3. Toxicity, Environmental Leak: On Pain and Menstrual Trauma

Tampon Toxicity and Unacceptable Menstrual Trauma

Toxic shock syndrome, first identified as a distinct condition in 1978, exists in two forms: one related to menstrual product usage, primarily of tampons (but also discovered in conjunction with menstrual cups), within the vaginal canal, which facilitates the release of toxins by Staphylococcus aureus bacteria, and the second unlinked to menstrual products and caused by group A streptococcus bacteria releasing toxins, usually in relation to surgery or wounding (Mitchell et al. 2015; Vostral 2017a, 4). Tampons are without a doubt products that have been, since their popularization in the 1960s, widely adopted by menstruators due to their many assets. Unlike bulkier pads, tampons allow for unimpinged movement and are for many much less uncomfortable. They are also less visible than menstrual pads, and in a culture attached to menstrual secrecy and discretion, this has also played a role in their popularization. While this is not true for all nonbinary and transmasculine menstruators, tampons and other internal menstrual products have felt like the only option for me for managing dysphoria, and even after TSS, when I was told by doctors not to return to tampons, I could not help but use them monthly. Using external products that felt thick between my legs and further reminded me of the menstrual experience was beyond what I could ask of myself. Because of their many essential attributes, tampons can be considered a life-affirming technology that vastly improves the lives of those menstruators who have access to them. Importantly, due to period poverty, many menstruators, not only globally but also within wealthy countries like the United States, do not have access to tampons.

Because tampons are such an essential product, it was all the more shocking when news of TSS outbreaks began to spread in the late 1970s and early 1980s. By the late 1970s, TSS had been labeled and attributed to tampon usage, specifically superabsorbent tampons. Yet menstrual product companies were resistant to acknowledging their culpability, and news media also dragged their heels on getting the message out around tampon-usage risk, including due to then-existing regulations around featuring mentions of menstruation and period-related language on mainstream television (Vostral 2018, 11). While not quite an epidemic, 1,660 cases of TSS had been reported to the Centers for Disease Control in the United States as of 1982; 88 resulted in death (Centers for Disease Control 1982). High-absorption tampons were found to be most deleterious, in particular Procter & Gamble’s new high-absorption tampon Rely, which appeared in 1975 and was taken off the market in 1980 (Vostral 2017b). Vostral, in her 2018 monograph on TSS, discusses how tampon manufacturers were innovating to create more and more absorbent tampons, drawing on synthetic materials, including plastics. Due to menstrual products being grandfathered into FDA regulations, these new superabsorbent products did not require intense safety testing or review (Vostral 2018, 32). Rely, specifically, implemented a new foam core and gelling substance within a polyester compartment that increased absorption and also proved to be particularly friendly to hosting Staphylococcus aureus bacteria, hence facilitating TSS (15). Having TSS recognized as a concern, “within the milieu of the time period, . . . [was] neither intuitive nor ‘common sense’” and took research and organizing at multiple levels (49). Vostral points out that TSS was finally recognized as a concern for menstruators who used tampons in 1980 because the TSS deaths consisted primarily of young white cisgender women and girls, who were seen as both in need of protection by the state and as lives worth saving (48, 50).

Importantly, the removal of Rely from the market and the labeling of tampons’ absorbency levels in 1990—which was fueled by consumer groups and women’s health advocates pushing for more transparency, including the involvement of Esther Rome from the Boston Women’s Health Book Collective that authored Our Bodies, Ourselves—did not effectively end the existence of TSS (Vostral 2017b, 727). I myself had TSS in 2001, not knowing at the time about the existence of TSS or the attention TSS received two decades prior. Yet in the emergency room, a doctor was able to diagnose my condition because of that groundwork of knowledge that existed around TSS and due to the degree of presence it had in mainstream culture. Even so, the TSS warning information that is included in tampon boxes to this day tends to place the responsibility on menstruators to be able to self-recognize TSS and use tampons at their own risk, and a list of ingredients is not required on the packaging (Vostral 2018, 13). Because TSS symptoms are initially so similar to those of a cold or flu (fever, weakness, puking), it is very hard for menstruators and loved ones to recognize when they have TSS. Such was also the case with me when my sister was unable to recognize I was truly unwell (rather than just ordinarily unwell).

