Data analysis identified three themes: “Systemic neglect of menstruation and the menstrual cycle”, “When “the private” becomes public: menstrual management” and “Navigating menstrual health: between medicalization and agency”.
Systemic neglect of menstruation and the menstrual cycle
There were two sub-themes regarding the systemic neglect of menstruation and the menstrual cycle: “Being “othered”: the invisibilization of menstruation and the menstrual cycle”, and “Why am I bleeding from down there?”: learnings on menstruation and the menstrual cycle”.
Being “othered”: the invisibilization of menstruation and the menstrual cycle
Participants treated menstruation as a taboo topic. It was socially considered “dirty” and against “women’s purity”: “It (menstruation) reminds you that it is an animal body, so then all this idea of an idyllic and virginal woman, so Virgin Mary does not exist (…), this stereotypical idea of a woman as all purity (…), so the period breaks that (image), because suddenly it is dirty and it bleeds and this is all opposite to the image of the clean and pure woman”-P27. Some participants mentioned how they were expected to conceal menstruation, especially in public as it was “something intimate”. Participants often refer to physical discomfort or illness instead of disclosing menstrual pain or other menstrual-related issues, as a way to conceal menstruation. Interestingly, many participants mentioned that they did not perceive menstruation to be a taboo for themselves and the same time, words like: “menstruation” “vagina” or “vulva” were often omitted. The words used instead were “period”, “down there”, “there” or simply paused for a moment to ensure the interviewer understood what they meant. Talking about “women-things” in front of men was uncomfortable for some and it was mostly avoided. In general, menstruation was perceived shameful when they were younger and more acceptable to talk about during adulthood, although most women and PWM still feared staining in public: “There was a girl in my school that had her period quite early and had very abundant periods and so she stained the chair with blood very often and all that (…) and so she told us to help her hide it, giving her a jacket, waiting for the boys to go to the playground so that we could later clean the chair before they saw it (the chair) like that”-P18.
When discussing the first photograph, as part of the photo-elicitation, participants thought it was “brave” to menstruate in public. This act was seen as undefeated and empowering: “I think it’s wonderful. And well, in fact, I see it as a vindictive act, right? (…) Very interesting, that she feels free. Of course, why would she stop running simply because her period has started”-P14. At the same time, some participants assumed that menstruating in public could only be an accident, implying that no one could actively decide to display menstrual blood in public spaces. They expressed empathy and compassion for “this incident”, while they thought public displays of menstruation were socially seen as unhygienic and dirty; “She is a pig, not wearing anything (menstrual products)”-P1.
Some participants explained that menstrual taboo was related to women being historically seen and treated as an object for social reproduction (i.e., self-care and care for others, including maintaining physical spaces and organising required resources to care, and human reproduction). Blood had negative associations with death, pain, hurt and satanic rituals. A few participants mentioned that bodily fluids had different connotations depending on where they come from. Those that came from the vagina were stigmatized: “It’s as if I’m sweaty and there’s a mark in my armpit, it is ok, but if it is a blood stain from the vagina, it’s not (ok)…”-P12. Participants also mentioned the role of religion, politics, gender roles and patriarchy to contribute to the invisibilization of menstruation: “As I said, religion (…) and I guess that they are things that have been perpetuated in society. Also, seeing women as something that has to be at home, really pulled away (…) it (menstruation) turns into something that has to be there, behind closed doors”-P19. Furthermore, one participant, who identified as non-binary, explained how what is not considered “normative” in an androcentric society is relegated to the private sphere, mentioning the invisibilization of people who menstruate who identify as men: “The androcentric society is sexist,… it is created based on androcentrism around the idea of the cis man, normative body, and everything else is relegated to the private sphere and also (…) bodies that can menstruate, for instance, (…) men who menstruate are totally invisibilised, and for example if they gestate they are directly seen as monsters and aberrant”-P18.
