Anne Sebert Kuhlmann on the Impact of Menstrual Poverty on Vulnerable Individuals

Siers-Poisson [00:00:06] Hello and thanks for joining us for the Poverty Research and Policy podcast from the Institute for Research on Poverty at the University of Wisconsin, Madison. I’m Judith Siers-Poisson. For this episode, Dr. Anne Sebert Kuhlmann joins us to discuss her research on the impacts of menstrual poverty on low-income and other vulnerable people, and what practice and policy options are available to alleviate the burden. Anne Sebert Kuhlmann is a professor in the College for Public Health and Social Justice at Saint Louis University and is also chair of the Department of Behavioral Science and Health Equity. Anne thanks for joining us today!

Sebert Kuhlmann [00:00:42] You’re welcome. Thanks for the invitation to be here.

Siers-Poisson [00:00:45] I’d like to start with some basics. How do you define menstrual poverty and are there any other terms that are used?

Sebert Kuhlmann [00:00:52] I usually refer to the terms menstrual hygiene management or menstrual health and hygiene, because these terms really refer from an all-encompassing perspective to all of the resources and knowledge and support that’s needed to maintain good health and hygiene during menstruation, and to do that without fear or stigma and having minimal impact on daily life. So when we talk about that, and when I use the term menstrual hygiene management, really referring to making sure we have sufficient quantities of clean, absorbent materials, whether they’re disposable or reusable, access to clean water, sanitation facilities, so places for disposal if you’re using disposable products or for being able to to wash and dry reusable products as appropriate. And then also thinking about the aspect of like knowledge and education, social support that is needed to be able to maintain that health and hygiene with minimal impact on daily life. You’ll also hear the term period poverty that’s often used in the vernacular in the US, which a lot of times when people are using period poverty, they’re referring in particular to access to products, and that side about sort of the accessibility and affordability of product. But I tend to use the menstrual hygiene management term more.

Siers-Poisson [00:02:18] And for those who might not be familiar, can you share what types of products like those you were just talking about may be needed and in what quantities during each menstrual cycle?

Sebert Kuhlmann [00:02:29] This is really based on the individual and based on preferences and the cycle rate, like how heavy the flow is, how long it lasts, that type of thing. But there’s there’s a set of disposable products, though, liners or pads that come in all varieties of absorbencies, with wings, without wings and then similarly with tampons, disposable tampons. So those are obviously inserted into the vagina and absorb the menstrual blood. And again, those come in a whole variety of absorbencies. They come with applicator, without applicator, plastic, cardboard, that type of thing. So those are really on the disposable product side and then there are some options in terms of reusable products. So you can have essentially cloth pads, right, that are sort of a little bit like the idea of cloth diapers, but they can just be hand washed in a sink and dried. There’s period underwear, which has some absorbency. So that’s sort of a similar idea. And then there are reusable menstrual cups that can be inserted into the vagina, catch the menstrual blood, and then need to be cleaned before use again. And in terms of thinking about quantity, again, that really depends on an individual’s menstruation. So on a regular basis, people on average have about 13 menstrual cycles per year and then you’re thinking about that menstrual cycle lasting 3 to 7 days per cycle and then anywhere between potentially like four and eight, if you’re using disposable products four and eight products per day. Recommendations are to change products every 4 to 8 hours or even every 2 to 4 hours, depending on flow.

Siers-Poisson [00:04:25] Before we go on, I just want to note that we may use the terms women or girls or female, but we are including other people who may also menstruate. So, Anne, for how many years does the average female have their period?

Sebert Kuhlmann [00:04:40] This is a really good question. Again, it depends on on the individual. The average age of menarche, which is first menstruation, is around 11.5 and is shown to be getting a little bit earlier in the United States. But that’s average age, so people can start anywhere from as early as nine years old or maybe as late as 14, 15 years old, and then continue to have periods until they reach menopause. So that would be in that 45- to 49-year-old range. But again, it varies. But, we’re talking about four decades of someone’s life.

Siers-Poisson [00:05:20] One of the aspects of menstrual poverty you mentioned earlier, and really this is in the menstrual hygiene area, are lacking access to soap and water for hygiene and the safety and accessibility of restrooms. Can you tell us a little more what that looks like?

