Solution ” (Business, April 10):

The nation’s current power lines that were built in the 1950s and 1960s have a 50-year life expectancy, meaning that they have surpassed their intended life span. As the U.S. evaluates how to meet new electric demand, the materials in the grid must not just be replaced, but also efficiently planned and upgraded.

To lower energy costs and improve reliable access to electricity, we should use new technologies that allow more power to be transported across the same size transmission towers that are currently in use. Further, the same amount of power could be transported across smaller, low-impact towers, which could reduce siting and permitting obstacles — thus saving time and money.

Significant transmission capacity is required to meet rising demands on the electrical system, withstand frequent extreme weather events and balance a changing resource mix. Deploying improved technologies in constructing a nationwide transmission grid is key to meeting these needs — because America needs a modern grid now more than ever.

Christina Hayes Washington The writer is the executive director of Americans for a Clean Energy Grid.

With “ O.J. and the Monster Jealousy ” (column, April 14) and “ Trump’s Insatiable Bloodlust ” (column, April 7), Maureen Dowd evokes two of Shakespeare’s greatest characters — Othello and Macbeth — to demonstrate that the playwright’s insights remain as perceptive and significant today as they were more than 400 years ago.

As his friend and fellow dramatist Ben Jonson wrote of Shakespeare, “He was not of an age but for all time!”

Brad Bradford Upper Arlington, Ohio

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Assigned Gender

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Assigned Gender , also called Assigned Gender at Birth (AGAB) , Gender Assigned at Birth (GAAB) , Designated Gender at Birth (DGAB) or Assigned Sex at Birth (ASAB) , is a gender or sex assigned to infants, usually based on genitalia alone and reported on the infant's birth certificate. [1] [2] [3] [4]

There are various definitions and versions of AGAB and its overall concept. These include:

• AGAB (Assigned Gender at Birth): Referring to one's assigned sex. An example of this is AMAB - 'assigned male at birth'. Despite the terminological difference between sex and gender, sex assignment is commonly referred to as an assigned gender. [5]
• AGAB (Assigned Gender at Birth): A less common use of the term - referring to the intangible decision made by the parent(s)/guardian(s) to treat the infant as a certain gender identity, which usually follows on throughout childhood and teenagehood. An example of this is AMAB - 'assigned boy /male at birth'. [6]
• AGAA (Assigned Gender at Age): Referring to the intangible decision made by the parent(s)/guardian(s) to treat the infant, child, or teenager as a certain gender identity. An example of this is AMAC - 'assigned boy/male at childhood'. citation needed
• CAGAB (Coercively Assigned Gender at Birth) / FAGAB (Forcefully Assigned Gender at Birth): Referring to one's coercive/forced sex assignment, usually in cases where an infant's body is medically altered to reflect either male or female genitalia. An example of this is CAMAB - 'coercively assigned male at birth'. [7] [8]
• IAGAB ( Intersex /Incorrectly Assigned Gender at Birth): Referring to an intersex infant's sex assignment, usually male or female especially in countries where intersex is not legally recognised or is unable to be assigned in one's birth certificate. May also refer to an incorrect assignment, especially in cases where the infant's intersex traits are not externally visible. [9]
• ASAB (Assigned Sex at Birth): Referring to one's assigned sex, based on the infant's birth certificate. This is usually used over AGAB as to affirm the differences between sex and gender identity. An example of this is AMAB - 'assigned male at birth'. [2]
• 1 Terminology and Usage
• 3 Recognition of Intersex or Other
• 4 Assigned Sexes
• 5 Resources

Terminology and Usage

Due to the definition of gender identity being a social/psychological aspect rather than a physical one (sex), AGAB can be a potentially confusing concept. Historically, AGAB was designed with gender's secondary definition in mind - where gender is a synonym of body sex. [10] Whilst the definition of gender has changed over the years, AGAB as a concept has stayed primarily the same. Despite the linguistic conflict, it is officially understood to refer to one's body sex, as that is how one's AGAB is determined. [1] Nearly all English birth certificates use 'sex' for one's gender assignment, and whilst ASAB may be more literally correct in terms of terminology, AGAB is far more commonly used.

Individuals who match their birth assignment are referred to as cisgender , while individuals who have a gender identity that differs from their assigned gender may identify as transgender . [11] The difference or relationship between one's gender identity and assigned birth is referred to as one's gender modality .

Gender assignment as a clinical definition was historically referred to as natal male/female. This terminology was changed with the publishing of the the DSM-5-TR (Diagnostic and Statistical Manual of Mental Disorders 5 Text Revision) in 2022, instead opting to use "individual assigned sex/gender at birth". [12] However, AGAB has existed earlier than 2022 and widely used amongst queer communities before its official presence in the DSM. [11]

Originally it was referred to as Sex/Gender Assigned At Birth (SAAB), and its usage traces back to the early 2000s. [13] Its variations also appeared in a similar timeframe, including CAGAB. [14] [15] [16]

The first appearances of AGAB are unknown, but it's been allegedly reported as appropriated from the intersex community. [17] Intersex individuals would use AGAB specifically in cases where an intersex individual is assigned a sex/gender other than intersex. This is reasoned with the notion that the definition of 'assigned' refers to the medical reassignment often prescribed to intersex infants, which differs to the literary recording of one's sex.

"Such people are often, unfortunately, “assigned” a sex (sometimes incorrectly) by doctors who perform a sex assignment [sic] surgery on the unconsenting child, to make their genitalia more closely resemble standard female or male genitals. This does not happen to non-intersex people, and it is not accurate to describe women or men as having been “assigned” a sex, when in actuality, their biological sex was simply observed and written down at birth." -TIMES-CALL LETTERS [17]

However this exclusivity has mostly been lost throughout the years, most likely due to the vague definition of 'assignment', that being "to designate or set (something) aside for a specific purpose"; as per linguistic manner, a recording of the birth sex (regardless of medical intervention) still meets the definition of an assignment. [18]

Recognition of Intersex or Other

Many countries do not legally recognize intersex or indeterminate as a valid record, and do not allow their documentation on birth certificates, passports, or other forms of identification. However some countries do allow the record and identification of intersex, including the correction of certificates for those that later discovered they were intersex. The amount of regions that have begun to recognize intersex classification have been steadily growing over the past few decades.

In 2016, Sara Kelly Keenan was the first US citizen to receive a birth certificate marking one's sex as intersex. [19] [20] Most Australians have been able to correct their birth certificates since 2009, or in some cases remove the sex field from their birth certificate entirely. [21] In 2013, German began to allow an 'indeterminate' sex option on birth certificates. [22] In 2018, Alex Juergen became the first Austrian to receive an intersex marked birth certificate. [23] In 2016, Canadian transgender parent Kori Doty opted to not record their newborn's sex at all. [24]

Some activists have taken to the idea of removing the sex on birth certificates altogether. [25]

"Having a gender identity that does not match the sex designation on a birth certificate can create confusion and potentially expose people to discrimination when an identity document is requested, such as when they register at a school or university or apply for a passport." -Dr Fiona Kelly [25]

"Removing sex from birth certificates would also eliminate the need for the parents of an intersex child to choose a sex for their baby to be publicly recorded. This can be a highly difficult and emotional decision for parents and, in some instances, will not reflect the child’s understanding of their gender later on. Leaving the birth certificate blank allows the child to make that decision once they have the knowledge and maturity to confirm their gender identity." -Dr Fiona Kelly [25]

