Trans bodies and trans lives have increasingly occupied space both within academic feminism (e.g., gender studies courses, feminist conferences, special issues of journals) and within the popular media. Necessary theorizing about the provocative role of trans bodies in the corpus of feminist theory1 alongside the interrogation of the tangible stressors and terrors of trans lives2 have thrust trans identities into the forefront of academic feminist theory. For example, clear articulations about the inclusion or exclusion of trans women from “women only” spaces have appeared as a major rift in conceptualizations of modern feminism. Whether “women only” spaces include only women-born women, or whether they should also include trans women, has recently made headlines, particularly as radical feminists and factions of the trans community clash about the meaning and role of trans bodies.3 However, while feminist theory has developed increasingly sophisticated and complex ways of imagining and theorizing trans bodies and identities, psychotherapy work, on the other hand, lags behind in the assessment and articulation of trans client experiences and needs.
Psychotherapy work on trans clients and trans identities has only recently begun to address the need for understanding the developmental, psychological, social, and relational needs of trans clients. A continued insistence on diagnosing all transgender clients as having “gender identity disorder” (and such diagnoses are currently required in order to obtain any health insurance coverage of trans surgeries and hormone therapies) falsely frames trans identities as necessarily pathological.4 Coupled with the reality that many trans clients must modify their gender presentation to secure their safety, or stay closeted at work to avoid losing their jobs, trans identities typically appear in the literature as a severe stressor or frank pathology rather than as a normal or healthy identity.5
Surprisingly little psychological work has refuted the positioning of trans identities as pathological, dangerous, or even monstrous,6 though some work has started to examine the more affirming dimensions of trans lives. For example, the focus on transgender identity affirmation, particularly helping trans clients to disclose their identities and gain recognition as trans, has formed a key part of the emerging literature on trans therapies.7 Activists have lobbied to have “gender identity disorder” removed from the DSM and have argued that requiring psychotherapy in order to obtain a letter of support for hormone therapy limits the meaningful work that could transpire between therapist and trans client.8 Depth therapy, a form of psychodynamic psychotherapy, has yielded success as one possible long-term technique for trans therapies, but it requires more than a short-term, health insurance–based investment for such work.9 Trans clients, for example, typically present to therapy with a range of goals: understanding and resolving their body-mind dissonance, negotiating and managing their identities, addressing minority stress, and undertaking the process of transitioning.10 Given the greater prevalence of male-to-female (MTF) versus female-to-male (FTM) trans clients, different ways of negotiating gender and treatment goals for FTM and MTF clients are needed in trans therapies.11 Such work typically has positive results, as trans clients who felt more congruence between their gender identity and external appearance reported more life satisfaction and life meaning alongside less anxiety and depression.12
In my therapy practice, I regularly hear from my trans clients that their previous therapists have overprioritized conversations where trans clients must educate therapists about their needs, lifestyles, surgeries, stressors, and the particulars of “how it works” to live in a trans body. The perceived need to educate counselors and therapists about trans issues is widespread; one study reported that trans patients described this as their biggest problem connected to seeing mental health professionals.13 For female-to-male trans men, this has resulted in feelings of isolation, depression, and difficulty in asking for help from therapists, particularly as therapy is often framed as a “feminizing” experience or as something that women ore often seek out;14 moreover, therapists typically reward female traits over male traits when assessing success in therapy.15 Further, trans clients have verbalized how difficult it is to negotiate coming to therapy for the dual purposes of addressing their psychological issues and obtaining support for surgery and hormone therapy. (Legally, trans patients need a supportive letter from a therapist in order to undergo medical treatment to remove their breasts or alter their genitals.) These goals often contrast, as trans clients sometimes feel they cannot tell the truth to therapists because it risks their ability to obtain the necessary diagnoses and treatment support letters they want. Coupled with high rates of trauma, for example, these blocks in dialogue and disclosure present formidable challenges to the patient-therapist relationship.16 The complex realities of trans therapies and the unique relationship between the trans client and the therapist (who essentially is tasked with making a decision about whether trans clients can and should medically transition) present a difficult backdrop for optimal therapeutic work.
