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Episode 11 Transcript

Non-Binary Pronouns & Hormone Therapy Options

Erin Everett:

Hey, everybody. Welcome to Exclusively Inclusive. I’m your host, Erin Everett, nurse practitioner. Really excited to be talking to you guys today as our subject is going to be about non-binary gender nonconforming or genderqueer individuals. I think it’s really important that we discuss this because there’s been a lot more talk about it in the community, but some people aren’t sure what that means, and as we’ve mentioned before in previous episodes when we’re talking about trans masculine, trans feminine, there are definitely people though who identify as gender fluid, which is also the reason why I try to refer to the community as a whole as gender diverse because people land on the gender spectrum at different places. And we have touched on it when I had Tali on the show about how the gender spectrum exists as far as gender identity, but then also gender expression. So sometimes people may not express their gender the way that they identify and that can also change on a daily basis. The gender expression can.

Non-Binary Gender Terms

For the most part, once people have identified their gender, they kind of sit there. Sometimes of course it can be fluid and it could change, but the gender expression is what mostly changes for a lot of people. And so under that umbrella of non-binary are very common terms, and some of those include Gender Fluid, gender ambiguous, Pangender, Neutrois, Gender Bender, Gender Blender, Gender Expansive, Genderqueer is one too, and androgynous. Androgynous was probably the most well known one a long time ago. But now we have more accepted terms in the community, such as gender fluid.

Basically what it means to be gender non-conforming or non-binary means that you don’t necessarily fit into the binary which is the two-part world that we live in, which was socially constructed. So instead of using pronouns such as she and her or he and his, a lot of patients who identify this way will use pronouns such as they, them and theirs.

Non-Binary Gender Pronouns

And there are definitely other gender neutral pronouns that can be used less commonly, probably. Would be Xe, Xer, Xer, Xers and Xerself. Another one that I learned about that I had not heard before was Per Per Pers and Perself. So that one was interesting and new for me as well, but I would say the vast majority of people when they’re nonconforming, non-binary, they usually use the pronouns they them and theirs.

Adding Non-Binary Gender Pronouns to Healthcare Paperwork

So as far as providing care for gender nonconforming non-binary people, it’s really important that if you are in the healthcare system in any kind of way providing care, it’s really important that you give the option to Mark that as a preferred gender on the intake paperwork.

Some offices will put down what was your sex assigned at birth and then also your preferred gender or gender identification. This way it gives people an opportunity to express their preferred gender without necessarily having to have a conversation about it, and that just helps normalize it.

Gender Affirmation for Non-Binary People

There are many ways that we can approach gender affirmation for gender non-binary people. Of course, some of those approaches include hormones, but not all of them do. Sometimes it can include surgeries and nonsurgical options as well, and sometimes people just need education on those things and aren’t necessarily seeking hormonal transition.

Non-Binary Hormone Therapy Options

But for people that are pursuing hormonal transition, one thing that I like to have a conversation with them about is, okay, well if you’re non-binary and on the spectrum, what kind of hormones are you looking to seek and how are you looking to express in a sense?

Feminine Leaning Non-Binary HRT

So some people who tend to be on the more feminine spectrum would have been assigned male at birth and have typical biological male parts, might just decide to block their testosterone for a little while. And we can do that with an androgen blocker. Sometimes they want a low dose androgen blocker and a low dose estrogen option, sometimes longterm or sometimes just for a short time just to see how they feel on it.

Some non-binary people just want some breast bud formation and then they opt to come off of the hormones because, again, not all people who identify as feminine who are assigned male at birth necessarily have genital dysphoria, so they still might want to be able to function actively with their genitals, but want to have some breast bud formation or other kind of emotional changes, and a little bit of fat redistribution, and that can all be achieved with low doses as well. And I always tell my patients, “You’re in charge of this. As long as you’re not going over my maximum recommended daily dose of hormones, which is what I would prescribe for a trans female, then it’s up to you how you want to dose it.”