Assigned Sexes

• ↑ 1.0 1.1 "Birth Assignment". translanguageprimer, https://translanguageprimer.com/birth-assignment/ . Accessed on 19 Jun, 2023.
• ↑ 2.0 2.1 "Glossary". Digital Transgender Archive, https://www.digitaltransgenderarchive.net/learn/glossary . Accessed on 21 Jun, 2023.
• ↑ "Birth certificate (Australian)". Unique Student Identifier, 14 Jun, 2023, https://www.usi.gov.au/students/identification/australian-birth-certificate .
• ↑ Raveenthiran V. Neonatal Sex Assignment in Disorders of Sex Development: A Philosophical Introspection. J Neonatal Surg. 2017 Aug 10;6(3):58. doi: 10.21699/jns.v6i3.604. PMID: 28920018; PMCID: PMC5593477.
• ↑ "Glossary of Terms: Transgender". GLAAD, https://glaad.org/reference/trans-terms/ . Accessed on 19 Jun, 2023.
• ↑ "LGBTQ+ Terminology / Vocabulary Primer". NewYork-Presbyterian, https://www.nyp.org/documents/pps/cultural-competency/Understanding%20Disparities%20-%20LGBTQ%20Terminology.pdf . Accessed on 21 Jun, 2023.
• ↑ "CAGAB". The Trans Language Primer, https://translanguageprimer.com/cagab/ . Accessed on 21 Jun, 2023.
• ↑ 8.0 8.1 8.2 8.3 coded-reality. "October 26: Intersex Awareness Day". Tumblr, 2020, https://coded-reality.tumblr.com/post/188611961035/october-26-intersex-awareness-day .
• ↑ 9.0 9.1 9.2 nonbinary-support. "Hey! I'm intersex.". Tumblr, 2016, https://nonbinary-support.tumblr.com/post/131461402043/hey-im-intersex-do-i-need-to-use-agab-language .
• ↑ Zhu, Handwiki. "Gender." Encyclopedia . Web. 07 November, 2022.
• ↑ 11.0 11.1 "Understanding Gender Identities". The Trevor Project, 23 Aug, 2021, https://www.thetrevorproject.org/resources/article/understanding-gender-identities/ .
• ↑ First MB, Yousif LH, Clarke DE, Wang PS, Gogtay N, Appelbaum PS. DSM-5-TR: overview of what's new and what's changed. World Psychiatry. 2022 Jun;21(2):218-219. doi: 10.1002/wps.20989. PMID: 35524596; PMCID: PMC9077590.
• ↑ "Intro to Understanding Sex, Gender and the Spectrum". kyberia, 21 Apr, 2007, https://kyberia.sk/id/3069259 .
• ↑ Bazant, Micah. "Trans Etiquette/Respect/Support 101". Transtorah, 2011, http://www.transtorah.org/PDFs/Trans_Etiquette_101.pdf .
• ↑ destroyedforcomfort. "AMAB/AFAB vs . CAMAB/CAFAB". Tumblr, 2013, https://destroyedforcomfort.tumblr.com/post/32011963208/amabafab-vs-camabcafab .
• ↑ "Transsexual". TVTropes, https://archive.md/dZncK#selection-4277.1-4401.19 . Archived on 30 Aug, 2017.
• ↑ 17.0 17.1 TIMES-CALL LETTERS. "‘Assigned at birth’ appropriated from the intersex community". Times-Call, 6 Feb, 2021, https://www.timescall.com/2021/02/06/letters-sexual-assignment/?fbclid=IwAR18338gF1mWlnVucksTF6R3MulLMQzltg4IT0JFNfla0STJOr6J7eUfNsI .
• ↑ "assign - transcription, translation and pronunciation online". myefe, https://myefe.com/transcription-pronunciation/assign#:~:text=designate%20or%20set%20(something)%20aside%20for%20a%20specific%20purpose .. Accessed on 22 Jun, 2023.
• ↑ 19.0 19.1 O'Hara, Mary Emily. "Nation's First Known Intersex Birth Certificate Issued in NYC". NBC News, 30 Dec, 2016, https://www.nbcnews.com/feature/nbc-out/nation-s-first-known-intersex-birth-certificate-issued-nyc-n701186 .
• ↑ Segal, Corinne. "Nation’s first known ‘intersex’ birth certificate issued in New York City". PBS News Hour, 5 Jan, 2017, https://www.pbs.org/newshour/nation/new-york-city-issues-nations-first-birth-certificate-marked-intersex#:~:text=Meanwhile%2C%20Keenan%20reached%20out%20to%20the%20New%20York%20City%20Health%20Department%2C%20who%20issues%20birth%20certificates%2C%20to%20request%20a%20change%20to%20the%20sex%20listed%20on%20her%20birth%20certificate ..
• ↑ Carpenter, Morgan. "On intersex birth registrations". Intersex Human Rights Australia, 13 Nov, 2009, https://ihra.org.au/4856/on-birth-registrations/ .
• ↑ Muller, Natalie. "Third sex". DW, 1 Nov, 2013, https://www.dw.com/en/third-sex-option-on-birth-certificates/a-17193869 .
• ↑ Savage, Rachael. Anarte, Enrique. "Austria issues first intersex birth certificate after four-year battle". Reuters, 17 Jul, 2020, https://www.reuters.com/article/us-austria-lgbt-rights-trfn-idUSKCN24H33M .
• ↑ 24.0 24.1 Koenig, Ronnie. "Transgender parent explains why they are raising baby without an assigned gender". Today, 18 Jul, 2017, https://www.today.com/parents/transgender-parent-leaves-their-baby-s-gender-unassigned-t113796 .
• ↑ 25.0 25.1 25.2 Dr Kelly, Fiona. "Removing sex from birth certificates". La Trobe University, 29 Oct, 2018, https://www.latrobe.edu.au/news/articles/2018/opinion/removing-sex-from-birth-certificates .
• ↑ "AFAB". Merriam-Webster, https://www.merriam-webster.com/dictionary/AFAB . Accessed on 19 Jun, 2023.
• ↑ beyond-mogai-pride-flags. "DFAB Flag". Tumblr, 15 Oct, 2020, https://archive.md/2022.02.12-070010/https://beyond-mogai-pride-flags.tumblr.com/post/632047659950194688/dfab-flag . Archived on 12 Feb, 2022.
• ↑ themogaidragon. "AIAB". Tumblr, 17 Sep, 2021, https://themogaidragon.tumblr.com/post/662581001970728960/aiab .
• ↑ "AMAB". Merriam-Webster, https://www.merriam-webster.com/dictionary/AMAB . Accessed on 19 Jun, 2023.
• ↑ beyond-mogai-pride-flags. "DMAB Flag". Tumblr, 15 Oct, 2020, https://archive.md/2022.02.12-084755/https://beyond-mogai-pride-flags.tumblr.com/post/632047211246764032/dmab-flag . Archived on 12 Feb, 2022.
• ↑ beyond-mogai-pride-flags. "AXAB Pride Flag". Tumblr, 9 Oct, 2020, https://archive.md/2022.02.12-094909/https://beyond-mogai-pride-flags.tumblr.com/post/631548226993012736/axab-pride-flag . Archived on 12 Feb, 2022.
• ↑ 32.0 32.1 interarchival. "fafab + famab". Tumblr, 27 Dec, 2021, https://web.archive.org/web/20230107041309/https://interarchival.tumblr.com/post/671776339598196736/fafab-famab . Archived on 7 Jan, 2023.
• ↑ 33.0 33.1 https://interarchival.tumblr.com/post/671769367452778496/iafab-iamab [Dead Link]
• ↑ beyond-mogai-pride-flags. "UAB Pride Flag". Tumblr, 3 Mar, 2019, http://archive.today/2022.04.20-012243/https://beyond-mogai-pride-flags.tumblr.com/post/183189528435/uab-pride-flag . Archived on 20 Apr, 2022.

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Pride Month

A guide to gender identity terms.

Laurel Wamsley

"Pronouns are basically how we identify ourselves apart from our name. It's how someone refers to you in conversation," says Mary Emily O'Hara, a communications officer at GLAAD. "And when you're speaking to people, it's a really simple way to affirm their identity." Kaz Fantone for NPR hide caption

"Pronouns are basically how we identify ourselves apart from our name. It's how someone refers to you in conversation," says Mary Emily O'Hara, a communications officer at GLAAD. "And when you're speaking to people, it's a really simple way to affirm their identity."

Issues of equality and acceptance of transgender and nonbinary people — along with challenges to their rights — have become a major topic in the headlines. These issues can involve words and ideas and identities that are new to some.

That's why we've put together a glossary of terms relating to gender identity. Our goal is to help people communicate accurately and respectfully with one another.

Proper use of gender identity terms, including pronouns, is a crucial way to signal courtesy and acceptance. Alex Schmider , associate director of transgender representation at GLAAD, compares using someone's correct pronouns to pronouncing their name correctly – "a way of respecting them and referring to them in a way that's consistent and true to who they are."

Glossary of gender identity terms

This guide was created with help from GLAAD . We also referenced resources from the National Center for Transgender Equality , the Trans Journalists Association , NLGJA: The Association of LGBTQ Journalists , Human Rights Campaign , InterAct and the American Psychological Association . This guide is not exhaustive, and is Western and U.S.-centric. Other cultures may use different labels and have other conceptions of gender.

One thing to note: Language changes. Some of the terms now in common usage are different from those used in the past to describe similar ideas, identities and experiences. Some people may continue to use terms that are less commonly used now to describe themselves, and some people may use different terms entirely. What's important is recognizing and respecting people as individuals.

Jump to a term: Sex, gender , gender identity , gender expression , cisgender , transgender , nonbinary , agender , gender-expansive , gender transition , gender dysphoria , sexual orientation , intersex

Jump to Pronouns : questions and answers

Sex refers to a person's biological status and is typically assigned at birth, usually on the basis of external anatomy. Sex is typically categorized as male, female or intersex.

Gender is often defined as a social construct of norms, behaviors and roles that varies between societies and over time. Gender is often categorized as male, female or nonbinary.

Gender identity is one's own internal sense of self and their gender, whether that is man, woman, neither or both. Unlike gender expression, gender identity is not outwardly visible to others.

For most people, gender identity aligns with the sex assigned at birth, the American Psychological Association notes. For transgender people, gender identity differs in varying degrees from the sex assigned at birth.

Gender expression is how a person presents gender outwardly, through behavior, clothing, voice or other perceived characteristics. Society identifies these cues as masculine or feminine, although what is considered masculine or feminine changes over time and varies by culture.

Cisgender, or simply cis , is an adjective that describes a person whose gender identity aligns with the sex they were assigned at birth.

Transgender, or simply trans, is an adjective used to describe someone whose gender identity differs from the sex assigned at birth. A transgender man, for example, is someone who was listed as female at birth but whose gender identity is male.

Cisgender and transgender have their origins in Latin-derived prefixes of "cis" and "trans" — cis, meaning "on this side of" and trans, meaning "across from" or "on the other side of." Both adjectives are used to describe experiences of someone's gender identity.

Nonbinary is a term that can be used by people who do not describe themselves or their genders as fitting into the categories of man or woman. A range of terms are used to refer to these experiences; nonbinary and genderqueer are among the terms that are sometimes used.

Agender is an adjective that can describe a person who does not identify as any gender.

Gender-expansive is an adjective that can describe someone with a more flexible gender identity than might be associated with a typical gender binary.

