“There Is Nothing to Do About It”: Nonbinary Individuals' Experience of Gender Dysphoria

Abstract

Purpose: Clinical definitions of gender dysphoria have primarily centered on a binary conceptualization of gender. This study aimed to understand nonbinary transindividuals' experiences of gender dysphoria.

Methods: Data were collected online from a nonclinical sample comprised of 205 nonbinary and agender participants. Analysis focused on answers to a single open-ended question prompting participants to describe their gender dysphoria as it relates to their body and/or appearance.

Results: First, content analysis was used to document 11 contextual elements in which participants described their dysphoria with regard to three overarching categories, including no gender dysphoria (no issues with body, no dysphoria), aspects of gender/sex (naming gender identity, naming assigned sex, gender role, or expression), and aspects of body (body shape, genitals, chest, secondary sex characteristics, hormones, reproductive capability). Second, thematic analysis revealed six central themes describing the unique way gender dysphoria is experienced by nonbinary individuals: (1) Androgyny or Fluidity, (2) Feminine and Masculine Traits, (3) Dysphoria vs. Expression or Appearance, (4) Varying or Shifting Dysphoria, (5) No Solution, and (6) Trade-off/Loss.

Conclusion: Results of this study suggest that nonbinary transindividuals experience gender dysphoria in unique ways. These findings highlight the need to develop clinical assessments of gender dysphoria that reflect nonbinary experience, and to outline explicit medical protocols for interventions tailored to achieve a desired outcome of physical androgyny.

Transgender identities are heterogeneous and are often conceptualized in ways that complicate binary assumptions of gender/sex.^1,2 Some transgender identities are conceptualized in relatively binary ways, including individuals who transition (medically or socially) from one binary gender to the other,³ while other identities are conceptualized as nonbinary. Nonbinary transgender individuals may identify with both genders, with a gender different from female or male, outside the gender binary, or as not having a gender altogether.^4–9 Thus, nonbinary individuals may endorse a range of gender identity labels (including agender, genderfluid, genderqueer, nonbinary, gender nonconforming, trans).⁴ Transgender experience differs across gender identity, assigned sex, and approach to social and medical transition,¹⁰ and these factors simultaneously impact how an individual may experience gender dysphoria.¹¹ Although almost a third of transgender individuals identify as nonbinary,⁸ trans-related clinical research has predominantly focused on transwomen.¹²

Gender dysphoria refers to the distress that may occur when gender identity does not coincide with assigned sex.^13,14 Although not all transindividuals experience gender dysphoria,^15,16 it has been the predominant clinical framework from which transgender experience has been understood. While a gender dysphoria diagnosis may allow access to, and insurance coverage for, some transindividuals to obtain medically necessary treatments,^17,18 a mental health diagnosis is not always necessary for treatment.¹⁹ There has been much debate about the need for a gender dysphoria diagnosis,^19–23 and/or whether a diagnosis should be conceptualized as a medical or mental health disorder.²⁴ Also debated is the nature of distress; whether it is a pathological experience that originates with gender incongruence, whether it stems from stigma associated with cisnormativity,^25–27 and/or whether it is an expected and normal response to having a body that does not coincide with felt gender.¹⁹

Historically, gender dysphoria has been framed from a clinical lens, and has emphasized body incongruence and dissatisfaction.²⁸ Focused on transwomen, models of dysphoria have reinforced the “woman trapped in a man's body” narrative^29,30 and are reminiscent of outdated typologies based on transwomen that conflate gender identity with sexual orientation and attraction.^31–33 Models of gender dysphoria also reify binary understandings of gender/sex¹¹ where traditional clinical scales^34,35 use binary language and anchor those understandings based on assigned sex. Recent research has documented that many transgender and nonbinary individuals do not feel that these scales capture their experience of gender dysphoria. Subjective ratings of these scales differ across gender identity, where transfeminine individuals rate these scales as more reflective of their experience than do transmasculine individuals, and nonbinary/agender individuals are the least likely to feel that clinical scales capture their gender dysphoria.¹¹ In contrast, recent diagnostic criteria have shifted away from binary language (e.g., “the other gender,” Gender Identity Disorder [DSM-IV])³⁶ to using expanded language inclusive of nonbinary gender (e.g., “the other gender or some alternative gender different from one's assigned gender,” Gender Dysphoria [DSM-5]).¹³ Despite this, no research to date has centered the investigation on understanding nonbinary individuals' experiences of gender dysphoria.

