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Introduction

Toxic Shock Syndrome

I became aware of toxic shock syndrome (TSS) after my first period in 1982, while in eighth grade. During a subsequent menstrual cycle, I caught a cold and became increasingly worried that I had contracted TSS. This was not such an outlandish conclusion on my part. TSS was the third most reported-on news story in 1980, behind the Iranian hostage crisis and the presidential election. The NBC Nightly News was a dinnertime staple, I had a subscription to Seventeen magazine, and I flipped through my mother’s Good Housekeeping, and all had reported on this new illness. I absorbed reports of current events, and news sources warned that a tampon plus a fever equated to a scary disease, possibly even to death. My mother, a nurse, quickly rebuffed my concerns. She was a longtime Tampax user who trusted the safety of the product. I suspect she interpreted my concerns as the manifestations of an overreactive teenager. Despite her assurances, the message I received was loud and clear: TSS was a possible side effect from wearing tampons, and I must be vigilant to monitor my body for any sign of potential disease when I used them.

As I grew older and continued to use tampons, I neither contracted TSS nor died from using a tampon. My experience with them was incongruous with the warning label on the box, and I always wondered about these heavy-handed labels. Was I being reckless by disregarding the warning? Or was TSS still lurking, and only I could save myself from corporate malfeasance? For how long could I use tampons and not fall ill, thus have my cake and eat it, too? As an adult who has spent many years contemplating TSS, I am more sympathetic to the conundrum. While it is true that a confluence of corporate interests, epidemiological studies, women’s health activism, and women’s desires to use tampons influenced the politics of tampon-related TSS, there is one important common denominator. All were influenced by the belief that tampons are inert. This faulty premise and the consequences of assuming that tampons are inert provided the backdrop for the new illness. The prevailing notion of the inert nature of tampon technology explains why the devastating outcome of women’s deaths were so difficult to study and understand; this traditional way of thinking about disease, technology, and women’s bodies was insufficient in encountering what came to be identified as tampon-related TSS. Though it is not recognized as such, tampon-related TSS was a paradigm shift in the way that illness manifests because the supposedly inert tampon interacted with a common bacterium to cause sickness in otherwise healthy women. No longer was an infection the origin of disease, or a faulty product the direct cause of injury. Together, a new pathway to an illness formed, in which a supposedly inert tampon became interactive, and a bacterium, once held in bodily equilibrium, grew dominant and produced toxins. Toxic Shock: A Social History makes a case for understanding tampon-related TSS as the result of biocatalytic activity between technology and bacterium. Moreover, though women were the primary consumers, the bacterium became the unintended user. This unusual disease process challenged standard approaches to public health and required women to evaluate technological risk. It likely portends increasing incidence of injury related to medical devices used and worn within the human body.

Tampon-related TSS is unique in that it is contingent on both bacterium and technology interacting with one another. TSS is unusual in that it is an illness that strikes otherwise healthy individuals and is predominantly associated with a human-made technology. Many people had a difficult time accepting this relationship, believing that tampons were inert. And those who recognized that something was afoot could not necessarily prove scientifically the mechanisms by which TSS manifested. Because hundreds of thousands of women who menstruated used tampons, and many carried the requisite bacterial strain of Staphylococcus aureus, scientific findings about TSS were urgent. Health practitioners, corporate scientists, federal policy makers, and feminist political advocates shaped and defined the terms of the emergent illness. They both articulated and challenged notions of risk, the results of which changed the conceptualization of tampons from benign to dangerous, affecting all tampon users. Moreover, this tampon technology shares a legacy of silence and coded language linked with menstruation, at best tolerated and at worst shamed. Thus, presumptions about menstruation came to bear on tampon technologies, the conditions of illness, and how women should be warned about potential risk.

This book is a multifaceted history of tampon-related TSS as understood through distinct lenses: (1) technology and bacterium; (2) medicine and epidemiology; (3) communication and journalism; (4) law and litigation; and (5) policy and politics. TSS remains at the center of each chapter, but the conceptualizations, approaches, methods, and assumptions that different professionals and organizations brought to bear on this emerging health crisis demonstrate reactions to the revelation that tampons were not inert and, moreover, had the potential to cause irrevocable damage. Epidemiologists, corporate scientists, lawyers, and women’s health advocates each asserted different positions about how the emerging illness was related to supposedly inert tampons and how TSS affected menstruating women. The chapters are arranged thematically and overlap chronologically to address the ways that TSS was identified, crafted, constructed, and politically contained. My goal is not to complicate matters but to explain the history of a complicated illness by exploring it through different viewpoints, because a linear history restricts the narrative.

