Trans and nonbinary people and the subject of sex

Where we’ve been and where we’re going on matters of sex and knowledge production

A friend sent me a paper recently, which got me thinking about sex. Not physical acts, but “biological sex.” The way we name it, study it, talk about it, and now, as a major issue of the “culture wars,” civil rights, and dignity for trans people.

For the past few years across social media, I began to notice a rejection of the terms “AFAB” and “AMAB” from some trans and nonbinary people, with some even mentioning the terms were “TERFY.” This was mostly when I was on TikTok. This stunned me, having been in trans communities and around trans health research for nearly 20 years.

This post will offer some reflections on evolutions in terms that relate to sex used by trans researchers within the fields of trans health/trans studies/gender-affirming care. It will end with some concerns about the risks and pitfalls of rejecting sex as a construct in research and academic knowledge production that involves trans and nonbinary people.

Female-bodied, male-bodied, AFAB/AMAB

AFAB/AMAB were introduced first in intersex research, but later adopted by advocacy efforts to acknowledge that trans/nonbinary/intersex people exist and that sex + gender identity are not always aligned, and not always easily categorized. These terms are part of long-standing efforts to more accurately categorize and study real sex/gender-diversity that exists in the human population (but not without problems, thinking about some aspects of the history of sexology and psychiatry with sexual minorities). But AFAB/AMAB also come from a long lineage of efforts from within trans community to recognize, study, and discuss ways in which sex shapes some of our most important life experiences.

Other terms also did this, but by now have now mostly fallen out of favour (at least in my circles). When I came out as genderqueer and later as FTM/trans in 2009-2010, the term “birth sex” and “birth name” were floated around in the acceptable trans-inclusive lexicon. We also had “female-bodied” or “male-bodied” and “natal female” or “natal male.” I still occasionally see some older (think elder millennial or boomer-aged) trans academics or trans elders use these terms. So it’s been interesting to observe the unfolding discourse about “AFAB/AMAB” and what is considered “TERFY” or not. I’ve started to pay more attention.

I began to pick up that this implicit or explicit rejection of sexed terms like AFAB/AMAB was not only contained to online trans discourse. I’ve also noticed a bit more reluctance to collect and analyze data on sex within some my own research networks of trans or nonbinary (TNB) academics. I’ve been involved in projects in which the research team has been advised by some members of the trans/nonbinary community not to collect or report data on the assigned sex of the research participants. This is not such an issue when presenting data about trans men or trans women (where assigned sex can generally be inferred). But a generalist categorization of nonbinary people that leaves out whether participants are AFAB or AMAB can obscure important, granular intra-population differences that social science and health science benefits from knowing about, and that TNB people themselves have a right to know.

As an example, this hot-off-the-press paper, published in Preventative Medicine, presents an analysis of rates of reported “activity limitations” among trans and nonbinary Canadians, using Canadian census data. It’s titled “Gender identity and activity limitations: A national study on transgender and non-binary Canadians.” The researchers define activity limitations as physical, cognitive, and learning disabilities, mental health challenges, and access to healthcare infrastructure and community supports. Canada was the first country in the world to collect census data on both sex and trans identity data, so it’s really exciting to see papers such as these being published! (Note: I do know and have co-authored with a few of the authors on this paper.)

The paper presents a robust analysis with an important finding—that nonbinary people who are assigned female in birth reported the highest levels of activity limitations, disabilities, and adversities, compared to other TNB groups:

That is an important finding for mental and physical health care providers, occupational therapists, policy-makers, the TNB community, etc., to know and respond to, with improvements in formal supports and tailored policy interventions.

But it would not have been possible to discover this without somehow measuring sex-as-assigned!

Yet, I was struck by the following with regards to the sex-based aspect of the findings:

While some non-binary individuals use AFAB and AMAB to describe their experiences, these terms are not representative of all non-binary identities. We use this disaggregation to identify health disparities influenced by socialization, stigma, and biological factors, enabling more targeted interventions. However, we recognize that emphasizing sex differences within the non-binary category may inadvertently reinforce cisnormative frameworks contributing to systemic health inequities.

