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The social and cultural meanings of menstrual suppression Repta, Robin Ashley 2006

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THE SOCIAL AND CULTURAL MEANINGS OF MENSTRUAL SUPPRESSION by ROBIN ASHLEY REPTA B.A.H., Queen's University, 2004 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF ARTS IN THE FACULTY OF GRADUATE STUDIES (Human Kinetics) THE UNIVERSITY OF BRITISH COLUMBIA December 2006 © Robin Ashley Repta, 2006 ABSTRACT This study investigated how women interpret and experience menstrual suppression, the long-term limiting of women's menstrual cycles using hormonal interventions such as oral contraceptives (birth control pills) or Depo-Provera injections. Asserting that monthly menstruation is detrimental to both women's health and their lifestyles, some physicians and health care professionals are recommending menstrual suppression to women. Critics argue that menstrual suppression is unhealthy and has the potential to harm women physically, emotionally, and psychologically, as menstruation is commonly regarded as a key aspect of being female (Chrisler, 2000). To date, the research on menstrual suppression includes clinical studies and psychological investigations of women's knowledge and openness to menstrual suppression. However, the existing research has not investigated the relationships between women's feelings about their bodies, their senses of femininity and sexuality, their lived menstrual cycle experiences, and their perceptions of menstrual suppression. Building on the extant research, this study used in-depth interviews with 12 women aged 18 to 36 to examine the meanings that women give to menstruation and menstrual suppression. My findings suggest that women's experiences and perceptions of menstrual suppression are complex and bound up with issues of sexuality, femininity, body image, and socialization. The majority of the women described menstruation as a nuisance, embarrassing, "gross", and also as a marker of womanhood. The women also argued that Western culture promoted negative views of menstruation, and they described how they made sense of these menstrual taboos. The women maintained that they would consider menstrual suppression for reasons of convenience, to please their sexual partners, and to feel more positively about their bodies. Reasons to avoid suppressing menstruation included fears about compromising one's health, worries about altering the "natural" menstrual cycle, and uneasiness with pharmaceutical products in general. The findings are discussed in relation to feminist theorizing about menstrual culture and body work. The findings from my research underscore the need for more thorough clinical research on menstrual suppression. As menstrual suppression continues to be recommended to women as a healthier option than monthly menstruation, it is imperative that we understand the effects of menstrual suppression on women's health and lives~TN) iii TABLE OF CONTENTS ABSTRACT " TABLE OF CONTENTS iv LIST OF TABLES vi ACKNOWLEDGEMENTS vii CHAPTER ONE: Introduction 1 CHAPTER TWO: Literature Review 5 2.1 - Menstrual Culture 5 2.2 - Proponents of Menstrual Suppression 7 2.3 - Opponents of Menstrual Suppression 9 2.4 - Historical Views of Menstruation 11 2.5 - The Medicalization of Menstruation 16 2.6 - Menstruation and Femininity 19 2.7 - Menstruation and Body Image 21 2.8 - Menstruation and Sexuality 24 2.9 - Body Practices as Social Control 26 2.10 - The All-Encompassing Nature of Body Work 27 2.11 - Existing Studies of Menstrual Suppression 29 2.12 - Summary: Situating my Research 31 2.13 - Research Question 33 CHAPTER THREE: Method 34 3.1 - Grounded Theory and Symbolic Interactionism 34 3.2 - Feminist Methodology 35 3.3 - Linking Theory and Method 38 3.4 - Rationale for this Research 40 3.5 - Reflexivity 40 3.6 - Recruitment 42 3.7 - Sample 43 3.8 - Interview Structure 46 3.9 - Data Analysis 48 CHAPTER FOUR: Findings 50 4.1 - Women's Feelings about and Experiences of Menstruation 50 4.1.1 - Menstruation as a Nuisance 51 4.1.2 - Painful Periods 53 iv 4.1.3 - Menstruation as Manageable 56 4.1.4 - Menstrual Taboos 59 4.1.5 - Menstruation as Embarrassing 62 4.1.6 - Menstrual Blood as Gross 64 4.1.7 - Menstruation and Sexuality 66 4.1.8 - Menstruation as Feminine and as a Marker of Womanhood 70 4.2 - Women's Attitudes Towards and Experiences of Menstrual Suppression 74 4.2.1 - Motivations to Suppress Menstruation: Convenience 74 4.2.2 - Motivations to Suppress Menstruation: Identity 77 4.2.3 - Motivations to Suppress Menstruation: Women's Feelings about their Bodies 80 4.2.4 - Motivations to Suppress Menstruation: Reducing Pain 82 4.2.5 - Motivations to Menstruate: Health 85 4.2.6 - Motivations to Menstruate: Natural is Best 87 4.2.7 - Motivations to Menstruate: Distrust of Pharmaceuticals 90 4.2.8 - Motivations to Menstruate and Suppress: Physicians' Opinions 93 4.2.9 - Motivations to Suppress: Western Culture 96 CHAPTER FIVE: Discussion 99 5.1 - Effects of Menstrual Taboos 99 5.2 - Predictions about Pain 101 5.3 - Our Western Culture of Convenience 102 5.4 - Menstruation and Sexuality 104 5.5 - Menstruation and Femininity 105 5.6 - Menstruation and Body Image 107 5.7 - Menstruation as a Form of Body Work 108 5.8 - Natural Menstruation and Medicalization 111 CHAPTER SIX: Conclusion 117 REFERENCES 121 APPENDIX A: Recruitment Poster 130 APPENDIX B: Information Letter and Consent Form 131 APPENDIX C: Biographical Data Form 133 APPENDIX D: Interview Questions 134 v LIST OF TABLES Table 1 - Sample Characteristics 44 Table 2 - Sample Characteristics - Menstrual Suppression 45 vi ACKNOWLEDGEMENTS I am grateful to a number of individuals who have made this thesis possible. Thank you, Dr. Laura Hurd Clarke, my supervisor, for the opportunity to conduct this research, and for your support and guidance along the way. You are an inspiring supervisor and your passion for your research is contagious - I believe I've "caught" the research bug from you! Thank you to Dr. Patricia Vertinsky and Dr. Jerilynn Prior, my committee members, for your expertise, insightful comments, and assistance. It has been a pleasure to work with both of you. I would like to express my gratitude to the women who participated in this research study and who gave their time to share their personal stories with me. I enjoyed meeting all of you and am very grateful for your contributions to the project. This study could not have happened without you. Finally, a special thank you to all of my friends and family who encouraged me to pursue this degree, and who sustained me during this research project with their phone calls, visits, dinners, discussions, and enduring support. Most importantly, thank you Mom, Dad, V, Gram, and Grandma for your love: I dedicate this thesis to you. vii CHAPTER ONE: INTRODUCTION Women's reproductive systems have long been a subject of discussion and debate within medicine, academe, and feminism. Today, some researchers are arguing that monthly menstruation is "obsolete" and even unhealthy for women (Coutinho and Segal, 1999, p. 1; Kaunitz, 2000; Miller and Notter, 2001; Thomas and Ellertson, 2000), which has publicized and encouraged the practice of "menstrual suppression", the long-term limiting of women's menstrual cycles using hormones (Johnston-Robledo, Ball, Lauta, and Zekoll, 2003, p. 1). Drs. Elsimar Coutinho and Sheldon Segal (1999) popularized the idea of menstrual suppression in their controversial book, Is Menstruation Obsolete?, in which they argue that monthly periods are not only a nuisance for women, but also a contributing cause of health disorders such as anaemia, endometriosis, and pre-menstrual syndrome (PMS). As such, Coutinho and Segal recommend that women suppress their menses long-term for both health and lifestyle benefits. Other researchers and individuals have echoed Coutinho and Segal's sentiments, recommending menstrual suppression not only for women who experience menstrual disorders, but also for athletes, women in the military, adolescents, perimenopausal women, and anyone else who would prefer a menses-free existence (Kaunitz, 2000; Miller and Notter, 2001; Thomas and Ellertson, 2000). Advocates of this practice also advertise menstrual suppression as the answer to special occasions where menstruation is viewed as a hassle, including events such as honeymoons, vacations, and athletic activities (Coutinho and Segal, 1999; Kaunitz, 2000). 1 However, not everyone agrees with reducing women's menses: many individuals oppose menstrual suppression and assert that Coutinho and Segal's book is both inaccurate and misogynistic (Grant, 2000; O'Grady, 2001; Prior, 2000; Rako, 2003). Some researchers and women's health activists argue that menstrual suppression is yet another example of the medicalization of the female body, and that it stands to seriously harm women's emotional, psychological, and physical health (Johnston-Robledo et al., 2004; O'Grady, 2001; Prior, 2000; Rako, 2003). Women's health experts often describe menstruation as a "critical indicator of women's overall health", and are, therefore, wary of suppressing women's menses (Wershler, 2004, p. 105). Susan Rako (2003) warns that women's cardiovascular health, bone density, and sexual response are at risk when women suppress their menses, as sex hormones play a role in these physiological systems. Thus, she cautions against tampering with hormone levels, as she argues that to do so is detrimental to women's health on many levels (Rako, 2003). Other critics worry about the effect of menstrual suppression on women's relationships with their bodies, as the menstrual suppression movement seems to implicitly reject women's menstrual cycles. In the same way that many feminists maintain that women should accept and appreciate their individual body sizes, shapes, and unique features, these critics insist that accepting one's menstrual cycle is an important part of women's health and overall well-being (Lippman, 2004). As follows, feminists view rejecting one's menstrual cycle as unhealthy (Lippman, 2004). Menstrual suppression expanded from medical circles into the larger public consciousness in large part due to the Food and Drug Association's approval of a 2 new drug in the United States in 2003 called Seasonale (Hitchcock and Prior, 2004). Seasonale is advertised primarily as a menstrual suppressant, although it is essentially a re-packaged birth control pill with a longer duration of active, menses-inhibiting pills, creating a menstrual period only four times a year in users (, 2006). The approval of Seasonale in the United States has generated a great deal of media response as the perceived merits and dangers of menstrual suppression have been debated publicly: magazines have featured articles with titles such as "The end of menstruation" (George, 2006, p. 41) and "Kiss your period good-bye" (Grumman, 2000, p.1), television shows have addressed the topic (20/20, 2003) and individuals have discussed menstrual suppression on their personal websites (, May 23, 2006;, April 10, 2006). Seasonale is not yet available in Canada, however, Seasonale and two other menstrual suppressant drugs, Anya and Librel, are currently under review at Health Canada, and all three are expected to be popular, and thus profitable for pharmaceutical companies, if approved (George, 2005; O'Grady, 2006; Zanna, 2003). Until then, women can suppress their menstrual cycles using regular birth control pills, or hormonal injections such as Depo-Provera, which some health professionals have recommended (Miller and Hughes, 2003). For these reasons, it is timely to investigate how women are responding to the idea of menstrual suppression. Building on the extant literature, this study examines the meanings that women give to menstruation and menstrual suppression, and offers an in-depth understanding of how some women are making sense of their reproductive bodies in 3 the wake of the menstrual suppression movement. In this thesis, I first describe how current literature and historical contextualizing can aid in our understanding of menstrual suppression. Next, I discuss the methodology I used in my qualitative, interview-based study. Finally, I present and discuss my findings. Ultimately, the purpose of this study is to address the research question: How do women perceive and/or experience menstrual suppression? 4 CHAPTER TWO: LITERATURE REVIEW 2.1 Menstrual Culture The extant literature is replete with studies of women's experiences of menstruation (Houppert, 1999, Lee and Sasser-Coen, 1996), feminist theorizing about the invasive and oppressive nature of reproductive technologies (Corea, 1988; Rushing and Onorato, 2003; Sekhon, 2003; Sen and Snow, 1994) and investigations about how the female body is "medicalized" in ways that encourage women's subordination (Nicolson, 1995; Sievert, 2003; Vertinsky, 1994). Theorists have discussed the way that menstruation is constructed as a "dirty" taboo in Western society, and how this devaluation of menstruation is harmful to women (Houppert, 1999; Lander, 1988). Houppert (1999) states that our "culture of concealment" (p. 33) benefits sanitary-product manufacturers as their tampons, douches, and other cleansing, concealing commodities sell based on the assumption that women will want to hide any sign of menstruation. Kissling asserts that the "so-called feminine hygiene industry" capitalizes on discourses that construct menstruation as either "an illness to be managed or a hygienic crisis to be cleaned up and hidden" (Kissling, 2006, p. 1). Kissling argues that these perceptions of menstruation promote the use of pharmaceutical products which eliminate menstruation (Kissling, 2006). Furthermore, theorists have repeatedly highlighted the fact that menstruation is rarely talked about openly in Western societies and is instead portrayed as a messy, annoying bother (Houppert, 1999; Kissling, 2006; Lander, 1988; O'Grady, 2001). 5 Feminists hold that menstruation is devalued because it is inherently feminine and in our patriarchal society, we diminish what is feminine and privilege what is masculine (O'Grady, 2001; Prior, 2000). Feminists contend that Coutinho and Segal's book, and the menstrual suppression movement, rest on this negative view of menstruation as something to be hidden and possibly eliminated. They point to the fact that there are very few occasions where menstruation is celebrated in Western culture and instead messages proliferate about the embarrassing, painful, and dirty aspects of menstruation (Houppert, 1999; O'Grady, 2001; Prior, 2000). Cultural dialogues about menstruation affect how women feel about their menstruating bodies (Lee and Sasser-Coen, 1996). Lee and Sasser-Coen have examined women's experiences of menarche and they reveal that women have varied and mixed feelings about their first menses (Lee and Sasser-Coen, 1996). Attitudes towards menarche reflect societal opinions of menstruation, as young women are often excited, anxious, and/or unhappy with their menarche (Lee and Sasser-Coen, 1996). This mirrors society's ambivalent feelings about menstruation, as it is at the same time both a sign of maturity and normal female development, and a despised, sordid event (Lee and Sasser-Coen, 1996). Film and television representations of menstruation are rare, but when they do exist, they generally portray menstruation as an embarrassing inconvenience, though sometimes as a source of feminine pride (Kissling, 2002). Nevertheless, menstruation is rarely shown in the media and is merely hinted at in most cases. Kissling (2002) points out that while it is commonplace to see blood on-screen nowadays, television programs, movies, and even commercials for menstrual 6 hygiene products avoid using the word blood and have only recently begun to use the word "period". Additionally, advertisements for menstrual products tend to use blue ink to symbolize blood, which suggests that menstruation should never be openly discussed or directly symbolized (Houppert, 1999). Lastly, representations of menstruation in television programs and movies reinforce gendered behaviours (Kissling, 2002). Women are socialized to be embarrassed, ashamed, and proud of their menstruation, while men are socialized to be distant, uninformed, and unaware of menstruation. Furthermore, men learn to be extremely embarrassed when they are involved in discussions or events related to menstruation (Kissling, 2002). These examples indicate that menstruation remains a secretive topic in our society that is not discussed openly (Houppert, 1999; Kissling, 2002; Lee and Sasser-Coen, 1996). The end result is that menstruation is a complex and contradictory event, as it is simultaneously "the last unmentionable taboo" in our society (Houppert, 1999, p. 1), a "hygiene challenge" (Stubbs and Costos, 2004, p. 4), and an important marker of womanhood (Lee and Sasser-Coen, 1996). 2.2 Proponents of Menstrual Suppression Proponents of menstrual suppression insist that reducing women's menstrual cycles is healthier than menstruating monthly (Coutinho and Segal, 1999; Kaunitz, 2000; Miller and Hughes, 2003; Miller and Notter, 2001; Thomas and Ellertson, 2000). They recommend that women use oral contraceptives (birth control pills) or Depo-Provera injections continuously, reserving the hormone-free week of bleeding for once every couple of months, yearly, or even less frequently. As Miller and 7 Notter describe, menstruation is understood to be detrimental to women's health: "The pill-free week perpetuates conditions, such as anemia and dysmenorrhea [painful menstrual cycles], and those associated with feminine hygiene product use, such as vulvar inflammation and toxic shock syndrome" (Miller and Notter, 2001, p. 777). The rationale behind menstrual suppression is that women in earlier societies had far fewer menstrual periods as a result of later menarche, earlier first births, more frequent pregnancies, and longer periods of breastfeeding between pregnancies during which menstruation was absent (Thomas and Ellertson, 2000). As a result, modern women allegedly experience up to 400 more menstrual cycles than earlier women, which is viewed as less natural and unhealthy (Miller and Notter, 2001; Thomas and Ellertson, 2000). Additionally, menstrual suppression advocates point out that contraceptives were designed to mimic the natural menstrual cycle, complete with a week of withdrawal bleeding every month. However, considering our foremothers' schedules of menstruation, the idea of natural monthly menstruation is disputed. Advocates of menstrual suppression argue that we should recognize this discrepancy and limit the number of "withdrawal bleeding episodes" (Kaunitz, 2000, p. 227) in women. Proponents of menstrual suppression also acknowledge that many women dislike their monthly menstruation and are embarrassed, inconvenienced, and/or disabled by it: Any woman can tell you that menstruating is a pain, literally and metaphorically. At a minimum, it is a nuisance that requires planning and expensive sanitary supplies and paracetamol [Tylenol] to avoid messy discomfort for about 1 week each month. In many cases, however, menstruation has a far greater impact on the female population. It can debilitate, and it constitutes a significant and largely unacknowledged cost to society... (Thomas and Ellertson, 2000, p. 922). 8 These physicians and researchers emphasize that it is advantageous for both women and society to limit menstruation in women, therefore, they encourage all women to suppress their menstruation using hormonal contraceptives. Menstrual suppression supporters insist that it is important for health professionals and women to be aware of this body practice, as it provides a simple, inexpensive, and readily available method of avoiding menstruation and should be an accessible choice for women. 2.3 Opponents of Menstrual Suppression Opponents of menstrual suppression state that women's health and liberty are both at risk when considering menstrual suppression. Drs. Jerilynn Prior and Susan Rako are adamant that menstrual suppression has not been adequately studied to support the broad health claims and recommendations that are made by its promoters (Prior, 2000; Rako, 2003). In fact, Rako asserts that, "manipulating women's reproductive hormonal chemistry for the purpose of menstrual suppression would be the largest uncontrolled experiment in the history of medical science" (Rako, 2003, p. 97). Prior and Rako challenge much of Coutinho and Segal's book, refuting many of the health benefits of menstrual suppression that the authors cite. For example, Rako argues that using menstrual suppression to treat conditions such as iron-deficiency anaemia would simply mask nutritional deficits rather than treating the illness itself, as anaemia is typically caused by an unbalanced diet (Rako, 2003). Additionally, Rako states that menstrual suppression threatens women's cardiovascular health, as higher levels of stored iron, due to less frequent menses, 9 increase women's susceptibility to heart attacks, strokes, and other cardiovascular disorders (Rako, 2003). Furthermore, Prior (2000) asserts that the majority of menstrual problems are not caused by menstruation but by ovulatory disturbances. Therefore, menstrual suppression would not cure any real disorder and again could mask the symptoms of an unrelated health issue. Feminist researchers criticize the language and inherent ideology used by menstrual suppression advocates, as they seem to emphasize the supposed negative, messy, and embarrassing aspects of menstruation (Lippman, 2004; O'Grady, 2003; Prior, 2000). Opponents of menstrual suppression often point to the ways that menstruation is described by its supporters as a "needless loss of blood" (Coutinho and Segal, 1999, p. 159), "a nuisance" (Thomas and Ellertson, 2000, p. 922), "a pain, literally and metaphorically" (Thomas and Ellertson, 2000, p. 922), and "a burden" (Kaunitz, 2000, p. 277). In this way, advocates of menstrual suppression consistently portray menstruation as a curse and use pathological language that encourages its treatment (O'Grady, 2000). Kathleen O'Grady argues that menstrual suppression changes women's physical bodies (O'Grady, 2006), and she and other feminists worry about the potential effect of menstrual suppression on women's body image, as women are encouraged to suppress a key aspect of being female (Chrisler, 2000). Feminists worry that women's physical health, emotional well-being, and social position are all vulnerable in the wake of the menstrual suppression movement, as for the first time in the history of humanity, women are facing the decision of whether or not to menstruate (Rako, 2003). 10 2.4 Historical Views of Menstruation In order to fully understand current views of menstruation and the concept of menstrual suppression, it is important to review the history of menstruation in Western society, as menstruation has not always been viewed as a dispensable body process. Throughout history, women's bodies and their associated meanings have been discussed in terms of women's reproductive function, in which menstruation was viewed as both "the seat of life" and "strictly forbidden" (Poorthuis and Schwartz, 2000, p. 149). Dating back to Biblical times, menstruation was representative of both life and death, health and disease (Douglas, 1966). Historically, menstrual blood was considered to be "dirty" and "polluted" (Douglas, 1966, p. 13) and women were deemed unclean during their time of menstrual bleeding: When a woman has a discharge of blood that is her regular discharge from her body, she shall be in her impurity for seven days, and whoever touches her shall be unclean until the evening. Everything upon which she lies during her impurity shall be unclean; everything upon which she sits shall be unclean (Leviticus 15: 19-22, Revised Standard Version). Mary Douglas argues that these rules are not about hygiene concerns, but rather fears about dirt and pollution as threats to the social and moral order (Douglas, 1966). Douglas explains that uncontrollable aspects of life cause extreme cultural and social anxiety as she asserts that "dirt is essentially disorder" (Douglas, 1966, p. 34). As follows, pollution behaviours, such as menstruation, are dangerous and powerful, which is evidenced by their volatile status in society. By defining what is polluted, people classify their lives according to what is acceptable and 11 unacceptable. These ideas lead us to read Leviticus as a text that maintains asymmetrical power relations between the two sexes, as it places restrictive rules upon women and classifies them as inferior to men (Douglas, 1966). As Douglas confirms, "many ideas about sexual dangers are better interpreted as symbols of the relation between parts of society, as mirroring designs of hierarchy or symmetry which apply in the larger social system" (Douglas, 1966, p. 52). In this manner, historical texts such as the chapter Leviticus in the Bible are considered to have profoundly influenced Western societies' views of women's bodies, women's role in society, and Western social and moral codes (Ellens, 2003). The view of menstruation as both necessary and polluting endured throughout the Roman and Greek eras of medicine, where menstruation was viewed as an essential cleansing process and as a means of expelling excess blood from the flawed female body (van de Walle and Renne, 2001). During this time, we see the first historical discussions of amenorrhea, the absence of menstruation, referred to then as "menstrual retention" (King, 1998, p. 22). Menstrual retention was considered to be a severe illness, and emmenagogues and other herbal remedies were prescribed to restore menstrual flow1. Van de Walle and Renne (2001) argue that this tradition of menstrual management to promote regular menstrual flow continued throughout the 18th and 19th centuries and remained unchallenged until the 1960s: "Physicians almost universally considered menstrual pathologies as a cause for concern" (van de Walle and Renne, 2001, p. xxiii). Therefore, the tradition of regular menstrual flow and the pathological nature of menstrual retention have 1 Menstrual retention led to bloodletting for both women and men. Menstruation was viewed as both physically healthy, and as symbolically powerful, thus men throughout the ages developed complex bleeding rituals that can be viewed as parallel "menstruation" experiences (Grahn, 2002). 12 been important concepts in historical Western medical philosophies. It is only recently that we view amenorrhea as a positive and healthy phenomenon. Historian Patricia Crawford states that: A study of beliefs about menstruation is neither a mere feminist redressing of historians' balance of interest nor a mere revelation of the superstitions of the past. It is essential for an understanding of the position of women in the society (Crawford, 1981, p. 47). For these reasons, Crawford emphasizes the importance of contextualizing medical discussions of menstruation with the social circumstances of the time period. In this way, we can see "retention of the menses" (King, 1998, p. 22) as a social rather than biological event by considering the medical remedies prescribed for this affliction. In the 18 th and 19 th centuries, marriage and childbirth were the healthiest recommendations for young women who experienced irregular periods or amenorrhea, as childbirth was thought to open uterine vessels to let the flow pass (Lord, 1999). Furthermore, 18 th and 19 th century prescriptions reveal cultural beliefs about the links between menstruation and femininity, as amenorrheaic bodies were considered unfeminine and in a state of "gender-limbo" (Strange, 2001, p. 249). Women who did not menstruate regularly in the 18th and 19 th centuries were warned that they would lose their feminine attributes and develop male characteristics, such as prominent body hair and "masculine" feelings (Strange, 2001, p. 249). These sexist interpretations meant that 18 th and 19 th century physicians were quick to discourage women from participating in various aspects of public life, as women's health was assumed to be more secure within the confines of the 13 home (Vertinsky, 1994). Thus, the notion of menstruation as a disability served to reinforce gender norms and strengthened an inequitable distribution of power among the sexes (Vertinsky, 1994). These historical accounts of menstruation are meaningful, as our present-day views of menstruation and the female body have been influenced by earlier belief systems. Today, menstruation is still viewed as a disability requiring medical and pharmaceutical assistance. Menstrual suppression is based on the idea that monthly menstruation is unhealthy, thereby necessitating medical and pharmaceutical interventions. What has changed, very recently, is the idea that monthly menstruation is a necessary and healthy body process; some physicians today are now recommending that women limit their monthly bleeding, as monthly menstruation is considered to be unhealthy. This sudden shift in medical knowledge points to the socially constructed nature of health, and raises suspicion about the benefits of menstrual suppression. Additionally, the history of menstruation in Western society highlights the fact that our understandings of women's menstrual cycles are always moderated by powerful social discourses, which reflect ideas about women's role in society. Historical accounts of menstruation were used as evidence of women's inferior.physical and mental state, and justification for their lesser status in society. In the same way, current understandings of menstruation and menstrual suppression also reinforce hegemonic power relations. Menstrual suppression arguments which hold that women's natural state is to be pregnant and breastfeeding frequently can be seen as a direct nod to these historical ideas, as they seem to suggest that women's role in life is to birth and feed children above all 14 else. Furthermore, some arguments made by menstrual suppression advocates imply that women are less productive during their menstruation: Menstrual disorders cost US industry about 8% of its total wage bill. Expenses are particularly concentrated in sectors that employ predominantly women. For example, Texas Instruments found a 25% reduction in the productivity of female workers during the paramenstruum...There can be no other disease or condition that affects so many people on such a regular basis with consequences, at both the individual and societal level, which is not prioritized in some way by health professionals or policy makers (Thomas and Ellertson, 2000, p. 922). These types of statements promote a view of women as less mentally stable during phases of their menstruation, and ultimately discourage women's participation in the workforce. Perspectives which allege that women's productivity is affected by menstruation also imply that society suffers as a result of women's menstruation, and therefore seem to encourage women to suppress their menstrual cycles as part of their civic duty. Continuing this line of reasoning, it is possible that those women who refuse to suppress their menstrual cycles could be blamed for causing undue harm to society, by continuing to menstruate without medical interventions. By contextualizing the current discussion of menstrual suppression in historical accounts of menstruation, it becomes apparent that women's menstrual cycles have consistently been a source of stigma and discrimination throughout history in Western societies. These historical accounts emphasize the connections between the promotion of menstrual suppression and power relations within society, which will be discussed further in future sections of this thesis. 