The Stigma Surrounding Menstruation: Attitudes and Practices Regarding Menstruation and Sexual Activity During Menstruation

Abstract

This article describes the findings of a mixed-methods study aimed to understand attitudes and practices regarding menstruation and sexual activity during menstruation due to stigma. Findings from the surveys (n = 439), eight in-depth interviews, and four expert interviews show that both men and women hold stigmatizing attitudes toward menstruation and sexual activity during menstruation. Most respondents were not sexually active during menstruation. Stigmatizing attitudes resulted in constant physical and mental menstrual management for women, negatively influencing their lives. Surinamese women displayed significantly more stigmatizing attitudes and practices than Dutch women. Results imply that improving menstrual education could have a destigmatizing effect.

Keywords:

• Menstruation
• sexual activity
• stigma
• coping
• mixed methods
• ethnicity

Introduction

Menstruation, rooted in complex value systems, is accompanied by various myths, taboos, and stigmatizing, negative and shameful sentiments (Barrington et al., 2021; Hensel et al., 2007). Often euphemisms such as “aunt flow,” “time of the month,” and “on the rag” are used by both men and women to refer to menstruation, reflecting the taboo and stigma surrounding it (Newton, 2016). Across different cultures, menstruation is stigmatized and conceptualized as something that is “dirty” or “impure” and that should be kept private (Barrington et al., 2021; Hennegan et al., 2021). Society as a whole also believes that menstruating women are physically (during the menstrual phase) or mentally (during the premenstrual phase) disordered, perceiving them as out-of-control, ill, crazy, and unfeminine (Johnston-Robledo & Chrisler, 2020). These negative views toward menstruation and menstruating women are related to stigma and society’s views of women in general (Johnston-Robledo et al., 2007).

Goffman (1963) defines stigma as any mark or stain that sets apart one person or group from the others. People who possess this mark are devalued by society because it reflects a defect of the body or a character that taints one’s appearance or identity (Goffman, 1963; Johnston-Robledo & Chrisler, 2020). For women, menstrual blood would be considered the stigmatizing mark. Goffman distinguishes between three categories of stigma: abomination of the body, blemish, and social marker (Goffman, 1963; Johnston-Robledo & Chrisler, 2020). Abomination of the body concerns physical deformities such as bleeding, Blemish relates to “blemishes to one’s character,” and social markers are linked to (discriminated) group affiliation. Using Goffman’s categories of stigma, Johnston-Robledo and Chrisler (2020) conceptualize menstruation stigma as the negative perception of menstruation and those who menstruate, and consider it a hidden stigma because discovery would lead to stigma (Johnston-Robledo & Chrisler, 2020). Consequently, women go through great efforts to conceal their “menstruation” status and prevent stigma-related “leakages” from occurring.

The stigma associated with menstruation is communicated to us every day from a young age, through a variety of sociocultural routes (Johnston-Robledo & Chrisler, 2020). Many girls and boys grow up believing that menstruation is dirty, embarrassing, and something that needs to be camouflaged or kept hidden for women to function in their everyday life (Barrington et al., 2021; Peranovic & Bentley, 2017). Menstruation stigma is further perpetuated by the media through, for example, menstrual product advertisements which emphasize secrecy, avoidance of embarrassment, and freshness, and the use of images (e.g., flowers) and colors (i.e., blue rather than red) to euphemistically describe menstruation and promote secrecy and delicacy (Fahs, 2020a; Johnston-Robledo & Chrisler, 2020; Sveen, 2016). Menstruation stigma can also be transmitted through (educational) books, communication or the lack thereof (i.e., silence), and through the type of language used to describe it (i.e., euphemisms) (Johnston-Robledo & Chrisler, 2020).

The stigma surrounding menstruation can lead to negative consequences for women’s physical and mental health, sexuality, social status, and quality of life (Barrington et al., 2021; Johnston-Robledo & Chrisler, 2020; McHugh, 2020). Women who internalize negative attitudes toward menstruation often seek to regulate their behavior accordingly to avoid stigma by making active efforts to conceal their menstrual status (e.g., avoiding activities, wearing baggy clothes) and avoiding discovery (e.g., visible pads, menstrual blood) (Barrington et al., 2021). This constant determination to conceal their menstrual status is associated with heightened self-consciousness, hypervigilance, and menstrual shame (Johnston-Robledo & Chrisler, 2020; McHugh, 2020). Failure to conceal is associated with feelings of personal failure to maintain social feminine standards or “correct” menstrual etiquette (Barrington et al., 2021).

Moreover, menstruation stigma can also negatively impact women’s sexual activity because sexual activity during menstruation is often considered taboo (Allen & Goldberg, 2009; Hensel et al., 2007). Both women and men may refer to menstruation and sexual activity during menstrual bleeding with negative terms such as awkward, dirty, disgusting, smelly, and messy (Allen & Goldberg, 2009). Men and women who are younger, single, and less sexually experienced are more likely to avoid sexual activity during menstruation and use negative language to describe sex during menstruation (Allen & Goldberg, 2009). Sexual activity during menstruation is more frequently viewed as appropriate and pleasurable among older, more experienced couples (Allen & Goldberg, 2009). Women in particular, as they get older, become more open, secure, and comfortable with their sexual attitudes and have more positive attitudes toward their menstruation (Rempel & Baumgartner, 2003). Overall, research shows that women who engage in sexual activity during menstruation are significantly more comfortable with their menstruation, have higher partner support, are less sensitive to disgust, and are more aroused by romantic and unconventional sexual activities (Hensel et al., 2007; Rempel & Baumgartner, 2003). Men’s attitudes toward menstruation may influence their attitudes toward sexual activity during menstruation (Barrington et al., 2021; Hensel et al., 2007). However, research studies addressing menstruation experiences in relation to sexual activity are limited (Barrington et al., 2021; Fahs, 2020a) and often conducted from the perspective of women (Fahs, 2020a; Peranovic & Bentley, 2017). Additionally, to our knowledge, thus far no studies have addressed this issue in the Netherlands, a society which generally has positive attitudes and approaches toward sex and sexuality. Therefore, to better understand menstruation stigma in the Netherlands, including stigma associated with sexual activity during menstrual bleeding, this study had two aims: (1) to provide insights into the perceptions and attitudes toward menstruation among men and women and (2) to explore the impact of menstrual attitudes on the menstrual experiences of men and women, including sexual activity during menstruation.

