9 questions about trans issues you were too embarrassed to ask

A protester supporting Black trans lives during a march in Los Angeles, California, on June 14. | SOPA Images/LightRocket via Getty Images

From pronouns to sports to puberty blockers, here are answers to the most common questions about trans issues.

In 2014, Time declared American culture had hit “The Transgender Tipping Point.” The magazine featured trans actress Laverne Cox on the cover, with an article that trumpeted that trans people were “emerging from the margins to fight for an equal place in society.” Perhaps just as radical was the article itself. Many in the US were just getting familiar with trans people — those whose internal sense of their gender doesn’t match their assigned sex at birth — and mainstream media was taking note.

Then came Caitlyn Jenner’s very public coming-out the following year, which made pronouns (Caitlyn was now “she” and “her”) and deadnaming (do not call her by her old name) national talking points. The public saw her on reality TV, and watched other shows, such as Cox’s Orange Is the New Black, Transparent, Pose, and, more recently, AMC’s Dispatches From Elsewhere, where trans people were portrayed with inner lives and some nuance. By 2016, 33 percent of people said they personally knew a trans person, up from 9 percent in 2013.

But while awareness of trans people has grown in recent years, trans people have existed since the dawn of time. “Third genders,” as they’re sometimes called, were accepted in Indigenous societies in North and South America, Africa, India, and Polynesia, among others.

Monica Schipper/WireImage via Getty Images

So has more visibility and a vocabulary lesson led to greater equality in recent years? Many trans people would say no — especially since they are still fighting against run-of-the-mill transphobia. While a Supreme Court ruling in June declared discrimination against trans people in employment decisions illegal under federal civil rights law, discrimination still happens in other areas of everyday life, including in housing, health care, and public accommodations.

According to the National Center for Transgender Equality, 29 percent of US trans people live in poverty, and one in five trans people in the US will be homeless at some point in their lifetime. The numbers are even starker for Black trans people: A 2015 report by two leading think tanks found that 34 percent of Black trans people live in extreme poverty, compared to 9 percent of Black cis people.

Visibility also has a downside. Social conservatives who had largely moved on from fighting against gay rights have turned their attention to undermining the advancements of trans people. Propaganda by far-right conservatives and trans-exclusionary radical feminists (sometimes called TERFs or “gender critical” feminists) has sought to build animus toward trans people, portraying them as predators and accusing them of “recruiting children.”

These as well as other less flagrant misconceptions are still commonly held in society, and are commonly exploited by right-wing and anti-trans political actors — resulting in the sudden calls for “bathroom laws” and a ban against transgender soldiers.

To help break it all down, here are nine questions that get at the heart of what trans people are fighting for — and against — every day:

1) What does it mean to be trans?

A trans person is someone who feels that their internal sense of their own gender does not match their assigned sex at birth. Most people are familiar with binary trans people: trans women, who were assigned male at birth and later came to understand their gender to be female (Cox, Jenner); and trans men, who were assigned female at birth and later came to understand their gender to be male (Chaz Bono).

But “transgender” is also an umbrella term to describe a diverse set of communities of people whose gender doesn’t match their assigned sex, including those who occasionally don the clothes of a different sex but don’t take steps to medically transition and those don’t feel their gender can be categorized.

This includes nonbinary people who don’t subscribe to the binary notions of gender — i.e., that humans should be organized into either male or female categories, with prescriptive roles and identities based on external genitalia. That’s not to say being nonbinary means placing your gender identity somewhere in between male and female; there’s no one single way to be nonbinary.

“People are most familiar with the canonical trans person who spent a lot of their life knowing they were a girl or a boy, and to varying extents maybe tried to make that work or maybe it didn’t work at all, and they eventually transitioned,” trans feminist activist, writer, and biologist Julia Serano told Vox. “A lot of people might not identify with the gender they were assigned at birth, but they might not know for sure whether they fit into the so-called other gender. As a result, a lot of us who are trans do a lot of questioning of gender with regards to society and how we categorize people.”

