Since becoming a health editor for publications that cater to a largely female-identifying audience, I’ve spent a lot of time editing stories about reproductive health, periods, and hormones. It’s kind of the bread and butter of my job. And I’ve become super aware of one particular thing when editing stories on these topics: the tendency to use very gendered language. Think, calling vaginas and vulvas “lady bits” instead of using their actual names, or saying that periods are something “that makes you a woman.” This might seem harmless to some (and it’s certainly been normalized in American culture), but linking periods to womanhood is problematic and, in some cases, dangerous.

This isn’t just because many people don’t have periods due to PCOS, birth control, a hysterectomy, or menopause. It’s also because many transgender women without uteruses may not get periods, while trans men or gender non-conforming folks who have uteruses may. To put it simply: Not every woman has a period, and not all people who have periods are women.

This isn’t a niche concern. While exact statistics on the transgender and gender non-conforming population are hard to come by, experts estimate that there are at least one million transgender adults in the U.S. According to a 2012 Human Rights Campaign survey of LGBTQ youth, nearly 10 percent of respondents identified themselves as “transgender” or “other gender.” (And you likely don’t need me to tell you that visibility of the trans and gender non-conforming populations has only increased in the six years since that survey was taken.) This is a sizable population, yet the way that we talk about periods doesn’t reflect that diversity at all—which can have big implications for the health and mental well-being of people with uteruses who don’t fit neatly into the “woman” box.

The harm of gendering one’s health needs

The view that only women (specifically, cisgender women) have periods can impact the ability of transgender and gender non-conforming people to access the health-care services they need. “Many of my patients will say that they don’t feel comfortable talking about their bodies or sexual reproductive health when going to a doctor’s office,” says Meera Shah, MD, the medical director for Planned Parenthood Hudson Peconic. “They may fear that they will be stigmatized or discriminated against.”

The assumption that only women have periods and need gynecological care is so pervasive that Dr. Shah says many of her trans and gender non-conforming patients have felt in the past like they have to teach their medical providers how to take care of their needs—consistently having to explain that they’d still like to have a pap smear or an HPV vaccine despite presenting as male, for example, or reminding them over and over of their pronouns.

“If somebody presents as male and ‘passes’ as male in society, they may go to a doctor’s office to get screened for a sexually transmitted infection and not get all of the tests that they need.” —Meera Shah, MD

If a person doesn’t have a supportive medical provider or isn’t willing or able to do that emotional labor, their doctor may make assumptions about their health-care needs based on their appearance. “If somebody presents as male and ‘passes’ as male in society, they may go to a doctor’s office to get screened for a sexually transmitted infection and not get all of the tests that they need or maybe miss out on an opportunity to get a pregnancy test because they haven’t been asked about their body parts or if they’re having sex in a way that could get them pregnant,” says Dr. Shah.

It can even become an issue with insurance access, says Anna Kiesnowski, LSW, the gender affirming services manager at the Mazzoni Center in Philadelphia, which provides comprehensive health and wellness services in an LGBTQ-focused environment. “Health insurance systems are still very binary,” she says—meaning that if you are a transgender man, for example, but were assigned female at birth, you may still have an F in the sex or gender box on many of your official documents (birth certificate, passport, driver’s license, and yes, your health insurance paperwork.) But Kiesnowski says that if said transgender man were able to change all of his paperwork to reflect his true gender, his health insurance provider may deny coverage for certain health-care needs down the line (like antibiotics for a yeast infection, for example, or hormonal birth control) because those services are typically only approved for women. It serves as yet another barrier to a person getting the care that they need just because of their gender, Kiesnowski says.

Compounding stigma and shame

Beyond physical health, the feminized way we talk about periods can have emotional implications, too. “One of the first entry points young people have to sex and sexuality is shame,” says Joanna McClintick, LMSW, the youth sexual health coordinator at The Center in New York City, an advocacy, health, and cultural organization dedicated to needs of the LGBTQ community. Most people’s first encounters with sex, she says, are very loaded—like looking at porn, which is often laded with moral connotations, or accidentally walking in on their parents having sex, which is embarrassing. It’s similar, McClintick argues, to the way we learn about and talk about periods—often in secret, often with embarrassment or shame. “And a lot of people do associate getting your period with becoming able to get pregnant,” McClintick says, so the two concepts are often linked in people’s minds with similar amounts of shame and disgust. (Hello, period stigma!)

