How menopause symptoms shape experiences of the criminal legal system: A qualitative study across the United States

Abstract

Introduction:

The number of midlife individuals involved in the criminal legal system has increased significantly in recent decades. Despite this growth, little is known about the ways in which experiences of midlife, including the menopause transition, shape experiences within the criminal legal system. This study explores the intersection between people’s experiences of menopause and experiences of the criminal legal system.

Methods:

We conducted semi-structured in-depth interviews with individuals who experienced the menopause transition while involved with the criminal legal system. In-depth notes or transcripts from each interview were analyzed using the RADaR technique for data reduction. We identified emergent themes and developed an overarching thematic framework.

Results:

We conducted interviews with 29 individuals (mean age 56.9 years). Participants reported a wide range of menopause related physical, emotional, and social changes. Menopause related changes considerably shaped participants’ experiences within the criminal legal system. Three distinct themes emerged to characterize how menopause impacted experiences in the criminal legal system: 1) shame and stigma; 2) loss of control; and 3) criminalization and collateral consequences.

Implications:

There is a growing and largely understudied population of individuals going through the menopause transition while involved in the criminal legal system. Our data suggests that the experience of going through the menopause transition compounds dehumanization and deprivation of autonomy in carceral settings.

INTRODUCTION

Nearly 200,000 people assigned female at intake are currently experiencing incarceration across jails, prisons, and other carceral facilities in the United States (US), with around 1,000,000 under the surveillance of the broader criminal legal system including community supervision (e.g., probation and parole).¹ While many of those assigned female by the criminal legal system identify as women, this group also often includes transgender men, non-binary people, and others with gender-expansive identities. Here, we will use the terms “women” and “female” when they appeared in prior publications, and “people” as an inclusive term. In 2022, 1 out of every 141 female adults in the US were impacted by the criminal legal system.¹ These numbers reflect the consequences of a rapid increase in the rate of incarceration of people identified as female as well as an increase in sentence lengths that has occurred over recent decades. Globally, more than 740,000 people identified as female were incarcerated as of 2022, which is a 60% global increase since 2000.² To an outsize degree, this increase is driven by mass incarceration in the US, rooted in systemic racism. Despite these increases, available data suggests the criminal legal system is poorly equipped to accommodate gender specific needs.^3,4

One growing yet understudied sub-population consists of people who are approaching midlife and undergoing the menopause transition while incarcerated. In 2022, 37% of female individuals in US state and federal prisons were aged 40-60 and 48% of all individuals in US jails were aged 35-64.^5,6 Several factors have led to increasing incarceration during the menopause transition – recent years have seen increases in incarceration at midlife,⁶ and approximately 10% of women sentenced at any age receive long sentences (i.e., 10 years or more), another uniquely US phenomenon.^7,8 Incarceration of women, including with long sentences and at midlife, most commonly results from drug, property, and violent charges in the context of substance use, physical sexual, and emotional abuse, and material poverty.^8-11

There is a lack of evidence around the impact of incarceration during the midlife period and on the experience of the menopause transition.¹² The menopause transition lasts on average just over 10 years and is associated with a wide range of physical and psychological symptoms including vasomotor symptoms (e.g. hot flashes), unpredictable mood swings, and irregular menstrual bleeding.¹³ Factors associated with more severe menopause symptoms, including low socioeconomic status and histories of trauma and abuse, are disproportionately also experienced by people with criminal legal system involvement.^14,15 People in carceral facilities report that menopause is an important health issue and conditions prevalent in this population may complicate the management of menopausal symptoms.^16,17

A pilot study consisting of four qualitative interviews highlighted various ways in which constraints of US carceral facilities render menopause symptom management more difficult and meaningfully shape people’s experiences of the menopause transition.¹⁸ We report now on an expansion of our pilot study to include a racially and geographically diverse sample of individuals who went through the menopause transition while involved in the US criminal legal system. Our aim was to explore the overlap between experiences of incarceration and experiences of menopause and to characterize the ways in which they impacted one another.

METHODS

We conducted semi-structured in-depth interviews with individuals who experienced the menopause transition while involved with the criminal legal system. Broadly, involvement with the criminal legal system encompasses incarceration in jails, prisons, community correctional or detention centers, as well as probation and parole. This study was approved by the UNC Chapel Hill institutional review board (# 19-3421).

