The individual interviewed for this illness narrative has given express permission for this narrative to be published on our course website publicly as long as their last name is protected; all individuals referenced have been assigned pseudonyms. The individual understand that they can alter these permissions at any time.
“now that poems’ve got everything in them
even rhetoric and dailiness plus the names of things again
including flowers like the spotted touch-me-not
so inviting to hummingbirds
and I’m writing one
I’d like to mention or say blatantly
I got my period today
probably like nobody
certainly in the nineteenth century ever did
and if you really wanna know
most of us you know
all get ours on the same day no kidding
and we talk about it frequently and peripatetically
Alice with Peggy Peggy with Marion Marion with me me
with Anne
Anne with Alice Peggy with me Grace with Peggy Marion with Grace
So Friends! Hold the bloody sponge up!
For all to see!”
— Excerpt from “Ode on Periods” by Bernadette Mayer (1945)
Act. I I was a performer
I interviewed Mandy, a thirty-five-year-old woman currently living in a suburb of Chicago about her experiences with endometriosis. My initial goal was to shed some light on an inconspicuous condition, to share the diagnostic, the symptomatic and the treatment process. After reading about how “federal funding for endometriosis research doubled from $13 million to $26 million after Representative Abby Finkenauer of Iowa, 32, shared her own endometriosis journey on the House floor” in October 2020, I was compelled to amplify more voices hoping to make a difference (Gross para.6). Before interviewing Mandy, I became angry after rounds of research, about the fact that our current rudimentary level of understanding of its pathogenesis, diagnosis, and therapy is contradictory to its prevalence. I attributed its stagnant development to the limitation in medical research. However, as the conversation with Mandy proceeds, I realized that societal factors are the ones holding back potential progress. In hindsight, I should have recognized that technology can’t be the only challenge when virtually every disease is receiving breakthrough findings. I am inclined to uncover the significance of stigma and the role of culture in terms of an endometriosis patient’s illness narrative and to make sense of what any individual can do to provide support for these patients. The shifts in a society’s tone and attitude can drive medical advances and reshape the current economics and politics of health.
Not even a heartbeat passed after I popped the first ice breaker question, Mandy answered without hesitation, “This is funny. I don’t really do a lot. I realized my passion very early on, which is music. I studied musical theater. That is the only thing I’ve been passionate about”, but then she slowed down, “I tried to get into the field. I didn’t. So, and that’s fine, um, I come to terms with it. You know, still a little upset, it hurt. You know, I’ll sing, I still practice, I play the piano.”
Mandy went to the Chicago Academy for the Arts (CAFTA) as I later come to find out. She only told me that she went to a prestigious high school and it was her “very well known, kept secret.” According to Mandy, “at that point in my life, I was just going, going and going. I started my day at 6am, didn’t get home until 6pm. I had a 4-hour commute both ways. Two hours one way.” In response to my gasp at this notion, Mandy, giddily but proudly, confirmed that “this place was kind of a big deal” and admitted that she always “brag” about her high school.
Later on, Mandy would reflect back on how she found her passion, “I started learning piano when I was little and I was really good. And then I started singing a couple years later. That was the end all be all.”
And then she would reflect on it a bit more: “I was so jealous of people who didn’t have a passion, because where my passion lied, was so hard to get into, and I was like I wish I loved something else, or that I didn’t know what I loved and could explore on my own. Instead, I knew exactly what I wanted to do and I knew how hard it was. Every ten to twenty failures, you might get one yes.” I began to wonder whether her dedication to her musical theatre career path has influenced her approach to the ongoing battle with endometriosis, or vice versa, or both. I couldn’t arrive at a conclusion but I was certain about Mandy’s quality of perseverance in the face of adversity.
Act. II I am a woman with endometriosis
According to the U.S. News, endometriosis is one of the top fifteen most agonizing medical conditions (Esposito, para.8). Acknowledging the criticisms that link this publication with inaccurate rankings, I think we can agree that there is a kernel of truth to this one. Endometriosis is comprised of three symptoms: dysmenorrhea, dyspareunia, and chronic pelvic pain (Vincent et al. 63). Mandy described her pain level as “debilitating”.
