Breaking the endometriosis silence: a social norm approach to reducing menstrual stigma and policy resistance among young adults

Objective: Endometriosis is a menstrual disorder that affects one in ten women. Diagnosis often takes several years due to low awareness and menstrual stigma. In this study, we employed a social norm approach (SNA) to investigate the effects of an educa - tional leaflet on endometriosis knowledge, menstrual stigma, and acceptance of paid menstrual leave among women and men.

The 3  ×  2 online experiment tested the influence of either descriptive norm messages or both descriptive and injunc - tive norm messages (compared to a control group, factor 1) in an educational leaflet by taking the role of addressee’s sex into account (quasi-experimental factor 2). The study included 796 German participants aged 16–35.

Men exhibited significantly poorer knowledge, stronger menstrual stigma, and weaker policy acceptance compared to women. No significant main effect of the social norm messages on menstrual stigma was found. In contrast, the combined norm mes - sages seem to be beneficial when addressing policy acceptance. Moreover, compared to the control group, the intervention mate - rial indirectly influenced stigma and policy acceptance through increased knowledge.

Providing information about social norms appears to be an effective strategy for educating not only women but espe - cially men about menstrual disorders like endometriosis. The vast majority of women 1 under the age of 25 experience menstrual pain (Armour et  al., 2019; Parker et  al., 2010). Even if this pain is severe, it is often dismissed as a ‘normal, natural part’ of being a woman (Krebs & Schoenbauer, 2020). However, dysmenorrhea may also be a symptom of menstrual disorders, such as endometrio - sis—a disease where tissue similar to the lining of the uterus grows in other parts of the body (National Institute of Child Health and Human Development, 2022), resulting in painful menstrual cramps, pain during or after sex, or infertility. © 2023 t he a uthor(s). Published by Informa UK limited, trading as taylor & Francis group CONTACT a nne Reinhardt [email protected] Department of c ommunication, University of Vienna, Waehringer s trasse 29, Vienna, 1090, a ustria supplemental data for this article can be accessed online at https://doi.org/10.1080/08870446.2023.2277838. https://doi.org/10.1080/08870446.2023.2277838 t his is an o pen a ccess article distributed under the terms of the c reative c ommons a ttribution-Noncommercial-NoDerivatives license (http://creativecommons.org/licenses/by-nc-nd/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited, and is not altered, transformed, or built upon in any way. t he terms on which this article has been published allow the posting of the a ccepted Manuscript in a repository by the author(s) or with their consent. ARTICLE HISTORY Received 19 June 2023 Accepted 26 October 2023

Social norm approach; endometriosis; stigma; policy acceptance; women’s health; health promotion 882 A. REINHARDT AND S. EITZE Endometriosis affects ~1 in 10 women worldwide (Viganò et  al., 2004) and is therefore as common as diabetes (CDC, 2022). Despite the disease burden, the average delay between the onset of the first symptoms and the final endometriosis diagnosis is seven years (Nnoaham et  al., 2011). One of the primary drivers of this significant diagnostic delay is menstrual stigma (Guidone, 2020; Gupta et  al., 2018), which is rooted in the social norm that menstruation is surrounded by shame and disgust (Zaman & Mohiuddin, 2023). Stigma defines what is considered acceptable or not, and, unfortunately, talking about period pain or other menstrual symptoms is still considered socially unacceptable (Olson et  al., 2022). Certain aspects of menstrual stigma also come to light within the ongoing discourse surrounding the implementation of menstrual leave policies within the workplace (Levitt & Barnack-Tavlaris, 2020). For instance, when Spain became the first European country to cover sick leave for menstruating workers in 2022, this topic prompted extensive media coverage and discussion (BBC, 2022). While such policies would be a great relief for women who experience severe menstrual pain, some scholars have expressed concerns that these policies may violate social norms surrounding menstrual non-disclosure in the workplace and even perpetuate menstrual stigma, potentially leading to unhealthy and discriminatory practices (King, 2021 ; Levitt & Barnack-Tavlaris, 2020). Hence, there is a great need for public health interventions aiming at the reduction of menstrual stigma to promote women’s health and well-being. Indeed, recent health interventions have made efforts to enhance awareness concerning menstrual health and disorders. However, these endeavors often fall short in their scope (Olson et  al., 2022). On one hand, matters linked to menstruation are frequently perceived as specific to women (Levitt & Barnack-Tavlaris, 2020), leading most interventions to focus solely on female audiences. We contend that educating men about menstrual disorders, such as endometriosis, holds equal significance. Historically, men have marginalized menstruating women by characterizing them as ‘hysterical’ and ‘overly emotional’ , thereby perpetuating and internalizing prevailing social norms surrounding menstruation (Cleghorn, 2022; Olson et  al., 2022). On the other hand, Olson et  al. (2022) found that existing policy initiatives often struggle to effectively challenge or dismantle menstrual stigma. While they succeed in raising awareness about menstru - ation, they concurrently advocate concealing visible signs of menstruation, emphasizing bodily management over individual agency and autonomy. Thus, interventions are needed that (1) correct the social norms surrounding men - struation and (2) follow a holistic approach recognizing the importance of educating not only women but also men about menstrual disorders. In this study, we adopt a social-psychological lens to investigate how social norm correction messages impact young adults’ understanding of endometriosis, the persistence of menstrual stigma, and the acceptance of paid menstrual leave. Additionally, we aim to discern the direct and moderating effects of recipients’ biological sex on the effectiveness of social norm correction messages to ensure that social norm interventions on endometriosis do not backfire in male samples. The study contributes theoretically by deepening our understanding of the intricate dynamics between biological sex, social norms, and stigma in the context of health interventions for menstrual disorders. Practically, the findings underscore the potential of strategically designed interventions to not only PSyCHOLOGy & HEALTH 883 alleviate stigma but also foster a more inclusive and informed societal perspective on menstrual health and related policies. To begin, we establish the groundwork by explaining the core concepts of social norms and the enduring stigma surrounding menstruation and endometriosis. Subsequently, we delve into existing research on interventions targeting stigma reduc - tion through social norm interventions, whereby we also explore the potential chal - lenges of norm correction messages among male audiences. Then, we shift our focus to the pivotal role of knowledge in reducing stigma. Lastly, the methods and results are described and discussed. Social norms and stigma toward menstruation Social norms play a significant role in predicting health behavior and are integral to several health behavior theories, such as the Theory of Planned Behavior (Ajzen, 1991), the Health Belief Model (Rosenstock, 1974), and the COM-B Model (Michie et  al., 2011). Social norms refer to ‘rules and standards that are understood by members of a group, and that guide or constrain social behaviors without the force of law’ (Cialdini & Goldstein, 2004, p. 152). They can be classified into two distinct categories (Dempsey et  al., 2018; Smith et  al., 2012): descriptive norms, reflecting perceptions of others’ engagement in a behavior, and injunctive norms, relating to the perceived approval of others. Social norms towards menstruation, such as the concealment of menstrual pain or visible signs of menstruation (Olson et  al., 2022), have resulted in the stigmatization of menstruating women (As-Sanie et  al., 2019). Menstrual stigma manifests in various ways, including the view of menstrual blood as a disgusting bodily fluid that should be handled secretly (Bramwell, 2001; Roberts et  al., 2002). Additionally, menstruating women are perceived as more irrational, impure, and irritable than women in general (Forbes et  al., 2003). Lastly, menstruation is inevitably linked to the female sex, marking women as different from the ‘normal’—that is, male—body ( young, 2005). The menstrual stigma causes two trends in public discourse about menstrual pain (Krebs & Schoenbauer, 2020): first, a discourse of psycho-abnormality that discredits menstrual pain as imagined and not real, and second, a discourse of biological normality that considers severe menstrual pain as a natural part of being a woman. Women with endometriosis are particularly affected by menstrual stigma since most symptoms are directly linked to their menstruation (overview of menstrual stigma and endometriosis: Sims et  al., 2021). Matías-González et  al. ( 2021) demonstrated through a qualitative study that endometriosis patients often feel dismissed as excessive complainers without serious reason by their family members, peers, and doctors. Moreover, women felt not taken seriously in their private and professional environments and were even accused of malingering because of their menstrual pain (Seear, 2009). Similar findings were found by Gupta et  al. ( 2018) among a youth sample. As a result, women have learned to conceal their period and avoid discussing this topic in public (Johnston-Robledo & Chrisler, 2020). The established taboo on conversations about menstruation negatively affects women’s health by hindering the exchange of experiences: Patients with severe menstrual pain often feel alone 884 A. REINHARDT AND S. EITZE and abnormal, thereby delaying the time until they finally seek help (Hudelist et  al., 2012). In conclusion, social norms about menstruation influence human behavior in terms of what is socially accepted and expected, such as concealing menstrual pain and menstruation