Imagine looking into the mirror every day and seeing a stranger. Imagine waking up in the morning and feeling that the essence of who you are is wrong. Imagine feeling lost and uncomfortable in your own skin. For 50 years this is exactly how Catherine lived her life.

“When I looked in the mirror I saw someone I didn’t know,” Catherine said. “Everything about me was wrong. I was given a vessel that I was allowed to drive around in but I didn’t like it. I had no clue how it worked and I didn’t want it.”

Catherine, a 52 year-old transgender woman whose last name has been omitted for privacy reasons, knew she was different when she was only four or five years old. However, in the 1960s, transgender identity was an even more taboo subject than it is today and Catherine had no word for what she was feeling.

Back then, according to Katherine M. Franke’s article, “ The Central Mistake of Sex Discrimination Law,” the traditional social understanding was that gender is defined by one’s sex. Today, gender is typically understood as being on a spectrum that is not simply based off of what a doctor declares at birth.

Grasping the terminology

It’s important to note that the term trans man refers to female-to-male transgender people, and trans woman refers to male-to-female transgender people. While some people may self-identify as transgender, the transgender identity umbrella includes sometimes-overlapping categories. These categories include transsexual, transvestite or cross-dresser, genderqueer, androgyny, and bigender. Although transgender and transsexual can be interchangeable terms, some trans individuals, like Catherine, prefer to identify themselves as transsexual rather than transgender.

“I’m transsexual because I’m on the far end of the spectrum, which means my gender dysphoria has gone to the point where I’ve opted for surgery and body modifications to completely change my identity to a female,” Catherine said. “I totally identify as female 100 percent. A true transsexual feels that they were born in the wrong body and that their body doesn’t match their gender.”

Unlike Catherine, Jenn Goodman, a transgender woman in the middle of transitioning, dislikes the term transsexual.

“The problems that transgender people have have nothing to do with sex, and the word transsexual conveys the wrong message to people,” Goodman said. “It’s not a sexual thing, it’s a gender thing.”

On the opposite end of the spectrum are cisgender individuals. Cisgender is a term referring to non-transgender people; i.e. those who identify with their gender assigned at birth. While transgender or transsexual people identify as a member of the sex opposite to what they were assigned at birth and desire to live and be accepted as such.

One of the ways in which transgender people go about living as their desired sex is through gender affirmation surgery, the process of aligning one’s gender expression or presentation with their internal gender identity. Once the transition process is complete and individuals are able to successfully blend, or pass, as their desired gender, they may or may not necessarily identify as transgender or transsexual any longer, but simply as a man or a woman.

“I don’t identify as a trans person anymore. I am a woman,” Catherine said. “It’s very tempting for me sometimes to just leave the trans community behind because there’s plenty of us who have gone away. But if you’re like me and you want to help and you want to educate and make a difference, then that’s the price you pay. It’s not easy still being trans after you’ve completely transitioned, you’re essentially thrashing at old wounds.”

Those, like Catherine, who continue identifying as transsexual men or women may not want to ignore their pre-transition life, and may continue strong ties with other trans people and raising social consciousness.

Similar to Catherine, Goodman said she believes that the act of disassociating from the trans community once the transition is complete is problematic.

“It creates an illusion,” Goodman said. “The community is actually a lot larger than it appears, but we’re not seeing the thousands of men and women who have successfully transitioned. Granted, they don’t want us to see them, but it doesn’t help advocacy and it doesn’t help the community when everyone just disappears.”

Redefining gender identity

“Trans usually implies a destination – that you’re either going from male to female or from female to male. However, we have a lot of people who say, ‘I’m sort of in between but I don’t really have a destination.’ Maybe they feel neither male nor female,” Matthew Antonio Bosch, the director of Elon University’s Gender and LGBTQIA Center, said.

According to Bosch, an old-school way to think about the gender spectrum is picturing a straight line with male on one side and female on the other. In the middle there’s some sort of continuum. Today however, it’s becoming more common for people to openly associate with no gender, or as a-gender, and then later in life start associating as a male or female. Sometimes people don’t ever feel comfortable fully associating with either gender.

Jessica Fox, a transgender woman who is in the process of transitioning, can relate to feeling lost when trying to relate to the traditional gender spectrum.