Mandy remarked that she is creative with words, therefore I challenged her to really describe the pain. After much contemplation, she carefully began to paint the picture for me, and once she started, she couldn’t stop: “It feels like a tire around the whole stomach and back that’s inside you, simultaneously pressing in and out like it’s deflating and inflating, at the same time you have golf balls swimming around your uterus like ‘woshhhhh’. That’s exactly what it feels like, for me.” Mandy had a talent with speaking, I can only assume that it came from her theater background. Even though I could only hear her voice, all the details came vividly together.
When inquired upon her diagnostic journey, Mandy chuckled: “Well, it was pretty easy.” (After hearing her full story, I realize that the ease was referring to how she knew something was wrong and not to knowing exactly what is wrong.) She got her period for the first time when she was a freshman in high school, which can be considered as late. It is common for periods to take a while to regulate, however, hers never regulated. It could appear after a month; it could appear after four months. After getting extremely heavy and irregular periods for two years, her mom finally took her to see the family gynecologist. “The reason being was that I started to get my period just about every other week or two weeks. And it was heavy and it would last a week or longer. And I couldn’t stay awake at school. First off, never been great at staying awake at school anyway, but this more like they notice something was wrong with me.” This high school experience doesn’t sound like it came from the same person who repeatedly made laborious treks to go to a competitive, private performing arts high school out of her district.
Mandy didn’t get an examination upon her first visit, she was put on the oral birth control after her gynecologist concluded that “sometimes this happens”. Mandy only briefly mentioned this detail and she brushed it off quickly, however, the physician’s behavior contributes to a larger phenomenon. “Medical gaslighting” is endured disproportionately by women and people of color, where these patients’ “symptoms [are] inappropriately dismissed as minor or primarily psychological by doctors” (Moyer, para.4). For a variety of diseases that affect both biological genders, women are misdiagnosed at are much higher rate than men. The difference in diagnostic errors is partly due to physicians’ internal biases and the fact that the women’s body is less studied and understood than men’s. Before the NIH Revitalization Act of 1993 was passed, women and minorities were included much less frequently and comprehensively in medical research (NIH Policy and Guidelines 3). The reality has grown to be such an issue that Dr. Alyson McGregor, co-founder and director for the Sex and Gender in Emergency Medicine division at Brown University, suggested that “it really helps if you have an advocate there that can intervene and say things like, ‘She is not normally in this much pain’” to women and minority patients, or even to “see another doctor if you feel dismissed” (Moyer, para.4).
The birth control definitely helped Mandy, however, it was still “ridiculously” heavy and painful. Mandy doesn’t remember how long she waited before an internal exam was ordered, but she does remember sitting in the office with her mom waiting for a diagnosis. The gynecologist delivered the news. Even though Mandy waited two years before seeing a doctor and another few years before getting an examination, she is still considered one of the luckier ones. There is usually a longer than eight years diagnostic delay for endometriosis patients (Bontempo 98). Diagnostic disparity often results from lack of awareness and the likelihood of endometriosis being confused with other disease that share overlapping symptoms. For these patients, difficulty of receiving a proper diagnosis has led to difficulty receiving proper treatments. Treatment disparity can also be compounded by the lack of available and effective treatment options.
Mandy had forgotten her condition called when she got home, but she just knew she had it. She remembers frantically looking it up and seeing the right information. “Anyways, years later, when I went back, [the gynecologist] was like ‘well, we do see some of the endometriosis’. And I was like ‘Right! Okay! Good! Found it!’ Ever since then I never forgot what it was called.” Mandy confirmed that it was comforting to be able to name her condition. Uncertainties can increase suffering for patients through psychological means aside from the existing physical effects. The ability to label one’s condition can improve response and performance significantly.