TSS was identified with the bacterium Staphylococcus aureus in 1978, and the illness was later linked with tampons in 1980. Toxic shock syndrome was an urgent epidemiological event because of the feared potential to harm hundreds of thousands of young women. Though the epidemic never emerged, it is better characterized as a health crisis that instilled fear due to unknown elements and the inability of health providers to offer immediate explanation, relief, and a cure. Medical science failed to produce a quick and accurate resolution to the illness, compounding fears because tampons were simultaneously ubiquitous and also indecorous. According to Arthur Reingold, an epidemiologist at the Centers for Disease Control (CDC), 70 percent of women used tampons in 1980, and a potential national recall of all tampon brands would have affected hundreds of thousands of women.1 News reports and press releases in the media unveiled women’s intimate bodily menstrual management practices, presumably inappropriate to air yet necessary to speak of when warning women about the dangers, including death, associated with tampons.

This is a story about technology and bacterium, and also about the interrelatedness of these two active components in precipitating illness. Indeed, TSS is frightening because the majority of menstruating women in the United States use tampons, and women cannot willfully control their periods or the makeup of their vaginal microflora. Though menstrual periods are one of the variables to the illness, eliminating them (though currently they can be pharmaceutically managed with synthetic hormones) is both impractical and not entirely desirable. When tampons are avoided, the options are to use sanitary pads, which is a nonstarter for many due to their discomfort. Menstrual cups are gaining in popularity, but they are an expensive up-front investment and do not work for all women. For many, tampons are nonnegotiable and the only method to manage periods well enough to hide them. This is important because there are no privileges to be gained for heavy periods or stains on clothing. As Gloria Steinem glibly points out in her 1978 essay “If Men Could Menstruate,” they “would brag about how long and how much,” with slang such as “He’s a three-pad man!” to boast about bodily performance and rationalize power justifications.2 With no such social benefits extended to women, tampons offer a pragmatic means to absorb menstrual fluid, keep bloodstains off of clothing (for the most part), and leave the body unencumbered, unlike sanitary pads. Thus, the fear of contracting TSS during a period due to tampon use is an entirely legitimate concern, despite the fact that it occurs in “1 to 17 per 100,000 menstruating women and girls per year” and can be treated with antibiotics if diagnosed early enough.3 In light of these statistics, the hype and concern seem overblown, while in other ways the risk is poorly clarified and contributes to ongoing misunderstandings that plague the worried well.

In part, the Rely tampon, culpable for most of the TSS cases until 1980, is no longer produced and sold, eliminating that particular risk factor while lulling many into a false sense of security. Though other tampon brands triggered TSS and may have even contained similar material components, Rely tampons, which were developed and manufactured by Procter & Gamble (P&G), shouldered the brunt of the responsibility for the outbreak, with epidemiologic data strongly correlating TSS with them. As such, I have put the bacterium of S. aureus and the Rely tampon at the center of this book, and I trace technological innovations, epidemiology, product liability, and health policy through them both as the story’s main protagonists. This history explains the intertwined techno-bacteriological illness of tampon-related TSS and traces the unfolding health crisis, the definition of the illness, the shaping of knowledge distribution, and the gendering of health policy.

More broadly, this book raises questions about the way certain bodies are subjected to risk while others are not, and about why we are willing to tolerate harm for some people. We operate under a collective illusion and even desire that technologies related to bodies are safe. When something goes wrong, it is preferable to blame user error, presuming things have been vetted technically, scientifically, and medically, because then the problem can be rationalized as an aberration rather than systemic. This, unfortunately, is not the case. Corporations have a large financial stake in making sure the status quo of products is maintained, and women, too, have been compliant by ignoring known risks in favor of technoscientific menstrual management. So deeply ingrained is this narrative of technological progress that journalists often ask me to predict the next menstrual management technology on the horizon. I tell them that what we need is not another technological fix, but a more compassionate attitude toward menstruation. My response is unsatisfactory to them because it challenges the uplift narrative and the hopes of a capitalistic solution for socially conscientious menstrual management. It is also unsatisfactory because it asks women to be better consumers, resist the mantra that “new is better,” and reject further synthetic and nonnatural fibers to be worn within the body. A deep understanding of tampons and their relationship to women’s bodies is vitally important: it can have life-or-death consequences. A reason I wrote this book is to share this knowledge, so each of us does not have to conduct independent research about TSS in order to make decisions about our own bodies. There is much pressure to believe that the technoscientific is the future, but “new” is not always better, and, in this case, the unintended consequence of “new” can be death.

