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The messiness of the menstruator: assessing personas and functionalities of menstrual tracking apps

The messiness of the menstruator: assessing personas and functionalities of menstrual tracking apps Journal of the American Medical Informatics Association, 29(2), 2022, 385–399 doi: 10.1093/jamia/ocab212 Advance Access Publication Date: 6 October 2021 Review Review The messiness of the menstruator: assessing personas and functionalities of menstrual tracking apps 1 2,3 4,5 6 Adrienne Pichon , Kasey B. Jackman , Inga T. Winkler , Chris Bobel , and Noemie Elhadad 1 2 Biomedical Informatics, Columbia University, New York, New York, USA, School of Nursing, Columbia University, New York, 3 4 New York, USA, New York-Presbyterian Hospital, New York, New York, USA, Institute for the Study of Human Rights, Columbia 5 6 University, New York, New York, USA, Legal Studies, Central European University, Vienna, Austria, and Women’s, Gender, and Sexuality Studies, University of Massachusetts, Boston, Massachusetts, USA Corresponding Author: Adrienne Pichon, MPH, Biomedical Informatics, Columbia University, 622 W 168th Street PH20; New York, NY 10032, USA; ab3886@cumc.columbia.edu Received 5 April 2021; Revised 8 September 2021; Editorial Decision 14 September 2021; Accepted 20 September 2021 ABSTRACT Objective: The aim of this study was to examine trends in the intended users and functionalities advertised by menstrual tracking apps to identify gaps in personas and intended needs fulfilled by these technologies. Materials and Methods: Two types of materials were collected: a corpus of scientific articles related to the iden- tities and needs of menstruators and a corpus of images and descriptions of menstrual tracking apps collected from the Google and Apple app stores. We conducted a scoping review of the literature to develop themes and then applied these as a framework to analyze the app corpus, looking for alignments and misalignments be- tween the 2 corpora. Results: A review of the literature showed a wide range of disciplines publishing work relevant to menstruators. We identified 2 broad themes: “who are menstruators?” and “what are the needs of menstruators?” Descrip- tions of menstrual trackers exhibited misalignments with these themes, with narrow characterizations of men- struators and design for limited needs. Discussion: We synthesize gaps in the design of menstrual tracking apps and discuss implications for designing around: (1) an irregular menstrual cycle as the norm; (2) the embodied, leaky experience of menstruation; and (3) the varied biologies, identities, and goals of menstruators. An overarching gap suggests a need for a human-centered artificial intelligence approach for model and data provenance, transparency and explanations of uncertainties, and the prioritization of privacy in menstrual trackers. Conclusion: Comparing and contrasting literature about menstruators and descriptions of menstrual tracking apps provide a valuable guide to assess menstrual technology and their responsiveness to users and their needs. Key words: personal health informatics, menstruation, mobile health, menstrual tracking INTRODUCTION wearables and sensors to smartphone apps, technologies have been 2–5 proposed to support self-discovery and body literacy, to While menstruation has been largely absent in technology, the 6–11 meet self-management needs for well-being and reproductive past 5 years have witnessed the sharp rise of FemTech. From new V The Author(s) 2021. Published by Oxford University Press on behalf of the American Medical Informatics Association. This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial License (https://creativecommons.org/licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com 385 386 Journal of the American Medical Informatics Association, 2022, Vol. 29, No. 2 12–14 conditions, and to promote feminist representation in technol- JSTOR, PubMed, OVID Medline, Web of Science, Cumulative In- ogy. Menstrual trackers are becoming mainstream commodities dex to Nursing and Allied Health Literature (CINAHL), Scopus, with high engagement, and the research community has started PsycINFO, ProQuest, and ACM Digital Library. assessing their design, intended use, and potential unintended conse- 17–21 quences. Menstrual tracking apps are a key area of personal in- Data extraction and analysis formatics, with the potential to empower users and challenge For each result, we extracted the full text, first author, year of publi- oppressive social structures while enabling individual-level and cation, publication type (eg, journal article, book chapter, editorial, population-level insights. or commentary, etc.), title, geographic location, and discipline using a Beyond FemTech, attention to menstruation has surged, with the data extraction matrix created by the authors. We examined trends in term menstruator emerging as a key focal point for ongoing conversa- publications across time and disciplines of study. For the thematic tions. The term is often accompanied by the refrain, “not all women 39 analysis, we coded all publications by themes to characterize who is menstruate, and not everyone who menstruates is a woman.” The considered a menstruator and what needs are identified in the litera- menstrual cycle is a sex-linked biological process regulated by repro- ture. Two coders (AP and KBJ) independently familiarized themselves ductive hormones (estrogen, progesterone, follicle-stimulating hor- with a subset of publications balanced over source and discipline of mone (FSH), and luteinizing hormone (LH)), culminating in several study. An initial list of themes was identified, then grouped into ma- days of menstruation, where the uterine lining along with an unfertil- jor themes, which were iteratively refined, named, and defined in a 22,23 ized egg is shed through the cervix and vagina . While irregularity codebook, which was then used to code all included texts. is common, many menstruators experience this cyclical process every 21–35 days. In the life cycle of a menstruator, the first period (men- Analysis of menstrual tracking apps arche) occurs around puberty and ends in middle age via menopause. Search strategy and screening Menstruation is a common experience, but menstrual experiences are To curate a corpus encompassing the broadest representation of neither universal nor monolithic. Even (and especially) beyond gen- menstrual tracking apps available and that potential users are most der, the menstrual experience varies. Intersectionality explains that likely to encounter, we undertook a multipronged search strategy an individual’s identity cannot be represented as merely a sum of its across both the Google and Apple app stores. First, we screened parts, but rather through a nuanced understanding of oppressive 18,19,40–44 apps included in prior menstrual tracking app reviews, experiences and discrimination (or privileges and advantages) that then we added apps from the top 50 results across 6 distinct searches 25–27 impact people differently based on the intersection of identities. (menstrual OR period AND tracker OR calendar OR diary) on both Across the lifecourse, culture, race, ethnicity, religion, caste, and so- app stores, ignoring duplicates. The first author (AP) completed the cioeconomic circumstances profoundly shape the menstrual experi- searches and data extraction in June 2020. We excluded apps that 28–33 ence. We describe menstruation as messy, not only because it is were categorized as fertility trackers and that listed fertility tracking a messy physiological process but also because it is situated within a as primary focus (while systematically applied, criteria sometimes multifaceted sociocultural context. With menstruation so deeply stig- required judgment calls). We also excluded apps for “low use” (de- matized, we call for embracing the experience of messiness as authen- fined as <200 reviews). We finally considered author expertise to tic and valid and reject the conception of menstruation as in need of ensure no major apps were left out, and added back any apps ex- concealment and regularization (“less messy”). cluded due to low use but nonetheless deemed relevant to the cur- Given that the term “menstruator” has evolved into a crystalliz- rent study. When both free and paid versions were returned, only ing point for discussing menstruation, we use it as the basis for our the description of the paid app was included; we attempted to distin- scoping review to capture relevant themes across disciplines that guish between free and paid features. characterize menstruators and their needs then apply this characteri- zation as an analytic lens to evaluate menstrual tracking apps. Moti- Data extraction and analysis vated by recent research tackling intersections of society and 3,34–37 Extracted data included: app title, text description, images (logo and health, we take up complex questions with an interdisciplin- screenshots), and metadata (number of ratings, star reviews, and ary team to attend to the sociotechnical configuration of menstrual app category). Three authors (AP, KBJ, and ITW) conducted quali- trackers, guided by these key research questions: (1) Who is a tative analysis following a Directed Content Analysis approach, “menstruator” and who are the intended users of menstrual tracking focusing on app descriptions. Using Dedoose for codebook develop- apps? (2) What are the needs of menstruators and what needs are ment and coding, we started with the themes generated in the scop- menstrual trackers responsive to? (3) Where does current technology ing review, and then iteratively revised the codebook through fall short? (4) What design directions can address these deficits? several rounds of double-coding subsets of the corpus and discussing how codes were applied. The codebook was revised until coders agreed that topics were meaningfully represented and could be ap- MATERIALS AND METHODS plied systematically. We reached saturation while developing the codebook and coding the text of the app descriptions. Scoping review of the literature Search strategy and screening To gather information about who a menstruator is and what their RESULTS needs are, we conducted a scoping review following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta- Findings of the scoping review Analyses) Extension for Scoping Reviews guidelines. Database Search results searches were conducted by AP in March 2019 and updated in The flow diagram is provided in Figure 1 (left). Searches in Google March 2020 to include literature through the end of 2019. Searches Scholar returned 314 articles, JSTOR returned 4 additional results, with the query “menstruator*” were conducted in Google Scholar, and the remaining databases returned only duplicates, irrelevant Journal of the American Medical Informatics Association, 2022, Vol. 29, No. 2 387 Figure 1. Flow diagram of search strategies for (left) scoping review and (right) curating app corpus. results, or no results. The title and abstract of 318 total results were lived experiences relevant to menstruation. Finally, it highlights the screened, leading to the exclusion of 132 results. Full-text screening inherent dynamic and irregular nature of the menstrual cycle. was completed on the remaining 186 results, leading to the exclu- sion of 48 results. Overall, there were 138 scholarly outputs in- Theme 1-1: Menstruators have been characterized by both sex- cluded in our synthesis; 39 of which were books. linked biological processes and social identity. Early articles in the biomedical literature refer to menstruators through their sex-linked traits, for instance comparing characteristics of “early menstru- Trends in academic publications ators” versus “late menstruators” (based on the age of menar- Figure 2 visualizes publications using the term menstruator across 46–48 che). The biological significance and evolution of menstruation decades and yearly for the 2010s. We note a striking uptick in the are also represented, citing the certainty of adaptive benefits and last decade, with an overall upward trend. uniqueness of human menstruation apart from other animals (ie, as We further note that the term menstruator appears in an increas- 49–51 “overt menstruators” and “copious menstruators”). ingly wide range of disciplines across time. Starting in 1953 until Later literature focuses on social identities rather than biological early 1980s, biomedical journals were the exclusive users of the functioning around menstruation. Many recent articles in gender term “menstruator.” Publications in anthropology take over in the studies, economics/development/policy, and the humanities/social sci- mid-1970s until early 2010s as the prominent field represented. In ences employ the widely used axiom “not all women menstruate, and the 1990s and beyond, gender studies publications become predomi- 52–55 not all menstruators are women,” centering gender (a social cate- nant. We also note an increase in publications discussing menstrua- gory) rather than sex (a biological category). This more recent use in tors from a variety of perspectives and applied fields, such as menstrual discourse is applied to signal inclusion of transgender men, economics, law, and more recently, technology. masculine of center individuals, and nonbinary people who men- struate. On the other hand, there are many reasons women and girls Themes do not menstruate, for example, premenarche, postmenopause, preg- An overview of themes is presented in Figure 3. nancy or lactation, surgery or medical treatment, illness, stress, travel, and physical activity. Intersex individuals may or may not menstru- Who is a menstruator? This scoping review highlights that ate. In addition, transgender women do not experience menstrual “menstruator” is used to be inclusive by broadening the scope of who bleeding but may undergo cyclical hormonal fluctuations. Many is perceived as a person who menstruates, while also narrowing and articles refer to these social categories, further complicating the con- 59–61 adding nuance to the description of menstruators. The term encour- structs of gender and sex. Nonetheless, womanhood is often re- 62,63 ages the inclusion of people who experience the biological process of ferred to when discussing menstruators, with a few articles menstruation, regardless of their gender. It also focuses on the varied arguing for menstruation to be inherent to womanhood, explicitly ex- 388 Journal of the American Medical Informatics Association, 2022, Vol. 29, No. 2 Figure 2. Characteristics of the literature: References over time by (left) discipline (by decade, all time) and (right) subdiscipline (by year, 2010s). Figure 3. Overview of themes from the scoping review and analysis of apps, and the gaps identified from the analysis. 