itself. Menstrual stigma acts as a control mechanism for those who do not adhere to these norms, which includes people openly talking about menstruation and menstrual pain (Smith et  al., 2016). Therefore, educational interventions on endo - metriosis correcting the perceived social norm towards menstruation might be able to reduce menstrual stigma and lead to greater acceptance of policy measures aiming to protect menstruating women, such as paid menstrual leave. The social norm approach In health promotion, social norm interventions have been found to be an appropriate strategy to lead to attitudinal and behavioral changes (for an overview of its appli - cation in various health fields, see, e.g. Dempsey et al., 2018). The social norm approach (SNA), also referred to as the norm correction strategy (Cislaghi & Berkowitz, 2021), proposes that negative health behaviors are driven by misperceptions of social norms, which can be corrected by providing information on actually reported norms. This approach has been tested in various fields, such as substance use (Foxcroft et  al., 2015; Moreira et  al., 2009), sun protection (Reid & Aiken, 2013), and handwashing (Lapinski et  al., 2013). Moreover, studies have found that providing descriptive norm corrections can effectively reduce mental health stigma (Botha et  al., 2017; Silke et  al., 2017). While most studies focused on testing descriptive norm messages, fewer studies used a mixed-norm approach by combining messages correcting descriptive and injunctive norms (for an overview, see Dempsey et  al., 2018). The findings indicate that providing descriptive and injunctive norm feedback may amplify the effects of descriptive norm messages alone (Dong et  al., 2022; Ridout & Campbell, 2014). Thus, in cases where descriptive norms may have an undesirable boomerang effect, adding an injunctive message that the desired behavior is approved could prevent such an effect (Schultz et  al., 2007). This pattern of effects was also demonstrated in a study on gynecological disease stigma. Dong et  al. ( 2022) tested the influence of a health intervention containing either descriptive or descriptive plus injunctive norms on women’s perceived stigma of a common gynecological disease, vaginal yeast infection. The first condition included messages informing about the prevalence of the disease (descriptive norm message: ‘According to the statistics, about 75% of women get vulvovaginal candi - diasis at least once, and 45% of women have experienced recurrent vulvovaginal candidiasis’), while the combined condition also provided behavioral recommenda - tions (‘We suggest you contact your healthcare provider to get testing and treatment if needed’). The version correcting both descriptive and injunctive norms demon - strated the greatest potential to reduce stigma, leading the authors to conclude that by providing information about the disease and behavioral recommendations, stigma-reduction interventions on gynecological diseases can reach their full potential. PSyCHOLOGy & HEALTH 885 However, it is still unknown whether this approach can be effective in addressing menstrual stigma, particularly among male audiences. Group identification plays a key role in explaining the impact of normative misperceptions on behavior (Dempsey et al., 2018). Social identity approaches emphasize the importance of self-categorization in conforming to group norms, particularly for individuals who closely identify with a social group (Hogg & Reid, 2006; Hornsey, 2008). Such individuals are more likely to follow the group’s norms as a means of fitting in and as a guide for their own behavior. In the context of women’s health, this ingroup-outgroup mentality becomes apparent, too. Studies demonstrate that the social norm of concealing menstruation and its symptoms is rooted in sexist and misogynistic structures (Cleghorn, 2022; Olson et  al., 2022), whereby menstruation is viewed through the male gaze —encom - passing heteropatriarchal views of how women are expected to behave and appear, and disassociating women from their own well-being and needs (Levitt & Barnack-Tavlaris, 2020). Therefore, it is likely that men internalized greater menstrual stigma and show stronger policy reactance than women. Research showed that individuals who hold negative attitudes towards a specific behavior may react with greater reactance towards descriptive norm messages than those with a more positive attitude (e.g. for the context of disaster preparation, see Ozaki & Nakayachi, 2020). Given our assumption that men show stronger menstrual stigma and less acceptance of paid menstrual leave than women, it is possible that the effectiveness of social norm messages is moderated by the audiences’ sex. However, we found no studies testing the role of the addressee’s gender in health interventions on menstruation or menstrual disorders, which is why this study will also delve into the main and interaction effects of the recipients’ biological sex on the effectiveness of a social norm intervention on endometriosis. This not only applies to the influence on menstrual stigma and policy acceptance but also to knowledge, which was found to be a major lever in stigma reduction. Stigma and knowledge As a result of menstrual stigma, endometriosis often goes unrecognized. Studies have found that only 50% of women have heard of the disease (Armour et  al., 2019; Shah et  al., 2010). Furthermore, most of those who have heard of endometriosis were unable to provide accurate information on the symptoms and risk factors (Shadbolt et  al., 2013). Among men, the percentage of those who are familiar with the term endometriosis is even lower (Shah et  al., 2010). This lack of knowledge is problematic, as it contributes to the diagnostic delay of endometriosis (Guidone, 2020; Hudelist et  al., 2012). Hence, social norm interventions providing information about endome - triosis (i.e. prevalence) have a great potential to impart knowledge about the disease. Knowledge gaps also play a significant role in perpetuating stigmatization (Fang et  al., 2021). Improving mental health literacy has been shown to lead to decreased stigmatizing attitudes and positive emotional responses (Chisholm et  al., 2016; Lopez et  al., 2018; Morgan et  al., 2018). Similarly, research on stigma related to HIV demon - strated that misconceptions lead to increased stigma and a lack of willingness to disclose ( yang et  al., 2006), and knowledge of the prevalence of HPV has been found 886 A. REINHARDT AND S. EITZE to be related to lower levels of stigma, shame, and anxiety (Waller et  al., 2007). However, we found no study investigating if knowledge of endometriosis can reduce menstrual stigma and the acceptance of policy measures, such as paid menstrual leave. The present study This experimental study aims to explore the impact of a health education intervention that addresses prevailing social norms related to menstruation. It focuses on young adults aged 16–35, a critical age group for endometriosis development and diagnosis. The study’s interests are 3-fold. Firstly, we seek to understand how social norm correction messages can influence perceptions of menstrual stigma and acceptance of paid menstrual leave policies. Building on previous research showing the effectiveness of messages combining descriptive and injunctive norms compared to descriptive norms alone (Dempsey et  al., 2018; Schultz et  al., 2007), and taking a cue from a similar context in women’s health promotion (Dong et  al., 2022), we propose the following hypotheses: H1: Health information with descriptive and injunctive norms will reduce menstrual stigma more effectively than health information with descriptive norms alone or a control group. H2: Health information with descriptive and injunctive norms will strengthen the acceptance of menstrual leave policies more strongly than health information with descriptive norms alone or the control group. Secondly, this study delves into the interaction between biological sex, social norms, and how they relate to the study’s goals. Recognizing that societal norms about menstruation are deeply influenced by misogynistic structures (Cleghorn, 2022), we expect differences in how both men and women have internalized menstrual stigma. Similarly, we expect that the acceptance of paid menstrual leave differs significantly between the target groups, as men are typically excluded from such policies (except for trans men, who face other forms of menstrual-related stigma, as discussed in Levitt & Barnack-Tavlaris, 2020). Considering these differences and acknowledging the importance of group identification in the context of stigma development (Dempsey et  al., 2018; Hogg & Reid, 2006), norm messages aiming to correct menstrual stigma might work differently for men and even have unintended backfire effects. Surprisingly, there is no research on this topic yet. Hence, the study presents the following hypoth - esis and research questions: H3: Women show (a) less menstrual stigma and (b) a stronger acceptance of menstrual leave policies than men. RQ1: Does the biological sex of the target group moderate the influence of health information with descriptive vs. with descriptive and injunctive norms on menstrual stigma? RQ2: Does the biological sex of the target group moderate the influence of health information with descriptive vs. with descriptive and injunctive norms on the acceptance of menstrual leave policies? Thirdly, we address the role of knowledge in mitigating menstrual stigma and fostering support for menstrual leave policies. Given the limited understanding of PSyCHOLOGy & HEALTH 887 endometriosis (Armour et  al., 2021), particularly among men (Shah et  al., 2010), there exists a significant opportunity to enhance awareness through health education interventions. Past research on stigmas related to mental health (Lopez et  al., 2018; Morgan et  al., 2018), HIV ( yang et  al., 2006), and HPV (Waller et  al., 2007) underscores the pivotal role of knowledge in diminishing stigma and its consequences (e.g. accep - tance of menstrual leave policies). We posit the following hypotheses: H4: Social norm interventions on endometriosis increase the knowledge of the disorder com - pared to a control group. H5: Women show a greater knowledge of endometriosis than men. H6: Social norm interventions on endometriosis will (a) reduce menstrual stigma and (b) pro - mote policy acceptance through knowledge.

