This chapter explores the histories of transgender expression, identities, communities, and activism globally in both premodern and modern eras. Histories of settler colonialism, slavery, war, and imperialism have transformed the terms and conditions by which people of transgender expression and experience understood themselves and were perceived by others. While an abundance of archival records chart widespread practices of “transing” gender globally, a complex web of factors influenced how a given community or individual defined, understood, and judged such efforts. Race, religion, region, culture and class are some of the key contextual forces that gave meaning to trans and gender variant sexualities throughout history. A wide range of concepts have been used to describe and make meaning of gender variant people throughout history, from two-spirit, hijra, and third gender to the more recent transgender, nonbinary, gender expansive. Many other terms that have been used throughout history were deemed derogatory by those individuals and/or communities to which they refer at the time or have since been determined to be derogatory by later generations looking back. This creates a fundamental tension for everyone writing these histories between the importance of recognizing the past on its own terms and the importance of not further perpetuating harm against a long-stigmatized group.

This chapter considers Shelley’s attempt to think before the “Error and Truth” of Enlightenment humanity, and before the binaristic split between the white male bourgeois Human and those not included in those definitions of humanity. Tracing his iconoclastic resistance to normative categories of gender, race, and the human as well as his idealistic attempt to recreate those categories in a reading of The Witch of Atlas, with its double creation of Witch and the Witch’s “sexless” creature, the chapter explores the poet’s radical understanding of gender and sex beyond the male–female binary alongside the poet’s commentary and critique on the dimorphic gender–sex systems circulating in discourse of his day. The chapter argues that his imagining of the creation of new beings – both the Witch and her creature – figure Shelley’s reply to Mary Shelley’s Frankenstein, as an alternative being beyond Western, Enlightenment notions of the human. Particularly through the envisioning of the nonbinary being of the Witch's creature as well as its flight through the world as an “image” and “sexless thing,” Shelley attempts to conceive of a continuum of gender and sex, one in which the gendered and racialized alterity of the Witch’s creature is embraced and prioritized, even though it may be imperfectly imagined.

Nonbinary people are those who do not self-identify within the gender binary system. Recently, scientific research has increasingly recognized that nonbinary individuals have specific social and health needs, which may be different from those of binary transgender people. Obstetricians and gynecologists (Ob/Gyns) are paying increasing attention to transgender clients, who are in need of care services for either screening purposes, genital complaints, or information on genital health maintenance. However, since the nonbinary population has only recently been acknowledged in legal, medical, and psychological systems, most Ob/Gyns are likely to be unaware of specific nonbinary clients’ particular experiences and challenges. For this reason, in accordance with an affirmative, individualized, and culturally competent approach, this chapter addresses the health needs and physical complaints of nonbinary individuals, by focusing on two main issues: (1) how an affirmative environment for nonbinary clients may foster the therapeutic alliance; and (2) which are the specific physical complaints of nonbinary clients within Ob/Gyn care.

Chapter 6 summarizes the changes to medical care in recent years. There is now a greater recognition that the projected social and psychological challenges of genital variations cannot be fixed by surgery. The first international consensus statement on intersex was published in 2006. The statement makes a number of recommendations to improve care. Controversially however, a new term disorders of sex development (and, later, differences in sex development, or DSD) was introduced to replace intersex and hermaphroditism. Biotechnological developments have been advancing rapidly. More has been learned about “normal” and “abnormal” sex development. However, parents still struggle to talk to children about their bodily variations, young people still worry about getting into relationships, childhood genital surgery is still considered the only way out of stigmatization, psychological expertise is still a low priority in specialist services and the huge potential of peer support is not fully realized.

This chapter will provide an overview of the stigma and resultant health disparities experienced by transgender and nonbinary (TNB) people worldwide, with a focus on disparities most relevant to clinicians providing sexual health and gynecologic care for transgender patients. Physical and mental health disparities impacting TNB populations have been widely documented, but clinical approaches frequently address individual risk factors and behaviors which contribute to only a small percentage of the disparities that occur. TNB people are embedded into political, economic, and social environments that contribute to stigma and make them more vulnerable to experiencing poor health outcomes as a population. This chapter offers a framework which considers the impact of structural forces and allows for a more holistic understanding of the underlying reasons for the dramatic differences in the health and well-being of TNB people as compared to cisgender populations. We will review evidence for the impact of resiliency factors on mitigating the negative impacts of stigma and ways in which healthcare professionals can promote resilience in their own practice with TNB patients.

