This post is a part of our Bioethics in the News series
By Sean Valles, PhD
Activism against “period poverty” has gone mainstream
Within the last month, Scotland became the first country to provide free menstrual products in schools, and London student Amika George earned a Campaign Award from the influential Bill and Melinda Gates Foundation for starting the #FreePeriods social activism campaign. Why is the accessibility of menstrual products getting attention from human rights activists and governments? Because for many people* they are basic necessities that remain out of reach.
A survey commissioned by Proctor and Gamble’s Always® brand of menstrual products reports “nearly one in five American girls have either left school early or missed school entirely because they did not have access to period products.” Take that survey with a grain of salt, given who sponsored it, but it provides a sense of the scope of a previously-known problem. Like most problems that disproportionately hurt people who are already most marginalized by society, “period poverty” has only received sporadic attention in media outlets and public conversation. Previous reporting on the subject includes discussions of the problem among people who are homeless in San Francisco, and among adolescents from low-income families, living in the Pine Ridge Indian Reservation and in the Nashville area.
“Period poverty” is gradually getting recognized as one piece of the complex cycle of poverty. Imagine finally getting a job interview after struggling with unemployment, only to have to choose between skipping the interview or trying to make a makeshift pad out of wadded toilet paper or an old sock, then hoping it doesn’t fall out or leak in front of the would-be boss. When one can’t afford the health/hygiene supplies to avoid bleeding on one’s clothes (nor afford to replace any clothes stained by a period), a lack of timely access to menstrual products can have the drastic effect of making it hard to participate in public life.
Bioethics of access to menstrual products
Access to menstrual products is clearly a problem, but is it a bioethics problem? Absolutely. As the FDA will tell you, menstrual pads, reusable menstrual cups, tampons, etc. are medical devices. Menstrual products are medical technologies used to manage one’s hygiene according to cultural norms. It is a bioethical harm to limit a person’s access to the tools a society has decided are necessary for meeting its basic standards of hygiene.
After decades firmly in the U.S.’ collective ethical blind spot, public opinion on how society ought to respond to “period poverty” is divided, and has a conspicuous gender gap. In the U.S., almost three-quarters of women support providing free menstrual supplies in schools, while just over half of men do. Half of women agree public bathrooms should provide free menstrual supplies while just over a third of men do. I’m a little surprised to see that latter set of numbers so low, but I suppose we’re still accustomed to the idea that toilet paper and hand soap are necessary health/hygiene products that must be available in every public bathroom, while menstrual supplies are typically kept in paid dispensers or not available at all.
Adding insult to injury, Michigan continues to impose a sales tax on menstrual products, whereas food and medicines are exempt. Most states have similar taxes on menstrual products, even though legal scholars, such as Crawford and Waldman, have argued that the taxes are doubly unconstitutional; they violate both the Equal Protection Clause and the core constitutional principal that laws must have a rational basis. Legislation to end Michigan’s “Tampon Tax” received unanimous supporting votes in the Senate Finance Committee in March of 2017, but has been effectively ignored by the Senate since then. I suspect that the lack of progress, despite unanimous committee support, is related to the fact that in Michigan’s legislature there are three male legislators for every female legislator (on a related note, take a look at the names of the authors in the bibliography at the end of this post).
That tax loophole is part of a category of problems: bioethical harms resulting from sexist economic inequities. It is not the only example, either. For instance, among personal care products that are marketed to men and women (e.g. razors and shaving cream), there is an average markup of 13% on the items marketed to women. Meanwhile, the gender wage gap leaves women only making around 80% of what men make.
Some of the problems hiding in our bioethical blind spot will be complex and difficult to solve, such as the problem that dental care has long been treated as separate from medical care (Medicare and Medicaid largely exclude coverage). By contrast, the inaccessibility of menstrual products would be far easier to fix. Very minor changes to tax policies and social norms could make menstrual products as widely available as toilet paper. Most households still buy the toilet paper of their choosing, but we expect even the shabbiest public bathrooms to have toilet paper in it for free.