“Up until recently I spent most of my time being genderless,” Fox said. “I finally had a breaking point where enough was enough. It wasn’t worth being miserable anymore.”

Fox now fully identities as female and since her transition process has begun, she said she has become infinitely happier.

“It’s amazing to be seen the way that I feel,” she said.

It was no secret that Fox felt different growing up, but it wasn’t until she was 15 years old that she actually had a word for her feelings – transgender.

“Today there are two arrows, instead of just one stagnant line, and you can be at different points on those arrows,” Bosch said. “That way you can say, ‘maybe I’m more male here but I’m more female here.’ This spectrum provides a different perspective as opposed to saying male and female are completely oppositional to one another.”

For some individuals this may be a challenging concept to grasp, which Bosch says is okay. Education is the first step in combating hate and prejudice.

“People who have a very limited understanding of gender tend to think that people who identify as trans are just gay or lesbian,” said Laura Ellington, a licensed therapist with her own practice in Mebane, North Carolina. “Society tries to put everyone into categories and when something like transgender identity doesn’t fit so nicely into any category they tend to negatively identify it since it’s confusing.”

Franke’s article, “The Central Mistake of Sex Discrimination Law,” further examines this topic. Franke states that it is now more accurate to view sex and gender as social constructions based upon gender stereotypes. According to her, gender and sex are both performative traits from birth.

This modern examination of gender identity may still be foreign to many people, but according to Bosch, familiarizing yourself with the terminology and keeping an open mind are positive first steps to take when addressing gender identity.

Rather than determining sex on the basis of biology and anatomy, let the way in which one acts and presents oneself indicate gender separately from sex. In this way, individuals may be outwardly identifiable as masculine women, feminine men, and other combinations.

“You probably wouldn’t see me as anything other than a woman, but if you’re unsure, don’t just assume my gender,” Catherine said. “If you’re not sure how to refer to someone, then ask. That’s the right thing to do.”

Altering the definition

In May 2010, the World Professional Association of Transgender Health released a statement urging the de-psychopathologization of gender nonconformity worldwide. This statement noted that “the expression of gender characteristics, including identities, 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.”

This statement helped bring attention to negative stigmas around the world associated with transgender identity and served as a catalyst for change.

“People think trans people are confused when oftentimes they’re not, they’re just masters of disguise because they’ve had to hide all their lives,” Bosch said. “There’s a difference between being a feminine male and being a male who feels they’re female.”

Such stigma can lead to prejudice and discrimination, resulting in “minority stress.” Minority stress is unique, socially based, and chronic. According to the Institute of Medicine, minority stress may make transsexual, transgender, and gender nonconforming individuals more vulnerable to developing mental health concerns such as anxiety and depression.

However, the most important thing to know is that these symptoms are socially induced and are not inherent to being transgender. Thus transgender individuals are not inherently disordered.

“It’s a lot easier for people to think that transgender individuals are mentally ill if they don’t know anyone who is transgender. More oftentimes than not, the people who think those things don’t know anyone in that group,” Bosch said. “More and more people are recognizing people who are trans and I see it causing a positive shift in attitude.”

One of those positive shifts occurred in December of 2012 when the American Psychiatric Association’s board of trustees approved changes to the latest version of “The Diagnostic and Statistical Manual of Mental Disorders” that removed the term “Gender Identity Disorder” from the book.

This marked a historic milestone for people who are transgender and gender non-conforming, as their identities are no longer classified as a mental disorder.

The current manual diagnoses transgender people with “Gender Dysphoria,” which communicates the emotional distress that can result from “a marked incongruence between one’s experienced/expressed gender and assigned gender.” This allows for affirmative treatment and transition care without the stigma of disorder.

In the sound clip below, Bosch explains how people’s awareness of gender identity has positively impacted the medical community’s reevaluation of gender dysphoria.

However, there are some professionals, such as Paul R. McHugh, the former psychiatrist-in-chief for Johns Hopkins Hospital and its current distinguished service professor of psychiatry, who believe that gender dysphoria should still be categorized as a mental disorder.

