Challenges in Menstrual Management Among Women with Visual Impairments: A Study of Riryouka Kyouin with Visual Impairments in Japan

Abstract

This study aimed to clarify the menstrual experiences and perceptions of women with visual impairments in Japan. An anonymous web-based questionnaire consisting of both multiple-choice (quantitative) and open-ended (qualitative) questions was administered to female Riryouka Kyouin (visually impaired teachers who provide instruction in traditional Japanese therapeutic practices—such as acupuncture, moxibustion, and massage—to students with visual impairments) employed at prefectural schools for the blind. The multiple-choice responses suggested several difficulties in menstrual management, including challenges in detecting menstrual blood, limited access to information, and concerns related to embarrassment. The open-ended responses revealed that participants, as individuals with visual impairments who also serve as educators and healthcare professionals, expressed efforts to manage menstruation appropriately in social contexts. These findings highlight the practical experiences of visually impaired women who are actively engaged in society and suggest the importance of support approaches that respect individual autonomy in managing menstruation—a bodily practice imbued with social meaning.

1. Introduction

For women with visual impairments, managing menstruation entails unique challenges due to the inability to utilize visual cues. These challenges may include difficulty noticing menstrual blood stains on clothing, obstacles in maintaining appropriate hygiene, and limited access to menstrual products or health-related information—factors that can impose multiple restrictions in daily life [1].

In recent years, studies focusing on these challenges have been reported in various countries, including Turkey [2], Nepal [3], India [4,5], and Rwanda [6]. These studies have identified a range of issues related to menstruation among women with visual impairments, including limited knowledge and inadequate hygiene practices [2,5,6], difficulties in menstrual management due to lack of visual information [2,3,5], and the influence of cultural taboos and behavioral restrictions [3,5]. In contrast, a qualitative study from Australia [7] revealed that some women address these challenges by creatively utilizing tactile cues and adapting their environments, offering practical insights for developing effective support strategies. Collectively, these findings indicate that empirical research on menstrual experiences among women with visual impairments is gradually emerging.

In Japan, menstruation has traditionally been regarded as a private matter. However, research conducted over the past decade has elucidated both the biomedical and sociocultural aspects of menstruation in Japan. Menstrual health is deeply intertwined with women’s quality of life, educational opportunities, and even the sustainability of employment, and social awareness of its importance has been steadily increasing [8,9,10]. Among key research themes, accumulating evidence includes the treatment of dysmenorrhea and its impact on quality of life [10,11], the association between premenstrual syndrome (PMS) and psychological distress during pregnancy [9,12], correlations with lifestyle factors such as sleep, diet, and physical activity [13], the relationship between menstruation and fracture risk in athletes [14], and epidemiological studies on menstrual cycle variability [15]. Moreover, cultural attitudes surrounding menstruation—such as the notion that it is something to be endured—have been identified as contributing to healthcare avoidance [16], further underscoring the importance of education and public awareness.

These findings highlight the need for knowledge, resources, and support to enable women to actively engage with and manage their menstrual health throughout all life stages, from adolescence to menopause [16,17]. Improving so-called “menstrual well-being” remains a critical issue for future women’s health policy and research in Japan.

A survey conducted in 2023 by Japan Beauty Blind—a Japanese private organization promoting social inclusion of visually impaired individuals through beauty and grooming—provided important preliminary insights into the menstrual health experiences of women with visual impairments [18]. In this survey of 282 visually impaired women, approximately 80% reported experiencing some form of difficulty or anxiety related to menstruation. Specific concerns included an inability to notice menstrual leakage, difficulty reading instructions on sanitary products, and limited access to necessary information at the time of purchase. Despite growing public interest in this topic in Japan, academic research focusing on menstruation among women with visual impairments remains scarce. Given the sensitive nature of menstruation, it is also possible that certain challenges remain underreported or are difficult for individuals themselves to articulate fully.

In light of these circumstances, the present study focused on female Riryouka Kyouin (visually impaired teachers who provide instruction in traditional Japanese therapeutic practices—such as acupuncture, moxibustion, and massage—to students with visual impairments). In Japan, Riryouka Kyouin are professionals who instruct students with visual impairments at public schools for the blind in preparation for national licensure in acupuncture, massage, and related manual therapies. Japan has an institutionalized system in which visually impaired individuals provide vocational training to others with similar disabilities, and Riryouka Kyouin play a central role within this framework. As both educators and healthcare practitioners, they offer a distinctive dual perspective. By conducting an anonymous survey with this population, the study aimed to obtain meaningful insights into how menstruation—a deeply personal and embodied experience—is perceived, managed, and articulated in concrete and objective terms.

