Androgynous college student has coffee with friendsGender nonbinary people—who often call themselves enby—do not identify with the male-female gender binary. There are a wide range of gender expressions and identities under the enby umbrella, including agender, gender outlaw, genderqueer, and genderfluid. Gender nonbinary people are not a monolith. Some see gender as a problematic concept to be rejected and fought. Others do not object to gender yet feel they personally do not fit into a specific gender identity. Many enbies identify as trans.

Trans people often report a feeling of gender dysphoria. This is stress, anxiety, and frustration associated with being labeled as a gender with which one does not identify. For example, a trans boy whose parents force him to wear dresses may feel intense gender dysphoria that affects his self-esteem and mental health. Gender dysphoria is highly prevalent among people who are not allowed to express their gender identity.

A person does not have to identify with either the male or female gender to experience dysphoria. Enbies can feel dysphoria, too.

What Gender Dysphoria Looks Like in Nonbinary People

Some of the DSM-5’s diagnostic criteria for gender dysphoria are inclusive of enbies. Common symptoms include:

However, the DSM-5 also focuses heavily on gender dysphoria as the desire to be the “opposite” gender. Because gender nonbinary people do not wish to be the “opposite” gender, they may not feel included in traditional diagnostic criteria.

Gender dysphoria in nonbinary people may manifest in slightly different ways, including:

Gender Dysphoria in Nonbinary Youth

Binary trans people—those who identify as male or female—and enbies generally report developing gender dysphoria around the same time. For most people dysphoria sets in around puberty, getting progressively more intense as puberty changes the body.

John Sovec, LMFT, a California therapist who works with LGBT clients, says, “Gender dysphoria is often discussed in the treatment of adult nonbinary clients, but it is important to also note its influence on the development of nonbinary adolescents. When you reflect on the pressures to fit in that already exist in a teen’s world, imagine the distress and anxiety that can manifest when gender dysphoria is present.

Adolescents are already experiencing the myriad changes that are occurring during the onset of puberty, and these changes in the body can magnify the feelings of dysphoria. “Adolescents are already experiencing the myriad changes that are occurring during the onset of puberty, and these changes in the body can magnify the feelings of dysphoria. What was once a generalized feeling of being uncomfortable with their physical sex and/or gender role can be heightened with the onset of puberty and manifest in feelings of depression, anxiety, shame, and self-hatred.

“It is important to assist adolescents in establishing their identity by actively exploring identity-related choices and encouraging identity development in their affirmed identity in a safe and supportive environment.”

Research suggests enbies face significant difficulty accessing gender-affirming health care. This may be because traditional notions of gender dysphoria take the gender binary for granted. A 2018 study of more than 800 trans youth found that just 13% of nonbinary youth sought hormone therapy, compared to 52% of binary trans youth. They were also more likely report encountering barriers to accessing hormone therapy.

The study also found that older enbies (aged 19-25) were significantly more likely than older binary youth to avoid necessary health care. However, younger enbies and binary trans people (aged 14-18) saw no differences in foregoing primary health care. Cultural shifts in attitudes regarding gender may play a role in this. As awareness of enbies increases, so too may the willingness of younger enbies to identify as nonbinary and demand gender-affirming health care.

When Nonbinary People Seek Treatment for Gender Dysphoria

Gender nonbinary people are sometimes reluctant to seek health care for gender dysphoria, as well as for unrelated issues. This may be because doctors commonly believe inaccurate stereotypes about enbies or are unaware of their existence.

A 2017 study of enbies seeking health care found that they often feel misunderstood, stigmatized, disrespected, or pigeonholed into the incorrect gender. Even when enbies seek care at gender-affirming clinics, they may encounter clinicians who are accustomed to relying on a strict gender binary. According to the study, nonbinary people may feel pressure to conform to the gender binary in health care settings.

In some cases, a health care provider may trigger feelings of dysphoria. For example, a doctor might call a chest binder a bra. This can deter enbies from seeking appropriate medical care and make it more difficult to access hormonal therapies and other treatments for dysphoria.

Research consistently shows significant health care disparities between trans and cis individuals. There may be similar disparities between binary and nonbinary trans people. This could affect access to all forms of health care, including potentially life-saving treatments that are unrelated to gender.

