The Journal of School Nursing2022, Vol. 38(6) 504–510© The Author(s) 2020Article reuse guidelines:sagepub.com/journals-permissionsDOI: 10.1177/1059840520974234journals.sagepub.com/home/jsn
Abstract
The purpose of this pilot study was to expand understanding of the experience of menstruation for girls in the United States and its impact in the school setting. A qualitative approach was used to gather data from focus group interviews. Descriptive content analysis was used to categorize the range and types of menstruation experiences described by 12 participants aged 12–16 years. Findings revealed four main themes: (1) learning about menstruation, (2) experiencing menstruation, (3) managing menstruation, and (4) social norms and meaning of menstruation. Participants described multiple challenges faced learning about and experiencing menstruation, especially in the school setting. Participants described the limited understanding of menstruation experiences and confusion about the use of menstrual hygiene products. Challenges experienced at school included not having adequate access to menstrual hygiene products, limited time for changing products, fear of leaking menstrual blood, and impacts on school attendance. School nurses are well-positioned to contribute to creating school environments that are supportive of menstruation.
Keywordsmenstruation, adolescent, puberty, health education
Over the past decade, menstruation has received growing attention as a critical global public health and gender equality issue (Sommer et al., 2015). In particular, much of the work has focused on access to needed resources to manage the experience of menstruation, especially in low-income countries. Less work has focused on menstruation experiences of women and girls in the United States (Sommer et al., 2019). Pubertal development during adolescence, including menstruation, is a critical time for building a strong foundation for sexual and reproductive health as adolescents transition into adulthood. Understanding how to capitalize on this window of opportunity requires an understanding of the intersectional experience of menstruation in the United States (Herbert et al, 2017).
Fundamentally, menstrual hygiene management (MHM) requires adequate access to needed sanitary supplies. In the United States, approximately one quarter of women report difficulty purchasing menstrual hygiene products in the past year (Alliance for Period Supplies, 2018). Further, 20% of women and girls report missing school or work due to a lack of supplies to manage menstruation (Alliance for Period Supplies, 2018). Among low-income women, 64% report being unable to afford menstrual hygiene products in the past year, while 21% report struggling to purchase supplies monthly (Kuhlmann et al., 2019). Compounding issues of access, MHM products are not covered by federal assistance programs in the United States including the Special Supplemental Nutrition Program for Women, Infants, and Children and the Supplemental Nutrition Assistance Program. When supplies are not available, women report using cloth rags, tissue, toilet paper, paper towels, and diapers for MHM. Women also report additional challenges managing a heavy flow with limited products, transportation to stores with lower prices products, and access to safe and secure public restrooms (Kuhlmann et al., 2019). The inability to adequately manage menstruation limits full participation in society, contributes to higher rates of school absenteeism and missed activities, and perpetuates gender and class inequities (Houston et al., 2006; Sommer et al., 2016).
While much of the response to the menstrual hygiene movement has focused on addressing sanitation needs, an intersectional approach requires a broader understanding of the menstruation experience. Shifting to a concept of menstrual health includes discussion of needs and experiences beyond simply managing menstruation (Thomson et al., 2019). The cumulative impacts of menstruation on physical and emotional health and well-being have been coined menstrual poverty (Crichton et al., 2013). Previous literature suggests that menstruation experiences are largely shaped by preparation for pubertal changes and timing of pubertal development. Experiences of menarche at a younger age are associated with more negative attitudes toward menarche, poorer body image, lower self-esteem, and earlier sexual debut compared to average or later age at menarche (Herbert et al., 2017). Other factors that must be understood are the experiences of nonbinary and transgendered menstruators and consideration of the influence of race, age, class, and ability across the life course on menstruation (Bobel & Fahs, 2020; Thomson et al., 2019; Winkler, 2019). Consideration of these aspects of menstruation is fundamental to understanding the impact of menstruation on health, education, and well-being (Sommer & Sahin, 2013).