64,65 cluding some sexual and gender minorities. Because of menstrua- barriers associated with disadvantaged social locations. In particu- tion’s complex relation between sex-linked traits, biology, gender, lar, access to hygiene for under-resourced communities is a primary and life context, menstruation is more than a bodily process and focus of the water, sanitation, and hygiene (WASH) sector, such as encompasses a social dimension. access to toilets that meet the needs of menstruators (eg, privacy, 66–69 safety, facilities to wash or change pads). More broadly, many menstruators have specific needs, including individuals experiencing Theme 1-2: “Menstruator” highlights the varied lived experiences of 70 71 homelessness, incarcerated persons, individuals with physical, groups that have been marginalized. The literature often uses mental, and developmental disabilities, migrants, refugees, and “menstruator” to focus on the menstrual experience of groups that 72 73 asylum seekers, racial and ethnic minorities, and people living in have been marginalized, centering functional needs and structural Journal of the American Medical Informatics Association, 2022, Vol. 29, No. 2 389 poverty. Specifically, because these menstrual needs are not ade- tute a fundamental aspect of care; suppressing menstruation can quately addressed, these often intersecting aspects of lived experi- mitigate burdensome symptoms and painful periods, empower men- ence and identity are further marginalized. Here, using the term struators with bodily agency, and resist harmful menstrual expecta- menstruator positions the relevant needs of individuals who men- tions. However, social pressure to suppress menstruation to avoid struate (based on “what”; context and relevant needs), rather than the burden, messiness, and embarrassment can bolster and repro- their identity (“who”; attributes such as sex/gender), thus weaken- duce discipline, surveillance, and policing imposed on menstrua- 90 43 ing the link of menstruation to gender and instead focusing on the tors. Considering technology, Eschler et al assert, “giving unique needs relating to an individual’s bodily function specific to menstruators the ability to manage their own information can be an menstruation. Although menstruation is a bodily function shared important aspect of resisting the ‘social control’ of medicalized biol- by many, it is experienced in diverse, context-specific ways. ogy and conditions.” Theme 1-3: The menstrual cycle is inherently variable across men- Theme 2-2: Equity underpins the needs of menstruators. The need struators and across cycles within individuals. The literature to promote equity from social, economic, and gender justice per- describes how the “normal” 28-day cycle, broadly applied, is not spectives is a prominent theme. Calls include advocacy to end the consistent with the reality of the dynamic menstrual cycle; in particu- “tampon tax” (ie, charging sales tax on menstrual products) and ad- 69,91–93 lar, a recent study using Clue data affirms, “menstruation is charac- vocating for free menstrual products in particular settings 75 74 terized by variability rather than by regularity,” demonstrating that (including eg, schools, shelters, detention). They also address ten- the menstrual experience between menstruators and even within an sions between affordable single-use products and their environmen- individual’s cycle varies with regard to length, frequency, and symp- tal sustainability, suggesting do-it-yourself menstrual materials. toms. Hasson proposes that “complex arrangements of organs, tis- Human rights discourse focuses on addressing needs specific to sues, hormones—produced in the body or taken in from outside— groups that have been marginalized, specifically structural barriers generate embodied experiences of regular, irregular, or absent beyond products and addressing underlying causes of unmet needs bleeding.” There is also longstanding evidence that new menstruators and ongoing stigma. generally have irregular cycles, and those going through the meno- Another equity-related topic calls for access to appropriate pausal transition experience disruption or absence of regular cycles. educational resources and better body literacy, as discussed across health-related humanities literature, early menstrual advocacy literature (eg, the seminal book “Our Bodies, Ourselves” What are the needs of menstruators? Our review highlights different from the Boston Women’s Health Collective ) and intersectional menstrual needs, including instrumental needs to manage menstrual 57,97 gender studies work. Some results emphasize personal narrative bleeding, which expand to other medical and wellness needs associ- and lay knowledge (potentially transformative), stories from ated with menstruation. Importantly, needs extend beyond material menstruators, and representing menstruation not as inherently prob- needs into cultural messaging that harms menstruators and larger 76,78,88,98,99 lematic. structural barriers that limit menstruators, particularly in accessing necessary resources. Theme 2-3: Stigma and shame imposed on menstruators continue to Theme 2-1: Medical management, support for health, and promo- be harmful. The literature interrogates shame and stigma related to tion of wellness are important to menstruators. Most biomedical menstruation and how pervasive and harmful menstrual norms are articles retrieved in our search, especially early ones, concentrate on socially constructed and reinforced. Particularly in anthropology, medical management of the menstrual cycle. Most prominently, the symbolic and religious attitudes toward menstruators highlight im- early literature from the 1960s, 1970s, and 1980s centers reproduc- purity, rituals for isolating menstruators, and menstruators as 47,48,77,78 tive health (fertility and contraception). Content also “weak bleeders” contrasted with warriors as “strong, masculine 100–104 79,80 details toxic shock syndrome, including the need for individual bleeders.” These older publications illuminate deep cultural, awareness of risks, generating scientific knowledge, and political ad- social, and religious interpretations underpinning stigmatizing men- vocacy to regulate and hold accountable corporations producing strual discourse. Across the corpus, publications and their findings commercial products. must be contextualized within the history of each discipline and Another pronounced body of work focuses on menstrual symp- interpreted cautiously with their limitations acknowledged. Nota- toms and disorders and treatments (eg, dysmenorrhea, chronic and bly, much of the older anthropological literature asserts a particular 46,52,59,81,82 cyclical menstrual pain, menstrual suppression), and dis- set of Western perceptions, rather than representing the voices of cusses care and self-management of chronic diseases, for example, menstruators themselves. 83 84 the impact of eating disorders, mental health, and spinal cord in- Articles critiquing attitudes toward menstruation span pop cul- juries on menstruation. Results call for robust menstrual health in- ture and media (eg, through analysis of menstrual products ads urg- 54,62,105–107 formation, mechanisms to support menstruators accessing care from ing concealment), film, television, and literature (eg, health providers, and tools to independently self-manage health and representations of menstruation as abhorrent, or in horror gen- 108,109 well-being. Results affirm that menstruation can be considered a vi- res), menstrual educational materials (eg, bodily surveillance 86,87 tal sign for both menstrual and overall health. However, some and management reinforcing menstrual normativity; problematic articles (particularly within gender studies) critique the medicaliza- framing of menstruation exclusively around fertility and reproduc- 110–112 tion of the menstrual cycle, explaining that even though menstrua- tion), and day-to-day stigma and shame inherently ascribed 76,97 tion is a common life process situated within the social realm, it to being a menstruator. A few authors discuss positive represen- 89,108 has been understood and problematized through the adoption of a tations or symbols of menstruation. Nonetheless, because 55,88,89 medical framework. For some menstruators, medical treat- menstrual shame and stigma are so prevalent, the motivation to ap- 113,114 ments such as contraception or hormone replacement might consti- pear as a nonmenstruator appears among articles retrieved. 390 Journal of the American Medical Informatics Association, 2022, Vol. 29, No. 2 Findings of the analysis of menstrual trackers Theme 1-3: Menstrual tracking apps are designed for regular men- struators but claim to support irregular menstruators and personal- Search results and app corpus ized menstrual dynamics. Assumptions about normal or typical A flow diagram is provided in Figure 1 (right). Our search yielded a menstrual cycles characterize the messages and features associated total of 256 apps. One hundred seventy-four apps were included for with many of the apps (see Table 1). Cycles are often assumed to be data extraction and full review to assess eligibility. Ninety-two apps regular (either explicitly or implicitly in predictions), with 28-day were excluded when assessed for eligibility to remove fertility track- cycles and consistency from one cycle to the next. Some app logos ers and apps with “low use.” After manual review, 3 were added to even incorporate “28” into their design (eg, app icons featuring the the final corpus (Apple Cycle Tracking; Oky by UNICEF; Fitr- number 28). Cycles are also assumed to be ovulatory, which is not Woman integrating physical activity and menstrual tracking) result- always the case (eg, due to polycystic ovary syndrome (PCOS) or ing in of 85 apps from across app stores for evaluation. App ratings hormonal contraceptive use). There is little mention of menstruators ranged between 2.35 and 4.9 stars, with a median of 4.55 and an across the lifecourse or transitions, with the exception of pregnancy. interquartile range of 4.3–4.7. Many apps purport to support users with irregular cycles (see Table 1), generally by allowing users to customize cycle length or by Themes using machine learning. Apps prompt users to log more data and Illustrative quotes from apps are presented in Tables 1 and 2. claim to use data science, artificial intelligence (AI), or special algo- rithms to predict and map onto irregular cycles or individual men- Who are the intended users of menstrual trackers? Menstrual track- strual dynamics. Despite complex menstrual cycle dynamics, they ers depict a largely normative representation of users. Users are as- promise reliability and accuracy of predictions but provide little in- sumed to be women, and womanhood is linked to menstruation and dication that these predictions may not be accurate. femininity. The lived experience of women is displayed as mono- lithic and privileged across domains (eg, race/ethnicity, sexuality, so- What are the needs the menstrual tracking apps respond to? Men- cioeconomic status, disability, access to housing, food, healthcare). strual trackers are designed to track, predict, and manage a menstru- Users are assumed to be regular menstruators, but apps claim to use ator’s menses and ovulation/fertility window. Beyond these primary machine learning to account for variation in cycles. goals, apps also claim to facilitate health and wellness and help users cultivate menstrual awareness, control their cycles, and conceal their Theme 1-1: Users are represented as women or girls. The gendered menstrual status. assumptions and stereotypes about women underlying menstrual tracking apps may be the most obvious finding; app store searches Theme 2-1: Apps give a limited view on managing menstruation and returned visually homogenous, overwhelming pink, pastel, and fertility that largely obscures other goals, lifecourse representations, flowery pages of results (images cannot be reproduced due to copy- intimacy, and sexualities. A primary function of menstrual tracking right, but we encourage readers to replicate the searches). Gender is apps is to log data about menstrual cycles to visualize, analyze, and implicitly and explicitly encoded using language (see Table 1) and predict the menstrual period (ie, when bleeding will start) with goals visuals, ie, feminine imagery (eg, app icons depicting pink, purple, to prepare for days of bleeding, “prevent an accident,” and plan (eg, and pastel colors with flowers, hearts, butterflies, or feathers) and for work or vacation). Apps also seek to predict the fertility win- images of women (eg, app icons featuring women with long hair dow/ovulation for preventing pregnancy or optimizing chances of and screenshots of users who are thin white women). A substantial conception. Users can log days of bleeding, descriptors of flow number of apps refer to anticipated users as women/ladies (n¼52, (heaviness of flow, clots, color), and sometimes associated signs and 61%), girl (n¼20, 24%), and females (n¼15, 18%). Overall, two symptoms. Many apps also keep track of ovulation information, for out of three apps (n¼57, 67%) use feminine gendered language. Of example, basal body temperature, cervical mucus, and ovulation the 28 apps without gendered language, another five include explicit tests. In reality, the menstrual cycle is a complex, dynamic cycle of images of women in the icons and screenshots; 17 more depict ste- hormones that fluctuates dynamically across time; nevertheless, reotypically feminine imagery and/or colors. Three apps are mostly most apps isolate 2 distinct events: bleeding and ovulation without neutral regarding gender, but still have pastels, hearts, or “cute” lan- mentioning other phases of the menstrual cycle (see Table 2). guage. What it means to be a woman is elaborated by these assump- However, some apps offer features to construct a more holistic rep- tions around femininity designed into visual elements. Some of these resentation of the menstrual cycle. Beyond details of flow and fertility, images and language are particularly infantilizing (eg, cartoon mer- users can track symptoms, mood, weight, physical activity, diet, sleep, maid and rabbit). Only three apps (4%) avoid gendered assumptions medications, and more. Customization of domains or app interface is in their language, images (eg, circles, spirals, cube, blood drop), and sometimes supported. Furthermore, apps commonly support free-text colors (eg, bold). notes, journal entries, or even photos to incorporate narrative alongside self-tracking and construct a comprehensive picture of the user’s life. Theme 1-2: Users are represented as having a monolithic lived expe- But these remain the exception and even when apps permit a more ho- rience. Representation of users are flat even beyond gender, as illus- listic representation, options are sometimes still limited and often draw trated by the use of the word “every” in many of the apps. App from reductionist assumptions and stereotypes around menstruation, descriptions send the message that they are a perfect, universal fit for example, “mood swings” and weight changes, which have been for every potential user; furthermore, apps make many assumptions, used to police girls and women and minimize their experiences. for example, that users are heterosexual, monogamous, and inter- As a result of their limited conception, menstrual trackers largely ested and able to focus on their fertility and family planning. Text obscure realities of transitions from a menstruator to a nonmen- often asserts that users work and take vacations, circumstances the struator, and vice versa, and changes across the lifecourse, especially app can apparently help handle. during perimenopause. One prominent exception, menstrual track- Journal of the American Medical Informatics Association, 2022, Vol. 29, No. 2 391 Table 1. Who are the intended users of menstrual trackers? Corresponding to themes in [Theme 1-1] Users are represented as women or girls. scoping review: The Easy Period Calendar is a must for modern women. (App 118) Menstruators have been It’s a smart and simple female period tracker. (App 145) It is period app for girls/women/ladies/teenagers. (App 087) characterized by both sex- The main objective of this ladies periods calendar is to record menstrual cycles and personal period log for linked biological processes teenage girls and women. (App 047) and social identity. Corresponding to themes in [Theme 1-2] Users are represented as having a monolithic lived scoping review: experience. “Menstruator” highlights the An essential menstrual recording tool for every girl’s life! (App 168) varied lived experiences of groups Discreet menstrual diary for every woman. (App 039) that have been marginalized. Woman Calendar, it is what every woman needs! (App 066) Corresponding to themes in [Theme 1-3] Menstrual tracking apps are designed for regular menstruators but claim to support irregular scoping review: menstruators and personalized menstrual dynamics. The menstrual cycle is Please note that this application is based on the assumption that your periods are fairly regular. The date of inherently variable across your next period and the fertile period will not be accurate if you have very irregular periods. (App 049) menstruators and across Contrary to others calendars, you only need your cycle start date and the cycle time (average 28 days) to cycles within individuals. configure it. (App 132) Menstrual cycle and ovulation calendar, for teens or women trying to keep a regular cycle. (App 137) Accurate period predictions even for irregular cycles. (App 146) Predict your period, menstruation, fertile days by machine learning no matter you