Gender transition is a process a person may take to bring themselves and/or their bodies into alignment with their gender identity. It's not just one step. Transitioning can include any, none or all of the following: telling one's friends, family and co-workers; changing one's name and pronouns; updating legal documents; medical interventions such as hormone therapy; or surgical intervention, often called gender confirmation surgery.

Gender dysphoria refers to psychological distress that results from an incongruence between one's sex assigned at birth and one's gender identity. Not all trans people experience dysphoria, and those who do may experience it at varying levels of intensity.

Gender dysphoria is a diagnosis listed in the Diagnostic and Statistical Manual of Mental Disorders. Some argue that such a diagnosis inappropriately pathologizes gender incongruence, while others contend that a diagnosis makes it easier for transgender people to access necessary medical treatment.

Sexual orientation refers to the enduring physical, romantic and/or emotional attraction to members of the same and/or other genders, including lesbian, gay, bisexual and straight orientations.

People don't need to have had specific sexual experiences to know their own sexual orientation. They need not have had any sexual experience at all. They need not be in a relationship, dating or partnered with anyone for their sexual orientation to be validated. For example, if a bisexual woman is partnered with a man, that does not mean she is not still bisexual.

Sexual orientation is separate from gender identity. As GLAAD notes , "Transgender people may be straight, lesbian, gay, bisexual or queer. For example, a person who transitions from male to female and is attracted solely to men would typically identify as a straight woman. A person who transitions from female to male and is attracted solely to men would typically identify as a gay man."

Intersex is an umbrella term used to describe people with differences in reproductive anatomy, chromosomes or hormones that don't fit typical definitions of male and female.

Intersex can refer to a number of natural variations, some of them laid out by InterAct . Being intersex is not the same as being nonbinary or transgender, which are terms typically related to gender identity.

The Picture Show

Nonbinary photographer documents gender dysphoria through a queer lens, pronouns: questions and answers.

What is the role of pronouns in acknowledging someone's gender identity?

Everyone has pronouns that are used when referring to them – and getting those pronouns right is not exclusively a transgender issue.

"Pronouns are basically how we identify ourselves apart from our name. It's how someone refers to you in conversation," says Mary Emily O'Hara , a communications officer at GLAAD. "And when you're speaking to people, it's a really simple way to affirm their identity."

"So, for example, using the correct pronouns for trans and nonbinary youth is a way to let them know that you see them, you affirm them, you accept them and to let them know that they're loved during a time when they're really being targeted by so many discriminatory anti-trans state laws and policies," O'Hara says.

"It's really just about letting someone know that you accept their identity. And it's as simple as that."

Getting the words right is about respect and accuracy, says Rodrigo Heng-Lehtinen, deputy executive director of the National Center for Transgender Equality. Kaz Fantone for NPR hide caption

Getting the words right is about respect and accuracy, says Rodrigo Heng-Lehtinen, deputy executive director of the National Center for Transgender Equality.

What's the right way to find out a person's pronouns?

Start by giving your own – for example, "My pronouns are she/her."

"If I was introducing myself to someone, I would say, 'I'm Rodrigo. I use him pronouns. What about you?' " says Rodrigo Heng-Lehtinen , deputy executive director of the National Center for Transgender Equality.

O'Hara says, "It may feel awkward at first, but eventually it just becomes another one of those get-to-know-you questions."

Should people be asking everyone their pronouns? Or does it depend on the setting?

Knowing each other's pronouns helps you be sure you have accurate information about another person.

How a person appears in terms of gender expression "doesn't indicate anything about what their gender identity is," GLAAD's Schmider says. By sharing pronouns, "you're going to get to know someone a little better."

And while it can be awkward at first, it can quickly become routine.

Heng-Lehtinen notes that the practice of stating one's pronouns at the bottom of an email or during introductions at a meeting can also relieve some headaches for people whose first names are less common or gender ambiguous.

"Sometimes Americans look at a name and are like, 'I have no idea if I'm supposed to say he or she for this name' — not because the person's trans, but just because the name is of a culture that you don't recognize and you genuinely do not know. So having the pronouns listed saves everyone the headache," Heng-Lehtinen says. "It can be really, really quick once you make a habit of it. And I think it saves a lot of embarrassment for everybody."

Might some people be uncomfortable sharing their pronouns in a public setting?

Schmider says for cisgender people, sharing their pronouns is generally pretty easy – so long as they recognize that they have pronouns and know what they are. For others, it could be more difficult to share their pronouns in places where they don't know people.

But there are still benefits in sharing pronouns, he says. "It's an indication that they understand that gender expression does not equal gender identity, that you're not judging people just based on the way they look and making assumptions about their gender beyond what you actually know about them."

How is "they" used as a singular pronoun?

"They" is already commonly used as a singular pronoun when we are talking about someone, and we don't know who they are, O'Hara notes. Using they/them pronouns for someone you do know simply represents "just a little bit of a switch."

"You're just asking someone to not act as if they don't know you, but to remove gendered language from their vocabulary when they're talking about you," O'Hara says.

"I identify as nonbinary myself and I appear feminine. People often assume that my pronouns are she/her. So they will use those. And I'll just gently correct them and say, hey, you know what, my pronouns are they/them just FYI, for future reference or something like that," they say.

O'Hara says their family and friends still struggle with getting the pronouns right — and sometimes O'Hara struggles to remember others' pronouns, too.

"In my community, in the queer community, with a lot of trans and nonbinary people, we all frequently remind each other or remind ourselves. It's a sort of constant mindfulness where you are always catching up a little bit," they say.

"You might know someone for 10 years, and then they let you know their pronouns have changed. It's going to take you a little while to adjust, and that's fine. It's OK to make those mistakes and correct yourself, and it's OK to gently correct someone else."

What if I make a mistake and misgender someone, or use the wrong words?

Simply apologize and move on.

"I think it's perfectly natural to not know the right words to use at first. We're only human. It takes any of us some time to get to know a new concept," Heng-Lehtinen says. "The important thing is to just be interested in continuing to learn. So if you mess up some language, you just say, 'Oh, I'm so sorry,' correct yourself and move forward. No need to make it any more complicated than that. Doing that really simple gesture of apologizing quickly and moving on shows the other person that you care. And that makes a really big difference."

Why are pronouns typically given in the format "she/her" or "they/them" rather than just "she" or "they"?

The different iterations reflect that pronouns change based on how they're used in a sentence. And the "he/him" format is actually shorter than the previously common "he/him/his" format.

"People used to say all three and then it got down to two," Heng-Lehtinen laughs. He says staff at his organization was recently wondering if the custom will eventually shorten to just one pronoun. "There's no real rule about it. It's absolutely just been habit," he says.

Amid Wave Of Anti-Trans Bills, Trans Reporters Say 'Telling Our Own Stories' Is Vital

But he notes a benefit of using he/him and she/her: He and she rhyme. "If somebody just says he or she, I could very easily mishear that and then still get it wrong."

What does it mean if a person uses the pronouns "he/they" or "she/they"?

"That means that the person uses both pronouns, and you can alternate between those when referring to them. So either pronoun would be fine — and ideally mix it up, use both. It just means that they use both pronouns that they're listing," Heng-Lehtinen says.

Schmider says it depends on the person: "For some people, they don't mind those pronouns being interchanged for them. And for some people, they are using one specific pronoun in one context and another set of pronouns in another, dependent on maybe safety or comfortability."

The best approach, Schmider says, is to listen to how people refer to themselves.

Why might someone's name be different than what's listed on their ID?

Heng-Lehtinen notes that there's a perception when a person comes out as transgender, they change their name and that's that. But the reality is a lot more complicated and expensive when it comes to updating your name on government documents.

"It is not the same process as changing your last name when you get married. There is bizarrely a separate set of rules for when you are changing your name in marriage versus changing your name for any other reason. And it's more difficult in the latter," he says.

"When you're transgender, you might not be able to update all of your government IDs, even though you want to," he says. "I've been out for over a decade. I still have not been able to update all of my documents because the policies are so onerous. I've been able to update my driver's license, Social Security card and passport, but I cannot update my birth certificate."

"Just because a transgender person doesn't have their authentic name on their ID doesn't mean it's not the name that they really use every day," he advises. "So just be mindful to refer to people by the name they really use regardless of their driver's license."

NPR's Danielle Nett contributed to this report.

• gender identity
• transgender

Understanding Gender, Sex, and Gender Identity

It's more important than ever to use this terminology correctly..

Posted February 27, 2021 | Reviewed by Kaja Perina

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Representative Marjorie Taylor Greene hung a sign outside her Capitol office door that said “There are TWO genders: MALE & FEMALE. ‘Trust the Science!’” There are many reasons to question hanging such a sign, but given that Rep. Taylor Greene invoked science in making her assertion, I thought it might be helpful to clarify by citing some actual science. Put simply, from a scientific standpoint, Rep. Taylor Greene’s statement is patently wrong. It perpetuates a common error by conflating gender with sex . Allow me to explain how psychologists scientifically operationalize these terms.

According to the American Psychological Association (APA, 2012), sex is rooted in biology. A person’s sex is determined using observable biological criteria such as sex chromosomes, gonads, internal reproductive organs, and external genitalia (APA, 2012). Most people are classified as being either biologically male or female, although the term intersex is reserved for those with atypical combinations of biological features (APA, 2012).