A Definition of Toxic Shock Syndrome

In order to understand the historical origins of tampon-related TSS, it is useful to begin with the clinical case definition of TSS put forth in February 1980 and established by the CDC. According to the CDC, a clinical case of TSS included a fever of 102 degrees or more, rash, desquamation (flaking, peeling skin), and hypotension (drop in blood pressure, dizziness). It also included the broad category of “multisystem involvement,” which encompasses three or more of the following: gastrointestinal distress (vomiting, diarrhea), muscular pain (creatine phosphokinase levels twice that of normal), mucous membrane issues (enlarged blood vessels within the eye, throat, or vagina), renal dysfunction (blood urea nitrogen or creatinine twice that of the normal level, without the presence of a urinary tract infection), liver dysfunction (serums twice that of normal), blood abnormalities (platelets less than 100,000/mm3), and central nervous system issues (disorientation). Lastly, tests for diseases such as measles and Rocky Mountain spotted fever had to be negative, and also negative throat, blood and cerebrospinal fluid cultures were necessary to eliminate other diseases with similar symptoms. The CDC also indicated that a TSS diagnosis of “probable” included five of the six categories, while “confirmed” included six of the six categories.4

This clinical definition fails to capture the materiality, suffering, and long-term effects for those who contracted it. Almost all cases start out with what appears to be the flu, with a fever, severe diarrhea, and vomiting. Most assume that they need rest and can sleep it off, only to find that they feel worse in the two to three days that follow. Personal blogs of women who contracted TSS describe a partner or close relative who insisted on taking them to the hospital, for at least a round of IV fluids. While there, the women, admitted as patients, were usually found to have very low blood pressure in the range of 70/40 and a high fever of 103 or 104 Fahrenheit. Molly, a blogger who contracted TSS in 2006 as a senior in high school, recalled horrible vomiting all day long and being so dizzy that she collapsed in the bathroom. She hallucinated and was unable to vocalize her need for help; after her mother took her to the physician, she was rushed to the hospital where she was diagnosed with TSS and treated with antibiotics, saline, and a plasma infusion. After being discharged, her hands and feet peeled like they had been sunburned.5 Michelle (age unknown) experienced TSS in 2007, and she recounted falling into a coma, needing kidney dialysis, and requiring a breathing tube. She bled from her eyes, and her feet and hands turned black and swollen as her organs shut down and limited circulation throughout her body. She emerged from the coma after a week and remained in the hospital, relearning how to do simple things such as getting dressed, feeding herself, and walking with a cane, which was a severe blow to her as a dancer. She also lost most of her hair, which grew back after about nine months. She returned to teach dance after a year, building up her strength to finally leap once again.6

Figure I.1. Peeling skin on the hands and feet is one hallmark symptom of TSS. Source: Public Health Image Library, ID #5119. Courtesy of the Centers for Disease Control.

These accounts are not meant to be voyeuristic or macabre, but to describe TSS in a more relatable manner. Though these are examples from two different women, TSS has been identified across the population, and it is somewhat of a misnomer to think of it as a specifically female ailment. It can present itself in children, men, and women who are not menstruating. Its etiology took a unique course when the overwhelming majority of cases at the outset were linked to tampon-using women. The toxin, a protein produced by the particular strain of Staphylococcus aureus responsible for tampon-related TSS, is specifically referred to as toxic shock syndrome toxin-1 (TSST-1). To further complicate things, there is also group A streptococcal TSS, though it is not associated with tampons. Throughout this book, I refer solely to tampon-related TSS, linked to Staphylococcus aureus.

Though TSS seemed to come out of nowhere, the bacterium S. aureus has many strains and is responsible for a variety of diseases, and about 20 percent of the general population carries S. aureus on the skin and in the nose. Named in 1884 for its yellow hued clusters, S. aureus produces a variety of ailments, including rashes, pimples, and boils.7 S. aureus has different relatives, some of which produce enterotoxins, harmful and toxic proteins specific to cells in the intestine and responsible for more serious bouts of food poisoning. Others create exotoxins, toxic materials secreted and released by the bacteria, which may travel throughout a person’s body. More recently methicillin-resistant Staphylococcus aureus (MRSA), currently known as the “super bug” contracted in hospital-like settings, has gained notoriety. S. aureus and its many bacterial derivatives can pack quite a punch in the realm of human diseases.

