Cycles of shame: menstrual shame, body shame, and sexual decision-making.

Although menstruation is a natural, reproductive process, it bears a strong cultural taboo that commands that it not be seen, discussed, or in most ways, acknowledged (Kissling, 1996a; Roberts, 2004). This desire to keep menstruation secret is often paired with an attitude that menstruation is dirty and disgusting (Martin, 1996; Roberts). Many girls report shame about being seen with a menstrual product or, worse yet, about bleeding through clothing, and some adolescent girls report that they are embarrassed simply by the fact that they menstruate (Lee & Sasser-Coen, 1996; Kissling, 1996b; Roberts). These feelings are likely compounded by media portrayals of menstruation as a hygienic crisis (Havens & Swenson, 1988; Raftos, Jackson, & Mannix, 1988; Simes & Berg, 2000).

Shame about menstruation is often extended to the vagina and its surrounding areas, which are considered by many women to be unspeakable and upleasant (Braun & Wilkinson, 2001; Lee & Sasser-Coen, 1996; Reinholtz & Muehlenhard, 1995). Participants in Lee and Sasser-Coen's (1996) qualitative study spoke of menarche as an experience that "contaminated" their bodies, and their genitals in particular. Despite recent attempts to celebrate the form and function of women's anatomy, such as Eve Ensler's "Vagina Monologues," and the growing comfort some women have with their bodies, it is still common for women to feel shame about their bodies, to use euphemisms so as to avoid naming their genitals (Braun & Kitzinger, 2001), or to experience confusion about the makeup of their external genitalia (Kirby, 1998). What are the implications of feeling shame about menstruation and the body? Conversely, might women's comfort with menstruation promote well-being in other areas of their lives?

This study considers how shame about menstruation is related to sexual decision-making. Because menstruation and sexual activity often share the same intimate location on women's bodies, shame regarding menstruation might influence a woman's general approach to her sexuality. Furthermore, girls are often socialized to connect menstruation with sexuality. Many girls first learn about menstruation in sex education classes, where both menstruation and sex are presented as means to the end of procreation (Martin, 1987). At the same time, much of early mother-daughter communication about sex focuses on menstruation (e.g., O'Sullivan, Meyer-Bahlburg, & Watkins, 2001), and likewise, much early communication about menstruation and menarche focuses on the emerging sexual potential inherent in a developing woman's body (Lee & Sasser-Coen, 1996). Because of these connections, girls' and women's attitudes about menstruation might shape their developing beliefs about sexuality and the sexual decisions they make, even when they are not menstruating.

Despite these conceptual connections, little research has explored connections between sex and menstruation. Previous research linking these phenomena found that girls who reach menarche early are more sexually active and sexually risky than girls who mature later; however, this finding is generally attributed to a tendency for early maturers to socialize in older peer circles (Flannery, Rowe, & Gulley, 1993; Marin et al., 2000; Mezzich et al., 1997). Recent work has found a specific link between menstrual attitudes and both sexual attitudes and sexual behavior (Rempel & Baumgartner, 2003; Schooler, 2001). In one study, undergraduate women who reported more comfort with menstruation also reported more comfort with sexuality and were more likely to engage in intercourse while menstruating (Rempel & Baumgartner, 2003). In a second study, undergraduate women who reported more shame about menstruation also reported engaging in less sexual activity overall and, if sexually active, reported engaging in more sexual risk-taking (Schooler, 2001). Evidence also indicates that undergraduate women who perceived their genitals as dirty, smelly, and shameful reported lower levels of participation in and enjoyment of sexual activity (Reinholtz & Muehlenhard, 1995).

These findings suggest that holding negative attitudes about their genitals and about menstruation, in particular, may curtail women's abilities to take pleasure in their bodies and sexual experiences, whether they are currently menstruating or not. Such disruptions, while troublesome, would not be unique, but would correspond with dominant discourses surrounding female sexuality, which characterize women's bodies not as sites of personal pleasure, but as objects of male desire. Whereas hunger and desire are requisite features of male sexuality, young women are not expected to assert their sexual needs; for the most part, young women are not expected to have their own sexual needs (Fine, 1988; Holland, Ramazanoglu, Scott, Sharpe, & Thompson, 1990; Tolman, 1999).

Many argue that these limiting definitions of female sexuality make it difficult for young women to make safe and proactive sexual decisions (Holland et al., 1990). Indeed, sexually assertive women who discuss their own desires, who are prepared with contraception, or who make sexual decisions based on their own needs, not their partners', run the risk of jeopardizing their relationships and of being labeled "sluts" (Holland et al). Caught up in these contradictory pressures, many young women report having difficulty requesting sexual activities, engaging in unwanted and risky sexual behavior, and drawing limited satisfaction in their sexual experiences (Abma, Driscoll, & Moore, 1998; Holland et al.). Menstrual and genital shame are also linked with these outcomes, namely, decreased sexual experience, increased sexual risk-taking, and reduced sexual satisfaction. This suggests that shame, and menstrual and body shame specifically, may play an important role in the larger complex of women's sexual socialization. The question, then, is how menstrual shame is involved in sexual decision-making.

