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Wednesday, March 19, 2025

Mushroom poisoning

From Wikipedia, the free encyclopedia
 
Mushroom poisoning
Other namesMycetism, mycetismus
Amanita phalloides accounts for the majority of fatal mushroom poisonings worldwide.
SpecialtyEmergency medicine, toxicology

Mushroom poisoning is poisoning resulting from the ingestion of mushrooms that contain toxic substances. Symptoms can vary from slight gastrointestinal discomfort to death in about 10 days. Mushroom toxins are secondary metabolites produced by the fungus.

Mushroom poisoning is usually the result of ingestion of wild mushrooms after misidentification of a toxic mushroom as an edible species. The most common reason for this misidentification is a close resemblance in terms of color and general morphology of the toxic mushrooms species with edible species. To prevent mushroom poisoning, mushroom gatherers familiarize themselves with the mushrooms they intend to collect, as well as with any similar-looking toxic species. The safety of eating wild mushrooms may depend on methods of preparation for cooking. Some toxins, such as amatoxins, are thermostable and mushrooms containing such toxins will not be rendered safe to eat by cooking.

Signs and symptoms

Poisonous mushrooms contain a variety of different toxins that can differ markedly in toxicity. Symptoms of mushroom poisoning may vary from gastric upset to organ failure resulting in death. Serious symptoms do not always occur immediately after eating, often not until the toxin attacks the kidney or liver, sometimes days or weeks later.

The most common consequence of mushroom poisoning is simply gastrointestinal upset. Most "poisonous" mushrooms contain gastrointestinal irritants that cause vomiting and diarrhea (sometimes requiring hospitalization), but usually no long-term damage. However, there are a number of recognized mushroom toxins with specific, and sometimes deadly, effects:

Toxin Toxicity Effects
α-Amanitin Deadly Causes often fatal liver damage 1–3 days after ingestion. The principal toxin in the death cap.
Phallotoxin Non-lethal Causes extreme gastrointestinal upset. Found in various mushrooms.
Orellanine Deadly Redox cycler similar to paraquat. Causes kidney failure within three weeks after ingestion. Principal toxin in genus Cortinarius.
Muscarine Potentially deadly Causes SLUDGE syndrome. Found in various mushrooms. Antidote is atropine.
Monomethylhydrazine (MMH) Deadly Causes brain damage, seizures, gastrointestinal upset, and hemolysis. Metabolic poison. Principal toxin in genus Gyromitra. Antidote is large doses of intravenous pyridoxine hydrochloride.
Coprine Non-lethal Causes illness when consumed with alcohol. Principal toxin in genus Coprinus.
Ibotenic acid Potentially deadly Excitotoxin. Principal toxin in Amanita muscaria, A. pantherina, and A. gemmata.
Muscimol Potentially deadly Causes CNS depression and hallucinations. Principal toxin in Amanita muscaria, A. pantherina, and A. gemmata.
Arabitol Non-lethal Causes diarrhea in some people.
Bolesatine Non-lethal Causes gastrointestinal irritation, vomiting, nausea.
Ergotamine Deadly Affects the vascular system and can lead to loss of limbs and/or cardiac arrest. Found in genus Claviceps.

The period between ingestion and the onset of symptoms varies dramatically between toxins, some taking days to show symptoms identifiable as mushroom poisoning.

  • α-Amanitin: For 6–12 hours, there are no symptoms. This is followed by a period of gastrointestinal upset (vomiting and profuse, watery diarrhea). This stage is caused primarily by the phallotoxins and typically lasts 24 hours. At the end of this second stage is when severe liver damage begins. The damage may continue for another 2–3 days. Kidney damage can also occur. Some patients will require a liver transplant. Amatoxins are found in some mushrooms in the genus Amanita, but are also found in some species of Galerina and Lepiota. Overall, mortality is between 10 and 15 percent. Recently, Silybum marianum or blessed milk thistle has been shown to protect the liver from amanita toxins and promote regrowth of damaged cells.
  • Orellanine: This toxin generally causes no symptoms for 3–20 days after ingestion. Typically around day 11, the process of kidney failure begins, and is usually symptomatic by day 20. These symptoms can include pain in the area of the kidneys, thirst, vomiting, headache, and fatigue. A few species in the very large genus Cortinarius contain this toxin. People having eaten mushrooms containing orellanine may experience early symptoms as well, because the mushrooms often contain other toxins in addition to orellanine. A related toxin that causes similar symptoms but within 3–6 days has been isolated from Amanita smithiana and some other related toxic Amanitas.
  • Muscarine: Muscarine stimulates the muscarinic receptors of the nerves and muscles. Symptoms include sweating, salivation, tears, blurred vision, palpitations, and, in high doses, respiratory failure. Muscarine is found in mushrooms of the genus Omphalotus, notably the jack o' Lantern mushrooms. It is also found in A. muscaria, although it is now known that the main effect of this mushroom is caused by ibotenic acid. Muscarine can also be found in some Inocybe species and Clitocybe species, in particular Clitocybe dealbata, and some red-pored Boletes.
  • Gyromitrin: Stomach acids convert gyromitrin to monomethylhydrazine (MMH). It affects multiple body systems. It blocks the important neurotransmitter GABA, leading to stupor, delirium, muscle cramps, loss of coordination, tremors, and/or seizures. It causes severe gastrointestinal irritation, leading to vomiting and diarrhea. In some cases, liver failure has been reported. It can also cause red blood cells to break down, leading to jaundice, kidney failure, and signs of anemia. It is found in mushrooms of the genus Gyromitra. A gyromitrin-like compound has also been identified in mushrooms of the genus Verpa.
  • Coprine: Coprine is metabolized to a chemical that resembles disulfiram. It inhibits aldehyde dehydrogenase (ALDH), which, in general, causes no harm, unless the person has alcohol in their bloodstream while ALDH is inhibited. This can happen if alcohol is ingested shortly before or up to a few days after eating the mushrooms. In that case, the alcohol cannot be completely metabolized, and the person will experience flushed skin, vomiting, headache, dizziness, weakness, apprehension, confusion, palpitations, and sometimes trouble to breathe. Coprine is found mainly in mushrooms of the genus Coprinus, although similar effects have been noted after ingestion of Clitocybe clavipes.
  • Ibotenic acid: Decarboxylates into muscimol upon ingestion. The effects of muscimol vary, but nausea and vomiting are common. Confusion, euphoria, or sleepiness are possible. Loss of muscular coordination, sweating, and chills are likely. Some people experience visual distortions, a feeling of strength, or delusions. Symptoms normally appear after 30 minutes to 2 hours and last for several hours. A. muscaria, the "Alice in Wonderland" mushroom, is known for the hallucinatory experiences caused by muscimol, but A. pantherina and A. gemmata also contain the same compound. While normally self-limiting, fatalities have been associated with A. pantherina, and consumption of a large number of any of these mushrooms is likely to be dangerous.
  • Arabitol: A sugar alcohol, similar to mannitol, which causes no harm in most people but causes gastrointestinal irritation in some. It is found in small amounts in oyster mushrooms, and considerable amounts in Suillus species and Hygrophoropsis aurantiaca (the "false chanterelle").

Causes

Immature, possibly poisonous, Amanita mushrooms
Edible shaggy mane Coprinus comatus mushrooms
Two examples of immature Amanitas, one deadly and one edible
An edible puffball which closely resembles the immature Amanitas
Jack-O-Lantern, a poisonous mushroom sometimes mistaken for a chanterelle
"Chanterelle", edible

New species of fungi are continuing to be discovered, with an estimated number of 800 new species registered annually. This, added to the fact that many investigations have recently reclassified some species of mushrooms from edible to poisonous has made older classifications insufficient at describing what now is known about the different species of fungi that are harmful to humans. It is now thought that of the approximately 100,000 known fungi species found worldwide, about 100 of them are poisonous to humans. However, by far the majority of mushroom poisonings are not fatal, and the majority of fatal poisonings are attributable to the Amanita phalloides mushroom.

A majority of these cases are due to mistaken identity. This is a common occurrence with A. phalloides in particular, due to its resemblance to the Asian paddy-straw mushroom, Volvariella volvacea. Both are light-colored and covered with a universal veil when young.

