There are so many reasons that menstrual health and hygiene management is important and should be addressed by Occupational Therapists (OTs) and other healthcare providers as a matter of course. Menstrual hygiene management (MHM) falls within the scope of OT as an Activity of Daily Living; it’s not a “little thing”; it can have major impacts on a woman’s chosen occupations; and as a public health and women’s rights issue it can have long-term consequences on her education, financial stability, independence and her whole community. Menstruators with disabilities often face additional challenges in MHM tasks, and as holistic healthcare professionals it is critical that this ‘Activity of Monthly Living’ is addressed with the same focus and depth as showering, cooking or community mobility would be.
Within the Scope of OT
The American Occupational Therapy Association (AOTA) Occupational Therapy Practice Framework: Domain & Process (3rd Ed) states clearly that “caring for menstrual and continence needs” (p. S19) fall under toileting and toilet hygiene as an Activity of Daily Living (or ADL). Indeed, perhaps the better term is ‘Activity of Monthly Living’? Whatever it is called, menstrual hygiene management tasks — such as shopping for period products, changing a pad or tampon, and disposing of it — certainly fall under the category of occupations that “…people need to, want to and are expected to do”. (World Federation of Occupational Therapists, 2013), and thus are within the scope of practice of Occupational Therapists.
“Menstrual hygiene management tasks… certainly fall under the category of occupations that “…people need to, want to and are expected to do”.
Menstrual hygiene management tasks fall under the category of self-care occupations in the Canadian Model of Occupational Performance and Engagement or CMOP-E (Townsend & Polatajko, 2007). Occupational Therapy Australia includes activities required to take care of oneself in their description of the role of Occupational Therapists (2020), and the Royal College of Occupational Therapists state that Occupational Therapists are involved in enabling clients in their own self-management (2019). Unfortunately, it appears that there is a lack of national Occupational Therapy professional associations explicitly stating that menstrual hygiene management is within the scope of practice of Occupational Therapy, which may prevent Occupational Therapists from being aware of this and addressing it in clinical practice.
It’s not a “little thing”
In the US, the average age of menarche (the onset of a girl’s first period) is 12.5 years (Chumlea et al., 2003), and worldwide, 13.5 years (Thomas et al., 2011); while worldwide, menopause (the cessation of periods) averages 49.24 years (Thomas et al., 2011). This means that generally, apart from while pregnant, every menstruator will have a period every month for 35.74 years. Each of these menstrual periods will last, on average, for five days. So that’s about 430 periods in a lifetime, for an average total of 2100 days! Clearly, this is not a “little thing” — it’s a significant life experience.
The phrase menstrual hygiene management is used in the scientific literature to describe the various tasks which are necessary to appropriately, effectively and socially-acceptably ‘manage’ one’s period. (The ‘hygiene’ part is in there to differentiate it from menstrual management, which is used to refer to the medical management of one’s period, such as using hormonal contraceptives or having a hysterectomy.) An activity analysis of ‘menstrual hygiene management’ will show a whole collection of tasks, each with their own set of potential challenges:
- Identifying when your period is due;
- Effectively positioning (so as to prevent a leak) a pad in your underwear;
- Effectively inserting a tampon;
- Identifying when that pad or tampon needs to be changed;
- Removing that pad or tampon;
- Disposing of it;
- Shopping for your preferred choice of menstrual products; and
- Identifying, and taking appropriate action, if a leak of menstrual fluid has occurred on your underwear or outer garments.
For a woman with any kind of disability, any of these tasks could pose a challenge… and that’s in addition to the emotional regulation skills required when dealing with the changes in attentional capacity, pain and discomfort, mood and energy which often come with one’s period!
On top of all this, sexual health education can be inaccessible or inadequate, and not every mother or family unit will have discussed or prepared a girl for her first period. Knowing what to expect at menarche, and having prepared and practiced for it, clearly falls under the scope of the client-centered, holistic, forward-thinking Occupational Therapist.
Impact on Occupations
Ask anyone who currently or previously had their period, and they will no doubt be able to tell you of at least one time when having their period prevented them in participating in an occupation that brought them meaning. Terrible period pain, feeling flat and lacking in energy, how heavy her period is, being unable to afford menstrual products such as pads and tampons (known as period poverty), the social pressure of disguising any evidence of menstruating and the fear of having a leak be seen on her outer garments may have stopped her from doing.
