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The environmental injustice of beauty: framing chemical exposures from beauty products as a health disparities concern

Open AccessPublished:August 15, 2017DOI:https://doi.org/10.1016/j.ajog.2017.07.020
      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
      American Congress of Obstetricians and Gynecologists Committee
      Committee opinion no. 575: Exposure to toxic environmental agents.
      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.
      • Di Renzo G.C.
      • Conry J.A.
      • Blake J.
      • et al.
      International Federation of Gynecology and Obstetrics opinion on reproductive health impacts of exposure to toxic environmental chemicals.
      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.
      • Chavis B.J.
      • Lee C.
      Toxic wastes and race in the United States: a national report on the racial and socio-economic characteristics of communities with hazardous waste sites.
      An understanding of how both social and environmental factors jointly may influence health is necessary for the elimination of health disparities.
      • Brulle R.J.
      • Pellow D.N.
      Environmental justice: human health and environmental inequalities.
      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.”
      • Di Renzo G.C.
      • Conry J.A.
      • Blake J.
      • et al.
      International Federation of Gynecology and Obstetrics opinion on reproductive health impacts of exposure to toxic environmental chemicals.

      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.
      • Chow E.T.
      • Mahalingaiah S.
      Cosmetics use and age at menopause: is there a connection?.
      • Mitro S.D.
      • Dodson R.E.
      • Singla V.
      • et al.
      Consumer product chemicals in indoor dust: a quantitative meta-analysis of US studies.
      • Woodruff T.J.
      • Zota A.R.
      • Schwartz J.M.
      Environmental chemicals in pregnant women in the United States: NHANES 2003-2004.
      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.
      • Chow E.T.
      • Mahalingaiah S.
      Cosmetics use and age at menopause: is there a connection?.
      • Dodson R.E.
      • Nishioka M.
      • Standley L.J.
      • Perovich L.J.
      • Brody J.G.
      • Rudel R.A.
      Endocrine disruptors and asthma-associated chemicals in consumer products.
      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 factorsVulnerable populationsProduct useChemical exposuresPotential adverse outcomes
      ColorismDark skinned women (globally)Skin-lightening creamsMercuryMercury poisoning, neurotoxicity, kidney damage
      Hair texture preferencesAfrican American women (United States)Hair relaxers and other hair care productsParabens and estrogenic chemicals from placentaUterine fibroid tumors, premature puberty, and endocrine disruption
      Odor discriminationAfrican American women (United States)Vaginal douches and other feminine care productsPhthalates and talc powderGynecologic 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.
      • Chow E.T.
      • Mahalingaiah S.
      Cosmetics use and age at menopause: is there a connection?.
      • Dodson R.E.
      • Nishioka M.
      • Standley L.J.
      • Perovich L.J.
      • Brody J.G.
      • Rudel R.A.
      Endocrine disruptors and asthma-associated chemicals in consumer products.
      • Pierce J.
      • Abelmann A.
      • Spicer L.
      • et al.
      Characterization of formaldehyde exposure resulting from the use of four professional hair straightening products.
      Exposure to ≥1 of these chemicals has been linked to endocrine disruption, cancer, reproductive harm, and impaired neurodevelopment in children.
      • Cogliano V.J.
      • Grosse Y.
      • Baan R.A.
      • et al.
      Meeting report: summary of IARC monographs on formaldehyde, 2-butoxyethanol, and 1-tert-butoxy-2-propanol.
      • Wang A.
      • Padula A.
      • Sirota M.
      • Woodruff T.J.
      Environmental influences on reproductive health: the importance of chemical exposures.
      • Diamanti-Kandarakis E.
      • Bourguignon J.-P.
      • Giudice L.C.
      • et al.
      Endocrine-disrupting chemicals: an Endocrine Society scientific statement.
      • Gore A.
      • Chappell V.
      • Fenton S.
      • et al.
      EDC-2: the endocrine society’s second scientific statement on endocrine-disrupting chemicals.
      Women 18–34 years old are more likely to be “heavy buyers” who purchase >10 types of products per year.

      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.

