Who Gets To Take Part In The Menstruation Conversation?

    When trans and gender-nonconforming people aren't recognized in the social and medical conversations around periods, their specific experiences are overlooked — and their access to adequate gynecological healthcare is jeopardized.

    Everyone with a uterus tends to have a complicated relationship with their period. There’s the bloody mess that can ruin a favorite pair of underwear; the shooting abdominal pain and uterine cramps; the often unwelcome whirlwind of emotions. For some, menstruation connects them either physically or spiritually to their bodies, while others consider their periods a monthly nuisance to battle through as gracefully as possible. For many trans and gender-nonconforming people, however, there can be a whole other layer of discomfort during that time of the month: dysphoria.

    Jessie Devine, a 23-year-old genderqueer writer and martial artist, tells BuzzFeed News that while on his period, “Things are happening around me and I’m not really a part of it [...] when people are talking to me, they’re really talking to a girl who’s not really there.”

    “There's this overwhelming sense of [my period] not being right — that it's not coming from my body, and it's something that shouldn't be happening to me."

    Devine is one of many people who, during menstruation, suffers from feelings of loss and detachment when their bodily functions don’t match up with their gender identity. Amy Leverington, a 27-year-old agender person, experiences something similar. “There's this overwhelming sense of [my period] not being right, that it's not part of my body — that it's not coming from my body, and it's something that shouldn't be happening to me,” they say. Frank Ly, who is genderqueer, also has a complicated relationship with their period: “I feel quite conflicted about it, because it is responsible for making me both feel like myself, yet feel less like the person I want to be.”

    Menstruation, a fact of life for half the human population, has long since been considered taboo in polite society — billions of people have periods, but no one is supposed to talk about them. Over the past year, conversations surrounding the destigmatization of menstruation have reached fever pitch. At the Australian Open in January 2015, tennis player Heather Watson blamed her mediocre performance on her period, saying, “I think it’s just one of those things that I have, girl things.” Later, in March 2015, Instagram notoriously deleted a woman’s period photos, after which the woman responded: “I will not apologize for not feeding the ego and pride of misogynist society.” But even as cisgender women have started speaking up about the facts of their bodies, transgender and gender-nonconforming people have been boxed out of the conversation — particularly because, in popular feminist discourse and medical practices alike, menstruation is so heavily equated with the “female body” and “women’s health.” Trans exclusion is all the more egregious here when considering that the needs of trans people so often go unmet in a health care system that can be oblivious to their existence.

    For many medical professionals, someone with a uterus is a woman in their eyes. Health care providers often use sex and gender interchangeably, according to a 2015 study in the Journal of Emergency Nursing. The conflation might begin as early as medical school. Elizabeth Sekera, RN and clinical director of Lyon-Martin Health Services in San Francisco, tells BuzzFeed News that oftentimes medical schools provide electives for trans care, but they are not required courses in the actual curricula. “I think many providers don’t educate themselves once they are in practice because seeing patients is complicated and there is always an incredibly large amount [to] learn,” she says. What a provider needs to do is “understand the issues the trans community is facing, and [decide] that is a priority.”

    Since many medical providers aren’t well-versed in trans issues, trans and gender-nonconforming people often bear the burden of educating their health care providers about gender identity. “I get misgendered all the time by doctors,” says Devine. “Even at a clinic that's supposed to be the ‘transgender health care’ clinic, people aren't educated. Even though they're supposed to be, and even though there's a space for ‘pronoun preference’ on the intake form. They're stuck in a binary method of thought.”

    “Many trans people, nonbinary people especially, feel like our bodies are fine. It's the public perception of our bodies that's messed up.”

    It’s gynecological care in particular that gets complicated. As a remedy for dysphoria resulting from bodily functions like menstruation, Courey E, 34, who’s nonbinary, tried to find a doctor who would perform an endometrial ablation — which reduces or fully prevents uterine bleeding — or a hysterectomy. “I have attempted to try to find a gyno that will remove my uterus, but without a 'problem' it seems like they won't,” they say. “If I say that it's for gender-related reasons, insurance will not pay for it and it is prohibitively expensive.” A hysterectomy often costs somewhere between $7,000 to $12,000. According to the American Congress of Obstetricians and Gynecologists (ACOG), most health insurance plans do not cover gender affirmation surgery.

    Courey is not alone in this battle. Megan Knouff, who is nonbinary, is also adamant about having a hysterectomy done. “I think there is that paternalistic idea of ‘Well, you will change your mind someday,’” says Knouff. Terry, 26, who’s genderqueer, is another person who has no intention of procreating and is seeking someone to perform the surgery. “I'm still trying to figure out a way to convince a doctor that yeah, I have a uterus, but no way in hell am I ever going to use it.”