Tampon-related TSS is not contagious and is not an infection. It relies on multiple factors that come into play for a very small set of women. It is a complex process, difficult to understand, and impossible to condense into a sound bite or a quick public health announcement, though many scientists and public health advocates have attempted to do so over the years. Many scientists and research groups have examined TSS and TSST-1 and published results in academic journals that detail various elements of its etiology and microbiology, some of which conflict. It is not the goal of this book to list all of the scientists who have researched S. aureus or TSS and adjudicate their scientific accuracy, but rather I wish to shed light on how the vagaries and incongruities of scientific thinking influenced policy decisions that ultimately affected women. Significantly, the multiple variables related to the illness’s occurrence and a lack of definitive evidence detailing its exact pathway intensified the health crisis. There was no scientifically agreed-on understanding about how tampons specifically triggered TSS, though the most promising research was presented in the proceedings Toxic Shock Syndrome by the Institute of Medicine in 1982.8 Tampon-related TSS challenged essentialist notions of women’s bodies; not all women were the same and vaginal flora differed from woman to woman. Though menstrual periods and tampons were involved, a simple formula of “mix both and stir” was implausible to re-create TSS because it simply was not a reality that every menstruating woman using a tampon contracted TSS. It also challenged essentialist notions of technology as inert; tampons broke down, sloughed, and caused change within the vaginal ecosystem, becoming a variable in and of themselves. Scientific assumptions had to shift. Women were not monolithic and neither were the tampons that they used.

Overview

This book draws on many interdisciplinary fields and is primarily situated within studies of gender and technology, histories of women’s health and women’s health activism, and also related literature about the history of menstrual hygiene, which is more currently referred to as menstrual hygiene management or menstrual management.9 It intersects studies of technology and disease that examine relationships of medical practice to medical instruments and medical devices. It contributes to studies about technology and risk, and it looks at the relationship of injury to law.10 In addition, it relates to concepts of biological technologies—not necessarily in the sense of biotechnology and genetic engineering but that of technology interacting with biological systems.11 Policy studies of technology also address the relationships of scientific practice to government regulations, and how implementation of policy affects users and communities.12 All of these threads interlace to inform my interpretation of the techno-bacteriological health crisis of TSS, that is, an illness resulting from a biological and technological interface, and one not easily quelled through the usual medical courses of action. Though there are scientific discussions about TSS, and passing references to it in women’s health literature and self-help sources from the 1980s, Toxic Shock explores TSS from gendered, political, and science and technology studies perspectives in order to understand the history of this health crisis and its influence on the world in which we live.13

Calling tampon-related TSS a “health crisis” is purposeful, especially because it did not become a full-blown epidemic, and it centered on a formerly trusted, presumably benign technology. It generated surprise and a swift response. Christopher Foreman, a fellow at the Brookings Institution, describes the fear generated by potential public health harms as an “infectious disease or dangerous product that victimizes quickly and perhaps in ways unfamiliar to the general public.” Characteristic of “emergent public health hazards” is speed, dissipation, and novelty that contribute to the fear. Fear is further heightened by the understanding that one chance encounter, versus long-term exposure, can bring serious illness or injury.14 TSS captured these elements. A chance encounter with a formerly trusted tampon could bring on a new illness within twenty-four hours, difficult to diagnose in the initial stages because it acted like the common cold. In addition, once the element of fear took hold, it had its own set of consequences, with audiences unable to “hear” and comprehend experts’ observations and conclusions.15 Though many diseases and outbreaks had been publicized by news outlets, what made this one different to report on was the combination of a consumer technology, linked with the socially indecorous bodily process of menstruation, together producing a seemingly new illness.

The grounding assumptions and conceptualizations of bacteria and gendered technology are the focus of chapter 1. In order to think through this relationship of bacterium and technology as active co-agents, I develop the term “biocatalytic technology.” The tampon, conceptualized as an inert plug to stop up the fluids of a mechanical body, instead served as a catalyst, prompting a bacterium that was at best in stasis to begin producing toxins. Individually both the tampon and bacterium were neutral, but due to ecological circumstances they triggered a harmful consequence. Constituent bacteria, menstruating bodies, and a reactive rather than inert technology converged to create the ideal environment for the S. aureus bacterium to live and flourish in some women. Opportunistic, the bacterium became the unintended user of the tampon technology. The inability to recognize the agency of these microbial entities within the larger scope of women’s bodies—historically constructed as “problematic”—has profound effects on everyday health. Tampon-related TSS is an unintended consequence of technological innovation engaging with vaginal microbes, resulting in an emergent illness. Accounting for microbial constituents and the ecological landscape of gendered bodies would help imagine and mitigate deleterious outcomes. The term “biocatalytic technology” highlights the interactive rather than inert capacity of tampons, and it helps to explain the potential consequences of bacteria as technological users on women’s health.

