Transforming the paradigm of nonbinary transgender health: A field in transition

It is exactly a decade ago that Sexual and Relationship Therapy published a special issue entitled “Gender Variance and Transgender Identity”, which was guest edited by Walter Bockting, former Editor-in-Chief of International Journal of Transgenderism (IJT). In his editorial Bockting wrote “[this issue] is comprised of a collection of articles that reflect a transition in this growing field from a disease-based to an identity-based model of transgender health. The disease-based model assumes that normative gender identity development has been compromised and that the associated distress can be alleviated by establishing congruence between sex, gender identity and gender role, if necessary through hormonal and surgical sex reassignment. The identity-based model assumes that gender variance is merely an example of human diversity and that the distress transgender individuals might experience results from social stigma attached to gender variance. The latter model views transgender people as having an experience, identity and sexuality distinct from those of both non-transgender women and men. This paradigm shift forms the context for nine peer reviewed articles….” (Bockting, 2009).

This special issue consists of more than double the amount of contributions than a decade ago, and concerns the area of nonbinary and genderqueer transgender health. Clearly a reflection of progress, progression and promise, albeit at a moderate pace. There is nevertheless reason for optimism. The multidimensionality and heterogeneity of gender identities and the idea that one’s gender identity can be a mix of both being a man and a woman, being somehow beyond the gender binary, or something completely else is increasingly acknowledged and recognized (Bockting, 2008; Harrison, Grant, & Herman, 2012; Herdt, 1993; Köhler, Eyssel, & Nieder, 2018; Kuper, Nussbaum, & Mustanski, 2012; Richards, Bouman, & Barker, 2018).

In the last decade in particular, there is growing evidence that in fact there is a sizable group of people who do not identify as binary trans. In parallel, language regarding gender identities has shifted and continues to evolve (Bouman et al., 2017), and although we will use the adjective nonbinary in this editorial to refer to people who identify between, outside and beyond the gender binary, we acknowledge that this is a reductionist approach and does not do justice to the realities of nuanced gender identity categories. We are also aware that the term nonbinary may well change in academic and legal discourse, especially once the terminology chapter of the 8^th version of the WPATH Standard of Care has been completed and published.

In terms of the prevalence of nonbinary identities then, Harrison, Grant, and Herman (2012) found that 13% of trans respondents (N = 6436) in their US sample preferred a different identity than: male/man, female/woman, or part time as one gender, part time an another in their community based survey; of the 860 written responses the majority of respondents wrote in genderqueer, or some variation thereof, such as pangender, third gender, or hybrid. Others chose terms that refer to third gender or genderqueers within specific cultural traditions, such as Two-Spirit (First- Nations), Mahuwahine (Hawaiian), and Aggressive (Black or African American) (Harrison, Grant, and Herman, 2012). The European LGBT Survey conducted by the Fundamental Rights Agency (2014) published data from 28 European countries showing that from their total sample of trans respondents (N = 6771), 8.7% identified as gender variant, 15.6% as queer and 20.4% as other (options also included: transgender (16.8%), transsexual (19.7%), woman with a transsexual past (5.2%), man with a transsexual past (2.1%), and cross dresser (11.4%). Those who choose “other” could add their preferred self identification: e.g., agender, bigender, dual gender, fluid gender, gender neutral, gender fluid, gender non-conformist, genderless, genderqueer, intergender, queer, neuter, no label, non-gender, pangender, polygender, third gender.

Moving from highly selected online samples to general populations Kuyper and Wijsen (2014) found that 4.6% of people assigned male at birth and 3.2% of people assigned female at birth reported an ‘ambivalent gender identity’ in their Dutch population sample. An ambivalent gender identity was defined as equal identification with other sex as with sex assigned at birth. This percentage was higher than the prevalence of gender incongruent identities (stronger identification with other sex as with sex assigned at birth). Similar, albeit slightly lower percentages were reported by Van Caenegem et al. (2015) who showed that the prevalence of ‘gender ambivalence’ was present in 2.2% of assigned male at birth respondents and 1.9% of assigned female at birth respondents in their Belgian population sample. Fontanella, Maretti, and Sarra (2014) observed 8.7% respondents who identified as both man and woman, 8.1% as neither man nor as woman, and 8.3% as “moving between genders” in their international convenience sample.