Though I had not originally intended to specialize in trans therapies, I began several years ago to receive an increasing number of referrals for trans clients (particularly FTM clients) who could not find trans-affirmative therapists where they lived. As a therapist who specializes in sexuality and body issues, the addition of trans clients to my caseload fit nicely with my areas of expertise. After all, trans clients often report distress about their body image, particularly related to not meeting the harsh dichotomized standards of traditional masculinity and femininity.17 (Gay and lesbian clients, too, often seek out LGBT-affirming therapists because they have so often encountered therapists with deeply entrenched prejudices and biases about sexual identity; see 18.) Since 2010, I have seen dozens of trans men in therapy, many of whom I have treated for longer-term therapies. Within these therapies, the topic of menstruation and its symbolic and literal meaning has been discussed repeatedly and often with much distress for FTM clients.
To date, surprisingly little work has interrogated trans men’s experiences of menstruation, particularly within feminist therapy work. A few studies suggest that menstruation matters to FTM patients, but they do not elaborate on just how it matters or the specific clinical issues that FTM patients present about their menstrual cycles.19 The limited available detailed work on the topic of trans men’s menstruation experiences has appeared in more informal places like blogs and Tumblr posts,20 leaving a notable gap in academic scholarship on the topic.
This essay highlights my work with three FTM trans men in psychotherapy who initially discussed their menstrual cycles as a source of unhappiness, stress, and, at times, trauma. By unworking essentialist notions of male and female bodies and questioning the inherent meanings and symbolism around menstruation, I outline the complexities of situating menstruation as a signifier of a “gendered self,” followed by an articulation of what I see as the transgressive potential in imagining space for menstruating male bodies within feminist politics. Ultimately, trans men’s menstrual cycles can serve a powerful literal and metaphorical role in challenging their ideas about masculinity, femininity, cycles, and transitioning.
Nash, a thirty-six-year-old white FTM trans man, entered therapy as part of a court-ordered anger management program related to explosive outbursts with his wife and a custody battle about his son, Lawrence. Nash had started identifying as trans at age ten and had changed his name to Nash as soon as he turned eighteen; he presented in therapy as friendly, doggedly macho, and relatively uncomfortable talking about his feelings. As a long-haul truck driver for a major transportation company, he worked long hours and reported that he liked the money but did not care much for his job. Nash had developed a technique of urinating while standing up and regularly used the men’s room at the various truck stops he routinely visited; he had thus far never been identified as trans by anyone in these truck stop men’s rooms, though he constantly feared others discovering his trans identity.
Identifying fully as male and rarely disclosing his trans status to others (he passed with remarkable ease in most public spaces), Nash said that he yearned to have top surgery on his breasts but remained firmly disinterested in bottom surgery on his genitals. In one of our early sessions, Nash described that he “spiritually had a penis” and that he could feel his penis psychologically and sexually during intercourse with his wife. He explained that if he believed enough in the presence of his penis, both he and his wife could feel it. Nash believed that his maleness stemmed from deep within; when talking about this, he referenced Native American two-spirit people and his affinity for that identity.
Despite his acceptance of his “spiritual penis” and his resistance to having bottom surgery, Nash adamantly wanted to have top surgery and to remove his breasts entirely. He had small breasts that he wrapped with extensive Ace bandages; he believed that even without this wrapping most people would not recognize his breasts as female per se (he thought they looked more like a “fat man’s boobs”). Still, the demands of his work and the long hours he put in wore him down physically; he wanted one less thing to manage physically. He sought out therapy to process whether the presence of his breasts had caused his anger to worsen and to explore possible psychological implications of having his breasts removed. He had recently had a series of explosive outbursts at his wife when she threatened to leave him, and she retaliated by promising to remove their son (he adopted Lawrence at an early age) if it happened again. Nash saw these outbursts and his feelings about his body as interconnected, and he expressed a frank need for help from “someone who understands what I’m going through.”
Nash approached therapy in highly practical terms and spoke quickly—almost frantically—during our sessions together. Nash had taken testosterone injections for years and had nearly perfected the art of speaking as a man; his tone, inflection, and performance of masculinity was unmatched among my trans clients. He showed up to most sessions in visibly dirty boots that flaked mud onto the floor, and he wore smelly clothes that reeked of gasoline and dirt (hazards of his job). His fingernails always had a crust of dirt around them. Nash commented once that his choice to shower infrequently and to wear dirty men’s Wranglers helped him feel like a “real man,” but he also apologized for getting the couch and floor dirty with his muddy boots. It took several sessions before we could unpack these aesthetic choices and his need to perform masculinity in this way during our sessions.
