Being outside the gender binary translates into worse health

Today, on World Mental Health Day, Transgender Europe (TGEU) is publishing a groundbreaking report on the experiences of trans people in healthcare with a focus on five European countries. The report reaffirms that trans people are routinely discriminated against in healthcare settings and their health and well-being is underserviced. It further finds that within the broader trans community, non-binary people face particular barriers in accessing healthcare services and they score lowest on self-reported physical and mental health.

People on a rally for transgender equality, sign saying "queer for care"
Teaser Image Caption
A rally in Washington, DC in support of the equal health and livelihood of trans people (2013)

Previous research findings have shown that within the European Union, trans people are most likely among LGBT people to face discrimination in healthcare, that one in every five trans people have personally faced discrimination and that 70% of trans people have undergone negative experiences in healthcare settings.

In 2016-2017, TGEU, Europe’s largest trans umbrella organization, conducted research in Georgia, Poland, Serbia, Spain and Sweden to further research the experiences of trans people in healthcare. TGEU’s country researchers gathered responses from 885 trans healthcare users and 888 healthcare providers. More than one-fourth (230) of healthcare users identified as non-binary.


Trans is an umbrella term for people whose gender identity does not match the sex that was assigned to them at birth. For instance, doctors and parents might assign someone to be a girl when they are born (they usually do this on the basis of the newborn’s physical  appearance one’s genitalia), but later in life this person might realize that they are a boy or that they are non-binary


Non-binary people do not identify with the sex that was assigned to them at birth and have a gender identity that does not correspond to being (exclusively) male or female. They might identify with being both, or neither of these two, their gender identity might be fluid, or they might not have a gender identity at all. 


Cis or cisgender is an umbrella term for everyone who is not trans.


Transitioning describes the process of accepting, affirming and making oneself feel at home in their gender identity. Transitioning has many aspects, including social, medical, or legal. Social transitioning for instance means telling people (family, friends, or doctors) that they are trans. Some trans people also transition medically: some take hormones and/or opt for surgeries. Some trans people do not go through any medical transition. Trans people are an extremely diverse group and as such, their needs in healthcare settings are also extremely heterogeneous. 

Legal gender recognition

Many trans people want access to legal gender recognition, which means changing their gender marker in their ID cards or passports so it matches their gender identity. This is not really a huge ask from the state, just consider how cis people never have to worry about their IDs matching who they are. In many European countries, trans people have to fulfil all or a combination of severely intrusive requirements to make this happen: be forcibly sterilized, receive a psychiatric diagnosis, take hormones, go through medical examinations, and/or get a divorce.

Research produced that specifically studies or explicitly includes the experiences of non-binary people has been scarce in particular with a specific focus on healthcare. TGEU’s report is therefore a groundbreaking contribution to mapping non-binary people’s experiences in Europe. Non-binary people have existed for centuries and across continents, surviving colonialist genocide and the violent erasure of their identities, cultures, and histories. Recently, media platforms have started to increasingly report on current non-binary activist work in Europe and issues non-binary people face. Consider the work of artist and poet Travis Alabanza, Brighton based educators and filmmakers Fox and Owl and their appearance on Good Morning Britain, or recent coverage by media outlets such as the Guardian. Many other non-binary activists and artists do powerful work all across the continent - see for instance Anja Koletnik who was the first non-binary person to come out in Slovenian media, queer Pakistani activist and writer Sabah Choudrey in the UK, Naomhan O’Connor who is currently suing the Irish state for the failure to provide legal gender recognition for non-binary people, Wiktor Dynarski long-time community organizer and advocate in Poland, Mina Tolu Maltese youth activist who recently called out Emma Watson for misgendering them or George-Kyveli Papadimitriou fighting the binary in Greece.

Self-reported health state

Numerous reports have highlighted before that trans people are particularly vulnerable to poor physical and mental health as well as suicidal ideation. TGEU’s health study found that 78% of respondents have thought of suicide and 25% have had at least one attempt. It is alarming that among the broader group of trans people, non-binary people are twice more likely to self-report their health as bad. They were also the group with the highest risk of poor mental health, including having low mood or being depressed. In Sweden, more than half of non-binary people reported that their health was bad, making them the group with the worst self-reported health. For instance in Spain and Sweden, non-binary people were also least likely to be able to live according to their gender identity. In Sweden, 85% of non-binary people are consistently misgendered, including in healthcare. Both of these phenomena can have a further negative impact on non-binary people’s health and well-being.

