The Stigma of a Stain: The Gap in Menstrual Education

INTRODUCTION

From the cough to cover the crinkle of a wrapper in a bathroom stall to euphemisms such as Shark Week and Aunt Flo, period stigma has long been ingrained in our society. It’s the sneaking tampons underneath a desk and the blush covering one’s cheeks whenever periods are mentioned. But, it’s also the cause of systemic imbalances in which women aren’t allowed to speak up, for fear of being called “emotional”. It’s the lack of access to period products in lower-income communities because menstruation isn’t discussed among legislators. It’s the millions of women whose healthcare concerns are completely overlooked and who consequently suffer from undiagnosed conditions. And, overcoming this stigma starts with education. The way one first learns what a period is forever shapes their view of how menstruation fits into society. From young girls whose mothers instilled in them a culture of shame to young boys who only learned about periods through whispers and rumors, a lack of understanding is what much of this stigma stems from.

Stigma is a systemic issue, yet its methods of perpetuation have varied over the years. Currently, other than word of mouth, the media plays one of the biggest roles. For many of us, the media is our first glimpse into how vast our world is. And, it is often vital when it comes to our first perception of unknown topics. Menstruation is no different. For years, menstruating women have been portrayed as everything from moody and weak, to frenzied and violent. In fact, the word “hormonal”, which was simply a scientific term, is now used to describe anyone displaying seemingly excessive emotions, especially in relation to women (Chrisler, 2013). This has led to assumptions about women’s professional, academic, social, and emotional capabilities while on their periods and an attribution to hormones whenever a woman dares to raise her voice. Even “informative” media maintains a stigmatized view of menstruation. Products like pads and tampons have long been called terms like “feminine hygiene products” or “sanitary napkins”, suggesting that there is something inherently unclean about periods (Chrisler, 2011). Advertisements for oral contraceptives go one step further, often promoting the fact that one of their common side effects is the suppression of one’s menstrual cycle. Yet, while they are almost suggesting it’s better for one not to menstruate, studies on the biomedical effects of menstrual suppression highlight how understudied the long-term effects of this are (Chrisler, 2013). The stopping of one’s cycle is paired with the suppression of hormones, which affects all parts of a woman’s body. And, therefore the scope of issues that could arise are much larger. Problems have already emerged, like the connection between oral contraceptives and blood clots, but this research took many years to be published, which is a historical pattern in relation to research surrounding female hormones (Centre for Menstrual Cycle and Ovulation Research, 2007).

The purpose of the review is to analyze the connection between menstrual stigma and education, determining the extent to which education creates stigma, and if it can serve as a solution. While the myriad of impacts that menstruation has on people with uteruses expands to more than just those who identify as female, this review will often only speak about period stigma in the gender binary. This is because menstrual stigma disproportionately impacts those who are feminine-presenting. Thus, it’s important to note that though many of the articles cited and arguments made only refer to periods within the gender binary, there are additional impacts on menstruators who may not be feminine-presenting.

BODY

Effects of Stigma

Perception

When it comes to menstruation, often none are more ignorant than those who will never experience it themselves. Yet, the blame doesn’t fall completely on men, because in a society where periods are so stigmatized, there are a multitude of incorrect assumptions that non-menstruators carry. As highlighted earlier, the media’s perception of menstruation is greatly skewed. Yet, this is often the only source of information for men, therefore it perpetuates many misconceptions and incorrect beliefs about periods. A 2011 study on X (formerly known as Twitter) analyzed the language that men used on issues surrounding periods. Men displayed a theme of treating themselves as the victims. They described being harassed by seemingly overly emotional women, being embarrassed to be seen with menstruating women, or being forced to find out a woman was on her period. The blame was completely on women, with multiple demands for women to change their behavior. Many of these statements were littered with biases, highlighting the skewed reality that these men experienced in the context of periods (Thornton, 2011).