We can fix this
When will we start treating menstrual products like the health/hygiene/medical necessities they are? Scotland has recognized that at the very least no student should miss class because they don’t have access to sanitary pads. What is the argument against this? Perhaps a generic political concern about former social privileges getting recast as legally-mandated rights or socially-demanded expectations? Whatever the merits of that general concern, nobody wins when low-income students miss school and low-income women miss job interviews because they don’t have pads. If nothing else, where is our human empathy for those suffering the preventable indignities of being stuck without a pad?
#FreePeriods.
*A note on biology
Sex, gender, and human bodies are complex and diverse. Not all post-adolescent/pre-menopausal women menstruate. Not all people who menstruate are women. Not all menstrual bleeding happens in the uterus: endometriosis is a common (but too rarely discussed in public) condition in which endometrial (uterine) tissue implants in other parts of the body and responds to menstrual cycles by bleeding much like the uterine tissue does. Complex and diverse.
Sean A. Valles, PhD, is an Associate Professor in Lyman Briggs College and the Department of Philosophy at Michigan State University. His book Philosophy of Population Health: Philosophy For A New Public Health Era was published by Routledge in May 2018.
Join the discussion! Your comments and responses to this commentary are welcomed. The author will respond to all comments made by Thursday, November 15, 2018. With your participation, we hope to create discussions rich with insights from diverse perspectives.
You must provide your name and email address to leave a comment. Your email address will not be made public.
More Bioethics in the News from Dr. Valles: Trump’s Attempt to Reignite the Coal Industry Is Another Health Policy Blunder; Politics and the Other Lead Poisoning: The Public Health Ethics of Gun Violence; Climate Change and Medical Risk
References
- Crawford, Bridget J. and Waldman, Emily Gold. 2018. “The Unconstitutional Tampon Tax.” University of Richmond Law Review, Forthcoming. https://ssrn.com/abstract=3239698.
- Doucleff, Michaeleen. 2016. “Do Women Need Periods?” National Public Radio. Accessed 10/9/18. https://www.npr.org/sections/health-shots/2016/05/23/478562615/do-women-need-periods.
- Ferrell Knisely, Amelia. 2017. “Teen Girls Are Missing School Because They Don’t Have Access to Feminine Hygiene Products.” Tennessean. Accessed 10/9/18. https://www.tennessean.com/story/news/education/2018/08/14/lack-feminine-hygiene-products-keeps-girls-out-school/948313002/.
- Food and Drug Administration. “Product Classification.” Accessed 10/9/18. https://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfpcd/classification.cfm?start_search=1&DeviceName=&ProductCode=&ThirdParty=&DeviceClass=1&SUBMISSION_TYPE_ID=4&GMPExempt=N&Panel=&RegulationNumber=884.5435&PAGENUM=10&SortColumn=DeviceName.
- Goldberg, Eleanor. 2017. “Why Many Native American Girls Skip School When They Have Their Periods.” HuffPost. Accessed 10/9/18. https://www.huffingtonpost.com/entry/what-its-like-to-be-a-teen-in-the-us-who-cant-afford-tampons_us_597216dde4b09e5f6cceddfb.
- Hegewisch, Ariane. 2018. “The Gender Wage Gap: 2017; Earnings Differences by Gender, Race, and Ethnicity.” Institute for Women’s Policy Research. Accessed 10/9/18. https://iwpr.org/publications/gender-wage-gap-2017/.
- Jone, Kenny. 2018. “Getting My Period Made Me Feel Like Less of a Man—Even Though I Knew I Was.” Self Magazine. Accessed 10/9/18. https://www.self.com/story/male-period-trans-model-kenny-jones.
- Lawler, Emily. 2017. “Bills to Strike ‘Tampon Tax’ Not on Fast Track in Michigan Senate.” MLive. Accessed 10/9/18. https://www.mlive.com/news/index.ssf/2017/03/bills_to_strike_tampon_tax_not.html.
- Office on Women’s Health. 2014. “Endometriosis.” Accessed 10/9/18. https://www.womenshealth.gov/a-z-topics/endometriosis.
