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First Blood: A Cultural Study of Menarche

Chapter 8

FROM MENARCHE TO WHERE?

Now it’s a different story.1

Inevitably women’s memories of menarche and the diverse cultural meanings attributed to it prompted me to think of the future and what this first menstrual period might mean for young girls in coming years. It is highly unlikely that the implications of menarche will carry the same significance as it did for my interviewees, whose menarcheal experience occurred in the 1930s–1960s, but where the changes in thought and attitude toward the menstrual process will be focused remains uncertain. Although regional and cultural differences are significant when considering such a future, it is the impact of media technology over the past two decades that is influencing rapid social change and the sharing of previously private knowledge and thoughts about the menstrual process, although in an uneven way according to accessibility. So while evidence indicates that women in the West are increasingly choosing to practise some form of menstrual suppression2 it is not yet clear whether the millions of women in developing countries, who still live menstrual lives in circumstances of extreme hardship, might accept such an option.

While it is apparent, among the changes affecting girls, that new concepts of menstrual management are creating conditions for further evolution of menstrual practices, progress comes at a cultural cost. For instance, successfully teaching menstrual management breaks down the cultural tradition of silence surrounding menstruation, allowing women a voice in community decision-making in matters relating to menarche and menstruation – a small start to wider participation. In other respects there is a certain resonance with the changes affecting young Western women from the early 20th century. The difference today is the social context in which these events are occurring in developing countries, including the influential reach of Western media as a learning device and a growing awareness of the harmful effects of the ever-increasing quantity of disposable menstrual absorbents on the environment.

In the preceding chapters I have examined the layers of meaning attributed to menarche and menstruation within various cultures. I have shown how medical thought in ancient societies constructed menarche as the symbol of instability in transition from child to reproductive woman, and how its onset was thought to be fraught with danger, particularly if any deviation from the culturally established norm occurred. Having defined normality, medical treatment of any deviation was instituted and surviving documentation provides evidence that menarche, specifically among the wealthier strata of societies, has a long history of being considered a medical concern. In the late 19th century medical debate over the effect of education on the future reproductive capabilities of middle-class young women included the voice of a woman medical practitioner who refuted the assertions made by her male counterparts. At the same time the rise of the hygiene movement and the development of disposable absorbents, initially marketed as surgical dressings and medical accessories for accouchement, became recognised by manufacturers as having the growth potential of a sanitary hygiene industry. Product promotion diversified to education, under medical supervision, introducing girls to a menstrual practice based on concealment of the biological process.

Until the Second World War, changes in menstrual thought and practice mainly affected girls and young women in wealthier urban areas, many of whom would, or already had, moved from the domestic sphere to the public workplace. Their menstrual management was, in part, facilitated by urban infrastructure in large towns and cities where running water and flushing toilets had been the norm for over a century. Household waste was regularly collected by city or town council employees and concerns about environmental degradation remained in the future. For the most part, however, girls living in less developed rural areas of Western countries continued to be influenced by older traditions, including belief in the dichotomous power of menarcheal blood to either cause harm or create vulnerability to harm. In some cultures, and in some religious belief systems, these beliefs are still transmitted inter-generationally at the time of menarche and are the cause for ritualistic seclusion and the symbolism of ceremony. Nor has this menstrual lore been entirely ignored by Western scientists, who sought a pharmacological basis for the belief that harm was caused to certain plants by the menstrual touch.

Where a culture entrenches certain practices, social change and the acceptance of scientific and technological advancements influencing such change, does not occur evenly or in isolation but within varying contexts of national economic systems and political and social power. The prospective financial gain by interested individuals and corporations, the recognition and reward of researchers, and the seemingly unequal relations between the testers and the tested at the level of trials to determine efficacy and potential development of the new, are also issues in any future outcomes for women in developing countries. Thus, while it is possible that menarche may continue being a cause of ritual seclusion for some, or celebration for others, it will depend on the continued relevance of existing cultural and religious belief systems or on the proliferation of fundamentalism. Alternatively, following the patterns of change in developed countries, menarche may become an increasingly isolated event, serving only to signify biological maturation, perhaps without further menstruation, or with controlled menstruation, as is beginning to be practised in Western countries. This latter movement is the result of advancements in biological research over the past 60 years, which have revolutionised Western women’s lives, and continue to do so, and will probably become an even larger part of the lives of young women in developing nations.

Today, poorer women in developing countries are being educated in hygienic menstrual practice for reasons of health. This is one of the current changes occurring at a community level that can be strongly resisted at the cultural level. For example, in 2008 the British Medical Journal reported the deaths of two young women in rural Nepal during menstrual seclusion. The deaths were attributed to extremes of weather and pre-existing colds and diarrhoea which worsened fatally during their four or five days in an outdoor shed lacking any facilities. This situation was common enough to have had a decision made by the Supreme Court of Nepal in 2005 declaring menstrual seclusion, or chhaupadi, illegal.3 The response in 2008–2009 was a study carried out in four urban and rural districts of Nepal, which sought to identify problems associated with menstruation in 204 post-menarcheal adolescent schoolgirls.4 Three major areas of concern were identified. First, the cultural influences affecting knowledge and beliefs, including the silence surrounding menstruation and the shock of menarche. This particularly affects girls belonging to the caste groups Bahun, Chhetri and Newar, who are ritually secluded in the dark at menarche for 7 to 11 days, during which they may not see either the sun or male relatives. For other girls the polluting power of menarche and menstruation is most commonly expressed in exclusion from religious activities and prohibition of food preparation. Yet there is some evidence that young girls are questioning cultural beliefs, with one relating that when menstruating and unobserved she touches all that is prohibited to her, with no repercussion beyond her own scepticism.5 The second concern is the way in which girls construct menstruation as an abnormal, often painful, physical condition causing them stress from fear of staining at school, and through absenteeism, with one girl from Lalitpur in Nepal, caught in the conflict between managing her period and performing well in her class IX exams, commenting that she wishes she did not have to menstruate, but she ‘knows’ that is impossible.6 A major issue is the link between menstrual hygiene practice and school absenteeism, attributed to lack of affordable sanitary pads, water and proper washing facilities for girls, who need privacy to wash both body and menstrual cloth after walking long distances to school. The other serious lack is an effective disposal system, resulting in used menstrual absorbents being discarded in the toilet pan, with resultant blockage or, in rural areas, being thrown into streams, with subsequent environmental implications.7

