‘Every boy should know about it’
Periods can be a difficult time for trans boys and men. But, as Serena Solomon finds, for Awatea Rotherham, it is made far worse by the pain of endometriosis.
Each month when Awatea Rotherham gets his period, he is often crippled with pain from cramping and the discomfort of nausea. He has to take days off school, which can add up to almost a month of missed classroom time in a year.
Rotherham is a trans teenage man, in his last year of high school in Wellington.
Menstruation can be a complicated time for trans boys and men, and for those who are nonbinary – people who are not exclusively masculine or feminine. It is a tangible reminder of the unease – and even hate – they might feel for a body and its functions that don’t line up with their gender.
In Rotherham’s case, that time of the month comes with a one-two punch. That’s because he has endometriosis, a painful disorder caused when tissue that lines the inside of the uterus grows elsewhere in the pelvic area, often producing cysts and scar tissue.
‘‘When you have something happening in your life that you don’t want to happen anyway, then for it to be a struggle, it’s not great,’’ said Rotherham.
It is estimated that one in 10 women have endometriosis. And that’s one of the issues for trans men or non-binary people – one in 10 women.
The area of endometriosis care is an example of a gendered space, like the exclusionary marketing of tampons and pads as ‘‘feminine products’’, where language and mindset tend to cater only to women. However, experts say that statistic is true for trans men and those who are non-binary, but labelled female at birth.
Endometriosis treatment can be tough and liberating for these two groups of people. Different treatments, like the contraceptive pill, can exaggerate feminine aspects of a body, causing trauma for some.
On the flip side, transition-related medical care, such as testosterone that often results in a lower voice and coarse facial hair, can also help endometriosis symptoms.
For all those who have endometriosis, treatment is often achieved through trial and error, with no guarantee of success.
‘‘You have to treat these patients with a multidisciplinary team and whether that involves individual surgeons, endocrinologists, sexual health physicians, and then also pain specialists, pain physiotherapists and pain psychologists,’’ said Dr Michael Wynn-Williams, an Auckland gynaecologist and endometriosis specialist who has worked with trans and non-binary patients.
‘‘Any person, whether they are cis [a person whose gender aligns with their birth sex] or transgender, you need to treat them holistically.’’
As an ‘‘early bloomer’’, Rotherham started his period around 11. His hips started to widen and breasts started to grow. It was a wakeup call that he wasn’t quite comfortable with his body.
His periods didn’t become debilitating with the telltale signs of endometriosis until he was in year nine.
‘‘It is a really isolating time of hormonal stress,’’ said Rotherham.
‘‘I was very uncomfortable that my body could just do this. I had no control over it.’’
Rotherham moved to Wellington in 2016 from Palmerston North at the beginning of year 10. Within an LGBTQI+ support group, he began trying out different pronouns like they/them/ theirs or ze/hir/hir. In the end, it was he/him/his that felt right.
At this time, he sought medical help for his period pain that just couldn’t be normal. A doctor told him he likely had endometriosis and put him on contraceptive pills, a common management strategy that can stop someone’s periods and the accompanying pain.
‘‘It was not effective for me,’’ said Rotherham. ‘‘I didn’t stop bleeding.’’
The daily pill he took for several months also came with a hormone imbalance, swelling, bloating, and general aches and pains. The cure
seemed worse than the disorder, so he stopped taking it.
Using contraceptives as a treatment for endometriosis can be problematic for some trans men and boys or non-binary people because potential side effects such as breast swelling and tenderness can aggravate their gender dysphoria, according to Dr Frances Grimstad, from the Division of Gynaecology at the Boston Children’s Hospital.
She recently co-authored what is believed to be the first study on endometriosis in trans boys and men, and non-binary people. Gender dysphoria is when a person experiences a mismatch between their gender and biological sex.
The language and spaces that surround gynaecological care and endometriosis is often feminised and geared towards women. This constructs additional barriers to access for trans men and the non-binary community, said Dr Jamie Veale from the School of Psychology at the University of Waikato.
‘‘There might only be women’s bathrooms in that area assuming that there are only women patients,’’ she said, as one example. Counting Ourselves, a 2019 report, found that 15 per cent of 1100 trans and non-binary people surveyed in New Zealand did not have access to appropriate bathrooms when accessing healthcare.
Both Veale and Wynn-Williams agreed inclusive healthcare has improved in recent years in New Zealand.
Rotherham came out to his parents several months ago. They are accepting of their son. His older sister has also been a sounding board through the journey to discovering his gender.
His whole family also supports him each month when he slips into the hardest days of endometriosis by bringing him plain toast, helping with his medication and just displaying empathy.
‘‘Not only is it painful but it is a really difficult, a physically and emotionally demanding time because in the end, it is linked to my identity,’’ said Rotherham.
Ultimately, he no longer wants to have a period. Not just because of the pain, but because it doesn’t line up with his gender as a man.
He plans to begin transition-related medical care in the next few years, which could involve taking testosterone. It will likely give him a deeper voice, increase muscle mass, and generate coarse facial hair, among other changes.
A surgical transition is also an option, but it is many years down the road for Rotherham, if at all. That could involve surgery to remove unwanted breast tissue. Removal of the vagina and uterus, and the construction of a penis, is also possible.
There can be an overlap between transitionrelated medical care and the treatment of endometriosis, said Wynn-Williams. Danazol was commonly used to treat endometriosis in the 1980s, but many cis-gender women were turned off the medication because of the androgenic effects of a deepening voice and coarse facial hair, which might be welcomed by trans men patients.
Testosterone, often used in a trans man’s transition-related medical care, can also help in the treatment of endometriosis by stopping menstruation in some patients.
However, in the recent study co-authored by Grimstad, testosterone helped the endometriosis symptoms in some trans boys and men, but not others. ‘‘We just are realistic that it might not help everyone,’’ she said.
Surgical solutions as part of an endometriosis treatment plan can also align with the trans men who opt to remove their uterus, ovaries, cervix, fallopian tubes, and surrounding areas, as part of their transition-related medical care. Cis-gender women who have endometriosis can have these body parts removed as part of their endometriosis treatment.
For those who have severe endometriosis, about one in 10 sufferers, they will need additional surgical steps to ensure the endometriosis is entirely removed, Wynn-Williams said.
As for Rotherham and all that he goes through each month, whether that is the pain of endometriosis or the emotional conflict between body and gender, he sees a silver lining to his experience.
‘‘The knowledge I have gained from having a period is invaluable,’’ he said. ‘‘Every boy should know about it.’’