15 2.5 The Medicalization of Menstruation Theorists have analyzed how menstruation has been medicalized by the medical and pharmaceutical industries and how this medicalization is a manifestation of societal power relations (Ford, 1986; Houppert, 1999; Lander, 1988; Vertinsky, 1994). The term medicalization refers to: Medicine's tendency to define normal events in women's lives and natural states as pathological and requiring medical attention... medicalization controls women, and deflects attention from unjust social conditions that prevent us from flourishing or even oppress us (Purdy, 2001, p. 249). Riessman argues that human experiences are increasingly being categorized as medical issues, as it is now appropriate to consult physicians about matters of sexuality, fertility, and childhood behaviour, which were previously outside the range of medicine (Riessman, 1983). Furthermore, Riessman aptly points out that "the medical professional's jurisdiction over these and other human conditions extends considerably beyond its demonstrated capacity to cure them" (Riessman, 1983, p. 4). In this way, medicalization is inextricably linked to power and control as the medical world is able to create and reinforce social norms when they categorize behaviours or conditions as pathological. Feminists argue that women's bodies and processes are more susceptible to medicalization than men's, as patriarchal medicine has defined health in masculine terms, rendering women's bodies and life experiences deviant and pathological. Indeed, life processes such as menstruation, menopause, and childbirth have been particularly vulnerable to the effects of medicalization (Riessman, 1983). For 16 example, Houppert (1999) criticizes the medical and pharmaceutical communities for treating pre-menstrual syndrome, or PMS, as an illness and a mood disorder rather than the result of added stress and responsibility in women's lives. Houppert contends that by perpetuating disabling notions of PMS, women are socially constructed to be physically and mentally unstable during their menstruation, which can warrant their exclusion from aspects of society (Houppert, 1999). Purdy (2001) and Reissman (1983) argue that medicalization is not necessarily the problem and instead that the culture of medicine is at fault for operating outside of a woman-centered health perspective. Reissman (1983) says the solution is "not to deny the biological components of experience but rather to alter the ownership, production, and use of scientific knowledge" (p. 16, italics in original). Theorists are equally critical of the pharmaceutical industry, which profits from medicalizing discourses of women's bodies. Ford (1986) has examined the pervasive influence of the pharmaceutical industry on women's health and argues that hormones have become necessary for women at almost every stage of life. Oudshoorn (1994) discusses the extensive use of the birth control pill to treat "conditions" such as acne, PMS, and irregular periods, and states that the wide range of conditions for which the pill is prescribed makes estrogen and progesterone the most widely used drugs in the history of medicine. These theorists are critical of the way that pharmaceutical companies continually carve out new market niches by medicalizing normal human experiences such as menstruation. They question the health ramifications of consuming hormones regularly as "treatments" (Ford, 1986; Oudshoorn, 1994; Rako, 2004). Laws (1990) argues that the medical field of 17 gynaecology serves to normalize and regulate women's bodies, as doctors attempt to determine the normal menstrual cycle, including menstrual symptoms, number of days, and related symptoms. Indeed, medical doctors have become experts in dealing with women's bodies, wrestling power away from women, collectively, and bestowing it upon (traditionally male) doctors (Laws, 1990). The trend towards medicalization has been well documented (Howson, 2004; O'Grady, 2001; Oinas, 1998; Purdy, 2001). In Finland, Oinas' review of women's magazines found that medical advice columns overwhelmingly promote a medicalized view of menstruation, encouraging girls and women to consult a doctor upon the slightest discovery of any abnormality (Oinas, 1998). Oinas argues that this is a clear indication of the medical world's willingness to take responsibility for and control of women's bodies (Oinas, 1998). Loshny (2004) likens the current debate over menstrual suppression to the controversial advice often given to menopausal women regarding the use of hormone replacement therapy during menopause. Loshny states that, "menstruation is being cast in the same way as menopause, as a problem of pathology that needs to be 'fixed' or 'eliminated'" (Loshny, 2004, p. 65). Thus, Loshny (2004) is critical of the menstrual suppression movement for the way it negatively portrays menstruation as an illness requiring medical intervention. Loshny and others encourage women to view menstruation and menopause as natural aspects of the female lifecourse and they recommend that women abstain from using pharmaceutical interventions to treat these events as much as possible (Loshny, 2004; O'Grady, 2001; Prior, 2000). Dr. Jerilynn Prior sums up this 18 viewpoint as she asserts: "Ovulatory menstrual cycles are not a problem: go with the flow!" (Prior, 2000, p. 1). Feminist critiques of menstrual suppression and medicalization often emphasize that menstruation is an important part of women's lives and a feminine body process that should be celebrated. 2.6 Menstruation and Femininity Femininity is typically described as the culturally and temporally-defined physical and mental attributes associated with the female sex, although this is a problematic category (Butler, 1990; 2004), as the characteristics of the female gender change over time and across cultures (Johnson, Greaves, and Repta, in press). Furthermore, the concept of gender is frequently positioned by feminist theorists as being separate from biological sex and existing on a continuum (Johnson, Greaves, and Repta, in press). Acknowledging that each woman's sense of femininity is varied and unique to her own experiences, I employ the definition of femininity used by Carrie, who described the concept as "all the stuff that comes with being a girl [woman]". The research suggests that there is a relationship between femininity and a woman's perception and experience of menstruation (Cosgrove and Riddle, 2003; Elson, 2002; Malson, 1998; Martin, 2001); however, the details of this relationship are unclear. Cosgrove and Riddle (2003) found that women who adhere to a more traditional feminine gender role tend to experience pre-menstrual syndrome, or PMS, more frequently and severely than women who do not adopt a traditional feminine role (Cosgrove and Riddle, 2003). Cosgrove and Riddle explain this finding in light 19 of gender roles: normative feminine gender roles expect women to be "serene" and do not allow for "negative" emotions (p. 47). Women who endeavour to live up to these feminine gender roles tend to position themselves as PMS sufferers, as that label acts as a legitimate reason for not maintaining one's feminine composure and gives women an excuse for acting in un-feminine ways. The "real" person is the woman who lives up to the feminine ideal, while the non-feminine person suffering from PMS is the "disordered aberration" (p. 48). Cosgrove and Riddle maintain that "menstruation comes to signify what women are at the most fundamental level, e.g., biologically-labile, messy, bleeding, and out-of-control, which is of course the antithesis of a socially sanctioned femininity" (Cosgrove and Riddle, 2003, p. 47). Cosgrove and Riddle (2003) conclude that cultural discourses of PMS substantiate and encourage traditional constructions of femininity, as PMS-sufferers often complain of feeling "faint", "forgetful", and of having "poor motor coordination", attributes which the authors say are cultural markers of feminine gender identity (p. 46). Thus, Cosgrove and Riddle's most interesting argument is that cultural discourses of menstruation and femininity actually shape individual women's experiences of their bodies, illustrating the powerful influence of these cultural scripts. Other theorists assert that menstruation is an inherently feminine aspect of the body. For example, Elson (2002) argues that "there is a strong association between menstruation and female gender identity" (Elson, 2002, p. 38). Furthermore, Martin describes menstruation as "a mark of womanhood" (Martin, 2001, p. 103) and states that: 20 The primary positive feeling many women have about menstruation is that it defines them as a woman...Sometimes the defining characteristic is closely linked with being able to have babies...But other times the defining characteristic is equally important apart from the potential to reproduce...A part of feeling joined together as women is feeling different from all men...When women talk about the disgusting mess or the discomfort, they do so with an implicit, often unstated understanding that there is another side to the process; it is part of what defines one as a woman, and it is something all women share, even if what we share is talking about the problem of dealing with this disgusting mess (Martin, 2001, p. 101-103). Menstruation has been shown to be a "uniquely feminine experience" (Drelich and Bieber, 1958, p. 324) which "signifies an individual's initiation into womanhood" (Elson, 2002, p. 39). Research suggests that the termination of menstruation at menopause is problematic for some women, as they experience it as a loss of femininity (Rogers, 1997). However, not all women mourn the loss of their menstrual cycles. Elson's (2002) study of women whose menses were terminated prematurely as a result of hysterectomies found that the majority of women were happy and relieved at the prospect of permanently ending their menstruation, as menstruation tended to be a very uncomfortable and painful experience for them. This finding supports Woods' (1986) theory that women whose periods are most painful will have the most negative view of menstruation. 2.7 Menstruation and Body Image Body image is a complex, multidimensional concept. While often thought of as simply a measure for body satisfaction, body image has at least 16 definitions, 21 including: "weight satisfaction, size perception accuracy, body satisfaction, appearance satisfaction, body esteem, body concern, body dysphoria, body dysmorphia, body schema, body percept, body distortion, body image, body image disturbances, and body image disorders" (Cash and Pruzinsky, 2004, p 7). Krueger (2004) defines body image in the following way: The body and its evolving mental representations form the foundation of a sense of self...'body self refers to a combination of the psychic experience of body sensation, body functioning, and body image. Thus body image is the dynamically and developmentally evolving mental representations of the body self (p. 30). Menstruation has been shown to be linked to women's body image (Benjet and Hernandez-Guzman, 2001; Fingerson, 2005; Roberts, 2004; Roberts and Waters, 2004). Benjet and Hernandez-Guzman (2001) have found that Mexican girls suffer lower self-esteem, more negative body image, and greater rates of depression following menarche than do boys of the same age who experience voice changes at puberty. Additionally, Roberts and Waters found that self-objectification in women is connected to their beliefs about menstruation (Roberts and Waters, 2004). For example, women who self-objectify, or see themselves as objects, are more likely to make statements such as "I find menstrual blood disgusting" (p. 16) and are more prone to depression and eating disorders (Roberts and Waters, 2004). It is not surprising that menstruation can affect women's feelings about their bodies, as women's lower status within patriarchal society has historically been attributed to women's inferior biology, and menstruation specifically has been held as proof of women's inadequacy (Roberts, 2004, Vertinsky, 1994). Jones, Vigfusdottir, and Lee 22 (2004) state that "societal factors have a powerful impact on the development and maintenance of body image through the creation of an appearance culture that values, reinforces, and models cultural ideas of beauty and body shape" (p. 323-324.) Women receive strong messages that menstruation is not only taboo, but also that their bodies are "unacceptable" while menstruating (Roberts, 2004, p. 22). Roberts (2004) conducted a study which found that women who participated more in self-objectifying practices (practices that prioritize one's physical appearance) had more negative attitudes towards menstruating. Roberts suggests that this is because women's practices of self-objectification involve "psychic distancing" from their physical bodies where they internalize a "sexually objectifying standard" and then feel negatively about their own bodies and body functions. Roberts (2004) does not make any conclusive links between self-objectification and menstrual self-evaluations, but maintains that cultural constructions of menstruation as "disgusting, shameful, and polluting" cannot help girls and women to feel positively about their own menstruation (p. 25). Fingerson (2005) has found that the unpredictable nature of menstruation made it an unpleasant experience for adolescent girls, and could actually distance them from their bodies, as a result of the perceived lack of control (Fingerson, 2005). However, Fingerson also found that the menstruating body could be empowering for some adolescent girls by creating personal responsibility, giving them experiential knowledge about menstruation, and affording them the opportunity to negotiate their own interpretation of menstruation (Fingerson, 2005). Thus, girls were found to 23 interpret their bodies in powerful ways, as their bodies could simultaneously exist as a source of oppression and power (Fingerson, 2005). Important research exists that indicates that body image fluctuates over the lifecourse and following body changes, whether due to surgery (Pruzinsky, 2004), cosmetic procedures (Sarwer, 2004), weight loss (Foster and Matz, 2004), aging (Hurd Clarke, 2002), or changes in health status (Fauerbach, Heinberg, Lawrence, Bryant, Richter, and Spence, 2003; Larouche, 2006). Sarwer (2004) notes that individuals who undergo cosmetic surgery are less embarrassed about their changed feature in public areas and social settings and also use fewer "camouflaging behaviours" post-surgery (p. 425). Additionally, Sarwer reports that the majority of individuals who elect to have cosmetic surgeries experience an improved body image after the procedures are completed. In this way, body image is a flexible and shifting concept which accommodates and adjusts to body changes. To date, there is no research on the connections between women's feelings about their bodies and menstrual suppression, however the budding literature on the connections between menstruation and body image provide a good foundation for this type of study. 2.8 Menstruation and Sexuality Theorists have argued that it is through a woman's first menstruation that she enters and becomes socialized into the world of heterosexuality (Lee, 1994; Lee and Sasser-Coen, 1996). Janet Lee states certain orifices and their secretions take on sexual significance at menarche, acting as a demarcation point for the female from 24 child to adult (Lee, 1994). Lee writes that menarche marks the time when a woman's body undergoes changes, such as the enlargement of breasts and hips, making her visible as a sexual being, as these are visual representations of female physical maturity (Lee, 1994). Thus, Lee argues that menstruation is a "crucial signifier of reproductive potential" (p. 346) which, therefore, embodies womanhood and sexuality (Lee, 1994). Hence, the desire to suppress menstrual blood contains implicit references to sexuality, as menstrual suppression physically removes a key indicator of sexual maturity. In other words, women who choose to suppress their menses can be seen as symbolically removing a sign of adult female sexuality. Lee writes that menstruation acts a barrier to sex for some women, who can use the excuse of menstruating to avoid sexual contact with their partners (Lee, 1994). Lee's research shows that men are unlikely and typically unwilling to have sexual relations with women who are menstruating (Lee, 1994). Similarly, Barnhart, Furman, and Devoto (1995) found that 72% of men and 70% of women avoid sexual relations during menstruation. Both men and women said that sex during menstrual bleeding was "not hygienic", but more men than women thought that sex during menstruation was "not erotic", "not pleasurable", and "not natural" (Barnhart et al., 1995, p. 4). Furthermore, Barnhart et al. (1995) discovered that methods of contraception can affect the intimacy of a couple, as couples will often choose a contraceptive method that does not hinder their sex lives. In this way, menstrual suppression could appeal to women who view it as a means of having sexual contact more frequently. 25 2.9 Body Practices as Social Control: Feminists and Foucault French theorist Michel Foucault describes the body as not solely a text, but rather as a site of control, where modern power assumes a dynamic, non-centralized form, creating "docile" bodies (Foucault, 1979). According to Foucault, power is not the possession of specific individuals, but rather something people have. This power, however, is configured in ways that privilege certain groups and ideologies (Foucault, 1977). Instead of sovereign power operating from above, modern, disciplinary power is scattered throughout society and can also work from below (Bordo, 1993). As a result, the individual self-disciplines: There is no need for arms, physical violence, material constraints. Just a gaze. An inspecting gaze, a gaze which each individual under its weight will end by interiorizing to the point that he is his own overseer, each individual thus exercising this surveillance over, and against himself (Foucault, 1977, p. 23). This idea applies to the politics of women's bodies, where unseen forms of power can control the female body and force it to submit to cultural notions of femininity (Bartky, 1988). Bartky (1988) argues that, "the disciplinary power that inscribes femininity in the female body is everywhere and it is nowhere; the disciplinarian is everyone and yet no one in particular" (Bartky, 1988, p. 57). Cultural beauty and body work practices can be considered forms of disciplinary power, as invisible, yet powerful, demands are placed on women to appear in certain ways in Western society. Numerous feminist theorists have discussed women's body maintenance practices as a method of exerting control over women's bodies (Bartky, 1988; Bordo, 1993; Gimlin, 2000; Jeffreys, 2005; Wolf, 1991). Feminists such as Sandra Bartky, 26 Susan Bordo, Debra Gimlin, and Naomi Wolf argue that body practices such as cosmetic surgeries, reproductive technologies, and even routine make-up and hair rituals are examples of the "manifestation of cultural norms on the female body" (Gimlin, 2000, p. 24). Feminists have long urged women to see the power behind the beauty routine and society's demand for ideal female bodies (Dworkin, 1974; Jeffreys, 2005; Wolf, 1991). Following these arguments, there is a large body of feminist theory that examines the power embedded in seemingly simple body maintenance practices and how these practices reinforce women's subordination (Bartky, 1988; Bordo, 1993; Dworkin, 1974; Gimlin, 2000; Jeffreys, 2005; Wolf, 1991). Menstrual suppression could also be a means of altering women's bodies in the name of Western body and beauty ideals, as menstrual suppression limits menstruation, which is generally described as a taboo subject and process in Western society. 2.10 The All-Encompassing Nature of Body Work Women's bodies have long been under siege by the pervasive and controlling beauty industry which emphasizes physical attractiveness above all else (Bartky, 1988; Bordo, 1993; Wolf, 1991). For centuries, women have arranged their hair, decorated their faces, and modified their bodies in accordance with societal expectations of beauty and womanhood (Labre, 2002; Wolf, 1991). Today, however, there is an increasing emphasis on the female genital region as a site requiring beauty interventions (Davis, 2002, 2003; Labre, 2002; Miller and Edenholm, 1999). Currently, women are encouraged by society to remove some, or all, of their pubic 27 hair (Labre, 2002), and to douche or cleanse the vagina with specific products (Cosentino, 2004; lannacchione, 2004). Additionally, women may undergo labiaplasty, a plastic surgery procedure that trims away labial tissue and/or injects fat into the labia to make the vagina appear more normal (Davis, 2002). These body practices are aimed at producing socially-acceptable, sexually attractive female bodies (Cosentino, 2004; Davis, 2002; lannacchione, 2004; Labre, 2002). Their link to capitalist society is evident, as waxing clinics, drugstores, and cosmetic surgery clinics, while very different services, all have a vested interest in women's body insecurities. For some women, menstrual suppression can be viewed as an extension of this type of work as it similarly aids in producing a sexually attractive and available female body, where menstruation cannot interfere with sexual intercourse (Barnhart et al., 1995). Additionally, the decision to suppress one's menses may be motivated by aesthetics, as eliminating menstruation could produce a more appealing body for women who see menstruation as "messy" or "smelly" (Laws, 1990; Lee and Sasser-Coen, 1996). Several researchers (Davis, 2002; Labre, 2002) have theorized that the move towards hairless, plump vaginas signals a cultural rejection of the adult female body and a move towards younger, childlike, female bodies. Labre contends that genital body practices can be seen as a way of revoking women's power by removing biological signs of adulthood, thereby rendering women childlike (Labre, 2002). Labre suggests that the increasing emphasis on genital appearance is an attempt by patriarchy to reinvent itself by promoting body maintenance techniques that appear to be a matter of choice, but which really appropriate control from 28 women in society (Labre, 2002). In other words, while individual women may seemingly decide for themselves whether or not to remove their pubic hair, douche, or suppress their menses, these decisions are moderated by powerful social discourses which encourage women overtly and covertly to subscribe to normative body ideals, which now include body maintenance in the genital area. Similar to the beauty routine, genital body work can be seen as a form of social control as it gives the impression that the female body is not attractive in its natural state and must be altered and improved to achieve acceptance by society. Menstrual suppression advertisements claim to produce a "cleaner", "more convenient" female body ( 2006), which certainly speaks to aesthetic appeal and sexual availability. 2.11 Existing Studies of Menstrual Suppression Despite the considerable amount of research on the importance of menstruation as a cultural ideology, the relevant theory supporting the important social consequences of body work, and the suggested links between menstruation, femininity, sexuality, and body image, there is little written about the practice of menstrual suppression. To date, there are only a handful of non-clinical studies of menstrual suppression, three of which I will be discussing here (Andrist, Hoyt, Weinstein and McGibbon, 2004; Johnston-Robledo et al., 2004; Miller and Smith, 1975). These important studies focus on women's feelings about menstrual suppression and all approach the topic from a psychological perspective. Miller and Smith (1975) were the first to address women's attitudes towards eliminating their 29 menstrual cycles, interviewing randomly selected young women and using self-report inventories to analyze the relationship between women's attitudes towards menstruation, their social position, and their willingness to eliminate their menstruation. They found that 80% of their participants indicated that they would be interested in eliminating their menses if the procedure was safe, temporary, and free. Women with the most favourable attitudes towards menstrual suppression thought that menstruation was messy and embarrassing, regarded elimination of the menses as a good method of birth control, and reported significant behaviour changes during the premenstrual and menstrual phases of their cycles (Miller and Smith, 1975). Although none of the social variables were found to be statistically significant, religiousity was the most important variable. Specifically, more religious women were found to be less willing to eliminate their menstruation than women who were not religious (Miller and Smith, 1975). Overall, the most significant variable was Female Role Orientation, as women who identified themselves as more traditional were found to be less willing to eliminate their menses (Miller and Smith, 1975). Andrist et al.'s (2004) more recent study looked at women's opinions of menstrual suppression in the United States by analyzing 221 women's questionnaire responses. Andrist et al. report that negative feelings about menstruation are correlated with interest in menstrual suppression and that the majority of their participants (over two-thirds) were interested in reducing menstrual pain and the amount of menstrual discharge (Andrist et al., 2004). Women who were not interested in changing their menstrual cycle patterns thought that reducing menstrual flow was not "normal" (Andrist et al., 2004). 30 Johnston-Robledo et al.'s (2004) study investigated young women's attitudes towards menstrual suppression and various psychosocial correlates of this attitude using a large-scale survey that they distributed to students at an American college in the Northeast. They reported that 35% of their sample was familiar with menstrual suppression, 12% had suppressed their menstrual periods using oral contraceptives continuously, and oral contraceptive users were more knowledgeable about menstrual suppression than other women (Johnston-Robledo et al., 2004). Johnston-Robledo et al. found that women who regarded menstruation as "a bothersome event" and as "disgusting or shameful" were more supportive of menstrual suppression than women with more positive attitudes towards menstruation (Johnston-Robledo et al., 2004, p. 69). Furthermore, women who scored higher on measures of body consciousness were not more likely to support menstrual suppression (Johnston-Robledo et al., 2004). A key point in this study is that the majority of women sampled were curious about menstrual suppression, signalling potentially greater interest in the future as the body practice continues to be advertised in the media and in doctor's offices. This study points to the need for additional qualitative research in order to investigate how femininity, sexuality, and body image relate to opinions of menstrual suppression, if at all. 2.12 Summary: Situating my Research The research to date focuses on the links between women's personal opinions of menstruation, their attitudes towards menstrual suppression, and their general knowledge of the body practice. Existing research has generated important 31 knowledge about menstrual culture at large, the medicalization of menstruation, and the links between menstruation, femininity, and sexuality. Additionally, research has documented women's interest in and knowledge of menstrual suppression, and has signalled the need for additional research in this area. However, despite these valuable studies, little is known about the relationship between women's attitudes towards menstrual suppression, their experiences of menstruation, and their perceptions of their own bodies. Specifically, research is needed that examines how menstrual suppression relates to women's feelings about their bodies, their senses of femininity and sexuality, and their lived menstrual cycle experiences. Menstruation is widely regarded as both a sign of physical health (Chrisler, 2000; Lee and Sasser-Coen, 1996) and a key aspect of being female (Kissling, 2002). Therefore, it is important and timely to research women's current attitudes towards menstrual suppression and how this practice affects women's definitions of femininity, sexuality, and identity. Given the increasing emphasis on physical appearance, maintenance of the body, and the medicalization of normal human processes (Brumberg, 1997; Howson, 2004; Purdy, 2001; White, Young, and Gillett, 1995), it is important to understand how women's perceptions of their own bodies relate to menstrual suppression and to their embodied experiences of their menstrual cycles. Acknowledging these gaps in the literature, this study complements the existing large-scale survey style research with qualitative, in-depth interviews. My research examines how individual women make sense of menstrual suppression and how menstrual suppression relates to women's body image, lived menstrual cycle experiences, and definitions of femininity and sexuality. 