“Just” a painful period: A philosophical perspective review of the dismissal of menstrual pain

Abstract

Science and society typically respond to dysmenorrhea—or painful menstrual cramps—as a normal, natural, and inevitable part of menstruation. This normalization has greatly contributed to the systemic dismissal of painful menstrual cramps. Stigma, secrecy, and the expectation to “cope” fuel the normalization of menstrual pain. In this article, I argue that the normalization of menstrual pain restricts the ability to share an excruciating menstrual pain in a way that would otherwise elicit alarm or concern. This can cause clinicians to downgrade menstrual pain, and even menstruating persons to downgrade their own pain. I refer to the dismissal of menstrual pain as an example of a pain-related motivational deficit. A pain-related motivational deficit describes instances in which an utterance fails to motivate due to societal practices and ideas that make it difficult to recognize the import of the embodied experience being shared.

Plain Language Summary

“Just” a painful period: why we are not concerned by reported menstrual pain

It is widely believed that painful menstrual cramps are just a normal part of the menstrual cycle; something that all menstruating persons are expected to deal with. There is also a stigma around periods and an expectation to keep the experience of periods hidden. This creates a process known as normalization. Because painful menstrual cramps are normalized, it is easier to dismiss patients who report painful menstrual cramps. In this article, I argue that the idea that painful menstrual cramps are normal makes it difficult for others to be concerned or alarmed by reports of menstrual pain. Reports of menstrual pain are downgraded or are seen as not that bad. When we are unable to see how bad a pain is because society believes the reported pain is normal, the pain report fails to elicit concern from the listener. I call this process a pain-related motivational deficit.

So, we’ve been enduring this pain for years and just going to work, buttoning up, because we are trained that way. In addition, I think these tampon commercials are detrimental. They’re always like “Oh, you’re on your period? Don’t let that stop you, girl! Get out there! Go surfing! Go play a sport! Get on a horse!”

Sasheer Zamata, The Stand Up Show with Jon Dore

Dysmenorrhea—or painful menstrual cramps—is one of the most reported gynecological symptoms. ¹ However, dysmenorrhea is widely dismissed. Painful menstrual cramps are often written off as a normal part of the menstrual cycle, or something that all menstruating persons are expected to live with.^{2 –4} The prominent notion that dysmenorrhea is a normal, natural, and inevitable feature of menstruation makes it difficult to recognize and respond to painful menstrual cramps as a legitimate health issue. This normalization of painful menstrual cramps has resulted in both patient and doctor delays in diagnosis of conditions like endometriosis. Studies have shown that patients who internalize the idea that severe menstrual pain is normal are less likely to seek medical help, and physicians are less inclined to search for other underlying causes of a patient’s dysmenorrhea.^{3 –6}

As early as the 19th century, medicine reflected the idea that emotional instability and pain are expected menstrual symptoms. However, this expectation was constructed from a patriarchal perspective of the female form as biologically inferior.^7,8 Male physicians, who had little clinical contact with menstruating persons, deemed severe and debilitating menstrual cramps as significant to the normal presentation of a menstrual cycle. ⁷ More specifically, the conflation of primary dysmenorrhea with debilitating menstrual pain stemmed almost entirely from physicians who interacted with individuals who either identified themselves or were later identified by others as experiencing secondary dysmenorrhea. ⁷ The idea that menses causes disability and suffering was so normalized that, in the 19th century, menstruating persons who experienced “easy enough” periods feared that they were somehow “abnormal.” ⁹ Presently, it is still difficult for many—both medical professionals and patients—to distinguish “normal” from “abnormal” menstrual pain. ⁶

Normal versus legitimate menstrual pain

Medical institutions play an important role in defining what is “normal” and what is a “legitimate” health concern. ¹⁰ When a pain is normalized, it will fail to elicit alarm. Our societal logic is one in which a “normal” pain is perceived as not warranting any special attention or care. As an illustration, consider the response a person might receive when they report sore arms to their trainer after working out in the gym. The trainer will likely believe the person’s pain report, but still be dismissive or downplay the reported pain given the fact that a little pain is treated as a normal, natural, and inevitable consequence of building muscle—as the idiom says, no pain, no gain.

