The obstetrics-gynecology community has issued a call to action to prevent toxic environmental chemical exposures and their threats to healthy human reproduction. Recent committee opinions recognize that vulnerable and underserved women may be impacted disproportionately by environmental chemical exposures and recommend that reproductive health professionals champion policies that secure environmental justice. Beauty product use is an understudied source of environmental chemical exposures. Beauty products can include reproductive and developmental toxicants such as phthalates and heavy metals; however, disclosure requirements are limited and inconsistent. Compared with white women, women of color have higher levels of beauty product–related environmental chemicals in their bodies, independent of socioeconomic status. Even small exposures to toxic chemicals during critical periods of development (such as pregnancy) can trigger adverse health consequences (such as impacts on fertility and pregnancy, neurodevelopment, and cancer). In this commentary, we seek to highlight the connections between environmental justice and beauty product–related chemical exposures. We describe racial/ethnic differences in beauty product use (such as skin lighteners, hair straighteners, and feminine hygiene products) and the potential chemical exposures and health risks that are associated with these products. We also discuss how targeted advertising can take advantage of mainstream beauty norms to influence the use of these products. Reproductive health professionals can use this information to advance environmental justice by being prepared to counsel patients who have questions about toxic environmental exposures from beauty care products and other sources. Researchers and healthcare providers can also promote health-protective policies such as improved ingredient testing and disclosure for the beauty product industry. Future clinical and public health research should consider beauty product use as a factor that may shape health inequities in women's reproductive health across the life course.
Key words
The American Congress of Obstetrics and Gynecology (ACOG) committee opinion
1
emphasizes that toxic environmental chemicals are a threat to human reproduction and that there may be differential vulnerability by life stage or social position. More recently, doctors around the world echoed these concerns through the International Federation for Obstetrics and Gynecology (FIGO) committee opinion. FIGO recommended that reproductive health professionals recognize disproportionate burdens to toxic chemical exposures in certain patient populations and champion policies that secure environmental justice.2
Environmental justice integrates concepts of environmental racism and inequality and is defined as the unequal distribution of environmental benefits and pollution burdens based on race.3
An understanding of how both social and environmental factors jointly may influence health is necessary for the elimination of health disparities.4
The Environmental Protection Agency definition, adopted by FIGO, elaborates on this principle for regulatory purposes and defines environmental justice as “the fair treatment and meaningful involvement of all people regardless of race, color, national origin, or income.”2
, 5
United States Environmental Protection Agency. Enviromental Justice Available at: http://www.epa.gov/environmentaljustice/. Accessed June 21, 2017.
Beauty product use is an understudied source of environmental chemical exposures and may be 1 avenue for health professionals to intervene among vulnerable populations such as women of color. Consumer products, and personal care products specifically, are a source of exposure to toxic chemicals for all women.
6
, 7
, 8
Beauty products (1 category of personal care products) have limited and inconsistent disclosure of chemical ingredients, and most lack adequate data on health and safety.6
, 9
Racial/ethnic differences in beauty product use are documented across multiple categories including skin care, hair care, and feminine hygiene (Table). However, evidence points to the limits of the examination of these exposures in isolation. Rather, we argue that health practitioners should consider an “environmental injustice of beauty” approach that incorporates the social factors that influence beauty product use and the potential for cumulative impacts that may arise because of co-occurring environmental exposures. This approach provides a more comprehensive picture of how environmental factors may shape reproductive health disparities.
TableExamples of disproportionate beauty product exposures among vulnerable populations
| External factors | Vulnerable populations | Product use | Chemical exposures | Potential adverse outcomes |
|---|---|---|---|---|
| Colorism | Dark skinned women (globally) | Skin-lightening creams | Mercury | Mercury poisoning, neurotoxicity, kidney damage |
| Hair texture preferences | African American women (United States) | Hair relaxers and other hair care products | Parabens and estrogenic chemicals from placenta | Uterine fibroid tumors, premature puberty, and endocrine disruption |
| Odor discrimination | African American women (United States) | Vaginal douches and other feminine care products | Phthalates and talc powder | Gynecologic cancers and endocrine disruption |
Zota & Shamasunder. Beauty products, environmental chemicals, health disparities. Am J Obstet Gynecol 2017.
