When Sham Ibrahim was 3 years old, he snuck into his mother’s room to try on her clothes and makeup.

Even though his parents found out and punished him, he didn’t stop. Nor did he stop playing with Barbie dolls.

In high school, he hid tights and makeup in his backpack to put on once he got to school. He fell into goth subculture, not for the music or the attitude, but because it afforded him a socially acceptable way to wear makeup.

“As I grew up and went into adulthood, even as a teenager and an adolescent, I began to understand what the words ‘gay’ and ‘transgender’ meant, and I realized that that was me,” said Ibrahim, 36, of Palm Springs, California, and owner of ShamPop Art, in an interview with Healthline.

Dawn Ennis, transgender from Los Angeles Image source: Courtesy of Rhys Harper

For transgender woman Dawn Ennis, 51, of Los Angeles, news editor for The Advocate and author of the blog Life After Dawn, the realization didn’t come until later in life.

After living for decades happily as a man named Don, married with three children, Ennis’ body began to change. Andropause had triggered a hormone imbalance that caused his body to begin to develop female features. And with a great amount of soul searching, he realized that this was only reflecting something that had been deep within him all along. He was actually a woman.

A whole spectrum of different stories can be found among the approximately 700,000 transgender people living in the United States.

One of them is Caitlyn Jenner. The 1976 Olympian formerly known as Bruce Jenner is the topic of the cover story in this month’s Vanity Fair, an article that has put a face on the transgender community.

Despite Jenner’s high-profile debut, however, a common feeling still lingers among almost all transgender individuals. It’s the desire to be understood.

What Does ‘Transgender’ Mean?

A transgender person is someone who identifies as the opposite gender of the one that he or she was assigned to at birth. The assignment is determined by the baby’s external genitalia, which are usually determined by the baby’s chromosomes.

“XX” chromosomes mean female genitalia and that equals girl. “XY” chromosomes mean male genitalia and that equals boy.

But not always.

At the age of five weeks, the developing fetus has no gender. It instead has undifferentiated genitalia and gonads, and both male and female internal ductwork. It’s only then that the active X or Y chromosome sends orders to the gonads to become ovaries or testes.

In turn, the newly developed ovaries begin pumping out estrogen, or the testes begin producing testosterone. These hormones flood the body, docking with receptors on all cells to instruct them to develop as either male or female. The genitalia develop for the designated sex, and the necessary ducts grow while the unnecessary pair whither away. If male, the testes descend.

And finally, the rush of hormones reaches the brain, instructing it to wire into different patterns depending on if it is to be male or female. Since the female brain is slightly smaller than the male brain, it requires different wiring solutions in order to pack the same processing power into a smaller space.

At every single step of this highly complex process, any kind of disturbance can cause variations in development. For example, complete androgen insensitivity syndrome (CAIS) is a rare mutation where the person has no androgen receptors on their cells. Although XY individuals with CAIS have male testes (undescended) that produce plenty of testosterone, there’s no way for the masculinizing signal to reach the cells and tell them to become male.

As a result, people with CAIS will develop as physically and mentally female, indistinguishable from an “XX woman” save for their lack of internal ductwork. Despite having male chromosomes, they usually identify as heterosexual women.

Although the process isn’t fully understood, more and more evidence is emerging to indicate that for transgender people, the brain migrated to one sex while the rest of the body migrated to the other.

“There is evidence that gender identity is irreversibly programmed in the brain during fetal brain development,” said Georg Kranz of the department of psychiatry and psychotherapy at the Medical University of Vienna. “It is not something that you can change at will. Two temporally separated processes regulate the sexual differentiation of the brain and the sexual differentiation of the genitals. Thus, the two processes can be influenced independently, which may result in trans identity. This puts gender dysphoria into the realm of human physiological variation.”

In one study, Kranz and his colleagues found noticeable differences in brain wiring between transgender subjects and others who identify with the sex assigned at birth (cisgender). Wiring pathways were most robust in cisgender women, followed by transgender men, followed by transgender women, followed by cisgender men.

Other research in more primal areas of the brain found an even clearer picture. The transgender female brains looked like cisgender female brains, and the one transgender male brain in the study looked like a cisgender male brain.

