International Review of Psychiatry

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Non-binary or genderqueer genders
Christina Richards, Walter Pierre Bouman, Leighton Seal, Meg John Barker,
Timo O. Nieder & Guy T’Sjoen
To cite this article: Christina Richards, Walter Pierre Bouman, Leighton Seal, Meg John Barker,
Timo O. Nieder & Guy T’Sjoen (2016) Non-binary or genderqueer genders, International Review
of Psychiatry, 28:1, 95-102, DOI: 10.3109/09540261.2015.1106446
To link to this article: http://dx.doi.org/10.3109/09540261.2015.1106446

Published online: 12 Jan 2016.

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INTERNATIONAL REVIEW OF PSYCHIATRY, 2016VOL. 28, NO. 1, 95–102
http://dx.doi.org/10.3109/09540261.2015.1106446

REVIEW ARTICLE

Non-binary or genderqueer genders
Christina Richardsa,b, Walter Pierre Boumana, Leighton Sealb, Meg John Barkerc, Timo O. Niederd
and Guy T’Sjoene

Downloaded by [212.200.65.127] at 12:21 18 February 2016a
Nottingham Centre for Gender Dysphoria, Nottingham, UK; bCharing Cross Gender Identity Clinic, London, UK; cDepartment of
Psychology in Social Sciences, Open University, Milton Keynes, UK; dInterdisciplinary Transgender Health Care Centre Hamburg,
Department for Sex Research and Forensic Psychiatry, University Medical Centre Hamburg-Eppendorf (UKE), Germany; eCentre for
Sexology and Gender, Department of Endocrinology, Ghent University, Belgium

ABSTRACTARTICLE HISTORY

Some people have a gender which is neither male nor female and may identify as both male andfemale at one time, as different genders at different times, as no gender at all, or dispute the very
idea of only two genders. The umbrella terms for such genders are ‘genderqueer’ or ‘non-binary’
genders. Such gender identities outside of the binary of female and male are increasingly being
recognized in legal, medical and psychological systems and diagnostic classifications in line withthe emerging presence and advocacy of these groups of people. Population-based studies show asmall percentage – but a sizable proportion in terms of raw numbers – of people who identify as
non-binary. While such genders have been extant historically and globally, they remain
marginalized, and as such – while not being disorders or pathological in themselves – people
with such genders remain at risk of victimization and of minority or marginalization stress as aresult of discrimination. This paper therefore reviews the limited literature on this field andconsiders ways in which (mental) health professionals may assist the people with genderqueer andnon-binary gender identities and/or expressions they may see in their practice. Treatment options
and associated risks are discussed.

Received 29 June 2015
Accepted 6 October 2015
Published online 8 January
2016

Introduction
Gender is often considered to come in two forms – male(masculine) or female (feminine). Indeed, it is frequently
elided with physical sex such that when a person is
assigned a female sex at birth – through visual inspectionof their external genitals – it is assumed that their gender
too will be female; that they will likely be feminine (theirgender role); and that they will most likely be sexuallyattracted to men when they reach sexual maturity. Of
course, this series of inferences is correspondingly madewith men - linking sex to gender, to gender role, tosexuality. It is a trivial assertion, however, to say thatthese inferences are not invariably correct. For example,
male people may be attracted to other male people;
people assigned male at birth may have a female gender
identity; and people assigned female may have a malegender identity but, for pragmatic reasons, have a female
gender role (Richards & Barker, 2013, 2015).
All these acknowledged variations nonetheless still
presuppose a binary system of male and female, albeit
that ‘male’ and ‘female’ here may be expressed indifferent ways, e.g. as gender, sex, gender role.
Notwithstanding this, people with an intersex or
CONTACT Christina Richards
christina.richards@nottshc.nhs.uk
3 Oxford Street, Nottingham, NG1 5BH, UK
ß 2016 Taylor & Francis

KEYWORDS

Gender; Genderqueer;
Non-binary; Transgender;
Transsexual

diversity/disorder of sexual development (DSD) condition (APA, 2013a) will have physical sexual characteristics which fall outside of this binary (Roen, 2015);
although the majority of people with this range ofconditions do still identify their gender within the binary –as men or as women (Harper, 2007; Richards & Barker,2013).
In contrast to this, there are a significant number ofpeople who do not have an (observable) intersex/DSD
condition, but who nonetheless identify outside of thegender binary. Such non-binary gender identity or
expression has been present over time and acrossdifferent global cultures (Herdt, 1996).
In the current Western context, however, some people
may identify as predominantly male, but with aspects ofthe ‘other’ gender and use the identity term ‘male’
generally; or may identify as predominantly female, butwith aspects of the ‘other’ gender and use the identity
term ‘female’ generally – but both groups of people may
define additionally as ‘genderqueer’ when necessary – forexample in accepting environments or when neither amale nor female identity suits. Those people who
incorporate aspects of both male and female, but who