How Therapy Can Help Nonbinary People with Gender Dysphoria

The right therapist can provide a supportive, affirming environment for enbies with gender dysphoria. In therapy, a nonbinary person can discuss their feelings about gender in general, as well as their own gender identity. Therapy that supports these feelings instead of stigmatizing them can be a powerful antidote to the pressure many nonbinary people face to conform to a gender binary.

A therapist may also:

In therapy, a nonbinary person can better understand their own identity, become a stronger advocate for their needs, and tackle internalized dysphoria and transphobia.

References:

  1. 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. Retrieved from https://www.tandfonline.com/doi/abs/10.1080/15532739.2017.1394954
  2. LGBTQ 101: terminology and tips. (n.d.) Retrieved from https://www.kenyon.edu/about-kenyon/diversity-at-kenyon/lgbtq-plus/terminology
  3. Lykens, J. E., Leblanc, A. J., & Bockting, W. O. (2018). Healthcare experiences among young adults who identify as genderqueer or nonbinary. LGBT Health, 5(3), 191-196. Retrieved from https://europepmc.org/backend/ptpmcrender.fcgi?accid=PMC6016091&blobtype=pdf
  4. Mamone, T. (2017, October 19). Yes, non-binary people experience gender dysphoria. Retrieved from https://theestablishment.co/yes-non-binary-people-experience-gender-dysphoria-c056eb3df3c9
  5. Providing affirmative care for patients with non-binary gender identities. (n.d.). Retrieved from https://www.lgbthealtheducation.org/publication/providing-affirmative-care-patients-non-binary-gender-identities

Rear view photo of two parents and child walking along path in park in autumnParents searching for a safe place for their transgender, gender nonconforming, or nonbinary child usually have a lot of questions. One of the first things parents who reach out to me ask is, “What is gender dysphoria?” This is usually followed by, “How is it affecting my child?”

Understanding gender dysphoria is an important part of the journey to support trans youth. But many parents may not be sure what this concept means. Put simply, gender dysphoria is an internal conflict between the sex a person was assigned at birth and the gender they identify with. It is often described as a feeling of discomfort with the body a person lives in and their deeper sense of gender. This conflict can be seen in many ways. Body dysphoria, depression, anxiety, eating disorders, and self-harming behaviors are a few, but there are others. All of these symptoms can be seen as attempts to manage the deregulation that can occur when a person’s body does not represent their gender.

Gender dysphoria may be first felt in puberty, when physical changes of development begin. Children can experience discomfort before puberty, but these feelings usually become stronger as differences between the physical body and internal sense of gender increase. Imagine knowing you are male, having a masculine sense of self—in a body that begins to develop breasts. This disconnect can cause extreme anguish and anger in adolescents. Many also say they feel trapped. [fat_widget_child_counselor_right]

How Does Dysphoria Manifest?

This internal conflict is different for each person, but it is often seen as depression or anxiety. Looking in the mirror and seeing a body that does not express your internal sense of self can cause pain, unsettled feelings, and disconnect. Psychological pain may show up in a child’s behavior. Many adolescents refuse to attend school and withdraw from social interactions. Your child may drop activities that require physical contact, like sports, and avoid situations where they would need to expose their body, like pool parties.

At its most intense, body dysphoria in teens can lead to suicidal thoughts and attempts, as well as self-harming behaviors and disordered eating. These actions often result from the need to control a body that feels completely out of control and to ease the pain of an internal disconnect. These symptoms are signs that a higher level of care is needed. A therapist trained to offer support to transgender, gender nonconforming, and nonbinary adolescents may be the best person to provide this care.

Help for Gender Dysphoria

A therapist who is well-versed in working with trans youth is vital for creating a safe space for kids and families to address the challenges of gender dysphoria. The goal in therapy is not to change how a person feels or expresses their gender. Rather, it is for children and their parents to explore tools and methods of support for the feelings that surround the distress of not being able to physically express their true self.

It is important for families to develop a dynamic that is informed, supportive, and curious about their child’s journey as they explore their gender. This dynamic can create a space where different expressions of gender can be safely explored. This exploration may help relieve distress that occurs with dysphoria.

It is important for families to develop a dynamic that is informed, supportive, and curious about their child’s journey as they explore their gender.

