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Transgender Health Expert Answers Your Common Questions

During Transgender Awareness Week, Nov. 13-19, Director of Cedars-Sinai’s Transgender Surgery and Health Program Shares the Top Questions He Receives

How does anyone know for sure that they were born the wrong gender? What should parents do when their child tells them? And how do transgender patients prepare for gender-affirming surgery, if that’s what they decide to do?

In recognition of Transgender Awareness Week, Nov. 13-19, 2023, the Cedars-Sinai Newsroom sat down with gender-affirming surgery pioneer Maurice Garcia, MD, director of the Cedars-Sinai Transgender Surgery and Health Program, to answer the questions he is asked most frequently about transgender health and medicine.

More than 1.7 million people in the United States identify as transgender—a gender that is different from their biological sex at birth—according to U.S. Census Bureau data from 2021.

Garcia, a reconstructive urologic surgeon and associate professor of Urology at Cedars-Sinai, has spent 20 years caring for transgender patients. He established the medical center’s Transgender Surgery and Health Program in 2017. He provides genital reconstructive surgery for transgender and cisgender women and men.

What services does Cedars-Sinai offer for transgender patients?

Cedars-Sinai offers comprehensive transgender medicine primary care, gender-affirming hormone management, HIV care, and gender-affirming surgery (facial, chest, genital). It is one of only four academic medical centers in the Western U.S. that offer male-to-female and female-to-male gender-affirming genital surgery, and we offer several other types of surgeries to meet the needs of our patients. Our specialists offer vocal cord and speech therapy, fertility preservation, and mental health and psychiatry services, as well as other support services. Our LGBTQ+ Center opened earlier this year and has specialists in primary care, pediatrics, transgender surgery, reconstructive surgery and cancer screening in an inclusive space. Everyone deserves to be treated with dignity and respect, especially at their doctor’s office.

How—and when—does a person know that they are transgender?

Being transgender occurs naturally. No one ever decides they are transgender—just as no person ever decides they are a boy or a girl. All people simply know what they are. Cisgender people’s gender typically aligns with the male or female sex of their body. Transgender people recognize that inside they feel, and know, they are a girl/woman, or a boy/man, and that their body does not align with or reflect this. Sex and gender are two very separate and different things. “Biological sex” is about the male or female features of the body, which are biological and can be seen, while “gender” is purely a sense of “self.” It cannot be seen or measured but can only be felt and expressed. With gender, no one really chooses their sexuality. For most, recognizing it is a normal part of growing up.

Gender is a spectrum and is diverse. That is, while most people’s gender is far to the man or woman end of the gender spectrum, a “nonbinary” person’s gender is somewhere between these two ends of the gender spectrum.

Children recognize their gender identity and know they are a boy or girl by age 2 or 3. In 2020, my group published a Cedars-Sinai study that found that gender dysphoria, or distress that a person experiences from living in a body that doesn’t align with their gender, can start as early as age 3.

A person undergoing gender transition is simply someone who has finally come out to themselves, and/or others, and wants to live their life as their true self.

What should the parents of transgender young people know?

Parental involvement and support of their transgender and gender-diverse children and teens is especially critical. Gender transition can be difficult and lonely without a supportive home and social environment. It is important that a parent listen to their child and make sure they know that they are loved and that the most important people in the world for them—their parent or parents—are there for them. Parents should consider reaching out to an expert who specializes in this area of counseling and support, to learn about how to be as helpful as possible for their child. Gender transition starts with understanding one’s true self, and then figuring out how to live life as their true self. Many children benefit from a short period of counseling. While puberty can be challenging for all young people, it can be especially challenging for transgender kids. Many age-appropriate treatment options exist and can be provided by primary care doctors and counselors. Cedars-Sinai’s Pediatric and Adolescent Gender Wellness Clinic treats patients and offers support resources for families. It is important to recognize that all people, regardless of age, begin to thrive once they start to live as themselves.  

How do patients know when they’re ready for surgery, and how do you, as their physician, know?

Every transgender person must decide if or when the time is right for them to take that step. It’s important that they first speak with a surgeon who can give them unbiased and accurate information. A good surgeon will walk the person through all options, explain the risks and benefits and discuss realistic timelines for recovery. I always say to colleagues that patients don’t know what they don’t know about surgery, and we doctors don’t know what we don’t know about the patient’s priorities about surgery. Both take time and discussion. I approach discussion of surgery options assuming that my patients know nothing about surgery (though I know that most everyone has read a lot already), just so that I can be sure that I share with them as much information as I have. I also give my patients the option for me to audio-record our visit, and then I send them a copy of the recording by email before they’ve left my office, so that they have every single detail of the typically one-hour discussion session at their disposal to re-listen to whenever, and with whomever, they want. I always tell people, “The only right choice for surgery is for the specific surgery that you decide is the best option for you. So, I don’t want you to necessarily decide today. Sleep on this, then come back and see me again, and let’s talk more as you have more questions. There’s no rush.”

Read more on the Cedars-Sinai Blog: Gender Affirming Cancer Screening