Methods

Design

Using a mixed-methods design consisting of a survey and two types of interviews, this study aimed to better understand prevailing stigmatizing attitudes and practices toward menstruation and sexual activity during menstruation in the Netherlands. Methodological triangulation using both qualitative and quantitative data was used to confirm findings, provide comprehensive data, increase validity and increase understanding (Bekhet & Zauszniewski, 2012). First, an online survey was distributed among the Dutch population with open and closed questions to explore the topic. Second, survey respondents were interviewed to explore the topic in depth. Third, experts were interviewed about their views on the attitudes and practices among the Dutch population regarding menstruation and sexual activity during menstruation. This research was approved by the Social Sciences Ethics Committee of Wageningen University and Research on October 23, 2018.

Sampling Procedure

The survey, which included closed and open questions, was posted online using Qualtrics on October 29 and closed on November 19, 2018. The survey was distributed using snowballing and through social media channels such as Facebook and LinkedIn. This included the Facebook group “Ladies’ Talks,” containing a diverse group of more than 42,000 women from the Netherlands. The website SurveySwap.io was used to recruit more male respondents. Respondents provided informed consent before starting the survey. Survey respondents could enter a lottery to have a chance of winning one of three €15 gift cards. Near the end of the survey, respondents were asked if they would be willing to participate in an interview. Of the 439 survey respondents, 85 respondents (78 women, seven men) were willing to participate in a follow-up interview. In November 2018, randomly selected respondents (11 women, four men) were invited for an interview. Six women and two men responded to this invitation. The first author conducted the interviews in a room or space chosen by the respondents that ensured privacy. These eight interviews yielded similar responses and patterns of information, which indicated that saturation was reached (Saunders et al., 2018).

The four interviewed experts were selected based on their work in different fields related to menstruation and found through the researchers’ network and via the snowball method. Expert interviews were held on the phone (n = 2) or face-to-face (n = 2).

Materials

The survey investigated Dutch attitudes and practices regarding menstruation and sexual activity during menstruation using open and closed questions. Questions in the survey were inspired by questions from existing questionnaires about menstruation (Nnoaham et al., 2009), about attitudes toward menstruation (Fitzgerald, 1990) and about menstruation and sexual activity (Barnhart et al., 1995). To develop the items that assessed menstruation stigma (using Goffman’s categories of stigma) among respondents, a brainstorm session of one hour with 12 academic scholars and students of Wageningen University and Research was held. Based on this brainstorm session, 12 stigma statements were developed that assessed the three categories of stigma (Goffman, 1963; Table 1). For some items respondents were specifically asked to empathize with how they would experience a situation if they were not familiar with the particular situation described in the survey statement. For instance, men were asked to empathize with menstrual situations.

Table 1. Scores and differences between men and women, and Dutch and Surinamese women, on 12 stigma statements composed by the authors (N = 439), inspired by Goffman’s stigma-theory (1963) (abomination of the body, 1–4; blemish, 5–8; social marker, 9–12).

Item	M	SD	t	p
1. Menstrual blood is more unpleasant than other bodily fluids (e.g., breast milk or saliva)	5.68	3.29	−.950	.343
Women	5.61	3.36
Dutch	5.47	3.22	−1.238	.217
Surinamese	6.04	3.39
Men	6.00	3.01
2. I feel comfortable when buying tampons and pads^a	7.90	3.33	2.459	.014
Women	8.08	3.33
Dutch	8.10	3.18	.732	.465
Surinamese	7.75	3.82
Men	7.08	3.25
3. I find menstrual blood dirty	5.22	3.28	.374	.708
Women	5.25	3.34
Dutch	5.03	3.25	−2.413	.017
Surinamese	6.15	3.22
Men	5.10	3.04
4. I believe others see menstruation as dirty	7.51	2.34	.923	.357
Women	7.56	2.42
Dutch	7.42	2.44	−1.710	.089
Surinamese	8.01	2.46
Men	7.29	1.93
5. I would feel embarrassed when I leak menstrual blood in my pants^b^,^c	8.47	2.28	3.419	.001
Women	8.71	2.04
Dutch	8.62	1.99	−2.407	.017
Surinamese	9.26	1.40
Men	7.49	2.99
6. I think others would feel embarrassed when they leak menstrual blood in their pants	8.62	2.06	1.964	.050
Women	8.71	1.97
Dutch	8.55	1.92	−1.152	.250
Surinamese	8.89	2.49
Men	8.21	2.42
7. I would sit next to a woman on the bus if I knew she was menstruating^a,b,^c	8.31	2.88	3.080	.003
Women	8.53	2.75
Dutch	8.75	2.54	1.764	.079
Surinamese	8.07	3.10
Men	7.32	3.27
8. I think others would sit next to a woman on the bus if they knew she was menstruating^a	6.78	3.10	1.088	.277
Women	6.86	3.13
Dutch	7.25	2.97	1.771	.078
Surinamese	6.48	3.31
Men	6.44	2.94
9. At their first menstruation, girls have become a woman^c,d	4.45	3.50	4.238	.000
Women	4.78	3.55
Dutch	3.72	3.30	−6.898	.000
Surinamese	6.88	2.97
Men	2.98	2.91
10. When girls start menstruating they should start acting like women^b,d	1.69	2.22	.674	.500
Women	1.72	2.25
Dutch	1.34	1.91	−3.595	.001
Surinamese	2.65	2.76
Men	1.54	2.10
11. Women are easily irritated when they are menstruating^d	6.22	2.67	.843	.400
Women	6.27	2.67
Dutch	5.63	2.62	−4.028	.000
Surinamese	7.11	2.44
Men	5.99	2.71
12. I think others see menstruating women as easily irritated^d	6.77	2.65	1.707	.088
Women	6.87	2.67
Dutch	6.56	2.63	−1.292	.198
Surinamese	7.07	2.99
Men	6.31	2.51

^aReversed question.