have irregular period or regular period. (App 087) Log more symptoms to get improved predictions if you have irregular periods. (App 003) Finally, an intelligent period tracker app that makes sense of what you track! Pslove Period Tracker not only accurately predicts your upcoming menstrual cycles & fertile days but also analyses trends in your body. It’s easy to get on top of your health! SEE THE FUTURE You can view your predicted periods and ovulation dates for months in advance. Using machine learning artificial intelligence, our predictions gets better over time to make the best calendar for women—the more you log, the higher the accuracy! (App 045) Learns from your inputs and makes better prediction of future periods and fertile windows through time, we use all up to date scientific methods available to track and plan your cycle. (App 093) Accurate & Reliable. Accurate predictions based on your own menstrual history. Becomes even more accu rate with usage, by way of machine learning (AI). (App 086) AI: artificial intelligence. ers often feature support for pregnancy (ie, pregnancy mode ac- and reports to use with providers) are either extremely basic or are counting for cessation of menstruation). Other nonmenstruating premium features requiring payment or subscription. users are not visible or supported by current app functionalities. Menstruators are often tied to their reproductive capacity (see Ta- Theme 2-2: Apps for empowering users and building body literacy ble 2), despite excluding apps that focus on fertility tracking. The fertile or imposing (scientific) explanations for the menstrual experience. window is frequently central to design and guides users in family plan- App descriptions explain that they can help users “learn more about ning—either to support conception or help prevent pregnancy. Apps your body” with self-tracked data and/or educational resources also use language such as “tracking intercourse” and finding a “safe (sometimes as premium/paid features) (see Table 2). Apps say they period” for “activity.” They do not include language about intimacy can help users “listen to yourself” to “better understand your cycle” or sexual pleasure, and sexuality is tied primarily to intercourse for the and “identify trends and patterns unique to your body.” Apps pro- purposes of family planning and managing fertility. Furthermore, dis- mote benefits for users who want “to monitor their cycle and be course around reproductive capacity assumes heterosexuality. aware of what is happening with their health.” However, apps also Beyond supporting users in managing menses and fertility, many claim they will “take out all the guess-work” and “give you all the apps claim to facilitate health and wellness goals (see Table 2). Some relevant information you need about your period.” Such claims that apps enable users to review data, generate reports, and apply data can make sense of the body can have harmful implications. Im- insights to monitor their health and identify anything that may be plying that users are “lost,” “confused,” “worried,” or “feeling in the “off.” A few explicitly mention breast health and cancer screenings dark” about their bodies/cycles, and need for apps to “show” them or (eg, pap tests). Some apps promote care, and others claim to support allow them to “observe” their cycles or that computational models wellness, for example, integrating menstrual cycle and physical ac- can “explain” menstrual experiences may actually disempower men- tivity, diet, and/or meditation data. struators by over-riding embodied lived experience with a presumably Sometimes users are encouraged to use their self-tracked data to more objective, quantifiable way to “know the body.” communicate with healthcare providers, with visualizations or exported reports. Other features for communicating with partners Theme 2-3: Apps assert that users can exert control over their men- or community forums also support users in health and wellness strual cycles and hide their menstrual status, perpetuating shame goals. However, many of these functionalities (eg, exports of data and stigma. Many apps (n¼ 27, 32%) also declare that users have 392 Journal of the American Medical Informatics Association, 2022, Vol. 29, No. 2 Table 2. What are the needs menstrual tracking apps are responsive to? Corresponding [Theme 2-1] Apps give a limited view on managing menstruation and fertility that largely obscures other goals, to themes in lifecourse representations, intimacy, and sexualities. scoping review: It’s easy to see predicted periods and fertility days—essential for planning dates and vacations and avoiding unpleasant Medical surprises! (App 009) management, DON’T FORGET Get reminders before your period & ovulation window arrives. You’ll never stain your undies or be support for health, caught without your trusty sanitary pads or tampons again. (App 045) and promotion With period calendar you can calculate your next menstrual period, ovulation days, fertile period. Menstrual cycle and of wellness are ovulation calendar will help both in planning for pregnancy and addressing the issue of contraception. (App 156) important to Track your menstrual cycle in easy to control calendar and predict ovulation, fertile days and next period. Add notes menstruators. about menstruation, symptoms or intimacy and keep your health under control. It will serve you as both menstrual cycle tracker and ovulation calculator for pregnancy. (App 039) A very simple and easy to use app. to monitor your periods, determine the date of ovulation and the fertile period. [...] It also calculates the time of ovulation and your fertile period. [...] helps you plan your activities better. (App 049) App helps both women looking to conceive and those trying to birth control. It tracks your periods, cycles, ovulation and the chance of conception. Helps birth control in a natural way. (App 100) Breast exam reminders. (App 024)//Keep track of you last Pap test. (App 056) ... will be your virtual gynaecologist, helping you to manage all aspects of female health and teaching you methods of prevention, crucial for the early diagnosis of tumours. (App 084) ... providing a hub of informative wellness tips and trends within an empowering women’s community! (App 090) Email and/or print your charts to share with your doctor, friends or family (App 060) Community provides an extended friend group for discussing sex & health. (App 011) SHARE WITH PARTNER feature allows you to share your emotional and physical health state with your Partner. (App 047) Corresponding to [Theme 2-2] Apps for empowering users and building body literacy or imposing (scientific) explanations for the themes in scoping menstrual experience. review: Listen to yourself, note your mood and symptoms to understand how they influence your health. (App 087) Equity underpins See your health data visualized in beautiful charts. Identify trends and patterns unique to your body. (App 011) the needs of Track your moods and symptoms to see the patterns and better understand your cycle. [.. .] see the statistics and iden- menstruators. tify trends and patterns. (App 146) ... wants to monitor their cycle and be aware of what is happening with their health. (App 006) More than just a period tracker: it provides you with cutting edge science that helps you keep track of your health, un- derstand what is going on with your body, flag potential issues and connect with a network of doctors and nurses to provide you the best health care. [...] Understand your health and the interplay of hormones in your body through our knowledge base. (App 060) ... exactly what you need to be in the know. (App 080) Track, monitor, and understand your menstrual cycle with an app that truly gets you. (App 055) If you feel lost and want to know more about your health, you can learn about your symptoms. (App 101) Ovulation, infertile days or the menstruation itself will not surprise you anymore. (App 126) No more surprises, worrying or feeling in the dark about your own reproductive health. [...] Take the guesswork out of predicting your most fertile days (App 018) The perfect app to take out all the guess-work. (App 137) Statistics: based on the information in your menstrual calendar, the app will give you all the relevant information you need about your period. (App 128) Personalized daily cycle stories that explain where you’re at in your cycle. (App 090) We’re not only backed by science; we’ve got period tracking down to a science. Track your menstrual cycle [...]to learn more about your body, mind, and self. (App 001) The period tracker app that uses science to help you discover the unique patterns in your menstrual cycle and support healthy habits. [...] Track your period and health cycles to keep all aspects of your health and fitness in check. (App 141) Corresponding to [Theme 2-3] Apps assert that users can exert control over their menstrual cycles and hide their menstrual status, themes in scoping perpetuating shame and stigma. review: Take control! (App 126)//An app that truly gets you. [...] putting you back in control. (App 055)//It will help you to Stigma and keep all monitored and controlled. (App 123)// .. . keep your health under control. (App 039) shame imposed [A] tool for any woman who wants to take more control over their body and health! (App 006) on menstruators A savvy period tracker and sex app for women who want to take control of their health and sex lives. (App 011) continues to be An elegant and easy-to-use period tracker that helps you take control of the many aspects of your menstrual cycle— harmful. from ovulation, fertility and periods, to birth control pills, moods and other symptoms. [...] Perfect for any woman to take control of her health and keep organized. (App 028) ... teaches you to live in your FLO so you can control your hormones, rather than letting them control you. Take your health into your own hands and relish being a woman instead of cursing your gender. (App 031, quote from doctor in text description) It is easy to track your menstrual cycle than ever before, take full control of your menstrual cycle by setting period reminders, fertile window reminder and ovulation day reminders. (App 105) (continued) Journal of the American Medical Informatics Association, 2022, Vol. 29, No. 2 393 Table 2. continued The application is elegant and very intuitive. Perfect for women who want to control the regularity of their menstrual cycle, check fertility and safely have sex. (App 118) For teens or women trying to keep a regular cycle. [...] stop guessing and stop worrying. [...] With this amazing, easy- to-use all-in-one cycle tracker, calendar and calculator, everything is totally under control. (App 137) The first-ever period tracker and fertility app that tells you what to do to be symptom-free. Learn why you have symp- toms and how to fix your period naturally. (App 031) FitrWoman is evidence-based and research driven, using the latest scientific research to provide simple changes and sol- utions that women can implement in their daily routine. (App 107) Discreet reminders/notifications. (App 047)//A neutral icon for home screen. (App 089)//DISCREET icon name (App 024) Discreet privacy mode. (App 045) Discreet reminders [...] Protect your most private data from curious eyes. (App 028) Can safely save your secrets and private notes. (App 118) Keeping your cycle information and period notes hidden from others. (App 093) SHHHH... IT’S A SECRET Our brand new Privacy Mode makes it easy for you to view your period countdown, even in a crowded space! You will no longer be self-conscious on checking on your periods in public. (App 045) Customize the notification text to make it discreet, to avoid never being embarrassed in public. (App 087) Your period will never awkwardly surprise you now that you can have a precise tracker and calculator. Download this app and make those bad days much easier! (App 150) control over their menstrual cycle and can manipulate it at their dis- ever, currently available apps largely hinder these aims by their lim- cretion (see Table 2). Descriptions instruct users to “take full control ited framing, flat representation, and treatment of the menstrual of your menstrual cycle,” and say they can instruct them how “to fix cycle as rigid, tidy, and quantifiable. This review affirmed that there your period naturally” by “telling you what to do to be symptom- are many kinds of menstruators, but current menstrual trackers free,” and how “to control the regularity of their menstrual cycle.” serve and advocate for a particular type of user, defined along nor- Apps claim to rely on “the latest scientific research.” However, it is mative expectations. Existing menstrual trackers are designed with unclear how apps enable control beyond the ability “to manage your narrow goals—managing menstrual bleeding and conception— period or get pregnant;” apps offer only the illusion of control. whereas the scoping review identified broader needs of menstruators Apps advertise their discreet designs so that users can conceal the across ensuring health and wellness, overcoming shame and stigma, app on their devices, hide or camouflage reminders on calendars, and ensuring equity. Others have also found that the needs of men- and avoid disclosure of menstrual status. Sometimes apps employ struators are not met with existing designs of menstrual track- 18,19,117 gender-neutral iconography in service of discreteness. Messaging ers, and the Human-Computer Interactions community has implies users should hide menstrual status and symptoms and that it recently highlighted these topics. Our findings and implications is something to be embarrassed about (see Table 2), which reinforces contribute toward the common goal of designing more inclusive the longstanding stigma around menstruation. Apps employ FemTech that meets the multifaceted needs of menstruators. “discreet privacy mode” as a veil for perpetuating stigma, which is An imagined FemTech future will require a fundamental refram- different from protecting data privacy, data ownership, or informed ing of the problem-solution coupling to expand what a “successful use of data for other purposes. period” looks like. It must avoid rigid, shameful, and negative but also overly romanticizing views, making room for different kinds of users/menstruators, and generating dialog to combat stigma and op- DISCUSSION pressive sociocultural norms. Søndergaard proposes “troubling Reviewing multidisciplinary literature enabled us to characterize the design” to address designing within this reframe. Fox et al explore identities (“who”) and needs (“what”) of menstruators. Using this “menstrual sensemaking,” emphasizing multiplicity over algorithmic framework for the analysis of menstrual tracking apps revealed their ways of knowing and dimensionality over norms, and troubling limitations and opportunities to support and empower menstrua- notions of the body as knowable, controllable, and presupposed for tors. Our findings highlight the narrow view of intended users and reproduction—promoting pragmatic technical adaptations, like uses of menstrual trackers. Key events, menstrual bleeding and ovu- richer capture of experiences, as a direction for future design. Fox lation, are overrepresented and detached from the menstrual cycle and Epstein suggest a modular approach that allows people to flexi- as a whole, which is seen as controllable. The lives of menstruators bly align designs with identity and goals. Almeida et al propose rec- are decontextualized and their experiences assumed universal. onceptualizing technology for women’s health as “intimate care Some medical experts have suggested menstruation should be technology,” where the care tasks involve interacting with bodily 86,87,115,116 considered “the fifth vital sign,” highlighting the poten- functions, products, and hygiene that are often hidden, private, and tial value of menstrual tracking apps and FemTech beyond self- intertwined with taboos. Here, technology is responsive to the body tracking. At the individual level, this may include designing per- in flux, including transitions and bodily health across the lifecourse, sonal informatics tools to empower and affirm the embodied experi- and can facilitate interactions with the “leaky” body to promote self- ences of users while gaining personalized insights and advancing knowledge and body literacy essential for self-care and well-being in precision medicine. At the population level, big data generated from relation to bodily experiences. Menstruation is inherently messy, and menstrual tracking apps can be used to fill knowledge gaps. How- designing to embrace this could better meet the resulting needs. 