Despite that about a third of transgender individuals identify as nonbinary,^8,37 clinical definitions of gender dysphoria have centered primarily on a binary conceptualization of gender.^11,12 This study investigates the way nonbinary individuals uniquely describe their experiences of gender dysphoria. We take a phenomenological approach in conducting two qualitative approaches to our analysis. First, we conducted a content analysis to describe the contextual elements participants used to describe their gender dysphoria. For this analysis, our research question focused on understanding how nonbinary transindividuals frame an understanding of their gender dysphoria. Second, we conducted a thematic analysis to understand the meaning participants make of their gender dysphoria. Specifically, we consider how nonbinary transindividuals uniquely describe their gender dysphoria in relation to their gender identity.

Method

Design overview

This study is part of a larger research study investigating transindividuals' experiences of gender dysphoria. Recruitment announcements were posted to social media sites and online message boards. Some of these resources were geared to certain aspects of the transgender community (e.g., female to male [FtM], assigned male at birth [AMAB], nonbinary), while others served the transgender community more broadly. Participants most frequently accessed the survey through Reddit (41.0%) and Facebook (38.0%). The remainder were referred through Twitter (4.9%), Tumblr (3.4%), by a friend (2.4%), or through another venue (10.2%). To be included, participants had to be ≥18 and identify as transgender, trans-sexual, nonbinary, or as having a transgender history. This study was approved by the Towson University IRB. No incentive was provided for participation. All participants completed an online survey regarding their experiences of gender dysphoria. Participants provided their gender identity label in their own words and were then asked to select the gender identity with which they most identified (i.e., transfeminine, transmasculine, nonbinary, agender). The present analysis focuses exclusively on responses from nonbinary and agender individuals, and analyzes their responses to a single open-ended prompt asking them to “describe your gender dysphoria or distress related to your body/appearance.”

Data analysis

The entire authorship team started by independently reviewing the data. During our first meeting, we discussed the complexity of the data and developed a two-tiered analysis plan to fully characterize responses without losing information. Due to multiple layers of meaning in the responses, we conducted a content analysis³⁸ to broadly frame the context in which all nonbinary participants in the sample described their gender dysphoria, followed by a thematic analysis^39,40 to characterize the way gender dysphoria was described by a subset of the sample who specifically focused on nonbinary characteristics in their responses.

The development of codes (content analysis) and themes (thematic analysis) was decided upon using an iterative process. After several rounds of coding and revision, final coding/thematic structures were agreed upon. Content analysis centered on 11 contextual elements in which participants described their dysphoria with regard to three overarching categories, including no gender dysphoria, aspects of gender/sex, and aspects of body. Second, thematic analysis revealed six central themes describing the meaning participants made of their gender dysphoria in relation to their nonbinary identity.

The second and third author independently coded the dataset with the first/senior author serving as external _auditor to ensure dependability in the coding.⁴¹ Final inter-rater reliability was 91.4%, and all discrepancies were resolved through consensus. Illustrative quotes are accompanied by participants' self-identified race/ethnicity, gender, and age. Several steps were taken to increase the validity of our results. First, the themes were thoroughly discussed, and clearly defined and operationalized by the entire research team. Because the authors have varied experiences with dysphoria, this diversity was a strength in our approach. Second, researchers coded data without knowing the identities of the participants. Third, each of the 11 codes and 6 themes were coded using a binary (1=present; 0=not present) system. Chi-square tests for independence revealed no significance across self-identification (agender, nonbinary), validating that the coding/thematic structure was salient to individuals regardless of gender identity.⁴²

Positionality

The research team included a Professor of Psychology who identifies as a biracial, bi/pansexual agender person, a second-year PhD student in Counseling Psychology who identifies as a White transmasculine nonbinary queer person, and a second-year MA student in Social Work, Education and Native American who identifies as Cherokee trans/nonbinary queer person. All members of the research team had training in both qualitative research and transgender research. Because of the range of our collective experiences across gender (identity, expression, dysphoria), we came to these discussions with different perspectives. At each coding meeting, we actively reflected on our reactions to the data, processed personal biases, and engaged in bracketing to increase the rigor of our process.⁴³