How to talk about variations in sex development is a major theme for impacted individuals and families. This is the topic of Chapter 12. The author summarizes the research literature with caretakers and with adults about the difficulties of disclosure. Considerable criticism has been levied at health professionals for failing to role model affirming communication. For sure there are gaps in health professionals’ talk, but the biggest contributor to the difficulties is to do with the widespread misunderstanding about the biological variations. Psychological care providers are not there to put a cheerful gloss over clients’ negative expressions. However, they can be part of the favorable social condition in which a wider range of meanings about bodily differences are negotiated. In the practice vignette, the author highlights how tentative and uncertain the enabling process is, where a negative view of sex variations is still widely endorsed in the social context.

Chapter 2 begins with a brief summary of typical embryonic development of the urogenital and reproductive systems. Where the sex chromosomes, reproductive organs and the genitalia in combination do not fit the social categories of female and male, doctors and scientists used to call these physical outcomes hermaphroditism and intersex. They debated for a long time on the “true sex” of the individuals but could not agree on which of the biological sex characteristics should count as their true sex – should it be the sex chromosomes, the gonads or the genitals? Although in the age of genetics, much more is known about how the atypical features have developed. At the same time, people who are impacted by the variations are increasingly disputing medical framing of their differences. The twenty-first century was to seed a new and ongoing debate between the new medical term, differences in sex development (DSD) and intersex, which is now reclaimed by many impacted adults.

Chapter 11 of the book reviews potential psychological contributions in the highly charged process of assigning legal gender to a newborn with genital variations. Although a number of psychological theories exist for understanding gender development, it is the brain gender framework that has been singularly privileged in intersex and DSD medicine. However, the decades of research cannot contribute to the certainty professionals and caretakers seek. Psychological care providers (PCPs) have other frameworks to draw from in order to work ethically and pragmatically with families. In the practice vignette, the author envisions how a highly skilled PCP in a high-functioning DSD team could work substantially to help caretakers to cope with uncertainty and minimize the need for psychosocially motivated medical interventions. In the vignette, the psychological care path is in position before medical investigations begin. It remains highly active long after the medical and legal processes are completed. Although the vignette is built around a child diagnosed with 17β-hydroxysteroid dehydrogenase-3 deficiency, the care principles are relevant to legal binary gender assignment for children born with a range of sex development variations.

Difficulties with communication about bodily differences are strongly linked to sexual experiences. In Chapter 13, the author critiques the dominant ways of talking about sexuality in the wider society. These oppressive ideas can give rise to insecurities, self-objectification and body shame for people in general. Adults who have been medically managed are particularly vulnerable to the effects of objectification and shame. The author outlines typical components of sex therapy programs. However, rather than fix sexual problems, which can perpetuate people’s sense of inadequacy, the author suggests that psychological care providers support clients to process any trauma and develop a more relaxed and appreciative relationship with the body. This work, which requires generic therapy knowledge and skills, can be integrated with a range of specific sex therapy techniques and resources to reimagine a sexual future that focuses on bodily pleasure rather than gender performance. Although the practice vignette is built around a female couple, one of whom has partial androgen insensitivity syndrome, the care principles have wide applications for people with variations more generally.

Not all sex variations are apparent at birth. Sometimes they are internal and therefore not visible, that is, children are born looking like a typical boy or girl. The child may be brought to medical attention much later, for example when puberty does not follow the expected path. Many of these care users were not told the truth about their biological variation because adults believed that the information would harm them. At the same time, the care users also noticed that they were fascinating to health professionals, who may examine them in droves. Some of them did not discover the truth about their diagnosis and the treatment until mid-life.

For children whose external genitalia look different, when surgical safety and techniques improved, it became routine to align the urogenital anatomy of newborns and young children to the assigned gender. The gender-genitalia alignment was believed to be important psychologically for child and family. Because surgeons found it easier to feminize than masculinize the genitalia, most babies with genital variations were assigned female. From the 1990s, some of these adults have spoken out, talking of too many operations, been too often examined by too many and not understanding what was happening.

