"Just because I don't bleed, doesn't mean I don't go through it": Expanding knowledge on trans and non-binary menstruators

Menstrual Dysphoria and Preferences for Menstrual Suppression in Transgender and Gender-Diverse Youth

INTRODUCTION

Menstruation can present a significant challenge for transgender and gender-diverse (TGD) individuals. While menstrual suppression can help alleviate this experience, research on the topic remains scarce. This study aimed to assess menstruation-related discomfort experienced by TGD individuals and to identify their preferences for menstrual suppression methods MATERIAL AND METHOD: This cross-sectional study was conducted between December 2021 and September 2023 with a sample of TGD individuals (n=21) aged 12-24, experiencing menstrual dysphoria. Participants completed an initial questionnaire assessing menstruation-related discomfort, followed by counseling on menstrual suppression options, including combined oral contraceptives, progestin-only pills, depot medroxyprogesterone acetate injection, levonorgestrel-releasing intrauterine device, and the etonogestrel implant. A second questionnaire evaluated factors influencing method preferences and documented the chosen suppression method. Descriptive statistical analyses were performed, with continuous variables presented as mean ± standard deviation and ordinal variables as numbers and percentages.

RESULTS

The conditions most frequently associated with severe discomfort related to menstruation were gender incongruence (81%), the carrying and use of menstrual products (95.2%), and the purchase of menstrual products (85.7%). The most popular method of menstrual suppression was combined oral contraceptives (63.1%). Several factors were identified as influencing the choice of method, including the estrogen content, frequency of use, and the necessity of a gynecological examination or visiting a different health facility.

CONCLUSIONS

The study underscores the considerable distress that menstruation can cause in TGD youth. Moreover, the importance of personalized, patient-centered counseling is emphasized, with the objective of empowering individuals to make decisions based on their specific needs.

Degendering Menstruation: A Scoping Review Exploring the Experiences of Transgender and Non-Binary People

Menstruation is a biological process experienced by up to 800 million people on any given day. Historically, menstruation has been studied from the female perspective. However, it should be considered that not all who menstruate are women. Therefore, the purpose of this research was to determine the status of evidence on transgender and non-binary individuals' experiences with menstruation. Arksey and O'Malley's (2005) framework for conducting a scoping study was used to guide this review. The authors used five steps of the six-step process to identify the research problem and search strategy, select studies based on defined inclusion and exclusion criteria, extract key information from five selected studies, and chart, summarize, and report the results as themes. The analysis resulted in the identification of four themes: (1) gender dysphoria and the influence on identity; (2) menstrual management and transformation as a turning point; (3) managing menstruation in precarious spaces; and (4) moving toward an open dialogue. Findings suggest a need for awareness of diverse and inclusive menstrual experiences. Inclusive advertising and menstrual products are needed to support transgender and non-binary people and reduce gender dysphoria. Policy initiatives should support the reconceptualization of infrastructure so that bathrooms are safe and comfortable places. Future opportunities for research exploring menstrual management within transgender and non-binary populations with emphasis on global research with diverse cultures and social structures is necessary to address gaps in the existing literature.

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.

"If everyone comes together, many things can be changed": A qualitative study on men's perspectives on menstrual health and equity in the Barcelona area (Spain)

There is a paucity of research exploring how men and individuals who do not menstruate comprehend menstrual health and equity. The objective of this study was to explore the conceptualization and attitudes towards menstruation and the menstrual cycle among men and people who do not menstruate aged between 18 and 55 in the Barcelona area. Furthermore, it examined their involvement in menstrual health and equity initiatives. This qualitative study employed a feminist critical perspective. Seventeen semi-structured photo-elicitation interviews were conducted. It was frequently observed that menstrual education was often inadequate and biomedical in nature. Participants often acquired knowledge about menstruation through interactions with menstruating sex-affective partners. Menstruation was generally perceived negatively, and menstrual taboo and stigma were apparent. Some participants expressed the view that men should raise awareness of a more positive stance on menstruation. The findings of this study highlight the need for structural menstrual policies and community programs where men and people who do not menstruate are involved.

