Bit-by-bit: Decoding Nonbinary Patients in the Emergency Department

The specific health care needs of nonbinary patients have not been well-studied - which negatively affects their health outcomes. Emergency physicians should know how to address, assess, and manage patients in all LGBTQIA+ subgroups.

Though there has been some research on lesbian, bisexual, and gay health in the care of emergency department patients, as well the beginning of literature on transgender/gender non-conforming (TG/GNC) as we begin to understand the roles of sex and gender on population health, little to no studies have been devoted to addressing the specific health care needs of the growing nonbinary (NB) patient population. Thus, it is likely one of the least studied LGBTQIA+ subgroups, along with having worse health outcomes than their cisgender binary and sometimes transgender binary counterparts.¹

Scandurra et al. found in their 2019 systematic review of 11 studies that health disparities and outcomes in nonbinary and binary transgender were mixed, although overall consistently worse than cisgender individuals.¹ Of note, the ongoing PRIDE Study is the first long-term, large-scale health study of individuals in the U.S. who are LGBTQIA+, that is trying to tease out the effects of being LGBTQIA+ on people’s physical, mental, and social health, and includes collecting information on NB identities and their health.²

Overall, there are no significant studies specifically devoted to treating NB patients in the ED and how that may be disparate from approaching binary TG patients. As a specialty, we need to be working to ensure that our patient care, education/training, and hiring practices reflect our values of inclusivity when it comes to nonbinary and gender-fluid individuals, which may be critical steps in the next few years. As part of that, patients should be asked to provide chosen names and their pronouns on forms along with other patient identifiers, such as sex assigned at birth. Thus, a multi-step process should be followed to capture information about sex and gender identity.^3,4

Growing in Numbers

An estimate from a February 2021 Gallup Poll places the growing LGBTQIA+ population in the U.S. at approximately 5.6% of the population, or 18.5 million people.⁵ Of those, other estimates show that 1.2 to 2 million people (6.5% to 11% of the LGBTQIA+ population) classify themselves as NB, with over 50% being between 18 and 29 years old.^5,6

Additionally, the Gallup Poll also found that 11.3% of LGBTQIA+ adult respondents self-identify as transgender.⁵ This is consistent with other recent estimates that report that 1.4 million or more individuals in the U.S. identify as transgender, accounting for around 0.6-2.7% of the population.^7,8 From the 2015 U.S. Transgender Survey, in can be said that 60% of TG people began to feel that their gender identity was different than what is on their birth certificate before age 10, with only 6% being over 21 years old.⁹

Additionally, the 2015 U.S. Transgender Survey showed that approximately 35% of the 28,000 transgender respondents to the survey self-identified as NB,^9,10 and 56% of NB people begin transitioning between the ages of 18-24.⁹ NB individuals are born with bodies that may be phenotypically and genotypically male, female, or intersex (a genetic pattern of sex chromosomes or a response to sex hormones that differ from typical XX, XY physiology), but their innate gender identity is something different than exclusively man or woman. They may lie on the man-woman spectrum and view themselves as both, lie outside the spectrum with a different or third gender identity, or may have no gender identity at all, as is the case with agender individuals. Though frequently cited to be under the TG umbrella and although studies are limited, it has been shown that approximately 43% of NB people identify as TG, meaning they have transitioned from their assigned gender at birth to a NB status - one of neither exclusively male nor female.

This has led to many NB LGBTQIA+ people to not self-identify solely as TG but specifically with a TGNB status.^6,11

Visibility vs. Invisibility

Certain personal identities are visible, while some are invisible. For instance, one’s sexuality could be considered an invisible identity since there is no specific finding that could pinpoint to an individual’s sexual or romantic orientation, regardless of whether they are queer/gay/straight/lesbian/bisexual/other. On the other hand, sex, gender, and racial identities can be externally visible, while gender identity with its corresponding expression could be either visible or invisible, particularly for NB individuals, as there is no one idea of what a NB person “should look like,” or what sex or gender they were assigned at birth.

Thus, it can be challenging to be “seen” by society and health care providers. For instance, if a patient is assigned female at birth, it is often assumed that their purpose of transitioning, whether it is surgically, hormonally, or socially, is to achieve the status of Man; to move from the box from “W'' to “M”. That may not be the case for many NB individuals. Many health care organizations still request patient gender and sex as entirely binary, often only ask for either sex or gender, and do not offer alternatives for patients to report themselves as having NB gender.¹² Due to NB gender markers being often unavailable in the medical record, patients are frequently at risk for being gendered incorrectly and therefore misunderstood by their medical providers. Additionally, identifying patients in this subgroup can be challenging as NB vernacular is relatively new.

