Non-Binary Transition - Part 3: Social, Medical, Legal Transition

by Micah at neutrois.me

The final installment of Non-Binary Transition presented at the Gender Odyssey Professional Conference in Seattle, August 2015.

Recordings are on YouTube, or follow along at your own pace with these slides containing speaker notes, essentially a transcription of the presentation, minus the audience. The workshop is 90 mins long, so it’s split into 3 parts.

All parts can be found here: http://neutrois.me/non-binary-transition

You are definitely encouraged to share with your provider, as well as family or friends, or yourself.  I only ask that you include  attribution or acknowledgement; the best way to credit me is linking to my site.

If you find value in this work, please consider a small contribution.

Hint: To get the most out of this, on the parts that say INTERACT, actually stop and give yourself a minute to silently provide an answer.

Now that we’ve defined Gender (part 1), we’ve defined Non-Binary gender, and we’ve defined Transition (part 2), we’re going to move on to the actual parts of transition.

The three parts are: Social, Medical, and Legal.

I’ll present a basic overview of the components in each part, so that you get a sense of everything that can go into transition.                 

Afterwards, you should go on to do more detailed research, depending on your needs.

I’ll also focus on the challenges that arise in each component specifically for non-binary transition.

Let’s talk about the first part:

Social

People perceive a lot of things about you, not just your gender.

However, Gender is usually the first category they notice.

And it’s a very narrow category, with only two options for 7 billion people.

INTERACT:

When you meet someone, how you do know whether they are a man or a woman?

We look to cues that signal someone’s gender.

A big part of transition is changing these cues to give the right signal to other people about who we are.

Everyone does this all the time, but perhaps transgender people do it more deliberately.

What sorts of cues can be manipulated to give the right “gender signal”?

Non-binary people may try to find cues that don’t fall into either “male” or “female” categories. We can call these “gender neutral” cues. 

They include things that don’t immediately signal that person’s gender, like ambiguous names, nicknames, various pronoun options, hairstyles or clothing options.

Remember this slide?

What happens when your public gender does not exist? 

Non-binary people don’t always “look” like their gender, because what does their gender “look” like?

That’s probably the toughest part about non-binary social transition:

We’ll probably never get to our ideal destination.

But we can try to get… closer to comfortable.

As we’ve seen, it’s not always the case that a non-binary person wants to be seen as neither a man or a woman.

Sometimes they want to be seen as both - maybe even simultaneously - or one gender more than the other, or it may depend on the day and how they’re feeling that day.

Different people will have different goals in how they want to be perceived.

An important way to achieve these goals is through cues.

The point in altering these cues is not to confuse other people. The point is to avoid being categorized incorrectly.

Because if someone sees us as male, or as female, they’re wrong, and it was yet another moment in which our gender was not seen.

Some of these cues are very easy to change.

You can go to the clothing store and buy new clothes - DONE!

You can order a binder online - DONE!

You can get a new haircut - DONE!

Some are difficult to change.

It can be very scary to go out in public wearing clothes you’ve never worn before.

Most importantly, many of these changes are Social: 

they depend on other people.

For example, changing your names and pronouns is also easy - you just declare a new name, and that’s it! Like this…

INTERACT: Name exercise.

Me: “This is my friend Alex. Stand up and say hi Alex.”

<Point to confederate in the audience, say a quick story about Alex>

(ask audience) “What is my friend’s name?”

Me: “Let’s ask Alex: What is your name?”

<Person says their name. It was not Alex.>

We never asked ___ what their name was. I - and all of you who believed me - decided for them.

So changing social cues is easy, BUT…

you have to get others to go along with your change.

This is the power of other people, and how much influence they can have in your transition.

Since social transition depends on other people following along, often the first step is to inform others about what’s going on.

Coming out is hard enough, but non-binary people face other types of issues:

Their gender and identity is hard to explain.

We’ve been talking about it for the last hour, and you’re all professionals in this space!

Many people - including the person coming out - are unfamiliar with non-binary gender, and/or non-binary transition.

Their identity is not taken seriously.

The stereotype of genderqueer people is that they’re playing dress up, just being rebellious, jumping on a trend.

When you tell a close, trusted friend your deepest, darkest secret about your core self, and they dismiss it - that can be a defining experience in what you do decide to do, or not do, next.

Aside from fear of rejection, which does turn into reality sometimes, some folks face serious threats to their safety when they come out.