Dysmenorrhea and the clinical encounter: testing a conceptual model of physician-patient interactions among emerging adults

ABSTRACT

Dysmenorrhea affects as much as 85% of female youth in Canada and the United States and can negatively impact academic performance, overall health, and mental well-being. The physician-patient relationship can play an important role in supporting patients with pain conditions, such as dysmenorrhea. Through effective communication, trust, and validation, physician-patient interactions can empower pain patients, potentially improving pain outcomes. To date, no studies have quantitatively examined the impact of physician-patient interactions on youth's experiences of dysmenorrhea. Therefore, our aim was to explore the relationships among perceived physician communication, pain invalidation, trust in the physician, treatment adherence, menstrual sensitivity, and dysmenorrhea symptom severity among emerging adults (EA) and test a conceptual model of potential interactions using partial least squares structural equation modeling (PLS-SEM). The online survey was administered to Canadian and American EA aged 18 to 21 (Mage = 19.4, SD = 1.1) years with dysmenorrhea. Two models were tested using PLS-SEM: model A only included participants who had received a treatment plan from their physician (n = 279) and model B included the full data set (N = 362). In both models, the perception of more effective physician communication and reduced pain invalidation were related to lower dysmenorrhea symptom severity through menstrual sensitivity. In model A, better physician communication and lower pain invalidation were also associated with higher reported treatment adherence by trust in the physician; however, neither treatment adherence nor trust in the physician were associated with dysmenorrhea symptom severity. Future research should include additional elements within the clinical encounter and further refine the model.

Period poverty and mental health among students attending a US university

OBJECTIVE

To determine the prevalence of period poverty in university students and if experiencing period poverty is associated with poor mental health outcomes.

METHODS

Participants were n = 311 females assigned at birth attending a university in the northeast US. Seven items assessed period poverty. Participants were also screened for depression, anxiety, and suicide ideation. Logistic regression models assessed main effects after adjusting for gender, sexual orientation, race, age, ethnicity, disability status, and income.

RESULTS

Overall, 18.3% experienced period poverty, with higher odds occurring in students identifying as trans-gender/nonconforming (OR[95%CI] = 3.34 [1.22,9.15]), LGB+ (OR[95%CI] = 1.94 [1.01,3.74]), and Black/African American (OR[95%CI] = 3.61 [1.30,10.0]). Period poverty was associated with higher odds of screening positive for depression (OR[95%CI] = 6.21 [2.45,15.7]), anxiety (OR[95%CI] = 4.01 [2.09,7.68]), and suicide ideation (OR[95%CI] = 2.85 [1.26,6.44]).

CONCLUSIONS

Period poverty is prevalent and is associated with adverse mental health outcomes in university students. Government agencies and universities should consider providing free period products to reduce health inequities.

Menstrual Equity

Menstrual equity refers to the access to safe environments in which to menstruate, including bathroom facilities and clean water, as well as access to menstrual products that allow for the ability to go to school, work, and engage in life with dignity. Menstruation is a physiologic process, not a reflection of maturity or self-worth. Providers within cultures should advocate that girls should be protected from abuse or shame related to menses.

Menstrual management in transgender and gender diverse individuals: psychiatric and psychosocial considerations

Transgender and gender-diverse (TGD) menstruators are individuals assigned female at birth (AFAB)*, who retain the capacity to menstruate and have a gender identity that differs from their natal sex. Reports indicate up to 1.6 million individuals in the US identify as TGD. Until recently, the mainstream menstrual discourse has failed to capture the experience of transmenstruators. However, a better understanding of the menstrual experiences of TGD-AFAB will allow for more individualized patient-centered care. In this review, we provide the relevant data necessary to inform the psychiatric management of menstruation in TGD-AFAB individuals, including experiences of menstruation, preferences for menstrual management, and the impact on mental health. Our review indicates that menstrual care in TGD patients must be tailored to the individual; clinicians should remain open-minded to the unique experience of transmenstruators; gender-affirming menstrual care is necessary to reduce psychological burden. It should not be assumed that TGD-AFAB menstruators are utilizing appropriate contraceptive methods and should receive contraceptive and fertility preservation counseling. We highlight the importance of having these conversations early in the reproductive arch, even before puberty onset. Keeping in mind the gender minority stress model, in the upcoming sections, we discuss the limited body of literature on mood disorders in TGD-AFAB individuals who menstruate, undergo menstrual suppression, or continue to ovulate. The psychological impact of hormonal therapies is also reviewed.

A qualitative inquiry into the lived experiences of menstrual health and hygiene in the transgender and non-binary people in urban areas of India

Significance

Most global research on menstrual health and hygiene (MHH) focuses on cisgender women and girls, with limited evidence on the experiences of transgender and non-binary (TNB) people. This study aimed to document the lived experiences of menstruation management among TNB people in urban India.

