Positioning Periods: Menstruation in Social Context: An Introduction to a Special Issue

Women's reproductive mental health: currently available evidence and future directions for research, clinical practice and health policy

Sex and gender differences in the epidemiology of mental disorders are well documented. Less well understood are the drivers of these differences. Reproductive health represents one of the gendered determinants of mental health that may affect women throughout their life course. In this paper, we review common reproductive events that may be associated with mental ill health, including menstruation (with premenstrual dysphoric disorder appearing for the first time in recent classifications of mental disorders), contraception, abortion, sexual dysfunction, hypersexuality, sexual violence, reproductive coercion, infertility and associated gynaecological conditions, and menopause. Such reproductive events may differentially affect women globally via a range of potential biological and psychosocial mechanisms. These include, for example, vulnerability to the physiological changes in hormone levels across the menstrual cycle; side effects of treatment of mental disorders; inflammation underpinning endometriosis and polycystic ovarian syndrome as well as mental disorders such as depression; intersections with gender disadvantage manifesting, for example, as structural barriers in accessing menstrual products and sanitation, contraception and abortion, underscoring the broader social determinants impacting women's mental health. Greater understanding of these mechanisms is guiding the development of effective interventions, which are also reviewed here. However, key evidence gaps remain, partly as a result of the historic gender bias in mental health research, and the neglect of reproductive health in clinical practice. Furthermore, while several women's health strategies have recently been proposed internationally, they do not usually include a focus on mental health across the life course, particularly for women with severe mental illness. Integrating co-designed reproductive health interventions into primary and secondary mental health care settings, providing tailored care, increasing the evidence base on effective interventions, and empowering women to make informed choices about their reproductive health, could improve not only reproductive health but also women's mental health across the life course.

Menstrual Health Symptoms and Literacy among Young Women in Aotearoa New Zealand: A Nationwide Cross-Sectional Survey

STUDY OBJECTIVE

To explore menstrual cycle symptoms, information sources, and menstrual health literacy in young women (age 13-25) and those who menstruate in Aotearoa New Zealand DESIGN AND SETTING: A cross-sectional online survey in Aotearoa New Zealand was used.

PARTICIPANTS

The participants were 1334 respondents (age 13-25 years, mean age 19.8) who had had at least 3 periods and were currently living in New Zealand.

INTERVENTIONS

An online survey was hosted by Qualtrics between October 2021 and January 2022.

MAIN OUTCOME MEASURES

Information was obtained on menstrual cycle characteristics and symptoms and menstrual health literacy.

RESULTS AND CONCLUSIONS

Respondents reported high rates of regular dysmenorrhea (89%), fatigue/tiredness (78.1%), and mood changes (72.5%) associated with menstruation. A higher proportion of rangatahi (younger generation) Māori reported irregular cycles (53.5%) compared with non-Māori respondents (41.7%). Normalization of symptoms, especially pain (80.2%), was high. Most respondents recognized the need to see a doctor for period pain that impacted their daily lives (84.7%). However, noncyclical pelvic pain (45.7%), heavy bleeding (39%), and intermenstrual bleeding (29%) were less likely to be recognized as symptoms that require a doctor's visit. The main sources of menstrual health knowledge before menarche were a family member (74.2%) and health and physical education classes at school (63.7%). Many young people reported receiving little or no information about periods before menarche (37.9%), with very few respondents receiving information on how to manage menstrual symptoms (15.1%). Menstrual symptoms are common, and the provision of culturally safe information and opportunities to learn is important for young people, whānau, schools, and health care practitioners.