“I certainly believe that the gender you identify with in your head is far more important and powerful than anything God and nature has granted you physically,” said Sylvia, a 28-year-old transgender woman from Orlando, Florida. “Besides, God and nature can also give you a differing gender identity, so is there anything unnatural about that? To me it feels as natural as the day I was born.”

Read More: Men’s and Women’s Brains Are Wired Differently, But What Does It Mean? »

So What’s to Be Done?

Transgender people often describe a sense of wrongness — like trying to write with your nondominant hand, said Ennis, the first transgender staff member at The Advocate.

“That’s what being trans is like,” she said. “It’s having to live a life in which it’s just not easy, it’s not natural, it doesn’t feel right, it feels like something’s off. To understand what transgender people in the world go through — you don’t have to be gay or trans or bi. You just have to understand that simple feeling of ‘I feel out of place.’ I don’t feel right. Something’s amiss, something’s wrong.”

That sense of wrongness, when it’s in regard to one’s physiological gender, is called gender dysphoria. And that’s the symptom that doctors helping transgender patients try to treat.

For many transgender people, getting social support and seeing a therapist is enough. They learn to understand their true gender and find ways to live that will make them happy. By using mindfulness or other acceptance techniques, they can find peace with a body that doesn’t fit them.

However, this isn’t the case for many transgender individuals. Feeling and dressing as their true gender isn’t enough. They feel trapped in the wrong body, with the wrong angles and curves, with genitalia that feel strange and out of place.

Many choose to take the hormones of their target gender. In the case of transgender men, this usually just means taking testosterone, which quickly overwhelms the female body’s estrogen. The voice deepens, facial and body hair begin to grow, and muscles develop more easily. They may also experience behavioral changes, such as increased aggression or libido.

Meanwhile, transgender women have a slightly more complicated hormonal mix: estrogen to replace what their bodies lack, and another chemical to soak up circulating testosterone so it can’t act. These hormones can make breasts develop, body hair recede, and cause fat to begin to deposit in a female-type pattern around the breasts, hips, and thighs. Although the voice doesn’t particularly change, voice coaching can go a long way toward developing a female voice.

For those with the money, stable health, and the courage to face surgery, the transformation can go even further.

“Top surgery” deals with breasts: either adding implants for transgender women, or removing breast tissue to create a smooth chest for transgender men.

Meanwhile, “bottom surgery” for transgender women involves removing the penis and testes and creating a vaginal canal. For transgender men it may just consist of removal of the ovaries and uterus. It may go so far as an attempt to construct a penis from the patient’s own tissue.

While the surgeries to create female genitalia are becoming increasingly successful, surgeries to create a functioning penis are still poor. 

New medical breakthroughs may offer hope for better surgeries in the future. In South Africa, doctors performed the world’s first successful penis transplant earlier this year, with the patient reporting that the organ became fully functional once it had healed. In another study, four teenage girls who had been born without vaginas successfully received transplants that had been engineered from their own cells.

For transgender youth who are too young for hormones or surgery, there are other options. Rather than have to develop as the wrong sex during puberty and then need expensive treatments to reverse the changes, they can talk to their doctor about taking a medication that delays puberty. This prevents the body from developing as male or female and buys the adolescent more time to explore their gender identity before deciding which gender to develop as. 

Read More: Scientists Report New Successes with Body Parts Grown in a Lab »

Getting the Look

Right now, surgical options are limited. As such, this creates a strange contrast for transgender men and women. Because transgender men can get lower voices and grow facial hair, it’s generally easier for them to “pass” as male.

Meanwhile, transgender women have a heavier bone structure to contend with, often finding it harder to appear as though they were physically female from birth. 

On the other hand, transgender men have fewer options for achieving the genitalia they desire, while transgender women can be quite successful. 

But transgender women looking to appear more feminine have further surgical options. A process called facial feminization surgery makes subtle adjustments to the structure of the face to hit the cues that the brain subconsciously associates with femininity.

The surgeon moves the hairline forward and rounds it out, smoothes and flattens the forehead, raises the eyebrows and opens up the eye sockets to allow in more light, adds definition to the cheeks, shortens the height of the upper lip so more teeth show in a smile, narrows the jaw, and gets rid of the Adam’s apple. 

