The article draws attention to sexualized aspects of menstruation and argues that looking at MHM through sexuality lens can provide new ways of understanding menstrual-related issues, and thus have the significant contribution for women’s and girl’s empowerment.
There is a widely held view that a poor Menstrual Hygiene Management (MHM) directly and indirectly is acting as a barrier to girls’ and women’s empowerment through an insidious impact on their ability to engage in education, paid work, and any form of social and cultural activities (Jewitt and Ryley.2014: 139; Mahon and Fernandez. 2010: 103). However, until very recently, MHM has been routinely overlooked within the water, sanitation, and hygiene (WASH) sector. The strong global movement efforts to close a gender gap in education drove the initial formulation of MHM as a public problem (Sommer and Sahin. 2013: 1558; Sommer et al. 2015: 1303).
Indeed, the World Health Organisation (WHO) and United Nations Children’s Fund (UNICEF) produced an extensive review for the purposes of informing post-2015 WASH targets, where MHM is one the topics of concern. The proposed MHM interventions basically rely on three domains: provision of sanitary pads, menstrual hygiene education and awareness, and single-gender sanitation facilities (WHO/UNICEF.2014:8-10). In other words, MHM is considered as a hygiene and health problem. Thus, hygiene education combined with delivery and provision of these sanitation implements, it is thought to be the best solution to overcome all menstrual-related problems in the Global South, and hereby have the far-reaching impact on girl’s and women’s empowerment.
Presenting the menstruation as a hygiene crisis leaves behind the context of social and sexual relationships in which women function and live. Women may be exchanged in marriage between families after their first menstruation, restricted in their mobility during menstruation, resorted to transnational sex in order to purchase ‘safe’ sanitary products or face various types of abuse and harassment from men when they detect that girls have reached menarche. As Dolan et al. (2014) point out, ‘menstruation does not operate in the vacuum’ and is affected by various cultural and religious processes, including gender a generational power structure (p.654). Thus, if we are to tackle menstrual-related issues in the Global South more comprehensive and strategic approach is needed.
Poor MHM in the Global South: Assessing the Impact
Poor menstruation hygiene combined with socio-cultural beliefs and taboos poses practical and psychological restrictions on girls’ and women’s mobility hereby excludes them from various aspects of social and cultural life. However, one major concern is the impact of cultural and religious practices and lack of services for MHM on girls’ access to education (Jewitt and Ryley.2014: 139; Mahon and u Fernandez. 2010: 103).
The intersection between school absenteeism for post-pubescent school girls and the poor MHM has not been definitively demonstrated with quantitative research, yet according to a review by Sumpter & Torondel, numerous qualitative studies identify a lack of MHM as a one of the major causes of school absenteeism (2013). For instance, the United Nations Children’s Fund (UNICEF) estimates that about one in ten school-age African girl didn’t attend school with the onset of puberty because the toilet facilities are not clean or do not provide privacy to girls while they are menstruating (2014: 15). In general, poor toilet and sanitation facilities in the whole Global South are considered as one of the key reasons for girls’ school absenteeism, eventually leading them to the permanent drop-out of school (Tearfund.2009: no page; House et al.2012:22). Another research study conducted in Ghana found that young adolescent girls were missing school up to five days each month due to inappropriate sanitary pads and cramping (Scott at al. 2009: 2). Indeed, due to lack of adequate sanitary facilities and menstrual products many girls prefer to stay at home during menstruation rather than confront managing menses in school and risking to face embarrassment of a menstrual ‘‘leak’’ (Sommer. 2010: 522, on Tanzania; Tegegne and Sisay.2014: 13, on Ethiopia; McMahon et al. 2011: 8, on Kenya).
In traditional and more conservative communities menstruation is still a taboo subject and is consequently ignored not only in schools but also in families. According to Malusu and Zani (2014), in the traditional African societies menstruation is often linked to sex and sexuality, therefore, is considered as a private issue about which is strictly forbidden to talk (p.94). Not being able to talk about menstrual experience and having poor menstrual education awareness means that menstruation often becomes ‘something shameful and something to hide’ (Kirk and Sommer. 2006:2). Moreover, a lack of menstrual awareness and information cause negative perceptions associated with menstruation which often continues into adulthood and perpetuates the cycle of gender exclusion and disempowerment (Dolan et al.2014:654).