Amanitas can be mistaken for other species, as well, in particular when immature. On at least one occasion they have been mistaken for Coprinus comatus. In this case, the victim had some limited experience in identifying mushrooms, but did not take the time to correctly identify these particular mushrooms until after he began to experience symptoms of mushroom poisoning.

The author of Mushrooms Demystified, David Arora cautions puffball-hunters to beware of Amanita "eggs", which are Amanitas still entirely encased in their universal veil. Amanitas at this stage are difficult to distinguish from puffballs. Foragers are encouraged to always cut the fruiting bodies of suspected puffballs in half, as this will reveal the outline of a developing Amanita should it be present within the structure.

A majority of mushroom poisonings, in general, are the result of small children, especially toddlers in the "grazing" stage, ingesting mushrooms found on the lawn. While this can happen with any mushroom, Chlorophyllum molybdites is often implicated due to its preference for growing in lawns. C. molybdites causes severe gastrointestinal upset but is not considered deadly poisonous.

A few poisonings are the result of misidentification while attempting to collect hallucinogenic mushrooms for recreational use. In 1981, one fatality and two hospitalizations occurred following consumption of Galerina marginata, mistaken for a Psilocybe species. Galerina and Psilocybe species are both small, brown, and sticky, and can be found growing together. However, Galerina contains amatoxins, the same poison found in the deadly Amanita species. Another case reports kidney failure following ingestion of Cortinarius orellanus, a mushroom containing orellanine.

It is natural that accidental ingestion of hallucinogenic species also occurs, but is rarely harmful when ingested in small quantities. Cases of serious toxicity have been reported in small children. Amanita pantherina, while containing the same hallucinogens as Amanita muscaria (e.g., ibotenic acid and muscimol), has been more commonly associated with severe gastrointestinal upset than its better-known counterpart.

Although usually not fatal, Omphalotus spp., "Jack-o-lantern mushrooms", are another cause of sometimes significant toxicity. They are sometimes mistaken for chanterelles. Both are bright-orange and fruit at the same time of year, although Omphalotus grows on wood and has true gills rather than the veins of a Cantharellus. They contain toxins known as illudins, which causes gastrointestinal symptoms.

Bioluminescent species are generally inedible and often mildly toxic.

Clitocybe dealbata, which is occasionally mistaken for an oyster mushroom or other edible species contains muscarine.

Toxicities can also occur with collection of morels. Even true morels, if eaten raw, will cause gastrointestinal upset. Typically, morels are thoroughly cooked before eating. Verpa bohemica, although referred to as "thimble morels" or "early morels" by some, have caused toxic effects in some individuals. Gyromitra spp., "false morels", are deadly poisonous if eaten raw. They contain a toxin called gyromitrin, which can cause neurotoxicity, gastrointestinal toxicity, and destruction of the blood cells. The Finns consume Gyromitra esculenta after parboiling, but this may not render the mushroom entirely safe, resulting in its being called the "fugu of the Finnish cuisine".

A more unusual toxin is coprine, a disulfiram-like compound that is harmless unless ingested within a few days of ingesting alcohol. It inhibits aldehyde dehydrogenase, an enzyme required for breaking down alcohol. Thus, the symptoms of toxicity are similar to being hung over—flushing, headache, nausea, palpitations, and, in severe cases, trouble breathing. Coprinus species, including Coprinopsis atramentaria, contain coprine. Coprinus comatus does not, but it is best to avoid mixing alcohol with other members of this genus.

Recently, poisonings have also been associated with Amanita smithiana. These poisonings may be due to orellanine, but the onset of symptoms occurs in 4 to 11 hours, which is much quicker than the 3 to 20 days normally associated with orellanine.

Paxillus involutus is also inedible when raw, but is eaten in Europe after pickling or parboiling. However, after the death of the German mycologist Dr. Julius Schäffer, it was discovered that the mushroom contains a toxin that can stimulate the immune system to attack its red blood cells. This reaction is rare but can occur even after safely eating the mushroom for many years. Similarly, Tricholoma equestre was widely considered edible and good, until it was connected with rare cases of rhabdomyolysis.

In the fall of 2004, thirteen deaths were associated with consumption of Pleurocybella porrigens or "angel's wings". In general, these mushrooms are considered edible. All the victims died of an acute brain disorder, and all had pre-existing kidney disease. The exact cause of the toxicity was not known at this time and the deaths cannot be definitively attributed to mushroom consumption.

However, mushroom poisoning is not always due to mistaken identity. For example, the highly toxic ergot Claviceps purpurea, which grows on rye, is sometimes ground up with rye, unnoticed, and later consumed. This can cause devastating, even fatal, effects, called ergotism.

Cases of idiosyncratic or unusual reactions to fungi can also occur. Some are probably due to allergy, others to some other kind of sensitivity. It is not uncommon for a person to experience gastrointestinal upset associated with one particular mushroom species or genus.

Some mushrooms might concentrate toxins from their growth substrate, such as Chicken of the Woods growing on yew trees.

Poisonous mushrooms

Of the most lethal mushrooms, five—the death cap (A. phalloides), the three destroying angels (A. virosa, A. bisporigera, and A. ocreata), and the fool's mushroom (A. verna)—belong to the genus Amanita, and two more—the deadly webcap (C. rubellus), and the fool's webcap (C. orellanus)—are from the genus Cortinarius. Several species of Galerina, Lepiota, and Conocybe also contain lethal amounts of amatoxins. Deadly species are listed in the List of deadly fungi.

The following species may cause great discomfort, sometimes requiring hospitalization, but are not considered deadly.

Evolution

Many different species of mushrooms are poisonous and contain differing toxins that cause different types of harm. The most common toxin that causes severe poisoning is amatoxin, found in various mushroom species that cause the most fatalities every year. Amanita, or “ the death cap”, is a type of mushroom named for its substantial amount of amatoxin, which has about 10 mg per mushroom, which is the lethal dose. Amatoxin blocks the replication of DNA, which leads to cell death. This can affect cells that replicate frequently, such as kidneys, livers, and eventually, the central nervous system. It can also cause the loss of muscle contraction and liver failure. Despite the severe and dangerous symptoms, amatoxin poisoning is treatable given quick, professional care.

Mushrooms have also been found to have evolved toxicity independently from each other. Researchers have found that different mushroom species share the same type of amatoxin called amanitin. They specifically looked at three of the deadliest species, Amanita, Galerina, and Lepiota. Through genome sequencing, a scientific process that determines the DNA sequence of an organism’s genome, closely related mushrooms obtained genetic information via horizontal gene transfer. Once assimilated, it can then be passed down to an offspring. The researchers also concluded that there is “an unknown ancestral fungal donor,” that allowed for horizontal gene transfer.

Mushroom toxins have appeared and disappeared many times throughout their evolutionary history. Many scientists believe that the toxins evolved in mushrooms are used to deter predation, either from fungivores or mammals. If mushrooms are consumed, it can negatively affect their ability to disperse spores, survive, and reproduce. Snails and insects are fungivores and many have learned or evolved to avoid eating poisonous mushrooms. However, it is believed that mammals pose a higher threat to mushrooms than fungivores, as larger body sizes mean they are more capable of eating an entire fungus in one sitting.

Some phenotypes, or observable characteristics, may co-occur with toxicity, and therefore act as a warning signal. The first potential warning sign is aposematism, which is an adaptation that warns off predators based on a physical trait of an organism. In this case, the researchers were interested in observing whether the color of a mushroom deters predators. This would suggest that toxic mushrooms are of different colors than non-poisonous ones. The visual cue of some colors should be enough for predators to know not to consume the mushroom. The second possible warning sign is olfactory aposematism, a similar concept, but instead of focusing on color, the odor of the mushroom would be what deters predation. This would again indicate that poisonous mushrooms would emit a different odor than non-poisonous ones. Alternatively, is the ability of organisms to learn from other organisms. This would suggest that avoidance of toxic mushrooms is a learned behavior. Organisms may avoid toxic mushrooms if they observed other organisms of the same species consume the fungus. Learned behavior is when an organism learns how to behave based on previous experiences. Some researchers believe that if an organism got sick or observed another organism get sick from consuming a poisonous mushroom, then they would know not to continue consuming it for fear of getting sick again.