Education is a right for all individuals that should not be compromised simply by being born female. Research from low- and middle-income countries has shown that girls are missing school due to menstruation issues (Crankshaw et al., 2020; Davis et al., 2018; Ellis et al., 2016). Reasons include the impact of physical symptoms such as cramping, feelings of shame, fear of leakage, a lack of access to products, and an inability to manage menstruation in the school setting (Davis et al., 2018; Secor-Turner et al., 2016; Sommer & Sahin, 2013; Sommer et al., 2015). Additionally, as the average age of menarche decreases in the United States, there is a widening gap in providing adequate menstruation-specific education and preparation (Herbert et al., 2017). Across multiple studies in the United States, girls and women report a lack of information and readiness for menarche. Although many girls report receiving some education prior to menstruation, most characterize their education as inadequate, impersonal, not applicable, and/or provided too late (Herbert et al., 2017; Rubinsky et al., 2018).
Community context, including gender and gender identity expectations, taboos, and stigmas around menstruation, can also impact the menstruation experience (Crisler et al., 2016; Thomson et al., 2019). Cultural meanings of menstruation may vary by context, yet negative views regarding menstruation are pervasive worldwide. Negative experiences associated with menstruation include fear of heavy bleeding, the embarrassment of bleeding through clothing, physical pain, negative judgment by men, and a perception that menstruation is always bad. However, some women report positive associations with menstruation including evidence of not being pregnant, indication that the body is “normal,” and characterization that menstruation is tolerable (Fahs, 2020). Culture also shapes the ways in which menstrual socialization takes place and has lasting impacts on sexual and reproductive health and well-being. Communication regarding menstruation that is insufficient and impersonal creates discomfort with the experience of menstruation. Positive communication can lead to increased comfort with menstruation, which has been associated with increased comfort with sexuality, more sexually assertive behaviors, and fewer sexual risk-taking behaviors (Rubinsky et al., 2018).
Current research focusing on the menstruation experiences of girls is predominately focused on girls living in low- and middle-income countries (Sommer et al., 2019). The purpose of this pilot study is to expand understanding of the experience of menstruation from a developmental perspective for girls in the United States and its impact in the school setting.
Following standard guidelines for community focus groups (Krueger & Casey, 2015), three focus groups, stratified by age (middle vs. high school), were conducted by a moderator and assistant moderator (notetaker), followed a semistructured interview guide, and were digitally recorded and transcribed verbatim by a professional transcriptionist. Participants included adolescent girls in middle and high school who had already experienced their first menstrual period and were at least 12 years of age. Focus groups lasted 30–35 min and took place at a local middle school, high school, or university campus. The interview guide asked participants about (1) how they first learned about menstruation, (2) their first menstruation experiences, (3) how they learned to use menstruation management products, (4) their experiences with menstruation in school, and (5) their perceptions related to the benefits of menstruation.
A convenience sample of participants were recruited through social media and established school networks (e.g., sports clubs, school offices) using electronic announcements and word of mouth. Participants were purposively recruited from middle and high schools located in an urban, Midwestern city. Adolescents who were at least 12 years of age, attended middle or high school in the community, and had experienced at least one menstrual period were eligible to participate. Participants received a $15 US gift card for participation. Study procedures were approved by the North Dakota State University Institutional Review Board. Parents gave written consent, and participants gave written assent prior to participation in the focus groups.
Descriptive content analysis previously described by Cavanagh (1997) was used to identify and categorize the range and types of menstruation experiences identified by participants. After reading verbatim transcripts in their entirety, the first author developed a coding scheme to reflect initial experiences that were assigned code categories. These individually coded experiences were then organized into four overarching categories using the interview questions as a guide (Krueger & Casey, 2015). Next, the first and second authors reviewed each transcript line by line and systematically identified and coded experiences of menstruation. Two researchers participated in the analysis to provide investigator triangulation to confirm findings and add breadth to the interpretation of findings through multiple perspectives (Carter et al., 2014). Limited disagreement between coders was resolved by consensus using the established coding scheme.