Some of the first ways this exploration may take place is with social expression. Through social expression, a child or teen can develop their sense of self and affirm their gender identity. Your child may try out different styles of clothing and new hairstyles and ask you to refer to them by pronouns that fit their gender. They may choose a new name or try out several new names before they determine the one that fits best. These expressions can be seen as the first step in aligning themselves with their internal sense of being male, female, some of both, or neither. By supporting your child’s expressions and identity, you can help ease their distress and help them find a deeper and clearer sense of self.

The next step may be medical transition. Medical treatments that help align physical characteristics with gender include:

It is important to understand that not all people who identify as transgender, gender nonconforming, or nonbinary are interested in pursuing complete medical transition. They may choose some aspects and reject others. For example, your teen may be interested in hormone therapy but not feel ready for gender confirmation surgery. This personal choice is a part of each person’s transition.

You can help your child by encouraging open discussion and taking their feelings and wishes into account. Ask what your child thinks about medical transition. Do your own research so you can have informed discussions with your child. Careful research can help you help your child make decisions based on accurate information and informed consent.

Exploring these topics can bring up strong emotional reactions. But it is important for both you and your child that you are able to support them during their transition and talk through their options from an informed, caring position instead of a fearful, reactive one. [amazon_affiliate]

Some families may need more help and support to explore these feelings and assist a child who is dealing with the painful reality of gender dysphoria. If you are struggling to find the best way to offer support to your child, you may find it helpful to talk through your feelings with your own therapist or counselor.

References:

  1. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
  2. Rood, B. A., Reisner, S. L., Surace, F. I., Puckett, J. A., Maroney, M. R., & Pantalone, D. W. (2016). Expecting rejection: Understanding the minority stress experiences of transgender and gender nonconforming individuals. Transgender Health, 1(1), 151–164. doi: 10.1089/trgh.2016.0012
  3. Sherer, I., Baum, J., Ehrensaft, D., & Rosenthal, S. M. (2015, January 1). Affirming gender: Caring for gender-atypical children and adolescents. Contemporary Pediatrics. Retrieved from http://contemporarypediatrics.modernmedicine.com/contemporary-pediatrics/news/affirming-gender-caring-gender-atypical-children-and-adolescents?page=full
  4. Steensma, T. D., McGuire, J. K., Kreukels, B. P., Beekman, A. J., & Cohen-Kettenis, P.T. (2013). Factors associated with desistence and persistence of childhood gender dysphoria: A quantitative follow-up study. Journal of the American Academy of Child and Adolescent Psychiatry, 52(6), 582-90.

Dear GoodTherapy.org,

I need some friendly feedback with a problem I am stuck with. I am a 60-year-old male who was diagnosed 23 years ago with gender dysphoria. I have just “dealt” with it by staying in the closet, seeing a therapist as needed, and basically choosing not to entertain the idea of transition for family concerns. I am now single again, have met a nice cis woman, and would like to get serious—but I am unsure if I should be totally open about this part of me. I have always been a person of integrity, honest and truthful, which sometimes hurts others but it’s who I am.

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When I shared this with a woman once before, it ruined a chance for marriage. She was unable to even talk about it and chose to walk away. I never transitioned even partially or lived as the opposite gender. Is it important that I mention this now?

I realize society is more supportive than ever before, but there are still plenty of folks in the world who abhor anything that does not fit into the male-female binary. I have read numerous accounts where other men in a similar situation never said anything, got married, then out of the blue would share this part of them or would start cross-dressing again and naturally the wife was taken by surprise, shocked, and confused. Usually, the marriage ends and everyone is hurt.

I haven’t cross-dressed in 20 years and have no plans to start up again, but this doesn’t ease my fear at what might happen if I come clean with my new partner and prospective wife. What to do? —Questioning

Dear Questioning,

Thank you so much for writing in with this topic.

When I first sat down to reply, my inclination was to offer what I hope will be received as comfort: reassurance that you have multiple choices regarding your own communication. You are under no moral obligation to disclose any idea about gender (or anything else) to another person if you don’t want to. Your gender is your truth, and your gender does not make up the entirety of who you are.

