A range of elements relating to the menstrual education and PE were discussed by pupils (Table 1). Similarities were reflected across focus groups in terms of current education and preferences, comfort of conversations, lack of school support and impact on PE. A word document of approximately 62,420 words of transcribed text was analysed. Through analysis, 12 sub themes and four main themes were developed a) Education preferences, b) Period positive environment c) Personal experiences d) Impact on school (Table 2), each of these is discussed below.
Table 1: Pupil focus group characteristics
School location
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Year Groups
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Total number of pupils
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London
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7-8 and 9
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9
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Derby
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7 and 9
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8
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Hereford
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8 and 10
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10
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Kent
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8
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4
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Torfaen
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7-8 and 9
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12
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Sheffield
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6
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5
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Table 2: Main and sub-themes from the focus groups
Main Theme
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Sub-theme
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Education preferences
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Lesson style and approach
Lesson content and delivery
Lesson timing
Education for non-menstruators
Physical activity and education
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Period positive environment
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Awareness
School support
External support
Communication comfort and confidence
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Personal experiences
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Symptoms
Negative experiences
Management
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Impact on school
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General school
Physical Education
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Education Preferences
Participants shared different experiences of menstrual education received at school. Pupils often explained their preferences to receive education separately from their male peers, to increase levels of comfort when having conversations and to reduce feelings of being judged or embarrassed. Where menstrual education was taught in mixed-sex classes, some pupils shared how boys responded in class also affected the content and reducing opportunity for conversation and questions.
However, pupils clearly voiced that boys should also receive education on the menstrual cycle to increase their understanding and compassion, either in separate lessons or initially receive lessons separately and then have a mixed-sex class; ‘If boys learn about it first, for two lessons, and then we had the lesson with them it would probably be alright’. If lessons were mixed, which some participants were comfortable with, there was the request for an additional opportunity with just girls to ask questions.
Although it may be more comfortable to have like a lesson with just females, the boys need to learn about it more because it is like a serious topic. They just joke about it’s the most embarrassing thing and it’s horrible.
Irrespective of sexes present within classes, smaller classes were requested to facilitate positive conversations compared to large classes which were described as ‘awkward’; ‘I think if it’s in a big class you feel more awkward trying to say what you’re trying to say than if you’re in a small group’.
Participants perceived teachers to be able to provide menstrual cycle education; ‘I don’t mind teachers telling us about it because it’s their job, they’re teachers’, although some instances there was a preference to learn about the menstrual cycle from a medical expert. If teachers were delivering this education, their level of confidence was of importance: ‘Because of her [teacher] confidence, that helps us gain confidence about asking questions’.
The preference was to receive education from female teachers due to their lived-experiences and perception of being more understanding than male teachers; ‘It would be better if a female teacher [delivered lessons] because they have periods. I had a male biology teacher, and you could just tell the male teacher didn’t really know what to say, he was just reading what was on the board’.
Pupils frequently disclosed they only had one menstrual education lesson at school and the content delivered was often perceived to not be supportive or useful. In some instances menstrual education was completely absent which was exacerbated during the COVID pandemic (March 2020-July 2021). The timing of delivery of menstrual education was frequently reported to be too late; ‘I think for younger years, like Year 7 or Year 8, it would be quite helpful’. This was a consequence of personal experiences where a lack of information was received prior to reaching menarche; ‘I think before I got my period I was so scared because they never told us’.
I feel like there’s a lot of people who don’t know what it [menstruation] is. But I think it should have been a lot earlier, like that’s a problem, everyone needs to be educated about everything about female puberty, like everything.
Commonly, information on what to expect and what to do on your first period was delivered in primary school (years 5-6) along with information on some period products (tampons and pads). Further information on reproduction was sometimes received during biology lessons, alongside symptoms (period cramps, mood swings, body changes) but this focussed on educational content of the Biology curriculum rather than considering the impact on individuals. Participants also reported a lack of education and information provided on the causes of symptoms, how to cope with the differing types of symptom, and recognising and dealing with irregularities. Even more so was the complete absence of any education on how to manage periods during PE. Participants felt it was ‘a tick box’ exercise with perceptions of ‘ok we have to get through these slides so we can move onto the next thing’ with lessons lacking personal/lived experiences, management of symptoms or any level of detail. Table 3 summarises content and information requested by participants.