For women, in general, menstruation often means being unable to leave home or participate in normal community life or even paid work (Chant and McIlwaine. 2016: 106). For instance, a study conducted in Bangladesh concluded that 73% of women factory workers missing work for an average of six days a month due to menstrually related infections which were a result of inappropriate and unhygienic sanitary towels (Aidara et al. 2013:18). Another study conducted in Lebanon revealed that one out of five women during their menstruation do not engage in social and cultural activities due to the negative cultural perceptions towards menstruation (Santina et al. 2013: 84). As a whole, women during their period are frequently restricted from any form of community activity and have to avoid contact with men because bodily excretions such as blood is considered to be ‘dirty’ and ‘impure’(Crots.2012: 3).
It is of note that cultural, religious and traditional beliefs lead to a range of restrictions and unwritten social rules being placed on women and girls during their menstruation not only in the public realm but also in a domestic and religious setting. For example, In India menstruation is considered a polluting factor among Hindus traditions, therefore, menstruating women and girls are not allowed to use water sources and are even obliged to refrain from using a household toilet (House et al.2012: 29; Shukla. 2005: 5). In fact, in many traditional societies menstruation is associated with ‘dirtiness’, ‘pollution’, yet exclusion from everyday tasks such as cooking, cleaning, attending religious ceremonies, socializing, or sleeping in one’s own home or bed are considered as an appropriate social norm (Sumpter and Tolender.2013:2).
Poor MHM combined with cultural and religious beliefs, directly and indirectly, restrict girls’ mobility and broader access to social capital resources such education, paid work or any form of social and cultural life. Moreover, stereotypes and cultural hunts surrounded menstruation create a negative image of menstruation and women’s body itself that forces women to keep their periods hidden and silenced. It not only devalues women’s self-esteem but also shapes how women relate to other situations in their lives involving their marriage, sex, pregnancy, self-realization in work and other socio-cultural activities (Roberts et al. 2002: 137-138; McMahon et al. 2011: 10; Joshi et al.2015: 54).
A sexualized menstruation
Socio-cultural beliefs and attitudes not only make discussion of menstruation almost impossible, but also shape its meaning and management. In many cultures, menarche is considered as a signal of reproductive capacity and adulthood that immediately brings with it new rules, restrictions and expectations (Patkar.2001: 2). Unsurprisingly, the onset of menstruation frequently leads to forced marriages, unexpected pregnancy, sexual violence and exploitation. In general, in the patriarchal societies women’s inferiority is characterized by what separates them from men. Menstruation therefore becomes an insignia of women’s inferiority and the basis of sexual discrimination (Malusu and Zani.2014:84, 87). Discrimination on the basis of sexuality obstructs women’s and girl’s human/sexual rights such the right to have control over their bodies, safe and satisfying sex, when and who to marry, have children or not. A lack of sexual rights produce a whole host of poverty-related outcomes, from physical insecurity to social, political and economic exclusion. Thus, denial of sexual rights and sexuality is a crosscutting issue that lies at the heart of women’s empowerment (Hawkins et al. 2011: 1-2; Rodenborg. 2008: 6-8).
MHM & Empowerment: An Intimate Connection
The term ‘women’s empowerment’ is often used in development context, yet it is a ‘fuzzy’ concept which is rarely defined. In fact, it is a ‘transformative’ term which frequently carries multiple meanings and implications (Eyben and Moore: 2009: 285, 288; Oxaal and Baden.1997:1).
Gender equality and women’s empowerment is the third of the eight Millennium Development Goal (MDG), increasing women’s access to education, paid work and women’s political representation in national parliaments are considered essential elements towards the achievement of this goal. There is a tendency to assume that each of these resources strengthens women’s agency therefore allows them to make strategic life choices that have a potential to bring positive changes in their lives. To put it briefly, women’s empowerment is a process of change, which refers to the female’s ability to make strategic life choices in a context where this ability was previously denied of them. It implies not only actively exercising choice, but also doing this in ways that challenge power relations. (Kabeer.1999:437; Kabber.2005:13-14, 22 ).