Over the course of the six months I worked with Nash, the subject of menstruation arose several times, particularly in relation to his vivid descriptions of how much he feared hate crimes. For Nash, menstruation symbolized his pervasive fear of being discovered as biologically female. He described how he typically managed his menstrual cycle by leaving a tampon in for twelve hours at a time (he refused to change tampons at any restroom other than his hotel restroom or sometimes in the back of his truck). Nash spent his entire menstrual cycle hoping not to bleed through, and he constantly feared that other men would hurt or even kill him if they discovered him as FTM. Menstruation felt like a lethal form of “outing” him as a trans man. He reported that he had tried spiritually and psychologically to block himself from menstruating, that he prayed to God regularly for his cycle to stop, and that he loathed and hated himself with great ferocity during his menstrual periods. He could not reconcile his feelings of being male with having a uterus, vagina, vulva, or menstrual period, and he described these conflicts not in academic or theoretical terms but instead by using the language of survival.
For Nash, merely tolerating his menstrual cycle could not sufficiently address the stress and trauma he felt about his menstrual cycle. We approached his negativity about menstruation by using multiple tactics and interventions. First, Nash had never heard of toxic shock syndrome and did not know about any risks of leaving tampons in for twelve or more hours at a time. I suggested that he change over to the DivaCup, a reusable menstrual cup that he could leave in for longer than conventional tampons. We talked about how to insert the cup, care for it, wash it, and use it in private and public spaces. Second, we worked on fundamentally reimagining menstruation as something that he could gender in highly male and masculine terms, much like he had rescripted his vaginal lubrication during sex as “semen” in a spiritual sense. Nash had a strong belief that his mind could impact the physical manifestations of masculinity; short of stopping his menstrual cycle altogether, our work to reframe menstruation as masculine targeted his beliefs, attitudes, and cognitions as well as his emotions.
These approaches to addressing Nash’s menstrual needs succeeded to varying degrees. Nash ended up liking the DivaCup and transitioned over to using it instead of tampons almost immediately. He complained that he did not know of its existence prior to starting therapy and that he felt frustrated that no one had ever told him about this method of menstrual management before. He practiced insertion and removal techniques privately for his first cycle and quickly figured out how to manage the cup while working on the road or while at home. (He also feared that his young son would discover that he was “not a real Dad” if evidence of menstrual blood or menstrual products were left at the house.)
In terms of working on the psychological and spiritual feelings he had about menstruation, Nash and I worked for months on how to masculinize his menstrual periods. He talked about menstrual blood as his body trying to get rid of his uterus (not anatomically or biologically true, of course, but he conceptualized it this way). In this sense, he reframed menstruation as his ally in ridding himself of his feminized womb. Nash also talked about how he did not feel more feminine when he connected to his emotions about his son and how, if he could see himself as a good father, he could also see his menstrual cycle as “just something that happened to me.” He thought deeply and talked openly about how much men bleed (and how blood is associated with masculinity) in mainstream Hollywood movies, describing his menstrual blood as a “war wound” and something I can get through.” In sum, Nash devoted great effort to reframing menstruation within the framework of traditional masculinity.
Notably, Nash did not want to see himself as genderqueer, partially trans, in transition, or anything in the middle of the gender binary. For Nash, “being male” meant being fully and exclusively male. Thus, he felt more at peace with his menstrual cycle when he used a product that better protected his secretive trans identity from others in public restrooms and when he reframed menstruation (and menstrual blood) as related to traditionally masculine things: war, fatherhood, and the expulsion of his womanliness/womb. By harnessing his tendency to cognitively challenge ideas about his own genitals (his “spiritual penis”), this reframe built upon work he had already done to undo the biological inevitability of his body and its meanings. Further, Nash’s therapy work demonstrated the importance of not only challenging gender binaries by imagining gender as in flux (or as fluid)—something that seems helpful to some trans patients but less helpful to others—but also by actively working to help trans male patients to infuse their own somewhat rigid definitions of maleness and masculinity with new conceptualizations of male sexualities, bodies, and identities. Nash had to create a masculinized menstrual experience that retained his self-image as fully male.