Trans identities only seem new or “different” in relation to Western notions of gender. The gender binary is a concept that largely, but not exclusively, grew out of Christian society to benefit the agrarian and military needs of developing nation-states: Western societies used manpower to supply armies and farms, while women were made responsible for tending to the home and creating more people — more men for manpower and more women for people-creating.

However, Indigenous societies in the Pacific Islands, the Americas, and India have long had gender systems that aren’t strictly binary.

“For thousands and thousands of years in North America, the social experience of Indigenous peoples was of inclusivity and accepting what creation had made,” said Albert McLeod, a longtime LGBTQ activist and co-director of Two-Spirited People of Manitoba, a Canadian two-spirit advocacy group.

According to McLeod, researchers and anthropologists who have studied Native history have discovered more than 150 words by Native tribes to describe queer and trans identities, such as agookwe, which means “hidden woman” in the Ojibwe language, or winkte, “halfman-halfwoman,” in Dakota.

“There was a place for everyone,” McLeod said. “With trans people, the family or the community adapted to that reality, which is very different than Western society.”

That language was lost when the US and Canadian governments forced Indigenous people to abandon their native tongues in English-only schools. “Those ethics [of trans inclusion] were embedded in the language,” said McLeod. “The language had to be prohibited in order to impose this binary worldview onto Indigenous peoples.”

People who are upset by trans people’s existence, one could argue, are threatened by the disruption of gender roles and the status quo. They are bothered by a person’s presentation. “Anti-trans activists are trying to defend a worldview that suggests your biology is your destiny,” Gillian Branstetter, a spokesperson at the National Women’s Law Center, told Vox. “When they make an issue over somebody with a Y chromosome using she/her pronouns, what they’re upset by is that pronoun’s name, clothing — all of this is not encoded into what is often referred to as your biological sex.”

This translates into mockery of trans people — and often so much worse. Conservatives and anti-trans feminists have tapped into the dangerous “man in a dress” stereotypes (seen throughout popular culture in movies like Psycho, Silence of the Lambs, and Dressed to Kill) to create fear around trans people and sway public opinion. In reality, trans people are just trying to live their lives, which is made harder by having to face such social exclusion.

2) Why should I care about trans issues?

At one time, nearly every major politician opposed marriage equality. Even Barack Obama did not support the issue during his first campaign for president in 2008.

But what transformed the marriage equality fight was personal contact with gay people who were willing to speak about their marginalized experiences in society. While “love is love” became the tagline of the marriage equality fight, it was also about access to spousal benefits like insurance and medical care, inheritance, tax breaks, and parental rights that came along with legal recognition. That strategy worked largely because roughly 3.5 percent of US adults are gay, lesbian, or bisexual, and a great many cisgender heterosexual people had at least one gay friend or family member who could personalize the issue. Over time, visibility and empathy led to a change in public opinion, which led to policy change.

But that strategy largely doesn’t work for trans people, who make up only about 0.6 percent of the adult population. While the percentage of people who know someone trans is higher now than it has ever been — several polls put the number of Americans who know someone who is trans at around 30 percent — there still tends to be an empathy gap when cis people discuss trans people. Trans experiences are often easily bundled into discussions by cisgender people — among academics, on social media, in op-eds on conservative websites — over the meaning of sex and gender. The humanity of trans people, meanwhile, is often missing from these discussions.

That’s because trans people are rarely employed in positions of power in academia, government, or media, and ultimately have very little institutional power to influence debates that cisgender people have about trans lives. So when cis academics who have no experience with being trans debate whether trans people exist or deserve basic respect under the law, the debate is missing the most relevant perspective and experience of all: a trans person’s.

There’s a long history of excluding trans people from careers and spaces that cis people often take for granted. This could contribute to the fact that trans people experience elevated levels of suicide and violence. With more social acceptance and access to critical services, trans communities will be safer.

