Across the world, an estimated 1.9 billion people menstruate, and yet about 500 million people experience substandard access, safety, and autonomy to manage their cycles—an epidemic of menstrual equity (1,2). In the United States, two-thirds of the 16.9 million menstruating people living in poverty could not afford menstrual products, with half of this population needing to choose between buying menstrual products or food (3).  Black and Latinx menstruators in the United States reported the highest level of “period poverty” experiences and studies report this inequity in access by culture and race will only continue to worsen (4). However, little information exists on the experiences of South Asian menstruators in the United States, raising concerns for understudied barriers to achieving equity for all American communities.

Menstrual equity is most recognized as access to affordable and safe menstrual products, to sanitary and stigma-free spaces to manage cycles, and menstruation education (2).  Most of the data on the challenges in accessing products remains globally focused, with notable emphasis on South Asia. Studies from India specifically note that about 40% of menstruators miss school and several use health damaging alternatives like “rags, hay, sand and ash”—data consistent with documented menstruator experiences in Bangladesh, Pakistan, Sri Lanka, and Nepal (5,6). Cultural and religious menstrual stigma is an additional concern in the South Asian subcontinent (7). Nepali and Indian Hinduism forbid menstruators from entering temples or kitchens or touching relatives; a qualitative study on attitudes and experiences of Nepali women reveals monthly ritual seclusion leading to missed school and social isolation despite a 2018 ban against this practice (7,8). In urban settings, menstruators in Bangladesh report poor work performance during their menses, leading to career impacts (9). This cultural stigma in South Asian communities raises concerns for ongoing, understudied cultural biases impeding menstrual equity in the South Asian diaspora in the United States (3).

While South Asians have been in the United States since the 1700s, it was only after the growing strength of the Civil Rights movement and passage of the Immigration and Nationality Act of 1965, that South Asians were able to migrate without facing discriminatory quotas (10). Second generation South Asians, however, note they continue to be seen as “foreign” despite being born in the United States and remain invisible in equity work (10).

Despite growth in the South Asian population in the United States from 2.2 million to 4.9 million from 2000 to 2015, these communities continue to be underrepresented in gynecological health disparities research (10). A scoping review on barriers to recruiting South Asians to research noted community concerns around “logistical challenges, language and cultural barriers, and mistrust of research” (17). Research on South Asians accessing mental health resources notes limited knowledge of available resources and low health seeking behaviors (18). There are no available articles describing South Asian gynecological representation in research in the United States.

Some speculate this is due to the model minority myth, a gross oversimplification of a complex and growing immigrant community in which Asian Americans are seen as a successful and high achieving monolith, hiding concerning disparities within these communities (16). The 2000 Census data notes that about 13.2 to 29.5% of the South Asian diaspora are living below 125% of the poverty level; these families likely face similar financial stresses as their White, Black and Latinx counterpart communities, who have long reported impeded access to menstrual products due to taxation and cost (10). South Asians also live in large numbers in areas of the United States, such as North Carolina and Georgia, where menstrual equity legislation is lacking (10, 11). Most importantly, South Asians represent a large diverse group of varying cultures, religions, and customs transplanted from their countries of origin. Articles by South Asian diasporic writers describe not being able to discuss their first period with their families or having to access other resources to address their questions (12,13). This silence around menstrual barriers at home persists even at the physician’s office.  Many obstetrician-gynecologists do not discuss menstrual equity or menstrual management technologies regularly in their counseling process (15). Several studies describe cross cultural communication challenges when discussing contraception for Black and Latinx patients, however, the shared issues of language and cultural barriers remain understudied in South Asian gynecological health decision making (15). Researchers conducted a qualitative study focusing on the access of sexual and reproductive health services among South Asian women in the United Kingdom (14). They found that many South Asian women were uncomfortable accessing services and asking health care professionals about their concerns (14).

The overall impact of these known political, cultural, and clinical factors on South Asian cultures on menstrual equity remains unknown, contributing to ongoing epidemic of reproductive disempowerment in the United States.  Access to safe reproductive care is being progressively limited by new state-based abortion restrictions after the Dobbs decision and state based transgender care restrictions (19). These laws further cement long known challenges to equitable gynecological care, such as forced sterilizations, contraception access, and infertility care. We call for action for community led research on the barriers to accessing menstrual products, to hopefully develop solutions to address the role, if any, of cultural and religious stigmas in the South Asian diaspora and their fight for menstrual equity. This includes increasing federal funding for South Asian gynecological research, inclusion of gynecological research in known South Asian Health Initiatives, studies on the impact of South Asian OBGYN physicians on improving access and choice to South Asian patients, and more research to detail the nuances in barriers to gynecological care for this diverse, complex community. A nuanced understanding of the determinants of menstrual stigma could effectively catalyze South Asian diasporic community towards cultural and clinical menstrual advocacy.

