Keywords
gender dysphoria - nonbinary - gender-affirming surgery - facial feminization surgery
- reconstructive craniofacial surgery
Introduction
In the United States, the prevalence of transgender individuals is estimated to be
0.5%, with over one in three individuals with gender dysphoria identifying as gender
nonconforming or nonbinary.[1]
[2] The term nonbinary describes a gender identity that is not male or female; some
may define their nonbinary gender identity as being a combination of these genders,
neither of them, or no gender at all.[3] These patients may present as feminine, masculine, both, or neither, regardless
of their sex assigned at birth.[3] There is also an apparent generational difference, with nonbinary individuals being
younger on average compared to binary transgender individuals.[1]
[4]
[5]
[6]
An increasing number of nonbinary patients are receiving gender-affirming procedures
due to improved access to care.[7] This is congruent with a rise in number of providers who are familiar with the nuances
of this patient population, as well as expanded insurance coverage.[8]
[9] Similar to reconstructive surgeries for binary transgender patients, these procedures
can range from facial surgery to top surgery (e.g., chest and breast reconstruction)
and bottom surgery (e.g., genital or reproductive tract reconstruction). Although
specific surgeries used to treat binary patients are largely the same as those available
to nonbinary patients, the desired surgical interventions nonbinary patients seek
are varied and have been previously poorly described.
Despite the recent growing interest in transgender and nonbinary health, the preferred
treatments for nonbinary patients are underinvestigated.[10] Studies are often focused on surgical techniques or outcomes, rather than the specific
surgical preferences and needs of these patients. In fact, most studies either exclude
the gender nonconforming patient population, combine all non-cisgender individuals,
or further stratify them in a binary fashion. This is problematic as there are remarkable
differences in binary transgender and nonbinary development and characteristics.[10]
[11]
Similarly, there are significant differences between the percentage of binary and
nonbinary individuals who desire hormonal therapy, with only 49% of nonbinary individuals
desiring treatment compared to 95% in the binary population.[1] The percentage of nonbinary patients who ultimately undergo hormonal treatment is
even less.
As more nonbinary patients seek treatment, it is important to recognize their unique
health necessities and provide appropriate, high-quality care. In this study, we investigated
the clinical management strategies for both nonbinary patients who were assigned male
at birth (NB-AMAB) and nonbinary patients assigned female at birth (NB-AFAB). Our
goal was to report the patient preferences as well as the ultimate treatments rendered
in this population.
Methods
This study was approved by University of California, Los Angeles Institutional Review
Board #19-001482 and #001571.
Patient Selection
A retrospective study of patients from the University of California, Los Angeles was
performed to evaluate treatment preferences and modalities in nonbinary patients.
Inclusion criteria were patients who identified as nonbinary, defined as providing
a gender identity not exclusively male or female. Specific gender identities included
“nonbinary,” “genderqueer,” “nonconforming,” “gender fluid,” or analogous terms. Patient
demographics, characteristics, and desired or completed surgeries were collected from
patient records in March 2020.
Patient Goals and Surgical Requests
A list of common reconstructive goals by nonbinary patients is reported in [Table 1]. These clinical requests were grouped into the recommended gender-affirming surgery.
Table 1
Surgical requests by type of gender-affirming surgery
|
Gender-affirming surgery
|
Request
|
|
Mastectomy
|
Gender neutral
Natural appearance
Does not want chest wall appearance of female
Does not want male physique
Reduction breast size
Flat chest
Appearance of male chest/masculine appearance of chest
|
|
Facial feminization surgery
|
Androgynous appearance
Widow's peak
Lower forehead
Overelevated eyebrows
Pointed chin
|
|
Breast augmentation
|
Body as female-only appearance
|
|
Bottom surgery
|
No visible sex organs
|
|
Orchiectomy
|
Absence of testosterone
|
Surgical Techniques
All gender-affirming mastectomies were performed as bilateral mastectomy with free
nipple graft (double incision technique). Facial feminization maneuvers, bottom surgeries,
and other gender-affirming surgery have been described previously.[12]
[13]
[14]
[15]
[16]
[17]
Statistical Analyses
All data were analyzed using SPSS software Version 25 (IBM, Chicago, IL). Descriptive
statistics were performed to evaluate demographic variables such as age, sex assigned
at birth, preferred gender pronoun, hormone treatment, and surgical intervention.
