The Woman’s Health Strategy for England neglects the realities of being a woman


House of Commons 



Dear Sir Barclay,

I am writing to you today in regards to the Women’s Health Strategy (WHS) for England, which you presented to Parliament in July 2022. You rightfully point out that for far too long, women’s voices have not been listened to, that there are significant disparities in women’s health across the country and that women spend a greater proportion of their lives with ill-health compared to men (Barclay, 2022). The recognition of women’s health needs is an important step forward, and I thereby applaud you and your co-workers for this initiative.

As a medical anthropology student, I have been taught to explore how political, social and cultural factors are continuously present in the lived experience of health, and have learnt to look at illnesses as biosocial phenomenons. This leads me to identify an important gap in the WHS: the neglect of gender relations, barriers and stigmas constituting women’s health.

During your speech in parliament you were repeatedly told by female MPs, such as MP Doyle-Price and MP Harris, that the strategy falls short of the realities of being a woman (Barclay, 2022). More specifically, I want to bring your attention to the WHS’ neglect of the menstrual stigma present in British society and healthcare, and its influence in preventing women from seeking medical care and thus delaying diagnosis (Sims et al., 2021). A nationwide survey on diagnostic delays estimates that six million women in the UK are suffering with undiagnosed women’s health conditions (Carter-Jones, 2023). A quarter of them have not started to seek medical help and almost half have sought to reduce their symptoms by undertaking lifestyle changes such as dietary changes. A delay in diagnosis can be detrimental to women’s health, and a simple medical check can be life-changing. But women keep silent. Stigmatization exacerbates the sufferings and negative effects of women’s health conditions (Corrigan, 2004).

I have spent the last nine months interviewing women with the condition of endometriosis, which is characterized by drastically painful menstruation. Women were ashamed to discuss their condition with me, some whispered for the entire interview, whilst others avoided discussing all kinds of menstrual details. One participant, Charlotte, stated: “These are things that are very difficult to live with but we don’t hear about them.” Self-stigmas, in contrast to public stigmas, indicate that women experience shame from disclosing personal experiences, which inhibits their willingness to seek help, discuss their experience with others, etc. (Mukadam & Livingston, 2012).

As an illustration, Ballard et al. (2006) analyzed how British women accommodated their endometriosis, developed strategies to control symptoms, and became ‘expert patients’ (which can lead to detrimental health effects) to avoid seeking professional medical help. A 41-year old woman diagnosed with endometriosis noted: “I used to get quite embarrassed, so I’d always play it down. If anything I’d try to act as normal as possible.” (Ballard et al., 2006: 1298). Dr. Morris, the president of the Royal College of Obstetricians and Gynaecologists, observed that women tolerate the ‘culture of normalization’ in British healthcare, in which their menstrual pains are normalized by health professionals, partially in order to avoid discussions on the topic (Devlin, 2022).

However, the first objective of the WHS aims to put in place various measures that ensure women are better listened to in the NHS and presents numerous clinically-based measures (Department of Health and Social Care, 2022). I therefore question how the NHS can listen better to women if they have internalized the stigma of menstruation, learnt to normalize menstrual pains and avoid discussions by fear of being stigmatized? Women are hiding their endometriosis amongst many other menstrual conditions, and this is ignored by the WHS. The WHS needs to intervene beyond clinical practice. I urge you to adopt a mixed-methods approach, which I hereafter layout.

First, whilst I recognise the success of the ‘Let’s talk about it’ survey (Department of Health & Social Care, 2021) used to develop the WHS, I urge you to conduct ethnography (combining participant observation and interviews) in order to inform the survey data. The medical anthropologist Byron Good (2008), argues that to help a community improve its health, one must learn to think like the people of that community. A survey with ‘box ticking’ answers prevents fruitful conversations with the women; their social context should be the first point of intervention (Walker, 1998). Laws & Campling (1991) ethnographically studied how British women describe their menstruating bodies as ‘badly designed’, ‘inherently sinful’ and ‘dirty’, and observed that mothers convey menstrual concealment and a sense of shame to their daughters. They exposed the menstrual etiquette and social imperative present in British society which influence women to not ‘offend anyone’ with knowledge about menstruation; and women noted feeling anxious about their menstruation being revealed in public (Laws & Campling, 1991). Through its benefit of observation, an ethnographic study would develop an understanding of how women internalize and embody the menstrual stigma, how it affects their diagnostic process, and how local manifestations of the menstrual stigma may vary. Ethnographic research would most importantly permit the deciphering of how menstrual concealment impacted the survey answers.