The Nepal example can be translated to other non-industrialised societies. There are many African and south Asian countries that have largely ignored the need women have for facilities for menstrual hygiene, partly as a result of the cultural silence around the subject of menstruation. In India, UNICEF8 has taken steps to break the silence about menstruation and to teach girls and women about menstrual hygiene in a shared association with the Government of India’s Total Sanitation Campaign and other similar programs. The result is a small booklet intended for girls and their families, titled Sharing Simple Facts, published in 2008 with translations into Hindi and other Indian languages planned. The booklet explains the physiological and emotional aspects of puberty, arguing against cultural belief that menstrual blood is impure, and integrating references to traditional menstrual practices that are unnecessary and undesirable in today’s communities. Menstruating girls are encouraged to participate in normal school activities and to negotiate at home over practices such as segregation of the sexes. Modernity is the weapon of persuasion and girls might point out that change is happening in households where parents are educated and progressive in outlook. Menarche ceremonies are fewer, attributed to the embarrassment caused to a modern young girl through advertising her newly arrived fertility, but also because of the health risks of early marriage and childbirth. Once again, modernity has influenced a lessening of the practice of menstrual seclusion, explained as a rest time from chores but now difficult to observe in nuclear families. Commercially manufactured sanitary hygiene products, familiar in the West, are listed together with those made by Self Help Groups (SHG), but there is no mention of tampons, which are culturally inappropriate for virgin girls. A comprehensive description of correct sanitary absorbent disposal methods is provided, with the warning that menstrual pads pollute the environment and generate problems for solid waste management.9 Sharing Simple Facts reflects Western input in the text, suggesting menstrual traditions are disappearing, but it has been pointed out that although schooling may provide a sense of choice for young girls, cultural traditions still obstruct change and explain school absence during menstruation, particularly among South- East Asian Hindus. Even now, in south India, menarche signals the end of schooling for many Hindu girls because marriage is arranged at, or soon after, the first period. Tradition also dictates that Hindu girls will avoid washing facilities at schools because of the risk of menstrual pollution to water sources, and those with access to flushing toilets will avoid them in case of blood staining.10

In the rural Shimla district of India, a study among predominantly Christian school girls, age 9–15 years, by interns and medical practitioners in 1994–1995, indicates girls are using clean home-made menstrual cloths or commercially-made sanitary pads in place of unwashed menstrual cloths. Fewer girls are ignorant about menstruation, reflecting better communication on the subject between the generations, but few learn from teachers or from books. Possibly as a result of Christian influence, less than 25 per cent of girls follow traditional menstrual prohibitions relating to physical contact with others, food preparation and religious devotions.11 In Mumbai, a study among rural women immigrants to the city, carried out from 1996 to 2000, reveals health problems due to crowded living conditions and lack of sanitary hygiene facilities. Women are prevented from washing their used menstrual cloths, which they bundle unwashed for re-use. In rural areas cloths are traditionally buried to prevent any practice of witchcraft but as urban slums lack burial space and privacy for such disposal, cloths are now thrown away. By necessity, changes to nuclear-family living conditions have also caused most of these women to discard the menstrual taboos of entering the kitchen and handling food.12

The habit of reusing menstrual cloths appears widespread and the reasons for the practice are similar. In Bangladesh the majority of women use pieces of old saris for menstrual cloths, washing them in a clay pot or basin of used water without soap, and hiding them to dry in a dark place, well away from the sight of men who might be harmed by them, according to cultural beliefs. The common practice of reusing damp menstrual cloths, resulting in vaginal and urinary tract infections, emphasises the need for girls and women to be educated in matters of menstrual hygiene.13 Subsequently, in 2005, Sanitation, Hygiene Education and Water Supply in Bangladesh (SHEWAB) developed a strategy for educating girls and women in menstrual management. Initially, cultural silence toward menstruation prevented the necessary communication between men and women at training level, but the cultural embargo was solved by constructing an educational program in partnership with Non-Government Organisations (NGOs), including UNICEF. As a result, community workers of both genders are now trained to address menstrual hygiene management at village level.14 The program, supported by local government and school management groups, centres on meetings attended by girls and women, including women teachers, held in local schools. The trained community workers provide menstrual hygiene education and support to the groups of women, inviting them to contribute ideas to planning water supplies and women-specific toilet facilities for their menstrual needs.15 SHEWAB has trained community workers to teach the benefits of disposable menstrual pads but, as they remain widely unavailable, hygiene practices taught relate only to menstrual cloths.16

Social changes brought about by industrialisation have alienated many young girls from their families, and Members of the Alliance for African Women’s Initiative in Ghana, (AFAWIGH), draw attention to several issues resulting from rapid urbanisation and widespread family dispersal. One problem discussed is young girls’ ignorance about menstrual matters. Previously at menarche a girl was taught about her expected future behaviour by her mother and other women of her community. Her menarche ceremony, conducted by the ‘queen mothers’ of the community, entailed instruction about menstrual and sexual hygiene and marriage, but today’s girls reach menarche earlier and without the social structures in place. They are left to make their own discoveries about their physical change. The women Members made the following recommendations. One, that programs be introduced to teach pre-pubescent primary school girls about menstruation and menstrual hygiene management and be followed through at secondary school as part of adolescent and reproductive health. Two, that calls be made for attitudinal change in religious organisations that prohibit menstruating girls from participating in prayers and religious activities because of the negative effects on the girls. Three, that calls be made for public education to reduce negative ideas surrounding menstruation, stemming from traditional beliefs and practices. Additional recommendations replicate those made in Bangladesh regarding the construction of girl-specific washing facilities at schools, with provision for disposal of menstrual pads. It is noted that girls’ menstrual absorbents in Ghana include vegetable matter such as leaves, toilet paper, or bits of sacking, and that their knowledge of the hygienic advantages of disposable sanitary pads remains limited due to either poverty or unavailability.17

The situation in Ghana is echoed in Uganda with the NGO Forum for African Women Educationalists (FAWE) campaigning to break the prohibition on speaking about matters related to menstruation, and advocating cheaper sanitary absorbents to be sold at local markets. Menstrual hygiene problems are stated to be the largest single cause for girls dropping out of school and are attributed to lack of access to menstrual absorbents due to poverty and sustained cultural beliefs and attitudes.18 Following a study made with 500 post-menarcheal girls in south-eastern Nigeria, recommendations include the use of the media in menstrual hygiene education. Also recommended is the promotion of menstrual education by women’s associations and NGOs through women’s conferences and seminars, and their assistance in the provision and distribution of pads at subsidised rates. Once again a call is made for the instruction of premenarcheal girls as part of the school curriculum, and for the provision of disposal facilities for used menstrual absorbents to combat menstrual absenteeism.19

