Transgender
Transgender people have a gender identity or gender expression that differs from the sex that they were assigned at birth. Some transgender people who desire medical assistance to transition from one sex to another identify as transsexual. "Transgender", often shortened as "trans", is also an umbrella term; in addition to including people whose gender identity is the opposite of their assigned sex (trans men and trans women), it may also include people who are non-binary or genderqueer. Other definitions of "transgender" also include people who belong to a third gender, or else conceptualize transgender people as a third  gender. The term "transgender" may be defined very broadly to include cross-dressers. Being transgender is distinct from sexual orientation. 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. The degree to which individuals feel genuine, authentic, and comfortable within their external appearance and accept their genuine identity has been called "transgender congruence". Transgender people are known to have existed since ancient times. A wide range of societies had traditional  third gender roles, or otherwise accepted trans people in some form. However, a precise history is difficult because the modern concept of being transgender, and gender in general, did not develop until the mid-1900s. Historical understandings are thus inherently filtered through modern principles, and were largely viewed through a medical lens until the late 1900s. Ancient Greek Hippocrates (interpreting the writing of Herodotus) discusses transgender individuals briefly. He describes the "disease of the Scythians" (regarding the Enaree), which he attributes to impotency due to riding on a horse without stirrups. Hippocrates' reference was well discussed by medical writings of the  1500s1700s. 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 Hippocrate's idea of it was claimed to be widely known, but remained poorly documented. Both MtF and FtM individuals were cited in European insane asylums of the early 1800s. The most complete account of the time came from the life of the Chevalier d'Éon (17281810). 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 1800's, cross-dressing and being transgender became viewed as an increasing societal danger. William A. Hammond wrote an 1882 account of transgender Pueblo shamans ("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 "transvestite" in 1910 as the scope of transgender study grew. 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. LGBT community. The concepts of gender identity and transgender identity differ from that of sexual orientation. Sexual orientation is an individual's enduring physical, romantic, emotional, or spiritual  attraction to another person, while gender identity is one's personal sense of being a man or a woman. Transgender people have more or less the same variety of sexual orientations as cisgender people. In the past, the terms "homosexual" and "heterosexual" were incorrectly used to label transgender individuals' sexual orientation based on their birth sex. Professional 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. For example, a person who is assigned male at birth, transitions to female, and is attracted to men would be identified as heterosexual. Despite the distinction between sexual orientation and gender, throughout history the gay, lesbian, and bisexual subculture was often the only place 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 often perceived gender-variant people more as homosexuals who behaved in a gender-variant way than as gender-variant people in their own right. In addition, the role of the transgender community in the history of LGBT rights is often overlooked, as shown in Transforming History. Sexual orientation of transgender people. In 2015, the American National Center for Transgender Equality conducted a National Transgender Discrimination Survey. Of the 27,715 transgender and non-binary people who took the survey, 21% said the term "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". And a 2019 survey of trans and non-binary people in Canada called "Trans PULSE Canada" showed that out of 2,873 respondents, when it came to sexual orientation, 13% identified as asexual, 28% identified as bisexual, 13% identified as gay, 15% identified as lesbian, 31% identified as pansexual, 8% identified as straight or heterosexual, 4% identified as two-spirit, and 9% identified as unsure or questioning. Healthcare. Mental healthcare. Most mental health professionals recommend therapy for internal  conflicts about gender identity or discomfort in an assigned gender role, especially if one desires to transition. 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; however, research on gender identity with regard to psychology, and scientific understanding of the phenomenon and its related issues, is relatively new. The terms "transsexualism", "dual-role transvestism", "gender identity disorder in adolescents or adults," and "gender identity disorder not otherwise specified" are listed as such in the International Statistical Classification of Diseases (ICD ) by the WHO or the American "Diagnostic and Statistical Manual of Mental Disorders" (DSM) under codes F64.0, F64.1, 302.85, and 302.6 respectively. The validity of the diagnosis and its presence in the forthcoming ICD-11 is debated. 