Terminology in this field varies in its usage between individuals and groups, and is constantly shifting. The Office for National Statistics anticipates that at least 80 different self-descriptions will be submitted in answer to the question about gender identity in the 2021 census. All the terms described below may become outdated. In addition, it is important to understand that ‘labels’, although essential to enable discussions about the following topics, are not always welcomed by those to whom they are applied. They should be used only when strictly necessary to clarify a point. These labels must be chosen by the individuals concerned, not imposed by others. This applies both to those outside the transgender community, as well as those within it.
The World Professional Association for Transgender Health states that “the expression of gender characteristics that are not stereotypically associated with one’s assigned sex at birth is a common and culturally diverse human phenomenon that should not be judged as inherently pathological or negative”. Descriptions, such as: gender diversity/ gender variance/ gender non-conformity embrace widely different outcomes and experiences.
The World Health Organisation dropped the outdated term ‘transsexualism’, and changed it to ‘gender incongruence’ in 2019. It is now under a non-psychopathologising classification in the International Classification of Diseases (ICD11). The new classification is based on “current scientific evidence and best practice”. Gender diversity, in its many manifestations, does not indicate mental illness.
Gender Incongruence describes the mismatch between the sex assigned at birth, and the gender identity. The identity is assumed to be congruent with the sex, which is determined on the basis of the genital appearance of the infant at birth, usually without regard for chromosomal or any other biological anomalies. It is anticipated that an infant having male genitalia will identify as a boy, and vice versa. For the majority, this is the case. However, where there is incongruence, and a child’s identity is not aligned with the apparent sex, the discomfort arising from this is described as ‘gender dysphoria’. This term describes the emotional unease with social interactions, as well as the discomfort with the physical sex characteristics. These may feel inappropriate and even cause a disgust with the body. These distressing experiences can be addressed and potentially overcome by aligning a person’s social gender expression with their identity, sometimes supported by medical interventions to align the physical characteristics with the gender identity.
Gender Identity, describes the psychosocial identification of oneself, typically, that is in the majority of the population, as a boy/man or as a girl/woman, known as the ‘binary’ model –you are either one thing or the other. As described above, there is also a presumption that this sense of identity will be consistent with the, respectively, male or female sex appearance of the infant at birth. Since this is the case for the majority, these binary social models exist in the understanding of most of the population. Where sex appearance and gender identity are congruent (those assigned ‘male’ at birth, identify as boys/men, and those assigned female at birth, identify as girls/women), the terms cisgender or cis apply. Therefore, most of the population is cisgender. Cis is the Latin prefix meaning ‘on this side of’ in comparison to trans which means ’on the other side of’.
However, some people experience a gender identity that is somewhat, or completely, incongruent with their sex appearance. The umbrella terms for those experiencing this mismatch are usually ‘trans’ or ‘transgender’. Historically, there has been growing recognition of the trans binary groups: those who, having been assigned male at birth, identify as women – trans women or trans feminine people; or, having been assigned female at birth, identify as men – trans men or trans masculine people. Many in this situation, having made adjustments to their appearance and other social factors such as names and pronouns, will simply identify as, and be regarded as, men and women who are still a part of the binary social model.
However, many more do not experience these binary gender identities, but regard themselves as gender neutral or embracing aspects of both man and woman and, therefore, falling on a spectrum between the two binary identities, or outside the spectrum. People have the right to self-identify, and those who reject the binary tick-boxes, may describe themselves as
Non-binary gender expressions
Non-binary identifications can lead to a variety of public gender expressions from a neutral androgynous appearance, to more masculine or feminine expressions. Some gender diverse people alternate between masculine and feminine gender roles and expressions. Most gender diverse people change some or all of the following: names pronouns, titles, and appearance. They comprise a much larger population than the trans binary population by a factor of 3-4 times more numerous.
Non-binary individuals may also have more specific identities, such as:
- pangender covering all genders;
- poly-gender having more than one identity;
- third gender a gender that is neither man nor woman;
- neutrois neutral gender;
- bi-gender a mix of both genders: woman and man;
- gender fluid fluctuating over time across a range of masculine and feminine identities;
- non-gender (or agender) people who do not experience a sense of having any form of gender identity, beyond just being a person – a human being.