Gender is related to but distinctly different from sex; it is rooted in culture, not biology. The APA (2012) defines gender as “the attitudes, feelings, and behaviors that a given culture associates with a person’s biological sex” (p. 11). Gender conformity occurs when people abide by culturally-derived gender roles (APA, 2012). Resisting gender roles (i.e., gender nonconformity ) can have significant social consequences—pro and con, depending on circumstances.

Gender identity refers to how one understands and experiences one’s own gender. It involves a person’s psychological sense of being male, female, or neither (APA, 2012). Those who identify as transgender feel that their gender identity doesn’t match their biological sex or the gender they were assigned at birth; in some cases they don’t feel they fit into into either the male or female gender categories (APA, 2012; Moleiro & Pinto, 2015). How people live out their gender identities in everyday life (in terms of how they dress, behave, and express themselves) constitutes their gender expression (APA, 2012; Drescher, 2014).

“Male” and “female” are the most common gender identities in Western culture; they form a dualistic way of thinking about gender that often informs the identity options that people feel are available to them (Prentice & Carranza, 2002). Anyone, regardless of biological sex, can closely adhere to culturally-constructed notions of “maleness” or “femaleness” by dressing, talking, and taking interest in activities stereotypically associated with traditional male or female gender identities. However, many people think “outside the box” when it comes to gender, constructing identities for themselves that move beyond the male-female binary. For examples, explore lists of famous “gender benders” from Oxygen , Vogue , More , and The Cut (not to mention Mr. and Mrs. Potato Head , whose evolving gender identities made headlines this week).

Whether society approves of these identities or not, the science on whether there are more than two genders is clear; there are as many possible gender identities as there are people psychologically forming identities. Rep. Taylor Greene’s insistence that there are just two genders merely reflects Western culture’s longstanding tradition of only recognizing “male” and “female” gender identities as “normal.” However, if we are to “trust the science” (as Rep. Taylor Greene’s recommends), then the first thing we need to do is stop mixing up biological sex and gender identity. The former may be constrained by biology, but the latter is only constrained by our imaginations.

American Psychological Association. (2012). Guidelines for psychological practice with lesbian, gay, and bisexual clients. American Psychologist , 67 (1), 10-42. https://doi.org/10.1037/a0024659

Drescher, J. (2014). Treatment of lesbian, gay, bisexual, and transgender patients. In R. E. Hales, S. C. Yudofsky, & L. W. Roberts (Eds.), The American Psychiatric Publishing textbook of psychiatry (6th ed., pp. 1293-1318). American Psychiatric Publishing.

Moleiro, C., & Pinto, N. (2015). Sexual orientation and gender identity: Review of concepts, controversies and their relation to psychopathology classification systems. Frontiers in Psychology , 6 .

Prentice, D. A., & Carranza, E. (2002). What women should be, shouldn't be, are allowed to be, and don't have to be: The contents of prescriptive gender stereotypes. Psychology of Women Quarterly , 26 (4), 269-281. https://doi.org/10.1111/1471-6402.t01-1-00066

Jonathan D. Raskin, Ph.D. , is a professor of psychology and counselor education at the State University of New York at New Paltz.

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Terminology

Many terms are associated with sexual and gender identities, and terminology continues to evolve. Below are some of the terms currently used by the Division of Adolescent and School Health.  This list and the definitions offered may change over time.

• Bisexual: A person who is attracted to both people of their own gender and other genders.
• Cisgender: Individuals whose current gender identity is the same as the sex they were assigned at birth.
• Gay: A person who is attracted primarily to members of the same gender. Gay is most frequently used to describe men who are attracted primarily to other men, although it can be used for men and women.
• Gender: The cultural roles, behaviors, activities, and attributes expected of people based on their sex.
• Gender Expression: How an individual chooses to present their gender to others through physical appearance and behaviors, such as style of hair or dress, voice, or movement.
• Gender Identity: An individual’s sense of their self as man, woman, transgender, or something else.
• Gender Minority: Individuals whose gender identity (man, women, other) or expression (masculine, feminine, other) is different from their sex (male, female) assigned at birth.
• Gender Nonbinary: Individuals who do not identify their gender as man or woman.  Other terms to describe this identity include genderqueer, agender, bigender, gender creative, etc.
• Gender Nonconforming: The state of one’s physical appearance or behaviors not aligning with societal expectations of their gender (a feminine boy, a masculine girl, etc.).
• Heterosexual or Straight: A man who is primarily attracted to women or a woman who is primarily attracted to men.
• Intersex: Persons with variations in physical sex characteristics, including variations in anatomy, hormones, chromosomes or other traits, that differ from expectations generally associated with male and female bodies.
• Lesbian: A woman who is primarily attracted to other women.
• LGBTQ: Acronym that refers to the lesbian, gay, bisexual, transgender, and queer/questioning community.
• Queer: An umbrella term sometimes used to refer to the entire LGBT community.
• Questioning: For some, the process of exploring and discovering one’s own sexual orientation, gender identity, or gender expression.
• Sex: An individual’s biological status as male, female, or something else.  Sex is assigned at birth and associated with physical attributes, such as anatomy and chromosomes.
• Sexual Minority: Individuals who identify as gay, lesbian, or bisexual, or who are attracted to or have sexual contact with people of the same gender.
• Sexual Orientation: Refers to a person’s sexual and emotional attraction to another person and the behavior and/or social affiliation that may result from this attraction (lesbian, gay, bisexual, etc.)
• SGM: Acronym for sexual and gender minorities.
• SGMY : Acronym for sexual and gender minority youth.
• SMY: Acronym for sexual minority youth.
• Transgender: Individuals whose current gender identity differs from the sex they were assigned at birth.

* Terms listed are referenced from APA’s Definitions Related to Sexual Orientation and Gender Diversity and the World Health Organization’s glossary of terms and tools .

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Sex Assigned at Birth and Gender Identity: What Is The Difference?

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A person’s sex assigned at birth, gender identity and gender expression can all be different. Is gender assigned male at birth or female at birth?

Gender identity: Assigned male or female at birth

This video discusses a person’s sex assigned at birth, gender identity and gender expression and how they can all be different. [AMZ-097]

Video : Is sex assigned at birth?

This sex education video explains that who someone is attracted to is not related to:

• Sex assigned at birth
• Gender identity
• Gender expression

“Sex assigned at birth” refers to the label a medical professional gives to a baby when it is born. A medical professional may say a baby is male, female or intersex, depending on what the medical professional observes about the baby’s body. For example, a baby with a vulva will be labeled a girl, and a baby with a penis will be labeled a boy. Some babies may have bodies or chromosomes that don’t fit the typical categories of male or female. A medical professional may label them as intersex. Sex assigned at birth is about how someone else sees our bodies and does not take into consideration how we feel inside.

Gender identity is all about how we feel inside about our gender. It is an internal feeling or sense a person has of being male, female, somewhere in between or something else altogether. Sometimes people’s gender identity matches their bodies, and sometimes it does not. A person may be born with a penis and identify as a boy or born with a vagina and identify as a girl. These people have a gender identity that is called “cisgender.” Or someone may be born with a penis and identify as a girl or born with a vagina and identify as a boy. These people may have a gender identity called “transgender.” The way some people feel or sees themselves may not fit into female-male categories. These people may call themselves “gender expansive,” “genderqueer,” “gender nonbinary” or something else. Some people may not want to use a label to describe themselves.

When you share your gender identity with the world through clothing, makeup, how you talk, act and more, it is called “gender expression.” A person’s sex assigned at birth, gender identity and gender expression can all be different. Who someone is attracted to—their sexual orientation—is not related to sex assigned at birth, gender identity or gender expression. Everyone has a sex assigned at birth, a gender identity and a sexual orientation.

What’s important to remember is that people deserve to express themselves in ways that feel right for them and to be respected no matter how they identify, look, dress or label themselves.

Yes, there are totally more than two genders! Some people identify as a gender that is not male or female, some identify as more than one gender, and some people don’t identify as any gender.

It’s okay if you can’t identify a person’s gender when you first meet. It’s more important not to judge someone based on the gender that person uses to identify themselves.

We usually assume people’s gender identity based on how they look or dress, but some people’s gender identity may not match how they look or dress. In some situations, when you’re not sure how someone identifies, it’s okay to say, “I want to be respectful of how you identify, so could you tell me which pronoun you prefer I use?” This gives the person an opportunity to tell you their pronoun (he, she or another word).

Lots of people have qualities that are associated with a different gender. If you feel like your gender identity does not fit neatly into a boy or girl category, that’s okay. You may choose to dress or style your hair in a way that matches how you feel. As you figure out what feels right for you, seeking the support of a trusted adult can be extremely helpful!

If you feel like your body does not match how you feel inside, then you should definitely talk to an adult you can trust. People who feel like their bodies do not match how they feel inside may identify as transgender or trans. You can get help figuring out how to have what you feel inside reflected on the outside with the help of trusted adults, like parents, counselors and doctors.

Related Videos

Being female, male, transgender or fluid, expressing myself. my way., gender identity: gender roles and stereotypes, my friend is transgender, puberty and transgender youth, range of gender identities, additional resources.

Sex assigned at birth or biological sex is the label a medical professional gives a baby when it is born. This assignment is usually based on what a doctor observes about a baby’s body. Babies born with penises are labeled male, and babies born with vulvas are labeled female. Babies whose bodies do not fit neatly into a male or female category are labeled intersex. Sex assigned at birth is about what someone observes about another person’s body, not how that person may feel internally about being male, female or another gender.