TSS is a confounding condition because, while motivated by tampons, it is not caused directly by tampons. Staphylococcus aureus bacteria are common to all bodies and might increase in number in the vaginal canal during menstruation due to pH level changes, but they are not innately dangerous to humans in small quantities. Yet during menstruation, when a tampon is used, it increases the amount of oxygen in the vaginal canal, encouraging the bacteria to multiply. This is also why advice to change out tampons more often may be misguided, because it could actually bring in even more oxygen for bacteria to further multiply when the process is already underway (Vostral 2018, 14). Further, the tampon itself creates a hospitable space for bacteria to multiply on. Increased oxygen levels are also the reason superabsorbent tampons are proven to raise the rate at which the bacteria multiply. Even so, it is not the bacteria themselves that are toxic but the toxin that they produce—toxic shock syndrome toxin-1 (TSST-1)—and whether it gets absorbed through the vaginal wall into the bloodstream. If TSST-1 does make it into the bloodstream, it causes TSS because it stimulates the release of cytokines (proteins used in cell signaling).

There is a dynamic set of conditions that must align for TSS to take form and for toxicity to be threatening to the menstruating body, which involves the tampon, bacteria, and menstrual blood in the vaginal environment. Vostral makes the really important point that both the bacteria and the tampon are, in a sense, dynamic, agentic, and animate entities. Agency here emerges as a dialogue, a relation, rather than the property of any one of these factors or of the human alone. We can also say that the necessary components engage in “intra-action,” to use Karen Barad’s (1998) term, in the sense that they emerge together and in dialogue with each other—a combination of human, bacteria, and technology. Vostral discusses “this relationship of bacterium and technology as active co-agents” using the term “biocatalytic technology” (2018, 10). While tampons, she argues, are commonly considered inert—“an inert plug to stop up the fluids of a mechanical body”—in relation to TSS, tampons serve as a catalyst, a site of interaction (10). Through being in relation, tampons, bacteria, and menstrual blood create a site of toxicity for the human body. As Vostral phrases it, tampons and bacteria “are quite more dynamic together than anyone ever imagined,” creating “a new illness entanglement” (21, 34). Vostral makes one other compelling claim that I want to point out, and that is that while menstruators were and are the expected users of tampons, the surprising user of tampons that emerges in TSS is the Staphylococcus aureus bacteria themselves, because they end up benefiting from the presence of the tampon in the vagina and propagate. As she writes, “A bacterium became the overlooked and unintended user of tampons, thus changing the relationship of user/technology. The bacterium advantageously capitalized on the technological innovation to reproduce and multiply” (21). Tampons are not directly toxic for human bodies, yet bacteria and tampons together can create sites of great toxicity for the menstruator.

Even more importantly, TSS received coverage, attention, and anxiety in 1980, though much less so now, because it was deemed inappropriate that young white cisgender women should be affected by toxicity. While menstrual pain remains untreated in many menstruators, seen as something one simply has to life with, TSS became the threshold for attention, an unacceptable amount of bodily trauma and toxicity. In the late 1970s and early 1980s, TSS was thought to affect more white cisgender women than any other racialization likely because more white women used tampons and found their ways to hospitals if they experienced TSS symptoms. Even so, leading up to 1980, some TSS patients were dismissed by doctors as having colds or flus and sent home only to have their conditions worsen. Further, more young girls and women experienced TSS leading up to 1980 when TSS received media attention because young people do not yet have antibodies against the bacteria as new bleeders and tampon users (Vostral 2018, 15). TSS became an unacceptable form of menstrual trauma, in the eyes of the public and journalists more so than in the eyes of the manufacturers of menstrual products, because, as Vostral points out, it was connected to young white femininity and lives perceived as worth saving. This also suggests that different degrees of harm, toxicity, and trauma are deemed acceptable for people based on their social location in relation to racialization, gender, ability, geographic location, age, and sexuality.