32 2.13 Research Question My study was guided by the following overarching research question: How do women perceive and/or experience menstrual suppression? Subsidiary questions were pursued in this context to address the various themes I have outlined above. These questions were: 1. How do women experience their menstrual cycles? 2. How do women's opinions about and experiences of their bodies, specifically menstruation, relate to their attitudes of menstrual suppression? 3. What are the relationships between menstruation, menstrual suppression femininity, and sexuality? 4. What are the social implications of having a drug specifically marketed for the purposes of suppressing the menses? The next chapter outlines the methodology and research methods that I employed in order to address these questions. 33 CHAPTER T H R E E : METHOD This chapter discusses grounded theory, symbolic interactionism, and feminist methodology, and how these theoretical perspectives shaped my research method. Specifically, this chapter outlines my research method design, including details regarding participant recruitment, my research sample, my interview structure, and my process of data analysis. 3.1 Grounded Theory and Symbolic Interactionism Given the paucity of qualitative research on menstrual suppression, it was appropriate to use grounded theory as a theoretical framework to investigate women's opinions of and experiences with menstrual suppression, as there is very little written about menstrual suppression from a qualitative perspective. Grounded theory is meant to examine individuals within the contexts of their everyday lives and to develop theories that capture the significant aspects of these everyday experiences (Strauss and Corbin, 1998). Grounded theory is a qualitative method developed by Glaser and Strauss (1967) that uses fieldwork interviews, observations, and documents to investigate individuals' lived experiences (Dey, 1999). The data are systematically reviewed to generate and refine the salient concepts, so that accurate theories may be developed that speak to the individuals' realities (Glaser and Strauss, 1967; Strauss and Corbin, 1998). Grounded theory originates from symbolic interactionism, which understands reality as a social construct (Kushner and Morrow, 2003). Symbolic interactionism is 34 interested in the meanings that individuals give to their interactions, behaviours, and "life-situations" (Prus, 1996, p. 24). Symbolic interactionism is based on the notion that people understand themselves as a result of their interactions in their social surroundings (e.g. by interacting with other people, learning the shared language and symbolic order of their world) and that it is through these interactions that individuals develop their sense of self. Thus, studying the human lived experience is necessary to understand both the nature of human behaviour, and also the effects of this social world on individuals (Prus, 1996). Focusing on the meanings that women construct and attribute to menstruation and menstrual suppression, my study was shaped by social interactionist grounded theory. This methodology lends itself well to qualitative interviews as a research method, as both theories are concerned with examinations of people's lived everyday experiences. 3.2 Feminist Methodology This study was also supported by a feminist methodology. Feminist theory works well with grounded theory and symbolic interactionism as both methodologies value individuals' experiences and perspectives, and are sensitive to people's socio-cultural backgrounds and their influence. Additionally, both grounded theory and symbolic interactionism have been shown to be important complements to feminist qualitative approaches (Elson, 2002; Hurd Clarke, 2001, 2002; Kitzinger and Willmott, 2002; Kushner and Morrow, 2003). Furthermore, the use of all three 35 methodologies provides an important intersection from which to conceptualize, conduct, and analyze research: Symbolic interactionist grounded theory provides an excellent point of departure for the generation of empirical theory grounded in everyday life and human health experiences. Both feminism and critical theory, as critical approaches, extend current developments in grounded theory and interpretive methodologies more broadly, to support integration of social structural analysis in the generation of explanations of human interaction in the social world. Critically, interested grounded theory methodology has important potential for contribution to the generation of substantive and formal middle-range theory that is relevant to everyday life experience and useful to the promotion of emancipatory social change to improve the health of populations (Kushner and Morrow, 2003, p. 42). Feminist theory, coupled with symbolic interactionism and grounded theory, provided an excellent methodological framework for this study. Feminist theory drives feminist research, which is meant to improve women's position in the world and to empower individual women in the research process (Caplan and Caplan, 1999). Thus, feminism is both "a theory and practice, a framework which informs our lives. Its purpose is to understand women's oppression in order that we might end it" (Kelly, Burton, and Regan, 1994, p. 28). Perhaps the most central tenet of feminist methodologies is the commitment to hearing women speak, in their own words, about their experiences (Kitzinger, 2003). This affirms the feminist credo that the personal is political and stands in opposition to positivist perspectives that have historically dismissed women's experiences and opinions as insignificant and not worthy of being researched. Within health research, feminists have been critical of the medicalization of women's bodies that occurs in clinical research and the subsequent refusal to acknowledge women's voices and 36 lived experiences (Cotterill, 1992; Maynard and Purvis, 1994). Therefore, qualitative research that allows women to speak about their own experiences is heralded as a woman-friendly approach (Harding and Norberg, 2005; Reinharz, 1992). Furthermore, while there is no one feminist method (Kitzinger, 2003), semi-structured interviews have been regarded as "the principal means by which feminists [seek] to achieve the active involvement of their respondents in the construction of data about their lives" (Graham, 1984, p. 4, italics in original). This perspective "offers researchers access to people's ideas, thoughts and memories in their own words" (Reinharz, 1992, p. 19). This type of research highlights and confirms women's lives as important sources of knowledge, thus validating women's experiences (Maynard and Purvis, 1994). Feminist interviewing tradition encourages a non-exploitative relationship between researcher and participant and tends to view research as a means of "sharing" information (Maynard and Purvis, 1994). However, it is naive to think that feminist qualitative work is free from biases. Indeed, while feminists stress the importance of qualitative methods, they criticize the implicit and essentially unavoidable power differences involved in research interviews, where the researcher occupies a position of power over the interviewee, especially in relation to the production of knowledge (Harding and Norberg, 2005). Feminists maintain that the recognition of issues of power and control are fundamental to the research process. Researchers are encouraged to minimize any power imbalances by recognizing control differentials, making the interview process as comfortable as possible (e.g. in a location of the participants' choosing), and by answering any 37 questions posed by participants honestly and with as much openness as possible (Cotterill, 1992). Acknowledging these limitations, feminist theory coupled with "symbolic interactionist grounded theory" (Kushner and Morrow, 2003, p. 42) provided an excellent lens and perspective for this study. 3.3 Linking Theory and Method With the goal of providing insight into the practice of menstrual suppression and its relationship to the experience of femininity, sexuality, and body image, I conducted a qualitative, interview-based, study which examined the attitudes of women of reproductive age towards menstrual suppression. Grounded theory, symbolic interactionism, and feminist methodologies all identify semi-structured, in-depth interviews as an important means of generating insights into the meanings that women give to their everyday life experiences. Consequently, semi-structured, in-depth interviews were chosen as I was attempting to discover and reveal attitudes towards menstrual suppression, perspectives that cannot be directly observed (Hammersley and Atkinson, 1995). Additionally, these methods were chosen as they have been shown to be particularly useful when addressing sensitive, personal issues (Caplan and Caplan, 1998; Cotterill, 1992; Hurd Clarke, 2003). More specifically, symbolic interactionism helped inform my study by focusing my attention to the women's socially constructed and negotiated perceptions of menstrual suppression relative to their life experiences. My symbolic interactionist lens also promoted a deeper consideration of the meanings of women's responses. As such, I probed to uncover the implicit value attached to the women's experiences 38 of menstruation and menstrual suppression and was careful not to take seemingly straightforward statements for granted. Feminist theory highlighted the importance of paying attention to issues such as reflexivity and power relations (Harding and Norberg, 2005; Kirsch, 2005; Reinharz, 1992). As a result, I was conscious of my role as a researcher and endeavoured to minimize any power differentials in my interactions with participants. I accomplished this by sharing personal information when I was asked (at appropriate times so as not to influence their opinions), and by conveying my appreciation for the participants' involvement. Also, I tried to emphasize the importance of the participant role in the research process. Furthermore, the use of semi-structured, open-ended interviews ensured that I acknowledged the worth of the women's personal experiences and afforded them opportunities to shape the research process. This meant that I was receptive to changes and unexpected turns in the interview schedule and did not try to re-focus the women to any charted course for the interview. Finally, my feminist methodology encouraged me to think about the concept of reflexivity, which is discussed in Section 3.5. Grounded theory's insistence on a "back and forth interplay with data" (Strauss and Corbin, 1998, p. 282) helped me to detect the salient themes in my research. Because grounded theory encourages constant re-reading of the data, I reviewed each of my interview transcripts several times before developing themes, codes, and proceeding with further analysis. This ensured that my findings were solidly grounded in the data. 39 3.4 Rationale for this Research Strauss and Corbin (1998), Elson (2002), and Kitzinger and Willmott (2002) report that themes begin to emerge after only several interviews with a relatively . homogenous sample. Similarly, I found that after conducting two interviews with 12 women, strong patterns were apparent in the data. My decision to interview women of reproductive age was motivated by the assumption that menstrual suppression would be more relevant for women who were still menstruating and who might, therefore, face the decision of whether or not to suppress their menses. Additionally, this study was designed to investigate women's personal feelings of menstruation and menstrual suppression. Thus, it was decided that it was appropriate to interview women who were currently of menstruating age. My decision to interview 12 women was also to ensure that the study was manageable, with adequate time for the participant recruitment, data collection, and analysis phases of the study. 3.5 Reflexivity Qualitative methodologies and feminist theory in particular have heavily criticized the idea of objectivity in research (Harding and Norberg, 2005; Reinharz, 1992). Feminists argue that it is neither possible nor desirable to separate the researcher from the research process. Thus, rather than attempting to conduct value-free research, feminists endeavour to be clear about how their beliefs and background influence their work (Harding and Norberg, 2005). This is often referred to as being reflexive in research settings. Reflexivity is the practice of reflecting 40 upon and critically examining the research process while being transparent about how data are created and how they are influenced by the researcher (Hall and Callery, 2001). It is for these reasons that I acknowledge my position as a 25-year old, single, white, heterosexual, upper middle class, well-educated Canadian woman from Southern Ontario who has very limited experiences with hormonal contraceptives and no experience with menstrual suppression. Additionally, I recognize my apprehensive stance towards menstrual suppression and my reluctance to use it myself. In an effort to maintain reflexivity throughout the research process, I kept a research journal which enabled me to document my reactions to and feelings about the data collection and analysis phases of the study. In this journal, I recorded my initial impressions of the research participants, my thoughts about things they said in interviews, and my emotions and moods following interviews. I also kept notes in this journal throughout the transcribing, coding, analyzing, and writing phases of this project. This was useful as I was able to consult my journal to remember how I felt about the women and their experiences, which made me aware of how I interpreted the data. For example, certain women were more similar to me in terms of education, family situation, personality, and age, and I endeavoured to be conscious of these similarities and differences while analyzing the data. It is possible, if not inevitable, that similarities between researcher and participant can lead the researcher to assume that she better understands the context of those women's lives who are more similar to her. For these reasons, it was important to let the data 41 speak for itself and to interpret each woman's words carefully and without presumptions. 3.6 Recruitment The women were recruited from various locations in Vancouver, British Columbia. Nine women were recruited from The University of British Columbia campus, two women were recruited from physician's offices, and one woman was recruited from a health store. The women were recruited with posters that described the study and invited interested participants to contact me by telephone. Snowball recruiting methods were also used, as friends, family members, and participants helped to recruit individuals. Of the 12 women, eight were recruited using snowball methods, whereby friends or family members specifically showed participants the recruiting posters, or told them about the study. In all cases, after the women learned about the study, they contacted me directly to learn more about the specific details of the research. Then, if they were still interested in participating after hearing the preliminary details, they were provided with an information and consent sheet which described the study in-depth (e.g. the time commitment involved, confidentiality, and the ethical guidelines of the study) and an interview time and location was set. The women were not given any financial compensation for their participation. 42 3.7 Sample The data for this study was collected from a sample of twelve women between the ages of 18 and 36, of relatively similar socio-economic and ethnic backgrounds. My sample was comprised of nine women who self-identified as Caucasian, White or European, two women who identified as European and Japanese, and one woman who identified as East Indian. All of the women lived in the greater Vancouver area, were Canadian citizens, and had obtained or were pursuing university educations. The women were diverse in terms of their ages, partner status, level of university education, employment status, and religious backgrounds (please see Table 1). The average age of the women was 24 years, and the median age of the women was 26.5 years. Of the women who were married, one had recently given birth to her first child, and another was pregnant with her first child at the time of the interviews. 43 Table 1 Sample Characteristics n = 12 Age n 18-20 2 21-23 1 24-26 3 27-29 3 30-32 2 33-35 0 36-38 1 Partner Status n Married 3 Married, common-law 2 Single 7 Education (Obtained or Currently Pursuing) n Bachelor's degree 5 Master's degree 3 PhD 2 Professional degree (e.g. MD or B.Ed.) 2 Employment n Full-time student 7 Professional 2 Administration 1 Server at restaurant/bar 1 Self-employed/semi-professional athlete 1 Religion n Christian 1 Christian, non-practicing 1 Hindu 1 No religious affiliation 9. Of the 12 women in my study, six women self-identified as having suppressed their menstrual cycles before while six women self-identified as never having suppressed their menstrual cycles. The women who had suppressed their 44 menstrual cycles previously used different methods of suppression, suppressed their menstruation for varying lengths of time, had different frequencies of menstruation while suppressing, and had made different decisions about their future use of menstrual suppression (please see Table 2). Lastly, it is important to note that the women self-identified as having suppressed their menstruation before or not. Therefore, while one woman used birth control pills to postpone her menstrual period (in order to avoid menstruating on certain days), she does not consider her experiences to be menstrual suppression. Thus, she is classified as having never suppressed her menstrual cycle. Table 2 Sample Characteristics - Menstrual Suppression n = 12 Experience with Menstrual Suppression n No experience 6 Suppressed menstruation using Depo-Provera 3* Suppressed menstruation using oral contraceptives 4* *one woman used both Depo-Provera and oral contraceptives to suppress her menses Lenqth of Time Spent Suppressinq Menstruation n Never suppressed menstruation 6 Suppressed one month of menstruation 2 Suppressed menstruation for less than one year 1 Suppressed menstruation for one to five years 2 Suppressed menstruation for more than five years 2 Menstrual Frequencv While Suppressinq Menstruation n Not applicable, have never suppressed menstruation 6 Suppressed one month of menstruation 1 Menstruated every 3 to 4 months while suppressing 1 Menstruated once or twice a year while suppressing 1 Did not menstruate at all while suppressing 3 Current Decisions Reqardinq Menstrual Suppression n Not interested at all 7 May be interested in the future 3 Plan to continue suppressing menstruation 2 45 3.8 Interview Structure Asking the women to reflect on their perceptions of menstruation and menstrual suppression, I conducted semi-structured, open-ended, in-depth interviews with the 12 women. Each woman except one was interviewed twice for a total of 23 interviews. With the consent of the women, all of the interviews, save one, were digitally recorded on an mp3 player and transcribed verbatim. One participant moved overseas in between the first and second interviews, so the second interview was conducted by telephone, rather than in person, and was tape-recorded. Field notes were also completed after each interview to capture the non-verbal aspects of the interview. The interviews were conducted at the most convenient place for the participants. Of the 23 interviews, 11 were conducted on The University of British Columbia campus, seven were conducted at the participants' home or office, three were conducted at my home, and one was conducted over the telephone. At the time of the first interview, the women were asked to sign the consent form, signalling that they understood the logistics and voluntary nature of the study. Then, I asked them to fill out a Biographical Data Form (Appendix D) in order to gain more information about their social position. On average, the interviews were approximately one and a half hours long. The first and second interviews were scheduled four to six weeks apart to allow time for the first interview to be transcribed and analyzed, so that appropriate questions could be developed for the second interview. Additionally, the time lapse between the first and second interviews allowed both the researcher and the participant to reflect on the issues discussed. 46 The interviews were semi-structured, with open-ended questions and a flexible outline that allowed the women to speak about their experiences uninterrupted and in-depth. Prompts were used to "clarify meanings, to extend the range and quality of replies, to examine consistency, to give encouragement and to reduce anxiety" (Keats, 2001, p. 11). The interview questions were developed around my main research question and subsidiary questions. My questions were intended to be "open-ended, neutral, sensitive and clear to the interviewee" (Britten, 2000, p. 12) in order to elicit important information from each participant and to ensure that the participants felt comfortable during the interviews. The first interview focused on the woman's background, her experiences of her menstrual cycle, and her perceptions and/or experiences of menstrual suppression, while the second interview asked about the woman's body image and her perceptions of femininity and sexuality with respect to menstrual suppression (Please see Appendix E for the Interview Schedules). The order of interview questions and themes were organized in an attempt to ask easier questions first, with more difficult and/or sensitive topics positioned later in the interview. This was again to ensure that the participants felt comfortable during the interview, and also so that they were gently familiarized with the interview process (Britten, 2000). Similarly, studies that deal with topics surrounding the body and personal experiences often begin by asking contextual questions about the participants' life histories and their experiences of their bodies (Hurd Clarke, 2001, 2003). This has been found to be useful in identifying the relevant and intended themes in the research (Hurd Clarke, 2001, 2003). Thus, the 47 questions for the first interview were more general, and specific, more theoretical questions were left to the second interview. 3.9 Data Analysis Glaser and Strauss' (1967) grounded theory approach was used to analyze the data. Grounded theory is the "discovery of theory from data systemically obtained from social research" (Glaser and Strauss, 1967, p. 55) and focuses on understanding "how individuals interact in relation to the phenomenon under study" (Dey, 1999, p. 1). Data analysis generally consists of reading the data multiple times to identify categories and connections between the texts (Creswell, 1998). From here, continuous comparison of the data ensures that the concepts that are developed are directly linked to the research texts. Following grounded theory methodology, the transcripts were read repeatedly to get an initial understanding of the data, with data analysis occurring simultaneously. These preliminary readings guided subsequent interviews, as particular ideas, arguments, and areas needing further explication emerged from the data. Glaser and Strauss describe this process of data collection driven by emerging analysis as theoretical sampling: Theoretical sampling is the process of data collection for generating theory whereby the analyst jointly collects, codes, and analyzes [her] data and decides what data to collect next and where to find them, in order to develop [her] theory as it emerges (Glaser and Strauss, 1967, p. 45) Hence, theoretical sampling is flexible to the emerging theory. 48 Following the reading and rereading of the transcripts, I began to identify "categories", or codes (Dey, 1999), which captured similarities in the data. In this process I compared transcripts with one another and with the emergent categories to ensure uniformity across the data. I proceeded until no new data were being added to the categories and until "an adequate theory had emerged from the analysis" (Dey, 1999, p. 8). At this stage of my analysis, I had developed a total of five major codes, which were: Perceptions and/or Experiences of Menstruation, Motivations to Suppress/Not Suppress, The Suppressed/Unsuppressed Body, The Embodied Period, and Socialization. These codes were sub-divided into 49 sub-codes, and included such categories as "Menstruation as a Nuisance", "Motivations - Convenience", and "Education about Menstruation". From here, the codes and sub-codes were further refined and 'fractured,' a term that refers to labelling, sorting, and organizing the data into specific concepts (Strauss and Corbin, 1990). As a result, my initial five codes were reduced to two overarching themes: 1. Women's feelings about and experiences of menstruation, and 2. Women's opinions and experiences of menstrual suppression, with the relevant sub-codes falling underneath one of these two major themes. These themes will be discussed in detail in the upcoming chapter on findings. 49 CHAPTER FOUR: FINDINGS This chapter conveys the profound and often conflicting thoughts and feelings that the women expressed about their menstrual cycles and menstrual suppression. The findings are organized into two main themes: 1. Women's feelings about and experiences of menstruation, and 2. Women's attitudes towards and experiences of menstrual suppression. The findings are described below and illustrated with verbatim quotations from the research participants. To preserve the women's anonymity, pseudonyms are used in conjunction with the verbatim quotations. When referring to the number of participants who discussed a particular theme, various phrases will be used: "A few" indicates that one or two of the women felt this way, "several" means three or four women shared an idea or feeling, "some" refers to five, six, or seven participants, "most" is used when eight or nine women agree on a certain topic, and "the majority" means that ten or 11 of the 12 women formed a consensus or had similar experiences. 4.1 Women's Feelings About and Experiences of Menstruation The data revealed that the majority of the women in my study disliked menstruation to varying degrees. Almost all of the women felt that menstruation was an undesirable event. At the same time, many women were appreciative of their menstrual cycles because of what their cycles represented to them, in terms of health or their senses of identity. Thus, while menstruation and the accompanying symptoms were often viewed as unpleasant, many women considered their 50 menstrual period to be a key aspect of being female and a natural, normal, inherently positive process, though painful, inconvenient, or embarrassing at times. Below are some of the ways that the women made sense of and described their periods. 