Does the average woman who doesn’t want children at the moment lives in constant and ever present fear that one day her luck might run out and she might get killed by a parasite that has infested her body? Probably no. As for me, I might not be a woman, but the patriarchal society has forced me to live with such a fear.
I have spent the last two years trying to obtain a hysterectomy. A transphobic surgeon kicks me out of their office, and I proceed to schedule another appointment with yet another doctor. Rinse and repeat. For the last two years I had been asking for “hysterectomy” to doctors in state owned hospitals. Here I wrote about how that didn’t work. In theory, European Union citizens have a right to gender reassignment surgery. In practice, it can be impossible for a patient to actually obtain it. And Latvian bureaucrats managed to successfully find a loophole how to get away with denying me the surgery I wanted.
Hysterectomy (surgical removal of the uterus) is the procedure I would have preferred. Given how I cannot get this procedure, I decided to settle for sterilization instead. That might not be my preference, but it would be better than nothing (a sterilization wouldn’t fix all my problems, but at least the risk of unwanted pregnancies would be greatly reduced). Anyway, in past I asked for a “hysterectomy” to doctors in state owned hospitals, this Friday I went to a private clinic instead and asked for “sterilization.” Here’s how the conversation started:
“Hello, how can I help you?”
“I want to sterilize myself.”
“How many children do you have?”
“None.”
“Then I’m afraid I cannot help you. I cannot sterilize you unless you have had at least two children.”
Here is a quote from Latvia’s “Sexual and Reproductive Health Law”:
Section 24. Choice and Provision of Contraception
(1) The use of contraception is a person’s voluntary choice.
(2) Only a gynaecologist (childbirth specialist) or a general practitioner is permitted to prescribe any medicinal contraceptives or the use of contraceptive medical technologies (except for surgical contraception), and provide for the further medical observation of the patient.
(3) Surgical contraception is applicable in the following cases:
1) to a patient of more than 25 years of age – upon his or her written consent;
2) in the case of medical indications, to a patient (also less than 25 years of age) on the basis of an opinion of the council of doctors [the council consists of a gynaecologist (childbirth specialist) or a urologist, depending on the sex of the patient, and two doctors – specialists of the relevant field of medicine] and upon the written consent of the patient (if the patient is a person lacking a capacity to act – upon the written consent of a guardian) in cases prescribed by the Minister for Health.
(4) Surgical contraception may be administered to a patient by a gynaecologist (childbirth specialist), a urologist or a surgeon.
In my opinion, the law is very clearly written. I am 27 years old. Thus I have a right to sterilize myself. There can be no extra requirements except for “written consent,” and I’m more than happy to sign all the papers.
Here are my reasons for wanting a surgery (text copied from this article I wrote a while ago):
I have multiple reasons for wanting a hysterectomy. I got unlucky to be born with a female body, but I don’t feel as a woman. I don’t want to live as a woman, I don’t want to have children, I don’t want to live with a uterus.
In addition to gender dysphoria, I also have several more practical reasons for wanting a hysterectomy. Firstly, I feel severe pain during my periods. For the first two days of each cycle I feel a disgusting mix of pain and nausea in my stomach. Taking painkillers like Ibuprofen helps a little, but it’s still very unpleasant.
Due to the heavy bleeding I experience, I have had anemia. Back when I got the diagnosis, my family was experiencing financial difficulties, so I tried to spend on food as little money as possible. It turned out that I cannot afford to subsist on cheap food with little iron in it.
On top of that, being denied a hysterectomy messes up my ability to avoid unwanted pregnancy. I refuse to use hormonal contraceptives, because birth control pills would raise my estrogen levels. I already have too much female hormones in my body, I don’t need any more of them. Being unable to access safer birth control methods like sterilization or hormonal pills puts me at an increased risk of experiencing an unwanted pregnancy. With typical usage, male condoms are about 85% effective; that means about 15 out of 100 women who use condoms as their only birth control method will get pregnant each year. I’m a risk-averse person, I prefer to be cautious. A 15% probability that I will get pregnant within the next 12 months is way out of my comfort zone for what I would deem “safe enough” to have a peace of mind.