Also of interest for me is that my own body—at the time still a child, white, feminine-presenting and assigned female, and mostly nondisabled—was deemed by doctors and family as okay to withstand severe and ongoing menstrual-related pain only months before my TSS incident, yet upon experiencing TSS, my body reached its perceived threshold of menstrual trauma and received expedited medical attention. Perhaps it should not be surprising that TSS in my body received fast medical attention because there were indicators of me getting very ill very quickly in a way that the emergency room is designed to address, yet at the same time I remain fascinated by what forms of menstrual trauma are deemed acceptable and for whom. With medical knowledge that TSS can lead to quick death and irreversible bodily damage, and with a history of whiteness and youth attached it to, TSS often exists—when believed and diagnosed quickly by medical professionals and loved ones—as unacceptable menstrual trauma, as death and disability worth avoiding. However, menstrual pain—chronic, ongoing, cyclical—causing no visible disability, offering no easy diagnosis, is provided little to no support. Chronic pain, while very hard to live with, does not necessarily indicate either bodily harm or injury, nor is it very spectacular to witness; it is not necessarily very “productive” pain.

I see menstrual trauma as a fruitful framing for accounting for how the difficulties associated with menstruation, such as the need to conceal blood and the pain often accompanying bleeding, are normalized as mundane and inconsequential in ways many other forms of trauma have also been. Through being deemed a “natural” effect of menstruating or of being a menstruating body, chronic pain has been socioculturally implanted as natural, normal, to be expected, and even necessary. Menstrual trauma related to menstrual and endometrial pain consists of both the reality of the pain, the ongoing realness of it, and a continuing culture of menstrual-pain skepticism that includes comments that undermine, belittle, ignore, and attempt to disprove the pain one experiences. While hard for others to understand, pain requires recognition rather than undermining; as Margaret Price writes, “That my experience is meaningful does not imply that the person or people with me are able to understand it, but rather that they take for granted it should be understood” (2015, 279). So for menstruators, the gaslighting work of having pain undermined, in addition to and in combination with the pain, the ongoing need to hide blood, the discourse that pain is of womanhood and thus a necessary component of bleeding, and perhaps internalized shame all function to accumulate what Charis Chambers refers to as period trauma, that “sustained . . . injury/distress related to or caused by menstruation” (quoted in Bunch 2021).

TSS, I believe, receives and received the attention it did because of the “shock” component. Not only is a young white menstruating body perceived to be unwell, but the unwellness comes as a “shock” to the body and to loved ones because of the speed at which it travels. TSS symptoms can arrive over the course of a day, and within a few days the person can be dead. This quick wounding model of toxicity, rather than the slow violence of many environmental forms of pollution, tends to attract more media and public attention and is again in direct opposition to the crip time of chronic pain that lingers, returns, and cycles in and out to no effect. In the following section, I think about tampon toxicity as it relates to environmental pollution and the slowly violent effects of toxic components in tampons.

Toxic Leak in and beyond the Body

Vostral argues that tampons are a technology that has “the ability to cause gendered injury, like many other technologies used to manage and regulate . . . reproductive bodies” (2018, 21). In this section, I explore a connected site of tampon toxicity: that of various plastic and volatile organic chemicals found in single-use menstrual products, which cause unknown and mostly unaccounted-for harm to menstrual bodies through a model of slow violence, as well as harm to the environment in their production and life beyond use. While this trauma is less easy to track and less studied than TSS, it nevertheless remains a toxic burden that menstruating bodies are expected to carry that bears effects beyond the short life of products’ intended use in the body, on the environments they are disposed into. As mentioned at the outset and drawing on Shadaan and Murphy’s (2020) work on endocrine-disrupting chemicals, understanding individual bodies in connection to environments is an important strategy for moving beyond individualistic models of toxic harm and toward acknowledging toxicity as “the structural and extensive reach of settler colonialism and racial capitalism” with links between bodies and land (7).

