research about gender binary

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The future of sex and gender in psychology: Five challenges to the gender binary

Affiliations.

1 Department of Psychology.
2 School of Psychological Sciences.
3 Departments of Psychology, Women's Studies, and Neuroscience.
PMID: 30024214
DOI: 10.1037/amp0000307

The view that humans comprise only two types of beings, women and men, a framework that is sometimes referred to as the "gender binary," played a profound role in shaping the history of psychological science. In recent years, serious challenges to the gender binary have arisen from both academic research and social activism. This review describes 5 sets of empirical findings, spanning multiple disciplines, that fundamentally undermine the gender binary. These sources of evidence include neuroscience findings that refute sexual dimorphism of the human brain; behavioral neuroendocrinology findings that challenge the notion of genetically fixed, nonoverlapping, sexually dimorphic hormonal systems; psychological findings that highlight the similarities between men and women; psychological research on transgender and nonbinary individuals' identities and experiences; and developmental research suggesting that the tendency to view gender/sex as a meaningful, binary category is culturally determined and malleable. Costs associated with reliance on the gender binary and recommendations for future research, as well as clinical practice, are outlined. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

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Gender can be a continuous variable, not just a categorical one: Comment on Hyde, Bigler, Joel, Tate, and van Anders (2019). Reilly D. Reilly D. Am Psychol. 2019 Oct;74(7):840-841. doi: 10.1037/amp0000505. Am Psychol. 2019. PMID: 31580111
Sex and gender are distinct variables critical to health: Comment on Hyde, Bigler, Joel, Tate, and van Anders (2019). Cretella MA, Rosik CH, Howsepian AA. Cretella MA, et al. Am Psychol. 2019 Oct;74(7):842-844. doi: 10.1037/amp0000524. Am Psychol. 2019. PMID: 31580112

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How Science is Helping Us Understand Gender

Freed from the binary of boy and girl, gender identity is a shifting landscape. Can science help us navigate?

Human Geography, Social Studies, Biology, Sociology, Geography, Genetics

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She has always felt more boyish than girlish.

From an early age, E, as she prefers to be called for this story, hated wearing dresses, liked basketball, skateboarding, video games. When we met in May in New York City (New York, United States) at an end-of-the-year show for her high school speech team, E was wearing a tailored Brooks Brothers suit and a bow tie from her vast collection. With supershort red hair, a creamy complexion , and delicate features, the 14-year-old looked like a formally dressed, earthbound Peter Pan.

Later that evening E searched for the right label for her gender identity. “ Transgender ” didn’t quite fit, she told me. For one thing she was still using her birth name and still preferred being referred to as “she.” And while other trans kids often talk about how they’ve always known they were born in the “wrong” body, she said, “I just think I need to make alterations in the body I have, to make it feel like the body I need it to be.” By which she meant a body that doesn’t menstruate and has no breasts, with more defined facial contours and “a ginger beard.” Does that make E a trans guy? A girl who is, as she put it, “insanely androgynous ”? Or just someone who rejects the trappings of traditional gender roles altogether?

You’ve probably heard a lot of stories like E’s recently. But that’s the whole point: She’s questioning her gender identity, rather than just accepting her hobbies and wardrobe choices as those of a tomboy , because we’re talking so much about transgender issues these days. These conversations have led to better head counts of transgender Americans, with a doubling, in just a decade, of adults officially tallied as transgender in national surveys; an increase in the number of people who are gender nonconforming , a broad category that didn’t even have a name a generation ago; a rise in the number of elementary school–age children questioning what gender they are; and a growing awareness of the extremely high risk for all of these people to be bullied, to be sexually assaulted , or to attempt suicide .

The conversation continues, with evolving notions about what it means to be a woman or a man and the meanings of transgender, cisgender , gender nonconforming, genderqueer , agender , or any of the more than 50 terms Facebook offers users for their profiles. At the same time, scientists are uncovering new complexities in the biological understanding of sex .

Many of us learned in high school biology that sex chromosomes determine a baby’s sex, full stop: XX means it’s a girl; XY means it’s a boy. But on occasion, XX and XY don’t tell the whole story.

Today we know that the various elements of what we consider “male” and “female” don’t always line up neatly, with all the XXs—complete with ovaries, vagina, estrogen , female gender identity, and feminine behavior—on one side and all the XYs— testes , penis, testosterone , male gender identity, and masculine behavior—on the other. It’s possible to be XX and mostly male in terms of anatomy, physiology, and psychology, just as it’s possible to be XY and mostly female.

Each embryo starts out with a pair of primitive organs, the proto-gonads, that develop into male or female gonads at about six to eight weeks. Sex differentiation is usually set in motion by a gene on the Y chromosome, the SRY gene, that makes the proto-gonads turn into testes. The testes then secrete testosterone and other male hormones (collectively called androgens), and the fetus develops a prostate, scrotum, and penis. Without the SRY gene, the proto-gonads become ovaries that secrete estrogen, and the fetus develops female anatomy (uterus, vagina, and clitoris).

But the SRY gene’s function isn’t always straightforward. The gene might be missing or dysfunctional, leading to an XY embryo that fails to develop male anatomy and is identified at birth as a girl. Or it might show up on the X chromosome , leading to an XX embryo that does develop male anatomy and is identified at birth as a boy.

Genetic variations can occur that are unrelated to the SRY gene, such as complete androgen insensitivity syndrome (CAIS), in which an XY embryo’s cells respond minimally, if at all, to the signals of male hormones. Even though the proto-gonads become testes and the fetus produces androgens, male genitals don’t develop. The baby looks female, with a clitoris and vagina, and in most cases will grow up feeling herself to be a girl.

Which is this baby, then? Is she the girl she believes herself to be? Or, because of her XY chromosomes—not to mention the testes in her abdomen—is she “really” male?

Georgiann Davis, 35, was born with CAIS but didn’t know about it until she stumbled upon that information in her medical records when she was nearly 20. No one had ever mentioned her XY status, even when doctors identified it when she was 13 and sent her for surgery at 17 to remove her undescended testes. Rather than reveal what the operation really was for, her parents agreed that the doctors would invent imaginary ovaries that were precancerous and had to be removed.

In other words, they chose to tell their daughter a lie about being at risk for cancer rather than the truth about being intersex —with reproductive anatomy and genetics that didn’t fit the strict definitions of female and male.

“Was having an intersex trait that horrible?” wrote Davis, now a sociologist at the University of Nevada, Las Vegas, in Contesting Intersex: The Dubious Diagnosis. “I remember thinking I must be a real freak if even my parents hadn’t been able to tell me the truth.”

Another intersex trait occurs in an isolated region of the Dominican Republic; it is sometimes referred to disparagingly as guevedoce— “penis at 12.” It was first formally studied in the 1970s by Julianne Imperato-McGinley, an endocrinologist from the Weill Cornell Medical College in the U.S. state of New York, who had heard about a cohort of these children in the village of Las Salinas. Imperato-McGinley knew that ordinarily, at around eight weeks gestational age, an enzyme in male embryos converts testosterone into the potent hormone DHT. When DHT is present, the embryonic structure called a tubercle grows into a penis; when it’s absent, the tubercle becomes a clitoris. Embryos with this condition, Imperato-McGinley revealed, lack the enzyme that converts testosterone to DHT, so they are born with genitals that appear female. They are raised as girls. Some think of themselves as typical girls; others sense that something is different, though they’re not sure what.

But the second phase of masculinization, which happens at puberty , requires no DHT, only a high level of testosterone, which these children produce at normal levels. They have a surge of it at about age 12, just as most boys do, and experience the changes that will turn them into men (although they’re generally infertile ): Their voices deepen, muscles develop, facial and body hair appear. And in their case, what had at first seemed to be a clitoris grows into a penis.

When Imperato-McGinley first went to the Dominican Republic, she told me, newly sprouted males were suspect and had to prove themselves more emphatically than other boys did, with impromptu rituals involving blades, before they were accepted as real men. Today these children are generally identified at birth, since parents have learned to look more carefully at newborns’ genitals. But they are often raised as girls anyway.

Gender is an amalgamation of several elements: chromosomes (those X’s and Y’s), anatomy (internal sex organs and external genitals), hormones (relative levels of testosterone and estrogen), psychology (self-defined gender identity), and culture (socially defined gender behaviors). And sometimes people who are born with the chromosomes and genitals of one sex realize that they are transgender, meaning they have an internal gender identity that aligns with the opposite sex—or even, occasionally, with neither gender or with no gender at all.

As transgender issues become the fare of daily news—Caitlyn Jenner’s announcement that she is a trans woman, legislators across the United States arguing about who gets to use which bathroom—scientists are making their own strides, applying a variety of perspectives to investigate what being transgender is all about.

In terms of biology, some scientists think it might be traced to the syncopated pacing of fetal development. “Sexual differentiation of the genitals takes place in the first two months of pregnancy,” wrote Dick Swaab, a researcher at the Netherlands Institute for Neuroscience in Amsterdam, “and sexual differentiation of the brain starts during the second half of pregnancy.” Genitals and brains are thus subjected to different environments of “hormones, nutrients, medication, and other chemical substances,” several weeks apart in the womb, that affect sexual differentiation.

This doesn’t mean there’s such a thing as a “male” or “female” brain, exactly. But at least a few brain characteristics, such as density of the gray matter or size of the hypothalamus, do tend to differ between genders. It turns out transgender people’s brains may more closely resemble brains of their self-identified gender than those of the gender assigned at birth. In one study, for example, Swaab and his colleagues found that in one region of the brain, transgender women, like other women, have fewer cells associated with the regulator hormone somatostatin than men. In another study scientists from Spain conducted brain scans on transgender men and found that their white matter was neither typically male nor typically female, but somewhere in between.

These studies have several problems. They are often small, involving as few as half a dozen transgender individuals. And they sometimes include people who already have started taking hormones to transition to the opposite gender, meaning that observed brain differences might be the result of, rather than the explanation for, a subject’s transgender identity.

Still, one finding in transgender research has been robust: a connection between gender nonconformity and autism spectrum disorder (ASD). According to John Strang, a pediatric neuropsychologist with the Center for Autism Spectrum Disorders and the Gender and Sexuality Development Program at Children’s National Health System in the U.S. capital of Washington, D.C., children and adolescents on the autism spectrum are seven times more likely than other young people to be gender nonconforming. And, conversely, children and adolescents at gender clinics are six to 15 times more likely than other young people to have ASD.

Emily Brooks, 27, has autism and labels herself nonbinary , though she has kept her birth name. A slender person with a half-shaved head, turquoise streaks in her blond hair, and cute, hipster glasses, Brooks recently finished a master’s degree at the City University of New York in disability studies and hopes eventually to create safer spaces for people who are gender nonconforming (which she defines quite broadly) and also have autism. Such people are battling both “ableism” and “transphobia,” she told me over soft drinks at a bar in midtown Manhattan, New York City. “And you can’t assume that a place that’s going to be respectful of one identity will be respectful of the other.”

As I sat with Brooks, talking about gender and autism, the bartender came over. “What else can I get you ladies?” he asked. Brooks bristled at being called a lady—evidence that her own search for a safe space is complicated not only by her autism but also by her rejection of the gender binary altogether.

There’s something to be said for the binary. The vast majority of people—more than 99 percent, it seems safe to say—put themselves at one end of the gender spectrum or the other. Being part of the gender binary simplifies the either-or of daily life: clothes shopping, sports teams, passports, the way a bartender asks for your order.

But people today—especially young people—are questioning not just the gender they were assigned at birth but also the gender binary itself. “I don’t relate to what people would say defines a girl or a boy,” Miley Cyrus told Out magazine in 2015, when she was 22, “and I think that’s what I had to understand: Being a girl isn’t what I hate; it’s the box that I get put into.”

Members of Cyrus’s generation are more likely than their parents to think of gender as nonbinary. A recent survey of a thousand millennials ages 18 to 34 found that half of them think “gender is a spectrum, and some people fall outside conventional categories.” And a healthy subset of that half would consider themselves to be nonbinary, according to the Human Rights Campaign. In 2012 the advocacy group polled 10,000 lesbian, gay, bisexual, and transgender teens ages 13 to 17 and found that six percent categorized themselves as “ genderfluid ,” “androgynous,” or some other term outside the binary box.

Young people trying to pinpoint their own place on the spectrum often choose a pronoun they’d like others to use when referring to them. Even if they don’t feel precisely like a girl or a boy, they might still use “he” or “she,” as Emily Brooks does. But many opt instead for a gender-neutral pronoun like “they” or an invented one like “zie.”

Charlie Spiegel, 17, tried using “they” for a while, but now prefers “he.” Charlie was assigned female at birth. But when he went through puberty, Charlie told me by phone from his home in Oakland, California, U.S., being called a girl started to feel unsettling. “You know how sometimes you get a pair of shoes online,” he explained, “and it arrives and the label says it should be the right size, and you’re trying it on and it’s clearly not the right size?” That’s how gender felt to Charlie: The girl label was supposed to fit, but it didn’t.

One day during freshman year, Charlie wandered into the school library and picked up I Am J by Cris Beam, a novel about a transgender boy. “Yep, that sounds like me,” Charlie thought as he read it. The revelation was terrifying but also clarifying, a way to start making those metaphoric mail-order shoes less uncomfortable.

A better fitting gender identity didn’t come along right away, though. Charlie—a member of the Youth Council at Gender Spectrum, a national support and advocacy group for transgender and nonbinary teens—went through a process of trial and error similar to that described by other gender-questioning teens. First he tried “butch lesbian,” then “genderfluid,” before settling on his current identity, “nonbinary trans guy.” It might sound almost like an oxymoron—aren’t “nonbinary” and “guy” mutually exclusive?—but the combination feels right to Charlie. He was heading off to college a few months after our conversation, getting ready to start taking testosterone.