Constructing a Model of Body Shame and Sexuality

In light of these findings, we proposed a model to understand how attitudes toward menstruation influence sexual decision-making. Specifically, we argue that shame about menstruation acts indirectly through a global sense of body shame to affect sexual behavior. In this model, we chose to focus on body shame rather than body dissatisfaction for two reasons. First, body shame involves both negative evaluations of one's body and an emotional component, a desire to hide oneself and one's body, which may not always accompany body dissatisfaction. Second, whereas body dissatisfaction tends to focus mostly on body size, shape, and weight, body shame pertains to these and to other aspects of women's embodied selves, including smells, nakedness, and body hair. Thus, we suggest that previous links between menstrual shame and sexual decisions are best understood in the context of the mediator body shame.

Baron and Kenny (1986) provided several criteria for establishing the occurrence of mediation. Accordingly, in considering body shame as a potential mediator between menstrual shame and sexual decision-making, it is first necessary to establish a link between menstrual shame and the sexual outcomes variables. As a second step, one must demonstrate the presence of association between menstrual shame and body shame. Next, it must be shown that body shame relates to the outcome variable, sexual decision-making. Lastly, to establish that body shame completely mediates the relationship between menstrual shame and sexual decision-making, it is necessary to show that once controlling for the mediating path, the direct relationship between menstrual shame and sexual decisionmaking becomes non-significant. Previous research suggested the presence of an association between menstrual attitudes and sexual decision-making (Rempel & Baumgartner, 2003; Schooler, 2001). Additionally, empirical and theoretical work lends support to each of the remaining pathways in our model.

Menstrual shame and body shame. The presence of a connection between menstrual shame and body shame, the first path of the mediated model, is supported by theory regarding the general role of shame in one's conceptualization of the self. In an influential work, Lewis (1971) made the distinction between shame and guilt based not on context or the eliciting event, but on the role of self and identity. Whereas guilt reflects a feeling that one has done something bad, shame focuses not on the act but on the self; one is something bad. Shame is extremely debilitating because "it's the entire self that is painfully scrutinized and negatively evaluated" (Tangney, 1996, p. 743). Consequently, because feeling shameful frequently evokes a critical evaluation of one's whole self, shame about menstruation is likely to extend more broadly to the body as a whole. It is not just the act of menstruating that is dirty and shameful; the young woman who menstruates becomes dirty and shameful.

Although empirical work has not directly explored connections between menstrual shame and body shame, evidence on related issues suggests that shame about menstruation might extend to and influence a woman's feelings about her body. More specifically, one set of findings suggests that shame about menstruation may relate to women's objectification of their own bodies (Roberts, 2004). Objectification has been defined as the process of seeing a person and her body solely as an object to be evaluated and consumed by others, and self-objectification occurs when this objectification process is turned on oneself (Fredrickson & Roberts, 1997). In an innovative experimental design, it was found that men and women were both more likely to objectify women after seeing a woman drop a tampon as compared to a hair clip (Roberts, Goldernberg, Power, & Pyszcynski, 2002). Roberts et al. (2002) suggested that a need to sanitize menstruation leads women to objectify both themselves and other women. Furthermore, research has linked menarche with the onset of body dissatisfaction, body objectification, and increased body monitoring (Lee & Sasser-Coen, 1996; Rierdan & Koff, 1980a; 1980b).

Body shame and sexual decision-making. Mediation further requires that body shame predict sexual decisionmaking. The literature surrounding the emotion "shame" supports such a possibility. Construed broadly, the potential consequences of shame include behaviors, such as social avoidance (Lutwak & Ferrari, 1997) and the use of avoidance coping mechanisms (Burgraff, 1995), as well as affective consequences, such as fear of negative social evaluation (Lutwak & Ferrari). When these responses are evoked in the context of the body, each could impact sexual decision-making so as to generate the pattern of decreased sexual activity and increased sexual risk-taking previously associated with menstrual shame.

First, because shame leads one to feel worthless and small, individuals experiencing shame often wish to "sink into the floor and disappear" (Tangney, 1996, p. 743). The resultant avoidance coping has been linked specifically to adolescent risk-taking, including risky sexual behavior (Cooper, Wood, Orcutt, & Albino, 2003). Second, social avoidance could lead a woman to avoid sexual situations in which she might be seen or judged, leading to lower levels of sexual experience. Indeed, women with high body dissatisfaction have been found to engage in less sexual activity, and they are especially apprehensive about sexual situations in which their bodies can be seen (Ackard, Kearney-Cooke, & Peterson, 2000; Faith & Schare, 1993; Trapnell, Meston, & Gorzalka, 1997; Wiederman, 2000). Furthermore, when self-objectification was experimentally induced, women reported decreased interest in the physical aspects of sex (Roberts & Gettman, 2004).

