The systematic denial of gender-affirming treatment to non-binary people
“At present, there is no healthcare cover for all non-binary people who do not, therefore, require hormone treatment.” This was the response from the Puerta del Mar University Hospital to a complaint from a non-binary person regarding the refusal of hormone treatment. And this is not an isolated case, neither at the Trans Unit in Cádiz nor at the eight Trans Units across Andalusia in general. Written refusals are rare, and the reasons vary; sometimes the refusal of treatment is justified by a “lack of clear gender dysphoria” or the absence of a visible social transition in the eyes of the doctor at the Trans Unit.
We have known for years that this is the situation. For this reason, most LGBTIQA+ organisations advise non-binary people who wish to start hormone treatment to lie, to present themselves at the Trans Unit as a trans man or trans woman. However, this also has its problems. On the one hand, on an emotional level, as, once again, one has to hide one’s identity, which often comes with the fear of being discovered and losing access to treatment. On the other hand, the treatments that can be obtained in this way do not necessarily meet individual needs, but instead follow a binary transition pathway, something that many non-binary people do not want.
Furthermore, this means that Trans Units do not have to justify themselves, as, apparently, non-binary people are almost non-existent.
The refusal to provide treatment to non-binary people: contrary to the law and the SAS’s own protocols
These refusals to provide treatment on the grounds of being non-binary – whether in writing or verbally – are discriminatory and unlawful. They cannot be justified under either the Spanish Trans Law or the Andalusian Trans Law, and constitute a clear violation of fundamental rights, such as the right to non-discrimination and the right to enjoy the highest attainable standard of health.
Unfortunately, these are not isolated cases, and this does not only happen in Andalusia. For example, the WPATH (World Professional Association for Transgender Health) Standards of Care for Transgender and Gender-Diverse People, Version 8, published in 2022, state the following regarding the experiences of many non-binary people with the healthcare system: “Whilst there are widespread barriers to care that transgender people must overcome, it is non-binary people who appear to experience the highest rates of difficulty in accessing both mental health and gender-affirming medical care. Many non-binary people report having had experiences with healthcare professionals who did not affirm their non-binary gender, and even experiences where healthcare professionals conveyed their belief that their gender was invalid, or that it was fundamentally more difficult to provide services to them.
Non-binary people often face assumptions from healthcare providers who presume that they do not need or want gender-affirming treatment, and have even reported being pressured to present as transgender women or men (within the binary gender framework) in order to access treatment. On some occasions, it was the non-binary people themselves who had to educate the healthcare providers they turned to for services, even though it is not appropriate for providers to rely primarily on their patients for their training.”
Article 10 of Law 2/2014, the Andalusian Trans Law, states: “The Andalusian Public Health System shall guarantee access to the existing range of services to all persons falling within the scope of this Law, in accordance with their gender identity. Furthermore, they shall receive care appropriate to their gender identity and, where different departments exist on the basis of sex, they shall be referred to the one corresponding to their request.”
The Regional Ministry responsible for health shall establish a care procedure for transgender people, which shall set out the criteria, objectives and standards of care contained in the relevant international recommendations; these must, in all cases, be compatible with the guiding principles of this Law. This procedure shall be drawn up in collaboration with transgender people and the organisations that represent them.”
The Regional Ministry of Health – now known as the Regional Ministry of the Presidency, Health and Emergencies – has published several guides on care for transgender people: one for the general public, and two for healthcare professionals – one on care for minors and another on care for transgender adults.
The guide on gender for the general public states: “To ensure the model of healthcare defined in the Care Pathways, the SSPA includes the following in its portfolio of services: Hormonal treatment to suppress pubertal development and ongoing monitoring. Cross-sex hormonal treatment and ongoing monitoring. Surgical procedures (hysterectomy, breast surgery, gonadectomy, penectomy, genitoplasty) and post-surgical follow-up. Voice treatments. Psychological and emotional support. Information and advice on social resources. Information on aspects relating to sexual and reproductive health. All treatments and procedures are carried out in accordance with a series of clinical criteria and legal requirements.”
