Milan Chhetri was 12 when his period first arrived. In his home in Dailekh, Karnali Province, the tradition was clear: anyone who menstruated did not stay in the house. For five days, he had to live with his sister. He could not see his father, his brothers or his grandfather. Back then, he did not have the language for what he knew about himself. He only knew that what was happening to his body felt like a punishment for something he had not done.

More than a decade later, Milan, now 24, still menstruates. He works as a social mobiliser in Thantikandh Rural Municipality, visiting schools as a part of his work. He gets his menstrual products from the schools as finding them in the market is not simple, and buying them as a man is an own ordeal in itself.

At one point, he used contraceptive injections for six months, obtained from a hospital in Surkhet, to stop his periods. But he stopped after worrying that if complications arose, doctors who had treated him poorly in the past might do so again, and that his family would blame his identity for whatever went wrong. His periods returned. Since then, he has managed them as he always has: quietly, carefully and mostly alone.

At home, he hides the fact that he is menstruating at all. His mother worries that the family will fall ill if they find out. “In our village, menstruating people are kept away from many activities,” he said. “Sometimes you are stopped from walking on certain paths if elderly people are nearby.” He refuses to go to the menstrual hut. He has learned, instead, to be invisible in other ways.

Nepal became the first country in South Asia to legally recognise transgender identities in 2007, following a landmark Supreme Court ruling. It has since been held up as a model of gender progressivism in the region. Yet its menstrual health system—from programmes distributing pads in rural districts to school lessons and clinical care—was built around a single assumption: that menstruation belongs to women. For trans men, that assumption is not an oversight. It is the architecture of their invisibility.

Six hundred kilometres southeast, in Janakpur, Nishant Jha encountered the same gap under different circumstances.

He was not thinking about the risks when he started taking testosterone in 2013. He wanted a voice that matched who he was, a beard and a body that felt like his own. A friend already using testosterone sourced it from Delhi and sold it to him for Rs250 to Rs300 a dose. Jha took it to a doctor in Janakpur to be injected. There was no prescription, monitoring or follow-up.

He took injections for hormones for about a year. His voice changed, he grew a beard and his periods stopped. Then a senior advised him to get a proper check-up. A trip to Kathmandu and full-body screening cost Rs15,000 to Rs16,000—more than he could afford. So he stopped.

“I didn’t think about side effects or how it would affect my physical health,” he said. “I just wanted to change my body to the way I felt about it.”

When his periods returned, the bleeding was heavier and the pain, he said, was three times worse. His cycle became unpredictable, sometimes lasting more than a week and sometimes only two days.

“I blame myself for not knowing better,” he said. “Not the doctor.”

Jha is now 24 and works as a legal administrative assistant at a queer youth group in Kathmandu. He has resumed hormone therapy, taking an injection every 21 days at Rs600 a dose. His symptoms have improved, but missing an injection brings a different kind of pain in his lower abdomen. His doctor has described it as a conflict between the hormones and his uterus and suggested a hysterectomy. Jha says he cannot afford the procedure and remains nervous about it.

“I carry the feeling that I might be in my period everywhere,” he said. “It is very hard to feel secure, even while taking hormones.”

What connects Jha’s experience to Milan Chhetri’s in Dailekh is not geography or circumstance, but the same institutional gap: Nepal’s menstrual health system was not designed with trans men in mind.

Radha Paudel, founder of the Global South Coalition for Dignified Menstruation, has spent years documenting that gap. She interviewed 30 trans men and reached about 400 others through online surveys across Nepal, India, the United Kingdom, Australia, South Korea and Thailand. Her finding is broader than Nepal: few countries have formally included trans men in their menstrual health systems.

The number of trans men who menstruate in Nepal is itself unknown. The national census does not count trans men as a distinct category, leaving the population affected by this exclusion effectively unmeasured.

Nepal’s policy failure predates the 2025 Resolution Motion on Dignified Menstruation. A National Policy on Dignified Menstruation was drafted in 2017 but never adopted. Some awareness activities followed in 2021 and 2022. Then, on March 21, 2025, the National Assembly unanimously passed a resolution—the first of its kind in the world—calling for legal frameworks that recognise all menstruators, including trans men, people with disabilities and non-binary people.

The Ministry of Women, Children and Senior Citizens—since renamed (The Ministry of Women, Children, Gender and Sexual Minorities and Social Security) was designated to draft the required Act. It has not done so. Paudel said the Act would provide the basis for municipal guidelines and inclusive school programmes.

The current Safe Motherhood and Reproductive Health Act of 2018, however, refers only to “woman” and “girl”. Trans men do not appear in it. Paudel argues that such laws need to refer more broadly to people who menstruate, including “persons born with a uterus”.

The changes she proposes are relatively simple: gender-neutral toilets in public places, health workers trained to treat anyone who menstruates, inclusive language in school curricula and the formal inclusion of trans men in menstrual health programmes.

The clinical system shows what happens when that inclusion is absent.

Shreyashi Aryal, a gynaecologist practising in Kathmandu, said she would not feel confident treating a transgender man who walked into her clinic.

She recalled asking a patient during a routine consultation: “When did you last menstruate?”

“I am a trans man. I don’t menstruate,” he replied.

“I went blank,” Aryal said. She completed the consultation but later realised she had used the wrong pronouns. The patient never returned.

Aryal began her MBBS in 2003 and later completed an MD in gynaecology. Neither programme included transgender health. The Nepal Medical Council has issued no specific guidelines, leaving clinicians to rely on guidance from organisations such as the UK’s Royal College of Obstetricians and Gynaecologists and the American College of Obstetricians and Gynecologists in the US.

A 2022 letter by gynecologists at Lumbini Medical College similarly found that reproductive health training in Nepal remains largely built around heterosexual, cisgender (gender assigned at birth) patients and leaves doctors ill-equipped to address the needs of trans men, from menstrual complications and hormone therapy to gender-affirming procedures.

The consequences are evident in Jha’s history. He took testosterone without medical monitoring, and stopping it resulted in painful and unpredictable bleeding.

“We understand we need to address their needs,” Aryal said. “But we don’t know where to start.”

The gap extends into schools. Richa Neupane, a member of the Gender, Disability and Social Inclusion thematic group under the National Curriculum Framework Review Task Team, said trans menstruation has never been included in Nepal’s curriculum. Her group plans to introduce language acknowledging gender and sexual minorities, with trans menstruation potentially included under comprehensive sexuality education. Whether that survives the approval process remains uncertain.

On the ground, inclusion varies. Pushpa Joshi, programme director at Yoshan Nepal, said her organisation uses “menstruating persons” rather than “women” and would include a trans student who came to collect pads or attend a session.

Maya Khaitu, executive director of Days for Girls Nepal, described a different reality. In the rural communities where her organisation works, trans men do not appear in its records.

“Discussing other levels of identity would feel like jumping ahead when we are still educating people not to stay in menstrual sheds,” she said.

The National Assembly passed the resolution motion unanimously. But the Act has not been drafted, curricula remain largely unchanged and clinical training has yet to catch up.

Nepal was the first in the region to recognise, in law, that trans people exist. It has yet to fully recognise, in policy, that some of them menstruate.