      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.
      • Di Renzo G.C.
      • Conry J.A.
      • Blake J.
      • et al.
      International Federation of Gynecology and Obstetrics opinion on reproductive health impacts of exposure to toxic environmental chemicals.
      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.
      • Morello-Frosch R.
      • Zuk M.
      • Jerrett M.
      • Shamasunder B.
      • Kyle A.D.
      Understanding the cumulative impacts of inequalities in environmental health: implications for policy.
      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.
      • James-Todd T.M.
      • Chiu Y.-H.
      • Zota A.R.
      Racial/ethnic disparities in environmental endocrine disrupting chemicals and women’s reproductive health outcomes: epidemiological examples across the life course.
      • Varshavsky J.R.
      • Zota A.R.
      • Woodruff T.J.
      A novel method for calculating potency-weighted cumulative phthalates exposure with implications for identifying racial/ethnic disparities among US reproductive-aged women in NHANES 2001-2012.
      • Branch F.
      • Woodruff T.J.
      • Mitro S.D.
      • Zota A.R.
      Vaginal douching and racial/ethnic disparities in phthalates exposures among reproductive-aged women: National Health and Nutrition Examination Survey 2001-2004.
      • Kobrosly R.W.
      • Parlett L.E.
      • Stahlhut R.W.
      • Barrett E.S.
      • Swan S.H.
      Socioeconomic factors and phthalate metabolite concentrations among United States women of reproductive age.
      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.
      • Adewumi-Gunn T.A.
      • Ponce E.
      • Flint N.
      • Robbins W.
      A preliminary community-based occupational health survey of black hair salon workers in South Los Angeles.
      • Quach T.
      • Gunier R.
      • Tran A.
      • et al.
      Characterizing workplace exposures in Vietnamese women working in California nail salons.
      • Quach T.
      • Tsoh J.Y.
      • Le G.
      • et al.
      Identifying and understanding the role of key stakeholders in promoting worker health and safety in nail salons.
      Cumulative assessments of environmental risk factors among socially marginalized groups historically have prioritized place-based pollution sources, such as polluting industries or high traffic density
      • Scammell M.K.
      • Montague P.
      • Raffensperger C.
      Tools for addressing cumulative impacts on human health and the environment.
      • Solomon G.M.
      • Morello-Frosch R.
      • Zeise L.
      • Faust J.B.
      Cumulative environmental impacts: Science and policy to protect communities.
      ; however, beauty product exposures may be elevated in some of the same communities that encounter disproportionate exposures to place-based pollution.
      • Harley K.G.
      • Kogut K.
      • Madrigal D.S.
      • et al.
      Reducing phthalate, paraben, and phenol exposure from personal care products in adolescent girls: findings from the HERMOSA Intervention Study.
      • Castorina R.
      • Bradman A.
      • Fenster L.
      • et al.
      Comparison of current-use pesticide and other toxicant urinary metabolite levels among pregnant women in the CHAMACOS cohort and NHANES.

       Social and economic dimensions of product use

      The beauty product industry is estimated at $400 billion globally.

      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.

      According to market analyses and consumer profiles, multicultural beauty products have outpaced the overall cosmetics market.

      Kline. 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.

      African American consumers purchase 9 times more ethnic hair and beauty products than other groups

      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.

      Mintel. Black Hair Care 2013. Available at: http://store.mintel.com/black-haircare-us-august-2013. Accessed July 31, 2017.

      and disproportionately purchase hair relaxers and straighteners. Latinos are the fastest growing ethnic beauty market segment,

      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.

      and Asian Americans spend 70% more than the national average on skin care products.