RECRUITMENT

The current study consisted of both participants who had been recruited into the pilot study and the expansion study.

We conducted pilot interviews with participants in Durham, North Carolina who were previously incarcerated or were participating in a diversion program during their menopause transition. Program administrators at two community programs provided information about the pilot study to program participants between 40 and 70 years of age. Pilot participants received either a $25 gift card or a gift basket of soap and lotion worth $25 if ineligible for gift card due to program policies.

For the expansion study, we recruited participants from an ongoing study of individuals who had experienced criminal legal system involvement. We offered information about this study to individuals participating in the Tri-City Cervical Cancer Prevention Study among Women in the Justice System (R01CA226838), a multisite study based in Birmingham, Alabama; Oakland, California; and Kansas City, Kansas/Missouri, including individuals who have recently returned to the community from carceral facilities, who are on probation, or who are participating in community supervision programs under legal oversight.¹⁹ Individuals contacted our research team via email, phone, or text and were eligible for participation if they had experienced menopause during their period of involvement with the criminal legal system. Participants received a $50 gift card for participation in interviews.

DATA COLLECTION

All participants provided informed consent. We adapted the semi-structured piloted interview guide with minimal changes informed by our pilot study. Interviews lasted 30-60 minutes. Pilot interviews were not recorded; the interviewer took in-depth notes during the interviews. Non-pilot interviews were recorded with the exception of one in which the participant declined recording and in-depth notes were taken instead. All interviews were conducted by a trained qualitative researcher who was not involved in any aspect of participant care or service provision (EJB). All interviews except one pilot interview were conducted by phone or virtually.

DATA ANALYSIS

Recorded interviews were transcribed verbatim and reviewed for accuracy. Given minimal changes to interview guide and thematic consistency across pilot and non-pilot interviews, we included pilot interviews in the present analysis. We analyzed the data using an inductive thematic approach and the Rigorous and Accelerated Data Reduction (RADaR) technique for qualitative data analysis.²⁰ This technique entails first reducing the text down to the excerpts responsive to the research question, then coding the data, and finally reducing to illustrative quotes for each theme. Two authors (EJB and SPP) reviewed all transcripts and created a codebook through iterative discussion, including a priori codes from the interview guide, emergent themes from pilot interviews, and inductive codes from discussion of initial transcript review. Twenty percent of transcripts were coded independently by two members of the research team (EJB and SPP) and any disagreements were resolved by discussion. Each participant was assigned a pseudonym.

RESULTS

We conducted four pilot interviews between September and October 2020. Following conclusion of pilot interviews, we received 37 discrete contacts to the study team. We completed interviews with 25 individuals between May and September 2023. Self-reported participant demographics are displayed in Table 1.

TABLE 1.

Participant Demographics

DEMOGRAPHICS (n=29)
Age
	Mean +/− SD	56.9 +/− 6.7
Race
	Black	15	52%
	White	13	45%
	>1 race	1	3%
Ethnicity
	Hispanic/Latina	0	0%
Gender Identity *
	Woman/Female	29	100%
Education level
	<12th grade	5	17%
	12th grade or GED	12	41%
	Some college	12	41%
State of residence
	Alabama	13	45%
	California	7	24%
	Kansas/Missouri	4	14%
	North Carolina	4	14%
	Other	1	3%

^*The interviewer asked all participants “What gender do you identify as?”; all participants self-reported either “woman” or “female.”

Participants had experienced menopause across criminal legal system settings, including during incarceration in a prison (16/29) and/or jail (22/29) and under parole or probation supervision in the community (14/29). Table 2 displays themes and subthemes reported in this manuscript, with descriptions of the primary contributing codes.

TABLE 2.

Themes, subthemes, and associated coding tree

Theme	Subtheme	Primary Codes	Code Description
Symptom Experience	Physical changes	Vasomotor symptoms	Hot flashes, night sweats (including sleep changes)
		Irregular menstruation	Any mention of bleeding, menstruation
		Genitourinary symptoms	Changes in urination or sexual function
		Pain	Tenderness, cramps, other physical pain descriptions
		Physical changes	Changes in weight, muscle mass, hair, skin, other aspects physical appearance or function
	Emotional changes	Mood	Mood swings, irritability
		Fatigue	Fatigue, exhaustion, “laziness” and “slowness”
		Overlap	Overlap with mental health conditions
	Social changes	Isolation	Social withdrawal and desire for isolation
		Relationship changes	Impact on relationships with partners, friends, family
Impact of Symptoms on Incarceration Experience	Shame & Stigma	What was endured?	Endured shame or stigma
	Loss of Control	What was lost?	Loss of control, loss of bodily autonomy, loss of hygiene, coping mechanisms, ways to cool down and stay dry, ways to clean clothes, menstrual hygiene products
	Criminalization	Compounding consequences	Receiving additional punishment due to symptoms or symptom management
		Retribution	Perception that enduring menopause while incarcerated is part of punishment