- gender queer is another term now widely understood to cover a range or identities and expressions that are not typically cisgender men and women. Note that the use of the word ‘queer’ is acceptable in this context, but it still causes discomfort for those who experienced, or witnessed, the persistent violent attacks on gay men, described at that time, as ‘queer’. This term should not be used with reference to gay men.
Transition is the term used to describe the permanent full-time adaptation of the gender role and expression in all spheres of life: in the family, among friends, at work, in leisure pursuits and in society generally, to align with the inner experience of the gender identity. A few people make this change overnight, but many do so gradually over a period of time, changing their gender expression intermittently.
Transition does not indicate a change of gender identity, but rather a public expression of the underlying identity which helps others to recognise the person’s real identity. The process of bringing the gender role and appearance into alignment with the gender identity, ‘affirms’ that identity. Thus, the term ‘affirmed’ gender, is now becoming more common in describing the post-transition gender status.
Despite the greater gender equality in modern Western culture, in terms for instance, of the subjects studied in school, university and other educational establishments, the choice of friends, work and domestic arrangements, dress and leisure pursuits, there is still a presumption of conformity with society’s ‘rules’ or expectations about what is appropriate for men and women, boys and girls, especially in terms of gender role and expression. So, in the manner of dress, hairstyle and general appearance, a significant departure from stereotypical gender expression often causes anxiety and discomfort in those who witness it. Their own discomfort may affect their attitudes and behaviours towards gender diverse individuals, causing a continuous source of stress in social situations, as well as in education and at work.
Transition will usually be preceded by ‘coming out;’ that is telling family members, friends and/or work colleagues in advance, so that they are prepared for the change. Not everyone transitions socially immediately after coming out, as it may take time for others to adjust to the impending changes. Families are not always supportive.
Inevitably, transition will, at some stage, be associated with change of names, titles and pronouns. This will necessitate some documentation and identification updates. It is likely to impact on how people use gendered spaces and services. Post transition, many, if not most, trans people become invisible because their past is no longer readily recognisable. This is sometimes referred to as ‘passing’; it is regarded as insensitive to use this term. However, those who ‘pass’, may choose to ‘go stealth’, that is, they tell none of their work colleagues or new friends, about their past.
De-transition is extremely unusual, but may happen, especially where transition is associated with rejection by the family. Other factors such as loss of job and social esteem may also have a very negative impact on an individual who has undertaken transition.
Part-time change of gender role
The gender diverse community includes a broad range of people, some of whom may not plan to undertake a permanent change of role, or feel unable to do so except perhaps on a part-time basis. This may be for personal and social reasons, for instance, to avoid the rejection referred to above. Some people may cross dress quite frequently, with no intention of undertaking transition, and may have more than one name and pronoun, depending on circumstances
Pronouns and titles
Those who are binary transgender, who change their gender expression from man to woman or vice versa, will change their pronouns from ‘he/him’ to ‘she/her’ and vice versa. Non-binary people usually use more neutral pronouns such as: ‘they’, ‘zie’, ‘hir’, or they may be comfortable with either she/they or he/they; non-gender people may use the pronoun ‘per’ (from ‘person’). Titles Mx or Pr may be preferred to Mr, Mrs, Miss or Ms.
Using the name that a person was given at birth, after they have transitioned is unacceptable, and may be referred to as ‘dead-naming’. Note also that it is best to avoid saying ‘preferred’ or ‘chosen’ pronouns and names, as others may infer that being trans is a choice or preference rather than an inherent characteristic.
Medical interventions / Gender affirming treatment
Although not inevitable, for most gender diverse people, transition is likely to be supported by some medical and related services. Hormone therapy is most likely to be sought by trans people, but also facial hair removal, wigs and voice therapy may be sought. Counselling may be helpful to cope with adverse reactions from family, friends, class mates in school, university students, co-workers, and people on the street.
Medical interventions usually start with the GP, who refers the individual to specialist services. Hormone therapy is usually recommended by specialist services, and provided by the GP.
Those seeking surgery will usually be referred to the relevant surgeon, by specialist services. Certain criteria must be fulfilled. The individual must have lived ‘in role’ that is, in contradiction to their assigned sex for up to two years. Non-binary people may also seek surgery, but the requirement to comply with living in a binary role, makes it hard for them to meet this criterion. Surgery may include aligning the secondary sex characteristics: breasts and genitalia, with the gender identity for both trans men and trans women, as well as non-binary and non-gender individuals. Such surgery may be referred to as gender affirming, or gender reassignment, surgery. The term ‘sex change’ is not considered appropriate. Surgeries such as facial feminising and body contouring may be chosen, but these surgeries may not always available on the NHS.
