Experiences of menstruation and schooling among female adolescents in Peru: Contributions from an ecological and gender perspective

Abstract This study focuses on the relationship between menstruation and the schooling experience of female adolescents in Peru from an ecological and gender approach. Qualitative data were collected from rural and urban areas through individual interviews and participatory activities with 277 participants, including adolescents and key informants. The participants were chosen through convenience sampling in 11 schools. The results were tripartite: (1) most adolescents experience fear and shame related to menstruation because of gender meanings about the menstrual body; (2) there is bullying and aggression associated with menstruation by male peers in the school grounds; and (3) the issues of menstruation in the institutional context are not sufficiently addressed in public policy, teacher training and provision of sanitation facilities. Therefore, a critical revision of the gender norms that place female adolescents at a disadvantage in school grounds is urgent in addition to improving water and sanitation infrastructure and maintenance.


Introduction
Currently, within the framework of the global goals of providing universal access to schooling and gender equity, more attention is devoted to how menstruation may constitute a barrier to adolescents completing basic education, especially in the Global South. 1 Menstruation is a physiological and socioemotional process that female adolescents experience which poses different challenges and expectations depending on the context. This study aims to address the challenges and impact of menstruation on Peruvian adolescents in the school context in a variety of settings. A better understanding of how adolescents experience menstruation could lead to the improvement of public policy and programs directed towards the secure access to and completion of quality education. This study contributes to the literature about gender and education by showing a multilevel approach to girls´ experiences about menstruation at the school in urban and rural contexts in Peru, where it is the first research addressing this relevant theme in the everyday life of female students.
During the last decade and a half, an emerging body of literature has focused on the impact of menstruation and menstrual hygiene management (MHM) in schooling, especially when schools lack female-friendly facilities. Related literature identifies 4 main issues: first, there is a lack of adequate and timely information. Chandra-Mouli and Vipul Patel (2017) demonstrate that most female adolescents in low-and middle-income countries have limited knowledge and understanding of menstruation before menarche, as is the case in India, Pakistan, and Bangladesh (Alam et al., 2017;Ali & Rizvi, 2010;Kansal et al., 2016;Sivakami et al., 2019); a similar situation is observed in Africa (Chinyama et al., 2019;Mason et al., 2013;Sommer, 2009;Umeora & Egwuatu, 2008) and the Bolivian Andes (Johnson et al., 2016;Long et al., 2013) and Colombia (UNICEF, 2017) in Latin America, although there are fewer studies in the later.
Although Latin America reflects a better gender parity index in basic education than other regions of the global south, it is a region where gender inequality and gender-based violence are prevalent and levels of social and economic inequality are high (CEPAL-Economic Commission for Latin America, 2021;Rettberg, 2020;Segato, 2016). Thus, it is necessary to understand the issue of menstruation against the backdrop of wider gender norms and inequalities in the region.
To address the issue of menstruation in the school context, the ecological framework proposed by Bronfenbrenner (1979) was adapted following other studies on the topic (Johnson et al., 2016;Long et al., 2013) and includes macro-social factors, institutional and environmental factors (school, health services, water, sanitation, and hygiene facilities), and interpersonal and personal factors, each contained within the next. The model is dynamic since each subsystem and the factors within them interact and impact each other permanently (see, Figure 1 for details on the factors considered). This model is complemented with a gender perspective that understands gender as a sociocultural construct and recognises the power dynamics of hierarchy and subordination in gender relations.
The following section presents the methods used.