4.1.1 Menstruation as a Nuisance One of the most common and recurring themes in this study was the perception of menstruation as a pain, bother, or annoyance. All of the women involved in this study, except one, described menstruation as a nuisance. Menstruation was viewed as an interruption that necessitated large and small changes in their daily lives. For many of the women, the inconvenience of menstruation was their primary complaint. For example, when asked how they felt about their periods, the women tended to respond as follows: I don't feel anything about [my period], it's just part of life...I can't say that I feel any particular emotion towards my period at all; it's just sort of a nuisance. Like I say, I do have heavy cramps, so I can rely on feeling pretty lousy for at least two days when I get it. And that's what I don't like, because it often comes at inconvenient times. (Susanna, age 30, has not suppressed her menstrual cycle) I really, honestly, think that having a period is a huge inconvenience, and I don't know why every girl has to have one...It would just be one other thing to stop me every month from doing what I want. (Meghan, age 19, has suppressed her menstrual cycle) Several women suggested that their menstrual cycles were a nuisance because of the inconvenience of having to buy and carry menstrual products: 51 I've quite enjoyed not having [my menstrual period, because I've been pregnant and breastfeeding]. It's one of those things that you kind of accept that it comes and then when you don't have it, it's quite nice... it's just one less thing to think about. You don't have to worry about carrying pads or tampons with you. You don't have to worry about, you know, when it's going to start, if you're going to be out somewhere. (Lauren, age 30, has not suppressed her menstrual cycle) Additionally, a third of the women talked about the inconvenience of having to change menstrual pads or tampons during the day: I find [my period] manageable and it's not a big deal, but it's a nuisance that I'd rather not deal with. That's how I feel, I feel like it's a nuisance. You know, it's heavy and it's gross and I have to go out and buy tampons and bring them to work with me. And I'm in the middle of a shift and I have to run downstairs and change my tampon... That's why I say I'm kind of in the middle of trying to decide what I want to do again, if I want to not get it or get it. I don't know. (Sophie, age 27, has suppressed her menstrual cycle) Sophie discussed how menstruation can be inconvenient because it is an interruption in terms of sexual activity, a theme that most of the women touched on: When you're seeing somebody, it's also kind of nicer if you don't have this [your period] and have to take this one week off [from sexual activity], you know what I mean? If you're intimate with someone. (Sophie, age 27, has suppressed her menstrual cycle) Talia had a slightly different perspective than the other women, as she argued that there was a positive aspect to the stereotype of menstruation being a hassle. Talia said that this stereotype actually worked in her favour, as an excuse for "bitchy" behaviour: I still feel like it's this hassle that I secretly think isn't that bad. Like, I make it seem like it's such a hassle, like oh, I have my period, blah blah 5 2 blah...I think I blame a lot of stuff on that too, like I'm just bitchy because I have my period...I use it as an excuse, it's like my big excuse. So if I didn't have it, I'd be like, 'Oh, what do I have to excuse my behaviour on?' (Talia, age 25, has suppressed her menstrual cycle) Paula was the only exception to the group, as she indicated that menstruation was not a nuisance for her: I've never felt that [my period] was [a nuisance]...I mean, I've always felt good about [my period]...I haven't felt that it was a nuisance or a worry or a bother. Like, I mean, having your period every month, it's like clockwork...You feel that okay, your body is working alright, there's no problem with it, everything's working perfectly...maybe it's my medical training or whatever, I don't know, I've never thought of it as a bother. (Paula, age 27, has not suppressed her menstrual cycle) Paula's answers were particularly interesting, given that she made changes in her life to accommodate her menstrual cycle. Specifically, she avoided her place of worship during her menses, although she did not consider this to be problematic or inconvenient. 4.1.2 Painful Periods Ten of the 12 women in my study experienced pain during their menstrual cycles. While acknowledging that it is difficult to compare pain thresholds in different individuals, it was apparent from their descriptions of their experiences that three of these women experienced severe pain, two experienced moderate pain, and the rest experienced mild to moderate pain and cramping. Menstrual symptoms typically consisted of cramping in the abdomen and sometimes the thighs, and sometimes included a headache. The methods the women used to control their pain 53 ranged from taking baths and engaging in physical exercise to consuming prescription medications and suppressing their menstrual cycles entirely. Regardless of the severity, painful periods were a normalized aspect of menstruation and were interpreted in various ways by the women who experienced them. Two of the three women who experienced severe pain talked about feeling frustrated or distressed with their bodies for causing them such pain: I've had a few problems with my's always been kind of heavy, and it'll last for...eight to nine days...About two years [ago], the cramps really started to hurt, and one time I almost blacked out., so eventually I got really frustrated... now I'm used to it so I'm not angry so much. I just expect it...I'm more pissed off at my body, but before I was angry. (Jenna, age 18, has not suppressed her menstrual cycle) I'll get a bit frustrated [when I have my period]. Like, frustrated that I have cramps, frustrated that I feel bloated, like that kind of stuff. {Talia, age 25, has suppressed her menstrual cycle) For most women, menstrual pain served as a reminder that they were menstruating and for a few, pain seemed to reinforce feelings of unpleasantness, or uncleanliness: I do get heavy cramps and I really feel it, so I'd always would've rather not had [my period]... it used to be so painful, like I said, that I had to take prescription medication for it, and I couldn't do anything. But now it's just kind of, it's a little bit of cramping, just kind of feeling gross, like clogged up down there or's not so bad now, but I'd still rather not have to feel like that every month. (Sophie, age 27, has suppressed her menstrual cycle) Talia talked about being vocal about her menstrual pain, which can be difficult in a society where menstruation remains a taboo topic: 54 I definitely think it's a very feminine thing. I don't think it's something you should be ashamed of...Some people never talk about it with their boyfriends, never mention it, you never even know they're having it. I'm one of those vocal period girls. I'm like, 'Oh my god, I have my period right now. I'm crampy and blah blah blah'. I like to like, totally vent about it and I just don't think it's something to be ashamed of at all. I'm just so open about it. (Talia, age 25, has suppressed her menstrual cycle) Some of the women considered their menstrual pain to be a sign that their bodies were functioning properly: Most of my friends don't experience intense pain, just like, you know, normal aches and pains, and they kind of take it for granted. They're always frustrated and pissed off with their bodies...I've come to accept it because I've experienced the pain and I understand why it's coming and yeah...I don't like it. But it's a fact of life, [if I didn't menstruate I'd be] worried because it could be a sign that something's physically not 100% in my body. (Jenna, age 18, has not suppressed her menstrual cycle) Viewing their menstrual pain as a commonality between women, some of the participants made comments such as the following: I would definitely say [menstruation] is a big part of being a [menstrual suppression]... I just think it takes away a common bond between takes away an important link of commonality that women share. (Carrie, age 26, has not suppressed her menstrual cycle) An exception to the general perception of menstrual pain, Juliana expressed appreciation for the physical discomfort associated with her monthly cycle: I like it. I like getting [my period]. When I was off the pill, it was fabulous, even though it hurt. I like feeling period cramps because I don't get them, like on the pill I never get them...[But] when I was off the pill I would get pretty serious cramps and I just liked them. I don't know. I liked the burn... 'Owww'. But I have a bit of a penchant for pain...I don't know, I kind of like that burning pain inside my body, I don't know why. Maybe 55 it's the childbirth thing that I really want to have. Maybe it's my little mini labour or something and I'm like, 'Oh, labour pains, I can do it' (laughs) it's a bit weird, but I kind of like feeling bodily sensations. I'm very much a person who's very kinesthetic and in my body, so I really enjoy bodily feelings. I'm very sensitive to my body, so I don't mind it. (Juliana, age 36, has suppressed her menstrual cycle) It was clear from the interviews that menstrual pain is a central aspect of menstruation for many women. As such, pain was considered to be a particularly important motivator for women to suppress their menses, which will be discussed in Section 4.2. 4.1.3 Menstruation as Manageable Another major theme in the interviews was the view that menstruation could, and should, be managed. All of the women talked about the ways that they managed their menstrual periods, from taking baths and using particular menstrual products to taking pain medications and suppressing their cycles. Managing menstruation was not just about minimizing discomfort but also about hiding one's menstruation, maintaining cleanliness and attractiveness, and ensuring optimal health. For example, lessening pain, bathing more frequently, and choosing discreet menstrual products and clothing to wear while menstruating were all important managing tactics that the women used. An important part of menstrual management was managing the physical symptoms of menstruation, usually with pain medications: I just have to be very aware of my cycle. Like, I can tell you two days in advance, alright, I'm going to get my period in the next couple of days. 56 And the day before [I get my period], I start taking drugs. And as long as I take three extra strength Advil every six hours for two days, it's okay, it's totally manageable. It still hurts. I know I have my period. It's kind of a pain. Um, and I think because I manage it that way, it's okay. Every once in a while I fall off, I slip, and I don't get in there quickly enough with the drugs and then it's very painful. And those are the days when I start thinking, 'Wow, maybe I should go back on the pill 'cause this really hurts.' (Susanna, age 30, has not suppressed her menstrual cycle) For many of the women, being able to predict when a menstrual period would begin was an important part of menstrual management and an appealing aspect of hormonal birth control methods: I like [my period] controlled, if that makes sense. I feel like it's usually shorter. I guess I know exactly when it's coming. It just feels like it's more, yeah, manipulated and controlled, which maybe isn't a good thing, but convenience-wise... it's just nice knowing, like, everything is neat and tidy. And it's only going to last 4 days and it's going to start exactly on this day, probably around's just nice knowing, it just makes everything easier and planned out. (Talia, age 25, has suppressed her menstrual cycle) Being able to predict one's menstrual cycle enabled the women to plan ahead for their menstrual bleeding week. Also, being able to predict when menstruation would start was valuable so that the women could prepare for this event and avoid staining their clothes and revealing that they were menstruating. A large part of menstrual management was concealing that one was menstruating from others. Here, the women illustrate some of the ways they hid the fact that they were menstruating: I was very secretive about [my menstruation], for like two years. Like, I wouldn't put tampons or pads in the bathroom. I'd hide them under my bed and take them into the bathroom, for two years, but then I got over it. I don't really know [why]. I think 'cause my sister got her period, so once 57 we both had it, my sister got hers a lot earlier than me, so once we both had it, it was different. I didn't feel as, not that my parents ever said anything to me, it was totally self-induced shame, or something. (Jill, age 25, has not suppressed her menstrual cycle) [I use] tampons during the day because it's easier in that it makes it as if you don't have your period. It just makes you feel like, you don't even notice it because no one can tell by your clothing, like if you're wearing tight jeans or whatever, no one can [tell], it's just more discreet or whatever ...I guess because with pads and stuff, I guess you don't feel like it's as hidden. It's more, like, not that anyone notices, but it's one of those things where I feel like it is [more noticeable], 'cause then I worry more. (Talia, age 25, has suppressed her menstrual cycle) In this way, menstrual suppression was viewed as an attractive option for times when a woman might accidentally reveal the fact that she was menstruating in public. For example, when wearing white clothing or a bathing suit where menstrual blood could leak and be visible. Three women talked specifically about using menstrual suppression for special circumstances where clothing choices meant that menstruation would be more readily identified: [When asked if she would ever suppress] Um, if I ever had any money and time to go down South and...I was going to have my period the whole time I was there, I'd take it. I'd suppress it...I can't think of any other situation where I would do it. I mean, if I was getting married and I didn't want to have my period when I was wearing a white dress, I might do it. So I guess yeah, maybe, if I was going somewhere and had bought a white dress or white pants or something like that. [If I was going] somewhere important, I might do it. (Jill, age 25, has not suppressed her menstrual cycle) Lastly, several women said they felt the need to bathe or shower more during the week of their menstruation: 58 Sometimes it does feel a bit like I'm not clean enough [during my menstruation], sometimes...Like When I'm busy doing something and have to change my pad but I don't really don't have the time. Say if I'm working at med school and I'm in the ER and I really want to change but, you know that weird feeling where you want to change...on that rare occasion I might not feel clean sometimes I took baths two times a day, just to make sure. (Paula, age 27, has not suppressed her menstrual cycle) In these ways, the women managed their menstrual cycles in order to preserve their cleanliness and to ensure that no one would know that they were menstruating. 4.1.4 Menstrual Taboos Menstruation remains a taboo subject in Western society, as evidenced by the women's discussions of their menstruating bodies and the need to hide or minimize any signs of menstruation, something to which all of the women referred: It seems like it's somewhat of a taboo, because I was just thinking, I had my period on the way home on the airplane, and I didn't want to take my whole purse into the change room because my purse is gynormous and the bathrooms are so small. So I'm trying to get it [a tampon] from my purse up my sleeve, because I don't want the people on the plane to know what I'm doing. But why? You know?... at the same time, I don't ever envision myself, even in my 40s, grabbing a tampon like this and strolling to the public bathroom...I don't know if that would be the definition of being ultra-comfortable with it. I don't know if we ever get there, I guess we just wait for menopause (laughs). (Jill, age 25, has not suppressed her menstrual cycle) The women revealed that menstrual taboos affected not only their own understandings of their menstruating bodies, but also their interactions with others and their ability to ask questions about and discuss menstruation: 59 [When asked where she learned about menstruation] I can't remember anyone ever saying, you know, that it was okay, or that it was normal. It was just kind of a thing that happened and you deal with it...I don't ever remember it being talked about that much... I can remember I was really, really embarrassed about it at first. I just pretended it never happened... it was something you didn't talk about. (Lauren, age 30, has not suppressed her menstrual cycle) For Paula, menstrual taboos prevented her from entering her place of worship during her menstruation: Yeah, in my province [in India], how it works is, if you have your period, for three days you are not allowed to go temple, when you have your flow...Our family is very religious. We go to temples every week... so that is one big 'don't do'... This is a rule that was made centuries back I'm sure. And I think the main reason is that...earlier people might have thought it was...a way for your body to get rid of some kind of impurities or whatever in your body. So that gives an idea or a sense that you yourself are kind of impure or not good or whatever during that three or four days. So you don't want something impure in a place of worship, right? So that's all I can say. 'Cause for me, it's like, okay, you have your period, don't go to I think that's the reason. Maybe they don't want all the impurities to go into the temple, they want to keep it clean...It gives you an idea that okay, this is something bad... This is not something you really need in a temple, so that means it's not really good. (Paula, age 27, has not suppressed her menstrual cycle) Paula went on to describe how the taboos surrounding menstruation prevented women from openly admitting that they were menstruating: They would say, 'Okay, I'm not coming to temple.' And you would probably assume they were having their periods. [Interviewer asks, 'What if they just weren't feeling well?'] If that were the case they would say, 'Okay, I'm having a headache, I'm not coming'...because you know, in India, it's not a very open society, you don't speak about all the things you do don't say, 'Okay, I'm having my period so I'm not coming to temple today.' You don't say that, you just say, 'Okay, I'm not coming to temple.' So people will assume, 'Okay, she might be having her period.'...That's the mindset of the people. I mean, it's something 60 that's been going on for centuries. I guess it takes a while to change. (Paula, age 27, has not suppressed her menstrual cycle) While the majority of the women described menstruation as a social taboo, they had different theories as to why this might be. Some women suggested that menstruation was similar to other private body functions that are commonly assumed to be "gross" or "disgusting": Why [do] we consider human bodily functions disgusting? I don't know, but we do, and it grosses me out. Blood makes everyone queasy...We talk about it like it's such a personal, private issue. And it is, but I think if we didn't have to put in that sense, then people would be less disgusted by it. Like, I mean, people do the same thing with every bodily fluid...No one wants to show that they have a runny nose, or if they have diarrhea, they're not going to tell everyone. Things like that...I think that if it just became more common and not something you had to hide, like a conversation you had to hide, then that would sort of change views. (Meghan, age 19, has suppressed her menstrual cycle) Other women contended that menstruation was a taboo subject because it was related to sexuality: I guess [menstruation is taboo] because it has to do with the whole sex thing. And since people don't talk about that, and this has to do with that, I guess [menstruation is also taboo]. And it's also, people sort of think it's unclean. I know we're reading a book on toilet training and the woman was saying, 'You know, people don't talk about that either 'cause it's dirty'. And it's something that happens but let's just not ever say it. ..You never see that on TV, or anything like that...So I guess that in some parts of society it's just kind of gross and no one wants to talk about it. (Lauren, age 30, has not suppressed her menstrual cycle) Maggie was unique in that she gave an example of how menstrual taboos are beneficial. She pointed out that because menstruation is taboo, women are able to use menstruation as an excuse, as they will rarely be questioned or asked to speak 61 about this issue. Maggie told a personal story about dealing with menstruation in the workplace and with male family members. In this story, Maggie was driving with a male co-worker as her father and other male co-workers followed behind in another vehicle: [I said] 'I really want to eat something', and he [co-worker] was like, 'Well your dad's right behind', and I was like, 'No, I'll deal with it, just pull in'. So he starts pulling in and my dad all of a sudden gets on the [walkie-talkie] and he's like, 'Where are you guys going?' And I picked it up and said, 'Dad, do you really want to know?' 'Nope', (laughs)...Just sort of insinuating that it could be [menstruation]. And because it was an all-male environment, he just didn't want to hear it. (Maggie, age 28, has suppressed her menstrual cycle) Menstrual taboos are sustained and perpetuated by social interactions which emphasize being discreet and quiet about menstruation. 4.1.5 Menstruation as Embarrassing References to menstruation as an embarrassing event in the women's lives were frequent. Most of the women talked about menstruation as an embarrassing topic to broach, particularly in their youth. Additionally, a few of the women mentioned that it was unusual to be discussing menstruation with me, a stranger. While menstruation is popularly assumed to be more accepted today than it has been in the past, my experiences interviewing these women revealed that menstruation is still a remarkably concealed event in women's lives. For example, the women expressed embarrassment at being caught with a tampon in one's hand 62 or revealing the outline of a bulky menstrual pad. Menstrual leaks and stained clothing were the most embarrassing events related to menstruation: It was in high school and I was working out with my rowing team...I was on the...hamstring curl, where you're lying on your stomach. And I think one of my friends was like, 'Um, I think got your period or you've got a red spot on the back of your yellow shorts'. And I was just like, 'Oh great'. And I was pretty embarrassed, also because I had a male coach. So it was pretty embarrassing. And I had to have the, you know, the old sweater tied around your waist for the rest of the workout. So that kind of sucked. (Sophie, age 27, has suppressed her menstrual cycle) Menstruation was particularly embarrassing for the women when they first began to menstruate. This meant that they were hesitant to discuss menstruation with other individuals, particularly parents and other adults: Yeah, I don't think I was super psyched about it... it was an embarrassing topic with my mom also...I wasn't going to go yell it on the rooftops. It was more of something that I was kind of embarrassed about. (Carrie, age 26, has not suppressed her menstrual cycle) Many of the women stated that they were too embarrassed to talk to certain individuals about menstruation when they were younger. A few women even tried to hide their menstruation from others: I got my period in January... I didn't say anything to my mom. Like, I stole pads from her... I think she ended up finding a pad in the garbage and was kind of like, 'Wait, I'm not on my period. [Carrie], has something happened?' And I'm like, 'Yeah yeah yeah', and she was like, 'Well here you go'...I avoided it...I don't ever remember my mom sitting me down and having a whole conversation about it, from what I can remember. Yeah, she might have mentioned it to me, and I was just like, 'Okay, great, thanks'. (Carrie, age 26, has not suppressed her menstrual cycle) 63 Some of the women talked about the messages they received from educational talks about menstruation from teachers, parents, older siblings, and friends. These lessons were often some of the first direct messages that the women received about menstruation and were important influences. These initial introductions to menstruation often gave the women the impression that menstruation was an embarrassing and taboo issue, as many women sensed that their educators had difficulty broaching the subject: Nobody really talked about [menstruation] very much. Like, it wasn't really a 'Yeah, I got it!' kind of thing...I guess I didn't think much of it at the time, but it was something that I would never talk about since nobody else had brought it up first. So I wasn't going to go and say anything about it. (Lauren, age 30, has not suppressed her menstrual cycle) I remember just before I got my period [my mom] gave me a book called 'Period'...she didn't really talk to me about it that much. She gave me the book and kind of like, 'This is what's going to happen'. So that's kind of how I figured it was my mom [who taught me about menstruation], but she did it by giving me this book. (Sophie, age 27, has not suppressed her menstrual cycle) In these ways, the women learned through educational interactions that menstruation was an embarrassing and awkward topic of conversation. 4.1.6 Menstrual Blood as "Gross" A common descriptor of menstrual blood used by the women was "gross", as they made comments such as: 64 [Menstruation is] bad, it's gross, those kinds of things are kind of engrained in you, yeah. (Jill, age 25, has not suppressed her menstrual cycle) Even those women who discussed menstruation in more positive ways spoke of the negative societal perceptions of menses: The week I'm on my period? I don't know. I think it's just the idea that a lot of people think it's kind of gross. I mean, if you saw a girl walking down and she had a period stain on her butt, like it just wouldn't be very attractive. Like, that's just not socially acceptable. (Meghan, age 19, has suppressed her menstrual cycle) Most of the women talked about menstrual blood as being perceived as disgusting by other people, particularly men: I wish we could talk about it [menstruation] with guys, but guys just get grossed out way too easily. So I don't think it's a good idea to bring it up with guys. (Jenna, age 18, has not suppressed her menstrual cycle) Many of the women talked about their first menses being "gross": [When asked about her first period] It was like nothing. I had no cramps. I had no, you know, signs/symptoms, whatever...! never had PMS-type things. So it wasn't that. I just thought it was disgusting. I just thought it was gross...I thought it was horrendously gross...[I] thought it was disgusting... Like, just like poo. Like a dirty diaper is gross, you know? I just thought it was gross in that way. (Jill, age 25, has not suppressed her menstrual cycle) Additionally, and perhaps most importantly, about half of the women talked about menstrual blood making them feel "gross" during their menstruation: Sometimes you just kinda feel gross, not gross, but just, I don't know how to word it. Not dirty, but you just feel kinda, yeah, I guess just kinda 65 unclean...I always have the urge to shower more and this and that. (Talia, age 25, has suppressed her menstrual cycle) Feeling "gross" during their menstruation affected how the women felt about their bodies and influenced several of the women's decisions regarding menstrual suppression. This will be discussed in Section 4.2. 4.1.7 Menstruation and Sexuality The women in this study stated that menstruation affected their sexuality in a myriad of ways. To begin, some women reported that menstruation made them feel less attractive and desirable: I wouldn't want anybody even near me [during my period], you know? Even if you're talking about a boyfriend, I wouldn't want a boyfriend to even touch me...Because I feel like I'm bigger than normal and I just don't want anyone to see that, I's just what I'm feeling, how I feel about my body I guess...