^bLevene’s test indicated unequal variances for comparison men/women: (Statement 5: F = 16.253, p < .001, df437→96; Statement 7: F = 9.019, p = .003, df437→105; or Dutch/Surinamese women (Statement 10: F = 25.391, p < .000, df249→91.64.

^cSignificant difference (p < .004) between men and women.

^dSignificant difference (p < .004) between Dutch and Surinamese women.

Using a semi-structured interview protocol, participants were interviewed about their views regarding menstruation, sexual activity during menstruation, and their idea of menstruation stigma. Interviews lasted between 25 and 62 min (M = 40 min). Experts were interviewed about their views on the attitudes and practices regarding menstruation and sexual activity during menstruation among the Dutch population with a similar semi-structured interview protocol. Interviews lasted between 30 and 51 min (M = 41 min). All interview participants included in the study gave their informed consent to have their interview recorded and fully transcribed using pseudonyms or numbers. For all interviews, anonymity and confidentiality were ensured throughout the study.

Participants

Demographic characteristics of the 439 survey responses can be found in Table 2. Women are overrepresented, as are participants with a non-Dutch background: 41.2% of participants have a non-Dutch background, compared to 25.4% of the general population in 2021 (CBS, 2022). Because non-Dutch female participants, and in particular Surinamese participants, were well represented in the survey, and because the literature suggests that differences in menstruation stigma exist between ethnicities (Fahs, 2020a), we examined differences between Dutch women and Surinamese women.

Table 2. Demographic characteristics of survey respondents.

	Total		Women		Men
	100%	(N = 439)	81.8%	(N = 359)	18.2%	(N = 80)
Age in years
Mean	24.8 (SD = 7.3)		24.5 (SD = 7.0)		26.1 (SD = 7.8)
Median	23		23		24
Range	17 − 63		17 − 63		17 − 62
Sexuality	%	N	%	N	%	N
Heterosexual	93.4	410	91.9	330	100	80
Bisexual	4.6	20	5.6	20	0.0	0
Homosexual	1.4	6	1.7	6	0.0	0
Other	0.5	2	0.6	2	0.0	0
Ethnicity	%	N	%	N	%	N
Dutch	57.9	254	51.0	183	88.8	71
Non-Dutch	42.1	185	49.0	176	11.3	9
Surinam	15.9	70	18.9	68	2.5	2
Antillean	8.0	35	9.8	35	0.0	0
Ghanaian	1.6	7	2.0	7	0.0	0
Turkish	1.6	7	1.7	6	1.3	1
Moroccan	1.6	7	1.7	6	1.3	1
Mixed ethnicity	3.6	16	4.5	16	0.0	0
Other	9.8	43	10.6	38	6.3	5
Attained education*	%	N	%	N	%	N
Higher	64.5	283	61.3	220	78.8	63
Middle	32.6	143	35.1	126	21.3	17
Lower	3.0	13	3.6	13	0.0	0

* = Higher education = Hoger beroepsonderwijs (HBO), wetenschappelijk onderwij (WO); Middle education = hoger algemeen voortgezet onderwijs (HAVO), voorbereidend wetenschappelijk onderwijs (VWO), middelbaar beroepsonderwijs (MBO) 2–4; Lower education = Voorbereidend middelbaar beroepsonderwij (VMBO), MBO 1.

The eight (six female, two male) interview respondents all lived in different places in the Netherlands. Ethnicities were Dutch (5), Colombian (1), Croatian (1), and Bosnian (1). Ages ranged from 19 to 24 years with a mean of 22.1 years (median = 23). The mean age of menarche of survey respondents was 12.3 years (median =12, range 9–18). The four experts represented different fields: the menstrual care industry, scientific research, and journalism.

Data Analysis

Quantitative data from the surveys were statistically analyzed using IBM SPSS Statistics 25. Because the 12 stigma statements reflecting the three categories of stigma assessed different aspects of stigma (i.e., personal and perceived attitudes, emotions, and behaviors), the items were analyzed separately. In this way, more detailed information regarding menstrual stigma can be provided. For each item, independent sample t-tests were performed to analyze differences between (1) women and men and (2) Dutch women and Surinamese women for the mean of the 12 stigma statements. Bonferroni correction was applied to reduce type I error, therefore p-values ≤ .004 (0.05/12) were considered significant (Armstrong, 2014). Chi-square tests were performed to examine the differences between ethnic groups (Dutch women vs. Surinamese women) in sexual activity during menstruation. The strength of association was evaluated using Cramer’s V test.

Qualitative data derived from the surveys and population and expert interviews were analyzed and coded using Qualtrics and Atlas.ti 8.0. Thematic analysis was conducted following the six steps of Braun and Clarke (2006): (1) two researchers (RvL, FG) became familiarized with the data, (2) created preliminary codes, and (3) sorted codes in overarching themes and subthemes. Next, (4) all authors reviewed themes to ensure an accurate representation of the data set and (5) further defined themes and generated names for the themes. Finally, (6) the four main themes were interpretated and summarized through a narrative summary. In the results section, survey respondents are cited using ^#X, interview respondents using a pseudonym, and experts by a number.

Quantitative Results

Table 1 summarizes the main findings from the 12 statements assessing menstruation stigma according to Goffman’s categories.

The data show that the highest level of stigma is reflected by statements 5 (M = 8.47) and 6 (M = 8.62), belonging to the “blemish” category of stigma, where respondents expressed that they (think others) would feel embarrassed when leaking menstrual blood on their pants. The lowest level of stigma is reflected by the reversed statement 7, where respondents stated they would be willing to sit next to a woman on the bus if they knew she was menstruating (M = 8.31), and statement 10, where respondents scored low (M = 1.69) on the statement “When girls start menstruating, they should start acting like women” (stigma category “social marker”). Respondents both are aware of the prevailing stigma and internalized this stigma. Statements in the stigma category. “abomination of the body” scored relatively high, indicating that both men and women considered menstruation as dirty. More so, respondents believed that others see menstruation as dirty (M = 7.51).

