As our understanding of transgender individuals and human sexuality improves, the terminology used by the transgender and medical communities continues to evolve. Substance abuse treatment professionals should use the definitions included here as a guide, with the caution that some transgender clients or health professionals may use slightly different definitions.

Transgender includes a continuum of gender expressions, identities, and roles that challenge or expand the current dominant cultural values of what it means to be male or female.

One’s gender identity is the gender (male or female) with which one identifies. A person may be biologically male and have a female gender identity (male-to-female, or MTF) or be biologically female and have a male gender identity (female-to-male, or FTM). Gender role refers to how individuals present their gender in the world (e.g., through the clothes they wear). The gender one defines as one’s identity is a matter distinct from sexual orientation.

One’s sexual orientation may be described as the sex or gender one is attracted to (see chapter 1). Many MTF transsexuals identify themselves as heterosexual (they are female identified and attracted to men). However, transgender individuals, including transsexuals, may identify themselves as heterosexual, bisexual, lesbian, or gay. Gender identity and sexual orientation are not the same thing, and all people have both. The common misconception about MTF individuals is that they are gay. This is often not true.

The terms “sex” and “gender” are often confused in common usage. Sex refers to the biological characteristics of a person at birth, while gender relates to his or her perception of being male or female and is known as the gender role. Many transgender individuals are born one sex and identify themselves as the opposite gender (for example, they are born biologically male and identify themselves as female).

Intersexed individuals are born with ambiguous biological sex characteristics. These individuals often are put through genital surgery, and their sex is decided by the doctor, sometimes with or without the parents’ consent. These individuals may later grow up to have gender identities that are the opposite of the manufactured sex constructed for them at birth and have feelings similar to transgender individuals. An international organization has been formed to help and advocate on behalf of individuals who are born intersexed or with ambiguous sexual characteristics.

Transsexuals are transgender individuals with the biological characteristics of one sex who identify themselves as the opposite gender. There are FTM and MTF transsexuals. Transsexuals usually desire to change their bodies to fit their gender identities. They do this through hormone treatment and gender reassignment surgery (sex change surgery). Transsexual individuals who have embarked on this process are often known as preoperative transsexuals (before the sex reassignment surgery). Transsexuals requesting this surgery must live and work as someone of the gender to which they are changing for at least 1 year prior to surgery and be evaluated by therapists. The costs of hormones, therapy, and surgery are highly restrictive and are not covered by most medical insurance. Some transsexuals identify themselves as nonoperative transsexuals because they have decided not to have surgery, either for medical or for other personal reasons. Transsexuals who are HIV positive are routinely denied surgery, and the surgeries currently available for FTM individuals are not functional or realistic. These nonoperative individuals make up the group most commonly referred to as transgender. They live and work as the gender opposite the one they were born with. Transsexuals who have completed their sex reassignment surgeries can and do live as someone with the new gender would and are legally either female or male. They are sometimes referred to as post-op (i.e., postoperative) transsexuals. Most will live as women or men, without being noticed. For personal or political reasons, however, they may continue to identify themselves as transsexuals even though technically they no longer fit the definition.

Cross dressers or transvestites are transgender individuals who usually identify themselves as of the same gender as their sex; however, they like to dress in clothing of the opposite sex for erotic or personal pleasure. Although by far the largest category of transgender individuals, they usually live a very closeted existence. Many of them are heterosexual men, married with families, often in stereotypically masculine jobs, who, on occasion, dress as females. A number of national and international organizations exist to provide safe places for cross dressers to meet, usually at social gatherings in private homes or private membership bars or clubs.

Drag queens (i.e., gay men who dress in female clothing) and female impersonators (who perform in clubs or cabarets) are not transgender individuals. The choice that these individuals make to dress in the clothing of the opposite sex is not a matter of gender identity. The same is true of drag kings (i.e., women who dress in men’s clothing) and male impersonators.

Bigendered transgender individuals may identify with both genders, or as some combination of both, while androgynous transgender individuals usually do not identify with either gender; that is, they identify as neither male nor female. These general definitions are not meant to be used as diagnostic criteria. In fact, it is extremely important that individuals presenting for treatment be allowed to self-identify whenever possible. Questions about whether someone is or is not a transgender individual should be asked privately and respectfully.