These aforementioned findings and observations affirm that the concept of gender identity as a binary entity does not reflect reality and without this affirmation these important realities remain invisible. There is an enormous diversity of terminology in how people self-identify their gender and there is not one single term which encompasses every unique and distinct gender experience or indeed provides an umbrella term for all; also, please note that there is an inconsistency regarding spelling of non-binary; and there are a significant amount of people, who identify between, outside and beyond the gender binary. What proportion of these people experience gender-related distress and/or wish to adapt their body to match their identification via gender affirming hormonal and/or surgical treatment remains largely unknown.

There have been other salient developments, which have increased the visibility and which stress the importance of validating non-binary identities in the last decade. These developments are interlinked and occurred in parallel with one another. Firstly, the World Professional Association for Transgender Health’s (WPATH) current Standards of Care version 7 for the health of transsexual, transgender, and gender-nonconforming people (Coleman et al., 2012) formally recognized individuals in their existence who “no longer consider themselves to be either male or female”, and who “describe their gender identity in specific terms such as transgender, bigender, or genderqueer, affirming their unique experiences that may transcend a male/female binary understanding of gender”. Other examples of international professional organizations making their position clear on non-binary identities include the Guidelines for Psychological Practice With Transgender and Gender Nonconforming People (American Psychological Association, 2015), which calls for gender to be understood as “a non-binary construct that allows for a range of gender identities”. The World Medical Association explicitly recognized genderqueer and nonbinary (GQNB) individuals in a statement on transgender people (World Medical Association, 2015). The WMA emphasized everyone’s right to determine their own gender as well as the diverse range of possibilities in this respect.

Secondly, the last decade has seen the publication of two new classification systems, which both recognize nonbinary gender identities, and hence also recognize the need for treatment for those people who wish to do so. The 5^th edition of the Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association (2013) utilizes the term ‘gender dysphoria’, which is described as a marked incongruence between one’s experienced/expressed gender and assigned gender, of at least six months’ duration, and which is associated with clinically significant distress or impairment in social, occupational, or other important areas of functioning (APA, 2013). The DSM-5 thus centralizes the distress, and not the gender. In the DSM-5, the incongruence between “experienced and expressed gender” and “assigned gender” is seen as unrelated to psychopathology. Only when gender incongruence results in relevant distress is it labeled a disorder. This remains – of course – a controversial position. Remarkably, the respective diagnostic criteria are not limited to binary identifications (e.g., trans man, trans woman). Non-binary or genderqueer gender identities or expressions are thus for the first time explicitly mentioned without attributing an inherent measure of psychopathology per se (“alternative gender different from one's assigned gender”).

The 11^th version of the International Classification of Diseases of the World Health Organization (WHO; 2019) use the term gender incongruence and likewise does not rely on a binary gender (Drescher, Cohen-Kettenis, & Winter, 2012). Crucially, the WHO have declassified trans identities as a mental disorder, and repositioned Gender Incongruence within sexual health conditions (WHO, 2019).

And it is here that the controversy lies, while diagnostic terms such as a diagnosis of gender dysphoria in the DSM-5 (APA, 2013) facilitate access to clinical care and insurance coverage for gender affirming treatment in the USA and many other countries, these terms can also have a stigmatizing effect. These changing diagnostic criteria and treatment policies are opening up avenues that are primarily aimed at reducing clinically relevant distress. In line with this, the paradigm shift in transgender healthcare aims to ensure access to transition-related interventions no matter what kind of gender identity or expression (binary or non-binary) is involved and regardless of where the distress originates from (Bockting, 2009; Nieder & Strauss, 2015). Thus, health-related needs of non-binary identifying people have already and will further become increasingly visible and recognized in clinical settings.

The field of binary and non-binary transgender healthcare continues to move forward and expand, clinically, academically, and politically.