    Dr. Cecile Unger, a pelvic reconstructive surgeon at the Cleveland Clinic, is part of a multidisciplinary team that treats transgender patients. Unger frequently performs hysterectomies on people who are in their twenties or younger. “The reason some GYNs are reluctant to perform hysterectomies on patients at such a young age is because of the risk of regret in the future,” Unger tells BuzzFeed News. “Patients need to understand that they will not be able to carry their own biological children if they have a hysterectomy. The other important consideration is the effect this may have on bone health in such young patients. They need to remain on their cross-sex hormones, vitamin D, and calcium to avoid detrimental effects to their bones from not having estrogen. These are important considerations, and providers may shy away from performing surgery because of the importance of these factors.”

    Even if Courey or Knouff found a health care provider who would perform a hysterectomy, that medical clinic might be many miles away from their homes. Quite a few of Unger’s patients do not live close to the Cleveland Clinic, but they come to her because they have been denied elsewhere.

    Not every trans or gender-nonconforming person is uncomfortable with their uterus, however. Many feel right at home in their bodies. But even those who don’t experience dysphoria come up against difficulties in the health care system, particularly when it comes to gynecology. “I know a trans man whose insurance refused to cover a pap test because his ID said ‘male,’” Devine tells BuzzFeed News. “How can a trans man, in the aforementioned example, take care of himself if insurance refuses to see him for who he is?”

    “I don't know why this is a revolutionary idea,” he added, “but health care needs to care for someone's body AND mind, even when those two things don't ‘match’ by commonly accepted standards. Many trans people, nonbinary people especially, feel like our bodies are fine. It's the public perception of our bodies that's messed up.”

    Public perception makes all the difference. According to Transfaith, a transgender faith and spirituality organization, 36% of nonbinary people have refused to seek health care out of fear of facing discrimination. Sekera, the RN in San Francisco, tells BuzzFeed News that sometimes providers will flat-out refuse to provide care or will act aggressively toward a patient because of that person’s gender identity. Even if a patient is able to find a competent provider, Sekera says, trans and gender-nonconforming people “often then face having to fight to have their medical needs covered by their insurance.” In order for a trans person to be prescribed hormone replacement therapy (HRT), for example, they oftentimes must first must be diagnosed with gender identity disorder, which many trans people feel reduces their gender identities as a whole — rather than just the symptoms of dysphoria — to a disease that needs curing.

    Gender essentialism not only permeates the medical world, but also the social/activist realms, where destigmatizing periods has long been a feminist goal. Last October, the rapper T.I. said in an interview that he didn’t want to vote for Hillary Clinton because of women’s tendencies to make “rash decisions emotionally.” Last August, after the Republican debate, Donald Trump tried to dismiss Megyn Kelly’s questioning by saying, “There was blood coming out of her eyes, blood coming out of her wherever." Although Trump later said that he meant her nose, the damage was already done and the stigma around periods reappeared once again in the public forum. But as our society is working toward calling out and eventually destigmatizing period-shaming, that destigmatization doesn't extend to everyone.

    Historically speaking, feminism has not always welcomed trans people with open arms — and plenty of subsets still don’t. During second-wave feminism in the 1970s and 1980s, icons such as Gloria Steinem believed that transgender people were atypical and did not belong in the movement (although she has since changed her stance). But many feminist thinkers are still adamantly trans-exclusionary. In a New York Times opinion piece, Elinor Burkett expressed her discomfort with Caitlyn Jenner, who she believes cheapens the idea of what it means to be a woman. She, like many others, believes that trans women cannot be included in feminist conversations, since they have not been shamed or harmed for their female-born bodies. In demeaning the experience of trans women, trans-exclusionary feminists neglect the experiences of other people assigned female at birth who don’t identify as women and yet have experienced shame and violation for their bodies all the same — arguably, in many instances, even more so than cis women.

    The experiences of those who have been left out of the national menstruation conversation are finally starting to get some attention. In summer 2014, New York–based underwear company Thinx created the tagline “Underwear for Women With Periods,” which was met with a lot of backlash. Thinx co-founder Miki Agrawal tells BuzzFeed News he received tons of emails from those who urged the company to be more inclusive. In November 2015, Thinx created a line of period underwear for trans men. A year earlier, in 2014, came the launch of a gender-neutral menstruation calculator app called Clue. And while medical institutions still have a long way to go, the University of Pennsylvania, as well as a few other schools around the country, launched programs in 2014 to improve the health of LGBT people.

    While anyone of any gender who menstruates can establish a rapport over mood swings, blood flow, and exhaustion, trans and gender-nonconforming people have specific needs around menstruation that often go unheeded. Only when we take the steps to hear others’ stories about the violence — both covert and overt — that they experience due to their periods will we be able to truly begin transforming public perception.