Results

Participants

Recruitment announcements for a study on gender dysphoria were posted to social media sites, including both general transgender sites and those geared toward certain aspects of the community (e.g., FtM, AMAB, nonbinary). Participants most frequently accessed the survey through Reddit (41.0%) and Facebook (38.0%). The remainder were referred to the survey through Twitter (4.9%), Tumblr (3.4%), by a friend (2.4%), or through another venue (10.2%). Table 1 displays demographic information, including gender identity, race/ethnicity, education, and sexual orientation, for both the content and thematic analyses samples. All participants in the study were included in the content analysis. This sample was comprised of 205 transgender adults who identified as agender (n=50) and nonbinary (n=155), and ranged in age from 18 to 61 (M=26.94, SD=7.83). The sample represents 18 countries, with the majority of the sample representing the United States (67.3% inclusive of 35 states and Washington, DC). The sample showed limited racial/ethnic diversity, with 78.3% of the sample identifying as White and 21.7% identifying as a racial or ethnic minority.

Table 1.

Participant Demographics

	Content analysis (n=205)	Thematic analysis (n=76)
Age, mean (SD)	26.76 (8.89)	26.99 (8.29)
Gender identity
Agender	50 (26.8%)	23 (30.3%)
Nonbinary	155 (73.2%)	53 (69.7%)
Race/ethnicity
American Indian/Alaskan Native	1 (0.5%)	0 (0.0%)
Asian/Asian American	5 (2.4%)	2 (2.6%)
Biracial/Multiracial	10 (4.8%)	6 (7.9%)
Black/African American	3 (1.4%)	1 (1.3%)
Hispanic/Latinx	10 (4.8%)	3 (3.9%)
White	162 (78.3%)	58 (76.3%)
No answer	4 (1.9%)	1 (1.3%)
Other	10 (4.8%)	5 (6.6%)
Education level
High school degree/GED	88 (42.5%)	30 (39.5%)
College degree	74 (35.7%)	28 (36.8%)
Graduate degree	34 (16.4%)	16 (21.1%)
Doctorate/terminal degree	9 (4.3%)	2 (2.6%)
Sexual identity
Asexual	33 (15.9%)	11 (14.5%)
Bisexual	30 (14.5%)	10 (13.2%)
Fluid	2 (1.0%)	1 (1.3%)
Gay	11 (5.3%)	4 (5.3%)
Heterosexual	3 (1.4%)	2 (2.6%)
Lesbian	9 (4.3%)	3 (3.9%)
Pansexual	49 (23%)	21 (27.6%)
Queer	52 (25.1%)	19 (25.0%)
Other	16 (7.7%)	5 (6.6%)

GED, general educational development.

Only participants who described their gender dysphoria in ways that were salient to nonbinary identities were included in the thematic analysis. This sample included 76 participants (23 agender, 53 nonbinary) who ranged in age from 18 to 61 (M = 26.99; SD = 8.29). There were no significant demographic differences between the larger (content analysis) sample and the thematic analysis subsample.

Content analysis

We conducted a content analysis and documented 11 contextual elements in which participants described their dysphoria, in relation to three main categories: no gender dysphoria, aspects of gender/sex, and aspects of body. Representative quotes are provided in Table 2. When asked to describe their personal experience, some participants' responses were categorized as no gender dysphoria. Participants noted this by citing no issues with body (4.2%), or by explicitly stating that they experience no dysphoria (3.4%). Participants also made salient aspects of their gender/sex in their descriptions of their gender dysphoria. Some participants specifically named their gender identity (8.1%), assigned sex (9.8%), and gender role or expression (12.2%) as important frames. Participants also referenced specific aspects of body when describing their dysphoria, locating their dysphoria in relation to body shape (12.2%), genitals (11.7%), chest (37.6%), secondary sex characteristics (13.2%), hormones (2.5%), and reproductive capability (8.3%).

Table 2.