An analysis of 245 North American mushroom species and 265 from Europe, revealed 21.2% of the North American species and 12.1% of the European ones as poisonous. After collecting this information, and using a neural network to classify all of the mushrooms based on color and odor, the researchers concluded that there was no correlation between cap color and mushrooms containing toxins. The cap is the top, rounded part of a mushroom and comes in different colors. This proposes that the cap color does not act as a warning sign to deter predators, providing no evidence that poisonous mushrooms may not signal their toxicity through visual or chemical traits. The three deadly mushrooms listed above, Amanita, Galerina, and Lepiota, are all of different colors, consisting of reds, yellows, browns, and whites. A possible theory as to why color is not a factor in determining whether a mushroom is poisonous is the fact that many of its predators are nocturnal and have poor vision. Therefore, viewing the different colors is difficult, and could result in inaccurate consumption. The study, however, did suggest that poisonous mushrooms do emit a smell that is unpleasant and therefore discourages consumption. Despite this result, there is no definitive evidence to suggest if the odor is a result of the production of the toxin or if it is intended as a warning signal. Additionally, many of the odors are not picked up by humans. This could suggest that there is another characteristic difference between poisonous and non-poisonous mushrooms to avoid predation from larger mammals or that there is another purpose for some mushrooms being poisonous that is not dependent on predators.

Prognosis and treatment

Some mushrooms contain less toxic compounds and, therefore, are not severely poisonous. Poisonings by these mushrooms may respond well to treatment. However, certain types of mushrooms contain very potent toxins and are very poisonous; so even if symptoms are treated promptly, mortality is high. With some toxins, death can occur in a week or a few days. Although a liver or kidney transplant may save some patients with complete organ failure, in many cases there are no organs available. Patients hospitalized and given aggressive support therapy almost immediately after ingestion of amanitin-containing mushrooms have a mortality rate of only 10%, whereas those admitted 60 or more hours after ingestion have a 50–90% mortality rate. In the United States, mushroom poisoning kills an average of about 3 people a year. According to National Poison Data System (NPDS) annual reports published by America's Poison Centers, the average number of deaths occurring over a ten-year period (2012–2020) sits right at 3 a year. In 2012, 4 out of the 7 total deaths that occurred that year, were attributed to a single event where a "housekeeper at a Board and Care Home for elderly dementia patients collected and cooked wild (Amanita) mushrooms into a sauce that she consumed with six residents of the home.". Over 1,300 emergency room visits in the United States were attributed to poisonous mushroom ingestion in 2016, with about 9% of patients experiencing a serious adverse outcome.

Society and culture

Folklore

Many old wives' tales concern the defining features of poisonous mushrooms. However, there are no general identifiers for poisonous mushrooms, so such beliefs are unreliable. Guidelines to identify particular mushrooms exist, and will serve only if one knows which mushrooms are toxic.

Examples of erroneous folklore "rules" include:

  • "Poisonous mushrooms are brightly colored." – Indeed, fly agaric, usually bright-red to orange or yellow, is narcotic and hallucinogenic, although no human deaths have been reported. The deadly destroying angel, in contrast, is an unremarkable white. The deadly Galerinas are brown. Some choice edible species (chanterelles, Amanita caesarea, Laetiporus sulphureus, etc.) are brightly colored, whereas most poisonous species are brown or white.
  • "Insects/animals will avoid toxic mushrooms." – Fungi that are harmless to invertebrates can still be toxic to humans; the death cap, for instance, is often infested by insect larvae.
  • "Poisonous mushrooms blacken silver." – None of the known mushroom toxins react with silver.
  • "Poisonous mushrooms taste bad." – People who have eaten the deadly Amanitas and survived have reported that the mushrooms tasted quite good.
  • "All mushrooms are safe if cooked/parboiled/dried/pickled/etc." – While it is true that some otherwise-inedible species can be rendered safe by special preparation, many toxic species cannot be made toxin-free. Many fungal toxins are not particularly sensitive to heat and so are not broken down during cooking; in particular, α-Amanitin, the poison produced by the death cap (Amanita phalloides) and others of the genus, is not denatured by heat.
  • "Poisonous mushrooms will turn rice red when boiled." – A number of Laotian refugees were hospitalized after eating mushrooms (probably toxic Russula species) deemed safe by this folklore rule and this misconception cost at least one person her life.
  • "Poisonous mushrooms have a pointed cap. Edible ones have a flat, rounded cap." – The shape of the mushroom cap does not correlate with presence or absence of mushroom toxins, so this is not a reliable method to distinguish between edible and poisonous species. Death cap, for instance, has a rounded cap when mature.
  • "Boletes are, in general, safe to eat." – It is true that, unlike a number of Amanita species in particular, in most parts of the world, there are no known deadly varieties of the genus Boletus, which reduces the risks associated with misidentification. However, mushrooms like the Devil's bolete are poisonous both raw and cooked and can lead to strong gastrointestinal symptoms, and other species like the lurid bolete require thorough cooking to break down toxins. As with another mushroom genera, proper caution is, therefore, advised in determining the correct species.

Notable cases

  • Siddhartha Gautama (known as The Buddha), by some accounts, may have died of mushroom poisoning around ~479 BCE, though this claim has not been universally accepted.
  • Roman Emperor Claudius is said to have been murdered by being fed the death cap mushroom. However, this story first appeared some two centuries after the events, and it is debatable whether Claudius was murdered at all.
  • The best-selling author Nicholas Evans (The Horse Whisperer) was poisoned (but survived) after eating Cortinarius rubellus.
  • The parents of the physicist Daniel Gabriel Fahrenheit, who created the Fahrenheit temperature scale, died in Danzig on 14 August 1701 from accidentally eating poisonous mushrooms.
  • The composer Johann Schobert died in Paris, along with his wife, all but one of his children, their maidservant, and four acquaintances after insisting that certain poisonous mushrooms they had gathered were edible despite the express warning of cooks at two separate restaurants to which he had taken the mushrooms.
  • July 2023 Leongatha mushroom poisoning − Four people in Leongatha, Australia were taken to hospital after consuming beef Wellington suspected to have contained death cap mushrooms. Three of the four guests subsequently died and one survived, later receiving a liver transplant. The woman who cooked the meal, Erin Patterson, was charged with murder in November 2023. Patterson has pleaded not guilty and the Supreme court is expected to hear her case on 28 April, 2025.
  • In August 2023, Professor Vitaly Melnikov, 77, who had headed the Moscow Department of Rocket and Space Systems at RSC Energia (Russia's leading spacecraft manufacturer), became suddenly seriously ill and subsequently died after eating inedible mushrooms.
  • Transgender

    From Wikipedia, the free encyclopedia

    The term transgender (often shortened to trans) refers to people whose gender identity differs from that typically associated with the sex they were assigned at birth.

    Often, transgender people desire medical assistance to medically transition from one sex to another; those who do may identify as transsexual. Transgender does not have a universally accepted definition, including among researchers; it can function as an umbrella term. The definition given above includes binary trans men and trans women and may also include people who are non-binary or genderqueer. Other related groups include third-gender people, cross-dressers, and drag queens and drag kings; some definitions include these groups as well.

    Being transgender is distinct from sexual orientation, and transgender people may identify as heterosexual (straight), homosexual (gay or lesbian), bisexual, asexual, or otherwise, or may decline to label their sexual orientation. The opposite of transgender is cisgender, which describes persons whose gender identity matches their assigned sex. Accurate statistics on the number of transgender people vary widely, in part due to different definitions of what constitutes being transgender. Some countries collect census data on transgender people, starting with Canada in 2021. Generally, less than 1% of the worldwide population is transgender, with figures ranging from <0.1% to 0.6%.

    Many transgender people experience gender dysphoria, and some seek medical treatments such as hormone replacement therapy, gender-affirming surgery, or psychotherapy. Not all transgender people desire these treatments, and some cannot undergo them for legal, financial, or medical reasons.

