Two weeks ago, we celebrated International Women’s Day. While there  should be no time-stamp on such celebrations, a specific day does  provide an opportunity for focus, for female issues to be raised and  discussed by experts and non-experts alike. At the United Nations office  in Geneva, the Water Supply and Sanitation Collaborative Council  (WSSCC) raised one such issue: menstrual hygiene.

Experts from the WSSCC, a multi-partnership organization hosted by the United Nations Office for Project Services (UNOPS), had previously reported  in February that over 300 million Indian women lack access to sanitary  menstruation products. The limited access is directly linked to taboos  surrounding menstruation. Menstruating women are stigmatized as unclean  and expected to manage menstruation in isolation. Not only are women  taught to feel shame with menstruation, but some are also forced to rely  on unsanitary materials like old rags, husks, and even ash or sand.  Furthermore, adolescents undergoing first menstruation are wholly  unprepared physically and psychologically. At a 2012 carnival hosted by  the WSSCC in five Indian states, ninety percent of the females  interviewed did not know what a period was before they started  menstruating.

For International Women’s Day, the WSSCC hosted a special seminar,  ‘Celebrating Womanhood’, at the UN headquarters, addressing how poor  menstrual hygiene affects health, work, and education. The  representative from the WSSCC, Archana Patkar, explained, “The lack of  information coupled with the stigma and the shame, is leading to very  poor hygiene — not enough washing, using materials way too long without  changing — also because there are no spaces to change, and the result of  that is really a whole string of infections”.

That women have differing views of menstruation is unsurprising;  strong personal, cultural, and societal views are associated with  menstruation throughout the world. What is surprising, though, is the  severe lack of accurate views of menstruation, of the process  itself and of the hygienic care that should be applied. Menstruation  taboos limit women’s access to these accurate views and to appropriate  resources for hygienic care. Estimates from the WSSCC suggest that such  menstruation-related taboos affect up to one-third of the world’s  population.

NOT-SO-SHOCKING NEWS

In the academic literature, this is by no means new news. Fear in  response to menstruation, as the WSSCC reported, was also the primary  reaction to menarche in a 1996 study in Indian adolescent females. None of the girls interviewed from Jammu, India in a 2004 study could give a scientific explanation for menarche, and menstruation knowledge among Taiwanese adolescents is also inaccurate. Menarcheal knowledge has also been found to be limited for Australian girls, many of whom believe incorrect, negative myths, and feel embarrassment and discomfort in response to this topic.

Such negative reactions are associated with lack of preparation for  menarche, and poor preparation equates to poor hygienic practices. One study  found that 98% of the girls surveyed from the Gujjar tribe of India  observe no bathing during menstruation and 87.5% reuse previously used  cloths for absorption. Without accurate knowledge about menstrual  hygiene, the girls adhere only to cultural practices and taboos. In  fact, bathing restrictions represent just one example of an entire range  of menstrual taboos worldwide. From dietary restrictions (including  milk, potatoes, meat or rice) to activity restrictions (including  visiting the temple or mosque, cooking, being near open water, or  changing one’s clothes) to the physical ostracisation of menstruating  females, menstruation taboos reflect an array of cultural and religious  rules and regulations. The academic literature on menstruation is  littered with evidence of these taboos, and has been for decades.

Indeed, the WSSCC reference to the ‘silence’ surrounding menstruation  in India, which only serves to perpetuate taboos, is not a new  observation. A 2001 study  found that menarche occurs within a ‘culture of silence’ in Delhi, with  many young women unaware that it will happen to them. Evidently, the  silence surrounding menstruation has remained, despite its  acknowledgement in academia. The information has been available, but  it’s stale; no one has done anything with it.

HOW DO WE BREAK THE SILENCE?

In their last tweet from coverage on the UN seminar, WSSCC called to  ‘Break the silence’. Through the International Women’s Day platform for  experts and non-experts to engage in female issues, the breaking of  silence has already commenced. The subsequent flurry of Twitter users  applying #MHM (for menstrual hygiene management) is evidence of a gap  bridged between what the experts know and what the non-experts now know.