Sampling procedures Before the data was collected, the study was preregistered ( https://osf.io/tdfaz/?view_ only=9fcb6935da21492387a021064b3ffa6e ) and approved by the IRB of the University of Vienna (ID 20220804_040). Participants were recruited in September 2022 via the online panel provider bilendi.2 The study collection took place in Germany. Participants were assigned to quota representative sampling by biological sex (female vs. male) and educational level (low vs. high). The focus was on 16- to 35-year-olds since endometriosis typically emerges during this age span. Because we were interested in the knowledge and perceptions of people not affected by endometriosis and did not want to risk additional confounding effects by cohorts, we apply this age range for both women and men. If participants did not match the criteria or quotas indicated that already enough participants with a characteristic, e.g. higher education, took part, participants were screened-out after the introduction page. Each participant received 1.40€ for completing the survey. Sample An a-priori power analysis revealed an estimated sample size of N = 566 to be suitable for the planned analysis ( f = 0.15, power = 0.95; g*Power, version 3.1.9.6 for macOS; Faul et  al., 2007). We decided to oversample for further analyses with diagnosed endometriosis patients (analyses are not part of this paper). In the end, we reached N = 859 participants. For this study, we excluded all participants who indicated that they had trouble seeing the stimulus material clearly ( n = 33) as well as participants with endometriosis diagnosis ( n = 30). We excluded the latter because it is highly likely that (1) they have been exposed to plenty of information before and (2) they hold experiential knowledge that makes them unsuitable for the experimental questions in this study. After data cleansing, the sample size was N = 796. Participants were on average 26.8 years old ( SD = 5.8), and 50.3% were female ( n = 400). 49.0% showed a lower level 888 A. REINHARDT AND S. EITZE of education (without university qualification, n = 390). 52.2% of participants ( n = 415) indicated having heard of endometriosis. The awareness among women was 73.3% (n = 293) and 30.9% ( n = 122) among men, respectively. Within the female sample, 93.2% regularly experienced menstrual pain ( n = 368), whereby 15.8% ( n = 58) indicated that pain medication does not provide any relief. Experimental design To test our assumptions, we conducted an online experiment with a 3 × 2 design with the following factors: social norm message (descriptive norm message vs. descriptive plus injunctive norm message vs. control group)  ×  participants’ biological sex (female vs. male). A health information brochure about endometriosis (adapted from an official bro - chure of the Endometriose-Vereinigung Deutschland e.V. , an NGO informing about endometriosis in Germany) served as the stimulus for both experimental groups. The manipulation of social norms was adapted from Dong et  al. ( 2022). The stimulus with descriptive norm messages contained information about the prevalence of endome - triosis. The messages with descriptive and injunctive norms further offered three behavioral recommendations (message overview: Table 1 ). Regarding the control group, we decided on a health information brochure that should be similar to the endometriosis leaflet in length and complexity, and should cover a gynecological topic as well. A health information flyer about HPV vaccination served as the stimulus in the control group. The experimental groups did not differ significantly in their distribution of sociodemographic variables (i.e. age, educational status). We asked about participants’ biological sex (male, female, divers) on the sociodemographic information page at the beginning of the questionnaire. The stimulus material as well as a flowchart diagram that depicts the step-by-step implementation of the design and measures can be found on OSF ( https://osf.io/dvztx/?view_only=721132a186204 54da0783571a2cced80 ). Procedure After giving informed consent, participants were randomly assigned to one of three conditions. In all conditions, participants were asked to carefully read a health infor - mation. Each page of the stimulus was displayed on separate web pages. To ensure that participants do not skip the informational leaflet pages, the Continue-button appeared 10 s after they entered each page. Afterward, the dependent measures and control variables were assessed. Measures The full operationalization can be found in Supplement S1 ( https://osf.io/dvztx/?view_ only=721132a18620454da0783571a2cced80 ). PSyCHOLOGy & HEALTH 889 Dependent variables Endometriosis knowledge: Participants’ knowledge was measured with nine questions. These include a correct definition, incidence, symptoms, consequences, diagnosis, symptoms, and treatment options. All items were designed as a single choice with one correct answer and three noises (e.g. ‘What is the most common symptom?’ [*] ‘severe pain during menstruation’ , [] ‘increased estrogen level’ , [] ‘photosensitivity’ , [] ‘joint pain’). Correct answers were summed up to form a knowledge score (0 = ‘no correct answers at all’ , 9 = ‘all answers correctly’ , M = 5.84, SD = 2.44, Cronbach’s α = 0.78). Menstrual stigmatization: We adapted the BATM Scale (beliefs about and attitudes toward menstruation, Marván et  al., 2006) to assess menstrual stigma. From the original 45 items in the validation paper, we took those with the highest factor loadings for the three subscales related to stigma ( secrecy, annoyance, disability ). Based on evidence about the public endometriosis discourse (e.g. Metzler et  al., 2022), we expanded the scale by two more subscales, covering the dimensions public discourse and weakness/disgust . Each of the five subscales was measured with two Likert-scaled items (1 = ‘do not agree at all’ , 5 = ‘totally agree’). Based on the first Cronbach’s alpha analysis ( α = 0.63), we decided to run an exploratory factor analysis (KMO = .82). Accordingly, items can be summed up to two factors, including the stigma dimensions concealment (e.g. ‘Menstrual pain should be kept as a secret’) and downplay of symptoms (e.g. ‘Menstrual pain has an impact on women’s capacity for daily business. ’). The detailed findings of the EFA can be found in Supplement S2 . The concealment scale (five items, including secrecy, public discourse, and disgust; M = 2.17, SD = .90, Cronbach’s α = 0.77) and the downplay of symptoms scale (five Table 1. o verview of social norm messages (stimulus translation). Descriptive norm message Descriptive  +  injunctive norm message endometriosis is not a matter of age: a dolescents can experience symptoms of the disease from their first menstruation. a ccording to estimates by experts, around 8–15% of all women between puberty and menopause develop endometriosis. t hat is about 2 million people in germany. […] Unfortunately, endometriosis is often detected very late. Due to poor information about the disease, an average of 6 years pass in g ermany between the onset of symptoms and the final diagnosis. endometriosis is not a matter of age: a dolescents can experience symptoms of the disease from their first menstruation. a ccording to estimates by experts, around 8–15% of all women between puberty and menopause develop endometriosis. t hat is about 2 million people in germany. […] Unfortunately, endometriosis is often detected very late. Due to poor information about the disease, an average of 6 years pass in g ermany between the onset of symptoms and the final diagnosis. […] l et’s talk about period pain! People with endometriosis often feel alone and misunderstood. Regardless of whether you are affected by endometriosis yourself or not—by following a few simple principles, you can contribute to a non-judgmental, informed atmosphere! • Menstruation isn’t a taboo! By talking about your pain or giving a sympathetic ear to others, you help to normalize communication about menstruation. • s evere menstrual pain isn’t normal! Be aware: s evere period pain should not be taken lightly. In this case, seeking medical advice is the best option. • take menstrual pain seriously! If you or your partner are experiencing severe period pain or other endometriosis symptoms, take these signals seriously and do not ignore your or her needs! 