‘Break the silence’ surrounding menstruation stigma to lessen inequities

Key takeaways:

• Even in the U.S., stigma surrounds menstruation discussions, and affordability and access to period products can be limited.
• New laws may substantially impede menstrual equity progress.

Menstrual inequity is experienced worldwide, even in the U.S., where stigmas surrounding menstruation continue affecting all forms of menstrual inequities such as period poverty, access issues and legal issues, according to experts.

Megha Desai, president of the Desai Foundation, said that in India, 23 million girls drop out of school due to a lack of menstrual hygiene facilities, one in 10 girls younger than 21 years cannot afford sanitary products and 70% of all reproductive issues are caused by poor menstrual hygiene.

The U.S. is no different, as two in five women and girls experience period poverty at some point in their life, and 40% of women report that pain associated with mensturation impacts their ability to work, Desai said. In addition, there are no expansive data spanning all aspects of menstrual inequities in the U.S., and more research is needed, according to Marni Sommer, DrPH, MSN, RN, professor of sociomedical sciences at Columbia University Irving Medical Center.

“Period inequity and menstrual inequity is pervasive throughout the entire world,” Desai told Healio. “There are very few parts of the world that are not impacted by menstrual inequity, because there are several forms of menstrual inequity. There’s period poverty, where you can’t afford the products that you need. There are access issues, where you don’t have the tools that you need to properly manage your period. There are legal issues, where rights are being taken away or being policed, especially here in the U.S. There are also stigmas that are told around menstruation that hold women back. Finally, there’s the issue of how menstrual inequity affects you to cultivate dignity and live your life.”

Megha Desai

Barriers to menstrual equity

The U.S. currently has 22 states that continue to tax period products. Some states have also developed laws that significantly impact progress to menstrual equity, such as Florida House Bill 1069, which opponents have called the “Don’t Say Period” law. This law recently went into effect in Florida on July 1, and prevents children, parents, teachers and nurses from talking about menstruation in school and will also bar instruction on human sexuality and STDs.

According to Desai, this law is “horrifying.” The average age of menarche in the U.S. is 12 years, so many girls experiencing their first period at age 9, 10 or 11 years will be unable to discuss this major change in school.

Marni Sommer

“It just doesn’t make sense to be policing health conversations in schools,” Desai said. “Menstrual equity is being used as a political football right now for other agendas and in people’s anti-trans agenda or their anti-sexual education agenda or their ‘parental rights’ agenda. It’s not fair for so many reasons.”

Silencing instead of educating people about menstruation will only cause further stigma to women, said Diana J. Mason, PhD, RN, FAAN, senior policy service professor at the Center for Health Policy and Media Engagement at George Washington University School of Nursing and professor emerita and co-director of the Center of Health, Media and Policy at Hunter College at the City University of New York.

Diana J. Mason

“You’re going to have young girls who are frightened by what is a normal experience for women and for some trans people,” Mason told Healio. “The fallout will be that young women will be shamed today, will continue to be shamed, and it will continue the stigma.”

In addition to laws that “take us back eons,” Mason said, there is also the prominent problem of stigma surrounding period and menstruation.

“Until we can talk about this and say that it’s not OK for women and girls to be unable to live their full lives when they’re having their period because they can’t afford the menstrual products, we’re not going to get rid of that shame and stigma and we’re not going to have the policies that we need to have in place to get rid of the period of poverty,” Mason said.

‘Break the silence’

Historically, menstruation has been a taboo topic that was relegated to more private situations and scenarios and shamed when spoken about publicly, according to Sommer. The U.S. is slowly progressing to speaking about menstruation in a public forum and with confidence, she said.

At a young age, women and girls are taught through parents, schools, peers, movies and magazines to hide their menstrual experience and told they cannot discuss it, Sommer said. This can cause menstruation to become an aspect of shame and embarrassment, which continues to enforce the stigmas surrounding menstruation. Stigma surrounding menstruation may lead to delay in seeking support or to avoidance of certain activities, according to Sommer.

“When you break the silence, and you start to talk about it, and you bring it into the public space and the media starts to cover it, you then enable pressure and exploration of inequities and what needs to happen to address it,” Sommer said.

People have been growing more comfortable over the past 20 years discussing menstruation outside the home, but there still is a long way to go to fully break the stigmas surrounding periods, Sommer said. Just like any other type of physical health, menstrual health is a fundamental part of understanding one’s body, according to Sommer.