A lack of education and understanding of the menstrual cycle by non-menstruators was a common issue in school. Participants reported that male teachers lacked knowledge, confidence and displayed feelings of discomfort during conversations. Some individuals did describe positive experiences of speaking to male teachers, or of the lessons taught by a male teacher:
He was confident speaking about it even though it hasn’t happened to him. He was still confident speaking which I think made the girls a bit more…he knew a lot about it surprisingly.
But this was inconsistent; ‘There are certain male teachers, but there are only some that really understand and stuff’. The perception and impact of boys was prominent. Pupils shared how boys’ lack of understanding, asking uncomfortable questions and laughing or making fun of the topic had a negative effect on girls; ‘Boys shouldn’t be teasing girls for something that is not their fault and it’s natural’. This was further emphasised by comments such as: ‘The boys in our school they thought like you could control when you had your period. Like you could be like, I want my period now and I don’t want my period now and yeah, I’m just going to make it stop,’ and ‘Because they make fun of it [menstruation], some people don’t change [period products] in school and that’s real bad’. Some participants suggested ‘Maybe if the teachers, like the male teachers got to know a bit more about it, maybe that would be a bit better’.
Pupils expressed desired changes in PE, education preference linked to activities and exercises. There was a consensus for greater flexibility in activity choices if experiencing menstrual cramps, with a preference for slow movement and exercise such as yoga, ‘if we did like a slower form of exercise’ or to be involved in a different capacity such as coaching. Year 10 pupils involved felt they had more choice, but suggested this should be throughout all school years, given not all girls began their periods in the same school year. The opinion within this group was quite clear, highlighting the need for options. It did not seem that girls did not want to participate, more so they wanted to better understand and be able to take part in PE that was more appropriate for their symptoms on that particular day.
It might be really encouraging for younger years to choose because if their influence at the age of 11 or 12 that doing sports on their periods is a really horrible thing they will take that with them as they get older which is not a good thing but if they choose their sports then enjoy that and then that would be really good thing
Education was required on how to manage periods whilst exercising, ‘we haven’t been told. Not by parents, not by teachers’ and requested support to use exercise to help manage symptoms, ‘rather than saying sit out of PE they [teachers] can give the girls who are on their periods like time to do exercise that helps with cramps or reduces pain’.
***Insert Table 3 near here***
Table 3: Lesson format, delivery, information and supported requested by pupils relating to menstrual education and school for a period positive environment
Lesson format and delivery
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Requested school support
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Mixed-sex classes with opportunity for girls only class after OR boys and girls separate and then a mixed-sex lesson after.
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Timing of delivery useful for pupils rather than convenient in the school year
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Frequent lessons to recap or talk/ask questions
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Avoid lessons being a ‘tick box’ exercise
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Smaller class size
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Aim to dispel myths e.g. not being able to do handstands whilst on periods!
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Female teacher to deliver lessons
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Access to toilets during lessons
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Teachers to be confident delivering
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Access to period products in toilets
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Lessons delivered at a younger age (year 10 too late)
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Male teachers having increased understanding
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Anatomy diagram where the reproductive system is and what this includes e.g. where does a tampon go and how to insert a menstrual cup
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Teachers to receive education
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PE lessons to include slower exercise or options e.g. yoga across all school years
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Empathy from PE teachers
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Information requested
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How to know when your periods start
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Teachers listen and acknowledge individual differences
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Why do females menstruate and what happens throughout the cycle
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Develop an open culture and normalising conversations amongst boys and girls
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How much blood is lost and how to manage heavy bleeding.