I’m glad that the researchers are being inclusive and sensitive to the way that trans and nonbinary people are affected by cisnormativity, sex dysphoria, and how we negotiate identity, language, and systems that are often non-affirming and exclusionary. Many gender-diverse people struggle with being thought of or classified in relation to assigned sex.

But, as a researcher, I am also very glad that the team analyzed both sex and gender identity-based differences on disability and limitations. Empirical trans health research, Trans Studies, Mad Studies, Disability Studies theoretical writings, and public health and health sciences all widely acknowledge that both sex and gender as significant social and biological determinants of health and well-being. However, I am not quite sure what is being implied by the notion that AFAB/AMAB is “not representative of all non-binary identities.” Is it that alternative terms to describe sex/gender may be more inclusive, such as transmasculine or transfeminine? Or is it meant as a nod to these broader debates and encouragement to reject sex as a category of relevance?

I wonder if this trend to reject or be more skeptical of sex in the broader community discourse is beginning to trickle into academic knowledge production. And it might be related to these two, interrelated aspects:

• 1) sex/gender dysphoria, that is, distress associated with sex characteristics and being seen and treated as a member of one’s assigned sex/gender, and discordance between sex/gender identity; and

• 2) a reaction to gender-critical/TERF rhetoric (e.g., “you can’t change sex”; “TiF” and “TiM”; only biological sex is “real” and gender identity is somehow “made up”; etc.).

Point 2 is also very likely amplifying point 1 and creating heightened sex/gender dysphoria and a reactionary response among the TNB people who are following these debates. There is also obviously an ideological battle and a political element that is outside of the scope of this writing… (More on Point 2 a bit later.)

If you have other interpretations, please share in the comment section below.

In my view this is somewhat new in the sense that I don’t recall there being much opposition to studying and talking about sex in the past. Despite often having sex/gender dysphoria, trans people have always found creative ways to recognize and talk about sex. Trans people have written great books on sex/gender. Trans people are sex researchers.

Because sex matters to trans people, too. Not because sex is destiny, or because sex traits are unmodifiable, but because it matters to trans healthcare, and to civil rights. Tacit recognition of the intersectional dimensions of sex/gender is baked into our community language practices—transmasculine or transfeminine, FTM or MTF.

Sex matters, for example, for medicine to masculinize or feminine our bodies.

Dr. Jamison Green, who was among one of the first well-known trans man activists and president of the World Professional Association of Transgender Health (2014-2016), wrote in 1996:

My first acquaintance with any literature on female-to-male (FTM) transsexuals occurred in 1984 when I was trying to determine what options were available to me as a male-perceived, masculine identified, female-bodied individual…

Green wrote this in a Foreward to FTMs: Female-to-male transsexuals in society, first published in 1997. This is a book written by another trans man academic, Dr. Aaron Devor, who was among the first to write about FTM identity development, female gender dysphoria, and all the unique experiences of trans men and other transmasculine people that are shaped by not only gender identity, but also by sex. Devor published Gender Blenders in 1989, which he believes to be one of the first academic books about nonbinary (AFAB) people. It was written before the words “nonbinary” or “transgender” were ever even popularized. At the time, he was writing about gender nonconforming AFAB people who did not fit neatly into psychiatry and sexology’s initial categorization of trans, in which there were only two types: transsexuals and transvestites. He once told me that, in hindsight, he was writing about nonbinary people. Gender blenders defied the earlier two-type trans classificatory system.

Sex also matters to understand whether we are transmisogyny exempt, or affected, and the impact that specific minority stressors might have on our lives—which is a way of tacitly recognizing that trans men and trans women have different experiences in society. Much of the minority stressors and life adversities that TNB people persistently contend with begin with biological sex, followed by (often unwanted) socialization into a sex/gender role that is eventually repudiated. And much of this begins with the way our caregivers (and the rest of society) respond to perceived discordances and deviations from expectations for sex/gender, and the way others respond to the desire and process of transitioning.

