An exploration of the lived experiences of non-binary individuals who have presented at a gender identity clinic in the United Kingdom

ABSTRACT

Background: Despite an increased awareness of non-binary identity in the current social landscape, the experiences and needs of this heterogeneous community are poorly understood and represented in the research literature. Evidence indicates that social exclusion is not uncommon for individuals expressing a non-binary gender identity, with reflections in the literature that this may in turn have an impact on their psychological wellbeing.

Aim: As non-binary individuals are increasingly presenting at UK gender identity clinics and requesting medical interventions, the aim of this study was to better understand their experiences and needs.

Method: Two focus groups were run consisting of eight service users of a National Health Service (NHS) gender identity clinic in the United Kingdom. The transcripts of these focus groups were analysed using thematic analysis.

Results: Five themes were identified: Invisibility, Managing non-binary gender identity in a binary world, Individuality, Gender dysphoria and Seeking interventions.

Discussion: Clinical implications are discussed, with the recommendation for an affirmative approach that offers space for the non-binary individual to articulate their desires and come to terms with their identity. This exploration must take into consideration the person's place within a social world that can be transphobic and limited in terms of potential medical interventions. Further research is needed to better understand this marginalised community.

Gender Dysphoria is, in the ICD-10, defined as the “desire to live and be accepted as a member of the opposite sex, usually accompanied by the wish to make one's body as congruent as possible with one's preferred sex” (WHO, 1992). This “adoption of a stable, integrated, unambiguous identification as 100% male or 100% female” (Diamond & Butterworth, 2008) was until recently, and for many even still is, considered the healthy endpoint in transgender health care. However, there are a significant group of individuals who do not subscribe to the binary framework of gender implicit in these descriptions, yet who still struggle with a sense of gender dysphoria.

These individuals, whom we have termed non-binary, go by a variety of labels, such as Androgynist, GenderQueer and Gender Blender (Factor & Rothblum, 2008), with some even creating and adopting titles unique to themselves: “birl, jest me, skaneelog, twidget, neutrois, OtherWise, gendertreyf, trannydyke genderqueer wombat fantastica, Best of Both, and gender blur” (Harrison, Grant, & Herman, 2012), and these terms can represent a variety of approaches to gender inclusive of, but not limited to, agender or an absence of gender, bigender or a blending of the binary genders and ambigender or a gender that alternates between the binary positions (Fiani & Han, 2018; Richards et al., 2016; Wickham, 2011). Moreover, individuals whose gender identity sits outside of the binary do not necessarily experience a need to seek out gender affirming medical interventions designed to alter their primary and/or secondary sex characteristics (Factor & Rothblum, 2008; Richards, Bouman, & Barker, 2017; Riley, Wong, & Sitharthan, 2011).

For those who do desire such changes, much like their binary counterparts (Dozier, 2005), they may seek them out due to an unhappiness with their bodies. However, unlike their binary counterparts, their approach to this may take on a more dynamic and less linear nature. As their identities can be “constantly changing, constantly evolving, constantly bending and flexing” (Diamond & Butterworth, 2008) so too may their approaches to transition be experienced as an “on-going thing” with “no finish line” (Wickham, 2011), with any medico-surgical interventions included in this potentially being designed to achieve an intersexed or asexual aesthetic (Hage & Karim, 2000). For these individuals transition may represent an open-ended process or project, rather than a shift from one clearly defined gendered position to another.

Accessing Gender Identity Clinics is, according to Ellis, Bailey, and McNeil (2015), primarily about allowing trans individuals to explore their gender identity and/or access gender affirming medical treatment. However, they also noted that over 50% felt unable to talk about any ambivalence or uncertainty they experienced in relation to this, with those holding a non-binary identity experiencing any imposition of a narrowly defined, binary, definition of gender as particularly problematic. This barrier to accessing healthcare has been highlighted in non-gender specific services as well, with a lack of access to knowledgeable, competent, and trans-friendly providers proving a not infrequent challenge for both binary and non-binary individuals alike (e.g., Clark, Veale, Townsend, Frohard-Dourlent, & Saewyc, 2018; Sanchez, Sanchez, & Danoff, 2009; Scheim, Zong, Giblon, & Bauer, 2017; Taylor, 2016).