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Peer support
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Menstrual irregularities, what is normal and abnormal including menstrual dysfunction
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Boys to receive lessons
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Causes of absent or missed periods
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Include parents in increased knowledge and support of the menstrual cycle
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Causes of different colour of period blood
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Causes of menstrual cramps and management strategies including exercise
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Causes of mood swings
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How to track the menstrual cycle
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Understanding of different menstrual products
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Management strategies for periods and staying physically active
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Who to talk to about the menstrual cycle and any issues
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Other management strategies available such as diet and medication
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Period Positive Environment
Participants displayed a lack of awareness relating to many aspects of the menstrual cycle within school and wider society, this included but was not limited to: 1) anatomical awareness ‘so where is your uterus, is it in your stomach?’, 2) menstrual cycle biology, 3) the importance of regular menstrual cycles and causes of irregularities, 4) what is deemed a normal menstrual cycle ‘I always thought like periods were like 24/7 like every day, all the time. That’s why I was like terrified’, 5) the age periods should start, 6) causes and management of symptoms ‘why do you have cramps, like, what causes them?’, 7) when and where to receive support in relation to their menstrual cycle and 8) application of products that are inserted into the vagina.
There were a couple of participants that displayed increased knowledge of the menstrual cycle; one pupil had an awareness of energy intake and missed periods ‘not drinking and not eating much like can cause irregular periods’, however, this level of understanding was rare.
It was consistently reported that some aspects of the school culture and environments were unsupportive for individuals menstruating. Some teachers were reported to lack awareness and perceived to not listen to individuals’ experiences of menstruation, ‘You just feel like they [teachers] don’t understand. It puts you in a worse mood knowing they [teachers] are not listening’ and ‘I have come to realise the school doesn’t have much sympathy when you are on your period. It’s very like oh get on and deal with it’. Frequently this was associated with PE ‘so basically if you had a period and you did PE like they [teachers] are not sympathetic like they don’t care’.
Access to toilets was discussed in all focus groups, many revealed that access to toilets is limited or not possible during lessons.
In lessons if you need to use the bathroom to change your pad or something, going to the toilet in lessons is very difficult and unless you specifically say I am on my period which for some people is embarrassing then it’s very difficult to go to the toilet during lessons
Mixed or unisex toilets caused unease due to comments from other pupils when changing period products, ‘the toilets, like the girls and boys mixed together, like sometimes I don’t feel comfortable, like if you have a pad and you are taking it out sometimes they will ask you what you are doing…it feels kinda weird’. Despite this, PE lessons were deemed most difficult by some with perceptions of some PE teachers lacking empathy or being unable to access toilets whilst out on the field during lessons: ‘they don’t really let you go to the toilet so it can be really stressful’.
All focus groups reported period products were available in their schools, yet there were varying degrees of embarrassment associated with accessing products. Some pupils felt too embarrassed to ask a teacher or school reception staff where they were stored. However, pupils did demonstrate an understanding as to why products were not supplied in toilets; ‘I think that if you put pads and tampons in the bathroom, some people might take them and be stupid with them’. Many pupils requested changes to where menstrual products were stored and better access to toilets as two important factors that would improve experiences whilst at school (Table 3).
Pupils did share positive examples of supportive environments that had been created within schools; ‘There’s an awareness to it [menstruation]; there’s little poster things telling you about the period products and ask the nurse if you need them’. Experiences of specific supportive teachers were also shared; ‘Well our PE teacher is quite um, well he understands when if we do have our period then he says if there is a spillage or anything then you can go straight to the toilet its fine, but he understands that some activities will be harder for us because of cramps’.