Sebert Kuhlmann [00:05:36] Yeah, so this aspect is really, really important, and I think an area that maybe we don’t focus enough attention on. But if you think about it with the hygiene, it’s not just changing products, but oftentimes you need to wash and clean yourself, that also really helps with odor, sanitation, but being able to do so in a safe place. And a lot of us have a different assumption that, everyone has access, you know safe access to a restroom. But that is not always the case. Folks who are maybe experiencing homelessness, folks who have unstable housing, the access to water and soap and a physical space for that sanitation, those practices, is really important too. The safety perspective, you know, we’ve had folks who have looked us in the eye and said, you wouldn’t dare go defecate or urinate or do anything at night after dark because you’re essentially a sitting duck, right? If you don’t have stable housing. And so you have to wait until daylight or wait until you can get to a safe place in the morning. And if you think about the fact we were just talking about recommendations for how frequently you should change products or may need to change products for hygiene and based on flow, oftentimes it’s dark for 12 or more hours a day. And thinking about not having accessibility to a safe restroom, to the sanitation facilities is a really important component of menstrual hygiene.

Siers-Poisson [00:07:08] Do we know how prevalent, we’ll call it menstrual poverty in this case, is in the United States?

Sebert Kuhlmann [00:07:15] We don’t have great national data on this because we don’t have sort of a standard measurement or definition and routine surveillance. We’re moving in that direction. But this is an issue that has only relatively recently been getting a decent amount of attention in the United States. So the data that we do have, there are a few kind of national online surveys that those suggest that about one third of menstruating adults in the United States and about a quarter of menstruating teenagers struggle with access to period products when they need them. If we take that and look at specific subgroups within the population, particularly those who are the most economically vulnerable individuals in the household, then that proportion is much greater. So, you know, we did one of the first studies around this issue in St Louis among adult women who were receiving assistance from community service organizations in the city, so among food pantries, day shelters, job training agencies, those sorts of things. And among that sample, we found that nearly two thirds so 64% reported that they hadn’t been able to afford period products when they had needed them at least once in the previous year and 20% of those reported that that’s what they experienced every month, every time that they had a period.

Siers-Poisson [00:08:43] So let’s break down the menstrual poverty landscape in the U.S. a little more from what you were just saying, Anne. What are the differences that you’re seeing by racial and ethnic groups?

Sebert Kuhlmann [00:08:54] Right, so, several studies have shown that Black and brown households tend to experience the highest level of period poverty. But we really see that economic status is a strong, strong predictor, sort of regardless of race and ethnicity.

Siers-Poisson [00:09:12] Do you see any difference in where someone lives? I’m especially wondering if there are differences, say, between rural and urban, which sometimes we see coming up in eaccess in other programs and supports.

Sebert Kuhlmann [00:09:24] So this is a great question and something that we’re starting to explore more. So, you know, just by chance, most of the first studies on this issue in the United States were done in urban areas. And so I think that’s shaped people’s perception, potentially thinking about it as an urban issue. But more recently, this issue, we started to look at it more in rural areas and what we’ve seen in some of those rural areas is similar patterns to what we see in urban areas. So there’s been in smaller towns in the Midwest, in rural Alabama, students, that type of thing, that those students are reporting some of the very same challenges as some of the studies that we’ve seen in the urban areas. For example, we did a study recently with school nurses across the state of Missouri, and one of the things that we looked at as the school district that the nurses were serving, were they in a rural designated area, an urban designated area. And what we saw was that there was no difference in terms of nurses reporting that they know students who are missing school due to their periods, regardless of urban area or rural area. What we did find as a predictor and the strongest predictor in that study was the percentage of students in the district who were eligible for free or reduced lunch. As that percentage increased, as a greater number of students in the district were eligible for free and reduced lunch, then we saw that school nurses were more likely to report that they knew students, who, the students and their families were struggling to afford the period products that they need.

Siers-Poisson [00:11:07] So what do menstruating people do if they can’t access the right products in sufficient quantities? I think, in some of your qualitative work, the phrase “making do” was used.

Sebert Kuhlmann [00:11:20] Yeah. We make do right? Women, girls anyone who menstruates. We make do. Anyone who has had a period is probably familiar with this. We’ve been doing it for thousands of years in that sense. That a quick stopgap, you know, your period starts unexpectedly, you do a stopgap, grab some toilet paper, wad it up, some paper towel, that sort of thing. But I think there’s a big difference between doing that once for a short period of time, or very intermittently for a short period of time until you can get home, or get to the store, get a product from a friend and thinking about that’s how you manage your entire menstruation, every time you have a period. All the days, whether it’s that three days or reaching to seven days. So really thinking about can you get access to the products that you need that work for you and the quantity that you need them. So we’ve seen in our work and others have reported that one of the big things that people do is when they do have products, they stretch the use of the products, right? So if they’re recommended to be changed every 4 to 8 hours, depending on absorbency and flow, they will push the use of that product much longer, which then puts them at risk, potentially, for infections and that type of thing. So wearing products much longer than recommended, resorting to homemade products, so again, frequently water out toilet paper or tissue paper towels using old rags or socks. And then we, especially in some of our early studies, had women who told us that they cut up their kids diapers. Diapers are really absorbent and you can make several highly absorbent pads out of one diaper. So they said it was easier at the time when we were doing these studies to get help if they needed for diapers for their kids than it was for them to find a way to access products.

