Menstrual health inequities and “period poverty” in Canada

Abstract

Period poverty is the lack of access to menstrual products, sexual and reproductive health education, safe waste management, and adequate facilities. Despite its being a public health issue and a significant concern for numerous Canadians, there is a lack of peer-reviewed research on period poverty in Canada. Existing Canadian research has primarily been conducted by non-profit organizations/charities or industry leaders for menstrual products, resulting in incomplete data. More research is needed to explore the menstrual inequities in Canada and their impact on the well-being of Canadians. This is a critical step to ensure the menstrual needs of Canadians are appropriately addressed.

Introduction

Period poverty is the lack of access to essentials such as menstrual products, sexual and reproductive health education, safe waste management, and facilities like toilets and handwashing stations (Rodriguez, 2022). It is a global health issue that affects menstruating individuals worldwide, including those residing in Canada. The consequences of period poverty include social isolation, lost opportunities in school or work (United Way British Columbia, 2021), shame/distress (Barrington et al., 2021), and suboptimal practices (Plan International Canada, 2022) that can result in urogenital infections (Das et al., 2015) such as toxic shock syndrome (Berger et al., 2019). Period poverty is also influenced by the stigma associated with menstruation. In many areas worldwide, menstruation is often viewed as something shameful or dirty that should be concealed (Hennegan et al., 2019). This social and cultural stigma prevents open discussions, the normalization of menstruation, and comprehensive menstrual health education (Hennegan et al., 2019).

Despite the potential social and physical health risks of period poverty, there is a stark lack of North American peer-reviewed research in this area with most focusing on low- and middle-income countries (Patel et al., 2022; Rossouw & Ross, 2021). While research from the United States and other high-income countries is mounting (Cardoso et al., 2021; Sebert Kuhlmann et al., 2019), Canada lags behind. Recent statements from large medical organizations have recommended increased awareness and research in this area to better understand the health implications of menstrual inequity (Harrison et al., 2022; Wyckoff, 2023). The majority of period poverty research in Canada has been conducted by non-profit organizations/charities or industry leaders for menstrual products leading to incomplete and potentially non-inclusive and biased data.

Period poverty in Canada

From the limited data available, period poverty appears to be a significant issue in Canada. In a recent Canadian non-profit organization survey, 21% of people who menstruate (> 13 years old, n = 1074) reported that they have struggled to access menstrual products for themselves or their dependents due to the high financial burden, and approximately one quarter have rationed or used menstrual products longer than recommended due to financial constraints (Plan International Canada, 2022). In 2019, it was estimated that people who menstruate pay at least $6000 in their lifetime for menstrual products in Canada (Craggs, 2018); this is likely an underestimate now given recent inflation in prices. The financial demands of menstruation also vary from person to person given individual variations in menstrual cycle length and flow, and product choice, as well as associated costs of items like pain relievers for those with painful periods. Additionally, the price of menstrual products increases in rural communities, where the cost can be almost doubled due to limited transportation (Craggs, 2018; United Way British Columbia, 2021). For example, in Indigenous communities, one box of tampons can cost between $16 and $45 (Rushowy, 2021).

Period poverty disproportionately affects marginalized and lower socioeconomic groups such as those with low income, those experiencing homelessness, and non-binary or transgender individuals (Barrington et al., 2021). Other socioeconomic factors include lower levels of education, living rurally, and poor housing quality (Rossouw & Ross, 2021). Furthermore, marginalized communities such as women, people experiencing homelessness, people living with disabilities, people involved in the justice system, immigrants and refugees, Indigenous people, racialized individuals, children and youth in care, and 2SLGBTQ + individuals are more likely to experience poverty in Canada (National Advisory Council on Poverty, 2023). Thus, these individuals are vulnerable to the high financial burden of menstruation as it can decrease their limited disposable income. In a survey conducted in British Columbia (n = 710), Indigenous people and people living with physical or mental disabilities were almost twice as likely to experience a period without menstrual products compared to others who menstruate (United Way British Columbia, 2021).

Another Canadian survey showed that over 50% of women and girls (14–55 years old, n = 2028) occasionally miss activities because of their period and concerns about inadequate access to menstrual products or appropriate facilities; 12% said they regularly do so (Plan International Canada, 2019). There is also a lack of standardized, consistent menstrual health education in Canada. In a survey sponsored by a menstrual product company, almost 25% of young people (13–21 years old, n = 1095) in Canada have inadequate knowledge about the biological process and management of menstruation (Always, 2020).

These surveys have shed some light on period poverty in Canada; however, there is still a lack of representation across Canada as some surveys focused only on one province (United Way British Columbia, 2021) or excluded the territories (Plan International Canada, 2019). Most surveys used online platforms (Always, 2020; Plan International Canada, 2018, 2019, 2022), which prevented those without internet access and devices from participating. In addition, these surveys run the risk of sampling bias when online survey panels from research companies are used (Plan International Canada, 2018, 2019, 2022), and some did not account for marginalized communities (Always, 2020; Plan International Canada, 2018, 2022).

One Canadian peer-reviewed study examined the impact of period poverty on adolescents (< 18 years old, n = 420) in Nova Scotia through a web-based questionnaire and found that access to menstrual products is a significant concern (Lukindo et al., 2022). Of 420 respondents, 65% shared that they occasionally could not purchase menstrual products due to a lack of funds; 37% have resorted to using rags and/or toilet paper as alternatives, and 22% have washed soiled disposable menstrual products for reuse (Lukindo et al., 2022). Furthermore, 40% of respondents have missed school, sports/gym, and/or social activities while menstruating due to a lack of menstrual products (Lukindo et al., 2022). Over half of respondents reported that having free menstrual products available in school has helped when they could not afford their own (Lukindo et al., 2022). This study, although small in size, highlights that poor access to menstrual products is an issue that requires more attention.