You can for one week, try the androgen blocker every day if you don’t like the way that feels, do it every other day. There’s really no harm because you’re still producing hormones, and also we’re giving low-dose hormones. So there’s no concern about not having enough hormones because a lot of people think that if they don’t do full transitional doses that they’re going to be damaging their bones or impacting their heart health. And that’s just not necessarily true.

Masculine Leaning Non-Binary HRT

For people who kind of identify more as on the mess masculine spectrum, but as still non-binary, I often offer low-dose testosterone options if they’re looking for hormones. Again, it’s a conversation you need to have with people. Like what does it look like? What kind of secondary sex characteristics are you looking to change? And then depending on what their preferences are, sometimes we have to have the conversation, okay, well that’s probably not realistic.

I cannot guarantee that I can give you a deeper voice without any additional facial or body hair growth. That can be really tricky. And again, for people coming in who don’t want their voice deeper than I discourage them from using testosterone, because it’s hard for me to say what dose testosterone will change the vocal cords. But testosterone almost always lengthens the vocal cords, which is irreversible and results in a deeper voice.

So if people are very skittish about that and definitely don’t want that as a side effect, then I definitely caution them on even taking testosterone, period. For some people who want their menstrual cycle to stop, we can do higher doses of testosterone, but that also would result in a more pronounced secondary sex characteristics, which means facial hair growth, sometimes too clitoral enlargements, libido changes, mood changes, deepening of the voice, those types of things.

Menstrual Cycles & Birth Control Options

Because some of the low doses won’t stop the menstrual cycle. So if that’s the goal but they don’t want the higher dose of testosterone. We do have other options as well.

Progestins & IUDs

Some of the other options really include doing some sort of progestin. Progestin is a synthetic progesterone that is prescribed in different types of contraceptives. But contraceptives, as a broad term, it’s not always prescribed for birth control. There’s different progesterone IUD options that will reduce the frequency of the cycle. And then if you use one like Mirena, the cycle almost always goes away 90% of the time.

So if that’s causing a lot of dysphoria but you don’t want to do higher doses of testosterone, then I just connect you with a safe a gynecologist and I mean safe, like someone who’s culturally competent in the gender diverse community. So that when you go over there, you have a positive experience as well, not just for your healthcare, but also for your social needs. And when you get to that gynecologist too, they can also talk about other options, like the intramuscular progesterone shots.

There’s a Nexplanon which is implanted underneath the skin. That one lasts for three years, and then of course like I just mentioned before, the Mirena IUD. There is like three different main types that I’m aware of IUDs and each have their pluses and minuses and a gynecologist would go over that because they’re the ones that insert it. But those are just options really if people are having dysphoria about the menstrual cycle. Also too, if they want birth control, because sometimes people are still having penetrative intercourse with biological males, and so it’s really important to prevent pregnancy.

Surgical Options

One of the other surgical options to stop the menstrual cycle and this could result in a sterility or infertility I should say would be uterine ablation or hysterectomy. So depending on your age and your desire to procreate at some point, then those also could be discussed with your gynecologist.

Low-Dose Hormones for Non-Binary People

One of the other things too, for trans masculine or non-binary people who are on the masculine spectrum would be to discuss how long they want to take the low-dose testosterone. So one of the things too that needs to be discussed when talking with people about their low dose testosterone or low dose estradiol is how long they want to stay on it. They may not know when we first start prescribing it, but it is an option that some people don’t know of that you can just take hormones for short amount of time and then discontinue. Once you discontinue, as long as you still have your ovaries or your testicles, they will take over and continue to produce your original hormone that you had before.

The only concern is if you do end up getting your gonads or that your testicles, your ovaries removed, is that for whatever reason, if you did get a therapeutic orchiectomy or hysterectomy or you’ve had some sort of gender affirming surgery and those parts are no longer in place, then longterm hormone replacement therapy needs to be discussed, because otherwise then we’re looking at decreased bone mineral density and negative impacts on your cardiovascular system and at that point you can have a discussion with me or somebody else, either the person that’s prescribing your hormones about what type of hormone you want. So you might want to, if you’ve had a therapeutic orchiectomy, talk about still getting a compounded cream that has testosterone in it as well.

