Persons of Nonbinary Gender — Awareness, Visibility, and Health Disparities by Liszewski, Walter; Peebles, J. Klint; Arron, Sarah and Yeung, Howa The New England Journal of Medicine, 12/2018, Volume 379, Issue 25, pp. 2391–2393
Two-spirit, agender, gender fluid, genderqueer, gender-nonconforming, third sex: whatever the terminology, in many cultures throughout history, some people have identified as neither male nor female, or as “nonbinary.” As our society’s concept of gender evolves, so does the visibility of contemporary nonbinary people. Yet many members of the medical community may not know how to interact with nonbinary patients respectfully or recognize their unique needs and barriers to care.
Nonbinary people’s gender identity lies outside the boundaries of a strict male–female dichotomy. As a gender identity, it is independent of biologic sex (male, female, or intersex) and sexual orientation (heterosexual, homosexual, bisexual, or pansexual). Nonbinary and transgender persons are considered gender minorities, but there may be differences between the two (see Glossary).
Current data on health disparities affecting gender minorities come from two large surveys: the 2011 National Transgender Discrimination Survey (6450 participants, 33% of whom did not identify as exclusively male or female and 14% of whom identified as gender-nonconforming) (transequality.org) and the 2015 U.S. Transgender Survey (27,715 participants, 31% of whom identified as nonbinary) (transequality.org). As compared with the general public in other studies, gender-minority persons are more likely to live in poverty (29% vs. 12%), be unemployed (15% vs. 5%), be uninsured (14% vs. 11%), be the victim of intimate-partner violence (24% vs. 18%), have attempted suicide (40% vs. 4.6%), have experienced severe psychological stress in the past month (39% vs. 5%), and have HIV (1.4% vs. 0.3%). Thirty percent have been homeless at some time, and 9% report having been physically assaulted in the previous year because of their gender identity. Gender-nonconforming persons are more likely than transgender persons to have experienced mistreatment in school (70% vs. 59%) or by the police (29% vs. 22%) and are less likely to be “out” in the workplace (33% vs. 44%) or with family (35% vs. 64%).
Nonbinary persons often receive inadequate medical care or face discrimination. Among gender-minority patients, 19% have been refused treatment on the basis of their gender identity, 23% have avoided treatment in the previous year for fear of discrimination, and 33% have avoided medical care because of cost. These negative experiences may explain why in two studies, only 28% and 40% of gender-minority persons said that their health care provider was aware of their gender identity. Fear of discrimination is greater among nonbinary persons who are otherwise socioeconomically marginalized, such as people of color, disabled people, low-income people, and undocumented immigrants.