Bleeding beyond binaries: a critical interpretive review of trans, non-binary and gender non-conforming experiences with menstruation

While some barriers for managing menstruation have been mitigated for cisgender women, trans, non-binary, and gender non-conforming people still struggle to navigate menstruation in a gendered society. With an increasing number of young people identifying outside of the gender binary, there is an immediate need to identify and address the barriers to managing menstruation. This review sets out to explore how trans, non-binary, and gender non-conforming people experience and navigate menstruation. Using critical interpretive synthesis methodology, nine pieces of literature including peer-reviewed journal articles, graduate theses, a book chapter, and a conference poster presentation were reviewed using thematic analysis. Four primary themes were identified: (1) menstruation is strongly gendered; (2) there exists inadequate trans, non-binary, and gender non-conforming education and healthcare training; (3) the gendering of public toilets/washrooms poses a barrier to the management of menstruation; and (4) there exists a lack of diverse participants and attention to intersectional menstruation concerns. A set of recommendations, specific to a variety of stakeholders is provided, and implications for future research are discussed.

"Due to These Restrictions, Girls Think of Themselves as Nothing": A Qualitative and Quantitative Description of Menstrual Restrictions and Stigma Among Adolescent Girls Across Religious and Other Sociocultural Contexts

INTRODUCTION

Girls in Tanzania often experience menstrual restrictions (i.e., expectations about behaviors prohibited during menstruation) and menstrual stigma (i.e., negative attitudes toward people who menstruate). A better understanding of sociocultural contexts contributing to menstrual stigma and restrictions is needed.

METHODS

In 2018, two conceptually linked quantitative and qualitative studies were conducted to describe menstrual restrictions and stigma among girls in Tanzania, examine how sociocultural contexts influence menstrual restrictions and stigma, and investigate the relationship between menstrual restrictions and stigma. A cross-sectional survey of 509 post-menarche girls from five schools assessed associations between religion, religion-based menstrual restrictions, and menstrual stigma while controlling for differences between schools. In-depth interviews with 10 adolescent girls and 10 adult key informants explored broader menstrual experiences. We analyzed themes pertaining to sociocultural contexts and other mechanisms that shape menstrual restrictions and stigma, their impacts on girls, and opportunities for intervention.

RESULTS

In the surveys, 52% of Christian girls and 76% of Muslim girls experienced religion-based menstrual restrictions. Some restrictions, such as prohibitions against praying during menstruation, were more common among Muslim girls, who also had higher menstrual stigma. Menstrual stigma differed by school. Although menstrual restrictions did not show an association with stigma in the surveys, interview participants described how menstrual restrictions contribute to stigma and indicated that religion, tribe, education, family support, and menstrual resources influence menstrual restrictions and stigma.

CONCLUSION

Sociocultural contexts influence menstrual restrictions and stigma. Working with religious, school, and family leaders may provide opportunities to implement interventions to reduce menstrual stigma.

An intersectional approach on menstrual inequity as lived by women in circumstances of socioeconomic vulnerability in an urban and rural setting in Spain: a qualitative study

Since menstrual health and menstrual inequity are determined by social power structures, this study proposes to analyse, from an intersectional perspective, the experiences of menstrual inequity of women and people who menstruate (PWM) (≥18 years) under circumstances of socioeconomic vulnerability in an urban and rural setting in Catalonia (Spain), focusing on menstrual poverty, menstrual management and access to health care for menstrual health. An exploratory and interpretative qualitative study was conducted. Venue-based convenience sampling was carried out, recruiting women from a non-governmental organisation and a primary health care centre. Eighteen individual semi-structured interviews were conducted between October 2022 and February 2023. Data were analysed through reflexive thematic analysis. Analysis revealed that menstrual care was generally a distant preoccupation that revolved around circumstances of socioeconomic vulnerability, housing, and productive/reproductive work. Menstrual poverty, menstrual management and menstrual self-care challenges, barriers to accessing health care for menstrual health, and menstrual taboo, stigma and discrimination were commonplace and deepened by socioeconomic vulnerability. In this way, women's menstrual experiences were rooted in intersecting axes of inequity, based on gender, race and class. Intersectional and critical participatory research, policy and practice are imperative to develop counter mechanisms that confront systems of privilege-oppression to modulate menstrual experience, health and equity.

Moving from ethnic exclusions to cultural safety: how is athlete ethnicity discussed in research on menstrual health in sports? A scoping review

OBJECTIVE

This study aims to investigate how athlete ethnicity is discussed in the inclusion and exclusion criteria, methodology, findings, and conclusions of research focused on menstrual health in sports science and medicine.