Siers-Poisson [00:13:21] You discuss the health impacts of menstrual poverty in your research and you were just talking about some of the effects of, for instance, using a product longer than is recommended. Are there other physical health implications? I’m thinking when I was in high school in the early 80s, was when toxic shock syndrome was first really being talked about and it was scary.

Sebert Kuhlmann [00:13:46] The risk of infection is real. So, extending products we talked earlier about like not having access to soap and water and that for just basic hygiene right? And so that risk of infection, fortunately, toxic shock syndrome is relatively rare, but much more common urinary tract or vaginal infections and some skin infections. So those are certainly a risk from a physical health perspective. There’s also, very much and very importantly, I think, a mental, a psychological toll, right? Like lack of menstrual hygiene really takes a toll on folks who are experiencing it. And we’ve had women that, we’ve had participants in our studies look at us and say, imagine how it would make you feel when you can’t even take care of your own hygiene. Or, how are we supposed to take care of our kids when we can’t even take care of ourselves? And I think one that very much stuck out to me, especially thinking about the homemade pads and products, a woman explaining like, yeah, imagine what that’s like that’s what you do all month, every month, and you have one pair of underwear. So they get stained up they’re dirty but you don’t have any other choice. So I think really thinking about that psychological toll is important. And, you know, everyone deserves to be able to manage their menstruation with dignity and not have it have such a huge psychological and mental toll on them because they don’t have access to to hygiene. We should be able to help all in our society have that access.

Siers-Poisson [00:15:30] Well, and there’s such a stigma about menstruation in general. And then you add all of those other layers on. It seems overwhelming.

Sebert Kuhlmann [00:15:40] Yes. And I think, you know, the stigma, I think, is potentially there for all ages. It is, I think, particularly a concern with teens and students, you know those who are in their initial years of menstruation, and really trying to figure out the management of hygiene and just the concern about being stigmatized, like do I smell? If I stand up or my clothes are going to be stained? Are other kids noticing? I don’t want to dress out for gym because people might be able to tell that I’m on my period. Those are the types of things that we’ve heard, particularly from some of the high school students that we’ve worked with, and that that concern and that feeling of being stigmatized because you are having your period is definitely real.

Siers-Poisson [00:16:32] And I wanted to talk about some of the very concrete impacts of lack of access to menstrual products and, as you said, hygiene conditions. And let’s start since we were just talking about that, about school attendance and what that means for young people who are menstruating, who know they don’t have the materials they’re going to need to get through a day at school.

Sebert Kuhlmann [00:16:58] Yes. So I think school attendance is one of the areas where there’s been more work than in some of the other areas in some of our studies in the US with some high schools in the St Louis metro area. We’ve had students in surveys reporting that nearly 50% of those participating in the study, so all among students who have had their period that, you know, nearly 50% of them are reporting that they’re missing at least one day per month, due to their period. And about, depending on the study, Between 17 and 18% are reporting that they’re missing specifically because they don’t have products when they need them. So that 50% is more just anything related to their period. So when we ask about pain and cramping and odor, but it also includes those who don’t have access to the products when they need them. And then again, somewhere between about 17 and 18%. It’s specifically because they don’t have access to products. And if you think about that, 11, 11.5 for menarche, for that first period, the cumulative effect of missing one day per cycle or even just one day every few cycles, just the cumulative impact on the amount of school that students are potentially missing due to their periods is really pretty significant.

Siers-Poisson [00:18:36] What about employment? How does the lack of menstrual equity affect people’s ability to work?

Sebert Kuhlmann [00:18:44] So I think there’s been not quite as much research around impact on work and attendance, but there has been a bit. There is one study where we were looking at trends between 2018 and 2021 so that did include the height of the COVID pandemic and in 2021, both people who were working in person and virtually, adults, were reporting missing work due to their periods. So I think that this is an area where we need more research to understand better what the relationships are there are there particular types of work that might be more prone to people missing work because of their periods, that type of thing. What can we do to help support people?

Siers-Poisson [00:19:32] I’m glad you brought up that paper that was looking at trends in menstrual poverty from 2018 to 2021, because as you said, COVID falls right in there. And while many people were either out of work or sent home to work, a lot of those essential workers on the front lines were low-wage workers. And it seems like they would have been affected on so many levels if they couldn’t afford menstrual products.