If more young people are coming out as nonbinary, that’s partly because the new awareness of the nonbinary option offers “a language to name the source of their experience,” therapist Jean Malpas said when we met last spring at the Manhattan offices of the Ackerman Institute for the Family, where he directs the Gender and Family Project.

But as more children say they’re nonbinary—or, as Malpas prefers, “gender expansive”—parents face new challenges. Take E, for example, who was still using female pronouns when we met in May, while struggling over where exactly to place herself on the gender spectrum. Her mother, Jane, was struggling too, trying to make it safe for E to be neither typically feminine nor typically masculine.

The speech team that had performed in New York City the night E and I met was getting ready to travel to a national competition in the California, and Jane showed me the email she’d sent the coach to pave the way. E might be seen by others as male, Jane wrote, now that her hair was so short and her clothing so androgynous. She would probably use “both male and female bathrooms depending on what situation feels safest,” Jane informed the coach, and “will need to tell you when she is going to the restroom and what gender she plans on using.” I asked Jane, the night we met, where she’d place her daughter on the gender spectrum. “I think she wants to fall into a neutral space,” she replied.

A “neutral space” is a hard thing for a teenager to carve out: Biology has a habit of declaring itself eventually. Sometimes, though, biology can be put on hold for a while with puberty-blocking drugs that can buy time for gender-questioning children. If the child reaches age 16 and decides he or she is not transgender after all, the effects of puberty suppression are thought to be reversible: The child stops taking the blockers and matures into their birth sex. But for children who do want to transition at 16, having been on blockers might make it easier. They can start taking cross-sex hormones and go through puberty in the preferred gender—without having developed the secondary sex characteristics, such as breasts, body hair, or deep voices, that can be difficult to undo.

The Endocrine Society recommends blockers for adolescents diagnosed with gender dysphoria. Nonetheless, the blockers’ long-term impact on psychological development, brain growth, and bone mineral density are unknown—leading to some lively disagreement about using them on physically healthy teens.

More fraught than the question about puberty blockers is the one about whether too many young children, at too early an age, are being encouraged to socially transition in the first place.

Eric Vilain, a geneticist and pediatrician who directs the UCLA Center for Gender-Based Biology, says that children express many desires and fantasies in passing. What if saying “I wish I were a girl” is a feeling just as fleeting as wishing to be an astronaut, a monkey, a bird? When we spoke by phone last spring, he told me that most studies investigating young children who express discomfort with their birth gender suggest they are more likely to turn out to be cisgender (aligned with their birth-assigned gender) than trans—and relative to the general population, more of these kids will eventually identify as gay or bisexual.

“If a boy is doing things that are girl-like—he wants long hair, wants to try his mother’s shoes on, wants to wear a dress and play with dolls—then he’s saying to himself, ‘I’m doing girl things; therefore I must be a girl,’ ” Vilain said. But these preferences are gender expression, not gender identity. Vilain said he’d like parents to take a step back and remind the boy that he can do all sorts of things that girls do, but that doesn’t mean he is a girl.

At the Gender and Family Project, Jean Malpas said counselors “look for three things in children who express the wish to be a different gender”: that the wish be “persistent, consistent, and insistent.” And many children who come to his clinic meet the mark, he told me, even some five-year-olds. “They’ve been feeling this way for a long time, and they don’t look back.”

That was certainly the case for the daughter of writer Marlo Mack (the pseudonym she uses in her podcasts and blogs to protect her child’s identity). The family lives in the U.S. city of Seattle, Washington. Mack’s child was identified at birth as a boy but by age three was already insisting he was a girl. Something went wrong in your tummy, he told his mother, begging to be put back inside for a do-over.

As Vilain might have instructed, Mack tried to broaden her child’s understanding of how a boy could behave. “I told my child over and over again that he could continue to be a boy and play with all the Barbies he wanted and wear whatever he liked: dresses, skirts, all the sparkles money could buy,” Mack said in her podcast, How to Be a Girl. “But my child said no, absolutely not. She was a girl.”

Finally, after a year of making both of them “miserable,” Mack let her four-year-old choose a girl’s name, start using female pronouns, and attend preschool as a girl. Almost instantly the gloom lifted. In a podcast that aired two years after that, Mack reported that her transgender daughter, age six, “loves being a girl probably more than any girl you’ve ever met.”

Vilain alienates some transgender activists by saying that not every child’s “I wish I were a girl” needs to be encouraged. But he insists that he’s trying to think beyond gender stereotypes. “I am trying to advocate for a wide variety of gender expressions,” he wrote in a late-night email provoked by our phone conversation, “which can go from boys or men having long hair, loving dance and opera, wearing dresses if they want to, loving men, none of which is ‘making them girls’—or from girls shaving their heads, being pierced, wearing pants, loving physics, loving women, none of which is ‘making them boys.’ ”

This is where things get murky in the world of gender. Young people such as Mack’s daughter, or Charlie Spiegel of California, or E of New York City, must make biological decisions that will affect their health and happiness for the next 50 years. Yet these decisions run headlong into the maelstrom of fluctuating gender norms.

“I guess people would call me gender-questioning,” E said the second time we met, in June. “Is that a thing? It sounds like a thing.” But the “questioning” couldn’t go on forever, she knew, and she was already leaning toward “trans guy.” E had moved a few steps closer to that by September, asking people, including me, to use the pronoun “they” when referring to them. If E does eventually settle on a male identity, they feel it won’t be enough just to live as a man, changing pronouns (either sticking with “they” or switching to “he”) and changing their name (the leading candidate is the name “Hue”). It would mean becoming physically male too, which would involve taking testosterone. It was all a bit much, E told me. As their 15th birthday approached, they were giving themselves another year to figure it all out.

E’s thinking about where they fit on the gender spectrum takes the shape it does because E is a child of the 21st century, when concepts like transgender and gender nonconforming are in the air. But their options are still constrained by being raised in a Western culture, where gender remains, for the vast majority, an either-or. How different it might be if E lived where a formal role existed that was neither man nor woman but something in between—a role that constitutes another gender.

There are such places all over the world: South Asia (where a third gender is called hijra ), Nigeria (yan daudu), Mexico (muxe), Samoa (fa‘afafine), Thailand (kathoey), Tonga (fakaleiti), and even the U.S., where third genders are found in Hawai'i (mahu) and in some Native American peoples (two-spirit). The degree to which third genders are accepted varies, but the category usually includes anatomical males who behave in a feminine manner and are sexually attracted to men, and almost never to other third-gender individuals. More rarely, some third-gender people, such as the burrnesha of Albania or the fa‘afatama of Samoa, are anatomical females who live in a masculine manner.

I met a dozen or so fa‘afafine last summer, when I traveled to Samoa at the invitation of psychology professor Paul Vasey, who believes the Samoan fa‘afafine are among the most well-accepted third gender on Earth.

Vasey, professor and research chair of psychology at the University of Lethbridge in Alberta, Canada, returns to Samoa so frequently that he has his own home, car, and social life there. One thing that especially intrigues him about third genders, in Samoa and elsewhere, is their ability to shed light on the “evolutionary paradox” of male same-sex attraction. Since fa‘afafine almost never have children of their own, why are they still able to pass along the genes associated with this trait? Without offspring, shouldn’t natural selection pretty much have wiped them out?

Being fa‘afafine runs in families, the same way being gay does, Vasey said. (He said it also occurs at about the same rate as male homosexuality in many Western countries, in about three percent of the population.) He introduced me to Jossie, 29, a tall, slim schoolteacher. Jossie lives in a village about an hour from the capital, Apia. She giggled at my questions, especially when I asked about guys. For Jossie, being fa‘afafine is also a family trait. Several fa‘afafine relatives listened to our conversation: Jossie’s uncle Andrew, a retired nurse who goes by the name Angie; her cousin Trisha Tuiloma, who is also Vasey’s research assistant; and Tuiloma’s five-year-old nephew.

“In this village they don’t really like the ‘fa‘fa’ style,” said Angie, who emerged from the house she shares with Jossie wearing nothing but a long skirt, called a lavalava, tied at the waist. Back in her 20s Angie had thought it might be nice “to have an operation to be a woman.” But now, at 57, she said she’s happy without surgery. She no longer feels discriminated against. Fellow church parishioners might criticize the way she and Jossie dress or behave, but “our families here, they understand.”

Vasey is now investigating two hypotheses that might explain the evolutionary paradox of male same-sex sexuality.

The first, the sexually antagonistic gene hypothesis, posits that genes for sexual attraction to males have different effects depending on the sex of the person carrying them: Instead of coming with a reproductive cost, as happens in males, the genes in females have a reproductive benefit—which means that the females with those genes should be more fertile. Vasey and his colleagues have found that the mothers and maternal grandmothers of fa‘afafine do have more babies than the mothers and grandmothers of straight Samoan men. But they haven’t found comparable evidence among paternal grandmothers—or among the aunts of fa‘afafine, which would come closest to definitive proof.

A second possibility is the kin selection hypothesis—the idea that the time and money that same-sex-attracted males devote to nurturing their nieces and nephews make it more likely that the nieces and nephews will pass some of their DNA down to the next generation. Indeed, among the fa‘afafine Vasey introduced me to, several have taken siblings’ children under their wing. Trisha Tuiloma, who is 42, uses the money she earns as Vasey’s research assistant to pay for food, schooling, treats, even electricity for eight nieces and nephews. And in his formal research Vasey has found that fa‘afafine are more likely to offer money, time, and emotional support to their siblings’ children—especially to their sisters’ youngest daughters—than are straight Samoan men or Samoan women.

One other point about gender identity became clear when I met Vasey’s longtime partner, Alatina Ioelu, a fa‘afafine Vasey met 13 summers ago. When Ioelu first drove up to my hotel, my understanding of what it means to be fa‘afafine started to unravel. Ioelu was much more masculine than the other fa‘afafine I’d met. Tall, broad-shouldered, with an open, handsome face, he favored the same clothing—cargo shorts and T-shirts—that Vasey wore. What did it mean for someone who reads as a man to belong to a third gender that implies heightened femininity?

Gradually it dawned on me, as the three of us chatted through dinner, that Ioelu’s identity as a fa‘afafine shows how deeply bound in culture gender itself is. Vasey and Ioelu plan to marry and retire in Canada someday. (Vasey is 50; Ioelu is 38.) “There we’d be perceived as an ordinary same-sex couple,” Vasey told me.

In other words, the gender classification of Ioelu would change, as if by magic, from fa‘afafine to gay man, just by crossing a border.

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Non-binary/Genderqueer Identities: a Critical Review of the Literature

Variations in Orientation, Identity, Addiction, and Compulsion (E Coleman and J Vencill, Section Editor)
Published: 13 July 2017
Volume 9 , pages 116–120, ( 2017 )

Cite this article

Emmie Matsuno 1 &
Stephanie L. Budge 2

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Purpose of Review

The goal of this paper is to give current understanding of non-binary/genderqueer identities, non-binary mental health trends and identity development, unique experiences of non-binary individuals, and recommendations for clinicians and researchers.

Recent Findings

About one third of individuals who identify as transgender primarily identify as non-binary. Recent studies found that non-binary people are at higher risk for suicide, experience more psychological distress, and experience higher levels of depression and anxiety. New studies on identity development of non-binary individuals provide explicit and fluid understandings of gender identity development outside of male/female, man/woman, and boy/girl.

Overall, little research is focused on non-binary individuals even though non-binary people make up a significant portion of the transgender community and experience even greater negative mental health risks. Non-binary people face several challenges in a society that is structured around binary gender identities. We encourage psychologists to challenge the dominant binary assumption about gender and create environments that include and affirm non-binary individuals.

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Transgender — Living in a Gender Different from That Assigned at Birth

Factors that drive mental health disparities and promote well-being in transgender and nonbinary people

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

• Moradi B, Tebbe EA, Brewster ME, Budge SL, Lenzen A, Ege E, et al. A content analysis of literature on trans people and issues: 2002–2012. Couns Psychol. 2016;44(7):960–95. This article summarizes the literature on transgender people from 2002–2012

Budge SL. Genderqueer. In: The SAGE Encyclopedia of Psychology and Gender. Thousand Oaks, CA: SAGE.

• Singh AA, dickey lore m. Introduction. In: affirmative counseling and psychological practice with transgender and gender nonconforming clients. Washington, DC, US: 1. American Psychological Association; 2017. p. 4–18. A recent APA publication on affirming practice with transgender and gender nonconforming clients.

Brierley H. Gender identity and sexual behavior. In: Bisexuality in the United States: a social science reader. New York, NY: Columbia University Press; 2000. p. 104–26.

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Matsuno, E., Budge, S.L. Non-binary/Genderqueer Identities: a Critical Review of the Literature. Curr Sex Health Rep 9 , 116–120 (2017). https://doi.org/10.1007/s11930-017-0111-8

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Defending the Sex/Gender Binary: The Role of Gender Identification and Need for Closure

In the united kingdom and sweden, psychological factors including gender identification and need for closure are associated with binary gender/sex views, prejudice toward non-binary people, and opposition to gender-neutral pronouns..

Cite this Article

Morgenroth, Thekla, et al. “Defending the Sex/Gender Binary: The Role of Gender Identification and Need for Closure.” Social Psychological and Personality Science, vol. 12, no. 5, July 2021, pp. 731–740.

Morgenroth, T., Sendén, M. G., Lindqvist, A., Renström, E. A., Ryan, M. K., & Morton, T. A. (2021). Defending the Sex/Gender Binary: The Role of Gender Identification and Need for Closure. Social Psychological and Personality Science, 12(5), 731–740.