The most common acronym LGBT (lesbian, gay, bisexual and trans) brings together these groups. Historically, the groups were not always comfortable to be linked in this way, because gender identity (who you are) and sexual orientation (whom you are romantically attracted to) are different issues.
Recently, the acronyms have been lengthened to include ‘Q’, for ‘queer’ or ‘questioning’. ‘I’ for intersex (see below). The acronym looks like this: LGBTQI, and may grow further. Often the plus sign ‘+’ is added, to indicate that any, and all, kinds of trans, non-binary and non-gender presentations and sexual orientations, are welcome. Occasionally ‘A’ for ‘asexual is included. Sometimes an acronym is a clumsy tool for explaining sensitive issues. Some acronyms are distinctly binary and therefore potentially inaccurate. If used to describe a particular individual, they are impolite.
- AFAB, assigned female at birth; or AMAB, assigned male at birth; or
- MtF, male to female; or FtM, female to male.
Minority groups, such as those featured above, often experience discrimination, exclusion, and hostility. This causes a social unease referred to as minority stress. By working together, minority groups are better able to fight transphobia, homophobia and biphobia terms which describe the irrational hatred of trans, gay, lesbian and bi-sexual people.
Sex refers to the biological male/female physical development. In an infant, the sex is usually judged entirely on the genital appearance at birth, but internal reproductive organs, skeletal characteristics, musculature, and the brain, are all sex differentiated – not necessarily consistently – a mixture of maleness and femaleness exists in everyone, including in the brain. Several different biological correlations with gender identities have been shown to exist in trans people. The scientific evidence, as explained in the Introduction, has enabled the WHO to de-psychopathologise gender incongruence.
Chromosomal configuration (karyotype) is usually binary: XX=female; XY=male, but many anomalies exist, some of which are associated with Intersex or transgender outcomes (see below). Chromosomes are seldom tested at birth unless a genital anomaly is visible.
Genes on the chromosomes are also relevant to sex development, and may also be varied, for instance certain genes may be absent, or repeated, potentially giving rise to unexpected hormone (e.g. testosterone, oestrogen) levels which in turn impact on sex differentiation.
Intersex conditions, Differences of Sex Development
There are a number of Intersex conditions (now often described in medical literature as Differences of Sex Development, DSD). DSDs are congenital anomalies of the reproductive system which may involve chromosomes, genes, and hormones. Although present at birth, most of these conditions are not immediately identifiable, but in a minority of these cases, the appearance at birth is atypical, being neither clearly male nor female.
For many years, babies in this situation had surgery neo-natally to create, usually, a female appearance. Accordingly, the sex (surgically determined), and the anticipated gender identity (girl) assumed at that time, were not always consistent with these children’s gender identities as they grew up. This resulted in a need to transition to live as boys and men, at a later stage. This kind of early surgical intervention before the individual is able to give informed consent is now regarded as unethical and is considered unlawful in some jurisdictions.
These results also confirmed that the combined influences of sex appearance and gender of rearing, are not the critical factors in determining gender identity. Although the brain may be described as a mosaic of male and female development, typically, in terms of gender identity, the brain is consistent with the sex of the genitalia. However, sometimes the brain is inconsistent with other sex characteristics, so that a person is predisposed to experience a gender identity that is in contradiction to their sex as registered at birth. This atypical brain development overrides sex appearance and gender of rearing.
Other inconsistencies in development may be associated with anomalous sex chromosomes, such as Klinefelter syndrome (XXY), Jacob’s syndrome (XYY), or other atypical combinations of ‘X’ and ‘Y’, such as XXYYY, XYYY, X0, XXXY and mosaicism, where more than one chromosomal configuration/karyotype occurs in the same individual). Most intersex/DSD conditions, are associated with unusual pre-natal hormone levels. Other conditions such as Cloacal Extrophy may be included in this group since babies with this condition may have poor genital development and an external bladder which needs urgent correction; this has also led to male (XY) babies being surgically assigned as female and raised as girls. This strategy failed in this group also.