Chapter 2 addresses the medical facets of TSS and how a set of symptoms was stabilized into a defined illness with correlative healthcare practices. The illness challenged a medical assumption that tampons did not cause illness because they were an inert medical device. As such, scientific evidence was all the more crucial, and counterintuitive, to create a convincing case for tampon-related TSS. Medical professionals, including family physicians, pediatricians, nephrologists, and specialized epidemiologists at the state and national levels, encountered ill girls and women, and they puzzled over the quick decline of otherwise healthy individuals. Important to physicians in identifying this illness were their robust social networks, in which they described symptoms to each other, shared case studies, and suggested treatments while “in the field.” These networks influenced national-level conversations to establish a definition for the syndrome, and a comprehensive system of monitoring was developed for current and emergent cases. TSS arrived at a transitional time for the CDC, as the failed flu vaccine of 1978 created bad publicity about the effectiveness and necessity of the organization. AIDS also came on the heels of TSS. In retrospect, TSS was but a blip compared to the now global spread of HIV/AIDS, but by comparison TSS came to be viewed sympathetically, as an illness killing cherished mothers and daughters. Public health advocates’ work was also called into question by corporate researchers who represented tampon manufacturers who were none too keen on this illness threatening projected tampon sales and profits. They argued that the epidemiologic methodology was circumscribed as well as skewed toward finding fault with synthetic tampons. This resulted in conflicting hypotheses about the mechanism and role of the tampon in TSS, with many competing studies sponsored by corporate grants.

Following the medical identification of tampon-related TSS, there was an urgent need to alert the hundreds of thousands of women using tampons that they were potentially dangerous and deadly. Disseminating a message of risk challenged status quo journalistic practices, and chapter 3 examines the media coverage of a health crisis centered on women’s reproductive health and menstrual management practices. The press had to figure out a way to talk about TSS in overly simplistic terms, in an era when the Federal Communication Commission (FCC) had only recently allowed feminine hygiene sprays, and then sanitary napkins and pads, to be advertised on television. Despite the loosened policy, the words “tampon,” “menstruation,” and “period” were considered socially inappropriate for general audiences, and arguments about maintaining propriety versus informing women led to newsroom fights. As the CDC released findings from its studies linking superabsorbent tampons to TSS, the media’s squeamishness transformed into paternalism, with safety messages cast on a perceived audience of needy women. By September of 1980, the Food and Drug Administration (FDA) threatened P&G with a product recall, causing P&G to voluntarily withdraw Rely from store shelves, and it also required the company to alert women to stop using the product. Journalistic reports of TSS helped to shape women’s reception of the recall, both instilling fear and caution but also providing gentle assurances about the safety of tampons. This contributed to a sense that the problem had been solved, when only the issue of Rely tampons had been eliminated. Other biocatalytic tampons remained on the market.

Though the majority of women did not suffer from TSS, others experienced a flu-like illness, hospitalization, and even death from using Rely and other superabsorbent tampons. Lawyers filed lawsuits against all the major companies for selling a faulty product and failing to adequately disclose risk. Chapter 4 explores the 1982 federal court case Kehm v. Procter & Gamble in which the plaintiff’s argument sought to prove that tampons were not inert, thereby exposing that corporate presumption as well as announcing it to the broader public. The lawsuit also provides a window into the emotional suffering of the Kehm family, who lost a mother, wife, sister, and daughter with Patricia Kehm’s death as a result of using Rely during the fall of 1980. Much of the trial strategically deployed scientific witnesses from both sides to sway the jury. Corporate managers and scientists cast tampons and their components as inert, women’s bodies as interchangeable lab instruments, and vaginal microflora as unimportant, all of which were positions challenged and ultimately undermined by the plaintiff’s experts. Though P&G researchers tested individual components to ensure that they did not cause birth defects or cancers, and were neither poisonous nor prone to cause irritations, the trial revealed that, due to their assumptions, corporate-generated data did not predict the emergence of tampon-related TSS. In part, the ritual of safety testing proved to be a reassuring yet futile exercise that did not generate data indicative of true risk. Leaders at P&G insisted that TSS was an industrywide issue, tampons had a long record of safety, and Rely was singled out unfairly, despite the results garnered by the CDC indicating otherwise. Some of their points were credible, yet the lawsuit highlighted the need for better testing and product labeling in order to avert more TSS-related injuries and lawsuits.