      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.
      • Bristor J.M.
      • Lee R.G.
      • Hunt M.R.
      Race and ideology: African-American images in television advertising.
      • Parameswaran R.
      • Cardoza K.
      Melanin on the margins: advertising and the cultural politics of fair/light/white beauty in India.
      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.
      • Krieger N.
      Discrimination and health inequities.
      • Bailey Z.D.
      • Krieger N.
      • Agénor M.
      • Graves J.
      • Linos N.
      • Bassett M.T.
      Structural racism and health inequities in the USA: evidence and interventions.
      Targeted racial/ethnic marketing can influence product use and related health inequities by taking advantage of mainstream beauty norms.
      • Moore D.J.
      • Williams J.D.
      • Qualls W.J.
      Target marketing of tobacco and alcohol-related products to ethnic minority groups in the United States.
      • Smith N.C.
      • Cooper-Martin E.
      Ethics and target marketing: the role of product harm and consumer vulnerability.
      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 neighborhoods
      • Moore D.J.
      • Williams J.D.
      • Qualls W.J.
      Target marketing of tobacco and alcohol-related products to ethnic minority groups in the United States.
      • Smith N.C.
      • Cooper-Martin E.
      Ethics and target marketing: the role of product harm and consumer vulnerability.
      created a racialized geography of tobacco-related health disparities.
      • Yerger V.B.
      • Przewoznik J.
      • Malone R.E.
      Racialized geography, corporate activity, and health disparities: tobacco industry targeting of inner cities.
      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.
      • Peltzer K.
      • Pengpid S.
      • James C.
      The globalization of whitening: prevalence of skin lighteners (or bleachers) use and its social correlates among university students in 26 countries.
      • Dixon A.R.
      • Telles E.E.
      Skin color and colorism: global research, concepts, and measurement.
      Skin-lightening creams can contain hydroquinone, topical corticosteroids, or inorganic mercury.
      • Ladizinski B.
      • Mistry N.
      • Kundu R.V.
      Widespread use of toxic skin lightening compounds: medical and psychosocial aspects.
      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.
      • Chan T.Y.
      Inorganic mercury poisoning associated with skin-lightening cosmetic products.
      The US Food and Drug Administration set a maximum allowable level of 1 ppm of mercury in skin products.
      • McKelvey W.
      • Jeffery N.
      • Clark N.
      • Kass D.
      • Parsons P.J.
      Population-based inorganic mercury biomonitoring and the identification of skin care products as a source of exposure in New York City.
      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.
      • McKelvey W.
      • Jeffery N.
      • Clark N.
      • Kass D.
      • Parsons P.J.
      Population-based inorganic mercury biomonitoring and the identification of skin care products as a source of exposure in New York City.
      • Dickenson C.A.
      • Woodruff T.J.
      • Stotland N.E.
      • Dobraca D.
      • Das R.
      Elevated mercury levels in pregnant woman linked to skin cream from Mexico.
      • Agrawal S.
      • Sharma P.
      Current status of mercury level in skin whitening creams.
      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.
      • McKelvey W.
      • Jeffery N.
      • Clark N.
      • Kass D.
      • Parsons P.J.
      Population-based inorganic mercury biomonitoring and the identification of skin care products as a source of exposure in New York City.
      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.
      • Dickenson C.A.
      • Woodruff T.J.
      • Stotland N.E.
      • Dobraca D.
      • Das R.
      Elevated mercury levels in pregnant woman linked to skin cream from Mexico.
      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
      • Dixon A.R.
      • Telles E.E.
      Skin color and colorism: global research, concepts, and measurement.
      • Hunter M.K.
      Buying racial capital: skin-bleaching and cosmetic surgery in a globalized world.
      and colorism, a social hierarchy based on gradations of skin color that discriminates against darker skin.
      • Dixon A.R.
      • Telles E.E.
      Skin color and colorism: global research, concepts, and measurement.
      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.
      • Charles C.A.D.
      The derogatory representations of the skin bleaching products sold in Harlem.
      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.
      • Hunter M.L.
      “If You’re Light You’re Alright” light skin color as social capital for women of color.
      • Thompson M.S.
      • Keith V.M.
      The blacker the berry: gender, skin tone, self-esteem, and self-efficacy.

       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
      • James-Todd T.
      • Senie R.
      • Terry M.B.
      Racial/ethnic differences in hormonally-active hair product use: a plausible risk factor for health disparities.
      and to have their hair chemically or professionally treated.

      Mintel. Black Hair Care 2013. Available at: http://store.mintel.com/black-haircare-us-august-2013. Accessed July 31, 2017.

      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.
      • Wright D.R.
      • Gathers R.
      • Kapke A.
      • Johnson D.
      • Joseph C.L.
      Hair care practices and their association with scalp and hair disorders in African American girls.
      Hair products used by African American women are more likely to contain placenta (a potential source of estrogen hormones)
      • Li S.-T.T.
      • Lozano P.
      • Grossman D.C.
      • Graham E.
      Hormone-containing hair product use in prepubertal children.
      • Tiwary C.M.
      A survey of use of hormone/placenta-containing hair preparations by parents and/or children attending pediatric clinics.
      and industrial chemicals, such as parabens,
      • James-Todd T.
      • Senie R.
      • Terry M.B.
      Racial/ethnic differences in hormonally-active hair product use: a plausible risk factor for health disparities.
      that affect estrogenic pathways.
      • Myers S.L.
      • Yang C.Z.
      • Bittner G.D.
      • Witt K.L.
      • Tice R.R.
      • Baird D.D.
      Estrogenic and anti-estrogenic activity of off-the-shelf hair and skin care products.
      Premature reproductive development, such as breast budding, was documented in African American girls exposed to estrogen- or placenta-containing hair products.
      • Tiwary C.M.
      Premature sexual development in children following the use of estrogen-or placenta-containing hair products.
      Use of ethnic hair products among African American women has been associated with increased risk of earlier menarche
      • James-Todd T.
      • Terry M.B.
      • Rich-Edwards J.
      • Deierlein A.
      • Senie R.
      Childhood hair product use and earlier age at menarche in a racially diverse study population: a pilot study.
      and uterine fibroid tumors.
      • Wise L.A.
      • Palmer J.R.
      • Reich D.
      • Cozier Y.C.
      • Rosenberg L.
      Hair relaxer use and risk of uterine leiomyomata in African-American women.
      It has also been proposed as a plausible risk factor for excess premenopausal breast cancer risk that has been observed among African American women.
      • Donovan M.
      • Tiwary C.M.
      • Axelrod D.
      • et al.
      Personal care products that contain estrogens or xenoestrogens may increase breast cancer risk.
      Hair valuations of “good” (straighter/longer) and “bad” (tightly coiled/kinky) hair can place burdens on African American women to change their hair texture.
      • Banks I.
      Hair Matters: Beauty, Power, and Black Women’s Consciousness.
      • Robinson C.L.
      Hair as race: why “good hair” may be bad for black females.
      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.

