One change I have noticed over the last couple years is an increase in the number of youth coming in to our gender clinic describing a nonbinary gender identity. When the first gender clinics for youth were developed, descriptions of the care provided had no mention of nonbinary identity. The options provided for youth were described as if based on the assumption that all trans youth would identify as binary-trans. When prescribing blockers or hormones, these pioneering clinics first needed to make sure that the patient identified as the other gender.
Today we think of gender identity and medical treatments somewhat differently. Not all people with a difference in gender identity need or want treatment, and those who do may not need or want the same treatment. For example, one patient may only have distress about their breasts and may benefit from top surgery without needing or wanting testosterone. Another patient may desire many of the effects of estrogen but feel most comfortable keeping their facial hair. A third patient who desires an “androgynous” appearance may want to discuss taking low doses of testosterone for a short amount of time, with a plan to stop once they have achieved their goals.
One dilemma that doctors have is that there are no good “standards of care” out there to guide us in our approach to these types of patient requests. That, however, is changing. When the next iteration of the World Professional Association for Transgender Health’s (WPATH) Standards of Care guidelines are published, we are expecting to have a robust chapter on the management of nonbinary patients.
In the meantime, in our clinic we try to partner with patients and families to figure out what is needed, what can be done safely, and use the tools at our disposal to help nonbinary patients feel more comfortable in their own skin.
We are always impressed with how our youngest generation is reconsidering what gender means, and as physicians, we need to adapt to the changing conceptualizations of gender and the diversity of identity.
Dr. Daniel Shumer is a pediatric endocrinologist at Mott Children’s Hospital, and the founder and medical director of the Child and Adolescent Gender Clinic at Mott. His research has involved the mental health vulnerabilities of transgender youth. His medical degree is from Northwestern University, and he also has a Masters in Public Health from Harvard University. He has a son and lives in Ann Arbor, MI.