Chan M. “Overexposed and underprotected”: connecting structural racism to racial/ethnic disparities in age of menarche through personal care product use. HPHR. 2021;34.
Racial/ethnic disparities in the age of menarche are reported with Black girls reaching menarche at younger ages compared to other racial/ethnic groups. While research has identified a few drivers of this disparity, there is limited work examining the role of systemic racism. Through this commentary, the connections between systemic racism and racial/ethnic disparities in the age of menarche through personal care product use are identified. Specifically, examples from epidemiology, environmental health, psychology/social sciences, and news/media are highlighted to illustrate the potential pathways through which internalized, interpersonal, and institutional racism may act. Finally, the impact of the earlier age of menarche is discussed and the path forward is outlined.
Disparities in a wide range of health outcomes are reported in public health. While health status is predominantly attributed to an individual’s behaviors, lifestyle, and genetics (under lifestyle and biomedical epidemiologic theories) (Krieger, 2011), structural drivers, including structural racism have and continue to play a large role in health outcomes that disproportionately burden communities of color, notably Black communities. One health event, the age of menarche—or age of first menstrual cycle/menses—is racially patterned. This commentary aims to connect disparities in the age of menarche to structural racism through the path of personal care/beauty product use containing chemicals of concern. While at first, seemingly unconnected, examples and research will be drawn from epidemiology, environmental health, psychology/social sciences, and the media/news to highlight how structural racism may be a driver of reported disparities in the age of menarche.
Racial/ethnic differences in pubertal development are well documented (T. M. James-Todd et al., 2016). Specifically, Black girls experience their menarche earlier than White girls in the United States (Butts & Seifer, 2010; Ramnitz & Lodish, 2013). Research using the National Health and Nutrition Examination Survey (NHANES) found that the mean age of menarche was 12.1 years for Black girls compared to 12.7 years for White girls (T. Wu et al., 2002). Similarly, the Bogalusa Heart Study reported that the mean age of menarche for Black and White girls was 12.1 and 12.5 years, respectively (Freedman et al., 2002). The age of menarche for Black girls is also earlier than for Latinx girls (Chumlea et al., 2003). At the individual level, these reported differences in menarche may appear inconsequential and only differ by 4 to 6 months. However, at the population level, this shift in an important pubertal indicator is a cause for concern. Research into the differences in the age of menarche primarily focuses on anthropometric measurements (size at birth, birth weight) and body mass index (BMI), with some literature on socioeconomic status—however, there are varying results reported based on study design and the specific exposure examined (Anderson et al., 2003; T. James-Todd et al., 2010; Reagan et al., 2012). The few studies that explicitly consider the racial/ethnic differences in age of menarche present evidence of associations with weight and BMI (Anderson et al., 2003; Kaplowitz et al., 2001; Reagan et al., 2012).
Environmental chemical exposures are hypothesized to contribute to early menarche—and exposure to these chemicals are racially/ethnically patterned (Butts & Seifer, 2010; T. James-Todd et al., 2011; T. M. James-Todd et al., 2016). However, research and more broadly, dialogues surrounding this disparity in exposure have not considered the role of structural racism. Specifically, structural racism may act through different paths, such as personal care product use containing chemicals of concern. In general, beauty products are an understudied source of environmental chemical exposure (Zota & Shamasunder, 2017), and product use is typically viewed as a behavior (Chan, Parikh, et al., Unpublished Manuscript). However, personal care product use varies by race/ethnicity (Bellavia et al., 2019; Hart et al., 2020; T. James-Todd et al., 2011; Taylor et al., 2018; X. M. Wu et al., 2010), and Black women are more likely to use certain hair products, skin lightening products, and vaginal douches that contain chemicals of concern than White women (Branch et al., 2015; T. James-Todd et al., 2012; Zota & Shamasunder, 2017). The relationship between hair product use and menarche has been explored, and a study by James-Todd et al. found that women reporting the use of hair oil and hair perms in childhood had a risk ratio of early menarche of 1.4 (95% CI 1.1, 1.9) and 1.4 (95% CI 1.1, 1.8), respectively (T. James-Todd et al., 2011). While differences in product use have been attributed to culture and hair texture, there is a lack of discussion surrounding one potential root cause of these differences—structural racism.