EXPERIENCES OF MENOPAUSE

Participants reported a wide range of menopause related changes, including physical changes, emotional changes, and social changes.

PHYSICAL CHANGES

“It has been a lot of changes” — Barbara

Almost all participants reported vasomotor symptoms including hot flashes and night sweats, which often led to trouble sleeping and fatigue. Hot flashes were described as originating internally (“you get hot from the inside out” — Crystal). Hot flashes occurred regardless of outside temperature or efforts to cool down, and some participants felt as though they were “about to pass out” (Sandra) during a hot flash. One participant described it as:

“When you break out into a sweat, all of a sudden. You get moisture all over your body. And feel that you’re gonna’ faint or something’s gonna’ happen that’s not gonna’ be good or something so you get water and you start fanning. And then you come back to life.”

— Cynthia

Most participants reported experiencing irregular menstruation (“I didn’t never know when I was gonna’ start my cycle” — Linda) as well as heavier bleeding. Additionally, participants reported a range of genitourinary symptoms related to menopause including urinary changes (“my bladder been out of control” — Tracy), as well as vaginal dryness and changes in sexual functioning. Other physical symptoms that participants reported included those related to pain (e.g. more intense menstrual cramping and worse headaches) as well as changes in physical appearance and function. Reported physical changes spanned from weight changes, feeling bloated, and appetite changes to changes in hair growth and texture, breast tenderness and discharge, bone degeneration and decreased muscle tone.

EMOTIONAL CHANGES

“My feelings were all up in the air” — Patty

The most common emotional symptoms described were related to mood swings or the menopausal “roller coaster ride of emotions” (Lisa). Most of the emotional shifts were described as episodes ranging from anger to sadness though they were often accompanied by irritability and agitation. Another common emotional symptom endorsed was an overall feeling of fatigue and lack of energy (“It got me not wanting to move” — Tina), with multiple participants describing feeling “lazy.” One participant described this sense of weariness as “my body just changed. I don’t have any spirit in my body. I just be lazy” (Sharon). For some, fatigue and irritability were associated with vasomotor symptoms such as hot flashes (“the mood swings just kept on and on and on … I started getting aggravated and irritable when I got hot flashes” — Kendra) but for others feeling fatigued or irritable was the predominant symptom.

“I could not see the brighter side of things” — Sandra

Participants also described the overlap of emotional symptoms with those of pre-existing mental health conditions, and how mood swings exacerbated underlying symptoms. It was challenging for some participants to tell the difference between menopausal mood symptoms and symptoms of mental health conditions such as anxiety or depression (“I can be thinking I’m depressed because all these things are going on, and it’s just menopause, you know?” — Melissa). Multiple participants endorsed suicidal ideation that they attributed to mood symptoms of menopause:

“It changed my emotional health… I would think deeper than I normally would and not in a good way. Back to depression. You know, I would think deeper. I would say, actually, too deep. There were times I even felt like giving up. You know. Right. But I held on. Stayed, prayed, and I held on. Took a long time, but I did it.”

— Susan

SOCIAL CHANGES

“Catch me tomorrow cause’ I’m going through the pause” — Betsy

Menopause symptoms often led participants to seek social isolation. Most often the reason cited for avoiding social situations was a new desire to avoid interpersonal interaction (“I don’t really talk to many people anymore” — Tonya). In some instances this was driven by the feeling that “you don’t wanna be bothered” (Teresa), along with a lower tolerance for social interaction (“I don’t wanna’ deal with the public” — Jennifer) and a lower threshold for annoyance at others (“a lot of stuff just irritates me now that probably didn’t irritate me when I was younger…I just can’t stand too much of anything” — Tracy).