But I imagine you are writing to a therapy website for a reason. If you were okay continuing to do what you’ve already done in relationships (after at least one very powerful, very negative experience disclosing in the past), I don’t think you would have taken the time to construct this letter.

I would like to gently challenge the narrative you have about your disclosure “ruining a chance for marriage,” shifting the blame away from you individually. Was it not your partner’s rigidity about sex and gender that pushed you away? Can we think about this as a paradigm incompatibility rather than a mistake you yourself made?

In general, if someone is looking for a “serious” relationship (as you say you are now), a critical part of the early stages is getting to know the other person and collecting evidence for whether you will be compatible long-term, is it not? It sounds like some of the anxiety you are experiencing is the normal anxiety of any person in a new relationship—“Will this person turn and run if I share what I really feel inside? Is it safe to trust this person?” Of course, in your case, some of the baggage also carries a gendered focus you have been painfully discouraged from sharing in the past. So far, though, you’ve only alluded to a sharing of ideas, which I hope any partner would remain available for.

I think deconstructing and delineating gender roles is helpful in any relationship, not just in a relationship where one partner is transgender or gender dysphoric. It sounds like you may not decide to “medically” transition in a surgical or hormonal sense, but wouldn’t it be nice to break out of the confines of masculinity as they may be prescribed upon you?

I imagine you have witnessed a great deal of social change regarding gender roles across your lifespan. From this, and from other life experiences, what have you come you expect from yourself, and what do you need in order to feel supported, affirmed, and loved in your relationships? If this includes permission to be fluid and expansive in your expressions of gender, then that is something you are entitled to pursue. If this includes simply the space to air what you’re thinking, free of judgment, that is also completely reasonable. If the relationship is healthy, your partner should not attempt to serve as some sort of mind police for which thoughts are and aren’t okay for you to have and for you to explore. In my experience, our identities, thoughts, and desires are not very good at obediently conforming to socially-sanctioned categories.

When I am working with someone who has come to therapy to explore their sense of gender identity, one of my subgoals is to help them seek out affirming community outside of the therapy room. Whether you decide to formally “transition” or not, having folks around who will appreciate your honesty and not force you to adapt to rigid and even false categories will help you feel more liberated in all of your relationships.

You don’t mention what region you live in, but I will acknowledge that certainly some places are friendlier than others toward those who don’t fit into a simple male-female binary where biological sex and expressed gender align. I also won’t pretend that my own age bracket (I’m 29) isn’t generally more accepting of gender expansion than your generation in many cases. But that doesn’t mean the resources for support and understanding aren’t out there. To find in-person support, PFLAG, a wide-ranging national organization, should be able to connect you to affirming transgender resources within an hour’s travel or so of where you are living if you are living in the States. I’ve also listed some other online communities in the Resources section at the end of this article.

It is nice to have the freedom to speak difficult and complicated truths within our partnerships. But it’s not just nice: this freedom also forms the foundation of safety and trust.

I have found that establishing a social support net that can “catch” you when the going gets tough—whether this support comes remotely or in-person—can, in a sense, lower the stakes of a relationship. You have reinforcement. But that doesn’t mean that there isn’t a specially-reserved form of terror for our most intimate partnerships, particularly if we have experienced abandonment following the decision to open up in the past.

In 2007, I gave a report on what was then referred to as Gender Identity Disorder, which included a description of the legal entitlements of spouses to recipients of this diagnosis. If individuals were married, spouses used to be required to sign off on a medical decision if their partner was seeking sexual reassignment surgery. Remembering this report has me thinking now: what are the functions of disclosing gender dysphoria to one’s partner? Is it to clear the air, or is it maybe to help them plan for some sort of action? It summons the idea that our identities are most often formed in relation to others, and that to have a partner who challenges gender might mean we challenge our own identities, too. Marriage and intimate partnership can create a sort of collaborative identity formation, but this doesn’t mean you should sacrifice that which is precious to you.

Are you interested in wearing differently-gendered clothing in the presence of your partner or in trying out different kinds of sex other than p-i-v intercourse? These are behaviors of interest to a broad range of people, including those who do not identify as trans. I do not ask these things to suggest that gender dysphoria is the same as having a cross-dressing kink, or is a kink at all. I ask because my ideas about communication on the topic of gender dysphoria are informed by the same kind of openness and honesty I encourage when working with sexual minorities and kinksters.