Contextual Elements for Nonbinary Individuals' Descriptions of Gender Dysphoria

No body dysphoria	No issue with body	4.2%	For the most part, I love my body. It is strong, healthy, and beautiful. Sometimes I wish I were a little taller, that my breasts were smaller, that my hips were narrower, but overall I am grateful for my body and all that it allows me to do. (White agender person, 21)
			As I'm both male and female, I don't have real problems with my male body. But If I would wake up tomorrow as a woman, I would be fine too. It just doesn't really matter to me. (White male-female person, 28)
	No dysphoria	3.4%	I don't have this problem. I experience no dysphoria, I simply understand that my gender assignment by society is not based on reality but instead on arbitrary social constructs. (White person with no gender identity, 21)
			I do not experience gender dysphoria. (White demiguy, 38)
			I don't really? Other people are the problem (White genderfluid person, 18)
Naming aspect of gender/sex	Naming gender identity	8.1%	It really comes and goes for me, as I am genderfluid and genderflux. (White genderqueer person, 18)
			I don't have a problem with how my body looks and to me it's an agender body. (White agender person, 34)
	Naming assigned sex	9.8%	I was AMAB, so anything that corresponds with conventional masculine appearance distresses me, including facial hair, masculine musculature, so in my life, I de-emphasize these things. (White nonbinary transperson, 29)
			I was born AFAB. I always wear baggy shirts/jackets to hide my breasts when possible. I have also had breakdowns over the fact that it is most likely medically impossible for me to obtain a normally functioning penis. (Asian/Asian American agender person, 18)
	Gender role or expression	13.6%	I feel male, I identify with male gender role. (Black transmasculine person, 31)
			I don't see my body/self as having an inherent gender, hence agender. However, I do associate with a lot of normative masculinity in the expression, such as in clothes, mannerisms, and interests. I think of my expression as a queered masculinity. (White gender variant person, 28)
Naming aspects of body	Body shape	12.2%	Severe depression and anxiety especially centered around my breasts and soft facial features. I have panic attacks when expected to dress in a way that would show them off. (Biracial/Multiracial androgyne, 27)
			Dissatisfaction with shoulder vs hip ratio whenever looking at a full body mirror. A sense that they should be more equal… Feeling “betrayed” by my body, or cursed whenever imagining it. (Hispanic/Latinx man with gender nonconforming expression, 25)
	Genitals	11.7%	I have also had breakdowns over the fact that it is most likely medically impossible for me to obtain a normally functioning penis. (Asian/Asian American agender person, 18)
			I try to avoid mirrors up close when I'm in the bathroom. I cringe at the sight of my penis, and I try to avoid looking down at it. (Asian/Asian American nonbinary man, 21)
	Chest	37.6%	Looking at my chest without a binder causes a sudden rush of discomfort, negative thoughts, and lower mood. (Biracial nonbinary person, 20)
			Strong distaste of my breasts during sex and showers, when trying on clothes and they don't fit quite right, sends me straight into brooding and I become depressed, it can last days. (Middle Eastern genderqueer person, 32)
Naming aspects of body	Secondary sex characteristics	13.2%	I hate hair on my chest and my genitals. It causes intense anxiety for me and makes me dissociate from my body when I notice it. (White genderqueer person, 30)
			I have female sex characteristics and do not associate them as a part of my body despite their attachment. I still menstruate and whenever I think about it, I feel as though it is happening to someone else and not me. (White agender person, 18)
	Hormones	2.5%	When I have PMS, my thoughts feel more estrogen fueled than usual. This creates dysphoria for me. (White nonbinary person, 43)
			Before I took hormones, I also felt like I had the wrong hormones in my body. I didn't necessarily feel my body was wrong but the hormones in it felt like the wrong ones. (White transnonbinary person, 46)
	Reproductive capability	8.3%	I do not like the fact that I am able to reproduce/have periods. (Black agender person, 30)
			The thought that I could hypothetically incubate and feed a baby horrifies and disgusts me. (White nonbinary person, 32)
			The concept of pregnancy is terrifying, and even though I would not mind having children, I could not endure being pregnant due to dysphoria. (White genderqueer person, 34)

AMAB, assigned male at birth.

Thematic analysis

Thematic analysis revealed six main themes uniquely describing gender dysphoria in relation to their nonbinary identity: (1) Androgyny or Fluidity, (2) Feminine and Masculine Traits, (3) Dysphoria vs. Expression or Appearance, (4) Varying or Shifting Dysphoria, (5) No Solution, and (6) Trade-off/Loss. Table 3 illustrates the thematic structure, accompanied by the percentage of the sample expressing each theme. Themes are not mutually exclusive as individual responses could be coded as exemplifying more than one theme. Results are described using direct quotes, and are accompanied by participants' self-identified race/ethnicity, gender identity label, and age.