The concept of slow violence, originating from Rob Nixon, is well known in environmental studies and can be used to refer to the less sudden and dramatic forms of toxic leak and exposure that nonetheless enact harm over the span of years or decades. Nixon writes that by “slow violence” he means “a violence that occurs gradually and out of sight, a violence of delayed destruction that is dispersed across time and space, an attritional violence that is typically not viewed as violence at all” (2013, 2). While slow violence is becoming the reality for many with increasing environmental devastation, it most commonly acts as a form of environmental racism and most often affects BIPOC, people experiencing poverty, and people from low- and lower-middle-income countries most exploited by colonization (Taylor 2014). For example, in the United States, the dumping of radioactive and hazardous waste often happens near or on Indigenous lands that are deemed “sacrifice zones” and has immense health consequences for Indigenous people living in proximity to the waste that leaks into the land, water, and air (Taylor 2014, 54; Kuletz 1998). Slow violence also affects people with uteri, including cisgender women, who on a global scale are more likely to have lower incomes, work dangerous jobs, and be exposed to toxic leaks.

While access to single-use menstrual products is commonly branded as more “sanitary” and pushed on menstruators around the world as a superior form of menstrual blood absorption, it carries with it a huge chemical load both during its use and its life post-use, as it ends up in the waste stream, incinerators, or waterways. If TSS is an example of quick toxicity that is immediately evident, though sometimes hard to diagnose because its initial symptoms resemble having a cold or flu, there is also a durational toxic leak that accumulates in harm to menstruating bodies over the period of years of menstruating and using single-use menstrual products. This accumulative harm and toxic burden are part of menstrual trauma, understudied, unaccounted for, and rendered acceptable by menstrual product companies and regulatory mechanisms. As Nixon writes more broadly, “Violence is customarily conceived as an event or action that is immediate in time, explosive and spectacular in space, and as erupting into instant sensational visibility. We need, I believe, to engage a different kind of violence, a violence that is neither spectacular nor instantaneous, but rather incremental and accretive, its calamitous repercussions playing out across a range of temporal scales” (2013, 2). This provides a description of the not yet fully cataloged effects of menstrual product toxicity on both menstruators and their effects pre- and postdisposal. Because menstruators use menstrual products upon every period, for up to a week or more, and over the span of many decades and potentially forty years of their lives, the toxic leak and burden from disposable menstrual products is substantial.

Data that exists on disposable menstrual products indicates that they contain a host of potentially toxic elements, including plasticizers, volatile organic compounds, dioxins from the bleaching process, and synthetic fibers such as viscose rayon (Hand et al. 2023; Vostral 2018, 24). Tampons, mostly made of cotton, contain 6 percent plastic and rayon, which is derived from pulp fiber and heavily bleached with chlorine and thus contains dioxins, which are linked to endocrine disruption, cancer, and other forms of reproductive harm. Further, the cotton itself contains pesticides. Because the vulval and vaginal tissues are permeable, abounding in arteries and blood vessels, the occurrence of chemicals in menstrual products is especially dangerous and can have many long-term side effects, including cancer, damage to the liver and kidneys, endocrine disruption, reproductive issues, fetus birth defects, skin irritation, and respiratory issues (Lin et al. 2020). One recent study suggests that the following volatile organic compounds (VOCs) are found in tampons and other menstrual products, including those labeled “organic”: aldehydes, alkanes, aromatic hydrocarbons (such as benzene), chloroform, dichlorobenzene, dioxane, esters, halohydrocarbons, ketones, terpenes, and others. It also suggests that these and other VOCs are found in greater quantities in menstrual pads, scented menstrual products, and “feminine” sprays and powders (Lin et al. 2020). Other studies indicate the presence of dioxins tetrachlorodibenzo-p-dioxin and tetrachlorofuran, as well as pesticides such as dichlofluanid, fensulfothion, malaoxon, malathion, mecarbam, methidathion, piperonyl butoxide, procymidone, and pyrethrum (e.g., DeVito and Schecter 2002). Additional studies discuss how fragrances in tampons are likewise toxic, and because fragrances are a mix of thousands of ingredients, it is nearly impossible to parse their toxic effects (Scranton 2013). Unfortunately, this multiplicity of harmful substances makes menstrual product toxicity harder to regulate as it “subverts the ability to isolate the harmful effects of any specific exposure in an era when chemical exposures are only regulatable and litigable as specific entities” (Murphy 2008, 701). Menstrual products, under the FDA, are considered “Class II medical devices” and thus are not required to list ingredients or label what chemicals are contained within (Fourcassier et al. 2022, 7; Lin et al. 2020, 7). They are not subject to rigorous testing and do not commonly list expiration or manufacture dates (Lin et al. 2020, 4). As these details and studies indicate, there is a persistent negligence on behalf of menstrual product companies in collusion with state actors to disclose the ingredients and potential toxicity of menstrual product composition.