The aim of this study is to elucidate the menstrual experiences and perceptions of women with visual impairments in Japan through both quantitative and qualitative methods.

2. Materials and Methods

2.1. Participants

The participants of this study were female Riryouka Kyouin with visual impairments employed at schools for the blind in Japan.

This study targeted female Riryouka Kyouin across Japan. There are 68 schools for the blind nationwide, which collectively employ an estimated total of 500 Riryouka Kyouin. Among them, approximately 88% are persons with visual impairments, and about 35% primarily use braille as a means of communication [19]. While official data on the gender distribution of Riryouka Kyouin are not publicly available, national statistics from the Statistics Bureau of Japan [20] suggest that approximately 20% of Riryouka Kyouin are women, yielding an estimated total of around 100 female teachers across the country.

Valid responses were obtained from 13 participants in this survey (response rate: approximately 13%). The age distribution of respondents was as follows: seven in their 30s, two in their 40s, three in their 50s, and one in her 60s. Two respondents indi-cated that they had already reached menopause. In light of the diverse nature of visual impairments and the resulting differences in perceptual and functional capacities, participants were asked whether they were able to visually confirm menstrual stains. Six participants reported using visual confirmation, while seven indicated that they used non-visual methods.

2.2. Procedure

The survey was administered via the mailing list of the Japan Association of Riryouka Kyouin. This mailing list is, in principle, subscribed to by all currently active Riryouka Kyouin in Japan, and it is assumed that the survey information reached the entire population of such teachers. The invitation message included an explanation of the study’s objectives and ethical considerations, along with a link to the questionnaire created using Google Forms. The survey was conducted on a voluntary and anonymous basis, and the invitation clearly stated that submission of the online form would be regarded as an indication of informed consent.

2.3. Questionnaire Design

In this study, the research team developed a questionnaire with reference to prior studies [21,22] and designed it to reflect the specific characteristics of the target population. The content and wording of the questionnaire items were revised based on feedback from several women with visual impairments.

An anonymous, web-based questionnaire consisting of both multiple-choice and open-ended items was administered. The structure of the questionnaire is outlined below.

• Multiple-choice section:

In addition to general questions regarding menstruation, the questionnaire included items addressing topics such as methods of checking for menstrual stains on clothing and perceptions of menstrual education. Participants were also asked about their age, age at onset of visual impairment, age at acquisition of a disability certificate, and age at menarche. Additional items covered cohabitation status, regularity of the menstrual cycle, tracking of basal body temperature, severity of menstrual pain, use of medications for menstrual symptoms, and the frequency of gynecological visits.

Further questions examined the ability to self-check for menstrual stains on clothing, methods of detecting blood stains on underwear, use of oral contraceptives, sources of advice regarding menstruation and women’s health, and information sources concerning gynecological conditions. Finally, participants were asked for their perceptions regarding the adequacy of menstrual education provided to visually impaired women at school and at home.

• Open-ended section:

An open-ended question was included to elicit participants’ thoughts or concerns related to menstruation in their own words. The prompt was: “If you have any thoughts or concerns regarding menstruation, please feel free to write here”.

2.4. Data Analysis

The response data were compiled using Microsoft Excel, and descriptive statistics were conducted. Quantitative data were analyzed using cross-tabulation methods.

For the open-ended responses, two members of the research team conducted content analysis, identifying and categorizing recurring phrases and themes from participants’ answers. In cases of disagreement, classifications were finalized through discussion and consensus. All open-ended responses were documented. The categorization process was exploratory in nature and not based on a predefined methodological framework, but rather grounded in participants’ expressions and interpreted in alignment with the research objectives.

This article is an extended and revised version of a paper presented at the 21st Annual Meeting of the Japanese Society for Low-vision Research and Rehabilitation, Kyoto, Japan, December 2021 [23].

3. Results

3.1. Results of the Multiple-Choice Responses

Table 1. Overview of Responses to multiple-choice Questions.