Lastly, once in sexual situations, a woman who fears negative evaluation may focus more on her partner's judgments of her than on her own desires, safety, and pleasure. Fearing negative evaluation and focusing critically on one's own appearance can limit the pleasure drawn from these sexual experiences (Wiederman, 2001) and can make it difficult for women to enact safer sex practices (Wingood & DiClemente, 1992). At the same time, seeing themselves and their bodies as objects to be evaluated can cause women to become distanced from their own internal states (Fredrickson & Roberts, 1997). Separation from one's body in this way could be especially damaging in sexual situations. A woman who is separated from her inner feelings and experiences of arousal may find it difficult to assert her desires or to take satisfaction in sexual situations. Instead, she may let events unfold based on her partners' wants and interests. Previous research suggested that women who reported more body dissatisfaction were less likely to receive but not to perform oral sex (Wiederman & Hurst, 1998) and reported a later onset of masturbation (Wiederman & Pryor, 1997). These findings suggest that body shame may specifically inhibit women's ability to advocate for, or even acknowledge, their own pleasure.

Similarly, in distancing herself from her own interests, a woman who is experiencing shame may find it difficult to protect herself from infection and unintended pregnancy. Avoidance responses, fears of negative evaluation, and self-objectification may inhibit a woman's sexual agency; her ability to act in accordance with her own interests and assert her own desires may be impaired. As a result, body shame could present a serious risk to sexual well-being by predisposing women to risky behavior. It is therefore necessary to assess directly the association between body shame and sexual decision-making.

The Current Study

This study examined the role of menstrual attitudes and body shame in predicting sexual decision-making. Our first research question examined the direct relation between menstrual attitudes and sexual decision-making. Because of the centrality of agency in our conceptualization of sexual decision-making, we focused on sexual assertiveness as our primary sexual outcome. We defined sexual assertiveness as the ability to express one's preferences in sexual situations, whether that involves requesting wanted behavior, refusing unwanted activity, or negotiating the use of protection. We expected that women who reported more shame about menstruation would report less sexual assertiveness, and consequently would report less accumulated sexual experience and more risky sexual behavior.

Our second research question examined the first path of the mediational model, exploring whether menstrual shame relates to a more generalized body shame. We expected that higher levels of menstrual shame would predict increased body shame. Our third research question examined the next path of the mediated model, investigating how body shame relates to sexual decision-making. Specifically, we expected that women who reported more body shame would be less sexually assertive, and therefore would report less accumulated sexual experience and more sexual risk. Our fourth research question used structural equation modeling to examine a mediated model whereby menstrual shame acts indirectly through body shame and sexual assertiveness to predict lifetime sexual experience and sexual risk. We expected that women who reported higher levels of menstrual shame would report less lifetime sexual experience and more risky sexual behavior, but that the strength of these relations would diminish once we accounted for body shame and sexual assertiveness.

As a secondary research question, we explored the extent to which particular aspects of women's backgrounds, such as age of menarche, race, and religiosity, contributed to their menstrual attitudes and sexual behavior. Consistent with previous research, we expected that women who had reached menarche earlier would report higher levels of menstrual shame, and subsequently, less healthy patterns of sexual decision-making. Ethnic group membership has also been found to contribute to women's sexual behavior (e.g., CDC, 1997; Gomez & VanOss Marin, 1996; Wyatt et al., 2000), although many of these outcomes are believed to be driven by socioeconomic status (SES; Bingham, Miller, & Adams, 1990; Wyatt, 1997). SES-related differences in menstrual attitudes have been documented as well (Kissling, 1996b; Lichtenstein & Nansel, 2000; Martin, 1987), such that low-income women appear to be less likely to celebrate menstruation. Consequently, both race and SES were examined as possible correlates of menstrual shame, body shame, and sexual decision-making. Finally, religiosity is a consistent predictor of sexual behavior, associated with both delayed sexual onset among teens (e.g., Herold & Goodwin, 1981) and infrequent condom use among nonvirgins (e.g., Zaleski & Schiaffino, 2000). Additionally, some religious traditions convey strong taboos regarding menstruation and proscribe ritual cleanings, such as the Mikvah in Jewish tradition (Delaney, Lupton, & Toth, 1988). Accordingly, religiosity was explored as a possible correlate of the central variables.

METHOD

Participants

We recruited 199 female students from an undergraduate psychology class at a large midwestern university. College students were an appropriate population to investigate because most have experienced menstruation for a number of years, and many have been involved in sexual relationships. Participants ranged in age from 17 years to 23 years (M = 19.7). Of our sample, 131 women identified themselves as White (67%), 37 as Asian (19%), 14 as biracial or multiracial (7%), nine as Black (5%), and five as Latina (3%). Among the women of color, only the sample of Asian women was sufficient to include as a demographic variable in future analyses, although all women were retained in the sample. One hundred ninety-two women identified themselves as heterosexual (97%), 2 as bisexual (1%), 2 as homosexual (1%), and 2 as unsure (1%). Body Mass Index scores (BMI = weight [kg] / height [[m].sup.2]) ranged from 17 to 38 (M = 22.7), matching estimates of the population mean of 22.7 (Flegal & Troiano, 2000). With parental education serving as an index of socioeconomic status, participants reported that their mothers and fathers had received an average of 16 (SD = 2.2) and 17 (SD = 3.0) years of education, respectively. Fifty-two percent of fathers and 32% of mothers had completed some graduate work. Twelve years and four months emerged as the mean age of menarche (SD = 1.5 years), with women reaching menarche as early as nine years and as late as 17 years.