Also, trans issues don’t just affect trans people. As Vox reported in July, the Trump administration is proposing a rule that attempts to link certain physical traits, like height, facial hair, and the presence of an “Adam’s apple,” to detecting a homeless person’s “biological sex” for placement in a housing shelter. Under the rule, anyone that a shelter’s staff believes may be trans can be separated out and asked for further proof of their assigned sex at birth. The rule would very obviously fall hardest on trans women, but cis women with some of those same masculine traits would also be subject to potential humiliation.

Trans people have challenged the gender binary in ways that previous generations haven’t been able to, to the benefit of everyone in society. “Unless there’s a very small minority of people who are completely masculine men and completely feminine women, if you don’t fall into these categories, then you have a stake in the idea of making our concept of gender more flexible and more inclusive of everybody,” said Serano.

Michael Noble Jr./Getty Images

3) What about the pronouns thing?

We all have pronouns — cis people have pronouns, trans people have pronouns, even ships can have pronouns. And if you don’t know a trans person’s pronouns, it’s fine to ask! It’s even okay to stumble and apologize. Don’t make it a big deal, just don’t misgender trans people on purpose.

An individual’s gender is typically a deeply held part of their internal sense of their identity, and pronouns are inextricably linked to that identity. To trans people, using someone’s stated pronouns is a matter of respect, not debate.

As Serano puts it, “How would you feel if Monday, everyone just started calling you the wrong pronouns, and if you complained about it, they still did it anyway? You would probably feel pretty crappy about that.”

Trans people have also pushed for more regular acknowledgment of nonconventional gender pronouns, and mainstream culture is being more receptive: Last year, the singular “they” was named Merriam-Webster Dictionary’s word of the year. As Vox’s Anna North reported, when people use “they” and “them” pronouns, it’s a way of reclaiming a history of the English language in which “they” has long been used in a gender-neutral way; as a singular pronoun, it can be traced back to the late 1300s.

But beyond she, he, and they is a whole world of neo-pronouns, or nontraditional pronouns, which can denote all kinds of gender identities, like zir, fae, and xe.

For Newton Brophy, a 25-year-old gender-nonconforming trans man from Tampa, Florida, finding the right pronoun, sé/é (pronounced shay/ay), was a deeply personal process. “I found if I use they/them, people assume I’m non-binary, and from there, give themselves license to slip into she/her pronouns, or to treat me like a cis woman,” sé told Vox. He/him didn’t quite feel right either; then sé found out the Irish language’s masculine pronouns were sé/é and loved the sound of it. “I feel like a guy who is a she. But you can’t really explain that to most people.”

4) What issues are trans people fighting for?

The policy changes trans people are asking for now — legal protections against discrimination in employment, housing, health care, and public accommodations — are also the same legal protections women, people of color, and LGB Americans have had to fight for in the past, and continue to fight for.

Trans people disproportionately live in poverty in large part because of familial rejection and discrimination. Across large swaths of the US, trans people have no legal protections against discrimination in housing and public accommodations. In 26 states, a trans person can be evicted if their landlord finds out they’re trans. Trans people can be harassed and kicked out of public bathrooms in 27 states.

While a June Supreme Court decision decreed that firing a trans person for being trans is illegal under existing civil rights law, trans people can still be skipped over during the job application process as long as the employer doesn’t get caught, in part because discrimination can be hard to prove.

According to a 2017 survey by New York City’s Anti-Violence Project, transgender New Yorkers were more likely to have a college degree than the general population, but just 45 percent had full-time jobs. Overall, transgender workers are more likely to be unemployed compared to their cisgender counterparts.

Because of a cycle of discrimination and poverty, trans people are more likely to turn to dangerous or illegal means, like sex work, in order to survive. Police, meanwhile, are often trained to look for Black and Latinx trans women on the street to pick up on suspicion of being a sex worker.

