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

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

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

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

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

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

Constructing a Model of Body Shame and Sexuality

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

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