890 A. REINHARDT AND S. EITZE items, including annoyance, disability, and weakness; M = 2.07, SD = 0.71, Cronbach’s α = 0.81) are analyzed separately. Menstrual leave acceptance: Participants’ attitudes toward menstrual leave policies were measured based on the findings of Barnack-Tavlaris et  al. ( 2019). The generated five-point Likert scale consists of ten items (e.g. ‘Pain and other symptoms of menstruation make workplace menstrual leave necessary’ , 1 = ‘do not agree at all’ , 5 = ‘totally agree’). The scale demonstrated a good internal consistency (Cronbach’s α = 0.73; M = 2.98, SD = 0.64). Control variables Sociodemographic variables: We decided to control for educational level (1 = low, 2 = high) and age. Working in healthcare (yes/no) was assumed to be a beneficial factor for knowledge and policy acceptance and a decreasing factor for stigma, therefore, we included this as well. Analytical approach Data was analyzed using R (version 2022.07.2 Build 576). We used ANCOVAs to deter - mine if knowledge about endometriosis or policy acceptance is different between experimental conditions or sex groups. Divergent from the preregistration, we used two ANCOVAs for the two identified stigma dimensions (i.e. concealment and downplay of symptoms) instead of an overall analysis of stigma. We used age, education level, and working as a healthcare professional as covariates to estimate their effects on the dependent variables. Mediation models (PROCESS Model 4, Hayes, 2017) were used to see if the experimental conditions (when compared to the control group) increased knowledge, which, in turn, may be associated with (a) a decreased concealment stigma, (b) a decreased downplay of symptoms stigma, and (c) an increased policy acceptance.

Results for the stigma subscales are shown in Figure 1, and results for knowledge and policy acceptance are shown in Figure 2 (respective ANCOVA tables can be found in Supplement S3-S7, https://osf.io/dvztx/?view_only=721132a18620454da0783571a2cced80). Manipulation checks As part of the knowledge measurement, we asked participants to indicate the endo - metriosis prevalence in Germany (multiple choice, one correct answer). Chi-square tests revealed that participants in the experimental groups performed significantly better in estimating the endometriosis prevalence compared to the control group, showing that the manipulation of the descriptive norm messages was successful [χ2(2) = 60.19, p < .001; percentage of correct answers in the control group: 20.0%; percentage of correct answers in the descriptive norm group: 49.4%; percentage of correct answers in the descriptive plus injunctive norm group: 47.4%]. To control for the variation of the injunctive norm messages, participants had to indicate if the brochure suggests that ‘Talking about menstrual pain is unpleasant’ PSyCHOLOGy & HEALTH 891 (1 = absolutely not, 5 = absolutely). As intended, the experimental group receiving descriptive plus injunctive norm messages showed less agreement with this statement (M = 2.12, SD = 1.24) compared to those who received descriptive norm messages alone ( M = 2.37, SD = 1.24), F(2, 790) = 3.86, p < .05. However, they did not differ to the control group ( M = 2.10, SD = 1.18). Possible explanations for this finding will be discussed later. Figure 1. Raincloud-plots including distribution, box plots, and unadjusted means with 95% confi - dence intervals for hypotheses for both stigma dimensions. Note. t he means and confidence inter - vals for stigma scales are shown alongside of boxplots and distributions for all conditions ( a,c ) and for male and female participants (B,D). stigma is higher in men (both scales). t here is no effect of experimental condition on any of the stigma subscales. 892 A. REINHARDT AND S. EITZE Effects of social norm messages and gender on stigma (H1, H3a, RQ1) The stigma hypotheses are partially confirmed. Regarding the effects of gender (H3a), both stigma dimensions were higher in male than female participants [concealment: F(1, 790) = 112.94, p < .01, η 2 = .13; downplay of symptoms: F(1, 788) = 94.64, p < .01, η 2 = .11]. In contrast, we found neither a main effect of the experimental condition (H1, ns) nor an interaction effect with gender (RQ1, ns). Repeating the analysis with Figure 2. Raincloud-plots including distribution, box plots, and unadjusted means with 95% confi - dence intervals for pre-registered hypotheses for knowledge and policy acceptance. Note. t he means and confidence intervals for knowledge and policy acceptance scores are shown alongside of boxplots and distributions for all conditions ( a,c ) and for male and female participants (B,D). PSyCHOLOGy & HEALTH 893 control variables did not change the pattern of results. However, for the concealment dimension, higher education [ F(1, 783) = 15.96, p < .001, η 2 = .02] and lower age [ F(1, 783) = 5.10, p = .002, η 2 < .01] were related to less concealment. No effects of the covariates occurred for the subscale downplay of symptoms. Effects of social norm messages and gender on policy acceptance (H2, H3b, RQ2) As postulated in H3b, women stated higher policy acceptance than men, F(1, 790) = 29.04, p < .001, η 2 = .04. Moreover, the experimental condition with combined norm messages led to a higher policy acceptance compared to descriptive norm messages alone (H2), F(2, 790) = 3.48, p < .01, η 2 < .01. There was no interaction between group and gender, F(2, 790) = 1.03, p = .36, η 2 < .01 (RQ2). The intervention effect did not persist when control variables were included in the model. Of all covariates, only age did have an additional (negative) impact on policy acceptance, F(1, 783) = 7.56, p < .01, η 2 = .01. Effects of social norm messages and gender on knowledge (H4, H5) As pre-registered, post-hoc tests revealed that both intervention groups resulted in a higher knowledge about endometriosis than the control group, F(2, 790) = 91.82, p < .01, η 2 = 0.19, confirming H4. In accordance with our hypothesis 5, women have higher knowledge about endometriosis than men, F(1, 790) = 120.60, p < .01, η 2 = .13. Repeating the analysis with control variables did not change the pattern of results. Higher education further explained endometriosis knowledge, F(1, 783) = 12.58, p < .01, η 2 = .02. Indirect intervention effects on stigma and policy acceptance through knowledge (H6) We were also interested in multivariate relations between educational material, knowl - edge, and menstrual stigma/policy acceptance. Using mediation analyses, we tested if the interventions (both intervention groups are tested together against the control group) increased knowledge and if this, in turn, was associated with reduced stigma - tization (H6a) and increased policy acceptance (H6b). To test these hypotheses, we used PROCESS Model 4 (Hayes, 2017). As independent variable (X) we used the group distinction (1: both interventions vs. 0: the control group). As mediator (M) we used the knowledge score. The dependent variables in the three respective models were concealment stigma ( y1), downplay of symptoms stigma ( y2), and policy acceptance (y3). We are interested in the direct effects of X to y and X to M, as well as in the indirect effect, explaining the relation between experimental influence on knowledge and its association with stigma and policy acceptance. Figure 3 shows the results of the mediation analyses. The findings demonstrate that experimental conditions increased knowledge significantly. Moreover, higher 894 A. REINHARDT AND S. EITZE knowledge was significantly associated with lower stigma (for both dimensions). The indirect effect of the experimental conditions through knowledge of stigmatization is significant, confirming hypothesis 6a. The remaining direct effect on stigmatization is positive. Regarding policy acceptance, higher knowledge about endometriosis was related to greater policy acceptance. In accordance with hypothesis 6b, the indirect effect of the experiment over knowledge on policy acceptance is also significant. Hence, knowledge is an important mediator for both stigma and policy acceptance.