Unfortunately, a relative lack of evidence-based work with regards to the non-binary community (Richards et al., 2016, 2017), along with its heterogeneity, make it difficult to offer a robust review of their experiences. However, there are a few nascent themes emerging from the literature in terms of poor psychological wellbeing and social exclusion (Rimes, Goodship, Ussher, Baker, & West, 2018; Scottish Trans Alliance, 2015; Warren, Bryant Smalley, & Nikki Barefoot, 2016). Sadly, this experience of social exclusion, in the form of harassment and discrimination, is very common (e.g., Harrison et al., 2012; Miller & Grollman, 2015), with Claire and Alderson (2013) reporting that individuals who embody a gender non-confirming identity “experienced clear feedback that they were not meeting society's norms” with this non-conformity being met with “judgemental looks, staring, rude comments [and] harassment” or even the “threat of violence”. These experiences in turn may lead to “fears of never finding acceptance and never having others validate…worth” (Saltzburg & Davis, 2010) resulting in potential attempts at conforming to social expectations, often through compromise of one's gender expression (Claire & Alderson, 2013). As transphobia is rife (e.g., Chen & Anderson, 2017; Hill & Willoughby, 2005), and as it may occur as a result of the discomfort arising from the trans person's violations of gender norms (Adams, Nagoshi, Filip-Crawford, Terrell, & Nagoshi, 2016), the resultant tension between the social expectations of gender (constructed along binary lines) and an internal sense of (non-binary) gender may lead individuals to expend “a great deal of time participating in their own gender oppression via gender policing themselves” (Stachowiak, 2016).

That minority stress (e.g. Bockting, Miner, Swinburne, Hamilton, & Coleman, 2013; Goldblum et al., 2012) and poor psychological wellbeing exists in the wider transgender community (e.g., Heylens et al., 2014) is well established, as is the positive impact of social acceptance and support upon this psychological wellbeing (e.g., Budge, Rossman, & Howard, 2014; Clements-Nolle, Marx, & Katz, 2006). However, as non-binary individuals appear to face greater challenges in accessing social acceptance than their binary counterparts (Harrison et al., 2012) they may experience a greater degree of psychological distress; whilst the lack of language available to them, as well as their inherent individuality, may also act to contribute to them having to “figur[e] out who and what you are” (Wickham, 2011) in isolation, thus potentially confounding their sense of wellbeing further.

Ultimately, despite this tribulation, isolation and discrimination and the “mental energy” (Claire & Alderson, 2013) required to manage it, there is for some an authenticity to be found in identifying as “genderqueer” (Stachowiak, 2016), with an experience of empowerment and agency being gained from embodying an androgynous appearance. Indeed, some individuals even “enjoyed making their gender difficult for others to read” (Claire & Alderson, 2013) through engaging in the activity of “gender fucking”.

Rationale

There is a paucity of literature in this field, especially with regards to those non-binary individuals who seek out gender affirming medical interventions. Many such individuals may be reticent in seeking such support (Richards et al., 2016, 2017), but this may change as documents that guide services and service providers become increasingly inclusive of non-binary gender identities (e.g., British Psychological Society, 2012; Royal College of Psychiatrists, 2013) and as national service specifications increasingly cater to individuals who do not seek medical and surgical interventions within a binary framework (e.g., NHS England, 2017). As suggested by Richards et al. (2016), there is a need to develop a greater understanding of the experiences these individuals bring with them when entering services; this project was designed to explore just such needs, with the intention of developing our service's ability to act compassionately and affirmatively when reflecting upon and supporting our growing number of non-binary service users.

