queer—a rejection of the traditional binary classification of gender). Gender identity can be congruent or incongruent with one’s sex assigned at birth based on the appearance of the external genitalia. Gender expression denotes the manifestation of characteristics in one’s personality, appearance, and behavior that are culturally defined as masculine or feminine. Gender role conformity refers to the extent to which an individual’s gender expression adheres to the cultural norms prescribed for people of his or her sex.

Gender dysphoria refers to a discomfort with one’s sex assigned at birth (Fisk, 1974). This dysphoria can manifest itself in a persistent unease with one’s primary and secondary sex characteristics, a sense of inappropriateness in one’s gender role, and a strong and persistent identification with and desire to live in the role of the other sex, which has been classified as gender identity disorder in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) (American Psychiatric Association, 2000).

The term transgender has come to be widely used to refer to a diverse group of individuals who cross or transcend culturally defined categories of gender (Bockting, 1999); that is, they depart significantly from traditional gender norms. This group includes transsexuals (who desire or have had hormone therapy and/or surgery to feminize or masculinize their body and may live full time in the cross-gender role); cross-dressers or transvestites (who wear clothes and adopt a presentation associated with the other gender for emotional or sexual gratification, and may live part time in the cross-gender role); transgenderists (who live full time in the cross-gender role, may take hormones, but do not desire surgery); bigender persons (who identify as both man and woman, may take hormones, and may live part time in the cross-gender role); drag queens and kings (who dress in clothes associated with the other gender, adopt a hyperfeminine or hypermasculine presentation, and appear part time in the cross-gender role); and other identities, such as gender queer or two-spirit—a term used by some Native Americans for individuals who possess feminine and masculine qualities (who may or may not desire hormones or surgery, and may or may not live part or full time in the cross-gender role). Definitions of these categories vary and continue to evolve over time. The term transgender is increasingly used to encompass this family of gender-variant identities and expressions, but opinions on the term vary by geographic region and by individual. For example, some transsexual women differentiate themselves from those who self-identify as transgender to underscore that they are not gender variant or nonconforming, but instead identify unambiguously with the other gender. As explained in the previous chapter, a person whose gender identity differs from a male sex assignment at birth is often referred to as a male-to-female transgender woman. A person whose gender identity differs from a female sex assignment at birth is often referred to as a female-to-male



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