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The International Journal of Transgenderism logoLink to The International Journal of Transgenderism
. 2019 Feb 10;20(2-3):263–274. doi: 10.1080/15532739.2018.1538840

Gender congruence and body satisfaction in nonbinary transgender people: A case control study

Bethany A Jones a,b, Walter Pierre Bouman a, Emma Haycraft b, Jon Arcelus a,c,✉
PMCID: PMC6830978  PMID: 32999612

Abstract

Background: Binary transgender people access gender affirming medical interventions to alleviate gender incongruence and increase body satisfaction. Despite the increase in nonbinary transgender people, this population are less likely to access transgender health services compared to binary transgender people. No research has yet understood why by exploring levels of gender congruence and body satisfaction in nonbinary transgender people.

Objective: The aim of this study was to compare levels of gender congruence and body satisfaction in nonbinary transgender people to controls [binary transgender people and cisgender (nontrans) people].

Method: In total, 526 people from a community sample in the UK took part in the study (97 nonbinary, 91 binary, and 338 cisgender identifying people). Participants were asked to complete an online survey about gender congruence and body satisfaction.

Results: There were differences in gender congruence and body satisfaction between nonbinary and binary transgender people. On sex-specific parts of the body (i.e., chest, genitalia, and secondary sex characteristics), nonbinary transgender people reported significantly higher levels of gender and body satisfaction compared to binary transgender people. However, there was no difference in congruence and satisfaction with social gender role between the two transgender groups (nonbinary and binary). Cisgender people reported significantly higher levels of gender congruence and body satisfaction compared to transgender people (nonbinary and binary).

Conclusions: There are differences in gender congruence and body satisfaction between nonbinary and binary transgender people. Nonbinary individuals may be less likely to access transgender health services due to experiencing less gender incongruence and more body satisfaction compared to binary transgender people. Transgender health services need to be more inclusive of nonbinary transgender people and their support and treatment needs, which may differ from those who identify within the binary gender system.

Keywords: Nonbinary, gender congruence, body satisfaction, gender affirming medical treatments, transgender health services

Introduction

Transgender health research, which is a relatively new field, has demonstrated that many of the people accessing transgender health services experience very low levels of gender congruence (i.e., they do not feel that their body matches their gender identity) and body satisfaction (e.g., Bandini et al., 2013; Becker et al., 2016, 2018; de Vries et al., 2014; de Vries, Steensma, Doreleijers, & Cohen-Kettenis, 2011; Röder et al., 2018; van de Grift et al., 2016, 2017). Body satisfaction has been found to be much lower than what is found within the cisgender population (i.e., people who do not experience incongruence between their sex assigned at birth and gender identity) (Witcomb et al., 2015). However, gender congruence and body satisfaction of treatment-seeking transgender people have been found to increase following gender-affirming medical treatments (GAMT), such as cross-sex hormones and genital affirming surgery (e.g., Bandini et al., 2013; Becker et al., 2018; de Vries et al., 2011, 2014; Jones, Haycraft, Murjan, & Arcelus, 2016). Research has shown that GAMT also increases mental well-being (e.g., Bouman et al., 2016a, 2017; Davis & Colton Meier, 2014; Dhejne, Van Vlerken, Heylens, & Arcelus, 2016) and quality of life (e.g., Gorin-Lazard et al., 2012; 2013; Nobili, Glazebrook, & Arcelus, 2018) in binary (treatment-seeking) transgender people. In this article, when referring to binary transgender identity, we are describing a spectrum of transgender people, who seek cross-gender identification and a complete change in social gender role status (i.e., from one gender to the other; Richards & Barker, 2013).

As societies’ understanding of gender expression and diversity has evolved, people have had the freedom to express their gender and to be able to identify outside and other than the binary gender concept of exclusively male or female (Richards et al., 2016; Richards, Bouman, & Barker, 2018). We use “nonbinary” as an adjective and umbrella term for people who self-identify as such and include all other identities than male or female, such as gender neutral, gender fluid, agender, nongender, or gender queer, for example (Arcelus & Bouman, 2017; Bouman et al., 2017b; Richards et al., 2016, 2018). In the Western world, the number and visibility of people identifying as nonbinary and binary transgender has increased considerably over the past few years (Richards et al., 2016, 2018). Kuyper and Wijsen (2014) examined self-reported gender identity and dysphoria in a large Dutch population sample (N = 8064, aged 15–70 years old), and found that 4.6% of people assigned male at birth and 3.2% of people assigned female at birth reported an “ambivalent gender identity” (defined as equal identification with other sex as with sex assigned at birth) and 1.1% of people assigned male at birth and 0.8% of people assigned female at birth reported an “incongruent gender identity” (defined as stronger identification with other sex as with sex assigned at birth). Similarly, van Caenegem et al. (2015) reported results based on two population-based surveys, one of 1832 Flemish persons and one of 2472 sexual minority individuals in Flanders, Belgium examining the prevalence of “gender ambivalence” and “gender incongruence”. In the general population, gender ambivalence was present in 2.2% of male and 1.9% of female participants, whereas gender incongruence was found in 0.7% of men and 0.6% of women. In sexual minority individuals (lesbian, gay, bisexual), the prevalence of gender ambivalence and gender incongruence was 1.8 and 0.9% in men and 4.1 and 2.1% in women, respectively (Bouman, de Vries, & T’Sjoen, 2016b).

Historically, the medical establishment prevented nonbinary people from accessing GAMT, as they did not fit the stereotypical binary concept or the binary diagnostic criteria in the Diagnostic and Statistical Manual of Mental Disorders (DSM; American Psychiatric Association (APA)); or, the International Classification of Diseases (ICD; World Health Organization (WHO)). The diagnostic labels “Gender Identity Disorder (DSM-IV; APA, 1994)” and “Transsexualism” (ICD-10; WHO, 1992), and associated criteria have been heavily criticized for not being inclusive of people with a nonbinary gender identity. This is valid and significant as having a gender-related diagnosis is instrumental in accessing GAMT (Beek et al., 2016; Richards et al., 2015). However, more recently, the APA (DSM-5; APA, 2013) have updated their criteria to encapsulate nonbinary transgender people and the WHO are expected to replicate this with the release of ICD-11 which is anticipated in 2019 (Beek et al., 2016). It is hoped that improvements in diagnosis will allow for more nonbinary transgender people to access GAMT. However, there are also a lack of specific clinical guidelines and treatment protocols for nonbinary transgender people wanting to access clinical services, including GAMT, which further compounds the issue.