Compared to men, women score significantly higher on the statement “I would feel embarrassed when I leak menstrual blood in my pants.” Similarly, women agreed significantly more than men with the statement that girls become a woman at their first menstruation (stigma category “social marker”). Adversely, women would be more willing than men to sit next to a menstruating woman on the bus if they knew she was menstruating.

Compared to Dutch women, Surinamese women scored significantly higher on the statements “At their first menstruation, girls have become a woman,” “When girls start menstruating, they should start acting like women,” and “Women are easily irritated when they are menstruating.”

Most survey respondents (68.3%, n = 300) chose to not participate in sexual activity during menstruation. Both gender and ethnicity were significantly associated with sexual activity during menstruation. Men engage significantly more in sexual activity during menstruation than women (X2(1, N = 439) = 15.20, p < .0001, Cramer’s V = .186). Dutch respondents were significantly more likely to engage in sexual activity during menstruation compared to Surinamese women (X2(1, N = 251) = 16.80, p < .0001, Cramer’s V = .259). Table 3 presents the distribution of reasons participant gave to avoid or engage in sexual activity during menstruation. Reasons to not engage in sexual activity during menstruation, for example “It is not hygienic,” “It is dirty,” and “I learned I should not,” were more often prevalent among Surinamese women compared to Dutch women.

Table 3. Distribution of reasons to avoid or engage in sexual activity during menstruation.

I do engage in sexual activity during menstruation because (n = 139):	Women (n = 99) %	Dutch women (n = 71) %	Surinamese women (n = 8) %	Men (n = 40) %
It does not bother my partner	65.6	62.0	62.5	50.0
It does not bother me	57.6	56.3	50.0	62.5
I do not find it dirty	32.3	35.2	12.5	45.0
It is pleasurable	32.3	29.6	40.0	20.0
No particular reason	25.3	21.1	37.5	35.0
My partner likes it	15.2	16.9	12.5	22.5
I do not engage in sexual activity during menstruation because (n = 300):	Women (n = 260) %	Dutch women (n = 112) %	Surinamese women (n = 60) %	Men (n = 40) %
It is not hygienic	67.7	55.4	85.0	50.0
It is uncomfortable	62.3	58.9	73.3	27.5
It is dirty	57.3	46.4	80.0	45.0
It is embarrassing	46.5	50.0	51.7	35.0
It is not erotic	30.0	24.1	33.3	32.5
My partner does not like it	20.8	21.4	23.3	22.5
I learned I should not	21.5	10.7	45.0	10.0
It is not pleasurable	19.2	17.0	21.7	20.0
It produces pain	12.3	8.0	6.7	0.0

Note: Numbers represent the percentage of the study sample that answered with this response. Respondents were able to give multiple answers. Sorted by total % of choices (high-low).

Table 4 shows the participants “main beliefs regarding sexual activity during menstruation. In open questions, respondents described sexual activity during menstruation as dirty (n = 129), never wanting to engage in it (n = 92), unhygienic (n = 90), and uncomfortable (n = 82). Beliefs such as “Not natural,” “Unhealthy,” and “Something that can give me a disease” were more often prevalent among Surinamese women compared to Dutch women. As a percentage, men scored sexual activity during menstruation more often as “Erotic” than women.

Table 4. Main beliefs regarding sexual activity during menstruation (N = 439).

I believe that sexual activity during the menstruation is:	Women (n = 359) %	Dutch women (n = 183) %	Surinamese women (n = 68) %	Men (n = 80) %
Not hygienic	71.0	62.8	85.3	48.8
Not comfortable	62.7	56.8	67.6	41.3
Not pleasurable	53.5	49.7	61.8	40.0
Not erotic	43.2	45.9	36.8	40.0
Not a sin	27.3	35.5	14.7	45.0
Natural	26.5	33.9	11.8	33.8
Not something that can give me a disease	32.3	31.7	8.8	37.5
Not painful	27.0	26.2	8.8	33.8
Not natural	20.9	10.9	33.8	11.3
Healthy	18.7	19.1	5.9	21.3
Painful	16.4	10.9	5.9	2.5
Unhealthy	15.3	6.0	22.1	8.8
Pleasurable	9.2	9.8	2.9	11.3
Something that can give me a disease	7.5	2.2	14.7	5.0
Erotic	5.3	3.3	1.5	7.5
A sin	3.9	0.5	2.9	3.8
Hygienic	2.5	2.2	0.0	5.0

Thematic Analysis Results

The Fear of Discovery and Stigmatization Causes Discomfort

Many girls experienced menarche feeling unprepared—making it an experience that comes with discomfort, feelings of panic, and embarrassment. All six interviewed women could easily remember the day of their first menstruation, of which five with a considerable degree of specificity: “When I menstruated for the first time, I was very startled by the amount of blood I lost. I even got anxious by it.”^#224 Jenna: “I sat on the toilet in the morning, lowered my underwear, and saw lots of blood. It was difficult because I went on a middle school trip for a few days. I didn’t want to tell my classmates or friends because I felt like I was young and would have been the first of everyone.” Many women were concerned about showing visible signs of menstruation, such as menstrual blood, due to the fear of being stereotyped as someone who menstruates and thus as someone dirty and unclean. Therefore, women made strong efforts to hide their menstruation to avoid being stigmatized. For example, Daria mentioned not wearing tight pants during menstruation so that her pads would not become visible, and Alexa mentioned quickly putting a tampon in her pocket so that no one would notice the tampon. There is a generally known Dutch word for leaking menstrual blood through your clothes. doorlekken (literally translated: leaking through), which was mentioned by most interviewed women. Jenna’s response reflected the internalization of these negative stereotypes, expressed in terms of feeling “embarrassed” and “ashamed” if one’s menstrual status would be discovered: “It never really happened luckily, but if I would leak through, I would be so embarrassed, and I would be so ashamed. If someone would see me with red stains on my pants. . . . Oh no, that would just be super awkward if that happened.”