Sometimes it doesn’t even involve coming out - just trying to be who they are on the outside can be dangerous.

Non-binary people may not look like what others expect men or women to look like, and others are threatened by this.

Coming out sounds like it’s a one time thing. It implies one event that can be over and done with. But that’s not the case at all.

That’s why I like to call it disclosure. And like everything else, it’s a spectrum, an ongoing individualized process.

Again, all these parts are separate, and can happen in different instances, with different people, in different situations.

  • Who to disclose to:

friends, family, therapist, teachers, co-workers.

  • What to disclose:

changing name, getting surgery, inner identity.

  • Why to disclose:

to inform others of changes, to get support, to share a part of yourself

  • When to disclose:

before an event, after the event; a pre-planned disclosure, a spontaneous one; early on in transition, later on in transition; never is an option too.

INTERACT: What can you as a provider do to ease disclosure?

Who has to go to the bathroom?

Bathrooms are a touchy subject, and they always come up. Why?

Because all of us have to pee. It’s impossible to go anywhere without having to use a public bathroom.

We all know the types of issues trans people face in bathrooms.

Other people police our external gender: if someone doesn’t look like the “man” or “woman” they’re expecting, they freak out.

But, why are bathrooms particularly stressful for non-binary people?

Because bathrooms force you to gender yourself. In public!

Bathrooms literally require you to pick a gender.

Not just pick a gender, but announce that choice to everyone within view of said bathroom.

We are forced to choose, because we have to pee.

We are forced through this choice pretty much every day, many times a day.

This can be extremely stressful, even dangerous, or just plain tiring.

So, which one do we choose?

The best option is a gender-neutral option. This alleviates any sort of stress around bathrooms.

After all, we don’t segregate bathrooms by gender in our house!

It’s not as hard as most people think to provide a gender-neutral options.

Think of accessible restrooms, and how that has become law in the last 20-30 years, even changing physical structures around us.

And they don’t just benefit trans or non-binary people - everyone wants a little privacy now and then.

So, advocate for gender neutral bathrooms everywhere you can.

In lieu of that option, the choice really depends on the person: what they look like on the outside, which one they are accustomed to using, their location, especially perceived safety.

To minimize anxiety, I used to have a bathroom checklist: Which option is the safest? Am I more likely to get weird looks in one? Which one is the cleanest?

I would go through each item in order of priority every time.

Everyone should develop a strategy for this, because it’s certain they are going to come across a public bathroom.

Never assume, Always Ask.

This is the biggest lesson. Repeat it as a mantra.

You will never know how someone identifies. Their outer expression might not reflect their inner identity.

A good tip for providers: always ask.

Because our identities might change.

Or, even if they don’t change, the way we express them might be changing, especially during transition.

It can be very scary to tell your provider, once again, that you have a new new name, or a new set of pronouns.

The best thing you can do to support someone in transition: leave the door open for changes. Remove any friction in making those changes.

It’s a huge relief if they ask or check-in about any changes up front.

Next component: Medical transition.

This section will cover hormones and surgery.

Let’s go over some basics first.

WPATH: World Professional Association of Transgender Health.

Standards of Care: outlines framework for medical transition.

        Newest version was released in 2011, v7.

The newest SOC v7 are inclusive of non-binary gender:

  • our identities are acknowledged
  • inclusive language such as “target” gender instead of “opposite” gender
  • non-binary identity is no longer a barrier to access services
  • options are presented as less linear
  • the requirements are less interdependent (for example, hormones are not a requirement for most surgery)

While its focus is on medical transition, we’ll see how medical transition - and the WPATH Standards of Care - informs other parts of transition, like social and legal.

It’s important to remember that SOC are guidelines, not rules.

It says so in the document itself.

This means, each individual should be treated on a case-by-case basis. Not everyone will fit the mold, exceptions are ok.

Your role as a provider is to use these guidelines to help understand your patient’s needs, not as a checklist of requirements to prevent them from being treated or accessing services.

Informed Consent plays a big role in the newest version. The next slide talks about this more, because it’s important.

Lastly, there are a lot of myths that have surprisingly stuck around, even though they are extremely outdated.

I want to highlight one of these, called “RLE” or real life experience.

Before you were “allowed” to embark on any medical transition, you had to live and be recognized as your target gender for at least 12 months.

Well, aside from being antiquated hogwash, non-binary genders present a problem for this.

What does it mean to “be recognized as your target gender” when most of the world doesn’t know that your gender exists?