Research context and settings
The research team worked in 11 rural and urban locations across four regions: Huancavelica, Lima, Loreto, and Ucayali, between March and July 2019. Huancavelica is located in the central Andes 3767 m above sea level; most of its population over 5 years old (65%) speaks Quechua (an indigenous language). Lima, the capital of Peru, has approximately 10 million inhabitants; this study was conducted in Carabayllo-a district on the periphery where poverty is higher than the average in the rest of the city. Loreto is the largest region in the country and the most culturally diverse with 27 indigenous groups inhabiting the region. Ucayali is the second largest region of the country and has 18 indigenous groups. The latter two regions are located in the Peruvian Amazon.
The research team worked together in Lima, but later it was divided in two parallel teams to work simultaneously in Loreto and Huancavelica, each comprised three researchers joined by one of the principal investigators each. Later, a team of three researchers from the previous teams and a principal investigator conducted the fieldwork in Ucayali. The team worked in one school at a time in each region and then move to the next. In each case it was the first contact of the research team with each school, but we had the aid of UNICEF staff to prepare such contact. In rural schools at Huancavelica and Ucayali, students were mostly indigenous Quechuas and Shipibos respectively. The translation was done by one of the members of the research team who was fluent in Quechua and a Shipibo translator.
The research reported here was conducted for UNICEF Peru, which was working at that moment with 52 public schools in Peru. UNICEF requested the research to be conducted within the schools they work with as the results will be helpful for their current projects. Therefore, we selected 11 schools out of the 52, by combining urban, peri-urban, and rural schools in each region (except in Lima where UNICEF was not involved with rural schools). The already established relationship between UNICEF and the schools facilitated access to the schools and educational authorities in each region. This relationship was also helpful to put in place protocols for safety and security of students during research. The names of the villages and schools were removed for confidentiality purposes.

Research participants
In total, there were 277 participants as detailed in Table 1. They were selected by convenience sampling according to the type of participants. The main group of participants were 112 female adolescents in 2 age groups: 10-13 (50%) and 14-17 (49%). 2 We interview female adolescents in order to gain insight into their current experiences of menstruation in the school context, as it is a topic barely attended. Most of the adolescents were secondary school students (88%) whilst the remaining (12%) were primary school students. Students were approached in schools, randomly selected and invited to participate voluntarily in the study. The second group were 66 male adolescents, 89% in the age group of 14 to 17 years old. They were approached in the same way than female adolescents. We consider important to know better the perspective of boys in schools, whether or not they know or care about menstruation and how is the dynamics with girls in this regard. We consider important to talk as well with mothers, since they are the main source of information for girls in most cases, as literature indicates, and provide information on how they manage the issue at home. Thus, we requested advise from the principal in each school, who invited in advance a group of 8 to a collective interview (although not everyone showed up: groups ranged from 2 to 6 participants). All principals and one local teacher per school were interviewed; as well as one health worker and, one local leader per community. Their perspectives provide important information on institutional and environmental factors related to the school, the health centre and the community. For teachers, we requested the principal to nominate one teacher in charge of areas related with the topic (tutorship, social sciences or science education); for health workers we choose those in charge of attending adolescents, for local leaders we choose those linked with community services or activities related with the topic. All participants participated voluntarily and remained until the end of the study.

Procedures
The study used qualitative methods to generate data: (1) Participant observations in school settings regarding gender interactions among students and availability and use of water, sanitation and disposal infrastructure and services; (2) In-depth interviews and participatory activities with schoolgirls; (3) Participatory activities and informal group discussions with boys, (4) Key informant semi-structured interviews; and (5) Document reviews of health, sanitation, and educational policies and materials. These methods were inspired by similar studies (Ames et al., 2010;

Participant observation
The research team observed school grounds at different times, focusing on the inter-and intragender relationships among students during breaks and dismissal times.
The team also observed the water, sanitation, and hygiene facilities (to be referred as WASH from now on) according to a checklist based on the WASH in schools monitoring package produced by Keast et al. (2011). This observation proved to be very useful as principals' reports and school statistics indicate only the total number and not the actual condition of WASH facilities.

