Trans persons generally do not identify, or only partially identify, with the gender assigned to them at birth. Some people do not identify as entirely male or female, as some combination, or feel as much or just as little male as female, or do not identify with either – we call these individuals ‘non-binary’. Just like the term ‘transgender’, the term ‘non-binary’ is also an umbrella term: there are different types and terms for people who identify with a gender that falls outside the binary male/female division. How non-binary persons name themselves and their identities thus varies widely – additional terms that are often used include ‘(gender)queer’, ‘agender’, ‘bigender’, ‘genderfluid’, ‘androgynous’, and ‘polygender’. Some non-binary persons count themselves as ‘transgender’, others do not.

Both trans specific studies as well as general population studies indicate that the non-binary subgroup is quite large. In trans specific studies numbers go from 13% in the US (Harrison, Grant, & Herman, 2012) up to 50,3% the latest FRA LGBTI 2019 survey. In general population samples, numbers of people reporting an ‘ambivalent gender identity’ range from 2,2% – 4,6% of people assigned male at birth and 1,9% – 3,2% f those assigned female at birth (Van Caeneghem et al., 2015; Kuyper & Wijsen, 2014).

Non-binary persons might opt for gender affirming care, although studies show this is less often the case compared with trans men or trans women (Burgwal et al., 2019; Scheim & Bauer, 2015). Others manifest their gender expression with clothing, hair and other features. Again, what a person deems necessary is a highly personal choice, which differs greatly from person to person.

In health care settings, asking how a person identifies and which terminology and pronouns they use is a respectful way to take into account people with a non-binary gender identity. Health care providers should be aware that these labels and pronouns can shift during the life course.

Specific Challenges

Trans persons who do not fit within the binary gender categories can experience other problems or face other challenges than trans persons who identify themselves as men or women.

First, non-binary persons remain often invisible to society even more than binary trans persons. Non-binary persons might encounter various problems in their daily lives – in most administrative procedures, everyone is obliged to choose male or female as identification. Legal recognition of non-binary persons does not yet exist in most countries. Malta has opted to create a third category, ‘X’ or ‘other’, but although this policy is adopted by government entities and can be reflected in ID Cards and Passports, it is yet to be mainstreamed. The Maltese and English language are also not yet adapted to non-binary gender identities: we currently only know the male and female form of address. Alternative terms that are sometimes used for he/she; hu/hi and his/hers; tiegħu/tagħha are they/them; huma and tagħhom.

Second, studies show that non-binary people showed significantly worse self-reported health and worse general well-being in comparison to trans men and trans women respondents (Burgwal et al., 2019). They are often unknown to, or misunderstood by, health-care providers working with trans people, and this may result in refusing access to care (Eyssel et al., 2017). They might keep the non-binary concept of their gender hidden, and present themselves as a binary trans person in the hope of increasing their chance to access treatment (Richards et al., 2016). Especially in young persons, non-binary identifying treatment seeking transgender youth seem to be at increased risk of developing anxiety, depression, and low self-esteem compared to binary transgender youth (Thorne et al., 2018; Clark et al., 2018).

Health care professionals working with non-binary clients should get familiar with, and sensitive to, the diversity of non-binary experiences (Vincent, 2018; Motmans et al., 2020). Making sure that clinical information (e.g., websites), forms (e.g., intake surveys), and other materials are inclusive of non-binary identities and experiences conveys that non-binary people are welcome (Hagen & Galupo, 2014).

References:

  • Burgwal, A., Gvianishvili, N., Hård, V., Kata, J., Nieto, I. G., Orre, C., . . . Motmans, J. (2019). Health disparities between binary and non-binary trans people: a community-driven survey. International Journal of Transgenderism, 20(2-3).
  • Clark, B. A., Veale, J. F., Townsend, M., Frohard-Dourlent, H., & Saewyc, E. (2018). Non-binary youth: Access to gender-affirming primary health care. International Journal of Transgenderism, 19(2), 158-169. doi:10.1080/15532739.2017.1394954
  • Eyssel, J., Koehler, A., Dekker, A., Sehner, S., & Nieder, T. O. (2017). Needs and concerns of transgender individuals regarding interdisciplinary transgender healthcare: A non-clinical online survey. PloS One, 12(8), e0183014. doi:https://doi.org/10.1371/journal.pone.0183014
  • ​FRA (European Union Agency for Fundamental Rights). (2014). Being Trans in the European Union. Comparative analysis of EU LGBT survey data. Luxembourg: Publications Office.
  • Hagen, D. B., & Galupo, M. P. (2014). Trans* Individuals’ Experiences of Gendered Language with Health Care Providers: Recommendations for Practitioners. International Journal of Transgenderism, 15(1), 16-34. doi:10.1080/15532739.2014.890560
  • Harrison, J., Grant, J., & Herman, J. L. (2012). A gender not listed here: Genderqueers, gender rebels, and otherwise in the National Transgender Discrimination Survey. LGBTQ Public Policy Journal at the Harvard Kennedy School, 2(1).
  • Kuyper, L., & Wijsen, C. (2014). Gender identities and gender dysphoria in the Netherlands. Archives of Sexual Behavior, 43(2), 377–385.
  • Motmans, J., Nieder, T. O., & Bouman, W. P. (Eds.). (2020). Non-binary and genderqueer genders. London: Routledge.
  • Richards, C., Bouman, W. P., Seal, L., Barker, M. J., Nieder, T. O., & T’Sjoen, G. (2016). Non-binary or genderqueer genders. International Review of Psychiatry, 28(1), 95-102. doi:10.3109/09540261.2015.1106446
  • Scheim, A. I., & Bauer, G. R. (2015). Sex and gender diversity among transgender persons in Ontario, Canada: Results from a respondent-driven sampling survey. Journal of Sex Research, 52(1), 1–14. 00224499.2014.893553
  • ​Scottish Trans Alliance. (2016). Non-binary people’s experiences in the UK.
  • Thorne, N., Witcomb, G. L., Nieder, T., Nixon, E., Yip, A., & Arcelus, J. (2018). A comparison of mental health symptomatology and levels of social support in young treatment seeking transgender individuals who identify as binary and non-binary. International Journal of Transgenderism, 1-10. doi:10.1080/15532739.2018.1452660
  • Van Caenegem E., Wierckx K., Elaut E., Buysse A., Dewaele A., Van Nieuwerburgh F., De Cuypere G. & T’Sjoen G. (2015). Prevalence of Gender Nonconformity in Flanders, Belgium. Archives of Sexual Behavior.
  • Vincent, B. (2018). Transgender health: A practitioner’s guide to binary and non-binary trans patient care: Jessica Kingsley Publishers.