Chi-square test was used to analyze categorical variables. t-Test was used to analyze continuous variables such as age and duration of hormone
therapy. A p-value of 0.05 was considered significant.
Results
Patient Characteristics
Sixty-seven (18%) nonbinary patients (mean age 30.6 ± 11.3 years) were reviewed. Most
nonbinary patients were assigned male sex at birth (n = 57, 85%) ([Table 2]). Almost half of the nonbinary patients preferred the gender pronoun they/them/theirs
(n = 33, 49%), followed by she/her/hers (n = 23, 34%), then he/him/his (n = 7, 10%). A few patients used two gender pronouns (n = 3, 5%).
Table 2
Patient demographics in the total nonbinary cohort and compared between male and female
sex assigned at birth
|
All nonbinary, n = 67
|
Male sex assigned at birth, n = 57
|
Female sex assigned at birth, n = 10
|
p-Value[a]
|
|
Age at review, mean ± SD
|
30.7 ± 11.3
|
30.5 ± 11.1
|
31.3 ± 12.7
|
NS
|
|
Sex at birth, n (%)
|
|
57 (85)
|
10 (15)
|
< 0.001
|
|
Preferred gender pronoun, n (%)
|
|
|
|
|
|
They/them/theirs
|
33 (49)
|
26 (46)
|
7 (70)
|
NS
|
|
She/her/hers
|
23 (34)
|
23 (40)
|
0 (0)
|
0.013
|
|
He/him/his
|
7 (10)
|
6 (11)
|
1 (10)
|
NS
|
|
She/her/hers and they/them/theirs
|
2 (3)
|
1 (2)
|
1 (10)
|
NS
|
|
She/her/hers and he/him/his
|
1 (2)
|
1 (2)
|
0 (0)
|
NS
|
|
Age aware of gender identity, mean ± SD
|
16.8 ± 4.0
|
16.4 ± 8.1
|
19.1 ± 7.8
|
NS
|
|
Age at first transition consultation, mean ± SD
|
28.3 ± 9.8
|
28.5 ± 10.2
|
27.0 ± 7.2
|
NS
|
|
Age at first treatment, mean ± SD
|
28.1 ± 10.2
|
28.3 ± 10.9
|
27.2 ± 7.1
|
NS
|
|
Socially transitioned, n (%)
|
58 (87)
|
50 (88)
|
8 (80)
|
NS
|
Abbreviations: NS, not significant; SD, standard deviation.
a
p-Values obtained from chi-square tests for categorical, and t-test for continuous variables between male sex assigned at birth and female sex assigned
at birth cohorts.
Nonbinary patients were aware of their gender identity at a mean age of 16.8 ± 4.0
years, but did not meet with a physician to discuss transitioning until mean age of
28.3 ± 9.8 years. Of those who received medical or surgical treatment (n = 51), average age at first treatment was 28.1 ± 10.2 years old. Most patients had
socially transitioned (n = 58, 88%) at the time of the study ([Table 2]).
Medical Transition
Six patients used breast binders (9%) and two patients underwent voice therapy (3%)
([Table 3]). A total of 44 nonbinary patients (66%) received hormone therapy for an average
of 2.5 ± 3.6 years. Majority of patients (n = 39, 58%) received estrogen, while five patients (8%) received testosterone.