Method

Participants

As specific experiences of gender identity were required of participants, and to ensure a richness of information was collected (Patton, 2002), a purposive sampling method was used. This was complimented with snowball sampling, due to the hidden nature of the population under study. Eight participants were recruited via the online support networks associated with the gender identity clinic at which this study was conducted, via clinicians interacting with their non-binary service users and via recruitment information in the clinic's waiting area. All participants were over the age of eighteen, were current service users at the clinic, and were self-identified as non-binary. A review of their demographics is presented in Tables 1 and 2.

Table 1.

Self-reported demographics of first focus group.

Participant number:	1	2	3	4
Sex Assigned at Birth	Female	Female	Male	Male
Gender Identity	Demiboy/Agender/Boy Genderfluid	Male NB	Non-binary	Transfeminine
Ethnicity	White British	White Mixed	British White	White British
Spirituality	Humanist	N/A	N/A	Overrated/None
Education	A level	–	International Baccalaureate	A Level
Occupation	Student	Student	Apprentice IT Tech	Administrator
Sexuality	Demiromantic/asexual	Asexual	Bi-curious	Pansexual
History of Self-Harming	No	No	No	Yes
History of Suicidal Ideation	Yes	Yes	No	Yes
History of Attempted Suicide	Yes	No	No	No
Age of Onset for NB Identity	11	9	22	22
Age at referral to a gender clinic	15	18	22	23
Learning Disabilities	—	—	No	—
Lifetime Mental Health Difficulties	Depression, anxiety, OCD, OCPD	Depression, anxiety	Depression, anxiety	Low self-esteem

Table 2.

Self-reported demographics of the second focus group.

Participant number:	5	6	7	8*
Sex Assigned at Birth	Male	Male	Male	—
Gender Identity	Transfemale/Genderfluid	None	Genderless/Transfemale	—
Ethnicity	White	White	White Other	—
Spirituality	Agnostic	—	Buddhist	—
Education	College	A Level	Graduate Certificate	—
Occupation	—	Student	Not Working	—
Sexuality	Gay girl who likes girls	—	Asexual	—
History of Self-Harming	Yes	Yes	Yes	—
History of Suicidal Ideation	Yes	Yes	Yes	—
History of Attempted Suicide	No	No	Yes	—
Age of Onset for NB Identity	14	—	0	—
Age at referral to a gender clinic	22	—	48	35
Learning Disabilities	Autism	—	ASC Query	—
Lifetime Mental Health Difficulties	Anxiety, stress, depression	—	CPTSD	—

^*declined to answer/spoiled questionnaire as didn't agree with being asked about their sex assigned at birth

Procedure

As this inquiry involved a stigmatised group, focus groups, being identified as ideal for exploring the experiences of vulnerable populations (Krueger & Casey, 2000) and enabling disempowered patient populations an opportunity to find ‘mutual support’ in articulating their experiences (Kitzinger, 1995), were selected as the most appropriate form of data collection. To support this a semi-structured interview was used, with the single question: "How do you experience non-binary gender identity? This was done so that participants could most readily “explore issues of importance to them, in their own vocabulary, generating their own questions and pursuing their own priorities” (Kitzinger, 1995). Ethical approval for this service evaluative project was granted by the local NHS Trust Research and Development team and informed consent was obtained from all individual participants included in the study. A demographic questionnaire was given, which a single participant despoiled in protest at being asked to identify their sex assigned at birth. Ultimately, two small groups were run simultaneously by different facilitators and these lasted between 1.5 and 2 hours, with each group containing four participants and a single facilitator. Two of the authors then transcribed the audio recordings verbatim, and each was checked by all authors for accuracy.