The principal cause of girls dropping out of school in developing countries is indisputably linked to cultural beliefs and attitudes, but it is also one of logistics caused by the problem of disposal of menstrual waste in areas of extreme poverty. It is a widespread situation throughout the south Asian area, including East Timor where an Australian Volunteers International community worker, Sarah Angus, spoke of her proudest achievement being the construction of a school toilet block in Uai-Bua because until then menstruating girls would not attend school.20 There is little doubt that the betterment of women’s lives and health begins at menarche, when good menstrual hygiene practices, as well as an understanding of the body, can be taught by trained instructors at community level. The system appears effective but there is another aspect that has come under scrutiny. Financial support for menstrual health campaigns has been given by various NGOs and other corporations, including a guaranteed US$5 million by the sanitary hygiene company Proctor and Gamble for menstrual education and distribution of pads. The Clinton Global Initiative subsidises African businesses with US$2.8 million to provide inexpensive pads to help girls stay at school. The costs and benefits of these programs drew the attention of economists Emily Oster and Rebecca Thornton, who argue that menstrual hygiene products make little difference to girls’ school attendance. They base their assertion on two issues: that the reports of menstrual absenteeism from school are anecdotal and lack hard evidence, and that a trial they ran in the Chitwan area of Nepal with 198 participants provided evidence to the contrary. Oster and Thornton contend their findings are due to their analysis of the patterns of menstrual absence which fail to indicate any significant impact on schooling, although it is noted that in the previous year 48.3 per cent of the girls participating in the study reported menstrual absence due to cramps, and 20 per cent remained at home because of concerns of mobility and lack of washing facilities at school for washing menstrual rags.21

An additional randomised test against the known reasons for menstrual absence from school, carried out by Oster and Thornton, studied the efficacy of an advanced sanitary hygiene device known as the menstrual cup. The cup, which collects menstrual blood rather than absorbing it, is made from industrially manufactured silicone, bell-shaped, long-lasting, washable, and reusable. It is inserted into the vagina without risk of toxic shock.22 Its use is evaluated in regard to school attendance with 100 girls taking part, of whom 50 were given a cup. The results show no change to the existing minimal school absence of 0.4 school days in the 180-day school year due to menstruation, but there is marked enthusiasm reported by the participants about their experience of the menstrual cup, its facilitation of mobility, and the time saved in washing and drying menstrual cloths. No reference is made to cultural views on virginity regarding the use of a vaginal device, nor is the number of Hindu participants known, although one mother–daughter decided not to accept the cup. Neither is there any way of proving the device was actually used.23 However, the most concerning problem with Oster and Thornton’s findings, which they argue may be generalised outside Nepal, is the risk of withdrawal of program funding, and the possible ripple effect on other projects related to good menstrual management for future health.

The issues of cultural acceptance, cost, accessibility and supervision are influential in acceptance of innovations such as the menstrual cup, which may alter the perceptions of girls and women to menstruation. These factors have yet to be studied. Meanwhile information about cultural menstrual practices continues to be collected, particularly by volunteer workers at times of social dislocation, providing information for immediate help and for shaping future policy. One example is Pakistan, following the earthquake in 2005, when thousands of Muslim women and girls in the tented villages were visited by Oxfam partner staff, proficient in the local language, to discuss their needs including those related to menstrual hygiene practice. The significance of the key issues identified is their relevance to all Muslim women in developing countries, including the absolute necessity for menstrual hygiene educators and sanitary engineers to be women. Additionally, community workers must understand the cultural attitudes dictating the silence surrounding menstruation, and the need for any discussions to be totally private and restricted to girls and women. Effective menstrual hygiene practice has to acknowledge the pollutant aspect of menstruation by requiring concealed disposal facilities for used sanitary pads to avoid public display. Menstrual cloths must be of dark fabric to conceal blood and washing facilities must be plumbed to conceal blood-stained water drainage.24

This overview of the situation shows that many women in developing countries share poor menstrual practice for identical reasons based on cultural and religious traditions, including silence in matters of menstruation. There is evidence of the problem being managed in almost identical ways, through opening channels of communication within communities to provide girls with the knowledge of menarche, menstruation and good menstrual hygiene practice. Village women are becoming involved in planning facilities for women’s menstrual needs, and being made aware of the availability and disposal of menstrual absorbents. Additionally, there is evidence that women working through NGO groups and women’s associations are driving change in the developing south Asian and African countries referred to, as well as indications that young girls are questioning cultural traditions such as menstrual prohibition. Change caused by industrialisation and rural migration to overcrowded urban space has resulted in hardship for women trying to maintain cultural practices associated with menstruation, some of which have been discarded in new forms of nuclear family life.

Historian Andrew Shail argues the consciousness of late capitalism shapes ideas of waste in the minds of consumers, with disposable menstrual absorbents being the classic example of unending waste and equally unending manufacture, maintaining the system.25 This is apparent in the growing demand for disposable menstrual absorbents among impoverished women in Bangladesh and the response in 1999 by the Bangladesh Rural Advancement Committee (BRAC). A manufacturing industry making disposable menstrual pads was established, offering paid women employees incentives for promotion and sales. The total daily output is 6,000 packets, each containing 12 looped pads of cotton-filled gauze, sterilised, and sealed in plastic packets. Sales are mainly to district health workers who on-sell door-to-door at a profit, but pads are also sold through local markets at greater profit, while undercutting known brands. Yet the problem of disposal remains unsolved. Used pads are thrown into a pit and covered with soil.26 Similar enterprises have been developed in other areas, including in the Indian state of Chhattisgarh, where rural women in 50 villages have learned how to manufacture disposable cloth pads, which are discarded in a sanitary pit after use.27

