A qualitative inquiry into the lived experiences of menstrual health and hygiene in the transgender and non-binary people in urban areas of India.

Significance: 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. This study aimed to document the lived experiences of menstruation management among TNB people in urban India. Methods: We 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. Interviews were audio recorded, transcribed, de-identified, and cleaned. After a deductive and inductive process of developing a code book, we coded transcripts and developed code summaries to identify emergent themes. Results: We 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. Discussion: Documenting the lived experiences of menstrual health and hygiene among TNB people supports the call to 'de-gender' menstruation. Magnifying the voices and lived experienced of TNB people can bolster the development of effective interventions to enhance their wellbeing.