Understanding menstruation among tibetan buddhist nuns: a perspective of local knowledge

The perception of menstruation among Tibetan buddhist nuns

Menstruation refers to the cyclical shedding of the uterine lining with associated bleeding due to the periodic fluctuations in ovarian hormones. In traditional Chinese culture, it was historically referred to as “monthly matter” (yue shi), “monthly water” (yue shui), or “monthly signal” (yue xin). It is a physiological phenomenon unique to women of reproductive age. In many cultures, the behavior of menstruating women is subject to specific social constraints. While menstruation is a normal biological function, girls are often categorized as “impure” from the onset of menarche [7]. In some communities, menstruating women are prohibited from participating in religious rituals; in others, they may even be subject to physical seclusion. Among certain ethnic minorities, menstruation is viewed as unclean, giving rise to a wide range of menstrual taboos and practices [8].

In local Tibetan communities, traditional beliefs about the impurity of menstrual blood have led to restrictive customs and, compounded by limited living conditions, to inappropriate menstrual care practices that significantly harm women’s physical and psychological health. As a distinct subgroup of local women, ordained Tibetan Buddhist nuns often exhibit ambivalence in their perceptions of menstruation. On the one hand, they are influenced by customary views that regard menstrual blood as impure and shameful – something to be hidden. On the other hand, Buddhist teachings reference menstruation in more constructive ways. Scriptures speak of life as originating from the father’s semen and the mother’s menstrual blood, emphasizing the role of menstruation in bodily formation. Within the Nyingma school of Tibetan Buddhism, a young girl’s menstrual blood may even be regarded as a sacred offering. This results in a complex duality in how nuns view menstruation – both as contaminating and sacred.

In Tibetan, the term for menstruation is “zla mtshan”. However, in conversation, local women often use euphemisms such as sked pa, meaning “waist”, to discreetly refer to menstruation – “the waist has come” implies “the period has arrived”. Menstrual taboos are a common cultural feature across human societies. Although details vary across ethnic groups, there is a general consensus in many traditions that menstrual blood is unclean and menstruating women are dangerous or polluting [9]. Locally, girls are taught from menarche onward – typically by older female relatives – that menstrual blood is dirty and must be kept hidden. During childbirth, the blood is also viewed as impure; families often hang a tuft of white wool at the door to signal outsiders not to enter the household, lest they bring misfortune [10]. As a result of these taboos, all menstruation-related topics are treated as unspeakable. Even among close female peers, such discussions are rare and conducted in hushed tones. Moreover, due to a lack of access to physiological and hygiene education, elder women in families seldom pass on menstrual health knowledge. Many nuns, before ordination, had experienced what may be termed menarcheal fear – a culturally induced anxiety surrounding their first period.

Rig vdzin sgrol ma^[3] (Ren zeng zhuo ma) recounted:

I got my period when I was 12, and now I’m 50 and still haven’t stopped. I don’t know why – it’s just such a hassle, I hope it ends soon. I didn’t have a mother growing up and used to sleep next to my father. One day, I went to the toilet and saw blood all over my thighs. I thought I must have injured myself climbing trees, so I kept quiet about it for a whole day. I kept wondering what was happening, then remembered that my sister-in-law once mentioned something about menstruation while we were herding cattle. That’s when I thought – maybe it’s this.

Her experience echoes the fear and confusion many Tibetan girls face during adolescence, due to silence and secrecy from older female figures. The association of menstruation with shame can follow women into adulthood. The family is a site of social experience that significantly shapes one’s view of health; parents exert the most lasting influence on their children’s health behaviors. For nuns, who serve as intermediaries between the divine and laypeople – representatives of spiritual purity – menstrual impurity must be hidden. Menstruation, as an unavoidable biological event, must be managed discreetly to maintain a sacred appearance before others. Consequently, nuns tend to be even more avoidant than lay Tibetan women regarding menstruation.

