by Rose George
By 1932 he was working in his basement on a “catamenial device” that consisted of five pieces of cotton sewn together, then stored in an applicator that can be used to insert the device into the vagina. Other tampons had been tried since Aveling’s. But these “objectionable” devices, wrote Haas, were “unsanitary; inconvenient and disagreeable to insert; difficult to withdraw when filled with absorbed fluids; and liable to separate in the vagina so as to leave fibers or a portion of the pad remaining therein.” Haas’s cotton was longitudinally stitched to give it better tensile strength, then shaped under high pressure into a cylinder and inserted in a cardboard tube that also served as an applicator. The innovations were the details: the nature of the applicator—more hygienic than a wooden rod—and the robust stitching (Haas recommended a chain stitch “such as employed for closing flour sacks”). It would be easier to insert, would be easier to withdraw, and would not leave scraps of itself inside the vagina. It was a hands-free, longitudinally stitched little plug of freedom.19
I’m fascinated by this patent and the details of it. It’s a rare example of relative transparency in an industry that in its 150 years of existence has become highly competitive and consequently secretive. When a Reddit user started a thread called “I design tampons, ask me anything,” he was stuck online for ten hours answering a flood of questions. Among his answers: a tube is not the optimum tampon shape because an unaroused vagina, seeing as you asked, “is more like a flattened balloon, since it’s being crushed by other organs”; vibrating tampons have been invented but are not for sale; and he doesn’t use the word menses—or know how to spell it—because a) he’s a “dude” and b) the industry word is “fluid.”20
Disappointed by a lack of interest from companies already producing sanitary napkins, Haas sold the patent in either 1933 or 1936 to a woman named Gertrude Tenderich, who is usually described as industrious or an immigrant or both.21 She took the patent and the name—Haas had devised “Tampax” from “tampon” and “vaginal pack”—and ran up tampons on her sewing machine, then began larger-scale manufacture in a Denver loft. But pharmacists wouldn’t stock them. Tenderich had come up against the same essential problem that has confronted makers of sanitary pads, tampons, condoms, and toilet paper: How do you market the unmentionable? The developing world uses the acronym BPL to mean “below the poverty line.” This industry was below the panty line, and it was a tricky place in which to do marketing.
Tenderich tried her best. She was innovative. She recruited nurses to give talks on menstruation, linking commerce with education, sort of, in the same way that massive global corporations today sell themselves as a resource for puberty, biology, and enlightenment. She sent around persistent salesmen (not women). She had some success but not enough, and so sold Tampax to Ellery Mann, a rotund man of terrific charm. “He could talk you off your chair,” said Gertrude’s daughter, Mary Kretschmar, “and then sit on it.”22 Ellery Mann made Tambrands a huge corporation, and Tampax—and tampons—ubiquitous, at least in some countries.
Today, the average woman in an industrialized country with access to a wide variety of sanitary choices for her menstrual period might use 11,000 to 16,000 sanitary products in her lifetime. Persuasive data on how many women use what are scanty, but a Euromonitor survey of American women aged twelve to fifty-four found they bought on average 116 pads a year, but only 66 tampons.23 Worldwide the absorbent device of choice is definitely external. Insertion taboos stop many women from using tampons: the only thing you insert in there should belong to your husband, and it’s not a tampon. The choices, then, are cloth or a sanitary pad, or towel, or napkin, or whatever we are supposed to call them. Feminine protection (from what?). Feminine hygiene (are we dirty?). Feminine Needs. Feminine Care. Feminine Accessories, as if tampons were earrings. I’d love to see a shop or supermarket that dared have an aisle called Menstrual Products. Blood Absorbers. Plugs and Wads. But plain speaking and feminine hygiene have never been comfortable companions. The advertising of sanitary products on TV and radio in the United States was banned until 1972. Despite one letter writer asking the agony aunt Dear Abby in 1984, “Please tell me what can be done to stop the advertising of personal feminine products on television,” the word period wasn’t spoken on American television until the following year, when a young Courtney Cox starred in an ad for Tampax. The company used the scandalous word, its advertising agency executive said, “because it happened to fit the campaign. We asked the networks to let us prove that it wouldn’t be offensive. […] It just doesn’t make any sense any longer to show a woman in a long white dress, drifting through a field of wildflowers, saying something like, ‘It makes me feel fresh.’”24 He was wrong about that. This is an industry that has developed like another industry shut out of sight and mind: slowly. Eighteenth-century plumbers could easily fix a modern toilet. In a whole century, there have been only three big inventions for something that affects three billion people: the tampon, the adhesive strip on a sanitary pad, and a menstrual cup.