    The legal status of transgender people varies by jurisdiction. Many transgender people experience transphobia (violence or discrimination against transgender people) in the workplace, in accessing public accommodations, and in healthcare. In many places, they are not legally protected from discrimination. Several cultural events are held to celebrate the awareness of transgender people, including Transgender Day of Remembrance and International Transgender Day of Visibility, and the transgender flag is a common transgender pride symbol.

    Terminology

    Display on gender identity, Bell Gallery, Elmer L. Andersen Library, University of Minnesota, Minneapolis, MN

    Before the mid-20th century, various terms were used within and beyond Western medical and psychological sciences to identify persons and identities labeled transsexual, and later transgender from mid-century onward. Imported from the German and ultimately modeled after German Transsexualismus (coined in 1923), the English term transsexual has enjoyed international acceptability, though transgender has been increasingly preferred over transsexual. The word transgender acquired its modern umbrella term meaning in the 1990s.

    Health-practitioner manuals, professional journalistic style guides, and LGBT advocacy groups advise the adoption by others of the name and pronouns identified by the person in question, including present references to the transgender person's past.

    Transgender

    Although the term transgenderism was once considered acceptable, it has come to be viewed as pejorative, according to GLAAD. Psychiatrist John F. Oliven of Columbia University used the term transgenderism in his 1965 reference work Sexual Hygiene and Pathology, writing that the term which had previously been used, transsexualism, "is misleading; actually, transgenderism is meant, because sexuality is not a major factor in primary transvestism". The term transgender was then popularized with varying definitions by transgender, transsexual, and transvestite people, including Christine Jorgensen and Virginia Prince, who used transgenderal in the December 1969 issue of Transvestia, a national magazine for cross-dressers she founded. By the mid-1970s both trans-gender and trans people were in use as umbrella terms, while transgenderist and transgenderal were used to refer to people who wanted to live their lives as cross-gendered individuals without gender-affirming surgery. Transgenderist was sometimes abbreviated as TG in educational and community resources; this abbreviation developed by the 1980s. In 2020, the International Journal of Transgenderism changed its name to the International Journal of Transgender Health "to reflect a change toward more appropriate and acceptable use of language in our field."

    By 1984, the concept of a "transgender community" had developed, in which transgender was used as an umbrella term. In 1985, Richard Ekins established the "Trans-Gender Archive" at the University of Ulster. By 1992, the International Conference on Transgender Law and Employment Policy defined transgender as an expansive umbrella term including "transsexuals, transgenderists, cross dressers", and anyone transitioning. Leslie Feinberg's pamphlet, "Transgender Liberation: A Movement Whose Time has Come", circulated in 1992, identified transgender as a term to unify all forms of gender nonconformity; in this way transgender has become synonymous with queer. In 1994, gender theorist Susan Stryker defined transgender as encompassing "all identities or practices that cross over, cut across, move between, or otherwise queer socially constructed sex/gender boundaries", including, but not limited to, "transsexuality, heterosexual transvestism, gay drag, butch lesbianism, and such non-European identities as the Native American berdache or the Indian Hijra".

    Transgender can also refer specifically to a person whose gender identity is opposite (rather than different from) the sex the person had or was identified as having at birth. In contrast, people whose sense of personal identity corresponds to the sex and gender assigned to them at birth – that is, those who are neither transgender nor non-binary or genderqueer – are called cisgender.

    Transsexual

    Inspired by Magnus Hirschfeld's 1923 term seelischer Transsexualismus, the term transsexual was introduced to English in 1949 by David Oliver Cauldwell and popularized by Harry Benjamin in 1966, around the same time transgender was coined and began to be popularized. Since the 1990s, transsexual has generally been used to refer to the subset of transgender people who desire to transition permanently to the gender with which they identify and who seek medical assistance (for example, sex reassignment surgery) with this.

    Distinctions between the terms transgender and transsexual are commonly based on distinctions between gender and sex. Transsexuality may be said to deal more with physical aspects of one's sex, while transgender considerations deal more with one's psychological gender disposition or predisposition, as well as the related social expectations that may accompany a given gender role. Many transgender people reject the term transsexual. Christine Jorgensen publicly rejected transsexual in 1979 and instead identified herself in newsprint as trans-gender, saying, "gender doesn't have to do with bed partners, it has to do with identity." Some have objected to the term transsexual on the basis that it describes a condition related to gender identity rather than sexuality. Some people who identify as transsexual people object to being included in the transgender umbrella.

    In his 2007 book Imagining Transgender: An Ethnography of a Category, anthropologist David Valentine asserts that transgender was coined and used by activists to include many people who do not necessarily identify with the term and states that people who do not identify with the term transgender should not be included in the transgender spectrum. Leslie Feinberg likewise asserts that transgender is not a self-identifier (for some people) but a category imposed by observers to understand other people. According to the Transgender Health Program (THP) at Fenway Health in Boston, there are no universally-accepted definitions, and confusion is common because terms that were popular at the turn of the 21st century may have since been deemed offensive. The THP recommends that clinicians ask clients what terminology they prefer, and avoid the term transsexual unless they are sure that a client is comfortable with it.

    Harry Benjamin invented a classification system for transsexuals and transvestites, called the Sex Orientation Scale (SOS), in which he assigned transsexuals and transvestites to one of six categories based on their reasons for cross-dressing and the relative urgency of their need (if any) for sex reassignment surgery. Contemporary views on gender identity and classification differ markedly from Harry Benjamin's original opinions. Sexual orientation is no longer regarded as a criterion for diagnosis, or for distinction between transsexuality, transvestism and other forms of gender-variant behavior and expression. Benjamin's scale was designed for use with heterosexual trans women, and trans men's identities do not align with its categories.

    Other terms

    • Transfeminine is a term for any person, binary or non-binary, who was assigned male at birth and has a predominantly feminine gender identity or presentation. Transmasculine refers to a person, binary or non-binary, who was assigned female at birth who has a predominantly masculine gender identity or presentation.
    • Transgendered is a common term in older literature. Many within the transgender community deprecate it on the basis that transgender is an adjective, not a verb. Organizations such as GLAAD and The Guardian also state that transgender should never be used as a noun in English (e.g., "Max is transgender" or "Max is a transgender man", not "Max is a transgender"). "Transgender" is also a noun for the broader topic of transgender identity and experience.
    • Assigned Female At Birth (AFAB), Assigned Male At Birth (AMAB), Designated Female At Birth (DFAB), and Designated Male At Birth (DMAB) are terms used to represent a person's sex assigned at birth; they are considered to be more gender-inclusive than the related terms biological male or biological female.
    • The term trans* (with an asterisk) emerged in the 1990s as an inclusive term used to encompass a wide range of non-cisgender identities. The asterisk represents a wildcard, indicating the inclusion of various identities, beyond just transgender and transsexual, such as gender-fluid or agender, within the transgender umbrella. The use of the asterisk in "trans*" has been debated; some argue that it adds unnecessary complexity, while others say that it enhances inclusivity by explicitly recognizing non-normative gender identities.

    Shift in use of terms

    Between the mid-1990s and the early 2000s, the primary terms used under the transgender umbrella were "female to male" (FtM) for men who transitioned from female to male, and "male to female" (MtF) for women who transitioned from male to female. These terms have been superseded by "trans man" and "trans woman", respectively. This shift in preference from terms highlighting biological sex ("transsexual", "FtM") to terms highlighting gender identity and expression ("transgender", "trans man") reflects a broader shift in the understanding of transgender people's sense of self and the increasing recognition of those who decline medical reassignment as part of the transgender community.

    In place of transgenderism, terms such as transness, transgenderness, or transidentity, have been suggested, corresponding to their cisgender counterparts, such as cisness, cisgenderness and cisidentity.

    Sexual orientation

    Gender, gender identity, and being transgender are distinct concepts from sexual orientation. Sexual orientation is an individual's enduring pattern of attraction, or lack thereof, to others (being straight, lesbian, gay, bisexual, asexual, etc.), whereas gender identity is a person's innate knowledge of their own gender (being a man, woman, non-binary, etc.). Transgender people can have any orientation, and generally use labels corresponding to their gender, rather than assigned sex at birth. For example, trans women who are exclusively attracted to other women commonly identify as lesbians, and trans men exclusively attracted to women would identify as straight. Many trans people describe their sexual orientation as queer, in addition to or instead of, other terms.