Twelve participants who ranged in age from 12 to 16 years (mean age 14 years) participated in three focus groups: two high school groups (n = 3, n = 6) and one middle school group (n = 3). All participants identified as female and the majority (n = 11) identified as White and participants within each group already knew one another.
Experiences of menstruation described by participants were categorized into the following four overarching categories: (1) learning about menstruation, (2) experiencing menstruation, (3) managing menstruation, and (4) social norms and meaning of menstruation.
Learning about menstruation. Participants described learning about menstruation at school and at home. All participants remembered having a specific session during grade school in which the class was separated by gender and the school nurse presented information about puberty including menstruation. Participants recalled these talks being focused primarily on anatomy and physiology with little attention to managing menstruation and variation in experiences of menstruation. A high school participant described, “I feel like they spent too much time on the actual science of it ...but they didn’t tell us a lot about when to be prepared and a tampon.” A middle school participant described feeling scared from a lack of information about tampons. She stated,
It’s horrifying. It’s like, I don’t know. It’s shoving a piece of cotton inside your body, and, I looked it up, and apparently, yeah, if you keep it in for like, an hour, over four hours, you might die of cotton fever.
The presentation of a standard menstruation experience also led to confusion for some participants. As one high school participant described, “I assumed everyone got cramps because that’s just what they told us. I didn’t get any so I was confused.” Participants also described being made to feel that menstruation should be kept secret and that they should not talk about what they learned about menstruation with the boys in their class. One middle school participant said, “Because they gave us these little packets ...when they were doing the puberty talk. They gave us deodorant and a pad ...and they told us to hide them before the boys came, for some reason.” Another middle school participant added, “They said if they found out the boys found out and that you had told them, you would get in trouble.”
Participants described varying experiences of learning and communicating about menstruation at home. Many participants received information from their mothers and others turned to their older sisters for information. A high school participant said,
I felt like I got it so young. It was sixth grade, so it wasn’t that young. But, I like really didn’t think any of my friends, like got it. So, I didn’t really talk to them about it at the time. So, it was mainly my older sisters.
Overall, participants reported that information from their mothers and siblings was supportive and provided more instruction on using menstruation management products, for example, how to use a tampon. In contrast to feeling scared by the information presented at school, participants felt their mothers conveyed more excitement and normalized the experience of menstruation. A participant in high school described her mother’s reaction to her first period, “It’s like my mom will go, oh my God, you got your first period and ...they’re so happy and then like school makes it so scary.”
In addition to participants themselves learning about menstruation, a few participants described providing education about menstruation to their opposite gender friends and fathers. Among older participants, they described becoming more comfortable with the experience and not hiding it from boys and men. A high school participant described how comfortable her group of girlfriends was with the boys in their friend group answering questions about menstruation. She said, “They just ask, like, ...does it hurt when it comes out? Can you feel it? They just think it’s weird.” Another high school participant described her experience of normalizing talking about menstruation with her father. She said,
I talk to my dad about it all the time. He used to be like, that’s so gross, stop talking about that. And then just some more. I’m very open and the more I talked about it, he was like, “Really?” Now, he knows.
Experiencing menstruation. All participants clearly remembered and articulated the onset of menstruation. For most participants, their first period occurred at home. Other participants experienced their first period at school, gymnastics practice, and on a camping trip. Although they reported receiving information about menstruation prior to its onset, many participants still described being surprised and not really believing it was actually a “real period” when they began menstruating. As one high school participant described, “When I got my first one, I was camping. I was kind of expecting it but when I got it I was telling myself, okay, this is not your period.” Another high school participant described trying to ignore it when first beginning menstruation, “I tried to be like, this is not happening. Just ignore it.” Other participants described feeling embarrassed and alone when first menstruating, especially among participants who began menstruation before their friends. One high school participant said, “I don’t know, just feeling embarrassed that you got it first but it’s not something to be embarrassed about. But when I was younger, I was like, ‘This is so weird. Why did I get it so early?’” Another high school participant simply stated, “I wanted to cry.”