But how do we continue breaking the silence? We’ve engaged in the  first step of recognizing the problem (and indeed, even sharing this  post is part of that engagement), but the next step is the most  important: applying solutions.

With adolescents altogether unaware of menarche, unprepared for  menarche, or adhering to unhygienic (and thereby unhealthy) taboos,  critical health information is obviously lacking. But any preparatory  information given to adolescents must balance medical perspectives with  cultural perspectives.

What information will be given then, and by whom? The WSSCC provided a  public health initiative through their carnival event, but this was a  one-off. Similarly, the UN seminar was a solitary event; experts met  only briefly and already the Twitter activity with reference to the  WSSCC’s #MHM has drastically reduced.

From school nurses to family doctors to public health workers, the  healthcare providers, not the academics or the experts or the  policy-makers, are those who have direct contact with adolescent girls.  As such, these healthcare providers need to be targeted directly.  Moreover, healthcare providers need to be supplied with a practical,  sensitive tool for disseminating menstrual hygiene information, such as  the method of ‘cultural competence’ presented by Campinha-Bacote.  Her proposal disseminates healthcare information in  culturally-sensitive ways, utilizing an ongoing process that allows the  healthcare provider to work within varying cultural contexts.

This model would allow for a synthesis of different sources of  menstrual information — including physiological, practical, and social —  and for the effective communication of this synthesis within  individual, familial, and communal contexts. Importantly, the inclusion  of these contexts necessarily engages parents and peers, key sources of  information and attitudes regarding menstruation. For instance,  Taiwanese boys in the study referenced earlier have more negative  outlooks on menstruation than girls. Any gain in positive, accurate  understandings of menstruation for girls could be undermined by the  exclusion of peers or parents from the healthcare discussions.

THEN LET’S MAKE NOISE

The ‘cultural competence’ model may seem to burden only the  healthcare provider with the task of disseminating information. However,  the healthcare provider must work within a supportive system. The  management of MHM should involve a coordinated activity, a multi-layered  approach enlisting the participation of governmental and  non-governmental organizations alike. While the healthcare provider may  offer preparatory information, the provisioning of resources for  hygienic care and the monitoring of accurate hygiene information need to  involve governmental and non-governmental initiatives.

Indeed, healthcare providers are not always accessible. For those  living in rural, impoverished, or underdeveloped areas, contact with  healthcare providers may be extremely limited. In these cases, the role  of health intervention through aid organizations is of utmost  importance. Of course, it should be noted that the long-term, ideal goal  is to wean away from outside aid to the point at which a  self-sustaining healthcare infrastructure is established. That is why  the WSSCC has pushed for menstrual hygiene to be considered a  development issue. The Council has lobbied for the inclusion of  menstrual hygiene management in the UN’s Sustainable Development Goals, succeeding the Millennium Development Goals.

We, the non-experts, the non-healthcare providers, the non-UN  representatives, also have the opportunity to keep menstrual hygiene an  ongoing action item. We just need to make some noise. The WSSCC  International Women’s Day seminar created some attention, but we need to  keep talking about this subject and maintain a feedback loop between  the experts and non-experts. While we may not do the physical groundwork of MHM, we can enable  the groundwork to be laid by targeting healthcare policy-makers and  officials and encouraging them to make this a priority. A lack of  response to the silence we now know exists would only serve to  perpetuate that very silence.

It should also be noted that there may exist a different breed of  silence in societies without strict menstrual taboos. With an  established trend in decreased ages of menarche in the United States and  Europe, the issue of when information should be given must be  raised. If menstruation is not discussed early enough, then earlier  maturing girls may be unprepared psychologically and physically.  Therefore, even in societies where the silence is broken by sufficient  educational programs, the silence may remain for the earliest maturing  girls. While the programs may be set up to match ages at which the  majority of girls start menstruation, the issue of when to prepare the  earliest maturers (which may represent certain cohorts of ethnicity or  obesity) is less straightforward and unresolved.

When information should be given in instances of unhygienic  practices, however, is much more straightforward: as soon as possible.  The issue of unhygienic practices must no longer be ignored or confined  to academic journals. Let’s spread the issue and break the silence.