394 Journal of the American Medical Informatics Association, 2022, Vol. 29, No. 2 Gaps and design implications leaky body as abhorrent. Menstruators are told to conceal and to be discreet. Messages around the need (and ability) to plan for, man- Broadly, this review demonstrates menstruators have varied identities age, control, and hide menstruation are harmful. Enabling users to and needs; however, existing menstrual trackers do not account for pass as nonmenstruators reinforces stigmatizing messages. the messiness inherent in the menstrual cycle and are not adequately The rich, unruly experience of menstruation is flattened by limi- designed to support the range of menstrual experiences. Specifically, tations in data capture and disjointed data streams from various we have identified 3 clusters of messiness and one overarching gap sources. In the apps, fields available for tracking are limited (and that menstrual tracking apps do not currently support; we offer tinged with assumptions and stereotypes, eg, about mood changes), implications for enhancing design to fill these gaps. and structured tool designs restrict what can be documented, ham- pering crafting a holistic person-centered representation. The men- Messy gap 1: Irregularity is the norm, but apps are designed to treat strual experience is reduced to quantifiable data points, and these users as “regular” menstruators “objective” data elements often prioritized above the menstruator’s The menstrual cycle is complex, and irregularity is in fact the lived experience. As a result, menstrual tracking apps construct a 75,120–124 norm; yet menstrual tracking apps, and especially their pre- data-mediated body privileging science and quantitative metrics dictions, are designed to treat users as “regular” menstruators, based over embodied lived experiences of menstruators. on the “ideal” 28-day cycle. Assumptions impose prescriptive, nar- row expectations about periods/ovulation (length, duration, regular- Design implications. Menstrual tracking apps need a reframe. In- ity, pain levels) based on limited, outdated studies, and reduce the stead of hiding, controlling, shaming, and policing menstruating menstrual cycle to bleeding and ovulation, rather than acknowledg- bodies, a new framework should enable menstruators to engage ing its complex and often unpredictable dynamics. Sociocultural 20,21 with the embodied messiness of their cycle with curiosity and self- norms also come into play (eg, Fox connects 28-day norms to discovery to facilitate developing body and menstrual literacy. To the fertility awareness method, explaining that design decisions in- reflect the messy realities of menstruators, tools could extend be- scribe particular histories so apps inherit computational and moral yond tracking and predicting bleeding and ovulation to incorporate orientations). Finally, apps lack references to fluctuations, transi- the full, dynamic menstrual cycle and beyond the menstrual cycle to tions within an individual’s menstrual cycle, or shifts between cate- incorporate the full breadth of personal care. Menstrual tracking gories of menstruator and nonmenstruator (eg, due to menarche, apps should devise novel methods to capture and create workable menopause, lactation, hormonal treatments, therapies, weight, exer- representations of these experiences by integrating quantitative and cise, illness, travel, or stress). qualitative data capture, both directly related to the menstrual cycle and across other domains. Furthermore, apps should enable users to Design implications. Rather than relying on prescriptive norms, use narratives to tell their stories, reflect on their experiences, and apps should retool these narrow expectations. Apps could facilitate generate and document insights about their lived experiences. exploring the menstrual cycle and personal data with curiosity, for example, with visualizations or without quantification. When quan- tified, messaging should explain to users that menstrual cycles are Messy gap 3: Menstruators have varied biologies, identities, and inherently unpredictable and variable. Computational approaches goals, but users of menstrual tracking apps are represented as flat can also extend beyond using only cycle history to incorporate con- with monolithic experiences textual and day-to-day data for predictions. Menstruators have varied biology, identity, and goals, but users of Enabling health and wellness goals for both individuals and the menstrual tracking apps are represented as homogeneous, drawing population at large by using the menstrual cycle as a vital sign could from and reinforcing harmful, exclusionary stereotypes. Users of facilitate care, help monitor one’s health, and alert users and health- menstrual trackers are assumed to be feminine, female menstruators, care providers about potential concerns. This vital sign is quite indi- with a narrow scope of goals centered on reproduction and bleeding vidualized, so apps should allow users to construct a picture of their management. App design needs to accommodate different kinds of own “normal,” supported by novel computational approaches. users, across tangled spectrums of sex and gender, and at the inter- Customization tailored for a user’s menstrual cycle could personal- section of various other axes of identity and structural marginaliza- ize the experience, enable users to compare their ongoing experien- tion. Considering diverse needs of users also highlights the personal ces with their own baseline rather than sending a universalizing informatics and care needs and possible cyclical patterns of nonmen- message about “what is normal.” At the population level, filling struators (including those with a menstrual cycle but no menses, eg, gaps in biomedical knowledge about the menstrual cycle and men- 19 with an IUD ) which are not easily separable from those of men- strual disorders demands we study variations among different popu- 58,127 struators who use menstrual trackers. An individual’s identity lations around the world with different cultural and environmental cannot be represented as merely a sum of its parts, but rather exposures; this large-scale characterization depends on common through a nuanced understanding of oppressive experiences and dis- data elements, interoperability, and data quality. crimination that impact people differently based on the intersection 25–27 of identity categories. Attending to and incorporating complex and overlapping identity perspectives supports design that is respon- Messy gap 2: Menstruation is an embodied, leaky experience, but sive to intersectional identity-related experiences. apps flatten the experience and compel menstruators to hide and control their menses The menstrual experience is often messy and requires engaging with Design implications. Users of menstrual tracking apps differ in iden- one’s body parts and bodily fluids. However, apps reinforce the ne- tity, needs, and sociocultural experiences. Thus, no universal design cessity of concealment. The norms of keeping menstrual experiences will meet these diverse design requirements. Nevertheless, there is an hidden are a consequence of menstrual stigma. Across history, the unmet need to support diverse goals and diverse users (across cul- female body has been positioned as monstrous or dangerous and the tures, religions, identities, communities). Enabling personalization/ Journal of the American Medical Informatics Association, 2022, Vol. 29, No. 2 395 customization of the app interface, data fields, and goals offers one benefit from more data for training their analytics and for boosted key way this can be addressed. Designers could recruit diverse vol- app engagement. Furthermore, upstream data issues around classifi- unteers for participatory design, which seeks to design apps that al- cation and collection impact the success of models and encode sys- low users to explore and engage with their menstrual experience. tematic bias into AI, for example, binary gender classification Bardzell suggests “designing from the margins,” which reframes excludes nonbinary people from datasets and models and ignores marginality as a resource, and incorporates expertise of diverse per- their lived experiences. spectives that promote inclusive and responsive technology. The Apps also assert that they protect user privacy; but instead of resulting designs could challenge normative assumptions of feminin- protecting the user’s data and app usage, privacy is framed around ity, fertility, able-bodiedness, etc., even beyond individual users. maintaining secrecy around a user’s menstrual cycle and hiding their Expanding depictions of a “successful” or “acceptable” menstrual period. As others have documented, many apps for intimate care do cycle (or lack of), rather than imposing either a shameful or overly not take data privacy seriously leading to risks of exploiting 40,132,133 positive lens, can more meaningfully address the assorted needs of data. menstruators. By designing technology to account for the embodied 36,37 experience of menstruation, a feminist approach to design has Design implications. Human-centered AI aims to cultivate a syner- the potential to transform apps from body management tools into a gistic partnership between users and their technologies. Especially for nurturing and empowering experience. apps released commercially, user-centered design methods should rely Menstrual tracking apps could facilitate connecting with one’s on and elevate the lived experiences and needs of end-users, particu- body, identities, and communities, with the potential to affirm gen- larly users who have been historically excluded. Input from these der, whatever that means to the user. For some women who men- users can inform inclusive data definitions and mitigate concerns of struate, the menstrual cycle is a way to celebrate their womanhood failing to capture and account for important nuance and complexity. or femininity; others may find the link dysphoric or may not link To address limitations in computational approaches and to in- their gender and their period at all. For men or masculine people crease control of end-users over automated insights, design solutions 134–137 who menstruate, these apps can provide practical day-to-day secu- can draw from research in open-source, interpretable models 138–140 rity and support long-term gender affirmation and wellness. On and explainable AI to clearly communicate expectations the other hand, nonmenstruators may also use these apps to affirm about the accuracy of prediction models and explain which data 141–143 their identities and messy, embodied experiences. Women (who may were used for calculations. Designers can also explore mecha- or may not have ever menstruated, voluntarily or involuntarily, tem- nisms to communicate about uncertainties in the algorithmic pro- porarily or permanently) could use menstrual trackers to affirm rela- cesses and for particular predictions. And rather than offering tions with their bodies and aspects of (menstrual) cycles outside of certainties, technology could offer mechanisms to explore the men- bleeding and ovulation. Transgender women may experience hor- strual cycle rather than seeking to explain it. monal cycles that could be tracked and cared for with these care When it comes to person-generated health data, there is a need tools, in addition to affirming their gender. Not all validation must for policy around data ethics related to data ownership and privacy. be positive—those with chronic illness or painful menstruation may Regulatory oversight needs to hold businesses accountable for how use tools to validate their illness experience and communicate with users’ data are collected, stored, used, and shared, beyond obscure 40,44,144 family and providers. A further messiness is accommodating users terms and services. Users need more control over who has across transitions, for example, adolescents premenarche may bene- access to their data and how to revoke this access. Designers and fit from getting to know themselves as they go through puberty (sim- entrepreneurs should take ethics seriously, instead of sending users ilarly, transgender people undergoing gender-affirming hormone stigmatizing messages about hiding their period. The menstrual cy- therapy may experience puberty or “second puberty” that aligns cle is a messy biological process, which could be embraced instead with their gender ) menstruators experiencing perimenopause-re- of trying to force menstruation and menstruators into a clean, tidy lated fluctuations, and myriad reasons someone might start, stop, or experience. connect with the menstrual cycle. Although it may seem like a messy contradiction, including nonmenstruators in the design of FemTech Limitations may be necessary to meet needs across the spectrum of users. The scoping review may have been limited by our focus on the term “menstruator” rather than comprehensively reviewing the literature Overarching gap: the need for human-centered AI for transparency on the menstrual cycle. This allowed us to key into a specific dy- of uncertainties and the regulation and prioritization of privacy in namic around this term but may have also obscured other relevant FemTech literature that could have informed our analysis. In addition, selec- A final gap spanning several key findings calls for human-centered tion and use of databases may limit results returned, although we re- AI to address technical limitations, design choices, and policy con- lied on a range of databases to capture literature from different cerns related to menstrual trackers. Apps make big promises for of- disciplines. Still, limitations on what is published in the literature fering predictions and personal insights with data science and AI, and biases in the research presented mean further work is needed to assuring accurate, precise, and reliable calculations. Users, particu- document and address the needs of menstruators. Finally, this re- larly irregular menstruators, are directed to track more volume of search predominantly focuses on an English-speaking, Global North personal data, with assurances that this added detail will improve perspective of menstruation. predictions and insights about the body. However, there is no dis- cussion or transparency about the inherent unpredictability of men- struation, limitations of analysis methods, or disclosures of CONCLUSIONS (un)certainty of predictions, while their promises go beyond current state-of-the-art capabilities. It is not clear that more data improve This paper provides an analysis of menstrual tracking apps that lev- individual predictions; however, technology companies certainly erages a rich multidisciplinary body of literature to generate a frame 396 Journal of the American Medical Informatics Association, 2022, Vol. 29, No. 2 4. Norooz L, Mauriello ML, Jorgensen A, et al. BodyVis: a new approach of analysis that we use to interrogate the framing, messaging, and to body learning through wearable sensing and visualization. In: Pro- design of apps. We identify gaps as well as opportunities to support ceedings of the 33rd Annual ACM Conference on Human Factors in diverse menstrual needs with technology. Our interdisciplinary team Computing Systems; 2015 Apr 18; New York, NY: ACM; 2015: utilized data sources and methods that allowed us to triangulate 1025–34. doi: 10.1145/2702123.2702299. findings from other studies and enabled us to identify a key area ripe 5. Almeida T. 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The messiness of the menstruator: assessing personas and functionalities of menstrual tracking apps

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Oxford University Press
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© The Author(s) 2021. Published by Oxford University Press on behalf of the American Medical Informatics Association.