The United States’—and most societies’ with a history of European colonization—definition of physical attractiveness is rooted in Eurocentric beauty standards, which has embedded a single ideal of beauty into society (D. K. Teteh et al., 2020). The result is that physical attributes not only denote beauty, but also social status and economic mobility (Hunter, 2011; Johnson & Bankhead, 2014). This racial capital or economic and social value derived from certain physical attributes is linked to hair texture and skin tone (Hunter, 2011; Robinson-Moore, 2008). “Good hair” is considered “long, straight, silky, bouncy, manageable, healthy, and shiny” (Johnson & Bankhead, 2014; Lester, 2010; Robinson, 2011). Lighter skin is associated with beauty, social status/class, marriage, and financial opportunities (Alrayyes et al., 2020; Peltzer & Pengpid, 2017). These racialized beauty standards have shaped society and are continuing to provide opportunities and advances for select groups whose appearances align with these beauty standards while creating restrictions and barriers for others.
One historic example of the impact of racialized beauty standards is Clark and Clark’s 1947 “Doll Test” which demonstrated the negative effects of discrimination and segregation on the self-perception of Black children (Clark & Clark, 1947). The study results may be seen as an example of internalized racism where the children’s racial preferences highlighted their feelings of inferiority compared to White children. The study was repeated by a student 58 years later and the original findings of the preference for White dolls were supported (Bryant, 2013). While both studies highlighted internalized racial preference, there also was a recognition of the inherent complexities and multiplicity of the children’s views driven by their experiences (Tuck, 2009). Internalized racism may not be the only type of structural racism that is connected to beauty standards, and interpersonal racism may play a role in both self-perception and product use.
Specifically, research focused on hair texture and skin tone found that women learn from their families what is considered socially acceptable (Bryant, 2013; D. Teteh et al., 2019; D. K. Teteh et al., 2020). For example, one study of college students reported a relationship between the student’s views of their skin tone and the skin tone idealized by their family (Coard et al., 2001). Families may play a large role in the perceptions of beauty held by their offspring/the individual(s) they are caregiving for, but it is important to recognize and acknowledge the potential experiences that have shaped the caregiver’s own perceptions of beauty. Cycles of racial trauma may be multi or transgenerational, and scholars hypothesize that these early life experiences with racism permeate throughout the life course and across generations (Robinson-Moore, 2008).
Outside of familial influence, the media upholds and perpetuates racialized beauty standards. Specifically, mainstream beauty celebrates European skin tones, hair textures, and body shapes (Ashe, 1995; Byrd & Tharps, 2002). It may be argued that the media is a route for interpersonal racism to act through. Specifically, in the age of social media, people have the ability to reach out to and connect with others like never before. While there are positives stemming from this now predominant form of media, there are also negatives such as targeted posts on explore pages that idealize Eurocentric beauty standards as well as increased opportunities for interpersonal racism. For example, social media can be used to amplify hate speech and one comment can be shared, liked, or reposted innumerable times and live online for the unforeseeable future. Media, more broadly, can also perpetuate stereotypes and may frame public perception by speaking about individuals or groups of individuals using certain racist terms or phrases.
These examples are just a few ways in which internalized and interpersonal racism shape beauty standards that persist to this day. Arguments may also be made that media is an institution and as a result, a path for institutional racism to act through; however, this argument makes assumptions that the media is one entity, and the media is a formal institution.