      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.

      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.

      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.
      • Branch F.
      • Woodruff T.J.
      • Mitro S.D.
      • Zota A.R.
      Vaginal douching and racial/ethnic disparities in phthalates exposures among reproductive-aged women: National Health and Nutrition Examination Survey 2001-2004.
      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.
      • Branch F.
      • Woodruff T.J.
      • Mitro S.D.
      • Zota A.R.
      Vaginal douching and racial/ethnic disparities in phthalates exposures among reproductive-aged women: National Health and Nutrition Examination Survey 2001-2004.
      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 pregnancy
      • Sathyanarayana S.
      • Barrett E.
      • Butts S.
      • Wang C.
      • Swan S.H.
      Phthalate exposure and reproductive hormone concentrations in pregnancy.
      and may increase the risk of adverse health outcomes in offspring.
      • Swan S.H.
      • Main K.M.
      • Liu F.
      • et al.
      Decrease in anogenital distance among male infants with prenatal phthalate exposure.
      • Engel S.M.
      • Miodovnik A.
      • Canfield R.L.
      • et al.
      Prenatal phthalate exposure is associated with childhood behavior and executive functioning.
      Vaginal douching can also increase risks of bacterial vaginosis
      • Holzman C.
      • Leventhal J.M.
      • Qiu H.
      • Jones N.M.
      • Wang J.
      Factors linked to bacterial vaginosis in nonpregnant women.
      and pelvic inflammatory disease
      • Scholes D.
      • Daling J.R.
      • Stergachis A.
      • Weiss N.S.
      • Wang S.-P.
      • Grayston J.T.
      Vaginal douching as a risk factor for acute pelvic inflammatory disease.
      and has been discouraged by ACOG.
      American College of Obstetricians and Gynecologists
      Committee opinion no. 345: vulvodynia.
      Use of talc powder on the genitals is another practice that is practiced disproportionately by US African American women.
      • Wu A.H.
      • Pearce C.L.
      • Tseng C.-C.
      • Pike M.C.
      African Americans and Hispanics remain at lower risk of ovarian cancer than non-Hispanic Whites after considering non-genetic risk factors and oophorectomy rates.
      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.
      • Terry K.L.
      • Karageorgi S.
      • Shvetsov Y.B.
      • et al.
      Genital powder use and risk of ovarian cancer: a pooled analysis of 8,525 cases and 9,859 controls.
      These risks may be greater among African American women than white women.
      • Cramer D.W.
      • Vitonis A.F.
      • Terry K.L.
      • Welch W.R.
      • Titus L.J.
      The association between talc use and ovarian cancer: a retrospective case-control study in two US states.
      • Schildkraut J.M.
      • Abbott S.E.
      • Alberg A.J.
      • et al.
      Association between body powder use and ovarian cancer: the African American Cancer Epidemiology Study (AACES).
      Odor discrimination is a less described but important driver of the feminine cleansing practices described earlier. According to Ferranti,
      • Ferranti M.
      An odor of racism: vaginal deodorants in African-American beauty culture and advertising.
      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.
      • Ferranti M.
      An odor of racism: vaginal deodorants in African-American beauty culture and advertising.

       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.
      American Congress of Obstetricians and Gynecologists Committee
      Committee opinion no. 575: Exposure to toxic environmental agents.
      • Bennett D.
      • Bellinger D.C.
      • Birnbaum L.S.
      • et al.
      Project TENDR: targeting environmental neuro-developmental risks: the TENDR consensus statement.
      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.

      National Institute of Environmental Health Sciences. 2012-2017 Strategic plan: advancing science, improving health; a plan for environmental health research. US Department of Health and Human Services; 2012 (NIH Publication No. 12-7935).