DESIGN

A scoping review of sports-based research conducted on athletes related to (1) menstrual health and ethnicity, (2) how researchers include/exclude participants based on ethnicity and (3) how ethnicity is discussed.

DATA SOURCES

Electronic search of PubMed and ProQuest.

ELIGIBILITY CRITERIA

Articles were included if they met the following criteria: (1) published before September 2023, (2) published in peer-reviewed journals, (3) participants were women athletes, (4) published in English and (5) relating to menstrual health. Articles were assessed as good, fair or poor quality using the Inclusion of Participant Ethnicity Quality Assessment Criteria.

RESULTS

From the 1089 studies available from the initial database search, 55 studies considered ethnicity. Nine studies met the inclusion criteria and were assessed as either good (22%), fair (44%) or poor (33%) in quality in their consideration of athlete ethnicity. 81% of research articles on menstrual health in sports do not consider athlete ethnicity, and when ethnicity is discussed, it rarely meets the criteria for cultural safety in the research process. Most studies did not factor ethnicity into the analysis and lacked cultural considerations in the research design and interventions.

CONCLUSION

More careful inclusion of ethnicity in sports menstrual health-related research and recognition of social and cultural influences on health and research outcomes for indigenous and other ethnic minority groups is needed. Such research is required to support coaches, medical personnel and support staff in designing culturally safe environments for sportswomen from diverse cultural and ethnic backgrounds.

Menstrual attitudes in adult women: A cross-sectional study on the association with menstruation factors, contraceptive use, genital self-image, and sexual openness

BACKGROUND

Menstruation is a central part of the everyday life of most women, and menstrual attitudes may impact health and well-being.

OBJECTIVES

This article aimed to map menstrual attitudes among adult women and examine factors associated with these attitudes, such as aspects of menarche and current menstruation, and rarely studied factors, such as genital self-image and sexual openness.

STUDY DESIGN

A cross-sectional online survey.

METHOD

A sample of 1470 women, aged 18-50 years, were recruited through social media sites. The Menstrual Self-Evaluation Scale was used to measure three different attitudes: menstruation as natural, shameful, and bothersome. Multiple linear regression analysis was used to investigate the relationship between each attitude and factors related to menarche and current menstruation, contraceptive use, genital self-image (assessed by Female Genital Self-Image Scale), and sexual openness (Personal Comfort with Sexuality Scale). Sociodemographic variables were included into the models as covariates.

RESULTS

Agreeing with the attitude of menstruation as something natural was predicted primarily by positive emotions at menarche, experiencing less menstrual pain, using no or nonhormonal contraception, and having a positive genital self-image. Perceiving menstruation as bothersome was predicted by a lower educational level, experiencing stronger menstrual pain, having more perimenstrual psychological symptoms, and using hormonal contraceptives. Menstruation as something shameful was chiefly predicted by lower sexual openness and a negative genital self-image.

CONCLUSION

Many women held attitudes about menstruation as both something natural and bothersome. Menarche and current menstruation experiences, and contraceptive method, played central roles in shaping attitudes toward menstruation as natural and bothersome. Viewing menstruation as shameful stood out from other attitudes by indicating a triad of self-objectified shame that includes menstruation, sexuality, and genital self-image. Further research into the relationships between menstruation, contraceptive use, sexuality, and body image is needed to enhance our understanding of women's menstrual health.

“But I think there’s always been that stigma”: Adult women’s perceptions of menstrual product advertising

The global value of the menstrual product market recently surpassed 40 billion dollars, yet little attention has been paid to how menstrual product advertising may impact women's perceptions of menstruation. We interviewed a diverse cohort of 18 adult women to understand how menstrual product advertising shapes women's interpretations of their bodies and the menstrual process. Three themes emerged, including gendered stigmatization, depictions of hyper-feminine women, and false narratives about periods. We concluded that dominant patriarchal images of women on their periods persist in female-targeted advertising and offer solutions for advertisers to eliminate stigmas and encompass inclusivity.