“Menstrual health is as important as any other component of your physical and mental health, and it should be integrated just the way you learn about other things. This should be something you learn about,” Sommer said. “You really want a young person to know about periods before their first period, so they are not afraid or embarrassed when it happens.”

In addition, Sommer said, given that the onset of menstruation occurs in late elementary or early middle school for many young people, all children should learn about menstruation in elementary school and middle school to aid in early support and avoid possible teasing or early shaming and stigmatization. As children mature, they can be educated more about how the menstrual cycle works and influences health and well-being.

“This is not some niche topic. It affects every single person, so we should be brave enough to have these conversations [about menstrual health] early,” Charis Chambers, MD, FACOG, an OB/GYN and founder of The Period Doctor, said during the 2023 Pledge Your Period panel, hosted by the Desai Foundation. “For parents, this means getting the education you need in order to guide your child through their menstrual journey, which is not so different from what a parent is supposed to do — guide your child through life so that they can be a functional adult. It’s not just about little girls. All too often nonbinary and trans people who are very much capable of menstruating are excluded from the topic. This is why we need to include everyone in this conversation. That’s how we truly affect change.”

Improving menstrual equity

Other countries have made progress in menstrual equity, such as the U.K., according to Desai, where they are making headway in lessening inequities surrounding women’s health in general. The U.S. has made slight improvements in menstrual equity by lowering the number of states taxing period products and beginning to start a conversation around menstruation without shame, noted Desai.

Another movement to improve menstrual equity in the U.S. is the reintroduction of the Menstrual Equity for All Act by U.S. Rep. Grace Meng, D-N.Y., in May. This bill would require public school systems and public places to provide period products for free. According to Sommer, this bill is reintroduced yearly and, though it has not yet passed, components of what is included within have been utilized. For example, during the COVID-19 pandemic, menstrual products were included as relief to households as medical and health expenses, and credit has been given to Meng’s language in the bill, Sommer said.

However, despite these achievements, the U.S. has a long way to go in menstrual equity, according to Sommer.

“We don’t even understand enough about this issue yet and the way it impacts people across the country. That is an area that needs great attention and resource support, so we know what we need to do and we can see when there’s progress,” Sommer said. “We have a long way to go in terms of making sure there’s some kind of universal access to products. I would like to walk into any public bathroom — workplace bathroom, school bathroom, transit station bathroom — and see menstrual products available the same way we see toilet paper available.”

Mason said it is imperative that all health care practices provide free menstrual products in their offices. Primary care providers should also be asking patients on Medicaid or who are uninsured about whether they are able to get the menstrual products they require and be able to refer them to resources to receive products or get support if they are struggling.

According to Mason, another important step in improving menstrual equity in the U.S. is to vote out politicians who put policies harming women and girls in place.

“It’s going to take women standing up and saying this is not OK,” Mason said. “An important piece is whether women and men raise awareness of the issue. If we can raise awareness, I’m confident that we can fix this and make it so that menstrual supplies, like toilet paper in bathrooms, are there for people to use.”

Menstrual health literacy and education are a fundamental part of child and adolescent development and lifelong health and well-being, Sommer said. No single set of actors is solely responsible for educating children about menstruation; young people require multiple accurate sources of information to inform them of their own bodies, she said.

Desai encourages everyone to inform themselves about laws in their states surrounding menstrual equity and to call local legislators and local Congress members to voice support for menstrual equity. It is also important to speak to every gender about menstruation, Desai said, as change can happen only if both men and women are educated. Finally, Desai highlighted the importance of breaking stigmas surrounding periods in regular day-to-day situations, but also in TV and film, to cultivate dignity.

“Issues around menstrual health go from care and compassion to control when you say that – on one hand – you can’t educate women about menstrual health, reproductive health and mental health, and then – on the other hand – ban folks from getting birth control and abortions,” Desai said. “All of these laws are about control, not about life, and certainly not about health.”

For more information:

Megha Desai, can be reached at megha@thedesaifoundation.org.

Diana J. Mason, PhD, RN, FAAN, can be reached at djmasonrn@gwu.edu.

Marni Sommer, DrPH, MSN, RN, can be reached at ms2778@cumc.columbia.edu.