Preexisting vulnerabilities and cumulative impacts
Beauty products contain multiple chemicals, such as formaldehyde, phthalates, parabens, lead, mercury, triclosan, and benzophenone, that can adversely impact health.
6
, 9
, 10
Exposure to ≥1 of these chemicals has been linked to endocrine disruption, cancer, reproductive harm, and impaired neurodevelopment in children.11
, 12
, 13
, 14
Women 18–34 years old are more likely to be “heavy buyers” who purchase >10 types of products per year.15
These women and their offspring may experience heightened vulnerability to toxic environmental chemicals if products are used during sensitive periods of development such as preconception or pregnancy.Tabs Analytics. Millennial Women Key to Growth in Cosmetics Industry. 2016. Available at: http://www.tabsanalytics.com/blog/millennial-women-key-to-growth-in-cosmetics-industry. Accessed July 31, 2017.
2
Low-income and racial/ethnic minority groups may be further susceptible because they are exposed more frequently to multiple environmental and social risk factors and face poorer health outcomes.16
Nationally representative data of US reproductive-aged women suggest that women of color have higher levels of certain endocrine-disrupting chemicals, such as phthalates and parabens, in their bodies compared with white women and that these racial/ethnic differences are not explained by socioeconomic status.17
, 18
, 19
, 20
Workers in the beauty industry, who are predominantly women of color and immigrant women, can also face occupational health hazards from chemicals in professional cosmetic products and ad-hoc workplace safety standards.21
, 22
, 23
Cumulative assessments of environmental risk factors among socially marginalized groups historically have prioritized place-based pollution sources, such as polluting industries or high traffic density24
, 25
; however, beauty product exposures may be elevated in some of the same communities that encounter disproportionate exposures to place-based pollution.26
, 27
Social and economic dimensions of product use
The beauty product industry is estimated at $400 billion globally.
28
According to market analyses and consumer profiles, multicultural beauty products have outpaced the overall cosmetics market.Gyan R, Analytics. Global Beauty Care Market (2014-2018) - Research and Markets. 2014. Available at: https://www.marketresearch.com/product/sample-8483698.pdf. Accessed July 31, 2017.
29
African American consumers purchase 9 times more ethnic hair and beauty products than other groupsKline. Multicultural Beauty and Grooming Products: U.S. Market Analysis and Opportunities, 2014. Available at: http://www.klinegroup.com/reports/brochures/y746/brochure.pdf. Accessed July 31, 2017.
30
, Nielsen. African-American Consumers are More Relevant Than Ever. 2013. Available at: http://www.nielsen.com/us/en/insights/news/2013/african-american-consumers-are-more-relevant-than-ever.html. Accessed July 31, 2017.
31
and disproportionately purchase hair relaxers and straighteners. Latinos are the fastest growing ethnic beauty market segment,Mintel. Black Hair Care 2013. Available at: http://store.mintel.com/black-haircare-us-august-2013. Accessed July 31, 2017.
32
and Asian Americans spend 70% more than the national average on skin care products.Nielsen. Hispanic Consumers Are the “Foundation” for Beauty Category Sales. 2015. Available at: http://www.nielsen.com/us/en/insights/news/2015/hispanic-consumers-are-the-foundation-for-beauty-category-sales.html. Accessed July 31, 2017.
33
Nielsen. Beauty Is More Than Skin Deep for Asian-Americans. 2015. Available at: http://www.nielsen.com/us/en/insights/news/2015/beauty-is-more-than-skin-deep-for-asian-americans.html. Accessed July 31, 2017.
Mass distribution of images that idealize whiteness can influence sales of hair straighteners, skin lighteners, and odor-masking products.
34
, 35
Racial discrimination based on European beauty norms can lead to internalized racism, body shame, and skin tone dissatisfaction, factors that can influence product use to achieve straighter hair or lighter skin. Thus, beauty product use may be 1 way that structural discrimination becomes biologically embedded.36
, 37
Targeted racial/ethnic marketing can influence product use and related health inequities by taking advantage of mainstream beauty norms.