Endometriosis causes severe pain in the lower abdomen, because tissues (endometrium) that are supposed to line the inside of the uterus end up growing outside the uterus or on other pelvic organs such as the ovaries and fallopian tubes. The clinical presentation varies drastically. Mandy told me that “you can have a lot of it lining around the outside and have almost no pain”, but in her case she doesn’t that much on the outside, but “it’s debilitating”, she repeated. What Mandy told me aligned with my research result. The pain level is not an indicator for the intensity of the condition, which means that mild endometriosis can lead to severe pain but advanced endometriosis can result in no pain but potential organ damage. (Deeply Infiltrative Endometriosis para.1)
“I get nauseous. I can’t stand, like it hurts to stand. I’ve actually lost a few jobs because I just couldn’t … do it. I’ve thrown up from it. I lost a couple of jobs because of this, because I was so sick. You try and explain, but they are thinking: ‘it’s just a regular period’. You don’t want to go into the gross medical details but you are like ‘it isn’t.’” Mandy pointed out that the situation get worse and more awkward when it comes to male managers. She had to leave the shift early one day because of the pain. After hearing her reasoning, her male boss announced: “So you have a stomach ache?” Shivering in pain, Mandy could only say: “Ehh … not quite, I will have my doctor send you a note.” It is common for patients to experience “medical gaslighting” outside of the hospital as well. Misunderstanding led the manager to downplay Mandy’s symptoms and dismiss her. The misunderstanding exists in the first place because the society lacks the curriculum that teaches boys about periods and the space for all to learn safely and unbiasedly. Instead, the society “monsterize” and mystify it. The existing environment not only aggravate the gender health gap, the toxicity is also propagating to the next generation. Therefore, a welcoming and inviting landscape where men can educate themselves on inequalities that don’t affect them but are created by them could never be built. The cycle repeats itself and rolls the quality of life backwards.
There are a lot of reasons why endometriosis is neglected in the medical realm as well as in daily life, despite the fact that it affects approximately one in ten menstruating people of reproductive age (Endometriosis para.1). I asked Mandy to think from a patient’s perspective, why don’t people talk about endometriosis as often. “I know there’s other ladies out there with situations similar to mine, but we don’t sit around and share you know… lady blood stories. It’s normal in the world to talk about cancer, people feel bad for you. If you say you have endometriosis, people are not like ‘oh my gosh, I’m so sorry!’” Mandy’s dramatic acting created a humorous effect, yet it was not enough to disguise the disappointing contrast between the impalpable amount of pain that endometriosis patients go through and the insubstantial amount of understanding and willingness to understand for this chronic illness. Lack of awareness from the general public makes getting sick leaves onerous; lack of attention from the medical sphere makes effective treatments and a cure impossible to be realized. The lack of funding for this illness have impeded progress in treatment development. Dr. Griffith, a biomedical engineering professor who pivoted her research focus to studying her own condition in the latter part of her career, referred to her niece at a medical conference, declaring: “There’s no better treatment for her, 30 years younger than me, than there was for me when I was 16”(Gross para.10).
“Especially when it hurts so much, when you get through it, you don’t want to think about it or talk about it anymore, you are just like ‘let me move on’. I don’t know if taboo is the right word, like I said earlier, it’s just gross. I mean I’m used to it, so it’s not gross to me. If you are just a regular girl with a regular period, people don’t really want to hear about that. And that’s normal. And when you have something this off, it’s way too much.”
“And it is, it’s GROSS, let’s be honest, it’s GROSS.” Mandy kept repeating it.
What is wrong with our popular culture that it prompts women to feel embarrassed about their own natural bodily processes that allow child rearing and essentially the continuation of human kind? Quite a few aspects of endometriosis are prone to be stigmatized. Causes (menstruation and the uterus) and symptoms (infertility) of this disease are still considered taboo topics in some parts of the society. With it being a disease that only affects menstruating people (females and transgender folks), it is often overlooked. Traditionally, only men are allowed to become physicians, which means that females’ medical conditions are less understood than general or male-specific ones. Endometriosis wasn’t “discovered” until 1940. It is often deemed unimportant by those unaffected as it is not lethal. There are other instances where Mandy demonstrates that she herself has embodied the internalized stigma, unknowingly: “I remember I was dealing with it and I was actually shopping for my wedding dress. And I haven’t even gotten it yet but the pain is so bad that I couldn’t… I was so bloated it was embarrassing trying on a wedding dress, like they couldn’t even zip me up like they got to get the clamp to hold the dress.” Although Mandy is ashamed, she is not the one to blame, we all know who the culprit is.
Mandy expressed that the biggest change she wants is the treatment, because the existing methods don’t address the root cause. “As far as I know, there is no cure for it. I know some women have said that it helps if they get their uterus removed. My gynecologist said honestly it is not for sure, going through that process it’s so painful and it has such a long recovery time. She is like there’s no guarantee that it will work.” I was shocked to find out that the surgery to remove the uterus (hysterectomy) and ovaries (oophorectomy) were once the most recommended treatment for endometriosis (Hysterectomy for Endometriosis para.14). It is extensive and permanent but still not the ultimate cure because the pain has been reported to come back.