“That’s putting somewhat of a dent in my relationship — Tonya

Other social changes frequently reported by participants related to changes in romantic and family relationships. Genitourinary symptoms and sexual dysfunction were not only sources of physical discomfort, but also had detrimental impacts on relationships with sexual partners:

“I’ve heard a lot of women say that during menopause sex was painful, it’s never been painful. It was just I didn’t have a sex drive and I could under no circumstance have an orgasm…It makes you feel awful. And just frustrated and the man thinks he’s not doing something right”

— Crystal

Additionally, participants explored how the desire for isolation, menopausal emotional changes, and perceived contribution of menopause to their criminal legal process strained their relationships with family members.

HOW MENOPAUSE SHAPED EXPERIENCES OF INCARCERATION

Across physical, emotional, and social changes related to menopause, we identified three cross-cutting themes to characterize how menopause shaped participant experiences of incarceration. First, participant narratives were saturated with shame and stigma, whether caused by symptoms, limitations on capacity to manage symptoms, or the dehumanizing conditions in which participants were experiencing menopause. Next, participants described feeling a loss of control related to menopause. There was a loss of control due to unpredictability of menopause symptoms, a loss of autonomy and external capacity to manage menopause related health needs, as well as a loss of self-identity and self-control. Third, menopause perpetuated and deepened the criminalization imposed on participants by the criminal legal system by compounding the extent of punishment. An emergent subtheme was the perception that suffering from menopause was part of retribution for prior actions.

SHAME AND STIGMA

“Made you feel dirty and uncomfortable” — Laura

The experience of going through menopause itself was cited as a cause of shame and stigma, with participants describing that it “makes you feel different” (Mary). Shame and stigma were amplified by carceral environments. With irregular bleeding, for example, humiliation was exacerbated by insufficient or inadequate menstrual hygiene supplies in carceral settings (a woman don’t like to bleed all over herself — Denise). Sources of shame related to inability to manage symptoms included restrictions on the number of facility-issued clothing items (they just give you that one orange suit — Dawn), limited ways to wash clothing (they had a little sink in there…I washed them out, and hung em’ up in the cell — Dawn), and delays in receiving clean clothing in the event of bleeding or sweating through.

“I had gotten blood all over my clothes… I was embarrassed for one thing. Cause’ I had to walk around. It’s not like they instantly brought my clothes up to me. I mean, I had to walk around for some time with blood on my clothes. It was just embarrassing.”

— Heather

Participants described not only feeling shame around menopausal symptoms but experiencing teasing from other women and facility staff.

“Other women there would say nasty stuff to you. If they see blood on me or whatever…It made me feel like I was dirt…everybody in there has had a period, and they know what it was all about. Why do you wanna’ try to put somebody else down? Make fun of them it really, really, really makes you feel so horrible when people talk to you like that.”

— Linda

Genitourinary symptoms were also a source of shame and stigma.

“Sometimes I have a little urine leak. No. I don’t really think I was ever really dry…It was kind of embarrassing to me. You know, I know nobody could see it and stuff but, it was kind of embarrassing just knowing that you were going through it and there was nothing you could do about it.”

— Rebecca

“I didn’t even wanna’ go out to eat chow, so I just stayed in my cell” — Dawn

Shame around menopause symptoms led participants to isolate from others. Specific to physical changes, reasoning around self-isolating was often related to fear of humiliation due to sweating, leaking urine, or bleeding through clothes. One participant explained:

“Because if you go out somewhere and still having them hot flashes, you know, sweating, people will think that you have a disease or something”

— Teresa

For emotional symptoms, easily triggered mood swings and fear of outbursts led individuals to isolate (“I wanted to not participate in anything or go to work or go to classes … I was afraid of starting my period or having outbursts” — Patty). This was sometimes managed by voicing a need to be alone, when possible: (“I just get to myself until I just come back around…They be like what’s wrong with you?” — Rebecca). However, others saw the subject of menopause as taboo, adding an additional layer to the shame of going through symptoms and seeking isolation: “I didn’t want no one to know” (Cynthia).

LOSS OF CONTROL

“It just come all of a sudden” — Rebecca

Across narratives, menopause symptoms were characterized as unpredictable and “very overwhelming” (Wendy). Hot flashes onset quickly with no warning (all of a sudden it goes really haphazardly, and you get real hot” —Barbara) and often this resulted in becoming suddenly soaked in perspiration (“I bust out with that sweat” — Nicole). Patterns of menstrual bleeding were also erratic (“I was scared that blood would come out — Sharon). Despite occurring with frequency, onset of symptoms continued to be sudden and surprising (“I would get surprised about bleeding or sweating real bad” — Patty). Shifts in mood were also rapid and unpredictable, often with no trigger or sometimes highly reactive to a trigger disproportionate to the emotional reaction.