Category	Item	Visual Detection	Non-Visual Detection
Age Group	30s	3	4
	40s	1	1
	50s	1	2
	60s	1
Age at Onset of Visual Impairment	0 years	3	4
	3–10 years	1	1
	14–20 years	2	2
Cohabitation Status	Lives alone	1	4
	With others (no sighted)	1
	With others (incl. sighted)	4	3
Age at Menarche	10	–	2
	11	1	1
	12	3	1
	13	1	2
	14	1	1
Menstrual Condition	Regular	2	1
	Mostly regular	2	3
	Not very regular	–	3
	Menopause	2	–
Menstrual Pain	No/minimal pain	5	5
	Managed with meds	1	1
	Uncontrolled (with meds)	–	1
Basal body temperature (BBT) Tracking	Not necessary	5	4
	Not tracking but interested	–	2
	Tracked when considering pregnancy	1	–
	No response	–	1
Use of Pain Medication for menstrual symptoms	None	4	3
	OTC use (occasional/regular)	1	2
	Prescription meds	1	–
	Low-dose pill	–	1
	No response	–	1
Gynecological Visits	Never	3	2
	Occasional (pregnancy or past illness)	3	–
	Regular	–	3
	No response	–	2
Use of Contraceptive Pills	Not using	6	5
	Using for symptoms	–	2
Primary Consultation Sources for Menstrual or Women’s Health Concerns (Multiple responses allowed)	Medical professionals	6	5
	Friends	3	4
	Mother	1	3
	Spouse	1	–
	Sister	–	1
Preferred Information Sources Regarding Gynecological Concerns (Multiple responses allowed)	Internet	5	5
	Magazines	–	1
	Asking others	1	1
	Primary care physician	1	–
Method of Confirming Menstrual Stains on Clothing	Can self-check	4	1
	Ask others to check	2	2
	Unable to check, hesitant to ask	–	3
	No response	–	1
Perception of Menstrual Education	Adequate	4	2
	Inadequate	2	4
	No response	–	1

presents an overview of responses to the multiple-choice questions, covering menstrual characteristics, self-care practices, sources of information, and experiences with gynecological care. Participants who had reached menopause responded based on their past experiences with menstruation. No clear trends were observed with regard to the participants’ degree of visual impairment and variables such as age at menarche or severity of menstrual pain. However, some variation was observed between Visual Detection and Non-Visual Detection groups in terms of menstrual management behavior and health information access.

3.2. Results of the Open-Ended Responses

All open-ended responses in this survey were collected, extracted, and utilized for analysis. As responses to the open-ended items were optional, some participants left them unanswered.

The following themes were derived based on the authors’ interpretive categorization of the open-ended responses. The open-ended responses were thematically analyzed and categorized into four main areas. All comments are presented in

Table 2. Thematic Categorization of All Open-Ended Responses.

Theme	All Comments Corresponding to the Theme
(1) Gaps in Menstrual and Sexual Health Education	“There was a student who did not know that menstruation occurs only in women.” “I felt a significant gap between the content and level of school-based sex education and the actual understanding of sexuality among visually impaired female students.”
(2) Menstrual Etiquette and the Role of Shame in Product Management	“A student had left sanitary pads openly in the classroom, so I advised her to keep them in a pouch or similar container.” “At [name of] school for the blind, disinfectant wipes are provided to clean toilet seats.” “There have been reports at my workplace that blood stains are often found on toilet seats.” “Because some students do soil the toilet seat, greater awareness of maintaining cleanliness in restrooms is necessary.”
(3) Hygiene Challenges Specific to Visual Impairment	“A student from the general education program who is totally blind once asked me whether there was blood on her underwear.” “I have provided guidance to an adult student who is totally blind and had soiled the toilet seat.”
(4) Educator Roles and Support Practices in Menstrual Guidance	“A middle school staff member once consulted me regarding menstrual support for a student with total blindness and additional disabilities.” “To avoid embarrassment in public, students should receive proper instruction in junior and senior high school and learn to manage menstruation independently.”

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4. Discussion

This study was conducted to investigate the menstrual experiences and perceptions of female Riryouka Kyouin with visual impairments. The questionnaire included both multiple-choice and open-ended questions and was designed to gather comprehensive information on participants’ living environments, menstrual experiences, health literacy, and self-management behaviors.

This study was not originally designed based on a specific theoretical framework; however, in analyzing and interpreting the open-ended responses, the social model of disability was drawn upon as a guiding perspective. While the primary aim of the study was to identify challenges in disability support and environmental accommodations through the perspectives of teachers with visual impairments, the responses also revealed strong expressions of agency and a desire for full social participation among the respondents. This interpretation is discussed in greater detail later in this section, with reference to participants’ free-text responses and relevant literature. These narratives align with the core tenets of the social model, which locates disability not within the individual but within societal structures, and they point to the need for broader cultural and social inclusion that goes beyond conventional support frameworks.

The analysis of the open-ended responses was conducted in an exploratory manner without employing a formal coding scheme. However, representative responses were selected based on overall tendencies, with the intention of making the interpretive process transparent to the reader.

Although the response rate for this survey was not high, several factors may have contributed to this outcome. In addition to the sensitive nature of the topic, which may be difficult to discuss openly in the Japanese context, it is also possible that the response process posed challenges, despite the survey being designed to allow input from multiple individuals with visual impairments. While the quantitative data remain limited, the open-ended responses included highly insightful comments. Given the circumstances, the responses collected can be regarded as valuable contributions that provide meaningful perspectives.