Regarding what can be expected from care at Trans People’s Care Units, the guide states, for example: “To establish hormone treatment on an individualised basis, taking into account the person’s preferences and pre-existing health conditions, as well as the risk-benefit ratio of the medicines, both for puberty-blocking treatment and for cross-sex hormone therapy.”
Although the section on treatment examples in the guide only includes examples of trans men and trans women, this does not mean that non-binary people can be excluded from hormone treatment. On the contrary: hormone treatment should be tailored to the individual, as the guide states.
The guide on the Integrated Care Process for adult transgender people, published by the Regional Ministry of Health in 2016, also does not permit the exclusion of non-binary people from treatment. The recommendations section of this guide states: “For people who clearly request hormone treatment, information shall be provided on the main benefits and risks of cross-sex hormone therapy. All information provided regarding hormone therapy must be recorded in the patient’s medical records, with particular emphasis if a medicine is used under conditions other than those authorised. Cross-hormone therapy shall be tailored to the individual, taking into account the person’s preferences, their age, the presence of any pre-existing conditions (obesity, dyslipidaemia, hypertension, etc.), and the risk-benefit ratio of the medicines.”
The guidance also includes the following as one of the ‘do not’ recommendations: ‘Apply diagnostic codes for medical conditions to transsexuality.’ This includes gender dysphoria.
Furthermore, the guide states the following regarding care provided by Trans Units: “Cross-hormone therapy will be initiated in cases where the individual so decides, having understood the benefits and risks of hormone therapy (side effects, reversibility/irreversibility of the effects). Cross-sex hormone therapy will be tailored to the individual, taking into account their preferences, their age, the presence of any pre-existing conditions (obesity, dyslipidaemia, hypertension, etc.), and the risk-benefit ratio of the medications”.
International standards: personalised treatments for non-binary people
The World Professional Association of Transgender Health makes the following recommendations for healthcare provision for non-binary people: “We recommend that healthcare professionals carry out an individualised assessment of non-binary people and provide them with treatment that affirms their non-binary gender experiences. We recommend that healthcare professionals consider providing medical interventions (hormone therapy or surgery) to non-binary people even in the absence of social gender transition. We recommend that healthcare professionals be prepared to provide gender-affirming surgical interventions to people who are not undergoing hormone therapy, unless hormone therapy is a prerequisite for achieving the desired surgical outcome. We recommend that healthcare professionals provide information to non-binary people on the effects of hormone therapy or surgery on future fertility and discuss the options available for preserving fertility before commencing hormone therapy or undergoing surgery.”
With regard to recommendation 8.2, WPATH states: “Framing access to healthcare in the context of a person undergoing a ‘social gender transition’ when ‘they are living in accordance with the gender that is congruent with the person’s gender identity’ does not align with the way in which many TGD people understand themselves and their personal transition process. For some, ‘living in a way that is consistent with their gender identity’ does not include changing their name, pronouns or gender expression, although medical intervention may still be necessary.
Even though a person may live in a manner consistent with their gender identity, it may be difficult for an outside observer to perceive this in the same way if they do not know, directly from that person, how they understand their own experience in this regard. Expecting a ‘social gender transition’ may not be helpful when considering whether a person meets the eligibility criteria for gender-affirming interventions—such as hormones and surgery—and rigid expectations of how a ‘social gender role transition’ ‘should’ be may actually constitute a barrier to accessing care.”
The systematic refusal to provide personalised hormone treatments cannot be justified either by the Andalusian Trans Law or by the guidelines of the Integrated Care Process issued by the Regional Ministry of Health. At the same time, as this is not a problem confined to a single Trans Unit or specific endocrinologists, but rather a widespread issue, we can only conclude that this is a policy driven by a binary gender system. Binary transitions, which do not challenge the dominant binary gender system, are permitted, but treatment is denied to non-binary people who do challenge this binary system.
Gender-affirming surgery: barriers with no medical justification
Whilst the refusal to provide hormone treatment to non-binary people cannot be justified even under the protocols of the Integrated Care Process for trans people (adults or children/adolescents), these protocols do establish barriers for non-binary people who wish to undergo surgery – barriers for which there are no medical justifications. According to the guidelines of the Integrated Care Process for adult trans people, within the Andalusian public healthcare system, all surgical procedures are subject to the following requirement: “Sex reassignment surgery shall commence after 12 months of continuous hormone treatment for those who do not have any medical contraindications”.
