Non-binary Gender Identities

‘Non-binary’ is an umbrella term for genders outside of the binary framework of ‘man/male’ or ‘woman/female’.  Different non-binary identities may be experienced as somewhere between this, or occupy a third, separate category. Non-binary genders may be fixed or fluid, singular or multiple. It is important to acknowledge that non-binary is a term originating in white, Western contexts, and its application to non-Western genders loses critical context.4

Non-binary identities include genderqueer (a connotation of non-conforming gender expression), agender (gender is neutral or absent), genderfluid (gender shifts over time), and bigender (two gender identities). Ask your patient how they identify and consider what this means for them in having to navigate in a binary social context. The most common pronouns used by non-binary people are singular ‘they and them’, but don’t assume. Some non-binary people will still use he/him or she/her, and there are others such as ‘ze/hir’, known as neo pronouns. It is vital to ascertain pronouns in order not to inadvertently misgender your patient when referring to them either in writing, or in dialogue with other healthcare staff.

Some non-binary people assigned female at birth seek bilateral mastectomy with chest reconstruction surgery, and no hormone therapy. For others, a bespoke regimen of testosterone may help them to achieve a closer approximation to their internal identity from a physical and psychological perspective. In a similar way, oestrogen therapy and/or an androgen-blocker might be suited to some people assigned male at birth, particularly some non-binary people. For all trans people, the requirement for, or type of gender-affirming medical interventions cannot be reliably extrapolated from their gender identity. This is covered in the module on transgender health

Changing personal details on the medical record is straightforward, and no special permission or process is needed. Being under the care of a Gender Identity Clinic or holding a GRC (Gender Recognition Certificate) is not a requirement.

With a signed letter from the patient or either a deed poll or a statutory declaration (although neither are obligatory) the surgery administrator can start the process.Mx’ may be a preferred title among non-binary people, and gender marker options include ‘unspecified’ or ‘unknown’, although these should not be assumed to be desired by non-binary people. Some may wish to keep the marker associated with birth assignation, others may wish to use the marker associated with the other binary option. Patients should be informed that their gender marker will determine the notifications they receive for national screening programs, so due care and attention should be paid to ensure the relevant units are contacted for an invitation.5

The UK does not legally recognise a third gender category, so cannot be reflected on a birth certificate, passport or driving licence. At this current time, the Gender Recognition Act 2004 is not inclusive of non-binary people, and it is therefore not possible for them to acquire a Gender Recognition Certificate. They may still decide to apply for one, as being recognised/positioned as the ‘other’ binary gender may be preferable

Practical Tip

Ensure that allied staff undertake trans awareness training and are familiar with the procedure of changing name, title, and gender marker on a medical record and informing the National Back Office.

You probably aren’t an expert in trans issues—that’s OK. With any change of gender marker, it is important to put in place screening alerts on the software as clinically appropriate. Automated national screening program call-up is directly linked to this marker.


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