Ye she sgrol ma (Yi xi zhuo ma) shared a particularly revealing story about the tension between purity and pollution:

One time, I went to Hezuo with another a ne.^[4] Everything was fine when we left, but I got my period after we arrived, and I didn’t even notice – it was the other a ne who saw it. I was chatting happily with her when she suddenly said, ‘You’re on your period – it’s on your gzan.^[5]’ I was so embarrassed and terrified. Just imagine – a nun, in public, with blood on her robe – it was mortifying. I quickly took off the gzan, rearranged it so the stained part was under my arm and hidden. It was so humiliating. Another a ne I know had it even worse – she got her period while chanting at someone’s house. She couldn’t stand up, couldn’t sit still, and an a ke^[6] named Thupten was there too. She waited until everyone left, then poured water into a bowl, held it in her mouth, and sprayed it onto the stained white wool felt mat. Then she picked at it with her fingers to remove the blood.

Since menstrual blood is discharged from the reproductive organs, it is considered similar to other bodily excretions and therefore unclean. It is viewed as out-of-place, a threat to order – something disgusting that must be swiftly removed [11]. For Tibetan women, menstrual blood is always something shameful that should not be seen – let alone for nuns, whose identities are invested with sacredness. Given menstruation’s inevitability, the most appropriate strategy becomes concealment: it must neither be spoken of nor seen. This imperative – to maintain bodily purity in service of spiritual ideals – renders menstruation a deeply taboo topic within monastic life. Unlike explanations based on pathogens or hygiene, this concept of impurity belongs to a symbolic system of pollution.

Cleanliness and pollution are not always absolute opposites; rather, they can be relative categories. Something considered clean in one context may become unclean when associated with another, and vice versa. The concept of pollution thus becomes a complex algebraic problem, where different variables must be evaluated within their contextual frameworks. As Mary Douglas noted in Purity and Danger, when a goddess visits a village, people show their respect by washing her feet with cow dung. Similarly, menstrual blood – ordinarily regarded as filthy in secular contexts – is considered pure enough to serve as a supreme offering to deities within the Nyingma tradition [12]. Consequently, nuns’ perceptions of menstruation reflect a dual influence: on the one hand, they are subtly shaped by local customs that stigmatize menstrual blood; on the other, they are profoundly influenced by Buddhist culture, leading to understandings that differ from those of lay Tibetan women.

Rig vdzin sgrol ma (Ren zeng zhuo ma), the highest-ranking nun in the monastery, exemplifies the impact of religious ideology on menstrual cognition. Older nuns, having spent longer periods immersed in monastic teachings, follow the Tibetan Buddhist curriculum that progresses “from exoteric to esoteric”, granting them access to deeper tantric rituals and doctrine. This spiritual education enables them to attain a more profound and transcendent comprehension of menstruation beyond mundane conceptions.

Although menstruation may appear unclean, it is permitted for nuns to enter the scripture hall during their periods, provided they maintain bodily cleanliness. Advanced Buddhist texts assert that the menstrual blood of twelve- or thirteen-year-old virginal nuns is especially auspicious and is offered to the Buddha. The menstrual blood of adolescent nuns is dried and placed into boiling tea, which is then poured over dor ma^[7] offerings used in rituals, constituting a high-level sacrificial practice. Contrary to common notions of cleanliness, esoteric teachings hold that what appears impure in the secular world may be the purest in the spiritual realm. At the highest spiritual attainment, distinctions between clean and unclean lose their significance; paradoxically, what the world deems most impure may be considered most pure in doctrine.

From a religious perspective, sacrificial offerings must be pristine and perfect. Menstrual blood attains sanctity because holiness is measured by wholeness. A virgin who has not engaged in sexual intercourse is regarded as physically intact, and physical integrity equates to sanctity – thus, her menstrual blood is deemed sacred. This explains why menstrual blood from adolescent nuns is considered a premium offering; their bodies are intact and holy, rendering their menstrual blood clean and uncontaminated. Since the majority of nuns are ordained before marriage, they maintain bodily integrity. Therefore, menstrual blood flowing from a holy body is pure. But what about the few nuns who married before ordination? Though their bodies may be considered incomplete, they believe that the ordination ceremony functions as a ritual baptism, purging secular impurities. Upon becoming a sacred religious official, their bodies attain holiness, which in turn sanctifies their menstrual blood. As Ye she sgrol ma (Yi xi zhuo ma) explained:

Scriptures do not say menstruation is unclean; without menstruation, there would be no new life. Menstrual blood is not considered very dirty in the texts, but it is taboo to let others see it, especially in the scripture hall. Deities such as Kangdzorma and Tara are women and also menstruate, so menstruation cannot be said to be impure. However, the scripture hall is a sacred place, with male Buddhas and bodhisattvas present. It is sinful if they see menstrual blood. The main scripture hall is where everyone chants together – a sacred gathering place. Though menstrual blood is not impure, common people still regard it as dirty. If the Buddhas saw it, they would be displeased.

This passage illustrates that older nuns with deeper religious understanding hold a more expansive conception of menstruation, encompassing two dimensions. First, their views are rooted in religious doctrine. The classical Tibetan medical text Four Medical Tantras records that male semen and female menstrual blood are internal causes of bodily formation; without menstrual blood, new life could not begin. Menstruation is thus linked to fertility, and from this perspective, menstrual blood is not polluting. Tibetan medicine, one of the 10 traditional Buddhist sciences – “Rig gnas bcu” (shi ming), is also part of the nuns’ education. While lay Tibetan women may vaguely associate menstrual blood with childbirth – often in the negative sense that postpartum blood is considered dirty. In contrast, nuns have greater physiological knowledge from scripture study, enabling a more objective appreciation of menstruation’s role in reproduction. Second, menstruation is associated with sanctity. The Buddhist pantheon includes many female deities. As female deities, they embody physiological femininity, and their bodies – and the menstrual blood flowing therein – are sacred. Likewise, nuns’ bodily holiness confers purity upon their menstrual blood, negating notions of pollution.

As Clifford Geertz has famously stated, every act of cognition, every matching of mind to object (event, action, or emotion), occurs against an appropriate symbolic backdrop [13]. From a secular standpoint, menstrual blood is polluted. Menstrual bleeding leaves a profound, unsettling, and fear-linked impression on ancient peoples. No one could ignore bleeding; it portends terrible consequences that have to be guarded against, and one of the best safeguards is to consider all phenomena related directly or indirectly to bleeding as unclean. Locally, from menarche onward, elder female relatives teach girls that menstrual blood is unclean and must be hidden. Even after ordination, this belief often persists and influences menstrual management. Yet, from a Buddhist perspective, menstrual blood is clean. Whether female deities or nuns, despite undergoing this unavoidable biological process, their blood flows from a sacred body. Since the body is holy, excretions from it must also be pure. Compared to lay Tibetan women’s view of menstrual blood as polluting, nuns hold a dual conception of menstruation as both impure and pure – shaped by their religious culture.

This cognitive tension directly shapes a set of intertwined and seemingly contradictory practices. On the one hand, influenced by the perception of menstrual blood as impure, nuns engage in avoidance and deliberate concealment of sanitary pads that carry menstrual discharge. On the other hand, their understanding of cleanliness leads them not to reject menstruation itself, but rather to adopt proactive care strategies to maintain bodily health. This mode of navigating apparent contradictions – evading the symbolic “pollution” of blood while simultaneously accepting and carefully tending to the menstruating body – is far from a simple logical paradox. Instead, it vividly externalizes and embodies the multiple, and at times conflicting, meanings ascribed to menstruation within a specific religious and cultural framework. It reveals, in a profound way, how individuals under powerful cultural constraints negotiate and integrate abstract cultural meanings (impurity/purity) with concrete bodily experiences (menstruation), thereby weaving a distinctive tapestry of embodied life practices.

