The study was conducted in Kisumu, Western Kenya, situated on the shores of Lake Victoria approximately 320 km from Nairobi. The population is predominantly of the Luo tribe. Roughly half of the population lives in informal settlements (13). This area has a high HIV rate, with over 15% of the general adult population diagnosed with HIV/AIDS (14). Although sex for economic livelihood is criminalised in Kenya, a 2017–2018 nationwide assessment suggests that there are over 5,000 women engaged in sex for livelihood in and around Kisumu City (15).

This qualitative study is nested in a single-arm trial amongst FSWs to evaluate the safety and effectiveness of a reusable menstrual disc that can be inserted during sex (16). In this study, we examine the perceptions and experiences of a convenience sample of FSWs at approximately 6 months after they receive a menstrual disc. We also include data from focus group discussions (FGDs) with male clients of these FSWs who were interviewed primarily for an investigation into their changing relationships with these women at times of economic stress, but from whom we took the opportunity to ask about their knowledge, experience with, and views on having sex with an FSW who was wearing a menstrual disc to provide a full account of user and client perspectives of the menstrual disc. Content from the pertinent sections of the transcripts was analysed to add full perspectives for this paper.

We chose to collect data by using FGDs as FSWs are part of a close-knit community and would therefore likely contribute to a lively discussion. Similarly, a previous experience of conducting FGDs with male clients had provided a wealth of data..

Aiming for approximately 8 participants per FGD, with each 50 FSWs provided with their disc, a simple random sample of 12 participants was drawn, assuming that some women may not want to participate in the FGDs or may not be available. Each participant listed was invited by phone to participate in an FGD by the study coordinator. Names were added to the list if fewer women were recruited. We aimed to conduct six FGDs at the outset; however, after each FGD, a debriefing discussion was held with the moderator, note-taker, PI, and lead author, which noted key findings and suggested possible refinements to the semi-structured guide or further prompts. After three FGDs, we noted that no new findings emerged; but conducted a fourth FGD to confirm data saturation had been reached.

Male participants who were clients of FSWs were recruited using convenience sampling, deemed most feasible given the nature of the target population. Peer educators and FSWs enrolled in the trial helped identify potential male clients from designated hotspots (e.g., bars, brothels, guesthouses, and streets). These clients were approached by peer educators who shared their contact details with the study coordinator if they were amenable to participating in the FGDs. We aimed for eight participants per group, but we oversampled due to potential under-attendance. A total of nine FGDs were conducted with clients of the FSWs. Whilst we found that data saturation was reached very quickly pertaining to information required for the purpose of this paper (four FGDs achieved this), our primary data objective required additional data collection. We included relevant data from all nine FGDs within the current analysis.

All FGDs took place in a private room. Written informed consent was obtained from each participant in their preferred language (English, Dholuo, or Kiswahili), including explicit permission for audio recording. Prior to beginning the discussion, participants were reminded of the study purpose and what their involvement would entail. They talked through and agreed on a set of ground rules, including the need for confidentiality and to respect each other's opinions. Anonymity of the recordings was preserved by using a participant number that each participant was asked to state as they began speaking. The female project coordinator/moderator and female note-taker who led all FSW FGDs were fluent in English, Dholuo, and Kiswahili, and participants were given the option of speaking in whichever language they were most comfortable with. Similarly, the moderator and note-taker for the male client FGDs were fluent in all three languages, and the participants were similarly free to speak in their preferred language. The moderator led the FGDs using a semi-structured guide. The key questions and prompts were developed to assess the thoughts and experiences of FSWs on menstrual cup use and cup use during sex (Supplementary File S1), and for clients, the key questions and prompts were designed to elicit knowledge of having had sex whilst a disc was being used, what their experience of it was, and their thoughts on it being used and informed about it (Supplementary File S2).

FGDs were digitally recorded then transcribed verbatim using a local transcription service. Each transcript was checked for accuracy whilst listening to the recordings. Any Dholuo and Kiswahili transcripts or sections were translated into English, with a sample back-translated for a consistency check.

