“Girls May Bleed Through Pads Because of Demerits”

Research Design

This qualitative and participatory study was adapted from a previously used research methodology conducted with adolescent girls in Baltimore, U.S.A. (Herbert, 2018) and numerous low-and-middle income (LMIC) countries (Sommer, 2013, 2015, 2020; Mumtaz et al., 2019). Data collection methods included: (1) Participatory Methodologies (PM) sessions with cisgender adolescent girls aged 15 to 19; (2) In-depth interviews (IDI) with cisgender adolescent girls aged 15 to 19, and (3) Key Informant Interviews (KII) with adults interacting in girls’ daily lives, such as teachers, guidance counselors, coaches, healthcare workers and religious leaders. Older adolescent girls were purposively sampled given their ability to reflect on the experience of puberty, including their menstruation experiences and recommendations.

Research Setting

The research sites included the three most populous and ethnically diverse U.S.A. cities: New York City (NYC), Los Angeles (LA) and Chicago (U.S. Census, 2016). Each of these cities has high levels of poverty, illustrated by 19.5% of NYC residents (The Mayor’s Office for Economic Opportunity, 2018), 19.1% of LA residents (U.S. Census, 2019b), and 12.4% of Chicago residents living below the poverty line (U.S. Census, 2019a). In addition, all three of these cities has large, funding challenged public school systems, with such disparities often exacerbated across demographic and racial lines (Boschma & Brownstein, 2016^; National Equity Atlas, 2017).

Sample and Recruitment

Across the three cities, a total of 73 adolescent girl participants (15–19 years old) were involved in the PM sessions (see Table 1). IDIs with additional adolescent girls (n = 12) were conducted using a semi-structured questionnaire. All participants (IDI and PM groups) were recruited directly through local partners, including school administrators or teachers from public and charter school institutions, or through staff working at local youth-serving non-profits. Adolescent girls were purposively sampled to ensure a diversity of experiences, including different ethnic, racial, geographic, and educational backgrounds. Given that participants came from a range of educational institutions (current and previously attended), they were asked to share generalized observations and perspectives from across their schooling experiences. Although participants who experience menstruation were intentionally sampled, young people were not asked to self-report their menstruating status during the research as we did not want to inadvertently create discomfort if the young person had not publicly identified their gender identity. The PM sessions participant demographics were 52% Black, 44% Latina and 4% other. Despite recognizing the importance of Black and Latina girls unique lived experiences growing up in the U.S.A., findings generated from this study cannot be attributed to individual participants of a specific race or ethnicity due to the participatory data collection process utilized.

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The KIIs with adults (n = 23) were also purposively recruited from a range of professions and organizations that directly interact with low-income adolescent girls in each of the three cities. KIIs participants were recruited directly from the schools or non-profits involved in the PM groups or through recommendations from colleagues, which was primarily due to their professions and/or unique expertise (e.g., adolescent pediatricians, school nurses, sports coaches, religious leaders). Seven of the KIIs worked at the organizations or schools where girls were recruited from for the PM sessions.

The findings shared in this paper are derived from the three following data sources:

PM sessions: Groups of 8 to 10 girls were gathered in each city in a confidential space for 1.5-hour sessions. Each PM group met three times over a 2 to 3-week period. On average, the PM sessions had a high retention rate (~80%) over the course of all three sessions. The PM sessions included a range of activities with the results in this paper derived from three specific activities and fieldnotes. These include (a) First Period Stories Activity: Girls anonymously wrote personal narratives describing their first menstrual experiences, including how they reacted, how they coped, what they wished they had known prior to that experience, and their advice for younger girls; (b) Girl-Friendly Schools Brainstorm: In small groups, girls were asked to brainstorm how they would make their school environments more girl-friendly, including more period supportive, with an imaginary $1 million improvement budget; and (c) Draw a Girl-Friendly Bathroom: Girls were individually asked to draw and annotate what an ideal girl-friendly bathroom in schools would look like.

IDIs: We utilized semi-structured interview guides which allowed for an in-depth examination of girls’ experiences, including questions which explored girls’ interactions with the physical and social aspects of their schools’ environments when menstruating, how their relationships with their classmates and teachers impacted their period experiences, and recommendations on how to improve bathroom environments and policies.

KIIs: We utilized semi-structured interview guides for the adults in girls’ lives that sought to identify perspectives on the body and development issues facing adolescent girls, including how school environments, policies and other societal factors impacted girls’ experiences with menstruation and their changing bodies.