Menstrual management among nuns

In ancient times, cloths used by women to absorb menstrual blood were known by various names such as “women’s cloth”, “menstrual cloth”, “menstrual garment”, or “monthly blood fabric”, and such items were frequently mentioned in traditional medical texts. In modern terms, sanitary pads are absorbent materials primarily composed of cotton pulp and superabsorbent polymers, designed to absorb menstrual blood discharged from the vagina during menstruation. Previously, local women, who traditionally did not wear pants, allowed menstrual blood to flow directly onto their robes, subsequently treating it with ash or soil. Before pants became more common, women used strips cut from old, worn-out clothes, sewing these into menstrual belts to manage menstrual flow, or wore multiple pairs of pants to absorb the blood directly. Later, women used folded grass paper strips. Nowadays, sanitary pads are widely used, fixed to underwear to absorb menstrual flow. nuns, like all local women, have undergone a transition in menstrual management practices from traditional to modern methods. Rig vdzin sgrol ma (Ren zeng zhuo ma) recalled:

When I first became a nun, I was very afraid of menstruating during religious ceremonies. Before sanitary pads were available, menstrual flow was very heavy. Now with sanitary pads and paper, it’s actually less. Back then, without paper or pads, we nuns used many layers of old cloth sewn into strips with straps tied around the waist. After menstruation, we locked the door, washed the cloth strips, and dried them where no one could see.

Since sanitary pads were introduced in China in the 1980s, their convenience, comfort, and hygiene qualities have gradually made them popular among women in ethnic minority areas, replacing traditional menstrual products such as grass paper and cloth strips. With social and economic development improving living standards, local women no longer rely on old, worn cloth or homemade menstrual belts but generally use sanitary pads. Regarding the advantages of sanitary pads, Ye she sgrol ma (Yi xi zhuo ma) explained:

I think sanitary pads are especially good; you can wear one for two or three days without changing, and it won’t leak through like the old cloth strips did. Unlike cloth, which can chafe when blood dries and hardens, sanitary pads don’t hurt the skin. The material keeps the blood on top, like water on paper – always soft.

Although sanitary pads are convenient and favored by nuns, they commonly report feeling embarrassed to purchase them due to their monastic identity. Chos skyong sgrol ma (Qu jun zhuo ma) said:

We are nuns, not laypeople; it’s too embarrassing to buy sanitary pads at the store. Sometimes female donors provide pads during ceremonies, which is very good because otherwise, we would have to buy them ourselves, and that’s too shameful.

Though sanitary pads and toilet paper are ordinary hygiene products, in this context – due to their association with menstruation and underwear – they become taboo items that are carefully concealed. They are not visible in the main rooms of the nunnery, often hidden in secluded places such as wood storage rooms, and are not sold in the monastery’s small shop. Even the monastery’s pit latrines rarely show any evidence of pad usage. Ye she sgrol ma (yi xi zhuo ma) described:

After ordination, sanitary pads gradually appeared. I use one every day. Used pads are either buried in a pit, usually at night when no one is around, or the door is closed, they are soaked in water, cut up, mixed with ash, and then disposed of. Though pads are easy to use, disposal is a headache. Before there were toilets, we buried pads or threw them into marmot holes in the grassland. If someone, especially a man, saw this, it would be extremely shameful – like having a knife to your throat.

The taboo surrounding sanitary pads leads them to be handled with extreme caution and secrecy, to avoid being seen. The notion of menstrual blood as impure transforms an otherwise mundane personal item into a forbidden object and contributes to widespread ignorance about proper sanitary pad use. Modern markets offer a wide range of sanitary pads – daytime, nighttime, ultra-thin, extended, cotton-lined, mesh-covered, and so forth. Urban women usually choose pads based on flow volume. However, in economically disadvantaged northwest ethnic regions with low living standards and limited female education, basic menstrual hygiene knowledge is lacking. This is especially true in remote, isolated places like monasteries. Due to this lack of health education, nuns often do not know the importance of changing sanitary pads frequently to maintain vulvar dryness. To “make the most of it”, the typical pad usage lasts at least a full day.

Several factors contribute to this situation. First, a lack of necessary menstrual hygiene knowledge: sanitary pads are essential companions during menstruation, but taboos related to menstrual blood prevent many nuns from learning proper use or openly discussing it. Even when opportunities arise, their monastic identity may deter them from seeking information, resulting in improper practices. Second, limited income: according to the abbot of Q Monastery, most nuns receive a monthly subsistence allowance of only 54 yuan. For women who carefully budget even heating coal, sanitary pads – non-essential for livelihood – are viewed as a luxury, prompting frugality. Third, disposal challenges: used pads are generally buried or wrapped and discarded far from the monastery, but frequent pad changes would increase the workload. To avoid this, nuns minimize changing pads, despite hygiene risks.