More importantly, I have a naturally elevated testosterone level due to having polycystic ovary syndrome. That means irregular periods. It’s perfectly normal for me not to have a period for up to 16 weeks at a time. Here’s the problem—in Latvia an abortion is legal only for the first 12 weeks of the pregnancy. I’m very scared to miss an unwanted pregnancy for a while only to realize that it’s already too late to get an abortion. Whenever I haven’t had a period for at least nine weeks, I have to get a pregnancy test. The cheap tests that are sold in pharmacies are unreliable. With those a false negative is possible. This means that each time I have to go to a clinic for a hCG blood test. In the year 2019 I have had two pregnancy tests already. In January the result was 7.04. An hCG level of less than 5 mIU/mL is considered negative for pregnancy, and anything above 25 mIU/mL is considered positive for pregnancy. An hCG level between 6 and 24 mIU/mL is considered a grey area. How do you think I felt for some days following that test result? Nervous obviously. This constant fear is messing with my mind.
If I got pregnant and realized it at a moment when it’s already too late for a legal abortion, I’d have to risk killing myself. DIY abortions are dangerous. And, yes, I’d take the risk. I’d prefer to die than to deliver a baby. I’m 27 years old already. So far I have been lucky. I have never gotten pregnant; I have never needed to get an abortion. But I know that I’m pushing my luck. Statistically, it’s quite likely that one day my luck will run out.
After the disastrous beginning, I decided to try to talk with the doctor anyway. She totally failed to understand why I don’t want hormonal contraceptive pills. In fact, she insisted that I need them. According to her, polycystic ovary syndrome is an illness that needs fixing. I, on the other hand, love having it. Since doctors have denied me access to testosterone injections, I’m happy that I at least have a naturally elevated testosterone level. That’s one thing I actually like about my body.
The doctor seemed surprisingly progressive and non-transphobic. At least that’s how her statements sounded. She didn’t tell me that “God wants me to have children” (yes, that’s an actual quote I have been told by another gynaecologist). Nor did she call me “a delusional lunatic” (that’s another quote from a surgeon who couldn’t accept my masculine-leaning gender identity).
Instead she talked about how she is worried that I might later change my mind about not wanting children and sue her for money. I tried to explain to her the current Latvian law and the fact that there exist consent forms. I’m not sure I managed to convince her. The doctor’s visit ended with her promising that she will check the law and corresponding consent forms and call me later.
Being a cynic, I expect that she won’t call me. Usually that’s just a polite way how people tend to get rid of me. Besides, half a year ago, another surgeon promised to learn about the necessary paperwork and call me. I patiently waited for his call for a month. Then I scheduled another appointment with this doctor, during which he said that he refuses to treat me.
Anyway, this Friday I just wasted 32 euros for another useless doctor’s appointment. Over the last two years I have had so many unpleasant doctors’ appointments, that I now dread seeing another doctor. In the morning, I felt like shit and I had butterflies in my stomach. In the afternoon, I felt like shit and I was emotionally drained and empty. As I type this blog post, there’s a bit of anger, some sadness, and this vast sense of dull emptiness. It’s not even a lack of energy, it’s just that I have no will or desire to do anything. Just an overwhelming sense of apathy and hopelessness. Nowadays I feel like this after every doctor’s appointment; usually I get better after a few days.
Oh well, at least now I have a blog, and I can vent online. Typing a blog post is more useful than just lying in bed doing nothing and feeling sorry for myself. This is a simple enough and relatively mindless task that I can manage even in my current state of apathy.
Being denied healthcare messes up a person’s mind. Sometimes medical problems are incurable, and there’s nothing anybody can do about it. But my medical problems would be easily solvable. I know that neither the state nor the insurance pay for sterilization or gender change procedures. Fine, I get this. I am willing to pay the full price from my own pocket. But no, doctors won’t let me have it. This intentional malice is so damn depressing. Doctors could easily fix my problems and make my life more convenient, but no, they won’t do it. The society shouldn’t abuse me like this. I feel angry, sad, and I keep on whispering to myself “not all doctors, not all doctors, not all doctors” in order to stop myself from starting to hate doctors as such. Why must they torture me like this?
Why does the world have to be so damn unfair? I was born with the wrong body, that’s nobody’s fault. No human could have done anything about this bit of unfairness. But most of my problems are caused by the society I live in. Being aware that other people could fix my problems but refuse to do so feels terrible, it is much worse than getting hurt by the laws of nature.
I hate all those monstrous doctors who patronize me, deny my bodily autonomy, and even claim that they are doing this for my own benefit, because I might regret my choices later in the future. It’s my body, it should be my choice. Since I have already written about patronizing attitudes before, this time I’ll abstain from further elaborating the topic.
