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The terms and language about trans people can seem somewhat bewildering. To the beginner they may even be a source of anxiety: will one say the wrong thing and insult someone? (Sometimes you might be unsure whether the person is trans, and wonder whether to ask will offend them, whether or not they are trans. In that case it’s safer not to ask.) The best policy is to allow the trans person you are talking with to lead the conversation. If they’ve not already mentioned it (and you think it appropriate) ask them to tell you the terms and pronouns they would prefer you to use. Remember, though, that some people may not actually want you to draw attention to the fact that they are trans.

In meetings that are intentionally inclusive of gender-variant people it has become the custom to ask everyone present to declare their preferred pronouns. This is an example of good practice. Asked what would make them feel comfortable at church, Ed said:

I guess it would come from interacting with people… I guess them being receptive to using my correct pronouns… Or at least making an effort to… Kind of being on board with that is a good way of like showing me… Acknowledging me… Yeah… That’s an immediate sign I guess.

The reason there are so many terms is because trans people have a long history and have existed in many different cultures. Mollenkott (2001) cites examples from the ancient Near Eastern world, including ancient Egypt, as well as contemporary examples. For example, acault ‘males’ in Myanmar Buddhism are believed to have been chosen by a female spirit, and like the Hijras in India and Pakistan, perform a sacred alternative gender role. ‘Two-Spirit people’ among Native American tribes and society are another well-known example.

Part 1 of Trans Britain (Burns 2018) includes stories of trans people who were around in the mid-20th century and earlier, some of whom found it necessary to hide the fact they were trans. In those days, the most widely available term was ‘sex change’ which was common in tabloid newspaper narratives. This sensationalised trans people’s lives. It is no longer an acceptable term because transition involves ‘confirming’ one’s gender identity and not altering it. It is the trans person’s gender expression, gender presentation or gender role that changes. The intention is to claim the gender identity that they have always had but may have supressed to that point, rather than acquiring a different gender.

Like most human groups trans people are also quite diverse and one term is not enough. We tend to use the neat catch-all, trans as a term to include all gender nonconforming identities but there are different communities under the trans umbrella. In the modern West, trans people’s care has been supervised by the medical profession for well over a century. Doctors love to coin clinical terms with a Greek or Latin etymology.

Transsexual is a good example. It is a combination of two Latin words: ‘trans’ meaning crossing over, and ‘sexual’ which refers not to the libido, but to the sexed body as being either male or female. Some trans people still use this term, but it belongs to an earlier clinical era and is less common today. There are several reasons why it’s dropped out of use.

First, during the past half century we have gone through a social and linguistic revolution which has led to differences between male and female being discussed in terms of gender rather than sex. As a result, we use the term transgender. Trans people are often happier with the term ‘transgender’ which clearly indicates that their concern is with their gender identity, not their sexuality.

Second, the older term ‘transsexual’ tends to be associated with the idea that someone who transitions is ‘crossing over’ from one gender to another. But as we have explained, someone who transitions is not changing their gender, (though they could be said, should they undergo a medical transition, to have changed their sex). They are taking steps to be recognised by those around them as the gender they have identified with for the whole of their lives. This is why we prefer the term gender confirmation surgery rather than gender reassignment surgery.

Despite common assumptions to the contrary, not all surgeries are genital. For many trans men, ‘top surgery’, or double mastectomy, is an essential step, as facial feminisation surgery can be for some trans women. For many trans people these are more important than genital surgery, as they help them to navigate the world with more confidence in their gender presentation.

Third, ‘transsexual’ like the more recent term gender dysphoria (which refers to the discomfort or distress trans people can experience until they transition) is a clinical term, and trans people are beginning to set aside this medical model of ‘diagnosis’ and ‘treatment’ and articulate their experience for themselves. A consultation to reform the UK’s Gender Recognition Act 2004 was held in the autumn of 2018. Its premise was that the gender recognition process should be less medicalised, without the need for a ‘diagnosis’ of gender dysphoria or the submission of clinical notes. Trans people don’t necessarily feel dysphoric about their gender variance, nor do they always see a clinician; some simply transition with or without hormones, though hormone therapy should always entail medical supervision.

Modern medicine has played a crucial role in the care of trans people, enabling them to transition in ways earlier generations of gender-variant people could only dream of. This has enabled people to appreciate that gender and sexual orientation are two different aspects of human experience. I (Tina) can remember, back in the 1960s, a boy from my school being arrested for cross-dressing (wearing the clothes of the opposite sex), and who in retrospect was presumably trans, but the main charge was for soliciting sex with men. There was a confusion of sexuality and gender identity then that would be less likely to happen today.

Gender identity clinics, which began to open from the 1960s (the oldest, founded in 1966, and probably the most well-known, is the clinic originally based at Charing Cross1) helped trans people to escape criminalisation and turned them into patients. This was not all gain, as being a patient could mean loss of autonomy and trans people were made to jump through unreasonable clinical hoops to receive treatment. Prior to this date these treatments had only been available to those who could afford them. It would take decades for trans people to be seen as clients and stakeholders with regard to their treatment, due to the stigma attached to being gender-variant.

