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JAMA Forum
August 19, 2021

Period Poverty and Promoting Menstrual Equity

Author Affiliations
  • 1Department of Sociomedical Sciences, Mailman School of Public Health, Columbia University, New York, New York
  • 2Center for Health Policy and Media Engagement, George Washington University School of Nursing, Washington, DC
JAMA Health Forum. 2021;2(8):e213089. doi:10.1001/jamahealthforum.2021.3089

Many people acknowledge that menstruation—notably equal access to menstrual hygiene products—is an equity issue. It does not require a commission to address it. What is needed is for health care clinicians and administrators to be in the forefront of a growing movement to ensure that all adolescent girls and women have access to safe, hygienic menstrual management and assured menstrual health.

An estimated one-fourth of the world’s population of women and adolescent girls of reproductive age—approximately 500 million—say that they do not have everything they need to manage their menstruation. “Period poverty” has been defined by the American Medical Women’s Association as inadequate access to menstrual hygiene tools and education, “including but not limited to sanitary products, washing facilities, and waste management.” An expanding body of evidence from low-, middle-, and high-resource countries indicates significant menstruation-related challenges faced by schoolgirls, displaced adolescent girls and women, and women in the workplace—challenges that include menstrual stigma, insufficient menstrual education, and limited access to menstrual materials, toilets with water, mechanisms for disposal of used materials, or privacy.1,2 This disparity is exacerbated by the pandemic.

In the US, about 20% of teenage girls live in poverty, and are vulnerable to challenges around managing menstruation, including negative effects on their school engagement.3,4 But it is not just adolescent girls who are affected. A 2019 study of low-income women (aged ≥18 years) recruited from 10 nonprofit community-based organizations in St Louis, Missouri, found that two-thirds of them were unable to afford menstrual products at some point during the past year. Women who could not afford absorbent pads or tampons sometimes accessed less-absorbent products from community organizations or would take them out of emergency department bathrooms and elsewhere. One-third of the women used cloth, tissue paper, rags, or other material to absorb their menstrual blood but the ineffectiveness of these substitutions results in overflow, leakage, and embarrassment.5

More recent evidence highlights how people who menstruate and are experiencing homelessness face challenges that go beyond access to products, including in New York City, where legislation mandating the provision of free products at shelters and service organizations has been insufficiently funded and enforced.6,7 This population encounters additional barriers to managing their periods with dignity, ranging from insufficient access to toilets during daytime and nighttime, inadequate opportunities for bathing and laundering stained clothing, and widespread menstrual stigma. Such challenges reinforce, at a minimum, the need for access to free menstrual products in all public spaces, as Scotland has done.

Insufficient funding for research on menstrual health has limited our understanding on a range of issues, including the effect of workplace environments that are not conducive to managing periods and improved understanding of adolescents’ experiences seeking care for menstrual disorders.2 The stigma associated with menstruation perpetuates a culture of silence that may keep the issue hidden from policy makers and others positioned to address it.

Breaking the taboos and silence about menstruation includes educating young people who menstruate, their parents, and communities about this normal physiological process. Health care organizations and associations can play a key role as trusted sources of information about menstruation.8 For example, the Royal College of Nursing in the UK has an initiative to engage the public in understanding the importance of menstrual health and period poverty.9

In 2020, the American College of Obstetricians and Gynecologists reaffirmed a 2006 committee recommendation that menstruation be considered a vital sign and assessed regularly with every menstruating person. Addressing the issue requires better research and education of all clinicians on the needs of people who menstruate, potential menstrual problems, and interventions that work to promote menstrual health.

There are additional ways that menstrual equity can readily be promoted:

  1. Policy makers in the US should eliminate state sales taxes on menstrual products. The majority of states (27) continue to tax menstrual products; 23 states do not. The American Medical Association has called for the removal of all sales taxes on the products and for the Internal Revenue Service to declare menstrual products to be “medical necessities.”

  2. Schools, prisons, homeless shelters, and health care facilities should have high-quality menstrual products available for free.

  3. Every health professional and health care administrator should advocate for hospitals and other health care organizations to provide free access to menstrual products and to bill payers, when necessary, particularly with Medicaid and the Children’s Health Insurance Program.