The analysis began by reading and re-reading the transcripts for familiarity. The transcripts were imported into NVivo v14 for organisational purposes. The data were explored using thematic analysis (17), chosen because of its flexibility in supporting interpretation of data, allowing themes to be linked with the research questions with transparency and reproducibility, and suitability for projects involving teamwork. A deductive approach was used as we intended the analysis to inform specific study objectives. We analysed the FSW data first and then we analysed the client data separately using the same techniques and triangulated findings in the discussion where relevant. The initial coding frame included codes identified a priori comprising key question responses and from themes identified during the debrief (discussions that took place after each FGD) Further codes were added for new detail and information arising from the participant narratives. All transcripts were coded against this frame with new codes added in the process as needed. After all codes were identified, they were grouped into major themes and sub-themes. Using these themes and sub-themes, a narrative was written with a check to ensure where shared features, consistent patterns, and deviant examples were noted. The narrative was supported using illustrative quotes. The transcripts were then re-read for interrogation purposes to ensure that the narrative represented what the authors deemed was a representative portrayal of the data, and that responses to our research questions were reliable. Checks were made to ensure that views were not under-represented or over-exaggerated and amended where necessary.

The first and lead authors/analysts acknowledged their positionality as senior academics at Western Universities and had non-Kenyan backgrounds, which had the potential to bias their interpretation of the study findings. We reduced the possibility of such bias through the following ways. All data collection was undertaken by a Kenyan moderator and note-taker. After each FGD, a debrief was held with the moderator, note-taker, first author, and lead author to discuss the findings and their interpretation. The first author then held several meetings with another member of the team FOO, a male Kenyan, to facilitate her understanding and interpretation of all client transcripts. Member checking was conducted at FSW peer review meetings, where the findings were discussed and verified and any queries resolved. Data source triangulation was conducted during the analysis, with notes made during the FGDs. The moderator and note-taker reviewed and concurred with the final draft, making minor suggestions for amendments.

All FSWs were first made aware of the menstrual disc when they were recruited to the study, and prior knowledge of it was rare. Most were curious, even eager to see it, primarily because of its name; others were doubtful wondering how the disc (which participants called a “cup”) could be utilised as a menstrual absorbent.

Reactions on seeing it varied from remarking on how small it was to being “afraid”—musing how it could fit into their vagina. A few participants anticipated pain, although others were immediately reassured because the cup was smaller than they had anticipated.

Despite some clients having been told about the menstrual disc, or even shown one by their female sex worker, many men seemed not to know anything about it but were curious for more information. One group (FGD7) had no clients who had heard about it or seen it. Most men had a positive response to the information and the disc itself and asked many questions of their moderator.

Some FSWs spoke of being able to insert and wear the menstrual disc comfortably at their initial attempt. Typically, across all FSW FGDs, women were apprehensive to insert it, encountering difficulties on insertion the very first time but either continued to try until succeeding or waited to attempt again during their next menses. A few FSWs reported reaching out for help outside of the monthly study phone calls and either spoke to one of their peers or with one of our project staff who gave instructions. A couple reported asking a peer to insert it for them. The overwhelming sense voiced by FSW was that they were determined to master and be able to wear the menstrual disc within the first few tries. Most described how after a few attempts it just seemed to “go in” without a problem, and from then on, they were comfortable and able to use with ease. Some mentioned with hindsight that they had either been inserting it incorrectly or had been too tense. A few women spoke of having difficulties in removing the disc, some of whom reached out for help. Once given advice such as positioning themselves better or relaxing, or occasionally receiving physical help from a colleague or friend, they were able to remove it. Only a couple of women stated that it wasn't until the third month that they were able to use it comfortably. This was the longest duration that any woman reported needing to become confident in disc insertion and removal. The following excerpts illustrate participants' initial experiences of using the disc.

Once insertion and removal were mastered, the FSWs agreed that the disc was easy and convenient to use, with many using the word “comfortable”. This mostly referenced physical comfort, typically like “This cup, am just comfortable with it” (R8 G3), but also sometimes indicated psychological comfort, indicating that they were free from the fear of, or having to check for, leaking, staining, or odour. Frequently, the participants related their comfort of wearing the cup to using a pad, and in every instance, they favoured the disc. The following quotes, similar to the above excerpts, are typical of narratives across all groups.