Even while single-use menstrual products are marketed as “sanitary,” “hygienic,” and “clean,” they carry a chemical burden for menstruators and accumulate in large numbers in the waste stream. Disposable menstrual products are devastating in terms of waste accumulation. Commercial period pads are composed of about 90 percent plastic and tampons contain about 6 percent plastic, including low-density polyethylene, but they also often contain plastic applicators and plastic packaging. These products are estimated to take about five hundred to eight hundred years to break down, though as scholars of plastic point out, it is impossible to fully determine plastic’s lifespan because it was introduced so recently into the environment in terms of geological time (Fourcassier et al. 2022, 1; Davis 2022). Plastics are also well known to indefinitely persist in the form of microplastics, being absorbed into the food stream. In this sense, plastics not only pollute but also become part of the fabric of life (Liboiron 2021, 17). Rachel Vaughn examines how waste collectors in India, mostly poor girls and women, have undertaken activist organizing, calling for used menstrual products to be properly labeled when disposed of. Vaughn’s analysis of campaigns such as Solid Waste Collection and the Red Dot Campaign in Pune, India, which calls for the labeling of used menstrual products with red dots or in red bags so that they are not handled by waste collectors, draws attention to how menstrual products affect both land and human bodies after their disposal. Importantly, more sustainable menstrual product options are available, many of them stemming from initiatives in lower-income countries (Vaughn 2020). These include compostable pads made by local initiatives that provide lower-cost products to menstruators made from absorbent natural fibers such as water hyacinth, banana skins, bamboo, papyrus, hemp, and cotton (Hand et al. 2023). In Western countries, washable menstrual cups and period underwear are highly effective options that are less harmful for the environment, are able to be reused countless times, and are less or not toxic (Fourcassier et al. 2022; Vaughn 2020).

When plastics were first marketed in the 1950s, their disposability was a key selling point, offering ease and reduced cleaning time for middle-class living (Davis 2022, 23l; Liboiron 2021). Plastic disposability has only grown exponentially as a necessary device for wealth generation, with single-use plastics being the largest category of plastic waste worldwide. To comfort people regarding the inordinate amount of plastic waste being generated, the fantasy of plastic recycling was created in the 1970s. Realistically, only a small percentage of all plastics are recycled (estimates vary, but it is well under 10 percent), and plastics can only be recycled several times before they deteriorate—upon recycling plastic degrades, so rather than recycled it is downcycled (Davis 2022, 8). The result is a world inundated with plastic, where plastic and “nature” are mutually comingling, since plastics persist in time and break down into microplastics that enter the bodies of organisms (Davis 2022). Further, plastic production contributes greatly to fossil fuel emissions (about 10 percent of global oil production is used for plastic production) and has toxic effects through its production process, especially on communities—often BIPOC and experiencing poverty—that live in the vicinity (30). Notably, in the United States and Canada, the pollution of land, water, and air through plastic manufacture and disposal is also colonial violence or “waste colonialism” (Davis 2022).