It’s also unfair. Cis men don’t have to fear unwanted pregnancies. Cis people in general don’t have to prove to hostile doctors that they are crazy enough to need some body modifications but not too crazy so as to be total lunatics who must be locked up in white rooms. If some gender neutral pronoun was the norm, if I was allowed to use either a male name or some gender-neutral name, if unisex toilets and dressing rooms were the norm, then that alone would solve a significant portion of my problems. If doctors did the few procedures I want, then that would solve the rest of my problems. The emotional pain I have to experience is not caused by an unfortunate accident of birth. Instead I live in a society that could solve all my problems, yet this society so adamantly refuses to do so, instead doctors are making me suffer “for my own benefit,” because if I was allowed to have bodily autonomy, then “I would make a huge mistake I would later regret.”
Moreover, there’s the fear itself and all the resulting stress. I perceive pregnancy as an inherently feminine experience that would be incompatible with my gender identity. I know that there exist trans men who become fathers, but I absolutely don’t want that. There can be no biological children for me.
If my body became pregnant, I would perceive that as mutilating. I already dislike the fact that my body is too feminine for my own taste, but I can cope with my existing problems. Nonetheless, the thought of my body even potentially becoming any more feminine freaks me out. I keep my body thin, because the thought of having even more fat on my hips or in my breasts freaks me out. Thinking about a pregnant belly or breast milk simultaneously with thinking about my own body makes me highly uncomfortable. If you are cis, imagine an evil alien experimenter implanting in your body organs that are exclusive to the other sex. That’s about how the thought of pregnancy makes me feel.
My fear that my body might get pregnant against my will is seeping though and spreading also to other aspects of my life. There is no rational reason why I should feel uncomfortable while looking at other people’s babies or other people’s pregnant bellies. It’s not like a baby could “infect” me and make me pregnant. Nonetheless, the fear that is lingering at the back of my mind spikes every time I am reminded of childbirth per se.
For example, one of Freethoughblogs bloggers tends to regularly post photos of his grandchildren. Whenever the title of some blog post suggests that there might be baby photos in it, I won’t click on this link. But often baby photos appear on my computer screen unexpectedly. It’s not like “trigger warning: maternity or baby images” was a common thing. While browsing the Internet, I regularly run into photos of babies and pregnant bellies. Each time this happens, I experience a slight jolt of revulsion. And fear. That a parasite might mutilate or kill me.
The fear that I might accidentally get pregnant and fail to notice it until it is already the 13th week (making an abortion illegal in Latvia) is a constant worry lingering at the back of my mind. Of course, this messes up my brain.
Instead of getting the healthcare I need, I am feeling like shit and googling about DIY abortions after the 12th week in case someday the worst actually happens. By the way, here, on page 3, you can find the World Health Organization’s guidelines for how to use misoprostol and mifepristone in order to terminate a pregnancy between 12 and 24 weeks. The bad news is that at this point complications are much more likely compared to using the same pills earlier in the pregnancy, and the patient will probably need medical assistance. The good news is that these medications cannot be detected in blood tests, thus doctors working at the ambulance might assume that they are dealing with a naturally occurring spontaneous abortion, which means that the patient might not end up in the jail. And, of course, as long as you have money and know how to pay with Bitcoin, misoprostol and mifepristone can be shipped to anywhere in the world.
This Friday, I didn’t tell this doctor about my fears. If I want a surgery, I must pretend to be normal and sane. If an AFAB person tells, “I hate children,” then they will be perceived as a loveless monster who deserves to suffer. Amusingly, men don’t get the same treatment. I know a guy who has had a vasectomy. At first his doctor seemed hesitant. Once the guy said “I hate children,” the doctor immediately agreed to perform the procedure. Men who want a vasectomy don’t go through the same shit that has been going on with me for the last two years. Has a man ever been told, “You cannot have a vasectomy unless you already have at least two children”? I hate the sexist society we live in.
For the record: I have never hurt any child. I have arranged my life so as to be able to stay away from other people’s children. I absolutely condemn every form of child abuse and neglect. Each child deserves to grow up in a healthy environment, and I fully support state funded education, free healthcare for children, and so on. Even though being confronted with babies makes me uncomfortable, I do not want any of them to suffer for any reason.