“Birth control, what it was intended for — to control having birth. It is solving our symptoms but we are not using it to not have babies. We are using it to control the actual medical problem. There is a stigma around that. When I was young, I was having a hard time getting birth control without them being like you know…being 16-year-old and my mom was taking me paying full price. And I was like no, this is not…for sex, this is for an actual medical reason. And that was a hard thing at first. And I think it has come a long way since then, but still, there is this whole thing. I remember being really broke after moved in to the first apartment with my ex-husband and I went to the clinic, and they were like babies babies babies, and I’m like ‘No, this is not for babies! I’m like I’m in pain and I need this to stop!’” Mandy was great at storytelling, with spices such as the ups and downs in her tone, the anticlimactic start and the dramatic stop coupled with humor, mimicking different characters comes natural for her. No ounce of frustration was lost during the telephone transmission.
Mandy is right, the term “birth control” is a misnomer when it comes to many other applications. Nowadays, because of its ability to control hormones, birth control is commonly used to regulate periods, manage cramps and even cure acne. However, most girls on birth control are still discrete about their regimen or even hiding them. The many interest groups lobbying to limit access to birth control blaming it for the “increased promiscuity” are certainly not helping the girls to be more comfortable with their body and accepting of their medical conditions. Mandy has been put on three different types of birth control to regulate her period and pain. She doesn’t use it for contraceptive reasons, like many others. “Originally, I was on the pill, just your regular birth control pill. And then this new thing came out, it was called the ‘patch’.” “My friend has it on her arm I think”, I responded. “Right, I used to stick it on my thigh, because I didn’t want people to think I had a nicotine patch at like 17 years old. But then if I went swimming or something and it would fall off and I’m like crap. I was on that for a long time.” Some treatment options become less ideal and harder to administer because of seemingly unrelated societal perception and misperception. It is normal for teenagers to fear for judgement, we need to correct where the judgement come from. “Right now, I actually use the NuvaRing, you can insert it yourself, it looks like a rubber band. I can leave one in for four weeks and I just put another one in.” Although Mandy is satisfied with her current pain management option, mostly because it takes the memorization requirement out of the administration equation, NuvaRing has risks include heart attack, stroke, blood clots, and liver tumors (Birth Control Vaginal Ring para.2). Many other women are risking their life just to manage the pain.
As difficult as it is to have endometriosis, patients with public health insurance or no insurance may struggle with an even harder time than patients with private insurance. In Mandy’s case, she bounced between the most basic and high-end reproductive health care. Her experiences highlight the disparities within the affected population. The family planning place she sought after when she lost her insurance and other means to pay out of pocket for her normal gynecologist only had the pill. When she got back on her feet, she went back to her familiar practitioner (a gynecologist from Northwestern whom she has had for twenty years) and was introduced to the Nuva ring. However, she had to seek other clinics in between her care there because the practice stopped accepting Medicaid. She couldn’t afford the 800 dollars NuvaRing prescription anymore. She had to be on the phone for 5 hours with the Medicaid help desk. Eventually, she found another doctor who accept her insurance plan, where she could get the prescription for nothing, which is what it used to be for her. However, Mandy still misses her old gynecologist, she misses the comfort, she misses the professionalism, and also because “she is the best and she is so good at telling you something is wrong without scaring you.” Although Mandy was limited in her resources at times, she is a native speaker in the most recognized language in this country and she was educated enough to utilized the internet. The scenario may play out differently and not result in a “happy” ending for another person who doesn’t share her privilege. The logistical and financial hurdles that marginalized patients have to jump through are that much higher. As other less understood diseases, there is currently a knowledge gap on how this condition affect populations of different race and ethnicity. Usage of hospital, laboratory, pathology and radiology is reported three times lower in the public sector as opposed to the private sector. Laparoscopy is the only reliable diagnostic method as of now. However, it is inaccessible to patients in lower socioeconomic groups, “women in the public sector were 3.5 times less likely to have a laparoscopy” (Fourquet 623). Specialized medical services such as obstetrics and gynecology were used more than two times more frequently for patients in the private sector than those in the public sector. Public health advocacy and measures are in demands to promote equal access regardless of socioeconomic status for a condition that is already impacted by gender inequality.