Experiences of menstruation at school were particularly challenging as participants described not having adequate time to use the bathroom between classes and being discouraged to use the bathroom during class. In addition, some participants described having to leave school because they did not have menstruation supplies or had bled through their clothing. A high school participant described not receiving extra credit because she had used a pass during the semester to use the bathroom during her period. She remembered,
The past couple months, my period has been really, really heavy. I bleed through my tampon in an hour. So, that’s been really difficult. Because, especially in school, they just don’t let you go to the bathroom or have a certain number of passes you can use and it’s really frustrating. If you don’t use all the passes, you can turn them in for extra credit at the end of the semester.
One high school participant described being threatened with a tardy for taking too long in the bathroom. She stated,
The teacher was like ...“that took way too long” because I went to the bathroom and didn’t realize I got it. So, I had to go back to my locker and go back and he was like, “Next time, that’s going to be a tardy.” And I didn’t want to tell him like well you know what was happening. I was like, okay.
Another high school participant described having to leave school unexcused to change clothing after bleeding through her clothes at school. She said,
I had to leave school because a teacher didn’t let me go to the bathroom and it’s like I obviously bled through. So I live half a block away. So I walked home and changed whatever and then I came back. But, it was just so bad.
Participants also described how cramps and fear of leaking created barriers to participating in daily activities during menstruation. Cramping contributed to missing school, opting out of sports participation, and concerns over how much cramps are “supposed” to hurt. A high school participant described, “One of my friends, she, whenever she’s on her period, like in the morning, she has to skip a couple periods [of school].” Another high school participant added, “Sometimes my cramps are terrible ...if I like planned a workout that day that wasn’t required to go to like practice for our sports, I wouldn’t go because I would not want to.” Despite learning about cramps, participants also described confusion about the experience of cramping. Some participants felt a lack of cramps was abnormal, while other participants wondered what was considered a normal amount of pain. One middle school participant asked,
For me, it’s really had to get comfortable or think or something because ...is it supposed to hurt? Because for me, it hurts a lot. I have to take two Advil a day so that it wouldn’t hurt that much. Is it supposed to?
Managing menstruation. Participants described a constant need to be on guard and prepared for menstruation. One high school participant stated, “You’re constantly on guard. Just have to be prepared.” Younger participants described irregular periods that made it difficult to track them, while older participants described their periods becoming more regular and easier to track. Strategies participants described using for tracking menstruation cycles included using a period tracking app on their phones and watching for premenstrual syndrome symptoms including, but not limited to, crying a lot, irritability, and cramps. However, some participants reported no warning signs for their menstrual cycle. Another high school participant described, “I don’t get cramps or anything, so I just have no warning.” Strategies for being prepared for menstruation included keeping menstrual hygiene products in their lockers, backpacks, and purses. Participants also described keeping extra clothing in their lockers at school in case they bled through their clothing. For example, one middle school participant stated, “I have a little bag with pads and stuff in my gym locker and have that with deodorant and an extra pair of underwear.” Another participant in high school described, “I have a hoodie in my locker just in case if I have to tie it around my waist.” When participants did not have menstrual hygiene products at school when needed, they reported asking friends for products or going to the school nurse. All participants reported menstrual hygiene products were not available in their school bathrooms, even for purchase. As a high school participant describes, they preferred getting products from friends, “The nurse is my second resort. If I can’t find someone who has a tampon, then I’ll just go to the nurse.”
Managing menstruation also required learning how to use menstrual hygiene products. While most participants felt confident using pads and reported learning how to use pads in school, many participants described discomfort and fear about using tampons. Participants reported a range of ways they learned about tampon use including from their mothers and friends, through trial and error, and needing to just figure it out. One participant in high school described the experience of her friend trying to figure out using products like this,
My friend did not know how to use a tampon. Like she got her first period in the middle of seventh grade and she did not know how to use a tampon. Like she put it in like with the plastic thing in. Then, the day after, she came in and like she didn’t take the plastic off the pad either.