As discussed above, poor MHM combined with cultural and religious beliefs restrict girls’ mobility and broader access to social capital resources such education, paid work or any form of social and cultural life. Thus, it obviously weakens women’s agency and limits their ability to make strategic life choices that could challenge deeply embedded (patriarchal) power relations and consequently bring positive changes in their lives. For example, gender socialization in most conservative societies, tend to be patriarchal. This deeply embedded patriarchal power relation eliminates women from decision-making process. Inability to engage in decision-making not only weakens women’s capacity to have control over their lives, but it also means that women’s needs- for instance, MHM- are not met because they do not directly affect males.(Mahon and Fernandez.2010: 99,101-102; Malusu and Zani. 2014:84;). Thus, one the one hand lack of support for MHM weakens women’s ’s agency therefore is acting as a barrier to women’s empowerment, on the other hand a ‘disempowered women’ do not have capacity to engage in decision-making, consequently women’s needs like MHM is unlikely to be met. Fallowing this, the relationship between MHM and women’s empowerment is closely intertwined.
Sexuality is a neglected issue in development
Sexuality, in general, is a missing and neglected dimension in development policy and practice. Indeed, among development practitioners has been a widely held view that sexuality is a private matter from which development policy must keep its distance (Cornwall.2008: 5). According to the World Health Organization’s (WHO) definition sexuality is ‘ is a central aspect of being human throughout life and encompasses sex, gender identities and roles, sexual orientation, eroticism, pleasure, intimacy and reproduction. ‘Sexuality is experienced and expressed in thoughts, fantasies, desires, beliefs, attitudes, values, behaviours, practices, roles and relationships. While sexuality can include all of these dimensions, not all of them are always experienced or expressed. Sexuality is influenced by the interaction of biological, psychological, social, economic, political, cultural, ethical, legal, historical, religious and spiritual factors’ (WHO, cited in Roderborg.2008:5).
Thus, sexuality is influenced by the interaction of economic, political, cultural, religious and social norms, yet it is an intensely public and political concern (Hawkins et al. 2011:10). Indeed, across cultures, societies and historical periods, the state, religious authorities and other social institutions have sought to regulate sexuality and sexual expression. Not fitting into these ‘norms’ of sex and sexuality often leads different forms of oppression from sexual harassment and sexual violence to social, political and economic exclusion. Hence, The issues concerning sexuality arise in almost every area of development work such education, employment, political participation, women’s empowerment and etc. Unfortunately, rarely has development work sexuality has been taken on the more comprehensive approach, and rarely has it been addressed in other sectors. When it is addressed, only in relation to physical health and disease prevention, and less on sexual health and rights (Runeborg.2008:3-5). In general, sex has been regarded as a source of disease, danger and harm. In this context, women are thought to be fearful or shamed about sex or their sexuality. From this perspective, women are portrayed as inferior to men or victims of all sexual encounters, and incapable to realize their sexual rights. Not being able to realize sexual rights affects women’s well-being and ultimately undermines political, social and economic empowerment that leads to social exclusion and marginalization (Cornwall. 2006:273-275; Hawkins et al.2011:1).
Thus, sexuality is not just about sex and sexual pleasure, on the contrary, is closely intertwined with core development concerns of poverty and marginalization (Cornwall.2008: 5-20). Disclaiming of sexual rights is a cause of poverty and poverty obstructs sexual rights. Sexuality matters because without basic sexual rights to have control over our own bodies and over fundamental life choices, many other rights become simply unobtainable (Rodenborg.2008:7).
read more Women Economic Empowerment and Care Work
MHM interventions in the post-2015 WASH agenda
As sexuality is a rarely addressed issue in development policy and practice this is also the case of MHM initiatives which leave behind sexualized aspects of menstruation.
The World Health Organisation (WHO) and United Nations Children’s Fund (UNICEF) produced an extensive review for the purposes of informing post-2015 WASH targets, where MHM is one the topics of concern. The solutions they propose for the MHM basically rely on three domains: distributing or promoting use of sanitary pads, providing hygiene education, and ensuring adequate sanitation facilities (WHO/UNICEF.2014:8-10). In other words, MHM is primarily considered as a hygiene and health problem.
The developmental notion of MHM is clear; MHM is a hygiene and health problem, therefore, focusing on teaching girls and women discreetly and effectively manage their menstruation, it is thought to be the best solution to all associated problems with menstruation (Sommer et al. 2015: 1303; Dutt.2015: 1159).