Morgenroth, Thekla, M. Gustafsson Sendén, A. Lindqvist, E. A. Renström, M. K. Ryan, and T. A. Morton. “Defending the Sex/Gender Binary: The Role of Gender Identification and Need for Closure.” Social Psychological and Personality Science 12, no. 5 (July 2021): 731–40.

Thekla Morgenroth

Marie gustafsson sendén, anna lindqvist, emma aurora renström, michelle kim ryan, thomas morton.

Introduction
Methodology

Many Western cultures have traditionally ascribed to the sex/gender binary – the belief that sex is binary and determines gender. "Sex" refers to a person's biological makeup and "gender" refers to the social roles associated with men and women, for instance. The sex/gender binary has been challenged in recent years by changes such as the adoption of gender-inclusive language, implementation of government policies recognizing a third sex, and growing profiles of non-binary individuals. These changes have been met with resistance, however, and trans- and cisgender individuals who violate gender norms have faced backlash.

Strategies for combatting this resistance include policies that challenge binary views of gender/sex through either de-gendering (the practice of removing or minimizing the importance of the gender/sex division by replacing he/she with “they”, for instance) or multi-gendering (the practice of emphasizing the non-binary nature of gender/sex by recognizing a third sex/gender, for instance). It is unclear, however, which approach is more effective in dislodging binary views of gender/sex and which provokes greater resistance.

This two-part study examines the psychological factors underlying the defense of the gender/sex binary. To do so, it explores the roles of a) gender identification (individuals' psychological investment in gender as self-defining category providing a sense of identity ) and b) need for closure (individuals' need for clear answers) in shaping reactions to a de-gendering policy, a multi-gendering policy, and a non-gender related control policy, as well as these factors' correlations with attitudes that reinforce the gender/sex binary.

Both gender identification and need for closure were associated with binary gender/sex views, prejudice toward non-binary people, and opposition to gender-neutral pronouns. De-gendering policies were seen as more unfair than multi-gendering policies among people with strong gender-identification.

There was no statistically significant difference between de-gendering policies and multi-gendering policies in terms of unfairness.
Gender identification was positively associated with gender/sex essentialism (the belief that women and men are two distinct, natural groups) and ideologies that maintain the gender/sex binary, but not with gender/sex stereotyping or prejudice toward non-binary people.
Gender/sex essentialism and binary views were positively associated with prejudice against non-binary people.
Gender identification was positively associated with perceived unfairness of the de-gendering proposal.
Both gender identification and need for closure were positively associated with binary gender/sex views and prejudice against non-binary people.
Gender identification was negatively associated with support for gender-neutral pronouns.
Need for closure was positively associated with prejudice against non-binary people and negatively associated with support for gender-neutral pronouns.
Binary gender/sex views were positively associated with opposition to gender-neutral pronouns and prejudice against non-binary people.

These results provide insight into the psychology of opposition to changing views of gender. The implications of these results have the potential to shape policies intended to support more diverse expressions of gender/sex.

In Study 1, 489 heterosexual British men and women were recruited through an online recruitment website. Participants first indicated their gender/sex and completed a measure of gender/sex identity centrality. They were then randomly assigned to read a fictitious article describing one of three hypothetical policies implemented by a well-known clothing retail company: 1) a de-gendering policy removing gender/sex labels and store sections, 2) a multi-gendering policy introducing a non-binary label and store section, or 3) a control policy regarding the company's spring and summer collection. Afterwards, participants answered questions including measures of perceived unfairness of the policy, binary views of gender, gender essentialism, gender-stereotyping, and prejudice toward non-binary people. "Gender essentialism" refers to the belief that women and men are two distinct, natural groups.

In Study 2, 415 heterosexual Swedish men and women were recruited through a polling firm. Participants first indicated their gender/sex and completed a measure of gender/sex identity centrality. They then were completed an assessment of their need for closure. Participants were then randomly assigned to read a fictitious article describing one of three hypothetical laws regarding children's clothing: 1) a de-gendering law making it illegal to sell clothing in separate sections for girls and boys or to sell clothing explicitly targeting girls or boys, 2) a multi-gendering law requiring the addition of a non-binary section in all children's clothing stores, and 3) a control proposal regarding stronger regulation of chemicals in children's clothing. Afterwards, participants answered questions including measures of perceived unfairness of the law, binary views of gender/sex, prejudice toward non-binary people, and views on the gender-neutral pronoun used in Swedish, hen.

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Creating, Reinforcing, and Resisting the Gender Binary: A Qualitative Study of Transgender Women’s Healthcare Experiences in Sex-Segregated Jails and Prisons

Jaclyn m. white hughto.

1 Yale School of Public Health

4 The Fenway Institute, Fenway Health

Kirsty A. Clark

2 University of California Los Angeles School of Public Health

Frederick L. Altice

3 Yale School of Medicine

Sari L. Reisner

5 Boston Children’s Hospital/Harvard Medical School

6 Harvard T.H Chan School of Public Health

Trace S. Kershaw

John e. pachankis.

Incarcerated transgender women often require healthcare to meet their physical-, mental-, and gender transition-related health needs; however, their healthcare experiences in prisons and jails and interactions with correctional healthcare providers are understudied.

Design/methodology/approach

In 2015, 20 transgender women who had been incarcerated in the United States within the past five years participated in semi-structured interviews about their healthcare experiences while incarcerated.

Participants described an institutional culture in which their feminine identity was not recognized and the ways in which institutional policies acted as a form of structural stigma that created and reinforced the gender binary and restricted access to healthcare. While some participants attributed healthcare barriers to providers’ transgender bias, others attributed barriers to providers’ limited knowledge or inexperience caring for transgender patients. Whether due to institutional (e.g., sex-segregated prisons, biased culture) or interpersonal factors (e.g., biased or inexperienced providers), insufficient access to physical-, mental-, and gender transition-related healthcare negatively impacted participants’ health while incarcerated.

Research implications

Findings highlight the need for interventions that target multi-level barriers to care in order to improve incarcerated transgender women’s access to quality, gender-affirmative healthcare.

Originality/value

This study provides first-hand accounts of how multi-level forces serve to reinforce the gender binary and negatively impact the health of incarcerated transgender women. Findings also describe incarcerated transgender women’s acts of resistance against institutional and interpersonal efforts to maintain the gender binary and present participant-derived recommendations to improve access to gender affirmative healthcare for incarcerated transgender women.

INTRODUCTION

Transgender women, individuals assigned a male sex at birth who now have a feminine gender identity or expression, experience pervasive stigma in the U.S. ( White Hughto et al., 2015 ). Stigma restricts access to resources for transgender women, including employment and housing, leading some to turn to street economies, such as survival sex work, or substance use to cope with mistreatment; these activities then place transgender women at risk for arrest and incarceration ( Garofalo et al., 2006 , Grant et al., 2011 , Nemoto et al., 2011 , Mizock and Mueser, 2014 ). Biased policing and sentencing practices also contribute to high rates of incarceration among transgender women ( Wolff and Cokely, 2007 , Grant et al., 2011 ). Lifetime estimates of incarceration range from 19% to 65% among transgender women ( Reisner et al., 2014 , Garofalo et al., 2006 , Clements et al., 1999 , Grant et al., 2011 ), compared to less than 3% of the U.S. general population ( Glaze and Kaeble, 2014 ). Once incarcerated, transgender women are typically housed in sex-segregated facilities according to their genitalia; thus, transgender women who have not had gender confirmation surgery are placed in male facilities where they are at-risk for mistreatment ( Jenness et al., 2009 , Emmer et al., 2011 , Lydon et al., 2015 ).

Due to the stigma attached to their feminine gender identity and/or expression, transgender women incarcerated in male facilities are especially at risk for verbal harassment, physical violence, and sexual assault ( Jenness et al., 2007 , Jenness et al., 2009 , Emmer et al., 2011 , Lydon et al., 2015 ). While victimization often occurs at the hands of inmates, transgender women also report being victimized by jail and prison staff. For example, a U.S. study of 6,450 transgender individuals found that among 749 transgender women in the sample who had been incarcerated, 38% had been harassed, 9% had been physically assaulted, and 7% had been sexually assaulted by facility staff ( Grant et al., 2011 ). While research points to mistreatment by custody staff, a dearth of empirical research explores the nature of transgender women’s interactions with healthcare providers (e.g. doctors, nurses, psychologists, counselors).

Like all detainees, incarcerated transgender women may need to access physical and mental health services to meet their preventative, chronic, and urgent healthcare needs; some transgender women also require medical care in order to “transition” or medically affirm their gender. Medically affirming ones gender can include the use of exogenous hormone therapy (e.g., estrogen) or surgery (e.g., medical confirmation surgery) to feminize the body, with hormone therapy often being the first and sometimes only gender transition-related intervention sought ( Coleman et al., 2012 ). Hormone therapy is an essential component of healthcare delivery for some transgender people, as it alleviates the psychological distress of gender dysphoria ( APA, 2008 , Coleman et al., 2012 ), and has been linked to improved mental health outcomes (e.g., reduced depression and anxiety) and quality of life ( White Hughto and Reisner, 2016 , Murad et al., 2010 ). Given that transgender women may require a variety of health services while incarcerated, access to supportive medical providers, who are knowledgeable about transgender individuals and their healthcare needs, is essential to ensuring the health of incarcerated transgender women.

The extent to which transgender women are able to access quality, gender-affirmative general and gender transition-related care while incarcerated is not well-documented in the empirical literature. Prior qualitative research in non-criminal justice settings highlights providers’ lack of training on how to provide gender-affirmative care to transgender patients, and transgender women consistently report provider bias and limited transgender-specific healthcare knowledge as a barrier to receiving adequate healthcare ( Lurie, 2005 , Poteat et al., 2013 ). In regards to healthcare in criminal justice settings, a 2014 survey of 1,118 lesbian, gay, bisexual, transgender, and queer (LGBTQ) detainees from across the U.S. found that 21% of respondents were treated disrespectfully by correctional medical staff and/or therapists; however, the report did not define the term “disrespect” and the experiences of transgender respondents were not reported separately from non-transgender respondents. Similarly, a 2009 survey of 59 transgender and gender-variant inmates in Pennsylvania found that 42.4% of the sample believed their needs were not taken seriously by medical staff, however, the survey did not report the experiences of transgender women separately from the full sample. Like the national study, the Pennsylvania study relied primarily on quantitative methods, which precluded the nuanced exploration of unique participant experiences. Further, a dearth of empirical research qualitatively explores key interpersonal or provider-level factors that may shape the delivery of care, such as provider comfort, attitudes, and knowledge about transgender people or their care.

While interpersonal factors may contribute to access to care barriers, structural or institutional factors (e.g., culture, norms, practices, and policies) may also shape the delivery of care for incarcerated transgender women. In terms of transgender-specific correctional policies, an investigation found that only 16 out of the 26 U.S. states surveyed had explicit policies enabling transgender individuals to continue hormone therapy once incarcerated and only four states had clear policies allowing transgender inmates to initiate hormones under certain circumstances ( Brown and McDuffie, 2009 ). Further, research with transgender people from across the U.S. suggests that prison policies often translate into restricted access to hormones. For example, a survey of 27,715 U.S. transgender people found that 37% of the 321 participants who had been incarcerated in the last year and were taking hormones prior to incarceration were prohibited from continuing their hormones while incarcerated ( James et al., 2016 ). When examining hormone access among transgender women specifically, a U.S. study found that 24% of the 749 transgender women in the sample who had been incarcerated in their lifetime had been denied hormone therapy while incarcerated. While these studies offer important insights into the prevalence of hormone access barriers faced by transgender individuals in prison, they do not provide an in-depth exploration of how these barriers are personally experienced by transgender women specifically. Qualitative research that explores how transgender women navigate prison policies and explores the role of institutional culture in the delivery of care is necessary to inform intervention efforts that are responsive to the needs of incarcerated transgender women.

Despite transgender women’s documented need for general and transition-related healthcare while incarcerated, a dearth of research has examined the structural and interpersonal barriers to gender-affirmative healthcare from the perspectives of transgender women themselves. Guided by the socio-ecological model ( Bronfenbrenner, 1994 ), the present study utilizes interviews with formerly incarcerated transgender women to: [1] assess their experiences receiving physical-, mental-, and transition-related healthcare in correctional settings; and [2] document potential structural, interpersonal, and individual barriers to healthcare that can be targeted in future, multi-level intervention efforts to ensure access to quality, gender-affirmative care for incarcerated transgender women.

Semi-structured interviews with 20 formerly incarcerated transgender women were conducted between July and August 2015. Participants were recruited through multiple purposive sampling strategies, which included posting paper and electronic recruitment flyers at community organizations and transgender-specific websites and list-serves. Eligible participants were age 18 years and older; self-identified as a transgender woman, transsexual woman, or female who was born male, or on the trans-feminine or male-to-female spectrum; assigned a male sex at birth; and had been incarcerated in a U.S. jail or prison within the past five years for one week or more.

After providing written informed consent, participants completed semi-structured interviews assessing their experiences accessing healthcare while incarcerated, including individual (e.g., healthcare avoidance), interpersonal (e.g., patient-provider dynamic, provider attitudes and knowledge) and structural factors (e.g., institutional policies and practices). The one-on-one, in-depth interviews lasted approximately 45–60 minutes and were conducted by the first author, who has extensive experience conducting community-based research with transgender women. The interviews were audio-recorded and transcribed verbatim. Participants also completed a brief survey via pen and paper, which assessed participant demographics, incarceration history, and healthcare utilization during and prior to incarceration. To protect anonymity, participant names were changed. Participants received a $50 gift card as compensation. The study was approved by the Institutional Review Board of Yale University.