Impacts on Health Outcomes

There is often confusion and frequent misunderstandings, both on the part of patient and clinician.¹³ In fact, in a study of TG and NB university students, Goldberg et al., found that NB persons reported more misgendering by health providers -- in other words being called by incorrect pronouns, or providers making incorrect assumptions about their patients having certain hormone status or organs. Additionally, NB participants were 76% more likely than binary TG participants to be “misgendered sometimes or often” by health care providers.^1,14 They also receive lower rates of support from family and friends compared to TG counterparts, have higher levels of anxiety and depression compared to binary TG individuals, and have higher rates of smoking and drug use, all of which could impact medical and mental health needs when presenting to the ED.^1,15-18 

A 2018 study by Clark et al. found that NB participants had 62% higher likelihood of non-suicidal self-injury compared to binary TG individuals.¹⁶ They were also more likely to report increased alcohol use than binary TG and smaller odds of having a family doctor than their binary TG counterpart.^1,16 All of these could contribute to more frequent and more severe health outcomes when these patients eventually present to the ED. 

Additionally, interviews of NB patients by Lykens et al. in 2018 showed that NB individuals frequently felt misunderstood as their health care teams were often only familiar with the binary concept of medical care.¹⁹ This is congruent with Goldberg et al. who found that NB students reported increased misgendering and less trans-affirming care by health care providers, compared to binary TG students.¹⁸ NB patients felt pressure to conform to binary medical narratives, self-modified the care they received, or went without medical care altogether.¹⁹ Additionally, a 86% of nonbinary respondents to the U.S. Transgender Survey reported that, regarding their gender identity, “people do not understand so they do not try to explain it”.⁹ Approximately two-thirds reported being NB is often judged as being a phase or not a true identity, and 43% of NB respondents feared violence, while 20% of NB patients have avoided medical care due to fear of being disrespected or mistreated by a health care provider.⁹

On the other hand, there has also been some evidence that binary TG individuals have worse health outcomes related to emergency medicine care compared to NB patients. Though, as above, NB patients tend to present with more non-suicidal self-harm, they are less likely to attempt suicide.²⁰ NB patients avoid medical care due to fear of being disrespected or mistreated by treatment team at lower rates compared to binary TG men, 20% vs 31%, respectively.⁹ Additionally, HIV status appears to vary greatly by gender identity, with trans men and NB people having rates of 0.3-0.4%, whereas approximately 3.4% of trans women report being HIV positive.⁹

An interesting 2016 study of over 3,000 LGBTQIA+ participants by Smalley et al. showed that binary TG and nonbinary individuals have very different risk-behaviors, with NB having lower risk of sexual risk-taking, substance use, and medical risk-taking. Additionally, the same study showed that while many of the subcategories under LGBTQIA+ are typically condensed into one category, they show variable risks when examined individually.²¹

Role of EM Physicians and Departments

In general, emergency medicine physicians should be aware that not all identities are necessarily visible (eg, sexuality and NB gender are not always visible to others), but all are valid. Given that EM physicians often treat children, it is important to know that 60% of TG/GNC people began to feel that their gender identity before age 10.⁹ Additionally, NB patients may have a different medical narrative than binary TG individuals, they are also at higher risk of self-harm but lower risk of suicide attempts compared to TG binary patients.^16,20 There is also evidence that NB patients report higher risk of excessive alcohol use, as well as smoking and drug use, though some smaller studies disagree.²¹ In general, NB patients and trans men tend to have lower rates of being HIV positive compared to trans women; NB patients also have lower rates of having a primary care provider, thus may have higher likelihood of presenting to the ED when unwell.^1,16

Compared to other gender-expansive patients, NB patients experience increased misgendering and less trans-affirming care by health care providers, which can lead to distrust and lack of following clinical discharge instructions.^1,14 In general, NB patients feel pressure to conform to a binary narrative.¹⁹ Finally, NB patients do undergo hormone and surgical affirmation though at lower rates than TG binary individuals.^8,9

Emergency medicine departments should make it a policy to consistently ask about gender, pronouns, chosen name, sex assigned at birth on (non-emergent) presentation, hormonal status and organ inventory. Departments should document these findings in the EMR when possible, as this will allow for further research in this poorly studied population. In general, EDs should encourage health care teams to communicate and use everyone’s correct pronouns/chosen name – and be willing to offer your own. This is important: though there are no known studies collecting information about the proportion of NB or LGBTQIA+ residents as a whole, in the Moll et al. paper from 2021, authors showed that the majority of respondents surveys at residency programs across the country were aware of known LGBTQ+ faculty and residents at their programs.²²

Additionally, departments should screen for self-harm in the NB population, as well as depression/anxiety, and substance use. They should educate and have designated areas in the curricula for these discussions for all members of the health care team, as well as registration, on how to correctly gather information and affirm patients’ identities.