The amount of nonbinary transgender people accessing transgender health services and undergoing GAMT remains low (e.g., Beek, Kreukels, Cohen-Kettenis, & Steensma, 2015; Clark, Veale, Townsend, Frohard-Dourlent, & Saewyc, 2018; Doan, 2016; Government Equalities Office, 2018; Jones et al., 2017; Thorne et al., 2018). A recent survey from the UK found that only 7% of nonbinary transgender people accessed transgender health services in comparison to 50% of transgender men and 43% of transgender women (Government Equalities Office, 2018), which is in keeping with findings in other European countries (Motmans & Burgwal, 2018). Additionally, in Canada, fewer nonbinary transgender youth (13%) have been found to access cross-sex hormone treatment compared to binary transgender youth (52%) (Clark et al., 2018). This study also found that nonbinary transgender youth had more difficulties accessing cross-sex hormones compared to binary transgender youth (Clark et al., 2018). Similarly, Taylor, Zalewska, Gates, and Millon (2018) found that nonbinary transgender patients, who would like to undergo some GAMT were rejected by transgender health services due to their gender identity. The National LGBT survey in the UK found that 76% of nonbinary transgender people hide their gender identity from others due to fear of negative evaluation (Government Equalities Office, 2018). People with nonbinary gender identities have also reported feeling socially invisible as they do not meet gender norms in Western society (Motmans & Burgwal, 2018; Scottish Trans Alliance, 2015; Taylor et al., 2018). This maybe therefore suggest that a larger amount of nonbinary identifying transgender people than expected may be accessing clinical services, including GAMT and withholding their nonbinary gender identity. Alternatively, nonbinary transgender people may not be attending transgender health services as they experience manageable levels of gender congruence and body satisfaction and consequently do not wish to undergo GAMT.

To date there has been no empirical research that has investigated why fewer nonbinary transgender people may be accessing transgender health services by exploring levels of gender congruence and body satisfaction in this population. As most transgender health research has recruited those attending clinical services and accessing GAMT, the existing knowledge regarding the treatment wishes and needs of this population are largely unknown and appear to be largely extrapolated from the wishes and needs of binary (treatment-seeking) transgender people. Information regarding nonbinary transgender people accessing clinical services is limited to a few recent studies which have found that this population appears to present to such services with higher levels of mental health problems than binary transgender people (e.g., Rimes, Goodship, Ussher, Baker, & West, 2017; Thorne et al., 2018). Consequently, there is a lack of knowledge about interventions that nonbinary transgender people may wish to undergo to increase gender congruence and body satisfaction.

Previously, research with binary transgender people has focused mainly on gender congruence and body satisfaction with sex-specific characteristics (e.g., Jones et al., 2016; van de Grift et al., 2016, 2017, 2018). However, one study involving binary transgender people found that body features associated with social gender role recognition (e.g., hairstyle, clothes, mannerism) which cannot be altered through GAMT were the strongest predictors of overall body satisfaction (van de Grift et al., 2016). In addition to this, age has been found to have a positive relationship with body satisfaction in both cisgender men and women (e.g., Peat, Peyerl, Ferraro, & Butler, 2011; Tiggemann & McCourt, 2013). Consequently, sex-specific characteristics as well as social gender role recognition should be explored to obtain a broader understanding of gender congruence and body satisfaction in nonbinary transgender people, whilst controlling for age.

Objective

In light of this gap within the literature, the aim of the current study was to explore levels of gender congruence and body satisfaction among nonbinary transgender people and to compare these levels to controls (binary transgender people and cisgender people). Only transgender people who had not undergone GAMT were selected for this study as GAMT has been found to increase gender congruence and body satisfaction (e.g., Bandini et al., 2013; de Vries et al., 2011, 2014). Age was also controlled for as it has been shown to have a positive relationship with body satisfaction in both cisgender men and women (e.g., Peat et al., 2011; Tiggemann & McCourt, 2013). It was hypothesized that there would be a difference in gender congruence and body satisfaction between nonbinary and binary transgender people. It was also hypothesized that cisgender people would report higher levels of gender congruence and body satisfaction compared to transgender people (nonbinary and binary).

Method

Participants and recruitment

Transgender (nonbinary and binary) and cisgender participants aged 18 and over were invited to take part through snowball sampling. The invitation to participate was initially distributed to lesbian, gay, bisexual, transgender, transsexual, queer (LGBTQ) organizations within the UK, via email and social media sites. The content of this advertisement was same for transgender and cisgender people. All participants were asked to pass on the survey link to potentially interested parties.

Procedures

Participants were asked to read through the information sheet. Individuals who decided to take part were then asked to complete a survey online which took approximately 20 minutes to complete. The study was approved by Loughborough University Research Ethics Committee at Loughborough University, UK.

Measures

Socio-demographics

Participants were asked to provide information about their age, sex assigned at birth and gender identity. For this study, people who selected their gender identity as transgender male or transgender female were classified as binary transgender people. Participants who selected androgynous, gender neutral, nonbinary, pangender, bigender, gender queer, gender fluid, or other were classified as nonbinary transgender people. As an example, people who selected “other” self-identified as “intergender”, “agenderflux”, “gender creative” and “agender”. Participants were also asked to provide information about cross-sex hormone use and gender-affirming surgeries.

Gender congruence and body satisfaction

To assess gender congruence and body satisfaction in transgender people, the Transgender Congruence Scale (Kozee, Tylka, & Bauerband, 2012) and Hamburg Body Drawing Scale (Becker et al., 2016) have been employed (e.g., Jones et al., 2016; Jones et al., 2018a). In addition to this, a newly developed tool (Gender Congruence and Life Satisfaction Scale; Jones, Bouman, Haycraft, & Arcelus, 2018a) was employed. This measure was developed including nonbinary and binary transgender people and provides an understanding of gender congruence and body satisfaction simultaneously by exploring specific body features (Jones et al., 2018). The three measures employed in the study are discussed in more detail below.

