Breaking barriers… Why decent menstruation education is critical for human health

15 November 2017.

Last month,  I was thrilled to be invited to speak at a workshop hosted by  Plan UKNo More Taboo and Freedom4girls.

As you can probably guess from the event title [see image above], we were focusing on the intersections between UK-based menstruation education, period poverty (when menstruating people are unable to access/pay for adequate menstrual management products) and the on-going fight against social stigma caused by the menstruation taboo.

I was asked to speak about how poor menstruation education has contributed to health-inequalities, as summarised here under three interconnected topics;

1. Shame

As previously discussed, the menstrual taboo is largely perpetuated by silence, both literally in the sense that patients and doctors feel discouraged from talking about menstruation and related topics, but also conceptually, in that the menstrual cycle is frequently ignored, or denied, as being a possible factor in female-prevalent ill health. Such silence contributes to shame- both internal (within every menstruating person), and external (social actions/ institutions that [albeit, largely unconsciously] exclude or discriminate against people who menstruate).

This shame is compounded by another related taboo, regarding sexuality- specifically the idea that genitals  (perhaps particularly female ones?) are somehow exclusively sexual in nature, despite plenty of well-established scientific evidence to the contrary. The shame associated with menstruation and/or female genitalia directly leads to health inequalities;

  • An Eve Appeal survey of 1000 UK women discovered that one in five incorrectly thought that gynaecological cancers were caused by sexual promiscuity. Plus, one quarter of the women would not talk to their GP about gynaecological problems because they did not want to talk about their sexual history. Sadly, this shame has prevented people from accessing life-saving interventions [1].

quote-dr-olaitan

  • In my own work, I frequently hear from people who are too ashamed to seek medical advice in regard to vaginal infections, especially Bacterial Vaginosis (BV) and Thrush, because they wrongly assume that they must be sexually-transmitted. Some individuals have tried to cope with severe and life-affecting symptoms (e.g. intense itching, unusual smelling/ creamy discharge, painful urination, or pain during sex) for well over a year… And yet both BV and thrush are usually very easily treated!

  • Embodied shame can lead to low self-esteem, particularly in regard to sexuality, self-worth, and gender identity. In the UK, there has been a worrying trend for elective labiaplasty. This surgery, which involves the labia being reshaped or shortened, is available on the NHS to adults (i.e. aged 18 and over) who have a proven medical reason for requiring it, supposedly ensuring it’s not a cosmetic procedure. But, leading adolescent gynaecologist, Dr Naomi Crouch, told the BBC that girls as young as nine were seeking the surgery because they were distressed by the appearance of their vulva. More than 200 girls under 18 had labiaplasty on the NHS in 2015-16 – more than 150 of whom were under 15, according to the BBC. It is highly unlikely that this many children had proven medical reasons for surgery [2].
  • Shame can also reinforce incorrect (and sexist) ideas about female reproductive health and genitalia, e.g. that people who menstruate, or have a female reproductive system, are somehow naturally ‘smelly’, ‘dirty’, ‘immoral’, ‘weak’, ‘irrational’, ‘hypochondriac’, ‘hysterical’, or otherwise ‘abnormal’. Such assumptions can, and do, lead to misdiagnosis, and inequitable treatment. For example, female-prevalent chronic illness symptoms are more likely to be misunderstood, disbelieved, or dismissed by others, including clinicians [3-5].

We have evidence that over half of our patients have to see three clinicians before somebody takes them seriously.” -Lawrence Nelson, a gynaecologist at the US National Institute of Health (NIH) [6]

2. Lack of knowledge

We already know that people in the UK often struggle to find the correct words to describe symptoms associated with the female reproductive system.  Another Eve Appeal study found that 44% of female respondents were unable to identify the vagina on an anatomical diagram; with 60% also unable to identify the vulva [7]. Shame and embarrassment also result in many patients (and clinicians) resorting to using euphemisms to describe body parts, the menstrual cycle, or associated symptoms [8]. Without the right words, people may feel reluctant to speak to a doctor, or accidentally mis-communicate their problem, when they do.

Building on this cultural ‘vocabulary’ knowledge-gap, is a much more personal one. Many people with female reproductive systems feel afraid, or otherwise reluctant, to examine, touch, or otherwise get to know their own body, or changes associated with the menstrual cycle. This is a direct result of the embodied shame caused by the menstrual taboo. There is absolutely no good reason why a human should not feel able to touch their own body. There is nothing inherently dirty, sexual, or irreligious, about the vagina- it is just another part of the body (albeit a pretty important one!).