The menstrual health risks commonly observed among the nuns at Q Monastery stem from multiple intertwined factors: a relative lack of physiological knowledge about menstruation, deeply ingrained socio-cultural taboos surrounding menstruation, and generally low economic income. These collectively create practical barriers to accessing and using menstrual hygiene products. Among these factors, the culturally entrenched notion of menstrual blood as “impure”, combined with the special status of nuns, compels them to be particularly vigilant in concealing any signs of menstruation. This culturally driven behavior – such as reducing the frequency of changing sanitary products or avoiding seeking professional medical help – often runs counter to the fundamental hygiene principles of keeping menstrual products dry and preventing bacterial growth. Consequently, it significantly increases their risk of reproductive tract infections and other gynecological diseases.

However, since nuns acquire more knowledge from scriptural teachings than local laywomen, they are able to view the physiological significance of menstrual blood with greater objectivity. In the absence of adequate external medical knowledge and resource support, they primarily rely on their own lived experiences together with the local cultural and religious knowledge system. Over time, this has led them to develop a distinctive set of self-perceptions and practical approaches to menstrual care. Such practices constitute not only an adaptive response to structural constraints, but also, in an unspoken way, further reinforce their existing cognitive framework and modes of management.

Menstrual care among nuns

The system of disease cognition reflects the cultural characteristics and value orientations of the patients’ social context, guiding them to adopt what they perceive as the most reasonable methods to maintain their health [14]. Influenced by local traditional customs, nuns generally hesitate to disclose menstrual discomfort unless the pain becomes unbearable and prompts them to seek professional medical treatment. Otherwise, they typically rely on personal or communal past experiences for managing symptoms. To Bde dbyangs sgrol ma (De yang zhuo ma), visiting a hospital for gynecological issues related to menstruation is an extremely “shameful” act:

I became ordained when I was still a young girl and have never exposed my body to others. I would rather die than see a doctor for this illness. Yet I could not bear the pain anymore. The hospital examinations made me feel ashamed and hurt inside. I only went when I really could not endure it.

According to Tibetan medicine, gynecological diseases can result from various factors including inappropriate diet and lifestyle habits. Common external treatments include bathing therapy, poultices, and moxibustion. Thub bstan sgrol ma (Tu dan zhuo ma), who suffers from menstrual irregularities, has had to be hospitalized for treatment during autumn in recent years.

I have been treated in Tibetan hospitals with Tibetan medicine, moxibustion, and herbal baths. When visiting for menstrual disorders, Tibetan doctors always explained clearly that the problem stems from cold exposure. They advised keeping warm, avoiding cold water and spicy foods, abstaining from beverages, and ensuring sufficient rest. After hearing their advice, I take care accordingly.

The “popular sector” represents the largest component of the medical system and forms the foundation for healthcare choices. When individuals receive treatment from folk healers or professional doctors, they bring relevant knowledge back into the popular domain, guiding future healthcare behaviors [15]. Benefiting from the relatively objective and de-stigmatized understanding of menstruation embedded in their religious beliefs, the community of nuns has, through long-term lived experience, gradually combined accumulated popular health knowledge with diverse treatment experiences – both folk and professional – to develop a set of effective menstrual care practices. Rig vdzin sgrol ma (Ren zeng zhuo ma) explained:

Menstruation always coincides with important days, such as the 8th or 15th, which are days of religious ceremonies. When it comes, I feel lower abdominal pain and swelling all over. I drink large amounts of black tea with brown sugar to feel better. When I was younger, I used to drink cold water and work through the pain without discomfort. Now that I am older, I dare not do that anymore. Cold water makes my stomach hurt.

