How Myths about Nonbinary People Impede Delivering Quality Care

I am nonbinary and a psychiatric nurse. This may strike you as a rare crossover of identities, but I have met several colleagues in London alone who share the center of this Venn diagram with me.

Nonbinary is an umbrella term for a kaleidoscope of genders that do not fit the male/female dichotomy More specifically I am a genderqueer trans person. Part of what this means for me is that I am on hormone replacement therapy and my pronouns are they/them, but that is not the case for all nonbinary people; everyone has their own way of doing gender.

Different trans identities come with different struggles. Trans women are the people most likely to experience violent hate crime, for example, and I don't want my discussion of the particular struggles of non-binary people to be seen as minimizing the struggles of others. I am not one the worst off in the trans community, far from it, but there are many myths about my gender that I want to dispel here. Figure 1 presents some common myths about nonbinary genders.

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Figure 1

Ideas about nonbiliary genders that question their validity.

These myths persist even in supposedly trans-friendly spaces, and are espoused by many people who claim to stand against transphobia. A lot of this stems from the common understanding of history: that throughout time and space there have been only men and women. Sure, some people are born “in the wrong body” and need support to become the man or woman they have always known themselves to be, but someone saying they are neither a man nor a woman seems like a Dadaist intrusion into an otherwise simple narrative. This is where we get people who dismiss my existence outright, jokingly claiming to identify as penguins (Deen, 2019), without listening to nonbinary people or trying to understand our history and experiences.

I don't want to go too deeply into the fallacy of biological sexual dimorphism, because it too easily slips into using intersex people as a means to make a point, which does them a disservice. Instead I will focus on the cultural understanding of there being only two genders, which is a surprisingly modern and western concept, exactly what nonbinary genders are accused of being. All over the world and throughout history, many cultures have had names for people who are something other than men or women, from the Two-Spirit gender of Native America and the Canadian First Nations to the Hijra of the Indian subcontinent. For more about this subject, I recommend the book Third Sex, Third Gender: Beyond Sexual Dimorphism in Culture and History (Herdt, 1996).

So why does it seem like the number of people identifying as trans and nonbinary is on the rise (Zucker, 2017) here and now? Most people who are dismissive of nonbinary genders have made the correct link but for the wrong reasons: it's the Internet.

When I was growing up, the Internet existed, but in nowhere near the form it is today. If I wanted to look something up I had to Ask Jeeves, on the one family computer in the lounge, and any results I got were extremely inconsistent. I grew up knowing that something was off in terms of how I was supposed to feel about my gender versus how I actually felt about it, but I didn't even hear the word nonbinary until I was in my early 20s. There was never anyone I could point to and say “Them! They're like me!” Because in the 1990s the media was still getting its head around giving women representation, never mind gender minorities.

What the rapid evolution of the Internet provided me with was an ocean of people who were expressing what I had always felt, and a language to describe it that I had never had access to before. The Internet didn't make me nonbinary; the Internet gave a voice to this nonbinary person.

When it comes to the demographics of nonbinary people, I would argue that it is only to be expected that most of the people who feel safe to be open about being nonbinary are White middle-class people who were assigned female at birth. Of the hundreds of trans people who are murdered world-wide every year, the vast majority of them are trans women of color (Human Rights Campaign, 2019). Distancing yourself from the gender you were raised as is more dangerous for some people than for others; keeping a low profile out of self-preservation is not the same as not existing.

The final myth is where I come to psychiatric nursing. Putting together a case study it is very easy to fall down a rabbit hole of attachment theory, trauma-informed explanations, and family dynamics. We are taught that understanding the cause of a problem is the key to meaningful change and, as a result, it is very tempting to tie everything up in a neat bow, all the better to then untie it. I have heard fellow nurses speculate that patients are trans because it is a form of escapism from their difficult home life; it is a way to distance themselves from a previously violated body; it is an attempt to exert control in a life in which they have had very little control; or it is a way to draw enough focus to stop the family unit from falling apart. The list goes on, but you get the idea. Trans people are overrepresented in psychiatric services, but mental health professionals who look for a trauma that caused these people to be trans are again, as with the correlation of the rise in Internet use and nonbinary identities, getting the cart before the horse.