Data Analysis

Participant interviews were coded and analyzed using an iterative and inductive approach borrowed from grounded theory ( Strauss and Corbin, 1997 ). The first author began by open-coding the transcripts for broad analytic themes. Codes were subsequently grouped into categories and compared to each other in the process of constant comparative analysis. After creating an initial codebook, the first and second authors and a trained third researcher coded six transcripts using Dedoose software ( Lieber and Weisner, 2010 ). Coded transcripts were then compared and modifications were made to improve clarity and reduce codebook redundancies. Upon finalizing the codebook, the first author coded all the interviews, which were then double-coded by the two other coders (ten transcripts each). The coders and authors met frequently throughout the coding process to discuss any uncertainties in code application and ensure consistent application of codes across transcripts.

Theoretical Framework

In organizing the coded transcripts into written results, the authors drew on the socio-ecological model, which was first developed by Bronfenbrenner (1994) to explain how multiple systems beyond the individual shape human development and was later adapted and applied to numerous health-related outcomes ( Baral et al., 2013 , Link and Phelan, 2006 , Auerbach et al., 2011 ). Recently, the socio-ecological model was adapted to describe the structural- (institutions, culture, policies), interpersonal- (interactions with others), and individual- (behavioral reactions, beliefs, and coping responses of transgender individuals) levels at which transgender stigma is produced, enacted, and managed to ultimately influence health ( White Hughto et al., 2015 ). This conceptual model describes a bidirectional relationship between factors at each level such that structural factors can influence interpersonal interactions, which can in turn shape individual behaviors and vice versa. The present study extends the application of the socio-ecological model of transgender stigma to describe transgender women’s experiences receiving healthcare in correctional settings (See Figure 1 ).

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Transgender Women’s Experiences Accessing Healthcare in U.S. Jails and Prisons and Recommendations to Resist the Gender Binary at Multiple Levels

Participant Characteristics

Participant characteristics are reported in Table 1 . Briefly, participants’ mean age was 36.9 years (SD=10.0) and the majority (70.0%) were women of color, had a high school degree or less (75.0%), were unemployed or on disability (90.0%), and earned less than $18,000 annually (95.0%). Participants had been incarcerated an average of 8.2 times (SD=6.9) and most had been incarcerated in county jails in one or more New England states, including Massachusetts, Rhode Island, Connecticut, and Maine.

Demographics, healthcare utilization, and incarceration history characteristics in a sample formerly incarcerated transgender women (n=20).

DEMOGRAPHICS


Range: 22 to 53	36.9	10.00


18–29	30.0	6
30–39	30.0	6
40–49	20.0	4
50+	20.0	4

White, non-Hispanic	30.0	6
Person of color	70.0	14
White	45.0	9
Black	50.0	10
Hispanic/Latina	25.0	5
American Indian or Alaskan Native	10.0	2
Asian or Pacific Islander	5.0	1
Other race	25.0	5

Less than a high school degree	35.0	7
High school degree	40.0	8
Some college	25.0	5

Student	5.0	1
Employed full time	5.0	1
Unemployed	90.0	18

Yes	55.0	11
No	45.0	9

< $6,000 a year	75.0	15
$6,000 to $11,999	15.0	3
$12,000 to $17,999	5.0	1
Don't know	5.0	1

Positive	35.0	7
Negative	60.0	12
Don't know	5.0	1




Yes	90.0	18
No	10.0	2


n=17: Range (11–32)	22.0	6.2


Yes	25.0	5
No	75.0	15

Yes	0.0	0
No	100.0	20




Yes	60.0	12
No	40.0	8

Yes	33.3	4
No	66.7	8

HIV/AIDS	25.0	5
Diabetes	5.0	1
Insomnia	5.0	1
Cold	5.0	1
Skin infection	5.0	1
Urinary tract infection	5.0	1
Dental problem	10.0	2

Anxiety	5.00	1
PTSD	5.00	1

Yes	70.0	7
No	30.0	3





Range: (1 to 20 times)	8.2	6.9

Range (1 week to 30 years)	3.1	6.6


0 to < 6 months	35.0	7
6 months to < a year	10.0	2
1 to < 2 years	10.0	2
2 to < 5 years	20.0	4
5 to < 10 years	5.0	1
10 or more years	20.0	4

Youth or juvenile detention	5.0	1
County jail	80.0	16
State facility	15.0	3
Other (transportation jail)	5.0	1

Participant Narratives

Findings from participant narratives are presented in the top portion of each concentric circle (above the circle titles) of the adapted social-ecological model shown in Figure 1 . In the sections below, we draw from participant narratives to describe transgender women’s experiences accessing physical-, mental-, and transition-related healthcare in male correctional facilities and describe how these experiences relate to the creation, reinforcement, and resistance against the gender binary (i.e., the classification of sex and gender into two distinct and opposite categories of male and female, masculine and feminine ( Fausto-Sterling, 2012 )). Utilizing the socio-ecological model, we describe how the gender binary is created at the structural-level (institutional culture and policies relating to gender identity and expression) and reinforced at the interpersonal-level (provider interactions with transgender women). At the individual-level (transgender women’s beliefs and behaviors), we describe the ways in which transgender women reinforce or resist the gender binary, with implications for health. We then conclude with participants’ recommendations to improve correctional healthcare through behavioral, educational, and policy efforts that aim to resist or dismantle the gender binary at each level of the institutional environment. Pseudonyms are utilized in presentation of these data.

“This is not a Girl’s Unit” – The Institution’s Role in Creating the Gender Binary at the Structural-Level

Recently incarcerated transgender women described the sex-segregated structure of jails and prisons and the experience of being housed in a male facility according to their genitalia. Taylor, a 50-year-old participant described the prison systems’ disregard for transgender inmates’ feminine gender expression noting: They don't care if you got a beautiful face. Beautiful breasts, beautiful hips, beautiful legs, beautiful voice, feminine personality. If you got [a penis]… You're going to a men's prison.” Similarly, Abby, a 28-year-old participant, described the institutional focus on genitalia over gender identity: “Because I’m still physically male, and in the eyes of the [state] if you’re physically male, you’re gonna be put on the men’s side, even if you identify as female.”

In the sex-segregated environment of male correctional facilities, feminine gender expression was viewed as “abnormal” and participants described being controlled, belittled, and demoralized as a result. Institutional concerns about femininity were often enacted into policies that restricted inmates from having a feminine gender expression. For example, Elle, who had been incarcerated for a total of 5 years, described the enforcement of prison policies designed to restrict feminine gender expression among inmates in male facilities: “If you ran your hair through an elastic, and put it in a ponytail, some of the officers be like, ‘Do not, this is not a girl's unit. Take that out of your head.’” The enforcement of policies that favor masculinity and trivialize the feminine gender expressions of transgender women were also described by Ebony, who had been incarcerated for a total of 6 months. Here, she recalls how custody staff reacted to transgender women’s feminine gender expression, noting: “They would do whatever they could to like, dismantle your femininity. Like if you had a wig on, they'll take your wig off. They’d laugh at your clothes, stuff you'd be wearing, they made it a huge point to say ‘you're a male,’ you know, they pick at you.” In addition to describing the existence of policies and practices that maintain the gender binary by forcing conformity to masculine gender norms, Elle and Ebony’s quotes highlight an institutional culture in which transgender women are regularly ridiculed for having a feminine gender expression, a theme that emerged across interviews.

Restrictive policies regulating access to transition-related medical care served as another means through which male correctional facilities sought to maintain the gender binary. Indeed, nearly all participants noted that hormone therapy could only be obtained if they provided sufficient documentation showing that they were prescribed hormone therapy prior to incarceration. Abby, who had not been using hormones prior to being incarcerated for two months, noted: “I wasn’t even allowed to have my hormones. I was trying to get on them when I went in, but they wouldn’t give them to me. You had to be on them when you were on the outside.” Abby was not alone in facing challenges accessing hormone therapy, as participants who had been on hormones prior to incarceration also described structural barriers to care. For example, Taylor, who had been homeless prior to being incarcerated for two years, described the challenges she faced providing sufficient documentation of her prior hormone use:

I told them, ‘please, I need my hormones.’ Nope, no hormones. ‘you gotta get a letter from your doctor.’ How am I gonna get my letters? How am I gonna call my doctor? I don't have nobody to call. My parents are dead. I didn’t have no information…no numbers…I didn't have nothing .

Like many other participants, Taylor’s inability to document her hormone use according to institutional standards (i.e., verification of prescription by an outside physician) restricted her access to hormones in prison. Taylor’s quote also highlights how hormone documentation requirements are particularly challenging for unstably housed individuals as well as those who lack social support on the outside – a common theme among the sample’s more marginalized participants.

Participants who had been taking street hormones outside of a physician’s care also faced significant barriers to continuing hormone therapy once incarcerated as “street hormones” were not recognized as legitimate according to prison policies. Brandy, a Black participant who had been taking street hormones for 10 years prior to being incarcerated for 3 months, described the implications of hormone-related correctional policies: “I didn't have a prescription for hormones, so they wouldn't give me any.” Similarly, Elle a White participant described her experience trying to access care during her longest, 2 year sentence, noting: “No, no, no. They’re saying I’m not trans - even though I was transitioning. I was doing it on the outside, but they stopped my hormones because I was doing street hormones.” While Elle had been incarcerated for a longer period of time than Brandy, their quotes illustrate that incarceration length had no barring on ability to access hormones if prior hormone use could not be verified. Elle’s quote also highlights how prison policies served to erase her transgender experience, reinforcing the gender binary and making her invisible in a male facility.

Participant narratives highlight how the sex-segregated structuring of the institution rendered them “abnormal” and fostered an institutional culture in which transgender women, and feminine expression more generally, are stigmatized. Transgender stigma appeared to be further embodied in the policies of the correctional institution, which forced transgender women to conform to male gender norms by limiting their use of female hormones and restricting their feminine gender expression (e.g., hair style, clothing).

“What is this – Conversion Therapy?” – Provider’s Role in Reinforcing the Gender Binary at the Interpersonal-Level

Providers regularly reinforced institutional policies and practices that stripped transgender women of their femininity. Participants described primary care providers’ attempts to maintain the gender binary by creating barriers to accessing feminizing hormones. For example, Sierra, a 49-year-old participant who had been incarcerated for a total of 5 years, recalled providers’ roles in delaying her access to hormones:

It took me a [long time] to get my hormones this last time I was in jail because they had to go through all this paperwork and madness. The [providers] would send a paper and call the hospital, but then say they can’t get in touch with my doctor. They kept on putting it of, and putting it off, and putting it off. It took me months to be able to get my hormones .

Several participants reported that providers disregarded the importance of hormone therapy, which led to inadequate care. For example, Chrissy, who had been incarcerated less than a month and who had been prescribed hormones prior to being incarcerated, described her experience trying to receive her full dose of hormone therapy, stating: “They kept skipping doses, 'cause I was supposed to get them four times a day, and I'm like, okay, I need my hormones. Then they go and give it to me like twice a day. But they would give me my psych meds though.” Similarly, all of the participants who sought treatment for HIV (n=5) during their last prison or jail stay were able to easily access care; however, several reported challenges accessing hormones. For example, when asked about whether she was able to receive her HIV medications, Elle, who had been incarcerated on and off for a total of 5 years, stated: “Yeah, I didn’t have an issue with medical.” However, when asked about hormones specifically she stated: “Uh no, no, no, no,” as she had been on street hormones prior to incarceration and therefore wasn’t able to access hormones while incarcerated. Several participants attributed inadequate access to hormone therapy and the prioritization of other medications over hormones to providers’ perceptions that hormone therapy lacks a significant health benefit. For example, Ebony, who had been incarcerated for 6 months, noted: “Being a trans woman in jail, like, they kinda brush stuff like hormones aside. They’d wait ‘til you are absolutely gonna die before they do anything.” Ebony’s quote suggests that providers may be unaware of the physical and psychological benefits of hormones or may perceive hormones to be less medically necessary than medications for other health conditions (e.g., HIV/AIDS, psychiatric conditions).

Participants indicated that some providers used the threat of gender-based violence by inmates and staff as a rationale for withholding transgender women’s access to hormones. Ebony recalled her most recent 6-month sentence when she was briefed by a doctor about the dangers of being a transgender woman in a male facility, noting: “The doctor came and talked to me and said that because I'm transgender that I could be raped. I could be physically harmed.” Correctional institutions are tasked with ensuring the safety of inmates; thus, the femininity of transgender women in male facilities poses challenges for the institution, challenges that providers often play a role in managing. Cassandra, who had been incarcerated for 2 years, described providers’ attempts to maintain the gender binary as a means to control the threat of victimization, she noted: “They really don’t want to give [hormones]. They’re too afraid we might blossom into beautiful women.” Cassandra’s quote suggests that providers’ fears regarding the consequences of being visibly feminine in a male facility may ultimately drive providers’ decision to deny transgender women access to hormones.

Not all participants described such paternalistic “benevolence” on the part of healthcare providers. Several participants instead described outright mistreatment on the part of medical and mental health providers that derived from transgender bias. For example, Sabrina, a Latina participant who had been incarcerated for a total of 4 years, described a healthcare environment in which transgender individuals were consistently treated poorly, saying: “It's like once the [providers] see you're transgender, they treat you like shit.” For some participants, mistreatment by healthcare providers included a lack of respect for one’s feminine gender identity such as the repeated use of male pronouns. For example, Tina, a White participant who had been incarcerated more than 20 times for short periods of time (no more than 3 months at a time), described encounters with a mental health counselor who regularly mis-gendered her:

Being called ‘he’, ‘him’, ‘sir’ and all this. I said, ‘What is this, conversion therapy?’ And the counselors kept doing it. I'd state, ‘I'm transgender’ and they just kept on with this ‘sir’ stuff, and I was like, ‘Is this conversion therapy? ’

Tina experienced the regular act of being mis-gendered by providers as an attempt to reinforce the gender binary by forcing her to embrace a male gender identity as a form of conversion therapy. Experiences of provider mistreatment were also described by Ebony, a Black participant who spent 6 months in prison: she stated: “The nurse, she makes it a point to defeminize you. They say things like, ‘you're not a girl, you're a he.’ They would say very derogatory things just to break your spirit.” In addition to noting a nurse’s attempt to force her into the gender binary, Ebony’s quote also described the ways in which the behavior of healthcare providers had the potential to negatively impact her mental health.