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have a fixed identity, may identify as ‘androgynous’,‘mixed gender’ or sometimes ‘pangender’ as the latter is a
flexible term. In contrast, people who move between
genders in a fluid way may identify as ‘bigender’, ‘gender
fluid’ or sometimes ‘pangender’ again. Some people
move between more than two genders and so identify as‘trigender’, and sometimes ‘pangender’ as it is a flexible
term. Some people identify as a specific additional
gender (either between female and male or otherwise
additional to those genders) and identify as ‘third
gender’, ‘other gender’, and sometimes again as ‘pangender’. Then there are those people who disrupt thegender dichotomy though challenging its very ontology
and/or veracity and so identify as ‘genderqueer’ or‘genderfuck’. And there are also people who have nogender and so identify as ‘agender’, ‘gender neutral’,‘non-gendered’, ‘genderless’, ‘neuter’, or ‘neutrois’.
An example of this is present in Bockting (2008) who
found in the course of a US online study a variety ofidentities amongst 1229 transgender individuals thatwere not reconcilable with a binary understanding of sex.
These included ‘shemale, bigender, two-spirit, gender
neutral, genderless, androgyne, ambiguous, intergendered, third gender, pan-, poly- or omni-gendered,dynamically gendered, gender fluid, nonbiological intersexed, in-between and beyond’ (Bockting, 2008, p. 214).
In her qualitative study, Hines (2007) quotes such
further non-binary identities as ‘gender terrorist, intersex
by design, intentional mutation, hermaphrodyke, queer
trannie boy’ (Hines, 2007, p. 80). All of the above terms
are often subsumed within the umbrella terms of ‘nonbinary’ or ‘genderqueer’ identities. In this emerging fieldterms are likely to change, however, and, as usual, we
should attend to people’s own preferred terms when
undertaking clinical work. Moreover, it is important touse people’s preferred pronouns (in addition to names
and terms for gender). Some non-binary people use they/
their/them/themselves or an explicitly developed termsuch as xe/xyr/xem/xyrself rather than he/his/him/himself or she/her/her/herself. With all these aspects, ‘ask’
etiquette is appropriate (Richards & Barker, 2013) whichsimply involves asking what terminology people preferand how they experience their gender. This movetowards a more accepting and accommodating approach
towards non-binary and genderqueer people is mirroredin generally more favourable media reporting within the
global North and West, especially in online and youth
oriented media. Within mainstream media there is still atendency towards a perhaps patronizing ‘interest’ whichsituates non-binary and genderqueer people as ‘other’ tothe assumed norm of the viewer – something which canbe tiring for these minority groups (Sue, 2010).

This paper then, consists of a necessarily extremely
brief overview of the current psychiatric literature
pertaining to such non-binary or genderqueer identities
as these have formed the basis of the literature until now.
It then considers how (mental) health professionals
might assist these groups of people within clinicalpractice in a non-pathologizing manner, which recognizes the pressures and needs of this group of people atthis time in history.

Prevalence of non-binary people
Two population studies have aimed to estimate theprevalence of people who identify as non-binary. Kuyper& Wijsen (2014) examined self-reported gender identityand dysphoria in a large Dutch population sample(N ¼ 8064, aged 15–70 years old), and found that 4.6% of
people assigned male at birth and 3.2% of people
assigned female at birth reported an ‘ambivalent gender
identity’ (defined as equal identification with the othersex as with the sex assigned to them at birth) and 1.1% of
people assigned male at birth and 0.8% of people
assigned female at birth reported an ‘incongruent gender
identity’ (defined as stronger identification with theother sex as with the sex assigned to them at birth).
Recently, Van Caenegem et al. (2015) reported results
based on two population-based surveys, one of 1832
Flemish individuals and one of 2472 sexual minority
individuals in Flanders, Belgium, examining the prevalence of ‘gender incongruence’ (defined as identifying
stronger with the other sex than with the sex assigned atbirth) and ‘gender ambivalence’ (defined as identifying
equally with the other sex as with the sex assigned atbirth). Their findings showed that the prevalence of‘gender ambivalence’ or non-binary gender was 1.8% in
natal men and 4.1% in natal women.
In terms of trans populations more specifically, one
UK study found that 5% of Lesbian, Gay, Bisexual, Transand Questioning (LGBTQ) youth identified as neither
male nor female (METRO Youth Chances, 2014); a US
study found that 13% of trans people surveyed were ‘agender not listed here’ (Harrison et al., 2012, p. 14); anda Scottish study on trans mental health (McNeil et al.,2012) found that over a quarter of survey participants
identified as non-binary.
Turning to wider gender experience and expression,
rather than specific identities, it seems that the figures
are likely to be much higher. Joel et al. (2013) surveyed
people in the general population in Israel and found that,out of 2225 participants, over 35% felt that they were tosome extent the ‘other’ gender, ‘both’ genders, and/or
neither gender.