Participants also indirectly referred to the stigmatization of “the menstruating woman”, seen as hysterical and irrational beings unable “to control themselves”: “Menstruating woman equals hysteria and hormonal lack of control. (…) there might be a hormonal dysregulation (…) but that doesn’t mean that I do not know how to control myself (…) I think this is all a structural problem”-P23. In line with this, a few participants referred to their partners as more reliable sources than themselves, to determine whether or not they experienced emotional changes throughout the menstrual cycle: “No, I don’t experience (emotional) changes, this is something that my husband can answer, he will say yes. No, no, I don’t experience them… (…) No, because look, I’ve just had my period and he hasn’t said anything to me… right now… he hasn’t said anything to me. No, my period just ended and he hasn’t said anything, so no, no… I don’t think I experience changes.”-P33.
“Why am I bleeding from down there?”: learnings on menstruation and the menstrual cycle
Menstrual education were generally depicted to be insufficient and often late. Participants learned about menstruation mainly through informal education (family, friends, and others). Even if participants appeared to have had access to positive learnings on menstruation, they described how they still held negative perspectives on menstruation when they were young: “I still don’t understand very well… I remember that my mum had not had many period problems and so… that’s why I’m telling you that I don’t know where this idea that “periods are shit” came from, you know?”-P21. Most participants cited their family members as their first and most accessible source for menstrual education: “I know more or less what it is, menstruation, because in my house…. My grandmother had talked about it… or my mother had explained it to me. If I had to ask, I would ask and they would explain it to me”-P26. Menstruation was almost exclusively discussed with other women and PWM.
Not all participants had access to formal menstrual education. The formal education encountered was mainly at school, where the focus was on reproductive and sexual health more than menstrual health. Participants mentioned that boys were rarely included or participated in menstrual education, which was criticized by some who demanded menstrual education regardless of sex/gender. Menstrual education should be adapted to each person and include all options for menstrual management (including free bleeding). Although most participants did not consider school an important source of information, it was for one participant: “Luckily at school they already tell you about these things, so I was not caught off guard (at menarche)”-P11.
Interestingly, most participants considered having learned more about menstruation and the menstrual cycle through their own experiences and being autodidactic: “Like everything (…) One learns to walk by walking… so… every month I learnt something, mainly to understand your body (…) But I’m not conscious of it until… relatively until recently”-P33. Social media was used as a platform for menstrual education during adulthood by some participants. However, access to menstrual education was mentioned to be unequal, as it was dependent on one’s family, the school they attended, and their access to self-learning. Some women explained how it was more difficult for them to access to menstrual education pre- and post-menarche in their countries of birth.
Some participants did not know what menstruation was at menarche. Some learned about menstruation over time through friends or other sources (e.g., the internet or TV): “Yes, the period (…), they have not explained it well (…). Until I searched for “why is blood coming out from me down there”, nobody ever explained this to me”-P30. Menarche was symbolically perceived as a transition into womanhood and adulthood. This was often perceived to be distressing (and even traumatic), especially if menarche was at an early age and they were the first ones in their friend groups to menstruate.
Participants generally had no information on how a healthy menstruation and menstrual cycle looked like, so participants appeared to construct their perceptions and believes comparing their experiences to women and PWM around them:” I don’t have the ideal menstrual cycle that everyone dreams of, but I have also seen other realities that are worse”-P11. If participants had questions or concerns, they usually turned to friends, family, and the internet before asking a healthcare professional.
Overall, participants agreed that menstrual education should be fully available and accessible, to promote positive views on menstruation and the menstrual cycle; men should be included. Those participants who were mothers reflected on how they would educate their children on menstruation: “Well me with my child (male child), I want to speak with him mainly like this, an open conversation and all and explain things not to repeat mistakes… (referring to her parents)”-P34.
When “the private” becomes public: menstrual management
Three sub-themes were identified, related to menstrual management and its impact on participants’ lives: “Managing menstruation in public”, “Menstrual products are necessity goods: menstrual poverty”, and “Menstruation’s impact on daily life: social participation and paid labour”.
Managing menstruation in public
Overall, menstrual management was perceived as “uncomfortable” and “annoying”, and to create a mental load women and PWM had to endure. In general, participants shared that managing menstruation at home was easier: “I know that I am comfortable at home (…), I change it (menstrual product) much more often, but if I am at work instead, I know that I cannot get up every now and then to go to the bathroom and such”-P29. In fact, managing menstruation in public spaces was deemed difficult by participants, mostly due to the lack of adequate facilities. Consequently, managing menstruation in public was generally seen as unhygienic, associated with health problems (especially if menstrual products could not be changed timely and hygienically), and avoided by some. In order to be considered adequate, menstrual management spaces had to be clean, contain a sink, a bin and a hanger for clothes within the bathroom stall, and have a door that could be properly locked.