Credibility and analysis

Following transcription, the data was independently analysed by all authors before an iterative process of regular meetings was used to discuss and re-examine the emergent codes and themes until consensus was reached. During the analysis of the results the presentation of faithful descriptions of participants accounts (Koch, 1994) was paramount. This focus on the credibility (Guba & Lincoln, 1985), or the confidence in the ‘truth’, of the results was enhanced through the application of an inductive (Thomas, 2006) thematic analytic approach, utilising Miles and Huberman's (1994) guidelines for qualitative descriptive work (Sandelowski, 2000). This enabled the analysis to be free from underlying theory (Braun & Clarke, 2006) and thus allowed for the broadest possible scope in exploring the phenomenon under study. The triangulation outlined above was also supported through the seeking of participant validity, obtained through the soliciting of feedback regarding the finalised results (Barbour, 2001). The researchers (some of whom identified as binary trans, others as cisgender) also met with a group psychotherapist to help them identify and reflect on assumptions and responses to the data. For example, this involved thinking about how the limitations of language which participants described, was also reflected in the research process through difficulties in the naming of themes.

Results

An analysis of the data identified five pertinent themes, which are outlined in Table 3 below. There was a degree of overlap between themes.

Table 3.

Themes constructed from two focus groups, with self-identified non-binary individuals (N = 8).

Themes
Invisibility
Managing Non-Binary Gender Identity in a Binary World
Individuality
Gender Dysphoria
Seeking Interventions

Invisibility

For participants, there was an understanding that “…when [others] come across non-binary, they have probably never heard of it”² and that it was “definitely a big problem that people, people don't know, and they have no reason to learn…”³. This lack of awareness on the part of others was reported as leading to assumptions about non-binary identities, such as when participants were assumed to be binary:

My experience of being in a local choir of, like, semi-retired, quite well-off people who can't, they just think in terms of ‘well you're a man or a woman’ and, like, I've had a woman there ask me ‘so when, when, are you planning to start wearing women's clothes?’⁷

Alongside this persistence of the binary, however, participants found themselves “being actively erased and ignored”⁴ and “completely dismissed”⁸. Participants reflected on this pervasive pressure to conform: “You know, I asked Nationwide to add Mx like three/four years ago, to their system, and they still haven't done it…the buggers. They ‘accommodated’ me by taking my title off stuff; I still occasionally get sent stuff in Mr.”³ Exacerbating this experience of invisibility was a sense that “there was no language or model outside the binary for me to make sense of myself”⁷, with this leading to it being “so hard to vocalise what you want”⁴ as “you have to give them a word that means something, but it might not mean you”². This lack of language would then lead individuals to rely on negation (“like trying to constantly prove that we're not something”¹, “we constantly reply with things we're not”²) and metaphor and analogy to convey their experiences and identity. This reliance on negation to articulate identity created a conflict, as there was also a need to be defined and understood as a person, not merely an absence: “We want to be who we are … and that is a thing, we are not a lack of a thing, we are a thing”².

Managing non-binary gender identity in a binary world

This invisibility seemed to be linked to the fear of retribution at speaking up, of feeling “too scared to say anything”² lest one be perceived as a “nuisance”⁴ or a “special snowflake”³. There was a belief that “there's a lot more scope for you getting trouble from other people, if you're in the wrong place”⁷, with the risk of “heavy consequences of not looking the part…when you're trans”⁸. For most participants, this was responded to through “constant compromise”³, such as through conceding to the binary to avoid potential discrimination (“you are just gonna put male and female, so you can get a job”¹). However, there was frustration at this (“Why are we having to make this decision?”³), which in some led to resistance:

The whole thing was kind of geared around me accepting that people don't accept me and I thought that was quite damaging so I didn't, I didn't go to it, you know, I just challenged them about misgendering me intentionally and, you know, making me trying to believe there I am a problematic thing for other people⁸

When this resistance did occur there was a sense of admiration and pride (“I think that, I feel like, the fighting back is brave and I respect that people do that”¹), but this was often marked with an awareness of the effort it takes to maintain such a stance (“I would not want to have to put myself through that on a day to day basis”¹, “you know, it takes energy to do it”³, “it's a fight that I just really don't want to pick on a day-to-day basis”⁴). Ultimately, for some, this was too much and they experienced a sense of resignation (“most of us have just given up when it comes to pronouns”²) and a drive to isolate themselves (“I probably do restrict my social circles to a degree”³, “I do that quite a lot and don't bother going to people who I know I have to be hidden from, even if they are my friends”²).