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97

These are clearly significant proportions of people;
however, comparatively few appear to seek any form ofassistance at gender identity clinics. For example, in Beek
et al. (unpublished), out of 360 applicants for gender
reassignment treatments only four explicitly stated that
their non-binary identity was their motivation fortreatment. This may, of course, be related to thenumber of non-binary people who feel able to be open
about their identities in such settings.

the last revision to the American Psychiatric
Association’s (APA, 2013a) Diagnostic and statisticalmanual fifth edition (DSM-5). The DSM-5 removed theDSM IV-TR (APA, 2000) diagnosis of gender identity
disorder which considered wishing to change one’s
gender to be a disorder and only recognized the genderbinary of male and female. The DSM-5 instead includes
the diagnosis of gender dysphoria which explicitly
recognizes that having a different gender is not adisorder (APA, 2013b) and crucially includes the criteria:

Human rights and legislation for non-binary
people

Many of the non-binary groups of people listed above
will use their birth-assigned gender as a matter ofnecessity in day-to-day business and bureaucracy due tothe fact that many systems (including health systems)
and social circles only recognize binary genders. This ischanging, however. For example the European Union’s
Council of Europe Parliamentary Assembly Resolution
2048 6.2.4 recommends that European Parliaments‘Consider including a third gender option in identity
documents for those who seek it’ (Council of Europe,2015). Similarly, the United Nations’ (UN) General
Assembly Report of the United Nations HighCommissioner for Human Rights Discriminatory laws
and practices and acts of violence against individuals
based on their sexual orientation and gender identity(United Nations, 2015) advocates for fair treatment ofLGBT people in all UN member states and notes that:
The terms lesbian, gay and bisexual and transgender areused throughout the report, but often abbreviated toLGBT. These terms are used to refer to same-sex
behaviour, identities or relationships and non-binary
gender identities. (United Nations, 2015, p. 4; italics notin the original.)

Thus the report includes non-binary people within
its purview and consequently within international law.
Notably, holders of New Zealand passports may alreadyhave their gender marked as male (M), female (F), or as
neither male nor female (X). More broadly, organizations from Facebook to the United Kingdom’s Royal
Mail are including non-binary genders as gender options
for their customers. It follows, therefore, that healthprofessionals should attend to this cultural shift in theirwork.

Diagnostic classification concerning non-binary
peopleThis trend toward acceptance, as well as a greater
understanding of the diversity of gender, has beenreflected within the context of mental health care as in

4. A strong desire to be of the other gender (or somealternative gender different from one’s assigned gender) 5. A strong desire to be treated as the other gender(or some alternative gender different from one’s
assigned gender) 6. A strong conviction that one has the typical feelings
and reactions of the other gender (or some alternative
gender different from one’s assigned gender). (APA,
2013a p. 452; italics not in the original.)
Thus non-binary genders are recognized with the APA’s
diagnostic taxonomy also. There are, of course, strong
arguments for removing diagnoses pertaining to genderfrom the DSM entirely as there are no higher rates ofpsychopathology in this demographic (Cole et al., 1997;
Colizzi et al., 2014; Haraldsen & Dahl, 2000; Hill et al.,2005; Hoshiai et al., 2010; Kersting et al., 2003; Simon et al.,2011). Of course this does not include wider psychologicaldistress, most commonly minority or marginalizationstress, which is stress caused by being in a group which
is discriminated against and so may lead to psychopathology – it is the discrimination rather than the membershipof this specific group which is psychopathogenic.
Nonetheless, gender diagnoses have been retained
predominantly for the purely pragmatic reason thatsome people who do not remain in the gender they wereassigned at birth wish for interventions such that they
have a more holistically congruent self. This might
include such things as hormones, chest surgeries, andgenital surgeries of various sorts to give people a bodymore in keeping with their gender; or psychological andcounselling assistance to assist with psychosocial transitions (Richards et al., unpublished). Consequently theWorld Health Organization’s (WHO) forthcoming revision of the International classification of diseases andrelated health problems (ICD-11), which is expected to be
published in 2017 will likely remove the diagnostic
category ‘gender identity disorders’ from chapter V(Mental and behavioural disorders) of the ICD-10(WHO, 1992) (which again used a disorder and binary
gender model). The recommendation from the Working
Group on the Classification of Sexual Disorders andSexual Health is to replace it with a diagnosis of ‘gender