    For much of the 20th century, transgender identity was conflated with homosexuality and transvestism. In earlier academic literature, sexologists used the labels homosexual and heterosexual transsexual to categorize transgender individuals' sexual orientation based on their birth sex. Critics consider these terms "heterosexist", "archaic", and demeaning. Newer literature often uses terms such as attracted to men (androphilic), attracted to women (gynephilic), attracted to both (bisexual), or attracted to neither (asexual) to describe a person's sexual orientation without reference to their gender identity. Therapists are coming to understand the necessity of using terms with respect to their clients' gender identities and preferences.

    The 2015 U.S. Transgender Survey reported that of the 27,715 transgender and non-binary respondents, 21% said queer best described their sexual orientation, 18% said pansexual, 16% said gay, lesbian, or same-gender-loving, 15% said straight, 14% said bisexual, and 10% said asexual. A 2019 Canadian survey of 2,873 trans and non-binary people found that 51% described their sexual orientation as queer, 13% as asexual, 28% as bisexual, 13% as gay, 15% as lesbian, 31% as pansexual, 8% as straight or heterosexual, 4% as two-spirit, and 9% as unsure or questioning. A 2009 study in Spain found that 90% of trans women patients reported being androphilic and 94% of trans men patients reported being gynephilic.

    Non-binary identity

    Some non-binary (or genderqueer) people identify as transgender. These identities are not specifically male or female. They can be agender, androgynous, bigender, pangender, or genderfluid, and exist outside of cisnormativity. Bigender and androgynous are overlapping categories; bigender individuals may identify as moving between male and female roles (genderfluid) or as being both masculine and feminine simultaneously (androgynous), and androgynes may similarly identify as beyond gender or genderless (agender), between genders (intergender), moving across genders (genderfluid), or simultaneously exhibiting multiple genders (pangender). Non-binary gender identities are independent of sexual orientation.

    Transvestism and cross-dressing

    A transvestite is a person who cross-dresses, or dresses in clothes typically associated with the gender opposite the one they were assigned at birth. The term transvestite is used as a synonym for the term cross-dresser, although cross-dresser is generally considered the preferred term. The term cross-dresser is not exactly defined in the relevant literature. Michael A. Gilbert, professor at the Department of Philosophy, York University, Toronto, offers this definition: "[A cross-dresser] is a person who has an apparent gender identification with one sex, and who has and certainly has been birth-designated as belonging to [that] sex, but who wears the clothing of the opposite sex because it is that of the opposite sex." This definition excludes people "who wear opposite sex clothing for other reasons", such as "those female impersonators who look upon dressing as solely connected to their livelihood, actors undertaking roles, individual males and females enjoying a masquerade, and so on. These individuals are cross dressing but are not cross dressers." Cross-dressers may not identify with, want to be, or adopt the behaviors or practices of the opposite gender and generally do not want to change their bodies medically or surgically. The majority of cross-dressers identify as heterosexual.

    The term transvestite and the associated outdated term transvestism are conceptually different from the term transvestic fetishism, as transvestic fetishist refers to those who intermittently use clothing of the opposite gender for fetishistic purposes. In medical terms, transvestic fetishism is differentiated from cross-dressing by use of the separate codes 302.3 in the Diagnostic and Statistical Manual of Mental Disorders (DSM) and F65.1 in the ICD.

    Drag

    A drag queen performer. Drag performers are not inherently transgender.

    Drag is clothing and makeup worn on special occasions for performing or entertaining, unlike those who are transgender or who cross-dress for other reasons. Drag performance includes overall presentation and behavior in addition to clothing and makeup. Drag can be theatrical, comedic, or grotesque. Drag queens have been considered caricatures of women by second-wave feminism. Drag artists have a long tradition in LGBTQ culture.

    Generally the term drag queen covers men doing female drag, drag king covers women doing male drag, and faux queen covers women doing female drag. Nevertheless, there are drag artists of all genders and sexualities who perform for various reasons. Drag performers are not inherently transgender. Some drag performers, transvestites, and people in the gay community have embraced the pornographically derived term tranny for drag queens or people who engage in transvestism or cross-dressing; this term is widely considered an offensive slur if applied to transgender people.

    History

    A precise history of the global occurrence of transgender people is difficult to assess because the modern concept of being transgender, and of gender in general in relation to transgender identity, did not develop until the mid-1900s. Historical depictions, records and understandings are inherently filtered through modern principles, and were largely viewed through a medical and (often outsider) anthropological lens until the late 1900s.

    Some historians consider the Roman emperor Elagabalus to have been transgender. Elagabalus was reported to have dressed in a feminine manner, preferred to be called "Lady" instead of "Lord" and may have even sought a primitive form of gender-affirming surgery.

    Worldwide, a number of societies have had traditional third gender roles, some of which continue in some form into the present day. The Hippocratic Corpus (interpreting the writing of Herodotus) describes the "disease of the Scythians" (regarding the Enaree), which it attributes to impotency due to riding on a horse without stirrups. This reference was well discussed by medical writings of the 1500s–1700s. Pierre Petit writing in 1596 viewed the "Scythian disease" as natural variation, but by the 1700s writers viewed it as a "melancholy", or "hysterical" psychiatric disease. By the early 1800s, being transgender separate from Hippocrates' idea of it was claimed to be widely known, but remained poorly documented. Both trans women and trans men were cited in European insane asylums of the early 1800s. One of the earliest recorded gender nonconforming people in America was Thomas(ine) Hall, a seventeenth century colonial servant. The most complete account of the time came from the life of the Chevalier d'Éon (1728–1810), a French diplomat. As cross-dressing became more widespread in the late 1800s, discussion of transgender people increased greatly and writers attempted to explain the origins of being transgender. Much study came out of Germany, and was exported to other Western audiences. Cross-dressing was seen in a pragmatic light until the late 1800s; it had previously served a satirical or disguising purpose. But in the latter half of the 1800s, cross-dressing and being transgender became viewed as an increasing societal danger.

    William A. Hammond wrote an 1882 account of transgender Pueblo "shamans" [sic] (mujerados), comparing them to the Scythian disease. Other writers of the late 1700s and 1800s (including Hammond's associates in the American Neurological Association) had noted the widespread nature of transgender cultural practices among native peoples. Explanations varied, but authors generally did not ascribe native transgender practices to psychiatric causes, instead condemning the practices in a religious and moral sense. Native groups provided much study on the subject, and perhaps the majority of all study until after WWII.

    Critical studies first began to emerge in the late 1800s in Germany, with the works of Magnus Hirschfeld. Hirschfeld coined the term "Transvestit" in 1910, borrowed from 19th-century French word travesti with the same meaning, as the scope of transgender study grew, and it was translated to English as "transvestite". His work would lead to the 1919 founding of the Institut für Sexualwissenschaft in Berlin. Though Hirscheld's legacy is disputed, he revolutionized the field of study. The Institut was destroyed when the Nazis seized power in 1933, and its research was infamously burned in the May 1933 Nazi book burnings. Transgender issues went largely out of the public eye until after World War II. Even when they re-emerged, they reflected a forensic psychology approach, unlike the more sexological that had been employed in the lost German research.

    Healthcare

    1879 photograph of Edward de Lacy Evans, upon his admittance into Kew Lunatic Asylum. Evans identified as a man for the majority of his life, later becoming known in Melbourne as the "Wonderful Male Impersonator".

    Mental healthcare

    People who experience discord between their gender and the expectations of others or whose gender identity conflicts with their body may benefit by talking through their feelings in depth. While individuals may find counseling or psychotherapy helpful, it is no longer recommended as a prerequisite for further transition steps. Research on gender identity with regard to psychology, and scientific understanding of the phenomenon and its related issues, is relatively new. The term gender incongruence is listed in the ICD by the WHO. In the American (DSM), the term gender dysphoria is listed under code F64.0 for adolescents and adults, and F64.2 for children. (Further information: Causes of gender incongruence.)