Today, and then, ads appealing to women overwhelmingly used two things—fitness and fashion—to sell convenience, untainted clothing, and cleanliness (a code for not smelling of period blood). Sporty women abounded, as did glamorous evening gowns. “The filmy frocks that women used to fear now bring security,” wrote Ellen J. Buckland, the registered nurse hired by Kotex to write its advertising copy in the 1920s.25 Back then, there was more emphasis on medical approval. Tampax consistently used the tagline “approved for advertising in the American Medical Journal” as if it meant something other than that someone picked up the phone to the ad sales department. It boasted that Tampax was “perfected by a physician” (not an osteopath). I don’t find any advertising mentioning a letter to the British Medical Journal in 1942 by a female family doctor from Oldham. Shopkeepers had informed her, wrote Mary G. Cardwell, that young girls of eleven, twelve, and thirteen, and young women in general, were asking for these “internal sanitary towels.” She had medical misgivings. Some were using them as a preventive “in conditions of promiscuous intercourse.” But also, these internal towels entailed “undesirable handling of the vulval area.” Many young girls, she wrote, “insert the tampons by the aid of a looking glass. The psychological ill-effects are obvious.”26
If only a woman could have something that allowed her to entirely hide the fact that she was menstruating, she could not only live her life without being troubled by what one doctor dismissed as “the so-called difficult days,” but also not trouble society with it. Kotex, Tampax, Meds, Modess: all the early brands had the same object, to deal with “women’s greatest hygienic problem.” Kotex offered its products alongside a special deodorizer “thus ending ALL fear of offending.” Fear of offending is why girls have grown up wondering why they don’t excrete blue liquid, like on TV. In fact, there are no rules governing the use of blood in sanitary pad advertising in the UK, only that sanitary products should not be advertised too close to children’s programming or cause general offense.27 It’s tricky to know what this might mean. In 2014 a Tampax ad showing “a woman wearing a red top attending a rock concert and an animation showing how the Tampax worked” attracted twenty-two complaints, mostly about the timing and the imagery. The complaints were not pursued.
If red tops can raise red flags, perhaps advertisers are right to be timid. Internalized shame is the hardest to reach and redress. Once, a female airport security employee, emptying my bag, took my packet of sanitary pads and carefully hid it under my books. I asked her why and she looked surprised. “Most women ask me to.” In the UK, where I grew up, I have had access to sanitary hygiene and—though I can’t remember learning about it—information. But I still hide a tampon when I go to the toilet. I still remember looking at a lipstick in my pocket and worrying it looked like a tampon, and this was just after I’d given a talk about menstrual hygiene stigma at WaterAid. When a taxi driver retrieved a stray tampon from his car trunk and handed it to me, he wasn’t embarrassed, but
I was. I can’t remember being taught about periods in high school, but I’ve had years of surround-sound indoctrination anyway. Hide. Dissimulate. Be quiet.
It was only in 2011 that an Always ad dared to show a red spot in the middle of a sanitary pad. In the words of one unimpressed advertising journalist, it looked like a “You Are Here dot on an airport map.”28 (The headline in Adweek read, PAD AD TAKES THE BOLD STEP OF SHOWING PERIODS ARE ACTUALLY RED.)29 In 2016, the sanitary pad company Bodyform released a powerful ad that was widely praised and considered groundbreaking. It was expensively and stirringly shot and showed women boxing, cycling, surfing, and playing rugby to a soundtrack of powerful Native American drums. No different so far from Kotex’s tennis girls or Tampax golfers. Except this time the women played sport and bled when they did, because we do. A runner tumbled in a forest. A rugby player bled from a head wound. A dancer peeled back bandages on her bloodied foot, the blood sticky and sticking. The theme, clearly, was power and freedom, and the tagline fitted fine, as it was “No blood should hold us back.” I like the advert, but it was missing one thing. I wrote to Bodyform several times to ask why it had shown all sorts of blood except the menstrual kind, and was told it was unable to “progress [my] request.” (Bodyform released an ad showing menstrual blood the following year.)
