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Introduction: Founded in 1998, the Transgender Day of Remembrance on Nov. 20 honors those murdered as a result of anti-transgender prejudice. According to the Gay, Lesbian and Straight Education Network, 16.8 percent of transgender students report being physically assaulted because of their gender expression and 32.1 percent experience physical harassment. Education about transgender issues can play a role in increasing acceptance of and curbing violence against the transgender community.

Walter Bockting, PhD, is professor of medical psychology (in psychiatry and nursing), co-director of the LGBT Health Initiative, Division of Gender, Sexuality, and Health, and a research scientist at the New York State Psychiatric Institute/Columbia University Medical Center. He is the principal investigator of a multisite, longitudinal study of transgender identity development across the lifespan, funded by the National Institute of Child Health and Human Development, the MAC AIDS Fund, and a number of other private foundations. He has worked with transgender individuals, their families and communities for over 25 years, and is a past president of the World Professional Association for Transgender Health. He was also a member of the APA Task Force on Guidelines for Psychological Practice with Transgender and Gender Non-Conforming Clients.APA recently asked Bockting the following questions:

________________________________________APA: What is the psychological meaning of the term transgender? How is it different from – and related to – the term sexual orientation?

Dr. Bockting: Transgender refers to having a gender identity that differs from one’s sex assigned at birth. Gender identity refers to the basic conviction of being a man, woman or other gender (e.g., bigender, genderqueer, gender questioning, gender nonconforming). Sexual orientation refers to one’s sexual attraction, sexual behavior and emotional attachments to men, women or both.

APA: Do all people whose gender differs from their sex assigned at birth identify as transgender or take steps to transition socially? Why or why not?

Dr. Bockting: Some transgender people do transition and others do not. Transition is not for everyone. Transition refers to a change in gender role. This may be a major change, identifying and presenting as much as possible as a member of the other sex. Hormone therapy and/or surgery to feminize or masculinize the body may be part of that. A change in gender role may also be part time or involve changes in some parts of gender expression and not in others. For example, some transgender women only present in the female gender role at the time of their choosing while socializing. A transgender man may present as male, have chest surgery, but not take masculinizing hormones. In other words, people find different ways and may need different medical interventions to find a comfortable gender role and expression. Also, among the younger generation, there are transgender individuals who feel that transitioning from A to B does not apply to them. Rather, they say that they always have been C (i.e., transgender or genderqueer). In short, transition is a means to affirm gender identity, and includes steps and interventions that are implemented to varying degrees by people within this diverse community.

APA: Is there an age at which transgender people typically realize they do not identify with the sex they were assigned at birth? Given the recent media coverage of Caitlyn Jenner and her gender transition, is it typical for a person to “come out” as transgender so late in life?

Dr. Bockting: Transgender individuals may come out at any age. In more recent years, the general trend has been that people come out at earlier and earlier ages. This is likely due to greater visibility of gender diversity and increased social acceptance. However, there have always been people who do not come out until mid- or later life. This may be because they were not ready to come out earlier, or it may be because over the course of their lifetime, their gender identity further developed into a direction that differs from their sex assigned at birth.

APA: What advice do you have for parents whose child may be showing signs of gender non-conformity?

Dr. Bockting: First of all, parents should give the child permission to explore gender and indicate that this is something that you are comfortable learning about and discussing. Then I would then encourage parents to educate themselves using the many resources available today, both online and offline, and consider talking with other families with children who are also gender nonconforming. I would also encourage parents to obtain clinical consultation from a provider knowledgeable in transgender health when one or both of the following situations arise: (1) the child appears to be negatively affected by stigma attached to gender nonconformity, (2) the child is showing signs of experiencing gender dysphoria, which refers to distress they may experience as a result of a conflict between sex assigned at birth and gender identity/role.

APA: The DSM-5 [the Diagnostic and Statistical Manual, published by the American Psychiatric Association] no longer lists “gender identity disorder” as a diagnosis but instead refers to “gender dysphoria.” Why and how did this come about, and what is the difference between the two terms?

Dr. Bockting: Gender dysphoria is a term that reflects more accurately than gender identity disorder when an individual is distressed about a conflict between their sex assigned at birth and their gender identity/role. Gender identity disorder suggests that their gender identity is disordered, yet having any gender identity, including a transgender identity, is not a disorder. However, the distress that some transgender people may experience at some point in their lives may be of clinical concern and can be alleviated through clinical management. The change in the DSM from gender identity disorder to gender dysphoria was a way to depathologize having a gender identity that differs from one’s sex assigned at birth and recognize the concern and clinical care that transgender individuals may need to achieve comfort with their gender identity, their body and gender role.

APA: How have the media contributed to awareness and education about what it means to be transgender?

Dr. Bockting: Throughout the years, increased media attention has helped to raise awareness and foster public discourse on transgender people’s lives and experiences and gender diversity more generally. In recent years, media attention has been more frequent and less sensational, instead offering positive role models, affirming transgender identity and gender diversity, and raising more awareness about the struggles that transgender people continue to face. These struggles are related to social stigma attached to their gender nonconformity. Our society still does not accommodate gender diversity and in particular non-binary gender identities very well. It has also been very gratifying to see transgender people find their own voices and to see greater representation of the diversity, in race/ethnicity and age found among this population.

APA: What are some of the biggest psychological challenges that transgender people face?

Dr. Bockting: Health disparities in the area of mental health are well documented among this population. Transgender people are more vulnerable to symptoms of depression and anxiety, which is at least in part attributable to the social stress they experience as members of a gender minority population. Transgender people may also face challenges related to the need to affirm gender identity and the social and physical changes this may require. This process requires courage and understanding of self and loved ones, and often includes a series of concrete steps and changes for which support remains too limited. Here, psychologists can play an invaluable role. This includes assisting transgender people in exploring and affirming their gender identity, whether this be on an individual, interpersonal or social/community level. The psychologist can also assist transgender individuals in recovering from the negative impact of social stigma on their health and well-being, and to facilitate positive experiences of coming out with family, friends and community. Over and over again, transgender people have shown great resilience in coping with the stigma-related psychosocial challenges they face. Understanding and compassionate mental health providers have often been an important part of that.

APA: What are the most effective ways to respond to discrimination against transgender people?

Dr. Bockting: On the part of society, we need anti-discrimination protections and equal opportunity legislation. We need education of families, schools, workplaces, health care and social service providers, faith communities, and the wider public that provides a more accurate and complete understanding of the realities of transgender people’s lives and their needs. On the part of transgender individuals, psychologists and other health and social service providers can empower them to develop resilience in coping with stigma and discrimination and to take on leadership roles in bringing about greater understanding and acceptance.

Dr. Bockting can be contacted at wb2273@cumc.columbia.edu or (646) 774-6953.

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