Last year, an NYPD officer testified at a deposition that he would drive around looking for women with “Adam’s apples” to stop on suspicion of solicitation. Under the law in New York and many other states, discovery of a condom in a purse is sufficient evidence to arrest a trans woman on prostitution charges. A Black trans activist in Arizona was infamously arrested in this fashion in 2014, while another Black trans woman traveling through Iowa was arrested after hotel staff, suspecting that she was a sex worker, called the police.

It’s not surprising, then, that 21 percent of Black trans women will face incarceration at least once in their lifetime, a rate significantly higher than the general population. Additionally, there have been reports of police sexually assaulting trans women going back decades.

Essentially, discrimination — from housing to employment — leads to the odds of trans people falling into a cycle of poverty, incarceration, and homelessness that’s disproportionate to cisgender people in society. Breaking the cycle begins with creating policies that ban discrimination and put trans people on equal footing with everyone else.

5) Why are we always talking about trans issues?

The same arguments around trans issues have been happening for decades, but it’s only since the American religious right has invested effort and money in targeting trans people in recent years that the rest of society has taken notice.

That effort kicked off in earnest in 2015, mere months after Caitlyn Jenner’s Vanity Fair cover and the Supreme Court’s landmark Obergefell ruling, in a Houston referendum over the city’s LGBTQ nondiscrimination ordinance. Focusing on the law’s public accommodation protections allowing trans people to use bathrooms according to their lived gender, conservatives seized on a narrative that trans women are really just creepy men who didn’t belong in women’s restrooms.

“The right has worked to make it an electoral issue. We see this across the board — they try to posture trans rights as extreme and a danger particularly to children,” Brennan Suen, LGBTQ program director at Media Matters, told Vox. This is why, he said, conservatives have focused so much on legislation regarding transition care for trans minors, bathrooms, and trans athletes in sports. “They are able to reach those voters who might not know a trans person and give them misinformation and bigoted information that honestly scares them.”

It’s part and parcel of the modern conservative electoral strategy, which often leans into demonizing vulnerable communities on issues such as immigration, criminal justice, and reproductive rights.

“The right often seizes power by targeting marginalized people,” Suen said. “And as trans people have really been more visible in the media … we’ve seen the right really ramp up their attacks.”

Suen pointed to last year’s governor’s race in Kentucky as an example. As then-incumbent Republican Gov. Matt Bevin fell behind in a race against Democratic challenger Andy Beshear, political groups supporting the governor leaned into transphobia to try to eke out a win.

An out-of-state-based group called Campaign for American Principles Kentucky aired an ad attacking Beshear for allegedly supporting trans girls in girls’ high school sports (a similar ad from the same group geared toward the presidential election was recently blocked by Facebook). Though Bevins lost in the end, some conservatives think the trans attack ads helped win over undecided voters. “It really is this strategy of ‘Get people out to vote or your way of life is going to be threatened,’” said Suen.

As the right wing has become more obsessed with the issue, matters have only gotten worse for trans people. According to a 2020 Media Matters report of 225 trans-related articles shared on Facebook — about anything from trans athletes to trans kids — 65.7 percent of the 66 million Facebook interactions generated by those articles came from those put out by right-wing sources.

Seeing how trans issues rile up the far right, the Trump administration has leaned into targeting trans people to feed its base. Almost immediately after President Trump took office in 2017, the administration rolled back an Obama-era memo directing schools to protect trans students from discrimination. Then that July, Trump announced that he would order the military to ban trans people from serving. The administration went after trans prisoners as well in May 2018, deciding that in most cases, trans people should be housed according to their assigned sex at birth. That’s in addition to the homeless shelter rule proposed this summer.

Perhaps most critical was the administration’s attack on LGBTQ nondiscrimination protections in the Affordable Care Act, finalized in a new rule on June 12 that has since been blocked by two federal courts. The rule would let doctors and health care companies deny care and coverage to trans people.

In less than four years, Trump has essentially wiped out a decade of policy progress for the trans community.

6) What’s the deal with bathrooms?