Physical

Stigma is a social issue. Thus, many people aren’t aware of the many physical effects that menstrual stigma can have on those with periods. Studies have demonstrated that women who believed periods were largely negative were more likely to face premenstrual or menstrual distress (Hoerster et al., 2003). Further, multiple studies have demonstrated that women who believed periods to be a largely negative thing, were more likely to have negative experiences with their periods. And, if they believed certain physical and physiological effects of menstruation to be true, they were more likely to actually experience those effects (Hoerster et al., 2003). This was further seen in young girls and their experiences with their first menstrual cycle. If their preconceived notions of periods were more negative or if they felt underprepared, they were more likely to report having premenstrual and menstrual distress. This often led to them to feel self-conscious of their bodies (Hoerster et al., 2003). While body insecurities can be tied to a multitude of struggles with mental health, in relation to menstruation specifically, it also can manifest as physical harm. Studies have shown a direct connection between women’s opinions on their body and their frequency of receiving reproductive preventative care. When menstrual stigma and insecurities carry this culture of shame surrounding women’s bodies, many women find it difficult to communicate, even with medical professionals, about their bodies. This can preclude women from receiving reproductive preventive care, including everything from discussing contraceptive options to annual mammograms. But, this care is essential to their well-being, as it can greatly improve women’s health outcomes. (Holland et al., 2020).

In addition to stigma preventing women from seeking medical help, stigma can also prevent medical professionals from providing help. In terms of women’s health concerns, the medical community has a long history of being dismissive towards women’s reports of pain. Women with many serious conditions have been ignored, their pain and symptoms simply attributed to their periods. Endometritis is often cited as one of these conditions. Women have described family members dismissing their concerns as just part of their periods. Even worse, many describe their interactions with medical professionals who responded to their symptoms with condescending diagnoses, without doing any further tests. Endometritis is a serious condition that affects 1 in 10 women of reproductive age (Sims et al., 2021). However, since many of its symptoms coincide with those commonly associated with periods, such as pain in the pelvic region, many of these women were dismissed and left to suffer instead of receiving the medical attention they required (Sims et al., 2021). Given that this is coming from doctors who have medical training, this highlights that if stigma can even reach professionals trained to know the reproductive system, it can affect anyone.

Social

The topic of menstruation is so stigmatized that euphemisms are used to describe it more than the actual word. Hiding tampons in your sleeves and waiting for the flush of a toilet to open your pad is normalized behavior, but this has long-standing impacts on billions of menstruators. As mentioned previously, studies have demonstrated a connection between menstrual stigma and self-consciousness. When young women were asked about their emotions surrounding their first period, shame was the most commonly reported emotion, even from those who were reportedly excited because they saw it as a sign of maturation (Chrisler, 2011). This shame has far-reaching effects; historically, groups that have been stigmatized have seen impacts on their self-esteem, social behavior, as well as academic and work performance. Multiple studies have highlighted that shame has caused many women to believe that they would underperform in these arenas when on their period, even if this is not objectively true. And, due to this flawed belief, they would, in fact, unconsciously perform worse (Chrisler, 2011). A 2000 study affirmed this idea with a small social experiment consisting of 28 menstruating and 30 non-menstruating women. They were all interviewed by a male interviewer who either was or was not aware of the fact that they were on their periods. Women who thought that the interviewer was aware they were menstruating were more likely to assume he didn’t like them, but did little to remedy this because of an assumption that the interview was automatically going to be a failure. On the other hand, women who weren’t menstruating thought the interviewer viewed them in a better light and performed better during the interview (Kowalski & Chapple, 2000).

This stigma affects all aspects of our society. Research has shown that the stigma of a product or topic is usually transferred to the person discussing the topic or using the product. A study on the stigma of aging highlighted this when it asked college students to rate how uncomfortable they would be buying items on a shopping list. Adult diapers and other products related to aging were rated the highest. Even though it was obvious that the products weren’t for the students, the shame of association existed (Chrisler, 2011). While this suggests women feel shame when a tampon or pad falls out of their purse, it also suggests that researchers are unable to really discuss this topic without being forced to deal with the stigma themselves. This is particularly prevalent within the US government, where an inability to speak about menstrual cycles means that policies to counteract systemic stigma are not brought to the table, let alone implemented. And, even when policies are passed, without overcoming stigma, the policies are often ineffective. English researchers noted this in relation to period poverty, which, as defined by the National Institute of Health, is the lack of access to safe and hygienic menstrual products and the lack of accessibility to basic sanitation services and menstrual hygiene education(Jaafar et al., 2023). Free menstrual products are commonly suggested as a solution to this issue, but when studying a policy that provided them for menstruating youth, researchers noted that many girls didn’t use the products because of the shame associated with them (Bowen-Viner et al., 2022).