Yes, many doctors still believe this is a “rule” for transition!

In the olden days, providers acted more like gatekeepers. 

Doctors got to decide whether you were “eligible” to transition based on a set of rules.

Usually these rules involved heteronormative ideas of gender roles, ex: if you weren’t heterosexual or appeared stereotypically feminine/masculine, you were not allowed to transition.

Even today, many providers deny service to non-binary (and binary) people:

  • they aren’t “man” or “woman” enough
  • they don’t want or need medical transition bad enough
  • they are not “trapped in the wrong body” or they aren’t really trans.

Informed Consent is when an adult gives permission (consent) to make an adult decision for themselves [note: it is different for minors].

Nobody has to “approve” your medical transition.

It gives non-binary people more freedom to decide for themselves which parts of medical transition they undergo.

Many of these providers are doctors, but most are therapists.

With IC, a letter from a therapist is no longer a requirement for most services, including hormones and surgery.

Therapists are not determining whether someone is “ready” for medical transition. Instead, their role is to help the patient make that determination.

If therapy is not a requirement for medical transition, then

what is the role of mental health in all this?

SUPPORT!

There is still a lot that goes into transition - even just medical transition - that is not physical, but mental and emotional.

  • Cope or process the financial, physical, social consequences
  • Surgery is a novel and scary process for most people
  • Medical transition isn’t always an obvious step for non-binary people.
  • Working out how or why they want to go about it, and how it fits into their non-binary identity, should be part of therapy.

I always stress the role of mental health.

Figuring out your identity is complicated, and I encourage people to not go about it alone.

Above all, whether someone chooses to alter their physical body is not a reflection of the validity of their gender identity.

Many non-binary people choose to medically transition, many do not.

Many “binary” trans people choose not to medically transition.

Your body, your choice. The reasons behind each choice should be respected.

Let’s briefly go over Hormones, and how they impact the body.

Don’t worry if you are confused by the following slide.

It has a lot of details that you can always look up later.

Just pay attention to the main ideas behind hormones, and how they impact transition.

Female-assigned: may take Testosterone, or T to “masculinize”

The effects are: deeper voice, facial and body hair growth, balding, muscle growth, and hip fat redistribution.

Male-assigned: may take Estrogen to “feminize”

The effects include: breast growth, softer skin, reduced libido, reduced muscle growth, reduced hair growth.

There are also other hormones in this category, primarily anti-androgens.

If your body produces testosterone, its effects will continue (ie facial hair will keep growing throughout a person’s life; contrast this to female estrogen-based puberty, where once puberty is done, breasts don’t keep growing indefinitely.)

So, it can be necessary to block testosterone even after puberty (whereas you don’t have to block estrogen.)

This is important because it throws another factor into the mix.

There is no gender-neutral option: just these two.

Many people want to lose characteristics without gaining new ones.

There are still unknowns on whether it is medically sound to be without hormones at all, especially long term for young folks.

(Let’s talk about some of these specifics later.)

What do non-binary people want out of hormones?

Primarily, there are physical effects.

Traditionally we think of testosterone as masculinizing, but it can also serve to diminish “feminine” characteristics.  A high-pitched voice can sound female, so lowering the voice can make someone sound more androgynous, for instance.

Or people want both gendered characteristics — ie, to grow breasts and keep the beard.

In this example, voice can also be social — our physical aspects act as social cues that signal our gender.

So someone might takes hormones for their social effects — to shift perception of their gender to 50/50, or 60/40, or ambiguous.

Lastly, some people report feeling better emotionally while on hormones:

less anxious, less depressed, more mentally acute, more balanced.

But hormones are not perfect. They are a package deal, like 2-1 shampoo.

You cannot pick and choose what changes you get.

Many times non-binary people only want to acquire a specific set of changes, and actively want to avoid another set.

        On T, you can’t get a deeper voice without also sprouting facial hair.

        On E, you can’t get softer skin without breast growth.

While we generally know what the effects of hormones are, the extent of these is unpredictable.

How much facial hair? How fast is your voice going to deepen? How big will your breasts grow?

It’s impossible to know beforehand. It depends on genetics, age, other.

Hormones have two sets of changes.

Reversible 

are those that take effect only while you are on hormones.

As soon as you are off, the changes revert back.

ie, increased muscle growth on T, or skin softness on E.

Permanent 

changes will never go away, even if you stop taking hormones.

ie, facial hair growth and voice deepening on T, breast growth on E.