Having made affordable disposable menstrual pads for poorer girls and women, and having informed millions about the association between menstrual hygiene practices and health, the issue of environmental awareness has emerged as a shared concern, not confined to developing countries but reaching into the minds of Australian and New Zealand women through conservational promotion and awareness-raising events. In the Melbourne suburb of Moreland, for example, Zero Waste for a Week Challenge was held in November 2010, during which time women in the community were made conscious of the annual landfill containing over 700 million tampons and 1 billion menstrual pads, together with their plastic packaging. Women were asked to consider reusable menstrual pads or menstrual cups in preference to disposable menstrual absorbents.28 In New Zealand, Pip Lynch draws attention to a growing awareness of environmental degradation in alpine, bush and coastal terrain through the effects of disposable menstrual absorbents. Many of the manufactured products contain chlorine-bleached fluff-making kraft or sulphate pulp, with anti-bacterial properties capable of destroying healthy micro-flora in soil so that decomposition of buried pads and tampons is delayed, with potential effects on groundwater, vermin and flies. In addition, toxic chemicals released by synthetic products during degradation and incineration have the potential to cause toxic pollution. Women are recommended to consider alternative menstrual management, including use of the environmentally sound menstrual cup which has no harmful components.29

Education leading to change in menstrual management practice and avoidance of ecological degradation presents women in both developed and non-developed countries with challenges for the future. It might be argued that no menstrual absorbent, be it disposable or washable, is without hazard to health or environment. Furthermore women’s menstrual life is longer. In 1976 R. V. Short drew attention to the earlier menarche and subsequent fertility experienced by girls in developed countries and how the socially imposed period of infertility, helped by contraception, allows intellectual maturity to catch up with that of the physical.30 Girls in developing countries experience a later menarche, attributed to reduced body mass and its effect as an ovulation suppressant, the body’s own contraceptive, not dissimilar to the effects of weight loss in anorexia nervosa-affected young women in Western nations.31 As living conditions undergo change in developing countries, the future patterns of fertility may follow those of today’s Western women with earlier menarche, reduced reproduction and lactation time, and an extended menstrual life of about 30 years. Most significantly, according to Short, this situation has neither evolutionary precedence nor genetic adaptation. Consequently it is in the interest of women’s health to reduce bleeding. While this may be of limited impact in developed countries it could have considerable advantage for women in developing nations where protein deprivation and vulnerability to diseases such as malaria or hookworm reduces their potential for good health.32

Menstrual suppression was always possible with the ‘Pill’ from its initial government approval in 1957 as treatment for menstrual irregularities and infertility.33 However, in the days before pregnancy kits were easily obtained from supermarkets, researcher and inventor Gregory Pincus and co-inventor gynaecologist John Rock believed that women would want a pseudo-period to reassure them they were not pregnant. Rock, a devout Catholic, wanted the Pill to duplicate the natural female bodily function, signifying it as a ‘natural’ combination of hormones that extended the theologically acceptable ‘safe period’ of a woman’s reproductive cycle, of importance to Roman Catholic theologians who were opposed to artificial forms of fertility control.34 So alternative dosage regimes of the drug to suppress menstruation were not included in the information sheet enclosed in every packet of oral contraceptives sold. Furthermore, medical practitioners rarely explained to patients that if they wished to avoid a period they could ignore the differently coloured placebo (sugar) pills in the tablet pack. It was left to the agency of women to specifically ask their doctors for guidance pending particular activities – a honeymoon, a holiday, sports participation – and they would then be advised.35 The withdrawal bleed for one week in every 28 days was considered by many women to be menstruation and the fact that there is little endometrial lining to shed continues to be poorly understood.36

Should women understand more about a drug that has such profound effect on their bodies? The idea of menstrual suppression creates considerable debate from health professionals, some funded by pharmaceutical companies, studying women’s responses to the concept.37 Common to their findings is a marked lack of knowledge about the menstrual process by young women, associated with a lack of understanding of how oral contraception suppresses bleeding. Many young women gain their knowledge of menstrual suppression from popular magazines and the media, with resultant biases reflective of marketing promotion.38 Their shared concerns include side-effects and long-term effects on health and fertility, but some also fear menstrual suppression will prevent them recognising pregnancy.39 For others, the influence of traditional ideas about menstruation being the vital essence of femininity, and the cleanser of toxic waste, contests the potential desirability of total menstrual suppression.40

One area in which menstrual suppression remains most controversial, both medically and socially, is that of the young non-sexually active girl, although there are indications that this is changing through second-generation familiarity with the Pill. Gynaecologist Andrew M. Kaunitz identifies two advantages to suppressing menstruation. The first is the benefit to bone health offered by reduction of blood loss, hence of iron-deficient anaemia, resulting in improved sporting activity levels and fewer musculoskeletal injuries. The second is that girls with earlier menarche will have less absenteeism from school due to painful periods, and be able to participate more in school activities. Kaunitz points out that many US doctors are now prescribing oral contraceptive pill regimes for young non-sexually active girls to regulate their menstrual cycles and reduce discomfort, and he recommends that doctors in general be confident about informing young girls and their mothers of the improved quality of life that menstrual suppression provides.41 Furthermore, it is suggested by US paediatrician Ellen Rome that medical practitioners prescribe a monophasic monthly pack, with its equal quantities of oestrogen and progesterone, for young girls, instructing them to ignore the placebo pills and continue the active pills for up to 84 days. This particular regime reduces the incidence of spotting or bleeding, while allowing girls the convenience of choice in the timing of their pseudo-period during the last week or so.42 However, menstrual manipulation in the young is not without certain risks. One being that social acceptance of it may lead to use by increasingly younger girls influenced by negative attitudes to the menstrual process or who simply do not want to have periods. The other concern is the effect on reproductive health, which menstrual cycle researcher, Christine Hitchcock, contends has not yet been adequately assessed and is due to continuous oral contraceptive use having an increasingly suppressive effect on the hypothalamic-pituitary axis during the 12 or so years after menarche when the endocrine system is still developing.43