Procedure

As one of several extra credit options, all students enrolled in the introductory psychology class were invited to complete a packet of survey measures investigating college students' sexual attitudes, body attitudes, media use, and sexual behavior. Approximately 79% of the enrolled students participated. Survey packets containing the instruments were distributed in class, and participants completed the measures on their own and returned their completed questionnaire in a closed envelope to class the following week. Written consent was obtained from all participants. Only data from the female participants were used in this study.

Measures

Menstrual attitudes. Attitudes toward menstruation were assessed using three subscales from the post-menarcheal version of The Adolescent Menstrual Attitude Questionnaire (Morse, Kieren, & Bottorff, 1993). The Negative Feelings subscale contains 18 items, such as, "I am terrified that people will find out I have my period." The Positive Feelings subscale contains 11 items, such as, "I feel proud when I have my period." The Openness subscale contains 5 items, such as, "I often talk about my periods with my friends." Using a 5-point scale, from 1 (strongly disagree) to 5 (strongly agree), respondents indicated how strongly they agreed with each of the 34 statements. Mean scores were created for each subscale so that higher scores indicated more negative feelings (alpha = .84), more positive feelings (alpha = .85), and greater openness (alpha = .63).

Body shame. Two scales assessed participants' shame about their bodies. Both scales were selected because of their focus not only on dissatisfaction with one's body, but also on discomfort with having the body seen or sensed, and as such reflected shame about the body. The Body Comfort/Body Modesty Measure (BCBM; Merriwether & Ward, 2002) contains 29 items that focus on one's comfort with the appearance and function of one's body. Participants indicate on a 9-point Likert scale, from 1 (totally uncomfortable) to 9 (totally comfortable), how comfortable they are with their body in several different situations. Items included, "How comfortable are you changing clothes in front of other women?" and "How comfortable are you with the smell of your sweat?" A mean score was created across the items (alpha = .93), such that higher scores indicated more comfort. To assess body shame in intimate situations, we included the Body Image Self Consciousness Scale (BISC; Wiederman, 2000). With this measure, respondents indicate on a 6-point Likert scale how much they agree with 15 statements, such as, "The worst part of having sex is being nude in front of another person." A sum score was created across the items (alpha = .96) so that higher scores indicated more self-consciousness.

Sexual assertiveness. To determine participants' ability to assert themselves in sexual situations, the 25-item Hurlbert Index of Sexual Assertiveness (Hurlbert, 1991) was included. Using a 5-point Likert scale, from 1 (none of the time) to 5 (all of the time), participants indicated how accurately each statement described them and their experiences. Items included, "I communicate my sexual desires to my partner," and "I find myself doing sexual things I do not like." After reverse scoring the necessary items, we created a mean score (alpha = .92) to reflect overall Sexual Assertiveness.

Lifetime sexual experience. To obtain information about participants' own level of experience with sexual relationships, we asked several questions about their accumulated experience with kissing and petting, oral sex, and vaginal intercourse. Participants were asked to indicate whether they had engaged in each of eight sexual behaviors and with how many partners. Behaviors included light kissing, prolonged kissing, breast touching, touching genitals over clothing, touching genitals under clothing, performing oral sex, receiving oral sex, and vaginal intercourse.

Three subscales of sexual behavior, with three levels each, were created to capture Kissing and Petting Experience, Oral Sex Experience, and Vaginal Intercourse Experience. Participants who received a 1 for Kissing and Petting (15%) reported engaging in light or prolonged kissing with 2 or fewer partners and reported no breast or genital touching. Participants who reported engaging in some amount of breast touching and genital touching of any form with no more than 2 partners received a score of 2; 33% of participants met these criteria. The remaining participants (52%) reported engaging in genital touching with 3 or more partners and received a score of 3.

We created a similar subscale to measure Oral Sex Experience. Twenty-four percent of participants reported that they had neither performed nor received oral sex. These participants received a 0 for Oral Sex Experience. Participants who reported that they had either performed or received oral sex with 1 or 2 partners received a score of 1 for Oral Sex Experience; 33% of participants met these criteria. The remaining participants (43%), scored as level 3, reported both performing and receiving oral sex and reported 3 or more oral sex partners. Finally, we created a subscale to measure Vaginal Intercourse Experience. Almost half (47%) of participants reported that they had never engaged in vaginal intercourse and received a 0 for Vaginal Intercourse Experience. Twenty-eight percent of participants reported engaging in vaginal intercourse with one partner, and these participants received a Vaginal Intercourse Experience score of 1. The remaining participants (25%) reported that they had engaged in vaginal intercourse with two or more partners and received a score of 2 for Vaginal Intercourse Experience. These three subscales were summed to create an Index of Sexual Experience ranging from 1-7.

Sexual risk-taking. Because of the central role of condom and contraceptive use in protecting oneself from sexually transmitted infections and unwanted pregnancy, we chose as risk indicators women's condom and contraceptive use, including measures of condom use self-efficacy and actual condom and contraceptive use. The Precautions subscale of Sexual Self Efficacy Scale (SSE; Rosenthal, Moore, & Flynn, 1991) contains 5 items that focus on one's ability to enact certain safer sex behaviors related to condom and contraceptive use. Participants indicate on a 5-point Likert scale, from 1 (very uncertain) to 5 (absolutely certain), how confident they were in their ability to perform tasks such as "discuss using condoms and/or other contraceptives with a potential partner" and "buy condoms/contraceptives." We created a mean score across the items (alpha = .85), such that higher scores indicated stronger safe sex self-efficacy.