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 behaviors 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. Acknowledgment of the lack of clinical training has  increased; however, 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. Others regret having undergone the procedure and wish 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 therapistsMaster's degree, PhD levelthey'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 February 2010, 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 substantially lower rates of suicidal thoughts and attempts. 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. 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 "GRS" and "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. Trans men who have not had a hysterectomy and who take testosterone are at increased risk  for endometrial cancer because androstenedione, which is made from testosterone in the body, can be converted into estrogen, and external estrogen is a risk factor for endometrial cancer. Law. 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 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 people 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. 36 countries in Europe require a mental health diagnosis for legal gender recognition and 20 countries still require sterilisation. In April 2017 , the European Court of Human Rights ruled that requiring sterilisation for legal gender recognition violates human rights. Denmark. Since 2014 it has been possible for adults without the requirement of a psychiatric evaluation, medical or surgical treatment, divorce or castration, to after a six-month ‘reflection period' have their social security number changed and legally change gender. Germany. In November 2017, the Federal Constitutional Court ruled that the civil status law must allow a third gender option. Thus officially recognising "third sex" meaning that birth certificates will not have blank gender entries for intersex people. The ruling came after an  intersex person, who is neither a man nor woman according to chromosomal analysis, brought a legal challenge after attempting to change their registered sex to "inter" or "divers". 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 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. India. 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", adding: Hijras face 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. Religion. The Roman Catholic Church has been involved in the outreach to LGBT community for several years and continues doing so through Franciscan urban outreach centers, for example, the Open Hearts outreach in Hartford, Connecticut. The Vatican, however, holds that transgender people cannot become godparents and compares transitioning to self -harm. Feminism. Feminist views on transgender women have changed over time, but have generally become more inclusive. 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. Self-proclaimed feminists who do not accept trans individuals may be labeled "trans-exclusionary radical feminists" or TERFs, for short. Discrimination. Employment discrimination. Transgender individuals experience significant rates of employment discrimination. Approximately 90% of trans people have encountered some form of harassment or mistreatment in their workplace. Moreover, 47% have 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. Support. Studies in several cultures have found that cisgender women are more likely to be accepting of trans people than cisgender men. Scientific studies of transsexuality. A 1996 study of Swedes estimated a ratio of 1.4:1 trans women to trans men for those requesting sex reassignment surgery and a ratio of 1:1 for those who proceeded. A study in 2020 noted 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 now equal the number of trans women seeking this treatment. An observational study revealed that transgender people receiving hormone therapy from the Amsterdam University Medical Centre in the Netherlands had higher mortality rates than the general population, and that this did not decrease during the duration of the study (1972 to 2018). Other studies have also found increased mortality in transgender people. 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. Asia. In Thailand and Laos, the term kathoey is used to refer to male-to-female transgender people and effeminate gay men. 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. European Union. According to Amnesty International, 1.5 million transgender people live in the European Union, making up 0.3% of the population. UK. 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. Canada. LGBT community. The 2017 survey of Canadian LGBT+ people called "LGBT+ Realities Survey" found that of the 1,897 respondents 11% identified as transgender (7% binary transgender, 4% non-binary transgender) and 1% identified as non-binary outside of the transgender umbrella. The 2019 survey of the Two-Spirit and LGBTQ+ population in the Canadian city of Hamilton, Ontario, called "Mapping the  Void: Two-Spirit and LGBTQ+ Experiences in Hamilton" showed that 27.6% of the 906 respondents identified as transgender. Canadian population. In April 2022, Statistics Canada released findings from the 2021 census, making Canada the first country to ask a core question about gender identity, and found that 59,460 Canadians identified as transgender 41,355 as nonbinary. The "Trans PULSE" survey conducted in 2009 and 2010 suggest that as many as 1 in 200 adults may be trans (transgender, transsexual, or transitioned) in the Canadian province of Ontario. 