Transgender health clinics are sprouting up where there once were none in every region and continent globally often initiated by professionals with a special interest in transgender health and a strong sense of social justice. Existing transgender health services are growing, but often cannot cope with the rising demand resulting in excessive waiting times for patients. There is increasing evidence to move to a more flexible, patient-centered approach with an informed consent model of care provision (Jones et al., 2017). Clinical data show that non-binary people represent a significant proportion of patients in clinical transgender health services, which traditionally used to offer gender affirming medical interventions on a binary treatment pathway (Beek et al., 2015; Köhler, Eyssel, & Nieder, 2018). Increasingly, treatment pathways for binary and nonbinary transgender people are changing to reflect patient choice as an autonomous agent making decisions based on informed consent.

There is thus a welcome and ongoing shift from medical paternalism towards patient autonomy. The World Health Organization has recognized the depathologisation of transgender identity, and consequently Gender Incongruence is no longer deemed a mental illness in the ICD-11 (WHO, 2019). We would expect the American Psychiatric Association to follow suit by removing Gender Dysphoria from the DSM-5 (APA, 2013), whilst ensuring access to care in North America. It is no longer acceptable and justifiable to retain Gender Dysphoria as a diagnostic entity in a manual for mental disorders for the sole purpose of ensuring access to care for binary and non-binary trans people. Further discussion falls outside the scope of this editorial, but we made our position clear elsewhere (Bouman et al., 2010; Bouman & Richards, 2013; Nieder & Richter-Appelt, 2011; Richards et al., 2015).

The forthcoming Standards of Care version 8 (SoC 8) of WPATH is likely to move towards an informed consent based model of providing transgender healthcare. Non-binary identities are a new chapter in the SoC 8. Academically, there has been a significant increase in publications in the field of transgender healthcare (Sweileh, 2018). Research in non-binary transgender health is relatively young and novel, and this volume is a timely collection of a substantive amount of academic work in this area from a wide variety of international clinicians, and/or academics and/or activists.

Politically, there is a growing socio-political acceptance of changes in understanding gender binaries, referring to the recent steps in several countries, such as Argentina, Australia, Canada, New Zealand, and Uruguay where legal gender recognition procedures have opened up space for more than two gender identifications (Ryan, 2018). Also, in different European member states such as Germany, Austria, and Belgium, the Constitutional Courts have paved the way for an ‘X’ gender marker and legal changes are to be expected soon, as is already the case in Malta and Denmark. Ultimately, official identity marks the status by which one can gain, or lose, access to certain social rights, responsibilities, and privileges. The ability to alter one’s official identity is a key mechanism whereby one can essentially change who they are, and what they can become, in the eyes of the law.

This special issue is dedicated to all professionals, communities and other stakeholders, who strive to give visibility to people who identify between, outside and beyond the gender binary; and by doing so make these identities part of language, culture, society, and crucially, reality and history. They are here to stay and clinicians must consider their treatment wishes equally. The center of clinical decision making in modern medicine is the moral imperative to respect the autonomy of the patient to make an informed decision regarding any treatment modality (Beauchamp & Childress, 2009; O’Neill, 2002). As there is general agreement that in ethical matters like cases should be treated alike (Veatch, 2003), medical and psychological paternalism potentially breaches the autonomy rights of nonbinary patients through failing to consider them to be moral equals and treating them instead as less-than-independent determiners of their own good. Clinicians must consider nonbinary trans identifying people to be moral equals and treat them as any other people; there is no justification to do otherwise (Bouman et al., 2014).

This special issues consists of two guest editorials, one systematic review, 14 original research papers, one book review, and 4 letters to the editor.

The first guest editorial entitled “Non-binary and gender queer: An overview of the field” by Monro (2019) summarizes key areas of relevant theory and indicate possible directions for future research, which include areas such as policing and community safety; asylum and refugee rights; social care; the specific identities and needs of intersex non-binary people; and importantly, recommends more intersectional research concerning non-binary and gender queer identities. Monro’s thought-provoking, inspiring and humane editorial raises many pertinent issues that are worthwhile of serious reflection, consideration, and study. Vincent’s (2019) analytic editorial entitled “Breaking down barriers and binaries in trans healthcare: The validation of non-binary people” stimulates careful consideration of a range of factors regarding treatment of nonbinary people in clinical contexts, including sensitivity and cultural competency on the subject of language, bedside manners, and important aspects of endocrine, surgical and non-medical treatments. They suggest that hearing nonbinary people is essential for practitioners to achieve a holistic, individualized, culturally nuanced approach to care.