We also included 6 items about participants' actual condom and contraceptive use during vaginal intercourse, which were combined to create an index of sexual risk-taking. Participants were asked how frequently they had sexual intercourse with a casual acquaintance without using condoms, how frequently they had sexual intercourse with a casual acquaintance without any form of contraception, how frequently they had sexual intercourse within a relationship without using condoms, and how frequently they had sexual intercourse within a relationship without any form of contraception. Response options for these questions ranged along a 5-point scale, from 1 (never) to 5 (frequently). To correspond with previous sexual-risk indices (e.g., Ward & Wyatt, 1994), these variables were converted to dichotomous variables along a median split, with higher risk responses assigned a value of 1 and lower risk responses assigned a value of 0.

Two additional dichotomous questions were included: "Did you use contraception/protection the first time you had sexual intercourse?" and "Did you use contraception/protection the most recent time you had sexual intercourse?" For each of these questions, higher-risk responses (i.e., not using protection) were again assigned 1 point toward a composite risk index, and lower risk responses (i.e., using protection) were assigned 0 points. For each participant, an index was created by summing the points assigned for each of the six items. Accordingly, scores for this index ranged from 0 to 6, with higher scores indicating higher levels of risk of pregnancy and of disease transmission.

Religiosity. A religiosity score was created based on responses to three questions: "How religious are you?"; "How often do you attend religious services?"; and "How often do you pray?" Response options for each question ranged from 0 (not at all/never) to 4 (very/very regularly). We averaged responses across the three items (alpha = .76), yielding a total religiosity score ranging from 0-4 (M = 2.3). Higher scores indicated higher levels of religiosity.

RESULTS

Preliminary Analyses

Descriptive statistics for the central independent and dependent variables are provided in Table 1. Participants generally reported moderate to low levels of both Negative and Positive Feelings about Menstruation and moderate to high levels of Openness. Participants also reported moderate Body Comfort, low Body Image Self-Consciousness, and high levels of Sexual Assertiveness. Roughly half of the women in this sample (52%) had already engaged in sexual intercourse, and most of these women reported having had only one partner in their lifetime. The vast majority of sexually active women (87%) reported use of contraception at first intercourse, and roughly the same amount (88%) reported contraceptive use at most recent intercourse.

To determine whether demographic variables related to our predictor variables, we ran a series of zero-order correlations between the seven demographic variables (age, age at menarche, body mass index, religiosity, mother's education, father's education, and a dummy code for Asian ethnic group membership) and the three menstrual attitude subscales and the two measures of body shame. Because a number of correlations were to be performed, we utilized a Bonferroni correction to partially control for Type I errors, and accordingly set the p-value at .001. One significant finding emerged. Women whose mothers received more education reported higher levels of Body Comfort, r (190) = .20, p < .001. Accordingly, maternal education served as a covariate in later analyses.

To determine whether demographic variables related to sexual behavior, we ran a series of zero-order correlations between the seven demographic variables and the participants' Sexual Assertiveness, Sexual Experience, Risky Sexual Behavior, and Condom Use Self-Efficacy, again using a p-value of .001. Several significant findings emerged. Compared to other women, Asian women reported significantly lower levels of sexual experience, r (153) = -.27, p < .001, and condom use self-efficacy, r (186) = -.38, p < .001. Similarly, women who were more religious reported lower levels of condom use self-efficacy, r (189) = -.25, p < .001. No other relations were significant at the .001 level. These significant demographic correlates served as covariates in later analyses.

Menstrual Attitudes and Sexual Decision-Making

Our first research question examined whether menstrual attitudes related directly to sexual decision-making. We conducted partial correlational analyses between the three menstrual attitude subscales and the four sexual decision-making outcomes, controlling for relevant demographic correlates (maternal education, being Asian, and religiosity). As expected, women who endorsed more negative attitudes toward menstruation reported significantly less sexual assertiveness, r (165) = -.40, p < .001, and condom use self-efficacy, r (175) = -.30, p < .001. Women who endorsed more openness about menstruation reported significantly more sexual assertiveness, r (165) = .26, p < .001, more sexual experience, r (142) = .17, p < .05, and greater condom use self-efficacy, r (175) = .17, p < .05. Expressing positive feelings about menstruation was unrelated to any of the sexual outcome measures. As expected, women's attitudes toward menstruation were significantly related to sexual assertiveness, sexual experience, and sexual risk. Because no direct associations were found between positive feelings about menstruation and the sexual outcome variables, this subscale was excluded from future analyses examining the possible mediation of direct relationships.

Menstrual Attitudes and Body Shame

Our second research question examined the first path of the mediational model. To examine whether attitudes toward menstruation predicted body shame, we conducted partial correlational analyses between the two menstrual attitude subscales and the two body shame measures, controlling for relevant demographic correlates (maternal education, being Asian, and religiosity). As expected, women who endorsed more negative attitudes toward menstruation reported experiencing more body image self-consciousness, r (174) = .34, p [less than or equal to] .001, and less body comfort, r (180) = -.41, p [less than or equal to] .001. At the same time, women who endorsed more open attitudes toward menstruation reported experiencing less body image self-consciousness, r (174) = -.16, p [less than or equal to] .05, and more body comfort, r (180) = .24, p [less than or equal to] .001. Thus, as expected, women's attitudes toward menstruation were significantly connected with their general levels of comfort with their bodies.