Latvian law appears to be about the same as Swedish law, but I remember a long gripe posted by an archaeologist who had reached age 25, wanted no kids, and was often in remote locations where pregnancy was a really bad idea. She had the same set of problems and refusals you’ve endured, but finally was able to get the job done by some GynDoc who inflicted a very painful treatment in her. I’ve know two gals in the USA who’ve managed to find a helpful ObGynDoc and had the tubes tied w/ no difficulty and virtually no pain. My own late wife obtained hysterectomy with difficulty, despite clear evidence that severe endometriosis made pregnancy impossible, or nearly so. Sweden isn’t far away from you. If you can afford it, at least you’d have a larger field of physicians to seek among. Any hope of raising funds to do this with GoFundMe?
secmilchap @#1
Only people who have the citizenship of select few countries are eligible to use GoFundMe. I have Latvian citizenship, thus I cannot possibly use this website.
Airplane tickets are the cheaper part of getting healthcare abroad. Paying for the actual procedure is what’s expensive. My chances of being able to afford healthcare abroad are actually better in a cheap place like Thailand. That being said, I have looked at how much various procedures cost in Thailand, and I cannot possibly afford it. I have way too little income.
For me the answer was yes. Even while on the birth control pill or with IUD (copper, as hormones became counter-indicated for me) in place. For years I had pregnancy tests around so I could be sure to detect said parasite early so I could get rid of it ASAP. Now menopause has made this unnecessary.
Other people (mostly ciswomen in Childfree groups) report the same issues.
My recommendation to them (and an option for you) is to file a complaint with a medical board against those who refuse treatment. Anything that can taint or end a doctor’s career gets their attention quickly.
Pardon me for flogging two of my own pages from the past on the topic.
Intransitive @#4
Doctors are smarter than that. They kick me out of their offices verbally. They don’t give me written refusals. When I write a complaint letter, the doctor responds with claiming that I merely went for a gynecologist consultation and didn’t ask for any surgeries. At this point I cannot prove to the medical board that I actually asked for the surgery and got refused.
On one occasion, I actually managed to get a written refusal, but even then doctors found a way how to get away with it. I wrote about that here: https://andreasavester.com/my-country-wants-me-to-suffer-for-my-own-benefit/
Could you consensually record the consultation to “help you remember” the doctor’s advice?
Andreas, I am really struggling here.
You are claiming doctors deny you a hysterectomy because they are “transphobes” when it seems it is more that they don’t like the idea of sterilising childless women. No doubt this has far more to do with the traditional and catholic mindset of Latvians than any phobia.
Now, don’t get me wrong, in my ideal world, any woman wanting a hysterectomy would be able to get one, provided there was clear evidence of non-coerced consent. 50 children or no children, it should make no difference.
I am further confused, in that previously you have claimed to be a gay man, yet your fear of pregnancy makes me wonder if you are enjoying vaginal sex. Yes, I know semen can leak from anus to vagina, but there are mechanisms other than just condoms to reduce that possibility to almost zero.
If you are enjoying vaginal sex, how many gay men do you know who are “into” that? Not many, if any, I’m guessing. In fact, I am pretty sure that gay men are not at all attracted to people with vaginas and breasts.
Not sure who is the more confused here, me not understanding, or you not being who you think you are.
steppemwolf, what makes someone a gay man is that they identify as masculine and are attracted to people who identify as masculine. Specifics of genitals of the person or their partner as well as their sexual habits are not part of the definition.
anat, I doubt you know many gay men.
What makes someone a gay man is that they identify as male and are attracted to people who identify as male. They are not attracted to people who identify as female, no matter how masculine they may appear.
Some gay men are attracted to other gay men who are quite effeminate. Not at all masculine. Yet the effeminate gay men still possess all the accoutrements of a gay man, and that excludes having a vagina. And the effeminate gay men do not claim to be women.
There are quite a lot of lesbians who are very, very masculine, and oddly enough, gay men don’t seem to find them sexually attractive. Why is that, do you think?
So if Eva Mendez or Naomi Campbell suddenly “identify as masculine” gay men will be attracted to them?
I don’t think it works that way.
steppenwolf, I deliberately used ‘masculine’ to include male-leaning non-binary people of any assigned gender. But yes. gay men are men who are attracted to men. Neither anatomy nor specific sex acts are part of the definition, so I don’t see why Andreas’ preferences in this regard would be disqualifying.
And since there isn’t one person whom all people with a particular attraction find attractive, I don’t see how your #10 is an argument for anything. There are many ways for men to look, there are many anatomies men can have, somewhere out there there will be a gay man or straight woman who will find such a man attractive.
My sympathy; not ideal circumstances.
You can certainly minimise the likelihood of becoming impregnated, but bureaucracies are more problematic, so that’s not the real problem.