Ty, a twenty-four-year-old biracial African American/white trans man, presented for therapy with distress about his body, problems with depression and self-destructive tendencies, and a desire to start testosterone hormone therapy. Overweight and often unkempt, Ty had struggled with depression for many years and sometimes felt passively suicidal; he had begun cutting himself two years ago while in high school and had recently broken up with his (heterosexual identified) girlfriend. Most of his other relationships occurred online through various gaming sites like World of Warcraft, and he rarely had contact with people outside of his job at a local restaurant. Ty had started identifying as male a year ago and had recently come out to his religious and conservative family; they had reacted to the news of Ty’s trans identity by consigning him to “a life of Hell” and strongly proclaiming it as “just a phase.” His aunt had chided him as “gay but not admitting it,” and his mother believed that trans and gay identities happened because gay priests had recruited people to the gay lifestyle. Ty worked hard to embrace his trans identity and to believe he could endure the hardships that such a life would entail, though he also knew that getting top surgery, starting hormones, and living as a male constituted “a dream that seemed too far away.” When Ty started therapy, he wore large baggy sweatshirts, cut his hair short, and adopted a punk aesthetic complete with dyed black hair, nose rings, ear gauges, and various chains around his neck. He described a variety of ongoing stressors related to money issues, aloneness, constantly feeling unable to support himself, underemployment, body image problems, religious conflicts both with others and within himself, and a near-permanent sense that he had “no way out.” He had, for a time, considered going into the military but faced the reality that trans identities would pose a threat to the traditional sorts of masculinity required in the military and that he would not earn others’ acceptance as a trans man. Ty also assumed that his dreams of going to college would never come to fruition, both because of his limited finances and because his family described going to college as “frivolous and worthless.”
Several weeks into the therapy, Ty started to mention his menstrual cycle with increasing regularity, citing his irregular periods as a “gift from God” and saying that when he had his period, he would shower for a full hour to clean himself. Ty believed that his irregular periods were “a sign” that God made him male. He talked about his vagina and vulva as “down there” and rolled his eyes whenever he looked down at his body during session. Ty felt resolutely opposed to any positive emotions about his menstrual cycle and expressed certainty that someday he would rid himself of it permanently. Any efforts to help him make peace with bleeding—by constructing it as temporary, nonthreatening, or possibly masculine—had failed. He told me that he wanted to rip out his uterus and that he “could not be the person I was meant to be” as long as he bled.
Several months later, we talked about what sort of man he wanted to be after he completed his transition. Ty described his ideal masculinity as, surprisingly, quite traditionally feminine. He wanted to provide financial support and physical protection to his partner (more traditionally masculine), but he also wanted to cry, express emotional connection, bond with his partner and their children, and “spoil” his partner with love, affection, and gifts. He admitted, for the first time, that he did not want to have bottom surgery and that “keeping my parts intact” would allow him to stay emotional and connected to others. He believed that removing or tampering with his uterus or “girl parts” would strip him of the ability to maintain emotional connections with his future partner and their future children. The gender binary, in short, had not totally absorbed his feminine self.
Using this gender fluidity as a basis, we worked on ways to imagine his menstrual cycle as also a part of his emotional connection to the world. Ty admitted that when he menstruated he often cried more and felt more in tune with others’ feelings; building upon this, he said that he could maybe see his menstrual period as helping him to “keep it real, emotionally.” For Ty, being feminine and having a male identity could perhaps coincide, as long as he identified as male, used the male pronoun, had top surgery, took testosterone, and successfully convinced others to see and acknowledge him as male. He said, poignantly, “If other people call me a man, then I can keep the parts of me that are a woman.”