These struggles were also common in workplaces and schools, not just because of the lack of appropriate menstrual management facilities but social barriers. P26 shared how she was questioned about her reasons for using the bathroom, a basic need, in school: “So you had to tell them, please, I need to go to the bathroom because I’m on my period, and I need to go to change well, it’s like… you have to explain everything that happens so that they let you go… and of course you had to say it in the middle of the whole class, like they were like “wow, she has her period, she's going to change” … it was like … pf … you know, some uncomfortable moments”-P26.
Menstrual products are necessity goods: menstrual poverty
All participants considered menstrual products as necessity goods, although one participant (P9) mentioned how they were only perceived to be necessary since menstruating in public was socially unacceptable. Most considered menstrual products unjustly expensive. They thought that taxes on menstrual products, and/or their price, should be lowered: “They have super high taxes, when it is a basic need’s product”-P24. While some participants advocated for the need of free menstrual products, at least for more vulnerable people, a few claimed that menstrual products should not be free as other essential products are not. Two participants (P33, P34) expressed their concerns if menstrual products were free; they said that this measure would need to be implemented carefully, implying that some people might re-sell menstrual products: “That is a complicated topic because everything that is for free I believe that in some way people try to take advantage (…) There would need to be a lot of control. Too much control to start giving out things for free and that they do not escape to the “black market””-P34.
Some participants had experienced menstrual poverty (P1, P3, P9, P18, P19, P25, P26, P29, P30, P31) at some point in their lives. P1 shared that she had struggled to afford menstrual products sometimes if menstruation came before her salary, or if the usual cheap pads were sold out. In these cases, she would use toilet paper or borrow menstrual products from friends. Menstrual products’ price seemed to be the main reason for participants not being able to buy the products they preferred, even if they caused discomfort and health issues: I do not buy the pads non-branded. But I do buy the tampons non-branded. Maybe that's why it hurts (laughing) (…). Tampons (branded) are more expensive than pads (branded). Buying the two things (branded) is not feasible for me to be honest.”-P30. Other participants used menstrual products for a longer time than recommended when they could not afford menstrual products, or to save money. When having more financial issues, other participants decided to use the cheapest products available. However, a few participants attributed using cheap products to vaginal infections. Still, a few participants chose the cheapest products that did not cause them health issues.
On the other hand, a few participants had been forced to prioritize purchasing menstrual products over other goods or activities. Menstrual products were prioritized as they were considered necessity goods: “So I knew that, (…) I am a woman and that it (menstruation) came every month. So, I knew that food and my (menstrual) product could not be missing. Then I would see about the rest”-P29. Another participant shared a similar story: “It was either pads or going for a bite? The pad goes first”-P30.
Accessibility to menstrual products was also mentioned to be compromised depending on the type of product used and whether women and PWM lived in rural or urban areas. For instance, reusable, organic (without endocrine disruptors) and non-reusable products were more difficult to access, especially in small shops and rural areas. Assuming that women and PWM could always freely choose menstrual products was actually challenged by P14. She critically argued that the energy and time to look for less available products compromised the use of less mainstream (but healthier) options: “It is not so much of a choice because I…, if all products were on the shelfs (…) And you really have them equally accessible, you are deciding more freely indeed. But if they are offering you a particular product that has a way higher cost. Well you have to find the time to do these things (find menstrual products), but in the end you don’t have it (time), to be honest. And you go and look for the quick solution”-P14.
Migrant and second-generation migrant participants also described how it was harder to access menstrual products in their countries of origin (Morocco, Pakistan, Jordan, Brazil and Philippines), especially tampons, organic and reusable products (except for cotton cloths or self-made menstrual pads). This was negatively linked to menstrual health: “Unfortunately there are many women in other parts of the world, we are not talking only in Europe where we have everything in our reach. But in other areas (…) then, of course, they can’t feel the menstrual health”-P25. The idea that reusable products have to be promoted was shared by some participants, although personal choice needed to be respected and free-will ensured. Others mentioned the importance of men being involved in promoting menstrual products’ accessibility.