Transgender congruence scale (TCS)

This measure has 12 questions which assess gender congruence. Nine items correspond with the “appearance congruence” subscale (e.g., “My outward appearance represents my gender identity”; “I am generally comfortable with how others perceive my gender identity when they look at me”) which was used in the current study. The measure also has three items relating to “gender identity acceptance” (e.g., “I am not proud of my gender identity”) which were not used in the current study (Kozee et al., 2012). Responses are rated on a 5-point scale from 1 = strongly disagree to 5 = strongly agree. A higher score indicates a higher level of “appearance congruence”. This measure has been found to have good reliability (α = 0.93; Kozee et al., 2012) and the appearance congruence subscale had excellent reliability in the current sample (α = 0.96).

Hamburg Body Drawing Scale (HBDS; originally developed by Appelt & Strauss, 1988; revised version by Becker et al., 2016).

This scale assesses body satisfaction and has been validated with the binary transgender population (Becker et al., 2016). There is an item that assesses overall satisfaction with appearance, which was the only item used in the current study. The subscales were not used as they are different for people assigned male and female at birth and therefore subscales are not comparable. Participants are asked to rate their responses on a 5-point Likert scale (1 = very dissatisfied; 5 = very satisfied) and therefore a higher score indicates a higher level of body satisfaction. Becker et al. (2016) found the HBDS subscales to have good reliability in a transgender population (α = 0.62–0.91). As it is not possible to conduct reliability analysis with just one item, this was not calculated in the current study.

Gender congruence and life satisfaction scale (GCLS)

The GCLS aims to measure improvements in gender congruence, body satisfaction, related psychological well-being, and life satisfaction during a gender transition (Jones et al., 2018a). In addition to the TCS and HBDS, this tool was chosen as it was specifically developed to be inclusive of nonbinary and binary transgender people (Jones et al., 2018). The items in the GCLS are gender neutral and the same subscales can be administered to everyone regardless of sex assigned at birth or gender identity. Participants are asked to rate their responses on a 5-point Likert scale (always = 1; never = 5). A higher score is associated with a positive outcome (i.e., greater gender congruence, greater body satisfaction, greater gender-related well-being, and greater life satisfaction). Mean scores are also calculated for each of the seven subscales, four of which (relating to body congruence) were used in the current study: genitalia, chest, other secondary sex characteristics, and, social gender role recognition. Within the current sample, the Cronbach’s alphas for the subscales used within the current study was very good (α = 0.77–0.95).

Analysis

The data were analyzed using SPSS 23 (IBM, 2016). The data were not normally distributed and as there were no nonparametric alternatives, robust parametric tests were selected (Field, 2009). For descriptive purposes, a Chi-Square Test was conducted to explore differences in sex assigned at birth between nonbinary, binary, and cisgender people. An ANOVA was conducted to explore differences in age between nonbinary, binary, and cisgender participants. Post-hoc (Sidak) tests were conducted to explore where difference lied in relation to age. To explore differences in gender congruence and body satisfaction between nonbinary transgender people and controls (binary transgender people and cisgender people), a series of one-way ANCOVAs were conducted, controlling for age. The sample was divided by sex assigned at birth (i.e., male or female) and these groups were analyzed in relation to gender identity (i.e., nonbinary transgender, binary transgender, or cisgender). This analysis was then followed up with post-hoc tests (Sidak) to determine where any significant difference lay. The significance level was set at p < .05.

Results

Descriptive analysis

In total, 833 people were recruited into the study. Seven people were removed as they provided no information about their gender (sex assigned at birth or gender identity) and a further 37 people were removed as they identified as cisgender, but reported that their sex assigned at birth was different to their gender identity. For the purpose of this study, only people who were yet to undergo GAMT were included in the analysis. Therefore, a further 263 people were removed. The final sample consisted of 526 people. Of this sample, 97 were nonbinary transgender people, 91 were binary transgender people, and 338 were cisgender people. The distribution of sex assigned at birth is displayed in Table 1.

Table 1.

Age and assigned sex for nonbinary transgender people, binary transgender people and cisgender people.

  Cisgender (n = 338) Nonbinary (n = 97) Transgender (n = 91)
Mean (SD) age in years 36.32 (12.03) 32.72 (12.17) 35.44 (16.48)
Sex assigned at birth (n (%))      
 Female 254 (75.1) 66 (67.3) 46 (50.5)
 Male 84 (24.9) 31 (31.6) 45 (49.5)
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There was a significant effect for sex assigned at birth between nonbinary and binary transgender people (χ2 = 5.97; p < .015; Cramer’s V = 0.18; p < .015). The standardized residuals demonstrated that there were significantly more people assigned male at birth in the binary transgender group (z = 1.4) compared to the nonbinary transgender group (z = −1.3). In addition, there were significantly more people assigned female at birth in the nonbinary transgender group (z = 1.1) compared to the binary transgender group (z = −1.1).

The mean age of the whole sample was 35.70 years (SD = 13.16). For the mean age of each group, see Table 1. There was a significant group effect for age (F(2, 519) = 3.14, p = .044). Post-hoc tests revealed that cisgender people were significantly older than nonbinary identifying transgender people (Mean difference = 3.80; p = .037). There was no significant difference in age between cisgender people and binary identifying transgender people (Mean difference = 0.69; p = .960).

Body congruence in individuals assigned male at birth: comparing cisgender, nonbinary, and binary transgender people

A total of 31 nonbinary people (assigned male at birth) were compared on measures of body congruence to 45 transgender females and 84 cisgender males. There was a significant difference between these three groups on the appearance congruence subscale from the TCS after age was controlled for (Table 2). Post-hoc tests revealed that on the TCS appearance congruence subscale, cisgender males scored significantly higher (more congruence) compared to both nonbinary (Mean difference = 2.24; p < .001) and binary transgender people (transgender females) (Mean difference = 2.51; p < .001). There was no significant difference between nonbinary and binary transgender people assigned male at birth (Mean difference = 0.27; p = .166). This indicates that cisgender males experience more gender congruence with their appearance compared to transgender people assigned male at birth (nonbinary and binary) and that there is no difference in the levels of appearance congruence between nonbinary and binary people assigned male at birth.