Methods

We conducted 13 semi-structured interviews with TNB adults aged 19-40 years in three major Indian cities in collaboration with community organizations. We asked participants to share their experiences of managing menstruation in multiple spaces of life, e.g. at home, school, workplace, and other public spaces. Interviews were audio recorded, transcribed, de-identified, and cleaned. After a deductive and inductive process of developing a code book, we coded transcripts and developed code summaries to identify emergent themes.

Results

We identified three major themes in MHH for TNB urban Indians: (i) gendering of menstruation, (ii) navigating physical aspects of menstruation, and (iii) challenges beyond bleeding. 'Gendering of menstruation' shaped overall experiences of MHH among participants. Gendered expectations upon menarche triggered gender dysphoria. Participants reported having little knowledge about menstruation prior to menarche, which led to a state of confusion and shame, and exacerbated their dysphoria from gendering of norms around menstruation. 'Navigating physical aspects of menstruation' was less challenging in familiar, private surroundings, however, accessing public spaces and bathrooms remained a major challenge and stressor. Though many participants reported undergoing hormonal replacement therapy (HRT) in part to suppress menstruation, they continued experiencing menstrual symptoms which triggered continued dysphoria. Participants reported facing 'challenges beyond bleeding' which included burden of multiple diseases, mis-gendered healthcare services, and lack of social support.

Discussion

Documenting the lived experiences of menstrual health and hygiene among TNB people supports the call to 'de-gender' menstruation. Magnifying the voices and lived experienced of TNB people can bolster the development of effective interventions to enhance their wellbeing.

Perspectives on menstrual policymaking and community-based actions in Catalonia (Spain): a qualitative study

BACKGROUND

Menstrual research and policymaking have become imperative worldwide. It is necessary that these are informed by women and people who menstruate (PWM) alongside expert professionals and activists.

METHODS

The main aim of this study was to identify and propose policies and community-based actions to address menstrual inequity and promote menstrual health in Catalonia (Spain). This study consisted of two qualitative studies: (a) 34 individual photoelicitation interviews with women and PWM, (b) a World Café study with 22 professionals and activists. Sampling for both studies was purposive and selective. Recruitment was conducted through healthcare centres, social media, key contacts, and snowball sampling techniques. Data were collected in December 2020-September 2022, and analysed using Framework Analysis.

RESULTS

Participants considered the implementation of menstrual policies that address the taboo and stigma of menstruation to be crucial. They stressed the need for menstrual education, which should be integrated into formal education curricula. Participants, and especially women and PWM, highlighted the need to improve the access and quality of healthcare services, so that the menstrual cycle and menstruation are seen as health indicators. Health professionals should encourage agentic informed decisions, hence why both participant groups considered menstrual health education amongst health professionals to be pivotal. Taking action to improve the access and affordability of menstrual products was also imperative for participants, especially for socioeconomically vulnerable populations. Participants agreed on guaranteeing fully equipped menstrual management facilities, and and professionals discussed gender-neutral and sex-segregated bathrooms. Workplace menstrual policies to accommodate and ensure menstrual self-care were also suggested.

CONCLUSIONS

Our study highlights the need for multi-dimensional menstrual policies. These should include actions to address menstrual taboo and stigma, to promote menstrual education that goes beyond the hegemonic biomedical prism, to improve the access and quality of menstrual health services, along with policies ensuring adequate menstrual management facilities in public spaces and the access to menstrual products. Policymaking should also focus on how to ensure menstrual management and care in workplaces. Menstrual policies and community-based actions should be framed within intersectionality, to consider how societal structures of power and oppression influence menstrual experiences.

Research priorities for improving menstrual health across the life-course in low- and middle-income countries

BACKGROUND

Research on menstrual health is required to understand menstrual needs and generate solutions to improve health, wellbeing, and productivity. The identification of research priorities will help inform where to invest efforts and resources.

OBJECTIVES

To identify research priorities for menstrual health across the life-course, in consultation with a range of stakeholder groups from a variety of geographic regions, and to identify if menstrual health research priorities varied by expertise.

METHODS

A modified version of the Child Health and Nutrition Research Initiative approach was utilized to reach consensus on a set of research priorities. Multisector stakeholders with menstrual health expertise, identified through networks and the literature, were invited to submit research questions through an online survey. Responses were consolidated, and individuals were invited to rank these questions based on novelty, potential for intervention, and importance/impact. Research priority scores were calculated and evaluated by participants' characteristics.