The normalization of a particular pain can also be internalized, causing a person to be dismissive or downplay their own pain experience. For example, the person lifting weights may feel pain, but because they interpret their own pain as “normal,” and thus not worthy of alarm, the person continues to “push” through.

Similarly, science and society interpret painful menstrual cramps as a normal, natural, and inevitable experience for anyone with a uterus or female reproductive organs. “Normal” can refer to both the frequency and the expectation that something will occur. In the case of painful menstrual cramps, “normal” indicates both the expectation of experiencing severe pain during menstruation and the acceptance of that embodied experience as the norm or standard. Consequently, this can delegitimize attempts by menstruating persons to adopt illness behaviors.^{11 –13} Recognizing a pain experience as a “legitimate” health concern affords individuals with certain privileges that they would otherwise not have, such as permission to enter the sick role—that is being excused from day-to-day duties (e.g. school, work, and family) and entitled to, or even expected to, seek medical care and attention.^{10,14 –16} Diagnoses like endometriosis or fibroids wield a lot of power in legitimizing a patient’s report of painful menstrual cramps because a diagnosis labels an embodied experience as “abnormal.^13,17 Although a diagnosis can confer legitimacy to a reported pain, diagnoses reflect the dominant biomedical explanation of a symptom, which may misalign or even deny individuals” lived experiences. ¹³

Painful menstrual cramps can negatively impact a person’s life. In the largest online survey of reported menstrual symptoms, on a pain intensity scale of 0 to 10, with 0 being no pain and 10 the worst pain imaginable, respondents rated abdominal pain during menstruation an average score of 6. ¹ Of those who reported abdominal menstrual pain, 75.9% reported having to push themselves to continue with their daily activities, 8.3% reported that they perform fewer activities, and 6.7% reported that they could do almost no activities at all. ¹ Interestingly, only 9.8% of respondents were diagnosed with a medical condition that could potentially explain their symptoms. ¹ It is possible that many survey respondents are experiencing secondary dysmenorrhea and have yet to formally receive a gynecological diagnosis. However, even for those with documented primary dysmenorrheic pain, a 26% reduction in overall quality of life was observed. ¹⁸

Symptoms that are perceived as normal are typically viewed as being more appropriate for self-care rather than formal help-seeking. ¹⁹ As a result, menstruating persons can perceive themselves as not having a legitimate reason to elicit help.^5,19 In another online survey, despite having significant dysmenorrhea, 51% of respondents thought that their menstrual experience was normal and, of those, only 11% engaged in help-seeking behaviors. ²⁰ One explanation is the fact that menstruating persons are frequently inundated with the idea that painful periods are a part of life, something that a menstruating person is expected to “get on” or “deal” with.^4,6 Family, friends, and medical professionals can reinforce this message.^5,6

This is well illustrated in Kallia O. Wright’s personal essay, You have Endometriosis”: Making Menstruation-Related Legitimate in a Biomedical World. Wright recounts how her mother responded to her menstrual pain with frustration (“I had bad cramps too when I was you age, and I dealt with it like every other woman.”); her friend responded to her menstrual pain with annoyance (“Kallia! Stop being a baby! You’re not sick”); and her gynecologist normalized her menstrual pain by comparing Wright to other women (“Some women just have stronger cramps than others . . . But more importantly, you’re not telling me anything that sounds out of the ordinary or beyond what other women experience”). ⁵ Consequently, Wright internalized the societal message that severe menstrual pains would not warrant alarm. For example, even as sharp menstrual cramps violently woke Wright from her sleep, she could not get herself to call 911 (“What would I tell them? My tummy really hurts?”). ⁵

Normalization as a motivational deficit

Pain expressions have evolved to function as both a signal that one is in pain and a cue for assistance. ²¹ Normalizing painful menstrual cramps can disrupt pain communication because a menstruating person’s pain report is prevented from eliciting the care or assistance that it otherwise given to an expression of pain. In previous works, I refer to this as an example of what I call a pain-related motivational deficit ²² . A pain-related motivational deficit occurs when a listener believes a person’s pain report, but because of certain social practices, like the normalization of menstrual pain, the person’s pain report is diminished or downplayed ²² . The reported menstrual pain would have otherwise motivated alarm if not for the effects of a patriarchal ideology in our society.