Education

Impact of Gender

As previously discussed, the media plays a big role in society’s perception of the menstrual cycle. But, while women usually also receive other sources of information, including their own personal experience and knowledge from peers, men are often much more influenced by popular media (Hoerster et al., 2003). In the US, when we educate children about puberty, many classrooms are split up by gender, leaving most boys in the dark about this biological process. This is even more true at home, where one study noted that parents were much more likely to talk to their daughters about puberty than their sons (Omar et al., 2003). Yet, even with this, the most common way boys found out about periods was through their families, a 2011 study noted. Out of this study’s sample, most boys learned about menstruation from their sisters. The impact of a girl they knew experiencing a period for the first time had a much larger effect on them than any other educational material they had received. But, many boys noted that, even with sisters in the house, their family remained silent on the topic of menstruation, and they were left to their own devices to understand menstruation. This was the situation many boys found themselves in, which often led to unanswered questions, incorrect assumptions, and prejudices. Some boys even stated that because they weren’t female, there was no reason for them to understand menstruation, while others were only focused on themselves and how they could avoid menstruation affecting their own lives. Most of these boys started out as curious, but when silence was the only response, these biases and prejudices were quick to form (Allen et al., 2011).

Youth

Though menstrual education affects all age levels, younger individuals are often the most affected. Young girls are lacking in personal experience, and so they are usually the most impacted by the plethora of misconceptions surrounding periods and the most in need of a quality education. Girls who have a more positive attitude toward periods have been shown to feel more prepared (Hoerster et al., 2003). This attitude is often based on their source of information when learning about periods. Having adequate preparation, biological knowledge, learning about hygiene, and being aware of the negative and positive aspects of menstruation, all make sure that young girls feel in control of their bodies and therefore have a more positive experience with menstruation (Hoerster et al., 2003). But, often girls don’t receive all of these tools to properly address their periods. Usually, the only trustworthy sources girls have are their schools and the women in their lives, most commonly their mothers. Mothers have an enormous impact on a girl’s outlook on periods, especially when schools fail to provide any information outside of the strictly biological (Schmitt et al., 2021; White, 2012). Therefore, as multiple studies have shown, a mother’s stigma can very easily be passed down to her daughter (White, 2012). While this applies to both positive and negative attitudes surrounding periods, the latter is often more prominent. Studies have shown that many mothers are actually unprepared to teach their daughters about menstruation because of the lack of proper education they received. They, of course, have their own personal experiences, but when that experience is littered with bias, it doesn’t serve as a good educational tool. Researchers noted that many of mother’s of the mothers in studies were secretive about periods and only focused on negative messaging, and so the mothers of current young girls often passed down this same message, thus perpetuating the cycle of stigma (White, 2012). This is why it’s important to note the significance of sex education taught in public schools because while each mother’s opinions may differ, public schools have the propensity to serve as an unbiased tool that allows all youth to have access to proper menstrual education. Sadly, this doesn’t seem to be the case contemporarily. In fact, a 2021 study highlighted that many girls believed their school’s sex education to be lacking. More so, they reported that being taught how to manage periods at school, like learning to handle stains and deal with cramps, would have greatly decreased their anxiety and improved their experience. (Schmitt et al., 2021).

Racial and Class Differences

This lack of education both at schools and at home is further highlighted by stark contrasts in different neighborhoods. Culture and income status often determine where many people grow up, and these factors can also impact their menstrual education. Studies have highlighted that girls in higher-income homes tended to have mothers who gave them much more positive messaging surrounding periods in comparison to mothers in lower-income households. Therefore, girls in higher-income families often had a more positive attitude surrounding menstruation, leading to better overall health outcomes (White, 2012). Culture also plays a factor, especially in perpetuating stigma. For example, a 2021 study of young girls in urban cities noted that many families held a cultural stigma against tampons, believing that they would ‘take away’ their daughters’ virginity and that tampon use was ‘dirty’ (Schmitt et al., 2021). Furthermore, many families completely avoided the topic, seemingly rationalizing this by the belief that schools would do a good enough job of educating their children. This belief was especially common among parents who immigrated from other countries and were therefore unfamiliar with the US school system (Schmitt et al., 2021). Yet, as previously highlighted, despite this need for good education, youth are currently not receiving adequate instruction.

Benefits of Education

The presence of menstrual stigma in our society has long been reported, but its connection with education is not as well-studied. Education plays a key role in stigma, as it serves as one of the biggest perpetrators of stigma. But, when done right, it can also serve as one of the biggest solutions. When looking at the various practices around the perpetuation of menstrual stigma, it seems much more realistic to create a better education system than to dismantle every other systemic prejudice. One study of an intervention for girls in low-income countries highlighted the impacts a good education can have. Girls were taught about menstrual cups, the more positive aspects of menstruation, and ways to make the experience of menstruating more comfortable. The interventions immediately resulted in significant positive changes. These individuals were more open to discussing their periods and said that they felt more comfortable when they were menstruating. Thus, demonstrating the impact that adequate and holistic education can have on girls’ experiences with their periods (Shannon et al., 2020).