  4. There are myriad options for helping people who menstruate afford menstrual products. The CARES Act classified menstrual products as expenses covered by health savings accounts and flexible savings accounts, which opens the door for coverage under Medicaid. Medicaid, the Supplemental Nutrition Assistance Program (SNAP, formerly known as food stamps), or the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) should evaluate the risks and benefits of allowing women to use these monies to buy menstrual products and increase the monthly benefit accordingly. Illinois is applying for a federal waiver to permit women in the state to use WIC and SNAP benefits for menstrual products. Others have proposed a “feminine hygiene supplemental program” for women and adolescent girls living below the poverty level. The Temporary Assistance for Needy Families could increase the monthly benefit for adolescent girls and women of childbearing age.

  5. Global policy makers should underscore the relevance of menstrual health and hygiene to all the United Nations (UN) 17 Sustainable Development Goals. For example, as the UN and countries address access to clean water and sanitation, they should ensure that people who menstruate have access to running water, private toilets, and places to dispose of used menstrual products.10

Menstrual equity is a human rights and public health issue. Racial, socioeconomic, and sex disparities are intertwined. As the nation reckons with the structural barriers to equity, period poverty could easily be addressed. Women, adolescent girls, and all people with periods in the US and around the world must be able to manage their periods with dignity and comfort, without stigma or shame.

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Article Information

Correction: This article was corrected August 26, 2021, to revise the Conflict of Interest Disclosures section.

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2021 Sommer M et al. JAMA Health Forum.

Corresponding Author: Diana J. Mason, PhD, RN, Center for Health Policy and Media Engagement, George Washington University School of Nursing, 1919 Pennsylvania Ave NW, Ste 500, Washington, DC 20006 (djmasonrn@gmail.com).

Conflict of Interest Disclosures: Dr Mason reported receiving personal fees from the National Academies of Sciences, Engineering, and Medicine for writing a profile for the Future of Nursing, 2020-2030 report on a period poverty initiative by the Royal College of Nursing. No other disclosures were reported.

References
1.
Sommer  M, Sahin  M.  Overcoming the taboo: advancing the global agenda for menstrual hygiene management for schoolgirls.   Am J Public Health. 2013;103(9):1556-1559. doi:10.2105/AJPH.2013.301374PubMedGoogle ScholarCrossref
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Hennegan  J, Shannon  AK, Rubli  J, Schwab  KJ, Melendez-Torres  GJ.  Women’s and girls’ experiences of menstruation in low- and middle-income countries: a systematic review and qualitative metasynthesis.   PLoS Med. 2019;16(5):e1002803. doi:10.1371/journal.pmed.1002803PubMedGoogle Scholar
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American Civil Liberties Union. The unequal price of periods: menstrual equity in the United States. Accessed August 6, 2021. https://www.aclu.org/sites/default/files/field_document/111219-sj-periodequity.pdf
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Sebert Kuhlmann  A, Key  R, Billingsley  C, Shato  T, Scroggins  S, Teni  MT.  Students’ menstrual hygiene needs and school attendance in an urban St Louis, Missouri, district.   J Adolesc Health. 2020;67(3):444-446. doi:10.1016/j.jadohealth.2020.05.040PubMedGoogle ScholarCrossref
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Gruer  C, Hopper  K, Smith  RC, Kelly  E, Maroko  A, Sommer  M.  Seeking menstrual products: a qualitative exploration of the unmet menstrual needs of individuals experiencing homelessness in New York City.   Reprod Health. 2021;18(1):77. doi:10.1186/s12978-021-01133-8PubMedGoogle ScholarCrossref
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Sommer  M, Gruer  C, Smith  RC, Maroko  A, Kim Hopper.  Menstruation and homelessness: challenges faced living in shelters and on the street in New York City.   Health Place. 2020;66:102431. doi:10.1016/j.healthplace.2020.102431PubMedGoogle Scholar
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Adams Hillard  PJ.  Menstruation in adolescents: what do we know? and what do we do with the information?   J Pediatr Adolesc Gynecol. 2014;27(6):309-319. doi:10.1016/j.jpag.2013.12.001PubMedGoogle ScholarCrossref
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National Academies of Sciences, Engineering, and Medicine.  The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity. National Academies Press; 2021.
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Sommer  M, Torondel  B, Hennegan  J,  et al; Monitoring Menstrual Health and Hygiene Group.  How addressing menstrual health and hygiene may enable progress across the Sustainable Development Goals.   Glob Health Action. 2021;14(1):1920315. doi:10.1080/16549716.2021.1920315PubMedGoogle Scholar
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