Individuality

Running throughout the groups was an experience of gender as “too tight a fit”⁷, with a sense that it “just stops you from being yourself…it stops everyone from being themselves”². Gender was voiced as being restrictive (“I wanna do more feminine things, like wear make-up, but I've been told that people would question my identity if I did that, so I feel restricted in that way”¹) and oppressive (“it's not so much about not having an outlet but being forced into a binaried outlet, or binaried box”³). Ultimately, it was experienced as a “model that seems to work for a lot of people but doesn't make any sense of my experience”⁷. Non-binary identity, on the other hand, was seen as “more of an umbrella term for different things, like agender, demigender, things like that”¹, and was experienced as “not very constrictive, it usually encapsulates”³. It was valued and experienced as an identity that “isn't sort of one kind of thing”⁸, that “lets me choose in my head what it means specifically”⁴.

Alongside this was a sense for some that they “always tried to maintain individuality over gender identity”⁵, that they were “less about a particular identity and more just kind of a person, you know, not really influenced or associated with a gender or anything like that”⁶. This individuality was experienced as “empowering”⁵ and was imbued with a sense of agency:

I mean, I look at it like a sand-castle…you can have a sandcastle…at the moment we've got two different sandcastles with the buckets on…you can have a sandcastle that's that shape but you don't have to keep the bucket on it and stop it from being whatever it is….you know, we're sort of moulding ourselves to how we wanna be and sort of saying ‘hey you know you don't have to have a bucket on top of you; if you wanna stay that shape, that's fine, you just don't need to restrict’…why place an unnecessary restriction on yourself?³

Gender dysphoria

There was a sense that “the problem for a lot of say dysphoric non-binary people is really, it's the starting point is the problem”⁸, that “…all the medical treatment I went through was just to get away from my birth sex, rather than to become something else”¹. Indeed, whilst participants experienced a discomfort with their sex assigned at birth (“I'd never really been interested in being male or male things or anything”⁴, “…all I've ever really known is that I'm not a boy and that was…causing me upset during those teenage years”⁵, “I realised I was a bit uncomfortable as male”⁶) there was a less pronounced affinity for the opposite sex (“kinda feeling more female”³,“partially a boy”¹, “…I prefer being called a girl than a boy and, it's a bit more accurate”⁵), with this being experienced in association with an absence of any gender identification (“not a strong identification as male or female”⁸, “that I wasn't really strongly one way or the other”⁶). These experiences, for some, corresponded with a desire to embody an androgynous position (“I sort of want a really androgynous appearance”¹, “I would like to appear androgynous to society”⁴), whilst for others their non-binary experiences were more focused on a social sphere, sitting alongside a more binary understanding of sex and their bodies: “I've never had a gender identity, but I have a sex identity so I always knew I was female”⁷.

Seeking interventions

In relation to the variation in participants’ experiences of gender dysphoria there was an awareness of the difficulties in addressing these experiences from a non-binary perspective (“I experience gender dysphoria, right? So how, as a non-binary person then, do I kind of work that out, right? As sort of solution to ease the sense of dysphoria”⁸), and participants presented with a multiplicity of understandings in relation to their pursuit of physical interventions: for some, with regards to these interventions, there was a sense of fitting into a more “traditional” binary transition:

I have a sex identity so I always knew I was female, in the sense of this body needs to be, to catch up with what my somatic sense of it says it should be, which is why I transitioned physically⁷

For others there was an appreciation of transition as a form of “body modification”⁸ that was open ended and dynamic (“it's not gonna have an end point until I'm dead, so…that's where I see it, I'm trying to make the ideal corpse"⁵). Whilst some participants had clear ideas of what they were seeking, others acknowledged the difficulty in resolving their desires through medico-surgical interventions:

Uhm, in terms of where I, I'd like to be in my body, it's, uhm… it's kind of a weird impossibility: I would either like to…be…a, you know, fully fledged hermaphrodite, not physically possible…or I would like, uh, a closet full of bodies that I could change…”⁶

