Researchers Response.

The content of this site addresses the topic from a moral, humanistic and medical position. The site identifies commercial/economic and feminist views, as they are necessary but secondary to the main aim.

The study identifies that gender is a social construct, and people who menstruate may distinguish themselves as male-female, non- binary and fluid. Accordingly, the pronouns used throughout the text will be in a neutral title such as 'them', 'they', person or 'people'.

25% of the global population are of menstruating age; furthermore, 2.4 billion people are not provided access to sufficient sanitation. A large number of research documents that people of whom have 'disabilities' are presented with obstacles when accessing suitable water and sanitation aids in low and middle-income countries. (6)

The World Health Organisation (WHO) and the United Nations Children Fund (UNICEF) establish menstrual hygiene management as:

"Women and adolescent girls using a clean menstrual management material to absorb or collect blood that can be changed in privacy as often as necessary for the duration of the menstruation period, using soap and water for washing the body as required, and having access to facilities to dispose of used menstrual management material. They understand the basic facts linked to the menstrual cycle and how to manage it with dignity and without discomfort or fear."(7)

The UNICEF menstrual health and hygiene guide also define menstruators as:

"A menstruator is a person who menstruates and therefore has menstrual health and hygiene needs – including girls, women, transgender and non-binary persons. Throughout this guidance, the term 'girls and women' is used as a shorthand term to increase readability and refers to all menstruators regardless of gender identity."(8)

The definition is relatively inclusive, as it addresses the diversity of people who menstruate, as well as explaining that menstruators require menstrual health and hygiene necessities. However, the list does not discuss the physicality of managing Menstruation. The potential challenges that menstrual management and symptoms pose to specific individuals. Such as people with physical and intellectual 'disabilities.'

Around 75% of menstruators encounter premenstrual syndrome (PMS).(9)The symptoms of PMS range from emotional and physical signs such as Mood swings, irritability or anger, anxiety, Appetite changes and food cravings, Poor concentration, Weight gain related to fluid retention, Fatigue, Constipation or diarrhoea and many more.(10) Premenstrual Dysphoric Disorder (PMDD) is known as "severe PMS", which causes a higher level of rigour with physical and/or emotional symptoms.(11)The extensive range of symptoms and levels of PMS severity demonstrates the diversity of additional challenges, aside from managing menstrual blood.

In some cases, the lack of access to both sanitation facilities and menstrual management materials can be a result of numerous reasons. The affordability of menstrual products is an issue that can be identified globally. Especially in lower socio-economic groups, according to studies in many low-income countries, people have been known to manage menstrual blood with materials such as bark, paper, sand, mud or cloth.* Also, there is data proof of adolescent girls in western Kenya involved in transactional sex in order to purchase sanitary products.(12)

The socio-ecological awareness for menstrual hygiene management and inclusion for low-income countries has expanded over the last few years and is part of the sustainable development goal 6. This focus is promising. However, other efforts concerning menstrual hygiene management must apply the same centre of inclusion. In cases of persons with 'disabilities' in low-income countries, research shows that in locations such as Uganda and Zambia, 'disabled' people are deemed 'unclean' and infectious and can be prevented from occupying public lavatories and/or water points.(13)

In the likelihood of a menstruating 'disabled' person in a low-income country, Resources for sanitation services and menstrual products are harder to obtain due to the layers of discrimination and cultural beliefs, which can diversify for people with varying 'impairment' types.

The word 'disability' is an umbrella description that carries many forms of intellectual and physical 'impairment.' However, being unable to take part in particular systems within the community produces the term 'disabled', a title given to certain individuals by society.

The lack of consideration of diversity and users of systems or design excludes many from having access to fully participating within society.

In this section, I will respond to these issues concerning the participants quoted experiences.

I am grateful for the opportunity to collaborate with a participant and gain an insight into their encounter of exclusivity and discrimination.

The participant's purpose for this study is to share an experience which explicitly reveals the reality of discrimination and exclusivity to people with unique requirements. The overarching aim of inclusive design thinking leads this narrative to a conceptual correlation between menstrual management and medical necessity.

Following on from the participant's description of the engineer who designed specially made prosthetics, feeding and dressing aids to suit their physical 'impairment'. The thinking behind these design motives was to manage movements and tasks in a 'normal' manner. However, the participant chose not to use these tools, instead, embraced their unique ability and adaption to managing these tasks without assisting agents. If there were any problem with these alternative methods, it would be down to societies perspective and acceptance. 'Normality' should be accepting this 'difference', all forms of living.

It is essential not to generalise the user requirements in the design process, and it is critical to collaborate with the client to get the most accuracy within the design thinking. The participant mentioned that they had more of a voice in the design process as they got older. The participant initiated the question of menstrual management as they wanted to use tampons as opposed to multiple pairs of underwear and towels. After some discussion and attempts of trial and error, creating a mechanism to aid the insertion and removal of a tampon, was not a possibility in this case.

Does this lack of innovation beg the question that perhaps designing for menstrual management should be of more specialised practice, a practice in which demands varied knowledge concerning the anatomy, and a design process where the actual design is navigated by the user, with the input of various disciplines?

Much like participants navigation in design processes, the same respect of partnership and collaboration is applied to this research site, with the aim not to presume or generalise the diverse set of experiences in the world.

Individual voices can be heard on a case the case basis, which allows an accurate distinction of uniqueness and attention to specific innovation concerning Menstrual hygiene management with physical impairments. Furthermore, highlighting the challenges of different lifestyles, probe the much-needed change of perspective among society.

As seen in the participant quote section, they were unable to use any source of available menstrual product; And the appointed engineer achieved no modification. Thus the only option for the participant's case was to suppress Menstruation. An option that was thankfully an effective and practical strategy for the participant. However, this synopsis confirms the point of exclusion and the circumstance of limited support, demanding a medical alternative.

In the area of healthcare science, the profession of rehabilitation engineer varies on what they specialise in, such as designing for special seating, wheelchairs, artificial limbs and robotic aids. The occupation responds to the needs of people with the unique requirements with assistive technology, however, based on the participant's user experience within this filed, the push for menstrual management is not enforced or explicitly offered.(14)

Layers of Discrimination. (The association of sensitive subjects)

Menstruation and Disability are two subjects which are highly discriminated, taboo and shamed. Communicating around these associated subjects is a complex and contentious topical area, which can result in political disputes, neglect and dishonour.

Have these points been so concealed that any thought of innovation in this area ceases to grow?

As quoted by the participant;

"The biggest misconception of 'disability', is the fact the world does not adapt itself to 'disability', 'Disability' adapts to the world."

Is it the mix of involuntary adaption and controversial subject matters, what steers the shift for inclusive design?

Issues with exclusiveness in this area are especially vital to address and develop, as the choice concerning natural bodily functions and reproduction impact more than just the individual.

Or is societies perception of people with physical impairments reproducing, a further exclusion?

"Disability and menstruation do not go hand in hand."

Does the association between 'Disability', sex and Menstruation need to be destigmatised in order to develop?