The Path to Menstrual Health
The word hygiene is often understood to mean cleanliness, but its roots were more similar to health. And while cleanliness is definitely part of the road to health, there is much more to it. It is essential, then, to consider this when we talk about menstruation. In a world where menstruation is shrouded in stigma and women's health remains relatively poorly understood, it is important to view the problem in its entirety. On this World Menstrual Hygiene Day, let's talk about menstrual health.
Despite being a physiological process, there is a wide range of issues associated with menstruation. Even without a disease, menstruation takes a heavy toll on the lives of women. Symptoms can range from heavy menstrual bleeding to painful periods. In fact, heavy bleeding is a leading cause of anaemia in menstruators. According to NFHS-5 data, 57% of women between the ages of 15 and 49 are anaemic.
Painful periods (also known as dysmenorrhea) is another common concern. Although many cases do not have an identifiable cause, and there are several reports of misdiagnosis and undertreatment, dysmenorrhea can point to underlying conditions such as endometriosis where the uterine tissue (that is supposed to be shed every month) is present outside the uterus. Commonly it may cause pain during urination, bowel movements or intercourse.
A systematic review analysing 25 studies from India found that 43% of menstruators experience premenstrual syndrome (PMS). Premenstrual disturbances can range from mood issues such as anxiety, irritability and depression to physical symptoms such as bloating, breast tenderness and headaches. The same study estimates that 8% of menstruators experience premenstrual dysphoric disorder (PMDD), which is a more severe form of PMS. Premenstrual disturbances can negatively impact work and education. These are a small glimpse into the difficulties surrounding menstruation, yet most large-scale efforts are unable to address the diverse difficulties menstruators face.
The Supreme Court of India, in April 2023, said that there should be a “uniform national policy” to ensure that menstrual hygiene products, along with separate washrooms for girls, are available in every school. Unsurprisingly, the Draft Menstrual Hygiene Policy (September 2023), which was released by the Government of India, focuses on menstrual hygiene management centring school-going girls. In its current form, the policy does not address the large gamut of menstrual disorders and the entire range of conditions associated with menstruation.
This draft document is progressive in its own right with gender-neutral language and attempts to focus on positive health. However, despite the draft menstrual hygiene policy vision saying that “all women, girls, and people who menstruate” should be able to experience menstruation in a safe and healthy manner, it excludes several sections. Older women especially those nearing menopause, queer people, sex workers and even adolescents who are not in school are barely addressed and likely to fall through the gaps. Even with the limited goal of ensuring menstrual hygiene management, these groups are not included.
This approach focusing on menstrual products is in a country that reels from far more deep-seated issues. Within the last one year or so, we have witnessed the murder of a young girl because her elder brother (apart from having highly misogynistic ideas) didn't understand menstruation. We have also seen a young girl die by suicide even as she struggled to come to terms with the difficulties associated with menstruation. How far can an adolescent’s knowledge of hygienic menstrual practices counter this stigma? There is an equal need for evidence-based awareness campaigns among men, boys, parents, older women and religious leaders, if we are to tackle the discrimination and stigma associated with menstruation in India.
Menstrual health is essential for gender parity; however, it is also true that gender parity is essential for the maintenance of menstrual health. Lack of adequate support at the workplace can cause more limitations than menstruation itself. Lack of access to water, sanitation and hygiene (WASH) facilities and reasonably timed shifts are challenges, especially for workers in the informal sector. Media reports showed roughly 4,605 women underwent a hysterectomy (removal of the uterus) over the last three years in the Beed district of Maharashtra. The majority of them are sugarcane cutters who work long hours under harsh conditions without access to WASH facilities. Many were also punished with fines for taking a day off from work. Another demand of people who menstruate has been menstrual leave. While the policy emphasises that “flexible working arrangements” like work from home and menstrual leave are recommended by the policy, there has barely been any active uptake of this by government or private organisations. Thus gender sensitivity at the workplace is essential for ensuring menstrual health.
Along with the disproportionate focus on menstrual hygiene products, there is increasing emphasis on the promotion of “sustainable” menstrual products. The idea may be noble and reducing menstrual waste would be ideal but is it fair to place the burden of mitigating climate change on an underprivileged menstruator?
Even as menstrual cups are introduced in several pilots, we know that access to water remains difficult. Several workplaces are not conducive to switching to newer menstrual hygiene products. Additionally, the stigma attached to the insertion of a hygiene product makes it difficult to bring about voluntary change. Archaic ideas of virginity and the conditioning surrounding it are attempted to be countered by the knowledge of menstrual products.
Menstrual health is thus a layered issue. Menstrual health is affected not only by physiological factors but also by psychological and social context. Improving access to period products for five days in the cycle is but a small step. The World Health Organisation in its 2022 statement called for a shift towards a rights-based, complete life course approach, from menarche to menopause. As we await the final Menstrual Hygiene Policy for India, we hope that this “hygiene” in this policy will come to mean the entire set of conditions required for ensuring health.
Dr Shivangi Shankar is a public health researcher and medical doctor. Her work and interest areas include climate change and health, mental health, nutrition, health rights, queer health, health systems and adolescent health. She hopes to make health systems more equitable through practice, advocacy and research. X: @doctorandall, Instagram: @doctor.and.all
Dr Soumya Thomas is a medical doctor interested in adolescent sexual and reproductive health, rural primary healthcare and the scope of medical education. X: @SoumyaTho
Vaishnavi Mangal is a public health and health policy researcher. Her primary areas of research are community-level healthcare workers and digital health and health policies. Currently she is a Doctoral Candidate at the Norwegian University of Science and Technology, Norway. X: @MVaish06; Instagram: @mvaish06
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