38
, 39
In a well-described example of the influences of marketing practices on health disparities, highly targeted menthol cigarette marketing in low-income inner city African American neighborhoods38
, 39
created a racialized geography of tobacco-related health disparities.40
Targeted marketing of beauty products may similarly influence reproductive health disparities.We document evidence of demographic differences in product use and chemical exposures in the beauty industry. We then describe how external factors, such as targeted advertising, can influence product use.
Skin-lightening face creams
Women in Africa, India, the Middle East, Southeast Asia, and the Americas regularly use skin-lightening cosmetics.
41
, 42
Skin-lightening creams can contain hydroquinone, topical corticosteroids, or inorganic mercury.43
Multiple cases of mercury poisoning, which is characterized by damage to the kidneys and the central nervous system, have been reported after use of skin-lightening products.44
The US Food and Drug Administration set a maximum allowable level of 1 ppm of mercury in skin products.45
However, skin products with mercury continue to be unregulated and available outside of the United States, and these products are still used by certain populations in the United States, including Dominican and Mexican American women.45
, 46
, 47
In a population-based study of New York City residents, those with the highest urine mercury levels were foreign-born Dominican women of reproductive age, and skin-lightening creams were identified as a source of exposure among highly exposed populations.45
Similarly, a medical case study reported that a pregnant Mexican American woman’s elevated blood mercury level of 15 μg/L (nearly 3 times the Centers for Disease Control and Prevention early reporting threshold) was linked to face creams that contained >20,000 ppm of mercury.46
Skin-lightening creams are sold globally, marketed to darker skinned women. Scholars point to the success of the global skin-lightening industry as evidence for the global preference for white/light skin
42
, 48
and colorism, a social hierarchy based on gradations of skin color that discriminates against darker skin.42
A study of 45 skin-bleaching products that were sold in Harlem, NY, found product marketing of skin lighteners traffics in derogatory images that devalue African American skin to sell these products.49
Lighter skin tone is an important predictor of higher self-esteem for African American women and is associated with higher educational attainment and earnings among women of color.50
, 51
Hair relaxers and straighteners
Compared with white women, African American and African Caribbean women are more likely to use a greater number and variety of hair products
52
and to have their hair chemically or professionally treated.31
Use of these products often begins at an early age; in a survey of 201 African American girls, almost one-half of the parents/guardians reported the first application of chemical relaxers to their child’s hair between the ages of 4 and 8 years.Mintel. Black Hair Care 2013. Available at: http://store.mintel.com/black-haircare-us-august-2013. Accessed July 31, 2017.
53
Hair products used by African American women are more likely to contain placenta (a potential source of estrogen hormones)54
, 55
and industrial chemicals, such as parabens,52
that affect estrogenic pathways.56
Premature reproductive development, such as breast budding, was documented in African American girls exposed to estrogen- or placenta-containing hair products.57
Use of ethnic hair products among African American women has been associated with increased risk of earlier menarche58
and uterine fibroid tumors.59
It has also been proposed as a plausible risk factor for excess premenopausal breast cancer risk that has been observed among African American women.60
Hair valuations of “good” (straighter/longer) and “bad” (tightly coiled/kinky) hair can place burdens on African American women to change their hair texture.
61
, 62
African American women experience more hair-related anxiety and are twice as likely than white women to experience social pressure at work to straighten their hair.63
For example, the US army historically banned several hairstyles traditionally used by African American women, such as twists and multiple braids, in favor of styles that encouraged straightening or other practices to change hair texture.Johnson AM, Godsil R, MacFarlane J, Tropp L, Goff PA. The “Good Hair” Study: explicit and implicit attitudes toward black women’s hair: the Perception Institute, 2017. Available at: https://perception.org/wp-content/uploads/2017/01/TheGood-HairStudyFindingsReport.pdf. Accessed July 31, 2017.
64
James-Todd T, Fitzgerald T. Caution: ‘Acceptable’ Black Women’s Hairstyles May Harm Health. WBUR: CommonHealth, 2014. Available at: http://www.wbur.org/commonhealth/2014/07/14/black-womens-hairstyles-health. Accessed July 31, 2017.