Table 2.

Mean (SD) and ANCOVA test scores for nonbinary and binary transgender people assigned male at birth and cisgender males on measures of body congruence.

  Cisgender males (n = 84) Nonbinary transgender people (n = 31) Transgender females (n = 45) F
TCS: Appearance congruence 4.46 (0.56) 2.19 (0.65) 1.90 (0.63) 299.41***
HBDS: Body satisfaction 3.58 (0.95) 2.65 (1.05) 1.81 (0.79) 49.56***
GCLS: Genitalia 4.49 (0.32) 3.90 (0.64) 2.71 (0.88) 120.24***
GCLS: Chest 4.54 (0.57) 3.82 (0.69) 2.29 (0.78) 151.89***
GCLS: Secondary sex characteristics 4.83 (0.48) 2.78 (1.01) 1.66 (0.62) 348.73***
GCLS: Social gender role recognition 3.94 (1.08) 3.10 (0.82) 2.77 (0.78) 22.06***
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GCLS: Gender Congruence and Life Satisfaction Scale; HBDS: Hamburg Body Drawing Scale; TCS: Transgender Congruence Scale.

***p < .001.

There was also a significant main effect for body satisfaction, as measured by the HBDS, after controlling for age (Table 2). As expected, cisgender people scored higher (most body satisfaction) compared to nonbinary transgender people (Mean difference = −0.95; p < .001) and binary transgender people (Mean difference = 1.79; p < .001; see Table 2). Body satisfaction scores on the HBDS were also significantly higher for nonbinary transgender people when compared to binary transgender people (Mean difference = 0.84; p < .001). This indicates that while body satisfaction is highest in cisgender people, nonbinary transgender people have higher levels of body satisfaction (on the HBDS) than binary transgender people assigned male at birth (transgender females), after controlling for age.

To obtain a more in-depth understanding regarding gender congruence and body satisfaction in these three groups, differences were explored using the GCLS. For people that were assigned male at birth, there was a significant difference between nonbinary transgender people, binary transgender people (transgender females) and cisgender males on the chest, genitalia, secondary sex characteristics, and social gender role recognition subscales of the GCLS (Table 2). Post-hoc tests showed that cisgender people scored significantly higher on the chest (Mean difference = 0.73; p < .001), genitalia (Mean difference = 0.60; p < .001) and secondary sex characteristics (Mean difference = 2.05; p < .001) subscales of the GCLS compared to nonbinary transgender people. Cisgender people also scored higher compared to binary transgender people on the chest (Mean difference = 2.26; p < .001), genitalia (Mean difference = 1.81; p < .002), and secondary sex characteristics (Mean difference = 3.22; p < .001) subscales of the GCLS. Nonbinary transgender people scored significantly higher on the chest (Mean difference = 1.54; p < .001), genitalia (Mean difference = 1.21; p < .001), and secondary sex characteristics (Mean difference = 1.15; p < .001) subscales of the GCLS compared to binary transgender people (transgender females). These findings indicate that for those assigned male at birth, nonbinary transgender people have higher levels of gender congruence and body satisfaction regarding their chest, genitals, and secondary sex characteristics compared to binary transgender people (transgender females), but lower than cisgender males after controlling for age.

On the social gender role recognition subscale of the GCLS, cisgender males scored significantly higher compared to both nonbinary (Mean difference = 0.84; p < .001) and binary transgender people (transgender females) (Mean difference = 1.18; p < .001). There was no significant difference in congruence between nonbinary and binary transgender people on the social gender role recognition subscale (Mean difference = 0.34; p = .343). This indicates that transgender people (both binary and nonbinary) assigned male at birth experience less congruence and satisfaction with their social gender role compared to cisgender people but there is no difference in social gender role congruence between both groups of transgender people after controlling for age.

Body congruence in individuals assigned female at birth: comparing cisgender, nonbinary, and binary transgender people

In total, 66 nonbinary transgender people were compared to 46 binary transgender people (transgender males) and 254 cisgender females. It was found that there was a significant main effect between these groups on the appearance congruence subscale from the TCS (Table 3). Post-hoc tests showed that cisgender people scored significantly higher on the TCS appearance congruence subscale compared to nonbinary (Mean difference = 2.24; p < .001) and binary transgender people (transgender males) (Mean difference = 2.43; p < .001). There was no significant difference between the nonbinary and binary transgender people on this subscale (Mean difference = 0.19; p = .356). These findings demonstrate that cisgender females experience more gender congruence with their appearance compared to both nonbinary and binary transgender people (transgender males) assigned female at birth after controlling for age.

There was also a significant main effect of body satisfaction, as measured by the HBDS, between the three groups (Table 3). As expected, cisgender people scored significantly higher compared to nonbinary transgender people (Mean difference = 0.945 p < .001; see Table 3) and binary transgender people (Mean difference = 1.67; p < .001). It was also found that nonbinary transgender people scored significantly higher (more body satisfaction) compared to binary transgender people (transgender males; Mean difference = 0.71; p < .001). Findings from the HBDS therefore suggest that, after controlling for age, cisgender people are the most satisfied with their body, followed by nonbinary transgender people. Binary transgender people (transgender males) are the least satisfied with their bodies.

Table 3.

Mean (SD) and ANCOVA test scores for nonbinary and binary transgender people assigned female at birth and cisgender females on measures of body congruence.

  Cisgender females (n = 254) Nonbinary transgender people (n = 66) Transgender males (n = 46) F
TCS: Appearance congruence 4.51 (0.60) 2.30 (0.84) 2.12 (0.78) 409.35***
HBDS: Body satisfaction 3.68 (0.93) 2.73 (1.31) 2.02 (0.93) 58.57***
GCLS: Genitalia 4.54 (0.34) 3.80 (0.86) 2.52 (0.93) 256.83***
GCLS: Chest 4.62 (0.47) 2.91 (1.16) 1.54 (0.66) 434.39***
GCLS: Secondary sex characteristics 4.78 (0.47) 3.53 (1.19) 1.91 (0.91) 304.37***
GCLS: Social gender role recognition 4.06 (1.07) 2.62 (0.84) 2.63 (0.76) 77.57***
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GCLS: Gender Congruence and Life Satisfaction Scale; HBDS: Hamburg Body Drawing Scale; TCS: Transgender Congruence Scale.