The movement to end period poverty

There has been a global movement to end period poverty. In 2020, Scotland was the first country to pass a law that ensured menstrual products were free and accessible to any person who needs them (Rodriguez, 2021). In New Zealand, Kenya, and Botswana, free menstrual products are provided to all students in public schools (Rodriguez, 2021). France has also made it a requirement for French universities to install free menstrual product dispensers to support post-secondary students (Rodriguez, 2021). In the USA, multiple states such as Virginia, Illinois, Washington, and New Hampshire have passed legislation to increase access to menstrual products (Rodriguez, 2021).

Across Canada, there have been several policies and programs created to address period poverty. In 2015, the federal government removed the Goods and Services Tax (GST) on menstrual products to help alleviate the financial burden (National Union of Public and General Employees, 2022). In 2021, the federal government promised to provide free menstrual products to all students in First Nations–operated schools on First Nations reserves and in federal schools across Canada (George, 2022). For First Nations and Inuit students living in Yukon, Northwest Territories, and Inuit Nunangat, the federal government has committed $2.5 million to increase access to menstrual products (George, 2022). The government also allocated $25 million in 2022 to create the Menstrual Equity Fund for non-profit organizations, charities, and community organizations to increase the accessibility of menstrual products in Canada (National Union of Public and General Employees, 2022; The Canadian Press, 2023). In addition, the federal government has amended the Canada Labour Code in 2023 to ensure free menstrual products are provided in federally regulated workplaces (The Canadian Press, 2023).

Canadian provincial governments are also taking steps to stop period poverty, each with varied approaches. British Columbia, Ontario, Nova Scotia, and many other provinces now provide free menstrual products to students in public schools (National Union of Public and General Employees, 2022). In New Brunswick, schools with grade 6–12 students have free menstrual products provided in female and gender-neutral washrooms and locker rooms (National Union of Public and General Employees, 2022). In Newfoundland and Labrador, the government committed to offering free menstrual products in at least 1 washroom in every school with students in grade 4 and above (National Union of Public and General Employees, 2022). After receiving feedback from youth, pediatric hospitals like CHEO in Ontario provide free menstrual products in all of the hospital washrooms as well (Raymond, 2020).

Measuring the impact of addressing period poverty

The potential impact of providing free products is significant, from increasing school and work attendance to decreasing financial burden and inequalities among menstruators, as well as reducing stigma. One high school in New York found a 2.4% increase in attendance after a pilot project where free menstrual product dispensers were installed at their school (Pennell, 2016). A recent qualitative study done in Indiana examined students’ experiences of free period products on a university campus and found a link between the school providing free products and an attitude shift regarding menstruation; students felt that providing free products helped reduce the social stigma of menstruation for many (Rawat et al., 2023). Research is needed on the current initiatives in Canada to evaluate their effectiveness in reducing period poverty and the impact on Canadians (United Way British Columbia, 2021).

Environmental considerations

Another area of important focus is the impact and feasibility of reusable menstrual products on reducing period poverty in Canada (United Way British Columbia, 2021). Although measuring the environmental impact of disposable menstrual products is complex, it has been shown that the manufacturing processes and the ingredients used in the products themselves (cotton versus plastics) and their packaging as well as the volume of products used and disposed of globally all contribute to fossil fuel depletion, gas emissions, and tons of non-biodegradable waste in landfills (Harrison & Tyson, 2023). Single-use menstrual products (and their packaging) are one of the most commonly found items on beaches and in oceans (Peberdy et al., 2019). Reusable menstrual products, such as the menstrual cup, reusable pad, and period underwear, are thought to decrease the environmental load for a variety of reasons, including creating less waste overall per menstruator, although research is ongoing. Most reusable products are more expensive than disposable products upfront; however, they appear to be more cost-effective in the long run (Mahajan, 2019; van Eijk et al., 2019). That said, they also require access to safe water and facilities for cleaning (Harrison & Tyson, 2023). Some remote areas in low-middle-income countries are tackling poor menstrual product access and high costs by making reusable pads locally (Tamiru et al., 2015). Further research exploring the environmental impact of both disposable and reusable period products is needed, as well as more examination of how reusable products could lessen period poverty.

Future directions

More peer-reviewed research is needed to explore the menstrual inequities in Canada and how they affect the overall physical and mental health of Canadians, especially historically excluded populations. Understanding the barriers that disproportionately impact marginalized communities will help ensure that Canada’s approach to ending period poverty is equitable. Additionally, the less recognized components of period poverty (such as private facilities, waste disposal, and menstrual health education) need to be explored more deeply and the impact of new initiatives needs to be measured in a continuous, multifaceted way.

Conclusion

Menstruating safely and comfortably is a human right and is a public health issue (Sommer et al., 2015). Healthcare providers are encouraged to increase their own awareness of period poverty and take action from an advocacy level whether it be for their individual patient, their workplace, or at a greater systems level. Higher-quality and larger-scale research is needed to better define period poverty in Canada and its health ramifications; this will ultimately guide where and how policies/initiatives should be implemented or altered to address the menstrual needs of all Canadians.

Author contributions

ACL contributed to the design, drafting, and revision. LT contributed to the design and revision. MEH contributed to the conception, design, and revision. All authors approve this manuscript for publication and agree to be accountable for all aspects of the work.

Availability of data and material

Not applicable.

Code availability

Not applicable.

Declarations

Conflict of interest

The authors declare no competing interests.

Ethics approval

Not applicable.

Consent to participate

Not applicable.

Consent for publication

Not applicable.