- Owen, Charlotte. 2018. “Amika George On Period Poverty, Beating Trolls, & Fighting Gender Inequality On A Global Scale.” Bustle. Accessed 10/9/18. https://www.bustle.com/p/amika-george-on-period-poverty-beating-trolls-fighting-gender-inequality-on-a-global-scale-11995993.
- Rifenburg, Lisa. 2018. “Nearly 1 in 5 American Girls Have Missed School Due to Lack of Period Protection1: Always® Joins Forces with Gina Rodriguez & Feeding America® to Help #EndPeriodPoverty and Keep Girls in School.” Proctor & Gamble News. Accessed 10/9/18. https://news.pg.com/press-release/pg-corporate-announcements/nearly-1-5-american-girls-have-missed-school-due-lack-perio.
- Simon, Lisa. 2016. “Overcoming Historical Separation between Oral and General Health Care: Interprofessional Collaboration for Promoting Health Equity.” AMA Journal of Ethics. 18(9) 941-949. https://journalofethics.ama-assn.org/article/overcoming-historical-separation-between-oral-and-general-health-care-interprofessional/2016-09.
- Vonberg, Judith. 2018. “She Had No Sanitary Pads. No One Knew and No One Helped.” CNN.com. Accessed 10/9/18. https://www.cnn.com/2018/10/03/health/uk-period-poverty-asequals-intl/index.html.
- Bessendorf, Anna. 2015. ”From Cradle to Cane: The Cost of Being a Female Consumer—A Study of Gender Pricing in New York City.” New York City Department of Consumer Affairs. Accessed 10/9/18. https://www1.nyc.gov/assets/dca/downloads/pdf/partners/Study-of-Gender-Pricing-in-NYC.pdf.
- Weiss-Wolf, Jennifer and Laura Epstein-Norris. 2016. “Blood In The Streets: Coping with Menstruation While Homeless.” HuffPost. Accessed 10/9/18. https://www.huffingtonpost.com/jennifer-weisswolf/blood-in-the-streets-menstruation-homelessness_b_9019638.html.
- Women’s Legislative Network. 2018. “Women in State Legislatures for 2018.” National Conference of State Legislatures. Accessed 10/9/18. http://www.ncsl.org/legislators-staff/legislators/womens-legislative-network/women-in-state-legislatures-for-2018.aspx.
- YouGov NY. 2017. “Feminine Hygiene Products.” Accessed 10/9/18. https://d25d2506sfb94s.cloudfront.net/cumulus_uploads/document/4ntl7ouhsc/Copy%20of%20Results%20for%20YouGovNY%20(Feminine%20Hygiene%20Products)%20219%2010.20.2017.pdf.
MSU Bioethics 
I once had someone tell me that if I ever wanted to help a homeless woman, fill and old purse with pads and tampons and give it to her. My jaw dropped and I was shocked, because like many, it had never crossed my mind. This was an eye-opening moment for me that I will never forget, and I am very thankful to see more attention being brought to this topic. I had to ask myself, why did I never think of that? I have found that those who are privileged enough to have access to menstrual products (or have no need for them) don’t realize the implications that can exist without it. I believe this is where some of the shocking statistics, particularly from men, come from. Not only is it the social norm of proper hygiene, it can also be a serious health concern. A woman who only has access to three tampons will likely make one last as long as possible, rather than changing it in the reccomended amount of time, putting herself at risk for serious infections. It is a huge concern of mine and something I have educated other people about since I became educated myself. I think everyone should have access to these products, especially young girls and college students. The price markups and taxes are a very real thing that we have came to accept. If we continue to bring awareness to the topic and educate people around the concern, I believe we can see a very positive change for woman everywhere. Congratulations to Scotland for taking this huge step!
Very well said! That point about the health risks of delaying changing one’s pad is very important, and something I really ought to have mentioned in the original piece. Here’s hoping the international conversation is at a turning point on this topic!