A pain-related motivational deficit differs from what philosophers call a testimonial injustice, or more specifically, an identity-prejudicial credibility deficit. An identity-prejudicial credibility deficit occurs when a speaker is given less credibility than what would have otherwise been given and this is due to an identity-based prejudice on the end of the listener. ²³ In medicine, pain patients are generally considered “unreliable narrators” and their credibility downgraded. ²⁴ Pain patients who are also a member of a marginalized community are more likely to experience testimonial injustice.^25,26 For example, in a recent study examining the relationship between pain-related stereotypes and perceivers’ pain estimation, participants were more likely to underestimate women’s pain and were more likely to judge women patients as higher in catastrophizing their pain compared with men patients despite the two genders reporting and exhibiting the same intensity of pain. ²⁷ Further findings suggest that perceivers’ stereotypical belief that women are overly expressive influenced these pain estimations. ²⁷ The downgrading of menstrual pain is related but distinct to dismissing women in pain as “emotional” or “hysterical.” The dismissal of menstrual pain primarily manifests as a lack of concern or alarm, while the credibility deficit assigned to women in pain primarily manifests as a lack of trust or belief. Moreover, a credibility deficit primarily reflects a prejudice against the social identity of the speaker while the dismissal of menstrual pain primarily reflects a societal prejudice against the embodied experience of menstruation itself.

When a pain-related motivational deficit occurs, the listener believes and acknowledges that the pain exists, but the listener is improperly motivated by the speaker’s pain report ²² . Even if a menstruating person reports severe or debilitating menstrual cramps, a listener can fail to be concerned or alarmed due to societal practices that causes the listener to misperceive the reported pain as “normal.” A pain that is interpreted as “normal” is likely to be interpreted as low in motivational appraisal, or import. According to Bennett Helm’s evaluativist pain philosophy, pains are feelings in which the negative import, or badness, of what is going on in our bodies “impresses itself on us, exerting a basic attraction upon our minds, foremost with respect to our attention, but in consequence with respect to our motivation” (p. 71). ²⁸ Thus, to recognize a pain experience as having import is to recognize the pain as worthy of attention and immediate action. Dismissing a painful menstrual cramp as “just” a painful period both normalizes this embodied experience and downgrades the ascribed import. The notion that painful menstrual cramps are “normal” makes unimaginable the idea that an excruciating menstrual pain could be worthy of alarm.

When a painful menstrual cramp is not recognized as being worthy of attention and alarm, an uptake distortion has likely occurred. Uptake is the recognition of the meaning and force of what was said. An uptake distortion occurs when there is a discrepancy between the uptake given and the intention behind what was said such that the force of what was said is weaker than what would have otherwise been produced. ²⁹ Consider, for example, a factory floor manager who intends to issue orders to her majority male employees. However, because of the manager’s gender, the workers downgrade the motivational force of the managers’ orders and instead respond to her utterances as requests. Orders have a stronger motivational force because they come from a place of authority and impute an obligation to act in a certain way; requests have a weaker motivational force because a recipient is free to grant or refuse what is being requested.^29,30 Sometimes, an uptake distortion is so strong that no uptake is given at all; the speaker issues an order or provides a reported menstrual pain, and it is treated as “pure noise with no communicative force at all” (p. 188). ³¹

Alma is a 30-year-old woman who experienced extreme menstrual pain since the age of 14. Her experiences were shared in the Medical News Today article, Endometriosis Experiences: The Painful Road to Diagnosis. Alma’s experiences provide a firsthand account of how the normalization of menstrual pains can lead to a pain-related motivational deficit and delayed endometriosis diagnosis. On average, menstruating persons wait between 7 and 9 years to be diagnosed with endometriosis. ³² Alma’s gynecologists assumed that she was experiencing a “‘normal’ albeit very painful period” even though Alma reported excruciating menstrual pains and vomiting to the point of visual hallucinations. ³³ From Alma’s perspective, an underlying condition was not considered, and nobody regarded her pain as something worthy of treatment. She was informed that it was “just” a painful period and to mostly deal with it. Regarding one physician’s response, Alma wrote,