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C. RICHARDS ET AL.

Table 1. Number of PubMed results by term.
Qualifying search term
Search term

(None)

Non-binary

Genderqueer

Genderqueer
Non-binary
Trans

5
54
264,5310n/a4Transsexual

9760Disorder of sexual development
Diversity of sexual development
Intersex

17,871705
36,855

0
0
0

n/a
n/a
1(Moody &Smith, 2013)
1(Moody &Smith, 2013)
00
0

Downloaded by [212.200.65.127] at 12:21 18 February 2016

n/a, not applicable.

incongruence’, which does not include the assumption ofdisorder and again includes non-binary or genderqueer
identities. They further asserted that based on morereflective and contemporary scientific evidence and bestpractice there is merit in placing gender incongruence inan entirely separate ICD chapter that would contain noother entities (Drescher et al., 2012).

Prevalence of studies in the literature
A PubMed search was carried out on 10 April 2015 in an
endeavour to undertake an examination of the extant
peer-reviewed medical literature (see Table 1). Some
items returned multiple false positive entries (i.e. transbecause it is a homonym) in which case only the first 100
entries were reviewed and articles were excluded asnecessary.
As peer reviewed literature on genderqueer and nonbinary identities is evidently extremely rare, that which
was found was snowballed to further include literature
which electronic engines have not adequately catalogued.
Further, the authors’ own very recent work was included,
as well as the legal and prevalence items mentioned
above. Lastly, some consideration was given to the grey
and community literatures as these are a rich source of
information on this emerging field, which will not belisted on PubMed. Given the heterogeneity of thisliterature, both in source and type, it has been included
in a bricolage above and below, rather than in a positivist
fashion.

A discussion of the literature
Non-binary people might appear to be a relatively recent
and under-researched phenomenon, but it is likely thatsome people who previously would have identified astrans(sexual) – that is within the gender binary, butmoving across it – may have identified outside of thebinary if that discourse had been available to them.
However, it is very likely that they were not distinguishedas such but were instead diagnosed as having a gender

identity disorder not otherwise specified by gender teams
at medical centres; and have only become increasingly
visible in recent years (Hage & Karim, 2000, Nieder &Richter-Appelt, 2011). An analogy may be drawn with
the number of lesbian and gay people who became able
to identify their sexualities within contemporary
Western societies when the possibility to do so became
more available and the identities became more widely
understood and accepted. This also applies, to a lesser
extent, to bisexual people, as bisexuality remains relatively invisible (Barker et al., 2012). Further, some nonbinary and genderqueer people may have been reticent
to foreground their identities for fear that they would notreceive the physical testaments they desired. Hopefully,
compassionate clinical practice is now assisting thisgroup of people to feel comfortable presenting to gettheir true needs met.
People who are now re-self-defining to a non-binary
identity are also increasingly availing themselves of thepossibilities afforded by the change in legal and bureaucratic systems – for example by using the title ‘Mx’ andmaking a change of name to reflect their gender moreaccurately (a non-gendered name, initials only, or
including both masculine and feminine names, forexample). Other strategies enabling genderqueer people
to express their non-binary identifications appropriately
in a day-to-day context include the following(for detailed information see Nieder, 2014):
Stretching: Making the established identity categories
of femininities or masculinities more flexible(Connell, 2005),
 Diversifying gender: Based on the concept of acontinuum whose graduations manifest themselves
via the interaction of sex characteristics, subjective
gender experiences, and expressions (Monro, 2007), Dissolution or negation of sex difference: Pursued by
the genderqueer movement in particular (Bornstein& Bergman, 2010; Nestle et al., 2002) with the goalof a ‘non-gendered social order’ (Monro, 2010, p. 246),
 Creating ambiguity: To express gender in a way that
defies a mono-sex assignment that is exclusive andfixed over the life course (Engel, 2002).
It is therefore beholden on (mental) health careproviders to respect these different strategies and tointegrate them into their work.
When working with people who are existing psychiatric patients, professionals may understandably beconcerned that an ‘atypical’ gender is as a result ofsome psychopathology such as psychosis or emotionallyunstable personality disorder. However, as with thepathologization of homosexuality in the past, it is vital
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INTERNATIONAL REVIEW OF PSYCHIATRY