In-depth interviews and participatory activities with schoolgirls
The research team comprised only female researchers to facilitate communication with female adolescents. They conducted individual in-depth interviews to ensure privacy and confidence. Participatory activities "which emphasize an equalizing and dynamic exchange between researcher and participants" according to Sommer (2009:388), were integrated within the interviews: (1) Story completion: female adolescents had to complete a fictional story-one about a girl who experiences her first period and another about a girl who got her period at school and was unprepared. These stories worked as projective devices to help them talk about the process in their homes, schools, and communities; (2) Menstrual narratives: after narrating the fictional story, adolescents were asked to describe their actual first period experience (taken from Sommer, 2009); (3) List of suggestions: adolescents were asked to list the things they would change in their schools to feel better during menstruation; (4) Box of questions: adolescents were asked to write down the questions they have about puberty and menstruation, the responses to which were provided at the end of the week. All interviews were conducted in the school premises in a room with sufficient privacy.

Participatory activities and informal group discussions with boys
Boys were invited to participate in group discussions to explore their knowledge and attitudes toward menstruation. Participatory activities were integrated with the discussions: (1) Story completion (same as the ones given to the girls); (2) Daily life of adolescents: boys were asked to think of a fictitious character and detail their daily routine, first for a female adolescent in their community and then for a male one; (3) Box of questions: the boys were asked to write down questions they have about puberty and menstruation, the responses to which were provided at the end of the session.

Key informant interviews
Adult perspectives were collected through individual semi-structured interviews for schoolteachers and principals, health workers, and local leaders (both male and female) and group sessions for the parents (after careful consideration, only mothers were invited to participate, as menstruation is culturally considered a female issue and women might feel uncomfortable discussing it if men were present).

Document review
To look for the presence of menstruation in contents, materials, and specific actions, 15 policy documents in four main sectors were reviewed: Education (7), Health (4), Sanitation (1), and Child Protection (3).

Data analysis
We analysed qualitative data according to the categories considered in the ecological model presented in the introduction (see, Figure 1; thematic coding). Individual and collective interviews were summarized and reduced into categories, then entered into a matrix to identify common patterns. Only the responses of female adolescent interviews were quantified for the analysis: their responses were codified and counted in relation to several categories. This quantitative data was analysed through descriptive statistics. Documents were reviewed to identify what they say (or not) about key topics such as: Menstruation, Sexuality, Body, Puberty and Hygiene, showing gaps, contrasting approaches and limited presence of many of them.

Ethical considerations
Institutional ethical approval was obtained from the Ethical Research Committee at Pontifical Catholic University of Peru with number 004-2018/CEI-PUCP. All adolescents were asked for verbal assent, and their parents provided written consent. We provided written consent forms to adolescents participating in the study, they bring the forms signed the next day, before participating in interviews. The verbal assent was taken by the researcher at the beginning of each interview. All the other participants provided verbal (recorded) consent prior to the interview, to the researcher conducting the interview. No compensation was provided to the participants. All participants' data were registered by assigning codes and numbers to ensure confidentiality. Only the research team had access to the recorded interviews. A number of interviews were transcribed. Members of the research team and transcribers signed confidentiality agreements. Data was stored in a shared folder, managed by research team. Participants' names and contact details were collected solely to return the study's results (in the form of infographics) through email, prints, or WhatsApp messages.
Research into a private and rather sensitive topic such as menstruation involved several challenges. We considered a qualitative approach was better suited to research the topic as it would allow to understand the experiences and meanings related with menstruation more in depth. However, there were still issues to face. Would girls will be willing to talk about the issue at all? Would the parents give permission or attend collective interviews? Would teachers be open to talk about it? Would school authorities give authorization to conduct the study in schools? These questions were constant during the design of the research and when conducting fieldwork. Several decisions were taken to minimize potential difficulties and facilitate the research. To begin with, the research team was composed solely by female researchers, as we envisage female adolescent will be more comfortable talking about menstruation with another woman. To approach educational authorities and school staff, the previous work of UNICEF in the area proved to be very helpful as they introduced us and the study. For research activities, we offered a private space in a known and familiar place such as the school premises, using school breaks or after school hours (except for health workers and community leaders who were interviewed in the places where they work). We share a snack during the interview and try to make participants feel comfortable. We also have this in mind when designing the research instruments, building different moments along each one to construct more confidence to approach progressively the main topic and combining interview with participatory activities in the case of adolescents. Respect for participants was a key issue to plan, conduct or interrupt the research activity. We were surprised on how well participants responded to our approach, sharing their experiences with the researchers. Adult women find useful to talk about the topic and reflect on the changes between their own experiences and those of her daughters. Female and male adolescents appreciated answers to their questions they do not usually get from surrounding adults; some were shyer than others but all participated. Principals and teachers become more aware of the topic, as well as community leaders and health workers. It seems thus that conversations around menstruation were indeed necessary, if conditions are display to foster such a dialogue with respect and openness.