Inconsolable distress is neither a universal nor inevitable response to inability to have biological children. In Chapter 14, the author criticizes research with clinic samples that has produced a problem-saturated account of childlessness that obscures a wide range of alternative responses. The author examines the influence of pronatalist ideology on people who are impacted by infertility including many people with sex variations. Away from the treatment context, psychological input can guide individuals, couples and groups to explore personal meaning of nonparenthood. It can facilitate service users to grieve for what is not possible, challenge feelings of deviance and shame, reengage with a range of life goals and, perhaps most important of all, recast adult identities. Through the practice vignette built around a heterosexual couple, one of whom has a late diagnosis of Klinefelter syndrome, the author teases out the difficulties of working psychologically in a treatment context, where complex existential issues and relational dynamics are compressed into the frame of pressurized treatment decisions.

Chapter 9 tackles the theme of choosing “normalizing” interventions, which applies to children and adults with variations. It explores the limits of choice regarding invasive and irrevocable “normalizing” interventions in the field of sex development. It considers the role of emotion in decision-making and the complexities of obtaining informed consent. In the practice vignette, demand for surgery by a young person (with CAH) is a foregone conclusion – a familiar scenario in DSD services and one that places the psychological care provider (PCP) in an ambiguous position. The service user also has clear psychosocial care needs. She brings a unique suite of intersecting social circumstances that place demand on the PCP to be fluid and responsive to the dynamic and challenging referral context. The PCP in the vignette does not have the answers, but it is hoped that the story opens up conversations on the theme.

Psychological care is endorsed in DSD medicine. Psychosocial research has been on the increase. But these positive moves have not given psychological practice the kind of collective focus that is enjoyed by the biomedical disciplines. However, psychological care providers have a wide variety of thinking tools and practice techniques to draw on, if to work in an ad hoc way at times. These tools and techniques do not change, but some are more useful and relevant than others for this service context. In Chapter 7, the author discusses the strengths and weaknesses of key theoretical frameworks in healthcare psychology. A major weakness of the individualistic models is their lack of capacity to address structural inequalities in psychological wellness and distress. The author introduces aspects of the Power Threat Meaning Framework and describes how to draw from its theoretical richness to think systemically about what sex variations pose to individuals and families in the social context and how they are responded to. The Framework provides the theoretical backbone for some of the practice vignettes in the final section of the book (Chapters 9–14).

In the 1990s, some former patients mounted street protests in front of medical conferences to draw attention to their trauma. They reclaimed intersex as a personal identity and campaigned for healthcare reform. These developments are the focus of Chapter 5. Intersex is coming out of the closet more and more, through being a topic in television documentaries, novels, films and art. Intersex activists challenge medical authority to change practice. Furthermore, they are not waiting for doctors and scientists to come to their viewpoints. They have successfully lobbied human rights agencies to position childhood genital surgery as a violation of their human rights. They demand that surgery is delayed until the child can give informed consent or is at least old enough to participate in the discussion and offer their agreement.

Care for trans and gender nonconforming individuals will become a substantial part of Ob/Gyn practice. However, at present, many Ob/Gyn professionals experience insufficient knowledge and skills to accommodate this group. In this chapter, four key principles will be described to improve clinical services for this group. Key to this is a gender-affirmative approach and a sensitive stand by healthcare professionals, as well as a willingness to assess one’s own assumptions and knowledge (gaps). Also, one is encouraged to openly interact with local trans communities to design clinical services with a welcoming environment and low barriers to care, and to engage individuals in shared decision-making.

Grammatical gender in German has traditionally been described as a rather arbitrary system. This is not the case in regard to terms of person reference, where natural gender assignment is the norm: masculine and feminine grammatical gender largely correlate with the extralinguistic assignment of male and female gender. Neuter gender predominantly denotes inanimate entities. The use of neuter gender in reference to women nevertheless has a long history in German, usually with pejorative connotations. In contemporary standard German, the use of neuter articles and pronouns instead of feminine ones appears as a discursive tool to denigrate and dehumanize women whose gender performance does not conform with hegemonic concepts of femininity. The dehumanizing use of neuter gender can further be found in online hate speech directed at trans women and nonbinary individuals. This chapter presents an analysis of the discursive manipulation of grammatical gender as a linguistic tool of dehumanization. It first presents an overview on the distribution of neuter grammatical gender for nouns denoting women within the language system and uses this as a backdrop to analyse occurrences of neuter reference to women and nonbinary people in hateful social media discourse. These findings are explained and theorized from a frame semantic perspective.