PolicyLab

Editor’s note: This is part of our Teen Health Week blog post series, which focuses on understanding and addressing the unique health needs of adolescents. We invite you to check back for new posts or to follow along for updates on Twitter at @PolicyLabCHOP.

Period poverty is defined as inadequate access to menstrual hygiene tools and education, including but not limited to sanitary products, washing facilities and waste management. While the term period poverty is relatively new in medical literature, menstrual hygiene management has been discussed for decades in the context of the gender gap in education for youth living in low- and middle-income countries.

As a group of adolescent health specialists and advocates with lived experience on this issue, we are breaking down how this affects youth globally and locally, offering our personal insights on the real-life impacts of period poverty on youth (indicated by italics) and sharing ways everyone working with adolescents can make a difference.

A global perspective on period poverty

According to a 2014 United Nations Educational, Scientific and Cultural Organization (UNESCO) report, 1 out of every 10 menstruating youth misses school during their menstrual cycle due to lack of access to menstrual products and resources. For example, menstruators in developing parts of the world, such as sub-Saharan Africa, are prone to using paper, old clothes, leaves, cotton, or wool pieces rather than more traditional menstrual products like disposable pads or tampons. Many schools in developing nations have insufficient toilets and inadequate privacy measures, as well as poor water, sanitation and hygiene infrastructure, making it difficult for students to safely manage their menstrual cycle.

Grace Clarke, an assistant researcher at Children’s Hospital of Philadelphia (CHOP) and master’s of public health student at La Salle University, grew up in Monrovia, Liberia and shares her experiences with this issue:

I personally had instances when the only means to manage my menstrual cycle was to use old clothes or tissue because my family couldn’t afford to purchase menstrual products. As I gained more knowledge of period poverty in my community, I became more passionate about addressing this issue. In 2019, my younger sister, Lovetta Qualah, and I founded a nonprofit organization called Positive Action Driving Safety for Girls (PADS for Girls). We provide sanitary products to young, disadvantaged youth in rural parts of Liberia. By improving access and education about basic health needs, we are able to help youth at risk of poor health outcomes due to the undermining forces of poverty and stigma.

What do we know about period poverty in the United States?

The lived experiences around menstruation for people living in poverty in the U.S. are quite similar to those in low- and middle-income countries. Shelby Davies, a fellow in CHOP’s Division of Adolescent Medicine, shares how this has impacted her patients in Philadelphia:   

In spring 2020, as the COVID-19 pandemic began to shut down access to many services, I was approached by a colleague about a patient who badly needed menstrual products but could not afford them. Knowing my interest in the area, my colleague asked if I had any resources to share. The patient was in her late teens and had reached out in a moment of crisis in need of free menstrual pads. Her family did not have money for pads, and she often needed to use toilet paper as a replacement, which was both annoying and embarrassing. She had also become quite dependent on the pads she receives from her school, which was now closed due to the pandemic. I was saddened to learn that there were so few local organizations that could offer assistance.

Menstrual products are expensive in the U.S. In a national survey of 1,000 menstruating teens, 1 in 5 struggled to afford period products and 4 in 5 either missed or knew someone who missed class time because they did not have access to period products. Unfortunately, government benefits, such as the Supplemental Nutrition Assistance Program (SNAP) and the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), do not cover the cost of these necessary supplies. While the Coronavirus Aid, Relief, and Economic Security Act made period products medical expenses eligible for purchase with flexible spending accounts or health savings accounts, uninsured individuals cannot access this benefit.  

Many students rely on menstrual products purchased and supplied by school districts and stored within a school clinic or school nurse’s office. There are at least 14 states and local jurisdictions with proposed legislation to ensure that menstrual products are readily available in school bathrooms. However, many of these bills don’t allocate corresponding funding, leaving it up to school districts to purchase these products. Despite local efforts, menstrual products provided by schools are now unavailable to many youth with school closures due to the pandemic.

What is CHOP doing to raise awareness about period poverty?

Recognizing that this could be an unmet need for our adolescent patients, a team within CHOP’s Division of Adolescent Medicine is working on a quality improvement project to assess period poverty among youth seen in our adolescent specialty clinic. For youth who screen positive, we created a handout with resources for free or low-cost menstrual products in Philadelphia, and we hope to expand screening efforts into the CHOP Primary Care Network.

We have also started recruitment for a PolicyLab pilot grant research study that aims to use personal narratives to explore the lived experiences of adolescents who menstruate, understand the barriers and facilitators to adequate menstrual health and hygiene, and investigate the impact of shame and stigma on menstruating teens. In addition, we have expanded our efforts into the community through a spring 2020 CHOP Cares Grant to assess the need for menstrual products among youth experiencing housing instability in CHOP’s Homeless Health Initiative shelters. 

What can researchers, providers, policymakers and adolescent health experts do to help?

Based on what we have learned from our own work, we can offer a few insights and tips for those who want to make an impact here in our community and around the world.

1. Normalize conversations about periods. This is crucial to reducing shame and stigma and offering effective solutions.
2. Talk to teens about how they purchase menstrual products. This is as important to understanding their menstrual health as frequency or duration of periods.
3. Continue research to better understand the scope of the problem. We know this issue is impacting youth, but more research will be critical to further advocacy efforts.
4. Build a coalition of advocates within the medical community. Lack of access to period products can lead to poor health outcomes and should be seen as a medical issue. Children’s hospitals should consider availability of menstrual products within their own institutions and how they can position themselves as a part of the solution.
5. Serve as advocates for key issues. There are several bills in Pennsylvania that could have an enormous impact on accessibility and affordability of menstrual products in the state, including bills that require Pennsylvania public schools and colleges and agencies that serve low-income, homeless and incarcerated populations to supply free pads and tampons. We encourage policymakers to support and invest in policies that not only improve widespread access to menstrual products but also help cover the cost when these products are distributed by school districts.

By addressing period poverty head on, one day, when a patient asks for help, we may be able to offer a concrete solution. And perhaps, one day, our patients may not even need to ask at all.

Shelby Davies, MD, is an affiliate trainee at PolicyLab and a medical fellow in Children’s Hospital of Philadelphia’s Division of Adolescent Medicine.

Grace Clarke is an MPH student at La Salle University.

Noreena Lewis, JD, is the community pediatrics and advocacy program coordinator for CHOP’s Residency Program.