Transgender and gender diverse menstruators' experiences of their/his/her period(s)

Virtual

Presenting Author(s)

Arslaan (Ari) Arshed, MD, MS, MHA (he/him/his)

Clinical Assistant Professor
New York University
New York, New York

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Co-Author(s)

SP

Stephanie Pottinger, MD

Resident Physician
NYU Langone Medical Center
New York, New York
Sharon B. Madanes, MD, MFA

Assistant Professor of Clinical Psychiatry
Weill Cornell Medical College
New York, New York
Allison B. Deutch, MD

Program Director, Women's Mental Health Fellowship
NYU Langone Health, Manhattan Campus
New York, New York
MA

Marra G. Ackerman, MD (she/her/hers)

Director Ambulatory CL Psychiatry
NYU Langone Health
New York, New York

Abstract: Background/Significance

Transgender and gender-diverse (TGD) menstruators are individuals assigned female at birth (AFAB), who continue to menstruate, and have a gender identity that differs from their natal sex. Reports indicate up to 1.6 million individuals in the US identify as TGD. Despite the increased visibility in the media, publicized gender transitions, and discourse surrounding inclusive language, contemporary medical providers are underprepared in managing transmenstrual care. In the 2022 US Transgender Survey (USTS), 24% of TGD individuals did not see a physician within the last year due to fear of mistreatment, and of those that did, 48% reported at least one negative experience of being misgendered, refusal of treatment, utilization of harsh language, or the provider being physically rough or abusive (James et al., 2024).

Through the minority-stress framework, which describes the complex interplay between majority (cisgender) and minoritized groups (TGD), gender dysphoria, and hormone-related mood disorders, we aim to provide a comprehensive review of the experiential and clinical data necessary to inform our care of TGD-AFAB menstruators.

Methods

We conducted a review of the medical literature and World Professional Association for Transgender Health (WPATH) guidelines and investigated popular media to explore TGD-AFAB individuals’ experiences of menstruation, preferences for menstrual management and the impact of these experiences on their mental health.

Results

While not all TGD-AFAB individuals experience dysphoria or distress around menstruation, the possibility that menstrual periods may be distressing for some informs the rationale for clinical interventions like menstrual suppression. Beyond the menstrual bleeding itself, the management of menstruation can be a source of distress for TGD-AFAB menstruators. If desired, amenorrhea can be achieved with gender affirming hormonal treatment (GAHT): testosterone (T), norethindrone acetate (NETA) or depo medroxyprogesterone (DMPA) either as monotherapy or adjunctive to T.

TGD-AFAB individuals that undergo GAHT have improved self-reported quality of life and self-esteem, decreased rates of depression (in all studies 2013-2018) and gender dysphoria. There is no consistent association or correlation between anger and serum testosterone levels, however if irritability, mood changes or anger occur at all, they are more likely within the first year of GAHT.

Discussion

Menstruation has a polarizing significance throughout history and across cultures, more often through a patriarchal lens. The management of menstruation in TGD-AFAB individuals allows providers to dissect this binary and provide individualized patient-centered care. Our review indicates that the more open ended, inclusive, and affirming care is provided, psychological distress will decrease. We highlight the importance of having these conversations prepubertal, during puberty, when considering pregnancy, contraception and fertility preservation, and menarche.

Conclusion/Implications

Although there is more literature needed on transmenstrual care in TGD-AFAB individuals, there are several ways that providers can inclusively take care of diverse patients.

References

James, S.E., Herman, J.L., Durso, L.E. and Heng-Lehtinen, R., 2024. Early Insights: A Report of the 2022 US Transgender Survey.

Schwartz, B.I., Bear, B. and Kazak, A.E., 2023. Menstrual management choices in transgender and gender diverse adolescents. Journal of Adolescent Health, 72(2), pp.207-213.

Presentation Eligibility: This manuscript was generated as part of a special issue of Frontiers in Psychiatry with a due date for submission of April 17, 2024, with a publication date to be determined.

Diversity, Equity, and Inclusion: This presentation reflects the intersections amongst transgender and gender diverse individuals, a minoritized and marginalized population that C-L psychiatrists can provide affirming care, and target mood disorders. We recognize that there is a diversity of gender identity, and goals surrounding hormonal suppression and family planning. Despite varying legislation perpetuating stigma and barring gender affirming care, our collective belief is that access to healthcare should be equitable for all individuals regardless of their race, gender, or socioeconomic status. This poster is presented by cis-gendered individuals, who aim to create an increasingly inclusive environment to improve psychiatric care.