“When I started getting the menopausal symptoms, it just seemed like it came on really fast, too. It's like all of a sudden, I'm overly emotional and/or going into depression… It was very distressful…being happy at one moment, then terribly depressed another”

— Lisa

As such, participants reported feeling a loss of control around mood swings as well as emotional outbursts.

“I couldn’t cool myself off” — Heather

Participants also described a loss of control over ways to manage symptoms related to menopause (“You ain’t got no mechanism to really tame it… You gotta’ learn how to maneuver it”— Betsy). This loss of control led to increased suffering from hot flashes and night sweats in carceral settings, as the heat was intensified by warm environments often with no fans or air conditioning, restrictions on cool drinks and showers, and overall few ways to cool down.

“We were in the city jail back when that was happening. We were lucky if we had a fan in the dorm, the block that we were in which probably held 100 women. It used to be so hot in there that we would lay in there as naked as possible on the floor, on the cold cement floor. Closest to a fan that we could get if there was one. And then if not, just on the floor because the concrete was cold. Summertime was horrible.”

— Jennifer

Confinement, not only to facilities but within them (e.g. to cells, bunks, or indoor spaces only) presented challenges to managing symptoms:

“You don’t’ wanna be walking around, you’re in an 8-man cell, you don’t wanna be walking around nobody else, on top of anybody else’s head while they’re sleeping. That’s dangerous. You’re in an 8-man cell on bunk beds. It’s not that big.… You can’t go anywhere but to the sink with your towel and wash your face. Maybe get a cold towel and put it on your neck to try to bring your body temperature down. That’s about it. Take the covers off. Try it again.”

— Tracy

Participants described limited or no access to air conditioning, fans, cold drinks, or being able to wear light clothing. Instead, they cooled down by fanning with paper or books, showering as frequently as was allowed, or finding areas that were more temperate such as storage closets or the “holding tank.” Alternative strategies to dealing with the heat centered on acceptance and resignation (“I just accept it baby” — Betsy), such as lying down and waiting for the heat to pass (“just keep still and be quiet”— Barbara). One participant described coping with humor and bonding with others: “we kind of laughed about it too, you know, being there together” (Patty). Other participants described distracting themselves with activities such as breathing (“I had to breathe through it” — Kimberly), meditating, reading, praying, and other activities.

“You have no freedom, you have no choice” — Wendy

The distinct loss of bodily autonomy during incarceration was in contrast to participant experiences of managing menopause symptoms at home:

“It’s different on the outside. On the inside, you don’t have no freedom of speech. You don’t have no, you know. You only have limited access to things. Out here, you can do a lot of things to make those things go away. There’s a lot of things you can do on the out than the in. You know, in, you’re limited. Out, you can do all kinds of things. You can go meditate. Go take all your clothes off. You can walk around butt naked. You know, but there you can’t do none of that.

— Betsy

Specifically, the concept of being stripped of freedom emerged frequently:

“Whenever you’re at home, you’re able to go at your own free will. You’re able to make adjustments and do things. But in prison, you just have to make it work with whatever you can think of”

— Laura

Participants compared the experience of managing vasomotor symptoms while incarcerated to managing them at home.

“You can’t have fan directly on you when you go to sleep. You can’t go get ice whenever you want. Shower lines. You don’t have any freedom in jail, so it’s not like you’re home alone or in your own home. You don’t have the comforts of home, you know.”

— Wendy

Overall, symptoms were more salient in carceral settings (“it feels like I noticed it more or it bothered me more because I’m not in the free world” — Cynthia).

“We don’t pick when we bleed” — Melissa

While access to ways to cool down was largely limited, access to laundry, clean clothes, and menstrual hygiene products was variable. Many participants reported cleaning their underclothes and uniforms in the sink:

“I had to wash my clothes with my hands… If I left them sitting there until laundry day, it would’ve been stained and I would have to pay for a new uniform. You don’t know what you’ll get back when you send out for a new uniform. It might be stained. It might be worse than the one you had. It might be the wrong size. It might be anything.”