This study aimed to explore the potential of an educational social norm interventions to address the societal taboo surrounding menstruation, which poses a significant barrier to women’s health in the context of menstrual disorders. Specifically, we Figure 3. Mediation analyses for menstrual stigma: concealment ( a ), menstrual stigma: downplay of symptoms (B), and policy acceptance ( c ). Note. N   =  790. PSyCHOLOGy & HEALTH 895 examined the impact of health information brochures containing descriptive norm messages versus brochures containing both descriptive and injunctive norm messages on endometriosis knowledge, menstrual stigma, and policy acceptance among both men and women. Given the high prevalence of endometriosis among women and the low rates of individuals actively seeking help for their menstrual issues, it is crucial to expand our understanding of this topic to develop effective and evidence-based communication strategies that promote women’s health. In our sample, as expected, both dimensions of stigma were higher among men compared to women, highlighting the significant role that men play in perpetuating the communication taboo surrounding menstrual pain and tending to downplay its consequences. Interestingly, contrary to the findings of Dong et  al. ( 2022) on stigma toward vaginal yeast infections, we did not observe any differences between inter - ventions containing descriptive norm messages versus those containing combined social norm messages. This finding can be interpreted in the following ways: Firstly, our stimulus material corrected the descriptive norm pertaining to endometriosis and provided behavioral recommendations for individuals experiencing severe menstrual pain (injunctive norm messages). However, it is possible that menstrual stigma and endometriosis stigma do not entirely overlap, and that correcting social norms spe - cifically related to endometriosis may not be sufficient to address menstrual stigma. Further research is needed to explore how menstrual and endometriosis stigma share similar characteristics or if they each possess unique features that should be consid - ered when measuring the construct. Secondly, the absence of a main effect could also suggest that menstrual stigma is more enduring than stigma associated with other non-menstrual gynecological diseases (Dong et  al., 2022). Consequently, reducing menstrual stigma may require more than a single exposure to an educational social norm intervention. Long-term interventions that target the public from an early age (e.g. educational interventions in school settings that focus on adolescents) may prove to be more effective. Thirdly, an alternative interpretation for the lack of differences between interventions containing descriptive norm messages and those containing combined social norm messages could involve the intricacies of social norm percep - tion. Since social norms are complex, multifaceted constructs, they might extend beyond the specific messages provided in our interventions. Moreover, participants’ pre-existing beliefs, cultural contexts, and personal experiences might interact with the intervention content, shaping their responses. In this light, the absence of distinct effects could indicate that the impact of social norm interventions on menstrual stigma reduction is influenced by a multitude of factors that extend beyond the scope of the immediate intervention. We also want to highlight the findings of our manipulation check. While partici - pants who received the combined norm messages showed significantly lower agree - ment toward the statement ‘Talking about menstrual pain is unpleasant’ than those who received the descriptive norm messages alone, the combined messages did not differ significantly from the control group. Therefore, even in the absence of a main effect of the experimental conditions on menstrual stigma, this finding suggests that it may be advisable to combine informational material on menstrual pain and endo - metriosis with an injunctive norm correction. Otherwise, the material may lead to backfire effects, wherein recipients perceive talking about menstrual pain as more 896 A. REINHARDT AND S. EITZE unpleasant after reading the informational material than they would if they had not read the brochure at all. This finding is in line with previous research, demonstrating that by adding an injunctive message potential backfire effects of descriptive norm corrections might be prevented (Ozaki & Nakayachi, 2020; Schultz et  al., 2007). Due to the scarcity of studies and the complexity of this topic, further research is war - ranted investigating in more detail which aspects of menstrual stigma are prone to potential backfire effects of social norm messages, ultimately aiding the development of more refined and effective interventions to improve women’s health. Regarding policy acceptance, we found that women exhibited significantly higher levels of acceptance toward menstrual leave policies compared to men. However, both women and men expressed moderate levels of acceptance, suggesting that the controversy surrounding menstrual leave policies in media portrayals might not entirely align with public attitudes. Analyzing the effects of the experimental conditions, we observed that brochures containing combined social norm messages significantly increased acceptance of menstrual leave policies compared to brochures containing descriptive messages alone. The results highlight the importance of addressing both factual information and behavioral recommendations in awareness campaigns related to endometriosis and menstrual pain. Combining these elements not only enhances individuals’ understanding of the seriousness of the condition but also contributes to increased acceptance of menstrual leave policies. This implies that policy initiatives should emphasize the prevalence of endometriosis and its impact on individuals’ lives, aiming to reduce stigma and promote a more supportive attitude towards menstrual health. However, it should be noted that the main effect of the social norm message did not persist when control variables were included in the analysis. This outcome accentuates the potential interplay of various factors in shaping policy acceptance, and it is imperative to consider these influences in designing and implementing effective interventions. For instance, the negative effect of age on policy acceptance shows that in endometriosis policy acceptance, older people would be the target for acceptance interventions. This effect is consistent with findings from other health policies, such as parental leave policy perceptions (e.g. Lott & Klenner, 2018). Correcting social norms regarding this topic has been found to be of great impor - tance in relation to knowledge. In comparison to the control group, both experimental conditions increased endometriosis knowledge, which emerged as a significant medi - ator in reducing stigma and promoting policy acceptance. Hence, these findings indicate that addressing the descriptive norm toward endometriosis can contribute to changing the social norm surrounding the non-disclosure of menstruation. These insights have valuable implications for campaign design and employment law. Therefore, when disclosing information about menstrual pain and implementing men - strual leave policies, it is crucial to accompany these initiatives with widely dissemi - nated knowledge campaigns, highlighting the prevalence of the disease. The second lesson derived from the mediation analyses is the presence of a positive direct effect between the experimental conditions and stigma. The unexpected positive direct effect suggests the presence of potential additional mediators. This presents an avenue for future research to delve deeper into understanding these mediating factors and their role in shaping attitudes. Identifying and addressing these factors could enhance PSyCHOLOGy & HEALTH 897 the effectiveness of interventions aimed at reducing