Improving menstrual equity in the USA: perspectives from trans and non-binary people assigned female at birth and health care providers

Elementary School Nurses' Perceptions Regarding Menstruation Education: An Exploratory Study

Menarche can be a difficult transition for young people. With appropriate education, youth can feel more positively about the menstrual experience. Since many elementary teachers are not equipped with menstrual health knowledge, the education falls to the school nurse. However, it is unknown if school nurses feel comfortable communicating about menstruation with young people. The purpose of this study was to explore school nurses' perceptions regarding menstrual health education in elementary schools (grades K-5).An online mixed-methods survey was established using Qualtrics. Through snowball sampling, 30 elementary school nurses responded. Using the Integrated Behavioral Model (IBM) as a framework, a deductive semantic thematic analysis was used to identify themes for each question.Data suggested that elementary school nurses would participate in professional development regarding menstrual health and hygiene. School health nurses are receiving limited knowledge/skills surrounding pedagogy and are not familiar with cultural differences when it comes to menstrual health.

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.

Understanding period poverty and stigma: Highlighting the need for improved public health initiatives and provider awareness

Period poverty affects millions of people who menstruate, but there is limited research to fully understand the scope and impact. Societal stigmas and cultural taboos negatively affect menstruation, a natural, biologic process. When unable to afford or find appropriate menstrual products, individuals may resort to alternative, poorer quality items, which increase their risk of infections. In addition, lack of products may cause individuals to miss events and have negative emotions. Implicit sexism and gender inequality are notable through the high cost of essential period products. Uncomfortable environments prevent patients from openly discussing menstruation with health care providers, who may lack training to competently assess needs and address barriers. Period poverty is a public health issue that not only needs to be addressed by our health care providers but also through increased education in schools and changes in local and federal legislation. In this paper, we discuss the financial, physical, and mental health impacts of period poverty and describe our experience creating a period pantry at a free medical clinic.

Menstrual health matters. Period

Menstrual health is composed of physical and psychosocial factors and fundamental to the well-being of menstruating individuals. Clinicians are urged to assess markers of menstruation as a vital sign, informing potential current and future health risks. Period poverty, or lack of access to menstrual hygiene products, sanitation, and clinical support, is a concern worldwide, particularly for vulnerable populations. As global health authorities and professional medical associations call for menstrual health as a priority, pharmacists are well-positioned to contribute solutions through access, education, advocacy, and research.

A pilot survey of students' menstrual attitudes, experiences, and needs on an urban university campus

BACKGROUND

In the United States, many menstruators face barriers to period management, such as period poverty, or the lack of access to relevant knowledge and affordable menstrual products. Our current understanding of the social, emotional, and physical impacts of period poverty on students in post-secondary institutions is largely limited.

OBJECTIVES

The purpose of this pilot study is to assess period poverty, period-related class disruption, and avoidance of menstrual hygiene management on campus among students and to identify recommendations for action at the University of Illinois Chicago and other urban universities.

DESIGN

An online cross-sectional study from February to May 2023.

METHODS

Enrolled students who were at least 18 years old completed an anonymous, self-administered online survey. Through descriptive statistics and chi-square tests in SAS version 9.4, we analyzed the sociodemographic, academic, and menstrual characteristics of those who had a period in the past 12 months. We also performed a thematic analysis of students' open-ended responses regarding their menstrual experiences on campus.

RESULTS

Of our sample (N = 106), 17.1% of students have faced period poverty, 55.8% experienced period-related class disruption, and 47.5% avoided changing their menstrual products on campus. The relationships between the three menstrual experiences were statistically significant. In the open responses, students reported that their personal experiences with menstruation were largely painful and disruptive. We identified the following themes: (1) inadequate water, sanitation, and hygiene facilities; (2) understocked, empty, or non-existent menstrual product dispensers; (3) a desire for additional resources for menstruation; and (4) the unpredictability of menstruation.

CONCLUSION

Our findings indicate that students continue to face obstacles to menstruation management due to inadequate support related to menstrual infrastructure, products, and pain. We outline several recommendations for university/college institutions to prioritize a more inclusive and supportive educational environment for all students.