Results
The results reported in this study focus on (1) the fear and shame related to the experience of menstruation, (2) the presence of bullying and aggression by male peers in the school grounds, and (3) the institutional context regarding educational policy, teachers' training, and sanitation facilities provided in schools. All of these might impact the adolescents' well-being, school assistance, and ability to perform and take advantage of the school lessons.

Fear and shame related to the experience of menstruation
In contrast with the study reports in Asia and Africa, a majority of Peruvian adolescents reported having some knowledge of menstruation prior to menarche: 87% were informed, 3% uninformed but had not reached menarche yet, and 10% were uninformed until they reached menarche. Those who were uninformed experienced menarche with fear and surprise. For most of the adolescents, as in other countries, their mothers were the main source of information about menstruation (64%), followed by older sisters (12%), female friends (8%), teachers (4%), and other persons (9%). Three percent of adolescents did not receive any information.
However, the knowledge that the female adolescents had before and after menarche was found to be superficial and incomplete. Mostly, mothers stressed that menstruation was something that happens to every woman (a phrase we heard repeatedly in the interviews) but did not explain why and how it happens or which body processes and parts were involved. Information in school appears to be rather scarce as well, since menstruation is a topic that is hurriedly addressed, without delving into it at depth, when teaching about puberty. As a result, most female adolescents (54%) did not know how and where the menstrual blood originated, and only 7% could offer a coherent explanation. It is observed that body parts are rarely named: mostly, general terms such as belly or intimate parts were used; however, some named the uterus, vagina, or ovaries. The questions they put into the box also revealed their immense thirst for information related to many aspects of menstruation and the related physical changes to their body. The physical external changes concurrent with puberty and menarche were more clearly identified by adolescents, as were changes in mood and behaviour.
When asked why menstruation happens, the adolescents provided general explanations: 20% indicated that it is part of growing up while 21% said that it is normal. Another 21% indicated that menstruation is the expulsion of a "bad blood"-something the body does not need anymore-and if it is not expelled it could cause illness or discomfort; to avoid retaining it in the body, certain foods and activities are restricted (such as cold beverages and citric fruits, or bathing in cold water and carrying weight). Although the idea of "bad blood" could be associated with negative attitudes, it could also be related to the body's cleansing and renewal cycles-a thought that requires further research.
A further 21% provided explanations that combine medical and local terminology without providing a clear account: Mainly they teach us that menstruation happens when the ovum matures and breaks, and blood is expelled because it is bad; this is what I understood (schoolgirl) Only 4% provided an explanation related to the sexual maturation of the female body while 13% stated they did not know why menstruation occurs. Among the boys, 1 indicated that there could be some failure in women's bodies which leads to menstruation, while the rest believed that it is normal, although they did not have much knowledge about it.
The limited information adolescents have concerning menstruation could fuel a feeling of fear and shame. Most female adolescents feel embarrassed to talk about menstruation with men; these adolescents think that menstruation is a feminine and intimate issue which should be discussed only with mothers or other trusted women. In this sense, it was a sensible decision to put together an all-female research team as adolescents felt more comfortable talking about the topic with a woman. Most of the boys reported that they were also ashamed to talk about menstruation, fearing that their male peers will make fun of them while others fear that girls would feel embarrassed to discuss it with them. The team provided a safe place to share boys' questions and concerns by showing their questions will be responded and not avoided. In this way boys were more comfortable to talk about the topic.
Most of the female adolescents (99%) say they have felt fear or shame when menstrual blood stains their clothes because of the odour in addition to being visible. Menstrual bloodstains on clothes are stigmatising as they reveal matters of the female body that must remain hidden because it is associated with dirt and disgust-ideas related to the notion that menstrual blood is "bad blood".
Menstrual bloodstains on clothes are one of the main reasons for discomfort at school, where 95% of the participants who menstruate said they felt such discomfort or difficulty during their period. Although female adolescents use sanitary pads, there is a chance of leakage and consequent staining which could lead to their classmates laughing at them.
About menstrual care in Peru it should be said that there are different menstrual products such as disposable sanitary pads, tampons, washable fabrics, with the most recent presence of menstrual collectors, cloth sanitary napkins and menstrual sponges. The most used are the disposable sanitary pads, and we found this is the situation in the schools visited (82% of menstruating girls), with a smaller proportion of girls using a combination of sanitary pads and fabrics (18%), None reported using menstrual tampons nor collectors or sponges.
The risk of staining is more uncomfortable for those who use fabric or do not have enough sanitary pads (as is the case in the rural indigenous village in Ucayali), as chances of staining are higher and fabrics would be bulky and more noticeable on their clothes. In general, the fear of staining leads most adolescents to limit their movements and remain seated throughout the day.
Moreover, the fear of staining their clothes with menstrual blood is one of the reasons for taking leave or interrupting the school day to go back home. Although most female adolescent said they went to school, 37% said that they had missed school occasionally during their period, Another recurring fear for adolescents is the risk of becoming pregnant: the most repetitive advice from their mothers and other female relatives when girls reach menarche is that they "must be wary of boys" because they could become pregnant. Adolescents are told that the main way to avoid pregnancy is to "be wary of boys" or "not walk alone on the street"; however, knowledge about contraceptive methods and the menstrual cycle is not provided. Those who identified the menses as a fertile period (24%) avoided physical contact with their boyfriends for fear of getting pregnant.