    France removed gender identity disorder as a diagnosis by decree in 2010, but according to French trans rights organizations, beyond the impact of the announcement itself, nothing changed. In 2017, the Danish parliament abolished the F64 Gender identity disorders. The DSM-5 refers to the topic as gender dysphoria (GD) while reinforcing the idea that being transgender is not considered a mental illness.

    Transgender people may meet the criteria for a diagnosis of gender dysphoria "only if [being transgender] causes distress or disability." This distress may manifest as depression or inability to work and form healthy relationships with others. This diagnosis is often misinterpreted as implying that all transgender people suffer from GD, which has confused transgender people and those who seek to either criticize or affirm them. Transgender people who are comfortable with their gender and whose gender is not directly causing inner frustration or impairing their functioning do not suffer from GD. Moreover, GD is not necessarily permanent and is often resolved through therapy or transitioning. Feeling oppressed by the negative attitudes and behaviours of such others as legal entities does not indicate GD. GD does not imply an opinion of immorality; the psychological establishment holds that people with any kind of mental or emotional problem should not receive stigma. The solution for GD is whatever will alleviate suffering and restore functionality; this solution often, but not always, consists of undergoing a gender transition.

    Clinical training lacks relevant information needed in order to adequately help transgender clients, which results in a large number of practitioners who are not prepared to sufficiently work with this population of individuals. Many mental healthcare providers know little about transgender issues. Those who seek help from these professionals often educate the professional without receiving help. This solution usually is good for transsexual people but is not the solution for other transgender people, particularly non-binary people who lack an exclusively male or female identity. Instead, therapists can support their clients in whatever steps they choose to take to transition or can support their decision not to transition while also addressing their clients' sense of congruence between gender identity and appearance.

    Research on the specific problems faced by the transgender community in mental health has focused on diagnosis and clinicians' experiences instead of transgender clients' experiences. Therapy was not always sought by transgender people due to mental health needs. Prior to the seventh version of the Standards of Care (SOC), an individual had to be diagnosed with gender identity disorder in order to proceed with hormone treatments or sexual reassignment surgery. The new version decreased the focus on diagnosis and instead emphasized the importance of flexibility in order to meet the diverse health care needs of transsexual, transgender, and all gender-nonconforming people.

    The reasons for seeking mental health services vary according to the individual. A transgender person seeking treatment does not necessarily mean their gender identity is problematic. The emotional strain of dealing with stigma and experiencing transphobia pushes many transgender people to seek treatment to improve their quality of life. As one trans woman reflected, "Transgendered individuals are going to come to a therapist and most of their issues have nothing to do, specifically, with being transgendered. It has to do because they've had to hide, they've had to lie, and they've felt all of this guilt and shame, unfortunately usually for years!" Many transgender people also seek mental health treatment for depression and anxiety caused by the stigma attached to being transgender, and some transgender people have stressed the importance of acknowledging their gender identity with a therapist in order to discuss other quality-of-life issues. Rarely, some choose to detransition.

    Problems still remain surrounding misinformation about transgender issues that hurt transgender people's mental health experiences. One trans man who was enrolled as a student in a psychology graduate program highlighted the main concerns with modern clinical training: "Most people probably are familiar with the term transgender, but maybe that's it. I don't think I've had any formal training just going through [clinical] programs ... I don't think most [therapists] know. Most therapists – Master's degree, PhD level – they've had ... one diversity class on GLBT issues. One class out of the huge diversity training. One class. And it was probably mostly about gay lifestyle." Many health insurance policies do not cover treatment associated with gender transition, and numerous people are under- or uninsured, which raises concerns about the insufficient training most therapists receive prior to working with transgender clients, potentially increasing financial strain on clients without providing the treatment they need. Many clinicians who work with transgender clients only receive mediocre training on gender identity, but introductory training on interacting with transgender people has recently been made available to health care professionals to help remove barriers and increase the level of service for the transgender population. In May 2009, France became the first country in the world to remove transgender identity from the list of mental diseases.

    A 2014 study carried out by the Williams Institute (a UCLA think tank) found that 41% of transgender people had attempted suicide, with the rate being higher among people who experienced discrimination in access to housing or healthcare, harassment, physical or sexual assault, or rejection by family. A 2019 follow-up study found that transgender people who wanted and received gender-affirming medical care had significantly lower rates of suicidal thoughts and attempts. Another study on the impact of parental support on trans youth found that among trans children with supportive parents, only 4% attempted suicide, a 93% decrease.

    Suicidal thoughts and attempts by gender affirmation milestones
    Intervention Category Suicidal Thoughts (Past 12 Months) Suicidal Attempts (Past 12 Months) Lifetime Suicidal Thoughts Lifetime Suicidal Attempts
    Want hormones and have not had them 57.9 8.9 84.4 41.1
    Want hormones and have had them 42.9 6.5 81.9 42.4
    Want reassignment surgery, have not had 54.8 8.5 83.9 41.5
    Want reassignment surgery, have had 38.2 5.1 79.0 39.5
    Have not "de-transitioned" 44.2 6.7 81.6 41.8
    Have "de-transitioned" 57.3 11.8 86.0 52.5

    Autism is more common in people who are gender dysphoric. It is not known whether there is a biological basis. This may be due to the fact that people on the autism spectrum are less concerned with societal disapproval, and feel less fear or inhibition about coming out as trans than others.

    Physical healthcare

    Medical and surgical procedures exist for transsexual and some transgender people, though most categories of transgender people as described above are not known for seeking the following treatments. Hormone replacement therapy for trans men induces beard growth and masculinizes skin, hair, voice, and fat distribution. Hormone replacement therapy for trans women feminizes fat distribution and breasts, as well as diminishes muscle mass and strength. Laser hair removal or electrolysis removes excess hair for trans women. Surgical procedures for trans women feminize the voice, skin, face, Adam's apple, breasts, waist, buttocks, and genitals. Surgical procedures for trans men masculinize the chest and genitals and remove the womb, ovaries, and fallopian tubes. The acronyms "Gender-affirming surgery (GAS)" and "sex reassignment surgery" (SRS) refer to genital surgery. The term "sex reassignment therapy" (SRT) is used as an umbrella term for physical procedures required for transition. Use of the term "sex change" has been criticized for its emphasis on surgery, and the term "transition" is preferred. Availability of these procedures depends on degree of gender dysphoria, presence or absence of gender identity disorder, and standards of care in the relevant jurisdiction.

    Health risks among transgender people largely align with those of cisgender people with the same hormonal makeup, and the same routine cancer screenings are generally recommended as for cisgender people with the same organs. It has been suggested that trans men who have not had a hysterectomy and who take testosterone may be at increased risk for endometrial cancer due to the presence of external estrogen, but this theoretical risk has not been proven in a clinical setting, and providers do not recommend any additional preventive measures or routine screening.

    Detransition

    Detransition refers to the cessation or reversal of a sex reassignment surgery or gender transition. Formal studies of detransition have been few in number, of disputed quality, and politically controversial. Estimates of the rate at which detransitioning occurs vary from less than 1% to as high as 13%. Those who undergo sex reassignment surgery have very low rates of detransition or regret.

    The 2015 U.S. Transgender Survey, with responses from 27,715 individuals who identified as "transgender, trans, genderqueer, [or] non-binary", found that 8% of respondents reported some kind of detransition. "Most of those who de-transitioned did so only temporarily: 62% of those who had de-transitioned reported that they were currently living full time in a gender different than the gender they were thought to be at birth." Detransition was associated with assigned male sex at birth, nonbinary gender identity, and bisexual orientation, among other cohorts. Only 5% of detransitioners (or 0.4% of total respondents) reported doing so because gender transition was "not for them"; 82% cited external reason(s), including pressure from others, the difficulties of transition, and discrimination. "The most common reason cited for de-transitioning was pressure from a parent (36%)."

