Menstrual health management: Practices,challenges and human rights violations

Introduction

A person aged between 10 and 19 years is considered an adolescent in transition between child- and adulthood. ¹ This time is marked by considerable growth and development, with significant physical, psychological and biological changes. ² Menstruation is a monthly occurrence initiated during this time that persists for the 1.8 billion adolescent girls, women, transgender men and female non-binary persons for the duration of their reproductive lives. Despite the normality of this process, millions of menstruating females across the world are denied the right to manage their monthly cycles in a dignified and healthy manner. Gender inequality, discriminatory social norms, cultural and religious taboos, poverty and lack of basic services often cause menstrual health and hygiene needs to go unmet. Adolescent girls may face stigmatisation, harassment and social exclusion during menstruation. Transgender men and non-binary persons who menstruate may also face discrimination due to their gender identity that prevents them from accessing the materials and facilities that they require. ³

Menarche is an important biological milestone for a woman, as it marks the onset of the reproductive phase of her life. The average age of menarche is generally between 12 and 13 years of age. ⁴ Menstruation is, however, still a taboo topic in certain contemporary societies such as India, as it is often considered unclean, and therefore those who are menstruating are thought of as dirty, impure or the harbingers of bad luck. ⁴ , ⁵ There are over 355 million menstruating women and girls in India, but millions of women across the country still face significant barriers to a comfortable and dignified experience with the management of their menstrual hygiene. A study found that 71% of girls in India had no knowledge of menstruation before their first period. ⁴

When menstruation is mentioned, it is rarely spoken of directly but more often euphemistically. For example, in Victorian times, women used phrases such as ‘turns’, ‘monthlies’, ‘poorliness’ or ‘the curse’, and in some cultures today, this persists with phrases such as being ‘unwell’, or it being the ‘wrong time of the month’. ⁶

Menstruation, a taboo

An example of ongoing religious discrimination against menstruating women is exemplified in the following statement:

It is certain that men will be born as bullocks in their next life if they consume food cooked by menstruating women … this is written in our shastras [scriptures]. If a menstruating woman cooks food for her husband, she will definitely be born as a female dog in her next life.

These utterances were part of a sermon delivered in India by Swami Krushnaswarup Dasji. ⁷

In Indian culture, the stigma associated with menstruation may be partially derived from an ancient myth in which Indra (the mighty God of Hindu Vedas and the King of the Heavens) ⁸ is said to have killed Vishvarupa, a Brahmin (demi-god) with a thunderbolt. The sin of killing a Brahmin led to Indra’s exile from heaven. To escape from the guilt of murdering a Brahmin, he then distributed his sin, and thus a woman’s menstrual cycle is accepted as being the curse of Indra. ⁶

Taboos in contemporary India surrounding menstruation also persist in excluding women and girls from many aspects of social and cultural life, with potentially harmful implications. ⁹ Restrictions imposed on menstruating females involve limiting cooking activities, denying access to certain foods and reducing interactions with male members of their family. Restrictions on worshipping are also common across communities; for example, Muslim girls are not permitted to say namaz (daily prayers/supplication) or touch the Quran during menstruation. Similarly, Hindu girls have to abstain from performing puja (offerings/ceremonial worship) and touching pictures of the Gods. ¹⁰ , ¹¹ Thus, the occurrence of menstruation is used to deprive women of their rights to worship freely.

In certain cultures, women/girls may even have restrictions placed upon their freedom to enter their own house; in fact, in some places, the moment a girl begins to menstruate she is taken to a small ‘hut’ on the outskirts of the settlement, where she is expected to stay for five days, or she may have to sleep in a cattle shed. ¹² Such accommodation has on occasion been responsible for the death of these women/girls. For example, a 12-year-old girl in India’s southern Tamil Nadu state died in a cyclone after she was expelled to a decrepit thatched outhouse behind her home because she was menstruating. ¹³ In Nepal, a 15-year-old girl died from smoke inhalation after being isolated in a ‘menstruation hut’. The local custom called chhaupadi banishes women during their periods. Although chhaupadi was criminalised in 2017, it persists in rural areas, ¹⁴ , ¹⁵ resulting in a mother and her two sons dying of presumed carbon monoxide toxicity in another ‘menstruation hut’. Other deaths have occurred from suffocation and snake bite. ¹⁵ The initial menstrual period is also often a traumatic and very negative experience for many young girls, exacerbated by these cultural restrictions. ¹⁶