Another high school participant described figuring out how to use a tampon because she needed to participate in gymnastics. She stated,
I was in gymnastics practice and we had to go change into our leos [leotards] and I was in the bathroom and then I saw it and then nobody had pads so I had to put in a tampon ...so I just had to figure it out.
Societal norms and meaning of menstruation. While describing their experiences with menstruation, participants also reflected on the societal norms associated with menstruation, including social stigma. In particular, participants described menstruation as being portrayed as disgusting and secret by society at large and especially by boys. One middle school participant described,
Whenever some people talk about it, like girls, they think it’s like just a big pain or something. It’s really not anything positive. But boys, they always say, oh my gosh, that’s so gross. You shouldn’t be talking about it.
Another middle schooler added,
Because it always seems like this in movies, where someone says, “oh it’s a girl thing.” All of the boys are like, oh my gosh! No! I mustn’t hear about this! It’s too delicate for my fragile ears or something.
However, some older participants felt menstruation was becoming more normalized. As one high school participant stated,
I think it’s changed a lot though compared to ...how it used to be. Obviously, people that aren’t exposed to it and guys that don’t have sisters will be like, “That’s disgusting.” But now I feel, it’s a normal thing but more people view it as normal and our guy friends aren’t afraid to talk to us about it.
In addition, participants did associate menstruation with some benefits including a sign of transition to womanhood and an excuse to be emotional. Menstruation provided a link to a shared experience with other women and conveyed a clear sign of growing up and maturity. One participant in high school stated, “My mom was like, ‘This is womanhood. We have to celebrate!’” The experience of premenstrual syndrome and menstruation also compelled some participants to feel entitled to act more emotional. One high school participant described it as, “An excuse to be a little sassy. A little moody.” In addition, participants mentioned both the benefit and risk of the association between menstruation and pregnancy.
Findings from this study describe the challenges and barriers adolescents face learning about and experiencing menstruation, especially in the school setting. Similar to findings in low-income countries, participants described the limited understanding of menstruation experiences prior to onset and confusion about the use of menstrual hygiene products. In addition, findings reflect similar school experiences in which participants describe not having adequate access to menstrual hygiene products, limited time for changing products, fear of leaking menstrual blood, and impacts on school attendance (Davis et al., 2018; Sommer & Sahin, 2013; Sommer et al., 2015).
Because menstruation is a fundamental part of the health of girls, women, and others who menstruate, consideration of the impact of menstruation must be included as a holistic part of health and human rights. There are clear implications of the experience of menstruation on education including school attendance and school experience (Crankshaw et al., 2020; Davis et al., 2018; Ellis et al., 2016; Sommer & Sahin, 2013; Sommer et al., 2015).
The small size and homogeneity of this study sample limit its generalizability to other contexts and populations. In addition, two of the focus groups had only three participants, limiting diverse perspectives within the groups. However, because the convenience sample recruited participants who already knew one another, the small group size allowed for deep conversation facilitated with established comfort with one another which may have not been possible with larger groups. Although an iterative process of recruitment to reach thematic data saturation was not used in this study, our small number of focus groups using convenience sampling did reach data saturation strengthening the findings for this small sample.