Characteristics of Menstrual Suppression and Its Association With Mental Health in Transgender Adolescents

OBJECTIVE

To investigate the prevalence, nature, and effectiveness of menstrual suppression in transgender and gender-diverse (TGD) adolescents, and to explore whether there is an association between menstrual suppression and mental health in this population.

METHODS

A cross-sectional study was performed of TGD adolescents assigned female at birth attending their first appointment at a specialist pediatric gender service between February 2017 and December 2021. Demographic and mental health data were collected using a questionnaire at the time of first visit, and information regarding menstrual suppression at this time was retrieved from the medical record.

RESULTS

A total of 530 TGD individuals were included; 131 (24.7%) were on menstrual suppression at their initial visit, mainly to help alleviate gender dysphoria. Combined oral contraceptive pills were the most common agent used (n=61, 46.6%), followed by norethindrone (n=39, 29.8%) and intramuscular medroxyprogesterone (n=19, 14.5%). Rates of effectiveness (in stopping menstruation) and patient satisfaction were high. Among the 399 individuals not on menstrual suppression, there was strong interest in starting this treatment. No differences in the risk of gender dysphoria, depression, or anxiety were observed between those who were receiving menstrual suppression and those who were not.

CONCLUSION

Effectiveness of and satisfaction with menstrual suppression were high in TGD adolescents receiving this treatment. These findings support the routine exploration and management of menstrual health in TGD adolescents. However, menstrual suppression was not associated with any difference in gender dysphoria, depression, or anxiety symptoms in this cross-sectional study, and longitudinal studies are required to better investigate this.

Experience of menstruation with the use of reusable menstrual products: a qualitative study among menstruators in Israel

Menstruation is an embodied experience that influences menstruators' perceptions of the self and body. The stigma surrounding menstruation and its negative representation in popular culture has consequences for women's sexual and reproductive health. In this study, semi-structured interviews were conducted with forty 18-50 year old participants who used reusable menstrual products to examine their experience of menstruation and how their use of these products shaped their self-body image. Data were analysed using thematic analysis. Participants commonly reported physical, medical and emotional improvement in menstrual experience and improved acceptance of the menstrual body alongside changes in feeling towards menstrual products and related issues. The participants described menstruation, menstrual blood, and the menstrual body more positively than before, reported a high comfort level with and in their bodies, and rejected common representations of menstruation. Findings suggest that using reusable menstrual products can contribute to body appreciation. Given these benefits, further research is needed to assess how knowledge of alternative menstrual products can stimulate positive views about the menstruating body and contribute to menstrual health.

A Modified Menstrual Attitudes Scale: Heteronormative Attitudes, Sexism, and Attitudes Toward Menstruation in Male and Female Adults

Social shame and stigma surround menstruation, which may compromise women's health and rights in various contexts. Men's attitudes are particularly important because men often hold positions of power that influence women's experience. This study examined factors associated with menstrual attitudes, including heteronormative attitudes, sexism, and family influences. A cross-sectional Qualtrics panel survey (n = 802; aged 18-44; 50.8% female) was performed. We tested a revised menstrual attitudes scale based on items drawn from previously validated measures. Data were analyzed using a structural equation modeling framework. Factor analysis identified and confirmed a 5-factor model for menstrual attitudes. Men endorsed more negative attitudes toward menstruation than women; however, this difference was largely explained by factors other than gender in the structural equation model. After controlling for family and demographic characteristics, attitudes toward openness and secrecy surrounding menstruation were most strongly associated with gender role expectations and hostile sexism. Benevolent sexism was associated with finding menstruation debilitating, denying menstrual symptoms, and endorsing avoidance of activities during menstruation. Heteronormative and sexist attitudes were associated with more negative menstrual attitudes, while increased menstrual knowledge was associated with more positive menstrual attitudes. The difference in menstrual attitudes between males and females was explained largely by heteronormative attitudes and sexism. This suggests that attitudes toward menstruation are closely linked to social ideals about men and women.