— Linda

For menstrual hygiene products, there was variation in quantity, distribution intervals, and equitable allocation. Some participants reported only receiving products at infrequent intervals:

“I just a lot of time just roll up toilet paper and use that, it sounds gross, but, the other option was gonna be, you know, wearing the same pad or tampon cause you’re gonna, you’re gonna wait most definitely. Probably one out of ten times you ask you’ll get it…You know who’s gonna give you a tampon and who’s not.”

— Melissa

Others described distributions that were more frequent but only at pre-specified intervals. Less commonly, participants reported unlimited access to products. When products were provided at no cost, they were usually only pads, with some participants able to purchase tampons from a commissary. Several participants described how distribution of hygiene products was not a fair process, but a first-come, first-served allotment of limited quantity, leading to unequal allocation:

“They don’t have good sanitary products there… if it’s 20 girls in a section, they may bring 20 pads in there … You know when someone is flowing real heavy, and you need more, you have to wait until they make the rounds, it was just hard. I don’t know whether the guards didn’t want to do it, or they just have to bring them when they do rounds. When you be mashing the buzzer telling them you be flowing heavy.”

— Rachel

Overall, quality of hygiene products was described as poor, with one participant noting that “it wasn’t the real deal…Everything in county jail is generic. They don’t get the real deal” (Mary). Some participants reported that when the quantity or quality of products was inadequate, they utilized resourceful methods to control their bleeding, either fashioning their own products (“in the jail, we made our own tampons out of the pads” — Jennifer), or repurposing other distributed clothing items to catch menstrual bleeding:

“It felt bad. I had to put socks and underwear down there to where I’m running around without socks or underwear because I had to use them for the pads. Y’all don’t know.”

— Kimberly

One participant was incarcerated with someone who would make extra-thick underwear out of the sports bras bought from the commissary for additional protection from irregular bleeding. In some cases, an inability to maintain hygiene due to menopause symptoms led to desperation and enabled abuse:

“The men guards were having sex with the inmates, female inmates and things of that nature for a little napkins, soap… That’s illegal. But some of the ladies was doing it because they were desperately in need.”

— Susan

“Something’s taking over my body” —Tonya

Participants felt as though menopause itself was a cause of lost bodily autonomy (“it feels like I don’t have control over my own body anymore” — Tonya), and for some, a fractured self-identity. The loss of control around symptoms in some instances made participants directly question their sense of self (“it did make me a different person” — Patty). Notably, multiple participants described menopause as something that happened to them, made them feel as if they were not in control of their own bodies (“it’s something I just hate that’s happened to me, I just hate it” — Amy). Further, some described menopause not only as a cause of lost control but as an agent that had taken over control:

“It's so hard to believe what we're going through, that that our bodies would do this. It's almost like your body's against you.”

— Lisa

In several instances, feeling out of control due to menopause, particularly emotional volatility, contributed to how participants understood the factors leading to involvement in the criminal legal system.

CRIMINALIZATION OF MENOPAUSE

“I lost some time for it. They can take time away from you” —Tracy

Participants discussed multiple ways in which menopause symptoms or efforts to manage menopause symptoms had ramifications on their criminal legal process. Most cited were various punishments received for soiled clothing or other consequences of menopausal symptoms, including disciplinary write-ups which often led to additional days added to total incarceration time or periods in solitary confinement (“you can land yourself right in the hole” — Betsy). Participants reported receiving additional punishments when they would have emotional outbursts related to menopause mood swings:

“I was hot, irritated… I was overheating as far as in my brain or whatever. That’s why I got sent to solitary”

— Kimberly

“My mood swings got me in trouble. I was in administrative segregation because I was having mood swings…I know it was my mood swings because they gave me hell. One cuffed me and put me in segregation. It made me mad at myself, wishing I never did or said nothing.”

— Amy

“I saw women go from being model inmates to getting back-to-back write-ups [as they experienced menopause emotional changes].”

— Rhonda

One participant described that her explanation attributing behavior to menopause was dismissed by the officers who sent her to solitary confinement while in prison:

You argued, you were going to jail. You fought, you were going to jail. You talked back, you were going to jail. They would say ‘that’s not an excuse’ when we said we were menopausal.”