While some participants often attributed provider mistreatment to transphobia, other participants linked their poor interactions with providers to a lack of knowledge about how to appropriately meet the needs of transgender people. For example, in describing her overall perception of healthcare in prison, Tina noted: “I mean it's just down there [in the medical unit], the providers are not educated on the transgender issue at all.” Providers often demonstrated their lack of knowledge and exposure to transgender patients via their attempts to “study” transgender patients, experiences which many transgender women found discomforting. For example, Evy, a Latina participant who had been incarcerated for less than a year, recalled an initial evaluation in which providers scrutinized her feminine gender expression:

I felt like it’s still in unsure waters. People were unsure about the whole [transgender] thing. It was so foreign, so new to them, where everybody was making decisions first out of nervousness maybe or liability-wise. Like, ‘what should we do?’ Like, ‘oh my God, maybe you should go talk to the psychiatrist.’ Then this woman came with a recorder. And I’m just like, ‘oh my God, do I really need a recorder?’ I’m sure I’m not the only one that has panties, honey .

while Evy noted that she was not the only woman in the male facility where she was housed, her quote suggests that her femininity generated anxiety on the part of providers who lacked prior exposure to transgender women. According to Evy and others, providers’ anxiety around how to care for transgender patients often led providers to treat transgender patients as phenomena to be studied rather than human beings in need of supportive and affirmative care.

The limited knowledge of healthcare providers was also demonstrated by reports that providers consistently asked transgender patients invasive questions about their bodies and medical and life histories. For example, Brandy recalled medical encounters in which medical and mental health providers regularly asked her to educate them on transgender health:

They asked a lot of questions. I was kind of like the token tranny and answered most of them because there was nothing else to do. It was a little embarrassing.…but after a while, you're gonna like, just ignore it .

Brandy’s quote highlights how providers’ limited knowledge regarding transgender health places a burden on transgender women receiving care in jails and prisons and fosters a sense of uneasiness in an already oppressive institutional setting.

While participants overwhelmingly described their healthcare interactions as not being affirming of their gender, a handful of participants described satisfactory or even positive interactions with healthcare staff. For example, Cassandra, who had been incarcerated for 2 years, noted that the: “people who worked inside the infirmary weren’t too bad.” Alicia, who had been incarcerated for a year, indicated that there were a few nurses with whom she felt comfortable seeking out care, but others she specifically avoided based on the experiences of other trans women. She noted: “There was one or two nurses that I was fine with. The rest of ‘em I didn’t really like. They were just really rude. But I paid attention to the other trans girls, so I knew who to go to and who not to go to.” Incarcerated on and on off over the course of 4 years, Sabrina was the only participant to describe a fully supportive relationship with healthcare staff. In comparing her interactions with various staff members, she noted: “Well most of the guards are pigs, but the counselors would come around. I would talk to them and I felt talking to them, and well, I felt safe.” These quotes illustrate that while bias and lack of transgender health knowledge exist among the correctional healthcare providers with whom transgender women in this sample interacted, there were a handful of providers that were able to meet patients’ physical and mental health needs.

“I Just Wasn't Willing to Give Up my Femininity” - Transgender Women’s Agency in Resisting the Gender Binary at the Individual-Level

Participants’ prior and anticipated experiences of mistreatment in correctional settings, including with healthcare providers, shaped their behavior while incarcerated. For some participants, the fear of being treated poorly by providers, custody staff, and other inmates led them to conform to male gender norms and reinforced the gender binary, while others actively resisted the gender binary by maintaining and/or amplifying their feminine gender expression.

Nearly every participant expressed concerns about being victimized by staff or inmates due to their feminine identity or expression. Alicia, a Latina participant who had been incarcerated once, highlighted the fear of being victimized and the consequence of standing up for herself, noting:

I feel like living in fear in there, not knowing if someone’s going to try to kill you for standing up for yourself is 10 times harder than being in general society. Like people might discriminate against you in the general society, but being in there it’s like you literally have to stand up for yourself and do whatever you have to do to survive .

For some participants, a desire to survive the prison experience relatively unscathed motivated them to conceal their transgender identity and/or feminine gender expression for the duration of their sentence. Tina, a White woman with a more fluid gender expression, described her rationale for not publicly identifying as a transgender woman while incarcerated, explaining: “I did not identify as transgender in jail. Because that would be dangerous and it could cause conflicts that I just preferred not to have. What they don't know won't hurt me.” Like several other participants, Tina had been incarcerated many times and had witnessed inmates being victimized for displaying any signs of femininity – experiences that motivated her to conceal her transgender identity. Some participants also described being motivated to conceal their gender when first entering jail or prison as they did not want to attract “unnecessary attention” and increase their risk of victimization. The ability to conceal, however, was only available to participants who were not visibly feminine (e.g., did not have breasts) and could pass as male.

While some participants never openly identified as transgender, others chose to downplay their gender expression in an effort to avoid mistreatment. One strategy some participants used to conceal their femininity and conform to male gender norms was going off hormone therapy, as hormone therapy not only feminizes the body, but taking hormones alerts staff and others to one’s transgender status. For example, Evy, a visibly feminine Latina participant, described going off hormones to prevent stigma noting:

I stopped taking the estrogen… I never brought the estrogen back up again. Because I felt if I brought it up maybe I would be looked at as a certain individual or maybe even a risk factor, because, you know, differences and stuff like that. People look at things and they categorize you as, ‘oh, that’s a risk, you know? ’

Evy’s quote suggests that femininity is viewed as a problem or “risk” that correctional institutions must manage – a label that transgender women could avoid by pausing hormone therapy and concealing their transgender identity.

While concealing a transgender identity and/or feminine gender expression could be beneficial in terms of avoiding mistreatment, some participants were unable to conceal their femininity, for example if they had breasts, and others were unwilling to conceal their gender identity or feminine gender expression regardless of the consequences. For example, Taylor described her attitudes towards another transgender woman who concealed her transgender history in prison due to safety concerns noting: “There was one girl who ‘turned boy’ for a while inside the prison. She turned back to boy. She felt threatened. Afraid, like I did. But I just wasn't willing to give up my femininity just for the fear.” Taylor’s quote illustrates how her desire to maintain her authentic self led her to actively resist the gender binary despite the fear of being victimized. Like several other participants who resisted the gender binary, Taylor had been living as woman for many years before being incarcerated and thus felt incapable of living as a man, despite the potential health benefit of concealment. Further, some participants, particularly those who had been incarcerated before or who knew other inmates from the “streets,” felt they had the social capital and mental and physical toughness to manage the threat of victimization that came with being a transgender woman in a male facility.

Several participants described their resistance against the gender binary, finding ways to express their feminine gender despite the threat of mistreatment by providers, custody staff, and inmates. Indeed, some participants challenged the gender binary in small ways, such as Abby a White participant who had been incarcerated for 2 months, who noted: “Oh, I kept myself clean-shaven the entire time, and I still showed that walk.” Other participants expressed their femininity in more obvious ways and described the ways in which maintaining their feminine gender expression benefitted their mental health. For example, Evy, a Latina participant who had been incarcerated for about a year said: “I would draw on eyebrows…They had one of these good pens. A State pen. And I used it. I probably could have took my eye out, but I used it, and it got me through.”

Another way participants challenged the gender binary was by seeking out and often fighting to receive hormone therapy regardless of the barriers or potential consequences they faced. For example, Sierra highlighted how the bureaucratic jail system and lack of urgency on the part of providers created delays in accessing hormone therapy during her last sentence, which was just over 3 years: “It took me about a few months to get my hormones in jail. My lawyer had to fight for them. I had to fight for everything I got.” Like Sierra, many participants described fighting to access medically necessary hormones. For these participants, the very act of accessing hormone therapy in a male institution served to challenge institutional efforts to defeminize them and gave them a small, but meaningful, sense of empowerment that helped them cope with the challenges of being incarcerated in a sex-segregated institution.

“The Healthcare Systems in the Prisons Definitely Need to be Looked At” - Transgender Women’s Policy and Training Recommendations

Many participants highlighted specific concerns about the inadequate, and often biased, care they received while incarcerated, and noted specific ways that correctional healthcare could be improved. For example, Brandy noted: “I just feel like the healthcare systems in the prisons definitely need to be looked at.” When asked what could be done to improve healthcare for incarcerated transgender women, several participants, including Brandy and Evy cited the need for better access to care.

I think hormones and services should be available for everyone at request…. They have to offer some type of services because people need different kinds of help . Why would you stop your transition due to being incarcerated? If something is going on that needs medication it’s not safe to stop and keep on going…It should be a little more easier [to get hormones], because there is silent discrimination and harassment going on with it .

Another primary way that participants believed that healthcare access, and the overall treatment of incarcerated transgender people, could be improved is through training providers and other correctional staff. Sierra and Nadia, both Black women who had each served more than 2 years in prison, highlighted the need for cultural competency training, noting:

Education. You know what I’m saying? Just a lot of education. A lot of training that we are not bad people, we’re just trying to be ourselves . Teach cultural sensitivity, don’t gawk at people, don’t make people feel different…We didn’t ask you to draw blood but you’re still working with the public, and you owe the public…it’s a disservice for you to allow certain things, like calling someone a fucking freak. There needs to be more cultural sensitivity in jails. It needs to start with staff .

Transgender women described exposure to transgender people and their stories as an essential component of educational efforts to improve the cultural competency of providers. For example, Rosa, a Latina participant, and Chrissy, a White participant, noted:

Educate them when it comes to anything that they believe that they haven't seen, I think educate them with that. Why not give them a chance to know there’s gay people out there, trans people, there's even [trans men]. Let them know so when weird things come in they won't even think it's weird, they'll be like 'oh, oh okay'. You know? Give them sensitivity training where they can actually get to know peoples' stories. It's about exposure and more or less understanding. Once we get clear of that ignorance, [transphobia] is not something that will be tolerated .

Rosa and Chrissy highlight how exposure to the experiences of transgender people can help normalize transgender individuals and lead to better treatment by providers and other staff.

Finally, several participants cited the necessity for correctional institutions to become better prepared to meet the needs of the transgender inmate population. The urgent need for transgender cultural and medical competency in jails and prisons was best noted by Cali, a 28 year-old participant who had been in and out of county jails, noted:

They need to be more sensitive and understand transgender [health]. They need to go through that type of training because being transgender is common now. This is not, ‘you see one person one year, and two more people come out the next year.’ It's a whole nation of us now, so at the end of the day people need to start opening up, to want to learn a little bit more about transsexuals, point blank. Period .

Findings from this qualitative study of formerly incarcerated transgender women illustrate how institutional policies and a correctional culture of transphobia serve to create and reinforce a gender binary environment where one’s gender identity and expression are required to align with one’s assigned sex at birth. Participant narratives found that transphobic attitudes and policies were regularly enacted at the institutional-level, shaping transgender women’s access to quality, gender-affirmative care. The frequent mistreatment by biased or untrained providers and other staff ultimately shaped the behaviors of incarcerated transgender women, leading some to discontinue their hormone use and/or conceal their transgender identity as a form of stigma management ( White Hughto et al., 2015 , Goffman, 1963 ). Despite the risk of mistreatment and the challenges posed by fighting back against a disempowering institution, a subset of transgender women in this study actively challenged institutional and interpersonal efforts to maintain the gender binary. Findings from this study highlight the need for policy and training interventions to improve the cultural and clinical competency of correctional healthcare providers and access to quality, gender-affirmative care for incarcerated transgender women.

Structured according to sex, and more specifically genitalia, jails and prisons are ripe for the production and reification of transgender stigma. At the institutional-level, transgender women reported the enforcement of policies that required them to conform to masculine gender norms by removing hairstyles, clothes, and accessories perceived to be feminine – a finding that aligns with 2014 survey results in which the majority of 221 transgender inmates sampled were not allowed to access underwear and cosmetics that match their gender identity ( Lydon et al., 2015 ). Healthcare policies further restricted the feminine gender expression of some transgender women who were unable to provide documentation of their prior hormone use. Extending 2009 survey research conducted with transgender and gender variant inmates in Pennsylvania ( Emmer et al., 2011 ) several participants reported taking street hormones outside of a physicians’ care prior to incarceration and were unable to prove the medically necessity of hormones according to the standards of the facilities where they were detained. Participants who were marginally housed prior to incarceration also faced challenges documenting their prior hormone use, despite having been prescribed hormones by a licensed physician. Participants described the toll that barriers to hormone access had on their wellbeing, namely the stress caused by challenging the institution in which one held little power and their forced conformity to male gender norms. Prior research demonstrates an association between an inability to access hormones and a range of physical and mental health harms including irregular blood pressure, hair loss, anxiety, panic attacks, depression, auto-castration, and death by suicide in samples of incarcerated and non-incarcerated individuals ( Summers and Onate, 2014 , Brown, 2010 , Huft, 2008 , Spicer, 2010 ). Findings from this study suggest that despite the negative health consequences of restricting transgender people’s access to hormones, and activist efforts to improve access to care for transgender inmates (e.g., Sevelius and Jenness, 2017 ), restrictive hormone policies persist in many U.S. jails and prisons and/or supportive policies are not being routinely enforced. Findings warrant mixed-methods research to document current healthcare policies involving transgender inmates and explore the extent to which policies are enforced through interviews with correctional administrators and providers.