DISCUSSION

Relevance

My interest in educating the world about period stigma is not new, but my inspiration for the specific topic of this paper, surrounding menstrual education, was based on Florida’s House Bill 1069. This bill, which the media has colloquially referred to as the “Don’t Say Period” bill, addresses banning Florida’s public schools from providing sex education to their students prior to 9th grade (Heubeck, 2023). When I began my research, the bill had already passed in the state house, and in the duration of my research, the bill was also passed by the state senate. It was signed by the governor on May 17, 2023, and went into effect on July 1, 2023 (FL. S., 2023). Florida is one of 21 states that don’t require sex education and one of 13 that doesn’t require “medically accurate, culturally responsive, or evidence-based” education (The Siecus State Profiles - The State of Sex Ed, 2023). Yet, this policy takes their lack of sex education to new extremes by completely banning it as a whole. There are a multitude of problems surrounding this bill in all aspects of sex education, and when it comes to menstruation the impacts are immense. The Center for Disease Control (CDC) has made it clear that this bill harms children. They pointed out that most girls start puberty between 8 to 13 years of age. And, the entire range of these ages takes place before 9th grade Therefore, thousands of girls are left at risk of being completely in the dark regarding what will happen to their own bodies as they begin menstruating. (Heubeck, 2023). Many of the politicians, who are mostly male, are unaware of these facts surrounding the female reproductive system, yet their decision will impact generations of girls in Florida (Weiss-Wolf, 2023). Currently, the US has shown a rise in bills targeting education and sexuality, and with already lacking sexual education policies, this bill is likely to inspire other states, only spreading the harm to more young children. These politicians argue that it’s the family’s job to educate their children, yet when families are often only bearers of stigma and shame or a complete lack of information, school often serves as the only real source of information. And consequently, these kids are left alone during one of the biggest changes in their lives.

Impacts on the Future

The importance of menstrual education in our schools cannot be undermined. Stigma begins in our education, and current academic forms of instruction are lacking in preventing this. The reactions surrounding Florida’s bill have highlighted the importance of menstrual education, which will hopefully work to awaken constituents to the impact of this bill. But, much of this conversation has also made it seem like as long as sex education exists, schools are doing their part, but it’s much more nuanced than this. While accurate and factual sex education is important to have, it is not enough to have that alone. Multiple studies have shown girls repeatedly noting that their schools were unable to fully prepare them for menstruation. Because menstruation is much more than just a biological topic, it has physical, mental, and social impacts. Girls described not knowing how they should actually respond to the flow of blood, what to do if they stained their clothing, and how to handle period pain at school (Schmitt et al., 2021). These seemingly small things provide girls with essential knowledge that prevents a first period from being a scary event, instead framing it as simply a change. Teaching girls about the female reproductive system and handing them a pad doesn’t prepare them for the realities of periods and the impacts periods can have on every part of their lives. Our society often frames menstruation as solely a reproductive change and we forget to teach young girls about the parts of menstruation that impact them in other ways. They do need to learn about pregnancy and what periods mean for their body, but instead of simply treating them as a precursor to pregnancy, we could simply teach young women that periods are a sign their body is healthy (Diorio & Munro, 2000). Recent studies in England and Northern Ireland have mirrored this idea, noting that education policies should focus on the multitude of ways that menstruation impacts one’s life (Bowen-Viner et al., 2022).

Yet these studies remain far and few in between and policies remain lacking. For all the sound logic and studies that these papers cite, stigma remains rampant. Throughout my research process I noted that many studies highlighting menstrual stigma were more than 50 years old. While this details how far-reaching stigma is, it also highlights how understudied this topic is, as many of those papers were the most recent on those topics. The stigma of periods affects menstruation research, and it is important to note that more research on this topic is needed. Even with the information that we do have, we can see the impacts of the young girls of today. Policies such as the “Don’t Say Period” bill in Florida highlight how ignorant the world is to the importance of period education. We must tackle misinformation with facts and work to create change in our education systems and own homes. It is critical to speak up because silence was always the greatest weapon of shame.