      Researchers are trying to integrate beauty products into the exposome by characterizing the biologic activity of beauty products using in vitro study designs
      • Myers S.L.
      • Yang C.Z.
      • Bittner G.D.
      • Witt K.L.
      • Tice R.R.
      • Baird D.D.
      Estrogenic and anti-estrogenic activity of off-the-shelf hair and skin care products.
      and estimating the joint effects of chemicals and psychosocial stress on reproductive endpoints.
      • Barrett E.S.
      • Parlett L.E.
      • Sathyanarayana S.
      • Redmon J.B.
      • Nguyen R.H.
      • Swan S.H.
      Prenatal stress as a modifier of associations between phthalate exposure and reproductive development: results from a Multicentre Pregnancy Cohort Study.
      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.

      References

        • American Congress of Obstetricians and Gynecologists Committee
        Committee opinion no. 575: Exposure to toxic environmental agents.
        Fertil Steril. 2013; 100: 931-934
        • Di Renzo G.C.
        • Conry J.A.
        • Blake J.
        • et al.
        International Federation of Gynecology and Obstetrics opinion on reproductive health impacts of exposure to toxic environmental chemicals.
        Int J Gynaecol Obstet. 2015; 131: 219-225
        • Chavis B.J.
        • Lee C.
        Toxic wastes and race in the United States: a national report on the racial and socio-economic characteristics of communities with hazardous waste sites.
        United Church of Christ Commission on Racial Justice, New York1987
        • Brulle R.J.
        • Pellow D.N.
        Environmental justice: human health and environmental inequalities.
        Annu Rev Public Health. 2006; 27: 103-124
      1. United States Environmental Protection Agency. Enviromental Justice Available at: http://www.epa.gov/environmentaljustice/. Accessed June 21, 2017.

        • Chow E.T.
        • Mahalingaiah S.
        Cosmetics use and age at menopause: is there a connection?.
        Fertil Steril. 2016; 106: 978-990
        • Mitro S.D.
        • Dodson R.E.
        • Singla V.
        • et al.
        Consumer product chemicals in indoor dust: a quantitative meta-analysis of US studies.
        Environ Sci Technol. 2016; 50: 10661
        • Woodruff T.J.
        • Zota A.R.
        • Schwartz J.M.
        Environmental chemicals in pregnant women in the United States: NHANES 2003-2004.
        Environ Health Perspect. 2011; 119: 878
        • Dodson R.E.
        • Nishioka M.
        • Standley L.J.
        • Perovich L.J.
        • Brody J.G.
        • Rudel R.A.
        Endocrine disruptors and asthma-associated chemicals in consumer products.
        Environ Health Perspect. 2012; 120: 935
        • Pierce J.
        • Abelmann A.
        • Spicer L.
        • et al.
        Characterization of formaldehyde exposure resulting from the use of four professional hair straightening products.
        J Occup Environ Hyg. 2011; 8: 686-699
        • Cogliano V.J.
        • Grosse Y.
        • Baan R.A.
        • et al.
        Meeting report: summary of IARC monographs on formaldehyde, 2-butoxyethanol, and 1-tert-butoxy-2-propanol.
        Environ Health Perspect. 2005; 113: 1205
        • Wang A.
        • Padula A.
        • Sirota M.
        • Woodruff T.J.
        Environmental influences on reproductive health: the importance of chemical exposures.
        Fertil Steril. 2016; 106: 905-929
        • Diamanti-Kandarakis E.
        • Bourguignon J.-P.
        • Giudice L.C.
        • et al.
        Endocrine-disrupting chemicals: an Endocrine Society scientific statement.
        Endocr Rev. 2009; 30: 293-342
        • Gore A.
        • Chappell V.
        • Fenton S.
        • et al.
        EDC-2: the endocrine society’s second scientific statement on endocrine-disrupting chemicals.
        Endocr Rev. 2015; 36: E1-150
      2. 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.