Alas, pretty much all you can do is to always attempt to communicate with ever higher functionaries and/or seek recourse with a politician while document everything, and persevere.
—
BTW, I’ve seen programs showing the risks (and outcomes) of surgery in less-developed countries, too. Surgery deserves respect.
If you do go for it, I hope you are sufficiently informed regarding the specific procedure.
Your experience leads me to realize this is more common than I thought; I ran into quite a number of people in the states who thought that it was illegal for a single, never-married man to get a vasectomy.
Re: not getting any written refusals from doctors, would it help if you recorded your conversations with them? Then at least you could point out they’re lying when they say you didn’t ask for any surgeries.
Wow, Anat. Just wow!
I really didn’t want to hijack Andreas’ post, as my questions to him are a genuine attempt to understand. But how can you twist your thinking that far?
non-binary people of any assigned gender
I understood that a lot of trans thought is based around sex being assigned at birth, gender being something a person chooses for themselves. Or are you saying that gender can only be assigned? And if so, by whom or what power? Is Andreas a woman by assignation, or a man by choice? It cannot be both, and I am sure Andreas would say it is the latter.
Neither anatomy nor specific sex acts are part of the definition,
In that case, you haven’t been keeping up with the complaints from trans women that lesbian women won’t date them. Seems its something about Lesbian women preferring partners without any masculine appendages. This, somehow, makes a member of an oppressed class (Lesbian women) become oppressors in the eyes of some, simply for having a preference for partnering with people of the sex, and who don’t think that gender is an issue in that case.
Gender, as I understand it, is a social construct. It is not something innate in humans, it is something that some of us place more value and emphasis on than others do. It appears to be of bigger concern in relatively wealthy and politically free societies. It doesn’t seem to be a major concern for people in China, Iran, Somalia, or Afghanistan, for example. However, for gays and lesbians in those and similar countries, it is quite a problem.
If I have misunderstood your position or the way gender works, I am sorry. That’s the trouble, sometimes nuance is hard on the internet with people from diverse national, cultural, and linguistic backgrounds.
Stepppenwolf @#7
I usually call myself an “agender person with stereotypically masculine lifestyle preferences.” I don’t call myself a “gay man” (then somebody might object that I am not “gay enough” or “manly enough”). I’m even semi-reluctant to call myself a trans man, because then somebody might cluelessly ask why I’m still not taking testosterone or say that I am not “trans enough.” Assuming we use labels “transsexual” versus “transgender,” then I qualify as transgender but not as transsexual.
I’m more interested in living as a man, I’m less concerned about getting a phalloplasty or making my body as masculine-looking as possible. I do like looking more masculine, for example, I wear male clothes and I also use a binder in order to flatten my chest, but looking like a man isn’t my main goal in itself. Besides, the current state of phalloplasty surgeries is not exactly awe-inspiring. Plastic surgeons simply cannot create penises that were identical to natural ones. Unless these surgeries get much better in the next few decades, I won’t be surgically changing my genitals.
I think that at some point in the future I will decide to get testosterone and have a breast removal surgery, but for now those aren’t my priorities. My current priority is to get a hysterectomy (or if that’s impossible, then at least a sterilization).
The label “agender” is also more accurate, because it describes my absence of female gender identity. I want to live as a man, be treated as a man, and have my preferences respected. Being treated as a woman or being expected to live as a woman feels annoying for me. But my identity can be more accurately described as “human,” or “definitely not a woman.” This could be partially because so many people refuse to recognize me as a man, thus it is easier for me to insist that I am a human instead of insisting that I am a man. Here I wrote more about my sense of identity— https://andreasavester.com/why-humanity-should-stop-enforcing-mandatory-self-identities/
I qualify as bisexual. I am forced to use this label, because there is no other more accurate and widely recognized label. I am sexually more attracted to people who have various traits that our society has labeled as “masculine.” This includes also trans men, female bodybuilders, and even ordinary cis women. For example, I perceive deeper voices as more sexy. But those are only vague generalized trends about whom I tend to find sexually attractive, in reality it depends on the person, and I will date anybody with whom we have mutual attraction.
What people find sexually attractive differs by person. There’s a wide variety in what people like, and words like “homosexual,” “heterosexual,” and “bisexual” are just crude labels. Just look at my own murky sexual preferences for an example that doesn’t neatly fit any label. Of course, it is possible to say that, “Most men who call themselves ‘gay’ like this and that.” But such general trends aren’t always applicable to individual people, it depends on the person. And my current partner doesn’t even call himself “a gay man.”