[Interviewer asks, do you feel attractive or sexy then?] Oh God no. I feel horrible. (Sophie, age 27, has suppressed her menstrual cycle) As discussed previously, many of the women conveyed feelings of being "gross" or "messy" during their menses, and suggested that these feelings contributed to their hesitation to engage in sexual activities during menstruation. Menstruation was a limitation to sexual contact for all of the women, though some women said they were comfortable with having sexual relations during their menstruation (but did not often do so). Most of the women abstained from sexual relations during their menstruation because they did not feel sexy or attractive at that 66 time, and because they did not think that their partners would be interested in having relations with them: If I have my period, I generally don't have sex. I don't feel less sexual, it's more [my partner] too. He doesn't want to have sex if I'm on the period, so, even if I felt interested [I couldn't]... I've always been with guys who've been like, 'Ehh, wait 'til it's done'...I don't really blame him. I don't think I'd want to. It's just messy, right? (Maggie, age 28, has suppressed her menstrual cycle) Indeed, the women's concerns about abstaining from sexual activity seemed to stem from fears about their partners' reactions and their partners' desire to be sexual at that time, rather than the women's own sexual needs. The majority of the women asserted that they did not mind abstaining from sexual activity during their menstruation: [When asked, 'do you ever wish you could have sex during your period?'] No, not really. I mean, if I really wanted to, I would. I think people are out there that think it's wrong, and I don't buy into that at all. I think it's fine. It's just messy and that's okay..., I don't have an extremely high sex drive, or an extremely low sex doesn't bother me not to have sex for a couple days in a row. (Susanna, age 30, has not suppressed her menstrual cycle) Sophie stated that her ex-boyfriend was happy with her decision to use menstrual suppression as he was not comfortable with her menstruation: I just feel gross, you know? I've got my cramps and I'm bloated and I'm like, 'Ugh, like, just don't touch me'. I just like to be alone, you know? Like, don't touch me, don't try to cuddle me, like, ack...when I'm not feeling well I just like to be on my own. But also...when I think of one of my boyfriends and how he complained about his last girlfriend having her period and how shitty it is for the boyfriend, you know what I mean?... from the get-go when I told him that I don't get my period, it was (emphasis) fan-tas-tic for him, great. You know what I mean? So if 67 it's great when I don't get it, what is it when I do? A big pain...My ex-boyfriend said, he's like, 'We can be together whenever we want [because you suppress]. It's great, I don't have to worry about this once a month'. I just don't think [boyfriends/male partners] are comfortable with the whole physical thing. We're bleeding, and I don't think most men are really down with that or interested in it. And they definitely don't want to see it. (Sophie, age 27, has suppressed her menstrual cycle) Partners' messages could reinforce feelings of being "gross" or undesirable. Other women spoke about their partners positive reactions to their menstruation and stated that these positive messages made them feel less self-conscious or embarrassed: He's so matter of fact with [menstruation], which has made me more matter of fact about it. Like it's been since meeting him that all this stuff has started to not bother me so much. I'm not as embarrassed about it. He's so easy-going about any sort of gross subject. He doesn't care, so he's totally fine about it. And if I ever do say, 'Oh you probably don't want to hear this', he's like, 'I don't care, tell me anyway''s totally made me less self-conscious about stuff. Yeah, like I said, before meeting him I never talked about any of that kind of stuff, I hid it all. And he's totally out in the open which has made me less self-conscious. (Lauren, age 30, has not suppressed her menstrual cycle) Talia expressed an important alternative to this partner-centered notion of limited sexual contact as she asserted that her bleeding time was her own personal time: I think when I have my period, it's just time to go in that, not hibernation mode, because you're still living your life. You're still working and working out and doing stuff, but I just feel like in a way it's like my's private time for me and I'll have baths and I'll just relax. And sometimes you just don't want to share your body during that time. (Talia, age 25, has suppressed her menstrual cycle) Additionally, one woman said that her extremely painful menstrual cycles were the primary reason that she refrained from sexual activity during her menstrual period: 68 With the pain that I go through, I really try to avoid sex during most of my period. (Susanna, age 30, has not suppressed her menstrual cycle) Viewing their menstrual cycles as fundamental aspects of their health, some women insisted that their menstruation was an important factor in fostering their sexuality: I find cyclically my sexuality changes. There are certain points in my cycle where I would like to have more sex than at other points in my cycle... [My period] is a barrier to sexual activity when I've got it, usually, but I think there's the other end of the cycle where it's a doorway to sexual activity. (Susanna, age 30, has not suppressed her menstrual cycle) In this way, almost half of the women considered their menstrual cycles to be essential aspects of their sexual selves. Similarly, four of these women experienced a lowered libido while using hormonal contraceptives. As a result, they agreed that non-medicated menstrual cycles were an important part of their sexuality: One of the side effects, I do think [Depo-Provera] lowers your sex just dry up inside. Like, it just felt like a little raisin or something, you know? Your uterus is just barren... I didn't really have a huge sex drive, and that was one of the side effects for Depo-Provera, it does dry you up. (Ashley, age 21, has suppressed her menstrual cycle) Several women interpreted their menses in positive ways, arguing that menstruation is a natural and normal event in women's reproductive lives and, therefore, an important part of sexuality: I think [when you have your period], not that you feel more sexy, but you feel more like your body is functioning normally. So therefore you feel more at peace with your're feeling like you're functioning normally, so therefore, the other times of the month you feel sexy because you know that your body is healthy and normal. (Talia, age 25, has suppressed her menstrual cycle) 69 Indeed, some of the women felt that menstruation was an important part of their sexual identity, while others felt it inhibited them from sexual contact and made them feel less sexy and desirable. 4.1.8 Menstruation as Feminine and a Marker of Womanhood Most of the women in the study discussed menstruation as a key marker of womanhood, and menarche as an important step in becoming a woman, if not "the entrance" to womanhood. The women tended to view menstruation as a sign that they were getting older and able to reproduce: I think it's...a pretty tangible sign that you're growing up and I think it's a part of being a woman. I would say that it's representative of being a woman. (Carrie, age 26, has not suppressed her menstrual cycle) Carrie talked about embracing her role as a woman by embracing her menstrual period. For her, viewing her period as an important and healthy aspect of womanhood outweighed any negative aspects associated with menstruation: I guess I've kind of embraced being a woman and the healthiness behind it [menstruation], you could say... I see [menstruation] as something healthy and empowering... whereas maybe someone else sees the messiness of it. Or they don't plan on having kids anytime soon...It's kind of looked at as something more superficial as opposed to something significant. (Carrie, age 26, has not suppressed her menstrual cycle) Similarly, seven of the 12 women viewed their periods in a positive light when referring to the fact that they were women: 70 I like [my period], I like getting it. I like being a woman and having that part of it. And yes, it can be messy and annoying but, I don't know, I like it, 'cause it just feels like it's a natural thing. (Talia, age 25, has suppressed her menstrual cycle) Jill talked about no longer being able to be a "pretend son" once she started menstruating: Well, I guess it wasn't just the period [that prevented me from being] a pretend son, it's the things that go along with the period...Like, it's just growing up and becoming a woman. And I mean, you get a period, you get boobs, you get hips. Well I did anyways -- boobs and hips and all those other wonderful things. So yeah, it was like I couldn't fool anybody anymore...It's not just the period I guess, it's just growing up-- puberty, becoming an adult and the things that go along with it. And your period was the start of that in a's like a physical marker. (Jill, age 25, has not suppressed her menstrual cycle) Meghan likened her experiences with menstrual suppression to being "like a guy", also reaffirming the notion that menstruation is a feminine concept: Um, I just think [menstruation is] not many of my friends get horrible, horrible cramps and they just complain about it. Like, I know one of my friends, she gets really, really heavy periods where when she goes to bed - it doesn't matter how many pads she wears, her sheets, she wakes up with her sheets bloody. And I just would not be able to handle something like that. That's just too much of an inconvenience in my life. So I prefer being like a guy and just not getting [a period]...guys systems aren't quite as confusing, and girls have a lot more to handle as far as that goes...they always talk about being such high-maintenance, for girls, and I don't like the high maintenance thing. (Meghan, age 19, has suppressed her menstrual cycle) An important exception to this notion of menarche as the entrance to womanhood, Lauren was quick to say that she did not make this connection, as girls are starting to menstruate at increasingly younger ages: 71 I would probably say no [menstruation is not the entrance to womanhood], because if somebody got it when they were 10 or something, I wouldn't consider them a woman. I mean, I think it means they're growing up but I wouldn't say that's womanhood... I taught grade four last year and I wouldn't call any of them women. (Lauren, age 30, has not suppressed her menstrual cycle) Most of the women used the terms "womanly" and "feminine" interchangeably. When asked about connections between menstruation and femininity, most of the women responded that the two were inextricably linked. Thus, menstruation was perceived as a "feminine" process by the majority of the women: Well yeah, [menstruation is] one big part of being feminine I guess, because that's not something men have. ...that's a big part of being a woman I would say, it is, a feminine part of your body. I wouldn't say having your period is the only way of getting in touch with your feminine self, there are different ways...But it is a big part. So in way they are right, deciding not to have your periods ever is one big change and that's going to be an interesting change. (Paula, age 27, has not suppressed her menstrual cycle) One important exception was Sophie, who argued that she did not feel feminine during her period: Well I feel like a period is part of what it is to be female. Like, I think that's a huge thing that differentiates us from males, but at the same time, it is a feminine thing but it doesn't feel very feminine, you know what I mean?...because I relate feminine to goodness and softness and compassion, and when I have my period, I feel 'Argh'. I feel like crap, I've got cramps...So I don't really feel like menstruation is feminine really. It's not anything else, but I just don't feel any more feminine when I have it. I don't feel like any more of a female. (Sophie, age 27, has suppressed her menstrual cycle) Therefore, aside from Sophie's comments, all of the women perceived menstruation as linked to both the notion of womanhood and the concept of femininity. 72 It was interesting that when asked if their periods affected their own sense of femininity or feminine self, only a few of the women talked about this being a connection for them. Instead, what was important to some of the women was feeling that they were included within their peer group of young women who were already menstruating, particularly when they were younger. Some of the women talked about anxiously anticipating their first menses as it meant they would be inducted into this world of womanhood, where peers were awaiting them. For this reason, it was important to menstruate to gain entrance into this group of women: I don't remember my first period really well. Um, I think more than anything it was kind of a sense of relief because...! was pretty much the last one to get it... so I kind of, 'Okay, I'm one of you now. I'm included and I can talk about it'. Because it was a big topic of conversation when we were young... we were always talking about it and I was always left out. So it was a sense of relief when I got it, so I was included with my friends. (Sophie, age 27, has suppressed her menstrual cycle) It was in these ways that women's menstrual cycles defined them as women and were viewed as feminine processes. Menstrual periods acted as an entrance into a world of womanhood, notably, a peer group who had already begun to menstruate. For these reasons, menstruation was an important aspect of women's lives. This section has illustrated the important ways that the women made sense of and experienced their menstrual cycles. These experiences and opinions were important in helping the women evaluate the advantages and disadvantages of menstrual suppression, which will be discussed in the upcoming section. 73 4.2 Women's Attitudes Towards and Experiences of Menstrual Suppression The following subsections outline the women's various motivations and uncertainties regarding menstrual suppression, demonstrating some of the ways that the women made sense of their menstrual cycles, and how they made decisions about their menstrual frequency. It is important to note that while most of the women had a fairly firm stance on whether they intended to suppress their menses in the future, they were all able to see the advantages and disadvantages of menstrual suppression. As such, the women who were not interested in menstrual suppression still commented on what they perceived to be the appealing aspects of menstrual suppression. Similarly, the women who were currently suppressing their menses theorized about why other women might not be interested in menstrual suppression. 4.2.1 Motivations to Suppress Menstruation: Convenience All of the women who had suppressed their menses in the past or were suppressing their menses at the time of the interviews cited convenience as the primary reason for their decision. Similarly, the majority of the women who had not suppressed their menses stated that convenience would be their main motivator. "Convenience" meant freedom from having to worry about managing menstruation and preventing pregnancy, buying menstrual products, abstaining from sexual activity, and from certain lifestyle events, such as traveling or holidays. I would argue that "impression management" (Goffman, 1959) was also a factor, as the 74 women who suppressed their menstruation would not have to be watchful for menstrual leak's or other events that could reveal that they were menstruating and embarrass them or make them feel less attractive. (This will be discussed further in Section 2.2). Most of the women viewed menstrual suppression as an effective means of birth control. Furthermore, a few women thought that menstrual suppression was appealing because it caused temporary sterility and was therefore a reliable method of contraception: f Well, I think [the] number one [reason for suppression] would be for the convenience of sterility. Like, not being able to get pregnant. And being able to have sex whenever you wanted and not worry about having to wear a condom or being pregnant. I think that's a huge deal. (Ashley, age 21, has suppressed her menstrual cycle) Several women talked about menstrual suppression being appropriate for vacations and special occasions: I've suppressed several times over the last six, seven years...for reasons like, I'm going away on a holiday and it just happens to hit that way...and I did a couple of times, just for convenience sake, because something special is happening. Or Valentine's Day, there I was going to have sex. So those are really the main reasons, that or weddings. Just whatever events that I would want to not have my period during. (Juliana, age 36, has suppressed her menstrual cycle) Most women thought menstrual suppression was appealing as it would afford more convenience in everyday life: Ah, I don't like getting my period every month, or actually about every three weeks. It just seems to go by really quickly, especially when you're on the pill because you can tell when you're going to get [your 75 period]. So I go, 'Oh my gosh, I've already gone through another cycle already,' you know?...So there's the's cheaper with tampons. I'm not convinced that tampons are that great for you anyways, because of all the bleach. And having sex, you know, it just interferes... it's a pain in the ass...Checking to make sure... there's a string attached [to a tampon]. It [menstruation] wipes out sex whenever you want...I guess they seem like little things, but when you have it, it seems like a big thing. You have to carry these things [pads, tampons] in your purse, sneak them into the bathroom. It's not like I swim a lot, but say that one time a year I want to go to the water slides, I don't know. (Maggie, age 28, has suppressed her menstrual cycle) Additionally, women who had never suppressed their menstrual cycles predicted that convenience would be a major factor in other women's decisions to suppress their menstruation: I could see people doing it, not because they're lazy but because they just don't want to deal with the whole thing. Just one less hassle. (Lauren, age 30, has not suppressed her menstrual cycle) Both of the women who were suppressing their menstruation at the time of the interviews talked about menstrual suppression being easier than monthly menstruation, which was viewed as a hassle: I choose to [suppress] because it's more convenient. Yeah, that's pretty much it, just one less thing to deal with... There's no cramps, there's no pain, there's no bleeding, there's no nothing. It's just one thing I don't have to worry about. I don't have to worry about taking a pill everyday. I just set the alarm on my phone every 10 weeks and go in and get a shot... I just see it [menstruation] as being really annoying. (Meghan, age 19, has suppressed her menstrual cycle) While menstrual suppression was perceived as convenient by almost all of the women, seven of the women were not willing to suppress their menses for this reason: 76 Well yeah, obviously it [menstrual suppression] appeals, because you wouldn't have the hassle [of menstruation]...but I still wouldn't do it. It does sound good, but I wouldn't do it for my own personal self. (Talia, age 25, has suppressed her menstrual cycle) Well I did enjoy being on the Depc.but it did feel weird...As much as I enjoyed the convenience, I felt even more like an automaton. But it was really convenient and I really enjoyed not having my period. (Juliana, age 36, has suppressed her menstrual cycle) As has been shown, menstrual suppression was perceived as being beneficial as it would make the women's lives more convenient. For the women who suppressed their menses and for those who were interested in menstrual suppression, convenience was the primary rationale. Many of the women were not willing to suppress their menses for the sake of convenience, for reasons that will be discussed below. 4.2.2 Motivations to Suppress Menstruation: Identity When asked to predict who might suppress their menses in the future, many of the women imagined that "menstrual suppressors" would be high-powered career women, too busy with their careers to menstruate. At the same time, these women also talked about menstrual suppression as a form of rejecting one's femininity, because menstruation did not fit with their view of themselves, or as a career strategy: I can see some women using [menstrual suppression] because they do feel like [menstruation] inhibits them somehow. Like, 'I can't make it in a man's world because [menstruation] is so woman'. So I could see a CEO thinking that, 'If I suppress my menstrual cycle, I could be better.' 77 You know what I mean?...And that's in the eating disorder literature a lot too - that women in powerful positions will do that, you know, so they don't stand out. So when they wear a black pant suit, there isn't much that distinguishes them from men. That's not something you can see, but I can see how psychologically...they would see it as an edge....I don't think most women feel that way, but I can see how if you felt like, Tm not getting anywhere in this job because I'm a woman', that you could psychologically convince yourself that this [menstrual suppression] was going to help. (Jill, age 25, has not suppressed her menstrual cycle) In these ways, a common motivation to suppress menstruation seemed to be the ability to manage one's identity and to change how the women felt about and perceived their own bodies. Asserting that menstruation was in fact connected to personal identity, Ashley argued that her own menstrual suppression experiences with Depo-Provera caused her to lose a key aspect of her feminine self, which she strongly regretted. Ashley stopped using Depo-Provera eight months prior to the interviews, but at the time of the last interview she had not yet begun to menstruate. As a result, she yearned for her menstruation as she felt it was an intricate part of her feminine identity: I don't know who I am and identity is such a huge, huge issue for me that I just can't define it. And so I really needed to narrow it down and discover why I feel this way and I discovered it was because I don't menstruate. And it was just like going back to that enormous sacrifice that I made for my boyfriend and sacrificing, you know, what made me female. And female is the bare bones of me. Like, I'm physically female in every single way, like I have breasts and a vagina and a uterus, but I'm not, like I don't feel emotionally it just kind of seems like I had to start with menstruation... because it's what I've based my feminine identity around, is having a period. And that's only because I haven't had it... I believe that because I made such an enormous sacrifice and because it's affected me really emotionally and psychologically, it's what I'm missing. Like I've identified what I'm missing and I don't like to feel that I'm not complete. And so not having 78 had my period and knowing that it happens to everybody else - it happens to every other woman on the planet - and knowing that it's not happening to me and I don't have that to relate to anyone else, I think that's why it's so important to me. (Ashley, age 21, has suppressed her menstrual cycle) Similarly, another woman said she did not feel like herself while she was suppressing her menses with Depo-Provera: I felt that way when I was on Depo - I felt more machine-like and not in touch with my body or with the world, like the Earth and the moon. I just felt out of touch. And I'm a very spiritual person so I felt like an automaton. I just felt 'faker' than ever when I was on Depo. (Juliana, age 36, has suppressed her menstrual cycle) One woman's long-term amenorrhea due to an eating disorder caused her to form an identity as someone who did not menstruate, thus the concept of monthly bleeding was foreign to her: [When asked, how did you feel when you began to menstruate again after recovering from the eating disorder?] It didn't seem normal, because it wasn't what I was used to. I think maybe it seemed like every girl had it, and that's fine, but it just wasn't something for me. Like, I had gone so long without it and while every other girl had it, I didn't. It just wasn't something I had to deal with...Yeah, I guess [I had formed an identity as someone who didn't menstruate], that would make sense. Like, I don't think I'd ever want one [a menstrual cycle]...I can't imagine...if I all of a sudden got a period again, I think that would be so weird. It would just be, whoa, just something I don't want to deal with once a month. Just stupid. I can't even get myself in the mindset of what it'd be like to have one now. (Meghan, age 19, has suppressed her menstrual cycle) Thus, menstruation, or the absence of menstruation, influenced the women's identities, albeit in different ways. For some women, the cessation of menstruation due to menstrual suppression was a positive prospect or experience, while other 79 women considered it to be a significant loss in their lives. What was clear was that menstruation, or its absence, was an important aspect of the women's identities. 4.2.3 Motivations to Suppress Menstruation: Women's Feelings about their Bodies Menstrual suppression appealed to many of the women because it could lessen the amount of time that a woman might feel "gross" or "dirty" as a result of her menstruation. Several women thought that menstrual suppression was appealing as a means of improving their aesthetic appearance: Aesthetically it could be [appealing] because maybe I don't have to feel badly about myself at that time every month...I get the feeling like it's dirty, I'm not clean, so I don't have to feel like that. (Sophie, age 27, has suppressed her menstrual cycle) This is telling because most of the women spoke about feeling less attractive during their menstruation: One of the first ways I can tell if my period's coming is I can look in the mirror and think, 'Ah, I look fat'. And then I think, 'Oh my period's going to be here in a couple of days'. Like, it's just that thought that indicates to me that something's coming up, so it definitely changes my body image. I don't know how much of that is physical water retention and that sort of thing and how much of it is just mental PMS sinking in, but the combination of two makes me [feel] horrendous. Whereas two days ago I could've been fine, and now just feel bloated, you feel big, you feel lethargic. You look in the mirror, you think, 'Oh my god, I'm fat, ugly, I'm huge'. And yeah, two days later, you look exactly the same as you did two days ago but you feel very different about it. (Susanna, age 30, has not suppressed her menstrual cycle) Similarly, a few of the women talked about feeling self-conscious when they were menstruating: 80 [When I get my period] I become more self-conscious, because I can feel my pad...I can feel it, so that's why it makes me self-conscious. Or, you know, maybe it'll leak...I know a couple of other girls who have had leaks and that's embarrassing... Because that's uncleanliness, your clothes aren't clean anymore... you'll probably be make fun of. And people will probably be disgusted. (Jenna, age 18, has not suppressed her menstrual cycle) Thus, several women suggested that menstrual suppression might be used by women who engaged in a variety of beauty practices to enhance their perceived attractiveness and sense of self: I can see [menstrual suppression] being big. But it would definitely be the people who are more willing to take medications for themselves. Not because it's curing them of something...Off the top of my head, it would almost go with the people who get Botox or something, you know? People are more willing to get medical procedures done just because they can...I'd picture that the same people that would do the Botox and everything would be the same people who'd do the suppression...! would think that somebody who's more comfortable with how they look and stuff, would be more comfortable with menstruation and how their bodies work. (Lauren, age 30, has not suppressed her menstrual cycle) Four women said that the reason behind a woman's decision to suppress her menstrual cycle was important. Women who suppressed their menses for health reasons (namely to reduce menstrual pain) were viewed differently than women who suppressed their menses simply to avoid menstruation, as the latter was considered cosmetic as opposed to medically necessary: [Talking about women who suppress their menstrual cycles to reduce menstrual pain and women who suppress because they don't like their menstrual periods] It's like teeth whitening versus a filling, you know? You have to have something done with your teeth, you get a filling because it's rotting the tooth. It's making you unhealthy, it's causing all these other problems. Whereas with the teeth whitening, it's just for show, you know? It's more's bettering your life in some 81 instances, but it's not bettering it to the point where you're healthier or, you know what I mean? (Maggie, age 28, has suppressed her menstrual cycle) Indeed, menstrual suppression was appealing or unappealing because of the potential effects it could have on the women's feelings about their bodies. Also, some women viewed menstrual suppression as a potentially cosmetic body practice if adopted for reasons other than health; therefore, menstrual suppression was unacceptable to them. 4.2.4 Motivations to Suppress Menstruation: Reducing Pain and Discomfort When asked who was most likely to suppress their menstruation, many women predicted that women with painful menstrual cycles would be interested in menstrual suppression: I'm sure there's all sorts of women who have severe menstrual pain and I'm sure that's the motivation for a lot of them [to suppress]. (Susanna, age 30, has not suppressed her menstrual cycle) Similarly, many women agreed that women who had uncomfortable menstrual cycles would be interested in menstrual suppression: The one woman I know who was [suppressing her menstrual cycle], it was because she got really bad cramps. So she did it for her own comfort...If you're going through pain every month then it would be nice not to have to do that every time. (Lauren, age 30, has not suppressed her menstrual cycle) 82 Two of the women, although adamant that they would not suppress their menstrual cycles, admitted that avoiding pain and physical discomfort was an attractive aspect of menstrual suppression for them: When I was in high school, I never had any problems [with my menstrual cycle]...maybe about five years ago, I was just home and I got my period and I was violently ill and I experienced all the...cramps and it just full on hit I was seriously bed-ridden... it was pretty much almost a month when...I was just not feeling well at all...That's when I'm like, maybe the suppression thing would be cool. At least just to lessen the symptoms. (Carrie, age 26, has not suppressed her menstrual cycle) However, while most women predicted that pain would be a motivator to suppress menstruation, only one of the women in the study who suppressed her menses stated that this applied to her situation: [Responding to why she suppresses her period] [My period is] not okay, you know. I don't have a light flow and I do get heavy cramps and I really feel it. So I'd always would've rather not have it...Going on the [21-day birth control] pill did help it, but I still feel it. (Sophie, age 27, has suppressed her menstrual cycle) All of the other women in the study, particularly the women who experienced severe menstrual pain, were not interested in menstrual suppression as a means of reducing pain: It's the trade-off. I'm just not willing to make the trade-off that would be necessary [to suppress]...if some fairy godmother came up to me and said, 'You could not have your period for the rest of your life if I say bingo three times', I might consider. But if it requires continued chemical intervention, I'm not willing to make that trade-off for pain I know how to manage and a nuisance that I know how to manage. (Susanna, age 30, has not suppressed her menstrual cycle) 83 Interestingly, eight of the women thought suppressing for medical reasons or pain was more justifiable and reasonable than suppressing for convenience or aesthetic purposes: I have so much pain myself that I can appreciate why other women would not want to go through that...I really can't appreciate the convenience argument... I'd be willing to hear if they were doing it because there were other health benefits or if they were just sick of having their period. I think there's a bunch of different reasons one could present. [Interviewer asks, 'Are they equally valid reasons?'] No...Pain [is the] primary [reason]. If you're going to claim that it's better for you for some reason, [that's] secondary. Convenience is third for sure. That's the ordinal rank of reasons I'll accept from my friends...I think it's just because I go through pain so I can really understand why someone would claim that as their reason. I don't know what it is about convenience that bothers me. (Susanna, age 30, has not suppressed her menstrual cycle) One woman thought that menstrual suppression was wrong either way, whether for convenience or medical reasons: I don't think there's any justification. I think that suppressing something biological, something that's supposed to happen to you, prohibiting it from happening, that's suppressing something. I don't think there's a difference. I don't think there's a difference in why you want to [suppress]. (Ashley, age 21, has suppressed her menstrual cycle) Another woman argued that menstrual suppression was reasonable whether for convenience or for medical reasons: No, I don't think there's anything wrong with it. It's not causing me any major health issues. There's no real consequence to it, so I don't see any problem with it, or health issues. I don't even think there's need for justification. I mean, if you're having really painful periods or you're having a problem, what's the difference between that and getting a hysterectomy? (Meghan, age 19, has suppressed her menstrual cycle) 84 In these ways, menstrual pain was a normalized aspect of women's lives, and was also thought to be a major motivator to suppress. Menstrual pain was seen as a more legitimate reason to suppress menstruation than convenience or aesthetic-based reasons. 