Nonetheless, oral contraceptives as menstrual suppressants are widely used with the introduction of the extended cycle oral contraception (ECOC), a 12-week cycle of 84 oral contraceptive pills and a seven-day placebo pill regime, providing four periods a year, and approved by the US Food and Drug Administration (FDA) in 2003.44 Currently manufactured by different pharmaceutical companies and trade-named Seasonale and Seasonique, their difference is in the seven pills to cause withdrawal bleeding.45 Seasonique contains minute quantities of synthesised oestrogen, ethinyl estradiol, to reduce second cycle spotting.46 Prescribing information published by the manufacturer states that 12-month clinical trials indicated Seasonique is both safe and effective for use by women of reproductive age, but is only expected to be the same for post-pubescent girls under the age of 18 years, and not indicated for use in girls who have not reached menarche.47 There is little doubt that the manufacturers believe their product is the way of the future for women because the first 365-day active pill regime with no placebo pills, trade-named Lybrel, was approved in the US by the FDA in May 2007, with applications made for the European Union market and for Australia and Canada with Lybrel trade-named Anya.48 In the interim a study was made to evaluate the effect of current contraceptive practices on menstrual frequency among Australian university students, resulting in public health researchers calling for medical re-evaluation of extended-use oral contraception by young women.49 Subsequently in 2012 an application for registration of the first ECOC, trade-name Yaz Flex, was approved by the Australian Therapeutic Goods Administration (TGA) and the drug became available by medical prescription. The active ingredients are ethinyloestradiol and a newer form of progesterone, drospirenone, which, according to some studies, is associated with an increased risk of venous thrombosis among women using ECOC. Nor is Yaz Flex to be used prior to menarche. The 120 pills come with a special dispenser allowing the user to read the status of intake, and consumer information advises a four-day break between extended cycles, reducing periods to three a year.50

Yet, as journalist Shelley Gare reports in an article titled ‘Secret Women’s Business’, Family Planning Australia has been instructing women in menstrual suppression since the 1980s. Gare interviewed two women doctors, finding that young women are increasingly suppressing their periods. Dr Terri Foran, a sexual health physician and past director of Family Planning in NSW, estimates a quarter of young women attending her clinic use the pill to suppress bleeding. In Melbourne at the Jean Hailes Foundation for Women’s Health, Dr Elizabeth Farrell observes an increase in menstrual suppression over the past decade, with more information about it being sought by teenagers and younger women. Farrell finds an association between menstrual suppression and the current social trends practised by teenagers and young women of total body epilation, and a demand for vaginal dryness, the latter regardless of explanation of purpose. She conjectures that having a period every month may become as gross as having hairy legs.51

We have seen the association between teenagers and menstrual suppression and the media and medical influences, both arguing social and educational benefits, and there are other groups also expressing the desirability of being free from menstrual bleeding. They include military service women deployed in a hostile environment.52 Among currently deployed women in the US military there is support for menstrual suppression because of the benefits gained by freedom from stress-related menstrual irregularities and other related health problems and from menstrual hygiene difficulties. The ready availability of continuous use oral contraceptives from medical clinics during deployment, compared with variable supplies of menstrual hygiene products, indicates US military approval of the practice.53 In civilian life women engaging in athletics who wish to eliminate bleeding and preserve bone health are using ECOC54 and an Italian study shows women’s preferences for varying durations of menstrual suppression as a means of improving their lives in the workplace, in clothing choice, in sporting activities and in sexual activity.55 Similar evidence gathered internationally indicates that women in industrialised countries prefer less bleeding for reasons of convenience.56

Convenience plays a part in women’s lives but long or extended-cycle oral contraception require women to remember to take a daily pill. An alternative is the injectable synthesised progesterone derivative, depot medroxyprogesterone acetate (DMPA), given the trade name Depo Provera. The drug, initially intended to prevent late-term miscarriage and premature labour in women, failed its trials in Brazil under the supervision of Dr Elsimar Coutinho, but unexpectedly produced evidence of ovulatory suppression with accompanying menstrual suppression, lasting up to six months following treatment. Cessation of Depo Provera allowed ovulation to resume, and pregnancy to occur, and during the time of menstrual suppression Coutinho found evidence of improved health in women with pre-existing anaemia, associated with higher resistance to disease and greater stamina due to increased levels of iron, hence haemoglobin or red blood cells. Moreover, women recognised the benefits of not menstruating.57

Having refuted the belief that menstrual suppression contravenes a law of nature, Coutinho insists that beliefs in the benefits of menstruation to women have no grounding in scientific evidence, but that menstruation exists only as a consequence of the process of reproduction.58 He argues the benefit of menstrual suppression in countries where early menarche is followed by pregnancy, drawing attention to the situation in the US where young girls of 10–14 years contribute some 12,000 babies to the statistics of babies born annually to children, and that in 1995 about 30,000 girls in Brazil, aged 10-11 years-old, became pregnant, many to family members. Thus, by impeding early menarche by delaying the hormonal activation of ovulation and slowing down sexual development, girls are given several additional menstruation-free years while reducing the risk of assault to the prematurely maturing body.59

Depo Provera, approved for contraceptive use in 1992 and available worldwide, is administered by four injections annually, allowing women the choice of remaining both pregnancy and menstruation-free.60 An information sheet about the drug, provided by the Royal Women’s Hospital, Melbourne, points out that women need to remember the injections must be repeated on 12-weekly basis for Depo Provera to remain effective. Women are also cautioned to think about the non-reversibility of the drug once the injection has been administered.61 The negative effects of any drug on bone health is a matter for concern, and in 2006 WHO issued a statement on depot medroxyprogesterone acetate (DMPA), Depo Provera, showing evidence of some effect on bone mineral density (BMD) in certain women and in adolescents who have not reached optimal bone mass. Results are variable and indicate that in girls from menarche to 18 years there is a loss of about 5–7 per cent after two years’ continual use of the drug, equating to that in lactating women, however the rate of loss appears to decrease over time and bone mineral density increases when the drug is ceased. WHO recommends that no restriction be imposed on the use of DPMA for adolescents from menarche to 18 years of age because the advantages of the drug outweigh the risks of bone fracture, however, lack of data with long-term users indicates reconsideration of use with individuals over time.62

Both the long or extended cycle oral contraceptive and the injectable depot medroxyprogesterone acetate have provided women in developed countries with choices and mechanisms of control over their fertility and their menstrual cycles. The negative aspects of side effects and remaining concerns felt by some women about issues of safety have not reduced the continuing interest in, and use of, these drugs, which are expected to be increasingly available in developing countries and promoted through the media.63

The extent to which menstrual suppression will be a choice for young women in developing countries is unclear due to several reasons. Women, particularly those in remote areas, are not accustomed to regular regimes of pill-taking or injections and their lack of education prevents them fully understanding information given about hormone-altering drugs and their side effects. Nor is it clear whether health workers will be adequately knowledgeable to instruct in these matters. The relationship between pharmaceutical companies and governments regarding distribution of menstrual suppressant drugs may also be based on state population control programs with few checks and balances protecting young women users.64 Nevertheless young women of the future will re-think menstrual practice in the knowledge of their world. There are strong indications that menstrual suppression will be part of the choices they make, although the historian Sharra Vostral argues that long-term menstrual suppression causes women to become estranged from their bodies and lose the cultural meanings attributed to menstruation.65 Thus, women in developed countries are no longer defined by their reproductive potential but by the skills and abilities that enable them to carry out multiple aspects of social life.