The Use of a Two-Phase Online Delphi Panel Methodology to Inform the Concurrent Development of a School-Based Ovulatory Menstrual Health Literacy Intervention and Questionnaire

Introduction

There are a high prevalence of ovulatory-menstrual (OM) dysfunction and low levels of menstrual health literacy in adolescents, yet few evidence-based OM health education resources for schools.

Method

This two-phase study used an online Delphi methodology to build consensus across thirty-five purposively selected professionals from the diverse professions of health and education. The panellists were tasked to inform the development of a school-based OM health literacy resources.

Results

In Round One, 86% of panellists determined the scope of these resources using guided and open-ended questions. The study then split into two phases which ran concurrently. In the first phase informing the intervention's development, 57% of panellists participated in Round Two, and 29% reviewed selected lessons. In the second phase informing the questionnaire's development, 51% of panellists participated in Round Two, and 69% in Round Three. The overall consensus reached for the intervention phase and questionnaire phase were 82% and 84%, respectively. The Panel's recommendations included a strengths-based position to counter menstrual stigma, teaching accurate self-report of cycle biomarkers, addressing multiple menstrual dysfunctions and adopting a whole-school approach.

Conclusion

Although time-consuming and requiring a sustained interest, this two-phase Delphi methodology offered anonymity to panellists from distinct professions which facilitated their independent contribution to developing OM health literacy school resources.

The messiness of the menstruator: assessing personas and functionalities of menstrual tracking apps

OBJECTIVE

The aim of this study was to examine trends in the intended users and functionalities advertised by menstrual tracking apps to identify gaps in personas and intended needs fulfilled by these technologies.

MATERIALS AND METHODS

Two types of materials were collected: a corpus of scientific articles related to the identities and needs of menstruators and a corpus of images and descriptions of menstrual tracking apps collected from the Google and Apple app stores. We conducted a scoping review of the literature to develop themes and then applied these as a framework to analyze the app corpus, looking for alignments and misalignments between the 2 corpora.

RESULTS

A review of the literature showed a wide range of disciplines publishing work relevant to menstruators. We identified 2 broad themes: "who are menstruators?" and "what are the needs of menstruators?" Descriptions of menstrual trackers exhibited misalignments with these themes, with narrow characterizations of menstruators and design for limited needs.

DISCUSSION

We synthesize gaps in the design of menstrual tracking apps and discuss implications for designing around: (1) an irregular menstrual cycle as the norm; (2) the embodied, leaky experience of menstruation; and (3) the varied biologies, identities, and goals of menstruators. An overarching gap suggests a need for a human-centered artificial intelligence approach for model and data provenance, transparency and explanations of uncertainties, and the prioritization of privacy in menstrual trackers.

CONCLUSION

Comparing and contrasting literature about menstruators and descriptions of menstrual tracking apps provide a valuable guide to assess menstrual technology and their responsiveness to users and their needs.

Understanding menstruation: Influence of gender and ideological factors. A study of young people's social representations

This research investigates social representations of menstruation. It analyses firstly how young Spanish people understand menstruation in their everyday lives. And secondly, it explores how gender and ideological factors (liberal vs. conservative; feminist vs. non-feminist) impact on the meaning of menstruation and its implications for acceptance of this process. A free association exercise elicited by the word “menstruation” was answered by 250 people and the content was examined by lexical analysis. The results divided social representations of menstruation into two levels: firstly, a traditionalist level that is clearly linked to a negative stigmatized discourse about menstruation; and, secondly, a progressive level where two different discourses emerge, one representing liberal men and the other representing feminist women. The results show that only the feminist conception of menstruation provides an empowered and emotionally positive representation. The concept of menstruation is concluded to emerge from various sources of information, values and social conventions that are somewhat removed from its scientific meaning. The representation of menstruation is therefore understood to be situated within a social, ideological and emotional context. Accordingly, health education campaigns should frame their discourse about menstruation within a feminist perspective as their point of departure, thereby increasing their effectiveness.