Presence of bullying and aggression by male peers in school grounds
Female adolescents who have heard jokes or been teased about menstruation in their schools, particularly by boys, constitute 57% of the participants. Those who have not heard them experience a latent fear of being ridiculed and try to avoid exhibiting any signs of menstruation. Male bullying and aggression are among the main reasons why menstruating adolescents experience extreme discomfort at school. Both boys and girls reported situations in which a girl's clothes were stained with menstrual blood and her classmates ridiculed her. The girl had to return home as she was ashamed and missed classes the following days to avoid extreme discomfort and humiliation: -Could you tell me what happened to your classmate?
We were in physical education class. We were running, and she (a girl) sat down because she was in pain. And then, she asked the teacher for permission to go to the bathroom, and when she stood up, she was all stained. My classmates began to make fun of her.
-What did they say?
The teacher scolded them and told them to be quiet because this situation is normal and happens to girls.
-What did the boys say? Do you remember? They said that she is with her rule, 3 that she is with her flag, 4 they said and began to laugh.
-What did she do?
She felt ashamed and crouched.
-You told me that the teacher made them keep quiet, right?
Yes, the teacher went to the bathroom with the girl.
-Did the girl go back to her house or .?
Yes. The teacher sent her to her house in a motorcar.
Did she go to school the next day?
No, she came back three days later (schoolgirl) The teasing and jokes allude to the fact that a girl is menstruating, by referring to the red colour of blood or falsely leading her to believe that she has stained their clothes. The boys' comments also refer to the dirtiness of menstrual blood, the displeasure it produces, and its connection to pregnancy. For instance, in Ucayali, adolescents report that when boys find out that a girl is menstruating, they make comments: "she is wet", "she has cut her vagina with a knife", "how disgusting, she is bleeding!", "ajj! Why are you bleeding so much?" "She is with her month [menstruating], and about to get pregnant". Such attitudes reflect a sense of aggression against female adolescents that could pave the way to unequal gender relations where they are disrespected and everyone tolerates it as these situations are "typical", thereby contributing to normalising it. Gender inequality was also evident when we reconstructed ideal adolescent characters' routines with the participants; the boys were portrayed as more independent, autonomous, rebellious, and strong, whilst girls were portrayed as well behaved and mostly stayed at home.
Simultaneously, some boys in the Amazon areas mentioned that it is important that males also know about menstruation to prevent their girlfriends from getting pregnant or to advise and explain it to their sisters or daughters. Similarly, in a school in Carabayllo, all but one of the boys say that menstruation is a subject that men should also know about, as it is "natural" and part of the development of adolescents. In addition, they say that it could help them be more understanding and prevent them from bothering or ridiculing the girls and support their sisters or girlfriends, for example, by buying sanitary pads.
Female adolescents are not passive with regard to menstruation and the facts associated with it. They have developed a certain individual and collective agency 5 to face the difficulties indicated previously. Thus, to avoid discomfort related to menstrual hygiene, they have learned to calculate the dates when their menstrual period is due and take their sanitary napkins to school; they borrow them from female classmates or ask friends or relatives to buy them. Similarly, to avoid teasing and the stigma caused by bloodstains on their clothes, they lend each other jackets or sweaters to cover their skirts, or they warn each other about visible stains. Most adolescents were happy to talk about menstruation with the research team (with few exceptions in Huancavelica) as the topic is rarely addressed in their daily lives. Although all of them wanted more information from their schools, that was not the case, as presented subsequently.