    Legality

    Camille Cabral, a French transgender activist at a demonstration for transgender people in Paris, October 1, 2005

    Legal procedures exist in some jurisdictions which allow individuals to change their legal gender or name to reflect their gender identity. Requirements for these procedures vary from an explicit formal diagnosis of transsexualism, to a diagnosis of gender identity disorder, to a letter from a physician that attests the individual's gender transition or having established a different gender role. In 1994, the DSM IV entry was changed from "Transsexual" to "Gender Identity Disorder". In 2013, the DSM V removed "Gender Identity Disorder" and published "Gender Dysphoria" in its place. In many places, transgender people are not legally protected from discrimination in the workplace or in public accommodations. A report released in February 2011 found that 90% of transgender Americans faced discrimination at work and were unemployed at double the rate of the general population, and over half had been harassed or turned away when attempting to access public services. Members of the transgender community also encounter high levels of discrimination in health care.

    Europe

    As of 2017, 36 countries in Europe require a mental health diagnosis for legal gender recognition and 20 countries require sterilisation. In April 2017, the European Court of Human Rights ruled that requiring sterilisation for legal gender recognition violates human rights.

    Canada

    Jurisdiction over legal classification of sex in Canada is assigned to the provinces and territories. This includes legal change of gender classification. On June 19, 2017, Bill C-16, having passed the legislative process in the House of Commons of Canada and the Senate of Canada, became law upon receiving Royal Assent, which put it into immediate force. The law updated the Canadian Human Rights Act and the Criminal Code to include "gender identity and gender expression" as protected grounds from discrimination, hate publications and advocating transgender genocide. The bill also added "gender identity and expression" to the list of aggravating factors in sentencing, where the accused commits a criminal offence against an individual because of those personal characteristics. Similar transgender laws also exist in all the provinces and territories.

    United States

    In the United States, transgender people are protected from employment discrimination by Title VII of the Civil Rights Act of 1964. Exceptions apply to certain types of employers, for example, employers with fewer than 15 employees and religious organizations. In 2020, the U.S. Supreme Court affirmed that Title VII prohibits discrimination against transgender people in the case R.G. & G.R. Harris Funeral Homes Inc. v. Equal Employment Opportunity Commission.

    Nicole Maines, a trans girl, took a case to Maine's supreme court in June 2013. She argued that being denied access to her high school's women's restroom was a violation of Maine's Human Rights Act; one state judge has disagreed with her, but Maines won her lawsuit against the Orono school district in January 2014 before the Maine Supreme Judicial Court. On May 14, 2016, the United States Department of Education and Department of Justice issued guidance directing public schools to allow transgender students to use bathrooms that match their gender identities.

    On June 30, 2016, the United States Department of Defense removed the ban that prohibited transgender people from openly serving in the US military. On July 27, 2017, President Donald Trump tweeted that transgender Americans would not be allowed to serve "in any capacity" in the United States Armed Forces. Later that day, Joint Chiefs of Staff Chairman Joseph Dunford announced, "there will be no modifications to the current policy until the president's direction has been received by the Secretary of Defense and the secretary has issued implementation guidance." Joe Biden later reversed Trump's policy when he became president in 2021.

    While the topic of trans rights in the United States has often been contentious, it has become a deeply partisan wedge issue in recent years; many pieces of legislation have been passed, and more proposed, that seek to limit the rights of transgender individuals, especially minors.

    India

    Jogappa is a transgender community in Karnataka and Andhra Pradesh. They are traditional folk singers and dancers.

    In April 2014, the Supreme Court of India declared transgender to be a 'third gender' in Indian law. The transgender community in India (made up of Hijras and others) has a long history in India and in Hindu mythology. Justice KS Radhakrishnan noted in his decision that, "Seldom, our society realizes or cares to realize the trauma, agony and pain which the members of Transgender community undergo, nor appreciates the innate feelings of the members of the Transgender community, especially of those whose mind and body disown their biological sex". Hijras have faced structural discrimination including not being able to obtain driving licenses, and being prohibited from accessing various social benefits. It is also common for them to be banished from communities.

    Sociocultural relationships

    LGBTQ community

    Despite the distinction between sexual orientation and gender, throughout history gay, lesbian and bisexual subcultures were often the only places where gender-variant people were socially accepted in the gender role they felt they belonged to; especially during the time when legal or medical transitioning was almost impossible. This acceptance has had a complex history. Like the wider world, the gay community in Western societies did not generally distinguish between sex and gender identity until the 1970s, and the role of the transgender community in the history of LGBT rights is often overlooked.

    Transgender individuals have been part of various LGBTQ movements throughout history, with significant contributions dating back to the early days of the gay liberation movement.

    The LGBTQ community is not a monolithic group, and there are different modes of thought on who is a part of this diverse community. The changes that came with the Gay Liberation Movement and Civil Rights movement saw many gay, lesbian, and bisexual people making headway within the public sphere, and gaining support from the wider public, throughout the latter half of the twentieth century. The trans community only experienced a similar surge in activism during the start of the twenty-first century. Due to the many different groups that make up the broader LGBTQ movement, there are those within the larger community who do not believe that the trans community has a place within the LGBTQ space.

    Religion

    Feminism

    Feminist views on transgender women have changed over time, but have generally become more positive. Second-wave feminism saw numerous clashes opposed to transgender women, since they were not seen as "true" women, and as invading women-only spaces. Though second-wave feminism argued for the sex and gender distinction, some feminists believed there was a conflict between transgender identity and the feminist cause; e.g., they believed that male-to-female transition abandoned or devalued female identity and that transgender people embraced traditional gender roles and stereotypes. By the emergence of third-wave feminism (around 1990), opinions had shifted to being more inclusive of both trans and gay identities. Fourth-wave feminism (starting around 2012) has been widely trans-inclusive, but trans-exclusive groups and ideas remain as a minority, though one that is especially prominent in the UK. Feminists who do not accept that trans women are women have been labeled "trans-exclusionary radical feminists" (TERFs) or gender-critical feminists by opponents.

    Discrimination and support

    Transgender individuals experience significant rates of employment discrimination. According to a 2011 aggregation of several studies, approximately 90% of transgender Americans had encountered some form of harassment or mistreatment in their workplace. 47% had experienced some form of adverse employment outcome due to being transgender; of this figure, 44% were passed over for a job, 23% were denied a promotion, and 26% were terminated on the grounds that they were transgender.

    Studies in several cultures have found that cisgender women are more likely to be accepting of trans people than cisgender men.

    The start of the twenty-first century saw the rise in transgender activism and with it an increase in support. Within the United States, groups such as the Trevor Project have been serving the wider LGBT community including people who identify with the term transgender. The group offers support in the form of educational resources including research, advocacy, and crisis services. The American Civil Liberties Unions (ACLU) also often represents members of the trans community.

    Other groups within the United States specifically advocate for transgender rights. One of these groups directly related to transgender support is the National Center for Transgender Equality (NCTE), which is committed to advocating for policy changes that protect transgender people and promote equality. Through their research, education, and advocacy efforts, the NCTE works to address issues such as healthcare access, employment discrimination, and legal recognition for transgender individuals. One prominent organization within Europe is Transgender Europe (TGEU), a network of organizations and individuals committed to promoting equality and human rights for transgender people within European borders. TGEU works to challenge discrimination, improve transgender healthcare access, advocate for legal recognition of gender identity, and support the well-being of transgender communities.

    Population figures and prevalence

    Little is known about the prevalence of transgender people in the general population and reported prevalence estimates are greatly affected by variable definitions of transgender. According to a recent systematic review, an estimated 9.2 out of every 100,000 people have received or requested gender affirmation surgery or transgender hormone therapy; 6.8 out of every 100,000 people have received a transgender-specific diagnoses; and 355 out of every 100,000 people self-identify as transgender. These findings underscore the value of using consistent terminology related to studying the experience of transgender, as studies that explore surgical or hormonal gender affirmation therapy may or may not be connected with others that follow a diagnosis of "transsexualism", "gender identity disorder", or "gender dysphoria", none of which may relate with those that assess self-reported identity. Common terminology across studies does not yet exist, so population numbers may be inconsistent, depending on how they are being counted.

    A study in 2020 found that, since 1990, of those seeking sex hormone therapy for gender dysphoria there has been a steady increase in the percentage of trans men, such that they equal the number of trans women seeking this treatment.