References:

1. The Kulczyk Foundation and Founders Pledge, A BLOODY PROBLEM: Period poverty, why we need to end it and how to do it, Report (Warsaw: The Kulczyk Foundation, October 2020).
2. Alison Choi, How Social Media Helps Reduce Menstrual Stigma, Blog (Washington: Borgen Project, October 30, 2020).
3. Michel J, Mettler A, Schönenberger S, Gunz D. Period poverty: why it should be everybody’s business. Journal of Global Health Reports. 2022;6:e2022009. doi:10.29392/001c.32436
4. Cardoso, L.F., Scolese, A.M., Hamidaddin, A. et al.Period poverty and mental health implications among college-aged women in the United States. BMC Women’s Health 21, 14 (2021).
5. Sommer M, Mason DJ. Period Poverty and Promoting Menstrual Equity. JAMA Health Forum.2021;2(8):e213089. doi:10.1001/jamahealthforum.2021.3089
6. What Is Period Poverty? | Feminism in India
7. Kuhlmann AS, Henry K, Wall LL. Menstrual Hygiene Management in Resource-Poor Countries. Obstet Gynecol Surv. 2017 Jun;72(6):356-376. doi: 10.1097/OGX.0000000000000443. PMID: 28661550; PMCID: PMC5482567.
8. Crawford, Mary, et al. “‘This Is a Natural Process’: Managing Menstrual Stigma in Nepal.” Culture, Health & Sexuality, vol. 16, no. 3/4, 2014, pp. 426–39. JSTOR, http://www.jstor.org/stable/24741288. Accessed 3 May 2023.
9. Zaman, R.T.and Mohiuddin, M.F. (2021), “Impact of menstruation-related stigma and behavior on female employee performance in Bangladesh: mediating role of non-work related stress”, South Asian Journal of Business Studies, Vol. ahead-of-print No. ahead-of-print. https://doi.org/10.1108/SAJBS-08-2020-0274
10. Microsoft Word – Demographic Characteristics of SA in US – 08.16.07 (saalt.org)
11. 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
12. McHugh MC. Menstrual Shame: Exploring the Role of ‘Menstrual Moaning’. 2020 Jul 25. In: Bobel C, Winkler IT, Fahs B, et al., editors. The Palgrave Handbook of Critical Menstruation Studies [Internet]. Singapore: Palgrave Macmillan; 2020. Chapter 32. Available from: https://www.ncbi.nlm.nih.gov/books/NBK565666/ doi: 10.1007/978-981-15-0614-7_32).
13. https://theswaddle.com/how-indian-womens-mental-health-is-deeply-tied-to-proper-menstrual-care/
14. Vaishali Kiridaran, Mehar Chawla & Julia V. Bailey(2022) Views, attitudes and experiences of South Asian women concerning sexual health services in the UK: a qualitative study, The European Journal of Contraception & Reproductive Health Care, 27:5, 418-423, DOI: 1080/13625187.2022.2096216
15. Liberty, Abigail MD, MSPH; Samuelson Bannow, Bethany MD; Matteson, Kristen MD, MPH; Edelman, Alison MD, MPH; Colwill, Alyssa MD, MCR. Menstrual Technology Innovations and the Implications for Heavy Menstrual Bleeding. Obstetrics & Gynecology 141(4):p 666-673, April 2023. | DOI: 10.1097/AOG.0000000000005126
16. Kim JHJ, Lu Q, Stanton AL. Overcoming constraints of the model minority stereotype to advance Asian American health. Am Psychol. 2021 May-Jun;76(4):611-626. doi: 10.1037/amp0000799. PMID: 34410738; PMCID: PMC8384115.
17. Quay, Teo AW, et al. “Barriers and facilitators to recruitment of South Asians to health research: a scoping review.” BMJ open5 (2017): e014889.
18. Islam, Farah, et al. “Mental health of South Asian youth in Peel Region, Toronto, Canada: A qualitative study of determinants, coping strategies and service access.” BMJ open11 (2017): e018265.
19. Kaufman R, Brown R, Martínez Coral C, Jacob J, Onyango M, Thomasen K. Global impacts of Dobbs v. Jackson Women’s Health Organization and abortion regression in the United States. Sex Reprod Health Matters. 2022 Dec;30(1):2135574. doi: 10.1080/26410397.2022.2135574. PMID: 36383177; PMCID: PMC9673802.

Authors

Prema Vyas

Prema Vyas is a medical student at the Texas Christian University School of Medicine and is a 2022-2023 Aseemkala Initiative Research Fellow. She is currently researching the experiences around menstrual equity in the South Asian diaspora.

Ruta Sachin Uttarkar

Ruta Sachin Uttarkar is a medical student and a masters of public health candidate at the University of Texas Southwestern Medical School. She is also a 2020-2021 Aseemkala Research Fellow and is currently researching contraceptive options and attitudes of the South Asian diaspora.

Shilpa Darivemula

Shilpa Darivemula is an obstetrician-gynecologist currently pursuing a Generalist Reproductive Health Fellowship, with a focus on clinical research and epidemiology, at University of North Carolina with the Department of Obstetrics and Gynecology and the Gillings School of Public Health. She is the director of the Aseemkala Initiative (www.aseemkala.org) and Race.Culture.OBGYN (www.racecultureOBGYN.org) with a dedication to improving reproductive medicine disparities research and cultural Health Humanities. Her work has been published in the AMA Journal of Ethics, Academic Medicine, in-House, Empiric Bioethics, and Journal of Women’s Health.

Declaration of interests

We have read and understood the BMJ Group policy on declaration of interests and declare the following interests: none.