Menstruation’s impact on daily life: social participation and paid labour
Menstrual pain appeared to have the biggest impact on participants’ lives, but also heavy bleeding, low energy levels, difficulty concentrating, premenstrual symptoms and emotional changes throughout the menstrual cycle. Even if participants mostly referred to the impact of menstruation on paid work, social participation was also mentioned. The latter were mostly adapted, but sometimes cancelled. Avoiding hard physical activities, sex, swimming, praying, going to the beach, exercising, and driving due to pain and/or heavy bleeding was common. Feeling unwell during menstruation or at any other time during the menstrual cycle had also an impact on other responsibilities such as those related to social reproduction: “Obviously our health is dynamic and our emotional state. And our responsibilities outside of the workplace”-P10.
Especially menstrual pain, but also emotional fluctuations related to the menstrual cycle and premenstrual symptoms, had an impact on paid labour. Many said it was more complicated to work while menstruating, due to the unavailability of spaces to change menstrual products and because of menstrual pain impacting their ability to focus. Presenteeism was common as absenteeism due to menstruation and was perceived as embarrassing and even unacceptable. This was due feeling that menstruation was not a “good enough reason” to stop working. In order to avoid absenteeism, participants either took painkillers (“When I feel the slightest bit of pain, I take something (painkillers), because if not, I already know that I will not be able to work, you know? (…) I know I should not do it like this. But if I don’t do it… Every month I would miss two days of work, you know”?-P12) or used HC to continue being productive at work, or to avoid managing menstruation in the workplace (“I cheat, because my period comes on Friday night, (…) because at the beginning I did have a little bit of a painful menstruation and I believe that it came in the middle of the week (…) and work-wise (…) that day I was useless”-P6). However, some mentioned having to take days off from work. For all, there was more presenteeism at work, while during their time at educational institutions there was more educational absenteeism. They had also experienced presenteeism at school/university when responsibilities (e.g., an exam) were unavoidable. One participant (P25) gave her daughter painkillers for menstrual pain to prevent her daughters’ school absenteeism. She explained that if her daughter could not attend school due to menstrual pain, she would not go to work.
As P8 explained, menstruation is wrongly perceived to be a burden as it does not fit into the current socio-economic system based on continuous productivity. She suggests the need of systemic changes towards a more cyclic productivity model based on the menstrual cycle: “Because you are as if you were ill, and ill people do not produce, and those who do not produce are less valued in society, and consequently in the working area it (menstruation) is seen as a burden (…) there is much that can (menstrual cycle) can contribute to qualitatively”-P8. One woman (P34) told the researchers how some work colleagues had been fired due to menstruation supposedly impacting their work performance. Most participants stated for the need for menstrual policies at workplaces. Working from home during menstruation was seemingly perceived ideal by most participants. Menstrual leave was mentioned too, for those who may need it “without having to feel bad, guilty, or that I’m a bad worker, or lazy”-P14.
When asked if they thought menstruating created a disadvantage compared to men and non-menstruating people, some participants perceived it as uncomfortable more than a disadvantage. Other women and PWM thought menstruating was a disadvantage if they experienced dysmenorrhea, because of the mental load of managing pain, or if their partners did not support them. Others said that society had created the disadvantage, rather than it being originated from menstruating itself: “Maybe we have to take a step back and see that the problem is not menstruation. Maybe it’s what we do with it…”-P12. The lack of research was also mentioned by one participant as contributing to the invisibilisation, lack of knowledge on menstruation and the menstrual cycle and subsequently resulting in a perceived disadvantage of menstruating.
Navigating menstrual health: between medicalization and agency
This theme includes data on participants’ accounts of two these two sub-themes: “Experiences and access to health services for menstrual health” and “Systemic medicalization of menstruation and the menstrual cycle”.
Experiences and access to health services for menstrual health
Overall, participants had previously sought medical help for menstrual-related issues, although some sought professional assistance only if they had issues getting pregnant. Despite a few participants mentioning that they had very good experiences accessing healthcare services, most shared negative experiences. They felt that they were not listened to and their concerns were easily disregarded and unattended. For instance, menstrual pain was normalized and dismissed within the healthcare system (as it was socially). Besides, health professionals often did not give enough information for women and PWM to make informed decisions: “Gynecologists, and my mum is one of them, do not always explain well how hormonal contraception works in the body, right? And the truth is that it is important that this is explained, and once you know how it works, you decide”-P21.