Table 3
Medical and surgical treatments
|
All nonbinary, n = 67
|
Male sex assigned at birth, n = 57
|
Female sex assigned at birth, n = 10
|
p-Value
|
|
Breast binding, n (%)
|
6 (9)
|
0 (0)
|
6 (60)
|
< 0.001
|
|
Voice therapy, n (%)
|
2 (3.0)
|
2 (3.5)
|
0 (0)
|
NS
|
|
Hormone therapy, n (%)
|
44 (66)
|
41 (72)
|
3 (30)
|
0.010
|
|
Duration hormone therapy (y), mean ± SD
|
2.5 ± 3.6
|
2.5 ± 3.8
|
2.4 ± 0.6
|
NS
|
|
Type of hormone
|
|
|
|
|
|
Estrogen
|
39 (58)
|
39 (68)
|
0 (0)
|
0.001
|
|
Testosterone
|
5 (8)
|
2 (4)
|
3 (30)
|
0.003
|
|
Other
|
4 (6)
|
4 (7)
|
0 (0)
|
NS
|
|
Completed GAS, n (%)
|
18 (27)
|
8 (14)
|
10 (100)
|
< 0.001
|
|
Completed or interested in GAS, n (%)
|
46 (69)
|
36 (63)
|
10 (100)
|
0.021
|
|
Completed GAS and hormone therapy, n (%)
|
11 (16)
|
8 (14)
|
3 (30)
|
NS
|
|
Completed/interested in GAS and completed hormone therapy, n (%)
|
32 (48)
|
29 (51)
|
3 (30)
|
NS
|
|
Age at first surgery, mean ± SD
|
31.8 ± 11.3
|
37.1 ± 13.7
|
27.5 ± 7.2
|
NS
|
|
First surgery, n (%)
|
|
|
|
|
|
Breast reduction
|
1 (2)
|
0 (0)
|
1 (10)
|
0.016
|
|
Facial feminization surgery
|
2 (3)
|
2 (4)
|
0 (0)
|
NS
|
|
Mastectomy
|
9 (13)
|
0 (0)
|
9 (90)
|
< 0.001
|
|
Orchiectomy
|
5 (8)
|
5 (9)
|
0 (0)
|
NS
|
|
Vaginoplasty
|
1 (2)
|
1 (2)
|
0 (0)
|
NS
|
|
Completed and desired surgery, n (%)
|
|
|
|
|
|
Body feminization, NOS
|
1 (2)
|
1 (2)
|
0 (0)
|
NS
|
|
Breast augmentation
|
8 (12)
|
8 (14)
|
0 (0)
|
NS
|
|
Breast reduction
|
2 (3)
|
1 (2)
|
1 (10)
|
NS
|
|
Facial feminization surgery
|
15 (22)
|
15 (26)
|
0 (0)
|
NS
|
|
Hair transplant
|
1 (2)
|
1 (2)
|
0 (0)
|
NS
|
|
Hysterectomy ± oophorectomy
|
1 (2)
|
0 (0)
|
1 (10)
|
0.016
|
|
Labiaplasty
|
1 (2)
|
1 (2)
|
0 (0)
|
NS
|
|
Mastectomy
|
11 (16)
|
1 (2)
|
10 (100)
|
< 0.001
|
|
Orchiectomy
|
9 (13)
|
9 (16)
|
0 (0)
|
NS
|
|
Penectomy
|
1 (2)
|
1 (2)
|
0 (0)
|
NS
|
|
Sex change from male, NOS
|
1 (2)
|
1 (2)
|
0 (0)
|
NS
|
|
Tracheal shave
|
4 (6)
|
4 (7)
|
0 (0)
|
NS
|
|
Vaginoplasty
|
15 (22)
|
15 (26)
|
0 (0)
|
NS
|
|
Voice surgery
|
6 (9)
|
6 (11)
|
0 (0.0)
|
NS
|
Abbreviations: GAS, gender-affirming surgery; NOS, not otherwise specified; NS, not
significant; SD, standard deviation.
Surgical Transition
Eighteen patients (27%) received some type of gender-affirming surgery, majority of
whom were previously on hormone therapy (n = 11, 61%) ([Table 3]). A total of 46 patients (69%) desired or completed gender-affirming surgery. Common
surgeries included facial feminization surgery (n = 15, 22%), vaginoplasty (n = 15, 22%), subcutaneous mastectomy with nipple reconstruction (n = 11, 61%), orchiectomy (n = 9, 13%), and breast augmentation (n = 8, 12%). The most common initial gender-affirming surgery completed were mastectomy
(n = 9, 50%) and orchiectomy (n = 5, 28%). Breakdown of completed versus desired surgeries are demonstrated in [Fig. 1].
Fig. 1 Completed and desired gender-affirming surgeries in nonbinary patients. Percentage
of completed (dark blue) and desired (light blue) gender-affirming surgeries in nonbinary
patients. NOS, not otherwise specified.
Nonbinary Assigned Male at Birth versus Nonbinary Assigned Female at Birth
When comparing nonbinary patients who were assigned male or female at birth, there
were no significant differences in age at presentation, mean duration of hormone therapy,
completion of both surgery and hormone therapy, or age at first gender-affirming surgery
([Table 3]). However, NB-AMAB patients were significantly more often treated with hormones
compared to NB-AFAB patients (72% vs. 30%, p = 0.010). Conversely, there was a significantly greater proportion of NB-AFAB patients
who underwent surgical intervention compared to NB-AMAB (100% vs. 14%, p < 0.001). The most common initial gender-affirming surgery completed was mastectomy
(n = 9, 90%) for NB-AFAB patients and orchiectomy (n = 5, 63%) for NB-AMAB patients.