I asked my [family doctor] for a doctor’s note, and he mocked me, repeating several times the phrase ‘you want a doctor’s note . . . for period pain. A doctor’s note . . . for . . . period pain,’ as if it was the most shocking thing he’d ever heard in his life, and how could I dare ask for such a thing. ³³

The idea of receiving a doctor’s note for menstrual pain was unimaginable to Alma’s family physician. Although the family physician was dismissive, Alma’s pain was acknowledged as pain. Alma was not told that she was mistaken about what she was experiencing; her pain was not denied, doubted, or referred to as “psychological distress.” This presupposes that both Alma and her reported menstrual pain were perceived as credible. Hence, I argue that describing Alma’s encounter as an identity-prejudicial credibility deficit inadequately captures this kind of pain dismissal. Alma’s pain was referred to as normal and “just” a painful period. This response simultaneously normalizes Alma’s embodied experience and negates the import of Alma’s pain. Colloquially, adding “just” in front of a noun signals a downgraded import or significance, that is it’s just an ant, it’s just cough, or they’re just a friend. In the clinic, “just” could insinuate that the symptom is not urgent or life-threatening, thus, justifying the de-prioritization of a reported symptom. However, in Alma’s case, “just” a painful period conveyed a stronger sense of de-prioritization: the menstrual pain is not only not life-threatening, but it is also not concerning.

The power stigma and secrecy

Finally, menstruation is both normalized and stigmatized. Stigma is defined as an attribute that is “deeply discrediting”; it conveys information that a person has a defect that reduces them “from a whole and usual person to a tainted, discounted one”(p. 13). ³⁴ To avoid social sanctions (such as ostracism or criticism), individuals are encouraged to conceal their menstrual.^6,35 Menstruating persons often adhere to a “menstrual etiquette,” or a set of rules that dictate how menstruation should be discussed and responded to. ³⁶

Menstruation is stigmatized as a shameful, disgusting bodily function; but in public spaces, it is not possible to know that an individual is menstruating unless they disclose it or menstrual blood leaks through their clothes. A “culture of concealment” makes it harder to conceptualize the idea that painful menstrual cramps have import by making menstruating persons’ lived experiences linguistically and culturally invisible.^{6,35 –38} Talking about one’s menstrual symptoms becomes a communication taboo; “menstruation” or “period” become “dirty words.”^6,35 Instead, we are encouraged to use euphemisms like “Aunt Flo” or “the curse” to further hide or neutralize the potential suffering associated with painful menstrual cramps.

A culture of concealment is further promoted by the expectation that menstruating persons use menstrual hygiene products and dispose or store them in a discrete way. ⁶ Companies that sell menstrual hygiene products have contributed to this culture by designing products that aim to absorb fluid and odors, be invisible through one’s clothes, and small enough to be discretely carried and disposed of in a bathroom container.^39,40 Furthermore, ads for menstrual hygiene products convey a message of secrecy surrounding menstruation and the societal expectation to “push through.” Adopting the sick role and engaging in illness behaviors (such as, staying in bed or seeking medical help) violate this menstrual etiquette. This in part explains the difficulties with perceiving and responding to reported menstrual pain as a legitimate health concern. By reporting pain menstrual cramps, a person is attempting to direct attention and concern to an embodied experience that has been marked as tainted by patriarchal ideology.

This perspective review article is limited to a conceptual analysis of the dismissal of menstrual pain. Although both quantitative and qualitative data are briefly cited, the evidence provided is largely composed of case reports and expert opinions.

Conclusion

In summary, menstrual pains are widely dismissed as “expected,” “normal,” or “just what is to have a period.” This form of dismissal is not the same as doubting or denying a patient’s pain. Because painful menstrual cramps are widely normalized, it is difficult to recognize the import of an individual’s reported menstrual pain. The normalization of painful menstrual cramps is further exacerbated by stigma and secrecy; the mere sharing of one’s menstrual pain can violate menstrual etiquette. Our society still features a culture of concealment, which ultimately bleeds into the clinic space. Addressing the pain-related motivational deficits that get assigned to reports of menstrual pain requires a cultural shift. As individuals’ lived experience of menstruation and menstrual pain becomes more visible, the idea that painful menstrual cramps can be alarming becomes more imaginable.