Gender Recognition Act (2004)
Gender Recognition Certificate and new Birth Certificate
A person who is living according to their affirmed gender will probably have adopted aspects of gender expression such as dress, hairstyle and general appearance that reflect their gender identity, rather than the sex assigned at birth. The term ‘affirmed’ should be used in preference to ‘acquired’; the latter is the language of the Act, but in fact trans people do not ‘acquire’ a new identity; they establish, legally and socially, the identity they already have.
The Gender Recognition Act (GRA) became effective in 2005. Currently (2020) the Gender Recognition Certificate (GRC) can be obtained by those who can demonstrate that they have lived for at least two years in their affirmed gender, and that they have a diagnosis of ‘gender dysphoria’. Those meeting these criteria, whose births were registered in the UK, qualify for a new birth certificate. They are to be treated ‘for all purposes’ in accordance with their legal gender identity.
However, those who are already in a legal relationship, either marriage or civil partnership, before they transition, must fulfil additional criteria in order to obtain a GRC. Their legal relationship must be aligned with the new gender status of the person who has transitioned. This requires the consent of their spouse/partner. Without that consent, the trans person is prevented from acquiring a GRC. This is known as the ‘spousal veto’.
Consent by the spouse/partner would enable conversion of the legal relationship either from:
- an opposite sex marriage/civil partnership, to a same sex marriage/civil partnership, or
- from a same sex marriage/civil partnership, to an opposite sex marriage/civil partnership.
Discussions are ongoing as to whether the UK will allow statutory ‘self-determination’ as sufficient for obtaining a GRC. This approach has already been adopted in several other countries, including the Republic of Ireland, without any adverse consequences.
Breaching the confidentiality of trans people without their consent is always unlawful, but if they have a GRC and the information is passed on by a person who has learned this information in an ‘official capacity’, that is, as part of their job, this could be a criminal offence. It is also unlawful to ask an individual if they have a GRC or not.
Sexual orientation is a separate issue from gender identity. Sexual orientation is the romantic attraction between one person and another. Trans people may be gay, straight, bisexual or, occasionally, asexual, but these terms do not always apply comfortably to trans situations. There is no specific vocabulary, for instance, in the case of couples who remain together when one of them transitions. The title of their legal relationship can be changed, but the nature of their sexual relationship cannot be categorised by any existing terminology, since the sexual orientation of the non-trans partner does not change; the sexual orientation of the trans partner may or may not shift. Trans people may also make lasting relationships with other trans and non-binary people, so the possibilities are many and varied, and do not necessarily fit into typical categorisations. Sometimes, for clarity, in clinical environments, the terms: androphylic (attracted to men); and gynaephylic (attracted to women) may be used.
Equality Act (2010)
The Equality Act defines the protected characteristic of ‘gender reassignment’. The legislation was written with the intention of covering only trans binary individuals, described people based on the criteria that they ‘propose to undergo, are undergoing or have undergone a process or a part of a process’ to reassign their gender away from the sex assigned at birth.
A court finding in 2020  has created the precedent which allows those non-binary, non-gender and intersex people, who meet the criteria cited above, to be protected under the Equality Act in the same way as binary trans people. Others who are perceived to have the characteristic, as well as those associated with them, such as family members or carers, are also protected against discrimination, harassment and victimisation. Public bodies have a duty to facilitate good relations between groups and provide equality of opportunity.
Schedule 3 under the Equality Act allows organisations caring for vulnerable people, to take ‘proportionate’ steps, commensurate with a legitimate aim’ to ensure that, in single-sex spaces, there is no danger or unreasonable discomfort caused to those occupying them
Trans people in prison and secure accommodation are also covered by the Equality Act.
 Reed and Diamond (2016) The Lancet. Biological correlations in the development of gender dysphoria.
 Examples of genetic anomalies that are particularly associated with unusual genital appearance are: Androgen Insensitivity Syndrome, Congenital Adrenal Hyperplasia, 5α reductase or 17β Hydroxysteroid Dehydrogenase (HSD) deficiencies.
 Op.cit. Reed T, Diamond M. The Lancet June (2016)
 Taylor vs Jaguar Land Rover’s plant. The complainant, Ms Taylor, who identifies as non-binary, won her case against her employer. Her complaint was that she was harassed and directly discriminated against on the grounds of gender reassignment. https://www.forbes.com/sites/jamiewareham/2020/09/16/non-binary-people-protected-by-equality-act-in-landmark-ruling-against-jaguar-land-rover/?sh=52cbc9ce79be