When comparing the number of NB-AMAB and NB-AFAB patients who had either completed
or were interested in gender-affirming surgery, NB-AFAB patient rates were still significantly
higher despite an increase in NB-AMAB patient interest in gender-affirming surgery
(100% vs. 63%, p = 0.021) ([Table 3]). NB-AMAB patients were interested in several different gender-affirming procedures,
such as facial feminization surgery (n = 13, 23%), vaginoplasty (n = 13, 23%), and breast augmentation (n = 8, 14%) ([Fig. 1]). NB-AFAB patients, on the other hand, had no additional surgical desires. Finally,
while most surgical treatments completed generally corresponded to sex assigned at
birth, one NB-AMAB patient underwent mastectomy due to breast development after estrogen
therapy.
Of the 57 NB-AMAB patients, 28 desired but had not undergone gender-affirming surgery.
The reasons for not having undergone gender-affirming surgery in this cohort are listed
in [Table 4]. The primary reason for not undergoing gender-affirming surgery was wanting to trial
medical treatment first (n = 8, 29%) and awaiting surgery (n = 8, 29%). Other patients were not yet ready for surgery but desired surgery in the
future (n = 6, 21%) or were still doing voice therapy prior to voice surgery (n = 3, 11%). Only two patients (7%) experienced issues with insurance coverage. Lastly,
one patient (4%) deferred surgery due to lacking a support system.
Table 4
Reasons nonbinary assigned male at birth patients desired gender-affirming surgery
but have yet to undergo surgery
|
Reason
|
No. of patients (%), n = 28
|
|
Trial medical therapy
|
8 (29)
|
|
Still doing voice therapy
|
3 (11)
|
|
Awaiting surgery
|
8 (29)
|
|
Not ready for surgery or wants surgery in the future
|
6 (21)
|
|
Insurance issue or payment issue
|
2 (7)
|
|
Lack of support system
|
1 (4)
|
Discussion
This study evaluated the preferences of both nonbinary assigned male at birth (NB-AMAB)
and nonbinary assigned female at birth (NB-AFAB) patients, as well as the medical
and surgical care they received. We found that nonbinary individuals comprised of
18% of our total transgender population. This value is lower than reported by the
2016 U.S. Transgender Survey at approximately 35%.[1]
[2] However, the survey study consisted of all respondents with gender dysphoria, whereas
our transgender cohort consisted of those seeking treatment. Further, while our value
is higher than that reported by Esmonde et al of 13%, their cohort only consisted
of transgender patients who completed gender-affirming surgery.[3]
Our study population was primarily assigned male sex at birth (85%). This was higher
than previous reports, which have reported between 0 and 50% of nonbinary patients
were assigned male sex at birth.[3]
[6] This discrepancy is likely explained by the relatively small sample size of the
total nonbinary population included in these studies, including ours. Our cohort was
also relatively young at an average age of 31 years at presentation and 32 years at
first gender-affirming surgery, which correlates with previous reports demonstrating
nonbinary individuals to be younger compared to binary individuals.[1]
[4]
[5]
[6]
In our cohort, 100% of the NB-AFAB patients and 63% of the NB-AMAB patients have completed
or are interested in gender-affirming surgery. All NB-AFAB patients underwent top
surgery. Conversely, only 14% of NB-AMAB patients completed or desired breast augmentation.
More NB-AMAB patients were interested in facial feminization surgery (26%) or vaginoplasty
(26%). Previous reports have shown transgender men self-reporting gender-affirming
surgery prevalence rates of 42 to 54%, transgender women at around 28%, and nonbinary
individuals at around 9%.[1]
[18]
We demonstrate in our cohort that a small percentage of NB-AMAB individuals actually
underwent gender-affirming surgery (14%). This was not due to a lack of desire for
surgery, but rather due to other circumstances. Most of these patients were either
still undergoing nonsurgical therapy such as voice therapy or hormonal therapy or
were awaiting surgery. Only two patients were denied insurance approval.