Women experienced the physical and mental management of their menstruation as tiring. The constant menstrual (hygiene) management was experienced as mentally tiring and exhausting. Alexa: “It’s so inconvenient to always have to think how many tampons you have to bring with you or where you are going. What is on the agenda for that week? All that annoying planning stuff. That you always must keep menstruation in mind. Always thinking: Okay, I have to go to the toilet at that time. That’s what I’m most busy with.”

Menstruation is Dirty—and Therefore Sexual Activity during Menstruation is as Well

Stigmatizing beliefs regarding menstruation were strongly reflected in participant narratives—especially the belief that menstruation is dirty. Words such as “dirty,” “disgusting,” and “unclean,” were used often by both men and women. Female respondents, in particular, viewed menstruation as dirty, reflected by statements such as “I don’t want to touch my blood” or “I feel dirty” when menstruating. These attitudes that menstruation is repulsive were primarily noticeable in the online survey and less so in the interviews. Menstruation was associated with contamination by some Surinamese women in the survey, who believe it is uncustomary to be in the kitchen during menstruation: “Among Surinamese people, we often call menstruation “sick”; also, you are not allowed to cook for others.”^#29 Not only menstruation but also menstrual products were associated with contamination. Ivan:

I was training, and during exercises, we sometimes had to switch places. At a given moment a tampon was laying on the ground and a guy screamed ‘Ew, there’s a tampon!’ even though it was packaged. … He made it clear that he found it very dirty or weird. Afterward, I went up to him because I found it remarkable and asked him why he reacted that way—it is just a piece of cotton, right? He said ‘Yeah … but this is a tampon…!?’ I was like “And…?” But he couldn’t put it in words.

However, attitudes about menstruation were not always binary, as respondents mentioned a mix of positive, neutral, and negative associations with menstruation: “My first association is that it is dirty, inconvenient, and painful. But it is also the most beautiful way to detoxify your body.”^#415

The negative attitudes about menstruation often translated to similar negative attitudes about sexual activity during menstruation. Based on the results of the interviews and surveys, three groups were identified regarding sexual activity during menstruation: those who view sexual activity as a no-go, those who engage in sexual activity in case the circumstances allow, and those who see positive aspects of sexual activity during menstruation.

The largest group of respondents viewed sexual activity during menstruation as a no-go. For this group it was self-evident that engaging in sexual activity is not something to be done during menstruation and viewed as dirty. Ivan: “Whenever it went that way of like … are we going to have sex? She quickly said she was on her period so then it wasn’t an option anymore.” Women were sometimes reluctant regarding sexual activity during menstruation because they believed that their partner “might find it dirty” or that they would not want their partner to see or smell the blood. This is supported by Expert 3: “I feel like guys are less grossed out than girls generally. Maybe because he wants to have sex no matter what, but I felt like girls were not into the idea.” Like menstruation, beliefs about sexual activity during menstruation were predominantly negative. This was illustrated in the answers of several respondents, such as “That is an absolute no go, that is dirty. I don’t get why people do that”^#13 and “That’s disgusting!! It’s a moment where your body cleanses itself.”^#251

A moderate group of people had mixed attitudes and engage only in sexual activity during menstruation under certain circumstances, for example on lighter days, in the shower, while wearing a condom, on a bed covered with a towel, or when not performing vaginal sex or oral sex on a woman. Vivian: “Sex during menstruation is a bit more standard because you know. … You must stay on top of the towel. So, you can’t do very special or wild things.” While sexual activity during menstruation was also addressed in the interviews, the negative attitudes were noticeably less intense than those in the survey. Daria: “I have done it in the past when I was having my period … but now I don’t do it anymore. It’s just … I don’t think it is dirty. But when you think about it with all the blood involved it is pretty dirty. And I don’t think it smells nice. Therefore, I feel like that activity becomes different when you are doing that together and blood is involved.” Multiple men associated menstruation with a time when they tend to receive oral sex from their partner instead of engaging in sexual intercourse. Mike: “If she’s on her period and is in the mood, usually nothing happens. If something happens, it’s usually me receiving oral.”

A small group of people saw sexual activity during menstruation as something that allows for more intimacy, tenderness, intensity, trust, and a deeper connection. Experts stated that people more open to such an experience are often more sexually experimental. Expert 3: “For example, women who go to a Kamasutra fair, who shop at Christine le Duc. The audience who is more open to that kind of stuff.” Expert 1: “You also have men who are drawn to it and experience it as a fetish, just like a latex fetish.” According to Expert 2, sex with orgasms during menstruation has benefits because it could relieve menstrual cramps: “The funny thing is … your period is one of the moments where you enjoy sex more because hormonal changes and orgasms can help relieve cramps. We should prescribe this to women who suffer from their menstruation, haha!”

Survey respondents also had positive associations with menstruation, along with a wish for a more positive discourse regarding menstruation. Positive associations of menstruation included menstruation representing fertility, normality or a natural process, good health, a time of creativity, or a moment of cleansing. In the interviews, various positive aspects of menstruation, such as fertility, a sign of being in good health, and the sense of coherence between women were also mentioned. Lauren: “It creates a bond between women. When you are with women, the topic always comes to menstruation at one point! I like that. It feels like we are in a Secret Service together or something.”

Experts encouraged the view of looking at your menstruation as an indicator of your health. Expert 1: “There is a small group, like a health group, who embraces menstruation and sees it as a period of increased creativity, a time to praise fertility. But that is a select group—most people want to have their menstruation pass by as effortlessly as possible.” All experts and several respondents expressed a wish to reframe the discourse surrounding menstruation and to create more room to focus on the positive aspects of menstruation.