it as pathology when it is ‘co-morbid’, in a way that wewould not with a binary gender (or heterosexuality).
Certainly there is no evidence to suggest that nonbinary genders are pathological. Indeed what evidence
there is suggests quite the reverse. It is worth consideringthat there are no psychological fields in which male andfemale are discrete (Fine, 2010) and that the overlap isalways greater than any difference (Maccoby & Jacklin,1974). This is clearly adaptive as it enables both men andwomen to carry out the variety of tasks required of them,and consequently those people who are more ‘sex typed’– that is further towards the ends of a notional gender
spectrum – are disabled by their rigid adherence to theirgender role (Bem & Lenney, 1976). Indeed, exposure togender role stereotypes diminishes confidence andinterest in ‘the other gender’s fields’ such as mathematics
for women (Correll, 2004), as well as actual performancein them (McGlone & Aronson, 2006).
(Mental) health professionals, then, may best serve
their patients by supporting them in their identities andexpressions and affirmatively exploring identities if thatis the presenting problem. Empirical research in this area
would also be most welcome. In addition, psychiatrists,
psychologists and other clinicians may usefully utilize
their clinical skills as necessary to assist with psychosocial transitions associated with non-binary genders.
This will include such things as addressing anxiety
around coming out to others and being seen in public,
consideration of intimate relationships and family,
sexuality and reproductive options, and considerationof physical interventions aimed at the bodily andpsychological comfort of the non-binary person.
Those non-binary people who are seeking approval
for physical interventions should be compassionately
assisted, perhaps referring to standards of care such as
the World Professional Association for Transgender
Health’s (WPATH, 2011) Standards of care for the heathof transsexual, transgender and gender nonconforming
people or the Royal College of Psychiatrists’ CR181, Good
practice guidelines for the assessment and treatment ofgender dysphoria (Wylie et al., 2014).
It is important to note here the differences andsimilarities between trans people who make physicalgender changes within the binary, and non-binary people
who do not, as this is important in planning appropriate
support for individuals. A significant number of transpeople decide not to undergo surgical interventions toaddress the incongruence between their physical andmental gender (Bockting, 2008; WPATH, 2011). This
does not, in and of itself, define the individual as having
a non-binary gender identity, and the support and healthcare needs of these individuals will differ from those witha non-binary gender identity.

99

When considering physical interventions then, themeans for achieving overt masculinization or feminization is quite established (Gooren, 2011) but in order toguide genderqueer individuals in hormonal and/or
surgical treatments, and to predict their effect shortor long term, we have to creatively rely on principles oftreatment in trans men or women, or – in the case ofhormones – on data and treatment from related
endocrine conditions such as hypogonadism, precocious
puberty, polycystic ovarian syndrome, menopausal
replacement therapy, infertility, DSD, and on principles
of hormonal contraceptives.
Indeed, when relying on such information we muchalso note that the physical intervention needs of nonbinary individuals are diverse. For example, as with transpeople within the gender binary, some do not desire any
such interventions. However, for a significant minority it
is most important to remove obvious markers ofmasculinity or femininity (e.g. breasts or facial/bodyhair). Others wish to combine such markers, or may betaking a more conventional trans masculine or feminine
treatment path whilst maintaining a non-binary identity.
For example, Rankin & Beemyn (2012) found that somenon-binary people who were assigned female at birth
had chest surgery and/or took hormones. Others did not
engage in these methods, but modified some visible
markers of gender in other ways, including breastbinding, having a traditionally male hairstyle, notshaving their body hair, bodybuilding, and/or packing
their groin region to give a stereotypically male contour.
Non-binary people who were assigned male at birthsimilarly had varying relationships to hormones/surgeries. They frequently did things such as wearing makeup, having long hair, removing body/facial hair, and/or
wearing ‘feminine’ jewellery. Some people liked todestabilize conventional markers of gender by dressing
androgynously, by combining ‘men’s’ and ‘women’s’
clothing, and/or by dressing in clothing associated with adifferent gender. Some made similar shifts in mannerisms such as gait, making eye contact, and sitting withlegs together or apart.
It is clear that the endocrine possibilities or limitations
for this specific group are, so far, not described in the
medical literature and indeed it is likely that a proportionof this group are self-medicating with the attendant risks(Rotondi et al., 2013). Further, cosmetic interventions
may be sufficient to achieve partial feminization. Breast
implants can be considered safe, as is laser epilation,even if the effect on skin is thought to be less successful
in the absence of hormonal treatment. The role of thehormone-prescribing physician is therefore to liaise withthe multidisciplinary team as necessary and to monitor the effects and mostly cardiovascular side effects ofDownloaded by [212.200.65.127] at 12:21 18 February 2016