stigma and promoting policy acceptance. When examining knowledge more closely, our study revealed significantly higher levels of endometriosis knowledge in women compared to men, highlighting the importance of educating men on this topic as well. Given the notable gender differ - ences observed in menstrual stigma and policy acceptance, the findings from the mediation analysis hold particular relevance for male recipients. By engaging in edu - cational efforts that aim to change the social norm toward menstruation, men can become advocates for women’s health rather than perpetuators of oppressive norms (e.g. by acknowledging that severe menstrual pain is not normal or natural, thus challenging prevailing social norms surrounding menstruation; Krebs & Schoenbauer, 2020). This finding is also significant in the context of the non-existent interaction effects between social norm messages and gender: Despite the higher levels of men - strual stigma and lower policy acceptance observed in men compared to women in our sample, we did not observe any backfire effects when implementing social norm corrections for male participants. This highlights the need for educational initiatives that engage both men and women in discussions about menstruation and its implications. When looking at the covariates, working in health care is not a significant predictor of the observed dependent variables. We conclude that endometriosis is not a salient diagnosis across all medical fields, even though patients have a higher risk for over 20 different comorbidities (Surrey et  al., 2018). Endometriosis awareness should be increased even in the health care system to increase understanding for burdened patients. The results have to be interpreted under the following limitations. First, the data was collected online. While this approach offers several advantages, such as conve - nience and reach, it is important to acknowledge its limitations. Online surveys may introduce a bias in the sample, as they might not capture the perspectives of indi - viduals who have limited access to the internet or who are not comfortable with digital platforms. Additionally, respondents might be more likely to participate if they have a higher level of interest or knowledge about the subject, which could introduce a selection bias. Therefore, the findings should be interpreted considering these lim - itations, recognizing that the sample might not be fully representative of the entire target population (Ball, 2019). However, the fact that we collected data from a young sample and we used a panel provider that is not restricted to health behavior research leads us to assume that the error might not be extensive. Second, we decided to stratify the sample to ensure that different groups were equally represented. Hence, it is essential to acknowledge that this deliberate strati - fication might not perfectly reflect the broader German population aged 16–35 years. However, as we used biological sex as quasi-experimental factor, we were interested in an equal representation of male and female participants. Moreover, we decided to stratify by educational level since it strongly correlates with health literacy, which is a central construct affecting health-related knowledge and attitudes (Van Der Heide et  al., 2013). Third, the focus on menstruation and menstrual-related disorders introduces a layer of sensitivity to the responses provided by participants. Individuals might be inclined 898 A. REINHARDT AND S. EITZE to provide answers that align with social norms and expectations, rather than their true thoughts and attitudes. This social desirability bias could lead to an underesti - mation of stigmatizing attitudes or an overestimation of socially acceptable perspec - tives. Although the study mitigated this to some extent by ensuring a high degree of anonymity through the online survey, the potential for this bias to influence the

should still be acknowledged. Fourth, the study incorporates insights from the social norms literature, which suggests that the source of feedback can impact how it is received and acted upon (Dempsey et  al., 2018). Thus, presenting feedback as emanating from an authority figure could lead to changes in behavior and attitudes based on compliance pressure or fear. While the study made efforts to avoid overtly authoritative presentation, there remains a consideration that participants might respond differently to perceived authority. To mitigate this, future research is suggested to explore the use of testi - monials or feedback from peers or individuals within the target group. This approach could potentially yield more authentic responses and insights, reducing the potential for undue influence on participants’ behaviors and attitudes.

Millions of women suffer from severe menstrual pain due to menstrual disorders like endometriosis. However, there is a significant delay in reaching a diagnosis, primarily caused by a lack of knowledge and the stigma associated with menstru - ation and menstrual pain. Our article sheds light on the potential and limitations of educational interventions that target social norms. From our research, we have identified three key findings. Firstly, endometriosis awareness and knowledge in Germany, particularly among men, remain insufficiently low. Secondly, menstrual stigma is a complex and deeply ingrained construct that is hard to directly address through norm correction messages on endometriosis solely. However, by providing educational material containing social norm corrections, interventions can enhance endometriosis knowledge, leading to reduced menstrual stigma and increased accep - tance of menstrual leave policies. Thirdly, it is essential to address not only women but especially men through social norm interventions, as they exhibit lower levels of knowledge and higher levels of menstrual stigma. Despite being underrepresented in communication studies, we argue that studying the promotion of women’s health within the context of menstruation from a communication perspective is vital for the development of effective, evidence-based health campaigns. Such campaigns can contribute to breaking the menstrual-related communication taboo that nega - tively impacts women worldwide. Author note Preregistration: https://osf.io/tdfaz/?view_only=9fcb6935da21492387a021064b3ffa6e Open data/Open material: https://osf.io/dvztx/?view_only=721132a18620454da078 3571a2cced80 PSyCHOLOGy & HEALTH 899 Notes 1. Reflecting literature on this topic, this paper focuses on young people who menstruate and identify as girls/women. However, we are aware that the diagnosis might be even more difficult for non-woman gender identities (e.g. trans men) due to transphobic norms in medicine (Krebs & Schoenbauer, 2020; Nadal et  al., 2012) and we clearly acknowledge that not every menstruating person identifies as female. 2. Bilendi is a European panel provider that is recruiting via online and telephone adver - tisement. During the time of the study, the German panel includes ~300,000 possible participants. Based on the inclusion criteria, possible participants were invited via mail. Disclosure statement No potential conflict of interest was reported by the author(s). Funding The author(s) reported there is no funding associated with the work featured in this article. ORCID Anne Reinhardt http://orcid.org/0000-0001-5231-0877 Data availability statement Data, R codes, stimulus materials, and supplemental materials are online accessible via OSF (https://osf.io/dvztx/?view_only=721132a18620454da0783571a2cced80).