Act. III I was a performer with endometriosis
Endometriosis is not only challenging for the daily aspects of womanhood, it presents even more obstacles in the work place, especially if the patient’s profession is high-demanding and under the spot light. I was interested in how has endometriosis impacted Mandy’s performance career.
“Here is something really crazy, when you have your period, it actually changes the tone of your voice. You can’t tell if you are just talking, but if you are a singer, it makes your voice go ‘flat’.” Mandy learned the fact from her high school vocal teacher who had been on Broadway. She recalled instances where the teacher would frustratingly claim: “you girls are all flat! Are you all having your periods right now? Oh my god. You are all on your period.” She was correct most of the times.
Mandy told me another story of her performing days, when she was Fantine in Les Misérables, a character who never gave up and continued to provide for her daughter amid enormous difficulties. The production comprised of scouted 13-18-year-old professionals. On opening night, Mandy was taking the train to Loyola campus with a couple friends who were also in the show. The pain came suddenly. “I was like crap, my stomach kind of hurt. I didn’t really notice it until I realized I got my period, and then the pain was like ‘WOOSH’, you know. I was wearing khaki shorts and I had bled through my shorts.” Mandy borrowed a sweatshirt from a friend and got through the train ride until her mom brought a different change of clothes. As she was getting ready in the dressing room, a girl walked in and said: “Mandy, do you need a tampon?” Mandy was surprised as to how she knew. “Well, the intercom is turned off here but it wasn’t turned off in the boy’s room or around the rest of the theater. Nick (the friend who lent Mandy a sweat shirt earlier) went on stage and yelled ‘Mike (director), do you have a tampon for Mandy, she got her period!?’” Mandy described the looks she received from other teenage boys as she came out of the dressing room, some giddy, some not-so-subtly pretending that they didn’t hear anything.
The narration was interrupted by a lot of giggling from Mandy and I. One time after she giggled, she excused herself and remarked that “this was just the funniest story”. She eventually performed:
“I had to adjust my singing and try not to sound flat for the rest of the weekend. It was opening night, so I really had to do something to… [salvage this]. It’s a singer’s trick that you do so you don’t go too sharp, because that’s also bad if you try to overcompensate. It was really difficult dealing with that. I managed to do it. I brought a heating pad with me. Everybody knew at that point, I wasn’t gonna hide it. And it was great, it was really great.”
Act. IV The final act
Many was reflective in many instances during of interview and philosophical at times perhaps without realizing: “When I was younger, it hurt really bad. But when I got older, it got worse. I think you know, things don’t hurt as much when you are young.”
Mandy also told me about her worst “episode”. It was bad enough that upon witnessing her suffering, her ex-husband wanted to bring her to the emergency room. Mandy rejected him because she simply thought “[the doctor] are not gonna do anything. What are they gonna do, give me Midol? Ibuprofen? I’m not paying ER prices for the doctors to tell me what I know they are going to say.” She ended up passing two different masses the size of a palm. One was just all clotted blood, very dark, almost purply. As for the second one, there was blood strands in it, but it was purely white. Mandy paused and let out a long sign before she continued. “It was a miscarriage.”
The other side of the phone became silent, leaving room for both of us to grasp.
I asked Mandy if she misses endometriosis since she doesn’t get her period anymore. The question was framed on the basis of comparing the condition to a toxic boyfriend. The idea that you know when something only brings negative aspects to your life, but you miss it when it is gone simply out of a force of habit and the constant companionship. Without a pause, Mandy exclaim: “No, I don’t miss it at all. When you go through the pain I had gone through, you DO NOT miss it.” After hearing about her miscarriage, I asked her if she wishes she never had endometriosis. There were some fragmented silences again, Mandy kept trying to start a sentence but fell back to silence again, finally, she said:
“One thing I will really say it’s that I never really had a regret in my life, I just kind of came into that. If bad things happen, it does make you stronger. For me, faith has always been a big thing for me. People who get sick, question god and I never question god, I’m like, there is a reason, there is a reason. I think having this condition has made me stronger, because I had to learn how to deal with it and still deal with the world. I don’t question it. Would have been easier not to have it, sure, but then I always like to look at the silver lining. What if I don’t want kids and I didn’t have this condition? At least I got birth control for medical reasons and now I got this safety net. Stuff like that, I always see the silver lining. So I won’t take it back. Every experience you have in life, whether good or bad, contributes to your identity, your personality, to who you are. And I like me, so.”