        • Morello-Frosch R.
        • Zuk M.
        • Jerrett M.
        • Shamasunder B.
        • Kyle A.D.
        Understanding the cumulative impacts of inequalities in environmental health: implications for policy.
        Health Aff (Millwood). 2011; 30: 879-887
        • James-Todd T.M.
        • Chiu Y.-H.
        • Zota A.R.
        Racial/ethnic disparities in environmental endocrine disrupting chemicals and women’s reproductive health outcomes: epidemiological examples across the life course.
        Curr Epidemiol Rep. 2016; 3: 161-180
        • Varshavsky J.R.
        • Zota A.R.
        • Woodruff T.J.
        A novel method for calculating potency-weighted cumulative phthalates exposure with implications for identifying racial/ethnic disparities among US reproductive-aged women in NHANES 2001-2012.
        Environ Sci Technol. 2016; 50: 10616-10624
        • Branch F.
        • Woodruff T.J.
        • Mitro S.D.
        • Zota A.R.
        Vaginal douching and racial/ethnic disparities in phthalates exposures among reproductive-aged women: National Health and Nutrition Examination Survey 2001-2004.
        Environ Health. 2015; 14: 1-8
        • Kobrosly R.W.
        • Parlett L.E.
        • Stahlhut R.W.
        • Barrett E.S.
        • Swan S.H.
        Socioeconomic factors and phthalate metabolite concentrations among United States women of reproductive age.
        Environ Res. 2012; 115: 11-17
        • Adewumi-Gunn T.A.
        • Ponce E.
        • Flint N.
        • Robbins W.
        A preliminary community-based occupational health survey of black hair salon workers in South Los Angeles.
        J Immigr Minor Health. 2016; : 1-7
        • Quach T.
        • Gunier R.
        • Tran A.
        • et al.
        Characterizing workplace exposures in Vietnamese women working in California nail salons.
        Am J Public Health. 2011; 101: S271-S276
        • Quach T.
        • Tsoh J.Y.
        • Le G.
        • et al.
        Identifying and understanding the role of key stakeholders in promoting worker health and safety in nail salons.
        J Health Care Poor Underserved. 2015; 26: 104-115
        • Scammell M.K.
        • Montague P.
        • Raffensperger C.
        Tools for addressing cumulative impacts on human health and the environment.
        Environ Justice. 2014; 7: 102-109
        • Solomon G.M.
        • Morello-Frosch R.
        • Zeise L.
        • Faust J.B.
        Cumulative environmental impacts: Science and policy to protect communities.
        Annu Rev Public Health. 2016; 37: 83-96
        • Harley K.G.
        • Kogut K.
        • Madrigal D.S.
        • et al.
        Reducing phthalate, paraben, and phenol exposure from personal care products in adolescent girls: findings from the HERMOSA Intervention Study.
        Environ Health Perspect. 2016; 124: 1600-1607
        • Castorina R.
        • Bradman A.
        • Fenster L.
        • et al.
        Comparison of current-use pesticide and other toxicant urinary metabolite levels among pregnant women in the CHAMACOS cohort and NHANES.
        Environ Health Perspect. 2010; 118: 856
      3. 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.

      4. Kline. 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.

      5. 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.

      6. Mintel. Black Hair Care 2013. Available at: http://store.mintel.com/black-haircare-us-august-2013. Accessed July 31, 2017.

      7. 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.

      8. 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.