Additional education at school was requested (Table 3), for instance there was a unanimous request for management strategies such as, ‘how to cope if you have cramps; diet or exercise that can help prevent it’ along with ‘tips to deal with it [menstruation], like from the older female pupils like they know more tips about it’and having a more open culture in school:
Maybe instead of having certain times that we do this [menstrual education] we should like every week [have] an open conversation where people can share their thoughts on it [menstruation]
Uniform and PE kit were discussed across the focus groups with mixed experiences; dark uniform was preferred, whilst there were negative experiences of skirts for PE kit; ‘don’t get me started with wearing a skirt during PE. I would just quit wearing those skirts’. Whereas there was a positive response where PE kit had been changed, ‘I really liked when the leggings first came out because it makes me feel more comfortable when I’m doing PE because if you leak, it’s not really noticeable compared to when you’re wearing a skirt or shorts’. It became apparent across the groups that choice was essential ‘I think it’s good of the school to at least not make you wear skirts, like you can wear joggers, you can wear shorts and leggings, there’s a variety of things you can wear’.
Pupils reported external support to ‘fill the gaps’ from information that had been received at school to increase their understanding of the menstrual cycle. Most frequently, social media (Instagram, TikTok) and the internet were identified as sources of information (YouTube): ‘this thing that I saw on TikTok and it’s called Polycystic Ovaries that can affect your period, right? I have never learned about that in school, and I learned [it] on TikTok and it’s really bad’ and ‘I didn’t find it out from school I found out from YouTube’. Others shared that family, especially mothers, provided menstrual cycle-related information and education at home.
Levels of comfort and confidence when conversing on the topic were variable amongst pupils and dependent on the person they were speaking to. Pupils tended to have conversations with mothers, family members and friends. In some instances, the preference was to speak to teachers over parent/guardians. However, this was not consistent across all pupils with others highlighting discomfort and consequently not talking to anyone due to being too uncomfortable or scared; ‘I wouldn’t speak to my teachers about it’.
Different factors were presented that affected comfort of conversation, this included 1) School environments: ‘it just wouldn’t feel appropriate [to talk] because my class is quite a handful and so like they’re [teachers] probably concentrating on other things’. 2) Gender and personal experience was summarised ‘I don’t really want to talk to a male teacher because it’s a kind of thing like they wouldn’t know much about’ and 3) Teacher openness; ‘they [teachers] never talk about it with us so I would just rather not’. 4) Perceptions of teacher awkwardness was another factor reported; ‘some teachers can be a bit awkward, I mentioned it to a boy teacher and he looked very panicked’. Additional factors such as 5) Familiarity with the teacher and 6) Surroundings; ‘but only in private, I wouldn’t really feel comfortable saying it when like the class is near’. 7) Initiation of conversation by another person was described as an influencing factor for conversation, for example, ‘if someone talks about it [menstruation] first, then I’ll talk to them back to give them advice or something and then we’ll get into a conversation about it, but I wouldn’t choose to start the conversation’. Finally, 8) Pupil openness was described and summarised by one pupil:
Personally, I think that the reason why most teachers are like that is because we weren’t open to them in the first place because I think maybe because like if we talked to them sooner or we told them a bit more they would be a bit more understanding
Personal Experiences
Pupils reported a wide range of menstrual-related symptoms experienced but a lack of management strategies whilst in school, due to limited education. Symptoms included physical (e.g. menstrual cramps) and psychological (e.g. mood swings); in one instance it was reported to affect mental health ‘it’s quite bad for my mental health’. The physical symptom of bleeding was associated with negative experiences at school, with pupils reporting their worry that others can see pads or know they are on their period ‘at school I’m conscious of anyone, if you can see it. If they can tell you’re on [menstruating].’ Getting changed in PE exacerbated this; ‘I don’t like getting changed in PE in case anyone sees anything’. A period starting during a lesson and the fear of leaking in lessons, was reported as being shameful and a nuisance. Words such as ‘embarrassing’, ‘suffering’, ‘inconvenience’ and ‘annoying’ were used to describe experiences of periods whilst at school. This was enhanced by the fear of boys’ reactions, and sometimes girls as well, making fun. The worry of irregular periods and bleeding unexpectedly was also evident.
