Genderqueer, gender non-conforming, and gender nonbinary (GNB) people do not live within the binary gender narrative. A brief discussion of terminology and pronouns will be followed by an overview of the unique considerations for nonbinary hormonal and surgical transition.
With a broad spectrum of gender identities and expressions, GNB people may identify as both male and female; neither male nor female; in between genders; on or outside the gender spectrum; or beyond the gender binary system, not having a gender at all-identifying as agender or genderless. Some may simply identify as "queer," which has been reclaimed as a respectful umbrella term encompassing a broad range of gender identities, expressions, and sexual orientations. GNB people are as authentic in their gender status as transgender people who present with more binary gender identities or expressions. Nonbinary gender terms evolve and change rapidly; spelling and hyphenation vary widely. Some additional examples of terms used by GNB people include :
- gender fluid
- gender ambiguous
- gender bender
- gender blender
- gender smoothie
- gender expansive
- masculine of center
- feminine of center
People who are gender nonbinary may choose to use gender neutral pronouns such as "they," "them," and "their," or other gender neutral pronouns such as "zie(ze)/hir," instead of she/her, he/his.
As with all transgender people, identifying and using the chosen name and pronoun are central to appropriate patient care. Providers are encouraged to familiarize themselves with the diversity of pronouns which may be used by GNB people (Table 1). It is not essential to memorize the chart, and if there are any questions as to how to use and conjugate pronouns for a specific person, it is recommended that you ask for clarification. Conjugation of gender neutral pronouns are described below:
|3rd Person Singular Subjective||3rd Person Singular Objective||3rd Person Singular Possessive||3rd Person Singular Reflexive|
|Source: Adapted from the University of Alberta Student Union|
As with people who have binary transgender identities, the process of gender affirmation and transition for those who are nonbinary is for some limited to an internal or purely social process; for others the process may involve a variety of gender affirming medical and/or surgical interventions. The WPATH Standards of Care Version 7 are now more inclusive of GNB identities and recognize the need for and appropriateness of an individualized approach. 
Specific approaches to gender affirmation for GNB people
The approach to hormone therapy should be guided by the person's desired configuration of secondary sex characteristics. Strategies may include using hormones at a lower dose or for a limited period of time. Nonbinary people on the feminine spectrum may choose to only use an androgen blocker, and/or use estrogen at a very low dose, or for a short time.
For those on the masculine spectrum, low dose testosterone can be acceptable, especially if menses is not a source of dysphoria, as low dose may not stop menses. If gender dysphoria worsens with menses, testosterone may be increased. If a GNB person does not want the degree of masculinization resulting from the higher doses of testosterone that could induce menstrual cessation, other approaches can be explored. These could include intramuscular medroxyprogesterone, the levonorgestrel intrauterine system or an etonogestrel implant, all of which also provide contraception. On occasion, masculine spectrum clients might choose continuous combined oral contraceptives for cessation of menses as well as for contraception. Surgical options for cessation of menses may include uterine ablation or hysterectomy.
It is important to remember to address reproductive and fertility considerations as part of informed consent for medical and surgical approaches, discussed in greater detail in other sections of this protocol. Limitations on the ability to predict specific outcomes with any given regimen should be discussed with GNB patients. Some desired combinations of results (such as a deepened voice without facial or body hair growth) may not be possible.
GNB persons may also pursue a variety of gender affirming surgeries and procedures, including chest reconstruction or breast augmentation and genital surgeries. A masculine spectrum nonbinary person may choose to keep their vagina when pursuing metoidioplasty; this is also an option for a more traditionally binary transgender man. A feminine spectrum nonbinary person may choose to have vaginoplasty but not desire breast development and not pursue hormonal transition; in these cases hormone replacement will be necessary after gonadectomy to maintain bone health, and surgery should only be pursued after an appropriate evaluation by an experienced and qualified mental health provider. Non-medical approaches such as packing, tucking, and binding may be central to a GNB person's expression. Some GNB people may express sharply contrasting masculine and feminine characteristics simultaneously; for example, breasts and facial hair as part of authentic expression.
Challenges for the gender nonbinary person include the lack of nonbinary gender markers for documentation in medical records and in legal identification, such as passports and drivers licenses. Advocacy groups are making efforts to challenge the binary system, introducing nonbinary gender concepts and terminology into legal, medical, mental health, and educational arenas.
A more substantial discussion of gender nonbinary experiences can be found in blogs and websites (e.g., Neutrois Nonsense)  and books such as Trans Bodies, Trans Selves.
- Ehrensaft D. 2011 Gender Born, Gender Made: Raising Healthy Gender-Nonconforming Children. New York, NY: The Experiment. 290 p.
- World Professional Association for Transgender Health (WPATH). Standards of care for the health of transsexual, transgender, and gender nonconforming people, 7th Version. WPATH; 2012 [cited 2016 Mar 10].
- Neutrois Nonsense: An intimate exploration of identity and finding life wisdom beyond the gender binary.
- Erikson-Schroth, L. 2014. Trans Bodies, Trans Selves: A Resource for the Transgender Community. New York, NY: Oxford University Press.