4.1. Overview of Quantitative Results

The data did not indicate any consistent patterns regarding age at menarche or severity of menstrual pain in relation to the degree of visual impairment. These observations are presented solely as descriptive characteristics of the sample.

In contrast, the data suggested that individuals with visual impairments face specific challenges and adopt particular strategies in areas such as checking for menstrual blood, accessing information, and seeking gynecological care. Among participants who were totally blind, some reported being unable to confirm stains on clothing by themselves or feeling hesitant to ask others for assistance, indicating that feelings of embarrassment or anxiety may influence their menstrual self-management. Additionally, there was a strong tendency to rely on the internet as a source of information about menstruation, highlighting the central role of online resources for individuals with visual impairments.

In this survey, five participants reported that they had never visited a gynecologist. Japanese women are generally considered to take a passive attitude toward gynecological care, often refraining from visiting a gynecologist unless they perceive a specific need. Previous studies [24,25] have also noted that, compared to women in other countries, Japanese women are more likely to avoid gynecological consultations due to reasons such as cost, inconvenience, and the absence of health concerns. Such tendencies are closely related to the cultural context of healthcare in Japan and prevailing perceptions of women’s health. The findings of this study suggest that even Riryouka Kyouin with medical qualifications may not have fully internalized the habit of routine gynecological visits. Therefore, it is important to incorporate education on the significance and necessity of gynecological care as a component of women’s health promotion.

4.2. Overview of Qualitative Results

The analysis of the open-ended responses yielded a range of insights into how women with visual impairments perceive and manage menstruation, which were categorized into the following four thematic perspectives.

4.2.1. Gaps in Menstrual and Sexual Health Education

Comments such as “There was a student who did not know that menstruation occurs only in women” and “There is a significant gap between the content of school-based sex education and the understanding of female students with congenital blindness” suggest that education on menstruation and sexuality may not be sufficiently reaching students with visual impairments. In particular, conventional sex education, which often relies heavily on visual materials, may pose structural barriers that prevent visually impaired students from acquiring appropriate knowledge.

In Japan’s special needs schools, the importance of sex education is widely recognized; however, it has been noted that there is no clear positioning of this subject within the official curriculum, resulting in instruction that is often fragmented and lacking continuity [26]. Therefore, for students with visual impairments, it is essential to implement sex education that ensures both accessibility and continuity—through the development of non-visual instructional materials and the establishment of teaching methods tailored to the learners’ levels of understanding.

4.2.2. Menstrual Etiquette and the Role of Shame in Product Management

Statements such as “I advised a student who had left sanitary pads uncovered in the classroom to use a pouch” and “Students should be taught how to avoid embarrassment in public” indicate that menstrual management was regarded not merely as a matter of hygiene, but also as a form of socially appropriate behavior or public etiquette. These responses suggest that individuals with visual impairments are motivated to regulate their conduct in ways that align with social norms and interpersonal expectations, reflecting a desire for social acceptance.

Japanese culture has been described as a “shame culture” in some literature, in which individual behavior is governed more by sensitivity to external evaluation than by an internalized sense of guilt [27]. This sociocultural context also influences individuals with visual impairments, potentially motivating them to conform to perceived social norms in areas such as menstrual management and sexual self-expression.

4.2.3. Hygiene Challenges Specific to Visual Impairment

Descriptions such as “providing guidance to a student who soiled the toilet seat” and “reports of blood stains on toilet seats at the workplace” highlight the difficulty individuals with visual impairments face in noticing stains, which emerges as a challenge in maintaining hygiene within toilet spaces. These situations involve not only practical difficulties but also psychosocial dimensions such as feelings of shame and consideration for others. Therefore, it is essential to move beyond behavioral instruction and focus on creating an environment in which individuals can manage menstruation with confidence and dignity.

Accordingly, it is essential to create an environment in which individuals with visual impairments can manage their bodies—including menstruation—with confidence and dignity [28]. Internationally, in the field of Water, Sanitation, and Hygiene (WASH), it is recognized that “safe, dignified access to WASH services is achieved by enabling people to reach and use the WASH services independently or with support from caregivers” [1]. Ensuring both support and dignity is also closely aligned with the core principle of the Sustainable Development Goals (SDGs): “Leave No One Behind”.

4.2.4. Educator Roles and Support Practices in Menstrual Guidance

Comments such as “responding to consultations from colleagues” and “being asked by students to check for stains” indicate that visually impaired teachers are not merely recipients of support, but also serve as providers—fulfilling support roles through activities such as offering advice, giving instruction, and responding to inquiries.