— Rhonda

Several participants described additional punishment or fear of additional punishment related to menstruation and associated symptoms such as cramping. One participant described noticing a period blood stain on her uniform and how she was not allowed to change out of it or into another item of clothing:

“I remember I’d showered and I’d gotten dressed, I’d put it on. I hadn’t paid attention and of course, there’s no mirrors so, can’t see what you look like so I had it on all day and so later I had to go to the bathroom and I’m standing there and I look down and the whole middle and back of my jumpsuit was I’m assuming a period blood stain…I didn’t want to put it back on, so I had to ring the buzzer and then literally the guards would not bring me another jumpsuit…I could not pull that thing back up. I missed breakfast…I was hitting the buzzer and of course no one brought me anything…I actually got in trouble because you can’t have your clothes off, you know, you have to be fully dressed. And so they do a check every hour and look in and so, I didn’t care cause I wasn’t putting it back on, but I got a write up.”

— Melissa

Other participants reported receiving additional consequences for menopause management:¹⁸

“When they yelled out the count time, you have to be on your bunk, but if I’m in the bathroom, obviously, I’m not on the bunk… And they give me write-ups…Probably at least twice a week.”

— Mary

“You have to have the covers on you, be under the covers. They would tap and say get under the covers as they go and peep in on you…Those are the rules.”

— Nicole

“I knew I couldn’t pee [because of medications for overactive bladder]. They were supposed to wait an hour, but they waited three. I got a writeup because I couldn’t fill the cup.”

— Rhonda

One participant, Dawn, reported that she served two additional months of incarceration due to write-ups related to menopause.¹⁸

“That’s my fault. I put myself there” — Wendy

Finally, there was a perception among participants that the challenge of enduring menopause while incarcerated was meant to be a part of their sentence. When describing how she experienced menopause symptoms in a jail, one participant said, “I had to pay the consequences of my past actions” (Jennifer). The additional layer of suffering and humiliation due to menopause and limitations on capacity for menopause management was perceived by some as an intentional deterrent perpetuated by the criminal legal system.

“It’s humiliating. It’s embarrassing. It’s shameful. It’s awful. It’s degrading. Make you feel less than, you know, because in there that’s the point. That’s how they want you to feel, so you don’t come back. It doesn’t make it right, but that’s what they do. It definitely doesn’t feel good; that’s for sure.”

— Tracy

One participant described that this message was one she had received from her family:

“My mom was just telling me, you know, I put myself in that situation to be in there, so I have to deal with it because if they don’t have anything, you can’t do anything but deal with it.”

— Dawn

DISCUSSION

This study is the largest conducted to date to explore the intersection between experiences of menopause and experiences of incarceration and criminal legal system involvement. Participants reported symptoms across the wide range of typical experiences of the menopause transition.²¹ Beyond describing symptoms, our data renders starkly evident the ways in which incarceration limits the ability to manage menopause related symptoms, particularly vasomotor symptoms, genitourinary syndrome, and irregular bleeding. Participants experiences coalesced into three overarching themes characterizing the ways in which menopause shapes experiences of incarceration: (1) shame and stigma, (2) loss of control, and (3) criminalization and collateral consequences.

Apparent across participant experiences in our study are the multiple ways in which sexism and mass incarceration serve as not independent but as intersecting systems of oppression for midlife people experiencing menopause. Menopause symptoms are known to be inciting factors for feelings of shame and stigma in non-incarcerated populations.²² Other scholarship explores how female bodily fluids such as perspiration, menstrual blood, and urine are viewed as uncontrollable, dirty, and a target upon which systems impose social control.^23-25 Our data demonstrates the ways in which this shame and control is compounded in carceral settings, through the intersection of menopause-based, gender-based, and criminal-legal-system-based stigma as well as restrictions on or lack of access to symptom management options that render menopause symptoms more publicly visible. These findings echo the extensive documentation of intersectional shame and stigma related to menstruation in criminal legal settings across the globe.^26-32

Our findings are also consistent with literature describing how restricting access to resources for gender specific concerns (in particular, menstrual hygiene products) can be weaponized within the criminal legal system as a form of coercion, gender-based control, and abuse.^3,33,34 We did not note substantial differences in experiences across sites of carceral involvement. While some state and all federal carceral facilities in the US are required to provide hygiene supplies, literature reflects that this may be a critical gap and ongoing challenge for the global population of people experiencing the menopause transition while navigating the criminal legal system. Most of these regulations reflect the best-practice standard to provide unlimited access to a range of menstrual products, including pads and tampons of varying absorbency. Our findings are consistent with prior reports of inadequate supplies across a more globally representative literature on experiences of menstruation and abnormal uterine bleeding in carceral settings, though this work is not specific to menopause.^{19-21,25,26,28} Inability to manage symptoms or maintain hygiene was often cited by participants as related to inability to change clothes after unanticipated bleeding or sweating due to menopause, suggesting that increased menstrual products may be necessary, but not sufficient to ensure a humane experience of menopause during incarceration. Based on other literature describing poor sanitary conditions for managing menstruation in the criminal legal system globally, menopause may present a compounding hygiene challenge.³⁶