Unfortunately, people sometimes want the reversible changes but not the permanent changes.

While the effects of hormones are messy and imperfect, they also give us a lot of flexibility and control.

The effects of hormones are gradual.

Unlike surgery, they are not instantaneous. It takes a while to see any changes. You don’t sprout a full beard overnight.

This gives you a lot of time to test them out. Take a little, see what happens, how you like it.

Low dose is a great option for non-binary people.

You can take a little or you can take a lot.

It makes the effects build up even more slowly, giving you more time to think and adjust to them.

You can be on low-dose indefinitely, to the point of seeing a plateau on the effects.

And you can always stop taking hormones.

Making the decision to go on hormones is not a forever one.

Likewise, the decision to stop hormones is also not final.

You can go back on hormones again.

You can choose to take hormones for a predetermined period of time, then re-evaluate.

Or they can be long-term (especially on low-dose).

Despite this flexibility and control, taking hormones can be a daunting decision for non-binary people.

Mostly because it involves some sort of compromise — physically, socially.

Here are some common reservations non-binary people have about hormones.

What if… I still don’t pass?

Passing is a relative term, because what are you trying to pass as: androgynous, masculine, feminine, neither, both?

What’s behind this fear is that hormones will have zero impact in how their gender is perceived.

They worry about passing “too much”

That they will now be seen exclusively as the opposite of their birth gender, which also makes them uncomfortable.

What if… I hate them?

They worry about whether they will be able to cope with the changes they want to avoid, especially the permanent changes.

Two common examples we’ve been repeating:

T: Wanting more androgynous (deeper) voice without gaining any facial or body hair.

E: Softer skin and less muscle mass while avoiding breast growth.

What if... I go all the way?

They worry about ending up on the other end of the spectrum.

        That one day, they’ll look in the mirror and realize they’ve gone too far, by accident.

Or that it wasn’t accident 

They’ve ended up with a binary look, on purpose, even though that’s not what they want right now.

Again, this is part of growth: it’s hard to imagine you’ll want something in the future you actively want to avoid right now.

Today’s truth might not be tomorrow’s.

Ultimately it’s about finding a balance in the compromises

(and this doesn’t just apply to hormones).

Sometimes the only way to achieve a social goal is through a physical change.

Sometimes, the need for desired effects outweigh the fear of undesired ones.

Some aspects of transition are deal breakers, while others are seen as more flexible.

Sometimes the only way to find out how we feel about something is to try it out, and with hormones this is somewhat possible.

These choices are very individualized.

Compromise is inherent in the non-binary experience.

A lot of the fears we just covered also apply to people considering surgery.

What does surgery entail?

[image of Dana, author of Outlaws, Photo Project]

Outside of the medical act of surgery, this part of physical transition is steeped in hurtful mythical connotations:

  • You have THE surgery and poof, you’re transformed into a man/woman.
  • You’re not really a man/woman until you have surgery.

Both assume there is only one surgical procedure, not several. Both of these do not really apply to non-binary people.

  • Transition isn’t really complete until you get surgery.
  • Surgery is the last step in transition.

Seen as culmination of transition, when it’s just one of many parts. And yes, it can happen at the beginning of transition.

  • It’s the magic solution to all your gender issues
  • If you don’t want it, then you aren’t really transgender, or you’re less than trans

A lot of lofty assumptions and expectations behind one medical procedure.

[image of Aidan Key, director of Gender Odyssey, and his twin sister Brenda]

One of the many myths is that there is one all-encompassing surgery.

In fact, there are many surgical procedures that a single person can opt for.

Here’s an overview: [slide text]

Surgery is less flexible than hormones in that there is no low-dose, it’s not gradual.

But there are many options and variations within those options.

Next, let’s take a look at what prevents non-binary people from accessing surgery.

First, issues around Identity.

Providers dismiss non-binary identities as not legitimate:

“Their genders aren’t real, so non-binary people do not deserve surgery.”

Many non-binary people end up lying to providers and doctors to reduce the risk of dismissal.

“Who will love me?” — how others will see their identity.

The non-binary person may fear having a non-standard gendered body, and rejection from that.

Some gender identities call for options that are not medically possible.

In most cases, these procedures are possible, but doctors are the barrier.

Doctor is unwilling to perform the exact procedure the patient wants (even though it is medically possible):

Complete rejection of non-binary identity: “unethical to leave patient in mixed-gendered state”

They mistakenly subscribe to outdated “rules” about gender transition:

Ex: RLE, or think hormones are requirement for surgery. Hormones are not a requirement!