“What we’re trying to do in facial feminization is adjust features of the person’s face so that when you see the person, you see them as the gender they want to be seen as,” explained Jeffrey Spiegel, professor and chief of facial plastic and reconstructive surgery at Boston University School of Medicine, in an interview with Healthline.

Spiegel contests that what he’s doing is making patients more beautiful. He says it’s about feminizing, which relies on an entirely different set of features. Such features can be quantified and measured scientifically, forming the basis of his work.

“Gender-confirming features of the face have nothing to do with one’s objective or subjective standards of beauty,” he said. “There are features of the face which are feminine and there are features of the face which are masculine. They’re not really up for our decision, they’re just the way things are.”

Related Reading: Facial Plastic Surgery Makes You Look Younger, But Not More Attractive »

The Cost Can Be Heavy

However, transgender surgeries can cost thousands of dollars.

Not every health insurance plan covers sexual reassignment surgery and many transgender people aren’t adequately covered.

GLAAD reports that 19 percent of transgender people have no form of health insurance and that transgender people live in poverty at four times the national average rate. The National Center for Transgender Equality also reports that 20 percent of transgender people will experience homelessness at some point in their lives. When it’s a struggle to make rent and put food on the table, expensive surgeries are far out of reach.

Other figures to consider:

50 percent of transgender people have experienced sexual violence

84 percent of transgender people have experienced verbal abuse and 34 percent have experienced physical abuse

42 percent of transgender people have experienced employment discrimination

41 percent of transgender or non-gender-conforming people have attempted suicide (compared to 0.5 percent of adults and 7.8 percent of students in the general U.S. population)

And for others who have existing medical conditions, hormones or surgery could be dangerous, and therefore not an option. Others still, like Ibrahim, who has not transitioned, don’t want to have any unnecessary medical procedures.

“If there was some magic pill that I could take that would bypass all that surgery and pain, I would be more than happy to do it,” she said. “If I could snap my fingers and be a female, I would have done that when I was 3 years old.”

Related Reading: Depression and Sexual Orientation »

An Unachievable Ideal

For most transgender people, the image that Caitlyn Jenner presents on the cover of Vanity Fair — a rich, white, powerful woman — represents an ideal that they will never achieve.

“She looks like a million bucks, and it probably cost her a million bucks to look that good,” said Ennis. “Not many transgender people have that kind of wherewithal to make that kind of transformation.”

Transgender star Laverne Cox from “Orange Is the New Black” praised Jenner’s courage in a Tumblr post, but she also wrote, “In certain lighting, at certain angles I am able to embody certain cisnormative beauty standards. Now, there are many trans folks because of genetics and/or lack of material access who will never be able to embody these standards. More importantly many trans folks don’t want to embody them and we shouldn’t have to to be seen as ourselves and respected as ourselves.”

Ennis is happy for Jenner, but also has her concerns about the wave of publicity she’s drawn.

“In the non-transgender community, a lot of people saw this as ‘Oh, so that’s what a transgender woman should look like,’” said Ennis.

In reality, many transgender women may not even come close to that vision.

Such imagery also pressures transgender women to feel like they should conform.

“We all want to be glamorous and look like Laverne Cox,” Ennis said. “There is no way, no matter how much money I have, that I’ll ever look as good as Laverne Cox. I’d just rather be the best that I can going into every day.”

Transgender man Lucah Rosenberg-Lee, 26, of Toronto, Canada, also weighs in. “I think as a whole, we should also put attention on the ways we can expand our thinking of ourselves and our genders,” he said. “And advocate for maybe not just more ways we as ‘trans’ people can get more ‘normal’ looking bodies but find ways for all our bodies to be accepted. Because even if you aren’t trans, the pressure to create a ‘normal’ sense of body is still very real and prevalent.”

Lucah Rosenberg-Lee of Toronto

For Lucah, passing is no problem. But having now experienced life as both a woman and a man, he’s become aware of much larger social issues around gender. He directed the documentary film “Passing” to explore this idea.

“When I first started transitioning to male, all I wanted to do was to ‘pass’ and be seen as male and never look back,” he explained. “But the experience ended up differently and the reality is that when you do pass, you see the world in a different way and you get exposed to sides of sexism, racism, trans phobia and homophobia that you previously weren’t.”