A few talked about improvement in their hygiene through not now having to conceal bleeding from clients by using cotton wool or tissue (locally known as ‘kasunda’) inserted into their vagina to soak up the blood:

The cup was also positively viewed in relation to sanitary pads when the participants were asked about the financial impact. They spoke of saving money that they would have spent buying pads previously. A few highlighted that the money they saved was now being spent on their children.

Some other women spoke of another financial benefit. Although some women had previously used kasunda and/or douching to hide or wash away their menstrual blood, others did not take clients while they were menstruating. Now with menstrual discs, they had a hygienic and comfortable method to keep working and thus earning money throughout their menstrual period.

Apart from initial issues in inserting and removing the disc, a few challenges in using it were acknowledged by FSWs when they were specifically asked about them. One report spoke of a woman losing her disc and another told of having her disc stolen. Women in three FGDs shared that they had accidentally dropped their disc on occasion, although none had in the other FGD. One woman spoke of how this occurred “many times,” and she reported, “It is an issue, the reason is, you are not accurate. You are supposed to be accurate when you are inserting it” (R1 G3). Other instances of dropping arose from being anxious when first using the disc, being in a hurry, or having had a few alcoholic drinks. A couple of women spoke of keeping the disc in for longer than the recommended period (i.e., for more than 12 h), when they had drunk too much alcohol or taken drugs. “Ahhh! Okay, I chewed, black[ed]out at two am and I woke up at nine pm in the evening” (R1 G3).

Others reported that they did not use their cup when they were going out drinking because they were worried about dropping it, or they feared forgetting they were wearing it and thus keeping it in for too long.

Alternatively, others concluded, “So you don't drink a lot, you control.” Her colleague, agreeing, added “If you are using it you don't drink too much” (both Rx G2).

Another stated firmly, “If am going to drink and am on my menses, I cannot have a client, I just drink my own money, that's my day to enjoy. It is very clear. So you cannot combine alcohol, combine cup, and combine with the client, you will die. [Laughter] I don't cheat you, you will die” (R7 G4). Her colleague added, “When am drunk client is no because somebody can play some games that are …” (R4 G4).

A few spoke of challenges in finding water to wipe the cup after changing, particularly if they were working or sleeping on the streets, and stressed the need for more provision of public washrooms. Yet, others reported taking water and/or wipes with them with seemingly little difficulty. A greater challenge appeared to be finding privacy to remove and empty the cup.

Planning in advance when and where to empty was suggested by others as a way to mitigate this issue.

The participants were asked whether they had sex while wearing the disc. Four women admitted that they had not tried it. One stated, “Because I'm afraid, I feel that when … that man will … whatever inside there. I always just wonder that it will get in and get lost” (R4 G4), while her two colleagues in the same group also admitted that they had not used it during sex because they were “scared.” Indeed, numerous FSWs spoke of being scared the first time they had sex whilst wearing the disc. A couple of participants said that they were worried that it would be displaced, and another said that blood would be pushed back “where it came from,” but most were concerned that the partner would feel it.

Consequently, many chose their partner carefully the first time they had sex while wearing the disc, either a boyfriend or a regular client. A couple of women instructed their partner to go slowly or gently on the pretext that they were not feeling very well. One woman had a ready response that it was a “family planning method” should the partner be able to feel it. After feeling perturbed initially, women were relieved to find that men did not feel it. While a few women asked their partner afterwards whether they had felt anything, and were told “no,” others came to the assumption that as nothing had been mentioned then the cup had not been sensed by their partner as their partner mentioned nothing about the cup or any such device.

After these first experiences, the FSWs realised that they could wear a cup without a partner knowing about it.