4.2.5 Motivations to Menstruate: Health The most commonly cited reason to avoid menstrual suppression was health. All of the women in the study acknowledged the possibility that taking hormonal contraceptives continuously might be detrimental to one's health. Most of the women who did not suppress their menstruation cited compromised health as their main reason for abstaining from menstrual suppression: I think [about] the long-term health ramifications. I don't think they can say that they know enough about it to guarantee that it's not going to be a detriment to your health in any way...again, it's how our bodies were created, I think it's how it's supposed to be. So I think to start messing with that, I don't think it's a good thing. (Carrie, age 26, has not suppressed her menstrual cycle) For the two women who were suppressing their menstrual cycles at the time of the interviews, the perceived potential health risks associated with menstrual suppression were their primary concern: I feel because of it [suppression] that maybe my body is unhealthy or maybe I am.hurting my body some how. But I guess logically I think, well that can't be true, so I just don't worry about it...I don't think of it now so much as unhealthy but I think that's just because I know what it is. And I just think, it's not proper, it's not normal, but it doesn't bug me to not be normal. Like, it doesn't bug me being abnormal or 85 I just don't care, it's what works for me. (Meghan, age 19, has suppressed her menstrual cycle) Several women worried about menstrual suppression because it would eliminate a perceived test for ensuring that they were healthy: I think [menstruation] is a signal that your body is functioning the way it's supposed to be...For people who don't get their periods, I just feel like you kind of lose your natural gauge for, Tm healthy and things are working'. (Carrie, age 26, has not suppressed her menstrual cycle) Thus, the majority of the women talked about the potential physical health risks involved with menstrual suppression. However, some women also talked about psychological and other types of health risks, appealing to a more holistic and inclusive understanding of health: Well, you'd be a different person, for sure [if you starting suppressing at a young age]... you'd be a different's kind of like initiation. Like, welcome to the club, doesn't it suck? (laughs) You know what I mean? And they would miss out on that. So I'm sure that must affect you somehow - psychologically, health-wise, I don't know. I know my Mom's dead set against girls going right onto those [Depo-Provera] shots, so I'm sure that there are risks...So maybe there's an affect on bone, maybe there's an affect on cancer, that kind of stuff. (Jill, age 25, has not suppressed her menstrual cycle) In these conversations, menstruation itself was constructed as an inherently healthy body process by the majority of the women, and thus, any deviation from this process was viewed as unhealthy: [Talking about why she takes a break from suppressing every three to four months] I think there's always that point where you eventually want to find out if [the birth control pills are] working and if you're pregnant...yeah, that and to make sure I'm still healthy. Because if 86 you're not going to get your period, then there might be something wrong, you know? So it's one of those things where if you get your period then there's more of a chance that you don't have cancer or something, or endometriosis. So it's more for peace of mind. Like okay, I'm not pregnant, and everything is working well. (Maggie, age 28, has suppressed her menstrual cycle) Monthly menstruation was viewed as the healthiest menstrual frequency. Therefore, when debating various forms of menstrual suppression, the methods that mimicked the monthly rhythm most closely were viewed as being healthier than others: There's a huge difference because you still get a period [with Seasonale, bleeding every 3 months]... [it's] more severe with Depo [menstrual suppression]. You're not getting [your period] at all, so I think that's a more severe form of suppression. But with the pill, at least you're still having a period. (Ashley, age 21, has suppressed her menstrual cycle) Thus, menstrual suppression using Seasonale birth control pills where the individual bleeds every three months was viewed as healthier than menstrual suppression using Depo-Provera injections, where an individual can go years without bleeding. The women's ideas about which contraceptives were healthiest were affected by notions of the "natural" menstrual cycle, which will be discussed in the next section. 4.2.6 Motivations to Menstruate: "Natural" is Best While debating the merits of menstrual suppression, many of the women appealed to the idea that what is "natural" is healthiest. The women tended to use the term "natural" to describe non-medicated, regular, monthly menstruation. Consequently, natural periods and natural menstrual cycles were viewed as 87 healthier than those regulated by hormonal methods of birth control. For these women, the further the method of birth control deviated from the natural cycle, the more suspicious it was. Hence, monthly, hormone-free menstruation was most healthy, which made menstrual suppression unhealthy: You're suppressing something natural...your body is built a certain way ,and there's so many interventions with medicine in today's society that I don't know. I just feel like to be natural is to be better. Like, your body was built this way for a reason and it does the things it does for a reason And so to stop that natural process... you're stopping something natural from happening. Who are we to say? It's definitely something that I battled with...I kind of feel a little bit weird about it...I'm doing something unnatural here, and I know that and I accept that, but this isn't the way it was meant to be. And that's kind of why I'm like teeter-tottering. Like suppress? Oh no, let's just go 'au naturel'. That's what I feel like, am I going to be natural or am I not? (Sophie, age 27, has suppressed her menstrual cycle) One woman stated that she was "natural to an extent" as someone who suppressed her menses. Additionally, she described her friends as "natural" people who were not interested in menstrual suppression because they felt that monthly menstruation was a natural process: Maybe they just can't imagine being without it [their regular menstrual cycle]... I think if it was a magic snap of the fingers and they knew there weren't any consequences to it, they would be interested [in menstrual suppression]. But I know a lot of people at work, at my old job, they used to be like, 'What? That's so weird. It's supposed to happen. That's the natural process,' right? So maybe that's why [menstrual suppression] disturbs some people. Because a lot of my friends are really healthy, like, natural kind of people. Like, I have three friends who just refuse to shave their armpits and their legs... I guess I'm natural to an extent, but it doesn't really bother me not to be natural. (Meghan, age 19, has suppressed her menstrual cycle) 88 Maggie was an important exception as she did not feel that menstrual suppression was any more unnatural than regular hormonal birth control: Yeah, I suppose there's two different schools of thought: the old school of thought where women should have their period monthly, blah blah blah. But the birth control pill isn't the most natural thing in the world anyways, so what does it matter? And then there's other ones...that realize it's unnatural and it's not a real period [when you take any hormonal contraceptive], so whatever... It's not natural. You're taking an unnatural substance, so what does it matter if you break for 12 times a year, or every three or four months?... It's just not natural...Okay, so say you smoke two packs a day of cigarettes, what's it going to matter if you only smoke one and a half packs a day? It's not natural, you know? (Maggie, age 28, has suppressed her menstrual cycle) The majority of the women viewed menstrual suppression as the most unnatural form of birth control and for this reason tended to be wary of the practice. Only two women, Maggie and Meghan, were undeterred by this rhetoric of natural/unnatural and were instead content with their schedules of menstruation with menstrual suppression. Maggie bled every three to four months, and Meghan did not menstruate at all. The idea that menstruation is natural may have originated, or been fostered, by messages that the women received about menstruation. Many of the women were told that menstruation was natural by mothers, teachers, and other individuals who educated the women about their menstrual cycles: [When asked, who taught you about menstruation?] My Mom must have...she just said that it would last for a week... [She said] it was part of nature, it was natural, and it was a sign of maturity. (Jenna, age 18, has not suppressed her menstrual cycle) 89 Again, this underscores the importance of educational messages, as they influenced the women's perceptions of their menstrual cycles and ultimately their attitudes towards contraceptives as well. 4.2.7 Motivations to Menstruate: Distrust of Pharmaceuticals Many of the women were wary of prescription medications and pharmaceutical products in general and thus were suspicious of menstrual suppression. In particular, the women who had never suppressed their menstrual cycles and the four women who had had negative experiences with hormonal birth control were distrustful of the medico-pharmaceutical industry that manufactures and markets menstrual suppression drugs. Four of the six women who had never used menstrual suppression indicated that they were apprehensive about consuming hormones on a daily basis, for fear that there would be health repercussions: I thought of [using hormonal birth control] just to get [my menstrual cycle] more regular and not as heavy and stuff, but just the idea of hormones and putting all that crap into your body. Like it's more my attitude to sort of suck it up and deal with it for that couple of days a month, as opposed to putting my body through that... I guess I don't really trust it...sometimes for soccer I'll take anti-inflammatory [pills] but that's about it. Yeah, I don't like the idea of taking a chemical consistently...I'm even the kind of person who's not the biggest fan of Advil... I guess I'm more natural, or at least try to be more natural in my thinking about health and stuff. So I think to take hormones or to take something that your body isn't producing, or make it produce more or whatever, I just don't think it's a good thing...I think to me it boils down to the fact that it's just not anything you have to take... You're supposed to get your period, so that why I'd think that it's unhealthy [to suppress]. (Carrie, age 26, has not suppressed her menstrual cycle) 90 Three women were already apprehensive about taking regular hormonal contraceptives, which made them very concerned about menstrual suppression. Two of these three women had had negative experiences with hormonal contraceptives, which permanently deterred them from either regular contraceptives or menstrual suppression regimes: I went on the birth control pill pretty young and stayed on it pretty much until, oh, five years ago I guess... I guess I came to a point in my life where I realized I didn't want to be putting drugs in my body unless it was absolutely necessary from a medical perspective...! really wasn't comfortable with that, sort of, hormonal manipulation're altering the chemistry of your system. You're altering your natural chemistry...I'm not really comfortable with hormones to regulate my hormonal cycle, and that's [menstrual suppression is] really messing it up. So it's a double whammy, you know? I'm uncomfortable enough with plan A, plan B is just, it's unthinkable to me... I mean, it's a chemical you're putting into your body that's inherently changing the way your body functions. And that's what all pharmaceutical products do, but...the way I see the pill is it's unnecessary. There are other ways to do what the pill does. I mean, they may be less convenient or what have you, but you can achieve the same end goal. (Susanna, age 30, has not suppressed her menstrual cycle) For three of the women, their past experiences with menstrual suppression resulted in their current rejection of the practice. These three women had tried menstrual suppression before, for various lengths of time, and at the time of the interviews were all regretful of their decisions to suppress their menstrual cycles. They insisted that they would never try menstrual suppression again: Maybe if I had never had a bad experience with [menstrual suppression] maybe I would do [suppression] again. You know, I can't really for sure say. But because of my experiences with it, I wouldn't mess around with it anymore...[menstrual suppression was] just upsetting my cycle. And like I said, I'd get my period longer, or heavier, or more often...I felt like my mood would be affected...! just felt more irritable, more sensitive, 91 breasts were more sensitive and more achy and stuff. Just those kinds of symptoms, just feeling not right, not feeling balanced. (Talia, age 25, has suppressed her menstrual cycle) Several women stressed the importance of researching the potential long-term health effects of menstrual suppression: What do I think about it?...Well first of all, all drugs have risks...I guess the main thing that comes to mind is health and just lack of longitudinal studies...I'm not a big jumper on...bandwagons, you know?...for me, there's just not enough studies to say it's okay. Whereas with what I'm taking (a regular birth control pill), like, people have been taking these for probably about 50 years I just feel it's safer. (Jill, age 25, has not suppressed her menstrual cycle) Thus, some of the women expressed concern that menstrual suppression was being presented as a fast and easy solution and thought that it was not something to be taken lightly. Additionally, the fact that menstrual suppression involved taking prescription pills on a daily basis was a deterrent for many of the women. However, while the many of the women expressed concern over the fact that hormonal contraceptives were serious pharmaceutical products, two women had reconciled any doubts and were confident that menstrual suppression was healthy for them: Why do I think it's healthy?...Well I know there's hormones there and that's what's stopping me from menstruating regularly...I think if I was amenorrheaic for other reasons and not because I'm adding hormones...maybe that would be unhealthy... [but] it doesn't feel unhealthy. Like when I wasn't eating it felt unhealthy. But I think because I know what I'm doing and how I take care of my body now, it's okay. I don't think I directly relate getting the shot and not having a period as being unhealthy right now. (Meghan, age 19, has suppressed her menstrual cycle) 92 4.2.8 Motivations to Menstruate and Suppress: Physicians' Opinions Physicians played an important role in socializing the women about menstruation and menstrual suppression as they were widely regarded as experts in these fields. Their opinions and advice influenced the women's experiences with contraceptives, as they frequently recommended types of contraceptives and brands: [When asked why she took a particular birth control brand] That's just what my doctor put me on. I didn't have any skin problems...! had no reason to take a particular kind, so that's just what he gave me...he asked me... 'Do you have acne?' 'No'. 'Do you have cramps, bloating, irregular cycles?' 'No.' And he's like, 'Here, take these.' (Jill, age 25, has not suppressed her menstrual cycle) Additionally, physicians encouraged or discouraged the women to suppress their menstrual cycles, which served to attract or deter the women from this practice. Some of the women who used menstrual suppression were warned against the practice by their doctors: I do tell my doctor now [that I suppress]... I'll come out and say, 'Yeah I just take [my birth control pills] continuously'. And I get mixed reactions. I have been going to female doctors for the past, I would say six years, and some of them were like, 'Okay, that's fine, it's perfectly healthy to [suppress]. And I've had other ones that will say, 'It's unnatural, you should be getting your period every month'...from the ones that say it's unnatural, I know I'm not going to see them again, I'm just there to get my refill, so I don't really care... I won't tell it to everybody, not to every doctor. It depends on the connection with them, how comfortable I feel, and how liberal they seem. Because some of them actually think it's appalling and I don't want the lectures so I just lie. (Maggie, age 28, has suppressed her menstrual cycle) Other women were reassured that menstrual suppression was not detrimental: 93 I have a new doctor from the one I first met and she said there's probably going to be no repercussions for having been anorexic... that I'll probably be able to have kids just fine and it's not a big deal... she said I could go on [Depo-Provera] early and I probably wouldn't have any repercussions. (Meghan, age 19, has suppressed her menstrual cycle) One woman's family physician recommended that she take Depo-Provera in order to prevent pregnancy, which caused her to cease menstruating: I started having sex when I was pretty young, like, I was 15 I think...So I was on birth control in grade nine, taking the pill...I was just, really inconsistent, and it scared my doctor just recommended the Depo shot. And he tells you all the side effects, like you're going to stop menstruation, you're gonna have awful mood swings, you might gain weight, and I didn't have anything like that, except for, I lost my period. I didn't have my period. (Ashley, age 21, has suppressed her menstrual cycle) Lastly, many women said that they would consider suppressing their menstrual cycles if a physician or another trusted individual recommended it to them: Maybe I'd switch to Seasonale, I don't know...I have no qualms about it. I have no risk factors for heart disease or blood clots or anything. I don't have high blood pressure. I don't have high cholesterol, so I don't feel that I'm personally someone who should avoid it...if I did [suppress] and I thought it was awesome, or if my doctor recommended it to me, or my Mom, I would probably switch [to Seasonale]. It is appealing to get fewer periods. (Jill, age 25, has not suppressed her menstrual cycle) In these ways, women's experiences with contraceptives and menstrual suppression were influenced by their physicians, who often prescribed, suggested, or warned against these measures and in doing so, cautioned, encouraged, and validated the women's decisions. 94 While discussing their experiences with menstrual suppression, two women talked about reproductive control and the power that physicians and the collective medical world exert over patients. Interestingly, the two women approached the issue from very different angles. One woman was agitated when physicians refused to provide her with enough birth control pills to suppress her menstrual cycle for months at a time, and talked about being forced to submit to a physical health exam: It doesn't seem like [the physicians] are caring about me. It's just sort of like, it was like they were trying to control my body in a sense...They won't give you the pill unless they give you an exam, so it's almost like they'd rather have you pregnant than give you a pill...Every time I go they say, 'When was your last exam' and I'll say, 'You know, a year and a half ago', and they say, 'Oh, well I'm going to give you one month [of pills] and you have to go see a doctor', that's it...Like if I want the birth control pill, just give me the birth control pill...Who are you to tell me I should have this physical every year to get it? I understand the point of it, but it's almost like they're forcing you to do it. (Maggie, age 28, has suppressed her menstrual cycle) Another woman talked about the power behind the menstrual suppression movement, such that she was encouraged to suppress her menstrual cycle by her family physician: My doctor just recommended the Depo shot... And at the time, I was like, 'Oh, no big deal'. You know, like, why would I even want my period anyways? ... But you have to sift through what you want to believe and what you don't want to believe. You can either go with tradition and history and think that [menstruation] is good and it should happen to you. Or you can...go with technology and whatever the doctor tells me is what I'm going to believe. So, there's a real vantage point...It's power. Whoever is in control will tell you what to believe. (Ashley, age 21, has suppressed her menstrual cycle) 9 5 Both women were aware of the medical worlds' power and influence, however they experienced different struggles in receiving the medical care they desired. Most importantly, they both had to work to have their reproductive choices validated by the physicians who cared for them. 4.2.9 Motivations to Suppress Menstruation: Western Culture Several women spoke about the effects of western culture on their attitudes towards their menstrual cycles, or their feelings about menstrual suppression. Three women were concerned with Western pharmaceutical culture: We live in a society that's obsessed with consumerism and convenience and I try not to buy into that...there's also this alarming dependence on pharmaceuticals in Western culture right now and I find it very alarming...I think with menstrual suppression, pain aside, it's just another way to make life more convenient and to make life easier. And you know, to make life less painful and all those things that we seem to strive to do. And another pharmaceutical to rely on, which is pushing money into Big Pharma... even within the last 10 years you see some very alarming changes in the way pharmaceuticals are used and distributed... now versus 15 years ago where you'd go into the drugstore and find Aspirin and you might find some sort of anti-allergy medicine, now we have these aisles and aisles that are dedicated to tailor-made products. And that's just a small scale indication of what's going on behind the scene with prescription pharmaceuticals I think... And I really see this topic of menstrual suppression as indicative of this one path we seem to be going down. (Susanna, age 30, has not suppressed her menstrual cycle) Additionally, several women attributed society's interest in menstrual suppression to the fact that women today are busier and trying to manage many responsibilities: I would imagine that women are doing more and working and they're trying to do so many things and it's one less thing on their mind. That's 96 why [menstrual suppression is appealing]. (Lauren, age 30, has not suppressed her menstrual cycle) Perhaps most interestingly, two of the women had spent long periods of time away from North America, and both had profound statements about what they viewed as "cultural" differences in attitudes towards menstruation and menstrual suppression: As a comparison in terms of life in Denmark versus life in Canada...I mean, when I'm in Canada, it's 'go, go, go, go', you know? Like eating is almost a pain in the ass 'cause I don't have time... And then you come over to a place like here [in Denmark]'s super laid-back and...just slow-mo compared to I almost want to say that menstrual suppression is more symptomatic of this high-stress, 'we don't have time for anything' mentality. 'We don't have time for something as natural as a period' type mentality that North America has...I think it's completely related to lifestyle...the person that 'doesn't have enough time'...that doesn't have time to spend a day or two feeling like crap in bed, [that's who will suppress]... I think that it just goes with a greater theme in our society of, 'We don't have time, we don't want any discomfort'. (Carrie, age 26, has not suppressed her menstrual cycle) I know from my three years here in North America, I think sometimes there is a sense that if you don't have your periods, you can do more than when you have your periods...If you don't have your periods, you can do lots more stuff...more activities, whatever it might be. So it gives an idea that this is something dispensable, you can live without [menstruation]...So probably if you have been learning that since childhood, saying that periods are something you can live without, you don't necessarily need them, you'd be more eager or willing to try out things to stop having your periods. If you don't need it, then why the hell do you have to go through it, right?...So probably that's... why people opt more for birth control over here [than in India]... I mean, we don't really think of [menstruation] as something you shouldn't be having [in India]...There it's more like, okay, now you have [your period], deal with it, don't go to the temple or whatever. But it doesn't give you the idea that you shouldn't have [your period]. Like you're not supposed to have it, you can live without it. You don't get that idea over there...It's basically the change in lifestyles, countries. I mean like, India and Canada are like two poles apart. (Paula, age 27, has not suppressed her menstrual cycle) 9 7 Lastly, Ashley talked about the influence of her favourite teenage magazines on her views of her menstrual cycle and on her decision to suppress her menstrual cycle: [YM] magazines were so bad for giving menstruation a really terrible rep. Yeah, they represented menstruation in a really bad way, because of the '10 Most Embarrassing Moments', eight of them would be, 'Oh, my tampon fell out while I was swimming', or, 'Oh, my pad leaked through my white skirt I was wearing at school,' you know? 'Oh, my Dad had to go buy me a box of tampons because I didn't have any, my Mom wasn't home one day', something like epitomized everything that you were afraid might happen when you were on your period...So that's where you got this idea that, 'Oh shit, you know, if my Dad has to buy me tampons, that's really embarrassing, you know?' So yeah, those magazines had such an impact on how you thought about your period... And everybody reads them... at your most impressionable age... We're culturally conditioned to think that way, yeah...The media definitely had an impact...on why I chose to do [Depo]. Because, you know, the whole reason for me to do Depo was...I was thinking, 'I don't even want my period, yeah, I might as well just get rid of it'...I totally think that it's linked, it's just your culture. It's really sad. (Ashley, age 21, has suppressed her menstrual cycle) In these ways, some of the women talked about the effect of Western culture on women's feelings about their menstrual cycles and their attitudes towards menstrual suppression. In this chapter, I have examined how the women in my study felt about and experienced their menstrual cycles and menstrual suppression. I have exposed the links between how the women felt about menstrual suppression and their feelings about their bodies, their sexuality, and their femininity, among other themes. In the next section, I will discuss the importance of these findings, and how they relate and contribute to the associated literature. 