The institutional context: an invisible issue and poor sanitation facilities
According to our ecological model, environmental factors are key to the way adolescents experience menstruation. This study focuses on the school context as health services were scarcely used by female adolescents in relation to menstruation or puberty.
Schools presented limited opportunities for adolescents to engage in meaningful learning activities related to menstruation. The school curriculum does not explicitly mention menstruation but includes it as a topic within the changes during puberty (personal development and citizenship course), the study of human reproduction (science, technology, and environment course), or related to the prevention of unwanted pregnancy (mentorship course). In addition, a course on integral sexual education should be developed in schools. Some teachers acknowledge skipping or skimming through sensitive topics such as menstruation and puberty, and sexuality in general, partly because they felt unprepared to address the topic. Further, they lack the appropriate educational materials to do so. Menstruation, puberty, human reproduction, and sexuality are approached superficially from a biomedical perspective, with limited discussion on the sociocultural and emotional aspects of adolescent sexuality. Teachers recognise that they try to avoid this issue in an attempt to prevent students (mainly male students) from disturbing the class and teasing. Some teachers are conservative while others perceive the community context as such and in both cases, the topic of sexuality or anything related is avoided. Teachers consider health services as a potential ally to address these topics: in some schools, there is a degree of coordination for an annual talk about unwanted pregnancies, puberty, and related issues delivered by a health worker at the school grounds.
Therefore, adolescents get little, incomplete, or no meaningful information from schools and menstruation remains unaddressed. It must also be noted that schools are insufficiently equipped in terms of sanitation to suit adolescents' needs.
Although WASH services are available at all schools in the study, 85% of the respondents indicated that they were not comfortable with their school bathrooms. This is because, in most cases, the bathrooms were unhygienic (bad odours, signs of faecal matter, presence of garbage, etc.) and lack supplies such as toilet paper and soap. In addition, sanitary facilities were damaged, and adolescents needed to use buckets to clean them. In some cases, the door locks were in a bad condition and the adolescents felt that their privacy was not ensured. Moreover, although there is access to water, the supply is not permanent at all schools. Consequently, many adolescents avoid using their school bathrooms, especially on the days they are menstruating and prefer to change their sanitary pads at home, where they feel they have adequate cleaning facilities and privacy.
Here in school I don't like to change [my sanitary pad] (. . .) when I enter the bathroom. I try not to sit in the toilet seat. I don't know why there are girls who are dirty; when there is no water they defecate, and the whole bathroom is soiled. (schoolgirl) Adolescents have menstrual hygiene supplies in their homes. Sanitary pads are present in the four study regions, in rural, urban and peri-urban areas. Menstruating respondents who use sanitary pads constitute 82% of the respondents; none indicated that they only used fabric. The remaining 18% of menstruating respondents indicated that they used both sanitary pads and fabric. No other supplies were mentioned. Female adolescents get access to these supplies with her family's money and it is the mother, the girl herself, or other family members who buy the sanitary pads.
Most students use sanitary pads they bring from home at school. In some schools, it was observed that sanitary pads were available in the school health services, kiosks inside schools that sell food and beverages, or photocopying services, for emergencies. However, 63% of the students declare that sanitary pads and other supplies were unavailable in their schools. Of those who said they had access to pads in school, 74% said they had to buy these supplies.