“To those people I say bullshit,” Catherine said. “It’s something that is hardwired into you and there’s medical proof and evidence that it is indeed a medical condition and within the normal spectrum of human development.”

Fox agrees.

“They’re flat out wrong. I can’t think of any medication I can take or therapy that would do any good other than suppress how I feel, and nobody deserves that,” she said. “It’s not like you can take a Xanax and be okay.”

Although Individuals like McHugh exist, they are in the minority amongst their peers. Today, the overwhelming consensus among the medical community is that gender dysphoria is not a mental disorder and effective treatment is possible through hormone induction and surgery.

Living transgender

Most transgender individuals do not view their lives as being different from any cisgender person. Just like cisgender individuals, members of the trans community grew up inherently knowing who they are.

When asked about the moment she knew she was transgender, Catherine usually answers with a question in return.

“I tell people, ‘when did you know you were cisgender? When did you realize you were straight? It’s the same for me, I just always knew – it’s been apart of who I am for as long as I can remember.”

Tony, a 32 year-old trans man whose name has been changed for privacy reasons, remembers that he was eight years old when he started exhibiting male tendencies.

“I wanted to run around with my shirt off and I felt more comfortable hanging with the boys,” Tony said. “Playing house I would always act the part of the man. In my head I just naturally assumed that one day I would have a wife and kids.”

For Fox, it wasn’t until she was 15 years old that she had a word for how she had always felt, but regardless of language, she knew that she was “not right” well before age 15.

She describes her experience as simply always knowing who she was supposed to be – despite what the outside world saw.

Similar to Fox, Goodman recognized that she was different from a young age. However, due to her southern, religious background, she assumed that her thoughts were due to her being mentally disturbed in some way.

“For most of my younger life I just assumed that my internal desires were because I was a pervert or a cross dresser,” Goodman said. “I didn’t know transgender was even a thing back then. It wasn’t until I had been married for a while when I came across the subject on the Internet.”

Goodman learned that you can be born a certain way yet your mind can tell you something else. For her this revelation was an eye opener. She began learning as much as she could about transgender identity and she eventually came out to her wife.

“I told her that I’m living a lie and I told her I needed to address this. I told her I should have been born a woman.”

According to Goodman things didn’t go well at first. The couple brushed the topic under the rug until 10 years later when Goodman met Shana G. Cole, a transgender specialist and licensed therapist.

“Meeting Shana got me thinking about it again,” she said. “I finally decided that it was time to try and deal with this. My wife was a bit more receptive the second time.”

Although Goodman’s wife has been supportive of her transition, it hasn’t been an easy road.

“You’re married to a man for 14 years and all of sudden that man comes to you and says, I want to swipe out parts. That’s pretty weird I can assume,” Goodman said. “She has commented that she misses having a male presence around.”

Similar to Goodman, Fox and Catherine were both married before they received their gender affirmation surgery. All three women are still married to their original spouses today.

Tony is also married but he wed his wife one year ago – seven years after he began the transition process. At the time of his interview, him and his wife were expecting their first baby.

For many married transgender individuals, support from their spouses doesn’t always come easily. That’s why Fox is thankful for her wife, who knew about Fox’s determination to transition right from the beginning of their relationship.

“We started dating when I was 16,” Fox said. “We got serious and I told her right from the get-go that that was the big reason why I had a lot of girly interests.”

The couple got married in 2008, well before Fox even started transitioning into a female.

“Her reaction to me actually transitioning was excitement more than anything because she knew how much it meant to me to go ahead and start it,” Fox said. “She already knew so she didn’t have an awkward time with it.”


Undergoing gender affirmation surgery can be a very emotional and personal process for many transgender individuals. It can take months or years for one to fully transition and along with the physical changes, one must be prepared to come out and explain themselves to family, friends, and at times even acquaintances.

“Telling the people close to me that I was going to transition into a female was terrifying,” Goodman said. “It was one of the scariest things I have ever done in my life and I’m ex-military. I’ve shot guns, worked on planes, I’ve made scary decisions that are life changing, but it was nothing like deciding to transition and telling others about it.”

Although deciding to transition and coming out to loved ones is difficult, in the end, the vast majority of transgender individuals do not regret their decision. It is a hard decision to make but one that is extremely empowering and rewarding for many.