If a person does not know what is ‘normal’ for them, in terms of anatomical appearance, menstrual cycle-related changes, or any associated health symptoms, they are unable to spot anything ‘unusual’. This means that the early signs of more serious health issues, such as gynaecological cancers, are likely to be missed, as well as information that could help a doctor to diagnose a hormonal factor in chronic ill health conditions e.g. asthma, anxiety, chronic fatigue, depression, irritable bowel syndrome, or migraine.

This is why I encourage people to track their menstrual cycle alongside any symptoms they may be experiencing- the only way to find out if there might be a hormonal cause… (I don’t care if you use a smartphone app rather than our tracker chart– just make sure you find out what is ‘normal’ for you!)

3. Ill-informed consent/ decision-making

This combination of shame and lack of knowledge affects the ability of people who menstruate to make informed decisions about their health and wellbeing;

  • First of all, most UK children are not told about the full range of menstrual management products available to them [9]. For example, most menstruation education lessons only mention disposable products- which are not only more expensive, and detrimental to the environment, but also contribute to the menstrual taboo by implying that menstruation is unhygienic, and needs to be kept hidden [9]. There are also health benefits associated with reusable products – outlined here – and I believe that menstrual cup use can actually boost self-esteem, especially in relation to self-worth, gender identity, and body confidence.
  • Similarly, many people are prescribed contraceptive medication, or devices, without being fully informed about their action, side effects, health implications of long-term usage (e.g. osteoporosis), or alternative contraception options. Hormonal medications are also known to affect a wide range of health conditions/ symptoms, and an informed patient is much more likely to notice and take action if they develop a negative reaction to their medication, or device.
  • Research shows that sex education is associated with healthier (less risky) sexual behaviours and outcomes as compared to no instruction. The protective influence of sex education is not limited to if or when to have sex, but extends to positive changes in social attitudes and values, contraception, partner selection, and reproductive health outcomes [10]. Decent menstruation education (for all children) is therefore also likely to counter some of the myths perpetuated by the menstrual taboo, as well as improve self-esteem, body confidence, and informed decision-making regarding reproductive health.

References:

1. Eve appeal (2016) Stigma around gynaecological cancers could be costing lives. [ONLINE] Available at: https://eveappeal.org.uk/wp-content/uploads/2016/07/The-Eve-Appeal-Vagina-Stigma.pdf. [Accessed 15 November 2017]

2. BBC. (2017) Vagina surgery ‘sought by girls as young as nine’. [ONLINE] Available at: http://www.bbc.co.uk/news/health-40410459. [Accessed 15 November 2017]

3. Hoffmann DE., Tarzian AJ. (2001) ‘The Girl Who Cried Pain: A Bias Against Women in the Treatment of Pain’. Journal of Law, Medicine & Ethics 29:13-27

4. Asbring P, Närvänen AL. (2002) Women’s experiences of stigma in relation to chronic fatigue syndrome and fibromyalgia. Qual Health Res.; 12(2):148-60

5. Leston, S. Dancey, C.P. (1996) ‘Nurses Perceptions of Irritable Bowel Syndrome (IBS) and Sufferers of IBS’ Journal of Advanced Nursing, Volume 23, pp.969-974

6. As quoted in an Al Jazeera news article ‘How menstruation stigma puts women in US at risk’, January 30th 2015, http://america.aljazeera.com/articles/2015/1/30/menstruation-stigma-puts-girls-at-risk.html

7.  Eve Appeal. (2016) Know your body. [ONLINE] Available at: https://eveappeal.org.uk/news-awareness/know-your-body/. [Accessed 15 November 2017]

8.  Menstrual Matters. (2016) Is this a monthly problem?. [ONLINE] Available at: https://www.menstrual-matters.com/blog/language/. [Accessed 15 November 2017]

9. Period Positive. (2017) Petition- Brands Off! Keep companies out of menstruation education. [ONLINE] Available at: https://www.change.org/p/brands-off-keep-corporations-out-of-menstruation-education?recruiter=293997837&utm_source=share_for_starters&utm_medium=copyLink. [Accessed 15 November 2017]

10. UNESCO. (2007) Review of Sex, Relationships and HIV Education in Schools Prepared for the first meeting of UNESCO’s Global Advisory Group meeting 13-14 December 2007. [ONLINE] Available at: http://unesdoc.unesco.org/images/0016/001629/162989e.pdf. [Accessed 15 November 2017]


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