*p < .05, **p < .01, ***p < .001.

Gender congruence and body satisfaction between these groups was explored in more detail using the GCLS. There was a significant main effect for the chest, genitalia, secondary sex characteristics, and social gender role recognition subscales of the GCLS (Table 3). Post-hoc tests showed that cisgender females scored higher on the chest (Mean difference = 1.67; p < .001), genitalia (Mean difference = 0.73; p < .001) and secondary sex characteristics (Mean difference = 1.21; p < .001) subscales compared to nonbinary transgender people. Cisgender people also scored higher than binary transgender people on the chest (Mean difference = −3.03; p < .001), genitalia (Mean difference = 2.02; p < .001), and secondary sex characteristics (Mean difference = 2.81; p < .001) subscales of the GCLS. Nonbinary transgender people scored significantly higher (more congruence) on the chest (Mean difference = 1.36; p < .001), genitalia (Mean difference = 1.28; p < .001), and secondary sex characteristics (Mean difference = 1.60; p < .001) subscales of the GCLS compared to binary transgender people (transgender males). These findings demonstrate that when age is controlled for, nonbinary transgender people experience more gender congruence and body satisfaction with their sex characteristics compared to binary transgender people (transgender males). However, cisgender females experience more gender congruence and body satisfaction with sex characteristics when compared to transgender people (nonbinary and binary).

On the social gender role recognition subscale of the GCLS, cisgender females scored significantly higher (more congruence) compared to both nonbinary transgender people (Mean difference = 1.49; p < .001) and transgender males (Mean difference = 1.50; p < .001). There was no significant difference in congruence between nonbinary and binary transgender people on the social gender role recognition subscale (Mean difference = 0.02; p = .994). Cisgender people, as expected, therefore report experiencing more gender congruence and body satisfaction with their social gender role compared to transgender people assigned female at birth (nonbinary and binary).

Discussion

This study explored levels of gender congruence and body satisfaction among nonbinary transgender people and compared these levels to two control groups, which included binary transgender people yet to undergo GAMT, and cisgender people. As hypothesized, there were differences in gender congruence and body satisfaction between nonbinary and binary transgender people. On sex-specific parts of the body (i.e., chest, genitalia, and secondary sex characteristics), nonbinary transgender people reported significantly higher levels of gender congruence and body satisfaction compared to binary transgender people. There was no difference in congruence and satisfaction with social gender role between the two transgender identifying groups (nonbinary and binary). As expected, cisgender people reported significantly higher levels of gender congruence and body satisfaction compared to transgender people (nonbinary and binary). The findings from this study may indicate that nonbinary individuals may be less likely to access transgender health services due to experiencing less gender incongruence and more body satisfaction compared to binary transgender people (e.g., Beek et al., 2015; Clark et al., 2018; Government Equalities Office, 2018; Thorne et al., 2018). However, gender congruence and body satisfaction with the chest, genitalia, and secondary sex characteristics is still much lower among nonbinary transgender people compared to cisgender people. Consequently, some nonbinary transgender people may wish to undergo GAMT. Clinicians working at transgender health services should be mindful of this and create an inclusive and supportive environment to enable transgender people to disclose their gender identity without this having any bearing on their desired gender affirming treatment, whether medical or other (Nicole Rider et al., 2018). Recent research in a UK transgender health service showed that clinicians need to adopt an affirmative approach to encourage nonbinary transgender patients to articulate their gender identity and treatment requests (Taylor et al., 2018). Transgender health services should also review their treatment pathway and protocols to be inclusive of nonbinary transgender people, and refrain from insisting on specific, fixed trajectories (i.e., hormone treatment before chest reconstructive surgery), as there is little empirical evidence to underpin the benefit of these. Further research that explores the long-term effects of various different treatment trajectories (e.g., gender affirming hormone treatment and/or surgery before or without social gender role transition; chest reconstructive surgery before or without testosterone treatment) among nonbinary transgender people would also facilitate the development of evidenced-based treatment protocols for this population.

In this study, both transgender groups (nonbinary and binary) reported less gender congruence and body satisfaction with their social gender role compared to cisgender people. There was no significant difference in congruence and satisfaction with social gender role between nonbinary and binary transgender people. Nonbinary transgender people have reported feeling socially invisible in social settings in particular, and society in general, which tend to adhere to and advocate a binary gender system, including a binaried language system (see for instance, Bradford et al., 2018; Nicholas, 2018). This tends to leave nonbinary transgender people not feeling accepted or validated by society (Saltzburg & Davis, 2010). Without a societal structure and a language reflecting the existence and experiences of nonbinary identifying people underpinned by legislation and supported by one’s country or State nonbinary people remain ignored and invisible. Invisibility and victimization in nonbinary transgender youth has been found to have an association with poor mental well-being (Rimes et al., 2017; Thorne et al., 2018). This is likely to further contribute to low levels of congruence and satisfaction with social gender role – i.e., if nonbinary people feel that their social gender role is not recognized and widely accepted by those around them. In contrast, binary transgender people have been found to be most dissatisfied with unwanted body features that are difficult to hide in everyday social situations such as the jaw, facial hair, hands, and hips (van de Grift et al., 2016). This may increase anxiety and distress relating to “passing” as their gender identity (i.e., male or female) (McGuire, Doty, Catalpa, & Ola, 2016). Therefore, it appears that nonbinary and binary transgender people experience (in)congruence and (dis)satisfaction with their social gender role in different ways. This may explain why no significant difference in gender congruence and body satisfaction with social gender role was found between the transgender groups in this study. Societal awareness of transgender people, especially nonbinary transgender people, should continue to be increased. This can be achieved through mass media awareness campaigns on television, by providing educational resources to schools, universities and workplaces, for example (e.g., Nicholas, 2018).