Table 3.

Thematic Structure and Frequency of Endorsement

Theme	%
Androgyny or fluidity	66.9
Balance of feminine and masculine traits	20.8
Dysphoria versus expression or appearance	16.0
Varying or shifting dysphoria	7.8
No solution	71.3
Trade-off/loss	7.4

Androgyny or fluidity

The first theme describing gender dysphoria in relation to nonbinary identity centered on the conceptualization of gender as androgynous or fluid. For many participants, descriptions of dysphoria made general references to an androgynous of fluid body ideal:

Looking in the mirror and seeing a masculine face and body, with the association of “man”—a label I don't identify with—and wishing I could be more androgynous or fluid. (White genderqueer person, 39)

I really wish I had more of a lithe figure, because lithe is androgynous. I don't necessarily mind having female parts. I just don't like looking in the mirror and seeing someone who looks like something they're not.…And yet I am so disgusted by me. Normally, when it crosses my mind, I just feel so disappointed in myself, as if I'm to blame for having two X chromosomes. (White nonbinary person, 24)

Sometimes androgyny was discussed with regard to the body or as an overall aesthetic. At other times, androgyny was discussed with regard to specific body parts or features:

Feeling distress because my voice doesn't sound androgynous. Moderate dissatisfaction with shoulder vs hip ratio whenever looking at a full body mirror. A sense that they should be more equal, that it would be better that way. (Hispanic/Latinx man with gender nonconforming expression, 25)

When describing an androgynous ideal, participants often spoke about being fluid or androgynous as a more authentic representation of their gender:

I get (gender dysphoria) from feelings that I'm not properly living the life I owe myself. We only get one chance, and I don't know if I'm doing this right. In the mirror, I see a non-binary person who lacks at presenting androgynously. (Hispanic/Latinx nonbinary transmasculine person, 37)

Feminine and masculine traits

When describing their body dysphoria, nonbinary participants described their attention to particularly feminine and/or masculine traits. Some participants described their dysphoria in reaction to being too masculine (e.g., Slight disgust at my masculine features. [White nonbinary person, 20]) or too feminine (e.g., As non-binary, I typically feel off and have to change if it's too feminine [White enby, 24]). Often this theme was expressed as a desire to attain a balance in feminine and masculine body parts or traits:

I am AMAB and I like my penis most of the time. About 60–70% of my dysphoric phases are me missing a vagina, right beneath my penis. While that is the case, the scrotum feels wrong. (White nonbinary, maybe intersex, unsure person, 24)

When walking by a reflective surface, I check how I look. Is the binder on correctly? How's my hair? The way I walk? As I leave the surface, my thoughts shift away to my mannerisms. Am I striking a good balance between masculine and feminine mannerisms? What about my voice? (American Indian/Alaska Native agender person, 24)

For some participants, feminine and masculine traits were described with regard to what feels or does not feel authentic or right:

Gender dysphoria for me, as a non-binary individual, typically resembles intense and often seemingly random visceral feelings and emotions about how my body looks wrong. I often want to appear more androgynous and will feel this way when I appear too masculine. (White nonbinary person, 23)

Participants also understood that the balance of feminine and masculine traits was tied to the way they were read by others as either female or male:

Feeling unease because chin is too prominent plus (my) cheeks are too deflated and gets me read as a male more often than I'd like (ideally it would be 65/35 instead of 80/20). (Hispanic/Latinx man with gender nonconforming expression, 25)

In addition to being (mis)classified by others with regard to gender, some of our participants understood that their unwanted feminine and masculine features/presentation were accompanied by unwanted gendered assumptions from others:

Anything that is obviously and definitively male or female does not appeal to me, and makes me feel trapped by gendered assumptions or destinies that don't fully suit me. (White genderqueer person, 28)

For others, the critique of feminine and masculine characteristics was tied to fears of being identified by others as trans:

Shorter than other men? Do they notice my hands? My tiny feet? At the rock wall, I worry that my harness emphasizes my hips, and that people notice. Do I touch my hair in a way that says “I USED TO BE A GIRL.” (Latino transmasculine person, 23)

Gender dysphoria versus appearance and expression

The third theme described by our nonbinary participants centered on the way gender dysphoria was discussed alongside appearance and gender expression. Participants often described that certain gendered presentations were linked to feelings of dysphoria:

I cannot wear dresses or bikinis without lots of discomfort, similar when it comes to makeup. (Black queer person, 20)

Participants described actively changing their appearance and gender expression in ways to offset the dysphoria or discomfort:

Getting uncomfortable when I notice my hips in tight pants and hiding them with looser pants/long shirts. (White nonbinary [aporagender] person, 25)

I naturally look masculine, and that makes me want to exercise less and shave my face and body, and style my hair to look androgynous. (White agender person, 18)

For some participants, managing dysphoria through changing gender expression and appearance was tied to self-efficacy and self-empowerment:

Being unhappy with how my body looks and changing clothes to make myself happier. (White nonbinary person, 23)

I take comfort in finding certain strong aesthetics to put on (like punk) and then I feel more cohesive as a whole, like there's something about my body and appearance I get a say in. And with the stronger aesthetics I can do more obvious things that make me feel better about my body, like wearing a chest binder as a regular shirt. If my clothes are particularly wild, and no one has dressed like that before, it's harder for people to assign a gender to them. (Biracial/Multiracial genderqueer/nonbinary person, 23)

Actively changing gender expression/appearance was discussed as a form of emotion regulation and strategy for managing gender dysphoria.

Varying or shifting dysphoria

A fourth theme characterizing gender dysphoria for our participants was the way that gender dysphoria varied or shifted in relation to their nonbinary identities. Participants uniquely connected their experience of dysphoria to their experience of gender outside the binary. For participants who experience their gender as fluid, gender dysphoria often fluctuated with felt gender:

It really comes and goes for me, as I am genderfluid and genderflux. On days when I am masculine and very gendered, I wear a binder because my chest feels heavy and awful. (White genderqueer person, 18)

Some participants described how their dysphoria changed in relation to their feminine, masculine, and androgynous features pre- versus posthormone replacement therapy (HRT):

Pre-HRT: I would look in the mirror and try to find myself in my reflection. I would cringe at how high-pitched my voice was. I'd feel betrayed by the curve of my hips and the slightness of my shoulders, and try to hide my breasts as much as possible. My body felt like a prison. Post-HRT: Sometimes I feel too masculine. I'm distressed by the body hair and facial hair that I've grown. I like my face now more than I did, but I wish it wasn't so unambiguously masculine. (White nonbinary person, 29)

Participants also noted changes in their gender dysphoria in relation to the way their sense of body androgyny shifted with changes in weight:

I would much prefer to sit in a queer identity neither male or female. So, I have a lot of trouble connecting to my curvy looking hips or my increase chest size as I gain weight. (White gender nonconforming person, 38)

No solution

The fifth theme that emerged regarding body dysphoria for nonbinary transparticipants focused on their sentiment that there was no clear solution to their gender dysphoria. While the literature emphasizes that for (binary) transindividuals social and medical transition can alleviate dysphoria, the same options did not offer similar relief or present as a solution for nonbinary participants. This theme was seen most frequently in this dataset.

Participants' descriptions of individual instances of dysphoria often detailed the sentiment that there was no solution to ease their dysphoria:

When I look in the mirror and I'm naked, I notice my broad shoulders, ribcage, and neck. I get depressed by it because I know there is nothing to do about it. (White nonbinary person, 31)

I get depressed because there's no answer. (White man, 26)

I feel uncomfortable and disgusted with (my breasts) and being called a woman, but being a man never sat right either. (Biracial/Multiracial androgyne, 27)

Central to the way participants expressed their hopelessness surrounding their gender dysphoria was the way their nonbinary identity could not be adequately translated into a nongendered body:

Crying about inability to change my body as I want to (I only desire about half the effects hormones would provide) (White gender nonconforming woman, 28)

My ideal body is one assigned male at birth i.e., flat chest, penis. I was born AFAB. I always wear baggy shirts/jackets to hide my breasts when possible. I have also had breakdowns over the fact that it is most likely medically impossible for me to obtain a normally functioning penis. (Asian/Asian American agender person, 18)

It's just really confusing and I feel crazy/fake/whatever because it's frustrating not knowing what I want and constantly thinking I've gotten to what I wanted and then feeling like that's not right either; thinking I should've stuck as something else or trying to find something else new. (Biracial/Multiracial nonbinary woman, 33)

Another participant described it in the following way:

My chest feels wrong, unnatural, like it's not supposed to be there. I feel gross and wrong and if I look in the mirror it makes me even more dysphoric. The pronouns she/her and he/him (the latter less so) feel foreign. I want my primary sex characteristics to be gone, but I don't want a penis, either. (White nonbinary person, 18)

Trade-off or loss

The sixth theme that emerged focused on the way nonbinary participants described their dysphoria in the context of a trade-off or loss. Participants often noted how leaning more feminine or masculine does little to offset the dysphoria, and how each binary expression is experienced as a concession or trade-off:

Wearing very feminine clothes is uncomfortable because I feel like I'm pretending to be someone I'm not and that I'm accentuating things I would rather hide. But wearing very masculine clothes can also be uncomfortable because I become self-conscious about the fact that I don't look like a man despite making these efforts. (White nonbinary person, 29)

Likewise, social or medical transition was presented as a no-win situation where addressing some aspects of gender dysphoria only exacerbated other concerning aspects:

Due to my fluid gender, I have some shifting dysphoria, especially as I progress on testosterone treatment and have to deal with my voice changing—something I did not want but accepted I'd have to deal with in exchange for relief of other dysphorias. (White nonbinary person, 22)

No matter what, it's a reminder of what I have. Thing is, I would hate the opposite even more. (White agender person, 32)

Discussion

This study utilized a nonclinical sample to directly characterize how nonbinary transindividuals experience gender dysphoria. Through content analysis, we identified 11 contextual elements that speak to the way participants framed an understanding of their gender dysphoria. These elements were relevant to three main categories, the first of which was no dysphoria. These responses are consistent with the past understandings that not all transindividuals experience gender dysphoria and with the literature that cautions against conflating gender identity and dysphoria.^15,16 When asked to describe their experience, 16 of the 205 (7.8%) participants noted that they did not experience gender dysphoria by explicitly stating either that they have no dysphoria or that they have no issue with their body.

Given the present focus on body and appearance it makes sense that the second contextual category centered on naming aspects of their body. Participants described gender dysphoria in relation to the body both generally (e.g., body shape) and in reference to specific body parts (e.g., genitals, chest, secondary sex characteristics) and functions (e.g., hormones, reproductive capability). Participants contextualized their experiences of body dysphoria by noting the way different body parts or features were gendered in (binary) ways that did not resonate with their nonbinary identity. In large part, these findings resonate with qualitative research on gender dysphoria among trans- and nonbinary individuals more generally²⁸ and with specific works on transindividuals' experiences with menstruation,⁴⁴ body hair,⁴⁵ and, more generally, body dissatisfaction.^46–48 These contextual elements are also consistent with factors that have been emphasized in measures of gender dysphoria^34,35 and incongruence.⁴⁹

Consistent with van Anders,⁵⁰ we use gender/sex strategically to emphasize that whole experiences/identities may not be specifically located in either sex or gender. Rather, gender/sex is multidimensional, including sex assigned at birth, gender identity, gender roles and expectations, social presentation, and gender evaluations.^50,51 Our participants' descriptions of gender dysphoria clearly engaged multiple dimensions, often naming an aspect of their gender/sex. Although gender dysphoria is traditionally defined as the distress that may occur when gender identity does not coincide with assigned gender/sex,¹³ our participants did not limit their discussion to assigned sex and gender identity. Their descriptions of dysphoria were just as often accompanied by mentions of gender role and expression. Recent qualitative research has emphasized that many trans- and nonbinary individuals locate their distress within a social context where the negotiation of gendered presentations including direct microaggressions and misgendering from others can serve to elicit gender dysphoria.²⁶ Our participants' descriptions, then, resonate with the literature that emphasizes both bodily²⁸ and social aspects²⁶ of gender dysphoria.