Sebert Kuhlmann [00:19:59] Yeah. So we did see that the percentage of the adult population who menstruates who were participating in that study that reported that they were currently struggling to afford period products increased from 2018 to 2021, with about 30% in 2018 to 38% in 2021. And then there’s, there is a similar report from an organization period.org that did a national online survey of teens looking at a similar period. So from 2019 to 2021, they reported an increase where in 2019, around 20% of the teens were reporting trouble accessing and affording period products, whereas by 2021 that was around 23%. So adults, teens, it does look like there’s been a bit of an increase over that time period and I think lots of factors have contributed to that, but including the COVID pandemic.

Siers-Poisson [00:21:11] Well, and I was thinking about how when schools closed or went to remote learning during COVID, the government moved to provide expanded food benefits to replace school lunches. I’m guessing a lot of school aged people had previously been able to get menstrual products for free at school. Anne were there any efforts to meet those needs, like the need for school lunches?

Sebert Kuhlmann [00:21:35] That’s a great question. Not that I’m aware of at a national or large scale. I do know anecdotally that some schools that had donated products or had supplies of products in school that they tried to use the food distribution, right, for lunches or if they were doing other food distribution, to also provide those products and distribute those products. But you’re right, it’s not the same as just being able to go pick up what you need and the schools were obviously very focused on food and then what they needed to do from an education perspective. So I do imagine that a number of students who sort of rely on getting products at school probably went without during that period of time.

Siers-Poisson [00:22:24] And before we move on from the COVID time period, I’m sure we all remember that there were many supply chain issues and increased prices for a variety of consumer products, and often you didn’t know when they were going to be available again or how much they were going to cost. Was that also the case for menstrual products?

Sebert Kuhlmann [00:22:43] There has been some documentation that, yes, the cost of period products went up during the pandemic and during these issues with supply chain. I’ve seen some news articles that have reported that.

Siers-Poisson [00:22:58] So looking particularly at the challenges for low-income menstruating people, we talked about just the cost of the products and we also talked about access to hygiene. There are sometimes places where you can get either cheaper supplies, for instance, a dollar store or maybe some nonprofit that offers them for free. But as we often see with low-income folks, transportation can be a real issue.

Sebert Kuhlmann [00:23:27] Yes, definitely. Definitely. And that’s something that we heard in some of the initial focus groups that we did is just the time and the cost of the transportation to get to places that might have larger quantities at lower prices per item or that sort of thing was a challenge. And so people were sort of stuck having to get products maybe closer by but smaller quantities, higher cost per per product. So that I think is definitely an issue that when we think about the challenges of transportation and we think about, you know, accessing food and health care and all of that type of thing, that period products is one of those things that is associated with that.

Siers-Poisson [00:24:19] We mentioned earlier that there are some parallels with diaper scarcity and menstrual poverty. And it seems like if someone can get to a nonprofit or maybe a food pantry that also offers menstrual products, there’s no guarantee that what they need would be available.

Sebert Kuhlmann [00:24:37] Yes, people definitely have preferences about products based on their needs. And we talked about, you know, everyone’s period is slightly different. And so based on what they’re doing, you know, some folks really love the overnight with wings because they’re highly absorbent and they can last longer. Others really prefer tampons because they’re not as outwardly visible. Some folks really like liners or might just have light spotting, but light spotting on a regular basis. And so they don’t need super thick absorbency, but they need something more consistently. So really, sometimes there can be a mismatch between what has been donated and what individuals are looking for to meet their needs. So I think that is one of the challenges when we have so many people reliant on donated products for a basic need.

Siers-Poisson [00:25:37] We talked earlier about homeless individuals having really several layers of challenges if they are not able to maintain menstrual hygiene. It seems like incarcerated individuals would be another group of particular concern when it comes to menstrual equity.

Sebert Kuhlmann [00:25:55] Yes, that is certainly true and there has been work in different states. So Missouri is actually one of the states that has passed legislation making quality period products freely available to incarcerated individuals. So there’s sort of a patchwork depending on whether the federal system…so there’s actually legislation at the federal level for incarcerated individuals. So if you’re in the federal system or in a state system where a state has passed laws, then there’s more access. But again, then there’s the local level and it’s a patchwork throughout the nation. But yes, it’s definitely a challenge.

Siers-Poisson [00:26:42] There’s an initiative called the Menstrual Hygiene Management in Ten Movement. It started in 2014, and here we are in 2024. So ten years later, can you tell us about that and what your assessment is of that effort?