"I stretch them out as long as possible:" U.S. women's experiences of menstrual product insecurity during the COVID-19 pandemic

BACKGROUND

A growing body of evidence highlights how the COVID-19 pandemic has exacerbated gender inequalities in the US. This resulted in women being more vulnerable to economic insecurity and decreases in their overall well-being. One relevant issue that has been less explored is that of women's menstrual health experiences, including how inconsistent access to menstrual products may negatively impact their daily lives.

METHODS

This qualitative study, conducted from March through May 2021, utilized in-depth interviews that were nested within a national prospective cohort study. The interviews (n = 25) were conducted with a sub-sample of cis-gender women living across the US who had reported challenges accessing products during the first year of the pandemic. The interviews sought to understand the barriers that contributed to experiencing menstrual product insecurity, and related coping mechanisms. Malterud's 'systematic text condensation', an inductive thematic analysis method, was utilized to analyze the qualitative transcripts.

RESULTS

Respondents came from 17 different states across the U.S. Three key themes were identified: financial and physical barriers existed to consistent menstrual product access; a range of coping strategies in response to menstrual product insecurity, including dependence on makeshift and poorer quality materials; and heightened experiences of menstrual-related anxiety and shame, especially regarding the disclosure of their menstruating status to others as a result of inadequate menstrual leak protection.

CONCLUSIONS

Addressing menstrual product insecurity is a critical step for ensuring that all people who menstruate can attain their most basic menstrual health needs. Key recommendations for mitigating the impact of menstrual product insecurity require national and state-level policy reform, such as the inclusion of menstrual products in existing safety net basic needs programs, and the reframing of menstrual products as essential items. Improved education and advocacy are needed to combat menstrual stigma.

“Girls May Bleed Through Pads Because of Demerits”: Adolescent Girls’ Experiences With Menstruation and School Bathrooms in the U.S.A

The aim of this study was to better understand the role of school bathrooms in shaping the menstrual experiences of adolescents in the U.S.A. The participants were Black and Latina, low-income adolescent girls (15–19) and adults interacting closely with youth in three U.S.A. cities (Chicago, Los Angeles, New York City). Data collection methods included: (1) Participatory Methodologies (PM) sessions with adolescent girls ( n = 73); (2) In-depth interviews (IDI) with adolescent girls ( n = 12); and (3) Key Informant Interviews (KII) with adults ( n = 23). Malterud’s “systematic text condensation,” an inductive thematic analysis method, was utilized to analyze the various data types (field notes, in-depth interviews, drawings). Key findings include, one, that menstruating girls experience embarrassment and a need for secrecy when accessing school bathrooms; two, the social and physical environments of school bathrooms, including poor design and maintenance, heighten girls’ discomfort, especially while menstruating; and three, school policies restricting students’ bathroom access are problematic for many menstruating students, especially those experiencing heavy and/or unpredictable bleeding. Schools and policymakers need to consider holistic approaches when addressing the menstrual needs of adolescents in U.S.A. schools, including better prioritizing issues related to menstrual stigma, school bathroom design and bathroom access policies.

Incarceration, menstruation and COVID-19: a viewpoint of the exacerbated inequalities and health disparities in South African correctional facilities

PURPOSE

The menstrual health and menstrual hygiene management (MHM) of incarcerated women remains relatively low on the agenda of public health interventions globally, widening the inequitable access of incarcerated women to safe and readily available menstrual health products (MHP). The COVID-19 pandemic has adversely impacted on the MHM gains made in various development sectors in the global North and South, through its amplification of vulnerability for already at-risk populations. This is especially significant to developing countries such as South Africa where the incarcerated female population are an often-forgotten minority.

DESIGN/METHODOLOGY/APPROACH

This viewpoint highlights the ignominious silence of research and policy attention within the South African carceral context in addressing MHM. The ethical and political implications of such silences are unpacked by reviewing international and local literature that confront issues of inequality and equitable access to MHP and MHM resources within incarcerated contexts.