RESULTS

Eighty-two participants proposed 1135 research questions, which were consolidated into 94 unique research questions. The mean number of questions did not differ between low- and middle-income country (LMIC) and high-income country (HIC) participants, but significantly more questions were raised by participants with expertise in mental health and WASH. Sixty-six participants then ranked these questions. The top ten-ranked research questions included four on 'understanding the problem', four on 'designing and implementing interventions', one on 'integrating and scaling up', and one on 'measurement'. Indicators for the measurement of adequate menstrual health over time was ranked the highest priority by all stakeholders. Top ten-ranked research questions differed between academics and non-academics, and between participants from HICs and LMICs, reflecting differences in needs and knowledge gaps.

CONCLUSIONS

A list of ranked research priorities was generated through a consultative process with stakeholders across LMICs and HICs which can inform where to invest efforts and resources.

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.

Transgender Youth's Perspectives on Factors Influencing Intended and Unintended Pregnancies

Drawing on data from focus groups with 152 trans youth aged 14-18 years in the United States, this article explores the factors that the participants understood as contributing to adolescent pregnancy among trans youth. Youth posited that unintended pregnancies occur due to barriers to contraceptives; a lack of gender-affirming sexual health education; sexual assault and dating violence; and mental health-influenced sexual risk-taking. Participants suggested that intended pregnancies may be a self-development strategy; a self-directed effort to repress/change gender modality or identity; and due to the perceived incompatibility between pregnancy and transition, where pregnancy must occur prior to transitioning.

Menstrual Suppression in Gender Minority Youth

The purpose of this case series was to evaluate menstrual suppression in sex assigned at birth female adolescents identifying as male or gender non-conforming. A retrospective chart review of four gender minority youth (GMY), age 14-17, was performed for gender identity history, type and success of menstrual suppression, method satisfaction, side effects and improvement in menstrual distress. Menstrual suppression was successful in three patients, one patient discontinued use due to side effects that caused an increase in gender dysphoria. Menstrual distress and bleeding pattern improved in the majority of GMY in this series but side effects, as well as contraindications, may limit their use. In conclusion, menstrual dysphoria can be life-threatening for GMY and it is important that clinicians consider menstrual suppression in GMY with menstrual dysphoria. This series emphasizes the importance of individualized treatment plans.

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

Menstruation research has largely focused on addressing menstrual management barriers facing cisgender women and girls in low and middle-income countries. Scant literature has assessed the menstrual management needs of trans and non-binary people assigned female at birth. To better understand these frequently invisibilised menstruation-related needs, we conducted a multi-method qualitative study in New York City which included: 17 in-depth interviews across trans and non-binary people (n = 10) and health care providers who serve them (n = 7); and seven anonymous post-interview participatory writing responses with trans and non-binary participants to further elucidate their lived experiences with menstrual management. Lack of health care provider transgender competency, public toilet design (i.e. gaps in cubicle doors and lack of in-cubicle menstrual product disposal bins), and the social dynamics of public toilets (i.e. work and school) were identified as significant barriers to managing menstruation safely and accessibly for trans and non-binary people. These findings have important implications for healthcare policy, public toilet legislation and advancing menstrual equity in the USA.

Menstrual considerations for transgender male and gender diverse adolescents who were assigned female at birth

Menstruation is a female normative process. Physiologically, it indicates that the hypothalamic-pituitary-ovarian axis is functioning appropriately, and all the correct female end-organs are intact. Menarche also heralds a girl's arrival into womanhood, which culturally is often celebrated. It is a sign of the possibility of fertility, pregnancy and motherhood. However, menstruation for transgender males, and other gender diverse individuals assigned female at birth, may be anything but celebratory. For these adolescents, menstruation is an indication that one's body is not functioning appropriately and that one does not have the correct organs congruent to their gender identity. Menstruation or the anticipation of menarche for many transgender males is often met with worsening of dysphoria, anxiety, depression and suicidal ideation. Therefore, to meet the physiologic and psychologic needs of transgender males, one needs to be aware of issues that may be present in relation to menstruation and be knowledgeable on how to medically proceed with sensitivity and respect toward one's gender identity. Research on menstruation, both from a physical and psychologic perspective, has been historically based on women and cannot be simply extrapolated to be the same for transgender males. Although there is a paucity of literature on the subject, over the past decade there has begun to be a great interest in the care of transgender individuals. This article focuses on concerns related to menstruation among transgender adolescent males and gender diverse individuals assigned female at birth, including suppression of menses, fertility, contraception, and pregnancy.

