Figure

Nonbinary describes any person who identifies with anything other than the strict binary of man and woman. Nonbinary people may identify as both man and woman, somewhere in between, or neither. Some nonbinary people reject the concept of gender altogether. This lack of strict definition can make it difficult for healthcare providers to feel confident in their wording, communication, and interactions with these patients. This can lead to misunderstandings at best and outright bias and discrimination at worst.

In the United States, about 1 in every 250 persons identifies as gender-diverse.1 The likelihood of encountering a gender-diverse patient in a medical practice is high, yet confidence in treating nonbinary patients remains low.2 Research shows that nonbinary patients face discrimination in all parts of their lives, including healthcare.2-5 These patients need respectful and culturally competent care.

TERMINOLOGY

A thorough understanding of the current terminology for gender identity is a first step toward building confidence in taking care of nonbinary patients (Table 1). The terminology a nonbinary person most identifies with varies from person to person. Identity categories are in a constant state of evolution, with new terms emerging and others becoming outdated.6 What is most important is using the terminology that the patient feels most comfortable using and understanding what it means to them. For example: “What would you consider your gender identity?” If a term is unfamiliar, a follow-up clarification question may be necessary. For example: “I don't like to make assumptions. What does that term mean to you? If you don't want to clarify further, that's fine, too.” Patients often are our best teachers, but they should not feel obligated to do the teaching.

TABLE 1. - Terms related to sex and gender identities2,10

Male/female—Refers to biological sex, though these terms are often (incorrectly) used to refer to gender

Man/woman or boy/girl—Refers to gender or gender identity

Nonbinary—Describes a person who identifies as neither man nor woman

Gender-fluid—Describes a person whose gender identity is not fixed and may change at different times

Agender—Describes a person who identifies as having no gender

Bigender—Describes a person who identifies as a combination of two genders

Gender-diverse, gender-queer—Describes a person whose gender identity differs from the sex assigned at birth

Transfeminine—Describes a nonbinary or gender-diverse person whose gender identity's directionality is feminine, with male sex assigned at birth

Transmasculine—Describes a nonbinary or gender-diverse person whose gender identity's directionality is masculine, with female sex assigned at birth

AVOIDING GENDERED TERMINOLOGY

A second step that can be taken to start practicing more gender-affirming care is to avoid specifically gendered terminology. Gendered identity terms, such as mother or father, may alienate nonbinary patients. Gender-specific language may deter gender-diverse patients from seeking needed care.5 For example, a well-woman visit might be avoided by a nonbinary patient. Clinicians cannot know a patient's gender identity just by looking at them or even hearing their voice. Initial communication with any patient can simply be nongendered: for example, “How are you today?” instead of “How are you, sir?” or “The restroom is down the hall” instead of “The ladies' bathroom is down the hall.” Using neutral terms with all patients creates an atmosphere of inclusivity and avoids inadvertently offending any patient. Another best practice in terms of gendered terminology is to avoid honorifics (such as Mr. or Mrs.) when addressing patients or calling them from the waiting room. Instead, consider using the patient's first initial and last name, or just last name.

Box 1USING CORRECT PRONOUNS AND PREFERRED NAMES

Avoiding gendered terminology and using gender-neutral terminology is different and separate from the concept of using gender-affirming terminology. Addressing patients by their preferred name and preferred pronouns is a gender-affirming practice. Using correct pronouns is essential for building a stronger patient-clinician relationship.2 Always use the patient's preferred terms and pronouns in charts and medical documentation and when discussing patients in their absence. As with terminology for gender identity, a nonbinary patient's chosen pronouns may differ from person to person. Some patients may still use binary pronouns such as she/her/hers and he/him/his; others may prefer they/them/theirs. Some nonbinary patients also choose to use no pronouns. The best way to find out a patient's preferred pronouns is to ask: for example, “My pronouns are she/her. Which pronouns do you prefer?” Another way to ask without self-disclosure: “I'd like to be respectful. What pronouns do you prefer to use?” For some nonbinary patients, gender identity can change over time, and for some, it exists on a continuum. Clinicians may need to confirm a patient's preferred name, gender identity, and pronouns at each clinical visit: for example, “At our last visit, your preferred name was Sam, and your pronouns were they/them/theirs. Is this still accurate?”

ANATOMICAL INVENTORIES

Avoiding assumptions about anatomy is particularly relevant to nonbinary patients, who may have had surgical intervention to affirm their gender identity even if they are agender or gender-fluid. Clinicians should clarify what anatomy a patient has and any interventions they have had related to their anatomy, and should do so in a respectful manner. Creating an anatomical inventory or survey for your patient can help assist with this and can help capture organ diversity.7 An anatomical inventory or survey is a form of documentation that lists the presence or absence of an individual's organs. The inventory also can list any surgeries a patient has had in relation to their organs—for example, breast reconstruction. An anatomical inventory can be used to tailor clinical management and preventive services specifically to the patient. It also can be used to tailor sexual history questions specifically to the patient by referring to anatomy and not a specific gender or sexual identity: for example, “Do you participate in receptive anal sex?” or, if a patient has a penis, “Do you participate in insertive or receptive anal sex or both?” instead of “Do you have sex with men or women or both?” An anatomical inventory is particularly useful for nonbinary patients but can be useful for all patients. For example, surgeries such as an appendectomy or oophorectomy are not always readily apparent, and knowledge of these procedures may inform future care.