In most rural areas of India, a cloth that can be washed and used again may serve as an absorbent pad during menstruation. However, washing and drying has to be done secretly, or in a secluded area, so that it cannot be seen by others, as it is still believed that menstrual fluids may be misused for black magic. Thus, women have to wash the wrapper/cloth worn during their menses only at night when others in the household are asleep. ¹⁷

Poor menstrual hygiene in India and its effects

It appears that as few as 18% of women in India have access to appropriate sanitary materials. ¹⁸ The majority of the remaining 82% are forced to use substitutes such as unclean cloths or other even less desirable alternatives such as sand, ash, jute sacks, leaves or old newspapers. ¹⁹ Many of these women, particularly in rural areas, still do not know what a sanitary napkin is and what it is used for. ¹⁸ , ²⁰

The use of unclean rags, soil/clay or newspapers, or even grass/hay may be injurious to health, and even life-threatening, because of the ever-present risk of sepsis. ²¹ Washing and attempting to dry cloths used as pads in the dark without the presence of sunlight may also enhance bacterial overgrowth. Preventing menstruating women and girls from accessing home toilets or washing areas may also add to this problem by either depriving them of a means to clean themselves or by forcing them to walk long distances from their village to access such facilities. ¹⁵ In India, 70% of all reproductive illnesses have been attributed to poor menstrual hygiene. ²²

A lack of access to menstrual hygiene products or private and clean toilet facilities also prevents millions of girls globally from attending school each month, ²³ significantly impacting upon their education.

Menstruation makes the need for sanitation, hygiene and safe water vital for women. According to a report published by Water Aid, illnesses related to a lack of clean water, basic sanitation and hygiene were responsible for the deaths of almost 800,000 women globally in a single year, making it the fifth biggest killer of women behind heart disease, stroke, lower respiratory infections and chronic obstructive pulmonary disease. ²⁴

Menstrual hygiene, human rights and menstrual hygiene management initiatives in India

The stigmatisation of menstruation and menstrual hygiene is clearly a violation of human rights, most importantly, the right to human dignity, but also the right to non-discrimination, equality, bodily integrity, health, privacy and the right to freedom from inhumane and degrading treatment and from abuse and violence. ²⁵

The right to the enjoyment of the highest attainable standard of physical and mental health, to give it its full name, is not new. Internationally, it was first articulated in the 1946 Constitution of the World Health Organization (WHO), where the preamble defines health as ‘a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity’. ²⁶

WHO and the United Nations Children's Fund (UNICEF) Joint Monitoring Programme (JMP) for drinking water, sanitation and hygiene has proposed the following requirements for menstrual health management, that:

Women and adolescent girls are using a clean menstrual management material to absorb or collect menstrual blood, that can be changed in privacy as often as necessary for the duration of a menstrual period, using soap and water for washing the body as required, and having access to safe and convenient facilities to dispose of used menstrual management materials. They understand the basic facts linked to the menstrual cycle and how to manage it with dignity and without discomfort or fear. ²⁷

However, clearly these goals are not being met.

UNICEF has also been instrumental in providing technical guidance and support toward raising awareness, addressing behavioural change, capacity building of frontline community cadre, sensitising key stakeholders and creating WASH (water, sanitation and health) facilities including safe disposal options. ²⁸ With the Swachh Vidyalaya Campaign (SBSV, or the ‘Clean India: Clean Schools’ initiative), the Government of India launched a nationwide campaign, in 2014, to make a visible impact on children's health and hygiene through improving both their health and hygiene practices, as well as those of their families and communities. Another aim was to improve the WASH curriculum and teaching methods while promoting hygiene practices and community ownership of water and sanitation facilities within schools. As a part of the WASH Programme, every school in India must have separate toilets for boys and girls, including the provision of soap, with adequate menstrual hygiene management facilities, private spaces for changing, adequate water for cloth washing and disposal facilities for menstrual waste. ²⁹