Only one FSW spoke of the cup being “displaced” but followed it up stating that she had not inserted it well; another reported that her boyfriend had felt it but then explained that he knew she was going to use it beforehand. A third regaled the group with the story that her client could feel it because they were having very rough sex:

When asked about the cup in all client FGDs, only two men thought that they may have had sex while the cup was in situ, having felt what they described as “something.” When pressed further, one reportedly felt something “in her body” but did not feel able to ask her about it. Only during the FGD did he conclude that it may have been a menstrual cup. The other described his reaction as follows:

All other clients reported that they had not had sex with an FSW who was wearing a cup, or more usually that they did not know if they had done or not.

Few FSWs had told a boyfriend or client that they were wearing a disc, and those they told were carefully chosen beforehand anticipating that their reaction would not be negative or violent. One exception was R4, who enthusiastically stated:

Narratives then explored whether clients should be informed when FSWs were wearing a disc. Replies varied, with some unsure: “Should I tell him I have something in my vagina?” (R9 G1), but many responded negatively. A common perception was that clients, particularly new or not regular ones, should not be told, primarily because they might then leave without paying or use the information as an excuse to pay less.

This point was echoed by several male clients when asked whether FSWs should tell them whether they were wearing a disc during sex. Those who were not in favour, over half of the men, generally felt that learning that a sex worker was on her menses would affect “morale,” a word used quite often, as was the phrase “it kills the mood”, and additionally, “I will just ‘deplete’.” As one succinctly stated:

A longer explanation was proffered in another FGD.

Those men who would prefer to be informed seemed unable to voice strong reasons for their choice, just making comments such as

A similarly nebulous explanation was provided in FGD 8 where, unlike the other FGDs, the majority of men did want to be informed.

A few FSWs suggested that the cup may be perceived by clients as a barrier like the condom, as one woman explained further: “So that is why if you tell him, if you realize he is a client who feels that condom is acting like a barrier he does not feel the whole of you the way he wants. If you tell him again that you are wearing that thing, he will have to leave you and he will go away” (F3 G3).

Others thought that men simply would not understand what the menstrual disc was and hence it would be an unnecessary complication to involve them, particularly as they cannot feel it in situ. They could remain ignorant of the situation. A couple of FSWs argued that men's lack of understanding, along with misconceptions, could prompt a reaction of violence if they were told.

There was little indication from the men’s FGDs that violence would be a common male reaction to learning that an FSW was wearing a disc during their sexual activity. However, two males in FGD 9 reacted quite strongly, with one stating that if he found out “I will be pissed off” (P11), and the other saying, “I will quarrel her” (P2). When asked why, the second reported, “I am really scared of blood.”

It appeared that other clients could have misconceptions, prompting a negative reaction, although not directed towards the FSW herself, as FGD2 reasoned:

“So, I felt I would hurt her. I don’t think I would have sex with someone knowing she has got that stuff inside there,” and later “I will not do it” (P3), the phrase repeated by P7, P6, P5, and P1. When asked why:

Notably, P5 and P1 became more nonchalant on learning more about the menstrual disc and that it would not hurt the FSW.

P4, however, remained adamant about repeating his previously voiced concerns:

Across all FGDs, however, there were some clients who reported that they would not be bothered whether a sex worker was using it as long as they did not know or could not feel it.

Although not mentioned by clients, some FSWs were more likely to believe that long-term partners such as boyfriends or regular clients could be told about the cup as they were often involved in paying or buying pads for the women and would therefore be happy to save money. As one FSW pointed out, not all were insensitive, saying, “Mmm, there are even some clients who are … a person who can just look at you and tell you like no, it seems today you are on your menses. Because you know some of us their faces usually change … if he sees you like today you just tell him that no, even if am on my menses, there is no problem because I am safe” (R9 G4).

Some FSWs altruistically suggested male clients could be informed so that they could then purchase a disc for their wives. Despite the majority not wanting individual clients to be told, many agreed that sensitising all men about the menstrual disc was a positive step forward. A few likened this to the female condom, where they reported that successful sensitisation had occurred over time and believed that the same could be achieved with the disc.

With only one exception, wherein an FSW who used the disc but stated that she was still a little afraid of using it, our discussions concluded with many positive remarks about it. The following excerpt from G2's discussion amongst FSW participants illustrates responses when the moderator asked their future intention on using the cup.