My concern for you continuing to maintain the status quo of past relationships is that our unrealized desires so often have a way of breeding resentment if pushed away or neglected for too long, either by ourselves or by our partners. It seems you have more than two decades of experience with this.

It is nice to have the freedom to speak difficult and complicated truths within our partnerships. But it’s not just nice: this freedom also forms the foundation of safety and trust. I am admittedly biased; as a relational therapist, I have a strong leaning to encourage others to put all their cards on the table and to keep the lines of communication open. But I’m not alone. For example, in his “sexpert” blog, Reid Mihalko claims that it’s what we’re NOT saying that’s damaging our relationships. He makes the following case for transparency:

“If you share the things you think might end the relationship and the relationship doesn’t end, now you’re having a Relationship with a Capital R! Sure it’s scary to say the scary things, and it’s bound to kick up a lot of emotional flotsam at times, but what if you and your partners could work through it? What if letting the “cat out of the bag” built more trust and a deeper sense of security and intimacy than wondering if your partner is withholding important things from you?

When you say what is not being said, especially the big, bad, hairy, scary stuff, you model for your loved ones that they can share all the things they’re not saying, too. Over time, you get to know your partners more as they get to know you more, and you’ll realize that they’re choosing to be in a relationship with the real you, not some façade of who you think they need you to be.”

I will admit that we do not live in a universally gender-progressive utopia, and it is certainly not often safe—emotionally or physically—to disclose our grapplings with traditional gender roles. As an example of complex intersectional identities, Asiel Adan Sanchez shares a complex narrative about how their relationship to a Mexican cultural identity complicates their gender identity narrative and how the traditional notion of coming out can lead to cultural and ethnic erasure. I won’t pretend these categories are simple. I also don’t know your cultural context, your given family history, or how long your previous relationships lasted: certainly these factors can reasonably affect your choices about how you experience and express gender. Since you are the only one who has to live your life, only you can know what decisions are best for your specific context.

Your letter brings to the surface so many ethical quandaries we all wrestle with regarding intimate disclosure! To what extent are our partners entitled to the regulation of our minds and of our bodies? No matter how you answer these questions for yourself and your new relationship, I sincerely hope you find a safe, affirming, and healthy way to explore feelings, roles, and identities—not just in a confidential therapy room or anonymous online forum, but in the safety of romantic partnership as well. I wish you the best!

Warmly,

Sharon Glassburn, LMFT

References:

  1. Adan Sanchez, A. (2017, July 7). The whiteness of ‘coming out’: culture and identity in the disclosure narrative. Archer Magazine. Retrieved from http://archermagazine.com.au/2017/07/culture-coming-out
  2. Mihalko, R. (2012, March 20). Say what’s not being said: Reid’s formula for difficult conversations. Reid About Sex. Retrieved from http://reidaboutsex.com/difficult-conversation-formula

Resources:

Tall person with short hair wearing bowtie, shirt, slacks, and heeled boots kicks out against splashes of paintSophia Dembling wrote, “One of the risks of being quiet is that the other people can fill your silence with their own interpretation: You’re bored. You’re depressed. You’re shy. You’re stuck up. You’re judgmental. When others can’t read us, they write their own story—not always one we choose or that’s true to who we are.”

But sometimes even when others could choose to “read” us—by being curious, asking questions, and collaborating with us and honoring what we value—they choose to write over us instead. This is particularly true when one person has more social power or when their values are already maintained by external forces. They have more permissions already; they have more of a voice. In these situations, we might not be quiet by nature so much as silenced.

Asserting Experience and Identity

Some aspects of our lives come more pre-packaged and scripted than others—namely, our stories about gender. And we haven’t got a fighting chance to tell our own gender story if it’s been decided for us before we are even able to speak or choose our own adornments—for most of us, this takes place before we are even born. Ideally, babies would come into a home where love can be flexibly provided for many variations of expression—but many of us will be subconsciously “shaped” into something “More Appropriate” if we deviate from culturally-sanctioned ideals. [fat_widget_right]

If you are cisgender, this may not feel oppressive. If your community affords men and women (and your gender is one or the other) a great deal of fluidity, flexibility, and freedoms, this may not feel so bad.