For a while, the most common issue associated with trans people was bathrooms. In 2016, North Carolina passed a bathroom bill declaring that trans people must use the bathroom conforming with the sex on their original birth certificate in all state-owned properties. Conservatives said this was meant to protect cisgender women. The idea, however, that some trans women are predators looking to access women’s spaces has largely proven to be an unfounded myth.

After an overwhelming backlash, North Carolina repealed the bill, at least partially. And while several conservative states proposed their own bathroom bills between 2016 and 2018, all were shot down. The anti-trans bathroom movement in the US seems to have since died out.

Yet due to conservative narrative, the bathroom predator trope prevails, and many trans people still fear going to public restrooms, afraid they’ll be accosted or attacked. According to the 2015 US Transgender Survey, 59 percent of trans people in the US reported that they had avoided using a public bathroom in the last year, 31 percent said they avoided eating or drinking for fear of having to use a public bathroom, and 8 percent reported having a kidney or urinary tract infection from avoiding the bathroom.

Confrontations in bathrooms over someone’s perceived gender can be awkward at best, or dangerous in the most extreme cases. And it’s not just trans and nonbinary people who have been accosted for being in the “wrong” bathroom. There have been several instances of butch women getting hassled or thrown out of women’s bathrooms.

“Nobody really likes using public bathrooms,” said Nahid, a trans woman from Austin, Texas. “You want to go in there, you want to do your business, you want to get out as soon as possible. You don’t want to hassle people. Trans people want all these things, too.”

7) What’s with the panic over trans women with penises and trans men who menstruate?

A recent YouGov poll of British attitudes toward trans people showed a dramatic split between support for trans-related policies when it came to trans women who had kept their penises versus not. Support was significantly lower for several key issues — like locker room access and toilets — when the question specifically asked about trans people’s anatomy.

Trans women who have their original genitalia tend to be the proverbial elephant in the room for cis people. For years, Hollywood has portrayed trans women as either sexually deviant threats or as the butt of the joke. The “penis reveal” movie trope has also helped form social opinion about so-called “devious” trans women, as was so brilliantly detailed in the Netflix documentary Disclosure, which recounts how movies from The Crying Game to Ace Ventura: Pet Detective have trained audiences to act with revulsion toward a woman with a penis.

In Western society, the penis is a symbol of virility and power. And for many feminists, the penis can be both the symbolic and quite literal source of female pain and oppression. To be a woman and to have a penis are simply two opposing possibilities for a large segment of society.

That conditioning starts very early in life, according to Serano. “When [kids] are first learning, they view [gender] as kind of a surface feature. They likely will interpret gender in terms of like what your hairline says or what clothes you’re wearing,” she said. Children also learn the fallacy of gender constancy — the idea that a person’s gender never changes — and to associate gender with the physical body and genitalia, Serano said.

These beliefs, for most people, hold into adulthood. So when a trans woman comes along who still has a penis, that can be a really difficult thing for the average person to accept.

But regardless of how society at large feels about trans women with penises, getting rid of one is no simple matter. Surgeries are expensive, even when they are covered by insurance. And some trans women have complicating health risks that make surgeries impossible, while still others are either too risk-averse or don’t have any dysphoria about their genitals.

Regardless of a trans woman’s personal feelings about her junk, you can’t tell who has had the surgery just by looking at them. So policies against trans women with penises accessing women’s spaces are really just policies against anyone who looks remotely trans.

The same goes for trans men who still menstruate. Not all trans men have had gender-affirming surgeries, nor do they necessarily want to, so some still get their periods. Testosterone therapy for transmasculine people stops periods in most but not all, and trans men can still get pregnant or have health issues related to their reproductive anatomy.

When trans men pop up in the discourse — which is much less often than trans women — it’s usually relating to their reproductive health. Sensational headlines about “pregnant men” have run in tabloids for years. And yet trans men and nonbinary people who were assigned female at birth are also frequently erased and marginalized from the reproductive health care they need because of an assumption that this kind of care doesn’t apply to men.