Rig vdzin sgrol ma (Ren zeng zhuo ma) prefers drinking “Da Cha”^[8] in her daily life. Normally, she does not add any ingredients to the tea as she believes it would spoil its original flavor. The exception is during menstruation, when she uses the warming effect of black tea with brown sugar to alleviate dysmenorrhea. According to Tibetan medicine, primary dysmenorrhea caused by cold stagnation (fu xue zheng) is primarily due to exposure to cold during menstruation, contact with water, consumption of cold foods, or living in damp environments. Cold and wind pathogenic factors invade the Chong and Ren channels, causing stagnation of menstrual blood and resulting in pain. Treatment emphasizes warming the channels, dispersing cold, removing blood stasis, and relieving pain.

This dietary and lifestyle menstrual care approach is common among nuns in the monastery. Chos vdzin sgrol ma (Qi zeng zhuo ma) also relies on drinking warm black tea with brown sugar during menstruation to dispel cold and keep warm, thereby easing menstrual pain:

When the pain is severe, I have to sleep – it’s impossible to stay awake. I warm the kang (heated bed), drink black tea with brown sugar, and lie on the hot kang. My mother told me that menstrual pain is due to cold, so I need to keep warm. I find that if I touch cold water or get chilled during menstruation, the pain intensifies. At those times, warming the kang and drinking warm tea and brown sugar helps alleviate the pain.

From the perspective of dietary efficacy, brown sugar is considered warm in nature, sweet in taste, and enters the spleen meridian. It has effects such as tonifying qi and blood, strengthening the spleen and warming the stomach, relieving pain, and promoting blood circulation to remove stasis. Brown sugar contains folic acid and trace elements that can accelerate blood circulation, increase blood volume, stimulate hematopoiesis, and improve the local supply of nutrients, oxygen, and moisture to the skin. Black tea, a post-fermented tea, not only serves as an important source of nutritional supplementation but also aids digestion and reduces greasiness. Moreover, it possesses specific pharmacological effects recognized by traditional Chinese medicine, such as warming properties that help dispel cold, thereby alleviating dysmenorrhea caused by cold-induced deficiency. Dngos krud sgrol ma (Ni zhou zhuo ma), in addition to taking black tea with brown sugar as an internal treatment, also uses other heating tools for external treatment.

When my menstrual pain is severe, I take a brick, heat it on the stove, and place it on my abdomen. I think this helps a lot. I forget which nun told me this. When I don’t take medicine, I boil some brown sugar in black tea and drink it. I don’t remember where I heard this, but I know it works. Also, I must avoid cold water and cold drinks. If I touch cold water within ten days before menstruation, the pain will be especially severe.

Heating bricks is likely a primitive method of warming and dispelling cold; nowadays, hot water bottles are more commonly used as substitutes and provide similar therapeutic effects. Besides being a simple warming device, hot water bottles have many medical and health care uses. For example, heat therapy can relieve joint pain, back pain, sciatica, and dysmenorrhea. Applying a hot water bottle to a painful area can significantly relieve pain. From a Western medical perspective, applying a hot water bottle to the abdomen can relax uterine smooth muscles and increase the pain threshold. Traditional Chinese medicine holds that using a hot water bag on the lower abdomen during menstruation promotes blood circulation, warms the uterus, dispels cold, and effectively relieves dysmenorrhea. Tibetan medicine typically combines heat therapy with the treatment of cold-type dysmenorrhea to warm the uterus, disperse cold, and relieve pain. This external treatment involves applying heat with medicine or objects to certain body parts or acupuncture points, utilizing medicinal properties and physical heat to unblock meridians, reduce swelling and stasis, and relieve pain. The mechanism of hot water bottles is similar to the Tibetan moxibustion method, which applies heat to the lower abdomen to remove stagnation, dispel cold, and warm the uterus.

Q Monastery is located in the relatively underdeveloped northwest ethnic region. Nawu Town, where it is situated, is remote and only has one community health clinic with limited medical services. Under this scarcity of medical resources, vulnerable nuns face multiple health challenges: lacking sufficient health information and resources, and having limited autonomy over rest time due to communal monastic life. Especially prominent is the stigma from traditional beliefs that menstrual blood is “unclean”, leading them to avoid discussing menstrual discomfort publicly and to delay seeking professional treatment. Nevertheless, benefiting from the relatively objective understanding of menstruation in Buddhist thought, these women have, through long-term coexistence with pain in daily life, gradually explored effective relief methods. Ultimately, they have developed a set of menstrual care practices based on community experience adapted to resource-limited settings. This popular-level physiological health knowledge positively contributes to protecting local women’s health, yet its acquisition and practice are culturally constructed through patients’ experiences, social systems, and cultural beliefs.