Women Don’t Feel Understood—Especially Not by Men

All interview respondents reported that women experience a lack of understanding from their environment, specifically men, regarding menstruation. Mike’s narrative clearly illustrates men’s lack of understanding regarding menstruation and women’s menstrual experience. “Last week my sister was talking about wanting to buy a certain car. I told her how that car was very strong and that that isn’t something she needs. And then … I don’t know what I said but she snapped and was like ‘Wow okay … I just wanted to advise you …’ Those are things you should be careful with in those periods. Not seeking too much confrontation.” At the same time, Mike recognized that such confrontations could result from a lack of understanding: “When a woman is menstruating and reacts differently than she would normally, … you have that piece of incomprehension, which expresses itself into frustration, and then I respond to that. Then it gets bigger each time. I think this is something that needs to be discussed.”

Not feeling understood by others could have serious health consequences for women, illustrated by Expert 4: “I was shocked, when I started this job, about the number of women who deal with such severe menstruations … that I, as a non-medical person, started to think: ‘Wow, this can’t be normal!’ Those women suffer continually, thinking it is something you must face as a woman. … That gives me the message that we don’t yet feel comfortable enough to talk about this and that we aren’t taken seriously at health-care institutions or by GPs.” This lack of understanding can have a perpetual influence on a women’s life, as Kim illustrates:

I am sometimes taught by an older man at the conservatory together with two boys. Last week I was on my period. During class I thought that I was going to leak through, so, I went to the toilet twice. I don’t feel like I can be honest about it, so I just said I had to pee. My teacher even told me that I should not be drinking so much. In my head, I was like “you have no idea what you’re talking about and what is going on right now!” But at that moment I don’t feel like I can say that.

Overall, men in this study acknowledged that they lack understanding of menstruation and menstruating women. Both Ivan and Mike could recall moments when they or their environment categorized menstrual-related behavior as overreacting. Learning more about menstruation by, for example, having a girlfriend helped them to better understand processes related to a menstrual cycle. Ivan: “If you have ‘woman A’ who can live as she normally does, and ‘woman B’ who can’t get out of bed because of cramps. That is quite a difference if the only thing you know about menstruation is that women bleed and can be more emotional. You would see ‘woman B’ as overreacting. But you do not have enough information to judge such a situation. That is why more information for men is necessary.”

Education as a Driver of Menstrual Attitudes and Beliefs

Most respondents learned about menstruation in their home situation or at school. Due to menstruation’s stigma and the stigma surrounding sexual activity during menstruation, sufficient education was lacking. For instance, menstruation is not openly discussed in school. Consequently, girls are not always or sufficiently educated about menstruation before their first menstruation. Expert 4: “That has to do with girls starting their menstruation earlier, but also with the educational program not being altered to this and with parents not openly talking about it.” As many as 86 survey respondents, both men and women, mentioned they were taught that menarche is the moment girls become women. However, for many women this statement is puzzling, and they have difficulties agreeing with it. Daria: “I received comments like “you are a woman now!” I only thought: “But I’m eleven …?” It felt like a misplaced moment to become fertile. As if I received a function I had to postpone for a very long time.”

Respondents from both the survey and interviews indicated that education had a large impact on the beliefs regarding menstruation for both women and men, and remembered learning about menstruation in detail. Alexa: “I was baking a cake with my mom. My brother and dad weren’t at home, so we could speak freely about everything. She made little drawings about the uterus and explained what everything meant and how everything worked.” Most survey respondents that expressed having received some form of menstrual education were satisfied with this. Answers in this group ranged from “I’m very grateful for my mother’s openness and help. That is why I was never ashamed about my own body”^#319 to “I would not have understood it either way.^#75. However, several respondents would have liked to have their menstrual education different: more explanation, openness, preparation, comforting and less secrecy, fear, and taboo—for example: “I did not know that it had so much impact on women. I noticed it about my sisters, but I would have liked to know that it was that intense,”^#337 and: “I wish someone would have explained to me what would happen the first time – I thought I had a disease or something when it happened.”^#108

Respondents in the survey mentioned that from a young age they are taught about the importance of menstrual hygiene, taking care of their body, and making sure it stays clean. Women are told with emphasis that “your body is sacred, so you have to be very careful and clean with it,”^#192 that others should never notice that you are menstruating and that it is unhygienic to engage in sexual activity during menstruation. These lessons and social norms led to women feeling pressured to constantly control, disguise, and conceal their menstruation. Results indicated that the current way of learning about menstruation is dominantly medical. Several experts and respondents wished for a more holistic approach to menstruation, where also attention is paid to other aspects of menstruation and when men are included in the learning process. Expert 2: “That’s very new among researchers—the holistic way to also, for example, talk about some mental cycles. That’s futuristic. Hopefully, it will become true somewhere soon.” This was supported by Expert 4: “Sexual and menstrual education is still biology-oriented. It could become more colorful and present-day. It being very medical does not make it easier or fun to talk about, it does not encourage a discussion. It is just a class you are more uncomfortable in compared to other classes. To normalize it, it’s important to also look at education for boys.”

Respondents and experts expressed their wish to improve education on menstrual products and to shed light on a greater variety of menstrual hygiene products, such as tampons made from purely cotton, different menstrual cups, and sponge tampons. Kim: “Look at menstrual hygiene products besides tampons and pads. I am so happy with my cup and it made my life so much better. That is what I would advise because no one ever told me about methods other than tampons or pads.”

Discussion

This study used a mixed-methods design that included a survey and interviews with citizens and experts to gain an insight into the attitudes and practices regarding menstruation and sexual activity during menstruation in the Netherlands. As far as we know, our study is unique in addressing menstruation and sexuality during menstruation, both sensitive topics, among women and men. Furthermore, our research reveals differences in attitudes and practices between Dutch and non-Dutch ethnicities, particularly Surinamese, respondents in the Netherlands.