Investigating trends in those who experience menstrual bleeding changes after SARS-CoV-2 vaccination

Early in 2021, many people began sharing that they experienced unexpected menstrual bleeding after SARS-CoV-2 inoculation. We investigated this emerging phenomenon of changed menstrual bleeding patterns among a convenience sample of currently and formerly menstruating people using a web-based survey. In this sample, 42% of people with regular menstrual cycles bled more heavily than usual, while 44% reported no change after being vaccinated. Among respondents who typically do not menstruate, 71% of people on long-acting reversible contraceptives, 39% of people on gender-affirming hormones, and 66% of postmenopausal people reported breakthrough bleeding. We found that increased/breakthrough bleeding was significantly associated with age, systemic vaccine side effects (fever and/or fatigue), history of pregnancy or birth, and ethnicity. Generally, changes to menstrual bleeding are not uncommon or dangerous, yet attention to these experiences is necessary to build trust in medicine.

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.

Experiences of menstrual inequity and menstrual health among women and people who menstruate in the Barcelona area (Spain): a qualitative study

INTRODUCTION

Menstrual health and menstrual inequity have been neglected in social, economic, healthcare and political spheres. Although available evidence is scarce, it already suggests a link between experiencing menstrual inequity (which refers to the systematic disparities in accessing menstrual health and education, menstrual products and spaces for menstrual management, among other aspects) and menstrual health outcomes. The aim of this study was to explore experiences of menstrual health and menstrual inequity among women and people who menstruate aged 18-55 in Barcelona and surrounding areas (Spain).

METHODS

A qualitative study, using a critical feminist perspective, was conducted. Sampling was purposeful and selective. Recruitment was through sexual and reproductive health centres, social media and snowball sampling techniques. Thirty-four semi-structured photo-elicitation interviews were conducted between December 2020 and February 2021. Interviews took place in sexual and reproductive health centres, public spaces, and by telephone. Data were analysed using Reflexive Thematic Analysis.

RESULTS

Three themes were identified: "Systemic neglect of menstruation and the menstrual cycle", "When "the private" becomes public: menstrual management" and "Navigating menstrual health: between medicalization and agency". Experiences of menstrual inequity appeared to be widespread among participants. They referred to the impact of having to conceal menstruation and the barriers to managing menstruation in public spaces. Choosing menstrual products was often influenced by price and availability; several participants reported menstrual poverty. A general lack of menstrual education was described. Menstrual education was usually gained through personal experience and self-learnings, or through families and friends. Menstruation and the menstrual cycle had a significant impact on participants' day-to-day. Accessing and navigating the healthcare system was challenging, as participants mostly reported feeling dismissed and almost exclusively offered hormonal contraception as a panacea to address menstrual health.

CONCLUSIONS

The impact of menstrual inequity appears to be far-reaching. Multidimensional structural policies should promote agency in individuals and communities to enable opportunities for menstrual education, access to menstrual products, healthcare services and adequate menstrual-management facilities. Health professionals' training is also necessary to improve access to and quality of menstrual healthcare. Policies need to be inclusive of non-binary and trans people, and vulnerable populations.

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.

The persistent power of stigma: A critical review of policy initiatives to break the menstrual silence and advance menstrual literacy

Menstruation is shrouded in stigma and shame-that is the common refrain in burgeoning initiatives on menstrual health and hygiene. Public policies alone cannot undo stigma and enact social change, but they do interact with social norms. They can reflect and adopt stigmatizing attitudes and, as a result, institutionalize, formalize, and legitimize stigma; or they can actively challenge and denounce it and mitigate existing discrimination. Against this background, we explored whether and how policies on menstrual health and hygiene address menstrual stigma and advance menstrual literacy based on an analysis of 34 policy documents and 85 in-depth interviews with policy-makers and advocates in four countries: India, Kenya, Senegal, and the United States. We found that policies recognized menstrual stigma and set out to break the silence surrounding menstruation and advance menstrual education, but they did not contribute to dismantling menstrual stigma. Policy-makers seemed constrained by the very stigma they sought to tackle, resulting in hesitancy and missed opportunities. Policies raised awareness of menstruation, often with great noise, but they simultaneously called for hiding and concealing any actual, visible signs of menstruation and its embodied messiness. Educational initiatives mostly promoted bodily management and control, rather than agency and autonomy. As a result, policies might have succeeded in breaking the silence around menstruation, but stigma cannot be broken as easily. We first need to recognize its (invisible) power and its impacts in all spheres of life in order to actively challenge, dismantle, and redefine it.