Thematic analysis revealed the unique way gender dysphoria is experienced by nonbinary individuals. When describing their gender dysphoria, the majority of our participants did so by referencing androgyny or fluidity. Sometimes this was articulated as desiring an androgynous body or gender presentation to better reflect their nonbinary identities. To attain the desired androgyny, participants described specific feminine and masculine traits that they either wanted to keep or desired to obtain. This conceptualization stands in contrast to the classic clinical conceptualization of gender dysphoria as based on rejecting one set of (binary) features in favor of the “opposite.” These findings also help explain why nonbinary individuals are the least likely among transindividuals to feel that traditional measures of gender dysphoria reflect their experience.¹¹

The majority of our participants described a sense of profound hopelessness surrounding their dysphoria, and expressed that there is no apparent solution to their distress. For many, hormone treatment or other gender affirmative treatments that are traditionally seen as providing necessary and lifesaving treatment for those with gender dysphoria¹⁴ were not seen as viable options for our nonbinary participants. These treatments that work to move bodily presentation from masculine to feminine or from feminine to masculine were conceptualized more as a trade-off than as workable solution. Our nonbinary participants expressed that while these options may address some aspects of their gender dysphoria, they would necessarily give rise to other troubling aspects of distress. So, for example, while hormones might shift body shape to be more androgynous, they may also impact voice or hair distribution in a way that shifts gender presentation to be more masculine or feminine, and introducing a new source of distress. The present findings extend recent research that suggests that nonbinary and genderqueer transindividuals are less likely to pursue medical transition^6,52 and provide a more nuanced understanding of why gender affirmation treatments may not present as a viable option for relieving gender dysphoria for these individuals.

In addition to their focus on the body, participants' descriptions of their gender dysphoria highlighted aspects of their gender expression or appearance as inducing their gender dysphoria. At times, participants described altering their gender expression and appearance in ways to offset their gender dysphoria. Finally, participants described their gender dysphoria as shifting and often attributed this to the shifting way that nonbinary individuals experience their gender.⁴

Limitations and implications

This study extends current understandings of gender dysphoria by focusing on the way it is uniquely experienced by nonbinary individuals. By design, we were not interested in accessing a clinical sample and chose to recruit a community-based sample online. Online surveys are particularly useful for reaching individuals with marginalized identities who may not be connected to community and who may have heightened concerns around identity disclosure and privacy.⁵³ This recruitment approach was successful in allowing us to reach a large sample that is geographically diverse. However, it is not without limitations. Our participants represent an online convenience sample, which have been known to oversample White, educated, and middle-class participants.⁵⁴ Our participant demographics were in line with this critique, and our results, then, should be interpreted in light of these sample demographics.

Our decision to engage a community (nonclinical) sample may mean that the experiences of nonbinary individuals undergoing hormonal or surgical transition (who may find medical solutions useful in addressing their dysphoria) are less likely to be reflected in these findings. Additional research will be necessary to understand how these findings are impacted by access to care, social economic status, and geographic/cultural factors.

Using an open-ended prompt allowed us to capture a rich dataset regarding nonbinary experience of gender dysphoria. In fact, the responses were nuanced enough that after the initial reading of the dataset we determined the need for two different analytical strategies to capture the different layers of meaning. However, a potential limitation remains, in that it was not possible to redirect and clarify responses as observed in other qualitative approaches, such as face-to-face interviews.

The present findings underscore the need for the development of clinical assessments and effective treatments for gender dysphoria, which better reflect that (1) not all trans- and nonbinary individuals desire a feminine or masculine presentation, (2) androgyny or gender fluidity may be regarded by some as the ideal presentation, (3) gender dysphoria is not static, and (4) traditional gender affirmation interventions may not address the unique concerns of nonbinary individuals. These findings may be particularly useful in guiding the development of clinical assessments, as traditional measures fail to reflect both contemporary understandings⁵⁵ and nonbinary experience¹¹ of gender dysphoria. The current findings also highlight the way many nonbinary individuals conceptualize their gender incongruence in relation to physical androgyny and see no available solution to their dysphoria. This may explain why nonbinary individuals are less likely to pursue available medical transition,^6,52 may pursue fewer treatments,⁵⁶ and highlights the need to develop explicit medical protocols for interventions, such as microdosing,⁷ that are tailored to avoid more binary expressions of gender, to achieve the desired outcome of physical androgyny.

Abbreviations Used

AMAB

assigned male at birth

FtM

female to male

GED

general educational development

HRT

hormone replacement therapy

Author Disclosure Statement

No competing financial interests exist.

Funding Information

No funding was received for this research.

Cite this article as: Galupo MP, Pulice-Farrow L, Pehl E (2021) “There is nothing to do about it”: nonbinary individuals' experience of gender dysphoria, Transgender Health 6:2, 101–110, DOI: 10.1089/trgh.2020.0041.