Nonbinary people have hormone therapy and surgery more often than you might think

(The authors say, throughout this article we reference people's presumed gender at birth, which may seem ironic as we are talking about people whose gender identity was assumed incorrectly. We use this to define the unmet medical needs of nonbinary people, as they must fit into a binary medicalized system, and as a way to make our comparisons easier for readers to understand.)

Because of this lack of awareness, nonbinary people often face greater rates of discrimination which can lead to higher rates of depression and suicide compared to trans women, trans men and their cis peers.

On this Trans Day of Visibility, it's important to spotlight nonbinary identities and experiences.

There are many nonbinary staff in the team at Trans Health Research (more than any other gender identity, in fact) and want more action to support nonbinary identities.

What does nonbinary mean?

Nonbinary is a broad umbrella term for people who have a gender that does not fit exclusively into the woman/man gender binary.

Under this umbrella, some people use more specific gender labels to describe their gender experience—including genderqueer, genderfluid and agender.

About 2% to 4.6% of the population is nonbinary.

Within the Australian trans and gender-diverse community, survey respondents were split approximately one-third trans women, one-third trans men and one-third nonbinary.

Like Australia's population as a whole, nonbinary people are highly diverse.

They may affirm their nonbinary gender in different ways, including social affirmation like changing clothing, name and pronouns, and legal affirmation, like changing their legal name and/or gender.

Although the Australian Government has recognized nonbinary genders for more than a decade (with an "X" gender or sex marker), nonbinary people continue to face barriers to legal recognition in some states and territories.

Just as nonbinary people are diverse in how they socially and legally affirm their gender, so too are the ways that they may or may not medically affirm their gender.

There is a common misconception that nonbinary people rarely, if ever, pursue medical gender affirmation—that is, gender affirming hormone therapy and/or gender affirming surgery.

However, as research in International Journal of Transgender Health shows, a growing number of nonbinary people have or want to affirm their gender medically.

Why do myths about nonbinary people persist?

For a very long time, nonbinary people faced significant barriers to accessing gender-affirming hormones and surgery.

Older treatment guidelines often involved mental health assessments and a requirement to conform to binary ideas of gender. Hormone therapy was only provided at full standard doses and only if someone had lived as a trans woman or trans man.

Nonbinary people often had to pretend they were trans women or trans men in order to access what they needed as many doctors refused to provide health care or alternative doses of hormone therapy to nonbinary people.

It was just over a decade ago, in 2013, that the American Psychiatric Association updated their holy grail, the Diagnostic and Statistical Manual (DSM), to stop pathologising trans people as having a mental disorder.

Thankfully, in recent years, a more individualized, patient-centered approach has shifted us to an Informed Consent Model of Care, which positions the trans person as the expert on their own gender.

This approach has improved access to gender affirming hormone therapy.

Recent research found only a 10% unmet need for hormones among nonbinary people. This is compared to older surveys in 2013 and 2020 which found nearly 50% had unmet need.

Similarly, barriers to surgery have also reduced.

What are the different approaches to hormones and surgery?

Nonbinary people (and all trans and gender diverse people) can take different approaches to hormone therapy and surgery.

Research showed that 44% of nonbinary people want both hormones and surgery, eight% don't want either and the remainder fall somewhere in between. Many nonbinary people said they were still thinking about what is right for them.

While some nonbinary people access hormone therapy doses that are typically associated with trans men or trans women (referred to as full standard doses), others use hormone therapy at lower doses or for shorter periods of time to achieve their gender affirmation goals.

There are also different approaches to surgery.

For example, while some nonbinary people presumed female at birth want a 'typically masculine chest," others may seek different surgical outcomes, like different nipple placement, complete removal of the nipples or a non-flat chest.

In nonbinary people presumed male at birth, different options may include the creation of labia without the construction of a vagina, removal of testicles without construction of a vagina or construction of a vagina while keeping the penis.

How common is hormone therapy and surgery for nonbinary people?

In a survey of 271 nonbinary Australians, 66% had used or wanted hormone therapy.

Among the nonbinary survey respondents presumed female at birth, nearly half reported that they were using testosterone therapy. In nonbinary people presumed male at birth, 59% reported they were currently using gender-affirming hormone therapy to either increase estrogen or to decrease testosterone.

When looking at gender affirming surgery, nearly half of the nonbinary people surveyed had or wanted surgery.

In nonbinary people presumed female at birth, 23% of people surveyed wanted but had not had any type of surgery. In nonbinary people presumed male at birth, 26% desired surgery but haven't accessed it yet.

Why is there an unmet need in Australia?

In general, the unmet need for all gender-affirming surgery remains very high.

In nonbinary people presumed female at birth who reported they had had or wanted surgery, around 43% had not been able to access surgery. No one surveyed had accessed metoidioplasty or phalloplasty (surgeries to create a penis).

In nonbinary people presumed male at birth, the unmet need for surgery was even higher—of those who had had or wanted surgery, 82% had not been able to access it.

In Australia, there's a profound lack of surgeons performing gender-affirming surgery and all these surgeries are performed in the private sector.

This means high out-of-pocket costs that range between $AU10,000 for chest surgery to over $AU100,000 for some types of phalloplasty, making it inaccessible for most.

In promising news, there has been a submission to the Medical Services Advisory Committee to create new gender affirming surgery item numbers. If successful, it will hopefully encourage more surgeons to train in gender-affirming surgery.

Contrary to the myth that nonbinary people rarely or never want hormones and surgery, it is in fact common.

Like trans women and trans men, nonbinary people can benefit immensely from access to hormones and surgery, improving their quality of life, mental health, with reductions in gender dysphoria and suicidality.

There must be more diverse approaches to gender affirmation for nonbinary people that provide individualized, patient-centered care that ultimately improves their physical and mental health as well as their quality of life.