The following FAQs are meant to address questions from both transgender youth and their families.  

What is gender?

Gender is a complex internal sense of being; it is being and identifying as a girl/woman, or a boy/man, or something in-between these. Gender is not “anatomy” (having girl or boy private parts), or DNA. Gender is a sense of being a girl, boy, or a gender in-between these, in that same individual’s social and cultural environment. When we try to define what it is to be a girl or a boy, we cannot help but define it in the context of the social/cultural environment where the individual lives, simply because we all develop our sense of what it means to be a “girl,” or a “boy,” or something in between, from the social and cultural world we live in. (This is because what people associate with “being a girl” or “being a boy” in one social and cultural environment may sometimes be quite different from another social/cultural environment.)

No one chooses their gender. Everyone just “is” something. For many people, their gender matches the body (i.e. a boy body or girl body) that they were born with. But for other people, while the body that they were born with may say to the outside world  “boy” or “girl,” inside they are and feel either the opposite (someone who is transgender), a gender in between “boy” and “girl” (these people sometimes refer to themselves as “non-binary gender,” or a gender that is not exactly one end of the spectrum or the other, but something in between).  

Children typically figure out that they are a “girl” or a “boy” between the ages of 3-5. Before this age, kids don't really think of themselves in strict terms as “I’m a boy” or “I’m a girl.” They are too busy just being (very little) kids, and figuring out the world around them. But, from around age 3-5 onward, they start to view themselves as one or the other. It is sometimes from this age range or soon onward that transgender kids start to figure out that their body doesn't exactly match how they feel on the inside. Alternatively, some start to figure out that while their parents, or rest of their family think of them as  “a boy” or “a girl,” inside they feel different (the opposite, or, a gender in between). 

Is gender the same thing as sexuality? 

No! This is something that a lot of people get confused with. Gender and sexuality are two very different things. While gender is one’s own internal sense of being a “girl,” or a “boy,” or, something “in between,” sexuality refers to someone’s romantic interests – whether they “like” (are romantically attracted to) girls, boys, people who feel and live as something in between what we consider boys or girls, or, even all of the above! The point is that while gender is about you (who you are), sexuality is about other people (people you are attracted to in a romantic way). 

Someone once described the difference between gender and sexuality as: “Sexuality is about the sex of the people you fall in love with, whereas gender is about who you fall in love as.”

What is gender dysphoria?

Gender dysphoria is the term for the anxiety/distress, and even for some a feeling of hopelessness, that someone experiences when there is a “mismatch” between that person’s gender and their body. For example, that person may feel, deep inside, that they are a girl, but they have the body (particularly the private parts) of a boy.  For trans boys it is the same: they feel and know that deep down they are a boy, but they have the body (and private parts) that girls have. For many transgender kids, what can make their gender dysphoria even worse is when the whole world around them insists on treating them as the gender that is opposite of how they feel inside.   

How do I know if I have it?

In part, if you think that you feel the way gender dysphoria is described above, but on a regular basis. But it is important to remember that it is normal for people, and especially young people, to sometimes wonder “what would it be like” to be the opposite sex. To wonder this and occasionally think about it is typically not “gender dysphoria”. Instead, a common characteristic of gender dysphoria for transgender people is that these feelings of “in in the wrong body” are consistent and persistent (i.e. they don't go away on their own). If you feel that you might have gender dysphoria, the best way of figuring out if you have it is to talk to someone about it! A good starting place is to tell someone you trust to discuss it with, like a parent or a teacher, or someone else that you trust you can talk to. 

What does it mean to be transgender?  

To be transgender just means that you are still you (something that is great!) and that nothing can or will ever change that. If you feel like a girl (or a boy) on the inside, then that is what you are! However, if you are transgender, not every part of your body reflects your gender on the inside. You will have the private parts (a penis or a vagina), for example, or body hair (if you've gone through puberty) typical of the opposite sex.  For some people, this is not at all a problem. They are ok with just dressing like the gender they identify with, and living daily life as the person and gender that they feel they are. Other people, though, may want to go one or more steps further and take hormones of the gender that they identify with to help change the shape and look of their body, and to feel more like the gender they identify with. Others may also want to have surgery to change the body parts that don't match the gender they identify with. For example surgery to have the private parts, and/or chest, and/or facial features of the gender they identify with.     

How do I know if I’m transgender?

People usually figure this out either on their own (can be hard) or, they figure it out with the help of talking with someone about it (examples include but are not limited to: a parent, a counselor, a doctor). They figure it out in part because the feeling of, deep down, being a gender that is different from what is typical for their body, or, being a gender that is different from what the whole world “sees” when they look at them. The best part of “figuring it out” is that it makes it that much easier to start to be who you truly are and to build the courage and determination to dress and act like you feel on the inside.  