Discussion
In contrast with the studies in Asian and African countries presented earlier, this study finds that most Peruvian adolescents (87%) have information on menstruation before menarche. However, their knowledge of the menstrual cycle and fertility periods is limited. This could make adolescents vulnerable with regard to unwanted pregnancies. Indeed, Peru has one of the highest adolescent pregnancy rates in the region (12.6%) and some areas in the Amazon have even higher rates, such as Loreto (32%) and Ucayali (20%) as reported in the National Demographic Survey of Family Health 2018 (INEI Instituto Nacional de Estadística e Informática INEI, 2019). The national curriculum includes mandatory integral sexual education in schools; however, teachers felt unprepared to discuss the issue with their students in addition to the lack of adequate support materials to do so. As a result, adolescents receive only superficial or incomplete information regarding menstruation from schools.
Most adolescents felt uncomfortable with the toilets at school during menstruation and avoided using them because they were unclean and lacked privacy, soap and toilet paper. Sanitary pads are also unavailable in most schools. The poor maintenance of WASH facilities reflects the low priority this issue has for school officers and local authorities, revealing a systematic discrimination against adolescents' needs. The annual allowance for school maintenance provided by the Ministry of Education, for example, could be used to maintain toilets, but if this is not considered a priority, the resources are used for other needs. When COVID-19 started, WASH facilities at schools became vital and was considered seriously; this raises the question as to why it is considered a problem only when it affects both boys and girls and not otherwise.
Although the shame and bullying associated with menstruation have been mentioned in the literature, our findings demonstrate that they deserve more attention from the perspective of gender, especially with regard to gender mainstreaming in addressing menstruation' sociocultural and material dimensions. Critical issues with a gender approach about menstruation in school contexts and beyond are the social constructs of a dirty and uncontrolled menstruating female body compared to the male body which is considered ideal (Martin, 2001;Sosa-Sánchez et al., 2014;Tarzibachi, 2017;Young, 2005) and shame as a tool to control and discipline the bodies and sexual behaviours of female youth (Rheinländer et al., 2019;Ussher et al., 2017;Yon, 2014). Shame remains unquestioned, facilitates the stigmatisation of menstruation and produces a negative impact in the school context: adolescents sacrifice their freedom to move, opting to remain seated, quiet, and uninvolved during the school day to avoid any risk of stains that would reveal they are menstruating. This conduct affects their participation in school activities and could impact their development, or the image they project among teachers and peers. Female adolescents protect themselves from bullying and aggression, but they should not need to do so. By allowing boys to tease and humiliate female adolescents because of menstruation, the school contributes to the reproduction of masculinity based on inequality, violence, and control.
Together with prior studies, our research findings about bullying related to menstruation at school suggest some clues for research and educational interventions to face this form of gender based-violence. A critical point in this regard is the diverse consequences of this violence against girls and their responses to them. Several studies have referred the effects of bullying related to menstruation on school absenteeism and limited participation due to "self-exclusion" and isolation of girls to avoid teasing and humiliation (Chinyama et al., 2019;Johnson et al., 2016;Long et al., 2013;Mason et al., 2015;McMahon et al., 2011;Sommer, 2010;Sommer et al., 2015). On the other hand, cultural and emotional impacts of this form of sexist teasing are suggested or briefly mentioned, but deserves deeper explorations and for which action-research approach could be worthy to consider. Jokes and harassment related to menstruation promote the devaluation of female body versus male body, the reproduction of negative meanings about menstruation, and gendered stereotypes about female and male sexualities, among both boys and girls. They are quotidian performances of sexism which reinforce the idea that a menstruating body is dirty and has not the ability to act freely; as