Conclusion

The future of menarche appears dependent on two issues: women’s education and the value society places on women as reproductive bodies. The historic influence of religious belief systems on control of the menstruating body, hence the sexuality of women, has been weakened in developed countries as a result of change in social values paralleling scientific and technological advancement which has advanced medical thought and practice. One result is that girls now reach menarche with the expectation of a future career, geographic mobility, continuous electronic communication and some knowledge of the existence of control over their fertility. Advancements in knowledge of women’s hormone function has enabled women to control menstruation and there is increased interest by post-menarcheal girls in menstrual suppression, a practice with positive and negative benefits under medical debate, as we have seen.

In developing countries the future of menarche is less clear. Change in cultural traditions and practices are slow and uneven, and many girls are still struggling to receive an education in societies where women are valued primarily for their reproductive body. Although interview data with Indian women indicates a diminishing cultural tradition of menstrual seclusion within urban, educated, families, several interviewees referred to its continuation among the poor and uneducated who also maintain the dowry tradition. However, it is significant that a number of the information sources used for reference in this chapter reflect educated Indian and African women’s association with NGOs, and their involvement with menstrual hygiene education and practice at village level. The formation of women’s cooperatives, including participation in local or regional manufacture and distribution of inexpensive disposable menstrual absorbents, has improved women’s menstrual health, but at an environmental cost caused by menstrual waste, a concern absent from my interview data, but one with increasing significance for the future. The acceptance of menstrual suppression by women in developing countries, while potentially beneficial physically and environmentally, contests the value associated with the menstrual evidence of their reproductive body.

Nonetheless, scientific and technological developments will continue to define the future of menarche as the starting point of a range of practices relating to menstrual life, extending from hygienic management to its complete avoidance.

1    Alisha, c.14 years old at menarche, India c.1943.

2    Jennifer Gorman Rose, Joan C. Chrisler, and Samantha Couture, ‘Young women’s attitudes toward continuous use of oral contraceptives: the effect of priming positive attitudes toward menstruation on women’s willingness to suppress menstruation’, Health Care for Women International, vol. 29, no. 7, 2008 and Christine M. Read, ‘New regimes with combined oral contraceptive pills – moving away from traditional 21/7 cycles’, The European Journal of Contraception and Reproductive Health Care, vol. 15, no. 2, 2010, and Alecia J. Grieg, Michelle A. Palmer, Lynne M. Chepulis, ‘Hormonal contraceptive practices in young Australian women (<25 years) and their possible impact on menstrual frequency and iron requirements’, Sexual and Reproductive Healthcare, vol. 1, no. 3, 2010. See also Shelley Gare, ‘Secret women’s business’, The Age Good Weekend, 1 May 2010, p. 51. Gare reports on interviews with Dr Terri Foran, medical director of Family Planning, NSW, and Dr Elizabeth Farrell, Jean Hailes Foundation for Women’s Health, Melbourne.

3    Khagendra Dahal, ‘Nepalese woman dies after banishment to shed during menstruation’, ‘News’ in British Medical Journal, vol. 337, 22 November 2008, p. 1194.

4    Om Gautam, ‘Is menstrual hygiene and management an issue for adolescent school girls in Nepal?’, Regional Conference on Appropriate Water Supply, Sanitation and Hygiene (WASH) Solutions for Informal Settlements and Marginalised Communities, Katmandu, Nepal, 19–21 May 2010, p. 170. Gautam is a social development adviser to WaterAid, Nepal. http://www.nec.edu.np/delphe/pdf/conference1pdf#page=192

5    Gautam (2010), pp. 175, 178–179.

6    Gautam (2010), p, 180.

7    Gautam, pp. 181–183.

8    United Nations International Children’s Emergency Fund.

9    Sharing Simple Facts: Useful Information about Menstrual Health and Hygiene, UNICEF and Department of Drinking Water Supply, Ministry of Rural Development, New Delhi, 2008.

10  Thérèse Mahon and Maria Fernandes, ‘Menstrual hygiene in South Asia: a neglected issue for WASH (water, sanitation and hygiene) programmes’, Gender and Development, vol. 18, no. 1, 2010, pp. 103–104. Fernandes is Programme Officer, WaterAid, Regional India, Bhopal and Mahon is Asian Regional Programme Officer, WaterAid, for India, Nepal, Bangladesh and Pakistan.

11  A.K. Gupta, A. Vatsayan, S.K. Ahluwalia, R.K. Sood, S.R. Mazta, R. Sharma, ‘Age at menarche, menstrual knowledge and practice in the apple belt of Shimla hills’, Journal of Obstetrics and Gynaecology, vol. 16, no. 6, 1996, pp. 548–550.

12  Suneela Garg, Nandini Sharma, Ragini Sahay, ‘Socio-cultural aspects of menstruation in an urban slum in Delhi, India’, Reproductive Health matters, vol. 9, no. 17, 2001, pp. 16–17, 21–22. The authors are socio-epidemiologists.

13  Rokeya Ahmed and Kabita Yesmin, ‘Menstrual hygiene: breaking the silence’, in WaterAid Beyond Construction: a Collection of Case Studies from Sanitation and Hygiene Promotion Practitioners in South Asia, James Wicken, Joep Verhagen, Christine Sijbesma, Carmen da Silva, Peter Ryan (eds), WaterAid London, 2008, pp. 283–284, http://www.wateraid.org/documents/ch21_menstrual_hygiene_breaking_the_silence.pdf. See also Shaheen Akhter, ‘Knowledge, attitudes and practices on reproductive health and rights of urban and rural women in Bangladesh’, Yokohama National University Repository, 2007, pp. 138–139, http://www.kamome.lib.ynu.ac.jp/dspace/bitstream/10131/3157/1/3-131-akhter.pdf

14  Kathryn Seymour, ‘Bangladesh: tackling menstrual hygiene taboos’, Sanitation and Hygiene, Case Study 10, http://www.UNICEF.org/wash/files10_case_study_BANGLADESH_4web.pdf, 2008, pp. 1–2. The program is run by the Sanitation, Hygiene Education and Water Supply in Bangladesh(SHEWAB) backed by UNICEF. See also Ahmed and Yesmin (2008), pp. 284–285.

