Hat Porter explores the difficulties faced by psychiatric inpatients accessing menstrual health support
Content note: mention of eating disorders, sexual abuse and psychiatric harm
When I started my first period – for the second time – I was in a child and adolescent mental health ward, miles from home. Having not had a period for about a year, I didn’t have any pads with me. I’d been in hospital for months for anorexia and as I’d gradually gained weight, my body had become healthy enough for my menstrual cycle to resume.
It was a Monday morning. I remember this vividly as Monday mornings were weigh-in days. I was forced, against my wishes and for no clear reason, to remove all my clothing except my underwear and to stand and be weighed and have my body inspected by the nurses.
Having started my period unexpectedly, and not having any pads, I had to stand there that morning with blood on my pants and legs – humiliated and ashamed. There weren’t any period pads in the hospital, so the nurse found me a tampon from her bag, but I was too embarrassed to say I wasn’t able to use tampons. I had to use wads of tissue paper, which I bled through quickly.
In later hospital admissions, there were never any period products freely available. Perhaps the staff would’ve given me some if I’d asked but I was always too scared to do so. When I tried to bring some pads in after being on leave, I was searched and they were confiscated as a risk item. I always had to improvise and make do with whatever I could fashion out of toilet paper.
The ward was a place where patients lacked privacy, where it was impossible to conceal our menstruation from those around us. But at the same time, menstruation was overlooked as though it hadn’t even occurred to staff that patients would menstruate. It was a stark contradiction. So exposed yet so unseen.
And, whilst I felt so exposed and vulnerable, nobody ever asked me what it was like to start my periods again after such a long time, or created the space to discuss why this was difficult for me. Being trans, autistic, and a sexual trauma survivor, this was a PTSD trigger for me.
It wasn’t until years later that I realised just how unjust and neglectful all of this was. It made me feel like I was the problem. Like I was disgusting for the natural cycles of my body. I never realised that I deserved better.
In 2023 I was commissioned by the user-led mental health charity NSUN to conduct some survivor-led research looking at experiences of menstrual health in psychiatric inpatient settings. (I use the term menstrual health as it focuses on the whole menstrual cycle and considers this as a matter of health rather than hygiene, as is often the case in discussion of menstruation). It’s a topic which, until this point, has been largely overlooked in mental health research, policy, and practice. I conducted this as research, but also as a campaign, to highlight the injustices patients’ experience and to enact change.
My research involved three stages, starting with online questionnaires completed by 101 patients and 67 staff members. I then conducted 10 interviews with patients and analysed a range of documentation obtained through freedom of information requests. I also searched existing literature, which I discovered rarely considered menstruation, even those studies that specifically focused on women’s experiences of mental health wards.
The research highlighted that patients’ experiences were influenced both by the restrictive institutional environments of the hospital, as well as interactions with staff and how they met (or didn’t meet) their care and support needs.
I used a process called thematic analysis to analyse the data from interviews and questionnaires. This involved finding patterns and commonalities amongst what research participants share and grouping these into categories.
I identified four key themes: accessing menstrual materials; lack of privacy when menstruating; the influence of staff attitudes and approaches; and the support patients needed with physical or psychological challenges related to their menstrual cycle.
Patients were not adequately supported with their menstrual health whilst in hospital, leaving people experiencing deprivation, neglect and injustice, and feeling humiliated and degraded.
Patients faced restrictions in their access to menstrual products, as well as other items such as hot water bottles, soaps, hygiene items, and medications. Where period products were available, they were often poor quality and didn’t meet patients’ needs. Some participants had been given incontinence pants or other inappropriate items as there were no period products available.
As staff generally controlled supplies of period products, patients had to request them one item at a time, compromising their control, privacy and dignity. The many patients who felt unable to ask were often deprived of these items altogether.
In many cases, period products (usually tampons) were actively banned because of the perceived risk of the item. This was not necessarily based on a specific incident or individual risk and didn’t consider the risk of withholding these items on patients’ health and psychological safety.
Mental health wards failed to provide the privacy that is needed during menstruation. Participants felt very exposed: for example, when being observed continuously by staff, or where there were environmental factors like ensuite bathrooms not having doors or the use of CCTV cameras in bedrooms.
More generally, menstruation was widely overlooked, making patients feel burdensome or an inconvenience. Many patients experienced psychiatric wards as enhancing their sense of shame, especially where staff expressed disgust or negative views towards menstruation.
In many cases, patients were not adequately supported with their physical needs around menstruation. For example, period pain was often dismissed, and this was especially difficult for those who also had gynaecological conditions or heavy and painful menstruation. Some participants described feeling that mental health services viewed their physical health as ‘someone else’s problem’ and didn’t recognise the complex relationships between mental and physical health, failing to view their needs holistically.
Finally, some patients shared how their mental health, distress and trauma shaped the way they related to their menstrual cycle. Some found certain types of period pains, or using certain period products, triggering in the context of histories of sexual traumas. Some participants drew parallels between their experiences of having period products withheld and their experiences of sexual traumas. This reflected the intimate and gendered nature of these restrictions, and the deep and profound impacts they had on patients.
It is important to note that some patients had more positive experiences where staff were supportive and considered the relationships between their menstrual and mental health. One person even felt that staff had supported them in unlearning shame around menstruation. This clearly shows that providing compassionate support for patients is not only necessary, but also very possible.
Following the research phases, I held a focus group and worked with five people with lived experience to develop some guidelines for tangible actions that services can take to address and support patients’ needs. To support their impact and implementation, I was able to get support from a range of stakeholders including the charities Mind, Rethink Mental Illness and Bloody Good Period.
The guidelines include recommendations to ensure patients have access to the items they need, that staff have training about menstrual and mental health – including around conditions such as premenstrual dysphoric disorder (PMDD) – and that patients are routinely asked (sensitively) about their needs related to menstruation to create space for these important conversations.
The campaign won’t end there. A huge amount of work is needed to ensure that the changes so desperately needed will really happen, and to reduce the injustices and abject neglect so clearly highlighted by this research.
I would like to thank the participants and co-authors of the guidelines who were so open in sharing their experiences and making this research possible. NSUN were incredible from start to finish. The full research report, guidelines, an Easy Read summary, an illustration and a video recording of the report launch presentation are available at: https://www.nsun.org.uk/resource/menstrual-health-in-psychiatric-inpatient-settings-2024/
Hat Porter (they/them) Twitter/X: @hatporter.
This is a sample article from the Autumn 2024 issue of Asylum Magazine (31.3). To read more. . . Subscribe to Asylum.