well as the transgressive nature of female sexuality since there is negative association between menstruation and a new sexual status of girls (Johnson et al., 2016;Mason et al., 2015;McMahon et al., 2011;Sommer, 2009). To sum up, these are disciplinary mechanisms to the social re-production of sexual differences and inequalities between male and female embodied subjects (Lozano, 2010). Although teasing and discrimination related to menstruation come mainly from boys in the research we carried out in Peru, other studies show that several girls also follow these practices when their female peers are menstruating or they suspect about that (Long et al., 2013;McMahon et al., 2011). This would be an expression of the normalization and incorporation of gendered meanings and hierarchies of value imposed on girls´ bodies, where mockery about a menstruating body grants a certain power by placing themselves, even momentarily, among those girls who are not menstruating.
Our study also suggests the lack of preparation of teachers to deal with bullying related to menstruation as part of the school violence that is intertwined with gender violence. Like it happens in our research in Peru, in a study carried out in Bolivia (Long et al., 2013), the teaching processes about menstruation were greatly hindered by both boys´ sexist jokes and girls´ shame to talk about this theme in front of boys. On the other hand, the principal from one of the Bolivian schools mentioned that when he saw boys teasing a girl about her period, he did not sanction these male teenagers but took advantage of this moment as a learning opportunity to teach them about menstruation (Op cit. p. 32). However, both in the Peruvian and Bolivian studies, when menstruation is a teaching or counselling topic at school, the approach is mainly focused on biological and hygienic issues than on the derogatory gendered meanings and forms of harassment related with this female process. Even more, in various schools, health care professionals are in charge to provide these contents because teachers are not trained for that.
By failing to educate girls and boys on menstruation from a gender approach, the school contributes to the silence and shame surrounding menstruation and the gender norms and violence that control adolescent bodies and sexualities. Girls and boys need to learn about the menstrual cycle; silence and secrecy about menstruation contributes to shame and the stigmatisation of a natural process (Klinter, 2021). Teachers and parents can contribute to normalising conversations about menstruation and questioning the discredited meanings and values about it. Shame reveals that poor WASH facilities and the lack of information are also complexly interlinked with gender inequalities that disregard the needs of female adolescents, forcing the silence around them. All of these critical issues contribute to the absence of adolescents from school, a violent and uncomfortable environment for their development, and the reproduction of gender inequalities and harassment.
Finally, this study is consistent with the systematic review of Hennegan et al. (2019) on qualitative studies on women's and adolescents´ experiences of menstruation in low-and middleincome countries, which highlights the need for an integrated framework for developing interventions that address the multiple and inter-related components of menstrual experience, which include, but are broader than, hygienic practices. This framework can contribute to expanding and strengthening both forms of adolescents' agency and school responses to menstruation, which are still shaped by gendered meanings about dirtiness and shameful female menstrual bodies. School responses to menstruation are crucial and significant ambits by which educational institutions can educate about gender and can help transform gendered meanings about the female body, as well as gender relations of power and gender based-violence.
This study explored the experience of menstruation in the school context in a variety of settings. However, this variety was limited to the schools working with UNICEF, which may not be representative of all Peruvian public schools. Indigenous students, for example, were underrepresented in at least one region. In addition, the sample is limited to public schools in a country where private schools are growing rapidly. The population in the public schools visited were primarily from a low socioeconomic status, and other social sectors could be approached to check the validity of these findings for a wider range of socioeconomic statuses.