* * *
Vagina. A word that should be pretty, with its melodious vowels, but isn’t. Perhaps the ill-favor of its name is why the vagina has been so ignored as a topic of study. Until 1992, the US National Institutes of Health had no programs for vaginal research.30 This is an extraordinary fact, because the vagina is an extraordinary thing. For a start, it is highly absorbent, more than skin. Its lining is covered with layers of defunct cells that form a barrier of mucous membrane. It protects the vagina against infection—despite multimillion-dollar sales of douches and deodorants, the vagina is self-cleaning—but not as forcefully as skin does. This makes the vagina walls highly porous so that they absorb chemicals without metabolizing them. Doctors know this: mine told me that I needed only half the dose of progesterone if I was taking it vaginally, as if it were obvious. Estrogen taken vaginally can produce blood serum levels ten times higher than with an oral dose.31 The vaginal walls are also loaded with tiny blood vessels, and the vagina is almost anaerobic. All this adds up to a perfect set of conditions for bacteria to thrive and this is desirable: of the thirty-nine trillion bacteria we’re now thought to carry (or perhaps they carry us), most are harmless.32 Even Staphylococcus aureus lives in the vaginas of 8–14 percent of women without causing harm.33 Our vaginal microbiome is useful and protective. But when certain conditions prevail, toxic strains of staph can flourish, particularly the toxic strain TSST-1, which in 1978 was first linked to what the pediatrician James Todd named “toxic shock syndrome” (TSS) after encountering a disturbingly virulent chain of infection in seven young children.34
I remember TSS, along with the punishing drought of 1976 and Duran Duran, as having a starring role during my teen years, because I knew it meant I should be scared of tampons. By the early 1980s, most women knew they should be afraid of them. In May 1980, reads the Centers for Disease Control website, “investigators reported to CDC 55 cases of toxic-shock syndrome (TSS) (1), a newly recognized illness characterized by high fever, sunburn-like rash, desquamation, hypotension, and abnormalities in multiple organ systems.”35 By the end of the year, there had been 890 cases, 91 percent of them in menstruating women. By June 1983, writes Philip Tierno in The Secret Life of Germs, “of the more than 2,200 cases reported to the CDC … ninety percent were associated with women who were menstruating at the time they became ill. Most of these women were young, and ninety-nine percent of them were using tampons.”
Tierno is a microbiologist who goes by “Dr. Germ” and who was instrumental in linking TSS to tampon use. The progression of Pat Kehm’s illness was typical. Kehm was twenty-five, the mother of two young daughters, and healthy until she wasn’t. “She woke up with a burning fever and chills. She soon began vomiting and having diarrhea. Meanwhile her temperature reached 103 degrees Fahrenheit.” Later that day, at the emergency department, the admitting doctor noted “sunburn-like rash, red flushing, severe dizziness, low blood pressure, and sore throat. Her chest and other parts of her body showed differences in color, and her legs and arms were starting to turn bluish.”36 Her heart stopped and she died.
Kehm had been using Rely, a superabsorbent tampon made by Procter & Gamble. Rely was great: you could insert it and leave it for hours. It swelled up into a mushroom shape, expanding sideways as well as vertically (and so much more suited to the vagina’s actual shape). It contained things like carboxymethyl cellulose, a hyperabsorbent chemical also used in laxatives, toothpaste, and artificial tears. The advertising archive at Duke University holds several TV adverts for the tampon. They’re not innovative—here is the swimming woman, the golfing woman, the tennis-playing woman—and the message isn’t revolutionary, either, as it consists of “remember they named it Rely,” one of the flattest flourishes in advertising.
Women with heavy periods liked it. Women who slept for more than eight hours a night liked it. By 1980, a quarter of American women liked it. But the toxic strain of Staphylococcus aureus really liked it, too. Science doesn’t yet understand why or how. Possibly, Rely was so absorbent that it dried out the vagina, making it more susceptible to tiny tears and abrasions (common in any tampon use) and giving it a direct line to the bloodstream, where staph could wreak toxic havoc. Or the materials used in Rely were to blame. In 1980, Tierno wrote a letter to the CDC, FDA, and Procter & Gamble that named four commonly used components of tampons: viscose rayon, carboxymethyl cellulose (CMC), polyacrylate rayon, and polyester. All, he determined, made for a very hospitable environment for TSST-1.