Mandy struggled to keep a steady job, partly due to endometriosis, partly due to her persuasion of the competitive field of theatre. However, she is now a manager at Walgreens and has been for a while. Currently, she is discovering a new passion. Although she will never be “as passionate about it as [she] was about performing”, she really gets “a kick out of leadership.” She is dating again after ending an eleven years relationship. One of her partner selecting criteria is that they have to understand the extent of her condition and be accommodating of it. Mandy was eager and excited to be interviewed, she wanted share her story.
Mandy, and patients like Mandy continue to showcase positivity and tenacity when facing endless societal and medical barriers due to their condition. It’s time for the rest of us get our act together and demonstrate the compassion and empathy they deserve, our collective effort is capable of rewriting the narrative and bring about real change, so our mothers, sisters, and daughters won’t have to suffer in silence anymore.
Works Cited:
Bontempo, Allyson C, and Lisa Mikesell. “Patient perceptions of misdiagnosis of endometriosis: results from an online national survey.” Diagnosis (Berlin, Germany) vol. 7,2 (2020): 97-106. doi:10.1515/dx-2019-0020
Deeply Infiltrative Endometriosis – Brigham and Women’s Hospital. https://www.brighamandwomens.org/obgyn/infertility-reproductive-surgery/endometriosis/deeply-infiltrative-endometriosis#:~:text=Endometriosis%20can%20invade%20organs%20that,within%20the%20tissue%20or%20organ. Accessed 26 Apr. 2022.
Endometriosis. World Health Organization (WHO), 31 Mar. 2021, https://www.who.int/news-room/fact-sheets/detail/endometriosis.
Esposito, Lisa. “On a Scale From 1 to 10: Most Painful Medical Conditions.” U.S. News, 6 Jan. 2022, https://health.usnews.com/health-care/patient-advice/slideshows/on-a-scale-from-1-to-10-most-painful-medical-conditions.
Fourquet, Jessica, et al. “Disparities in Healthcare Services in Women with Endometriosis with Public vs Private Health Insurance.” American Journal of Obstetrics and Gynecology, vol. 221, no. 6, Dec. 2019, p. 623.e1-623.e11. ScienceDirect, https://doi.org/10.1016/j.ajog.2019.06.020.
Gross, Rachel E. “They Call It a ‘Women’s Disease.’ She Wants to Redefine It.” The New York Times, 27 Apr. 2021. NYTimes.com, https://www.nytimes.com/2021/04/27/health/endometriosis-griffith-uterus.html.
“Hysterectomy for Endometriosis: The Pros and Cons.” Healthline, 21 Apr. 2021, https://www.healthline.com/health/endometriosis/hysterectomy-for-endometriosis.
Moyer, Melinda Wenner. “Women Are Calling Out ‘Medical Gaslighting.’” The New York Times, 28 Mar. 2022. NYTimes.com, https://www.nytimes.com/2022/03/28/well/live/gaslighting-doctors-patients-health.html.
NIH Policy and Guidelines on The Inclusion of Women and Minorities as Subjects in Clinical Research | Grants.Nih.Gov. https://grants.nih.gov/policy/inclusion/women-and-minorities/guidelines.htm#:~:text=The%20NIH%20Revitalization%20Act%20of,and%20minorities%20in%20clinical%20research.&text=The%20statute%20includes%20a%20specific,and%2C%20in%20particular%20clinical%20trials. Accessed 26 Apr. 2022.
NuvaRing | Birth Control Vaginal Ring | Estrogen Ring. https://www.plannedparenthood.org/learn/birth-control/birth-control-vaginal-ring-nuvaring. Accessed 26 Apr. 2022.
Smith [Pseudonym], Amanda. Telephone interview with the author, 9. April. 2021.
Vincent, Katy, et al. “Pain Scoring in Endometriosis: Entry Criteria and Outcome Measures for Clinical Trials. Report from the Art and Science of Endometriosis Meeting.” Fertility and Sterility, vol. 93, no. 1, Jan. 2010, pp. 62–67. PubMed Central, doi:10.1016/j.fertnstert.2008.09.056.
Featured Image Source:
Pexels, for free and fair reuse