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. With 95% confidence interval applied, this figure changes to a range of 0.16% to 0.36%. United States. The Social Security Administration, since 1936, has tracked the sex of citizens. Using this information, along with the Census data, Benjamin Cerf Harris tracked the prevalence of citizens changing to names associated with the opposite sex or changing sex marker. Harris found that such changes had occurred as early as 1936. He estimated that 89,667 individuals included in the 2010 Census had changed to an opposite-gendered  name, 21,833 of whom had also changed sex marker. Prevalence in the States varied, from 1.4 to 10.6 per 100,000. While most people legally changed both name and sex, about a quarter of people changed name, and then five years later changed sex. An earlier estimate in 1968, 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 population in 2011 gave a "rough estimate" that 0.3% of adults in the US are transgender. More recent studies released in  2016 estimate the proportion of Americans who identify as transgender at 0.5 to 0.6%. This would put the total number of transgender Americans at approximately 1.4 million adults (). A survey by the Pew Research Center in 2017 found that American society is divided on "whether it's possible for someone to be a gender different from the sex they were assigned at birth." It states, "Overall, roughly half of Americans (54%) say that whether someone is a man or a woman is determined by the sex they were assigned at birth, while 44% say someone can be a man or  a woman even if that is different from the sex they were assigned at birth." Native American and First Nations. In what is now 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, who possess the same gender identity of people assigned female at birth. 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 now 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. Deviating from the societal standards for sexual  behavior, sexual orientation/identity, gender identity, and gender expression have a single umbrella term that is known as "sexodiverso" or "sexodiversa" in both Spanish and Portuguese, with its most approximate translation to English being "queer". Ancient cultures. Among the ancient Middle Eastern Akkadian people, a "salzikrum" was a person who appeared biologically female but had distinct male traits. "Salzikrum" is a compound word meaning "male daughter." According to the Code of Hammurabi, "salzikrūm" had inheritance rights like that of priestesses; they inherited from their fathers, unlike regular daughters. A "salzikrum's" father could also stipulate that she inherit a certain  amount. In Ancient Rome, the Gallae were castrated followers of the Phrygian goddess Cybele and can be regarded as transgender in today's terms. In early Medina, gender-variant male-to-female Islamic people were acknowledged in the form of the Mukhannathun. Also, in Fa'asamoa traditions, the Samoan culture allows a specific role for male to female transgender individuals as Fa'afafine. Coming out. Transgender people vary greatly in choosing when, whether, and how to disclose their transgender status to family, close friends, and others. The prevalence of discrimination and violence (transgender people are 28% more likely to be victims of  violence) against transgender persons can make coming out a risky decision. Fear of retaliatory behavior, such as being removed from the parental home while underage, is a cause for transgender people to not come out to their families until they have reached adulthood. Parental confusion and lack of acceptance of a transgender child may result in parents treating a newly revealed gender identity as a "phase" or making efforts to change their children back to "normal" by utilizing mental health services to alter the child's gender identity. The internet can play a significant role in the coming out process  for transgender people. Some come out in an online identity first, providing an opportunity to go through experiences virtually and safely before risking social sanctions in the real world. Media representation. As more transgender people are represented and included within the realm of mass culture, the stigma that is associated with being transgender can influence the decisions, ideas, and thoughts based upon it. Media representation, culture industry, and social marginalization all hint at popular culture standards and the applicability and significance to mass culture as well. These terms play an important role in the formation of notions for those who  have little recognition or knowledge of transgender people. Media depictions represent only a minuscule spectrum of the transgender group, which essentially conveys that those that are shown are the only interpretations and ideas society has of them. However, 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. Research has found that viewing multiple transgender TV characters and stories improves viewers' attitudes toward transgender people and related policies . Events. International Transgender Day of 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 in 2009. Transgender Awareness Week. Transgender Awareness Week is a one-week celebration leading up to Transgender Day of Remembrance. The purpose of Transgender Awareness Week is to educate about transgender and gender non-conforming people and the issues associated with their transition or identity. Transgender Day of Remembrance. Transgender Day of Remembrance (TDOR) is  held every year on November 20 in honor of Rita Hester, who was killed on November 28, 1998, in an anti-transgender hate crime. TDOR serves a number of purposes: Trans March. 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. 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. Helms describes the meaning of the flag as follows: 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 ⚧.