Feminine hygiene and other fragranced products
African American women are more likely than white women to use vaginal douches and other fragranced feminine cleansing products such as sprays and wipes.
19
In a nationally representative sample of reproductive-aged women, those who reported frequent douching had 150% higher exposures to diethyl phthalate, which is a chemical commonly found in fragrances, than douche nonusers.19
Differences in diethyl phthalate exposures between African American and white women were no longer statistically significant after douching practices were accounted for, which suggests that vaginal douching may contribute to racial/ethnic disparities in phthalates exposure. Prenatal exposure to diethyl phthalate can alter maternal sex steroid hormone concentrations during pregnancy65
and may increase the risk of adverse health outcomes in offspring.66
, 67
Vaginal douching can also increase risks of bacterial vaginosis68
and pelvic inflammatory disease69
and has been discouraged by ACOG.70
Use of talc powder on the genitals is another practice that is practiced disproportionately by US African American women.
71
Talc-based body powder is a possible human carcinogen when used in the genital areas. A pooled analysis of epidemiologic studies found a 24% increased risk of ovarian cancer from genital powder use.72
These risks may be greater among African American women than white women.73
, 74
Odor discrimination is a less described but important driver of the feminine cleansing practices described earlier. According to Ferranti,
75
imagined odor of African American women was used historically as a basis for moral judgement and an attempt to control sexual behavior. As a result, African American women deodorized and douched to be identified with sexual virtue. Advertisers used targeted marketing towards African American women with messages that encouraged self-consciousness of potential vaginal odors. These habits became embedded as a cultural norm and now persist outside of marketing efforts.75
Comment
Obstetrics-gynecology providers should be aware of the potentially toxic effects of commonly used beauty products, recognize disparities across these demographics, and be prepared to counsel patients who have questions about these and other environmental exposures. Although there are few published clinical guidelines, emerging consortiums with published scientific consensus statements can provide support to clinicians.
1
, 76
Health professional societies can also promote health-protective policies that include improved ingredient testing and disclosure. Last, health scientists can collaborate in research to help address existing data gaps. Research on the “exposome,” or the totality of a person’s environmental exposures from conception to death, is a priority for the National Institutes of Environmental Health Sciences.77
Researchers are trying to integrate beauty products into the exposome by characterizing the biologic activity of beauty products using in vitro study designs56
and estimating the joint effects of chemicals and psychosocial stress on reproductive endpoints.78
Future research should also consider the heterogeneous social and economic factors that drive product use. Collectively, this multipronged approach can help advance the ACOG and FIGO recommendations to secure environmental justice and promote health equity.Acknowledgments
The authors thank Dr Tracey Woodruff (UCSF Program on Reproductive Health and the Environment, funded in part through the National Institute of Environmental Health Sciences and the US Environmental Protection Agency, no conflicts of interest) for her guidance on the manuscript development and Dr Robin Dodson (Silent Spring Institute; no conflicts of interest) and Ms Patrice Sutton (UCSF Program on Reproductive Health and the Environment, funded in part through the National Institute of Environmental Health Sciences and the US Environmental Protection Agency, no conflicts of interest) for their comments on an earlier draft of the manuscript; the anonymous reviewers for their insights; and Dr Nate DeNicola (GW School of Medicine & Health Sciences; no conflicts of interest) and Lois Wessel, CFNP (School of Nursing and Health Studies, Georgetown University; no conflicts of interest), who was funded in part by the Environmental Protection Agency, for helpful comments on our final manuscript.
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Article info
Publication history
Published online: August 15, 2017
Accepted:
July 15,
2017
Received in revised form:
July 7,
2017
Received:
May 6,
2017
Footnotes
Supported by a grant from the Passport Foundation and the National Institute of Environmental Health Sciences (NIEHS: R00ES019881) and faculty research support from Occidental College.
The content is solely the responsibility of the authors and does not necessarily represent the official views of any of the funding agencies.
The authors report no conflict of interest.
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© 2017 The Authors. Published by Elsevier Inc.
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