Exploring a Nonbinary Approach to Health

“Hi! My name is Natalia, and my pronouns are she/her/hers.” The first time I heard this introduction, I was confused. I mean, it was obvious to me that Natalia was a woman. Why were we spending time identifying the obvious?

Then I remembered my friend’s child. Assigned female at birth, at four years old Emma (a pseudonym, story shared with permission) started talking about not feeling like a girl and became increasingly sad and withdrawn over the next several years. After a long, thoughtful exploratory process with her family and an informed therapist, Emma adopted a new name, Justice, and a new set of pronouns — they/them/theirs. It was a little confusing for us to understand at first, and then hard for me to remember the new pronouns — but my kids were very good at reminding me. Over time, I realized that it came down to my comfort versus theirs. Seeing this child thrive in the non-binary space that our family helped support makes it all seem worthwhile. 

There are people who appreciate these spaces being made and others who are offended by any mention of their pronouns. “Gender inclusivity can build that rapport — and also undermine it,” reports a Washington Post article on the topic. Although many nonbinary patients who have faced years of intolerance, stigma, and discrimination in medical care welcome the standardized use of gender pronouns for everyone as a visible sign of support, other people are confused and uncomfortable with — or even hostile toward — being asked about their gender identity. This can leave care providers unsure of what to do. Gender-nonconforming healthcare providers are in an even more difficult position because they may be trying to provide informed care in an uninformed system, all while experiencing bias themselves.

As illustrated, conversations about gender and sex have become more complex these days. Or rather, they’ve always been complex, as a recent New York Times article documents, but the tension some people felt was rarely acknowledged. In any case, in 2021, we are in a moment when the struggles of trans and nonbinary youth are being more broadly acknowledged, including the concerning fact that more than half seriously considered suicide in the past 12 months. New data from the National Survey on LGBTQ Youth Mental Health 2020 highlight contributing reasons like discrimination and physical harm, housing instability, barriers to accessing mental health care, and the impact of conversion therapy. How best to apply the principle of primum non nocere (first, do no harm) seems less straightforward these days.

So, what is a well-meaning, equity-focused public health organization like NICHQ to do?

1. Recognize what has changed. What we may think of as “gender” and “sex” is not as straightforward as we may have learned. “Intersex” is a general term used for people who don’t fit the typical binary notions of male or female bodies – people who have differences in sex traits or reproductive anatomy. According to InterACT, Advocates for Intersex Youth, being born intersex is more common than being born an identical twin. Studies have shown that as much as 1.7% of the population globally has some sort of difference of sex development (DSD), meaning at the chromosomal level (XXY instead of XX or XY), related to reproductive anatomy (ovaries and testes), and/or variances in genitalia and secondary sex characteristics. It is a fact that our limited definitions of gender don’t always reflect the continuum of biological sex.
    
2. Consider a range of perspectives. In addition, our physical manifestations of gender vary based on culture and tradition as well as individual choices. We don’t always think about the day-to-day decisions we make and how we each adapt the rules to suit our needs – even those of us who identify with the gender we were assigned at birth. Many cisgender women have short hair and rarely wear dresses. Are they any less female? How do we feel about men in kilts or with long hair or who wear jewelry? These questions are posed to help us think more critically about the attitudes and beliefs we hold about gender, sex, and the expression of both.
    
3. Focus on your internal organization. NICHQ has been navigating this new territory, along with other nonprofits who serve diverse groups. We have made an explicit commitment to racial equity and have been examining our internal and external work, structures, and language. Gender identity and expression is a new part of our equity journey and an important component to holding space for intersectional identities. We have done a workshop on the topic and many of our staff have added pronouns to their work email signatures and Zoom identifiers. This is only a start, but we will approach this facet of equity work with the same openness and accountability as we do our racial equity work.
    
4. Ensure that your public work reflects your internal commitment. Our perinatal project portfolio has lent a new urgency to this issue. While a large majority of people giving birth identify as cisgender women, research in 2016 found that as many as 1.4 million American adults (0.6%) identify as transgender. If we imagine that maybe a third of trans men or nonbinary people get pregnant, that is more than 200,000 people who give birth but don’t identify as female (and who might not identify with the term “mother.”)
   
   At the same time, the title of “mother” will always have a special resonance in our society. We might refer to “birthing people,” but almost all of them will deliver in a “maternity ward” and many will benefit from “maternal” health research. How is the importance of addressing the U.S.’s high rates of maternal morbidity and mortality complicated by talking about birthing people in addition to moms? What harm is done by not providing compassionate healthcare to gender-diverse patients?

NICHQ is not abandoning the traditional use of the terms “mother” and “maternal.” We are embracing the inclusive language of “birthing person/people” across our work. A move toward inclusive language does not force us to stop using language that so many people identify with; at its core, inclusion is about creating more space for one another. We are taking care to expand the use of these terms in our communications, on our website, in our resources, and eventually, in all our projects. This evolution is another aspect of NICHQ’s commitment to equity in all forms, including race, nationality, gender identity, sexual orientation, and ability.

NICHQ’s vision is to create a world where “every child achieves their optimal health.” A commitment to optimal health does not guarantee children the same outcomes, but every child deserves informed care from professionals who are compassionate, open to learning, and most importantly – willing to change. Our shared commitment to create a world where every child achieves their optimal health is what will truly make a difference for children like Justice, who thrive most when they can live authentically. We are proud to serve all families, children, mothers, and birthing people, and we welcome you to join us on this learning journey.