Data Collection

The data collection team included three cisgender women research staff from (blinded) and three cisgender women data collection assistants. Prior to the data collection, the team conducted reflexivity exercises, considering our positionality in relation to the power dynamics of the research process, and reviewed our own current and previous experiences as menstruators. All PM and IDIs were conducted in private settings (e.g., school classrooms or non-profit offices). The KIIs were also conducted in private locations, or via video conferencing platforms (FreeConferenceCall.com) or phone. All data collection activities (PM, IDIs, and KIIs) were conducted in English. To ensure the comfort of participants, tape-recording was not used for the PM groups. Instead, careful notetaking was utilized, including the capturing of verbal and non-verbal responses. All IDIs and KIIs were recorded and transcribed. Parental consent was acquired for all of the adolescent girl PM and IDI participants under 18 years of age, who themselves provided assent. All participants 18 years of age or older provided informed consent. All study procedures were approved by the Columbia University Medical Center Institutional Review Board and the New York City Department of Education Institutional Review Board.

Data Analysis

The research analysis team, which was comprised of three research team members, reviewed all transcripts, PM drawings, and fieldnotes. Analysis was performed using Malterud’s “systematic text condensation,” a descriptive and explorative method for conducting qualitative thematic analysis of different types of qualitative data (Malterud, 2012). This approach utilizes sequential steps, which includes (a) broad impression (a review of the entirety of data), (b) identification of the key themes (distilling themes into codes), (c) condensing the text from the code and exploring meaning (reduction of data into a few meaningful code groups), and (d) synthesizing (building credible narratives which illuminate the study questions). Key themes identified were then disseminated to the wider research team for further discussion, validation, and consensus-building.

Secrecy and Embarrassment Related to Bathroom Usage While Menstruating

Across all three cities, adolescent girls indicated experiences of embarrassment or discomfort when needing to visit bathrooms during the school day to change their menstrual products. This often led to the adoption of secrecy practices, such as hiding menstrual products within their clothing or in a small bag to reduce the risk of others discovering their menstruating status. One adolescent girl from NYC explained this tension:

. . .I would take the pad with me, but I wouldn’t bring my bookbag because everyone would be like ‘hey you’re on your period?’ or ‘why are you taking your bag?’. . . so, I’d just grab my pad. One time I didn’t have my little bag [for hiding the pad] when going to the bathroom. . .so I’d put it in my sweater or my pants and my friends would be like, ‘why are you being so sneaky?’. . .

The menstrual stigma revealed by these secrecy practices suggests that many girls have discomfort not only with their peers knowing their period-related reason for visiting the bathroom, but also teachers and school staff. Girls often need to request permission to visit the bathroom during class to change a menstrual product, and numerous girls shared their anxiety surrounding this task. One Chicago non-profit coordinator described the intersection of girls’ hesitancy with existing school bathroom policies:

. . .[girls] were getting embarrassed about having to go to the bathroom and carrying in something [a pad]. Or having to keep the secrecy concept. . .having to ask for the hall pass to go to the bathroom is something girls never want to do.

Many girls confirmed having such discomfort when asking their teachers to use the bathroom. They also explained how the actual process of asking permission made them particularly vulnerable to disclosing their period status in front of their peers. An adolescent girl in LA described her anxiety with this task, explaining how “it was embarrassing. . .I was like in the back of the class and I had to walk to the front and whisper it to her [the teacher] and then she couldn’t hear me, so I had to say it a little louder.” Such episodes were described as even more embarrassing when they involved interactions with male teachers. In some cases, this discomfort resulted in girls refraining from going to the bathroom at all, even when needing to change a menstrual product. As one adolescent girl during a participatory session in LA explained, “I just hold it in and then lower my backpack and hope I don’t stain; then at lunch I go to the bathroom.” Delaying behaviors, however, were described as increasing the potential for menstrual stains, which numerous girls described as a potentially embarrassing incident.

Discomfort Surrounding Bathroom Social Environments

Girls across all three cities indicated that school bathrooms were popular locations for socializing, likely an outcome of their relative privacy within school environments. This social congregation, however, often exacerbated girls’ discomfort when using toilet facilities, especially when managing their period. Girls across all three cities described a range of social activities that often occurred in school bathrooms, including groups of students vaping (e.g., the use of e-cigarettes), smoking, talking or recording social media content. These activities, which happened directly outside of or inside toilet stalls, made girls inside neighboring stalls anxious, with particular worries about others hearing them change their menstrual product or unwrap a menstrual pad. As one adolescent girl in LA explained during an interview:

. . .there is a lot of people vaping in the bathroom, so they’ll take up the big stalls. Normally it’s groups of like 10 girls. . .and they’ll all just vape. Just using the bathroom in general is uncomfortable so when you’re on your period you’re always like, “do I really want to go in there?”. . .

