This is the first blog in our series that examines how social determinants influence gender biases in public health research, menstrual hygiene product development, and women’s health outcomes.
Worldwide, over 100 million women use tampons every day as they are the most popular form of menstrual products. U.S. women spent approximately $1 billion from 2016 to 2021 on tampons, and 22% to 86% of those who menstruate use them during their cycles, with adolescent girls and young adults preferring them. Tampons and pads are the most practical and common option for those who are working and have limited funds. Yet, a recent pilot study exposed concerning amounts of lead, arsenic, and toxic chemicals in tampons: 30 different tampons from 14 brands were evaluated for 16 different metal(loid)s, and tests indicated that all 16 metal(loid)s were detected in all different samples. This news comes as quite a shock to women who use these products. It raises many concerns and questions for those who do not have other viable options when they menstruate. We explore some of the major questions and concerns regarding the products on the market and their potential to increase the risk of exposure to harmful contaminants. It is clear that beyond this pilot study, further research is required to understand the potential health challenges.
Unpacking the potential risks for those who use menstrual products
Measurable concentrations of lead and arsenic in tampons are deeply concerning given how toxic they are. The World Health Organization (WHO) classifies lead as a major public health concern with no known safe exposure level. Arsenic can lead to several health issues such as cancer, cardiovascular disease, and diabetes. There are three ways in which these metal(loid)s can be introduced into the product: 1) from the raw materials that absorbed the soil and air, like the cotton used in the absorbent core; 2) contamination from water during the manufacturing process; and 3) intentionally being added during the manufacturing process for certain purposes. No matter how these metal(loid)s are introduced into the product, the pilot study stresses that further research must be done to explore the consequences of vaginally absorbed chemicals given the direct line to the circulatory system.
On an institutional level, the public health system has historically been biased toward the male perspective, essentially excluding research related to women’s health. In 1977, the U.S. Food and Drug Administration (FDA) recommended that women of childbearing age should be excluded from clinical research. Because of this gendered bias, many women now experience delayed diagnoses, misdiagnoses, and suffer more adverse drug effects; eight out of 10 of the drugs removed from U.S. markets from 1997 to 2000 were almost exclusively due to the risk to women. In 1989, the National Institutes of Health (NIH) amended its policy to include women and minorities in research studies, but it wasn’t until 1993 that this policy became federal law in the NIH Revitalization Act of 1993. Then, in 2016, the NIH implemented a policy requiring the consideration of sex as a biological variable in research.
Historically, women haven’t been in control of the various industries that support their unique health needs and develop products that allow them to manage their health in safe ways. In spite of this, women-owned businesses have increased over time, with many of them supporting a range of products, services, and health and child care needs. Changes in these industries can lead to a better understanding of how certain products aid or impede women’s health trajectories.
Racialized and gendered bias in health research
The life expectancy of women continues to be higher than men’s. That does not suggest there has been universal nor equitable support for women’s health issues and women’s health care. Black women are three times more likely to die from pregnancy-related issues. They also experience racism and differential treatment in health care and social service settings. This reality becomes starker when stigma and bias influence negative behaviors toward Black women and other women of color, and socioeconomic status limits access to preventative care, follow-up care, and other services and resources.
Toxic menstrual products are just the tip of the iceberg for gender bias in health research. Gendered bias extends into how health care professionals evaluate men and women differently based on the stereotypical ideas of the gender binary. This results in those who are perceived as women receiving fewer diagnoses and treatments than men with similar conditions, as well as doctors interpreting women’s pain as stemming from emotional challenges rather than anything physical. In a study comparing a patient’s pain rating with an observer’s rating, women’s pain was consistently underestimated while men’s pain was overestimated. Women’s pain is often disregarded or minimized by health care professionals, as they often view it as nothing more than an emotional exaggeration or are quick to blame any physical pain on stress. This has led to a pain gap in which women with true medical emergencies are pushed aside. For instance, the Journal of the American Heart Association reported that women with chest pain waited 29% longer to see a doctor in emergency rooms than men.
For people of color, especially Black women, the pain gap, as well as the gap in diagnoses and treatment, is exacerbated due to the intersectionality of gender, race, and the historical contexts of Black women’s health in America. Any analysis must consider the unique systemic levels of sexism and racism they face as being both Black and women. They face a multifaceted front of discrimination, sexism, and racism, in which doctors don’t believe their pain due to implicit biases against Black people—a dynamic that stems from slavery, during which it was common belief that Black people had a higher pain tolerance—and women. A study found that white medical students and residents believed at least one false biological difference between white and Black people and were thus more likely to underestimate a Black patient’s pain level.
Intersectionality, as well as sexism, further explains why medical students that believe in racial differences in pain tolerance are less likely to accurately provide treatment recommendations or pain medications. A Pew study found that 55% of Black people say they’ve had at least one negative experience with doctors, where they felt like they were treated with less respect than others and had to advocate for themselves to get proper care. Comparatively, 52% of younger Black women and 40% of older Black women felt the need to speak up to receive care, while only 29% of younger Black men and 36% of older Black men felt similarly. Particularly among Black women, 34% said their women’s health concerns or symptoms weren’t taken seriously by their health care providers. This even happened to Serena Williams!
Restructuring the health system
On Tuesday, September 11, 2024, the FDA announced they would investigate the toxic chemicals and metals in tampons as a result of the pilot study. This comes after public outcry and Senator Patty Murray’s (D-Wash.) letter to FDA Commissioner Robert M. Califf asking the agency to evaluate next steps to ensure the safety of tampons and menstrual products. In her letter, she specifically asks what the FDA has done so far in their evaluations and what requirements they have for testing these products, ensuring a modicum of accountability within this market. As of July 2024, the FDA classifies tampons as medical devices and does regulate their safety but only to an extent, with no requirements to test menstrual products for chemical contaminants (aside from making sure they do not contain pesticides or dioxin). The pilot study on tampons containing harmful metals was the first of its kind, which sheds light on how long women’s health has been neglected. Regulations requiring manufacturers to test metals in tampons need to be implemented, and future studies on the adverse health impacts of metals entering the bloodstream must be prioritized. The FDA investigation will hopefully be a step in the right direction toward implementing stricter regulations.
For too long, the health field has been saturated with studies by and for men. Women’s health, on the other hand, faces inadequate funding, a lack of consideration for women’s lived experiences, and the need for more women leading research teams investigating women’s health. Women, especially those who face economic and social disparities, have the capacity to break barriers and address real issues that impact millions of women each day but only if they are brought to the table. With structural change, we can address how women’s concerns are undermined and put forth efforts to determine new and effective measures for women’s health.
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Acknowledgements and disclosures
The Brookings Institution recognizes individual diverse gender identities and is committed to upholding our values of diversity, equity, and inclusion while striving to use gender-inclusive language in our publications. Based upon the literature we have examined, this series uses definitions to highlight the gender spectrum, and the preferred language will be to use “women” and “men” referencing those who self-identify as these genders. Brookings acknowledges that non-binary and gender non-conforming individuals may face similar and different barriers and challenges to those who self-identify as women and men. The term is intended to include those who are discriminated against based on their gender identities and biological sex.
Commentary
Toxic tampons and gender bias in health research
October 17, 2024