While only 30% of our NB-AFAB patients underwent hormone therapy, the majority (71%)
of our NB-AMAB patients underwent hormone therapy. Esmonde et al found that 64% of
their NB-AFAB patients received testosterone. Why fewer of our NB-AFAB patients underwent
hormone therapy may be explained by general preference against the more systemic effects
of hormone therapy such as body hair growth and muscle development. In addition, while
testosterone therapy has little effect on AFAB breast size, all of the NB-AFAB patients
did undergo mastectomy. On the other hand, hormone therapy may have been adequate
in achieving the desired features in our NB-AMAB patients.
Only one of our NB-AFAB patients underwent or desired bottom surgery, and the procedure
was a hysterectomy. On the other hand, completed and desired genital surgery in NB-AMAB
patients was relatively high (5 and 25%, respectively) compared to previous reports
demonstrating that in NB-AMAB, 1% have had vaginoplasty or labiaplasty, with 11% desiring
these surgeries.[1] We may see that as bottom surgery becomes more available, more NB-AMAB patients
will undergo these procedures.
Although chest surgery is one of the most commonly completed gender-affirming procedures,
we did not have a single patient who underwent breast augmentation, despite 14% of
the NB-AMAB patients desiring this surgery. This is comparable to the aforementioned
study by Esmonde et al that similarly found that no patients in their study population
underwent breast augmentation, as well as reports that demonstrated a 1% completion
and 16% desire for breast augmentation.[1]
[3] This suggests that top surgery was a smaller priority to NB-AMAB patients compared
to facial or bottom surgery. In addition, top surgery for NB-AMAB patients is rarely
covered by insurance compared to for NB-AFAB patients. As many patients alter their
desires and expectations based on what they assume will be covered, we suspect that
financial aspects are in part behind this. The most common surgery in the NB-AMAB
group was orchiectomy, with 9% undergoing this procedure. This is consistent with
their desire to decrease testosterone through estrogen therapy.
Compared to transgender men respondents in the 2015 U.S. Transgender Survey, completed
and desired mastectomies in NB-AFAB patients in our study were comparable at 97 and
100%, respectively.[1] Completed and desired hysterectomy rates were much higher in the transgender men
group (71%) compared to the NB-AFAB group (10%). This suggests that both NB-AFAB and
transgender men groups strongly desired chest masculinization, but differed in desires
for changing their internal reproductive anatomy. Completed and desired voice surgery
(19% vs. 11%), facial feminization surgery (50% vs. 26%), breast augmentation (51%
vs. 14%), orchiectomy (58% vs. 16%), tracheal shave (37% vs. 7%), and vaginoplasty
(66% vs. 26%) were all higher in the transgender women respondents compared to our
NB-AMAB patients.[1] This marks an important clinical difference between these two groups, as the desire
for all gender-affirming surgery is lower in the NB-AMAB population than in the transgender
women population.
There are several important limitations to our study. The generalizability of the
findings presented here is limited by the retrospective nature of the study and single-institution
patient cohort. Our population was also largely assigned male sex at birth, which
further limits the generalizability of the data. While we had a relatively robust
sample size, some clinical and surgical characteristics had smaller numbers of patients
contributing to the potential for type II error. Furthermore, nonbinary individuals
may identify themselves anywhere on a wide spectrum from masculine to feminine, so
to categorically group these patients inherently overlooks their differences. Finally,
we did not utilize postoperative patient satisfaction surveys or patient-reported
outcomes. Future studies should focus on outcomes of surgery and identify areas in
our health care system that can better serve this population.
This retrospective study is among the first investigations aimed at describing the
planning and goals of nonbinary patients seeking gender-affirming treatment. After
examining the frequency of top surgery, bottom surgery, facial surgery, voice surgery,
and hormone therapy, our data demonstrated that NB-AFAB patients in our cohort desired
and underwent surgical treatment, whereas NB-AMAB patients were predominantly treated
with hormone therapy. This study furthers examines the care of nonbinary patients
and illuminates many nuances in the decision-making process due to circumstance and
cost concerns. While the ultimate treatment plan of gender nonbinary patients necessitates
individualized approaches due to the diversity in goals of each patient, our experience
allows for a starting point for physicians in gender health care for the purposes
of determining potential referrals and common pathways of other nonbinary patients.