Beauty standards are only one piece of this story—and institutions themselves have instated discriminatory practices and policies that limit opportunities for Black communities. One that is currently widely considered in public health is redlining. Redlining was a discriminatory lending practice started by the Homeowners’ Loan Corporation (HOLC) in the 1930s where communities were rated from Grade A-D. Mortgage lenders would not give loans to individuals from specific communities (low-income Black and ethnic minority/immigrant neighborhoods) based on the neighborhoods’ lack of “desirability” and “perceived risk” of foreclosure (Nardone et al., 2020). In addition to redlining, exclusionary zoning practices, conflicting land use, and other federal initiatives guided certain activities/industries into neighborhoods and restricted opportunities (Cole & Foster, 2001; Johnston & Cushing, 2020; Morello-Frosch & Lopez, 2006; Nardone et al., 2020). However, research and discussions surrounding redlining and other discriminatory policies have not considered how they may also influence the personal care and consumer products sold in communities. Only a few studies—both academic and community-based—have begun to examine this version of “retailer redlining” and presented associations between proximity to dollar stores and neighborhoods of color as well as evidence of toxic products in dollar stores (Campaign for Healthier Solutions, 2015; Shannon, 2020). Even among these studies, beauty products are largely left out. This question about the safety of beauty products at the neighborhood-level is beginning to be explored (Chan, Parikh, et al., Unpublished Manuscript).
In combination with these policies that shape communities and may influence product use, decisions at the local, state, and federal levels continue to institutionalize and reaffirm race-based actions related to appearance. For example, the news in 2018 highlighted the stories of two students in separate schools (in New Orleans and Florida) who were sent home because of braided hair extensions and locs which “violated school rules” (Jacobs & Levin, 2018). These stories are only a few instances of the experiences that Black students face and speak to the history of discrimination that is institutionally embedded. Additionally, in 2016 the U.S. Circuit Court of Appeals ruled against a lawsuit filed by a woman whose job offer was terminated because she had her hair in locs. The court made a statement that while certain hairstyles are culturally associated with race they are not “immutable characteristics” (U.S. Court Rules Dreadlock Ban during Hiring Process Is Legal, 2016). As one final example, in 2005 the U.S Army instated regulations on authorized and unauthorized hairstyles (Regulation 670-1), with unauthorized styles including locks, twists, and braids larger than ¼ inch in diameter (Henderson & Butler, 2014). While not all of these examples are directly related to children and their experiences, they do demonstrate how institutional racism polices the physical appearance of Black communities.
Internalized, interpersonal, and institutional racism may contribute to racial/ethnic patterns of personal care product use. In terms of hair products, Black women are more likely to use hair oil, lotion, leave-in conditioner, and pomade (T. James-Todd et al., 2011, 2012; Taylor et al., 2018) compared to other racial/ethnic groups. Additionally, Black women and women and children of color more commonly use hair products containing hormones and endocrine disrupting chemicals (EDCs) (T. James-Todd et al., 2012; Tiwary, 1997, 1998)—exogenous substances that interfere with the body’s hormonal processes (e.g. synthesis, secretion, transport) (Diamanti-Kandarakis et al., 2009). Black women also more commonly use hair relaxers/perms which may be driven by beauty standards and barriers to educational/employment opportunities outlined previously (Gaston et al., 2020; T. James-Todd et al., 2012). Black girls follow these product use patterns and are found to be more exposed to personal care product-associated EDCs than children of other racial/ethnic groups (Kalloo et al., 2018; Stacy et al., 2017; Wolff et al., 2014). Additionally, one study examining products marketed to Black women and girls found that the highest levels of European Union banned or regulated chemicals were in the hair relaxer kit marketed to children, Just for Me (Helm et al., 2018).