Shame and Sexual Behavior

Our next research question examined the second path of the mediated model, investigating whether body shame related to sexual decision-making. Accordingly, we ran partial correlations between the two body shame measures and the four sexual outcomes (Sexual Assertiveness, Sexual Experience, Sexual Risk, and Condom Self-Efficacy), controlling for relevant demographics (maternal education, being Asian, and religiosity). As expected, greater body comfort predicted higher levels of sexual assertiveness, r (165) = .55, p < .001, higher levels of sexual experience, r (142) = .20, p < .05, lower levels of risky sexual behavior r (108) = -.19, p < .05, and greater condom use self-efficacy, r (176) = .51, p < .001. Conversely, greater body image self-consciousness predicted lower levels of sexual assertiveness, r (164) = -.55, p < .001, lower levels of sexual experience, r (137) = -.18, p < .05, and lower condom use self-efficacy, r (170) = -,48, p < .001. Therefore, as predicted, body shame was significantly connected with women's sexual attitudes and behaviors.

Path Analysis

With all three paths of the mediated model confirmed, we used structural equation modeling to determine whether body shame fully mediated the relationship between menstrual shame and sexual decision-making. Our theoretical model is shown in Figure 1. The two menstrual attitude subscales--Negative Feelings about Menstruation and Openness about Menstruation--are included as measurements of the latent construct Menstrual Shame. These two subscales were combined because of high intercorrelation (r = .40), and because together they capture the two relevant dimensions of shame, a negative evaluation of menstruation and a belief that menstruation should be kept secret. The latent construct of Body Shame is measured by two scales, the BCBM and the BISC. As with the indicators of menstrual shame, these two measures are highly intercorrelated (r = -.69), and they assess satisfaction with one's body along with comfort in having it seen. The latent construct of Sexual Risk is also measured by two scales: risky sexual behavior and condom use self-efficacy. Each of the latent constructs was scaled by setting the path to one indicator equal to 1. Assertiveness and Sexual Experience are measured by only one scale each and are therefore included in the model as manifest variables.

[FIGURE 1 OMITTED]

The hypothesized relations among the variables are represented by Paths A through E Path A indicates that Menstrual Shame directly predicts Body Shame. Sexual Assertiveness and the two sexual behavior variables are each predicted by Body Shame, as indicated by Paths B, C, and D. Furthermore, because Sexual Assertiveness is expected to influence sexual behaviors, each of the sexual behavior variables is also predicted by Sexual Assertiveness, as indicated by Paths E and F. As hypothesized, in this model there are no direct relations between Menstrual Shame and the sexual outcomes. Correlated errors between Sexual Experience and Sexual Risk reflect the other common predictors of these sexual outcomes that are not included in this model. Additionally, two demographic variables, being Asian and Religiosity, were selected for inclusion based on their influence on multiple outcome variables. These two variables were included as manifest variables and as correlates, and were allowed to predict all variables in the structural model. The paths from these two demographic variables are represented as dotted lines in the model. A correlation matrix of all included manifest variables is included in Table 2.

We evaluated our first model using Amos 4.0 (Arbuckle & Wothke, 1999). Missing data were estimated with the full maximum likelihood method in Amos. As goodness of fit measures, we included [chi square], comparative fit index (CFI), and root-mean-square error of approximation (RMSEA). A model that fits the data will have a non-significant [chi square], a CFI greater than .90, and a RMSEA less than .05. Probability of close fit (pclose) was also included as a significance test that RMSEA is not larger than .05. The initial model fit the data very well, [chi square] (20, N = 199) = 19.4, ns, comparative fit index (CFI) = 1.000, root-mean-square error of approximation (RMSEA) = 0.000, probability of close fit (pclose) = .89. Some of the paths, however, were not significant.

Paths that did not contribute significantly to the model were removed one at a time, and the model was re-estimated each time. The path between Body Shame and Sexual Experience (C) was removed, along with four of the paths from the demographic variables, resulting in the final model shown in Figure 2. The final model fit very well, [chi square] (26, N = 199) = 25.5, ns, comparative fit index (CFI) = 1.000, root-mean-square error of approximation (RMSEA) = 0.000, probability of close fit (pclose) = .92. In the final model, all paths between menstrual shame, body shame, and the sexual outcomes were significant at the p < .001 level. Standardized regression weights are shown in Figure 2.

[FIGURE 2 OMITTED]

Statistical evaluation of mediation can be conducted using a Sobel test, which determines to what extent the mediator carries the influence of the predictor variable to the outcome variable (Sobel, 1982). Sobel tests confirmed the significant mediating role of Body Shame in the relation between Menstrual Shame and Sexual Assertiveness (Sobel test = -3.86, p <.001), the significant mediating role of Sexual Assertiveness in the relation between Body Shame and Sexual Experience (Sobel test = -3.53, p < .001), and the relation between Body Shame and Sexual Risk (Sobel test = 3.74, p < .001).