Ultimately, Ty also started to question his traditional beliefs about gender, particularly his belief that providing financially for a partner constituted good or appropriate masculinity. Over the course of therapy, he decided instead that he would like a more egalitarian partnership with someone, one where they both had jobs and both took care of each other. He also reported that his body image had improved and that he felt more sexual and more in tune with his sexual desires. Though he still fantasized that he would eventually stop menstruating altogether, he nevertheless talked about his relief when he could “finally cry” during his period. For Ty, admitting that the traditionally feminine body did not feel entirely repulsive or negative constituted a major step toward accepting his current in-between male and female trans body. He also recognized that he could divorce his physical body from the emotional characteristics associated with men and women or, in the case of menstruation, could use his physical body to experience both his masculine and feminine selves.
Scott, an eighteen-year-old white trans male, had initially entered a four-year-long period of therapy at age fourteen during the summer before he started high school. He presented with symptoms of anxiety and depression related to his inability to feel fully masculine. His father, a single dad struggling to make ends meet for him and his younger sister, placed him in therapy because his mood had deteriorated and he had become agitated and defiant about his gender identity. His father wanted him to be happy, accepted his decision to call himself a boy, and wanted to support him in any way possible. His estranged mother, whom Scott only saw on rare occasion, refused to acknowledge Scott as her son and said that she “gave birth to a girl and Scott was a girl.” Scott had started calling himself a boy and using the male pronoun a few months prior to starting high school, but at that time had not yet gone through puberty. He stated as his goal for therapy: “I want people in high school to think I’m a boy.”
Scott generally presented with stable mental health and a positive outlook about his friendships and his relationship with his father and sister. He reported that he had quite a few friends in school and that kids at school thought it was “cool” that he identified as trans. He had grown increasingly uneasy about the possibility of starting high school as a trans male and instead wanted to “pass as a guy, not a trans guy.” He had recently started his period and had also started to grow breasts, both of which threatened his idea of the masculinity he so desperately wanted to cultivate. He fantasized about having a “straight girlfriend who will like me because I’m a guy,” and he wanted to grow muscles and have a stronger, more robust physical appearance.
When talking specifically about menstruation, Scott described his first period as the single most horrifying experience of his life. He had learned about menstruation in school but did not anticipate what it would feel like to menstruate, especially when he realized that he would have to use tampons or pads to manage his period. Because his father had largely ignored the topic and his mother never discussed it with him, Scott felt wholly underprepared to handle the stress of menstruation. He described feeling ashamed of using the men’s restroom at school to change his pads, but he said that the kids at school made fun of him when went into the women’s restroom. To address these tensions, he had punched several boys at school and had gotten into three fistfights during the last month of eighth grade. During high school, Scott felt intent upon controlling his anger and “starting to become a guy as soon as possible.”
After Scott started high school and tried to identify exclusively as male, he reported with distress that others could see that he wore breast binders and that most schoolmates knew Scott had been born female. He had started dating a girl in his class, but her parents felt uncomfortable with their daughter “being a lesbian” and had forbade further contact. Scott repeatedly exclaimed, “I just want to be a guy!” I responded in one of our sessions by explaining that there were many other categories besides male and female and that he might take comfort in examining the many options for labeling and identities. We talked about the difference between gender identity (one’s self-identified gender) and sexual identity (one’s sexual interest in others) along with the meaning of words and phrases like “gender fluidity,” “homoromantic,” “pansexual,” and “genderqueer.” Scott’s face lit up with excitement and he told me that he was definitely “genderqueer.”
Over the next several weeks he settled into a new understanding of his body and his identity, telling me that “genderqueer” made more sense while he waited for hormones, surgery, and “the rest of my life to happen.” Kids at school admired him for identifying as “genderqueer” and he liked explaining this definition to them. After researching online about “genderqueer” identities, Scott decided that he felt more comfortable in the middle of two genders or without a gender at all. During this process, he also became more comfortable with his menstrual cycle, allowing his period to merge with his conceptualization of someone who identified as “genderqueer.” (That said, he stopped using the restrooms at school entirely, often holding in his urine for eight hours at a time and refusing to drink much water during the morning or throughout the day.) For Scott, learning about and embracing new categories of identity aside from only male or female allowed him to accept the aspects of his teenage body that were becoming female (particularly breasts and menstruation), just as he could embrace the possibilities of his masculinity that went beyond fighting and grandstanding. For example, Scott and his dad took up hunting and fishing so that he could express himself more “as a guy.” Implicitly, Scott’s therapy work around menstruation demonstrated the critical importance of expanding the queer identity circle to include as many different variations of gender and sexual identities as possible, while also showing the very real psychological consequences of moving into a more middle space of gender. Scott’s menstrual narratives could more closely align with his emerging postpubescent body when he embraced the middle spaces of gender and sexual identity.
