Stigma and early-onset menstruation
Forty-six years after her first period Tanya Byham can still recall the shock and horror she felt when she saw the blood. “I was nearly 10 years old. I thought that I was haemorrhaging,” she says. “It was so painful that it felt like someone was pulling something from inside of me.
I thought it would never stop.”
Byham, who lives in Hobart, was the first of her friends to experience menarche – the onset of menstruation – and because it came sooner than expected, her mother hadn’t prepared her for the reality of puberty. Byham became withdrawn and antisocial. Her confidence ebbed away.
There were practical challenges, too. No bins in the primary school toilets meant Byham carried used sanitary pads around in her bag – “I will never forget the smell” – and being too young for tampons meant that during her period the pool and beach were out of the question. “I felt like a freak,” she says.
Statistics show the age at which girls typically start menstruating has dropped from 16.5 years to 12.5 years since industrialisation. But some girls start far sooner. In fact, some experts claim that as many as 8 to 10 per cent of girls get their first period before their 11th birthday.
Some take menarche in their stride. “I’ve seen girls who think it is a positive thing,” says Dr Charlotte Elder, of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists. “They feel proud that they are growing up and able to manage something adult, like a period.”
But for other girls with early menarche the mental health toll can be huge. “Some find it hard to manage their periods and have had accidents leaking onto their clothes. This can lead to stress and a few of my patients have anxiety around this,” Elder says.
The stress shouldn’t be underestimated. Elder notes that some of her young patients have required psychology or psychiatric care to help them adjust to life with a menstrual cycle.
Professor George Patton is an epidemiologist with a clinical background in child and adolescent psychiatry. He says there is a clear link between early menarche and mental health difficulties. “There is little doubt that girls who begin their periods at an earlier age tend to have higher rates of emotional problems, including anxiety and strong feelings of unhappiness and anger than those who begin periods later,” he says.
Patton says that some are more at risk of developing mental health difficulties than others. “Girls who have a history of difficulties in family and peer relationships are more at risk for emotional problems in the transition through puberty.”
Patton’s research has also found that children who grow up poor are much more likely to hit puberty early than children from higher socioeconomic groups.
Worryingly, the mental health issues that arise in puberty can hang around well into maturity. A new study from Cornell University found that girls who begin their periods early are more likely to experience psychological problems in adulthood. Researchers tracked 8000 girls from adolescence through to their late 20s. They found the younger the girl began menstruating, the more likely she was to report symptoms of depression. And as participants approached their 30th birthdays, the links between early periods and depression were still apparent. Dr Jane Mendle, who led the study, notes that the level of the association was just as strong as it had been in adolescence. “To me, that was the most interesting finding: that the effect lingered at the same strength,” she said.
Mendle says that there isn’t enough research available to explain why early periods could lead to psychological problems during adulthood. One hypothesis is that it’s because the propensity for depression has been sustained over time.
“Puberty is a complicated psychological experience and it holds repercussions for virtually all domains of life,” Mendle tells me. “Even though it’s a biological transition, it’s accompanied by dramatic changes in relationships, emotions, and how kids think about themselves and their place in the world.”
While Mendle notes that depression and antisocial behaviour are rooted in many different factors, with puberty playing only a small role, she says a lack of understanding about the long-term effects of early puberty is a public health issue.
Tanya Byham isn’t surprised to learn that girls who start menstruating early can experience mental health difficulties into adulthood. “I was only diagnosed with depression and anxiety in perimenopause even after going to the doctor for years asking for help,” she says.
Although Byham concedes she might have developed depression anyway, she can trace feelings of self-loathing back to her first period. “I had no confidence and despised how I looked. I thought everyone hated me. When I was young I was full of love and zest for life. Getting my period caused a 180-degree turn.”
The Victorian Women’s Trust has begun a large-scale project on menstruation and menopause, led by researchers Jane Bennett and Karen Pickering. The project draws on a survey of thousands of women and girls on their experience of menarche, menstruation and menopause. They report that women and girls have significant shame and stigma attached to their periods.
“In their homes, schools and social life, they get the strong message that a period is embarrassing, dirty and inconvenient,” Pickering says. “Women take these ideas into their adult lives, affecting their relationships, careers and decisions around their health and bodies.”
Bennett and Pickering note that if girls think periods are “gross”, and that their bodies are letting them down, then their sense of self is likely to become eroded.
“It’s shocking that girls and women should feel they have to expend so much energy on concealing this natural function of their body,” Bennett says. “Ask any woman how she feels about her period appearing in the bedroom, for instance, or if girls worry that someone at school will know she’s menstruating – the menstrual taboo is alive and well in contemporary Australia.”
There is much evidence of the menstrual taboo in popular culture. In 2016, Harley Weir, a high-profile photographer, had her Instagram account deactivated after posting photos showing menstrual blood. The company has form. In 2015 Instagram deleted a photograph of Rupi Kaur, an Indian–Canadian poet, with bloodstains on her sweatpants and sheets.
Bennett and Pickering tell me that addressing the menstrual taboo requires comprehensive menstrual education from an early age. They stress the importance of including education and mentoring for teachers and parents who may not have had positive modelling on the topic of menstruation.
“[Education] needs to include a positive view that engenders curiosity and pride in the amazing processes of the body, as well as emotional support for the changes of puberty, and learning to manage the physical and emotional phases of the menstrual cycle,” says Pickering.
Another approach to help normalise periods was launched by Plan International, a global charity, which last year began a campaign for a menstruation emoji.
“Given how many emojis are sent and received every day by teenage girls, one that depicts the ubiquitous experience of periods will certainly help those conversations flow,” Pickering says. “Kids use their own language to talk about everything – why not give them more tools to talk about their periods in a fun and cute way?”
Tanya Byham hopes normalisation of periods in popular culture and better education might make early onset menstruation less traumatic for young girls in the future.
“Getting your period may be a fact of life, but it is also a massive shock to the system,” she says. “No one prepared me for that.”
This article was first published in the print edition of The Saturday Paper on Jul 21, 2018 as "Periodic doubts". Subscribe here.