As with the marketized disposability of plastic, menstrual product disposability is likewise central to income generation for wealthy corporations, with menstrual products and “feminine” care in the United States alone generating an estimated $3 billion in sales annually (Lin et al. 2020, 1). And as with other forms of plastic waste, disposability is hard to give up for consumers who are habituated to its conveniences and to the idea that it goes away once disposed of. As Heather Davis writes, “We fear being smothered in plastic . . . yet, we are also attracted to it, and especially to its promises of a clean, sanitary, sterilized life. Despite the fear and revulsion that many now feel toward plastic, we cannot easily give it up” (2022, 8). Like with other forms of plastic, menstrual products are branded as sanitary because of their disposability, and because menstruators already navigate undue menstrual trauma, it is difficult for menstrual product consumers to turn away from the affordances of disposable menstrual products. While reusable menstrual gear does all but eliminate menstruators’ toxic burden, is easy to use, significantly decreases waste and pollution related to menstrual products (by up to 99 percent according to a Life Cycle Assessment study), and is cheaper in the long run, it can still be difficult to access, requires specialized knowledge and know-how not accessible to many in a climate of low menstrual education and menstrual negativity, and demands a higher up-front cost than disposable products (Fourcassier et al. 2022). Importantly, because menstruators already have to navigate so many elements of menstrual burden and trauma in their day-to-day lives that nonmenstruators simply do not even have to think about, doing what feels easier can feel like the only option.

Additionally, there has been an unfair burden placed on menstruators to take responsibility for menstrual product toxicity and pollution that has not been applied in the same way to nonmenstruators or to the industries that manufacture disposable menstrual products. For example, many other products have not been targeted for their toxicity and contribution to pollution in the same way that menstrual products have been. This additional burden of pollution guilt is especially unfair given that many menstruators, including in the United States, do not always have access to menstrual products. Further, individualizing issues tied to pollution, making them the responsibility of menstruators through a neoliberal language of “choice,” fails to address the complexities of menstrual trauma, the ongoing burdens menstruators already face, and issues of period poverty that make it unreasonable for most people to “make the right choice” that will reduce bodily and environmental toxicity. Shadaan and Murphy discuss how this individualist, consumer-oriented approach to toxicity is deeply convenient and internal to both capitalism and settler colonialism and “assumes that boundaries can be established between people and their environments, and erases the fact that toxics are ubiquitous in our surroundings” (2020, 5). They also draw on Norah MacKendrick (2015), who discusses how the pressure on consumers to make the right, toxic-free choice, or what she terms “precautionary consumption,” is an individualist avoidance of harm that leaves companies and states exempt from reducing harm. Shadaan and Murphy write that “organized through the feminization of reproductive labor, precautionary consumption places responsibility on women to purchase goods that are deemed non-toxic, natural, or organic in order to seemingly avoid toxic exposures. A signature aspect of environmental sexism is women’s disproportionate labor in managing environmental harms” (2020, 5). This extends directly to menstruators who, already taxed with issues of managing their periods and menstrual negativity, are also given the additional task of being made to feel like they themselves are responsible for the toxic burden attached to menstrual products and their impact on the environment. While consumer agency is important and does matter, government and corporate transparency and minimization of toxicity and a structural shift away from disposable menstrual gear are crucial. Hence, when menstruators are encouraged to feel guilty about the products they use, it triggers menstrual trauma rather than working to shift away from cultures of accepted and acceptable toxicity.

Tampons, while an integral technology for navigating menstrual blood flow, are clearly entwined in contributing to menstrual trauma through both bodily and environmental toxicity and pollution. Toxicity here emerges in conjunction with tampons across a great many sites: facilitating TSS within the body, leading to slow violence against menstruators with chemical leak, and polluting the environment through tampon disposability, plastic composition, and packaging. In this sense, tampons are a useful site for understanding both permissible and impermissible forms of toxicity and trauma when it comes to menstruating bodies. As a complex technology that helps menstruators navigate menstrual flow yet allows for immediate and slow forms of trauma, tampons are a prime example of the complexities of menstrual justice. The mere existence of menstrual products, while important, is not necessarily rooted in justice. Justice, instead, is a multifaceted process that must acknowledge structural causes of menstrual trauma and work toward shifting cultures that make such trauma permissible.