FINDINGS

Structural inequalities in various contexts around the world have exacerbated COVID-19 and MHM. Within the prison context in South Africa, women face multiple layers of discrimination and punishment that draw attention to the historical discourses of correctional facilities as a site of surveillance and discipline.

RESEARCH LIMITATIONS/IMPLICATIONS

This study acknowledges that while this viewpoint is essential in rising awareness about gaps in literature, it is not empirical in nature.

PRACTICAL IMPLICATIONS

The authors believe that this viewpoint is essential in raising critical awareness on MHM in carceral facilities in South Africa. The authors hope to use this publication as the theoretical argument to pursue empirical research on MHM within carceral facilities in South Africa. The authors hope that this publication would provide the context for international and local funders, to assist in the empirical research, which aims to roll out sustainable MHP to incarcerated women in South Africa.

SOCIAL IMPLICATIONS

The authors believe that this viewpoint is the starting point in accelerating the roll out of sustainable MHP to incarcerated females in South Africa. These are females who are on the periphery of society that are in need of practical interventions. Publishing this viewpoint would provide the team with the credibility to apply for international and national funding to roll out sustainable solutions.

ORIGINALITY/VALUE

It is hoped that the gaps in literature and nodes for social and human rights activism highlighted within this viewpoint establish the need for further participatory research, human rights advocacy and informed civic engagement to ensure the voices of these women and their basic human rights are upheld.

Use and perceptions on reusable and non-reusable menstrual products in Spain: A mixed-methods study

Background

Menstrual products are necessary goods for women and people who menstruate to manage menstruation. Understanding the use and perceptions of menstrual products is key to promote menstrual equity and menstrual health. This study aimed at assessing the use and perceptions on menstrual products among women and people who menstruate aged 18–55 in Spain.

Methods

A mixed-methods study was conducted, including a cross-sectional study (N = 22,823), and a qualitative study (N = 34).

Results

Participants used a combination of products. Non-reusable products were the most used, while over half used reusable products. Usage changed when data were stratified by age, gender identification, completed education, country of birth and experiencing financial issues. It also varied between trans and cis participants. Menstrual products’ use also shifted based on experiences of menstrual poverty and access to information and products. Overall, reusable products were perceived to be more acceptable than non-reusable. Barriers to use the menstrual cup were also identified, including experiences of menstrual inequity (e.g., menstrual poverty, lack of access to information or menstrual management facilities).

Conclusion

Perceptions and choices of menstrual products need to be acknowledged, especially when designing and implementing menstrual policies to address menstrual inequity and menstrual health.

Menstrual Equity Initiatives at USA Universities: A Multiple Case Study of Common Obstacles and Enabling Factors

Background: In recent years there has been growing momentum in the USA around addressing issues of “menstrual equity” and “period poverty,” including a proliferation of university-level initiatives seeking to provide access to free menstrual products. This multiple case study examined four such efforts at a diversity of tertiary institutions to identify the factors that facilitated or impeded success.

Methods: We conducted a qualitative multiple case study, including a desk review and key informant interviews with student and administrative actors from universities with free menstrual product initiatives. We sought to identify key learning regarding common challenges and obstacles, enabling factors which supported success and sustainability, and practical learning for future initiatives. From the desk review, four schools (n = 4) were purposively selected to represent a range of geographic regions, student population size, and university type. Purposive sampling was used to identify students and administrators engaged in the menstrual equity initiatives on each campus (n = 20; 4–6 per school). Data from the desk review and interviews were analyzed using thematic analysis.

Results: Key themes included (1) the critical role of champions, (2) the importance of social and financial support, (3) challenges diffusing menstrual equity from pilot to scale, and (4) recommendations for future initiatives. University initiatives varied greatly in terms of their scope, funding, and implementation strategy.

Conclusion: This multiple case study provides valuable insights regarding the facilitating factors and obstacles faced by initiatives providing free menstrual products at universities. To date, these initiatives have proven successful across the four case studies; however, in most cases, the scope of the initiatives was constrained by limited resources and sustainability concerns. Future campus menstrual equity strategies would benefit from cross-institutional learning and dialogue highlighting design and implementation successes and challenges.