The involvement of educators with visual impairments in menstrual support for students is considered significant not only in their formal capacity as teachers, but also as senior peers who share the lived experience of visual disability. In this dual role, they may offer psychological reassurance and empathetic understanding to students who are likewise visually impaired. This perspective aligns with findings from a prior study that analyzed the case records of 59 individuals with acquired visual impairments who received consultative support—referred to as peer support—from visually impaired staff at a community-based support center for persons with disabilities [29]. The study indicated that support provided by individuals with disabilities helped foster a sense of psychological security in recipients and promoted reciprocal relationships. At the same time, it also highlighted the limitations of peer support alone and emphasized the need for support providers with disabilities to collaborate with other professionals in building a more comprehensive and coordinated support system.

4.3. The Significance of This Study

This study, conducted among female Riryouka Kyouin with medical expertise, has shed light on aspects of menstrual health among women with visual impairments in Japan. Issues related to menstrual hygiene management are known to vary depending on cultural backgrounds, social environments, and characteristics of the target population, while also presenting certain commonalities across contexts. It is hoped that the present findings will contribute to a deeper understanding of the experiences of visually impaired women in Japan and serve as part of the broader international discourse on menstrual health.

Previous studies have identified various challenges related to menstruation among women with visual impairments, including difficulties in self-management, cultural constraints, and limited access to information [2,3]. Similarly, the present study also revealed difficulties in checking for menstrual blood and obtaining relevant information, aligning with these existing findings. In contrast, the open-ended responses from Riryouka Kyouin—who occupy multiple intersecting roles as women, healthcare providers, educators, and individuals with visual impairments—revealed not only their perspectives as recipients of support but also their awareness of themselves as providers of support to others. Insights gained from such individuals are particularly valuable for understanding practical peer support and modes of social participation among people with visual impairments. In this regard, the perspectives of highly independent individuals represent a key strength of the present study.

Statements such as “One should learn to manage menstruation independently to avoid embarrassment in public” and “Greater awareness of toilet hygiene is necessary” reflect an attitude that approaches menstrual challenges not merely as limitations, but as aspects of conduct aligned with social expectations and personal responsibility. This mindset reflects a desire to be recognized as a “normal” member of society, even with a visual impairment, and is consistent with the concept of empowerment—namely, the process through which individuals achieve social autonomy via self-determination. These findings also align with previous research conducted in Japan, which interpreted the act of putting on makeup and going out in public among blind women as an expression of the desire to be socially accepted as full members of society [30].

The findings of this study underscore the need for support for individuals with visual impairments to go beyond functional assistance and incorporate an empowerment-oriented approach grounded in social inclusion and acceptance.

4.4. Limitations and Future Directions

The findings are expected to contribute not only to the development of support strategies and the improvement of educational practices, but also to the creation of a social environment in which all individuals can manage menstruation with dignity and security.

This study explored the perceptions and practices related to menstruation among visually impaired women who live independently and work as professionals in education and healthcare, using their open-ended responses as a primary source of insight. However, several limitations should be noted.

First, data collection through open-ended responses is subject to individual variation in the amount and content of what is written, and may not comprehensively capture all experiences or perceptions. In particular, unarticulated difficulties or unconscious experiences may remain unexpressed; incorporating qualitative methods such as in-depth interviews could offer a more nuanced understanding. Second, the findings of this study may reflect the influence of institutional support systems (such as the Riryouka teacher system) and cultural contexts specific to Japan. Therefore, direct comparisons with the circumstances of visually impaired women in other countries may not be appropriate. Nevertheless, the practical insights provided by visually impaired women who participate in society independently within Japan’s unique support framework hold valuable implications that merit international attention and dissemination.

In the future, research targeting visually impaired women with more diverse backgrounds, as well as international comparative studies, will be essential for identifying shared challenges and effective support strategies that transcend cultural and institutional differences.

5. Conclusions

This study aimed to examine the menstrual experiences and perceptions of female Riryouka Kyouin with visual impairments in Japan. The quantitative findings revealed no significant differences in physical characteristics related to menstruation based on the presence or degree of visual impairment. In contrast, the qualitative responses reflected efforts to manage menstruation proactively, with attention to hygiene and the avoidance of embarrassment—suggesting a strong awareness of social norms. Notably, participants’ dual perspectives as educators and healthcare professionals indicated the importance of framing support not merely in terms of assistance but in recognition of visually impaired women as autonomous individuals. These findings highlight the need to reconsider support approaches that affirm the agency of individuals through the socially embedded and personally experienced context of menstruation.