There are ample studies demonstrating the potential for one’s period to impact their chosen occupations:
- A 2010 study by Zacharin et al. surveyed 103 carers of young women with cerebral palsy aged 12-18 in Australia. They found that 45% of respondents did not participate in school, social activities or physical activities during their menses.
- In a survey conducted in the US by menstrual product company Always, 1 in 5 girls reported missing school because of their period (Always, 2020).
- A study from Sweden with 1,500 women between the age of 40-45 years found that one third reported heavy periods, and of these women, a quarter of them did not participate in social activities because of this. Further, 16% of these women with heavy periods took days off work because of their period, reporting 6-10 days each year. Of the women who stated they have “normal” periods, 2% still refrained from social activities and stayed home from work for up to five days a year because of their period. (Marions via Lund, 2016).
- In the UK, a survey of 1000 young women between 14-21 years found that 49% missed a full day of school because of their period (of which 59% have made up a lie about why), and 64% have missed a PE lesson because of their period (Plan International UK, 2017).
- In India, 113 million adolescent girls were deemed at risk for dropping out of school entirely once they reached menarche (World Bank, 2016).
As stated by Grover (2011), “managing menses is about achieving optimal quality of life for the young woman. The definition of heavy or painful menses can be debated – but if the adolescent’s main social and physical activity is, for example, swimming, then the inability to go swimming may have a major negative impact on her quality of life.” (p. 611) As a factor that can affect participation in someone’s chosen occupations, menstrual hygiene management clearly should be of clinical importance to Occupational Therapists.
A Public Health and Women’s Rights Issue
Vital signs are physiological signs the body creates which provide healthcare practitioners with really valuable information about a person’s overall health; so valuable, in fact, it’s considered vital. Body temperature, heart rate, respiration rate and blood pressure are considered the four vital signs… but the American College of Obstetricians and Gynecologists wants the menstrual cycle to be considered the fifth vital sign. The menstrual cycle can provide all kinds of information about the body’s overall health and wellbeing, and if clinicians asked about it at every visit it would indicate it’s importance to patients.
More than just, ‘Oh, she might be pregnant’, if a woman is experiencing irregular cycles, really heavy flow, period pain or an absence of her period (called amenorrhea), investigation into potential hormone imbalances, stress, dietary habits, and underlying mental health issues may be warranted, and these underlying health concerns can be addressed in a timely manner… all by monitoring this fifth vital sign.
When tampons became available on the mainstream market, no one was aware that they could potentially cause harm. The understanding of Toxic Shock Syndrome emerged later: a series of symptoms which could lead to death, initiated by tampons being worn for extended periods of time. The current recommended practice of using a single tampon for no longer than four to eight hours stemmed from the discovery — and potentially lethal consequences — of Toxic Shock Syndrome. Clearly, if a mensturator is not aware of this risk, because, for example, she could not access the printed tampon instructions and warning included in a box of tampons, and because no one had told her, her health is at risk.
It has long been known in the international development sector that educating women is the most effective way to increase her future financial independence, her (and any of her future children’s) overall health, and the ripple created effects the whole community’s well being and begins lifting it out of the poverty cycle. USAID (2017) reports that:
- “An extra year of secondary school for girls can increase their future earnings by 10-20%.
- “In India, women with no formal schooling are less likely to resist violence than women with schooling.
- “In Burkina Faso, educated women are 40% less likely to subject their daughters to genital mutilation.
- “Girls with secondary schooling are up to 6 times less likely to marry as children than those with little or no education.
- “Each extra year of a mother’s education reduces the probability of infant mortality by 5%-10%.
- “If India enrolled one percent more girls in secondary school, their GDP would rise by $5.5 billion.”
Across cultures and around the world for generations, menstruation (and thus, those who menstruate) has been viewed as dirty and offensive, with all manner of inaccurate and negative superstitions affecting women’s self-confidence, place in the community, and ability to participate in her chosen occupations. Being banned from places of worship while menstruating and myths such as making children ill if they are held by a woman menstruating, curdling whipped cream or causing crops to die are not ‘just’ harmful to the individuals being labeled as unwelcome. As behavioral restrictions, they contribute to gender-based discrimination and continue to perpetuate the pervasive cultural taboo and menstrual shame associated with periods. With more than 5000 euphemisms reported from more than 190 countries in 2017, period still isn’t viewed as a ‘normal’ word.