Gender identity is the feeling someone has inside about being male, female or something in between. Everyone has a gender identity. Sometimes people’s gender identity matches their bodies, and sometimes it does not. A person may be born with a penis and identify as a boy or born with a vagina and identify as a girl. This person may have a gender identity that is called “cisgender.” Or someone may be born with a penis and identify as a girl or born with a vagina and identify as a boy. This person may have a gender identity that is called “transgender.”

Terms like “genderqueer,” “gender nonbinary” or “gender expansive” may be used to refer to anyone who identifies as neither male nor female, both male and female or a combination of different genders. “Genderfluid” is another identity that is similar to genderqueer. Some people experience their gender as fluid. This means they may feel like a mix of masculine and feminine qualities or feel more feminine sometimes and more masculine at other times. This is called gender fluidity, and it is not related to a person’s sex assigned at birth or biological sex.

People express a sense of masculinity, femininity or something in between through their daily choices about appearance. This is called “gender expression,” and it can be influenced by how someone feels inside, family expectations, society’s expectations and other influences. Sometimes people’s gender expression matches their gender identity, and sometimes it does not. Gender expression can also change throughout people’s lives as they learn more about themselves and what masculinity and femininity mean to them and how they choose to express themselves on any given day.

Gender identity and expression don’t tell us anything about who a person is attracted to. “Sexual orientation” refers to what genders we are attracted to.

Gender roles are the societal norms that dictate the types of behaviors that are generally considered appropriate for people based on their actual or perceived gender. As parents, guardians and other trusted adults, it is important that we recognize how harmful gender roles can be if we force them on young people. For example, insisting that a boy not cry when he is hurt or sad limits his ability to express a full range of human emotions and empathize with others. Gender roles can limit young people’s ability to be who they truly are when, for example, a girl who wants to play sports is instead encouraged to be “ladylike.” When children are encouraged in subtle—and not-so subtle—ways to adhere to strict gender roles, it can cause significant anxiety, insecurity, stress and low self-esteem for both boys and girls.  

With all this in mind, we can support children in shaping attitudes about gender that encourage respect for the many ways that people choose to identify and express themselves.

CONVERSATION STARTERS

There are lots of terms for gender identity, and it’s not important that you or your child memorize definitions. It is more important for children to understand that gender identity and expression are spectrums, and they don’t need to be afraid if they see someone different or if they feel different in terms of how they identify or express their gender. These conversation starters are a way to make sure your child feels comfortable asking questions and talking with you about these topics.

You can also talk with your children about cultural differences in terms of gender. A great way to start talking about these issues is learning about gender expression and how masculinity and femininity are defined in different cultures (e.g., Scottish kilts).

When you see people who challenge conventional ideas about gender identity and expression—like Prince (gender expression) or Caitlyn Jenner and Laverne Cox, who identify as transgender—you could also start a conversation with your child using some of the following:

Do you think someone like Prince was teased for being both masculine and feminine?

  It seems like it’s not easy when someone expresses their gender in a way that people don’t understand. What do you think?

  Have you ever seen someone teased for being too much like a girl or too much like a boy? How did that make you feel? What did you do?

National Sex Education Standards

Describe human reproductive systems, including the external and internal body parts and their functions, and that there are naturally occuring variations in human bodies (e.g., intersex, vulvas, circumcised and intact penises)

View all AP.8.CC.1 Videos

Distinguish between sex assigned at birth and gender identity and explain how they may or may not differ

View all GI.5.CC.1 Videos

Define and explain differences between cisgender, transgender, gender nonbinary, gender expansive, and gender identity

View all GI.5.CC.2 Videos

Explain that gender expression and gender identity exist along a spectrum

View all GI.5.CC.3 Videos

International Technical Guidance on Sexuality Education

The Social Construction of Gender and Gender Norms

View videos for 3.1 (ages 9-12)

Discussion Questions

• What are some traditional gender roles shown in the video?
• How might people express their gender in ways that don’t match traditional gender roles?
• How do you think it would feel to be able to express your gender in a way that doesn’t match traditional gender roles? Why?
• What are some things you can do if you see a person being bullied for expressing their gender in a way that does not match traditional gender roles?

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A Book About Bodies, Feelings, and YOU

Changing the Way We Talk to Kids About Sexuality, Values, and Health

Everything You Need to Know to Become Your Kids’ "Go-To" Person About Sex

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What Is Intersex? Here’s What the Term Means and How It Can Present

Including information on gender assignment surgery and how to provide support to the intersex community.

Jessica Migala has been a health, fitness, and nutrition writer for almost 15 years. She has contributed to more than 40 print and digital publications, including EatingWell, Real Simple, and Runner's World. Jessica had her first editing role at Prevention magazine and, later, Michigan Avenue magazine in Chicago. She currently lives in the suburbs with her husband, two young sons, and beagle. When not reporting, Jessica likes runs, bike rides, and glasses of wine (in moderation, of course). Find her @jlmigala or on LinkedIn.

If you've noticed the I in LGBTQIA+ , you may wonder what it means and where it came from. The I stands for intersex, a biological variance that means a person's sex doesn't fit neatly into the boxes of "male" or "female"—based on their chromosomes, genital presentation, reproductive tissue, or some combination of the three.

Learn more about what it means to be intersex and why more intersex individuals are embracing this identity.

What Does Intersex Mean?

Intersex is when a person is born with a body that doesn't fit into the definition of typical male or female genitalia—the external genitalia doesn't match the internal genitalia.

Intersex used to be known as hermaphroditism, but the latter term is outdated and no longer used. Instead, intersex conditions are referred to as disorders of sex development (DSDs). There are four categories of intersex:

• 46, XX intersex
• 46, XY intersex
• True gonadal intersex
• Complex or undetermined intersex

Categories of Intersex

Typically females carry two X chromosomes, and males carry one X and one Y chromosome. With people who are intersex, this isn't necessarily true.

46, XX Intersex

In general, an individual who is intersex may have female chromosomes but ambiguous or male-appearing genitals. This is called 46, XX intersex which can be caused by:

• Male hormones taken during pregnancy
• Male hormone-producing tumors in the pregnant person
• Aromatase (an enzyme that converts male hormones to female hormones) deficiency

46, XY Intersex

Alternatively, the individual may have male chromosomes but ambiguous or female-appearing genitals. This is called 46, XY intersex which can be caused by:

• Problems with the testes
• Problems with testosterone formation
• Problems using testosterone
• Androgen insensitivity syndrome (when the receptors to male hormones don't function properly)

True Gonadal Intersex

A person who is intersex could have what's called true gonadal intersex, having both ovarian and testicular tissue. The cause for true gonadal intersex is unknown although there has been research done in animals that links true gonadal intersex to exposure of common agricultural pesticides .

Complex Intersex

The last category of intersex is a complex or undetermined disorder of sex development that doesn't fit neatly into any of these categories. This involves chromosome configurations other than 46, XX or 46, XY that results in sex development disorders.

Symptoms of Intersex

Being intersex is not about gender identity or sexual orientation ; it's about physical sex traits and genes. Depending on the cause, symptoms related to being intersex could include:

• Having external genitalia that isn't clearly male or female at birth
• A smaller-than-expected penis
• A larger-than-expected clitoris
• Hypospadias (where the penile opening is not at the tip or the urethra is not separated from the vagina)
• Masses in the labia or groin
• Abnormalities with electrolyte levels
• Delayed or absent puberty
• Unexpected puberty changes

While intersex is typically discovered at birth, it is possible that it may not be diagnosed until puberty. Georgieann Davis, PhD , an associate professor of sociology at the University of New Mexico and author of "Contesting Intersex: The Dubious Diagnosis," was born with complete androgen insensitivity syndrome, which results in female-associated external genitalia but XY chromosomes and undescended testes.

"My parents, in my case and many others, didn't know I was intersex until I was in my teenage years and I didn't menstruate ," Davis told Health . "That's when they discovered what they didn't expect to find inside."

Gender Assignment Surgery

In the past, if a baby was born with intersex traits, healthcare providers and caregivers may have chosen a sex assignment for the child and may have elected for surgery so the child has a penis or vagina. Caregivers were often urged to make a quick decision and to have surgery as soon as possible.

"If something is framed as a medical problem or emergency, parents are likely to move forward with medical intervention because that's the option they're presented," said Davis. "Parents may later express decisional regret because they didn't have the information presented to them, that [intersex] is a natural variation of one's body that does not have to dictate one's gender identity."

Effects of Gender Assignment Surgery at a Young Age

While healthcare providers and caregivers still often choose gender assignment surgery for children who are intersex, this issue is not without contention.

Since intersex children are unable to make the decision for themselves, their caregivers choose to make that decision for them. This may result in decreased sexual function and increased substance use disorders and suicide .

More and more, caregivers forgo surgery and let the child decide at a mature age if surgery or treatment is desired. The ISNA advocates this shift—the organization recommends caregivers wait on genital surgery until a child is mature enough to make an informed decision for themself.

Before making a surgical decision, the ISNA also recommends that the child should be fully informed and introduced to people who have and have not had the surgery.

How To Provide Support

If you want to provide support for someone who is intersex, the best thing is to advocate for people to have the ability to make their own choices about their bodies, rather than a caregiver or someone else.

Social Support

Davis suggested that caregivers of intersex children reach out to other caregivers of intersex kids. Then, they can rely on other caregivers' experience and support so their children can make informed decisions about their bodies .

"I haven't met an intersex person or activist who's been against surgery," said Davis. "We're against having these surgeries done on those who don't have a say in what's done to their bodies."

