Healthcare outside the gender binary

Non-binary people have been largely underrepresented in research, policy, and healthcare initiatives. While we are making strides in access to social, legal, and medical gender affirmation for all gender diverse people, non-binary and gender queer people are still less likely to access desired gender affirming healthcare than binary transgender people.

There has been an uptake of the term “gender diverse” among sexual health academics in an attempt to break away from the binary gender trap. It is an umbrella term that includes anyone that is not cis-gendered, or doesn’t identify fully with the gender they were assigned at birth. This includes binary transgender (BT) individuals – those who identify as male or female. Non-binary and gender queer (NBGQ) has also been taken up to identify the subgroup of gender diverse people who are not binary transgender. 

Attempts have been made to include people beyond the binary by using terms like transgender, trans* or trans umbrella, but ultimately the “opposite” implied by the prefix trans makes identifying as non-binary a little confusing. For this reason, there are many people who identify somewhere outside that binary and don’t feel that these words apply to them. On the other hand, many do feel like they are part of the trans community or would like to be. NBGQ or gender diverse are now being used in academic contexts to be more inclusive, but the research is still catching up to the community’s understanding of what non-binary even is. 

Some of the most up to date gender research estimates that up to 53.5% of gender diverse Australians identify as non-binary rather than binary transgender, yet most past research has been focused on BT folks. Many studies on health and gender diversity have recruited transgender people without creating subgroups, which creates two issues. Firstly, they did not distinguish between binary and non-binary participants, and secondly, the specification of ‘transgender’ may have led potential non-binary participants to believe they weren’t welcome in these studies. This kind of exclusion from research makes it impossible for the scientific community to have realistic data on the unique needs of non-binary people. Unfortunately, the necessary changes made in legislation and norms in healthcare on a larger scale often rely on data that supports the need for change. We are doing more now, but there’s still a long way to go. 

From the research we do have, NBGQ and BT people experience different barriers to health and healthcare, different social and economic barriers, and even differ in the ages at which they come to understand their identity. Many of us are familiar with the story of the trans kid who has known since he was three that he’s really a boy. However, with NBGQ people, the average age of realizing their identity is older than it is for BT people. This could be related to social factors that reinforce the binary as well as differential developmental processes for these two groups. NBGQ people are more likely to be housing insecure and less likely to have familial and social support than BT people, which impacts everything from mental health to access to basic healthcare.

When it comes to the way we approach gender related healthcare, it’s important for everyone from GPs and nurses to gender therapists to have at minimum a basic understanding of gender diversity. Activism in social acceptance is invaluable, but for things to change in healthcare, we need activism in research. We need comprehensive studies that prove why healthcare workers need to be trained in gender diversity as a rule. 

All healthcare should be approached from a gender-sensitive lens. The role of educator is often left with the patient, as their GP, psychologist, or other doctors might know very little about gender diversity. NBGQ people are often left behind when it comes to sexual healthcare, in part because NBGQ people may feel uncomfortable going to doctors generally. Specifically for sexual health issues, they are more likely than even BT people to encounter insensitive and misgendering language use. Similarly, they may not feel confident negotiating safer sex with partners, as gendered terms and roles can induce feelings of dysphoria. If sexual health is hard to deal with at home, and harder with a GP, it’s easy to imagine the impact this could have on the sexual well-being of NBGQ people. 

A simple improvement is to ensure that intake forms include a preferred name and pronoun section. If you go to a GP for the first time, you may need to list your legal name and the sex on your legal documents, which is often difficult to have changed to reflect your gender identity. However, if my GP reads that I prefer to be called Julz, even though my legal name is Julianne, and I use they/them pronouns, they can then integrate that into their first meeting with me and avoid making me feel more uncomfortable than I need to be. All medical professionals can be encouraged to always use preferred names and pronouns, and ask if there are any changes to make sure their files are up to date. As language around gender changes, and enbies learn to better self identify, they may need to make these changes on occasion.

Gender diversity training resources for healthcare workers exist, but in most cases they are optional. Resources in NSW like Transhub are great places to search for doctors that already know this stuff – but realistically not everyone has easy access to supportive doctors. We shouldn’t be required to seek out specialists, or go far from home, when all we need is a GP, nor should we be required to see a local GP and be misgendered on our visits.

In addition to more training within general healthcare, we need to consider improvements we can make to access to gender affirming healthcare for NBGQ people. Gender affirmation is multifaceted, covering the ways in which a person may choose to more closely align their life with their gender. Gender therapy, social gender affirmation, hormone replacement therapy (HRT), gender-affirming surgeries, and legal gender affirmation are all potential aspects of gender affirmation. While none of these processes are necessary for someone to live as their gender, they can be valuable for reducing dysphoria and taking steps toward socially affirming your gender.

Legal gender affirmation is the process of changing your name and/ or gender marker on legal documents, such as your birth certificate and driver’s license. In NSW, your gender marker can be male, female, or other gender. This is an incredible update that opens up legal affirmation to more NBGQ people. However, this change currently requires the individual to have undergone at least one gender affirming surgery.  While there are differences between NBGQ and BT groups in desire for gender affirming healthcare, NBGQ participants that do hope to access these services are less likely to have done so. Because fewer NBGQ people have access to these interventions, and not all NBGQ actually want gender-affirming surgery, it is impossible for many NBGQ to have their gender and name changed legally. This can be detrimental to their mental health and can result in a reluctance to access healthcare resources, apply for new jobs, or generally socialize in unfamiliar settings. This is also relevant for many BT people, but they are both more likely to desire gender affirming surgery and more likely to have already had surgery. 

Considering the barriers NBGQ people face, it’s not surprising that NBGQ people in NSW are less likely than BT people to be socially, legally, or physically affirmed in their gender. Assuming that all gender diverse people want or able to access gender affirming surgery is discriminatory and insensitive. Policies that result in fewer barriers to legal gender affirmation wouldn’t just be good for enbies, as BT people would also benefit. 

Pressuring someone to make the choice between potentially unnecessary or inaccessible surgery, and being unable to change their gender markers, is no small decision. Legal, social, and medical affirmation should be available to all people in whatever capacity is appropriate for them. NBGQ people are frequently told that they are not real. Like the ever-present plight of bi-erasure, we are often told to pick a side – and we shouldn’t have to.

It’s important, as policies and norms evolve, that we keep in mind that all aspects of gender affirmation should be available to gender diverse people. With fairer policies and more educated healthcare workers, NBGQ people can work with their doctors and psychologists to make decisions around gender affirmation that are right for them. If we aren’t gathering sufficient gender research, this community will continue to be underserved as we don’t really understand their needs. As long as healthcare workers aren’t required to have gender diversity training, enbies will continue to be misgendered and feel unwelcome.