Changing sex traits is also the key objective of gender-affirming healthcare, which some clinics and researchers prefer to call transition-related care because its interventions are aimed to transition people’s bodies, to either masculinize or feminize their sex. This also includes nonbinary people who seek transition-related hormonal or surgical treatments.

Where we’ve been and where we’re going

A couple years ago I caught a post on Twitter made by, if I recall, Julia Serano (Switch Hitter on Substack). She once said something to the effect of not being a big fan of AFAB/AMAB and preferring FTM and MTF because “it says where you’ve been and where you’re going.” (My apologies if I have butchered this, or attributed it incorrectly. But the basic principle stuck with me.)

This of course applies mainly to transsexual/trans, and less to nonbinary (though I do know nonbinary FTMs and MTFs and nonbinary detrans folks, too). But it’s another way of talking about our assigned sex and the pursuit of changing sex characteristics. Today, to talk of “sex change” is pretty much seen as outdated. But I also know many trans people who, after hearing repeatedly that “you can’t change sex,” would like to bring it back into popular use.

FTM and MTF are still very much used as a short hand to signal specific transition trajectories and identities in trans online spaces and IRL. In detrans online spaces, people refer to themselves as FTMTF, MTFTM, or FTMTX or MTFTNB. Why? Because transitioning and detransitioning will typically involve, for many, efforts to change aspects of primary and secondary sex characteristics. Because physical sex traits directly affect how people perceive and relate to one another, socially.

Detransitioned people who have had a long medical transition with extensive transition-related hormonal and surgical care, particularly detrans women/females who have taken testosterone for many years, may have a tough time reversing some or all of the physical changes. Surgeries, particularly genital surgeries or gonadectomy, are completely irreversible. I know some people who have detransitioned after a complete “sex change” and 12+ years on T, completely stealth, who worked in male dominated labour careers before deciding to detransition. Not unlike an MTF transition, this is not often easy to do. Many of the testosterone-caused changes are irreversible or difficult to reverse. Despite often having a concordant assigned sex + gender identity after detransition (AFAB + woman; AMAB + man), there is still exposure to gender minority stressors and discrimination for being perceived as gender nonconforming, based on changed sex characteristics. Mainstream trans discourse would call this combination of assigned sex + gender identity “cisgender” and researchers might code it as such. But this is not a cisgender experience. Is it a transgender one? What if the person rejects in their strongest possible terms that they were ever transgender?

With detransition as an emerging experience in need of more research, particularly with regards to mental health and well-being, researchers will need to collect and analyze data on assigned sex, medical transition interventions received, along with multiple current and past gender identity measures. A simple binary trans/cisgender classificatory system is no longer sufficient.

There are very real and mounting threats to TNB people (and really all gender nonconforming people and sexual minorities) in this political moment, particularly in the UK and in the US. It has had a major impact on myself, my friends, my colleagues, and many people I know and love.

But I am growing concerned that, although justifiable and understandable, a community response to reject sex is unfolding in response to the rise of gender critical rhetoric and legislation that prioritizes sex over gender identity. And it is trickling into research and knowledge production endeavours. This is leading to some researchers feeling pressure to forget about sex or to minimize it in the name of inclusion, sensitivity, and epistemic justice for TNB people. But that would be a step backwards in my view, and it ignores decades of effort by trans people to advocate for collecting and reporting data on both assigned sex and gender identity, together.

It’s nearly impossible to think and write about TNB lives, and transition or detransition-related experiences, without accounting for sex in some way. I’m not even stuck on calling it AFAB or AMAB. But it does need to be named, studied, and accounted for due to the very real ways that it shapes our lives from the womb to adulthood.

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