Others reported a sense of ambivalence in relation to their desire for a resolution to their dysphoria: “I am personally I, I'm fine with my body…maybe I want some changes, or whatever, but I'm not going to get surgery or anything because I, I'm fine with my body. But, at the same time, I'm not”². Alongside this, participants also expressed frustration at the limitations imposed by healthcare providers (“I wish non-binary people, any non-binary people, could get laser treatment. Because, I wouldn't be allowed to because you have to tick the whole ‘male to female’ box, so they wouldn't let me”²) and the limitations of medical interventions themselves:

I currently have medication, I have done for months, just sitting on my shelf and I don't know, do I take this or not ‘cause there's bits of both I want and like, and some days I feel different ways⁶

Participants experienced a need to find a “practical solution”⁸ in the face of these and the more biological limitations they faced: “…you can't really express, well successfully express, as non-binary…because there isn't anything that caters towards that”⁶, “I sort of want a really androgynous appearance, but I knew testosterone wouldn't be able to do that”¹. Seeking interventions seemed to involve the desire for a greater sense of wholeness and coherence, “Trying to improve my sense of confidence and self-identity as a whole …because for me my identity is: I am I sort-of-thing … so for me it's just building all of that together into one picture”⁴. Ultimately it seemed to be that, when it came to seeking out interventions, non-binary individuals were “just trying to figure it out”⁶.

Discussion

The thematic analysis constructed from analysis of the transcribed focus groups suggested that participants’ experiences of their non-binary identity involved several challenges. These included feeling socially invisible and unintelligible. Participants expressed a struggle to be understood in a social context that relies heavily on binary constructs of gender. Non-binary identity was valued in its capacity to contain and articulate a very diverse range of individual, idiosyncratic gender identity positions. Gender dysphoria was experienced without an affinity for a different binary gender than that assigned at birth. In seeking a physical transition, participants navigated their own ambivalences and the limitations of medico-surgical interventions in an attempt to find a coherent self-identity within their environments.

In asking non-binary individuals who are actively seeking interventions about their lived experiences, this study offers novel insight into an under-represented group within the non-binary community (Factor & Rothblum, 2008), namely those who are seeking support in modifying their bodies. Despite the dearth of research within this field, the findings from this study broadly support existing research that indicates the heterogeneous and diverse nature of the non-binary community (e.g., Fiani & Han, 2018; Wickham, 2011), such that “non-binary” serves as an umbrella term rather than referring to a discrete, easily represented group of individuals. This study also supports the suggestion that stigma and social marginalisation play an important role in contributing to impoverished psychological wellbeing (Claire & Alderson, 2013; Harrison et al., 2012; Miller & Grollman, 2015), perhaps through the mechanism of minority stress (Bockting et al., 2013; Goldblum et al., 2012). In finding that participants struggled with the limitations of an inherently binary language to articulate their identities, this aligned with Saltzburg and Davis (2010) who argue that the limits of language can force non-binary individuals to face “fears that they may never be seen or known for whom they are, creating a sense of existential isolation”. The idiosyncratic range of medical interventions sought by participants confirms the suggestions of Richards et al. (2016) that goals of treatment for non-binary individuals can be very diverse, and Wickham (2011) who emphasises the dynamic and potentially on-going nature of transition, which might have no end-point.

One of the more original aspects of this study has been to give a voice to some of the tensions, paradoxes and contradictions that arose in participants’ attempts to challenge or transgress the gender binary. In acknowledging the impossibility of reconciling their, at times, conflicting desires (for example, one participant spoke of ambivalence regarding hormone treatment due to it producing some changes they would find pleasant, and others that they would not wish to initiate), participants were faced with a medical, linguistic and social world that failed to offer any definitive way out of the gender binary. It does not seem probable that there will ever be a set number of clearly defined medical interventions that will meet all the needs of non-binary people, as some participants were keen to emphasise the fluctuating and dynamic nature of their transitioning, such that it might never fully reach a stopping point. The particular, highly specific ways in which an individual finds their own pathway through gender-based healthcare services requires more research.