Indeed, there is a general agreement, despite some controversy, that the distribution and promotion of sanitary pads, combined with health education can successfully increase girls’ school attendance rate and lead to the greater women’s spatial mobility (Jewit and Ryley. 2014, on Kenya; Dolan et al.2014, on Ghana, Tegegne and Sisey. 2014, On Ethiopia). For example, Scott et al. (2009) study conducted in Ghana found that the provision of sanitary towels in tandem with menstrual hygiene education dropped down girls’ school absence rate by more than half. Montgomery et al. (2012) study concluded that provision of both pads and education resulted in a 9 per cent increase of school attendance after five months. With respect to adequate sanitation and bathing facilities, it is plausible to assume that safe, private, and single-gender sanitation facilities can help alleviate the burden girls and women face during menstruation, and in turn, lead to the greater women’s spatial mobility (including to reduce girl’s school absence), whereas there is no conclusive research that can prove this linkage (Sumpter and Torondel.2013: 14).
Sanitary pads, hygiene education, and adequate sanitation facilities have a positive impact on women’s and girl’s health, address some of the practical and emotional problems reducing girl’s absenteeism, minimize their risk of shame and embarrassment from the chance of spotting or smell, and help to face other challenges such discomfort, or difficulty concentrating (Jewitt and Ryley.2014:145). However, the medicalized notion of MHM cannot address wider challenges associated with sexualized notion of menstruation such negative perception of women’s bodies as ‘dirty’, ‘leaky’ and ‘polluting’, forced marriages, unexpected pregnancy, sexual harassment, exploitation and other forms of violence. Most importantly,
such perceptions and practices segregate and isolate women, deny their ability to realize sexual rights and have control over their bodies. Being unable to realize basic sexual rights, undermines women’s well-being and their ability to challenge gendered power relations and inequalities in access to social capital resources (Jewitt and Ryley.2014: 146). Looking at the menstruation as a hygiene crisis leaves behind the context of social and sexual relationships in which women function and live. As Dolan et al. (2014) point out, ‘menstruation does not operate in the vacuum’ and is affected by various cultural and religious processes, including gender a generational power structures (p.654).
Towards successful MHM
If we are to tackle all menstrual-related issues in the Global South more comprehensive and strategic approach is needed. I argue that in the current context of MHM, the combination of sanitation and hygiene initiatives with sexual health and sexual education interventions, may be seen as the best possible solution.
A good illustration of this is the US based Packard Foundation supported Regional Initiative for Safe Sexual Health by Today’s Adolescents (RISHTA) project implemented in Jharkhand state of Eastern India. In this project girls are not only educated about menstrual hygiene practices but also about sexual health and sex-related issues. Nevertheless, the important aspect of this project is that it targets both girls and boys by creating informed awareness about their physical and psychological changes as well as opening up discussions about gender roles, love, sex and sexuality (Roy. 2014: no page). This approach acts threefold: firstly, it can help to demolish the negative perceptions of menstruation and female’s body; secondly, it encourages girls to take their own decisions in making sexual choices; and thirdly, it forges a positive and pleasure-based approach to sex and sexuality. The latter is particularly important, because it challenges discrimination and different forms of oppression on the basis of sexuality. It also promotes a more liberating discourse of sexuality, when women are thought not to be fearful or shamed about sex or their sexuality. From this perspective, women are not portrayed as inferior to men or victims of all sexual encounters, instead they have control over their bodies, are able to assert their right to protection from sexual harassment and abuse, realize sexual rights such as the right to, when and who to marry, have children or not or safe and satisfying sex life (Cornwall. 2006:273-275).
This example shows that looking at MHM through sexuality lens provide new ways of understanding menstrual-related issues and also adds something very valuable to our efforts to promote women’s and girl’s empowerment. As it was shown above, discrimination on the basis of menarche/sexuality leads to different forms of oppression from sexual harassment and sexual violence to social, political and economic exclusion that ultimately undermines women’s and girl’s empowerment. (Hawkins et al. 2011: 1-2; Rodenborg. 2008: 6-8). Thus, including the sexualized aspects of menstruation in MHM interventions can be seen as the best possible solution.
writer Elvita Mertins Doctoral Candidate, University of Bern
Aidara R,. et al. (2013) We Can’t Wait. A report on sanitation and hygiene for women and girls (London: Unilever Domestos, WaterAid and the Water Supply &Sanitation Collaborative Council (WSSCC) Available online at http://worldtoilet.org/documents/WecantWait.pdf (Accessed on 15 October 2015).