Some electronic medical records (EMRs) have anatomical inventories available as standardized forms.7 If a standardized form is not available, a simple checklist can be used.7 An anatomical inventory in this format could be given to the patient to fill out themselves while they are waiting for their clinician. The form could then be referred to or clarified during the visit and later entered into the patient's chart. At subsequent visits, a patient could be asked, “Is there any need to update our anatomical inventory since the last visit?” This invites, in a neutral manner, a conversation about any anatomical surgeries a patient may have had or is planning to have. Another helpful practice is to use nonpossessive terms when referring to anatomy, either when referring to the anatomical inventory or when doing a physical examination: for example, “I need to examine the breast tissue” instead of “I need to examine your breasts.” This is an example of trauma-informed care that is particularly applicable to nonbinary patients.

PREVENTIVE CARE

Disparities in preventive care services have been seen in gender-diverse patients.8 Preventive care recommendations typically are sex-specific, and this can be inadvertently overlapped with gender identity, such as cervical cancer screenings for women and prostate cancer screenings for men. Cervical cancer screenings are for all patients with a cervix and prostate cancer screenings are for all patients with a prostate, regardless of gender identity. The US Preventive Services Task Force only recently started looking at using gender-neutral language in its guidelines and started to clarify between sex and gender.9 One strategy for creating a comprehensive preventive care plan for nonbinary patients is to consider preventive care in three categories:

Recommendations that are inclusive of any gender, such as annual hypertension and lipid screenings Recommendations that are associated with specific anatomy or sex assigned at birth, such as mammograms or osteoporosis screening Recommendations based on population membership, gender identity, or sexual identity and practices such as depression screening for a patient who is postpartum, breast cancer screenings in a patient taking estrogen who is nonbinary but was assigned male at birth, or anal Pap tests in those who engage in receptive anal intercourse.

With consideration of these three categories, nonbinary patients may present with unique preventive care needs. Clinicians need to be cognizant of these unique needs. A preventive care plan for nonbinary patients should be individualized and comprehensive. Full comprehensive preventive care guidelines are outside the scope of this article, but multiple well-respected guidelines include preventive care approaches for nonbinary patients. An excellent example is the UCSF Transgender Care Department of Family and Community Medicine's Guidelines for the Primary and Gender-Affirming Care of Transgender and Gender Nonbinary People.10

DOCUMENTATION

Advances in EMRs are creating new opportunities to increase the visibility of gender-diverse patients and improve the quality of their care.7 In 2015, the Office of the National Coordinator for Health Information Technology and the Centers for Medicare and Medicaid Services required all EMRs that were to be certified for meaningful use to include fields for gender identity and sexual orientation.11 Many EMRs have intake areas that go beyond the binary, including categories such as other, nonbinary, transgender female, or prefers not to answer, but not all do. If an EMR does not have a designated space that fits a patient's needs, a free-text space can be filled in with the appropriate information. A consistent space for this information can be designated in a medical chart. If an EMR does not allow space for information beyond man/woman or male/female, the appropriate information can be placed at the top of the history of present illness so that it is the first thing seen upon opening the chart.

Table 2 provides a list of questions we most likely want to document for all patients, but especially for patients who identify as nonbinary. Knowing a patient's preferred name versus legal name is particularly important for billing and insurance purposes.

TABLE 2. - Appropriate questions for documentation

Name—What is your preferred name?

Legal name—What name is listed on any documentation you might have (for example, a state ID or driver's license)?

Insurance ID—What name and sex are listed on your insurance card?

Gender identity—What is your gender identity? How do you identify your gender? (A list of possible terms can be provided if patients are having difficulty answering this question. Also offer patients the opportunity to not answer the question.)

Biological sex—Which sex were you assigned at birth? (This question also could be incorporated into an anatomical survey.)

Pronouns—Which pronouns do you prefer to use?

CONCLUSION

This article provides a basic foundation for the care of nonbinary patients. Appropriate terminology and word choices, including gender-neutral and gender-affirming language, as well as accurate and appropriate documentation are techniques that all healthcare providers can and should use. Gender-diverse patients are not uniform in their treatment needs or goals, and nonbinary patients have different medical needs as do the members of any patient population.12 However, nonbinary patients are particularly vulnerable to healthcare discrimination and often experience worse health outcomes across a variety of indicators compared with their peers.13 Appreciating each patient's unique needs and having active and sensitive communication about these needs are required to overcome barriers to effective care for nonbinary patients.14 Appropriate consideration by all clinicians is paramount to lessening the disparities that nonbinary patients face.

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