This study indicated that support should be offered, where appropriate, in facilitating non-binary individuals to develop and articulate their identities and desires. An affirmative approach that allows non-binary individuals to explore psychological, social, physical and legal expressions of their identities is essential. This exploration of identity would necessarily include broader considerations of the individual's embedding within a specific cultural and relational context, and would require thinking about intersecting aspects of identity, such as race, religion and class. There is an importance for healthcare providers to really listen to their non-binary service users, who might challenge their own assumptions about gender, to best provide treatment that directly responds to the needs of the individual in resolving as best as possible, some of the tensions involved in living outside of the binary. For service providers and commissioners, this might raise difficulties in terms of needing set pathways for purposes of funding and evidence-based practice, but finding that these may not adequately satisfy non-binary individuals’ specific requests. Another clinical implication is that it may be helpful to offer the non-binary person psychological support in navigating the limitations of the current medical treatments and a social environment which struggles to recognise their gender identity as legitimate. This also suggests that there is a role for healthcare providers to take a more active role in promoting understanding and acceptance of gender-diverse individuals in their local and wider communities.

The present study was limited by the data that was collected. There was a relatively small number of participants, and those that did participate may not have been representative of the very diverse and heterogeneous non-binary population as a whole. Given that this study was conducted as part of a service evaluation at the NHS gender identity clinic service in which the participants were also receiving treatment, this too may have impacted on their capacity to speak in an open and unguarded manner. It is likely that only those non-binary individuals who felt relatively stable and confident in talking about their identity would choose to participate in such a study as this, but there would be much to be learned from those who might be more inward-facing. Most participants were white and assigned male at birth, and our study would have benefitted from greater diversity. It was also the case that more data could have been collected by transcribing for pauses, stammers, and non-verbal utterances. There were points in the focus groups, particularly during discussion of bodies and physical interventions, where a limit seemed to be reached in terms of the capacity for words to articulate and express. It was at these moments where speech broke down that a more in-depth form of transcription may have been beneficial.

Further research must focus on follow-up of non-binary individuals who have received medical and psychological treatments in gender identity clinics, as there is still very little idea of the long-term implications and outcomes regarding satisfaction, on-going challenges, and whether further interventions will be sought. Finding out more about how non-binary people move on from their time in the clinic and how they interact with their social contexts is vital to better understand the potential prospects for people seeking interventions, and allow for a greater degree of informed consent in making treatment decisions. It would also be valuable to explore the phenomenon through which non-binary individuals face discrimination and harassment, perhaps through research on cisgender populations to explore their attitudes towards gender diverse people. It's possible that this phenomenon could operate along different lines than that directed against binary trans individuals, as in addition to violating gender norms, non-binary people can challenge perhaps at a deeper level what it means to be a person, destabilising deeply-held notions of self. Having a better understanding of such processes would result in an increased capacity to target discrimination through social education campaigns. More in-depth work could be done to research non-binary individuals’ relationships with their bodies, the different forms that gender dysphoria may take for them, and the meaning that physical interventions might have. As Budge et al. (2014) suggest, there is also little research at present on coping skills for non-binary individuals; understanding the resilience of gender diverse people could potentially lead to further developments in psychological interventions. It would be important to evaluate psychotherapy provided in gender identity clinics to non-binary people, to better understand what goals can be achieved through psychological work, and to construct outcome measures that effectively capture the changes that might occur through such work.

Conclusion

This study points to some of the difficulties non-binary individuals face in reconciling their personal identities with the limits of the medical treatments available and the confusion and intolerance of the social landscape. Finding a space to reflect on such tensions could be valuable in facilitating the non-binary person to find their own pathway or solution to the challenges involved in living outside of the binary. It is important for future research to speak to and try to understand this under-represented and diverse group of individuals who live under the banner of “non-binary”.

Declaration of conflict of interest

The authors declare that they have no conflict of interest.