Menstrual Trauma and Toxicity

Throughout this chapter, I have explored tampon toxicity across two sites, the bodies of tampon users and the environment, focusing on the complexities of tampon toxicity in relation to bacteria, plastics, and volatile organic compounds. I have also argued that menstrual trauma, accumulating over a menstruator’s life course from menstrual negativity, menstrual pain, misogyny, transphobia, period poverty, and other causes, is taken for granted as a permissible experience that menstruators must endure as cause and effect of being a menstruating body. At the same time, I looked at both research and my own experiences around TSS as an unusual instance of threshold trauma that is rendered unacceptable due to its fast and dramatic effects at the site of the interaction of Staphylococcus aureus bacteria, tampons, and the vaginal canal.

These two instances show how certain forms of pain and trauma are permissible for menstruating bodies, indeed expected for menstruating bodies, marking a correct course of gendered development into purported womanhood. These acceptable menstrual traumas include menstrual pain—even if chronic, inhibiting, and unbearable—the pressure to confine menstrual blood, continued shame around leaking, the continued pressure on individuals to seek out their own menstrual products whether or not they can afford them, dysphoria linked to menstruation, and so forth. Indeed, these experiences are never understood as traumatic, just as routine, an effect of being a menstruating body. Yet other forms of trauma are seen as too traumatic, and TSS, because it is a life-severing occurrence that in the late 1970s received media attention as it affected many young white menstruators, has become an unacceptable trauma.

While toxicity is increasingly a characteristic of life in the twenty-first century, it needs to be addressed for how it affects menstruators and contributes to their menstrual trauma. Menstrual justice, as this book argues, requires a multifaceted and dynamic understanding of menstruation at the site of body and culture. Part of this vision is not only access to menstrual products or being able to choose from an array of menstrual products but also a demand for products that are safe and free of toxins and that do not contribute to colonial pollution of the environment. Part of the project of menstrual justice is recognizing the pains and difficulties connected with menstruation as real and valid, even if smothered and undermined. Tampon toxicity is likewise complex because tampons are an easy-to-use and convenient technology that has been essential for millions of menstruators, myself included, even as they are the cause of multiple nodes of toxic leak.

Thinking even just about myself, shortly after TSS, my period resumed right on schedule, causing pain and dysphoria and also a new fear. Not only could my period cause me great physical pain, it could actually now kill me, as I had learned through the TSS experience. Nonetheless, because I was underage and my legal guardians did not permit me to undertake menstrual suppression due to fears that it would lead to my sexual promiscuity and to side effects like an increased chance of blood clots, I was willing—within weeks of having nearly died from a tampon-related cause—to use tampons. This might sound implausible but using tampons with the knowledge that I might have TSS again was still more feasible for my body, due to menstrual pain, dysphoria, and discomfort, than turning to a different, noninternal product. In other words, menstruators accept toxicity because too often they have no other option; there is not necessarily a “choice” for many menstruators. And because menstruation, through misogyny and transphobia, is already tied to ideas of suffering—and ideas of suffering as necessary for menstruators—trauma, pain, and toxicity become habituated as business as usual, part and parcel of being a menstruating body.

My motivation for and throughout this book has been to challenge the idea that as menstruators we have to suffer, endure trauma, or accept pain, as well as the ongoing epistemic harm of having those experiences undermined. I hold that a cranky approach to menstruation, one that recognizes limited choices for many and refuses to transform menstruation into a happy, commercialized experience, brings menstruators closer to visions of menstrual justice. Menstrual justice is not a final step but a process, a vision for prying menstruation away from gender and recognizing the harm in ignoring and diminishing menstrual pain and trauma.