        • Bristor J.M.
        • Lee R.G.
        • Hunt M.R.
        Race and ideology: African-American images in television advertising.
        Journal of Public Policy and Marketing. 1995; 14: 48-59
        • Parameswaran R.
        • Cardoza K.
        Melanin on the margins: advertising and the cultural politics of fair/light/white beauty in India.
        Journal of Communication Monographs. 2009; 11: 213-274
        • Krieger N.
        Discrimination and health inequities.
        Int J Health Serv. 2014; 44: 643-710
        • Bailey Z.D.
        • Krieger N.
        • Agénor M.
        • Graves J.
        • Linos N.
        • Bassett M.T.
        Structural racism and health inequities in the USA: evidence and interventions.
        Lancet. 2017; 389: 1453-1463
        • Moore D.J.
        • Williams J.D.
        • Qualls W.J.
        Target marketing of tobacco and alcohol-related products to ethnic minority groups in the United States.
        Ethn Dis. 1996; 6: 83-98
        • Smith N.C.
        • Cooper-Martin E.
        Ethics and target marketing: the role of product harm and consumer vulnerability.
        Journal of Marketing. 1997; 61: 1-20
        • Yerger V.B.
        • Przewoznik J.
        • Malone R.E.
        Racialized geography, corporate activity, and health disparities: tobacco industry targeting of inner cities.
        J Health Care Poor Underserved. 2007; 18: 10-38
        • Peltzer K.
        • Pengpid S.
        • James C.
        The globalization of whitening: prevalence of skin lighteners (or bleachers) use and its social correlates among university students in 26 countries.
        Int J Dermatol. 2016; 55: 165-172
        • Dixon A.R.
        • Telles E.E.
        Skin color and colorism: global research, concepts, and measurement.
        Annu Rev Sociol. 2017; 43: 405-424
        • Ladizinski B.
        • Mistry N.
        • Kundu R.V.
        Widespread use of toxic skin lightening compounds: medical and psychosocial aspects.
        Dermatol Clin. 2011; 29: 111-123
        • Chan T.Y.
        Inorganic mercury poisoning associated with skin-lightening cosmetic products.
        Clin Toxicol. 2011; 49: 886-891
        • McKelvey W.
        • Jeffery N.
        • Clark N.
        • Kass D.
        • Parsons P.J.
        Population-based inorganic mercury biomonitoring and the identification of skin care products as a source of exposure in New York City.
        Environ Health Perspect. 2011; 119: 203-209
        • Dickenson C.A.
        • Woodruff T.J.
        • Stotland N.E.
        • Dobraca D.
        • Das R.
        Elevated mercury levels in pregnant woman linked to skin cream from Mexico.
        Am J Obstet Gynecol. 2013; 209: e4-e5
        • Agrawal S.
        • Sharma P.
        Current status of mercury level in skin whitening creams.
        Current Medicine Research and Practice. 2017; 7: 47-50
        • Hunter M.K.
        Buying racial capital: skin-bleaching and cosmetic surgery in a globalized world.
        The Journal of Pan African Studies. 2011; 4: 142-164
        • Charles C.A.D.
        The derogatory representations of the skin bleaching products sold in Harlem.
        Social Science Research Network, Rochester (NY)2011
        • Hunter M.L.
        “If You’re Light You’re Alright” light skin color as social capital for women of color.
        Gend Soc. 2002; 16: 175-193
        • Thompson M.S.
        • Keith V.M.
        The blacker the berry: gender, skin tone, self-esteem, and self-efficacy.
        Gender and Society. 2001; 15: 336-357
        • James-Todd T.
        • Senie R.
        • Terry M.B.
        Racial/ethnic differences in hormonally-active hair product use: a plausible risk factor for health disparities.
        J Immigr Minor Health. 2012; 14: 506-511
        • Wright D.R.
        • Gathers R.
        • Kapke A.
        • Johnson D.
        • Joseph C.L.
        Hair care practices and their association with scalp and hair disorders in African American girls.
        J Am Acad Dermatol. 2011; 64: 253-262
        • Li S.-T.T.
        • Lozano P.
        • Grossman D.C.
        • Graham E.
        Hormone-containing hair product use in prepubertal children.
        Arch Pediatr Adolesc Med. 2002; 156: 85-86
        • Tiwary C.M.
        A survey of use of hormone/placenta-containing hair preparations by parents and/or children attending pediatric clinics.
        Mil Med. 1997; 162: 252-256
        • Myers S.L.
        • Yang C.Z.
        • Bittner G.D.
        • Witt K.L.
        • Tice R.R.
        • Baird D.D.
        Estrogenic and anti-estrogenic activity of off-the-shelf hair and skin care products.
        J Expos Sci Environ Epidemiol. 2015; 25: 271-277
        • Tiwary C.M.
        Premature sexual development in children following the use of estrogen-or placenta-containing hair products.
        Clin Pediatr. 1998; 37: 733-739
        • James-Todd T.
        • Terry M.B.
        • Rich-Edwards J.
        • Deierlein A.
        • Senie R.
        Childhood hair product use and earlier age at menarche in a racially diverse study population: a pilot study.
        Ann Epidemiol. 2011; 21: 461-465
        • Wise L.A.
        • Palmer J.R.
        • Reich D.
        • Cozier Y.C.
        • Rosenberg L.
        Hair relaxer use and risk of uterine leiomyomata in African-American women.
        Am J Epidemiol. 2012; 175: 432-440
        • Donovan M.
        • Tiwary C.M.
        • Axelrod D.
        • et al.
        Personal care products that contain estrogens or xenoestrogens may increase breast cancer risk.
        Med Hypotheses. 2007; 68: 756-766
        • Banks I.
        Hair Matters: Beauty, Power, and Black Women’s Consciousness.
        NYU Press;, New York, NY2000
        • Robinson C.L.
        Hair as race: why “good hair” may be bad for black females.
        Howard Journal of Communications. 2011; 22: 358-376
      9. 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.

      10. 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.