Discrimination in general healthcare settings

Trans people routinely face high levels of discrimination in general healthcare settings, i.e. when going to see their GP, dentist, or any other doctor. The EU Fundamental Rights Agency found that one in every five trans people are discriminated in healthcare. TGEU’s report reveals that trans people are often met with a lack of knowledge among healthcare providers on trans issues, receive inappropriate questions, are routinely misgendered, are not taken seriously, verbally abused or even refused treatment. Perhaps not surprising that roughly half of trans people delayed going to the doctor because of their gender identity - non-binary people scored the second highest on this question. They were also less open about their gender identity before their doctors than other trans people - in Spain, they were the least likely to be out. In Sweden, they were most likely to feel that healthcare providers did not want to understand their gender identity. Non-binary people were also the least likely to know trans-friendly doctors, 80% of them did not know a doctor they could turn to without fear of being discriminated.

Discrimination in trans-specific healthcare services

Trans-specific healthcare services include going to doctors for hormone blockers, hormones, or various surgeries or seeing mental health service providers for tests or a diagnosis. The report finds that doctors routinely act as gatekeepers between trans people and the healthcare they want to access: doctors commonly believe that it should be up to them to decide if a trans person should access hormones or surgeries, not the person themselves. Non-binary people seek trans-specific medical or psychological care less often than other trans people, and not because they would not like to. Rather, they are afraid of facing prejudice or have no confidence in the services. In Serbia, hormones are simply not available to non-binary people. This often results in trans people “illegally” buying hormones and taking them unsupervised, which can have serious health risk implications. Respondents shared that they had to lie to their doctor and say they were actually binary. In some countries, trans people need to see their doctors for years to get access to hormones or surgeries, so this can be a particularly draining process. In all participating countries of the TGEU report, non-binary people reported that they had to prove they were trans enough or fit the binary. In Poland for instance, 95% of trans people reported they had to prove being “trans enough” and 92% that they were forced into the gender binary when accessing services. Of the participating countries, only Sweden has medical guidelines that explicitly provides access for non-binary people to trans-specific healthcare services and says that these should be tailored to everyone’s specific needs. However, these guidelines are not mandatory to follow.

Legal gender recognition

In many European countries trans people have to be forcibly sterilized, receive a psychiatric diagnosis, take hormones, undergo medical examination, and/or get divorced - against their will. MaltaIreland and Denmark now allow for legal gender recognition on the basis of self-determination and without any intrusive medical requirements. However, there are only a handful of countries in the world where people outside the gender binary can have their gender identity recognized. In Europe, Malta introduced the third gender marker option ‘X’ in IDs and passports a few weeks ago. In Germany, a non-binary person recently won a court case to have their gender marker deleted from their ID. None of the five countries that participated in the research provide an option for gender markers that are neither male or female. As a result, non-binary people cannot have documents that match their identity as there is no appropriate box to tick. In Spain, the requirements of legal gender recognition, including a diagnosis and two years of treatment, are also inaccessible for non-binary people. Understandably, the vast majority of non-binary people thought that legal gender recognition should not have any medical requirements (98%) and that there should be a multiplicity of gender marker options in IDs (93%).

Non-binary people should not be left behind

It is essential that states and healthcare providers take note of the barriers that non-binary people face when trying to access general and trans-specific healthcare or legal gender recognition. It is crucial that non-binary people are included in programs aimed to improve the physical and mental health of trans people. It is important that any protocols on trans-specific healthcare are based on the individual’s needs and accommodate non-binary people. It is indispensable that training for healthcare providers explicitly covers the needs of non-binary healthcare users. Lastly, while it is commendable that more and more European countries provide for legal gender recognition on the basis of self-determination, they must also consider that non-binary people may be left without a box to tick. A simple, yet effective way to remedy this would be to have a multiplicity of gender identity options as well as not requiring anyone to have their gender marker on their IDs.

Main references:
• European Union Agency for Fundamental Rights. (2013). EU LGBT survey: European Union lesbian, gay, bisexual and transgender survey
• European Union Agency for Fundamental Rights. (2014). Being trans in the European Union. Comparative analysis of EU LGBT survey data.
• Transgender Europe. Overdiagnosed - Underserved. Trans healthcare in Georgia, Poland, Serbia, Spain, and Sweden: TGEU’s Trans Health Survey. October 2017.