By the end of 1980, thirty-eight women had died. Rely and similar superabsorbents were withdrawn; there were a thousand lawsuits.37 Tampons were now sold only with strict instructions that they should not be used for more than eight hours at a time, and with stern warnings about the symptoms of toxic shock syndrome. There was enough publicity and fearmongering that I grew up scared when I forgot to remove a tampon. Manufacturers stopped using CMC, polyester, and polyacrylates. Tampons still use rayon, a product derived from wood or sawdust, alongside their cotton content. Sanitary pads are 90 percent plastic.
Details of what goes into tampons and sanitary pads are sparse and cloaked in the opaqueness justified by commercial competition. In the case of sanitary products, this secrecy is also facilitated by regulators. The FDA does not require manufacturers to list ingredients on the packaging, unlike with food items. If we were inserting lollipops in our vaginas, we’d know a lot more about them.
Investigations into sanitary product ingredients have tended to come from NGOs and the very concerned, including a 2013 report from Women’s Voices for the Earth, Chem Fatale. This found the presence in tampons and pads of “dioxins and furans (from the chlorine bleaching process), pesticide residues and unknown fragrance chemicals.”38 Dioxins and furans are both persistent organic pollutants (POPs), which we mostly ingest through the food chain. Ninety percent of human exposure to dioxin, says the World Health Organization, comes via meat and dairy products, fish and shellfish. Dioxins “can cause reproductive and developmental problems, damage the immune system, interfere with hormones and also cause cancer.”39 Chem Fatale’s list of damage sounds worse: cancer, reproductive harm, endocrine disruption, and allergic rash.
I blame my endometriosis on disruption caused by environmental chemicals. I don’t know if they penetrated me from the air, the water, the soil, ice cream, or a tampon, and I have no proof that they have (although most humans now have background levels of dioxins). Primates—rats, monkeys, and mice—exposed to dioxins show increased rates of endometriosis. One dioxin, 2,3,7,8-Tetrachlordibenzo-p-dioxin (TCDD), is considered a human carcinogen, and when inflicted on rhesus and cynomolgus monkeys through diet, caused “a dose-dependent increase in th
e incidence and severity of endometriosis.”40 Cynomolgus is the monkey’s lab name, named by Aristophanes of Byzantium after a tribe of hunting men with long beards (the monkey has a beard) who apparently milked female dogs. It comes from the Greek words for “dog” and for “to milk.” I can find no authoritative backup for this, but I want it to be true. Whatever their name—you’ll know them better as crab-eating or bearded macaque—they were surgically implanted with endometriosis tissue that was enhanced and flourished after exposure to TCDD.
But, wrote Michael DeVito and Arnold Schecter in Environmental Health Perspectives, “no definitive human data refute or support the association between dioxin exposure and endometriosis or other reproductive tract diseases.” The sanitary hygiene industry says its products are safe. Dioxins are only trace, there is no chlorine bleaching anymore. On its website, Tampax is quite clear about how safe the manufacturing process is: very. Leading scientists from Harvard, Dartmouth, Wisconsin, Minnesota, and the CDC “have conducted extensive testing confirming that rayon and cotton are equally safe ingredients to include in tampons.” The site includes a handy chart listing tampon components, function, and material, including the “Thin Fabric Around the Absorbent Core,” which helps with smooth removal and “to remove the absorbent skirt on certain designs.”41 (I immediately Google “absorbent skirt” and lose several hours of life.)
Periodically, the FDA has written, “concerns are raised about dioxin in feminine hygiene products—especially tampons.”42 Somehow the sober FDA author of this manages to sound like he—I bet it was a he—was sighing. In 2009, FDA funded a Jeffrey C. Archer (he is left unidentified further but actually works for the FDA as a chemist, though he does not appear on the FDA’s useful list of popular investigators). He was tasked to examine dioxin content in seven brands of tampons. No brand identification was given, but various absorbencies were used. The testing used gas chromatography with a high-resolution mass spectrometer, and found that, although dioxins were present, they were within the recommended limits. How much dioxin are we meant to ingest safely? Safe is a dangerous term, but the Joint Expert Committee on Food Additives, a UN body, suggests 70 picograms (a trillionth of a gram) per kilogram of body weight per month. Jeffrey C. Archer’s results found that if a woman absorbed all available dioxin from a tampon, weighed 50 kilograms (110 pounds), and used twenty-four tampons a month, she would be exposed to only 0.2 percent of the “tolerable monthly intake” set by the JECFA. DeVito and Schecter’s research found that our exposure to dioxins through our food is 30,000 to 2.2 million times more than infants, for example, are exposed to by wearing diapers.