“My life has changed completely but I’m much happier, it’s a joyful process,” Catherine said. “I remember the first time I was actually able to step out into the world as Catherine – as me – and everything was right with the world.”

According to Shana G. Cole, the transition process is not as difficult as many people think. Cole is a transgender advocate who co-founded Tree of Life Counseling, a counseling center in Greensboro, North Carolina that offers a variety of services including gender-identity-focused therapy and services.

Cole said the hardest thing about transitioning is gathering the necessary funds. For Fox, who knew that surgery was her only option, money was the single thing standing in her way for quite some time.

“It was exciting when it finally became financially possible for me to transition,” Fox said. “It’s amazing to now be seen the way I’ve always felt.”

Since beginning her own transition a year ago, Goodman said she has transformed into a much friendlier person and she couldn’t be happier.

“May 2014 was the first day I took hormones – that’s a day you never forget,” Goodman said. “Things have been much better since I changed my chemistry. People don’t realize how much hormones change who you are. I went from an angry person filled with very bad emotion to people telling me I’m a happier person and that I treat everyone better now. Basically I’m not an asshole anymore and it just really surprised me how much beginning that transition processes changes you for the better.”

According to the World Professional Association for Transgender Health and the American Medical Association, both gender affirmation surgery and hormone therapy are proven to be highly effective treatments in assisting to alleviate gender dysphoria.

Satisfaction rates across studies range from 87 percent in male-to-female patients to 97 percent in female-to-male patients while regrets are extremely rare at 1-1.5 percent of patients.

The standards of care in place for transgender individuals today are clinical guidelines that health professionals are highly encouraged to follow. These standards of care include hormone therapy and surgical treatments. For many transgender individuals, these options are the only option.

At age 47 Catherine knew she had to do something to change her life. She had gotten to the point where she could no longer deal with her feelings of gender dysphoria. She was either going to end it all by opting out of life completely or do her research and seek professional help.

Catherine decided to join a support group and find a therapist.

“I fought it tooth and nail. I didn’t want to be transgender,” she said. “I was afraid of the consequences because I had built a life; family, children, grandchildren. I didn’t want to believe my therapist, I told her she was lying and that I was just a cross-dresser.”

However, once Catherine finally came to terms with her identity, she realized what she needed to do. Her first step was self-awareness, the next was telling her family.

“It was very emotional and I was nervous to go through with it,” Catherine said. “But in the end my whole family transitioned with me – you don’t transition in a vacuum.”

The medical transition begins with hormones, which consist of estrogen and t-blockers. T-blockers are hormones that block testosterone, most trans women take Depo-Provera or Spironolactone. Sometimes Progesterone is also added in order to enhance the effects of the estrogen. These hormones caused Catherine to immediately start seeing changes in her body.

“For me the change was quite dramatic,” she said. “Your face gets softer, your muscles start going away, and your fat goes to the right places like a female. It takes quite a while but it’s very powerful stuff.”

Catherine also grew her hair out and took voice lessons. She learned how to dress as a woman and had to change her mannerisms as well.

“I had a lot of anxiety at first, ‘are people going to see me as a guy in a dress?’ Learning how to do my hair and makeup helped with that though,” Catherine said.

Aside from the physical changes and coming out to her family, Catherine also had to deal with the government to change the name on her license, birth certificate, insurance cards, credit cards as well as on her degrees.

So far it has been a five-year process for Catherine but she says that it will always be a lifelong thing. She doesn’t mind though, she’s just happy that she finally made the decision that was right for her.

“For me I needed to have the surgery. I couldn’t look at myself in the mirror anymore and not be disgusted by it,” she said. “It was very emotional in the sense that you say goodbye to your old self and you know this is it – you can’t go back, but it was also necessary and I’m glad I did it.”

Finding advocates

Catherine, Tony, Fox, and Goodman all agree that transgender individuals want the outside world to see them as normal because that’s how they see themselves.

“There’s a major common thread amongst transgender individuals and it’s that we don’t want to be transgender,” Goodman said. “Transgender people are just like everybody else. I have the same dreams and goals as everyone else, I get up in the morning and put my clothes on in the exact same way everyone else does. I’m just a regular person who wants to live a normal life.”