Restrictive policies and a culture of transphobia guided the delivery of care and shaped the healthcare experiences of transgender women while incarcerated. Participants reported biased interactions with providers that mirrored the biased encounters they had with custody staff. Findings from this research extends prior survey research documenting the prevalence of disrespect by healthcare staff in a sample of incarcerated LGBTQ inmates ( Lydon et al., 2015 ), by examining the varied ways in which transgender women were mistreated by correctional providers. When asked to describe specific incidents of provider mistreatment, participants reported frequent attempts by medical staff to belittle and defeminize them by using male pronouns. Extending prior survey research in which the majority of transgender inmates reported receiving inadequate care ( Emmer et al., 2011 ), the present study contextualized the care experiences of incarcerated transgender women, as participants reported long delays accessing transition-related care, an ambivalence on the part of providers regarding the importance of accessing hormone therapy, and the prioritization of other medications deemed to be more medically necessary than hormones (e.g., mood stabilizing medications, HIV medications) – a finding unique to this research. Providers’ desire to prevent gender-based violence by limiting the feminine gender expression of transgender women was also cited as one rationale for withholding hormones – an act which serves as a form of symbolic violence ( Valentine, 2007 ), with dire health implications ( Summers and Onate, 2014 , Brown, 2010 , Huft, 2008 , Spicer, 2010 ). Given that lack of access to hormones can result in a variety of negative health consequences for transgender individuals, it is important that providers and administrators in correctional settings recognize hormones as being as important as any other medical treatment and ensure equitable and appropriate access to hormones for transgender people under their care.

While some participants attributed inadequate care to bias, other participants attributed provider mistreatment to lack of exposure to transgender individuals and limited knowledge on how to appropriately meet their healthcare needs. As a result of limited provider knowledge, some transgender women reported feeling as though they were a phenomenon to be studied. Research suggests that the prison environment is a de-humanizing experience for all inmates, and so it’s possible that the care participants received was not uniquely different from the care other inmates received ( Toch and Gibbs, 1992 , Vasiljevic and Viki, 2013 , Kelso, 2014 ). However, transgender people outside of prison report similar experience of being “studied” by inexperienced providers ( Poteat et al., 2013 , Lurie, 2005 , Snelgrove et al., 2012 ). Moreover, transgender people are inherently “othered” in the sex-segregated environment of correctional settings, thus the experience of being misgendered and further dehumanized may be particularly triggering for transgender people in carceral settings. Finally, it should be noted that while participants overwhelming described negative encounters with correctional providers, a few participants described satisfactory and even supportive interactions with primary care providers and counselors. These findings suggest that even in the oppressive environment of correctional settings, quality care is possible. Future qualitative research should seek to identify best practices for transgender care among supportive providers and leverage these findings in cultural and clinical competency trainings for healthcare staff working in jails and prisons.

Despite perceived and experienced stigma across the correctional environment, many participants were highly resilient, utilizing various strategies to protect their physical and emotional wellbeing. Consistent with prior research in non-correctional settings ( Mizock and Mueser, 2014 ), some transgender women choose to conceal or minimize their femininity, which served as a form of resilience against the harms of victimization. Still, many participants were unwilling to conceal their gender identity or expression despite the threat of victimization - acts which demonstrated their resilience against the harmful mental health costs of being forced into the male gender binary. Participants’ decision to conceal or disclose their transgender experience while incarcerated largely hinged on their ability to “pass” as male as well as the extent to which they anticipated victimization – perceptions that varied according to their incarceration history, relationships with other inmates, and perceived ability to prevent victimization. For those participants who challenged the gender binary through their clothes, mannerisms, or unwavering fight to access hormones, legal and media reports dating back to the 1990s highlight similar instances of transgender inmates who fought the system in order to live authentically while incarcerated (see legal reviews by Arkles, 2012 , Smith, 2006 , Jenness and Smyth, 2011 ). While some transgender inmates have been successful in overcoming institutional barriers to care, due to the little power held by detainees, particularly those who are highly marginalized, transgender inmates’ efforts to challenge institutional policies and practices could be met with further mistreatment. Consequently, interventions that seek to leverage the strengths and resiliencies of incarcerated transgender people in challenging institutional policies and practices should consider the risks and benefits of such efforts before being implemented.

Recommendations to Resist the Gender Binary: Needed Interventions

Drawing on participant interviews, and prior research and advocacy work with incarcerated transgender people (e.g. Sevelius & Jenness, 2017 ; Lydon et al., 2005), intervention strategies to resist the gender binary at each level are listed in the bottom portion of Figure 1 , under each concentric circle’s title. At the individual-level, transgender inmates should be informed of their rights and provided with guidance on how to obtain legal counsel when their rights are violated, however, individual efforts to challenge the gender binary, such as those described above, could threaten the safety of transgender inmates and therefore are not recommended as primary intervention approaches. Structural and interpersonal interventions that target the source of transphobia in correctional settings (e.g., policies and staff) should be developed and implemented to improve access to gender-affirmative care for incarcerated transgender people.

As noted by the formerly incarcerated transgender women in this study, transgender individuals have limited access to hormones in U.S. jails and prisons. According to a 2009 study ( Brown and McDuffie, 2009 ), the vast majority of jurisdictions have policies that allow transgender individuals to continue hormone therapy provided that they are able to provide sufficient documentation (i.e., medical records) proving that they were prescribed hormones by a physician prior to incarceration. Correctional healthcare providers report that the policies requiring documentation of prior use of hormones are in place to reduce healthcare expenditures and prevent inmates from exploiting their access to free healthcare by acquiring medications that were not deemed medically necessary prior to incarceration ( Clark and Hughto White, 2016 ). However, hormone therapy is a low cost intervention (e.g., generic estrogen pills cost less than $15 per month ( Consumer Reports, 2008 )) and therefore unlikely to place a large burden on correctional budgets. Given that correctional providers are able to diagnose and treat patients suffering from acute physical and mental health conditions (e.g. HIV/AIDS, depression) ( Ax et al., 2007 , Baillargeon et al., 2008 ), current policies that restrict hormone use in the absence of proper documentation represent structural forms of transgender stigma and must be changed. Policy changes that eliminate prior documentation of hormone use can ensure the continuity of medical gender affirmation for incarcerated transgender individuals with potentially powerful mental health implications, including reductions in gender dysphoria and depression and improved quality of life ( White Hughto and Reisner, 2016 , Murad et al., 2010 ).

In the absence of proper documentation of prior hormone use, correctional institutions should follow the same policies and practices they utilize to manage patients with other acute physical and mental health conditions; that is, diagnose and treat transgender patients in need of care ( Ax et al., 2007 , Baillargeon et al., 2008 ). For patients who are gender dysphoric, providers can utilize the criteria in version 5 of the Diagnostic and Statistical Manual to diagnose patients ( APA, 2013 ) and provide appropriate treatment (e.g., mental health counseling, hormone therapy) ( Coleman et al., 2012 ). Since a mental health diagnosis should not be required for transgender people to access medically necessary care, regardless of incarceration status, primary care providers can follow the informed consent model of care, by informing transgender patients of the risks and benefits of hormone therapy, and prescribe hormones following patient consent ( Cavanaugh et al., 2016 ). If restricted by institutional policies requiring verification of prior hormone use, providers could test for elevated-levels of cross-sex hormones in the blood ( Hembree et al., 2009 ). For transgender individuals who were taking low or irregular doses of hormones or hormones that cannot be detected in the blood (e.g., conjugated or synthetic estrogens) ( Hembree et al., 2009 ), providers could conduct a physical exam to detect the effects of hormones, such as assessing whether breast tissue is present in transgender women. While physical exams may not conclusively confirm prior hormone use, particularly among those who had initiated hormone therapy shortly before being incarcerated, such strategies would likely improve access to hormone therapies for patients with a longer history of taking hormones. Together, these strategies provide correctional providers with a set of tools to navigate restrictive hormone policies and play an active role in resisting the gender binary and ensuring transgender patients have access to medically necessary therapies while incarcerated.

When asked about what could be done to improve healthcare for incarcerated transgender women, the majority of participants cited the need for transgender cultural and clinical competency training for providers. Educational efforts to increase community healthcare providers’ transgender cultural competency (e.g.: “Transgender 101” trainings) have been successful in improving provider awareness and understanding of transgender patients by exposing them to the healthcare barriers that transgender people encounter ( Hanssmann et al., 2008 ). Interventions to improve providers' transgender medical knowledge have also demonstrated success, as a lecture covering the durability of gender identity and hormonal treatment regimens significantly increased physician-residents’ knowledge and willingness to provide hormonal therapy to transgender patients ( Thomas and Safer, 2015 ). While education is important, the current study, along with prior research with community providers, implicates lack of exposure to transgender people as a barrier to providers’ comfort and ability to care for transgender patients ( Lurie, 2005 , Poteat et al., 2013 ). Inter-group contact is effective in reducing prejudice among diverse populations ( Pettigrew and Tropp, 2006 ). Intervention research with correctional healthcare providers suggests that transgender cultural and clinical competence trainings, which incorporate exposure to transgender people and their stories, and account for the unique structural barriers to healthcare in jails and prisons, can help increase providers’ ability to care for transgender patients; pilot testing of this intervention is currently underway.

Limitations

The results of this study should be interpreted in light of several limitations. The present study examined the experiences of formerly incarcerated transgender women, the majority of whom had been incarcerated in male facilities in one or more New England state. Therefore, these findings may not transfer to other settings or populations (e.g., transgender men in male or female facilities, transgender women in female facilities, or transgender people in non-U.S. contexts). Due to many participants strong desire to affirm their gender, it is possible that participants more readily recalled negative healthcare experiences than positive encounters, thus the data may be subjects to recall bias. Nonetheless, our findings extend prior quantitative research documenting structural and interpersonal barriers to care among incarcerated transgender individuals (e.g., Brown, 2009 ; Lydon, 2015 ). Additionally, the findings reported here only represent the perspective of transgender women who sought healthcare while incarcerated, and do not account for the perspectives of providers in these settings. Providers may face unique barriers to providing gender-affirmative care that are not known to transgender inmates and thus not documented here. Furthermore, the study did not systematically examine the attitudes and behaviors of providers according to specialty. Future qualitative research exploring correctional providers’ perspectives and experiences caring for transgender patients, and exploring differences by provider training, would likely enhance care for incarcerated transgender women.

In sum, the present study suggests that transgender women face immense challenges accessing medically necessary care in correctional settings. Structural factors such as restrictive hormone policies and an institutional culture of transphobia limit hormone access and the feminine gender expression of incarcerated transgender women. Interpersonal factors, such as biased and uninformed providers, frequently limited access to general and transition-related care, but also demoralized many of the study participants and further contributed to their poor quality of life while incarcerated. Participant narratives show that despite being confronted with interpersonal stigma and structural barriers to care, the transgender women in this study are resilient as they used a variety of strategies to resist and survive the prison environment. The findings presented here serve as a starting point for future exploration into the delivery of healthcare to incarcerated transgender individuals and ultimately educational and policy interventions to improve access to gender-affirmative care for incarcerated transgender communities.

Acknowledgments

This research was conducted with support from the Yale Fund for Gay and Lesbian Studies. Jaclyn White Hughto is supported by the National Institutes of Minority Health Disparities (1F31MD011203-01). Kirsty Clark acknowledges funding support from the Graduate Division, UCLA Fielding School of Public Health (Fellowship in Epidemiology, #104733842). The authors would like to thank Laura Michelson for her support in coding the interview transcripts.

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October 22, 2018

13 min read

Sex Redefined: The Idea of 2 Sexes Is Overly Simplistic

Biologists now think there is a larger spectrum than just binary female and male

By Claire Ainsworth & Nature magazine

Gary Waters Getty Images

As a clinical geneticist, Paul James is accustomed to discussing some of the most delicate issues with his patients. But in early 2010, he found himself having a particularly awkward conversation about sex.

A 46-year-old pregnant woman had visited his clinic at the Royal Melbourne Hospital in Australia to hear the results of an amniocentesis test to screen her baby's chromosomes for abnormalities. The baby was fine—but follow-up tests had revealed something astonishing about the mother. Her body was built of cells from two individuals, probably from twin embryos that had merged in her own mother's womb. And there was more. One set of cells carried two X chromosomes, the complement that typically makes a person female; the other had an X and a Y. Halfway through her fifth decade and pregnant with her third child, the woman learned for the first time that a large part of her body was chromosomally male. “That's kind of science-fiction material for someone who just came in for an amniocentesis,” says James.

Sex can be much more complicated than it at first seems. According to the simple scenario, the presence or absence of a Y chromosome is what counts: with it, you are male, and without it, you are female. But doctors have long known that some people straddle the boundary—their sex chromosomes say one thing, but their gonads (ovaries or testes) or sexual anatomy say another. Parents of children with these kinds of conditions—known as intersex conditions, or differences or disorders of sex development (DSDs)—often face difficult decisions about whether to bring up their child as a boy or a girl. Some researchers now say that as many as 1 person in 100 has some form of DSD.

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When genetics is taken into consideration, the boundary between the sexes becomes even blurrier. Scientists have identified many of the genes involved in the main forms of DSD, and have uncovered variations in these genes that have subtle effects on a person's anatomical or physiological sex. What's more, new technologies in DNA sequencing and cell biology are revealing that almost everyone is, to varying degrees, a patchwork of genetically distinct cells, some with a sex that might not match that of the rest of their body. Some studies even suggest that the sex of each cell drives its behaviour, through a complicated network of molecular interactions. “I think there's much greater diversity within male or female, and there is certainly an area of overlap where some people can't easily define themselves within the binary structure,” says John Achermann, who studies sex development and endocrinology at University College London's Institute of Child Health.