Is there a minimum age for diagnosis?

Not really. Perhaps the minimum age is whatever age one needs to be to speak and communicate to the world around them who they are. Again, gender is not a “thing” that we can see, weigh or measure. It is just a deep internal “sense”, which is natural to each of us.  

A study by Garcia and colleagues asked transgender adults who were seeking gender affirming surgery how old they were when they first experienced gender dysphoria for the first time. The vast majority responded that they first experienced gender dysphoria between the ages of 3-7 years of age! This age range is in line with the typical age child psychologists have identified as the age at which children develop “gender permanence”- or a permanent sense of their gender as “boy” or “girl.”  

What is the treatment?

Gender dysphoria can certainly be treated. By treated, we mean that we can help people recognize their gender and learn to live as who they are without feeling the anxiety and/or depression that often accompanies gender dysphoria. By learning to live as who they are, whether it is as a girl, a boy, or a gender in between, most transgender people lead lives just like anyone else. 

Sometimes people ask, “Is there a way to treat being transgender?” The answer is a firm “no!” because there is absolutely nothing wrong with being transgender. Just like there is nothing wrong with being cis-gender. Being transgender or cis gender are just points on the spectrum of human diversity. And, we don't choose who or what we are. Our gender, whether trans or cis, is simply “natural” and “normal.”

Is gender dysphoria or being transgender a mental disorder?

Being transgender is absolutely not a mental disorder. As stated above, being transgender, just like being cis gender; it is just a point on the spectrum of human diversity. 

Gender dysphoria is often classified as a “disorder” because it is something that causes people distress, and modern medicine likes to refer to anything that affects our health (including mental health) as a “disorder.” Those of us who take care of transgender kids and adults do what we do to help people not feel gender dysphoria related to who they are. Surgeons, for example, help transgender people to change certain specific parts of their bodies so that they look and function more like they have the body parts of the gender that person identifies as. Therapists help transgender people explore and find ways to live their life in the gender roles of the gender they identify with, and to live as the gender they are. Pediatricians specialized in trans primary care, and some endocrinologists help treat gender dysphoria by prescribing the hormones of  the gender that the person identifies as, to help their body become more like the body of someone of that gender.     

Can I be medically treated if I'm under 18?

Yes! But, you may need the permission of either your legal guardian (for example your parent or the legal guardian who is responsible for taking care of you). Your doctors can tell you what the requirements are based on the U.S. State that you live in, as different states have different laws that govern trans care for people under age 18.  

Are there non-medical treatments and how old do I have to be for them?

Yes- there are. There are many trained therapists today who specialize in talking with and counseling transgender youth to help them learn to explore their gender identity and live in/as their gender identity. This “talk therapy” is for most people very effective and helpful. It is an opportunity to gain insights about who we are, and then about how to go about living as who we are. Different U.S. states have different rules and regulations regarding whether or not access counseling/behavioral therapy requires the permission of the young person’s parent or other guardian. In California, Health & Safety Code section 124260 allows a person to have talk therapy at the age of 12 (even without their parents’ permission in certain circumstances).

What is gender affirming surgery (also known by many names, such as “gender affirmation surgery”, “sex reassignment surgery”, and “gender reassignment surgery”)?

Gender affirming surgery (GAS) is surgery that aims to help better align the patient’s body with the gender with which they identify. For example, GAS for a trans woman aims to make her body less masculine by eliminating specific “male” body structures or features, and at the same time to help make the body more feminine. The same example applies to a trans boy: surgery helps eliminate some of the female anatomy or features that he was born with and then make their body more masculine by creating specific male structures or features. 

There are many different areas of the body that can undergo gender affirming surgery. Transgender women can undergo feminizing facial and vocal cord surgery, feminizing chest surgery (breast augmentation; also known as “top surgery”), body contouring surgery (e.g. liposuction, injection of filling agents), Dermatologic permanent hair removal treatments (for example, from the face), and, genital surgery (also known as “bottom surgery”), wherein surgeons remove all visible traces of the genitals of the person’s birth sex, and replaces these with the genital anatomy of the gender that the person identifies with. For transgender men, GAS can include removing most or all of the female chest and genital anatomy and creating a normal looking male anatomy ( for example, mastectomy to create a normal flat male chest, and phallourethroplasty to create a normal looking and functioning penis that they can urinate through).   

What exactly is “bottom surgery?”

Bottom surgery refers to surgery of the genital area—or one’s “private parts.” Bottom surgery really has two goals: First, to get rid of genital anatomy (private-area parts) down below that a patient was born with but don't belong there; and second, to create the anatomy (a private-area) down below that should have been there all along (e.g. a vagina for a trans girl, or a penis for a trans boy). The new anatomy should look and function normally, just as any other cis-gender person’s does.    