Since the threat of TSS subsided but remained, how to manage it became a politically contested issue. Chapter 5 addresses the political stakes of science-based policy used to warn women about the risk of tampon-related TSS. Different stakeholders, including the federal government, corporations, and women’s health activists, exerted pressure to control the terms of policy, product labeling, and the language of warnings printed on tampon boxes. Damage to women’s bodies did not end with the removal of Rely from store shelves. The solution entailed corporations calling on women to practice autosurveillance and self-police their bodies for symptoms of TSS, in essence exonerating manufacturers and outsourcing responsibility to women themselves by urging them to use the least absorbent tampon possible. But, without accurate labeling, this advice rang hollow. How to educate women and protect them from contracting TSS became a contentious labeling issue because corporations were not forthcoming with material ingredients, product absorbency, or a clear warning about TSS. To help women make informed decisions, feminist health advocates sought to provide science-based information about tampon absorbency rates, implement federal standards for descriptions such as “regular” and “super,” and also lobby for legislation demanding that tampon material contents be labeled on the box. In particular, Esther Rome of the Boston Women’s Health Book Collective (BWHBC) imparted feminist-minded standards challenging androcentric methods and models of the lab that determined these absorbencies, exemplifying why science and scientists must be accountable to communities and not just corporate data production.

The book concludes by examining the results and consequences of the bacteriological, technological, medical, journalistic, legal, and political influences on current-day understandings of TSS in the contemporary United States. Most are aware of controversies of hormonal birth control or the questionable safety of breast implants. However, the history of federal regulation of personal hygiene products, and activists’ efforts to improve safety, arguably touched more women than these other more familiar stories. Significantly, the actions of labeling tampon boxes, providing information about material and chemical content, and offering more understandable warnings about TSS remain incomplete. Congresswoman Carolyn Maloney (D-NY) first introduced the Tampon Safety and Research Act in 1997, reintroducing it again in 2003, 2005, 2008, and 2011, to no avail. On May 28, 2014, Menstrual Hygiene Day, she again proposed it as the renamed Robin Danielson Act regarding tampon safety, in recognition of Danielson’s death due to TSS in 1998 at age forty-four. The bill seeks further research into the chemical composition of tampons, additives, and their relationship to TSS since potential health hazards are not well researched or understood. This book supports the rationale for federal regulation and the need for transparent content labeling.

Contemporary Scientific Explanations

Current understandings about TSS are contested and evolving; moreover, succinct recommendations are difficult to crystallize. One hypothesis is that tampons alter the vaginal environment. Michael Osterholm, a Regents Professor at the University of Minnesota, who worked as an epidemiologist at the Minnesota Department of Health during the late 1970s and 1980s, specifically studied different brands of tampons and the relationship of absorbency to TSS. His studies identified higher absorbency tampons and their ability to hold oxygen within the otherwise anaerobic vagina as the key element in promoting toxin production.16 For Osterholm, the oxygenation made all the difference in providing an ideal environment for the S. aureus bacterium to grow. In my interview with him he recalled that many news reports stated that TSS was related to poor hygiene, and therefore the advice was to change tampons frequently. This, he said was wrong. The fresh tampons simply brought in more air, thus fueling the toxin production once it got rolling. His research pointed to all superabsorbent tampons, in which Rely was only one example, boosting the risk for TSS from three-fold to nearly ten-fold as absorptive capacity increased.17

Where Osterholm saw gradients in tampon absorbency as significant, others focused on the material composition of superabsorbent tampons, especially the all-synthetic design of the Rely tampon. Philip Tierno, a microbiologist, contends in his 2004 book The Secret Life of Germs that there were three major factors promoting TSS in women who used noncotton tampons and, in particular, Rely. First were the synthetic components of Rely, consisting of foam cubes and the gelling agent carboxymethylcellulose encased in a polyester pouch. Tierno suggests that the gelled carboxymethylcellulose in essence acted like agar in a petri dish, providing a viscous medium on which the bacterium could flourish. Along with this, the foam cubes offered increased surface area for rapid growth. Second was the changing pH of the vagina during menstruation, to about 7.4. The optimal pH for S. aureus to trigger TSS is 7, or neutral. The relatively acidic, nonmenstrual vagina measures a pH of about 4.2, which keeps S. aureus well in check. Tierno also supported Osterholm’s claim that a tampon introduces air into the usually anaerobic vagina, changing the environmental conditions. Finally, the pyrogenic toxins produced by S. aureus induced fever in humans. This fever of about 102 degrees proved to be the perfect temperature for S. aureus to reproduce and thus create further deadly toxins.18 An additional factor was a woman’s age; many adults had built up immunity to S. aureus and possessed the toxin antibody, while young women and teenagers were more susceptible without a developed immune response. As a result, TSS had a range of presentations from mild flu-like symptoms to literal septic shock.

