7 Questions Answered About Transgender People

— -- It is believed there have always been people whose brain and bodies are at odds when it comes to their gender. In the past two decades, the term “transgender” has been used to define this population. As part of Diane Sawyer’s exclusive interview with Bruce Jenner, a few experts offered to help answer questions often asked about the transgender community.

1. So How Many People Are Transgender?

While it’s impossible to know exactly how many transgender people live in the U.S., the most commonly cited estimate is 700,000—more than the population of Washington, D.C. Most experts on the transgender community believe that the number is probably higher.

“If you're in a high school of 2,000 kids, you're probably going to have somewhere between two and four trans kids in that school at any one time,” says Dr. Norman Spack, the co-director of the gender management clinic at Boston Children's Hospital.

Dr. Johanna Olson, the medical director of the transgender clinic at Children's Hospital Los Angeles notes that it would be helpful for the government to collect data about the community. “What we really need is a census bureau question that says, ‘Does anyone in your household identify as a gender different than the one they were assigned at birth?’” says Olson. “And that would probably give us a better prevalence number and a more accurate reflection of the trans experience.”

2. Is Being a Transgender Person Considered a Disorder?

No. And, as Dr. Olson says, “Being transgender is not a mental illness” either. In May 2013, medical professionals removed “Gender Identity Disorder” from the Diagnostic and Statistical Manual of Mental Disorders (DSM-V) -- replacing it with “Gender Dysphoria”. They also changed the criteria for diagnosis.*

“Gender Dysphoria” is the term medical experts use to describe the distress a person may feel when their gender identity does not match the gender they were assigned at birth. There are various treatment options available to manage this discontent including mental health services, hormonal treatments, and— in some cases— surgery. There is a debate in the medical and transgender communities about whether or not “Gender Dysphoria” should remain in the DSM. Some believe removing it could limit patients’ access to insurance coverage.

3. Are There Transgender Children?

Yes. Children can be transgender, but not all children who experiment with gender play or exhibit gender nonconforming behavior will be transgender adults. Experts say only a small fraction of young children who exhibit gender noncomforming behavior will go on to be transgender later in life. In other words, most of these children will go on to report that their sex assigned at birth aligns with their gender identity.

Children who are diagnosed with gender dysphoria and continue to experience these intense feelings through adolescence are referred to as persisters. Those who do not continue through puberty are desisters.

“Think of someone running a hurdle,” Dr. Spack says. “The persisters run over the hurdle and continue on the path to becoming a transgender adult. The desisters hit a wall and they do not transition. The first thing to know is that you can’t define children for sure until they hit puberty. We don’t have a litmus test.”

"What we need to understand is that in development, all of us get dramatically transformed over time,” says psychiatrist Dr. Stephen B. Levine of Case Western Reserve School of Medicine, who has treated hundreds of transgender people, “by forces we don't fully understand.”

Dr. Spack agrees, but adds that for that small fraction who persist, their feelings of gender dysphoria are a sign of who they will be as adults. “I take care of many children who lift the sheets before they go to bed and pray that they'll wake up with a different body,” Spack says. "And then they lift the sheets when they wake up and say, ‘Why did this happen to me? Why should I feel this way?’”

That’s why Dr. Spack tells concerned parents to get professional counseling.

"If your kid expresses issues around gender identity it is so, so important to take it seriously,” Spack says. “It is still all too common for transgender people to take their lives. Sometimes they don’t know there is treatment for them.”

As Jenner tells Diane Sawyer, his feeling of gender dysphoria started in childhood and “it never, never ever went away.”

4. What Treatment Is Given to Children?

“Most people know their gender in early childhood,” says Dr. Olson. So for an adolescent experiencing intense gender dysphoria, the first medical option is to take puberty blockers, which prevent physical changes such as breast development and facial hair—buying a child time before a surge of unwanted hormones. It’s important to know that puberty blockers are completely reversible, but are not without some risks including effects on bone development and height. After puberty blockers, the second step for a medical transition is cross-sex hormones which have irreversible effects, such as breast growth from estrogen and facial hair growth brought on by testosterone.

A small Dutch study —out just last year— of transgender adolescents who were started on puberty blockers as children suggests that those who undergo this treatment (followed later by cross-sex hormones and/or surgery) turn out just as happy as their peers, avoiding the depression that all too often plagues transgender youth.

Jenner notes that when he began hormones as an adult, the treatment immediately aided in quality of life. They “take the edge off,” Jenner says.

As Dr. Levine tells us, sometimes the most important step before any medical intervention is understanding. “I want every parent with a gender atypical child,” Levine tells ABC, “to be fascinated with that child, to be interested in that child, to protect the child and to help the child understand the world.”

5. Do All Transgender People Have Surgery?

No. Not all transgender people have surgery—or any medical intervention. Being transgender is not about physical changes—it is about gender identity. For a transgender person, their gender identity does not align with their biological sex.

As Dr. Spack says, “For transgender people, their bodies below the brain do not define their gender status.”

Not all transgender people report experiencing gender dysphoria -- the term that describes distress related to identifying with a gender different from the one assigned at birth. But for those who do, medical intervention can be a great relief.