Alternate Model

To evaluate the mediated model further, we evaluated an alternate model in which direct paths were included between Menstrual Shame and Sexual Assertiveness, Sexual Experience, and Sexual Risk, along with all paths from the theoretical model. This model fit the data equally well, [chi square] (17, N = 199) = 18.1, ns, comparative fit index (CFI) = 1.00, root-mean-square error of approximation (RMSEA) = 0.018, probability of close fit (pclose) = .81; however, none of the direct paths from Menstrual Shame to the three sexual variables was significant. Because the theoretical model and final models are both nested within this alternative model, it is possible to evaluate their relative fits by comparing the [chi square] statistics produced by the different models, relative to the difference in degrees of freedom (Steiger, Shapiro, & Browne, 1985). Specifically, the difference in [chi square] values between the alternate model and the final model is 7.4 (df = 9), ns, indicating the alternate model does not fit the data better than the condensed final model. Indeed, each of the comparisons of nested models produced nonsignificant [chi square] values. Accordingly, the final model can be considered the most parsimonious, while fitting the data as well as the theoretical and alternate models.

DISCUSSION

This study attempted to shed light on connections among menstrual attitudes, body shame, and sexual decision-making. Because previous research suggested that the silence and shame that surround adolescent sexuality might limit girls' sexual agency (Tolman, 1999), we expected that shame about menstruation could carry similar consequences. Findings confirmed our expectations. Consistent with previous evidence, menstrual shame was associated with decreased sexual experience and increased sexual risk-taking. Moreover, these relations between menstrual shame and sexual decision-making were fully mediated by body shame and partially mediated by sexual assertiveness. Women who reported shame about menstruation specifically and their bodies generally appeared to be uneasy and reserved about engaging in sexual activity and to have difficulty asserting and protecting themselves when they did become involved in sexual encounters. A woman who wishes to escape a shame-evoking situation might physically remove herself from a sexual situation to avoid being seen, but she might also remove herself emotionally and psychologically. By positioning herself as an outside observer instead of an active agent, a woman who is experiencing shame may expose herself to increased sexual risk.

Our findings suggest important contributions of menstrual attitudes to women's sexual decision-making, but we must also point out that causal conclusions are limited by the study's design. Although body attitudes may hinder sexual assertiveness and thereby alter sexual behavior, it is also possible that women's body attitudes are shaped by their sexual experiences; having one's body sensed and validated in wanted sexual situations may increase women's comfort with their own bodies, and engaging in sexual experiences that involve risk may lead women to feel worse about their bodies. Indeed, some women have indicated having sex to feel valued by their partner (Hill & Preston, 1996), and the reactions they receive in sexual encounters may be powerful in shaping their own attitudes about their body.

Furthermore, other factors not explored in this study may contribute to the central associations observed. Accordingly, longitudinal and intervention-based studies are needed to assess the full importance of menstrual shame in the context of sexuality. Additionally, the current path analysis was limited by the sample size, and conclusions should be drawn with some amount of caution. Yet overall, these data lend support to our concerns that silencing the topic of menstruation with a cover of shame may make it difficult for women to find their voices when it comes to sex.

Reducing the shame and stigma surrounding menstruation may be an important step toward increasing women's sexual agency. At a time when the choice to reduce or eliminate menstruation via contraceptive use is growing more popular (e.g., with Seasonale), the stigma placed on menstruation is as strong as ever. Thus, whereas menstruation may become a routine and normative experience for young women who experience it regularly, reducing the frequency of menstruation may disrupt this process, making women less comfortable with menstruation when it does occur. In one study, undergraduate women who endorsed contraceptive suppression of menstruation also reported more shame about menstruation and more body consciousness (Johnston-Robledo, Ball, Lauta, & Zekoll, 2003). As such, cultural norms promoting the elimination of menstruation may exacerbate the existing problem; women, even those who are satisfied with their size and shape, may experience body shame regarding their body functions, and this shame may disadvantage them in sexual situations.

Though troubling, these findings also point to potential sites for intervention. If women's body shame is associated with sexual passivity and sexual risk, then socialization that reduces shame could promote sexual agency. It is heartening that the women in this population were relatively comfortable with menstruation and their bodies, and this absence of shame may partially account for the high levels of sexual assertiveness and low levels of sexual risk reported. Previous research has explored various developmental trajectories leading to satisfaction

with the size and shape of one's body, implicating among other factors media use (e.g., Groesz, Levine, & Murnen, 2002), family dynamics (e.g., Field et al., 2001), and activity involvement (e.g., Richman & Shaffer, 2000). It is equally important for scholars to explore the antecedents of comfort with other aspects of women's bodies, and it seems likely that these same sources may be involved in the acquisition of attitudes about menstruation, sweat, and body hair. Previous research indicated that communication about menstruation among a community of women may be instrumental in lessening girls' later shame (Schooler, 2001). Accordingly, creating open channels for dialogue about menstruation among younger girls and adolescents may prove to be a protective factor for later sexual decision-making and may thus constitute an important aim for sex educators.