Helping transgender individuals live a normal life is what Cole does for a living.

“There’s not too many people out there who do what we do,” Cole said. “I saw a need for this type of therapy and so I created a safe place that is welcoming to all people.”

Cole is a licensed professional counselor as well as a certified rehabilitation counselor who specializes in gender identity and sexual orientation concerns. Due to her passion for the subject and her extensive training, Cole is considered a Transgender Specialist amongst her colleagues and other professionals in the medical community.

Aside from providing evaluations and referrals for transgender individuals so that they can begin cross-sex hormone treatment and/or gender affirmation surgery, Cole also helps her clients deal with the lifestyle adjustments they’re facing.

“I have a male to female client who is struggling with how to do her hair and makeup so we have sessions dedicated to makeup lessons. I even bring in wigs,” Cole said. “Being a trans specialist goes further than providing hormones and medical treatment. You have to get involved in the community itself.”

The transgender community is a population that has been harmed by many medical professionals, certain religious individuals, and even members of the public who simply don’t understand what transgender means. These harmful stereotypes associated with trans people range from people thinking they’re drag queens or prostitutes to people assuming that they’re just confused and need more male or females influences in their lives.

“People think they’re damaged somehow,” Cole said. “But they’re not. Someone who is trans is no different from you or I. They are just trapped in the wrong body and it’s like any other medical condition you could be born with.”

Catherine agrees.

“It’s important to understand that gender dysphoria is not a mental condition. It’s a medical condition,” she said. “It’s not something you choose, you’re born with it.”

Ellington, a licensed therapist in North Carolina, does not specialize in transgender identity but she has worked with a transgender patient in the past and according to her, transgender identity is treated as anything else in her field.

“Transgender identity is accepted and processed just as anyone’s gender identity is. We teach them to accept themselves even though society doesn’t,” she said.

Advocacy for trans individuals exists in safe spaces like Tree of Life Counseling, therapy groups, and LGBTQIA centers across the country. But advocacy can also be found in typically unexpected places, like the church.

When looking for acceptance and understanding, most trans individuals tend to shy away from religion. Traditionally, the church has held the notion that God does not make mistakes and that those who are suffering from gender dysphoria need to find God and should not resort to altering what God has given them.

“There’s nothing I can say to anyone who’s going to put religion before human decency,” Fox said. “I can’t even count the times I’ve heard that I’m going to hell. The people who say those things are not worth my time and I don’t think it’s any of their business.”

However, not all churches have that definitive viewpoint on transgender identity. The Elon Community Church located in Elon, North Carolina is an open and affirming church, meaning their church community is welcoming of all individuals – including members of the LGBTQIA population.

“I’m doing everything I can to learn about the transgender community,” Randy Orwig, senior pastor at the Elon Community Church, said. “I think you really have to look at what Christ says and that’s love your neighbor. Don’t let your faith denigrate other people, that goes against God-given scripture.”

Although Orwig does not know of any transgender individuals who are members of his church, he said that any transgender individual would be welcomed with open arms.

Becoming an advocate

According to the American Foundation for Suicide Prevention, transgender individuals are 40 percent more likely than cisgender individuals to commit suicide. One transgender teen, Ash Haffner, was lost to suicide earlier this year.

The North Carolinian was 16 years old when he committed suicide. According to Haffner’s mother, who was quoted in The Charlotte Observer, he had encountered bullying that had worsened once he began to transition publicly.

As reported in The Charlotte Observer, a note from Haffner’s iPad read, “If those people would have just stayed silent and kept their ignorant thoughts in their heads then maybe I wouldn’t have those scars on my arm.”

Becoming an advocate for transgender acceptance and transgender rights does not require understanding what’s going on in the mind of a trans person. According to Goodman, she doesn’t even completely understand everything that goes on in her mind. Being an advocate is simply about being there for someone and respecting their decisions, doing so can save lives.

Goodman said she wishes that the cisgender community understood one important fact about transgender individuals.

“I wish the world would understand us a little better,” she said. “We’re not weird or crazy people with strange fetishes. We live normal lives and that’s what I want the world outside my front door to understand.”