There are many resources when it comes to optimizing health outcomes of TG/GNC individuals, the LGBT Health Education Center at Fenway Institute has developed best practice guides, such as their “Do Ask, Do Tell” toolkit, which advises collecting gender identity, sex assigned at birth, chosen name, and pronouns used for optimal patient care.²³ Additionally, Society for Academic Emergency Medicine published an online guide on teaching and discussing the topic of Sex and Gender Minorities in the ED.²⁴

Table 1

Background

Though there has been some research on lesbian, bisexual, and gay health in the care of emergency department (ED) patients, as well the beginning of literature on transgender/gender non-conforming (TG/GNC) as we begin to understand the roles of sex and gender on population health, little to no studies have been devoted to addressing the specific health care needs of the growing nonbinary (NB) patient population.

Methods

Authors explore the pertinent literature and the current vernacular pertaining to the LGBTQIA+ community, with a particular focus on nonbinary patients in the ED, contrasted with LGB as well as transgender patients’ health outcomes and risk factors. We discuss the educational implications and make actionable suggestions to improve care of gender-expansive individuals in the ED.

Results

Emergency medicine physicians should be aware that not all identities are necessarily visible: Sexuality and NB gender are not always visible to others, but all are valid. NB patients may have a different medical narrative than binary TG individuals. NB patients experience increased misgendering and less trans-affirming care by health care providers and, in general, feel increased pressure to conform to a binary narrative. EDs should consistently ask about gender, pronouns, chosen name, sex assigned at birth, hormonal status, and organ inventory. Departments should document these findings in the EMR when possible, as this will allow for further research in this poorly studied population.

Conclusion

There are no significant studies specifically devoted to treating NB patients in the ED and how that may be disparate from approaching binary TG patients. As a specialty, we need to be working to ensure that our patient care, education/training, and hiring practices reflect our values of inclusivity when it comes to nonbinary and gender-fluid individuals.

Pertinent Terms Defined

Sex: a person's genotypic/phenotypic presentation, typically assigned male, female, or intersex at birth, typically corresponds to XX or XY or other combinations of chromosomes. Typically written as sex assigned at birth (SAAB), assigned female at birth (AFAB), or assigned male at birth (AMAB).

Gender identity: one’s deeply held, invisible concept of self in relation to being a woman, man, both, or neither (eg, agender or third gender) in context of one’s society or social environment. This identity may be concordant or discordant with sex assigned at birth (woman - female, man - male if concordant).

Gender expression: the external and more visible manifestations of conveying one’s gender identity, expressed through pronouns used, chosen or given name, clothing, hairstyle, behavior, voice, and/or body shape/characteristics, in the context of social gender expectations.

Transgender (TG): an umbrella term describing individuals whose gender differs from expectations associated with their sex and gender assigned at birth.²⁵

Cisgender (CG): Those individuals whose internal sense of gender identity corresponds to their sex and gender assignments at birth.

Gender diverse/non-conforming (GNC): term used to signify that one's gender identity or expression differs from cultural expectations, which could include transgender, nonbinary, and sometimes cis-gender individuals.

Nonbinary (NB): frequently cited as part of transgender identity (though not always⁶), those individuals do not fully see themselves in traditional man/woman categories. They may lie on the man-woman spectrum and view themselves as both, lie outside the spectrum with a different or third gender identity, or may have no gender identity at all.

Transition: the non-linear, non-obligatory process of TG/GNC individuals taking steps to have their outward presentation more closely aligned with their internal gender identity, which can include social (name/pronoun use), hormonal (estrogen/testosterone therapy), and/or surgical aspects (eg, top/bottom surgery).

Sexual orientation: “An inherent or immutable enduring [...] sexual attraction to other people,²⁶ not to be confused with an individual’s sexual practices, which may or may not match up with what they consider their sexuality

Romantic identity: An inherent romantic attraction to other people, which should not be confused with an individual’s romantic practices, which may or may not match up with their romantic identity

Emergency medicine departments should:

• Consistently ask about gender, pronouns, chosen name, sex assigned at birth on (non-emergent) presentation, hormonal status and organ inventory
• Document findings in the EMR, as this will allow for further research in this poorly studied population
• Encourage health-care teams to communicate and use everyone’s correct pronouns/chosen name — and be willing to offer your own
• Screen for self-harm in the NB population, as well as depression/anxiety, and substance use
• Educate and have designated areas in the curricula for these discussions for all members of the health-care team, as well as registration, on how to correctly gather information and affirm patients’ identities
• Use toolkits, such as the “Do Ask, Do Tell” by Fenway Health or “Sex and Gender Minorities” by SAEM to educate yourself and others.^23,24

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