Results of this study also highlight potential differences among women regarding attitudes toward menstruation and sexual behavior, and more work is needed to understand fully how these findings may or may not generalize to other populations. In our sample, Asian women reported greater feelings of shame about menstruation, lower levels of sexual experience, and higher levels of sexual risk. Although the current sample was largely White and affluent, these findings indicate that the experiences of menstrual shame may vary based on women's ethnic backgrounds and socioeconomic status. Future work that over-samples women of color and low-income women could explore how menstrual shame might function differently in different populations of women.

Additional work should also examine the relation between body shame and sexual decision-making among sexual-minority women, which we could not test in the current study because of the small sample of sexual-minority youth. Moreover, whereas emerging adulthood presents an important stage in which to examine these processes, future work would likely reveal different patterns among older and younger women. For example, Roberts (2004) found that menstrual shame and body objectification decreased with age. How might these trajectories impact sexual decision-making across the lifespan? Similarly, the associations between menstrual and body shame and sexual decision-making should be explored in younger adolescents as their attitudes about menstruation, their bodies, and sexuality are first developing.

Further study should also examine how menstrual attitudes contribute to other aspects of psychological well-being. If possessing healthy menstrual attitudes can lessen women's shame about their bodies, the ramifications may exceed increased sexual well-being. Fredrickson and Roberts (1997) discussed women's body shame as part of the complex of self-objectification that can lead to increased body monitoring, disordered eating, unipolar depression, sexual dysfunction, and a general reduced responsivity to internal body states. Future work should explore how menstrual shame might relate to self-esteem, dieting choices, and general well-being. Because attitudes toward menstruation are often adopted just as young women are first learning about and exploring their sexuality, it is important to promote healthy attitudes toward menstruation instead of shame. Promoting positive menstrual attitudes could be a first step toward protecting young women from many of the threats they face.

Note. We would like to thank Rosario Ceballo, Janna Kim, and several anonymous reviewers for their helpful comments on an earlier draft, and Amy Smith and Tami Van De Wege for their assistance on this project.

Manuscript accepted June 20, 2005

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Deborah Schooler

Center for Research on Gender and Sexuality, San Francisco State University

L. Monique Ward

University of Michigan

Ann Merriwether

State University of New York, Binghamton

Allison S. Caruthers

University of Michigan

Address correspondence to Deborah Schooler, Center for Research on Gender and Sexuality, San Francisco State University, 2017 Mission Street, Suite 300, San Francisco, CA, 94110: e-mail: [e-mail].

Table 1. Descriptive Statistics of Independent and Dependent Variables

                                  Mean    Std.    Min.    Max
                                           Dev
Menstrual Attitudes
  Negative Menstrual Attitudes    2.58     .53    1.39    4.28
  Positive Menstrual Attitudes    2.08     .63    1.00    4.55
  Openness about Menstruation     3.80     .59    2.00    5.00

Body Shame
  Body Image Self-
    Modesty (BCBM)                4.00    1.04     .70    6.67
  Body Image Self-
    Consciousness (BISC)         27.10   17.00    0.00   75.00

Sexual Behavior
  Sexual Assertiveness            3.46     .68    1.67    4.92
  Sexual Experience               4.67    1.81    1.00    7.00
  Risky Sexual Behavior           1.79    1.59    0.00    6.00
  Condom Use Self-Efficacy        3.88     .96    1.00    5.00

Table 2. Zero-Order Correlations Between Manifest Variables

             ASN          REL          NEG          OPN

ASN                       .11          .10        -.19 **
                         (196)        (190)        (190)
REL                                    .04         -.02
                                      (193)        (193)
NEG                                                -.40 ***
                                                   (193)
OPN

BCBM

BISC

SASS

EXP

RSB

             BCBM         BISC         SASS

ASN         -.17 *        .15 *        -.11
            (190)        (183)        (175)
REL         -.16 *        .10          -.14
            (194)        (186)        (178)
NEG         -.41 ***      .34 ***      -.40 ***
            (192)        (186)        (177)
OPN          .26 ***     -.17 *         .25 ***
            (192)        (186)        (177)
BCBM                     -.69 ***       .55 ***
                         (185)        (177)
BISC                                   -.53 ***
                                      (176)
SASS

EXP

RSB

             BCBM         BISC         SASS

ASN         -.17 *        .15 *        -.11
            (190)        (183)        (175)
REL         -.16 *        .10          -.14
            (194)        (186)        (178)
NEG         -.41 ***      .34 ***      -.40 ***
            (192)        (186)        (177)
OPN          .26 ***     -.17 *         .25 ***
            (192)        (186)        (177)
BCBM                     -.69 ***       .55 ***
                         (185)        (177)
BISC                                   -.53 ***
                                      (176)
SASS

EXP

RSB

Note. ASN = Being Asian, REL = Religiosity, NEG = Negative
Feelings about Menstruation, OPN = Openness about Menstruation,
BCBM = Body ComfortBody Modesty, BISC = Body Image
Self-Consicousness, SASS = Sexual Assertiveness, EXP = Sexual
Experience, RSB = Risky Sexual Behavior, SSE = Safe Sex
Self-Efficacy.

* p [less than or equal to] .05

** p [less than or equal to] .01

*** p [less than or equal to] .001.