Sebert Kuhlmann [00:26:57] Yes. So the MHM in Ten movement, I think has been really important to bring awareness to this issue, really initially to bring it on to the international development agenda, to help bring attention to the issue in lower-resource settings, lower-income countries. But I think it has the benefit of spillover in really encouraging attention to the issue in high-income countries like the United States as well. So I think from an advocacy, helping to break the taboo or drawing political attention, the MHM in Ten movement has been very, very important.

Siers-Poisson [00:27:39] So let’s move on to talking about policy approaches that could lessen menstrual poverty and increase menstrual equity. What do you see as vital to this effort from a policy perspective?

Sebert Kuhlmann [00:27:52] So I think it’s important from a policy perspective to think about the different avenues where we can provide a safety net to individuals who may need products and need access to menstrual hygiene resources overall. So whether that is through schools and providing them in schools, whether it’s through changes to programs like WIC and SNAP. I think one of the vitally important things for any of those policy changes is that they’re funded, that we don’t just change or put requirements in and ask schools to do more or say, okay, now you know, you can do this with WIC or SNAP, but without providing additional funding to do that. And so just making changes that then forces the school district to think, well, now I’m required to do this. I don’t have any more resources, so what am I going to cut? Or someone who’s using WIC or SNAP benefits of I need these benefits to cover what’s already covered but now maybe I can get over here. What am I going to cut out from there? So I think when we’re talking about any of these safety nets within our society, it’s really important to think about the funding aspect and that we don’t just pass the policy, but that we’re sure to fund what we are making the expansion for. Some of the other routes that I think are gaining some momentum. So there are a few municipalities that are starting to look at providing period products in public restrooms just like toilet paper and soap, kind of a standard thing that we expect when we go into a restroom. So Ann Arbor, Michigan, was the first municipality in the US to pass something like that. And that is similar to what we have seen in places like Scotland and New Zealand. There have been some of the first high-income countries that passed policies with essentially making period products freely available to those in need. Oftentimes through then working with churches or pantries or those types of things.

Siers-Poisson [00:30:15] What about how menstrual products are taxed? How do they compare to, say, how food is taxed, which is also another essential?

Sebert Kuhlmann [00:30:25] So the issue of taxation on period products is again a patchwork, just like any state and local taxes across the country. So there are some states that have absolutely no sales tax on anything and so menstrual hygiene products fall in that category and are not taxed. There are other states that have passed legislation where they either exempt period products or classify them as a medical good so that there is no tax on period products. And then there are other states that might reduce the tax to a lower level, similar to what maybe food and other essential goods might be taxed. And then there are states like Missouri where period products are still taxed at the full sort of luxury goods rate, even though they’re a basic necessity.

Siers-Poisson [00:31:24] What further research would you like to do or see done on this topic of menstrual equity?

Sebert Kuhlmann [00:31:31] We have so many questions that we still need to answer. Some of the important questions that I think are around intervention and the effectiveness of those interventions. Can we show that doing interventions through schools or through policy or through community service organizations reduces absenteeism at school and at work? That we do education and information campaigns that help reduce stigma? Can we show that we’re moving the needle? Awareness of this issue has increased pretty dramatically in the last 5 to 7 years in the United States. So we’re getting more and more research around what the issues are for whom under what circumstances. And we think the next step is really then to be able to show that we can have an impact, that we can make change for better.

Siers-Poisson [00:32:34] And Anne as we wrap up, is there one thing you’d like people to take away from this conversation?

Sebert Kuhlmann [00:32:41] Definitely. This is an issue that affects everyone. You personally might not have a period, but you know someone who does. Right? Loved ones, friends, mother, sister, daughter, girlfriend, partner. And so it’s really going to take all of us to address the issue that starts with talking about it, trying to reduce some of the stigma, the fact that it’s taboo. That’s a first step. Being willing to support interventions and policies that are designed to address it, supporting the individuals in your life who might be experiencing challenges with menstruation and menstrual hygiene. It’s really going to take all of us.

Siers-Poisson [00:33:26] Anne thank you so much for taking the time to discuss your research with us. It’s really interesting and really important work.

Sebert Kuhlmann [00:33:32] Well, you’re welcome and thank you so much for having me. It’s been my pleasure.

Siers-Poisson [00:33:37] Thanks so much to Dr. Anne Sebert Kuhlmann for joining us to discuss her research on the impacts of menstrual poverty and the practice and policy options that can increase menstrual equity. The production of this podcast was supported in part by funding from the U.S. Department of Health and Human Services Office of the Assistant Secretary for Planning and Evaluation. But views expressed by our speakers don’t necessarily represent the opinions or policies of that office or of any other sponsor, including the University of Wisconsin-Madison. Music for the episode is by Poi Dog pondering. Thanks for listening.