98 C H A P T E R FIVE: DISCUSSION In this thesis, I have examined women's attitudes towards and experiences of menstruation and menstrual suppression. Using semi-structured interviews, this study has investigated the embodied experiences of women between the ages of 18 and 36 and the meanings that they attribute to their menstruation and to menstrual suppression. My findings have revealed how individual women make sense of their own menstrual cycles and how they consider menstrual suppression, as a body practice and as a contraceptive choice. Furthermore, this study has revealed the connections between women's experiences of menstruation and menstrual suppression, their feelings about their bodies, their sexuality, and their senses of femininity. The findings from this study build upon existing research in the areas of menstruation, menstrual suppression, body image, and constructions of femininity and sexuality and their impact on individuals' health. In this chapter, these findings are discussed relative to the existing literature, and the significance of particular themes are elucidated. 5.1 The Effects of Menstrual Taboos Findings from this study suggest that menstruation is still not openly discussed in Western society, and that references to menstruation must be discreet and/or hidden. All of the women discussed the taboo nature of menstruation in Western society. Menstrual taboos relate to historical ideas about women's bodies, where menstruation was viewed as a polluting and dirty body process. My findings 99 suggest that these types of negative interpretations of menstruation continue to exist and serve to influence women's feelings about menstruation, menstrual suppression, and their own bodies. Similar to Roberts' (2004) findings about women's attitudes towards their bodies and menstruation, many of the women in this study had internalized menstrual taboos which promote views of menstruation as dirty, shameful, and disgusting, and which ultimately make menstruation a forbidden topic in society. Consequently, women who suppress their menstrual cycles can be seen as physically enacting menstrual taboos by eliminating their menstrual cycle entirely from their bodies. This may explain why some of the women asserted that menstrual suppression could alter a woman's identity: women who do not menstruate take on an alternative identity and can, therefore, distance themselves from any negative properties related to menstruation. Elson (2002) contends that "medical events have the power to generate biographical disruptions or turnings points; the individual's concept of who she or he is may never be the same as before" (p. 38). In this way, an appeal of menstrual suppression may be that it positively influences one's sense of identity, by distancing the self and the body from negative perceptions of menstruation and menstrual taboos. For example, even though she is not allowed to worship in her temple during her menstruation, Paula does not take issue with this custom, nor does she consider it to be an inconvenience. Paula explained that this custom was the result of long-standing "old traditions", which she predicted would change in the future. As a result, Paula seemed to be able to distance herself from the notion of menstrual impurities, such that the custom did not bother her. Thus, just as menstruation acted as an excuse 100 for the other women, Paula may have enjoyed being exempt from attending temple on certain occasions as a result of her menstrual cycle. To be sure, excuses related to menstruation appeared to be the one benefit of menstrual taboos. Several women spoke about incidences where menstruation acted as an excellent excuse that rarely provoked challenge from others. Menstruation was taboo enough that even the slightest mention or hint of "women's problems" allowed the women to get out of certain situations or responsibilities. Thus, the women were able to carve out small amounts of resistance and power within a culture that can be demanding of women and their time. Menstruation, or the excuse of menstruation, afforded the women some time to themselves, even if only for a few minutes. Additionally, it is clear that menstrual taboos influenced the women's attitudes towards menstrual suppression, as the strongest reasons to use menstrual suppression were to be less inconvenienced by menstruation, to adopt a non-menstruating identity, and to avoid negative feelings about one's body. Using the fact that some of the women were hesitant to speak about menstruation as evidence, I would argue that menstrual taboos are dangerous as they prevent girls and women from asking questions about menstruation, and from openly conversing about this important aspect of their bodies. 5.2 Predictions about Pain The women in this study echoed menstrual suppression researchers' predictions and theories (Kaunitz, 2000; Woods, 1986) as they supposed that women with painful menstrual cycles would be most interested in menstrual 101 suppression. However, as was shown, this was not the case. Of the six women in this study who had previously suppressed their menstrual cycles, only one woman counted pain reduction as a factor in her decision to suppress her menstrual cycle. All of the other women who had suppressed their menses did so for reasons of convenience or as a means of contraception. Additionally, several women described menstrual suppression as aesthetically appealing and as a means of avoiding feeling "gross" or "unclean" once a month. Considering this contrast to the literature, it is noteworthy that eight of the 12 women thought that menstrual suppression for pain management was a more legitimate and valid reason to use menstrual suppression than for convenience' sake or identity purposes. Perhaps this is why advocates of menstrual suppression (Coutinho and Segal, 1999; Kaunitz, 2000) emphasize pain reduction as a probable use for their product - suppressing menstruation is justifiable if for health rather than aesthetic reasons. 5.3 Our Western Culture of Convenience Findings from this study suggest that women are indeed socialized to view their menstrual cycles in negative ways. The fact that all of the women who were born and raised in Canadian Western culture considered their menstrual cycles to be inconvenient, while Indian-raised Paula disagreed, is telling. The sentiment that menstruation was inconvenient seemed paramount among the women, as almost all of the other negative traits related to menstruation (e.g. menstruation as painful, needing to be managed, an interruption in one's sex life, and taboo and gross and therefore needing to hidden) could also be classified as inconvenient. Indeed, it is 102 important to note that many of these other negative traits contributed to the view of menstruation as a nuisance and bother. For example, one of the reasons that menstruation was considered to be a nuisance by the women was because it required time and energy to be managed; it was inconvenient to be in pain for several days each month, or to be cautious about concealing one's menstruation and avoiding embarrassment for an entire week. I would argue that the act of hiding tampons and being watchful for menstrual leaks is draining for women and weighs on them, though often subconsciously. This effort to keep up appearances and hide one's menstruation significantly contributes to the view of menstruation as a nuisance. It is important to recognize as some of the women did, the effects of Western culture on the women's opinions and feelings. Some of the women pointed out that Western culture portrays menstruation in decidedly negative ways, as a disgusting, embarrassing, awkward event in women's lives (Houppert, 1999; Kissling, 2002). Thus, it is not surprising that many of the women in this study conveyed similar attitudes towards their own menstrual cycles. It is fascinating that both of the women who had spent long periods of time outside of North America considered menstrual suppression to be a Western phenomenon, synonymous with the West's "culture of convenience" and fast-paced lifestyle. These women's sentiments reinforce research by feminist and cultural theorists who blame Western culture for perpetuating negative, harmful messages about menstruation (Kissling, 2003; Lander, 1988; O'Grady, 2001; Prior, 2000). This also contextualizes clinical research on menstrual suppression and once again reinforces the fact that medicine 103 and illnesses are socially constructed entities and shaped by social and cultural values (Vertinsky, 1994). 5.4 Menstruation and Sexuality My findings reveal that the majority of the women felt that menstruation was a barrier to sexual activity. The anticipated or actual reactions of partners to the women's menstruating bodies were frequently cited as a reason for abstaining from sexual activity. The majority of the women spoke more about their partners' attitudes than they did about their own preferences for sex during menstruation, thereby supporting and extending Barnhart et al.'s (1995) and Lee's (1994) research in this area. Considering that the majority of the women had male partners, this finding points to the need for more comprehensive sexual health education for both sexes, as clearly men's opinions of, and reactions to, women's menstruation affect how individual women feel about their own menstrual cycles and their menstruating bodies. A few women discussed how menstrual suppression appealed to their male partners, which confirms and builds upon Barnhart et al.'s (1995) finding that methods of contraception can affect the intimacy of a couple. In the case of these women, choosing menstrual suppression meant that they were able to have more sexual contact with their partner, and also ensured that their partner would be attracted to them all month long. It is important to recognize that in a society where women are valued in terms of their sexual desirability, the possibility that a sexual partner would be repelled by a woman's menstruation could seriously influence her sexual decisions during menstruation. 104 The last important finding about women's sexuality was that almost half of the women insisted that menstruation was an important aspect of healthy sexuality. For these women, healthy, regular menstruation, with its accompanying hormonal fluctuations, meant that their bodies were working properly and their libidos were functioning normally. Many of these women experienced a lower libido, or other negative side effects, while using hormonal contraceptives. Therefore, they accepted that their sexuality was dependent on their un-medicated menstrual cycles. All of these findings are important as they emphasize that menstruation does affect women's sexuality in many ways, and, therefore, encourages women to think about the potential effects of menstrual suppression (e.g. lowered libido, more sexual activity during menstruation, etc.) before adopting the practice. 5.5 Menstruation and Femininity Another important finding is that most of the women spoke positively about their menstrual cycles when referring to the fact that they considered their menstruation to be a feminine and womanly process. This was one of the few times in the interviews that many of the women spoke positively about their menstrual cycles. A few women seemed to enjoy the fact that it was a common bond between women, while others were simply content to understand menstruation as an important aspect of being female. For some women, this positive aspect of menstruation seemed to reconcile the negative sides to menstruation. However, for a few women, the connection between menstruation and womanhood was nothing more than another detail and, therefore, did not seem to have any negative or 105 positive connotations. Ultimately, the findings reinforce Jean Elson's (2002) theory that feminine gender identity is connected to menstruation, and to Emily Martin's (2001) ideas about menstruation as a "mark of womanhood" (p. 103). The majority of the women spoke about menstruation being connected to womanhood, and their first menses as signals that they were becoming women and growing up. For this reason, it was important to menstruate to be included in the peer group of girls who had already begun to menstruate. The women's ideas about menstruation were intimately connected to their ideas about being female and women. This is noteworthy when one considers the possibility that menstrual suppression may become more popular and common in the future: if many women begin to suppress their menstrual cycles, what effects might this have on women's ideas about menstruation as a component of feminine gender identity? Judging from the results of this study, the potential for women to eliminate their menstrual cycles long-term could considerably change women's feelings about menstruation being connected to womanhood. Lastly, Ashley's experiences with Depo-Provera affected her feminine identity profoundly, and have important similarities to Jean Elson's (2002) study of women undergoing hysterectomies. Like the women in Elson's study, Ashley mourned the loss of her femininity, or feminine self, as she prematurely lost the ability to menstruate. This example serves as a cautionary tale for other women, as at the time this thesis is being submitted for defense, Ashley has yet to menstruate following her experience of menstrual suppression, almost two years after she discontinued suppressing her menstrual cycle. 106 5.6 Menstruation and Women's Body Image The findings indicate a strong link between menstruation and general feelings about the body. For example, many women used the term "gross" to describe their menstrual periods. The term "gross" is significant as it is a slang term, defined as "extremely objectionable, offensive, or disgusting" (Random House Dictionary, 2006). This alone illustrates how pervasive and acerbic menstrual taboos are in Western culture. However, this description of menstruation is more remarkable when it becomes apparent that "gross" also describes how many of the women feel about their bodies while menstruating. Indeed, many of the women in this study conveyed feelings of being unattractive during their menstruation. Some women thought that menstruation affected their body image, or the way that they felt about their physical appearance, affirming the work of Benjet and Hernandez-Guzman (2001), Fingerson (2005), Roberts (2004), and Roberts and Waters (2004). Building on this connection between menstruation and body image, my findings reveal that some of the women identified menstrual suppression as a means of avoiding feeling unattractive while menstruating. It is not surprising that menstrual suppression is appealing in Western culture, where women are judged by their physical attractiveness. It is difficult to feel attractive during menstruation if you believe your menstrual blood and the process of menstruation are "gross". This research strengthens Jones, Vigfusdottir, and Lee's (2004) findings that societal factors impact individuals' body images, as the women's internalizations of Western beauty and body standards led them to view their menstruating bodies negatively. Furthermore, this research discusses women's body images at a 107 specific moment during their menstrual cycle (the time they spend actually menstruating). This adds to the literature on the flexible and fluctuating nature of body image, as women's body images appear to be affected by their menstruation for a few days each month. Similar to Sarwer's (2004) finding that women who have cosmetic surgeries feel less embarrassed and perform fewer "camouflaging behaviours" (p. 435), menstrual suppression promises to eliminate an embarrassing aspect of women's bodies that also requires camouflaging. While the women in my study asserted that menstrual suppression was appealing as a means of feeling better about their bodies, only one woman acknowledged this as a reason behind her decision to suppress her menstruation. Nonetheless, this study shows that women's body images are affected by their menstruation, and that menstrual suppression can be viewed as a method of improving how women feel about their bodies. Thus, while my research does not address the multiple facets of body image, these findings do add a layer to the existing research on body image by revealing that women's feelings about their bodies are indeed influenced by their attitudes towards their menstruation. Furthermore, this research points to the impact of cultural scripts about menstruation and their influence on women's feelings about their menstruation, and their menstruating bodies. 5.7 Menstrual Suppression as a Form of Body Work At the same time, menstrual suppression may be viewed as a form of body work similar to practices such as make-up, hair dye, dieting, exercise, and cosmetic 108 surgeries such as liposuction. Several women identified menstrual suppression as a method of feeling better about their bodies, and made statements about menstrual suppression's aesthetic appeal. In addition, some women compared the relative necessity or excessiveness of menstrual suppression, taking into account the motivations behind a woman's decision to suppress her menstrual cycle. Thus, the women's comments were similar to feminist arguments about other types of body enhancements and cosmetic procedures, and when and where they are considered valid and worthwhile. Lastly, several women made bold predictions about the types of women who would suppress their menstruation. The women predicted that women who were concerned with their physical appearance and willing to go to more extreme lengths would be interested in menstrual suppression. As follows, I argue that menstrual suppression constitutes a form of body work, a means of improving one's physical appearance in accordance with cultural beauty scripts. One cannot ignore the "culture of concealment" (Houppert, 1999, p. 33) in which menstrual suppression is gaining ground, where menstruation and all things associated with the menstruating female body are considered taboo. Menstrual suppression seems to mirror other body/beauty enhancements and procedures as it involves women attempting to style their bodies in ways that render them more acceptable and appealing, particularly to men. A menstrually suppressed body can be seen as the ultimate rejection of menstruation and, therefore, is an extreme example of how cultural discourses can shape individual women's experiences of their bodies (Roberts and Waters, 2004). It is also important to note that menstrual suppression does not only improve women's perceived physical attractiveness, but 109 also women's sexual availability in instances where sexual activity during menstruation is not appealing. Furthermore, similar to other beauty routines that appear to be matters of individual choice, women's decisions about menstrual suppression are made within cultural contexts that privilege female beauty, attractiveness, and sexual desirability. Therefore, the notion of choice is complicated. Foucauldian theories of self-discipline and self-policing apply to menstrual suppression, as women seem to make independent decisions about their menstrual frequency, choosing for themselves if, when, and how to suppress their menstruation. However, as Bartky (1988) aptly describes, "disciplinary power" (p. 57) surrounds us and subconsciously and consciously encourages women to submit to culturally-defined feminine requirements. As such, individual women may seemingly decide for themselves to suppress their menstrual cycles. However, these decisions must be contextualized and viewed in light of the women's cultural surroundings and the beauty/body work scripts that proliferate in Western society and judge women according to their appearances. In societies where women are valued in limited ways, it is important not to overlook the significance of obtaining power through one's appearance and desirability. Lastly, the current conflation of health and beauty (White, Young, and Gillett, 1995) is relevant to the menstrual suppression debates, as advocates of menstrual suppression regularly tout the practice as a means of improving women's health, while there are clearly aesthetic motivations implicated in the practice as well. Coutinho and Segal (1999) and their followers assert that menstrual suppression will 110 benefit women with painful menstrual cycles and those with menstrual disturbances. However, as the women in this study have shown, it is the menstrual taboos and related accounts of feeling "gross", "embarrassed", or "inconvenienced" that seem to truly motivate women to suppress their menstrual cycles. Advocates of menstrual suppression use menstrual taboos to further their cause, as women's insecurities about menstruation spark their interest in menstrual suppression. Menstrual suppression is appealing in Western culture because women feel unattractive and undesirable during menstruation, and are encouraged by Western culture to self-discipline themselves in an effort to continually improve their physical appearance. Menstrual suppression works in this fashion, altering women's bodies in ways that make them more attractive, particularly to men. For these reasons, menstrual suppression should be considered a form of body work. 5.8 Natural Menstruation and Medicalization In this research, the concept of natural and unnatural menstrual cycles was important, as many of the women appealed to this dichotomy when interpreting their own experiences of menstruation. Additionally, the notion of natural/unnatural weighed heavily on the women's decisions to suppress their menstruation. However, it is interesting to note that the women used these terms in different ways, and placed varying amounts of emphasis on them. As evidenced by many of Maggie and Meghan's responses, some women appear to negotiate the perceived risks and benefits of menstrual suppression and make their decisions based on their own needs and beliefs. Still, all of the women expressed the idea that natural menstrual 111 cycles, meaning regular, un-medicated menstrual cycles, are healthiest, particularly when discussing various options for menstrual suppression. Seasonale, where menstrual bleeding occurs every three months, was viewed as healthier than continuous Depo-Provera injections, where menstruation was absent for months and potentially years at a time. Menstrual regimes that most closely resembled natural monthly menstruation were considered the healthiest by all but two of the women, those women who were suppressing their menstrual cycles at the time of the interviews. The concept of natural becomes more complex as technological improvements in health and medicine take us farther away from our understandings of appropriate medical treatment. This phenomenon is certainly enhanced by the uneasiness many women had with pharmaceutical products in general. Half of the women in this study expressed doubt about the effect of pharmaceutical pills, and four women had had negative experiences with hormonal contraceptives. These experiences reinforced feelings of distrust, and deterred the women from considering menstrual suppression. Therefore, while the women did not use the term medicalization, which has been so popular among feminist researchers (O'Grady, 2001; Rako, 2003), they did express discomfort with pharmaceutical culture today, where the daily consumption of medication is not only routine but recommended (Coutinho and Segal, 1999; Kaunitz, 2000). Additionally, many women asserted that menstrual cycles were a natural, normal, and healthy process that should not be suppressed. Therefore, they did not agree with menstrual suppression advocates' claims that menstrual suppression is healthier (Coutinho 112 and Segal, 1999; Kaunitz, 2000; Miller and Notter, 2001; Thomas and Ellertson, 2000). Of the two women who were suppressing their menstrual cycles and the one woman who was considering beginning menstrual suppression again, two of them acknowledged the possible risks involved with menstrual suppression. Maggie and Sophie both seemed to be well aware of the potential side effects and had weighed the risks and benefits of menstrual suppression in order to determine what was right for them. Meghan, on the other hand, did not mention any potential side effects and was resolute in her belief that menstrual suppression was indeed healthy for her. Meghan's commitment to a menses-free existence appeared to be the most important factor in her decision to suppress, thus, she did not waiver from her belief that menstrual suppression was not harmful. Taking into account the fact that Meghan was 19 at the time of the interviews, had been suppressing her menstrual cycle since age 17, and had previously suffered from a serious eating disorder that caused amenorrhea, it is likely that Meghan had formed an identity at an early age as someone who did not menstruate. Thus, Meghan's experiences suggest that in addition to affecting how women feel about their bodies, menstrual suppression can also affect women's identities, and whether they consider themselves to be individuals who menstruate. It is important to note that the two women who were suppressing their menstrual cycles at the time of the interviews were both concerned about the effects of menstrual suppression on their health. Menstrual suppression is being recommended to all women on the premise that it is a healthier alternative to 113 monthly menstruation, and women are interested in this practice, for many reasons that have been discussed above. Thus, it is essential that research be conducted on the long-term health benefits and risks of menstrual suppression, so that women like Maggie and Meghan can be confident that their reproductive choices are indeed safe and healthy. This study illustrated that physicians are gatekeepers to hormonal contraceptives and considered to be experts on women's reproductive health matters, therefore, their influence on the women's decisions regarding menstrual suppression and contraceptive use was undeniable. Ashley and Maggie's experiences with their physicians were particularly profound, as they illustrated the effect that physicians can have on women's menstrual choices: Maggie was counseled about her decision to suppress her menses and denied more than a months' use of birth control pills without submitting to a physical once a year, while Ashley's physician convinced her to try menstrual suppression as a teenager. In these ways, the women discussed their experiences as being mediated by differential power relations between them and their physician. Maggie in particular used the term "control" when talking about her experiences with her physician, specifically, when talking about her physicians' attempts to dissuade Maggie from using menstrual suppression. These stories of control are very significant because they illustrate not only how physicians' personal opinions about menstrual suppression affect their patients, but also how women in the 21 s t century still struggle over the right to make their own reproductive choices. This finding resonates with Elina Oinas' work (1998), as she writes of the medical world's 114 willingness to take responsibility for and control of women's bodies. Disappointingly, the concept of true reproductive rights for all women continues to be a worthy goal, rather than an accomplishment, at this point in history, which signals the need for further work in this area. Finally, it is important to recognize the social situation of the participants in this study, as they were all middle and upper class, urban dwelling, university-educated women. In addition to having greater financial and social access to choices, resources, and health care, the women's high levels of education undoubtedly shaped their attitudes and experiences. For example, many of the women had studied issues of medicalization, the status of public health systems, feminism, and other relevant topics in their undergraduate and postgraduate studies. This meant that they were both aware and critical of larger issues related to menstrual suppression, which they brought to their discussions in the interviews. Furthermore, it is important to acknowledge that while they did face obstacles in having their reproductive choices and views validated by the medico-pharmaceutical world, the women were all Canadian citizens residing in an urban community where they could access the public health care system. This meant that the women's experiences of menstruation, menstrual suppression, and other reproductive health matters were markedly different than the experiences of poor Canadian women living in under-served communities or individuals living in other parts of the world, where subsidized health care rights do not exist. This privilege was apparent as none of the women talked about the financial difficulties in making healthy reproductive choices, but rather their difficulties in negotiating the power differentials 115 within the health care system, or balancing their personal health philosophies with the dominant conventional model. This again is the result of the high socio-economic status of my research sample. 116 CHAPTER SIX: CONCLUSION In conclusion, interviews with 12 women, this study has revealed that women's menstrual experiences/their senses of femininity and sexuality, and their feelings about their bodies do in fact influence their perceptions of, and decisions about, menstrual suppression. Rather than providing firm connections in these areas, this study has shown that women have multiple and sometimes contradictory sentiments regarding their own menstrual cycles and menstrual suppression. This study has contributed to the literature in a number of ways. Substantively, this study has examined how women's feelings about their menstrual cycles, bodies, sexuality, and femininity are mutually influential. Additionally, this study reveals some of the ways that women are making decisions about menstrual suppression. While previous research has focused on women's interest in menstrual suppression, or their knowledge of the practice, my research discusses the ways that women make decisions about menstrual frequency and how they feel about this body practice. This study addresses gaps in the literature on menstrual suppression as, to date, there has not been research conducted on the links between menstrual suppression and women's embodied experiences of femininity and sexuality. Similarly, research connecting women's lived experiences of their menstrual cycles and their feelings about menstrual suppression was absent from the literature prior to this work. In these ways, this study has contributed to the fields of menstruation and menstrual suppression research. 