Ajzen, I. ( 1991). The theory of planned behavior. Organizational Behavior and Human Decision Processes, 50(2), 179–211. https://doi.org/10.1016/0749-5978(91)90020-T Armour, M., Hyman, M. S., Al-Dabbas, M., Parry, K., Ferfolja, T., Curry, C., MacMillan, F., Smith, C. A., & Holmes, K. ( 2021). Menstrual health literacy and management strategies in young women in Australia: A national online survey of young women aged 13–25 years. Journal of Pediatric and Adolescent Gynecology , 34(2), 135–143. https://doi.org/10.1016/j.jpag.2020.11.007 Armour, M., Parry, K., Manohar, N., Holmes, K., Ferfolja, T., Curry, C., MacMillan, F., & Smith, C. A. ( 2019). The prevalence and academic impact of dysmenorrhea in 21,573 young women: A systematic review and meta-analysis. Journal of Women’s Health , 28(8), 1161–1171. https:// doi.org/10.1089/jwh.2018.7615 As-Sanie, S., Black, R., Giudice, L. C., Gray Valbrun, T., Gupta, J., Jones, B., Laufer, M. R., Milspaw, A. T., Missmer, S. A., Norman, A., Taylor, R. N., Wallace, K., Williams, Z., yong, P . J., & Nebel, R. A. ( 2019). Assessing research gaps and unmet needs in endometriosis. American Journal of Obstetrics and Gynecology , 221(2), 86–94. https://doi.org/10.1016/j.ajog.2019.02.033 Ball, H. L. ( 2019). Conducting online surveys. Journal of Human Lactation , 35(3), 413–417. https:// doi.org/10.1177/0890334419848734 Barnack-Tavlaris, J. L., Hansen, K., Levitt, R. B., & Reno, M. ( 2019). Taking leave to bleed: Perceptions and attitudes toward menstrual leave policy. Health Care for Women International , 40(12), 1355–1373. https://doi.org/10.1080/07399332.2019.1639709 900 A. REINHARDT AND S. EITZE BBC ( 2022, May 12). Spain plans menstrual leave in new law for those with severe pain. News. Retrieved from https://www.bbc.com/news/world-europe-61429022 Botha, F. B., Shamblaw, A. L., & Dozois, D. J. A. ( 2017). Reducing the stigma of depression among Asian students: A social norm approach. Journal of Cross-Cultural Psychology , 48(1), 113–131. https://doi.org/10.1177/0022022116674598 Bramwell, R. ( 2001). Blood and milk: Constructions of female bodily fluids in western society. Women & Health , 34(4), 85–96. https://doi.org/10.1300/J013v34n04_06 CDC ( 2022). National Diabetes Statistics Report . Centers for Disease Control and Prevention. Retrieved from https://www.cdc.gov/diabetes/data/statistics-report/index.html Chisholm, K., Patterson, P ., Torgerson, C., Turner, E., Jenkinson, D., & Birchwood, M. ( 2016). Impact of contact on adolescents’ mental health literacy and stigma: The SchoolSpace cluster ran - domised controlled trial. BMJ Open, 6(2), e009435. https://doi.org/10.1136/bmjopen-2015-009435 Cialdini, R. B., & Goldstein, N. J. ( 2004). Social influence: Compliance and conformity. Annual Review of Psychology , 55(1), 591–621. https://doi.org/10.1146/annurev.psych.55.090902.142015 Cislaghi, B., & Berkowitz, A. D. ( 2021). The evolution of social norms interventions for health promotion: Distinguishing norms correction and norms transformation. Journal of Global Health, 11, 03065. https://doi.org/10.7189/jogh.11.03065 Cleghorn, E. ( 2022). Unwell women: A journey through medicine and myth in a man-made world (updated with a new preface) . Weidenfeld & Nicolson. Dempsey, R. C., McAlaney, J., & Bewick, B. M. ( 2018). A critical appraisal of the social norms approach as an interventional strategy for health-related behavior and attitude change. Frontiers in Psychology , 9, 2180. https://doi.org/10.3389/fpsyg.2018.02180 Dong, y., Chen, M., & Wu, y. ( 2022). Effects of social norms and message framing on reducing the stigma of gynecological diseases: A cognitive-affective-behavioral model. Applied Psychology. Health and Well-Being , 12433, online first. https://doi.org/10.1111/aphw.12433 Fang, Q., Zhang, T.-M., Wong, y. L. I., yau, y. y., Li, X.-H., Li, J., Chui, C. H. K., Tse, S., Chan, C. L.-W., Chen, E. y. H., & Ran, M.-S. ( 2021). The mediating role of knowledge on the contact and stigma of mental illness in Hong Kong. The International Journal of Social Psychiatry , 67(7), 935–945. https://doi.org/10.1177/0020764020975792 Faul, F., Erdfelder, E., Lang, A.-G., & Buchner, A. ( 2007). G*Power 3: A flexible statistical power analysis program for the social, behavioral, and biomedical sciences. Behavior Research Methods, 39(2), 175–191. https://doi.org/10.3758/bf03193146 Forbes, G. B., Adams-Curtis, L. E., White, K. B., & Holmgren, K. M. ( 2003). The role of hostile and benevolent sexism in women’s and men’s perceptions of the menstruating woman. Psychology of Women Quarterly , 27(1), 58–63. https://doi.org/10.1111/1471-6402.t01-2-00007 Foxcroft, D. R., Moreira, M. T., Almeida Santimano, N. M., & Smith, L. A. ( 2015). Social norms information for alcohol misuse in university and college students. In Cochrane database of systematic reviews (p. CD006748.pub3). John Wiley & Sons, Ltd. https://doi.org/10.1002/14651858. CD006748.pub3 Guidone, H. C. ( 2020). The womb wanders not: Enhancing endometriosis education in a culture of menstrual misinformation. In C. Bobel, I. T. Winkler, B. Fahs, K. A. Hasson, E. A. Kissling, & T.-A. Roberts (Eds.), The Palgrave handbook of critical menstruation studies (pp. 269–286). Palgrave Macmillan. Gupta, J., Cardoso, L. F., Harris, C. S., Dance, A. D., Seckin, T., Baker, N., & Ferguson, y. O. ( 2018). How do adolescent girls and boys perceive symptoms suggestive of endometriosis among their peers? Findings from focus group discussions in New york City. BMJ Open , 8(6), e020657. https://doi.org/10.1136/bmjopen-2017-020657 Hayes, A. F. ( 2017). Introduction to mediation, moderation, and conditional process analysis: A regression-based approach . Guilford Publications. Hogg, M. A., & Reid, S. A. ( 2006). Social identity, self-categorization, and the communication of group norms. Communication Theory, 16(1), 7–30. https://doi.org/10.1111/j.1468-2885.2006.00003.x Hornsey, M. J. ( 2008). Social identity theory and self-categorization theory: A historical review: Social identity theory and self-categorization theory. Social and Personality Psychology Compass , 2(1), 204–222. https://doi.org/10.1111/j.1751-9004.2007.00066.x PSyCHOLOGy & HEALTH 901 Hudelist, G., Fritzer, N., Thomas, A., Niehues, C., Oppelt, P ., Haas, D., Tammaa, A., & Salzer, H. (2012). Diagnostic delay for endometriosis in Austria and Germany: Causes and possible consequences. Human Reproduction, 27(12), 3412–3416. https://doi.org/10.1093/humrep/des316 Johnston-Robledo, I., & Chrisler, J. C. ( 2020). The menstrual mark: Menstruation as social stigma. In C. Bobel, I. T. Winkler, B. Fahs, K. A. Hasson, E. A. Kissling, & T.-A. Roberts (Eds.), The Palgrave handbook of critical menstruation studies (pp. 181–199). Springer Singapore. https://doi. org/10.1007/978-981-15-0614-7_17 King, S. ( 2021). Menstrual leave: Good intention, poor solution. In J. Hassard & L. D. Torres (Eds.), Aligning perspectives in gender mainstreaming (pp. 151–176). Springer International Publishing. https://doi.org/10.1007/978-3-030-53269-7_9 Krebs, E., & Schoenbauer, K. V. ( 2020). Hysterics and heresy: Using dialogism to explore the problematics of endometriosis diagnosis. Health Communication , 35(8), 1013–1022. https:// doi.org/10.1080/10410236.2019.1606136 Lapinski, M. K., Maloney, E. K., Braz, M., & Shulman, H. C. ( 2013). Testing the effects of social norms and behavioral privacy on hand washing: A field experiment. Human Communication Research, 39(1), 21–46. https://doi.org/10.1111/j.1468-2958.2012.01441.x Levitt, R. B., & Barnack-Tavlaris, J. L. ( 2020). Addressing menstruation in the workplace: The menstrual leave debate. In C. Bobel, I. T. Winkler, B. Fahs, K. A. Hasson, E. A. Kissling, & T.