Psychosocial Support

Davis also emphasized the roles of psychosocial support in the form of psychiatric counseling as well as support groups to help individuals who are intersex navigate any challenges. According to a study, 53.6% of the participants who were intersex self-reported that their mental health was fair or poor. On top of that, many of the participants noted that they were experiencing:

• Post-traumatic stress disorder (PTSD)

"We, as advocates, would like to see the psychosocial part of care be the predominant thing," said Davis. "While surgeons and endocrinologists are key, psychological counseling is of utmost importance in handling our unique identities and traits in day-to-day life. There's no proof that growing up with a body that looks different is inherently harmful."

A Quick Review

Intersex is a complex condition rooted in genetics. If a person chooses to pursue treatment for the condition, it should be on their own terms. Finally, being an ally to intersex individuals means ensuring that those individuals feel they have a sense of agency and autonomy.

Taylyn Washington-Harmon is the associate editor at Health.com. A former social media guru, she's worked for a number of lifestyle and beauty brands and has previously written for SELF and STAT. She loves skincare, anime, and her pitbull Momo.

MedlinePlus Medical Encyclopedia. Intersex .

American Academy of Family Physicians. Genital surgeries in intersex children .

Intersex Society of North America (ISNA). What does ISNA recommend for children with intersex? .

Rosenwohl-Mack A, Tamar-Mattis S, Baratz AB, et al. A national study on the physical and mental health of intersex adults in the U.S.   PLOS ONE . 2020;15(10):e0240088. doi:10.1371/journal.pone.0240088

Related Articles

GENDER ASSIGNMENT

the term used for the classification of an infant at birth as either male or female. Children born with ambiguous genitalia are usually assigned a gender by parents or physicians. See gender reassignment .

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What does it mean for someone to have the protected characteristic of “gender reassignment” under the Equality Act 2010? The government, public bodies, many employers and even employment tribunals are often confused about this.

Having the protected characteristic of gender reassignment does not mean that someone’s sex has changed or give them the right to make other people pretend that it has. 

These FAQs cover the definition of the characteristic and who it covers – and what this means for employers and service providers. 

Download these gender reassignment FAQs as a PDF.

What is the protected characteristic of “gender reassignment”?

What does it mean to have this characteristic , who can have this characteristic , does having the protected characteristic of gender reassignment mean that a person must be treated as the opposite sex , does the equality act outlaw “misgendering”, is it harassment to “out” a person as transgender , can employers have policies which require people to refer to transgender people in particular situations in a particular way , what should employers and service providers do to avoid the risk of harassment claims , should schools have rules about “misgendering”.

The Equality Act 2010 at Section 7 defines the protected characteristic of “gender reassignment” as relating to a person who is: 

“proposing to undergo, is undergoing or has undergone a process (or part of a process) for the purpose of reassigning the person’s sex by changing physiological or other attributes of sex.”

The law refers to this as being “transsexual”. But the term more commonly used today is “transgender” or “trans”. This broadly relates to anyone at any stage of a personal process. For example:

• A man tells his employer that he is considering “transitioning” and is seeing a therapist with the potential result of being referred for medical treatment.
• A man identifies as a “transwoman” without having any surgery or treatment.
• A woman identified as a “transman” for several years and took testosterone, but has now stopped and “detransitioned”.

The Equality Act protects people from direct and indirect discrimination, harassment or victimisation in situations that are covered by the Equality Act, such as in the workplace or when receiving goods or services.

Direct discrimination

Direct discrimination is when you are treated worse than another person or other people because:

• you have a protected characteristic
• someone thinks you have that protected characteristic (known as discrimination by perception)
• you are connected to someone with that protected characteristic (known as discrimination by association).

For example: an employee tells their employer that they intend to transition. Their employer alters their role against their wishes to avoid them having contact with clients.

The comparator is a person who is materially similar in other aspects but does not have the protected characteristic (“is not trans”). 

Indirect discrimination

Indirect discrimination happens when a policy applies in the same way for everybody but disadvantages a group of people who share a protected characteristic, and you are disadvantaged as part of this group. This is unlawful unless the person or organisation applying the policy can show that there is a good reason for the policy. This is known as objective justification .

For example: an airport has a general policy of searching passengers according to their sex. Everyone travelling needs to follow the same security procedures and processes, but it makes transgender travellers feel uncomfortable. This could be indirect discrimination, so the airport reviews its policy and changes it so that any passenger may ask to be searched by a staff member of either sex and have a private search, out of view of other passengers. 

Harassment is unwanted behaviour connected with a protected characteristic that has the purpose or effect of violating a person’s dignity or creating a degrading, humiliating, hostile, intimidating or offensive environment.

For example: a transgender person is having a drink in a pub with friends and is referred to by the bar staff as “it” and mocked for their appearance.

Victimisation

Victimisation is when you are treated badly because you have made a complaint of gender-reassignment discrimination under the Equality Act or are supporting someone who has made a complaint of gender-reassignment discrimination. For example:

For example: a person proposing to undergo gender reassignment is being harassed by a colleague at work. He makes a complaint about the way his colleague is treating him and is sacked.

The Equality Act also provides that if a person is absent from work because of gender-reassignment treatment, their employer cannot treat them worse than they would be treated if absent for illness or injury. 

Does a person have to be under medical supervision?

No. This was explicitly removed from the definition in 2010. Gender reassignment can be a personal process. 

Must they have a gender-recognition certificate or be in the process of applying for one?

No. The protected characteristic is defined without reference to the Gender Recognition Act.

Do they have to have made a firm decision to transition? 

No. Protection against discrimination and harassment attaches to a person who is proposing to undergo, is undergoing or has undergone a process (or part of a process).

During the passage of the Equality Act, the Solicitor General stated in Parliament: 

“Gender reassignment, as defined, is a personal process, so there is no question of having to do something medical, let alone surgical, to fit the definition. “Someone who was driven by a characteristic would be in the process of gender reassignment, however intermittently it manifested itself.  “At what point [proposing to undergo] amounts to ‘considering undergoing’ a gender reassignment is pretty unclear. However, proposing’ suggests a more definite decision point, at which the person’s protected characteristic would immediately come into being. There are lots of ways in which that can be manifested – for instance, by making their intention known. Even if they do not take a single further step, they will be protected straight away. Alternatively, a person might start to dress, or behave, like someone who is changing their gender or is living in an identity of the opposite sex. That too, would mean they were protected. If an employer is notified of that proposal, they will have a clear obligation not to discriminate against them.” 

In the case of Taylor v Jaguar Land Rover , a male employee told his employer that he was “gender fluid” and thought of himself as “part of a spectrum, transitioning from the male to the female gender identity”. He said to his line manager: “I have no plans for surgical transition.” He started wearing women’s clothing to work, asked to be referred to by a woman’s name and raised a question about which toilets he should use. The Employment Tribunal concluded that he was covered by the protected characteristic. 

Can children have the protected characteristic? 

Yes. In the case of AA, AK & Ors v NHS England , NHS England argued that children who are waiting for assessment by the Tavistock Gender Identity Development Service (GIDS) do not have the protected characteristic as they have not yet reached the stage of proposing to transition. The Court of Appeal rejected this argument. It noted that the definition of “gender reassignment” does not require medical intervention and can include actions such as changing “one’s name and/or how one dresses or does one’s hair”.

The court concluded:

“There is no reason of principle why a child could not satisfy the definition in s.7 provided they have taken a settled decision to adopt some aspect of the identity of the other gender.”

It noted that the decision did not have to be permanent. 

Is “Gillick competence” relevant to the protected characteristic?

No. “Gillick competence” refers to the set of criteria that are used for establishing whether a child has the capacity to provide consent for medical treatment, based on whether they have sufficient understanding and intelligence to fully understand it.

Having the protected characteristic of gender reassignment (that is, being able to bring a claim for gender-reassignment discrimination) does not depend on having any diagnosis or medical treatment. Therefore Gillick competence is not relevant to the Equality Act criteria. 

No. There is nothing in the Equality Act which means that people with the protected characteristic of “gender reassignment” need to be treated in a particular way, or differently from people without the characteristic. 

Article 9 and 10 of the European Convention of Human Rights protect the fundamental human rights of freedom of speech and freedom of belief. 

In the case of Forstater v CGDE [2021] it was established that the belief that men are male and women are female, and that this cannot change and is important, is protected under Article 9 and in relation to belief discrimination in the Equality Act. 

This means that employers and service providers must not harass or discriminate against people because they recognise that “transwomen” are men and “transmen” are women. Employers and service providers cannot require people to believe that someone has changed sex, or impose a blanket constraint on expressing their belief. 

No. “Misgendering” is not defined or outlawed by the Equality Act. 

In general, people who object to “misgendering” mean any reference to a person who identifies as transgender by words that relate to their sex. This can include using the words woman, female, madam, lady, daughter, wife, mother, she, her and so on about someone who identifies as a “transman”, or man, male, sir, gentleman, son, husband, father, he, him and so on about someone who identifies as a “transwoman”. 

Any form of words may be harassment, but this depends on the circumstances and the purpose and effect of the behaviour. Harassment is unwanted conduct related to a relevant protected characteristic that has the purpose or effect of violating a person’s dignity, or creating an intimidating, hostile, degrading, humiliating or offensive environment for a person.   An employment tribunal would also consider:

• that person’s perception
• the other circumstances of the case
• whether it is reasonable for the conduct to have that effect.