Thorne et al. (2019) provide a systematic review regarding the terminology of identities between, outside and beyond the gender binary. They observe that a multitude of terms have emerged, particularly within discourses from North America and Western Europe, which describe identities that are not experienced within the traditionally accepted binary structure of gender. Their review explores the origins and tracks the emergence of newer terms and definitions for identities between, outside and beyond the gender binary, outlines current trends in descriptors, and suggests the term gender diverse as a potential term wide enough to encompass all identities, whilst making the caveat that there is a drawback to such a solution too.

The first original research paper concerns a qualitative study by Bradford and colleagues (2018) from the National Center for Gender Spectrum Health in the Department of Family Medicine and Community Health in Minneapolis and the Department of Family Social Science in St Paul in the USA. “Creating gender: A thematic analysis of genderqueer narratives” explores how genderqueer identities are understood and managed in both personal and social domains through semi-structured interviews with 25 genderqueer-identified American adolescents and emerging adults. This study emphasizes genderqueer identities as a source of strength and positivity, and the importance of expanding beyond the dominant gender binary within research and clinical practice (Bradford et al., 2018).

Nicholas (2018) from Melbourne Gender in Australia argues in “Queer ethics and fostering positive mindsets toward non-binary gender, genderqueer, and gender ambiguity” that negative social responses to genderqueerness stem not only from overt prejudice in the form of transphobia, but from binary genderism. Nicholas further proposes a norm-critical approach to deconstructing gender norms, thus fostering positive attitudes to genderqueerness and consequently positive implications for the physical and social health and wellbeing of gender diverse people.

In another qualitative study Fiani & Han (2018) focuses on the conceptualization of gender identity formation through semi-structured interviews with fifteen binary and non-binary transgender and gender non-conforming (TGNC) adults and conclude that there is a significant lack of understanding regarding TGNC people within society, including within academia and clinical practice. Taylor et al. (2018) report on two focus groups consisting of eight non-binary identifying adults attending a transgender health clinic in the United Kingdom discussing how they experienced their non-binary identity. They conclude that non-binary people face challenges in reconciling their personal identities with the limits of the medical treatments available as well as encounter confusion and intolerance from society.

The next seven research papers all discuss aspects of healthcare for nonbinary gender identifying people. Bowling, Baldwin, & Schnarrs (2019) aimed to identify and understand resilience related to health and health care among a community sample of 21 gender diverse identifying adults and demonstrate how stakeholders can identify target areas for interventions and policy change aimed at improving resilience in gender diverse communities by utilizing the Resilience Activation Framework. Burgwal et al. (2019) look at health disparities between binary and nonbinary trans people with a community-driven survey in five countries (Georgia, Poland, Serbia, Spain, and Sweden) comparing overall health and well-being of genderqueer and nonbinary (GQNB) people with binary trans men and women, taking into account the impact of the additive effect of their socio-economic position, as well as their current need for gender affirming medical interventions. Their novel research found that GQNB people reported significantly poorer self-reported health and general well-being in comparison to binary trans respondents. Being in need of gender affirming medical interventions contributed significantly to poorer self-reported health, whereas a younger age contributed to poorer general wellbeing. Rimes et al. (2017) compare mental health, self-harm and suicidality, substance use and victimization experiences between non-binary and binary transgender youth from the United Kingdom in an online survey and found that assigned female at birth participants (binary and non-binary) were more likely to report a current mental health condition, a history of self-harm, and a history of sexual abuse than assigned male at birth participants (binary and nonbinary); a reverse pattern was found for lifetime physical assault relating to being LGBTQ. Interestingly, in their sample binary trans identifying participants reported lower life satisfaction than non-binary trans participants. Thorne et al. (2018) compare mental health symptomatology and levels of social support in a clinical sample of treatment seeking binary and non-binary trans youth in the United Kingdom. They found that non-binary identifying treatment seeking transgender youth are at increased risk of developing anxiety, depression, and low self-esteem compared to binary transgender youth and concluded that their findings support earlier findings by Clark et al. (2018) regarding the challenges and barriers non-binary youth faces in access to care.