Even in a recent 2016 interview in People magazine, JoAnn Pinkerson, a professor of obstetrics and gynecology and director of the Midlife Health Center, University of Virginia Health System, discussed how TSS can develop, but not its relationship to tampons. She deconstructed a four-step process of the illness in an attempt to simplify the explanation. The first step “is vaginal colonization with a strain of S. aureus, which can make the toxin,” and not all S. aureus strains do. The bacterium then produces the toxin, and enough must be produced to penetrate “across the vaginal epithelium.” Once this toxin leaves the confines of the vagina and enters the bloodstream, the illness requires “a lack of adequate titers of the neutralizing antibody to the toxin.”19 Though this description helps to explain the mechanism, it does not address the important variable of a tampon used to absorb menstrual fluid and its place within the chain of events leading to TSS. Furthermore, this is still not well comprehended by most women.

Patrick Schlievert, a microbiologist and head of the Microbiology department at the University of Iowa who studied S. aureus and TSS from the very beginning, argues that the particular strain that produced TSST-1 happened to gain traction about the same time that superabsorbents were marketed to women, so that the illness was coincidental.20 This strain made the difference in the presentation of illness, and not necessarily the components of the tampon. In an email conversation with him, he described S. aureus as tremendously adaptive, as a “facultative bacterium.” A facultative bacterium is quite resilient and able to assess changing environmental conditions. He explained, “It has oxidative metabolism for aerobic growth and fermentation for anaerobic growth,” meaning it can still produce its own energy in either aerobic or anaerobic environments. S. aureus can potentially grow in both, but it really flourishes when oxygen is present, introduced in this case by a tampon. In addition, the normally fluctuating pH of the vaginal ecosystem affects bacterial inhabitants, and S. aureus thrives in the less acidic menstrual medium and the newly oxygenated environment provided by a tampon. To add more variables, he explained that different bacteria such as a healthy population of lactobacilli interact with the body and affect vaginal pH levels as well, possibly holding S. aureus at bay during the nonbleeding weeks of the menstrual cycle, or prompting flare-ups during menstruation.21 The last element adding to the virulence of TSS is the powerful toxin, TSST-1, characterized as a protein and superantigen that disrupts and overactivates the immune system.22

In light of such a multifactored process with a menstrual management technology, and scientists’ differing explanations of it even now, it is no wonder confusion and justifiable fear reigned in the late 1970s and throughout the 1980s. Manufacturers currently recommend that women use the least absorbent tampons possible and change them often. This seems sound, yet tampons do not directly cause TSS per se, and limited use will not necessarily prevent the illness. And it is the toxin, not even the presence of the bacterium, that ultimately generates the symptoms. The only way to really prevent TSST-1 production is to avoid S. aureus altogether, which is impossible.

In addition, women are not usually tested to see if they have the antibody to the TSS toxin, which would indicate immunity. Without this antibody, a previous and recovered encounter with TSS indicates increased risk for its virulent expression the second time around, possibly leading to autoimmune issues for some women. Testing for the antibody may help point both to women who are more resilient to the toxin and to those who would need to steer clear of tampons.23 Instead, manufacturers rely on informed women knowing the signs and symptoms of TSS, which are deceptively similar to the common cold and difficult to discern as life threatening. This explains not only my generalized concern as a young teenager about contracting TSS, but also the daily pleas for help posted to social media outlets by young menstruating women, beseeching anyone for advice about whether or not they are experiencing TSS. The fears run deeper still, with researchers unsettled by the possibility of the TSST-1 strain and MRSA variant exchanging genes, which could create a very frightening “super bug” primed to affect tampon-using women.24