I mean, there’s many different options and it’s really when it comes to the gender spectrum and providing care for people who identify as non-binary, the conversation is just very different and more specialized than those who are trans male or trans female because it’s really kind of … Well, I mean, I don’t like to say cherry picking, but it is kind of a more selective process and trying to tailor the care to these people and make sure that it’s very individualized because there’s no one right or wrong way of doing this.

I briefly mentioned some of the affirming surgeries and procedures for non-binary people. Some of those can include chest reconstruction or breast augmentation and genital surgeries. So some people don’t want to do the transitional dose of testosterone, but do want their breasts removed and so we can offer the breast reconstruction surgery and again, non-binary people who are more on the feminine spectrum can decide to get breast augmentation or breast implants if they didn’t get a good response from their low-dose hormones, or if they opt out of low-dose hormones altogether. There are definitely people that go on to have vaginal metoidioplasty without having an official hormone replacement therapy program. There’s also some non-binary people that might want to go onto get vaginoplasty. Again, then the testicles would be removed, but they might want to get vaginoplasty but not get breast implants and then just go on to do low dose female hormones or even add a little bit of testosterone back in.

Non-Surgical Options for Dysphoria

But those are some of the like surgical options. But there’s also nonsurgical options to kind of help with dysphoria such as packing, tucking, binding, and some of those things that people might just need coaching on because they’re not aware of. There’s also getting rid of facial hair, someone who’s non-binary but as on the feminine side might want to be still appearing as somewhat male, but really hate their facial hair. So things that you could offer potentially would be referring them to someone who does electrolysis and those types of things.

Documentation for Non-Binary People

I think one of the hardest things for people who identify as non-binary is navigating their documentation and medical records and legal identification. Currently, I think California might be offering this option, but definitely not where I’m at in Georgia. Not offering any kind of non-binary pronoun selection on driver’s licenses, Passports, state IDs, and also depending on the clinic that they’re going to, there’s not a great way to document their non-binary pronoun status.

So at our clinic, when people are coming in, we document all that and we do offer it on our intake paperwork for them to identify their assigned sex at birth, but also what their preferred gender identification is. We also do a good job of documenting it through the chart, their preferred pronouns and gender identification. That way patients don’t have to feel like they’re coming in every single time and reminding people, “Hey, these are my preferred pronouns.”

But not every clinic is going to be so accommodating. And so that’s one of the biggest struggles is even if we can get clinics to get on board with LGBTQ care in general, often it’s very still binary where they’re catering to trans men and trans females, but the non-binary group has been kind of left out a little bit. So we’re working harder to increase awareness of people who don’t fit into the binary world.

Final Thoughts on Non-Binary Healthcare

And actually I think Michelle may have mentioned it on her episode, but she mentioned that non-binary people might be way more ahead of the game when it comes to deconstructing social constructs and just living as their true selves and not conforming to anybody’s preconceived notions of what they should look like. And actually really … I really love that. I love … Some of my most interesting patients have identify as non-binary and somewhat it’s like an art expression because they get to come in and express exactly how they feel without worrying about being masculine or feminine. It’s just kind of, I am who I am and it’s really … It’s really awesome, actually.

Well I just wanted to give you guys a brief segment on non-binary care and what all that means and kind of explain what the gender spectrum and the pronoun options are. So hopefully you’ve learned something so you continue to educate those around you so we can get more accepting of everybody on the gender spectrum and using pronouns such as they/them.

And also it’d be really nice to be able to go out in public and I myself, don’t like getting, ma’am’ed. So I’m sure somebody who doesn’t identify as female doesn’t like it either. But get to a place where in society, we’re not assuming people’s preferred pronoun based on how their gender expression looks. Okay everybody, thanks for tuning in, and until next time, remember to stay fierce and live your truth.