15  Ahmed and Yesmin (2008), pp. 285–286.

16  Seymour (2008), pp. 1–4.

17  ‘Sexual maturation and menstrual management practices associated with schoolgirls in Ghana’, Alliance for African Women’s Initiative, Ghana 2010, pp. 1–2, 4–5, http://afawigh.org/publication/sexual-maturation-and-menstrual-management-practices-associated-with-school-girls-in-ghana.html

18  Sowmyaa Bharadwaj and Archana Patkar, ‘Menstrual hygiene and management in developing countries: taking stock’, Junction Social, Mumbai, 2004, p. 11, http://www.mum.org/menhydev.htm

19  Uzochukwu Uzoma Aniebue, Patricia Nonelum Aniebue, Theophilus Ogochukwu Nwankwo, ‘The impact of pre-menarcheal training on menstrual practices and hygiene of Nigerian schoolgirls’, Pan African Medical Journal, vol. 1, no. 2, 2009, pp. 2–8, http://www.panafrican-med-journal.com/content/article/2/9/full

20  Carolyn Webb, ‘Christmas spirit knows no borders’, The Age, 23 December 2010.

21  Emily Oster and Rebecca Thornton, ‘Menstrual sanitary protection and school attendance: evidence from a randomized evaluation’, American Economic Journal: Applied Economics, vol. 3, no. 1, 2011, pp. 91–92, 97–98.

22  The menstrual cup used was manufactured by Mooncup and the authors do not declare receiving any financial support from them. See http://www.mooncup.co.uk

23  Oster and Thornton (2011), pp. 93, 94 and f.n 5, 95, 97, 99.

24  Jamila Nawaz, Shamma Lal, Saira Raza and Sarah House, ‘Oxfam experience of providing screened toilet, bathing and menstruation units in its earthquake response in Pakistan’, Gender and Development, vol. 18, no. 1, 2010, pp. 81–84.

25  Andrew Shail, ‘“Athough a woman’s article”: menstruant economics and creative waste’, Body and Society, vol. 13, no. 4, 2007, pp. 86–87.

26  Bharadwaj and Patkar (2004), pp. 12–13. See also ‘BRAC sanitary napkins and birthing kits’, http://www.brac.net/content/social-enterprises-health

27  Mahon and Fernandes (2010), pp. 109–110.

28  Moreland City Council, ‘Zero Waste for a Week Challenge’ November 2010, www.moreland.vic.gov.au/environment-and-waste/rubbish-collection/zero-waste-challenge.html

29  Pip Lynch, ‘Menstrual waste in the backcountry’, Science for Conservation:35, Department of Conservation, Wellington, 1996, pp. 5, 10–13.

30  R. V. Short, ‘The evolution of human reproduction’, A Discussion on Contraceptives of the Future, Royal Society, London, 1976, p. 11. Short is a Fellow of both the Royal College of Veterinary Surgeons and the Royal College of Gynaecologists. He was Foundation Director of the Medical Research Council’s Unit of Reproductive Biology in Edinburgh 1972–1982 and held the Chair in Reproductive Biology at Monash University, Melbourne 1982–1995. See also Rachel Blumstein Posner, ‘Early menarche: a review of research on trends in timing, racial differences, etiology and psychosocial consequences’, Sex Roles, vol. 54, nos 5–6, 2006, pp. 316, 320, which argues that social fear of emergent female sexuality led to G. Stanley Hall (1904) constructing the concept of the adolescent as a potential problem requiring behavioural therapy. Posner, a psychologist, contends the mean age of menarche in the US has been demonstrated to be unchanged over the past 50 years.

31  Short (1976), p. 14.

32  Short (1996), pp. 18–19.

33  For a history of the ‘Pill’ see historians Suzanne White Junod and Lara Marks, ‘Women’s trials: the approval of the first oral contraceptive pill in the United States and Great Britain’, Journal of the History of Medicine and Allied Sciences, vol. 57, no. 2, 2002 and Victor A. Drill, ‘History of the first oral contraceptive’, Journal of Toxicology and Environmental Health, Part A, vol. 3, no 1, 1977, pp. 133–134. Drill was Director of Biological Research 1953–1970 for G. D. Searle and Company, developers of the first oral contraceptive, Enovid, successfully trialled in 1956.

34  Malcolm Gladwell, ‘John Rock’s Error’, New Yorker Annals of Medicine, 13 March 2000, pp. 53–55. See also David F. Archer, ‘Menstrual-cycle related symptoms: a review of the rationale for continuous use of oral contraceptives’, Contraception, vol. 74, no. 5, 2006, pp. 361–362. Archer, a clinical researcher at Eastern Virginia Medical School, points out that today pregnancy testing is readily available, accurate and inexpensive, thus removing the role of the visible withdrawal bleed.

35  Elsimar M. Coutinho with Sheldon J. Segal, Is Menstruation Obsolete? Oxford University Press, New York, 1999, pp. 5–8. See also Archer (2006), pp. 361–362.

36  Sarah L. Thomas, Charlotte Ellertson. ‘Nuisance or natural and healthy: should monthly menstruation be optional for women?’ Lancet, vol. 355, no. 9207, 11 March 2000, p. 923. The authors are researchers in women’s reproductive health for the Population Council, Mexico.

37  Wyeth Pharmaceuticals funded a study on women’s thoughts about menstrual suppression that involved surveying 1000 women in Brazil. See Emilia Sanabria, ‘The politics of menstrual suppression in Brazil’, Anthropology News, vol. 50, no. 2, 2009, p. 6.

38  Ingrid Johnston-Robledo, Jessica Barnack, Stephanie Wares, “‘Kiss your period goodbye”: menstrual suppression in the popular press’, Sex Roles, vol. 54, nos. 5–6, 2006, p. 358.

39  Ingrid Johnston-Robledo, Melissa Ball, Kimberley Lauta and Ann Zekoll, ‘To bleed or not to bleed: young women’s attitudes toward menstrual suppression’, Women and Health, vol. 38, no. 3, 2003, pp. 70–72. The authors are US psychologists. See also Linda C. Andrist, Alex Hoyt, Dawn Weinstein, Chris McGibbon, ‘The need to bleed: women’s attitudes and beliefs about menstrual suppression’, Journal of the American Academy of Nurse Practitioners, vol. 16, no. 1, 2004, p. 35; and US psychologists Rose et al (2008), p. 698.