        • Sathyanarayana S.
        • Barrett E.
        • Butts S.
        • Wang C.
        • Swan S.H.
        Phthalate exposure and reproductive hormone concentrations in pregnancy.
        Reproduction. 2014; 147: 401-409
        • Swan S.H.
        • Main K.M.
        • Liu F.
        • et al.
        Decrease in anogenital distance among male infants with prenatal phthalate exposure.
        Environ Health Perspect. 2005; : 1056-1061
        • Engel S.M.
        • Miodovnik A.
        • Canfield R.L.
        • et al.
        Prenatal phthalate exposure is associated with childhood behavior and executive functioning.
        Environ Health Perspect. 2010; 118: 565
        • Holzman C.
        • Leventhal J.M.
        • Qiu H.
        • Jones N.M.
        • Wang J.
        Factors linked to bacterial vaginosis in nonpregnant women.
        Am J Public Health. 2001; 91: 1664-1670
        • Scholes D.
        • Daling J.R.
        • Stergachis A.
        • Weiss N.S.
        • Wang S.-P.
        • Grayston J.T.
        Vaginal douching as a risk factor for acute pelvic inflammatory disease.
        Obstet Gynecol. 1993; 81: 601-606
        • American College of Obstetricians and Gynecologists
        Committee opinion no. 345: vulvodynia.
        Obstet Gynecol. 2006; 108: 1049-1052
        • Wu A.H.
        • Pearce C.L.
        • Tseng C.-C.
        • Pike M.C.
        African Americans and Hispanics remain at lower risk of ovarian cancer than non-Hispanic Whites after considering non-genetic risk factors and oophorectomy rates.
        Cancer Epidemiol Biomarkers Prev. 2015; 24: 1094-1100
        • Terry K.L.
        • Karageorgi S.
        • Shvetsov Y.B.
        • et al.
        Genital powder use and risk of ovarian cancer: a pooled analysis of 8,525 cases and 9,859 controls.
        Cancer Prev Res. 2013; 6: 811-821
        • Cramer D.W.
        • Vitonis A.F.
        • Terry K.L.
        • Welch W.R.
        • Titus L.J.
        The association between talc use and ovarian cancer: a retrospective case-control study in two US states.
        Epidemiology. 2016; 27: 334
        • Schildkraut J.M.
        • Abbott S.E.
        • Alberg A.J.
        • et al.
        Association between body powder use and ovarian cancer: the African American Cancer Epidemiology Study (AACES).
        Cancer Epidemiol Biomarkers Prev. 2016; 10: 1411-1417
        • Ferranti M.
        An odor of racism: vaginal deodorants in African-American beauty culture and advertising.
        Advertising & Society Review. 2011; 11
        • Bennett D.
        • Bellinger D.C.
        • Birnbaum L.S.
        • et al.
        Project TENDR: targeting environmental neuro-developmental risks: the TENDR consensus statement.
        Environ Health Perspect. 2016; 124: A118
      11. National Institute of Environmental Health Sciences. 2012-2017 Strategic plan: advancing science, improving health; a plan for environmental health research. US Department of Health and Human Services; 2012 (NIH Publication No. 12-7935).

        • Barrett E.S.
        • Parlett L.E.
        • Sathyanarayana S.
        • Redmon J.B.
        • Nguyen R.H.
        • Swan S.H.
        Prenatal stress as a modifier of associations between phthalate exposure and reproductive development: results from a Multicentre Pregnancy Cohort Study.
        Paediatr Perinat Epidemiol. 2016; 30: 105-114

      Linked Article

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        American Journal of Obstetrics & GynecologyVol. 218Issue 2
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          The submitted letters by Berger1 and Walter et al2 follow up on important issues of regulatory gaps in cosmetic oversights that were addressed in our commentary.3 We concur that there is need for increased attention and funding to broaden Food and Drug Administration (FDA) authority over cosmetics. In addition, Walter et al2 point to another useful avenue for clinician involvement through the Center for Food Safety and Applied Nutrition Adverse Event Reporting System maintained by the FDA. We agree that clinicians can increase transparency of adverse events from beauty product use by making reports to the system when they encounter relevant cases.
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      • Better Reporting Needed for Cosmetics and Women’s Health
        American Journal of Obstetrics & GynecologyVol. 218Issue 2
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          Zota and Shamasunder1 call to attention the need for broader awareness regarding the safety of cosmetics and personal care products in women’s health. Despite being ubiquitously used, it is no surprise that women represent the single largest group of cosmetic users. The disproportionate exposure burden of potentially harmful chemicals in cosmetics for certain groups is rightfully concerning. A recent epidemiologic study demonstrated a differential risk of estrogen–receptor–positive breast cancer with darker hair-dye products that are used more often by African American women compared with Caucasian women.
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      • Understanding cosmetic product regulation could help reduce disparities
        American Journal of Obstetrics & GynecologyVol. 218Issue 2
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          Zota and Shamasunder1 discussed health concerns that are associated with certain skin-lightening creams, hair straighteners, and feminine hygiene products and their disproportionate impact on women of color.
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