The broad picture that emerged is that attitudes and practices regarding menstruation and sexual activity during menstruation among the Dutch public were highly negative. In general, women had (slightly) more stigmatizing attitudes toward menstruation than men. Women from non-Dutch ethnicities, particularly Surinamese, had generally more stigmatizing attitudes toward menstruation compared to Dutch women. Our results, for a large part, fit into the three categories of menstruation-stigma (Goffman, 1963; Johnston-Robledo & Chrisler, 2020), with the highest scores on items that asses the “blemish” category of stigma, e.g., feeling embarrassed when leaking menstrual blood. Many menstrual practices are impacted by the blemish category of stigma. Women went through great physical and psychological efforts to conceal their menstruation to avoid being labeled and linked to undesirable characters and thus blemished. “Abomination of the body” was expressed by labeling menstruation and sexual activity during menstruation as “dirty” and “disgusting.” The main “social markers” were that women are seen (by others) as easily irritated when they are menstruating. However, while the theoretical framework allowed for negative and stigmatized attitudes and practices to be included, our findings allowed for a broader perspective in which also mixed and positive attitudes and practices were included, as well as factors influencing the menstruation stigma such as education.

Women’s physical, mental, and emotional discomfort during menstruation affects their daily lives because they must deal with things like pain, severe bleeding, menstrual management in public places, embarrassment, and not being understood by men. Women in our study went to great lengths to conceal their menstruation because discovery would lead to stigmatization. In line with other research, our study shows that failing to conceal menstrual blood and/or menstrual products or the discovery thereof was considered a shameful experience (Grose & Grabe, 2014). Concealing has been theorized to adversely impact well-being through the cognitive stress of constantly trying to manage one’s “secret” (Quinn et al., 2017). Consequently, women’s excessive efforts to conceal their menstruation is problematic because the resourceful energy of women is wasted and they limit “women’s lived experiences” (Morris et al., 2014).

Menstruation was primarily associated with negative attitudes; these were especially notable in the survey and less so in the interviews. This could be explained by respondents willing to be interviewed about menstruation being more positive and comfortable with menstruation. Predominantly non-Dutch respondents, i.e., Surinamese women, mentioned attitudes about menstruation as unclean and menstruation as a time of cleansing. These findings are similar to that of Orringer and Gahagan (2010), who found that African, Mexican and European American girls were more likely to believe that menstruation serves a cleansing function compared to Arab American girls. However, some positive experiences were mentioned as well, such as associations with fertility and health. This entanglement of negative and positive attitudes regarding menstruation and sexual activity during menstruation causes most women to feel ambiguous toward their menstruation by, for example, associating menstruation as dirty and inconvenient, as well as a beautiful way to detoxify a body. Thus, our results showed that negative and positive menstrual experiences were often intertwined, which seems to differ from the study in 2013 by Fahs (2020b), who found the twenty interviewed US women felt overwhelmingly negative about menstruation, even when asked for positive experiences.

Women’s realization of the extent to which social rules influenced their menstrual attitudes and practices made them feel uncomfortable, consistent with the research of O’Flynn (2006). When women reflected on their menstrual attitudes and practices in the interviews, they (1) began feeling uncomfortable because they realized how much the stigma surrounding menstruation subconsciously influenced their menstrual attitudes and practices, (2) recognized the amount of concealing of menstruation that is asked from women, and (3) realized how much energy they exerted in managing their menstruation. The public negative attitudes toward menstruation and the misconceptions about menstruating women may also impact women’s health-seeking behavior. For instance, women in the study mentioned being reluctant to go to health facilities when they experienced serious menstrual-related symptoms because they felt like they were not understood, or their complaints were not being taken seriously by other people and health professionals. This concern was also expressed by the experts interviewed.

Sexual activity during menstruation was a no-go and most respondents strictly avoided this practice because it was—in line with perceptions about menstruation—perceived as unhygienic, uncomfortable, dirty, and embarrassing. Peranovic and Bentley (2017) also reported that for many people sexual intercourse during menstruation is seen as nonnegotiable and unacceptable. Men in this study engaged significantly more than women in sexual activity during menstruation. Some men distanced themselves from menstruation by avoiding the topic directly or reframing the situation as something they could benefit from and described it as a “blowjob week,” which was also reported by others (Allen et al., 2011). Dutch female respondents were significantly more likely to perform sexual activity during menstruation compared to female non-Dutch respondents. This is similar to the research of Fahs (2020a), where White women were more positive toward menstrual sex than women of color. Respondents who engaged in sexual activity during menstruation saw it as something that allows for more intimacy, tenderness, intensity, trust, and a deeper connection—especially in more steady relationships (Allen & Goldberg, 2009).

Our results showed the differences in stigma regarding menstruation between Dutch and Surinamese women, a minority group living in a Western country. These differences might stem from history and culture where, especially among the Creoles and Maroons, women had to isolate themself during their menstruation in huts and were not allowed to cook (Tjon a Ten, 2007). Menstrual blood was considered dangerous and could be used to impose her will on a man using black magic (wisi) (Garg & Anand, 2015; Tjon a Ten, 2007). Menstruating women were considered impure and unclean, and had to alter their daily activities such as using special pots and pans to cook food, living in a separate part of the house, or not being allowed at an official ceremony (Tjon a Ten, 2007). Thus, it might be that these attitudes stemming from Surinamese culture perpetuate into today’s attitudes among Surinamese women living in the Netherlands. However, future studies could look into what factors contribute to differences in the way non-Dutch women and Dutch women perceive menstruation and sexual activity during menstruation.

On the other hand, related to the culture of Dutch women, the Netherlands is imaged by many for its progressiveness regarding issues of sexuality (Roodsaz, 2020; van de Bongardt et al., 2013). The Dutch are known for their comprehensive sexual education and favorable sexual health outcomes, especially noted by high contraceptive use among young people and low rates of teenage pregnancies (Ferguson et al., 2008). Dutch National policy requires that secondary school students learn about sexuality, including contraceptives, identity formation, social skills, and sexual diversity. However, there is a lack of information on the content of sexuality education materials and programs. For example, Ferguson et al. (2008) do not explicitly mention that menstruation—other than the biological aspects—and sexual activity during menstruation is part of educational materials and programs. The widely used program Long Live Love addresses topics like safe sex, relationships and sexuality, and sensitive taboos, such as sexual orientation and masturbation (Ferguson et al., 2008; van Lieshout et al., 2017), but—to our knowledge—not (explicitly) stigma related to menstruation and sexual activity during menstruation. Recently, Cense et al. (2020) found that young people in the Netherlands are not satisfied with the sexuality education they receive in high schools. They want more lessons and more comprehensive sexuality education, and for sexuality education to move beyond biology and focus on matters that are relevant in their actual lives, such as online behavior, sexual pleasure, relationships, and sexual coercion.