Doctors can be ignorant about surgical alternatives:

They don’t know the option exists, or don’t think to present it as alternative.

ex: Hysterectomy: remove uterus, but leave ovaries in. Gives patient option to not be on HRT long-term.

Lastly, cost is a huge impediment. Surgery is expensive.

Most insurance doesn’t cover it, and when it does, the requirements may be “binary” (like requiring hormones) or following outdated standards.

If it’s difficult and costly to have surgery,

why would a non-binary person want to do it?

Usually it’s for the same reasons binary transgender people want surgery.

Physical

To alleviate extreme distress (dysphoria) caused by a certain body part.

usually chest (FAAB) or genitals (MAAB).

To treat a hormonal or internal side effect of a certain body part, ex:

orchiectomy (remove testes) to stop testosterone production

remove uterus to stop menstruation

To help with social “passing” 

Whatever those social goals may be (androgynous, ambiguous, less of their birth gender, safer to look traditionally male or female).

Remember, the decision to have surgery — any surgery in any variation — is an individual choice and not a test of someone’s identity.

Despite the misdirected misconceptions, surgery can be a cornerstone in someone’s transition.

Sometimes, it’s so important, that the need for surgery overshadows anything else in that person’s transition.

To the point that surgery is the only clear step.

It can even be the first step. Or the only step, ever.

It’s critical to recognize and support those folks through the process.

A key part of the process is simply information:

  • researching surgical options, how to get what you want
  • figuring out which ones fit with identity
  • finding respectful, knowledgeable providers, or those willing to learn

As providers, an important job is to educate other providers!

We’re almost at the end.

Let’s briefly go over the last component of transition: Legal changes

If you need to know one thing legal gender, it’s this:

Legal gender is only good as the document it’s on.

You can have different legal genders on different documents. It’s all relative.

That sounds like a non-binary dream? Not really.

Legal gender usually comes in two boxes: male or female.

So why would a non-binary person want to go through all the trouble to end up with a legal gender that is still incorrect?

Everyone has personal reasons to keep or change their gender markers.

A few examples:

  • very uncomfortable with birth gender
  • more comfortable with opposite gender
  • one option is safer
  • to affirm trans identity with a permanent change

The requirements for each document will vary.

  • Some require surgery
  • Medical treatment not always a requirement (increasingly true)
  • Use one document to change the rest

Ok… but you’re not a lawyer! 

Most providers here are not legal providers. So what can you do to help?

As a provider, you have power to “authorize” someone’s legal gender change.

Many legal gender changes require a medical sign-off of some sort (remember, WPATH Standards of Care, carry weight in the legal sphere).

It can be a vague sign-off, with a wide gray area open to interpretation.

like, “patient has been in my care and completed or is in the process of transition”

or, “has satisfied all medical treatment in line with their identity” which may be none

Providers can help shape law by pressuring local governments, or establishing “expert” opinions.

Because requiring someone to change their body infringes on their human rights

        

Legal Name Change can be a powerful, easier alternative

Not dependent on legal gender change

Affirms transition, affirms identity

Easy to obtain (in US)

Those were the three main components of transition:

Social, Medical, and Legal.

Hopefully you’ve gained a framework for understanding transition.

Transition

  • has lots of parts, each is a separate option
  • is a process: gradual, takes time
  • composed of individual goals, a motivation behind each component
  • unique goals, goals can change
  • it’s a journey
  • destination may be unknown

As a provider, help ease the path towards finding “comfortable”

With this framework, you’ve learned about

  • the components of transition (social, medical, legal)
  • how they relate to a non-binary identity
  • the specific challenges transition presents to non-binary people
  • what the non-binary options and alternatives are

Here are my 3 main takeaways:

Each individual will have their own path.

There is no right or wrong way to transition or to “do” gender or to be transgender or non-binary.

Each person has their own gender, own goals, own journey.

Get informed

Sometimes there is no answer.

“It depends” is my most common reply.

Research! The information is out there, it’s just hard to find.

You’ll never have all the information.  

Make a lot of educated guesses with the information you have.

Listen        . The answer is with your patient.

Your job is to guide them to the right answer, not to give them the answers yourself.

INTERACT: What are your 3 takeaways?

[For questions or comments, please get in touch]

Thank you for following along and learning about non-binary transition!

Visit neutrois.me/non-binary-transition and watch it all over again.

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