These discoveries do not sit well in a world in which sex is still defined in binary terms. Few legal systems allow for any ambiguity in biological sex, and a person's legal rights and social status can be heavily influenced by whether their birth certificate says male or female.

“The main problem with a strong dichotomy is that there are intermediate cases that push the limits and ask us to figure out exactly where the dividing line is between males and females,” says Arthur Arnold at the University of California, Los Angeles, who studies biological sex differences. “And that's often a very difficult problem, because sex can be defined a number of ways.”

The start of sex

That the two sexes are physically different is obvious, but at the start of life, it is not. Five weeks into development, a human embryo has the potential to form both male and female anatomy. Next to the developing kidneys, two bulges known as the gonadal ridges emerge alongside two pairs of ducts, one of which can form the uterus and Fallopian tubes, and the other the male internal genital plumbing: the epididymes, vas deferentia and seminal vesicles. At six weeks, the gonad switches on the developmental pathway to become an ovary or a testis. If a testis develops, it secretes testosterone, which supports the development of the male ducts. It also makes other hormones that force the presumptive uterus and Fallopian tubes to shrink away. If the gonad becomes an ovary, it makes oestrogen, and the lack of testosterone causes the male plumbing to wither. The sex hormones also dictate the development of the external genitalia, and they come into play once more at puberty, triggering the development of secondary sexual characteristics such as breasts or facial hair.

Changes to any of these processes can have dramatic effects on an individual's sex. Gene mutations affecting gonad development can result in a person with XY chromosomes developing typically female characteristics, whereas alterations in hormone signalling can cause XX individuals to develop along male lines.

For many years, scientists believed that female development was the default programme, and that male development was actively switched on by the presence of a particular gene on the Y chromosome. In 1990, researchers made headlines when they uncovered the identity of this gene, which they called SRY . Just by itself, this gene can switch the gonad from ovarian to testicular development. For example, XX individuals who carry a fragment of the Y chromosome that contains SRY develop as males.

By the turn of the millennium, however, the idea of femaleness being a passive default option had been toppled by the discovery of genes that actively promote ovarian development and suppress the testicular programme—such as one called WNT4 . XY individuals with extra copies of this gene can develop atypical genitals and gonads, and a rudimentary uterus and Fallopian tubes. In 2011, researchers showed that if another key ovarian gene, RSPO1 , is not working normally, it causes XX people to develop an ovotestis—a gonad with areas of both ovarian and testicular development.

These discoveries have pointed to a complex process of sex determination, in which the identity of the gonad emerges from a contest between two opposing networks of gene activity. Changes in the activity or amounts of molecules (such as WNT4) in the networks can tip the balance towards or away from the sex seemingly spelled out by the chromosomes. “It has been, in a sense, a philosophical change in our way of looking at sex; that it's a balance,” says Eric Vilain, a clinician and the director of the Center for Gender-Based Biology at the University of California, Los Angeles. “It's more of a systems-biology view of the world of sex.”

Battle of the sexes

According to some scientists, that balance can shift long after development is over. Studies in mice suggest that the gonad teeters between being male and female throughout life, its identity requiring constant maintenance. In 2009, researchers reported deactivating an ovarian gene called Foxl2 in adult female mice; they found that the granulosa cells that support the development of eggs transformed into Sertoli cells, which support sperm development. Two years later, a separate team showed the opposite: that inactivating a gene called Dmrt1 could turn adult testicular cells into ovarian ones. “That was the big shock, the fact that it was going on post-natally,” says Vincent Harley, a geneticist who studies gonad development at the MIMR-PHI Institute for Medical Research in Melbourne.

The gonad is not the only source of diversity in sex. A number of DSDs are caused by changes in the machinery that responds to hormonal signals from the gonads and other glands. Complete androgen insensitivity syndrome, or CAIS, for example, arises when a person's cells are deaf to male sex hormones, usually because the receptors that respond to the hormones are not working. People with CAIS have Y chromosomes and internal testes, but their external genitalia are female, and they develop as females at puberty.

Conditions such as these meet the medical definition of DSDs, in which an individual's anatomical sex seems to be at odds with their chromosomal or gonadal sex. But they are rare—affecting about 1 in 4,500 people. Some researchers now say that the definition should be widened to include subtle variations of anatomy such as mild hypospadias, in which a man's urethral opening is on the underside of his penis rather than at the tip. The most inclusive definitions point to the figure of 1 in 100 people having some form of DSD, says Vilain.

But beyond this, there could be even more variation. Since the 1990s, researchers have identified more than 25 genes involved in DSDs, and next-generation DNA sequencing in the past few years has uncovered a wide range of variations in these genes that have mild effects on individuals, rather than causing DSDs. “Biologically, it's a spectrum,” says Vilain.

A DSD called congenital adrenal hyperplasia (CAH), for example, causes the body to produce excessive amounts of male sex hormones; XX individuals with this condition are born with ambiguous genitalia (an enlarged clitoris and fused labia that resemble a scrotum). It is usually caused by a severe deficiency in an enzyme called 21-hydroxylase. But women carrying mutations that result in a milder deficiency develop a 'non-classical' form of CAH, which affects about 1 in 1,000 individuals; they may have male-like facial and body hair, irregular periods or fertility problems—or they might have no obvious symptoms at all. Another gene, NR5A1 , is currently fascinating researchers because variations in it cause a wide range of effects, from underdeveloped gonads to mild hypospadias in men, and premature menopause in women.

Many people never discover their condition unless they seek help for infertility, or discover it through some other brush with medicine. Last year, for example, surgeons reported that they had been operating on a hernia in a man, when they discovered that he had a womb. The man was 70, and had fathered four children.

Cellular sex

Studies of DSDs have shown that sex is no simple dichotomy. But things become even more complex when scientists zoom in to look at individual cells. The common assumption that every cell contains the same set of genes is untrue. Some people have mosaicism: they develop from a single fertilized egg but become a patchwork of cells with different genetic make-ups. This can happen when sex chromosomes are doled out unevenly between dividing cells during early embryonic development. For example, an embryo that starts off as XY can lose a Y chromosome from a subset of its cells. If most cells end up as XY, the result is a physically typical male, but if most cells are X, the result is a female with a condition called Turner's syndrome, which tends to result in restricted height and underdeveloped ovaries. This kind of mosaicism is rare, affecting about 1 in 15,000 people.

The effects of sex-chromosome mosaicism range from the prosaic to the extraordinary. A few cases have been documented in which a mosaic XXY embryo became a mix of two cell types—some with two X chromosomes and some with two Xs and a Y—and then split early in development. This results in 'identical' twins of different sexes.

There is a second way in which a person can end up with cells of different chromosomal sexes. James's patient was a chimaera: a person who develops from a mixture of two fertilized eggs, usually owing to a merger between embryonic twins in the womb. This kind of chimaerism resulting in a DSD is extremely rare, representing about 1% of all DSD cases.

Another form of chimaerism, however, is now known to be widespread. Termed microchimaerism, it happens when stem cells from a fetus cross the placenta into the mother's body, and vice versa. It was first identified in the early 1970s—but the big surprise came more than two decades later, when researchers discovered how long these crossover cells survive, even though they are foreign tissue that the body should, in theory, reject. A study in 1996 recorded women with fetal cells in their blood as many as 27 years after giving birth; another found that maternal cells remain in children up to adulthood. This type of work has further blurred the sex divide, because it means that men often carry cells from their mothers, and women who have been pregnant with a male fetus can carry a smattering of its discarded cells.

Microchimaeric cells have been found in many tissues. In 2012, for example, immunologist Lee Nelson and her team at the University of Washington in Seattle found XY cells in post-mortem samples of women's brains. The oldest woman carrying male DNA was 94 years old. Other studies have shown that these immigrant cells are not idle; they integrate into their new environment and acquire specialized functions, including (in mice at least) forming neurons in the brain. But what is not known is how a peppering of male cells in a female, or vice versa, affects the health or characteristics of a tissue—for example, whether it makes the tissue more susceptible to diseases more common in the opposite sex. “I think that's a great question,” says Nelson, “and it is essentially entirely unaddressed.” In terms of human behaviour, the consensus is that a few male microchimaeric cells in the brain seem unlikely to have a major effect on a woman.

Scientists are now finding that XX and XY cells behave in different ways, and that this can be independent of the action of sex hormones. “To tell you the truth, it's actually kind of surprising how big an effect of sex chromosomes we've been able to see,” says Arnold. He and his colleagues have shown that the dose of X chromosomes in a mouse's body can affect its metabolism, and studies in a lab dish suggest that XX and XY cells behave differently on a molecular level, for example with different metabolic responses to stress. The next challenge, says Arnold, is to uncover the mechanisms. His team is studying the handful of X-chromosome genes now known to be more active in females than in males. “I actually think that there are more sex differences than we know of,” says Arnold.

Beyond the binary

Biologists may have been building a more nuanced view of sex, but society has yet to catch up. True, more than half a century of activism from members of the lesbian, gay, bisexual and transgender community has softened social attitudes to sexual orientation and gender. Many societies are now comfortable with men and women crossing conventional societal boundaries in their choice of appearance, career and sexual partner. But when it comes to sex, there is still intense social pressure to conform to the binary model.

This pressure has meant that people born with clear DSDs often undergo surgery to 'normalize' their genitals. Such surgery is controversial because it is usually performed on babies, who are too young to consent, and risks assigning a sex at odds with the child's ultimate gender identity—their sense of their own gender. Intersex advocacy groups have therefore argued that doctors and parents should at least wait until a child is old enough to communicate their gender identity, which typically manifests around the age of three, or old enough to decide whether they want surgery at all.

This issue was brought into focus by a lawsuit filed in South Carolina in May 2013 by the adoptive parents of a child known as MC, who was born with ovotesticular DSD, a condition that produces ambiguous genitalia and gonads with both ovarian and testicular tissue. When MC was 16 months old, doctors performed surgery to assign the child as female—but MC, who is now eight years old, went on to develop a male gender identity. Because he was in state care at the time of his treatment, the lawsuit alleged not only that the surgery constituted medical malpractice, but also that the state denied him his constitutional right to bodily integrity and his right to reproduce. Last month, a court decision prevented the federal case from going to trial, but a state case is ongoing.

“This is potentially a critically important decision for children born with intersex traits,” says Julie Greenberg, a specialist in legal issues relating to gender and sex at Thomas Jefferson School of Law in San Diego, California. The suit will hopefully encourage doctors in the United States to refrain from performing operations on infants with DSDs when there are questions about their medical necessity, she says. It could raise awareness about “the emotional and physical struggles intersex people are forced to endure because doctors wanted to 'help' us fit in,” says Georgiann Davis, a sociologist who studies issues surrounding intersex traits and gender at the University of Nevada, Las Vegas, who was born with CAIS.

Doctors and scientists are sympathetic to these concerns, but the MC case also makes some uneasy—because they know how much is still to be learned about the biology of sex. They think that changing medical practice by legal ruling is not ideal, and would like to see more data collected on outcomes such as quality of life and sexual function to help decide the best course of action for people with DSDs—something that researchers are starting to do.

Diagnoses of DSDs once relied on hormone tests, anatomical inspections and imaging, followed by painstaking tests of one gene at a time. Now, advances in genetic techniques mean that teams can analyse multiple genes at once, aiming straight for a genetic diagnosis and making the process less stressful for families. Vilain, for example, is using whole-exome sequencing—which sequences the protein-coding regions of a person's entire genome—on XY people with DSDs. Last year, his team showed that exome sequencing could offer a probable diagnosis in 35% of the study participants whose genetic cause had been unknown.

Vilain, Harley and Achermann say that doctors are taking an increasingly circumspect attitude to genital surgery. Children with DSDs are treated by multidisciplinary teams that aim to tailor management and support to each individual and their family, but this usually involves raising a child as male or female even if no surgery is done. Scientists and advocacy groups mostly agree on this, says Vilain: “It might be difficult for children to be raised in a gender that just does not exist out there.” In most countries, it is legally impossible to be anything but male or female.

Yet if biologists continue to show that sex is a spectrum, then society and state will have to grapple with the consequences, and work out where and how to draw the line. Many transgender and intersex activists dream of a world where a person's sex or gender is irrelevant. Although some governments are moving in this direction, Greenberg is pessimistic about the prospects of realizing this dream—in the United States, at least. “I think to get rid of gender markers altogether or to allow a third, indeterminate marker, is going to be difficult.”

So if the law requires that a person is male or female, should that sex be assigned by anatomy, hormones, cells or chromosomes, and what should be done if they clash? “My feeling is that since there is not one biological parameter that takes over every other parameter, at the end of the day, gender identity seems to be the most reasonable parameter,” says Vilain. In other words, if you want to know whether someone is male or female, it may be best just to ask.

This article is reproduced with permission and was first published on February 18, 2015.

Watch This Next

Has Gender Always Been Binary?

Gender has historically been viewed in a more fluid manner..

Posted September 16, 2018 | Reviewed by Lybi Ma

The extent to which men conform to stereotypical masculine behaviors and interests and the extent to which women conform to stereotypical feminine behaviors and interests can be described as gender conformity . When individuals stray from their expected gender roles—or behave in gender non-conforming ways—they tend to be evaluated negatively, although such negative views are not meted out equally. For example, men who possess feminine qualities or interests are often evaluated much more harshly than women who possess masculine interests or qualities. One does not need to look any further than the differing connotations applied to the concepts of a tomboy girl versus a sissy boy to see how society responds differently to gender nonconformity as a function of whether one is adopting or abandoning masculinity.

The very notion of gender non-conformity is predicated upon a concept known as the gender binary.