I know who I am and how I want to live. Of course, I wish I were born with a male body. Then I would be just a normal guy and my life would have been much simpler. Unfortunately, the reality is the way it is, my genitals are shaped the way they are. Stimulating certain areas of my genitals feels pleasant and gives me orgasms, which feel nice. Stroking the skin inside my vagina gives me pleasant physical sensations, and I am not planning to stop doing that just because I wish my body was shaped differently. Wishful thinking and fantasizing about having a penis doesn’t give me orgasms.
For practical purposes, anal sex also requires preparation, and sometimes people just want some quick sex.
Ultimately, I have no choice but to get by with the genitalia I have.
One of the surgeons I have talked to told me, “If you don’t feel as a woman, then that makes you delusional and crazy, and you need to go to a psychiatrist in order to fix your head.”
In these conversations with surgeons I am always asked why I want this procedure and why I cannot just use hormonal birth control pills. Yes, many doctors believe that every person who is physically capable of giving birth to a child must have babies. That’s the influence of religion. But the moment I start explaining my reasons for wanting the surgery, all hell breaks loose and doctor’s hostility expands way beyond the usual distaste that’s reserved for people who want to remain childfree by choice.
stepppenwolf @#15
This topic has been discussed before, so I won’t elaborate.
https://freethoughtblogs.com/pervertjustice/2019/07/27/cotton-ceiling/
https://freethoughtblogs.com/atg/2017/08/02/trans-activists-insist-trans-people-are-human-but-have-trans-activists-gone-too-far/
To some extent, yes, my preferred gender expression is the result of social norms, which are an artificial construct of this society. If I lived in a society in which men wear dresses while women wear pants and neckties, then I would want to wear a dress and I would want to avoid pants and neckties.
However, my preference to live as a man is something I was born with and it was genetically determined.
Personally, I would thrive in a more gender neutral society. I’m fine with the pronoun “they,” I would be OK with having a gender neutral name, and I also want unisex toilets and dressing rooms. I also want a society in which every person, regardless of how their body is shaped, was free to pick and choose any forms of personal expression when it comes to clothing, jewellery, haircuts, mannerisms, lifestyle choices, etc.
But I also want a society in which people who choose to do so had the right to surgically alter their bodies to be either more masculine or feminine.
If I were starving, uneducated, had to work 60+ hour workweeks, and had no access to any healthcare at all, then yes, I wouldn’t worry about my gender expression, because I would have other more urgent problems like staying alive. Moreover, you are talking about political regimes which are so oppressive, that any deviance from social norms can result in getting murdered. Of course, in such places people are interested in hiding their gender dysphoria and pretending to be “normal” instead.
Tp stepppenwolf@15:
When an infant is born somebody decides, based on what the infant looks like (OK, based on the shape of their visible genitals), what gender that infant will be expected to have in that society. In western societies this is usually done by a member of the medical staff attending the birth (and the available genders are usually male and female, though sometimes the line on the form remains blank, or the gender is recorded as ‘unknown). This gender is then recorded in various items of official paperwork. This procedure is referred to as the assignment of gender. People sometimes argue that the forms record ‘sex’ rather than gender, but the information that is recorded is used socially – when someone, say a teacher or school administrator, knows that the form says ‘male’ they interact with the child as they would with a boy.
For most people there is no problem with which gender they were assigned (even if, like me, they are unhappy with many of the expectations society places on said gender) – we agree that our gender is the one we were assigned at birth (how we express it is a different matter). Some people discover that the gender they were assigned was wrong. To inform others of the correct gender they adopt manners of expression associated in that society with the correct gender, or wear buttons with their pronouns, and/or (to the extent that is legally possible) change official records to have correct information.
Thus you can have a child that is assigned the gender female at birth (AFAB for short) who discovers their gender is actually male and end up living in society as a boy and later a man. They don’t choose their gender, they discover it. Gender exists somewhere in people’s minds. What they choose is what to do about their gender – how to express it, how to communicate it to others.
Also, there are societies that recognize more than 2 genders and have specific social roles for people who fall outside of the 2 major genders according to how they are defined in those societies. For instance, Orthodox Judaism recognizes 4 categories that are outside of female and male and has different religious obligations for people in these groups, so functionally they are different genders.
How do you know that? I have met transgender people from developing countries, and they are very much like transgender people from the USA, with additional issues related to lack of formal recognition in their country of origin, lack of access to appropriate medical care in their country of origin, communicating about their gender with family members in the country of origin, etc.