That’s why advocates say it’s important to use inclusive language like “people who menstruate” or “pregnant people.” “As a trans guy who still, frustratingly, occasionally has periods, I support those terms,” said Wilson, a 36-year-old trans man from Baltimore. “They actually originated among trans men and were intended to support trans men.”

But since trans men are often more “invisible” than trans women, Wilson said those terms have become “erroneously associated with trans women” and a way to mock them. For example, in a tweet from June, best-selling children’s author and recently outspoken anti-trans activist J.K. Rowling poked at reproductive health language meant to include trans men, implying that all people who menstruate are women.

Ultimately, society tends to police male gender nonconformity more than female gender nonconformity, Wilson said, which goes back to the misogynistic notions of women being inferior or a joke. “There’s a normalization of masculine traits in women that doesn’t have a corollary in men — men with feminine traits are seen in a much more negative light. Pre- or early-transition trans men are often seen as just being particularly butch women by those who don’t know them, and it doesn’t arouse any particular ‘suspicion’ about their gender.”

8) But what about trans women playing women’s sports?

Much has been made over the past two years about the prospect of trans women playing — and dominating — women’s sports. Two years ago, Rachel McKinnon, who now goes by the name Veronica Ivy, won the Master’s Track Cycling World Championship in the 200-meter match sprint. The following year, she repeated, kicking off debate over the issue. CeCe Telfer, meanwhile, won the 2019 Div. 2 NCAA national championship in the women’s 400-meter hurdles. In Connecticut, two high school trans girls have dominated girls’ indoor and outdoor track sprinting.

Rudy Gonzalez/NCAA Photos via Getty Images

The successes of these handful of trans women has prompted worldwide outrage — and lawsuits — seeking to ban all trans women and girls from women’s sports.

At the heart of the issue is a perceived tension between access and fairness. Trans people point to the fact that trans women are still largely underrepresented in sporting participation numbers, and to the social and physical benefits that playing sports has long offered to their cisgender counterparts. On the opposite side are those who are concerned that trans women — and their “male biology” — are more naturally athletic and could soon end up dominating women’s sports.

But the science behind trans women athletes is still largely unsettled, and almost entirely filled with conjecture rather than actual, usable data.

Individual sporting administrators are responsible for making their own trans inclusion policies, but the NCAA and the International Olympic Committee both allow trans women to compete with women as long as they suppress their testosterone levels down to cis woman levels for at least a year before competing.

Estrogen is much less efficient at building and maintaining muscle than testosterone, and early research indicates that trans women lose significant strength through their transition-related hormone replacement therapy regimen.

So for trans women athletes, that means they need to take longer to recover between workouts than they did before transition, causing muscle loss. This alone makes them unlikely to be able to compete in a men’s category against cis men.

There are physical traits that cannot be changed through hormone replacement, such as height, which is critical in many sports such as basketball and volleyball. But human bodies aren’t cleanly split into two distinct body types, like store mannequins. In my own social circle, I know a 5-foot trans woman and a 6-foot-4 genderqueer person who was assigned female at birth. It would be odd to ban trans women on the basis of height while not holding unusually tall cis women to the same standard.

Part of the problem on the anti-trans side is that they’re starting from the base assumption that trans women are men, and substitute cis male physical traits when discussing whether trans women may have competitive advantages. They’ll argue that men have bigger hearts and more lung capacity, or produce more red blood cells on average than cis women, and then assume trans women’s bodies would be the same.

But initial scientific findings don’t necessarily support that, according to Loughborough University PhD student Joanna Harper, who has spent the past decade researching trans athletes. Harper noted that a trans athlete she previously studied at Arizona State University saw the ejection fraction rate from her heart drop significantly after HRT, meaning less blood was pumped with each beat. “The heart itself might be the same, but the muscles may not work as well,” she told Vox. “And if the ejection fraction goes down, who cares about the size of the heart. It’s how much blood you can pump that matters.”

