"Should I tell him I have something in my vagina?" Female sex workers' perceptions and experiences of using a menstrual cup, and client reactions: A qualitative study in Western Kenya.

Introduction: The menstrual cup is worn intravaginally, holding blood up to 12 h before emptying and reinserting. It offers protection from sexually transmitted infections and bacterial vaginosis, whilst preserving a Methods: In a qualitative design, our Kenyan study recruited 38 FSWs in 4 focus group discussions (FGDs) and 86 clients in 9 FGDs. Using a semi-structured guide, a Kenyan moderator and note-taker facilitated audio-recorded discussions. Following translation and transcription, the discussions were analysed using deductive thematic analysis. Results: Six themes emerged: Anticipation and reaction to seeing the menstrual cup, Apprehension and determination to use, Benefits, Challenges, Secrecy, and Use during sex. Some FSWs were able to insert the cup on initial attempt, typically others encountered discomfort, pain, or misalignment during insertion or difficulty in removing. By the end of the third month, the majority were using the cup without experiencing any leakage, pain, or concerns. Benefits noted included ease, convenience, reduced leakage, and comfort. Financial advantage over pads and ability to work regularly were also noted. Nearly all FSWs used the cup during sex, despite prior anxiety that a client would detect it and react negatively. In three instances, the FSWs reported that a client "may" have felt the disc, whilst noting just two clients "may" have felt something. None reacted badly. In summing up their experience, the FSWs spoke very positively about the disc, with the intention to keep wearing it in the future. Many clients were supportive of the disc but did not want to know whether an FSW was wearing it. Conclusions: The FSWs quickly adapted to using the disc, finding it a comfortable, reliable menstrual product with financial advantages. With clients remaining mostly unaware of its use, the FSWs enthusiastically embraced the disc with the intention to keep using it. These positive outcomes have implications for future scale-up and roll-out to other vulnerable female populations.