Non-Binary Gender Identities: Providing Affirmative Care

Katherine Nulicek MSW, Julie Rohovit, Ph.D.

Non-Binary Gender Identities

Gender identity, or an internal sense of ones self, develops over time and is not confined to sex assigned at birth. Gender identity can develop over the lifespan and may change over time. Thinking about gender as binary (assumes that there are only two genders, and they correspond to an individual’s sex. The idea that there are only two genders (girl/woman /feminine or boy/man/masculine), and that a person must strictly fit into one category as determined by their sex, is an idea deeply woven into many societies. A different way to think about gender is that it is fluid and more like a spectrum. A person who identifies as non-binary holds a gender identity that falls outside of the gender binary, and their gender identity doesn’t match the sex they were assigned at birth.

Glossary of Terms

  • Agender – (adjective) – Describes a person who identifies as having no gender, or who does not experience gender as a primary identity component.
  • Bigender – (adjective) – Describes a person whose gender identity combines two genders.
  • Gender fluid – (adjective) – Describes a person whose gender identity is not fixed. A person who is gender fluid may always feel like a mix of more than one gender, but may feel more aligned with a certain gender some of the time, another gender at other times, both genders sometimes, and sometimes no gender at all.
  • Genderqueer – (adjective) – An umbrella term that describes a person whose gender identity falls outside the traditional gender binary of male and female. Some people use the term gender expansive.
  • Non-binary –  (adjective) – Describes a person whose gender identity falls outside of the traditional gender binary structure of girl/woman and boy/man. Sometimes abbreviated as NB or enby
  • Pangender – (adjective) – Describes a person whose gender identity is comprised of many genders or falls outside the traditional cultural parameters that define gender.
  • Transfeminine –  (adjective) – Describes a person who was assigned male sex at birth, but identifies with femininity to a greater extent than with masculinity
  • Transmasculine – (adjective) – Describes a person who was assigned female sex at birth, but identifies with masculinity to a greater extent than with femininity.
  • Two-spirited – (adjective) – Describes a person who embodies both a masculine and a feminine spirit. This is a culture-specific term used among some Native American, American Indian, and First Nations people.

Adapted from Goldhammer, H., Malina, S., Keuroghlian, A. (2018). Communicating With Patients Who Have Nonbinary Gender Identities. The Annals of Family Medicine Nov 2018, 16 (6)


Chart – Pronoun examples: Subjective, Objective, Possessive

  • They, Them, Theirs
  • Ze, Hir, Hirs (Zee, Hear, Hears)
  • She, Her, Hers
  • He, Him, His

When people make assumptions about gender without asking an individual about their pronouns, the likelihood of misgendering someone increases. Misgendering is referring to someone using incorrect pronouns. Being misgendered is a common experience for non-binary individuals, and it creates a barrier to receiving affirming care. Despite a person’s intentions, a mistake without an apology can be harmful to nonbinary individuals.

Making mistakes

Providers may shy away from conversations about gender out of fear of making a mistake, misgendering, and hurting someone. It may take practice to become comfortable having conversations, and it is okay to make mistakes, as long as you show humility. If you do make a mistake, apologize and ask for an individual’s correct pronouns. Nonbinary individuals encounter discrimination that affects their experiences of care. A thoughtful apology after misgendering someone has the potential to repair the relationship after a mistake.

Best Practices

There are ways to affirm peoples gender identity in clinical practice

  • Ask for names and pronouns routinely – Someone’s name might not be the same as the name on their file. Ask and respect how to address individuals.
  • Receive permission to share a client’s name and pronouns with other staff so they can refer to clients respectfully.
  • Operate from an approach that is not limited to a gender binary
  • Be familiar with transgender resources for making referrals that are affirming and safe.
  • Take cues from clients using language they feel comfortable using.
  • Be honest and humble about your mistakes. Apologize and show a willingness to grow.


Clinician: Hi Jaqueline, thanks for coming in today. My name is Joss and my pronouns are she/her. Before we get started I like to check in with clients to make sure that I am using their preferred name and pronouns. How should I address you?

Client: I go by Jerri and use they/them pronouns.

Clinician: Ok, great Jerri. Thanks for letting me know. Are you comfortable with me making a note of this so that other providers know how to address you correctly?

Client: Sure, I’m ok with it.

Clinician: Thanks. I am committed to honoring all gender identities, that said if I miss-gender you, are you willing to draw my attention to the mistake If I don’t catch it?

Client: Sure.

Clinician: I appreciate your willingness.