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anti-androgens/oestrogens or testosterone treatment,
and to try to modify cardiac risk factors throughadvising diet, exercise, and smoking cessation, and toencourage routine surveillance of glycaemia, lipids,
haematocrit and bone mineral density. A second
important role is in counselling the individual about
what hormonal therapy is able to achieve, so that theindividual’s expectations of therapy can be aligned withwhat is possible with current hormonal treatments, andthe impact of treatment on physical health discussed.
Given the lack of literature on this topic, referral to an
endocrinologist may be useful. For people assigned maleat birth, the endocrinologist can decide with the client on
anti-androgen or oestrogen monotherapy, with variabledosage or intermittent use. Unfortunately, no data on
small dosage anti-androgen therapy is available.
Gonadotropin releasing hormone agonists or antagonists
may be less desired for this group since absolute
testosterone suppression would be achieved; however,used in combination with androgen and oestrogen they
could offer the possibility of tailoring the hormonal
milieu of the individual without surgical interventions
such as gonadectomy. Lower dosage oral anti-androgen
treatment (finasteride, cyproterone acetate or spironolactone) can create moderate androgen deprivation,
possibly leading to interruption of the process ofandrogenetic alopecia, somewhat less virilization, andthe development of the desired mild gynaecomastia.
Erectile dysfunction that may occur can be treated with
PDE-V inhibitors on demand. All hormonal interventions should, of course, be preceded by a discussion on
the effect on fertility (Richards & Seal, 2014; T’Sjoen
et al., 2013) although it is worth noting that interruptionof hormonal treatment is likely to restore spermatogenesis over a period of 6 months. The occurrence of
metabolic side effects of high-dose anti-androgen therapy, such as used in prostate cancer or sex offenders, canbe considered modest. If feminizing hormone therapy isused long term, without the desire for genital surgery,probably no specific oncological concerns are needed forthe testicular tissue, and breast cancer is rarely reported(Gooren et al., 2013). Indeed, prostate cancer is rarely
reported in trans women, but it does occur andcontinuous monitoring has to be considered in all
those undergoing anti-androgen therapy (Gooren &Morgentaler, 2014).
For people assigned female at birth, partial virilization
can be achieved through different therapies, dependingon the wish of the client. Interruption of menstrual
bleeding can be achieved by use of continuous progestins
or intrauterine devices. Prolonged intake of combinedoral contraceptive pills will lead to amenorrhoea, butclients have to be warned about the possibly of spottingor irregular and unpredictable menses as there will be a
30% increased oestrogen intake. Use of dihydrotestosterone is often desired, but remains barely described; as
is low dose or intermitted treatment with testosterone. It
has to be considered that exogenous testosterone isaromatized to oestrogen, and if no surgical steps aretaken, monitoring for breast, cervix, endometrium or
ovarian cancer remain necessary. Hormone-dependent
cancers have been rarely reported in trans men and so
may also be the case here. Fertility seems preserved, as
has been shown in popular literature, and virilization
does not disappear if testosterone is temporarily interrupted for this cause, but specific guidance remains
undescribed.

Conclusion
Recent reports indicate that the overall number ofindividuals with gender dysphoria who attend clinicalservices for an assessment has increased substantiallyover the years in many North American and European
countries (Aitken et al, 2015; De Vries et al, 2015). Thereis also a significant increase in people who self-diagnose
as suffering from gender dysphoria and gender incongruence (Kuyper & Wijsen, 2014; Van Caenegem et al.,2015).
Although the proportion of people who identify as
non-binary and seek gender-related treatment within the
aforementioned research remains unknown, it is highly
likely that an increasing amount of non-binary people
will present to clinical services seeking treatment. In theabsence of clinical guidelines and treatment protocols forthis group, prospective outcome studies are vital andtimely. In the mean time we urge careful compassionate
assistance for this patient group.

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

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