Differential product use extends beyond hair products, and colorism and odor discrimination drive the use of skin lightening products and vaginal douches/other menstrual products (Zota & Shamasunder, 2017). Skin lightening products may contain a range of active ingredients including mercury, hydroquinone, corticosteroids, and glutathione—some of which have limited safety information or are available at illegal concentrations (Chan, Dhillon, et al., Unpublished Manuscript). Although there are limited U.S.-based skin lightening use studies, one study found that Dominican and Mexican American women in the U.S. are two high use populations (McKelvey et al., 2011). Individuals of African descent are a high use community and one review of skin lightening practices in African countries reported a prevalence of use from 27-72.4% (Dadzie & Petit, 2009). Skin lightening practices are also found to occur during pregnancy as well as among children (Arinola et al., 2020; Mahé et al., 2007; Olumide et al., 2008).
These patterns of product use among Black women and children reflected throughout this commentary are also apparent in the use of menstrual products (e.g., douches, washes). Ferranti described how historically the fabricated odor of Black women was connected to sexual stereotypes and women began to use menstrual products, such as vaginal douches, to counteract this (Ferranti, 2011). The use of menstrual products is now considered a cultural norm, and research using NHANES found that Black women are more likely to use vaginal douches and other fragranced menstrual products (Branch et al., 2015). Concerns about vaginal douching stem from the chemicals found in the products (such as diethyl phthalate, an EDC) as well the increased risk of acute pelvic inflammatory disease and bacterial vaginosis (D et al., 1993; Holzman et al., 2001; Zota & Shamasunder, 2017).
It is important to reiterate that these racial/ethnic disparities in exposure reported above are not only among adults—and children/young adults may follow similar patterns of product use and have higher levels of personal care product-associated chemicals than their peers of other racial/ethnic groups. Research focused on disparities in children’s product use is limited potentially due to additional challenges associated with examining product use among children or it may be underreported by parents.
Structural racism’s role in differential product use is multi-faceted. However, the disparities are clear—Black women and children are disproportionately exposed to chemicals of concern from personal care products. Since childhood is a critical window of development, product use during this period may be a driver of early pubertal development, including menarche.
As discussed, the earlier age of menarche may not seem like a concern, however, there are a number of burdens and health outcomes that may be linked to an earlier age of menarche. Altered timing of puberty may increase the risk of substance abuse, antisocial behaviors, eating disorders, and emotional stress (Patton & Viner, 2007; Schoeters et al., 2008). These social burdens may add to the pre-existing cumulative stressors and racial trauma experienced by Black communities. Earlier puberty and menarche also contribute to the adultification of Black girls, where they are treated and perceived as less innocent and older (Epstein et al., 2017). In addition to these burdens, the earlier age of menarche has been examined as a risk factor for breast cancer and type two diabetes, diseases that burden Black women (Elks et al., 2013; D. K. Teteh et al., 2020).
This information and these connections between structural racism and the early age of menarche are overwhelming and at first, there may not seem like there is a clear path forward. However, this issue, like many in public health, is inherently complex. Solutions will require a multi-pronged approach that is rooted in structural changes and community-driven movements. We need policies that ban discrimination in academic and employment opportunities such as the Crown Act (which aims to protect individuals against discrimination based on traits associated with race) and updated military appearance standards (reported to have been instated in early 2021). We need policies that strengthen the oversight agencies—such as the Food and Drug Administration—to ensure that the products on our shelves are safe. We need to listen to community leaders and community organizations who are organizing and educating on the ground. We need to support movements that redefine beauty. And we need research that explicitly aims to connect the dots between structural racism and disparities in health outcomes, such as the early age of menarche. Beauty is not skin deep—and by reconceptualizing personal care product use as a significant source of environmental chemical exposure and understanding systemic racism’s role as a driver of product use, we can begin to consider lasting solutions.
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Marissa Chan is a recent graduate from the Department of Environmental Health at Harvard T.H. Chan School of Public Health. Her research interests and work experience focus on the intersection of place-based environmental hazards and product-based exposure to toxic chemicals in consumer products. Through her work she aims to assess racial/ethnic disparities in health outcomes, highlight the presence of endocrine disrupting chemicals in consumer products, and support communities’ voices and knowledge in environmental justice efforts.