Alongside the emotional aspects of managing at school, the physical symptoms were reported: ‘we all hate cramps’. Suggestions such as heat/hot water bottle use and exercise were shared as symptom management strategies. Sometimes the lack of management was related to limited knowledge, access to products and confidence to have conversations as summarised by one individual’s negative experience;
The first time I had my period was when I was wearing a skort and it was PE when I got my first period and I had to go into the bathroom but because I didn’t know a lot about it, I didn’t have any pads or anything so I had to use tissue and I was really scared cause I hadn’t known much about it and I didn’t really know what to do, so I didn’t tell anyone. I didn’t tell my mum. I used a pad when I got home in my bathroom. I just did that until I brought up the courage to tell my mum that had happened and that’s when we got the leggings because I felt more comfortable
Tracking of menstrual cycles was discussed as a management strategy, with the use of mobile applications supporting this: ‘I've got an app on my phone that I use. I think since using it... because before I used to get quite scared that like I was going to like start when I didn't have stuff on me, but now I know like a week before that I need to take stuff in’.
The length of time experiencing the menstrual cycle was synonymous with this. Some individuals reported exercise helped with the stress of periods, whilst other individuals shared community sport had supported with period management when being active, which they could apply in school to continue participating in PE: ‘I’m a gymnast myself, so like the gym are really supportive…so I’ve sort of learnt how to cope with it [menstruation]’.
Impact on School
Whilst some pupils acknowledged the menstrual cycle does not affect them in school, the majority discussed the negative impact it can have on learning, engagement and attendance. Generally, pupils reported that the first two days of their period were the worst for affecting their learning and engagement in lessons. Being distracted by stomach pain or the worry of leaking were discussed. Pupils talked about 1) Difficulties managing emotions and concentration, 2) Low motivation, 3) Increased tiredness and 4) Negative impact on school attendance and behaviour; ‘it affects how much I attend in lessons. Say, how much I get distracted or how much I just go, “No, I'm not doing it,” because I just don't feel like it’. School attendance was affected, with reports of menstrual cramps causing missed school days. Whilst another participant mentioned ‘we had SATs (Standard Assessment Tests) recently so if anybody had their period then that would be like really annoying’.
However, PE was the most affected aspect of school reported by participants.
PE on my period, it’s awful. The pain and uncomfortable, you feel like you are going to leak and stuff
Menstrual cramps affected participation in PE, with preferences not to exercise or take part in PE whilst menstruating. Timing of PE in relation to menstruation was a consideration for some pupils ‘if it’s the first two days it’s horrible to do it [PE]’ and the type of activity undertaken also being noted as a barrier by some ‘we were jumping and everything and I only jumped once because of how bad it [menstrual pain] was. I feel like I don’t want to do it because of how bad it is’.
It affects my ability to do some activities. For example, you can’t do swimming, I can’t, I love running and I can’t do running at break times because it hurts bad.
Leaking was also mentioned as a fear that impacted participation in PE, with the following experience summarising that of many pupils ‘The first time I put my leggings on, and I immediately bled through by accident, so I didn’t do PE and I was like really embarrassed’.
Menstrual-related breast pain was also reported to affect participation in PE, ‘period boobs, where it’s just like for example when you’re running, and it just hurts so much’. Both the fear of leaking and pain were attributing factors to the type of exercise participants were more likely to take part in (e.g. yoga) compared to those they would avoid. The activities reported to avoid included 1) Running and jumping 2) Gymnastics and 3) Swimming. Unfortunately, even pupils engaged in swimming felt they were unable to and had no choice. Whereas in other activities participants requested having the option to take part in a different capacity such as coaching.
Menstrual related symptoms such as low mood and ‘feeling extra tired’ also affected participation in PE. This influenced signing up for competitive events such as sports day, ‘you could have signed up for running the week before that, you wouldn’t know you would be due on [menstruating] you get to the day and don’t want to do it’. However, some participants had an enjoyment for PE or were not affected by menstrual cycle-related symptoms and therefore participated in PE and did not perceive to let periods stop them.