Do nonbinary individuals take hormone replacement therapy (HRT), such as estrogen or testosterone, as part of their gender affirmation process?

Do Nonbinary People Take Hormones?

Yes, nonbinary individuals do take hormone therapy as part of their gender affirmation process, though they may pursue tailored regimens that differ from binary transgender protocols to align with their specific embodiment goals. 1

Prevalence and Treatment Patterns

Nonbinary individuals represent a substantial portion of the gender-diverse population:

• Up to 9% of youth in the general population identify as nonbinary, and up to 55% of gender-diverse youth identify outside the binary. 2
• In specialized gender clinics, approximately 18% of patients seeking gender-affirming care identify as nonbinary. 3
• Among nonbinary individuals seeking care, 66-82% receive some form of hormone therapy. 4, 3

Types of Hormone Therapy Used

Nonbinary individuals may use the same medications as binary transgender people, but with modified approaches:

For Transfeminine Nonbinary Individuals (Assigned Male at Birth)

• Estradiol serves as the primary medication, available in oral, transdermal, or injectable formulations. 5, 6
• Anti-androgens (spironolactone, cyproterone acetate, GnRH agonists) are commonly added to suppress testosterone production. 1, 5
• Target testosterone levels are typically <50 ng/dL with estradiol in the cisgender female reference range for full feminization. 5, 6
• Nonbinary individuals assigned male at birth are more likely to receive hormone therapy (72%) compared to surgical interventions. 3

For Transmasculine Nonbinary Individuals (Assigned Female at Birth)

• Testosterone therapy induces virilization with target levels in the cisgender male range (300-1,000 ng/dL) for full masculinization. 6, 7
• Nonbinary individuals assigned female at birth are less likely to pursue hormone therapy (30%) compared to those assigned male at birth. 3

Tailored "Non-Standard" Regimens

A key distinction for nonbinary individuals is the frequent use of customized hormone protocols that differ from binary transgender treatment:

• Nonbinary individuals are significantly more likely to receive tailored hormone therapy compared to binary transgender people (11% vs. 4.7%). 4
• Tailored regimens may include lower doses, intermittent dosing, or selective use of specific medications to achieve partial rather than complete masculinization or feminization. 2, 8
• Some nonbinary individuals use estradiol alone without anti-androgens, resulting in higher residual testosterone levels than conventional feminizing protocols. 4
• Less commonly used medications such as selective estrogen receptor modulators may be employed for specific embodiment goals. 2

Clinical Approach and Monitoring

The same baseline assessment and monitoring protocols apply to nonbinary individuals as to binary transgender patients:

• Comprehensive baseline assessment includes complete blood count, liver function tests, lipid profile, glucose levels, and baseline hormone levels before initiating therapy. 6, 7
• Fertility preservation counseling must be provided before starting hormone therapy, as treatments may affect fertility. 5, 6
• Hormone levels should be checked at 3 months after initiation, then every 3-6 months during the first year, followed by annual monitoring once stable. 5, 6, 7

Expected Physical Changes

Physical changes depend on the specific hormones used and dosing:

With Feminizing Therapy

• Breast development, decreased muscle mass (3.0-5.5% reduction in lean body mass), softening of skin, decreased body/facial hair, decreased libido, and reduced erectile function. 1, 5
• Hemoglobin decreases to female reference range. 1, 5

With Masculinizing Therapy

• Deepening of voice, body and facial hair growth, menstrual suppression, increased libido, clitoral growth, and increased muscle mass. 6, 7
• Hemoglobin increases to male reference range within 3 months. 6

Important Caveats

Several critical considerations apply specifically to nonbinary hormone therapy:

• Current treatment guidelines do not include specific standardized regimens for nonbinary individuals seeking partial or selective physical changes. 4, 8
• There is a lack of research data regarding the efficacy and safety of tailored non-standard hormone protocols in nonbinary populations. 2, 8
• Nonbinary individuals who have not undergone gonadectomy and use tailored regimens may maintain higher levels of their endogenous sex hormones than those on conventional protocols. 4
• The same cardiovascular, thromboembolic, and metabolic risks associated with hormone therapy in binary transgender individuals apply to nonbinary people. 5, 6, 9
• Laboratory values should be interpreted based on affirmed gender for individuals on hormone therapy for ≥12 months, though this becomes complex with tailored regimens producing intermediate hormone levels. 6, 7