Tribunals have emphasised that when judging harassment context is everything, and warned against a culture of hypersensitivity to the perception of alleged victims.

Employment tribunal judgments

As Lord Justice Nicholas Underhill found in Dhellwal v Richmond Pharmacology [2009], a case decided under the Race Relations Act:

“What the tribunal is required to consider is whether, if the claimant has experienced those feelings or perceptions, it was reasonable for her to do so. Thus if, for example, the tribunal believes that the claimant was unreasonably prone to take offence, then, even if she did genuinely feel her dignity to have been violated, there will have been no harassment within the meaning of the section.”

In the Forstater case, the employment appeal tribunal said that it was not proportionate to “impose a requirement on the Claimant to refer to a trans woman as a woman to avoid harassment”. It said that:

“ Whilst the Claimant’s belief, and her expression of them by refusing to refer to a trans person by their preferred pronoun, or by refusing to accept that a person is of the acquired gender stated on a GRC, could amount to unlawful harassment in some circumstances, it would not always have that effect. In our judgment, it is not open to the Tribunal to impose in effect a blanket restriction on a person not to express those views irrespective of those circumstances.”

In the case of de Souza v Primark Stores [2017] , a transgender claimant who went by the name of Alexandra, but whose legal name was Alexander, was found to have been harassed by colleagues who made a point of using the male form of name when they knew he did not want them to, but not by being issued with a “new starter” badge that showed his legal name. 

In the case of Taylor v Jaguar Land Rover [2020] , a male claimant who wore women’s clothing  to work was judged to have been exposed to harassment by colleagues saying “What the hell is that?”, “So what’s going on? Are you going to have your bits chopped off?”, “Is this for Halloween?” and referring to the claimant as “it”. 

Not necessarily. 

A person can be “outed” as transgender in two different ways: 

• Their sex is commonly known and recorded, but their transsexualism is not (for example a man who cross-dresses at the weekend and is considering transitioning is “outed” at work by someone who has seen them at a social event).
• They are disappointed in the expectation of being treated as one sex when they are actually the other (for example a person who identifies as a “trans woman” is referred to as male by a woman in a changing room).

In Grant v HM Land Registry [2011] , which concerned the unwanted disclosure that an employee was gay, Lord Justice Elias found that this did not amount to harassment: 

“Furthermore, even if in fact the disclosure was unwanted, and the claimant was upset by it, the effect cannot amount to a violation of dignity, nor can it properly be described as creating an intimidating, hostile, degrading, humiliating or offensive environment. Tribunals must not cheapen the significance of these words. They are an important control to prevent trivial acts causing minor upsets being caught by the concept of harassment.”

The perception (or hope) of transgender people that they “pass” as the opposite sex is often not realistic. Their sex is not in fact hidden, but is politely ignored by some people in some situations. It is not reasonable for them to be offended by other people recognising their sex, particularly if they are seeking access to a single-sex service. Acknowledging someone’s sex, particularly where there is a good reason, is unlikely to be harassment. 

In the first-instance case of Chapman v Essex Police , a transgender police officer felt embarrassed and upset when a police control-room operator double-checked his identity over the radio because his male voice did not match the female name that the operator could see. The tribunal did not uphold a complaint of harassment, finding that the claimant was “too sensitive in the circumstances”.

Yes, but those policies must be proportionate. Employers cannot have blanket policies against “misgendering”, but can have specific policies concerning how staff should refer to transgender people in particular situations. Organisations should recognise that these policies constrain the expression of belief, and therefore they should seek to achieve their specific aims in the least intrusive way possible.

When determining whether an objection to a belief being expressed is justified, a court will undertake a balancing exercise. This test is set out in the case of Bank Mellat v HM Treasury :

• Is the objective the organisation seeks to achieve sufficiently important to justify the limitation of the right in question?
• Is the limitation rationally connected to that objective?
• Is a less intrusive limitation possible that does not undermine the achievement of the objective in question?
• Does the importance of the objective outweigh the severity of the limitation on the rights of the person concerned?

For example: 

• A company provides a specialist dress service to transsexual and transvestites. The men who use the service expect to be called “she” and “her” and referred to as Madam. It is justified for the employer to train and require staff to use this language when serving customers. 
• Staff at a full-service restaurant greet customers as “Sir” and “Madam” as they arrive. The restaurant’s policy is that staff should use the terms which appear most appropriate based on gendered appearance, and to defer to customer preference if one is expressed. This is justified by the aim of creating the service and ambience that the restaurant owners seek to provide. 
• A public body assesses claimants for medical benefits, including individuals with mental-health conditions. It directs its staff to refer to claimants using the terms which the claimants prefer, including using opposite-sex pronouns when requested, in order to make them feel comfortable. However, it recognises that in recording medical information, assessors must be able to be accurate about claimants’ sex. This is justified by the aim of providing a service that is accessible and effective for vulnerable clients. 

The case of David Mackereth v AMP and DWP concerned a doctor who lost his job undertaking claimant health assessments for the Department for Work and Pensions because he refused to comply with its policy on using claimants’ preferred pronouns. The employer’s policy was found not to have amounted to unlawful harassment or discrimination against Dr Mackereth, in the particular circumstances of his job. However, the Employment Appeal Tribunal stated that “misgendering” would not necessarily be harassment: 

“Such behaviour may well provide grounds for a complaint of discrimination or harassment but, as the EAT in Forstater made clear, that will be a fact-specific question to be determined in light of all the circumstances of the particular case.”

Relevant considerations

In Higgs v Farmor’s School [2023] Mrs Justice Eady sets out the considerations that are likely to be relevant considering whether constraining the expression of a belief (“manifestation”)  in order to avoid harassment or discrimination is justified in the context of employment. These include:

• the content of the manifestation
• the tone used
• the extent of the manifestation
• the worker’s understanding of the likely audience
• the extent and nature of the intrusion on the rights of others, and any consequential impact on the employer’s ability to run its business
• whether the worker has made clear that the views expressed are personal, or whether they might be seen as representing the views of the employer, and whether that might present a reputational risk
• whether there is a potential power imbalance given the nature of the worker’s position or role and that of those whose rights are intruded upon;
• the nature of the employer’s business, in particular where there is a potential impact on vulnerable service users or clients
• whether the limitation imposed is the least intrusive measure open to the employer.

Employers cannot force employees to believe that people can change sex, or prevent them expressing that lack of belief except in limited circumstances. So what should employers do to protect transgender people from harassment, and themselves from liability? 

They should have ordinary policies against bullying and harassment, including jokes, name-calling, humiliation, exclusion and singling people out for different treatment.

They should seek to avoid putting people in situations they will reasonably experience as hostile or humiliating.

Ambiguous rules put people in situations where it is reasonable to feel offended. For example, an employer provides “female” toilets, showers and changing rooms, but allows some male staff in because they identify as transgender. This creates a hostile environment: 

• female staff are surprised, shocked, humiliated and upset to find themselves sharing with a colleague of the opposite sex
• male staff members who want people to treat them as women may be challenged or face comments that are intended to intimidate, humiliate or degrade them.

This was the situation faced by the Sheffield Hospital Trust , which had a policy that transgender staff could use opposite-sex facilities. It had to deal with the fall-out when women complained about seeing a half-naked male in their changing room and the male staff member sued for harassment after being questioned about this.

Rather than putting these two groups of people together in a environment where both will reasonably feel harassed, employers should have clear rules about facilities that are single-sex, and also, where possible, provide a unisex alternative for anyone who needs it, including people who feel that they have “transitioned away from their sex” and therefore do not wish to use single-sex facilities shared with members of their own sex. The EHRC last year provided guidance on single-sex services which encouraged clear rules and policies.

It should be made clear to people who have the protected characteristic of “gender reassignment” that having this characteristic does not mean it is reasonable for them to expect others to believe or pretend to believe they have changed sex, or for them to be allowed to break (or expect to be an exception to) rules that aim to protect the dignity and privacy of others. 

If a person breaks a clear rule against entering a space provided for the opposite sex, it is not reasonable for them to feel offended when this is pointed out. 

No. It would not be lawful for schools to have a policy that forbids, punishes or denigrates pupils who use clear words about the sex of other people (such as pronouns, but also boy/girl, male/female and so on), nor to require pupils to refer to some classmates as if they were the opposite sex.

• To do so constrains the freedom of speech of pupils in a way that is unjustified and discriminates against them on the basis of belief. 
• It is inconsistent with schools’ safeguarding duty of care , and with their record-keeping responsibilities, for staff to misrepresent the sex of pupils in their records or in introducing them to their peers. 
• In order to explain and enforce sex-based rules designed to keep children safe (such as who is allowed in which showers, toilets, dormitories or sports teams), schools must be able to use clear and unequivocal language. 
• It is not reasonable to expect that a child at school, or transferring between schools, can avoid being “outed” as the sex that they are . 

We do not think that any policy which tells teachers or pupils to lie about the sex of pupils, constrains them from using clear sex-based language or treats them detrimentally if they do would pass the proportionality test. It is an unreasonable constraint on speech that is neither required nor justified in order to avoid discrimination on the basis of gender reassignment. 

Schools form part of a system that is regulated at a national level. In England that system is the responsibility of the Secretary of State for Education. It is the responsibility of the Secretary of State to make this legal situation clear across the English school system by issuing the long-awaited DfE guidance. 