A participant, who was born in Pakistan and worked as a cultural mediator in healthcare services, mentioned that disclosing vaginal pain or amenorrhea was difficult for some Pakistani women to share with healthcare professionals (P31). This was aggravated if the healthcare professional was a man. Another participant stated that not all women and PWM have the same access to healthcare services, and thus to have a good menstrual health: “I’ve you’ve got money you can afford it (…) economic differences can lead to differences in health, so, you can care for yourself more or less (…) You can attend to a doctor because you have less worries in relation to obtaining food or proper housing and so, and at the same time you can buy better-quality products or that better adapt to your menstruation”-P23.
Participants reported to have been diagnosed with several menstrual-related issues or health conditions: endometriosis, polycystic ovary syndrome, amenorrhea, adenomyosis, dyspareunia, anemia or acne. Many participants experienced dysmenorrhea and heavy bleeding. Menstrual pain, already mentioned as the most invasive menstrual issue in participants’ lives, was managed either by trying to relax and use natural methods for pain management (e.g. hot water bottles or teas), by taking painkillers or HC, or by disregarding it: “It depends if I’m at home or I’m out of home doing things, obligations that I cannot say no to. If I can I always try to rest (…) at home I can allow myself to be lying down (…) I use a hot water bottle or maybe I drink teas or hot things and I try to manage pain mentally. When it’s not possible (…) I would need to take a pill, some sort of painkiller, to do my tasks, otherwise it is impossible for me”-P8. Interestingly, both menstrual pain and abundant bleeding were often considered normal and “part of being a woman” for most participants.
The perceived lack of answers from the healthcare system appeared to leave participants to navigate MH on their own, while some had sought help from naturopaths and other non-medical professionals: “In reality, if I can avoid it I prefer no to go to traditional doctors (…) I would try to look for something like Chinese medicine, acupuncture, things like that”-P18. Managing stress and emotional distress, factors that a few participants associated with changes in menstrual patterns (e.g., intensified menstrual pain), was an approach for some participants. Making nutritional changes had also helped one participant (P8) to manage menstrual pain. For the same participant, having to manage pain on her own had led her to feel guilty for feeling pain at times.
Systemic medicalization of menstruation and the menstrual cycle
Participants generally expressed frustration over treatment options offered in healthcare services. Medicalizing with HC appeared to be the only option given: “It’s like the only thing (HC) that they give, the alternative to everything that happens to you with your menstruation is the “antibabies”-P12. HC was often prescribed as a “solution” for menstrual-related issues such as menstrual pain, irregular menstrual cycles, heavy bleeding, amenorrhea, and acne. Most participants distrusted the generalized prescribing of HC as an actual treatment for their health concerns, especially when they had no medical exams or tests to explore the reasons for menstrual-related issues. There was a general perception of HC being “harmful” and some participants expressed resistance to taking HC for reasons other than contraception: “If I will have a terrible acne breakout again… Uhm, I’d be looking for other ways to treat it”-P5. Still, many perceived HC as an “easy” and accessible option to manage MH. Many participants disclosed negative experiences with HC due to the secondary effects, which were often overlooked by healthcare professionals. P31 shared not being aware of the risks of taking HC until they told her to stop taking HC due to a blood clot: “it was a small blood clot, right? (…) Nobody had ever explained this (risk) to me”-P31.
At the same time, medicalization was sometimes perceived as a means to gain control over their menstrual cycle, or to have a “normal” menstrual cycle. Some participants perceived HC to “regulate” their menstrual cycle. P3, who used the vaginal ring, said the following: “That caught my attention, “wow, my period (cycle) was very controlled”-P3.
Similarly, there was resistance to taking painkillers for menstrual pain, although these were often considered indispensable to continue daily life. Seeking professional help for menstrual pain was sometimes perceived as difficult and frustrating: “I think it shouldn’t be normal for a woman to have to suffer these pains for menstruation… but as the specialists I have seen, told me the same thing, it has been well, so… whatever, I guess I will have to accept it (…) It is as if they don’t give importance to your pain, and (…) it makes you a bit angry, right? “-P12.