In Summary…
Talking about periods like they’re a normal thing — because they are — can help break down the stigma associated with them, and provide education to others (as well as the menstruator) about what’s going on in her body. Any fans of Harry Potter may remember Professor Dumbledore’s reasoning for using the name of the leader of the Dark Side — Voldemort — rather than the socially approved ‘He Who Must Not Be Named’ or ‘You Know Who’. “Always use the proper name for things. Fear of a name increases fear of the thing itself.” (Rowling, 1997.) It may take practice at first, but the more you say ‘period’, the less awkward it will get — and the more empowering and enabling you can be for your clients.
For a topic which is seen as culturally taboo and one that shouldn’t be discussed in polite company, Occupational Therapists, as healthcare professionals, need to rise above their personal feelings of comfort in order to provide effective, holistic, client-centered care. The take-home message comes from Rodgers & Lipscombe (2005), and a study they completed in England of 452 women (and/or their carers) aged 14-55 years who had an intellectual disability: regardless of task or level of disability, women were more likely to be independent in menstrual hygiene management if someone had tried to teach them.
Let’s get to it!
“… regardless of task or level of disability, women were more likely to be independent in menstrual hygiene management if someone had tried to teach them.”
References
Always (2020). The Always Confidence and Puberty Wave VI Survey, via Help Always #EndPeriodPoverty so no period holds her back. Retrieved from https://always.com/en-us/about-us/end-period-poverty
AOTA (2014). Occupational Therapy Practice Framework: Domain & Process (3rd Ed). American Journal of Occupational Therapy, American Occupational Therapy Association. https://ajot.aota.org/article.aspx?articleid=1860439
Chumlea, W. C., Schubert, C. M., Roche, A. F., Kulin, H. E., Lee, P. A., Himes, J. H. & Sun, S. S.(2003). Age at menarche and racial comparisons in US girls. Pediatrics, 111, 110-113.
Grover, S. R. (2011.) Gynaecological issues in adolescents with disability. Journal of Pediatrics and Child Health, 47(9), 610-613.
Lund, A. (2016). How menstruation affects women’s health. Karolinska Institute. Retrieved from https://ki.se/en/research/how-menstruation-affects-womens-health
Lusk-Stover, O., Rop, R. Tinsley, E. & Samah Rabie, T. (2016). Globally, periods are causing girls to be absent from school. World Bank Blogs. Retrieved from https://blogs.worldbank.org/education/globally-periods-are-causing-girls-be-absent-school
Occupational Therapy Australia (2020). What is occupational therapy? Retrieved from http://aboutoccupationaltherapy.com.au/
Plan International UK (2017). Plan International UK’s research on period poverty and stigma. Retrieved from https://plan-uk.org/media-centre/plan-international-uks-research-on-period-poverty-and-stigma
Rowling, J. K. (1997). Harry Potter and the Philosopher’s Stone. Bloomsbury.
Royal College of Occupational Therapists (2019). Self-management. Retrieved from https://www.rcot.co.uk/practice-resources/occupational-therapy-topics/self-management
Thomas, F., Renaud, F., Benefice, E., de Meeüs, T. & Guegan, J-F. (2011). International variability of ages at menarche and menopause: Patterns and main determinants. Human Biology, 73(2), 271-290.
Townsend, E. A., & Polatajko, H. J. (2007). Enabling occupation II: Advancing an occupational therapy vision for health, well-being, & justice through occupation. Ottawa: CAOT Publications ACE.
USAID (2017). Let Girls Learn fact sheet. Retrieved from https://www.usaid.gov/letgirlslearn/fact-sheet
WFOT (2013). Definitions of Occupational Therapy from Member Organisations. World Federation of Occupational Therapists. https://www.wfot.org/resources/definitions-of-occupational-therapy-from-member-organisations
Zacharin, M. Savasi, I. & Grover, S. (2010). The impact of menstruation in adolescents with disabilities related to cerebral palsy. Archives of Disease in Childhood, 95(7), 526-530. 10.1136/adc.2009.174680
Menstrual Health and Occupational Therapy 