But even if this is your experience, it is not everyone’s—or even most people’s—experience. Keeping this in mind, listen for stories that differ from your own.

Transgender and gender non-conforming folks claim the permission of asserting (not choosing) their gender identity and sense of self rather than accepting what has been assigned to them. This becomes increasingly necessary if what has been given to them (“prescribed” gender, typically based on the sex category assigned to a person at or before birth) never fit that person, no longer fits that person, or sometimes doesn’t fit that person. Transgender and gender non-conforming people are claiming their own power over their bodies and voice.

It is here I want to assert my position: unless a person is directly harming another person, how they want to speak or adorn themselves is not for us to decide—unless we are that person’s parent. When we take on a parental role with a person we are not parenting, we are indicating we have decided we are not equals with the person, that we cling to a sense of power over them. (For instance, when we become the “gender police.”)

Narrative Therapy: Co-Creating Meaning

The following description of narrative therapy comes from the Dulwich Centre in Adelaide, Australia: “Narrative therapy seeks to be a respectful, non-blaming approach to counselling and community work, which centres people as the experts in their own lives.” I distinguish here between therapy styles that give people expertise over their own lives vs. the power our mental health system has traditionally exerted over those who come for help. Narrative therapists co-create meaning with the people they are treating; traditional therapy prescribes meaning onto the experiences of the person in therapy.

Narrative therapy acknowledges the power discrepancies between therapist and person in therapy but seeks to minimize them as much as possible. This modality is a collaborative, democratic style of therapy where what something means to the person in treatment is equally or more valuable than what something means to the therapist.

(I don’t want to pretend a truly democratic relationship can exist between therapist and person in therapy. Not only is there a transaction of money, but—in the case of individuals advocating for their own gender transition and especially in the case of those desiring hormone therapy—therapists are also in a position to determine whether or not the individuals they are treating are “of sound mind.” Thus they are the gatekeepers of access to desired medical treatments.)

Narrative therapy acknowledges the power discrepancies between therapist and person in therapy but seeks to minimize them as much as possible. This modality is a collaborative, democratic style of therapy where what something means to the person in treatment is equally or more valuable than what something means to the therapist. It involves listening to the words of the person receiving therapy, tracking the themes relevant to their life, and determining which stories were authored authentically by the individual and what stories were told to them and enforced by the Powers That Be.

Tactics Used in Narrative Therapy

In an attempt to subvert some of the gatekeeping power that has existed within my profession since its origin, I wanted to write about some narrative therapy tactics that can be self-taught and used by the chosen family and communities of transgender and gender non-conforming individuals in order to support and enrich their loved ones’ sense of self! Chances are, you are already using some of them.

In Practice

How can we do this? One of my favorite exercises to facilitate with multiple people in therapy is to ask them to think of a time they felt confident and tease this out. I have them name what they valued about that version of themselves and what made it possible. The other person (or people) is/are assigned to “track” instances of when they caught that person exhibiting those traits in their present life, in their present interactions. This can be effective for people battling depression, when they feel the “old” them is lost, as this can serve to remind them their “true” self still exists—but this exercise can also be of great benefit in affirming the gender expressions of those we love!

If your friend or loved one is transitioning, find out the values of the gender identity they are looking to embody and affirm them! If your friend’s experience of self exists outside of the language surrounding gender, don’t praise them for being “rational and fair” or for being “so pretty and thin.” Instead, figure out what matters to them and make an effort to witness them living these values authentically in the world. See them in the ways they need to be witnessed and affirmed.

References:

  1. Blakeslee Salkil, S. E., & Goff, J. D. (2014). LMFT Exam Preparation Workshop [Powerpoint]. Self-Published: Family Education Resources, LLC.
  2. Dembling, S. (2012). The introvert’s way: Living a quiet life in a noisy world. New York, New York: Perigee Books.
  3. Dulwich Centre. (n.d.). What is narrative therapy? Retrieved from: http://dulwichcentre.com.au/what-is-narrative-therapy
  4. Family Solutions Institute. (2011). Marriage and family therapy national licensing examination preparation: MFT glossary. Jamaica Plain, MA: Self-published.
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