That stigma and shame can be all the more powerful when you don’t identify as a woman and yet have a period. “In terms of the gender non-conforming and transmasculine community, getting your period for the first time, or just having your period, might be really traumatic or disappointing,” says McClintick. For some kids she works with, she says their period can trigger sadness or anxiety about how they will grow into their adult bodies. “Those markers of puberty, and how biology is maybe determining how we will continue to grow, can be upsetting,” she says. Just the experience of having a monthly period can be gender dysphoric, she adds, making people feel even more at odds between their bodies and their identity.

“In terms of the gender non-conforming and transmasculine community, getting your period for the first time, or just having your period, might be really traumatic or disappointing.” —Joanna McClintick, LMSW

On the flip side, for transgender women and others who identify as feminine but may not have uteruses, a lack of periods may be equally upsetting. Kiesnowski says she has worked with many transgender women who feel “grief” over not having periods or being able to bear children themselves—not necessarily because they want to have children, but also because they hope that pregnancy would validate their womanhood. “And [women are] so much more than that,” Kiesnowski says.

A better way forward

So what can we do to change this? To start, let’s cool it on the super gendered language. “I do wonder if conversations or language were more inclusive and trans-affirming, if periods weren’t so associated with being a woman, it might not be so upsetting,” McClintick says. Both she and Kiesnowski use terms like “people with periods,” “people who menstruate,” or “people with uteruses” when working with their clients and in general.

Similarly, Dr. Shah says she’s gotten a lot of feedback from patients who feel that even the word “period” is loaded with such strong feminine associations and that they don’t like using it to describe their own experience, so she tries to keep her language as gender-neutral as possible. “I will always default to saying ‘monthly genital bleeding,'” she says. “If [my patients] say period, then I’ll use that language, but I open up with [monthly genital bleeding].”

Every individual’s preference with language can be different too, the experts add, which is why it’s important to meet a person where they are. “While one person might be talking about their genitals kind of generally, maybe another trans woman is comfortable about talking about their penis or their testes,” says Kiesnowski.

Beyond language, McClintick argues that companies that make products for periods have a long way to go to be truly inclusive. She cites the period underwear company Thinx, which made headlines in 2016 for featuring a trans man in an ad in the New York City subway. She says initially that was really exciting for many of the young people she worked with at The Center, until they went to the Thinx website, which has the URL of shethinx.com. “They felt this disappointment that this gender pronoun was used to describe the underwear, and so then it didn’t actually feel trans male or trans masc inclusive.” McClintick adds that menstrual products are consistently packaged in pinks and purples and are sold in the “feminine hygiene” section at the drugstore—all of which could make someone who doesn’t identify as a woman feel othered when shopping for those products.

In terms of health-care access, Dr. Shah recommends that providers focus on behaviors, not gender-based assumptions. “It’s really important to honor someone’s identity…but you also have to focus on the behaviors that they’re having with other individuals, like asking about what body parts are being used for sex,” she says—and being open and non-judgmental about those behaviors. That dialogue helps providers give the most accurate care (depending on what they hear, they’ll know to swab a person’s mouth and anus for STIs, not just their vagina, for example), and can ultimately lead to better patient outcomes.

All of us have a lot of work to do to strip the gender associations out of periods—and it will certainly take a bit of time for people to get up to speed. But it’s an important part of the ongoing fight against overall period stigma, says Kiesnowski. “We want to not only dismantle and bash that culture of embarrassment, we want to empower people to really talk openly,” she says. And that means all people, no matter how they identify or their current menstrual status, need to be a part of the conversation.

Looking to take down more BS around periods? Here’s the case for period neutrality. Also, hate to break it to you but period syncing is a total myth.