Across all three cities girls complained about the noise associated with changing menstrual products, especially the wrappers for menstrual pads. During an interview, an adolescent girl in NYC described her discomfort: “when you open a pad, it’s like so loud that now everyone knows ‘I have my period!’” Notably, when conducting the “draw a girl-friendly bathroom” participatory activity, groups of girls in both Chicago and LA indicated a desire to have background music playing in school bathrooms to specifically distract from the product wrapper noise. It was also suggested by a number of girls that taller or thicker bathroom stall doors and walls, similar to the toilet stalls often found in movie theaters, could help to reduce these noise concerns.

In some instances, girls described adopting coping strategies to avoid the uncomfortable social environments found in bathrooms, including preferences for single-use bathrooms when available. A school-based social worker in LA explained how “many students come to use the bathroom in the health office, and I think it’s just because they felt like there wasn’t any privacy [in other bathrooms].” Girls across the three cities echoed this sentiment, complaining about the lack of privacy they felt inside communal school bathrooms. The reasons girls cited included an insufficient number of stalls and the close proximity of many bathrooms to social congregation locations (e.g., cafeterias); which led to longer lines and more crowding, and thus less private, bathroom environments.

Bathroom Design and Maintenance Challenges

Across all three cities, girls indicated numerous physical design challenges which make bathrooms uncomfortable, especially while menstruating. During the “draw a girl-friendly bathroom” participatory activity, girls identified a series of factors which contributed to negative bathroom experiences, along with aspects they would like to see improved (See Figure 1).

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Numerous girls described how wide gaps between stalls, coupled with short stall door lengths, often resulted in others being able to peer into the toilet cubicle while they were inside. An adolescent girl in Chicago complained about the short bathroom stall doors and how they made her feel exposed, explaining: “we need a cover over the top because people like to play games and look over the top into a toilet stall. . . we just need taller stalls.” Teachers and school staff also observed the poor design of many bathrooms, explaining how many of the schools were located in older buildings, which often lacked sufficient ventilation or windows. As a former middle school assistant principal from NYC explained:

. . .just the way that they are set up. . .there’s like very little ventilation and sometimes the doors are not even like full height. . .you don’t really feel like you have a lot of privacy. . . it makes it really difficult to even use. . .it was not a super pleasant experience. . .

Girls also indicated privacy issues stemming from poorly functioning locks on stall doors. During the participatory groups, an adolescent girl in Chicago explained: “doors should have two locks; I feel like they always break and then we don’t have locks. . .people are always walking in on me and it is very stressful.” Across all three cities, girls identified a range of privacy concerns in school bathrooms, noting how improvements, as exemplified in Figure 1, would greatly enhance not only their comfort in dealing with their periods but their overall sanitation privacy.

Another design challenge emerged around the disposal of used menstrual products. Many girls complained about the inconsistent presence of trash bins for product disposal in school bathrooms. This includes trash bins or product disposal units located inside toilet stalls, or communal trash bins within the larger bathroom premises. One adolescent girl in NYC described her frustration, explaining: “there is nowhere inside the stall for disposing of used materials. You would have to flush it down the toilet. I bring a plastic bag with me, wrap it around and put it in the outside garbage [bin].” The latter meant potentially “outing” the menstruating status of a given girl. Almost all of the participants indicated a preference for the placement of menstrual disposal bins directly inside toilet stalls for improved period management privacy. Such measures might also reduce the menstrual products being directly flushed down toilets, which causes plumbing problems, as described by some school administrators, especially in older school buildings. Numerous girls mentioned that the general uncleanliness of school bathrooms, including overfull trash bins and clogged toilets, further contributed to their discomfort when using bathrooms while menstruating.

A final environmental design found to be problematic for some girls was the location of emergency menstrual products (e.g., for an unexpected period). Many schools’ policies required a girl to visit a school administrator or nurse to request a menstrual product, prior to visiting the bathroom for changing. This extra step for accessing a product resulted in them missing more class time, which concerned some students. One adolescent girl in NYC explained this tedious experience:

. . .in my schools. . .they don’t have products anywhere, so you have to go down to the nurse to get a pad. They take you to a back room and then [she] ask you lots of questions and then they will finally give you a pad. . .