After reading about the issue of ‘period poverty,’ it was definitely shocking to think that something that I am so used to having on-hand whenever I need it, is not available to everyone when it is a necessity to all women who get their periods. Some interesting and factual points that were brought up included how “items marketed to women were marked up 13%.” This is ridiculous because, as a woman, if I am already receiving less of an income than men and decide to go to the women’s section to buy a shirt, I may be paying more for the shirt just because it is in the women’s section of clothing. In my opinion, I support the idea of making tampons and pads available to all women, especially in schools and public restrooms. There is already a stigma when women do get their periods (especially in schools) and to not have the correct supplies is another inconvenience that they must deal with if they don’t have access to pads or tampons. I believe that, as the comment about has stated, this issue should be talked about in communities, government and in schools. It is people who will make a change and be the voice for people who are unable to obtain these necessities because of financial barriers. If this topic becomes more popular and is seen throughout the media and social media, people will see the impacts that this has on people who are not fortunate enough to have these essentials when they need them. Hopefully, with enough awareness and education, there will be changes to allow every women to have access to feminine products when it is their time of the month!
I agree. And I am somewhat heartened to see that yesterday Nevada just eliminated its “tampon tax”. As more states do this, I suspect (and hope) period poverty will get more attention in general. Though I think that awareness won’t be enough, unless it is accompanied by compassion. The long history of opposition to food assistance programs provides a sobering lesson—we all need to eat, but not all of us show much compassion for those left hungry.
Dr. Valles,
Thank you so much for shedding light on an issue many people seem to take for granted every day. I think the topic of the tampon tax as well as free tampons and pads for women can be an awkward subject among professionals as well as their clients. Women’s menstrual cycles are considered a “taboo” topic in our society. In a healthcare system that struggles to cover birth control and contraceptives for women, it would at least be assumed that menstrual cycle products would be provided for those who aren’t covered with contraception, but as you have pointed out, that is not the case. I admire that you gave the example of women not being able to participate in daily life due to the lack of medical supplies, and this is a very real issue! I can agree that the tampon tax should be considered unconstitutional as well.
Do you find that the biggest issue is the lack of awareness of how pervasive this problem is?
What steps can people in the community take to help create change?
Thanks for the thoughtful comment. I’ve been thinking about this after reading your post and the post by Brenda Cheung above, and started answering your questions in a reply to that other post. But you also asked about how to create change in the community. Drawing on the bioethics and public health literature on stigma, I am inclined to think that it will be very hard to get very far in fighting the effects of the stigma without fighting the stigma itself. See, for example: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3682466/. Stigma is partly a matter of exerting power over certain people, in this case sexist societies exerting power over female bodies (with exceptions and complications of course, as mentioned the note on biology). That use of power to shame and control women is horrible, and needs to be confronted head on, I think. We can keep on trying to get rid of tampon taxes, but I am skeptical of how far the fight for equitable access to menstrual supplies can go while menstruation is treated as inherently shameful.
Dr. Valles,
I truly appreciate you bringing such an important matter to light. I think, although society has become more accepting of periods in many ways, periods are still something that we, women, are supposed to keep a secret from men or even female strangers. Although I do not clearly remember being taught, I have noticed that like me, many other women hide their menstrual products when going to the bathroom. In my opinion, while periods are thought to be something to be ashamed of, there will continue to be a tampon tax.
I also think it is very important to talk about how much more expensive it is to be a woman. With the higher markup on women’s products compared to mens as well as the tampon tax and the wage gap women are punished just for being a woman. Do you think there is anything we can do as individuals to really try and change this? I think that if we were able to start a small movement, just here at MSU we could influence a much bigger change. Do you think that the biggest reason the tampon tax still exists is due to the shamefulness associated with periods?
Thank you very much for sharing these experiences and insights. I don’t think there is much we can do as single individuals acting independently to change these social problems. Community problems need to be addressed by communities working together. The question, I think, is how to get these issues taken seriously by the community. Starting relatively small, including perhaps at MSU, seems like a good path forward. I have suggested this topic to some student leaders and will continue doing so. Starting at a university also seems like a promising start since I take it that there is a generational shift wherein young adults are somewhat more open to discussing menstruation (though I could be wrong about that). I will do some more chatting with student leaders and other university leaders to look into this…