The findings of this study are strengthened by the fact that participants were recruited from the community as opposed to from a transgender health service. The number of nonbinary and binary transgender people recruited within this study were similar in size, which is another strength of this study. In contrast, research conducted in transgender health services has typically recruited much smaller samples of nonbinary transgender people (Taylor et al., 2018; Thorne et al., 2018). Participants in the current study may have felt empowered to be open and honest about their gender identity rather than feeling a need to withhold their nonbinary identity to satisfy clinical expectations and medical gatekeeping in order to obtain GAMT. Much of the current literature in transgender healthcare is often criticized for social desirability bias. When recruiting from clinical transgender health services, participants may over-report their distress and dissatisfaction and follow a specific binary transgender narrative to access GAMT in a timely manner. However, the current community study supports previous clinical literature that has found transgender people to report less body satisfaction compared to cisgender people (e.g., Witcomb et al., 2015).

It is noteworthy that “nonbinary” is a very broad term which captures a wide variety of different gender identities that fall between and outside the gender binary (Richards et al., 2016, 2017, 2018). This study therefore failed to capture nuances between people with different gender identities who fall under the umbrella term of “nonbinary”. Future research, therefore, may wish to refine this group further to explore differences in specific gender identities (e.g., gender fluid, gender queer, gender neutral). The findings of the study can also be only generalized to English-speaking transgender people within the UK. Countries differ in their tolerance of transgender people which will affect how comfortable people feel identifying as transgender (both binary and nonbinary) (e.g., Ahmadzad-Asl et al., 2010; Dhejne, Öberg, Arver, & Landén, 2014). Future research could consider exploring cross-cultural differences in nonbinary transgender individuals. The current study was also cross-sectional and future research would benefit from a longitudinal research design so that potential changes in gender congruence and body satisfaction in nonbinary and binary transgender people can be followed overtime.

Conclusions

Transgender health research has typically neglected the inclusion of nonbinary transgender people. This is an important omission as the current study has shown that there are nuances in gender congruence and body satisfaction between nonbinary and binary transgender people. Consequently, the GAMT that nonbinary transgender people wish to access in order to increase their gender congruence and body satisfaction may be different from that desired by binary transgender people. The implications of this research are that transgender health services need to be more inclusive of nonbinary transgender people and their treatment needs and adjust their treatment guidelines accordingly. This recommendation is similarly supported in the Standards of Care for transgender and gender non-conforming people (Coleman et al., 2012). Future research should explore gender congruence and body satisfaction longitudinally in nonbinary transgender people.

Funding Statement

Bethany Jones was supported by a PhD studentship co-funded by Leicestershire Partnership NHS Trust and Loughborough University. These funding sources were not involved in any way in this research project.

Acknowledgments

The authors thank all participants in the study for having given their time so generously.

Disclosure statement

No potential conflict of interest was reported by the authors.

