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Are You a Boy or Girl? No: Living Outside the Gender Binary


By Emmie Matsuno (Counseling Psychology doctoral student, University of California, Santa Barbara)

Transgender people are 25 times more likely to make a suicide attempt than the general population. Despite the high risk for a number of negative mental health outcomes, less than 30% of psychologists and psychology graduate students report familiarity with issues that transgender people experience. It’s likely that even fewer are familiar with non-binary gender identities.

Without knowledge about this vulnerable population and the best ways to support them, mental health providers may unintentionally mistreat gender non-binary people, who may perceive a lack of competence and resist treatment as a result. This article provides tips to mental health providers for working with gender non-binary clients. Even if a counselor has no experience working with any of these populations in the past, they can still be successful by avoiding assumptions and taking the role of a learner.

Gender non-binary is an umbrella term for many different gender identities, including identifying as both a man and a woman (bigender), neither a man nor a woman (agender), or another gender entirely (genderqueer). Although non-binary genders are not yet recognized in the U.S., other indigenous cultures around the world including India, Australia, and Germany are more accepting that there are more than two genders. In fact, currently 7 countries have legal gender markers outside traditional “female” and “male” categories.

Cultural competence for working with non-binary clients is important because:

  1. 30-40% of the transgender community identifies outside of the gender binary. That’s nearly a quarter of a million people in the U.S. (the equivalent of the entire population of Orlando, Florida).

  2. Some evidence indicates that gender non-binary people may be at the highest risk for mental health concerns within the transgender community.

  3. Gender non-binary people experience different kinds of stigma and discrimination compared to transgender people who identify as men or women (e.g., people thinking they are confused or that their experience is invalid).

So while gender non-binary people are a large portion of the transgender community and are at potentially even greater mental health risk than other transgender folks, little research has been conducted on gender non-binary individuals, and practical implications specific to this population remain unaddressed.

As a gender nonconforming counseling psychology PhD student, my research focuses on transgender mental health, and I work closely with the transgender community in clinical and community settings. Here are things I’ve found really useful to do in my work with this population.

  1. Avoid gender binary assumptions. Gender identity is not based on outward appearance. You can’t tell anyone’s gender by looking at him or her or them. If a client expresses that they are questioning their gender, avoid assuming that means they will want to transition into the other binary gender (e.g. “So you think you are actually a man?”).

  2. Understand there is no right way to “transition.” While many transgender people including gender non-binary clients do want to go through various medical procedures such as hormone therapy or surgery, some transgender people do not want a medical transition and don’t need one to feel satisfied in their bodies.

  3. Practice using “they”/“them” as a singular pronoun. Always follow the client’s lead in terms of what pronouns to use. For example, many non-binary clients use they/them pronouns. The singular “they” was announced word of the year by the American Dialectic Society in 2015. It is here to stay. So while it may be difficult to get used to, it is important to respect the pronouns that your client uses. Practice, practice, practice.

  4. Identify yourself as an ally. Transgender clients will often be on the look out to see whether they we be accepted and supported by the therapist. Having stickers, signs, or brochures that identify you as a transgender ally can go a long way in building trust with clients.

  5. Create inclusive forms. Intake forms can have a large impact on whether or not non-binary clients trust the therapist and/or agency. Forms can be inclusive of all transgender identities by having a write-in option for gender and by including a pronoun section. This simple step can go a long way.

These small steps can make a huge impact for gender non-binary people who experience severe anxiety from unaffirming environments and are desperately searching for a safe space to be themselves.


Emmie Matsuno is a third year PhD student in counseling psychology at University of California, Santa Barbara (UCSB). She works with Dr. Tania Israel and project RISE conducting research on LGBT mental health and well being. Her personal research focuses on creating inclusive and supportive environments for transgender people. In addition to research, Emmie is currently an intern at Pacific Pride Foundation and volunteers for other organizations including the Santa Barbara Transgender Advocacy Network (SBTAN), Just Communities, and the Trans Task Force at UCSB.

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