Making Space for the Menstruating Male Body
While all three of these cases clearly have different implications for masculinity, menstruation, and trans identities, they collectively reveal how therapy work that focuses on undoing binary notions of male and female bodies can powerfully resituate the implied meanings of and symbolism around menstruation. If trans male clients can reimagine menstruation as having different meanings beyond the “failing” male body, they can also work to make peace with the aspects of their bodies and identities that remain (and may always remain) attached to the stereotypically or traditionally female. If menstrual cycles become less threatening, so too might vaginas, uteruses, vulvas, and breasts; further, the traits that trans men see within themselves (e.g., Ty’s descriptions of emotionality) may also be expressed more freely and abundantly. These three cases highlight the importance of reconciling multiple coexisting genders, integrating masculine and feminine selves, and allowing room for reconciliation between distal points on the gender binary.
These cases also vividly show the distance between those who can take shelter within the more academic or theoretical aspects of trans identity (e.g., Scott’s enjoyment and embrace of the descriptor “genderqueer”) compared to those who live largely without such protections (e.g., Nash’s fears of being murdered in a bathroom at a truck stop). Understanding the menstruating male body, then, also connects deeply to the ways that trans men are understood and viewed. For those (like Scott) coming of age in fairly progressive high schools, less direct and overt hostility and more subtle barriers to full equality may be faced. For those living within more traditional and conservative communities, trans male identities may pose a greater threat to the existing social order and may elicit more fear, hostility, and even violence from others. Menstruation, then, becomes a space of both practical, physical management—for example, how to find a product that will allow absorption of menstrual blood for twelve hours or longer—and it relates to the symbolic and metaphorical weight of the menstruating male body. Such complicated terrain, particularly within a therapy office, can lead to fruitful and productive directions for trans men to explore about themselves.
Menstruating male bodies have transgressive potential both within psychotherapy and within feminist politics more broadly, particularly as notions of “the biological” fade away.21 Tensions between bodies and sexualities as utilitarian/practical versus abstract/theoretical can appear vividly in a therapy office, as a patient’s distress echoes loudly against the backdrop of gender and feminist theory. For example, how can therapists avoid imposing their own frameworks of gender and sexual identity while simultaneously challenging trans patients to critically examine their own bodies? How can psychotherapy work move beyond the mere assessment of so-called “pathology” and instead prioritize trans patients’ narratives of the body and self?
Ultimately, by examining psychotherapy work with menstruating men, the biological and supposedly “natural” process of menstruation, vividly remade in the male body, gives way instead to a rebellious, multigendered, and defiant experience for both male- and female-bodied people. The menstrual narratives of trans men truly exemplify the importance of queering menstruation and making space for nonessentialist modes of imagining menstruation. As these three examples show, many menstruating trans men have engaged in work to understand, unpack, and undo their ties to the inevitable and “natural”
body in ways that exemplify the powerful social justice implications of deconstructing binaries and promoting a social-constructionist perspective in psychotherapy.
This essay is reprinted from Breanne Fahs, Title: Out for Blood: Essays on Menstruation and Resistance, ISBN: 9781438462127 with the permission of the author, Breanne Fahs, and SUNY Press.
About the Author:
Breanne Fahs is a professor of women and gender studies at Arizona State University (ASU). She is the author of six books: Burn it Down!: Feminist Manifestos for the Revolution (Verso, 2020), Madness: Notes from the Edge (Routledge, 2019), Firebrand Feminism (University of Washington Press, 2018), Out for Blood (SUNY Press, 2016), Valerie Solanas (Feminist Press, 2014), and Performing Sex (SUNY Press, 2011). She is also the co-editor of two volumes: Transforming Contagion (Rutgers University Press, 2018) and The Moral Panics of Sexuality (Palgrave, 2013). She is the founder and director of the Feminist Research on Gender and Sexuality Group at ASU, and she also works as a clinical psychologist in private practice where she specializes in sexuality, couples work, and trauma recovery. Click here to learn more.