If I am interested in bottom surgery, is there just one option, or are there more than one? And, how do I know or figure out which one is best for me?

Fortunately, there are many surgery options available today for trans people to choose from.  Some surgery options have what we refer to as “pro’s and con’s”—that is, advantages as compared to other options, but also, possible down-sides. For example, some surgeries can offer additional advantages over others, but at the same time be more complex than other surgical options. Often, more complex surgery options carry with them greater chances of needing a longer recovery period after surgery, or, of needing future surgeries to make adjustments. Patients should discuss all surgery options that their surgeon’s offer, and, discuss the “pro’s and con’s” of each option, before reaching any decisions about what surgery they want to have. It is often also a good idea to consult with more than one surgeon, in order to be sure that, between all of the surgeons they meet with, they have learned about all of the different types of surgery they can have.    

If bottom surgery is something that I want, when, typically, is it done?

Different surgeons have their own views and policies regarding when is the earliest age to have bottom surgery. Some wait until the patient has already turned age 18, while others will offer surgery just before age 18. One consideration for many patients and their families to consider is how the timing of surgery will fit in to plans for starting college. Another consideration is paying for surgery and whether your insurance will cover it (most if not all will not cover it, if you are under 18). Patients should discuss the timing of surgery with their surgeon, and include the people who care for them (parent(s), family guardians, foster parents, etc.) in on the discussion, because while it is possible to have surgery just before or around the time the patient turns age 18, making the surgery a success will require help and participation from everyone close to the patient.     

What is required before I can have surgery?

Most surgeons in the U.S.A. adhere to care guidelines proposed by the World Professional Association for Transgender Health (WPATH). WPATH publishes these care guidelines (called the WPATH Standards of Care (SOC) Guidelines for care of the transgender people) and makes them available to the public and to all healthcare providers.  Health insurance companies, as well as the U. S. Department of Health and Human Services (DHHS) which determines policies and requirements for Medicaid and Medicare health insurances, all defer to WPATH SOC Guidelines.  Most all U.S. providers and health insurance companies adopt the SOC Guidelines. 

The WPATH SOC recommends that, before transgender people can be considered for bottom surgery, they should have: 

1. Successfully completed social transition (i.e. full-time life in their desired gender role) for a minimum of one year before bottom surgery;

2. Successfully completed hormone transition (i.e. used cross-sex hormones) for a minimum of 1 year before bottom surgery;

3. Two surgery referral letters from two different mental health providers (e.g. can be psychologists, psychiatrists, or mental health social workers), recommending that the patient is ready for surgery. This letter must say that the patient has gender dysphoria, that the patient has been able to successfully transition with social transition for at least one year, that they have taken and done well with cross-sex hormones for at least one year, and that they have a full and realistic understanding of what bottom surgery is, together with a solid understanding of the surgery-related risks, expected post-surgery recovery course, and follow-up plan with their surgeon. 

The two surgery referral letters should address any mental and medical health conditions the patient has, and speak to whether or not these are well controlled.  

The two surgery letters should also address the patient’s support structure (e.g. whether they have supportive parent(s) or guardians, stable and safe housing in which to recover from after surgery, whether they can afford (or access) transportation to and from their surgeon and other care providers for post-surgery follow-up visits in the weeks and months after surgery. 

Lastly, it is permissible for the two required letters from two mental health providers to be combined into one letter co-signed by two different providers. Most insurance companies require that the surgery referral letters be dated within 1 year of the date of surgery. 

What other things should I expect to have to do or prepare for before bottom surgery?

Depending on what bottom surgery you plan to have, it is likely that you will need to undergo permanent hair removal from skin areas that your surgeon will use for your bottom surgery. For trans women undergoing vaginoplasty, hair removal is typically required from the genital (penis) area, and may or may not require removal of hair from the scrotum. For trans men, permanent hair removal is often  required from the area where the surgeon will harvest skin to make the penis (typically the arm or thigh or tummy areas).   

It is essential to discuss what specific body areas your surgeon wants you to have permanent hair removal treatments to as early as possible when you are planning your surgery, so that you have as much time as is needed to complete treatments. Hair can be treated with Electrolysis or Laser to permanently eliminate hair growth in that area. Laser requires that the hair be naturally dark-pigmented in order to work. For people whose hair is blond, white, or red, the only option available to them for permanent hair removal is electrolysis. For those who can have laser, there are several benefits over electrolysis: when newer-generation lasers are used, laser treatment is just as effective as electrolysis, but with several additional advantages: it is more efficient (i.e. fewer treatments needed to eliminate hair re-growth); laser is minimally to not at all painful as compared to electrolysis, which typically requires injections of pain medication to the treatment area; laser overall appears to require far fewer treatments than electrolysis, which means that one completes the hair removal more quickly; and lastly, laser is significantly cheaper than electrolysis (5-7X cheaper).  