In the early days of sexology (the science of sexual orientation and gender variance), in the late 19th and early 20th century, anything other than cisgender heterosexuality was considered deviant. Gender variance was often seen as a subset of homosexuality and was treated (in some jurisdictions) as a mental illness that could be ‘cured’ by talking therapies or by invasive treatments like electro-convulsive therapy. Geoff Brown’s 1966 novel I Want What I Want is a transition narrative that I (Tina) read aged 15 when it was first published. It begins in a mental hospital where the protagonist (introduced with a male name) has been committed for cross-dressing. Once discharged, they transition as Wendy, but accessing treatment proves difficult. Medical transition was not then generally available, though this was just about to change.

Magnus Hirschfeld (1991, first published 1910) was a famous sexologist who worked with gender-variant people at the beginning of the 20th century. He concluded that trans people were a discrete group and pioneered humane methods of treatment that included gender confirmation surgery. In the mid-century Harry Benjamin, an endocrinologist, developed hormone therapy as a breakthrough treatment option and which continues today as part of people’s medical transition.

Neither of these clinicians regarded gender-variant people as deviant or mentally ill, but other sections of the medical establishment took longer to catch up. The Diagnostic and Statistical Manual for Mental Diseases continued to include the category of ‘gender identity disorder’ until 2013, when it was replaced by that of ‘gender dysphoria’, a term more acceptable to trans stakeholders. In 2018 the World Health Organization removed what it calls ‘gender incongruence’ from the mental health chapter in the International Classification of Diseases – 11 after consulting trans people and a rigorous review of the evidence. In both instances, being trans was declassified as a mental health problem. This is long after homosexuality was declassified in 1973. It is frequently observed that trans people often lag behind lesbian and gay people in terms of equality.

The same kind of debates that led to the conclusion that being gay or lesbian is a natural human variation are being repeated about trans people in our society at the moment. The media highlights trans celebrities, but trans people’s lives are constantly contested – for example, the slogan, ‘trans women aren’t real women’ adopted by some radical feminists (see Chapter 3).

Trans people are also more vulnerable to fragile mental health due to discrimination. The UK Government’s National LGBT Survey Research Report (HM Government 2018) noted that 40 per cent of trans respondents had experienced a negative reaction on accessing health services because of their gender identity, compared to 13 per cent of cisgender respondents, who were treated negatively because of their sexual orientation. Similarly, the Stonewall School Report (2017) shows that more than four in five (84%) of trans pupils have self-harmed, compared to three in five (61%) lesbian, gay or bi young people. More than two in five (45%) of trans pupils have attempted suicide, compared to one in five (22%) of cisgender pupils. In one of the workshops we held, the families of two young trans people told us that one had overdosed and another came close to it.

These mental health problems are usually related to the social stigma still attached to being trans and are not integral to being transgender. It is true that in the 1980s, consultant psychiatrists became the principal gatekeepers for trans people’s treatment, but this was mainly to ensure that the person had sufficient mental stability to transition. Today, the care of trans people tends to be multi-disciplinary in character.

The World Professional Association for Transgender Health (WPATH) is the leading international multi-disciplinary body in the field and its evidenced-based Standards of Care (SOC) Version 7 are emphatic that:

• Being transgender is a human variation and not a pathology.

• It is both ineffective and unethical to attempt to persuade someone to alter their gender identity – (i.e. being trans is not a ‘choice’).

WPATH emerged in the late 1970s and was originally named after the esteemed clinician of transgender care, Harry Benjamin. It aimed to promote humane, evidence-based treatment following the withdrawal of gender confirmation surgery by the gender identity service at Johns Hopkins University in the US. The withdrawal of confirmation surgery was at the instigation of Dr Paul McHugh, a conservative Catholic. McHugh continues to expound views that are contrary to what developed into the WPATH principles. He regards being trans as a mental illness and believes that trans people’s minds should be altered to prevent them from transitioning. His writings are seized on by conservatives, including conservative Christians, who often quote his belief that being trans is a mental illness to support their theological conviction that trans people’s behaviours can and should be restrained.

We return to this topic in Chapter 3 (where we look at the impact of the culture wars on trans people) but as a rule of thumb: talks or books that refer to trans people’s ‘gender confusion’ and emphasise their ‘gender dysphoria’ usually assume that trans people have a psychological ‘problem’ that can be ‘cured’. This is in defiance of the UK’s therapeutic consensus condemning conversion therapy and calls from Church and State for it to be banned.

The Memorandum of Understanding on Conversion Therapy, Version 2, of October 2017 was signed by many UK therapeutic bodies, including the Royal College of General Practitioners, the British Psychological Society and the British Association for Counselling and Psychotherapy. Version 1 aimed to protect the public from efforts to change a person’s sexual orientation. Version 2 extends this aim to gender identity.

There is a scientific basis to this therapeutic consensus. The significant study by Zhou and colleagues (1995) appears to be supported by subsequent research as summarised by Roughgarden 2017 (pp.50–2), who reports that ‘many studies are now reporting that the physical brain structure of transgender people more closely resembles the sex they identify with rather than with their genital sex.’ This evidence confirms that trans people are not confused cisgender people, sexual deviants or mentally ill. They are simply different from cisgender people and no less worthy of respect.

1 Now based in West London and part of the Tavistock and Portman NHS Foundation Trust.