    Asia

    Nong Tum, a Kathoey internationally recognized for her portrayal in the film Beautiful Boxer

    In Thailand and Laos, the term kathoey is used to refer to male-to-female transgender people and effeminate gay men. However, many transgender people in Thailand do not identify as kathoey. Transgender people have also been documented in Iran, Japan, Nepal, Indonesia, Vietnam, South Korea, Jordan, Singapore, and the greater Chinese region, including Hong Kong, Taiwan, and the People's Republic of China.

    The cultures of the Indian subcontinent include a third gender, referred to as hijra in Hindi. In India, the Supreme Court on April 15, 2014, recognized a third gender that is neither male nor female, stating "Recognition of transgenders as a third gender is not a social or medical issue but a human rights issue." In 1998, Shabnam Mausi became the first transgender person to be elected in India, in the central Indian state of Madhya Pradesh.

    Europe

    According to Amnesty International, 1.5 million transgender people lived in the European Union as of 2017, making up 0.3% of the population. A 2011 survey conducted by the Equality and Human Rights Commission in the UK found that of 10,026 respondents, 1.4% would be classified into a gender minority group. The survey also showed that 1% had gone through any part of a gender reassignment process (including thoughts or actions).

    North America

    The 2021 Canadian census released by Statistics Canada found that 59,460 Canadians (0.19% of the population) identified as transgender. According to the Survey of Safety in Public and Private Spaces by Statistics Canada in 2018, 0.24% of the Canadian population identified as transgender men, women or non-binary individuals.

    In the United States, over 1.6 million persons (ages 13 and up) identify as transgender, or 0.6 percent of people ages 13+, as of 2022. It's the case for 0.5% of adults (about 1.3 million persons) and 1.4% of youth (about 300,000 persons aged 13 to 17). Among adults, 38.5% (515,200) are transgender women, 35.9% (480,000) transgender men, and 25.6% (341,800) gender nonconforming. The Social Security Administration has tracked the sex of US citizens since 1936. A 1968 estimate, by Ira B. Pauly, estimated that about 2,500 transsexual people were living in the United States, with four times as many trans women as trans men. One effort to quantify the modern population in 2011 gave a "rough estimate" that 0.3% of adults in the US are transgender. In 2016, studies estimated the proportion of Americans who identify as transgender at 0.5 to 0.6%.

    In the United States and Canada, some Native American and First Nations cultures traditionally recognize the existence of more than two genders, such as the Zuni male-bodied lhamana, the Lakota male-bodied winkte, and the Mohave male-bodied alyhaa and female-bodied hwamee. These traditional people, along with those from other North American Indigenous cultures, are sometimes part of the contemporary, pan-Indian two-spirit community. Historically, in most cultures who have alternate gender roles, if the spouse of a third gender person is not otherwise gender variant, they have not generally been regarded as other-gendered themselves, simply for being in a same-sex relationship. In Mexico, the Zapotec culture includes a third gender in the form of the Muxe. Mahu is a traditional third gender in Hawai'i and Tahiti. Mahu are valued as teachers, caretakers of culture, and healers, such as Kapaemahu. Diné (Navajo) have Nádleehi.

    Latin America

    In Latin American cultures, a travesti is an individual who has been assigned male at birth and who has a feminine, transfeminine, or "femme" gender identity. Travestis generally undergo hormonal treatment, use female gender expression including new names and pronouns from the masculine ones they were given when assigned a sex, and might use breast implants, but they are not offered or do not desire sex-reassignment surgery. Travesti might be regarded as a gender in itself (a "third gender"), a mix between man and woman ("intergender/androgynes"), or the presence of both masculine and feminine identities in a single person ("bigender"); they are framed as something entirely separate from transgender women.

    Other transgender identities are becoming more widely known, as a result of contact with other cultures of the Western world. These newer identities, sometimes known under the umbrella use of the term "genderqueer", along with the older travesti term, are known as non-binary and go along with binary transgender identities (those traditionally diagnosed under the obsolete label of "transsexualism") under the single umbrella of transgender, but are distinguished from cross-dressers and drag queens and kings, that are held as nonconforming gender expressions rather than transgender gender identities when a distinction is made.

    Oceania

    On the 2023 New Zealand Census, 26,097 people self-identified as transgender, defined by Stats NZ as someone whose gender identity does not match their sex recorded at birth. This is 0.7 percent of all census-takers who were 15 years of age and older and usually residents of the country.

    Culture

    Coming out

    Coming out is the process of sharing one's identity with others, and can include sharing new pronouns and a new name. Individuals who have come out are known as out. The experience of coming out can change depending on whether the transgender individual is perceived as the gender with which they identify, which is known as passing. In certain environments, some passing transgender individuals can choose to be stealth, which means to deliberately avoid coming out, often to avoid transphobia; these individuals are often out in other environments. The decision for transgender people to come out to current or potential romantic or sexual partners can be especially difficult.

    The decision to come out is based on navigating others' gender expectations, reactions, and the threat of violence. Coming out is not a 'one-and-done' decision; rather, individuals make ongoing strategic decisions about their gender enactment and identity disclosure based on social contexts.

    The age at which transgender people come out can vary; some transgender individuals will know about and share their identities at a young age, while for others, the process is longer or more complicated. Different transgender individuals choose to come out at different times during the transition process and to different people. Some transgender individuals will choose to come out as bisexual, lesbian, or gay before recognizing their gender identity or choosing to come out as transgender. Although there are some similarities, coming out as transgender is different than coming out as a sexual minority, such as lesbian, gay, or bisexual. This is partly due to the relatively lower level of information that people have about transgender people compared to people who are sexual minorities. Some come out in an online identity first, providing an opportunity to go through experiences virtually and safely before risking social implications in the real world.

    It may take time for people to understand and respond when a transgender person comes out. Most transgender people feel healthier and happier when they come out and their gender identity is validated by others.

    Some transgender people choose not to come out at all. For some, this decision can be because of stigma, lack of knowledge (by whom?) or fear of rejection by friends and family. Upon coming out, transgender people can face discrimination, rejection, and violence. These risks are heightened when transgender individuals are members of other marginalized communities.

    Visibility

    Actress Laverne Cox, who is trans, in July 2014
    Trans March "Existrans" 2017

    In 2014, the United States reached a "transgender tipping point", according to Time. At this time, the media visibility of transgender people reached a level higher than seen before. Since then, the number of transgender portrayals across TV platforms has stayed elevated.

    Annual marches, protests or gatherings take place around the world for transgender issues, often taking place during the time of local Pride parades for LGBT people. These events are frequently organised by trans communities to build community, address human rights struggles, and create visibility. International Transgender Day of Visibility is an annual holiday occurring on March 31 dedicated to celebrating transgender people and raising awareness of discrimination faced by transgender people worldwide. The holiday was founded by Michigan-based transgender activist Rachel Crandall Crocker in 2009.

    Transgender Day of Remembrance (TDOR) is held every year on November 20 in honor of Rita Hester, who was killed on November 28, 1998. Her murder remains unsolved, but was described in 2022 as "a result of transphobia and anti-trans violence" by the Office of the Mayor of Boston, Michelle Wu. TDOR memorializes victims of hate crimes and prejudice and raises awareness of hate crimes committed upon living transgender people. Transgender Awareness Week is a one-week celebration leading up to TDOR, dedicated to educating about transgender and gender non-conforming people and the issues associated with their transition or identity. Several trans marches occur in cities around the world, including Paris, San Francisco, and Toronto, in order to raise awareness of the transgender community.

    There are also significant portrayals of transgender people in the media. Transgender literature includes literature portraying transgender people, as well as memoirs or novels by transgender people, who often discuss elements of the transgender experience. Several films and television shows feature transgender characters in the storyline, and several fictional works also have notable transgender characters.

    A pedestrian traffic light in Trafalgar Square, London with the ⚧ symbol, installed for the 2016 Pride in London

    Pride symbols

    A common symbol for the transgender community is the Transgender Pride Flag, which was designed by the American transgender woman Monica Helms in 1999, and was first shown at a pride parade in Phoenix, Arizona, in 2000. The flag consists of five horizontal stripes: light blue, pink, white, pink, and light blue. Other transgender symbols include the butterfly (symbolizing transformation or metamorphosis) and a pink/light blue yin and yang symbol. Several gender symbols have been used to represent transgender people, including ⚥ and .

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