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gender reassignment

Definition of gender reassignment

Note: This term is sometimes considered to be offensive in its implication that a transgender or nonbinary person takes on a different gender, rather than making changes to align their outward appearance and presentation with their gender identity. Gender transition is the preferred term in the medical and LGBTQ+ communities.

Word History

1969, in the meaning defined at sense 2

Articles Related to gender reassignment

Merriam-Webster's Short List of Gender...

Merriam-Webster's Short List of Gender and Identity Terms

In case you (or someone you know) has questions about what they mean

Dictionary Entries Near gender reassignment

genderqueer

gender reassignment surgery

Cite this Entry

“Gender reassignment.” Merriam-Webster.com Dictionary , Merriam-Webster, https://www.merriam-webster.com/dictionary/gender%20reassignment. Accessed 20 Apr. 2024.

Medical Definition

Medical definition of gender reassignment.

Note: This term is sometimes considered to be offensive in its implication that a transgender or nonbinary person takes on a different gender, rather than makes changes to align their outward appearance and presentation with their gender identity. Gender transition is the preferred term in the medical and LGBTQ+ communities.

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A decision to undertake gender reassignment is made when an individual feels that his or her gender at birth does not match their gender identity. This is called ‘gender dysphoria’ and is a recognised medical condition.

Gender reassignment refers to individuals, whether staff, who either:

• Have undergone, intend to undergo or are currently undergoing gender reassignment (medical and surgical treatment to alter the body).
• Do not intend to undergo medical treatment but wish to live permanently in a different gender from their gender at birth.

‘Transition’ refers to the process and/or the period of time during which gender reassignment occurs (with or without medical intervention).

Not all people who undertake gender reassignment decide to undergo medical or surgical treatment to alter the body. However, some do and this process may take several years. Additionally, there is a process by which a person can obtain a Gender Recognition Certificate , which changes their legal gender.

People who have undertaken gender reassignment are sometimes referred to as Transgender or Trans (see glossary ).

Transgender and sexual orientation

It should be noted that sexual orientation and transgender are not inter-related. It is incorrect to assume that someone who undertakes gender reassignment is lesbian or gay or that his or her sexual orientation will change after gender reassignment. However, historically the campaigns advocating equality for both transgender and lesbian, gay and bisexual communities have often been associated with each other. As a result, the University's staff and student support networks have established diversity networks that include both Sexual Orientation and Transgender groups.

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The Easy Peasy Guide to Gender and Sexual Identity Terms

Am I the only one who thinks that, like every day, there is a new term to describe an individual’s gender or sexual identity? Using a tired old sports analogy, keeping a score without a scorecard is hard. That is what it seems like some days with the seemingly constant flow of new terms and definitions.

The genesis of this article was when, the other day, I read a news story about someone who claimed they were abrosexual. Being exposed to a new term, I needed to look it up to understand the content and context of what was written. My curiosity got me thinking about the multitude of terms and subsequent definitions used to describe someone’s sexual orientation and gender identification.

What I learned is that the language surrounding sexual and gender identity is constantly evolving and diverse, reflecting the complexity of human experiences. For transparency, I used OpenAI ChatGPT only for the terms and definitions in the research. It was a great time saver.

Let me be clear: I am not taking any political, religious, biblical, judgemental, or any other position regarding how a person identifies their gender or sexuality. That is their business, period, end discussion.

As a result, here are two lists of terms and definitions as a reference guide regarding gender and sexual identity as I write this article.

Gender Identity

Cisgender (cis): A person whose gender identity aligns with the sex assigned at birth.

Transgender (trans): A person whose gender identity differs from the sex assigned at birth.

Non-binary: A person whose gender identity doesn’t fit within the traditional binary categories of male or female.

Genderqueer: A term used by some individuals whose gender identity doesn’t conform to societal expectations of masculinity or femininity.

Genderfluid: A person’s gender identity may change over time or in different contexts.

Agender: A person who identifies as having no gender or as neutral.

Bigender: A person who identifies as having two gender identities simultaneously or at different times.

Gender nonconforming: A broad term for individuals whose gender expression doesn’t conform to societal norms.

Two-spirit: Some Indigenous North American cultures use the term to describe individuals who embody masculine and feminine qualities.

Demigender: A person whose gender identity is partially but not fully aligned with one’s assigned sex or with the binary gender system.

Pangender: A person whose gender identity encompasses all genders.

Androgynous: A person whose appearance and/or identity blends masculine and feminine characteristics.

Neutrois: A non-binary gender identity that is neutral or null.

Gender questioning: A person who is exploring or questioning their gender identity.

Genderflux: A gender identity that fluctuates in intensity.

Intergender: A person whose gender identity is between or a combination of genders.

Multigender: A person who identifies with more than one gender.

Trigender: A person who shifts between three different gender identities.

Gender creative: A term often used for children whose gender expression or identity doesn’t conform to traditional norms.

Transmasculine: A term used to describe individuals who were assigned female at birth but identify more closely with masculinity.

Transfeminine : A term used to describe individuals who were assigned male at birth but identify more closely with femininity.

Sexual Identity

Heterosexual: Attracted to people of the opposite gender.

Homosexual: Attracted to people of the same gender.

Bisexual: Attracted to people of both genders.

Pansexual: Attracted to people regardless of their gender identity or biological sex.

Asexual: Experiencing little or no sexual attraction to others.

Demisexual: Experiencing sexual attraction only after forming a strong emotional bond with someone.

Queer: An umbrella term for sexual and gender minorities who are not heterosexual or cisgender. It can encompass a wide range of identities.

Polysexual: Attracted to multiple genders, but not necessarily all genders.

Fluid: A term used to describe a sexuality that is not fixed and may change over time.

Androsexual/Gynesexual: Attracted to masculinity/femininity regardless of gender identity.

Greysexual: Experiencing sexual attraction rarely or only under specific circumstances.

Lithsexual: Experiencing sexual attraction but not wanting it to be reciprocated.

Skoliosexual: Attracted to non-binary and transgender people.

Sapiosexual: Attracted to intelligence or intellect.

Autosexual: Finding oneself sexually attractive.

Ceterosexual: Attracted to non-binary people.

Reciprosexual: Experiencing sexual attraction only when it is reciprocated.

Abrosexuality :  Describes individuals whose sexual orientation is fluid and may change over time or in different cir cumstances.

Omnisexuality: A sexual orientation in which a person is attracted to people of all genders, including men, women, nonbinary people, and other gender identities.

It’s important to note that this list is not exhaustive, and new terms and definitions may emerge as our understanding of gender and sexuality evolves. Additionally, individuals may have unique experiences and preferences when describing their gender identity.

Now, you’ll understand what they are talking about. At least, I will, anyway.

Thank you for giving me the precious gift of your time and reading Perceptions, Observations, and Musings of an Old Man. 

T he opinions expressed are my own. ©Michael J Krivich 2024. All rights reserved.

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Supreme Court allows Idaho to enforce its ban on gender-affirming care for transgender youth

FILE - The Supreme Court of the United States is seen in Washington, March 26, 2024. (AP Photo/Amanda Andrade-Rhoades, File)

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WASHINGTON (AP) — The Supreme Court is allowing Idaho to enforce its ban on gender-affirming care for transgender youth while lawsuits over the law proceed, reversing lower courts.

The justices’ order Monday allows the state to put in a place a 2023 law that subjects physicians to up to 10 years in prison if they provide hormones, puberty blockers or other gender-affirming care to people under age 18. Under the court’s order, the two transgender teens who sued to challenge the law still will be able to obtain care.

The court’s three liberal justices would have kept the law on hold. Justice Ketanji Brown Jackson wrote that it would have been better to let the case proceed “unfettered by our intervention.”

Justice Neil Gorsuch of the conservative majority wrote that it is “a welcome development” that the court is reining in an overly broad lower court order.

A federal judge in Idaho had blocked the law in its entirety after determining that it was necessary to do so to protect the teens, who are identified under pseudonyms in court papers.

Lawyers for the teens wrote in court papers that the teens’ “gender dysphoria has been dramatically alleviated as a result of puberty blockers and estrogen therapy.”

The American Civil Liberties Union, representing the teens and their families, called the Supreme Court’s order “an awful result for transgender youth and their families across the state. Today’s ruling allows the state to shut down the care that thousands of families rely on while sowing further confusion and disruption.”

Idaho Attorney General Raúl Labrador said in a statement that the law “ensures children are not subjected to these life-altering drugs and procedures. Those suffering from gender dysphoria deserve love, support, and medical care rooted in biological reality. Denying the basic truth that boys and girls are biologically different hurts our kids.”

Gender-affirming care for youth is supported by every major medical organization, including the American Medical Association, the American Academy of Pediatrics and the American Psychiatric Association.

Medical professionals define gender dysphoria as psychological distress experienced by those whose gender expression does not match their gender identity.

The action comes as the justices also may soon consider whether to take up bans in Kentucky and Tennessee that an appeals court allowed to be enforced in the midst of legal fights.

At least 23 states have enacted laws restricting or banning gender-affirming medical care for transgender minors, and most of those states face lawsuits. A federal judge struck down Arkansas’ ban as unconstitutional. Montana’s ban also is temporarily on hold.

The states that have enacted laws restricting or banning gender-affirming medical care for transgender minors are Alabama, Arkansas, Arizona, Florida, Georgia, Idaho, Indiana, Iowa, Kentucky, Louisiana, Mississippi, Missouri, Montana, Nebraska, North Carolina, North Dakota, Ohio, Oklahoma, South Dakota, Tennessee, Texas, Utah and West Virginia.