Results of our study underline the need for more and better education on menstruation to reduce stigma and to increase cultural openness surrounding menstruation and sexual activity during menstruation. Almost 30% of respondents were dissatisfied with their menstrual education and felt unprepared for their first menstruation. Clue (2015) found that 19% of Dutch girls did not receive information about menstruation before menarche. In addition, men typically receive inadequate menstrual education both at home and in school, which results in attitudinal differences between men and women regarding menstruation and causes discomfort in women due to menstruation-related misunderstanding (Brooks-Gunn & Ruble, 1986). Men should be involved in menstrual education to increase positive attitudes regarding menstruation: men and women who find ways to share menstruation and its consequences experience an increase in bonding and trust (Allen et al., 2011; Peranovic & Bentley, 2017). In line with the experts interviewed in our study, there is a need for a more holistic approach in menstruation education.

A practical implication based on these results is to strive for a more positive discourse regarding menstruation and to create a social and physical environment in which menstruation is discussed openly and safely, so women experience less discomfort to manage their menstruation. For example, by using terminology that avoids stressing menstruation as being dirty or unhygienic (Hennegan et al., 2021), acknowledging positive aspects of menstruation and applying a more positive discourse regarding menstruation, e.g. encouraging the attitude that menstruation is natural. Moreover, consideration of menstruation as a public health issue in the Western world could be improved because this has been limited, including in the Netherlands (Barrington et al., 2021; Sommer et al., 2015). Because it remains unclear what the exact impact is of menstruation stigma and menstrual-related problems on a country’s public health (Sommer et al., 2015), this deserves to be studied and addressed more in depth.

Strengths and Limitations

A strength of this research is methodological triangulation by using an anonymous online survey and population and expert interviews, guided by the categories of menstruation stigma (Goffman, 1963; Johnston-Robledo & Chrisler, 2020). Remarkable is that the more negative attitudes regarding menstruation were primarily notable in the survey, and less so in the interviews. This could be explained by respondents willing to be interviewed about menstruation being more positive and comfortable with menstruation. It was expected that this potential sampling bias would not have a large effect on the external validity because the interview respondents were randomly chosen from 85 respondents, and the survey was accompanied by expert interviews and an anonymous online survey. Nevertheless, both survey and interview respondents shared also their mixed and positive attitudes about (sexual activity during) menstruation. A limitation is the relatively low number of interview participants, although data saturation was reached and methodological triangulation confirmed our findings.

Further strengths of this research are the large number of participants and the collection of more information about the menstrual experience in the Netherlands, as most research has been performed in the United States (e.g., Allen & Goldberg, 2009; Fahs, 2020a, 2020b) or the United Kingdom (e.g. Newton, 2016)). Where most menstruation studies only included women in their sample, this research also included—mainly Dutch—men in both the survey and the interviews. Besides, as most research on this topic has mainly been performed using a relatively homogeneous, White, young, and educated sample, the diversity of this study sample related to gender and ethnicity is a strength and provided the opportunity to compare data of Dutch and non-Dutch females, i.e., Surinamese women. For example, in our study, 15.9% of respondents had a Surinamese background, compared to 2.1.% of the general population based on figures of 2021 (CBS, 2022). However, it needs to be acknowledged that the notion of ethnicity is flexible and changeable, as categorization of ethnicity is not easy (Krebbekx et al., 2017). Also, we only could compare Dutch women and Surinamese-ethnicity women. It would be of interest to also study other ethnic groups.

Young, heterosexual, highly educated, and female adults were overrepresented in this sample, creating a lack of inclusiveness regarding different age groups, sexuality, educational level, and gender. Attitudes and practices related to (sexual activity during) menstruation could be different for different age groups (Allen & Goldberg, 2009; Rempel & Baumgartner, 2003). Also, information about the kind of relationships could have been of added value: Allen and Goldberg (2009) found that women in committed relationships did not use the language of disgust concerning sexual activity during menstruation. A recommendation for future research is to purposely select participants across demographics.

To gain an explorative idea of the current general attitudes and practices in the survey, “sex” included vaginal, oral, anal, and/or manual sex. Future research could investigate which sociocultural factors and types of sex relate to attitudes about cleanliness. Would participants, for example, who object to vaginal sex during menstruation also object to oral sex performed by menstruating women? In addition, the stigmatizing attitudes and practices regarding menstruation among Surinamese women and other ethnic groups could be investigated in depth.

Conclusion

The overall picture that emerges is that both women and men have highly stigmatized attitudes and practices regarding menstruation and sexual activity during menstruation. Surinamese women have slightly more stigmatizing attitudes toward menstruation than Dutch women. Stigma influences attitudes and practices regarding menstruation and sexual activity during menstruation—resulting in a perception of menstruation as dirty. These negative attitudes compel women to conceal their menstruation and adjust their daily practices to do this. The constant practice of menstrual management, both physical and mental, negatively influences women’s lives and causes discomfort. In addition, sexual activity during menstruation is a no-go area for two-thirds of the respondents. Our findings, however, also reveal a mix of negative and positive attitudes and practices, as well as factors influencing the menstruation stigma, such as education. Furthermore, there appears to be room for improvement in sexual education by involving boys, using more positive terminology to destigmatize menstruation, and recognizing positive aspects of menstruation and sexual activity during menstruation.

Acknowledgments

We thank all those who participated in this research.

Disclosure statement

No potential conflict of interest was reported by the author(s).