What is the recovery time after surgery?

The duration of recovery time depends on what surgery the person has had. Patients who have many different facial surgery options may spend none, or 1-2 nights in the hospital. Chest surgery often requires 0-2 nights hospital stay. Laparoscopic hysterectomy requires 0-1 nights in the hospital. Feminizing bottom surgery (e.g. vaginoplasty) requires anywhere from 3-6 days in the hospital, whereas masculinizing bottom surgery (e.g. metoidiolasty and phalloplasty) require 4-7 days in the hospital. At-home recovery times following release from the hospital have a wide range of times, so make sure to get this information from your surgeon.   

How old do I have to be to get surgery?

This varies state by state, but in many states (including California), young people under age 18 can have surgery but only with the consent (permission) of their parent or other legal guardian. 

Is surgery covered by insurance?  

The answer to this varies state by state. In many, (but not all) U.S. states, commercial health insurance (i.e. the insurance that you pay for out of pocket typically through your work) companies will cover GAS. In about 50% of all U.S. States, Medicaid will pay for the cost of GAS (but whether or not there are providers in that state willing to do it for Medicaid reimbursement is a separate matter). The best place to start to answer this question is to call your health insurance to ask what their policy is.  

Many states, including California, have laws in place that prohibit health insurance companies from denying coverage for GAS just because someone is transgender. In California, for example, all health insurance companies (including Medicaid and Medicare) cover GAS.   

How does a minor giving their own consent actually work?

In 2010, recognizing that parental consent can operate as a barrier to care for minors in certain instances, California lawmakers enacted Health and Safety Code Section 124260 with the explicit intent of “expand[ing] the rights of minors to receive outpatient mental health treatment or counseling services.” [See the August 31, 2010 Senate Floor Analysis for SB 543 at pages 2 and 4]. Pursuant to this code section, a California minor may consent to their own mental health treatment so long as the following requirements are met:

1. The minor must be 12 years of age or older; and

2. In the therapist’s opinion, the minor must be mature enough to participate intelligently in the therapy services.

This has been the law since January 1, 2011.

Treatment without parent consent is not automatic. It depends upon the professional opinion of the therapist. The therapist must evaluate the minor and determine that they are mature enough to participate intelligently in mental health treatment or counseling services. The therapist must also evaluate if it is appropriate to contact the parents, and if not, why not. This must all be documented in writing in the minor’s patient file.

The therapist’s initial consultation with the minor client may not necessarily result in a therapeutic relationship. It is during this consultation that the therapist and client will determine if they are a good fit to work together and if the minor client may proceed without parental consent. 

The therapist first will consider and document (1) if the minor understands basic concepts related to therapy (e.g. consenting to treatment, confidentiality, etc.); (2) if the minor understands the goals for their treatment; and (3) if the therapist believes they can provide effective treatment to the minor.

The therapist will also consider and document whether informing the minor’s parent(s) is appropriate. If in the therapist’s professional opinion informing the parents would be inappropriate, the therapist will document the reason(s) why. Some examples of why it may be inappropriate (and this is not an exhaustive list) are that the minor is fearful of their parents being involved, the minor would be in physical danger if the parent knew, the parents previously mocked the minor’s mental health issues, or that the minor is so intimidated by their parents that they will not be forthcoming during their treatment if the parents are aware.

It should be noted that even if this is the therapist’s determination initially, the assessment may change over the course of treatment. The therapist would then discuss with the patient why informing the parents at a later time may be appropriate. If the therapist were to determine it is appropriate to inform the parents, the therapist would discuss this with the minor. This discussion may include (1) whether the minor patient would like the therapist to communicate with their parent(s) or guardian(s) during treatment; (2) if so, what type of information would the minor feel comfortable with their parent(s) or guardian(s) receiving from the therapist; and (3) how frequently would the minor feel comfortable with the therapist providing the parent(s) or guardian(s) with information about the minor’s treatment (e.g. weekly updates, monthly updates, only when the parent(s) or guardian(s) reach out to the therapist, etc.)

The law requires therapists to consult with minors prior to determining whether it is appropriate to notify their parent(s) or guardian(s) that they will be receiving treatment via minor’s consent. Although it is important for therapists to consider minors’ perspectives when making such decisions, the therapist must ultimately determine whether parent/guardian notification is clinically appropriate (or inappropriate).

The full text of Health and Safety Code §124260 can be found here: HSC 124260

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