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Dissertation
Lived experiences of menstrual health and hygiene among persons of transgender and non-binary identity in India
University of Iowa
Doctor of Philosophy (PhD), University of Iowa
Spring 2024
DOI: 10.25820/etd.007505
Abstract
Most global research on menstrual health and hygiene (MHH) focuses on cisgender women and girls, with limited evidence on the experiences of transgender and non-binary (TNB) people. Social marginalization of TNB people may increase challenges for them in accessing MHH resources. In this dissertation, I used the socio-ecological model of health behavior to identify the individual, social, contextual, and environmental factors that help explain MHH among TNB people. Using a mixed-methods approach, I conducted three unique but complementary studies that contribute to the understanding of the MHH status among TNB people.
For the first study, I conducted a systematic review of global quantitative and qualitative studies of the lived experiences of MHH among TNB populations. The review established a need for more evidence on the topic. Four overarching themes emerged from data analysis and synthesis, which are (i) perceptions about cis-normative menstruation in a binary society, (ii) experiences of managing menstruation, (iii) accessing healthcare, and (iv) potential intervention points. Studies described menstruation as a source of gender dysphoria. Amenorrhea, the absence of menstruation, is a welcome relief. Quantitative studies focused on investigating the effectiveness of various contraception and hormonal therapy options to achieve amenorrhea, whereas qualitative studies focused on MHH’s physical, emotional, and environmental aspects. ‘Othering’ of the TNB population in all aspects of MHH, including the association of menstruation with women alone, accessibility of public bathrooms, and availability of menstrual products, was highlighted. Three areas for intervention emerged that could assist TNB individuals in managing menstruation and improving overall health: (i) creating inclusive and safe public spaces, (ii) improving menstrual and sexual and reproductive healthcare, and (iii) de-gendering menstruation.
The second study was a qualitative study conducted in India. I conducted 13 semi-structured interviews with TNB adults aged 19-40 years in three major Indian cities in collaboration with community organizations. We asked participants to share their experiences of managing menstruation in multiple spaces of life, e.g. at home, school, workplace, and other public spaces. I identified three major themes in MHH for TNB urban Indians: (i) gendering of menstruation, (ii) navigating physical aspects of menstruation, and (iii) challenges beyond bleeding. ‘Gendering of menstruation’ shaped overall experiences of MHH among participants. Gendered expectations upon menarche triggered gender dysphoria. Participants reported having little knowledge about menstruation prior to menarche, which led to a state of confusion and shame, and exacerbated their dysphoria from gendering of norms around menstruation. ‘Navigating physical aspects of menstruation’ was less challenging in familiar, private surroundings, however, accessing public spaces and bathrooms remained a major challenge and stressor. Though many participants reported undergoing hormonal replacement therapy (HRT) in part to suppress menstruation, they continued experiencing menstrual symptoms which triggered continued dysphoria. Participants reported facing ‘challenges beyond bleeding’ which included burden of multiple diseases, mis-gendered healthcare services, and lack of social support.
Using the findings from the first two studies, I cross-culturally adapted the Menstrual Practice Needs Scale—a 36 items validated scale measuring aspect of menstruation - including developing new items within the original scale for assessing TNB peoples’ menstrual needs, as well as developing a new scale around menstruation-related dysphoria. The adaptation process entailed multiple steps, each informing the following. These steps involved systematic translation, followed by consistency comparison between the original and translated scale. The above steps resulted in modifying items to ensure contextually appropriate language and adding four new items. This step was followed by interviews with experts to review the adapted scale with no significant modification but a few suggestions on the sensitivity and training of administrators of this scale.
Together, results from these studies indicate that the menstrual health for TNB populations is a complex phenomenon being influenced by factors at each level of the ecological model. Documenting the lived experiences of menstrual health and hygiene among TNB people supports the call to ‘de-gender’ menstruation and ultimately bodies. The studies highlighted several challenges and unique needs for MHH vocalized by TNB populations, as well as an urgent need for more research to guide intervention and program development.
Details
- Title: Subtitle
- Lived experiences of menstrual health and hygiene among persons of transgender and non-binary identity in India
- Creators
- Priyanka Dubey
- Contributors
- Rima Afifi (Advisor)William T. Story (Committee Member)Shannon Lea Watkins (Committee Member)Kelly K. Baker (Committee Member)M. Sivakami (Committee Member)
- Resource Type
- Dissertation
- Degree Awarded
- Doctor of Philosophy (PhD), University of Iowa
- Degree in
- Community and Behavioral Health
- Date degree season
- Spring 2024
- DOI
- 10.25820/etd.007505
- Publisher
- University of Iowa
- Number of pages
- xiii, 168 pages
- Copyright
- Copyright 2024 Priyanka Dubey
- Language
- English
- Date submitted
- 04/22/2024
- Description illustrations
- Illustrations, tables, graphs, charts
- Description bibliographic
- Includes bibliographical references (pages 125-149).
- Public Abstract (ETD)
Most research on menstrual health and hygiene (MHH) focuses on cisgender women and girls, with limited evidence on the experiences of transgender and non-binary (TNB) people. In this dissertation, I used a combination of research methods, including a scoping review, a qualitative study with TNB persons, and a scale-adaptation process - to identify the individual, social, contextual, and environmental factors that help explain MHH among TNB people.
Menstrual health and wellbeing for TNB people is a complex phenomenon influenced by multiple factors beyond individual-level factors. It would be challenging to point out one factor that played the most critical role in affecting the menstrual health of TNB people because the factors all interact and intersect. Broadly, their perceptions and experiences are affected by the reality that the world over, menstruation is perceived to be a cisgender phenomenon. TNB individuals navigate a society where menstruation is primarily associated with cisgender women, leading to constant feelings of exclusion and ‘othering.’ The challenges TNB individuals encounter in managing the physical aspects of menstruation include purchasing menstrual material in a supermarket, using menstrual material that may evoke dysphoric feelings, and accessing suitable public spaces and bathrooms. In a country like India, these challenges become even more pronounced due to the lack of acknowledgment of gender-minoritized populations. TNB people use several menstrual suppression mechanisms such as HRT, oral contraceptive pills, and IUDs to feel more aligned with their gender identity. Despite these menstrual suppression efforts, many still experience symptoms, perpetuating menstruation-related dysphoria and adding to the burden of managing their menstrual health and overall wellbeing. The challenges faced by TNB persons extend way beyond the physical aspects of menstruation and include difficulty in accessing quality healthcare and social support. TNB individuals face barriers to accessing inclusive and respectful healthcare services. Misgendering, lack of knowledge among healthcare providers, and inadequate social support contribute to their challenges beyond menstruation, such as coping with multiple health conditions and navigating a healthcare system that does not cater to their needs. These findings helped inform the adaptation of the menstrual practice needs scale-36 items, which can be used to assess TNB peoples’ menstrual needs. The adaptation process entailed multiple steps, modifying items to ensure appropriate contextual language, and adding four new items
This work contributes to the emerging body of literature on MHH among TNB people. The findings of this dissertation call for the urgent need for more research to guide intervention and program development. It also highlights the need for interventions targeting multiple ecological levels to address the challenges faced by TNB people.
- Academic Unit
- Community and Behavioral Health
- Record Identifier
- 9984647356602771
Metrics
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