Minority stress is a term that refers to the psychological impact of discriminatory events experienced by someone who belongs to a minority group (Meyer, 2015). Hate crime against trans people has trebled since 2014 in England and Wales (Marsh, Mohdin, & McIntyre, 2019), but minority stress also includes day-to-day insults like chronic misgendering and institutionalized erasure. Research consistently shows that trans people are more likely to experience mental health problems if they face a high level of enacted stigma, whereas strong social support and access to gender-affirming health care are protective against mental health problems (Rood et al., 2016; Thorne et al. 2018; Veale, Peter, Travers, & Saewyc, 2015).

As a nurse, I can think of multiple occasions where I have been so overworked and stressed that a seemingly small thing has led to me crying in the break room. Minority stress works the same way. Being mis-gendered is something that nonbinary people are used to (most cis people are too comfortable being able to assume they know a stranger's gender and having a good chance of being right), but that does not mean we are hardened to it. Think instead of getting dozens of tiny paper cuts one after another; eventually you're going to get distressed about it, but the person who witnesses only the final paper cut is likely to think you are being a drama queen, or, to use clinical parlance, you are emotionally dysregulated.

So what can we as nurses do to support nonbinary patients who are under a lot of minority stress? The Transgender Resilience Intervention Model (TRIM; Matsuno & Israel, 2018) collates findings from research on the mental health of trans people to produce a picture of the environment most likely to facilitate resilience. Those of us who experience minority stress from stigma, discrimination, and hate crime want to be resilient so that we can survive in a way that is meaningful, and can create change so that those who come after us experience these hardships less keenly. Resilience is good, but it cannot be wished into existence purely from knowing that it is good to have. Resilience is a house that community builds; simply telling an individual to “build resilience” is about as helpful as telling a homeless person to build a house.

TRIM categorizes resilience factors at the individual and the group level. Self-definition and identity pride are important at the individual level. The introspective aspect of this work can be done through exercises such as those found in The Queer and Transgender Resilience Workbook: Skills for Navigating Sexual Orientation and Gender Expression (Singh, 2018).

The simplest and most obvious way for nurses to support a nonbinary patient in self-definition is to believe them. Use the name and pronouns they tell you are correct, regardless of what their old medical notes may say. Next is advocating for them: if a colleague purposely misgenders them or rolls their eyes when their gender identity is mentioned, make it known that that behavior is inappropriate.

Community resilience factors include social support, both having and being a role model, trans activism, and community belonging. In my work supporting trans clients, a lot of my interventions are social. I have folders full of every type of LGBT+ group you can imagine: mental health drop-in mornings, board game afternoons, alcohol-free club nights, knitting circles, and so on. I use these because, in the city of London where I work, there are so many opportunities for community that to allow someone to struggle in isolation would amount to neglect.

A common obstacle to nonbinary people taking part in the community is the fear that they are not “trans enough” to deserve access to community support. This is something that held me back from engaging with trans spaces for a long time: I didn't feel like I had the right. This internalized stigma is understandable given the common attitudes examined earlier in this article, and makes it all the more important for the people around them to support the validity of their identity.

I knew I was probably trans for a long time before I came out, but it took me talking to a nonbinary friend about how I felt, then adding the caveat, “But I know I'm not really trans,” and them responding, “Why not?” for me to feel I was allowed to be trans. Having just one trans person explicitly tell me that they would be happy to count me as one of their number felt like a door had been opened. This offhand, casual expression of acceptance was such a small thing to my friend that they do not even remember it. That is the other side of minority stress: It makes you so primed for rejection that even the smallest kindnesses are incredibly powerful.

That, if nothing else, is what I want my fellow nurses to take away from this. You may be intimidated by the idea of caring for a nonbinary patient because it sounds complex and messy, but good care for nonbinary patients boils down to the universal basis of nursing: listening, believing, and being kind.