-A. Roberts (Eds.), The Palgrave handbook of critical menstruation studies (pp. 561–575). Springer Singapore. https://doi.org/10.1007/978-981-15-0614-7_43 Lopez, V., Sanchez, K., Killian, M. O., & Eghaneyan, B. H. ( 2018). Depression screening and ed - ucation: An examination of mental health literacy and stigma in a sample of Hispanic women. BMC Public Health , 18(1), 646. https://doi.org/10.1186/s12889-018-5516-4 Lott, y., & Klenner, C. ( 2018). Are the ideal worker and ideal parent norms about to change? The acceptance of part-time and parental leave at German workplaces. Community, Work & Family, 21(5), 564–580. https://doi.org/10.1080/13668803.2018.1526775 Marván, M. L., Ramírez-Esparza, D., Cortés-Iniestra, S., & Chrisler, J. C. ( 2006). Development of a new scale to measure beliefs about and attitudes toward menstruation (BATM): Data from Mexico and the United States. Health Care for Women International , 27(5), 453–473. https:// doi.org/10.1080/07399330600629658 Matías-González, y., Sánchez-Galarza, A. N., Flores-Caldera, I., & Rivera-Segarra, E. ( 2021). “Es que tú eres una changa”: Stigma experiences among Latina women living with endometriosis. Journal of Psychosomatic Obstetrics and Gynaecology , 42(1), 67–74. https://doi.org/10.1080/01 67482X.2020.1822807 Metzler, J. M., Kalaitzopoulos, D. R., Burla, L., Schaer, G., & Imesch, P . ( 2022). Examining the influence on perceptions of endometriosis via analysis of social media posts: Cross-sectional study. JMIR Formative Research , 6(3), e31135. https://doi.org/10.2196/31135 Michie, S., Van Stralen, M. M., & West, R. ( 2011). The behaviour change wheel: A new method for characterising and designing behaviour change interventions. Implementation Science , 6(1), 42. https://doi.org/10.1186/1748-5908-6-42 Moreira, M. T., Smith, L. A., & Foxcroft, D. ( 2009). Social norms interventions to reduce alcohol misuse in university or college students. In Cochrane database of systematic reviews (p. CD006748.pub2). John Wiley & Sons, Ltd. https://doi.org/10.1002/14651858.CD006748.pub2 Morgan, A. J., Ross, A., & Reavley, N. J. ( 2018). Systematic review and meta-analysis of mental health first aid training: Effects on knowledge, stigma, and helping behaviour. PLOS One , 13(5), e0197102. https://doi.org/10.1371/journal.pone.0197102 Nadal, K. L., Skolnik, A., & Wong, y. ( 2012). Interpersonal and systemic microaggressions toward transgender people: Implications for counseling. Journal of LGBT Issues in Counseling , 6(1), 55–82. https://doi.org/10.1080/15538605.2012.648583 National Institute of Child Health and Human Development ( 2022). Endometriosis . Retrieved from https://www.nichd.nih.gov/health/topics/endometriosis Nnoaham, K. E., Hummelshoj, L., Webster, P ., d’Hooghe, T., de Cicco Nardone, F., de Cicco Nardone, C., Jenkinson, C., Kennedy, S. H., & Zondervan, K. T. ( 2011). Impact of endometri - 902 A. REINHARDT AND S. EITZE osis on quality of life and work productivity: A multicenter study across ten countries. Fertility and Sterility , 96(2), 366–373.e8. https://doi.org/10.1016/j.fertnstert.2011.05.090 Olson, M. M., Alhelou, N., Kavattur, P . S., Rountree, L., & Winkler, I. T. ( 2022). The persistent power of stigma: A critical review of policy initiatives to break the menstrual silence and advance menstrual literacy. PLOS Global Public Health , 2(7), e0000070. https://doi.org/10.1371/ journal.pgph.0000070 Ozaki, T., & Nakayachi, K. ( 2020). When descriptive norms backfire: Attitudes induce undesirable consequences during disaster preparation. Analyses of Social Issues and Public Policy , 20(1), 90–117. https://doi.org/10.1111/asap.12195 Parker, M., Sneddon, A., & Arbon, P . ( 2010). The menstrual disorder of teenagers (MDOT) study: Determining typical menstrual patterns and menstrual disturbance in a large population-based study of Australian teenagers: The MDOT study. BJOG, 117(2), 185–192. https://doi.org/10.1111/ j.1471-0528.2009.02407.x Reid, A. E., & Aiken, L. S. ( 2013). Correcting injunctive norm misperceptions motivates behavior change: A randomized controlled sun protection intervention. Health Psychology , 32(5), 551– 560. https://doi.org/10.1037/a0028140 Ridout, B., & Campbell, A. ( 2014). Using Facebook to deliver a social norm intervention to reduce problem drinking at university: Social norm intervention using Facebook. Drug and Alcohol Review, 33(6), 667–673. https://doi.org/10.1111/dar.12141 Roberts, T.-A., Goldenberg, J. L., Power, C., & Pyszczynski, T. ( 2002). “Feminine protection”: The effects of menstruation on attitudes towards women. Psychology of Women Quarterly , 26(2), 131–139. https://doi.org/10.1111/1471-6402.00051 Rosenstock, I. M. ( 1974). The health belief model and preventive health behavior. Health Education Monographs , 2(4), 354–386. https://doi.org/10.1177/109019817400200405 Schultz, P . W., Nolan, J. M., Cialdini, R. B., Goldstein, N. J., & Griskevicius, V. ( 2007). The con - structive, destructive, and reconstructive power of social norms. Psychological Science , 18(5), 429–434. https://doi.org/10.1111/j.1467-9280.2007.01917.x Seear, K. ( 2009). The etiquette of endometriosis: Stigmatisation, menstrual concealment and the diagnostic delay. Social Science & Medicine , 69(8), 1220–1227. https://doi.org/10.1016/j. socscimed.2009.07.023 Shadbolt, N. A., Parker, M. A., & Orthia, L. A. ( 2013). Communicating endometriosis with young women to decrease diagnosis time. Health Promotion Journal of Australia , 24(2), 151–154. https://doi.org/10.1071/HE12915 Shah, D. K., Moravek, M. B., Vahratian, A., Dalton, V. K., & Lebovic, D. I. ( 2010). Public perceptions of endometriosis: Perspectives from both genders. Acta Obstetricia et Gynecologica Scandinavica , 89(5), 646–650. https://doi.org/10.3109/00016341003657900 Silke, C., Swords, L., & Heary, C. ( 2017). The predictive effect of empathy and social norms on adolescents’ implicit and explicit stigma responses. Psychiatry Research , 257, 118–125. https:// doi.org/10.1016/j.psychres.2017.07.033 Sims, O. T., Gupta, J., Missmer, S. A., & Aninye, I. O. ( 2021). Stigma and endometriosis: A brief overview and recommendations to improve psychosocial well-being and diagnostic delay. International Journal of Environmental Research and Public Health , 18(15), 8210. https://doi. org/10.3390/ijerph18158210 Smith, J. R., Louis, W. R., Terry, D. J., Greenaway, K. H., Clarke, M. R., & Cheng, X. ( 2012). Congruent or conflicted? The impact of injunctive and descriptive norms on environmental intentions. Journal of Environmental Psychology , 32(4), 353–361. https://doi.org/10.1016/j. jenvp.2012.06.001 Smith, W., Turan, J. M., White, K., Stringer, K. L., Helova, A., Simpson, T., & Cockrill, K. ( 2016). Social norms and stigma regarding unintended pregnancy and pregnancy decisions: A qual - itative study of young women in Alabama: Social norms and stigma around pregnancy decisions. Perspectives on Sexual and Reproductive Health , 48(2), 73–81. https://doi. org/10.1363/48e9016 Surrey, E. S., Soliman, A. M., Johnson, S. J., Davis, M., Castelli-Haley, J., & Snabes, M. C. ( 2018). Risk of developing comorbidities among women with endometriosis: A retrospective matched PSyCHOLOGy & HEALTH 903 cohort study. Journal of Women’s Health , 27(9), 1114–1123. https://doi.org/10.1089/ jwh.2017.6432 Van Der Heide, I., Wang, J., Droomers, M., Spreeuwenberg, P ., Rademakers, J., & Uiters, E. ( 2013). The relationship between health, education, and health literacy: Results From the Dutch adult literacy and life skills survey. Journal of Health Communication , 18 Suppl 1 (Suppl 1), 172–184. https://doi.org/10.1080/10810730.2013.825668 Viganò, P ., Parazzini, F., Somigliana, E., & Vercellini, P . ( 2004). Endometriosis: Epidemiology and aetiological factors. Best Practice & Research. Clinical Obstetrics & Gynaecology , 18(2), 177–200. https://doi.org/10.1016/j.bpobgyn.2004.01.007 Waller, J., Marlow, L. A. V., & Wardle, J. ( 2007). The association between knowledge of HPV and feelings of stigma, shame and anxiety. Sexually Transmitted Infections , 83(2), 155–159. https:// doi.org/10.1136/sti.2006.023333 yang, H., Li, X., Stanton, B., Fang, X., Lin, D., & Naar-King, S. ( 2006). HIV-related knowledge, stigma, and willingness to disclose: A mediation analysis. AIDS Care , 18(7), 717–724. https:// doi.org/10.1080/09540120500303403 young, I. M. ( 2005). On female body experience: “Throwing like a girl” and other essays . Oxford University Press. Zaman, R. T., & Mohiuddin, M. F. ( 2023). Impact of menstruation-related stigma and behavior on female employee performance in Bangladesh: Mediating role of non-work related stress. South Asian Journal of Business Studies , 12(2), 169–185. https://doi.org/10.1108/ SAJBS-08-2020-0274