40  Simone Ferrero, Luiza Helena Abbamonte, Margherita Giordano, Franco Allessandri, Paola Anserini, Valentino Remorigida, Nicola Ragni, ‘What is the desired menstrual frequency of women without menstrual-related symptoms?’, Contraception, vol. 73, no. 5, 2006, pp. 537, 540. The authors are from the department of obstetrics and gynaecology, San Martino Hospital and the University of Genoa. See also Maria Clara Estanislau do Amaral, Ellen Hardy, Eliana Maria Hebling, Anibal Faúndes, ‘Menstruation and amenorrhea: opinion of Brazilian women’, Contraception, vol. 72, no. 2, 2005, pp. 158–159. Amenorrhea is the absence of menstruation. The authors are from the faculty of medical sciences, San Paulo.Do Amaral and Hardy are nurses and Hebling and Faúndes obstetricians and gynaecologists.

41  Andrew M. Kaunitz, ‘Menstruation: choosing whether … and when’, Contraception, vol. 62, no. 6, 2000, pp. 280–281.

42  Caitlin W. Hicks and Ellen S, Rome, ‘Menstrual manipulation: options for suppressing the cycle’, Cleveland Clinic Journal of Medicine, vol. 77, no. 7, 2010, p. 447.

43  Christine L. Hitchcock, ‘Elements of the menstrual suppression debate’, Health Care for Women International, vol. 29, no. 7, 2008, pp. 710–711.

44  Jessica Shipman Gunson, ‘“More natural but less normal”: reconsidering medicalisation and agency through women’s accounts of menstrual suppression’, Social Science and Medicine, vol. 71, no. 7, 2010, p. 1324. Gunson is a sociologist.

45  Anita L. Nelson and Lawrence S. Neinstein, ‘Combination hormonal contraceptives’, in Lawrence S. Neinstein, Catherine M. Gordon, Debra K. Katzman, David S. Rosen and Elizabeth R. Woods (eds), Adolescent Health Care: a Practical Guide (1984), fifth edition, Lippincott Williams and Wilkins, Philadelphia 2008, p. 597. Nelson is professor of obstetrics and gynaecology and Neinstein associate professor of paediatrics, both at UCLA.

46  Hicks and Rome (2010), p. 447. See also Nelson and Neinstein (2008), p. 597.

47  Prescribing information, Seasonique, http://www.seasonique.com/docs/prescribing-information.pdf, July 2010. Clinical studies were carried out with diverse groups of women including Caucasian 80%, African-American 11%, Hispanic 5%, Asian 2% and other 2%.

48  Nelson and Neinstein (2008), p. 597. See also Hitchcock (2008), p. 704.

49  Jessica Shipman Gunson (2010), p. 1327; Alecia J. Greig, Michelle A. Palmer, Lynne M. Chepulis, ‘Hormonal contraceptive practices in young Australian women (<25 years) and their possible impact on menstrual frequency and iron requirements’, Sexual and Reproductive Healthcare, vol. 1, no. 3, 2010, pp. 99–102. The participants were from Griffith University, Gold Coast campus.

50  Yaz Flex ‘Public Summary’ and ‘Consumer Medicine Information’, Therapeutic Goods Administration (Aust) www.tga.gov.au/file/6491/download; ‘Product news’, Australian Pharmacist, December 2012, pp. 990–91; Sue Dunlevy, ‘New Pill adds comfort for women’, Daily Telegraph, 25 September 2012; Deborah Bateson, ‘What’s new in contraception?’ O&G Magazine, Vol. 14, no. 2, 2012, pp. 55–56.

51  Gare (2010), p. 51.

52  Diane Wind Wardell and Barbara Czerwinski, ‘A military challenge to managing feminine and personal hygiene’, Journal of the American Academy of Nurse Practitioners, vol. 13, no. 4, 2001, pp. 187–188. Wardell is professor of nursing at the University of Texas and Czerwinski is director of emergency room nursing at Ben Taub Hospital, Texas.

53  Lori L. Trego and Patricia J. Jordan, ‘Military women’s attitudes toward menstruation and menstrual suppression in relation to the deployed environment’, Women’s Health Issues, vol. 20, no. 4, 2010, pp. 291–292. Trego is a US army nurse and Jordan is a US research methodologist.

54  David F. Archer, ‘Menstrual-cycle related symptoms: a review of the rationale for continuous use of oral contraceptives’, Contraception, vol. 74, no. 5, 2006, p. 364.

55  Ferrero et al (2006), p. 539.

56  I. Wiegratz, H.H. Hommel, T. Zimmermann, H. Kuhl, ‘Attitude of German women and gynaecologists towards long-cycle treatment with oral contraceptives’, Contraception, vol. 69, no. 1, 2004, p. 41. The authors are gynaecologists.

57  Coutinho (1999), pp. 8–11, 117–118.

58  Coutinho (1999), p. 163.

59  Coutinho (1999), pp. 114, 162–163. The Australian figures for girls 15–19 years, which include girls less than 15 years, were 12,120 births in 2009. The pre Depo Provera figure for 1989 was 14,259 and this reduced to 12,853 in 1994 according to the Australian Bureau of Statistics: 301.0: Births, Australia, 2009. Summary tables: 2.20 Births, Australia – selected years at http://www.abs.gov.au/ausstats/abs@nsf/Products/5ECFEOF9C48

60  Coutinho (1999), pp. 10, 117–118. He draws attention to the availability of several other oral or vaginal progestins that can produce the same effect as Depo Provera.

61  ‘Depo Provera: a contraceptive injection’, http://www.thewomens.org.au/DepoProveraAContraceptiveInjection

62  Catherine d’Arcangues, ‘WHO statement on hormonal contraception and bone health’, Contraception, vol. 73, no. 5, 2006, pp. 443–444. D’Arcangues is a researcher in reproductive health for WHO.

63  Rose et al (2008), pp. 698–699.

64  Farida Akhter, ‘The state of contraceptive technology in Bangladesh’, Reproductive and Genetic Engineering, vol. 1, no. 2, 1988, pp. 159–161.

65  Sharra L. Vostral, Under Wraps: a History of Menstrual Hygiene Technology, Lexingham Books, Lanham, Maryland 2008, p. 171.

First Blood: A Cultural Study of Menarche

   by Sally Dammery