References

  1. Ahmadzad-Asl M., Jalali A. H., Alavi K., Naserbakht M., Taban M., Mohseninia-Omrani K., & Eftekhar M (2010). The epidemiology of transsexualism in Iran. Journal of Gay & Lesbian Mental Health, 15(1), 83–93. [Google Scholar]
  2. American Psychiatric Association (APA). (1994). Diagnostic and statistical manual of mental disorders: DSM-IV (4th ed) Washington, DC: American Psychiatric Association. [Google Scholar]
  3. American Psychological Association (APA). (2013). Diagnostic and statistical manual of mental disorders: DSM-5 (5th ed). Washington, DC: American Psychiatric Association. [Google Scholar]
  4. Appelt H., & Strauss B (1988). Psychoendokrinologische Gynäkologie. Stuttgart: Enke. [Google Scholar]
  5. Arcelus J., & Bouman W. P (2017). Language and terminology In: Bouman W. P. & Arcelus J. (Eds.). The transgender handbook – A guide for transgender people, their families and professionals (pp. 1–12). New York, NY: Nova Publishers. [Google Scholar]
  6. Bandini E., Fisher A. D., Castellini G., Lo Sauro C., Lelli L., Meriggiola M. C., … Ricca V (2013). Gender identity disorder and eating disorders: Similarities and differences in terms of body uneasiness. Journal of Sexual Medicine, 10(4), 1012–1023. [DOI] [PubMed] [Google Scholar]
  7. Becker I., Auer M., Barkmann C., Fuss J., Möller B., Nieder T. O., Richter-Appelt …., H (2018). A cross-sectional multicenter study of multidimensional body image in adolescents and adults with gender dysphoria before and after transition-related medical interventions. Archives of Sexual Behavior. Advance online publication. doi: 10.1007/s10508-018-1278-4. [DOI] [PubMed] [Google Scholar]
  8. Becker I., Nieder T. O., Cerwenka S., Briken P., Kreukels B. P. C., Cohen-Kettenis P. T., … Richter-Appelt H (2016). Body image in young gender dysphoric adults: A European multi-center study. Archives of Sexual Behavior, 45(3), 559–574. [DOI] [PubMed] [Google Scholar]
  9. Beek T. F., Cohen-Kettenis P. T., Bouman W. P., de Vries A. L. C., Steensma T. D., Witcomb G. L., … Kreukels B. P. C (2016). Gender incongruence of adolescence and adulthood: Acceptability and clinical utility of the World Health Organization’s proposed ICD-11 criteria. PLoS One, 11(10), e0160066. [DOI] [PMC free article] [PubMed] [Google Scholar]
  10. Beek T. F., Kreukels B. P. C., Cohen-Kettenis P. T., & Steensma T. D (2015). Partial gender request and underlying motives of applicants for gender affirming interventions. Journal of Sexual Medicine, 12(11), 2201–2205. [DOI] [PubMed] [Google Scholar]
  11. Bouman W. P., Claes L., Brewin N., Crawford J. R., Millet N., Fernandez-Aranda F., & Arcelus J (2017a). Transgender and anxiety: A comparative study between transgender people and the general population. International Journal of Transgenderism, 18(1), 16–26. [Google Scholar]
  12. Bouman W. P., Claes L., Marshall E., Pinner G. T., Longworth J., Maddox V., … Arcelus J (2016a). Socio-demographic variables, clinical features and the role of pre-assessment cross-sex hormones in older trans people. Journal of Sexual Medicine, 13(4), 711–719. [DOI] [PubMed] [Google Scholar]
  13. Bouman W. P., de Vries A. L. C., & T’Sjoen G (2016b). Gender dysphoria and gender incongruence: An evolving inter-disciplinary field. International Review of Psychiatry, 28(1), 1–4. [DOI] [PubMed] [Google Scholar]
  14. Bouman W. P., Suess Schwend A., Motmans J., Smiley A., Safer J. D., Deutch M. B., … Winter S (2017b). Language and transgender health. International Journal of Transgenderism, 18(1), 1–6. [Google Scholar]
  15. Bradford N. J., Nicole Rider G., Catalpa J. M., Morrow Q. J., Berg D. R., Spencer K. G., & McGuire J. K (2018). Creating gender: A thematic analysis of genderqueer narratives. International Journal of Transgenderism. Advance Online Publication, 1. doi: 10.1080/15532739.2018.1474516. [DOI] [PMC free article] [PubMed] [Google Scholar]
  16. Clark B. A., Veale J. F., Townsend M., Frohard-Dourlent H., & Saewyc E (2018). Non-binary youth: Access to gender-affirming primary health care. International Journal of Transgenderism, 19(2), 158–169. [Google Scholar]
  17. Coleman E., Bockting W., Botzer M., Cohen-Kettenis P., DeCuypere G., Feldman J., … Zucker K (2012). Standards of care for the health of transsexual, transgender, and gender-nonconforming people, version 7. International Journal of Transgenderism, 13(4), 165–232. doi: 10.1080/15532739.2011.700873. [DOI] [Google Scholar]
  18. Davis S. A., & Colton Meier S (2014). Effects of testosterone treatment and chest reconstruction surgery on mental health and sexuality in female-to-male transgender people. International Journal of Sexual Health, 26(2), 113–128. [Google Scholar]
  19. de Vries A. L. C., McGuire J. K., Steensma T. D., Eva C. F., Doreleijers T. A. H., & Cohen-Kettenis P. T (2014). Young adult psychological outcome after puberty suppression and gender reassignment. Paediatrics, 134(4), 1–9. [DOI] [PubMed] [Google Scholar]
  20. de Vries A. L. C., Steensma T. D., Doreleijers T. A. H., & Cohen-Kettenis P. T (2011). Puberty suppression in adolescents with gender identity disorder: A prospective follow-up study. Journal of Sexual Medicine, 8(8), 2276–2283. [DOI] [PubMed] [Google Scholar]
  21. Dhejne C., Öberg K., Arver S., & Landén M (2014). An analysis of all applications for sex reassignment surgery in Sweden, 1960–2010: Prevalence, incidence, and regrets. Archives of Sexual Behavior, 43(8), 1535–1545. [DOI] [PubMed] [Google Scholar]
  22. Dhejne C., Van Vlerken R., Heylens G., & Arcelus J (2016). Mental health and gender dysphoria: A review of the literature. International Review of Psychiatry, 28(1), 44–57. [DOI] [PubMed] [Google Scholar]
  23. Doan P. L. (2016). To count or not to count: Queering measurement and the transgender community. WSQ: Women's Studies Quarterly, 44(3–4), 89–110. 10.1353/wsq.2016.0037 [DOI] [Google Scholar]
  24. Field A. (2009). Discovering statistics using IBM SPSS statistics (3rd ed.) Thousand Oaks, CA: Sage. [Google Scholar]
  25. Gorin‐Lazard A., Baumstarck K., Boyer L., Maquigneau A., Gebleux S., Penochet J.‐C., … Bonierbale M (2012). Is hormonal therapy associated with better quality of life in transsexuals? A cross sectional study. Journal of Sexual Medicine, 9(2), 531–541. [DOI] [PubMed] [Google Scholar]
  26. Gorin-Lazard A., Baumstarck K., Boyer L., Maquigneau A., Penochet J.-C., Pringuey D., … Auquier P (2013). Hormonal therapy is associated with better self-esteem, mood, and quality of life in transsexuals. Journal of Nervous and Mental Disease, 201(11), 996–1000. [DOI] [PubMed] [Google Scholar]
  27. Government Equalities Office. (2018). National LGBT Survey: Research report. Retrieved from: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/722314/GEO-LGBT-Survey-Report.pdf
  28. IBM. (2016). IBM SPSS statistics for Windows. Version 23.0. Armonk, NY: IBM Corporation. [Google Scholar]
  29. Jones B. A., Bouman W. P., Haycraft E., & Arcelus J (2018a). Development and validation of a new scale to measure outcomes from transgender health services: The Gender Congruence and Life Satisfaction Scale (GCLS). International Journal of Transgenderism. Advance Online Publication, 1. doi: 10.1080/15532739.2018.1453425. [DOI] [PMC free article] [PubMed] [Google Scholar]