Ennis has also learned new things with her new perspective on being female.

“We are looked upon as objects, and we are seen as having to require a certain level of beauty to be accepted. As Jon Stewart from the Daily Show said [of Caitlyn Jenner], ‘Welcome to the world of women.’”

So does Jenner’s appearance help or harm the transgender cause? There’s no clear answer.

Ibrahim — who doesn’t pass as female — has experienced the ugly side but now sees a promising future.

“Pretty much all my life, every time I’ve walked down the street, I get someone spitting at me, harassing me, making fun of me, saying something derogatory, even threats of violence and violence itself,” said Ibrahim. “Simply because my appearance is not gender conforming. After that Vanity Fair issue came out, I think for the first time in my life, I walked down the street, and not one person said anything negative. Peopled smiled at me, people were complimentary to me. Having lived all my life getting that negative attention, I believe it has something to do with that.”

Protection Under the Law

In additional to social and medical issues, transgender people also have to intersect with the law.

Many choose to legally change their name. Changing their listed gender on official documents like driver’s licenses can be a larger challenge, with different restrictions for different states. Some do not permit this change at all, while others require that the individual have completed a certain stage of surgery or psychotherapeutic treatment.

Overseas, many countries in Europe require an even more severe step: forced sterilization. In order to gain recognition as the opposite gender, transgender individuals must submit to losing their fertility. This is changing, however. Sweden dropped this requirement in 2013. Denmark dropped it in 2014.

In the United States, no federal law explicitly protects transgender individuals. The proposed Employment Non-Discrimination Act (ENDA) would do so in the workplace, but it has not yet passed both houses of Congress. The American Disabilities Act (ADA) explicitly excludes transgender people.

However, the Equal Employment Opportunity Commission (EEOC), which is tasked with interpreting Title VII of the Civil Rights Act of 1964declared in 2012 that Title VII’s protections included transgender people. This means that employment discrimination against transgender employees on the basis of their gender identity is illegal at the federal level.

Other government agencies are getting up to speed. This year, both the Army and Air Force have decided to welcome openly transgender soldiers, so long as their gender identity does not disrupt their military duties. Earlier in June, the Occupational Safety and Health Administration (OSHA) published a guidebook for best practices regarding restroom access for transgender employees.

Read More: American College of Physicians Pushes for Transgender Rights »

Advice for Employers

Jen Cornell, a labor and employment law attorney at Nilan Johnson Lewis in Minnesota, advises that the best long-term solution for accommodating restroom needs is to offer unisex bathrooms, but acknowledges this often requires new construction.

“It’s not a solution that companies can necessarily institute overnight,” she said. “So you have usually this period of time where companies may have to come up with solutions around bathrooms that people are not going to be happy with. My advice to employers is to let the transgender individual use the restroom of their choice.”

As for dress codes, Cornell advises that employers use general language, such as “dress professionally” or “wear a certain color” or “dress to be able to lift so many pounds,” rather than specific language to address the attire of men and women separately.

In general, open communication is key.

“I encourage employers to communicate, educate, and accommodate, where feasible,” said Janet Hendrick, law attorney and Title VII specialist at Fisher & Phillips, in an interview with Healthline. “This is an area where employers cannot afford not to stay abreast of developments. Employers should be proactive and have a plan in place, with a designated contact person for both transgender workers and coworkers who have questions or concerns.”

What Can I Do?

For people trying to understand what it means to be transgender, Ibrahim has a solution.

“Have compassion and try to understand people rather than judge them,” she said. “Take the time to get to know somebody who’s transgender or gay. You’ll find that they’re real people.”

“Nobody who’s transgender is asking for other people to ‘tolerate’ us,” added Ennis. “We don’t want to be ‘tolerated.’ We have a right to be accepted. It’s not that we are looking for some kind of handout, we don’t want special rights, we just want what everybody else has: civil rights.”

Sham Ibrahim Image source: Courtesy of Celeste Octavia

Meanwhile, Rosenberg-Lee offers advice for people who are questioning their own gender identity.

“I would say continue to question and explore it. There is no rush to go on hormones and surgery. It’s hard to tell someone who desperately wants to pass that, but as someone who does, it is a lifelong journey and experience and it shouldn’t be rushed,” he said.