This requirement is not based on medical criteria, but on an understanding of gender and transition as binary concepts. Many non-binary people assigned female at birth wish to undergo a mastectomy, but do not wish to masculinise their bodies through testosterone treatment. As the WPATH states: “Perhaps the surgery that has a specific connection to non-binary people (which is also required by transgender men or undertaken by some cisgender women) is mastectomy in AFAB non-binary people who have not used testosterone – although testosterone is not a requirement for this type of surgery.”
The WPATH continues: “For procedures involving the internal reproductive system, such as hysterectomy, unilateral or bilateral salpingo-oophorectomy, and vaginectomy, hormone therapy is not required, but hormone replacement therapy (using oestrogen, testosterone or both) is recommended for those undergoing total gonadectomy in order to prevent adverse effects on the cardiovascular and musculoskeletal systems. For phalloplasty, although there is no surgical requirement per se to use testosterone for a minimum period, virilisation (or the absence of virilisation) of the clitoris and labia minora may influence the choice of surgical technique and affect surgical options.”
This isn’t the place to go into further detail, and I’m not a doctor either. However, according to the protocols of the Integrated Care Process for trans people, all these operations require at least 12 months of hormone treatment, just to get you onto the waiting list.
Once again, as there is no medical justification for requiring prior hormone treatment for most surgeries, we must point out that the protocols clearly establish a binary gender police for access to gender-affirming surgery. The consequences for non-binary people can be severe, particularly in terms of emotional wellbeing and mental health. Many non-binary people are looking for a way to raise the €5,000 or more needed to have a mastectomy privately. And this is against a backdrop of job insecurity and financial hardship faced by many non-binary people.
We’ve had enough!
Incidentally, in April this year, researchers published a study in the journal Archives of Sexual Behaviour based on the Cádiz Trans Unit, entitled Experience of a Gender Identity Unit in Spain (2015–2023): Trends, Treatments, Surgeries, and Detransitions. According to this study, only 2 per cent identified as non-binary or gender-fluid. This already suggests that the vast majority of non-binary people lie in order to access hormone treatment. According to various studies, around two-thirds of trans people currently identify as non-binary.
In 2015, Transit in Barcelona treated 15 per cent of non-binary people. A study in Catalonia found that the proportion of non-binary people at two different trans units ranged from 7 per cent to 22 per cent. Therefore, a more realistic figure for non-binary people over the last ten years would be closer to between 5 per cent and 15 per cent, but certainly not 2 per cent. The figures from the Cádiz study merely show that many non-binary people present as trans men or trans women, and are therefore included as such in the study’s statistics.
But we, as non-binary people, have had enough. We’ve had enough of having to lie. We’ve had enough of being denied treatment simply because we’re non-binary. We’ve had enough of having to go through a gender police.
We demand that those responsible for the care of trans people provide care for non-binary people in accordance with the Andalusian Trans Law and international standards. In other words, non-binary people have the same right to hormone therapy as trans men or trans women, without a pathologising diagnosis and without our gender identity or expression being judged. We also have the right to personalised treatment tailored to our needs, which goes beyond the patterns of a binary transition.
We demand a review of the guidelines for the Integrated Care Process for trans people to clarify this access to hormone therapy, and to remove the requirement for 12 months of hormone therapy prior to gender-affirming surgery where there are no medical grounds for such treatment. The inclusion of non-binary people and non-binary organisations in this process of reviewing the guidelines.
At Asociación Sexualiarte, we are collecting testimonies from non-binary people about their experiences with the Trans Units in Andalusia. If you have been denied treatment because you are non-binary, or if you had to lie to get your treatment, we want to hear from you. You can tell us about your experience. We are fed up with having to lie to get healthcare. We are fed up with having to hide. We exist, we resist!
Published originally (in Spanish) in El Salto Andalucia, 24 October 2026, https://www.elsaltodiario.com/opinion/unidades-trans-andalucia-policia-un-genero-binario
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