Gendered Approaches

A cornerstone of gender studies has been to question biological determinism and the fixity of binary meanings, such as man/woman, male/female, masculine/feminine. Women’s studies, gender studies, feminist theory, and queer studies have pressed hard against the notion of a universal male and androcentric conception of the world, with a growing awareness for more intersectional understandings of humans. Feminist theory has a large swath of scholarship addressing the body, its social construction, and how meaning is derived from embodiment. Elizabeth Wilson, a scholar of women’s and gender studies, argues that as important as this work is to the very identity and contours of feminist theory, it tends to be “antibiological.” She adds, “There is a powerful paradox in play: antibiologism both places significant conceptual limitations on feminist theory and has been one of the means by which feminist theory has prospered.”25 I have found my research in this paradox that Wilson describes. The material reality of menstrual fluid, the repeated cyclical nature of menstruation, and the illness of TSS are indeed visceral and biological, felt in real time by humans existing in day-to-day activities. I have also read my fair share of scientific journal articles for this research, trying to both understand TSS at the cellular level while also being mindful of the culture in which the science is situated, analyzing it with a feminist eye. While at the University of Illinois, my colleague Cris Mayo joked that I was the only person left in the department studying actual women’s bodies, the field had so moved into other areas. It is in this tension that research on biology about menstruation and the engineering of menstrual management technologies fall. It is the case of “both/and.” TSS is both technobiological and socially constructed, and it must be read back and forth and across.

Discussions about menstruation on the whole need more thoughtful attention to meanings and their implications. There has been an unquestioning link between menstruation and identities of womanhood, which falls back on an essentialist understanding of “woman,” and that conveniently sustains the man/woman binary. This reified notion, however, does not capture the whole picture of women or men or of the interplay of gender. The growing attention to transgender individuals has made it clear that biological body parts and processes do not define a woman. Yet menstruation has most definitely been a sign of being a woman, and as the feminist philosopher Denise Riley comments in Am I That Name?, menstruation summons a woman back to her body, often read as inferior to men, despite all the ways she may try to transcend prejudice with her mind, actions, and efforts.26 Thus menstruation has been a fraught subject of study, and in my book Under Wraps I traced how pro-woman physicians worked to break menstrual stigmas and conceptualize menstruation as normal rather than a sign of weakness and infirmity.

Menstruation remains a strong signifier of woman, yet this is not entirely accurate. When I refer to “women” and “woman” in this book, I fall into the trap of signifying those humans who menstruate, did menstruate, or could menstruate. Yet this is shortsighted, for there are many kinds of women among us who do not menstruate. Though this list is not exhaustive, menopause, hysterectomy, pharmaceuticals, pregnancy, lactation, endocrine issues, excessive exercise, and other causes, as well as being transgender, are all reasons why women might not menstruate. I used the term “menstruant” and referred to women using menstrual hygiene technologies who temporarily pass as “nonmenstruants” in Under Wraps, but perhaps it would be better to refer not to women, but to “menstruators” as Chris Bobel explores in her book New Blood: Third-Wave Feminism and the Politics of Menstruation, since all women, however that category is understood, do not menstruate.27 This would also allow space for those transgender men, along the various spectrum of transitioning, who do have periods. They are menstruators, too. It is not the intention of the book to write a queer history of menstruation, but one needs to be written, and I want to acknowledge the shortcomings of terms in writing about women and menstruation. Because I cannot escape the trap of language, in the book I employ the more historically bound usage of “women,” in large part because that is what the archival sources mean and what stakeholders understood within contemporary popular debates. In an effort to disaggregate essentialist terms, “menstruator” is far more accurate and I also utilize that term throughout the book.

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“[W]hat if you died from toxic shock syndrome and they put that in your obituary letting everyone know you died from a tampon[?]”28 This question from a Twitter feed captures the common knowledge that tampons cause TSS, and that death from a tampon would be embarrassing and shameful. It also implies it would be a stupid way to die, in that such a death is both unnecessary and preventable. This sentiment—that it should not happen and it is avoidable—haunts those who contract TSS, and it circulates as an urban/suburban myth, blaming women for their tragic illness. If only they followed the warning signs. This is quite unfair and displaces responsibility. Corporations must be more forthcoming with ingredient labeling, and medicine can and should offer preventative tests.

For menstruators who have used and do use tampons, the nagging warning about TSS is pervasive. I untangle the history of tampon-related TSS by examining scientific discovery and lack thereof, policy and lack thereof, as well as women’s reactions and the ways that many women paid the ultimate price by contracting a horrible illness and even dying due to the biocatalytic reaction that the tampon set into motion. Only extreme conditions prompted actions about tampon-related TSS, and this should be heeded as a warning for other similar kinds of unexpected and unintended techno-bacteriological illnesses. How tampon-related TSS was understood, reported on, and managed affects us to this very day and reveals the tensions inherent to relationships among feminism, medical science, technological developments, and bacterial agents of the human body.