Moving from youth to adult people Jones et al. (2019) conducted a case control study and compared mental health and quality of life of a community sample of non-binary trans adults with binary trans and cisgender people. They found that non-binary people reported significantly better mental health than binary trans people, but worse than cisgender people; and suggested that these results may reflect lower levels of body dissatisfaction among the non-binary population. In another case control study Jones et al. (2018) compared levels of gender congruence and body satisfaction in nonbinary trans people with binary trans and cisgender people and found that nonbinary trans people reported significantly higher levels of gender and body satisfaction compared to binary trans people, but there was no difference in congruence and satisfaction with social gender role between the two trans groups.

Rider et al. (2019) from the National Center for Gender Spectrum Health in Minnesota, USA present the Gender Affirmative Lifespan Approach (GALA), which is a psychotherapy framework based in health disparities theory and research, which asserts that therapeutic interventions combating internalized oppression have the potential to improve mental health symptomatology resulting in improved overall health and well-being for gender diverse clients. They discuss the application of the GALA model with nonbinary clients.

McGuire et al. (2018) from the University of Minnesota, USA in collaboration with the Center of Expertise on Gender Dysphoria in Amsterdam, the Netherlands developed the Genderqueer Identity (GQI) Scale and describe the measurement and validation of four distinct subscales with trans and LGBQ clinical and community samples in two countries (the USA and the Netherlands). They state that the GQI fills critical gaps in gender-related measurement including the ability to assess multiple dimensions of gender identity, and to assess gender identity across time. In a second article entitled “Predictive validity of the genderqueer identity scale (GQI): differences between genderqueer, transgender and cisgender sexual minority individuals”.

Catalpa et al. (2019) report strong predictive validity of the GQI in distinguishing binary trans persons from GQNB and cisgender sexual minority persons. Findings reveal that these three subgroups who might otherwise be similarly categorized (i.e., LGBTQ) show significant differences on challenging the binary, social construction, theoretical awareness, and gender fluidity constructs.

Finally, ““I love you as both and I love you as neither”: Romantic partners’ affirmations of nonbinary trans individuals” by Galupo et al. (2019) from Townson University in Maryland, USA focuses on microaffirmations specifically directed toward nonbinary transgender individuals within romantic relationships. They pay particular attention to understanding how microaffirmations operate to complicate binary notions of gender/sex and positively influence nonbinary transgender individuals in interpersonal relationships.

This special issue closes with a book review by Morrow (2018) of “Genderqueer and Non-Binary Genders” by Richards, Bouman, & Barker (2018), which is one of the first concise, academic introductions to a broad range of nonbinary issues, including gender affirming medical interventions.

Finally, there are four letters to the editor. The first one by Moser and Devereux (2016) proposes the creation and use of specific nonbinary gender neutral pronouns. There are three responses to this proposal, which are from the perspective of a transgender writer (Green, 2018), a clinician (Barrett, 2016), and academic linguists (Jones & Mullany, 2016) respectively.

Declaration of interest

The authors report no conflict of interest. The authors alone are responsible for the content and writing of this paper.

Joz Motmans
Center for Sexology and Gender, Ghent University Hospital & Ghent University
Ghent, Belgium
[email protected]
Timo O. Nieder
Institute for Sex Research, Sexual Medicine and Forensic Psychiatry, Interdisciplinary Transgender Health Care Center Hamburg, University Medical Center Hamburg-Eppendorf
Hamburg, Germany
[email protected]

Walter Pierre Bouman
Nottingham Center for Transgender Health & Institute of Mental Health, Faculty of Medicine & Health Sciences, University of Nottingham
Nottingham, UK
[email protected]