The gender binary refers to the notion that gender comes in two distinct flavors: men and women, in which men are masculine, women are feminine, and, importantly, men are of the male sex and women are of the female sex. Much of the world around us is based upon this binary understanding of sex and gender, such as the clothing we buy, barbershops vs. salons, and men’s rooms vs. women’s rooms. In fact, one of the first things new parents often learn about their future child is their sex, based on a grainy ultrasound image of tiny little genitals. From this point forward, a parent’s idea of who their child will grow up to be is significantly shaped by the sex, represented through the color of the nursery room, the types of clothing purchased, and of course, the list of potential baby names. Our expectations based on gender do not stop there. When we find out that a baby is a boy, we are more likely to describe him as strong, tough or handsome, whereas we will view baby girls as sweet, gentle and kind.

The gender binary is such a prevalent and well-accepted concept within our society that we tend to get upset when we are unable to place something or someone into one box or the other. We even extend this binary to our pets , often getting upset if people mistake our handsome boy dog for a girl, quickly correcting the offending stranger by emphasizing our response to “Ohhhh what a cute little puppy, what is her name?” with “ His name is Buddy!” This isn't to say that there is no such thing as a male dog or a female dog, but rather, it emphasizes our cultural investment in perceiving someone's (or some dog's) gender correctly and using that piece of information as an overarching tool through which to understand the person or dog that we have just encountered.

Yet, while the gender binary is certainly well anchored within society and our social mores, there is actually a long history of gender not being viewed in such a black and white manner. Indeed, many indigenous cultures around the globe held more fluid and dynamic understandings of gender before encountering Western theories of gender. Even within Western cultures, the characteristics associated with one gender or the other have changed stripes so many times through history that it is almost surprising how adamantly we now argue that heels , wigs, makeup , and the color pink are only for women and girls, when all of these things were previously reserved only for men and boys.

Thus, while it may seem like discussions about non-binary understandings of gender and acceptance of gender nonconforming behavior are new additions to the daily dialogue, there is perhaps more in our collective past to point us towards a more diverse understanding of gender than there is to keep us focused on rigidly defined, binary gender roles.

While these topics seem to come up most frequently when discussing transgender and non-binary individuals and their respective rights, as well as the controversies that surround their ability to access those rights, the concept of dismantling a binary view of gender is actually one that applies to everyone, whether you identify as cisgender (someone whose gender identity and expression is the same as the sex they were assigned at birth), transgender (someone whose gender identity and/or expression is different from the sex they were assigned at birth), non-binary (someone who does not define their gender based on the binaries of men and women) or agender (someone who identifies as not having a gender). Adopting a more open and fluid understanding of gender certainly makes it easier to accept transgender, non-binary and agender individuals, but it also makes it easier to be accepting of anyone who possesses, expresses, or desires qualities that have previously been earmarked as being the prevue of only one gender or the other.

In my next few posts, I will be exploring some recent research related to the gender binary, including a study that examined whether an individual’s gender non-conforming behavior is seen as more or less threatening when the individual is transgender vs. cisgender and a recent symposium that explored the experiences of transgender and gender nonconforming individuals around the globe.

Hoskin, R. A. (2017). Femme theory: Refocusing the intersectional lens . Atlantis: Critical Studies in Gender, Culture & Social Justice, 38 (1), 95-109.

Vasey, P. L., & Bartlett, N. H. (2007). What can the Samoan" fa'afafine " teach us about the Western concept of gender identity disorder in childhood? . Perspectives in biology and medicine, 50 (4), 481-490.

Sheppard, M., & Mayo Jr, J. B. (2013). The social construction of gender and sexuality: Learning from two spirit traditions . The Social Studies, 104 (6), 259-270.

Nanda, S. (1986). The Hijras of India: Cultural and individual dimensions of an institutionalized third gender role . Journal of Homosexuality, 11 (3-4), 35-54.

Aznar, A., & Tenenbaum, H. R. (2015). Gender and age differences in parent–child emotion talk . British Journal of Developmental Psychology, 33 (1), 148-155.

Lindgren, C. (2010). Pink Brain Blue Brain: How Small Differences Grow into Troublesome Gaps . Acta Paediatrica, 99 (7), 1108-1108.

Karen Blair, Ph.D. , is an assistant professor of psychology at Trent University. She researches the social determinants of health throughout the lifespan within the context of relationships.

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Published: 24 August 2024

Supporting and understanding non-binary & gender diverse youth: a physician’s view

Jamie Agapoff ORCID: orcid.org/0000-0002-6026-6463 1

Child and Adolescent Psychiatry and Mental Health volume 18 , Article number: 105 ( 2024 ) Cite this article

Metrics details

Non-binary is a gender identity term describing a person whose gender exists between or outside the gender binary. Non-binary is also an umbrella term encompassing other gender identities such as genderqueer, genderfluid, agender, demigirl, demiboy, bigender, and others. As non-binary persons identify with a gender other than the one assigned at birth, they may be classified as transgender, although some may not identify with that label [ 1 ].

Population estimates of transgender and gender diverse (TGD) youth are varied [ 2 , 3 , 4 ]. Among youth ages 13 to 17 in the U.S., about 1.4% (~ 300,000) identify as transgender [ 3 ], and 1 in 4 identify as non-binary [ 4 ]. According to survey-based studies of children and adolescents, about 1.2–2.7% identify as transgender and 2.5–8.4% as TGD [ 2 ].

Despite a growing number of studies on transgender topics, a majority of this research still comes from the U.S. and Western Europe [ 2 , 5 ]. This special issue includes studies from South America [ 6 ] and the Middle East [ 7 ] where there are a paucity of studies. International data is helpful for expanding global applicability of treatment guidelines such as the Standards of Care released by the World Professional Association for Transgender Health [ 2 ].

Studies from this collection show transgender and gender diverse (TGD) youth face significant minority stressors and mental health concerns [ 8 , 9 , 10 ]. For example, Haywood et al., found that many TDG youth still face high levels of non-acceptance and bullying even after social transition [ 8 ]. Another study found that the experience of trans hostility is associated with an increase in gender dysphoria and poor peer relations in TGD youth [ 9 ]. And, in a systematic review, TGD adolescents with gender dysphoria experienced a high co-occurrence of psychosocial and psychological vulnerability, leading to greater risk for suicidal ideation and life-threatening behaviors [ 10 ].

Previous research demonstrates that mental health symptoms and gender dysphoria improve with access to gender affirmative care including social, surgical and hormonal interventions [ 11 , 12 , 13 , 14 , 15 , 16 ]. In one study of nonbinary and gender diverse youth, use of puberty blockers and gender-affirming hormones were associated with 73% lower odds of suicidality and 60% lower odds of moderate to severe depression [ 13 ]. Importantly, access to gender-affirming hormones during adolescence has been found to improve mental health outcomes in adulthood [ 14 ]. And, surgical interventions such as chest reconstruction have been shown to improve dysphoria and body satisfaction in gender diverse youth [ 12 , 16 ].

Yet, gender affirming care for youth is under attack. Legislative efforts to restrict access to gender affirming care are rampant, coordinated, and pervasive. Within the U.S. alone, nearly 39% of transgender youth live in states where there are bans on gender affirming care [ 17 ]. In the United Kingdom, life-saving treatments such as puberty blockers have been banned [ 18 ].

While credible scientific evidence about the positive benefits of gender affirming treatments struggle to find wide public dissemination [ 11 , 12 , 13 , 14 , 15 , 16 ], biased and methodologically flawed reports like the Cass Review are elevated within the public domain [ 19 , 20 ]. Providers should understand, practice, and disseminate best practice guidance for the care of TGD youth as outlined by the American Endocrine Society [ 21 ] and the World Professional Association for Transgender Health [ 2 ].

Providers who care for TGD youth should strive to adopt inclusive models that value self-determination and an affirmative approach [ 22 ]. Defensive models of care that focus on fringe concerns such as transition regret and mitigatable side effects are not supported by international treatment guidelines [ 2 ]. Similarly, intrusive and/or prolonged assessments that interrogate a youth’s gender identity and delay social or medical transitions are more likely to cause harm than good [ 23 ]. Providers should strive to support transgender youth at all stages of their social, medical, and legal transitions, while empowering and supporting them toward authentic gender identity and expression.

Data availability

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NATURE INDEX
21 August 2024

How South Korea can build better gender diversity into research

Heisook Lee 0 &
Heajin Kim 1

Heisook Lee is president of the Korea Center for Gendered Innovations for Science and Technology Research in Seoul.

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Heajin Kim is a senior researcher at the Korea Center for Gendered Innovations for Science and Technology Research in Seoul.

When designing a research study, integrating sex and gender as variables , such as by including both female and male participants and ensuring transgender people and those who do not fall into binary categorizations are also accounted for, is key to ensuring robust and reproducible results. But this is not being done nearly enough. In medical research, for example, centuries of female exclusion have led to inadequate knowledge and funding of diseases that affect women . In the development of generative artificial intelligence (AI), a lack of sex and gender considerations has perpetuated biases and stereotypes in areas such as image creation and language translation. Such oversights not only skew research findings but also undermine opportunities for discovery. Significant advancements have been made in fields such as cancer immunotherapy, cardiovascular disease and osteoporosis as a result of using sex and gender analysis (SGA) in research, and it has revealed important differences in how men and women metabolize drugs, leading to safer and more effective doses.

Heisook Lee. Credit: GISTeR

Despite the clear need for SGA to become the norm in experimental design, there is much work to be done before the practice is standardized in research globally. In South Korea, SGA integration is encouraged and promoted through government initiatives, but more policy development and capacity building is needed to drive uptake. At the Korea Center for Gendered Innovations for Science and Technology Research (GISTeR) in Seoul, we are investigating the use of SGA in South Korean research. One analysis showed that between 2017 to 2021, just 5.65% of South Korean biomedical articles, on average, included SGA in the experimental or study design. This figure, which relies heavily on individual researchers choosing to engage with the practice, is lower than in countries where the integration of SGA is mandatory for research funding.

The increasing complexity of study designs makes SGA integration a challenge for scientists in South Korea, especially early career researchers, who are not typically taught the practice. The limited availability of sex-disaggregated resources — data, animals, cells and other materials that have been collected and analysed separately for male, female and non-binary participants — further complicates matters and emphasizes the need for training to encourage more researchers to consider SGA in their work. As the South Korean government ramps up funding and support for international collaboration, its researchers will need to get up to speed on SGA integration. Horizon Europe, the European Union’s flagship research-funding programme that South Korea joined in March, mandates SGA integration in the research it funds , for example.

Heajin Kim. Credit: GISTeR

Recent policy changes from the South Korean government have been encouraging, but they have not moved the needle much in terms of researcher and institution uptake of SGA. In 2020, amendments were made to the Korean Framework Act on Science and Technology to emphasize the importance of sex and gender characteristics. Two years later, Korea’s Fifth Science and Technology Master Plan, which outlines the country’s medium-to-long-term goals and priorities for 2023 to 2027, emphasized the importance of SGA integration.

We need buy-in from funding agencies, publishers and institutions to ensure that researchers are equipped and incentivized to implement the practice. We propose the following strategies. First, funding agencies in South Korea should consider mandating SGA integration in the research they fund, and more academic journals need to strengthen their editorial policies by requiring SGA integration in manuscript submissions.

The research community needs to ensure the management and standardization of resources, such as cells and biological models, and data that are sex or gender specific, so they can be used throughout the entire research process, from the initial design to the final analysis. At GISTeR, we are running training and outreach programmes in an effort to help researchers understand how to achieve this.

Line chart showing the proportion of biomedicine research papers that integrated sex and gender analysis into their studies for selected countries for the period 2000 to 2021

Source: Gendered Innovation for Science and Technology Research Center

Last, it is important that indicators of SGA integration in research outputs are being developed at a global level, mirroring established metrics on quantity and quality. This approach would highlight where SGA is needed and encourage its use.

It is crucial for South Korean science that improvements are made to SGA integration rates. This will not only elevate the quality of its outputs, but could help to solidify South Korea’s role in developing equitable and impactful solutions to the world’s most urgent societal challenges.

Nature 632 , S13 (2024)

doi: https://doi.org/10.1038/d41586-024-02688-9

This article is part of Nature Index 2024 South Korea , an editorially independent supplement. Advertisers have no influence over the content. For more information about Nature Index, see the homepage .

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The authors declare no competing interests.

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Defending the Sex/Gender Binary: The Role of Gender Identification and
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The future of sex and gender in psychology: Five challenges to the
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Gender Identification Beyond the Binary and Its Consequences ...
Recent societal initiatives (e.g., gender-neutral toilets, clothing, and language) highlight the ongoing shift of gender away from binary categories: "man" and "woman." We identified and investigated two reasons for this shift: that many people may not identify with strictly binary categories and that this may have negative social consequences. Employing a multiple-identification model ...
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Previous research demonstrates that mental health symptoms and gender dysphoria improve with access to gender affirmative care including social, surgical and hormonal interventions [11,12,13,14,15,16].In one study of nonbinary and gender diverse youth, use of puberty blockers and gender-affirming hormones were associated with 73% lower odds of suicidality and 60% lower odds of moderate to ...
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with a non-binary gender identity, reported for time points 1950, 2017, and 2090. ... sex-di erence research. Gender and Culture in Psychology. 2012; 159-177. Publisher Full Text .
How South Korea can build better gender diversity into research
The research community needs to ensure the management and standardization of resources, such as cells and biological models, and data that are sex or gender specific, so they can be used ...
Non-binary gender
In July 2021, Argentina incorporated non-binary gender in its national ID card, becoming the first country in South America to legally recognize non-binary gender on all official documentation; non-binary people in the country will have the option to renew their ID with the letter "X" under gender. ... although current research demonstrates ...

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