The Ministry of Drinking Water and Sanitation has published an operational Menstrual Hygiene Management Guideline to support all adolescent girls and women. It outlines what needs to be done by state governments, district administrations, engineers and technical experts in relevant departments, and also school teachers for improved menstrual hygiene management throughout the country. The guidelines specify that every adolescent girl and woman, and their families, including men and adolescent boys, must have an awareness of, and knowledge and information about, menstruation so that it is understood and can be managed safely with confidence and dignity. In addition, every adolescent girl and woman must have access to sufficient, affordable and hygienic menstrual-absorbent products during menstruation, and every adolescent school girl must have available a separate toilet facility with private space for cleaning and washing. This includes access to an adequate and sustained water supply and soap. Every adolescent girl must also have access to disposal facilities for used menstrual-absorbent products and should be instructed in their use. ³⁰

The Ministry of Health and Family Welfare has also focused on menstrual hygiene management as a priority area in the National Health Mission, and the Scheme for Adolescent Girls (SABLA) programme of the Ministry of Women and Child Development has incorporated an awareness programme on menstrual hygiene management. ³¹ Recently, on International Women's Day in 2018, the Government of India launched 100% biodegradable sanitary napkins ‘Suvidha’ in packs of four priced at Rs.10 ($0.13USD). ³²

Various campaigns and groups across India are also working on initiating discussions and creating awareness about menstruation and menstrual hygiene, and teaching people to produce reusable sanitary napkin kits. ³³

The Supreme Court of India on menstruation

It has been stated that ‘religious freedoms’ cannot be invoked as a ‘cover’ for discriminatory sexist policies, and so the Supreme Court of India ordered an historic temple to lift its ban on women ‘of menstruating age’. ³⁴ The Court held that exclusion of women between the ages of 10 and 50 years from entering the Sabarimala temple amounted to a violation of the right to practice religion and a violation of fundamental rights. Specifically, in view of the provisions of Section 3 and the proviso to Section 4(1) of the Kerala Hindu Places of Public Worship (Authorization of Entry) Act, 1965, custom and usage must make space to fulfil the rights of all sections and classes of Hindu society to offer prayers at places of public worship. Any interpretation to the contrary would undermine the purpose of the 1965 Act and incrementally impair fundamental rights to practice religion that are guaranteed under Article 25(1); therefore, Rule 3(b) of 1965 excluding women from entering the Sabarimala temple was ultra vires the 1965 Act. In this case, religious authorities argued that the rule was a fundamental component of their belief system, in recognition of the fact that the temple’s presiding deity, Lord Ayyappa, is celibate. Some of the leaders also suggested that menstruating women were ‘impure’. Restrictions such as those put in place by the Sabarimala temple, however, ‘cannot be held as essential religious practice’. The Chief Justice of India, Dipak Misra, observed that religion is a way of life intrinsically linked to the dignity of an individual and patriarchal practices based on the exclusion of one gender in favour of another could not be allowed to infringe upon the fundamental freedom to practice and profess one's religion. ³⁴

The Supreme Court of India sets an example on menstrual waste, to install sanitary napkin incinerators (2018)

The Supreme Court of India has also allocated finances to install three sanitary napkin vending machines and three incinerators for disposing of used pads in its premises. In July 2018, the University Grants Commission (UGC) had also urged several higher educational institutes to install sanitary napkin incinerators in women’s hostels to ensure proper disposal of menstrual waste. ³⁵

Conclusion

Menstruation remains a taboo topic markedly affected by cultural norms, parental, societal and religious influences, personal preferences, economic status and socioeconomic pressures. ³⁶ Lack of privacy is an issue at home, in the community and in schools; ignorance, misconceptions, unsafe practices, illiteracy and lack of knowledge on the part of mothers and children regarding menstruation are the major causes of ongoing problems.

Recommendations

Menstrual hygiene should be promoted by implementing courses on menstruation and menstrual hygiene management in schools and colleges.