As non-binary gender becomes more mainstream, it’s important for physicians to create a welcoming, care-centered environment for patients who identify as such.

In an opinion piece published in the New England Journal of Medicine, Walter Liszewski, MD, of the University of Minnesota in Minneapolis, and colleagues, laid out the case for greater sensitivity among clinicians for patients who do not identify as exclusively male or female.

The authors noted that as society’s concept of gender evolves, non-binary people — people whose gender identity is not defined by the strict male-female dichotomy — are becoming more visible. The authors pointed out that gender identity is independent of biologic sex and sexual orientation. Non-binary people have been recognized by several states and cities, where they are allowed a gender-neutral designation on driver’s licenses or birth certificates.

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Despite these advances, the authors noted that compared with the general public, gender-minorities are more likely to be poor (29% vs 12%), unemployed (15% vs 5%), uninsured (14% vs 11%), victims of intimate-partner violence (24% vs 18%), have attempted suicide (40% vs 4.7%), experienced severe psychological stress in the past month (39% vs 5%), and have HIV (1.4% vs 0.3%). Non-binary individuals are also more likely than transgender individuals to have undergone abuse in school (70% vs 59%) or by the police (29% vs 22%). They are also less likely than transgender people to be “out” in the workplace (33% vs 44%) or with family (35% vs 64%).

In addition to the challenges faced in everyday life, non-binary individuals also experience poorer healthcare than the population in general. Only 40% of gender-minority patients report that their healthcare provider is aware of their gender identity. Children face greater challenges yet, with 16% reporting having been attacked in school because of their gender identity; 10% report that they left school because of abuse.

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The authors suggested clearly documenting patients’ gender and pronoun preferences on intake forms and in electronic medical records. They noted that gender-neutral intake forms are available from the University of California, San Francisco and the National LGBT Health Education Center. The authors also suggested that healthcare teams receive training in respecting patients’ gender identity and gender expression, and advocated that the physical environment should be inclusive, with gender-neutral restrooms available wherever possible.

Another area of concern is research. Many American epidemiologic studies do not collect information on non-binary and transgender people, which may complicate efforts to identify health disparities. The PRIDE Study, however, is a promising exception: it is the first national long-term health study of sexual and gender minorities in the United States.

The authors concluded by pointing out that if clinicians have not yet encountered non-binary patients, they soon will. Making the healthcare environment welcoming and inclusive is an important goal.


Liszewski W, Peebles JK, Yeung H, Arron S. Persons of nonbinary gender—awareness, visibility, and health disparities. N Engl J Med. 2018;379:2381-2393.