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1067-5027
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1527-974X
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10.1093/jamia/ocab212
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Abstract

Journal of the American Medical Informatics Association, 29(2), 2022, 385–399 doi: 10.1093/jamia/ocab212 Advance Access Publication Date: 6 October 2021 Review Review The messiness of the menstruator: assessing personas and functionalities of menstrual tracking apps 1 2,3 4,5 6 Adrienne Pichon , Kasey B. Jackman , Inga T. Winkler , Chris Bobel , and Noemie Elhadad 1 2 Biomedical Informatics, Columbia University, New York, New York, USA, School of Nursing, Columbia University, New York, 3 4 New York, USA, New York-Presbyterian Hospital, New York, New York, USA, Institute for the Study of Human Rights, Columbia 5 6 University, New York, New York, USA, Legal Studies, Central European University, Vienna, Austria, and Women’s, Gender, and Sexuality Studies, University of Massachusetts, Boston, Massachusetts, USA Corresponding Author: Adrienne Pichon, MPH, Biomedical Informatics, Columbia University, 622 W 168th Street PH20; New York, NY 10032, USA; ab3886@cumc.columbia.edu Received 5 April 2021; Revised 8 September 2021; Editorial Decision 14 September 2021; Accepted 20 September 2021 ABSTRACT Objective: The aim of this study was to examine trends in the intended users and functionalities advertised by menstrual tracking apps to identify gaps in personas and intended needs fulfilled by these technologies. Materials and Methods: Two types of materials were collected: a corpus of scientific articles related to the iden- tities and needs of menstruators and a corpus of images and descriptions of menstrual tracking apps collected from the Google and Apple app stores. We conducted a scoping review of the literature to develop themes and then applied these as a framework to analyze the app corpus, looking for alignments and misalignments be- tween the 2 corpora. Results: A review of the literature showed a wide range of disciplines publishing work relevant to menstruators. We identified 2 broad themes: “who are menstruators?” and “what are the needs of menstruators?” Descrip- tions of menstrual trackers exhibited misalignments with these themes, with narrow characterizations of men- struators and design for limited needs. Discussion: We synthesize gaps in the design of menstrual tracking apps and discuss implications for designing around: (1) an irregular menstrual cycle as the norm; (2) the embodied, leaky experience of menstruation; and (3) the varied biologies, identities, and goals of menstruators. An overarching gap suggests a need for a human-centered artificial intelligence approach for model and data provenance, transparency and explanations of uncertainties, and the prioritization of privacy in menstrual trackers. Conclusion: Comparing and contrasting literature about menstruators and descriptions of menstrual tracking apps provide a valuable guide to assess menstrual technology and their responsiveness to users and their needs. Key words: personal health informatics, menstruation, mobile health, menstrual tracking INTRODUCTION wearables and sensors to smartphone apps, technologies have been 2–5 proposed to support self-discovery and body literacy, to While menstruation has been largely absent in technology, the 6–11 meet self-management needs for well-being and reproductive past 5 years have witnessed the sharp rise of FemTech. From new V The Author(s) 2021. Published by Oxford University Press on behalf of the American Medical Informatics Association. This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial License (https://creativecommons.org/licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com 385 386 Journal of the American Medical Informatics Association, 2022, Vol. 29, No. 2 12–14 conditions, and to promote feminist representation in technol- JSTOR, PubMed, OVID Medline, Web of Science, Cumulative In- ogy. Menstrual trackers are becoming mainstream commodities dex to Nursing and Allied Health Literature (CINAHL), Scopus, with high engagement, and the research community has started PsycINFO, ProQuest, and ACM Digital Library. assessing their design, intended use, and potential unintended conse- 17–21 quences. Menstrual tracking apps are a key area of personal in- Data extraction and analysis formatics, with the potential to empower users and challenge For each result, we extracted the full text, first author, year of publi- oppressive social structures while enabling individual-level and cation, publication type (eg, journal article, book chapter, editorial, population-level insights. or commentary, etc.), title, geographic location, and discipline using a Beyond FemTech, attention to menstruation has surged, with the data extraction matrix created by the authors. We examined trends in term menstruator emerging as a key focal point for ongoing conversa- publications across time and disciplines of study. For the thematic tions. The term is often accompanied by the refrain, “not all women 39 analysis, we coded all publications by themes to characterize who is menstruate, and not everyone who menstruates is a woman.” The considered a menstruator and what needs are identified in the litera- menstrual cycle is a sex-linked biological process regulated by repro- ture. Two coders (AP and KBJ) independently familiarized themselves ductive hormones (estrogen, progesterone, follicle-stimulating hor- with a subset of publications balanced over source and discipline of mone (FSH), and luteinizing hormone (LH)), culminating in several study. An initial list of themes was identified, then grouped into ma- days of menstruation, where the uterine lining along with an unfertil- jor themes, which were iteratively refined, named, and defined in a 22,23 ized egg is shed through the cervix and vagina . While irregularity codebook, which was then used to code all included texts. is common, many menstruators experience this cyclical process every 21–35 days. In the life cycle of a menstruator, the first period (men- Analysis of menstrual tracking apps arche) occurs around puberty and ends in middle age via menopause. Search strategy and screening Menstruation is a common experience, but menstrual experiences are To curate a corpus encompassing the broadest representation of neither universal nor monolithic. Even (and especially) beyond gen- menstrual tracking apps available and that potential users are most der, the menstrual experience varies. Intersectionality explains that likely to encounter, we undertook a multipronged search strategy an individual’s identity cannot be represented as merely a sum of its across both the Google and Apple app stores. First, we screened parts, but rather through a nuanced understanding of oppressive 18,19,40–44 apps included in prior menstrual tracking app reviews, experiences and discrimination (or privileges and advantages) that then we added apps from the top 50 results across 6 distinct searches 25–27 impact people differently based on the intersection of identities. (menstrual OR period AND tracker OR calendar OR diary) on both Across the lifecourse, culture, race, ethnicity, religion, caste, and so- app stores, ignoring duplicates. The first author (AP) completed the cioeconomic circumstances profoundly shape the menstrual experi- searches and data extraction in June 2020. We excluded apps that 28–33 ence. We describe menstruation as messy, not only because it is were categorized as fertility trackers and that listed fertility tracking a messy physiological process but also because it is situated within a as primary focus (while systematically applied, criteria sometimes multifaceted sociocultural context. With menstruation so deeply stig- required judgment calls). We also excluded apps for “low use” (de- matized, we call for embracing the experience of messiness as authen- fined as <200 reviews). We finally considered author expertise to tic and valid and reject the conception of menstruation as in need of ensure no major apps were left out, and added back any apps ex- concealment and regularization (“less messy”). cluded due to low use but nonetheless deemed relevant to the cur- Given that the term “menstruator” has evolved into a crystalliz- rent study. When both free and paid versions were returned, only ing point for discussing menstruation, we use it as the basis for our the description of the paid app was included; we attempted to distin- scoping review to capture relevant themes across disciplines that guish between free and paid features. characterize menstruators and their needs then apply this characteri- zation as an analytic lens to evaluate menstrual tracking apps. Moti- Data extraction and analysis vated by recent research tackling intersections of society and 3,34–37 Extracted data included: app title, text description, images (logo and health, we take up complex questions with an interdisciplin- screenshots), and metadata (number of ratings, star reviews, and ary team to attend to the sociotechnical configuration of menstrual app category). Three authors (AP, KBJ, and ITW) conducted quali- trackers, guided by these key research questions: (1) Who is a tative analysis following a Directed Content Analysis approach, “menstruator” and who are the intended users of menstrual tracking focusing on app descriptions. Using Dedoose for codebook develop- apps? (2) What are the needs of menstruators and what needs are ment and coding, we started with the themes generated in the scop- menstrual trackers responsive to? (3) Where does current technology ing review, and then iteratively revised the codebook through fall short? (4) What design directions can address these deficits? several rounds of double-coding subsets of the corpus and discussing how codes were applied. The codebook was revised until coders agreed that topics were meaningfully represented and could be ap- MATERIALS AND METHODS plied systematically. We reached saturation while developing the codebook and coding the text of the app descriptions. Scoping review of the literature Search strategy and screening To gather information about who a menstruator is and what their RESULTS needs are, we conducted a scoping review following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta- Findings of the scoping review Analyses) Extension for Scoping Reviews guidelines. Database Search results searches were conducted by AP in March 2019 and updated in The flow diagram is provided in Figure 1 (left). Searches in Google March 2020 to include literature through the end of 2019. Searches Scholar returned 314 articles, JSTOR returned 4 additional results, with the query “menstruator*” were conducted in Google Scholar, and the remaining databases returned only duplicates, irrelevant Journal of the American Medical Informatics Association, 2022, Vol. 29, No. 2 387 Figure 1. Flow diagram of search strategies for (left) scoping review and (right) curating app corpus. results, or no results. The title and abstract of 318 total results were lived experiences relevant to menstruation. Finally, it highlights the screened, leading to the exclusion of 132 results. Full-text screening inherent dynamic and irregular nature of the menstrual cycle. was completed on the remaining 186 results, leading to the exclu- sion of 48 results. Overall, there were 138 scholarly outputs in- Theme 1-1: Menstruators have been characterized by both sex- cluded in our synthesis; 39 of which were books. linked biological processes and social identity. Early articles in the biomedical literature refer to menstruators through their sex-linked traits, for instance comparing characteristics of “early menstru- Trends in academic publications ators” versus “late menstruators” (based on the age of menar- Figure 2 visualizes publications using the term menstruator across 46–48 che). The biological significance and evolution of menstruation decades and yearly for the 2010s. We note a striking uptick in the are also represented, citing the certainty of adaptive benefits and last decade, with an overall upward trend. uniqueness of human menstruation apart from other animals (ie, as We further note that the term menstruator appears in an increas- 49–51 “overt menstruators” and “copious menstruators”). ingly wide range of disciplines across time. Starting in 1953 until Later literature focuses on social identities rather than biological early 1980s, biomedical journals were the exclusive users of the functioning around menstruation. Many recent articles in gender term “menstruator.” Publications in anthropology take over in the studies, economics/development/policy, and the humanities/social sci- mid-1970s until early 2010s as the prominent field represented. In ences employ the widely used axiom “not all women menstruate, and the 1990s and beyond, gender studies publications become predomi- 52–55 not all menstruators are women,” centering gender (a social cate- nant. We also note an increase in publications discussing menstrua- gory) rather than sex (a biological category). This more recent use in tors from a variety of perspectives and applied fields, such as menstrual discourse is applied to signal inclusion of transgender men, economics, law, and more recently, technology. masculine of center individuals, and nonbinary people who men- struate. On the other hand, there are many reasons women and girls Themes do not menstruate, for example, premenarche, postmenopause, preg- An overview of themes is presented in Figure 3. nancy or lactation, surgery or medical treatment, illness, stress, travel, and physical activity. Intersex individuals may or may not menstru- Who is a menstruator? This scoping review highlights that ate. In addition, transgender women do not experience menstrual “menstruator” is used to be inclusive by broadening the scope of who bleeding but may undergo cyclical hormonal fluctuations. Many is perceived as a person who menstruates, while also narrowing and articles refer to these social categories, further complicating the con- 59–61 adding nuance to the description of menstruators. The term encour- structs of gender and sex. Nonetheless, womanhood is often re- 62,63 ages the inclusion of people who experience the biological process of ferred to when discussing menstruators, with a few articles menstruation, regardless of their gender. It also focuses on the varied arguing for menstruation to be inherent to womanhood, explicitly ex- 388 Journal of the American Medical Informatics Association, 2022, Vol. 29, No. 2 Figure 2. Characteristics of the literature: References over time by (left) discipline (by decade, all time) and (right) subdiscipline (by year, 2010s). Figure 3. Overview of themes from the scoping review and analysis of apps, and the gaps identified from the analysis. 