I recognise the potential time-related limitations of using ethnography, but rapid qualitative research is possible especially in the context of action-oriented research (Thurka Sangaramoorthy & Kroeger, 2020). As you highlighted, the WHS is the first governmental and biggest economic investment in women’s health, and this is long overdue (Barclay, 2022). I do not doubt that the methods used for this strategy can be taken beyond a survey and encompass much needed ethnographic research, delving into the social dynamics which constitute women’s health. You might also point to the subversiveness often associated with ethnographic work (Hart, 2022), as it gives a voice to previously silenced individuals and thereby takes a ‘bottom up’ approach. Ethnography in this case, would be used to the benefit of the strategy you are leading and have tirelessly worked on.

Secondly, in order to further prevent women’s internalization, the menstrual stigma needs to be actively tackled by challenging social understandings – by reworking general education. In the survey, you asked the women: “Did you know relationships, sex and health education, which covers menstruation, contraception, fertility, pregnancy and the menopause, is now a statutory part of the school curriculum?” (Department of Health & Social Care, 2021: 15), referring to the Relationships, Sex, and Health Education (RSHE) curriculum. But you ignore that the statutory guidance of the curriculum mentions the word ‘woman’ four times, includes five lines on menstruation and does not cite the words ‘taboo’ or ‘stigma’ once (Department for Education, 2019). How can the brief mentioning of these terms, within a 50-page statutory guidance, de-stigmatize menstruation for the next generations?

Moreover, Brown et al. (2022) studied teachers’ perceptions and experiences of the RSHE curriculum two years after its implementation. Teachers expressed that there is limited time to fit menstrual education in the curriculum, male teachers do not feel confident about the topic and others stated that they preferred to not teach about menstruation as students’ parents would be ‘mortified’. Some teachers also highlighted cultural influences by stating: “My school is located in a predominately Asian area where these matters [i.e. menstruation] are not discussed.” (Brown et al., 2022: 3). There must be an in-depth, ethnographically-informed section on women’s health and menstruation within the RSHE curriculum, and the curriculum must be adapted to tackle varying local interpretations around menstruation. The ethnographic research would provide an understanding of these local conceptions of menstruation, which could in turn inform the RSHE and survey answers. Anti-stigma programs should engage on a local level and avoid wide standardization (Mukadam & Livingston, 2012). Overall, changes in social norms and behaviors are more efficiently achieved through on-field research, by observing and working within communities (Patkar, 2020).

Finally, I ask you to take examples from countries such as France and past policies. During a presidential speech presenting the French national strategy against endometriosis, President Macron stated: “It is not a woman’s health issue but society’s issue” (Macron 2022, 01:45), explicitly noting that it is time to break the silence on menstruation. Similarly, in the National Dementia Strategy launched by your predecessors (2009), there was a clear section (Objective 1) dedicated to tackling the stigma behind the condition and ensuring better general education on dementia (Department of Health and Social Care, 2009). But the WHS proves that menstruation is still a stigma at policy-level.

Why should you act now?

As you said in Parliament, you are in the process of embarking on this mission. Research is still being done on its implementation and the changes of governments since July have led to a slowing down of its execution.

The future of the WHS cannot be successful if women are delaying diagnosis and not seeking medical care. Women are suffering in silence. I urge you to take action.

Yours sincerely,

– A woman who menstruates and is tired of being ashamed.


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Image source: Photo by Alexander Grey on Unsplash

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