  30. Jones B. A., Brewin N., Richards C., Van Eijk M., Stephenson-Allen A., & Arcelus J (2017). Investigating the outcome of the initial assessment at a national transgender health service: Time to review the process? International Journal of Transgenderism, 18(4), 427–432. [Google Scholar]
  31. Jones B. A., Haycraft E., Brewin N., Bouman W. P., & Arcelus J (2018b). The levels and predictors of physical activity engagement within the treatment seeking transgender population: A matched control study. Journal of Physical Activity & Health, 15(2), 99–107. [DOI] [PubMed] [Google Scholar]
  32. Jones B. A., Haycraft E., Murjan S., & Arcelus J (2016). Body dissatisfaction and disordered eating in trans people: A systematic review of the literature. International Review of Psychiatry, 28(1), 81–94. [DOI] [PubMed] [Google Scholar]
  33. Kozee H. B., Tylka T. L., & Bauerband L. A (2012). Measuring transgender individuals’ comfort with gender identity and appearance: Development and Validation of the Transgender Congruence Scale. Psychology of Women Quarterly, 36(2), 179–196. [Google Scholar]
  34. Kuyper L., & Wijsen C (2014). Gender identities and gender dysphoria in the Netherlands. Archives of Sexual Behavior, 43(2), 377–385. [DOI] [PubMed] [Google Scholar]
  35. McGuire J. K., Doty J. L., Catalpa J. M., & Ola C (2016). Body image in transgender young people: Findings from a qualitative, community based study. Body Image, 18, 96–107. [DOI] [PubMed] [Google Scholar]
  36. Motmans J., & Burgwal A (2018). Health disparities between binary and non-binary trans respondents: The role of gender identity and socio-economic background characteristics. International Journal of Transgenderism, Advance online publication, in press. [Google Scholar]
  37. Nicholas L. (2018). Queer ethics and fostering positive mindsets toward non-binary gender, genderqueer, and gender ambiguity. International Journal of Transgenderism. Advance Online Publication, doi: 10.1080/15532739.2018.1505576. [DOI] [PMC free article] [PubMed] [Google Scholar]
  38. Nicole Rider G. N., Vencill J. A., Berg D., Becker-Warner R., Candelario-Pérez L., & Spencer K. G (2018). The gender affirmative lifespan approach (GALA): A model for competent clinical care with nonbinary clients. International Journal of Transgenderism. Advance Online Publication, doi: 10.1080/15532739.2018.1485069. [DOI] [PMC free article] [PubMed] [Google Scholar]
  39. Nobili A., Glazebrook C., & Arcelus J (2018). Quality of life of transgender adults: A systematic review and meta-analysis. Reviews in Endocrine and Metabolic Disorders. Advance online publication. [DOI] [PMC free article] [PubMed] [Google Scholar]
  40. Peat C. M., Peyerl N. L., Ferraro F. R., & Butler M (2011). Age and body image in Caucasian men. Psychology of Men & Masculinity, 12(2), 195–200. [Google Scholar]
  41. Richards C., & Barker M.-J (2013). Sexuality and gender for mental health professionals: A practical guide. London: Sage. [Google Scholar]
  42. Richards C., Bouman W. P., & Barker M. J (2018). Genderqueer and non-binary genders. London: Palgrave MacMillan. [Google Scholar]
  43. Richards C., Bouman W. P., Seal L., Barker M. J., Nieder T. O., & T’Sjoen G (2016). Non-binary or genderqueer genders. International Review of Psychiatry, 28(1), 95–102. [DOI] [PubMed] [Google Scholar]
  44. Rimes K. A., Goodship N., Ussher G., Baker D., & West E (2017). Non-binary and binary transgender youth: Comparison of mental health, self-harm, suicidality, substance use and victimization experiences. International Journal of Transgenderism. Advance Online Publication. doi: 10.1080/15532739.2017.1370627. [DOI] [PMC free article] [PubMed] [Google Scholar]
  45. Röder M., Barkmann C., Richter-Appelt H., Schulte-Markwort M., Ravens-Sieberer U., & Becker I (2018). Health-related quality of life in transgender adolescents: Associations with body image and emotional and behavioral problems. International Journal of Transgenderism, 19(1), 78–91. doi: 10.1080/15532739.2018.1425649 [DOI] [Google Scholar]
  46. Saltzburg S., & Davis T (2010). Co-authoring genderqueer youth identities: Discursive tellings and retellings. Journal of Ethnic and Cultural Diversity in Social Work, 19(2), 87–108. [Google Scholar]
  47. Scottish Trans Alliance (2015). Non-binary people’s experiences in the UK. Edinburgh, UK: Author. [Google Scholar]
  48. Taylor, J., Zalewska, A., Gates, J. J., & Millon, G. (2018). An exploration of the lived experiences of non-binary individuals who have presented at a gender identity clinic in the United Kingdom. International Journal of Transgenderism. doi: 10.1080/15532739.2018.1445056. [DOI] [PMC free article] [PubMed] [Google Scholar]
  49. Thorne N., Witcomb G. L., Nieder T., Nixon E., Yip A., & Arcelus J (2018). A comparison of mental health symptomatology and levels of social support in young treatment seeking transgender individuals who identify as binary and non-binary. International Journal of Transgenderism. Advance Online Publication, doi: 10.1080/15532739.2018.1452660. [DOI] [PMC free article] [PubMed] [Google Scholar]
  50. Tiggemann M., & McCourt A (2013). Body appreciation in adult women: Relationships with age and body satisfaction. Body Image, 10(4), 624–627. [DOI] [PubMed] [Google Scholar]
  51. van Caenegem E., Wierckx K., Elaut E., Buysse A., Dewaele A., Van Nieuwerburgh F., … T’Sjoen G (2015). Prevalence of gender nonconformity in Flanders, Belgium. Archives of Sexual Behavior, 44(5), 1281–1287. [DOI] [PubMed] [Google Scholar]
  52. van de Grift T. C., Cohen-Kettenis P. T., Elaut E., De Cuypere G., Richter-Appelt H., Haraldsen I. R., & Kreukels B. P. C (2016). A network analysis of body satisfaction of people with gender dysphoria. Body Image, 17, 184–190. [DOI] [PubMed] [Google Scholar]
  53. van de Grift T. C., Elaut E., Cerwenka S. C., Cohen-Kettenis P. T., De Cuypere G., Richter-Appelt H., & Kreukels B (2017). Effects of medical interventions on gender dysphoria and body image: A follow-up study. Psychosomatic Medicine, 79(7), 815. [DOI] [PMC free article] [PubMed] [Google Scholar]
  54. van de Grift T. C., Elaut E., Cerwenka S. C., Cohen-Kettenis P. T., & Kreukels B. P. C (2018). Surgical satisfaction, quality of life, and their association after gender-affirming surgery: A follow-up study. Journal of Sex & Marital Therapy, 44(2), 138–148. doi: 10.1080/0092623X.2017.1326190. [DOI] [PubMed] [Google Scholar]
  55. Witcomb G. L., Bouman W. P., Brewin N., Richards C., Fernandez-Aranda F., & Arcelus J (2015). Body image dissatisfaction and eating-related psychopathology in trans individuals: A matched control study. European Eating Disorders Review, 23(4), 287–293. [DOI] [PubMed] [Google Scholar]
  56. World Health Organization (WHO). (1992). The ICD-10 classification of mental and behavioural disorders: Clinical descriptions and diagnostic guidelines. Geneva: World Health Organization. [Google Scholar]

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