Conclusions

As Lock proposed in the concept of “local biologies”, even though physiological processes may appear universal, people’s understanding of the body, symptom perception, treatment choices, and their social meanings are deeply embedded within specific cultural contexts [16]. Martin also pointed out that the metaphorical discourse in mainstream American medicine constructs a pathologized understanding of menstruation, profoundly influencing women’s perceptions of their own bodies and health [17]. The case of Tibetan Buddhist nuns in the Gannan region examined in this study vividly confirms the core proposition of “local biologies” from another cultural dimension. Through exploring their unique cognition of menstruation and menstrual practices, we can clearly observe how individual bodily experiences interact and negotiate closely with strict religious regulations and locally rooted sociocultural knowledge, jointly constructing the group’s specific and distinctive understandings and coping strategies related to menstruation. This case reveals the complex mutual constitution between bodily experience, religious discipline, and local knowledge, which together shape the “local” bodily practices and life experiences within a particular cultural context.

Although the menstrual management of Tibetan Buddhist nuns is influenced by religious disciplinary notions, they develop a set of informal, experiential bodily care strategies in daily life. These strategies integrate Tibetan medical knowledge, folk knowledge, religious experience, and individual bodily sensations. They do not rely entirely on modern medical systems but instead construct a pluralistic and flexible health maintenance mechanism within their cultural context. This indicates that within the structure of religious collective life, the female body is neither completely marginalized nor negated. Their health practices are the dual outcomes of their own cognition and cultural environment. These findings further confirm a central viewpoint of medical anthropology: disease, health, and healing are not merely biological events but products of social meaning, experienced, interpreted, and managed within specific historical contexts [18], 19]. Therefore, incorporating “cultural competence” into medical practice and reflecting humanistic care in disease interpretation, service delivery, and doctor-patient interaction are key to achieving “culturally appropriate care” [20]. This culturally conscious research approach can better attend to the intrinsic motivation and fundamental capacity of people to maintain their own health. It not only helps enhance the effectiveness and acceptability of medical services but also contributes to building a medical system with greater ethical awareness and social responsibility.

Nevertheless, this study also has several limitations. First, the sample size is relatively small and limited to a single nunnery in Gannan, which may constrain the representativeness of the findings. Second, due to the particularity of the research subjects, the menstrual perceptions and practices of Tibetan Buddhist nuns may be heavily influenced by their specific religious environment, making it difficult to fully reflect broader socio-cultural patterns. Third, the study primarily relies on qualitative interviews and participant observation, lacking quantitative analysis of physiological data, which may limit a comprehensive understanding of menstrual health issues. Finally, the restricted research period makes it difficult to capture the long-term influences and dynamic changes of cultural practices. Because of this temporal limitation, the study is unable to fully examine how the menstrual management and practices of Tibetan Buddhist nuns have historically formed, evolved, and interacted with broader social transformations.

Building on these findings, future research could proceed in several directions. First, expanding the scope to include nuns from different regions and sects of Tibetan Buddhism would allow for comparative studies of menstrual perceptions across diverse cultural contexts. Second, combining qualitative approaches with quantitative research – such as collecting and analyzing physiological data – would provide a more comprehensive assessment of menstrual health and its implications. Third, further exploration is warranted into the subjectivity and agency of Tibetan Buddhist nuns in their menstrual practices, particularly how they negotiate between religious discipline and individual needs. Finally, attention should be paid to the impact of social change on their menstrual perceptions and practices, especially in terms of interactions between medical modernization and religious tradition. Pursuing these research directions will deepen our understanding of the complex relationship between local knowledge and women’s health practices, while offering new insights for theoretical advancement and practical application in the field of medical anthropology.