According to Harper, there are myriad physical traits that may impact a trans woman’s athletic ability, but we don’t know enough specific science about trans women’s bodies yet to draw broad policy conclusions for trans athletes.

“Cis people see a lot of the instantaneous results of the coming-out process, so they assume it’s just a snap decision,” said Canadian sportswriter A.J. Andrews, a trans woman. “They don’t see the years of hormone therapy and the changes it does to a body, they just see the moment of public change and fear some giant bodybuilder is going to do the same thing.”

It’s easy to look at the likes of Ivy or Telfer for outrage fuel in this debate, but neither has competed at the very highest levels of their sport. Ivy won a master’s championship, which is an age-restricted category, meaning she was only competing against women in their late 30s. She is not a world elite rider and is not a likely competitor to make an Olympic appearance.

Ironically, it’s a trans man who may be the best American trans athlete competing according to their gender identity. In 2015, Chris Mosier became the first openly trans athlete to make a US national team in the gender they identify with.

His career alone pushes back on the idea that trans women are really men who have an unfair advantage versus women, while trans men are seemingly powerless to compete against cis men.

Ultimately, the trans athlete debate rubs against the sexist social belief that men are born physically superior to women. Undoing that attitude will take a lot more time.

9) I’m fine with trans adults, but what about trans kids?

While many cis people say they’re fine with an adult transitioning their gender, a large number of people feel more squeamish about trans adolescents doing the same. A 2019 PRRI poll reported that 63 percent of Americans would be very or somewhat comfortable if a friend told them they were transgender; however, just 48 percent said the same if their child told them they were.

Trans kids have always existed, and they’ve been studied for at least the past 50 years. Over time, treatment has evolved significantly. Until 2013, being trans as a child was considered a psychological disorder, called gender identity disorder, and early scientists initially recommended “conversion therapy” for gender dysphoric children.

As time went on, however, conversion therapy became less socially accepted (it’s now banned in 20 states and the District of Columbia), and scientists in the early 2010s sometimes sought softer forms of manipulation to dissuade kids from expressing an alternative gender identity — such as isolating kids from opposite-sex friends and banning gender nonconforming toys or clothes from a household. Overall, none of these “treatments” worked.

“In the past, doctors thought that gender diversity was a pathology, something that needed to be fixed,” said Jack Turban, a fellow in child and adolescent psychiatry at Stanford University School of Medicine, where he researches the mental health of transgender youth, in an email to Vox. “They would try to push kids to be cisgender. A recent study from our group found that transgender people exposed to attempts to make them cisgender had greater odds of attempting suicide.”

Nowadays, doctors recommend taking a humane and affirming approach when a child expresses that their gender may not match their assigned sex at birth. This affirmation includes allowing trans kids to socially transition (i.e., use whichever name, pronouns, and clothing make them comfortable); medical interventions — like puberty suppression or gender-affirming hormones like estrogen or testosterone — are only recommended for adolescents who have been insistent, persistent, and consistent in their gender identity over long periods.

The affirming model has been recommended by nearly every major American medical association, including the American Academy of Pediatrics, the American Medical Association, the American Psychological Association, the Endocrine Society, the World Professional Association for Transgender Health, the American College of Obstetricians and Gynecologists, and many others.

While the affirming model is often willfully misconstrued as instructing parents to accept a child’s gender identity and rush them off into medical interventions, it’s really more about creating a space for trans kids to explore their own gender expression and more thoroughly understand their dysphoria before deciding on whether to transition or not. Allowing a trans adolescent to go on puberty blockers is a decision most parents don’t take lightly. Transitioning is a slow, deliberative process for minors.

Justin Sullivan/Getty Images

“For young people, disclosing that they are transgender can be horrifying. Some may have read stories of parents kicking their transgender children out of the home and be afraid that will happen to them,” Turban told Vox. “It’s important to listen to young people when they express their gender identity and to keep an open mind. Create a nonjudgmental space. The most important thing is to not instill shame. That shame can lead to serious problems down the line with anxiety and depression.”

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