8 TRANSGENDER HEALTH ISSUES Physical Appearance Gender is typically assigned at birth, based on the appearance of the babyÊs genitals: „ItÊs a boy!‰ or „ItÊs a girl!‰ is typically proclaimed with- out any knowledge of the babyÊs chromosomal makeup. For most infants, the genitals and chromosomal makeup coincide, but in some cases it does not. For instance, as mentioned earlier, a baby with AIS has the outward genitalia of a female but the chromosomal makeup of a male. AIS may not be diagnosed until puberty, when the individual does not begin to have menstrual periods as expected. Similarly, a baby with CAH has the chromosomal makeup (46,XX) typ- ical of a female but may be born with ambiguous genitalia due to being exposed to high levels of androgens before birth. However, most CAH females have typical internal female reproductive organs (ovaries, fallo- pian tubes, and uterus), and most identify as female, so their sexual identifi- cation matches their chromosomal makeup. A small proportion of persons with CAH have the typical male chromosomal makeup (46,XY). Some may be born with ambiguous genitalia, but for most there are no indica- tions of CAH until they begin to experience premature onset of puberty (e.g., early appearance of pubic hair and deepened voice). Psychosocial Identity Gender identity refers to how a person perceives and experiences themselves·as male, female, or some other category·and does not bear a necessary relation to either chromosomal makeup or genitalia. The psy- chosocial aspects of gender identity and expression are newer topics for study than are the medical aspects of gender (chromosomes and genitalia), but the importance of this part of gender identity is increasingly accepted by the medical and psychological communities. Because gender identity is internal, an individual is the sole expert on their own gender identity, and it may or may not conform to the gender category they have been assigned. In addition, gender identity can change over a personÊs life course and is independent of other issues such as sexual identity or sexual behavior, so a transgender person could be straight, gay, bisexual, asexual, or prefer some other term to describe their sexuality. HOW MANY TRANSGENDER PEOPLE ARE THERE? ItÊs currently impossible to answer the question of how many transgen- der people there are in the world because no survey or census has been conducted that could answer that question. Most survey-based studies of
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