64,65 cluding some sexual and gender minorities. Because of menstrua- barriers associated with disadvantaged social locations. In particu- tion’s complex relation between sex-linked traits, biology, gender, lar, access to hygiene for under-resourced communities is a primary and life context, menstruation is more than a bodily process and focus of the water, sanitation, and hygiene (WASH) sector, such as encompasses a social dimension. access to toilets that meet the needs of menstruators (eg, privacy, 66–69 safety, facilities to wash or change pads). More broadly, many menstruators have specific needs, including individuals experiencing Theme 1-2: “Menstruator” highlights the varied lived experiences of 70 71 homelessness, incarcerated persons, individuals with physical, groups that have been marginalized. The literature often uses mental, and developmental disabilities, migrants, refugees, and “menstruator” to focus on the menstrual experience of groups that 72 73 asylum seekers, racial and ethnic minorities, and people living in have been marginalized, centering functional needs and structural Journal of the American Medical Informatics Association, 2022, Vol. 29, No. 2 389 poverty. Specifically, because these menstrual needs are not ade- tute a fundamental aspect of care; suppressing menstruation can quately addressed, these often intersecting aspects of lived experi- mitigate burdensome symptoms and painful periods, empower men- ence and identity are further marginalized. Here, using the term struators with bodily agency, and resist harmful menstrual expecta- menstruator positions the relevant needs of individuals who men- tions. However, social pressure to suppress menstruation to avoid struate (based on “what”; context and relevant needs), rather than the burden, messiness, and embarrassment can bolster and repro- their identity (“who”; attributes such as sex/gender), thus weaken- duce discipline, surveillance, and policing imposed on menstrua- 90 43 ing the link of menstruation to gender and instead focusing on the tors. Considering technology, Eschler et al assert, “giving unique needs relating to an individual’s bodily function specific to menstruators the ability to manage their own information can be an menstruation. Although menstruation is a bodily function shared important aspect of resisting the ‘social control’ of medicalized biol- by many, it is experienced in diverse, context-specific ways. ogy and conditions.” Theme 1-3: The menstrual cycle is inherently variable across men- Theme 2-2: Equity underpins the needs of menstruators. The need struators and across cycles within individuals. The literature to promote equity from social, economic, and gender justice per- describes how the “normal” 28-day cycle, broadly applied, is not spectives is a prominent theme. Calls include advocacy to end the consistent with the reality of the dynamic menstrual cycle; in particu- “tampon tax” (ie, charging sales tax on menstrual products) and ad- 69,91–93 lar, a recent study using Clue data affirms, “menstruation is charac- vocating for free menstrual products in particular settings 75 74 terized by variability rather than by regularity,” demonstrating that (including eg, schools, shelters, detention). They also address ten- the menstrual experience between menstruators and even within an sions between affordable single-use products and their environmen- individual’s cycle varies with regard to length, frequency, and symp- tal sustainability, suggesting do-it-yourself menstrual materials. toms. Hasson proposes that “complex arrangements of organs, tis- Human rights discourse focuses on addressing needs specific to sues, hormones—produced in the body or taken in from outside— groups that have been marginalized, specifically structural barriers generate embodied experiences of regular, irregular, or absent beyond products and addressing underlying causes of unmet needs bleeding.” There is also longstanding evidence that new menstruators and ongoing stigma. generally have irregular cycles, and those going through the meno- Another equity-related topic calls for access to appropriate pausal transition experience disruption or absence of regular cycles. educational resources and better body literacy, as discussed across health-related humanities literature, early menstrual advocacy literature (eg, the seminal book “Our Bodies, Ourselves” What are the needs of menstruators? Our review highlights different from the Boston Women’s Health Collective ) and intersectional menstrual needs, including instrumental needs to manage menstrual 57,97 gender studies work. Some results emphasize personal narrative bleeding, which expand to other medical and wellness needs associ- and lay knowledge (potentially transformative), stories from ated with menstruation. Importantly, needs extend beyond material menstruators, and representing menstruation not as inherently prob- needs into cultural messaging that harms menstruators and larger 76,78,88,98,99 lematic. structural barriers that limit menstruators, particularly in accessing necessary resources. Theme 2-3: Stigma and shame imposed on menstruators continue to Theme 2-1: Medical management, support for health, and promo- be harmful. The literature interrogates shame and stigma related to tion of wellness are important to menstruators. Most biomedical menstruation and how pervasive and harmful menstrual norms are articles retrieved in our search, especially early ones, concentrate on socially constructed and reinforced. Particularly in anthropology, medical management of the menstrual cycle. Most prominently, the symbolic and religious attitudes toward menstruators highlight im- early literature from the 1960s, 1970s, and 1980s centers reproduc- purity, rituals for isolating menstruators, and menstruators as 47,48,77,78 tive health (fertility and contraception). Content also “weak bleeders” contrasted with warriors as “strong, masculine 100–104 79,80 details toxic shock syndrome, including the need for individual bleeders.” These older publications illuminate deep cultural, awareness of risks, generating scientific knowledge, and political ad- social, and religious interpretations underpinning stigmatizing men- vocacy to regulate and hold accountable corporations producing strual discourse. Across the corpus, publications and their findings commercial products. must be contextualized within the history of each discipline and Another pronounced body of work focuses on menstrual symp- interpreted cautiously with their limitations acknowledged. Nota- toms and disorders and treatments (eg, dysmenorrhea, chronic and bly, much of the older anthropological literature asserts a particular 46,52,59,81,82 cyclical menstrual pain, menstrual suppression), and dis- set of Western perceptions, rather than representing the voices of cusses care and self-management of chronic diseases, for example, menstruators themselves. 83 84 the impact of eating disorders, mental health, and spinal cord in- Articles critiquing attitudes toward menstruation span pop cul- juries on menstruation. Results call for robust menstrual health in- ture and media (eg, through analysis of menstrual products ads urg- 54,62,105–107 formation, mechanisms to support menstruators accessing care from ing concealment), film, television, and literature (eg, health providers, and tools to independently self-manage health and representations of menstruation as abhorrent, or in horror gen- 108,109 well-being. Results affirm that menstruation can be considered a vi- res), menstrual educational materials (eg, bodily surveillance 86,87 tal sign for both menstrual and overall health. However, some and management reinforcing menstrual normativity; problematic articles (particularly within gender studies) critique the medicaliza- framing of menstruation exclusively around fertility and reproduc- 110–112 tion of the menstrual cycle, explaining that even though menstrua- tion), and day-to-day stigma and shame inherently ascribed 76,97 tion is a common life process situated within the social realm, it to being a menstruator. A few authors discuss positive represen- 89,108 has been understood and problematized through the adoption of a tations or symbols of menstruation. Nonetheless, because 55,88,89 medical framework. For some menstruators, medical treat- menstrual shame and stigma are so prevalent, the motivation to ap- 113,114 ments such as contraception or hormone replacement might consti- pear as a nonmenstruator appears among articles retrieved. 390 Journal of the American Medical Informatics Association, 2022, Vol. 29, No. 2 Findings of the analysis of menstrual trackers Theme 1-3: Menstrual tracking apps are designed for regular men- struators but claim to support irregular menstruators and personal- Search results and app corpus ized menstrual dynamics. Assumptions about normal or typical A flow diagram is provided in Figure 1 (right). Our search yielded a menstrual cycles characterize the messages and features associated total of 256 apps. One hundred seventy-four apps were included for with many of the apps (see Table 1). Cycles are often assumed to be data extraction and full review to assess eligibility. Ninety-two apps regular (either explicitly or implicitly in predictions), with 28-day were excluded when assessed for eligibility to remove fertility track- cycles and consistency from one cycle to the next. Some app logos ers and apps with “low use.” After manual review, 3 were added to even incorporate “28” into their design (eg, app icons featuring the the final corpus (Apple Cycle Tracking; Oky by UNICEF; Fitr- number 28). Cycles are also assumed to be ovulatory, which is not Woman integrating physical activity and menstrual tracking) result- always the case (eg, due to polycystic ovary syndrome (PCOS) or ing in of 85 apps from across app stores for evaluation. App ratings hormonal contraceptive use). There is little mention of menstruators ranged between 2.35 and 4.9 stars, with a median of 4.55 and an across the lifecourse or transitions, with the exception of pregnancy. interquartile range of 4.3–4.7. Many apps purport to support users with irregular cycles (see Table 1), generally by allowing users to customize cycle length or by Themes using machine learning. Apps prompt users to log more data and Illustrative quotes from apps are presented in Tables 1 and 2. claim to use data science, artificial intelligence (AI), or special algo- rithms to predict and map onto irregular cycles or individual men- Who are the intended users of menstrual trackers? Menstrual track- strual dynamics. Despite complex menstrual cycle dynamics, they ers depict a largely normative representation of users. Users are as- promise reliability and accuracy of predictions but provide little in- sumed to be women, and womanhood is linked to menstruation and dication that these predictions may not be accurate. femininity. The lived experience of women is displayed as mono- lithic and privileged across domains (eg, race/ethnicity, sexuality, so- What are the needs the menstrual tracking apps respond to? Men- cioeconomic status, disability, access to housing, food, healthcare). strual trackers are designed to track, predict, and manage a menstru- Users are assumed to be regular menstruators, but apps claim to use ator’s menses and ovulation/fertility window. Beyond these primary machine learning to account for variation in cycles. goals, apps also claim to facilitate health and wellness and help users cultivate menstrual awareness, control their cycles, and conceal their Theme 1-1: Users are represented as women or girls. The gendered menstrual status. assumptions and stereotypes about women underlying menstrual tracking apps may be the most obvious finding; app store searches Theme 2-1: Apps give a limited view on managing menstruation and returned visually homogenous, overwhelming pink, pastel, and fertility that largely obscures other goals, lifecourse representations, flowery pages of results (images cannot be reproduced due to copy- intimacy, and sexualities. A primary function of menstrual tracking right, but we encourage readers to replicate the searches). Gender is apps is to log data about menstrual cycles to visualize, analyze, and implicitly and explicitly encoded using language (see Table 1) and predict the menstrual period (ie, when bleeding will start) with goals visuals, ie, feminine imagery (eg, app icons depicting pink, purple, to prepare for days of bleeding, “prevent an accident,” and plan (eg, and pastel colors with flowers, hearts, butterflies, or feathers) and for work or vacation). Apps also seek to predict the fertility win- images of women (eg, app icons featuring women with long hair dow/ovulation for preventing pregnancy or optimizing chances of and screenshots of users who are thin white women). A substantial conception. Users can log days of bleeding, descriptors of flow number of apps refer to anticipated users as women/ladies (n¼52, (heaviness of flow, clots, color), and sometimes associated signs and 61%), girl (n¼20, 24%), and females (n¼15, 18%). Overall, two symptoms. Many apps also keep track of ovulation information, for out of three apps (n¼57, 67%) use feminine gendered language. Of example, basal body temperature, cervical mucus, and ovulation the 28 apps without gendered language, another five include explicit tests. In reality, the menstrual cycle is a complex, dynamic cycle of images of women in the icons and screenshots; 17 more depict ste- hormones that fluctuates dynamically across time; nevertheless, reotypically feminine imagery and/or colors. Three apps are mostly most apps isolate 2 distinct events: bleeding and ovulation without neutral regarding gender, but still have pastels, hearts, or “cute” lan- mentioning other phases of the menstrual cycle (see Table 2). guage. What it means to be a woman is elaborated by these assump- However, some apps offer features to construct a more holistic rep- tions around femininity designed into visual elements. Some of these resentation of the menstrual cycle. Beyond details of flow and fertility, images and language are particularly infantilizing (eg, cartoon mer- users can track symptoms, mood, weight, physical activity, diet, sleep, maid and rabbit). Only three apps (4%) avoid gendered assumptions medications, and more. Customization of domains or app interface is in their language, images (eg, circles, spirals, cube, blood drop), and sometimes supported. Furthermore, apps commonly support free-text colors (eg, bold). notes, journal entries, or even photos to incorporate narrative alongside self-tracking and construct a comprehensive picture of the user’s life. Theme 1-2: Users are represented as having a monolithic lived expe- But these remain the exception and even when apps permit a more ho- rience. Representation of users are flat even beyond gender, as illus- listic representation, options are sometimes still limited and often draw trated by the use of the word “every” in many of the apps. App from reductionist assumptions and stereotypes around menstruation, descriptions send the message that they are a perfect, universal fit for example, “mood swings” and weight changes, which have been for every potential user; furthermore, apps make many assumptions, used to police girls and women and minimize their experiences. for example, that users are heterosexual, monogamous, and inter- As a result of their limited conception, menstrual trackers largely ested and able to focus on their fertility and family planning. Text obscure realities of transitions from a menstruator to a nonmen- often asserts that users work and take vacations, circumstances the struator, and vice versa, and changes across the lifecourse, especially app can apparently help handle. during perimenopause. One prominent exception, menstrual track- Journal of the American Medical Informatics Association, 2022, Vol. 29, No. 2 391 Table 1. Who are the intended users of menstrual trackers? Corresponding to themes in [Theme 1-1] Users are represented as women or girls. scoping review: The Easy Period Calendar is a must for modern women. (App 118) Menstruators have been It’s a smart and simple female period tracker. (App 145) It is period app for girls/women/ladies/teenagers. (App 087) characterized by both sex- The main objective of this ladies periods calendar is to record menstrual cycles and personal period log for linked biological processes teenage girls and women. (App 047) and social identity. Corresponding to themes in [Theme 1-2] Users are represented as having a monolithic lived scoping review: experience. “Menstruator” highlights the An essential menstrual recording tool for every girl’s life! (App 168) varied lived experiences of groups Discreet menstrual diary for every woman. (App 039) that have been marginalized. Woman Calendar, it is what every woman needs! (App 066) Corresponding to themes in [Theme 1-3] Menstrual tracking apps are designed for regular menstruators but claim to support irregular scoping review: menstruators and personalized menstrual dynamics. The menstrual cycle is Please note that this application is based on the assumption that your periods are fairly regular. The date of inherently variable