117 Theoretically, this study explores the notion of menstrual suppression as a form of body work, providing an important example for feminist researchers studying body and beauty work procedures. Additionally, the concept of menstrual suppression as a form of body work gives those studying menstrual suppression a new perspective with which to view this practice. The use of feminist theory provided an excellent lens with which to address the socially constructed nature of the women's experiences of menstruation and menstrual suppression, and highlighted the important effects of culture and socialization on their views. Symbolic interactionism and grounded theory furthered my analysis of the meanings that women give to menstruation and menstrual suppression, and offers a new theoretical framework for menstrual suppression research. To date, the majority of menstrual suppression research has operated from a positivist, medical perspective. This research benefited from the combination of symbolic interactionism, grounded theory, and feminist methodologies, and thus, presents a new framework for future research on this topic. Lastly, methodologically, this study provides one of the first qualitative studies on menstrual suppression. This new methodological approach has generated important insights into women's lived experiences of menstruation and menstrual suppression, and complements the psychological research already completed in these topics. However, this study was hot without its limitations. My small sample size and relatively homogenous sample can be considered limitations. Future research on menstrual suppression should endeavour to conduct qualitative research with larger 118 and more heterogeneous groups of women and with representative samples. Additionally, future research should interview individuals who influence women's feelings about menstrual suppression, namely partners, parents, educators, and physicians, to investigate their role in perpetuating messages about menstruation, menstrual suppression, and themes of sexuality, femininity, and body image. Given the interesting comments about menstrual suppression being synonymous with Western culture, it would be fruitful to interview women outside of North America to examine how their cultural understandings of menstruation and menstrual suppression differ, if at all, from women who live in Western cultural contexts. Furthermore, textual analyses of hormonal contraceptive and menstrual suppression advertisements could generate valuable information about the degree to which advertisers use themes of body work/beauty enhancement, partner sexual satisfaction, and pain reduction in their attempts to entice future menstrual suppressors. Only with knowledge from clear, meaningful, ethical research do women have the proper tools to make safe, healthy choices regarding menstrual suppression. This underscores the importance of having ethical, double-blind, placebo-controlled, clinical research on the long-term impacts of menstrual suppression, research that has yet to take place today. It is important to inform women that research does not currently exist on the safety of long-term menstrual suppression, the effects of menstrual suppression on breast tissue or bone density, or on the return to normal reproductive function and fertility following menstrual suppression (Hitchcock and Prior, 2004). If menstrual suppression continues to be recommended to girls and 119 women as a healthier alternative to monthly menstruation, it is imperative that research be conducted in these areas so that women can be assured that their reproductive choices are indeed reliable and safe. This research study has examined women's perceptions and experiences of their menstrual cycles and menstrual suppression, particularly with reference to their feelings about their bodies, their sexuality, and their feelings of femininity. In these ways, this study has contributed to the relatively new field of menstrual suppression research, and has identified important areas for future investigation. It is my intent that this study enlightens and enriches the information available on menstrual suppression, enabling women to make more informed reproductive choices. 120 REFERENCES 20/20. Move over mother nature. New pill curbs periods to four times a year. September 19, 2003. ABC News. Andrist, L.C., Hoyt, A.H., Weinstein, D., and McGibbon, C. (2004). The need to bleed: Women's attitudes and beliefs about menstrual suppression. Journal of the American Academy of Nurse Practitioners, 16 (1), 31 -37. Barnhart, K., Furman, I., and Devoto, L. (1995). Attitudes and practices of couples regarding sexual relations during menses and spotting. Contraception, 51, 93-98. Bartky, S. L. (1988). Foucault, femininity, and the modernization of patriarchal power. In I. Diamond and L. Quinby (Eds.), Femininity and Foucault: Reflection of resistance. Boston: Northeastern University Press. Benjet, C. and Hernandez-Guzman, L. (2001). Gender differences in psychological well-being of Mexican early adolescents. Adolescence, 36 (141), Spring. Bordo, S. (1993). Unbearable weight: Feminism, Western culture, and the body. Berkeley, California: University of California Press. Britten, N. (2000). Qualitative interviews in healthcare research. In C. Pope and N. Mays (Eds.), Qualitative research in health care. London, UK: BMJ Books. 11-19. Brumberg, J.J. (1997). The body project: An intimate history of American girls. New York: Random House. Butler, J. (2004). Undoing gender. New York: Routledge. Butler, J. (1990). Gender trouble: Feminism and the subversion of identity. New York: Routledge. Caplan, P.J. and Caplan, J.B. (1999). Thinking critically about research on sex and gender. New York: Harper Collins College Publishers. Cash, T.F. and Pruzinsky, T. (2004). Understanding body images: Historical and contemporary perspectives. In T.F. Cash and T. Pruzinsky (Eds.) Body image: A handbook of theory, research, and clinical practice. New York: The Guilford Press. 3-12. 121 Chrisler, J.C. (2000). PMS as a culture-bound syndrome. In J.C. Chrisler, C. Golden, and P.D. Rozee (Eds.), Lectures on the psychology of women (2nd edition). New York: McGraw-Hill. 96-110. Corea, G. (1988). The mother machine: Reproductive technologies from artificial insemination to artificial wombs. Toronto: The Women's Press. Cosentino, B.W. (2004). To douche or not to douche. Nursing Spectrum, March 22. Cosgrove, L. and Riddle, B. (2003). Constructions of femininity and experiences of menstrual distress. Women and Health, 38 (3), 37-58. Cotterill, P. (1992). Interviewing women: Issues of friendship, vulnerability, and power. Women's Studies International Forum, 15 (5/6), 593-606. Coutihno, E.M. and Segal, S.J. (1999). Is menstruation obsolete? New York: Oxford University Press. Crawford, P. (1981). Attitudes to menstruation in seventeenth-century England. Past and Present, 91, 47-73. Creswell, J.W. (1998). Qualitative inquiry and research design: Choosing among five traditions. London: Sage. Davis, K. (2003). Dubious equalities and embodied differences: Cultural studies on cosmetic surgery. Oxford: Rowman & Littlefield Publishers Inc. Davis, S.W. (2002). Loose lips sink ships: Designer vaginas. Feminist Studies, 28 (1), March 1. Dey, I. (1999). Grounding grounded theory: Guidelines for qualitative inquiry. San Diego, CA: Academic Press. Douglas, M. (1966). Purity and danger: An analysis of the concepts of pollution and taboo. London: Routledge. Drelich, M.G. and Bieber, I. (1958). The psychological importance of the uterus and gender identity. Journal of Nervous and Mental Diseases, 126, 322-336. Dworkin, A. (1974). Woman hating. New York: E.P. Dutton. Ellens, D. (2003). Menstrual impurity and innovation in Leviticus 15. In K. DeTroyer, J.A. Herbert, J.A. Johnson, and A.M. Korte's (Eds.), Wholly woman, holy blood: A feminist critique of purity and impurity. Harrisburg, PA: Trinity Press International, p. 34 - 52. 122 Elson, J. (2002). Menarche, menstruation and gender identity: Retrospective accounts from women who have undergone premenopausal hysterectomy. Sex Roles, 46, (1/2), 37-48. Fauerbach, J.A., L.J. Heinberg, J.W. Lawrence, A.G. Bryant, L. Richter, and R.J. Spence (2003). Coping with body image changes following a disfiguring burn injury. Health Psychology, 21 (2), 115-121. Fingerson, L. (2005). Agency and the body in adolescent menstrual talk. Childhood, 12 (1), 91-110. Ford, A.R. (1986). Hormones: Getting out of hands. In K. McDonnell (Ed.), Adverse effects: Women and the pharmaceutical industry. Toronto: Women's Educational Press. 27-40. Foster, G.D. and Matz, P.E. (2004). Weight loss and changes in body image. In T.F. Cash and T. Pruzinsky (Eds.) Body image: A handbook of theory, research, and clinical practice. New York: The Guilford Press, 405-413. Foucault, M. (1979). Discipline and punish: The birth of the prison. New York: Vintage. Foucault, M. (1977). Power/knowledge. New York: Pantheon. George, L. (2005). The end of menstruation. Macleans, December 12-19, 40-46. Gimlin, D. (2000). Cosmetic surgery: Beauty as commodity. Qualitative Sociology, 23 (1), 77-98. Glaser, B.G. and Strauss, A.L. (1967). The discovery of grounded theory. Chicago: Aldine Publishing Company. Graham, H. (1984). Surveying through stories. In C. Bell and H. Roberts (Eds.) Social researching: Politics, problems, practice. London: Routledge and Kegan Paul. Grahn, J. (2002). Blood, bread, and roses: How menstruation created the world. Montreal: Fitzhenry and Whiteside. Grant, E. (2000). Dangers of suppressing menstruation. The lancet, 356, 513. Grumman, R. (2001). Kiss your period goodbye. Cosmopolitan, November, 249-251. 123 Hall, W.A., and Callery, P. (2001). Enhancing the rigor of grounded theory: Incorporating reflexivity and relationality. Qualitative Health Research, 11 (2), 257-272. Hammersley, M. and Atkinson, P. (1995). Ethnography: Principles in practice. New York: Routledge. Harding, S. and Norberg, K. New feminist approaches to social science methodologies: An introduction. Signs: Journal of Women in Culture and Society, 30 (4), 2009-2015. Hitchcock, C.L. and Prior, J.C. (2004). Evidence about extending the duration of oral contraceptives use to suppress menstruation. Women's Health Issues, 14,201-211. Houppert, K. (1999). The curse: Confronting the last unmentionable taboo: Menstruation. New York: Farrar, Straus and Giroux. Howson, A. (2004). The body in society: An introduction. Cambridge: Polity Press. Hurd Clarke, L.C. (2001). Beauty in later life: Older women's perceptions of physical attractiveness. Canadian Journal on Aging, 21 (3), 429-442. Hurd Clarke, L. (2002). Older women's perceptions of ideal body weights: The tensions between health and appearance motivations for weight loss. Ageing and Society, 22 (6), 751-773. Hurd Clarke, L. (2003). Overcoming ambivalence: The challenges of exploring socially charged issues. Qualitative Health Research, 13 (5), 718-735. lannacchione, M.A. (2004). The vagina dialogues: Do you douche? American Journal of Nursing, 104 (1), 40-45. Jeffreys, S. (2005). Beauty and misogyny: Harmful cultural practices in the West. York: Routledge. Johnson, J.L., Greaves, L, and Repta, R. (in press). Better science with sex and gender: Sex and gender analysis in women's health research. Vancouver: Women's Health Research Network. Johnston-Robledo, I. Ball, M. Lauta, K. and Zekoll, A. (2003). To bleed or not to bleed: Young women's attitudes toward menstrual suppression. Women and Health, 38 (3), 59-75. 124 Jones, D.C., Vigfusdottir, T.H., and Lee, Y. (2004). Body image and the appearance culture among adolescent girls and boys: An examination of friend conversations, peer criticism, appearance magazines, and the internalization of appearance ideals. Journal of Adolescent Research, 19 (3), 323-339. Kaunitz, A.M. (2000). Menstruation: Choosing whether...and when. Contraception, 62, 277-284. Keats, D.M. (2001). Interviewing: A practical guide for students and professionals. Buckingham: Open University Press. Kelly, L., Burton, S., and Regan, L. (1994). Researching women's lives or studying women's oppression? Reflections on what constitutes feminist research. In M. Maynard and J. Purvis' (Eds.) Researching women's lives from a feminist perspective. New York: Taylor and Francis, Inc., 27-48. King, H. (1998). Hippocrates' woman: Reading the female body in ancient Greece. London: Routledge. Kirsch, G.E. (2005). Friendship, friendliness, and feminist fieldwork. Signs: Journal of Women in Culture and Society, 30 (4), 2163-2172. Kissling, E.A. (2002). On the rag on screen: Menarche in film and television. Sex Roles, 46 (1/2), 5-12. Kissling, E.A. (2006). Capitalizing on the curse: The business of menstruation. Boulder, Colorado: Lynne Reinner Publishers, Inc. Kitzinger, C. (2003). Feminist approaches to qualitative research practice. In C. Seale, G. Gobo, and J. Gubrium (Eds.), Qualitative Research Practice. London: Sage. (p. 125-140) Kitzinger, C. and Willmot, J. (2002). The thief of womanhood': Women's experience of polycystic ovarian syndrome. Social Science and Medicine, 54, 349-361. Krueger, D.W. (2004). Psychodynamic perspectives on body image. In T.F. Cash and T. Pruzinsky (Eds.) Body image: A handbook of theory, research, and clinical practice. New York: The Guilford Press. 30-37. Kushner, K.E. and Morrow, R. (2003). Grounded theory, feminist theory, critical theory: Toward theoretical triangulation. Advanced Nursing Science, 26 (1), 30-43. 125 Labre, MP. (2002). The brazilian wax: New hairlessness norm for women? Journal of Communication and Inquiry, 26 (2), 113-132. Lander, L. (1988). Images of bleeding: Menstruation as ideology. New York: Orlando Press. Larouche, S.S. (2006). Changes in body image experienced by adolescents with cancer. Journal of Pediatric Oncology Nursing, 23 (4), 200-210. Laws, S. (1990). Issues of blood: The politics of menstruation. Houndmills, Basingstoke, Hampshire and London: The Macmillan Press Ltd. Lee, J. (1994). Menarche and the (hetero)sexualization of the female body. Gender and Society, 8 (3), 343-362. Lee, J. and Sasser-Coen, J. (1996). Blood stories: Menarche and the politics of the female body in contemporary U.S. society. New York: Routledge. Lippman, A. (2004). Women's cycles up for sale: Neo-medicalization and women's reproductive health. Network Magazine, Winter/Spring, 6/7 (4/1), 8-11. Lord, A. (1999). Issues of blood: The politics of menstruation. London: The Macmillan Press Ltd. Loshny, H. (2004). From birth control to menstrual control: The launch of the extended oral contraceptive, Seasonale. Canadian Woman Studies, 24 (1), 63-67. Malson, H. (1998). The thin woman: Feminism, post-structuralism, and the social psychology of anorexia nervosa. New York: Routledge. Martin, E. (2001). The woman in the body: A cultural analysis of reproduction (3rd Ed.). Boston: Beacon Press. Maynard, M. and Purvis, J. (1994). Doing feminist research. In M. Maynard and J. Purvis (Eds.) Researching women's lives from a feminist perspective. New York: Taylor and Francis, Inc., 1-9. Miller, L. and Edenholm, M. (1999). Genital piercing to enhance sexual satisfaction. The American College of Obstetricians and Gynecologists, 93 (5), 2, 837. Miller, L. and Hughes, J.P. (2003). Continuous combination oral contraceptive pills to eliminate withdrawal bleeding: A randomized trial. Obstetrics and Gynecology, 101, 653-661. 126 Miller, L and Notter, K. (2001). Menstrual reduction with extended use of combination oral contraceptive pills: Randomized controlled trial. Obstetrics and Gynecology, 98 (5), 1. Miller, W.B., and Smith, P.J. (1975). Elimination of the menses: Psychosocial aspects. Journal of Psychiatric Research, 12, 153-166. Nicholson, P. (1995). The menstrual cycle, science and femininity: Assumptions underlying menstrual cycle research. Social Science Medicine, 41 (6), 779-784. O'Grady, K. (2001). Are periods passe? Herizons, January, 14, 24-26. O'Grady, K. (2006). Another look at menstrual suppression. Network Magazine. Spring, 8 (3/4), 21-22. Oinas, E. (1998). Medicalisation by whom? Accounts of menstruation conveyed by young women and medical experts in medical advisory columns. Sociology of Health and Illness, 20 (1), 52-70. Oinas, E. (2001). Making sense of the teenage body: Sociological perspectives on girls, changing bodies, and knowledge. Abo, Finland: Abo Akademi University Press. Oudshoorn, N. (1994). Beyond the natural body: An archaeology of sex hormones. London and New York: Routledge. Poorthuis, M.J.H.M. and Schwartz, J. (2000). Purity and holiness: The heritage of Leviticus. In M.J.H.M. Poorthuis and J. Schwartz (Eds.), Jewish and Christian perspectives, Series 2. Leiden: Brill, 129-147. Prior, J.C. (2000, Summer). Ovulatory menstrual cycles are not a problem: Go with the flow! Quarterly Newsletter of the British Columbia Endocrine Research Foundation, 2, 1-5. Prus, R. (1996). Symbolic interactionism and ethnographic research. New York: Suny Press. Pruzinsky, T. (2004). Body image adaptation to reconstructive surgery for acquired disfigurement. In T.F. Cash and T. Pruzinsky (Eds.) Body image: A handbook of theory, research, and clinical practice. New York: The Guilford Press, 440-449. Purdy, L. (2001). Medicalization, medical necessity and feminist medicine. Bioethics, 15 (3), 1-14. 127 Rako, S. (2003). No more periods? The risks of menstrual suppression and other cutting-edge issues about hormones and women's health. New York: Harmony Books. Random House Dictionary (2006). Pearson Education Publishing. Reinharz, S. (1992). Feminist methods in social research. Oxford: Oxford University Press. Riessman, CK. (1983). Women and medicalization: A new perspective. Social Policy, 14, 3-18. Roberts, T.A. (2004). Female trouble: The menstrual self-evaluation scale and women's self-objectification. Psychology of Women Quarterly, 28, 22-26. Roberts, T. and Waters, P.L. (2004). Self-objectification and that "not so fresh feeling": Feminist therapeutic interventions for healthy female embodiment. Women and Therapy, 27 (3/4), 5-21. Rogers, W. (1997). Sources of abjection in Western responses to menopause. In P.A. Komesaroff, P. Rothfield and J. Daly (Eds.), Reinterpreting menopause: Cultural and philosophical issues. New York: Routledge. Rushing, B and Onorato, S. (2003). Controlling the means of reproduction: Feminist theories and reproductive technologies. Humanity and Society, 27 (3), 393-413. Sarwer, D.B. (2004). Cosmetic surgery and changes in body image. In T.F. Cash and T. Pruzinsky (Eds.) Body image: A handbook of theory, research, and clinical practice. New York: The Guilford Press, 405-413. Sekhon, J. (2003). Continuing control at the point of reproduction. Humanity and Society, 27 (3), 414-415. Sen, G. and Snow, R.C. (1994). Power and decision: The social control of reproduction. Boston: Havard University Press. Sievert, L.L. (2003). The medicalization of female fertility: Points of significance for the study of menopause. Collegium Antropologicum, 27 (1), 67-78. Strange, J.M. (2001). The assault on ignorance: Teaching menstrual etiquette in England, c. 1920s to 1960s. Social History of Medicine, 14 (2), 247-265. Strauss, A.L. and Corbin, J.M. (1998). Basics of qualitative research: Techniques and procedures for developing grounded theory. Thousand Oaks: Sage Publications. 128 Strauss, A. and Corbin, J. (1990). Basics of qualitative research: Grounded theory procedures and techniques. Newbury Park, CA: Sage. Stubbs, M.L. and Costos, D. (2004). Negative attitudes towards menstruation: Implications for disconnection within girls and women. Women and Therapy, 27 (3/4), 37-54. Thomas, S.L. and Ellertson, C. (2000). Nusiance or natural and healthy: Should monthly menstruation be optional for women? Lancet, 355, 922-924. Van de Walle, E. and Renne, E.P. (2001). Regulating menstruation: Beliefs, practices, interpretations. Chicago: Univeristy of Chicago Press. Vertinsky, P. (1994). The eternally wounded woman: Women, doctors, and exercise in the late nineteenth century. Urbana and Chicago: University of Illinois Press. Wershler, L. (2004). Depo-provera: Does this contraceptive choice support the health and well-being of adolescents and young women? Canadian Woman Studies, 24 (1), 105-108. White, P., Young, K., and Gillett, J. (1995). Bodywork as a moral imperative: Some critical notes on health and fitness. Leisure and Society, 18 (1 ),159-182. Wolf, N. (1991). The beauty myth: How images of beauty are used against women. New York: William Morrow. Woods, N.F. (1986). Socialization and social context: Influence on perimenstrual symptoms, disability, and menstrual attitudes. In V.L. Olesen and N.F. Woods (Eds.) Culture, society and menstruation. Washington, DC: Hemisphere. (2006). Last accessed Saturday, October 21, 2006. with lizbeth/2006/04/the blessings _o.html (2006). Last accessed Saturday, October 21, 2006. Zanna, J. (2003). Profits to flow for period-stopping drug. Herizons, 17 (1), 10-12. 129 APPENDIX A: Recruitment Poster VOLUNTEERS NEEDED! The Social and Cultural Significance of Menstrual Suppression What: Researchers at UBC are investigating what women think about 'menstrual suppression', which is taking contraceptives (e.g. birth control pills) continuously in order to stop menstruation. This project is part of a graduate thesis and involves 2 interviews Each interview will take about 1 hour. Who: Women ages 18-30 who have OR have not suppressed their menses (either way) By Whom: Dr. Laura Hurd Clarke and Robin Repta, a graduate student at UBC. If you are interested, please contact Robin at: xxx xxx-xxxx. Menstrual Menstrual Menstrual Menstrual Menstrual Menstrual Suppression Suppression Suppression Suppression Suppression Suppression Study Study Study Study Study Study Robin Repta Robin Repta Robin Repta Robin Repta Robin Repta Robin Repta xxx xxx-xxxx xxx xxx-xxxx xxx xxx-xxxx xxx xxx-xxxx xxx xxx-xxxx xxx xxx-xxxx 130 APPENDIX B: Information Letter and Consent Form Study Title: The Social and Cultural Significance of Menstrual Suppression Brief Description of the Study: This study is looking at how women of reproductive age view and experience menstrual suppression, which is typically defined as taking birth control pills continuously in order to stop menstruation. In particular, I am interested in finding out more about: • Women's general opinions of menstrual suppression and the idea of taking birth control pills continuously • How women's views of menstrual suppression are related to, or affected by, their feelings towards their menstrual cycles • Details on women's feelings of sexuality, femininity and body image with respect to menstrual suppression The goal of the study is to provide experience-driven research on menstrual suppression by examining how women interpret menstrual suppression. The hope is that the results from the study will help women's health practitioners, researchers and policy-makers more effectively understand the social and cultural effects of menstrual suppression, as informed by real women's experience. This study is part of a Master's of Arts thesis in the school of Human Kinetics at the University of British Columbia. The graduate student investigator is Robin Repta, a Master's candidate. What is involved in participating?: Your participation in this study would include 2 interviews. Each interview will take approximately one hour. The interviews would take place approximately one week apart. With your permission, we would like to tape record the interviews so that we can better concentrate on what you are saying. The interviews will take place at the university, or at another location of your choosing. Confidentiality: Your participation in this study is confidential. The interviews recordings and transcripts will be kept in a locked office on a password-protected computer. Pseudonyms will be used so that no names are associated with any of the data. You will not be identified by name in any report emerging from this study. Your Voluntary Participation: Your participation in this study is entirely voluntary. You are free to not answer any question, and you may withdraw from the interviews at any time. If you have any concerns about your treatment or rights as a research participant, feel free to contact the Office of Research Services at the University of British Columbia, at 604 822-8598. 131 Further Contact Information or Concerns: If you have any questions or desire further information about the project, please contact the graduate student investigator of the project, Robin Repta, at 778 786-2413. In addition, Dr. Laura Hurd Clarke, the research supervisor, is willing and available to answer and questions or discuss concerns. You can reach her at 604 822-4281. Consent Form Agreement: Your signature below indicates that you consent to take part in this study on menstrual suppression. Your signature indicates that the study has been explained to you and that you understand what is involved. Your signature below indicates that you have received a copy of this consent form for your own records. Lastly, your signature below indicates that you understand that this study is voluntary, that you may withdraw at any time, and that.your anonymity is assured. Signature: Printed Name: Date: 132 APPENDIX C: Biographical Data Form Study: The Social and Cultural Importance of Menstrual Suppression Instructions: The following questions are to obtain some background information about you. Please answer all questions as accurately as possible. 1. Name: 2. Address: 3. Date of birth: 4. Place of birth: 5. Marital/partner status: 6. Number of children: 7. Please indicate the highest level of education you have obtained: • Public school • Some high school • High school diploma • College or university - undergraduate • Technical school • Graduate school • Other - please specify: 8. What is your current occupation? 9. What is your religious affiliation? 10. Which income bracket do you fall under? • Under $10,000 • $10-20,000 • $20-30,000 • $30-40,000 • $40-50,000 • $50-60,000 • $60-70,000 • $70,000 + 11 .What is your ethnic background? 12. What health issues, if any, do you have? 133 APPENDIX D: Interview Questions Study: The Social and Cultural Meanings of Menstrual Suppression The following questions represent an overarching agenda for interviews with participants of this study. These questions will be asked in a flexible and open-ended manner and may altered or added to over time as different themes emerge in the data. Additionally, questions from Interview #2 could potentially be asked in Interview #1 should the need arise and vice versa. This interview schedule serves as an ideal guide, but will not be followed strictly. Interview #1: 1. Tell me a little bit about yourself and the history of your life. (Probe: Are you currently in a relationship? Do you have any children?) 2. Tell me about your personal history of menstruation. a) What was your experience of your first period like? b) Who taught you about menstruation? What did they say? c) Who taught you about hygiene and products to use when menstruating and what did they say? (Probe: Have you ever used the birth control pill? If not, why?) d) How long have you been menstruating for? e) How do you feel about your period? f) Have your feelings towards your period changed over time? Why or why not? g) How do you feel about your body? h) How do your feelings about your body change when you get your period, if at all? 3. Have you heard of menstrual suppression? a) How did you learn about it? b) Have you ever tried it? 4. What do you think about menstrual suppression? a) Does this practice interest you? Why or why not? 5. Have you heard of the drug Seasonale? a) What do you think of this product? b) How appealing is it to you? c) Why would you use it or choose not to use it? Interview #2: 1. How comfortable are you in talking about having your period with other people? (Probe for differences in relation to gender, age, and family/friend status differences) 2. What would you think about your body if you did not menstruate? If you eliminated your period, would you miss it? 134 3. What does femininity mean to you? How does have your period affect your sense of being feminine, if at all? 4. What does sexuality mean to you? How does having your period affect your experience of sexuality or your feelings about sex, if at all? 5. How would menstrual suppression affect your sense of sexuality and your experience of sex, if at all? 6. How does your partner feel about your period? What kinds of things does he/she say? 7. What kind of messages does your partner give you about your body and your appearance? 8. What products do you use when you have your period? 9. Why do you think some women choose to eliminate their menstrual cycles? Does that reason influence your opinion of menstrual suppression? (I.e. for health reasons versus personal comfort or aesthetic/convenience reasons) 10. How does this drug differ from other forms of menstrual suppression, namely taking a normal birth control pill continuously when you want to skip a period? 11. How do our cultural ideas of menstruation affect women's perceptions of their menstrual cycles and their views of menstrual suppression? 12. If you have a daughter someday, what will you tell her about her menstrual cycle? 13. Are there any questions that I should have asked, that I did not? 14. Do you have any final thoughts? 135 


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