Implications for school nursing practice. School nurses are uniquely positioned and possess critical skills, knowledge, and experience to support the health and well-being of adolescent girls in the school setting. In particular, school nurses can advocate for school environments that are supportive of menstruation. For example, ensuring schools providing adequate time and access to menstrual hygiene products has the potential to improve school attendance and diminish concerns regarding leaking menstrual blood at school. Further, school policies and training for school staff to consider how classroom rules regarding bathroom use may unfairly impact menstruating students should be implemented. Our findings suggest a lack of knowledge and consideration of the potential impact of menstruation for students by teachers, especially male teachers, who may impose indirect punishment or penalty for the universal experience of menstruation. Teachers could benefit from annual training to decrease gender stigma associated with menstruation. Finally, school nurses can be leaders in preparing and delivering comprehensive menstruation education that adequately prepares students for the experience of menstruation. For example, participants described understanding the basic physiology of menstruation, but they lacked fundamental understanding of variations in menstruation experiences and how to use menstrual hygiene products such as tampons. School nurses can be an important resource for addressing universal gaps in menstruation knowledge and empowering students to adequately prepare for menstruation. Puberty education should be implemented in ways that normalize menstruation and to reduce fear, shame, and stigma associated with menstruation and are culturally relevant and sensitive. For example, providing education about the range of experiences of menstruation and strategies for managing menstruation could normalize adolescents’ experiences and reduce fear and shame. To reduce gender-based stigma associated with menstruation, it is critical to include boys in discussion intended to normalize the experience of menstruation. In addition, education about gender nonbinary or gender expansive identity can be a more inclusive approach to gender stigma around menstruation. School nurses can be instrumental in facilitating changes to menstruation education at the school level and in their individual interaction with students experiencing menstruation at school.
Policy changes also have the potential to improve the menstruation experiences of adolescents. In particular, policies can improve access to menstrual hygiene products and potentially decrease inequities in MHM. For example, several states in the United States have now passed legislation to remove state sales tax from the cost of menstrual hygiene products (Weiss-Wolf, 2020). Providing free menstrual hygiene products in school can also contribute to menstrual hygiene equity (Cotropia, 2019). School nurses can play a critical role in advocating for policies at the school, local, and state levels to support access to menstrual hygiene products in schools. Funding for making menstrual hygiene products available in schools has the potential to decrease the burden of school nurses providing these products.
Improving the menstruation experiences of adolescents relies on a multifaceted approach. Interventions that include comprehensive education (Belay et al., 2020) in addition to policy, systems, and environmental changes to support and normalize menstruation can improve the health and wellbeing of adolescents (Girod et al., 2017; Setyowati & Ungsianik, 2019; Winkler, 2019). In addition, positive school experiences and school attendance have been documented as important protective factors for adolescent health (Allison & Attisha, 2019; Gilligan, 2000; McLaughlin & Clarke, 2010). Interventions to support adolescent experiences in school while menstruating can support the development of school-related protective factors. To develop inclusive interventions, future research should focus on a deeper understanding of the menstruation-related school experiences of adolescents in varying geographic, cultural, and economic contexts and include the perspective of males and gender nonbinary identifying adolescents.
Molly Secor-Turner contributed to conception, design, acquisition, analysis, or interpretation; drafted the manuscript; gave final approval; and agreed to be accountable for all aspects of work ensuring integrity and accuracy. Andrea Huseth-Zosel contributed to conception, design, acquisition, analysis, or interpretation; critically revised the manuscript; gave final approval; and agreed to be accountable for all aspects of work ensuring integrity and accuracy. Rachel Ostlund contributed to acquisition, analysis, or interpretation; critically revised the manuscript; gave final approval; and agreed to be accountable for all aspects of work ensuring integrity and accuracy.
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
The author(s) disclosed receipt of the following financial support for the research and/or authorship of this article: This work is funded by NDSU Provost Development Funds.
Molly Secor-Turner https://orcid.org/0000-0002-2360-4080
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Molly Secor-Turner, PhD, RN, FSAHM, is a professor in the School of Nursing at North Dakota State University, Fargo.
Andrea Huseth-Zosel, PhD, is an assistant professor in the Department of Public Health at North Dakota State University, Fargo.
Rachel Ostlund, BSN, RN, is a doctoral student in the School of Nursing at North Dakota State University, Fargo.
1 School of Nursing, North Dakota State University, Fargo, ND, USA
2 Department of Public Health North Dakota State University
Corresponding Author:Molly Secor-Turner, School of Nursing, North Dakota State University, PO Box 6050, Dept. 2670, Fargo, ND 58108, USA.Email: molly.secorturner@ndsu.edu