Our findings add to prior literature describing the perceived loss of control that accompanies the menopause transition among individuals in the general population.³⁷ Again, incarceration is a compounding force, here exacerbating loss of control related to menopause and ability to manage symptoms. Perceived loss of control may impact symptom experience; for instance, one study demonstrated that a high degree of perceived control over hot flashes was predictive of lower self-reported vasomotor symptom severity.³⁸ Overall, what our results emphasize is how limiting access to ways to cool down and stay dry serves as a reinforcement of gender-based shame and control.^3,34,39

The criminalization of menopause apparent in our data is highly concerning. Collateral consequences of experiencing various health conditions within the criminal legal system have been previously documented.⁴⁰ Our data is consistent with such discussions of penal harm, and reinforces how punitive policies and practices may be gendered.⁴¹ Women face higher rates of discipline relative to their male counterparts within the US criminal legal system in general; our study suggests menopause as a possible contributing factor among midlife individuals.⁴² In our study, multiple participants described the collateral consequences of menopause, such as receiving additional total time incarcerated and receiving time in solitary confinement. The ramifications of these findings are weighty, as both length of incarceration and solitary confinement are associated with increased risk of death after return to the community.⁴³

The primary limitation of this work is one inherent to qualitative methodology, which serves to surface, rather than to answer questions. However, given that literature on the intersection of menopause and the criminal legal system is extremely limited, a key strength of this study is that it generates areas of focus for future research. Further, the qualitative nature of our study centers the narratives of the individuals with lived experience of the issue. As such, this study does not include the viewpoints or practical insights that might be offered by administrators or frontline staff in carceral facilities or community supervision programs, or other criminal-legal system actors. An additional strength is the wide geographical representation among our participants, although our findings are limited by a lack of Latina voices represented in our sample. Although qualitative data are, by design, not generalizable, we achieved thematic saturation in an analysis that included criminal legal system experiences in Alabama, California, Kansas, Missouri, and North Carolina.

CONCLUSIONS

The subject of menopause during incarceration is drastically underrepresented in the global research agenda; only eight studies examine the intersection between menopause and incarceration,²⁵ and only two such studies examine a population outside of the US or Europe.^44,45 This presents a critical gap in the global literature, especially given the 60% increase worldwide in the past quarter century of individuals experiencing incarceration who have the capacity to experience the menopause transition.² Qualitative methodology is well suited to capture a broad range of experiences and identify common themes across narratives. Our findings on the unique experiences and perceptions of this growing yet understudied population can help to inform key areas for further research, policy development, and programmatic intervention. In particular, further research is needed to better characterize the ways in which individuals within the criminal legal system face collateral consequences related to menopause and menopause symptom management.

Efforts to reverse mass incarceration and trends in female incarceration rates are the clearest means to address the growth of the menopausal population in carceral facilities on a global scale. However, in the interim, policy and practice changes are needed to rectify the various ways in which carceral facilities continue to fall short in providing appropriate gender-based resources and environments, including around menopause related concerns. Our work is part of an emerging body of literature on menstruation and menopause in custody.^16,17,45,46 By expanding the focus beyond the impacts of the criminal legal system on contraception and pregnancy to include the entire reproductive life course – menstruation, pregnancy and birth, menopause – this work extends scholarship on reproductive injustices in custody.^47-50 Until all those experiencing the menopausal transition can return to safe communities, out from under criminal legal supervision, the criminal legal system must ensure humane conditions, sufficient menstrual products, access to medical care and emotional support. Additional efforts will be required to reduce gender-based stigma and to eliminate policies that criminalize experiences of menopause.

HIGHLIGHTS:

• Carceral settings severely limit menopause symptom management

• Menopausal symptoms compound shame, stigma, and loss of control in carceral settings

• People receive additional punishment for menopause symptoms and symptom management