across your next period and the fertile period will not be accurate if you have very irregular periods. (App 049) menstruators and across Contrary to others calendars, you only need your cycle start date and the cycle time (average 28 days) to cycles within individuals. configure it. (App 132) Menstrual cycle and ovulation calendar, for teens or women trying to keep a regular cycle. (App 137) Accurate period predictions even for irregular cycles. (App 146) Predict your period, menstruation, fertile days by machine learning no matter you have irregular period or regular period. (App 087) Log more symptoms to get improved predictions if you have irregular periods. (App 003) Finally, an intelligent period tracker app that makes sense of what you track! Pslove Period Tracker not only accurately predicts your upcoming menstrual cycles & fertile days but also analyses trends in your body. It’s easy to get on top of your health! SEE THE FUTURE You can view your predicted periods and ovulation dates for months in advance. Using machine learning artificial intelligence, our predictions gets better over time to make the best calendar for women—the more you log, the higher the accuracy! (App 045) Learns from your inputs and makes better prediction of future periods and fertile windows through time, we use all up to date scientific methods available to track and plan your cycle. (App 093) Accurate & Reliable. Accurate predictions based on your own menstrual history. Becomes even more accu rate with usage, by way of machine learning (AI). (App 086) AI: artificial intelligence. ers often feature support for pregnancy (ie, pregnancy mode ac- and reports to use with providers) are either extremely basic or are counting for cessation of menstruation). Other nonmenstruating premium features requiring payment or subscription. users are not visible or supported by current app functionalities. Menstruators are often tied to their reproductive capacity (see Ta- Theme 2-2: Apps for empowering users and building body literacy ble 2), despite excluding apps that focus on fertility tracking. The fertile or imposing (scientific) explanations for the menstrual experience. window is frequently central to design and guides users in family plan- App descriptions explain that they can help users “learn more about ning—either to support conception or help prevent pregnancy. Apps your body” with self-tracked data and/or educational resources also use language such as “tracking intercourse” and finding a “safe (sometimes as premium/paid features) (see Table 2). Apps say they period” for “activity.” They do not include language about intimacy can help users “listen to yourself” to “better understand your cycle” or sexual pleasure, and sexuality is tied primarily to intercourse for the and “identify trends and patterns unique to your body.” Apps pro- purposes of family planning and managing fertility. Furthermore, dis- mote benefits for users who want “to monitor their cycle and be course around reproductive capacity assumes heterosexuality. aware of what is happening with their health.” However, apps also Beyond supporting users in managing menses and fertility, many claim they will “take out all the guess-work” and “give you all the apps claim to facilitate health and wellness goals (see Table 2). Some relevant information you need about your period.” Such claims that apps enable users to review data, generate reports, and apply data can make sense of the body can have harmful implications. Im- insights to monitor their health and identify anything that may be plying that users are “lost,” “confused,” “worried,” or “feeling in the “off.” A few explicitly mention breast health and cancer screenings dark” about their bodies/cycles, and need for apps to “show” them or (eg, pap tests). Some apps promote care, and others claim to support allow them to “observe” their cycles or that computational models wellness, for example, integrating menstrual cycle and physical ac- can “explain” menstrual experiences may actually disempower men- tivity, diet, and/or meditation data. struators by over-riding embodied lived experience with a presumably Sometimes users are encouraged to use their self-tracked data to more objective, quantifiable way to “know the body.” communicate with healthcare providers, with visualizations or exported reports. Other features for communicating with partners Theme 2-3: Apps assert that users can exert control over their men- or community forums also support users in health and wellness strual cycles and hide their menstrual status, perpetuating shame goals. However, many of these functionalities (eg, exports of data and stigma. Many apps (n¼ 27, 32%) also declare that users have 392 Journal of the American Medical Informatics Association, 2022, Vol. 29, No. 2 Table 2. What are the needs menstrual tracking apps are responsive to? Corresponding [Theme 2-1] Apps give a limited view on managing menstruation and fertility that largely obscures other goals, to themes in lifecourse representations, intimacy, and sexualities. scoping review: It’s easy to see predicted periods and fertility days—essential for planning dates and vacations and avoiding unpleasant Medical surprises! (App 009) management, DON’T FORGET Get reminders before your period & ovulation window arrives. You’ll never stain your undies or be support for health, caught without your trusty sanitary pads or tampons again. (App 045) and promotion With period calendar you can calculate your next menstrual period, ovulation days, fertile period. Menstrual cycle and of wellness are ovulation calendar will help both in planning for pregnancy and addressing the issue of contraception. (App 156) important to Track your menstrual cycle in easy to control calendar and predict ovulation, fertile days and next period. Add notes menstruators. about menstruation, symptoms or intimacy and keep your health under control. It will serve you as both menstrual cycle tracker and ovulation calculator for pregnancy. (App 039) A very simple and easy to use app. to monitor your periods, determine the date of ovulation and the fertile period. [...] It also calculates the time of ovulation and your fertile period. [...] helps you plan your activities better. (App 049) App helps both women looking to conceive and those trying to birth control. It tracks your periods, cycles, ovulation and the chance of conception. Helps birth control in a natural way. (App 100) Breast exam reminders. (App 024)//Keep track of you last Pap test. (App 056) ... will be your virtual gynaecologist, helping you to manage all aspects of female health and teaching you methods of prevention, crucial for the early diagnosis of tumours. (App 084) ... providing a hub of informative wellness tips and trends within an empowering women’s community! (App 090) Email and/or print your charts to share with your doctor, friends or family (App 060) Community provides an extended friend group for discussing sex & health. (App 011) SHARE WITH PARTNER feature allows you to share your emotional and physical health state with your Partner. (App 047) Corresponding to [Theme 2-2] Apps for empowering users and building body literacy or imposing (scientific) explanations for the themes in scoping menstrual experience. review: Listen to yourself, note your mood and symptoms to understand how they influence your health. (App 087) Equity underpins See your health data visualized in beautiful charts. Identify trends and patterns unique to your body. (App 011) the needs of Track your moods and symptoms to see the patterns and better understand your cycle. [.. .] see the statistics and iden- menstruators. tify trends and patterns. (App 146) ... wants to monitor their cycle and be aware of what is happening with their health. (App 006) More than just a period tracker: it provides you with cutting edge science that helps you keep track of your health, un- derstand what is going on with your body, flag potential issues and connect with a network of doctors and nurses to provide you the best health care. [...] Understand your health and the interplay of hormones in your body through our knowledge base. (App 060) ... exactly what you need to be in the know. (App 080) Track, monitor, and understand your menstrual cycle with an app that truly gets you. (App 055) If you feel lost and want to know more about your health, you can learn about your symptoms. (App 101) Ovulation, infertile days or the menstruation itself will not surprise you anymore. (App 126) No more surprises, worrying or feeling in the dark about your own reproductive health. [...] Take the guesswork out of predicting your most fertile days (App 018) The perfect app to take out all the guess-work. (App 137) Statistics: based on the information in your menstrual calendar, the app will give you all the relevant information you need about your period. (App 128) Personalized daily cycle stories that explain where you’re at in your cycle. (App 090) We’re not only backed by science; we’ve got period tracking down to a science. Track your menstrual cycle [...]to learn more about your body, mind, and self. (App 001) The period tracker app that uses science to help you discover the unique patterns in your menstrual cycle and support healthy habits. [...] Track your period and health cycles to keep all aspects of your health and fitness in check. (App 141) Corresponding to [Theme 2-3] Apps assert that users can exert control over their menstrual cycles and hide their menstrual status, themes in scoping perpetuating shame and stigma. review: Take control! (App 126)//An app that truly gets you. [...] putting you back in control. (App 055)//It will help you to Stigma and keep all monitored and controlled. (App 123)// .. . keep your health under control. (App 039) shame imposed [A] tool for any woman who wants to take more control over their body and health! (App 006) on menstruators A savvy period tracker and sex app for women who want to take control of their health and sex lives. (App 011) continues to be An elegant and easy-to-use period tracker that helps you take control of the many aspects of your menstrual cycle— harmful. from ovulation, fertility and periods, to birth control pills, moods and other symptoms. [...] Perfect for any woman to take control of her health and keep organized. (App 028) ... teaches you to live in your FLO so you can control your hormones, rather than letting them control you. Take your health into your own hands and relish being a woman instead of cursing your gender. (App 031, quote from doctor in text description) It is easy to track your menstrual cycle than ever before, take full control of your menstrual cycle by setting period reminders, fertile window reminder and ovulation day reminders. (App 105) (continued) Journal of the American Medical Informatics Association, 2022, Vol. 29, No. 2 393 Table 2. continued The application is elegant and very intuitive. Perfect for women who want to control the regularity of their menstrual cycle, check fertility and safely have sex. (App 118) For teens or women trying to keep a regular cycle. [...] stop guessing and stop worrying. [...] With this amazing, easy- to-use all-in-one cycle tracker, calendar and calculator, everything is totally under control. (App 137) The first-ever period tracker and fertility app that tells you what to do to be symptom-free. Learn why you have symp- toms and how to fix your period naturally. (App 031) FitrWoman is evidence-based and research driven, using the latest scientific research to provide simple changes and sol- utions that women can implement in their daily routine. (App 107) Discreet reminders/notifications. (App 047)//A neutral icon for home screen. (App 089)//DISCREET icon name (App 024) Discreet privacy mode. (App 045) Discreet reminders [...] Protect your most private data from curious eyes. (App 028) Can safely save your secrets and private notes. (App 118) Keeping your cycle information and period notes hidden from others. (App 093) SHHHH... IT’S A SECRET Our brand new Privacy Mode makes it easy for you to view your period countdown, even in a crowded space! You will no longer be self-conscious on checking on your periods in public. (App 045) Customize the notification text to make it discreet, to avoid never being embarrassed in public. (App 087) Your period will never awkwardly surprise you now that you can have a precise tracker and calculator. Download this app and make those bad days much easier! (App 150) control over their menstrual cycle and can manipulate it at their dis- ever, currently available apps largely hinder these aims by their lim- cretion (see Table 2). Descriptions instruct users to “take full control ited framing, flat representation, and treatment of the menstrual of your menstrual cycle,” and say they can instruct them how “to fix cycle as rigid, tidy, and quantifiable. This review affirmed that there your period naturally” by “telling you what to do to be symptom- are many kinds of menstruators, but current menstrual trackers free,” and how “to control the regularity of their menstrual cycle.” serve and advocate for a particular type of user, defined along nor- Apps claim to rely on “the latest scientific research.” However, it is mative expectations. Existing menstrual trackers are designed with unclear how apps enable control beyond the ability “to manage your narrow goals—managing menstrual bleeding and conception— period or get pregnant;” apps offer only the illusion of control. whereas the scoping review identified broader needs of menstruators Apps advertise their discreet designs so that users can conceal the across ensuring health and wellness, overcoming shame and stigma, app on their devices, hide or camouflage reminders on calendars, and ensuring equity. Others have also found that the needs of men- and avoid disclosure of menstrual status. Sometimes apps employ struators are not met with existing designs of menstrual track- 18,19,117 gender-neutral iconography in service of discreteness. Messaging ers, and the Human-Computer Interactions community has implies users should hide menstrual status and symptoms and that it recently highlighted these topics. Our findings and implications is something to be embarrassed about (see Table 2), which reinforces contribute toward the common goal of designing more inclusive the longstanding stigma around menstruation. Apps employ FemTech that meets the multifaceted needs of menstruators. “discreet privacy mode” as a veil for perpetuating stigma, which is An imagined FemTech future will require a fundamental refram- different from protecting data privacy, data ownership, or informed ing of the problem-solution coupling to expand what a “successful use of data for other purposes. period” looks like. It must avoid rigid, shameful, and negative but also overly romanticizing views, making room for different kinds of users/menstruators, and generating dialog to combat stigma and op- DISCUSSION pressive sociocultural norms. Søndergaard proposes “troubling Reviewing multidisciplinary literature enabled us to characterize the design” to address designing within this reframe. Fox et al explore identities (“who”) and needs (“what”) of menstruators. Using this “menstrual sensemaking,” emphasizing multiplicity over algorithmic framework for the analysis of menstrual tracking apps revealed their ways of knowing and dimensionality over norms, and troubling limitations and opportunities to support and empower menstrua- notions of the body as knowable, controllable, and presupposed for tors. Our findings highlight the narrow view of intended users and reproduction—promoting pragmatic technical adaptations, like uses of menstrual trackers. Key events, menstrual bleeding and ovu- richer capture of experiences, as a direction for future design. Fox lation, are overrepresented and detached from the menstrual cycle and Epstein suggest a modular approach that allows people to flexi- as a whole, which is seen as controllable. The lives of menstruators bly align designs with identity and goals. Almeida et al propose rec- are decontextualized and their experiences assumed universal. onceptualizing technology for women’s health as “intimate care Some medical experts have suggested menstruation should be technology,” where the care tasks involve interacting with bodily 86,87,115,116 considered “the fifth vital sign,” highlighting the poten- functions, products, and hygiene that are often hidden, private, and tial value of menstrual tracking apps and FemTech beyond self- intertwined with taboos. Here, technology is responsive to the body tracking. At the individual level, this may include designing per- in flux, including transitions and bodily health across the lifecourse, sonal informatics tools to empower and affirm the embodied experi- and can facilitate interactions with the “leaky” body to promote self- ences of users while gaining personalized insights and advancing knowledge and body literacy essential for self-care and well-being in precision medicine. At the population level, big data generated from relation to bodily experiences. Menstruation is inherently messy, and menstrual tracking apps can be used to fill knowledge gaps. How- designing to embrace this could better meet the resulting needs. 