There are various reasons some transgender people do not have surgery. For many, the cost is prohibitive. For others, having surgery is not the most important way for them to express their gender. As Dr. Olson says, “There are some people that are completely fine—by the way—with the genitals they have.”

For those who do have surgery, the World Professional Association for Transgender Health (WPATH) recommends coming to the decision with the guidance of mental health professionals who specialize in transgender medicine. They also recommend living in the gender role a person identifies with for at least 12 continuous months. As Dr. Levine says, “This is not a cavalier thing.”

6. How Many Transgender People Are Lost to Suicide and Murder?

Following the death of Leelah Alcorn in late December -- the transgender young woman whose suicide note ended in the plea “Fix society. Please” -- there have been an additional eight transgender youth who have died by suicide in 2015. Nick Adams, who works for GLAAD and is a transgender man, says that all of us should be concerned about these tragic numbers. Adams says he believes the number of transgender people who commit suicide isn’t “because transgender people are more mentally unstable than non-transgender people—it's because we live in a society that gives us very little hope that we can be accepted and understood as our true selves. The culture needs to change so that transgender people can see a future for themselves and survive."

As for homicides, “In 2015,” Adams adds, “seven transgender women have been murdered in the United States.”

Dr. Olson says that some of these tragic findings apply even to her youngest patients, “There's a lot of self-harm, there's a lot of cutting, there's a lot of burning, there's a lot of suicidal thoughts,” Olson tells ABC News, “There's a lot of suicide attempts even in very young kids. And so it's a scary time. And it's a really important time to be listening if something's happening like that for a kid.”

“I would like to think we can save some lives here,” Jenner tells Diane Sawyer.

7. What About the Law? Are Transgender People Protected?

This year, Barack Obama became the first President to mention the community in an official address. “He actually was the first one to say the actual word, “transgender,” Jenner says. “I will certainly give him credit for that.” And just this past July, Obama signed an Executive Order prohibiting transgender discrimination for federal employees and contractors. But not every state has a law explicitly protecting all transgender workers.

Right now in 32 states there is no explicit state law protecting people from being fired for being transgender. Only 18 states (California, Colorado, Connecticut, Delaware, Hawaii, Illinois, Iowa, Massachusetts, Maine, Maryland, Minnesota, New Jersey, New Mexico, Nevada, Oregon, Rhode Island, Vermont and Washington) and D.C. currently prohibit discrimination based on gender identity. And according to the Human Rights Campaign, while “nearly 91% of Fortune 500 companies include sexual orientation in their workplace policies” only “61 percent include gender identity.”

As President Obama said when he signed the order, “Today in America, millions of our fellow citizens wake up and go to work with the awareness that they could lose their job, not because of anything they do or fail to do, but because of who they are: lesbian, gay, bisexual, transgender. And that's wrong.”

– Mary Kathryn Burke with reporting from Dr. Mark Abdelmalek

*“Gender Dysphoria in Children” Diagnostic Criteria

A marked incongruence between one’s experienced/expressed gender and assigned gender, of at least 6 months’ duration, as manifested by at least six of the following (one of which must be Criterion A1):

1. A strong desire to be of the other gender or an insistence that one is the other gender (or some alternative gender different from one’s assigned gender).

2. In boys (assigned gender), a strong preference for cross-dressing or simulating female attire; or in girls (assigned gender), a strong preference for wearing only typical masculine clothing and a strong resistance to the wearing of typical feminine clothing.

3. A strong preference for cross-gender roles in make-believe play or fantasy play.

4. A strong preference for the toys, games, or activities stereotypically used or engaged in by the other gender.

5. A strong preference for playmates of the other gender.

6. In boys (assigned gender), a strong rejection of typically masculine toys, games, and activities and a strong avoidance of rough-and-tumble play; or in girls (assigned gender), a strong rejection of typically feminine toys, games, and activities.

7. A strong dislike of one’s sexual anatomy.

8. A strong desire for the primary and/or secondary sex characteristics that match one’s experienced gender.

B. The condition is associated with clinically significant distress or impairment in social, school, or other important areas of functioning. Source: DSM-V, 2013“Gender Dysphoria in Adults” Diagnostic Criteria

A marked incongruence between one’s experienced/expressed gender and assigned gender, of at least 6 months’ duration, as manifested by at least two of the following:

1. A marked incongruence between one’s experienced/expressed gender and primary and/or secondary sex characteristics (or in young adolescents, the anticipated secondary sex characteristics).2. A strong desire to be rid of one’s primary and/or secondary sex characteristics because of a marked incongruence with one’s experienced/expressed gender (or in young adolescents, a desire to prevent the development of the anticipated secondary sex characteristics).

3. A strong desire for the primary and/or secondary sex characteristics of the other gender.

4. A strong desire to be of the other gender (or some alternative gender different from one’s assigned gender).

5. A strong desire to be treated as the other gender (or some alternative gender different from one’s assigned gender).

6. A strong conviction that one has the typical feelings and reactions of the other gender (or some alternative gender different from one’s assigned gender).

7. The condition is associated with clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Source: DSM-V, 2013

This chart outlines definitions for transgender terminology, along with appropriate ways to use each word.