Some girls indicated preferring to ask their peers for products in the event of a menstrual emergency, rather than going through school gatekeepers, as it was oftentimes easier and faster. The majority of girls across all three cities indicated the absence of menstrual product dispensers, free or for charge, directly inside school bathrooms. However, there was strong consensus among girls, that there would be many advantages to having period products available inside bathrooms. This would enhance period management privacy, with less people observing a girl’s movement to acquire a product within the school and reduce the amount of missed class time required for procuring a product.

School Bathroom Policies as a Barrier to Access

Across all three cities, girls, teachers and school staff shared various bathroom policies used to regulate toilet access by students. Schools exhibiting stricter bathroom policies described the rationale for these practices, including student safety concerns, such as issues of bullying and violence, coupled with heightened incidents of vaping and substance use; all activities which often occurred within bathroom spaces. One adolescent girl in LA described her school’s approach to reduce misuse:

. . .Since people vape in the restroom, now you need the key from the office. They open the restroom and now you have to sign in and sign out. They time you when you are in there. If it takes more than 5 min, they start knocking. . .

Numerous girls indicated frustration with the regulations surrounding their bathroom usage, especially when dealing with their periods. Some schools utilized even more severe measures to regulate bathrooms, such as locking toilet facilities during class periods. This practice resulted in short, concentrated time allotments for all student bathroom usage, and thus a higher frequency for lines during designated class breaks and lunch periods. A former middle school teacher from NYC explained observing issues of overcrowding in female bathrooms, describing: “you’re going in between classes when everyone else is going. . . some of those policies can make it more uncomfortable for young women.” Other school policies included bathroom pass quotas, in which students were given a limited number of bathroom passes each day or week. During the participatory activities, a Chicago-based adolescent girl explained the challenges she faced with quota practices while menstruating:

. . .At my school you have a certain amount of bathroom passes and if you run out then you can’t go to the bathroom. So, if you are on your period and go the bathroom every 3 hours like I do, then you don’t have enough passes to change throughout the day. . .

Adolescent girls that experience heavier menstrual bleeding may require changing menstrual products more frequently, making regulated one-size-fits-all approaches for bathroom access problematic. During an interview, an adolescent girl in LA described her anxiety around managing her heavy periods:

. . .I have a super heavy flow. . . my first 3 days are super heavy. I have to change it like every 30 mins. . .sometimes I get too scared to ask to go to the bathroom cause they [teachers] are like “finish this work” . . .and I’m like: ‘I can’t, my period is going to overflow. My pad cannot hold this’. . .

Although heavy bleeding created an increased sense of urgency for accessing bathrooms, many participants indicated the larger challenge to be the discomfort in providing teachers and school staff with reasons for frequent or pressing bathroom trips. Some girls feared getting in trouble for requesting increased access; others described situations in which school administration used negative deterrents, such as demerits, to reduce bathroom usage. A L.A. based middle school guidance counselor described her experiences while employed at another nearby Charter school, explaining:

. . .My old school has really strict bathroom usage rules; if you had to use the bathroom during class, you’d get a demerit, and we count those up weekly. We expect girls to use the bathrooms during lunch only, but now that I think about it, if you are wearing a pad and it fills up, waiting until lunch would be really difficult. . .so girls might bleed through their pad because of demerits. . .

Numerous girls shared that they felt resigned to wait until after class, often hoping their menstrual products did not leak. Such coping practices, however, left girls feeling distracted and anxious, and thus unable to fully engage or concentrate on learning activities.

Many teachers and school staff explained the rationale behind the complexity of such policies. In particular, they shared that schools must strive to balance girls’ unique bathroom needs with broader safety, disciplinary and health issues for their student populations. While acknowledging that many bathroom policy approaches were flawed, several teachers and school staff shared concerns about students taking advantage of more flexible policies. A school-based social worker in LA articulated his worries, “I think we need to fix the bathroom policy, but it’s tricky, because teachers will think girls will start taking advantage [of it], and boys will want special treatment too.” Such a gendered concern however could be addressed through improved school education around menstruation, thereby reducing menstrual stigma and increasing peer social support.

We would like to express our gratitude to the adolescent girls from Chicago, LA and NYC that participated in our research activities and shared their personal menstruation experiences. We would also like to thank the educators and staff from numerous non-profits and schools in all three cities that shared their valuable expertise during interviews in addition to facilitating study recruitment.