394 Journal of the American Medical Informatics Association, 2022, Vol. 29, No. 2 Gaps and design implications leaky body as abhorrent. Menstruators are told to conceal and to be discreet. Messages around the need (and ability) to plan for, man- Broadly, this review demonstrates menstruators have varied identities age, control, and hide menstruation are harmful. Enabling users to and needs; however, existing menstrual trackers do not account for pass as nonmenstruators reinforces stigmatizing messages. the messiness inherent in the menstrual cycle and are not adequately The rich, unruly experience of menstruation is flattened by limi- designed to support the range of menstrual experiences. Specifically, tations in data capture and disjointed data streams from various we have identified 3 clusters of messiness and one overarching gap sources. In the apps, fields available for tracking are limited (and that menstrual tracking apps do not currently support; we offer tinged with assumptions and stereotypes, eg, about mood changes), implications for enhancing design to fill these gaps. and structured tool designs restrict what can be documented, ham- pering crafting a holistic person-centered representation. The men- Messy gap 1: Irregularity is the norm, but apps are designed to treat strual experience is reduced to quantifiable data points, and these users as “regular” menstruators “objective” data elements often prioritized above the menstruator’s The menstrual cycle is complex, and irregularity is in fact the lived experience. As a result, menstrual tracking apps construct a 75,120–124 norm; yet menstrual tracking apps, and especially their pre- data-mediated body privileging science and quantitative metrics dictions, are designed to treat users as “regular” menstruators, based over embodied lived experiences of menstruators. on the “ideal” 28-day cycle. Assumptions impose prescriptive, nar- row expectations about periods/ovulation (length, duration, regular- Design implications. Menstrual tracking apps need a reframe. In- ity, pain levels) based on limited, outdated studies, and reduce the stead of hiding, controlling, shaming, and policing menstruating menstrual cycle to bleeding and ovulation, rather than acknowledg- bodies, a new framework should enable menstruators to engage ing its complex and often unpredictable dynamics. Sociocultural 20,21 with the embodied messiness of their cycle with curiosity and self- norms also come into play (eg, Fox connects 28-day norms to discovery to facilitate developing body and menstrual literacy. To the fertility awareness method, explaining that design decisions in- reflect the messy realities of menstruators, tools could extend be- scribe particular histories so apps inherit computational and moral yond tracking and predicting bleeding and ovulation to incorporate orientations). Finally, apps lack references to fluctuations, transi- the full, dynamic menstrual cycle and beyond the menstrual cycle to tions within an individual’s menstrual cycle, or shifts between cate- incorporate the full breadth of personal care. Menstrual tracking gories of menstruator and nonmenstruator (eg, due to menarche, apps should devise novel methods to capture and create workable menopause, lactation, hormonal treatments, therapies, weight, exer- representations of these experiences by integrating quantitative and cise, illness, travel, or stress). qualitative data capture, both directly related to the menstrual cycle and across other domains. Furthermore, apps should enable users to Design implications. Rather than relying on prescriptive norms, use narratives to tell their stories, reflect on their experiences, and apps should retool these narrow expectations. Apps could facilitate generate and document insights about their lived experiences. exploring the menstrual cycle and personal data with curiosity, for example, with visualizations or without quantification. When quan- tified, messaging should explain to users that menstrual cycles are Messy gap 3: Menstruators have varied biologies, identities, and inherently unpredictable and variable. Computational approaches goals, but users of menstrual tracking apps are represented as flat can also extend beyond using only cycle history to incorporate con- with monolithic experiences textual and day-to-day data for predictions. Menstruators have varied biology, identity, and goals, but users of Enabling health and wellness goals for both individuals and the menstrual tracking apps are represented as homogeneous, drawing population at large by using the menstrual cycle as a vital sign could from and reinforcing harmful, exclusionary stereotypes. Users of facilitate care, help monitor one’s health, and alert users and health- menstrual trackers are assumed to be feminine, female menstruators, care providers about potential concerns. This vital sign is quite indi- with a narrow scope of goals centered on reproduction and bleeding vidualized, so apps should allow users to construct a picture of their management. App design needs to accommodate different kinds of own “normal,” supported by novel computational approaches. users, across tangled spectrums of sex and gender, and at the inter- Customization tailored for a user’s menstrual cycle could personal- section of various other axes of identity and structural marginaliza- ize the experience, enable users to compare their ongoing experien- tion. Considering diverse needs of users also highlights the personal ces with their own baseline rather than sending a universalizing informatics and care needs and possible cyclical patterns of nonmen- message about “what is normal.” At the population level, filling struators (including those with a menstrual cycle but no menses, eg, gaps in biomedical knowledge about the menstrual cycle and men- 19 with an IUD ) which are not easily separable from those of men- strual disorders demands we study variations among different popu- 58,127 struators who use menstrual trackers. An individual’s identity lations around the world with different cultural and environmental cannot be represented as merely a sum of its parts, but rather exposures; this large-scale characterization depends on common through a nuanced understanding of oppressive experiences and dis- data elements, interoperability, and data quality. crimination that impact people differently based on the intersection 25–27 of identity categories. Attending to and incorporating complex and overlapping identity perspectives supports design that is respon- Messy gap 2: Menstruation is an embodied, leaky experience, but sive to intersectional identity-related experiences. apps flatten the experience and compel menstruators to hide and control their menses The menstrual experience is often messy and requires engaging with Design implications. Users of menstrual tracking apps differ in iden- one’s body parts and bodily fluids. However, apps reinforce the ne- tity, needs, and sociocultural experiences. Thus, no universal design cessity of concealment. The norms of keeping menstrual experiences will meet these diverse design requirements. Nevertheless, there is an hidden are a consequence of menstrual stigma. Across history, the unmet need to support diverse goals and diverse users (across cul- female body has been positioned as monstrous or dangerous and the tures, religions, identities, communities). Enabling personalization/ Journal of the American Medical Informatics Association, 2022, Vol. 29, No. 2 395 customization of the app interface, data fields, and goals offers one benefit from more data for training their analytics and for boosted key way this can be addressed. Designers could recruit diverse vol- app engagement. Furthermore, upstream data issues around classifi- unteers for participatory design, which seeks to design apps that al- cation and collection impact the success of models and encode sys- low users to explore and engage with their menstrual experience. tematic bias into AI, for example, binary gender classification Bardzell suggests “designing from the margins,” which reframes excludes nonbinary people from datasets and models and ignores marginality as a resource, and incorporates expertise of diverse per- their lived experiences. spectives that promote inclusive and responsive technology. The Apps also assert that they protect user privacy; but instead of resulting designs could challenge normative assumptions of feminin- protecting the user’s data and app usage, privacy is framed around ity, fertility, able-bodiedness, etc., even beyond individual users. maintaining secrecy around a user’s menstrual cycle and hiding their Expanding depictions of a “successful” or “acceptable” menstrual period. As others have documented, many apps for intimate care do cycle (or lack of), rather than imposing either a shameful or overly not take data privacy seriously leading to risks of exploiting 40,132,133 positive lens, can more meaningfully address the assorted needs of data. menstruators. By designing technology to account for the embodied 36,37 experience of menstruation, a feminist approach to design has Design implications. Human-centered AI aims to cultivate a syner- the potential to transform apps from body management tools into a gistic partnership between users and their technologies. Especially for nurturing and empowering experience. apps released commercially, user-centered design methods should rely Menstrual tracking apps could facilitate connecting with one’s on and elevate the lived experiences and needs of end-users, particu- body, identities, and communities, with the potential to affirm gen- larly users who have been historically excluded. Input from these der, whatever that means to the user. For some women who men- users can inform inclusive data definitions and mitigate concerns of struate, the menstrual cycle is a way to celebrate their womanhood failing to capture and account for important nuance and complexity. or femininity; others may find the link dysphoric or may not link To address limitations in computational approaches and to in- their gender and their period at all. For men or masculine people crease control of end-users over automated insights, design solutions 134–137 who menstruate, these apps can provide practical day-to-day secu- can draw from research in open-source, interpretable models 138–140 rity and support long-term gender affirmation and wellness. On and explainable AI to clearly communicate expectations the other hand, nonmenstruators may also use these apps to affirm about the accuracy of prediction models and explain which data 141–143 their identities and messy, embodied experiences. Women (who may were used for calculations. Designers can also explore mecha- or may not have ever menstruated, voluntarily or involuntarily, tem- nisms to communicate about uncertainties in the algorithmic pro- porarily or permanently) could use menstrual trackers to affirm rela- cesses and for particular predictions. And rather than offering tions with their bodies and aspects of (menstrual) cycles outside of certainties, technology could offer mechanisms to explore the men- bleeding and ovulation. Transgender women may experience hor- strual cycle rather than seeking to explain it. monal cycles that could be tracked and cared for with these care When it comes to person-generated health data, there is a need tools, in addition to affirming their gender. Not all validation must for policy around data ethics related to data ownership and privacy. be positive—those with chronic illness or painful menstruation may Regulatory oversight needs to hold businesses accountable for how use tools to validate their illness experience and communicate with users’ data are collected, stored, used, and shared, beyond obscure 40,44,144 family and providers. A further messiness is accommodating users terms and services. Users need more control over who has across transitions, for example, adolescents premenarche may bene- access to their data and how to revoke this access. Designers and fit from getting to know themselves as they go through puberty (sim- entrepreneurs should take ethics seriously, instead of sending users ilarly, transgender people undergoing gender-affirming hormone stigmatizing messages about hiding their period. The menstrual cy- therapy may experience puberty or “second puberty” that aligns cle is a messy biological process, which could be embraced instead with their gender ) menstruators experiencing perimenopause-re- of trying to force menstruation and menstruators into a clean, tidy lated fluctuations, and myriad reasons someone might start, stop, or experience. connect with the menstrual cycle. Although it may seem like a messy contradiction, including nonmenstruators in the design of FemTech Limitations may be necessary to meet needs across the spectrum of users. The scoping review may have been limited by our focus on the term “menstruator” rather than comprehensively reviewing the literature Overarching gap: the need for human-centered AI for transparency on the menstrual cycle. This allowed us to key into a specific dy- of uncertainties and the regulation and prioritization of privacy in namic around this term but may have also obscured other relevant FemTech literature that could have informed our analysis. In addition, selec- A final gap spanning several key findings calls for human-centered tion and use of databases may limit results returned, although we re- AI to address technical limitations, design choices, and policy con- lied on a range of databases to capture literature from different cerns related to menstrual trackers. Apps make big promises for of- disciplines. Still, limitations on what is published in the literature fering predictions and personal insights with data science and AI, and biases in the research presented mean further work is needed to assuring accurate, precise, and reliable calculations. Users, particu- document and address the needs of menstruators. Finally, this re- larly irregular menstruators, are directed to track more volume of search predominantly focuses on an English-speaking, Global North personal data, with assurances that this added detail will improve perspective of menstruation. predictions and insights about the body. However, there is no dis- cussion or transparency about the inherent unpredictability of men- struation, limitations of analysis methods, or disclosures of CONCLUSIONS (un)certainty of predictions, while their promises go beyond current state-of-the-art capabilities. 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Journal

Journal of the American Medical Informatics AssociationOxford University Press

Published: Oct 6, 2021

Keywords: personal health informatics; menstruation; mobile health; menstrual tracking

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