Chant, S, and McIlwaine, C. (2016) Cities, Slums and Gender in the Global South: An Anatomy of a Feminised Urban Future (Routledge, London).
Cornwall A. (2006) ‘Development’s Marginalisation of Sexuality: report of an IDS workshop’, Gender and Development 14.2 Available online at www.ids.ac.uk/download.cfm?downloadfile=945C472E-5056-8171- 7BBE29776F220ECE& typename=dmFile&fieldname=filename (Accessed on 18 December 2015).
Cornwall, A., Correa, S. and Jolly, S. (eds) (2008) Development with a body: sexuality, human rights and development (Zed Books, London).
Crotfs, T., (2012) Menstruation hygiene management for schoolgirls in low-income countries, Water, Engineering and Development Centre, Factsheet pp 1-7. Available online at http://wedc.lboro.ac.uk/resources/factsheets/FS007_MHM_A4_Pages.pdf (Accessed on 28 November 2015).
Dolan, C.S., Ryus, CR; Dopson, S; Montgomery, P. and Scott, L (2014) A Blind Spot in Girls’ Education: Menarche and its Webs of Exclusion in Ghana, Journal of International Development, 26, 643–57.
Dutt. K.,L. (2015) Medicalising menstruation: a feminist critique of the political economy of menstrual hygiene management in South Asia, Gender, Place & Culture, 22:8, 1158-1176.
Eyben, R., and Napier-Moore, R. (2009) Choosing Words with Care? Shifting meanings of women’s empowerment in international development, Third World Quarterly, 30:2, 285-30. House S; Mahon, T and Cavill, S (2012) Menstrual Hygiene Matters – A Resource for Improving Menstrual Hygiene around the World (London: WaterAid).
Jewitt, S and Ryley, H (2014) ”It’s a Girl Thing”: Menstruation, School Attendance, Spatial Mobility and Wider Gender Inequalities in Kenya, Geoforum, 56, 137–47.
Joshi, D., Buit, G.,Gonzalez-Botero, D. (2015) Menstrual hygiene management: education and empowerment for girls? Waterlines Vol. 34 No. 1, 51-67.
Kabeer, Naila (1999) Resources, agency, achievements: reflections on the measurement of women’s empowerment. Development and Change, 30:3, 536-464.
Kabeer, Naila (2005): Gender equality and women’s empowerment: A critical analysis of the third millennium development goal 1, Gender & Development, 13:1, 13-24.
Kirk, J., Sommer, M., 2006. Menstruation and Body Awareness: Linking Girls’ Health with Girls’ Education. Royal Tropical Institute (KIT), Special on Gender and Health 1–22.
Mahon, T. and Fernandes, M. (2010) Menstrual Hygiene in South Asia: a Neglected Issue for WASH (Water, Sanitation and Hygiene) Programmes, Gender and Development, 18:1, 99-113.
Malusu, L.N. and Zani A.P (2014) An Evaluation of the Perception of Secondary School Students towards Menstruation in Kenya. African Journal of Education and Technology. Vol. 4 No 1, 83-96.
McMahon, S., Winch, P., Caruso, B., Obure, A., Ogutu, E., Ochari, I., Rheingans, R., 2011. ‘The girl with her period is the one to hang her head’. Reflections on menstrual management among schoolgirls in rural Kenya. Biomedicalcentral 11, 1–10.
Montgomery, P., Ryus, C.R., Dolan, C.S., Dopson, S. and Scott, L.M. (2012) ‘Sanitary pad interventions for girls’ education in Ghana: a pilot study’, Plos One. Available online at A<http://dx.doi.org/10.1371/ journal.pone.0048274> (Accessed on 8 January 2016).
Oxaal, Z., and Baden, Z. (1997) Gender and empowerment: definitions, approaches and
implications for policy. BRIDGE (development – gender) Institute of Development Studies.
Report No 40 pp 1-35 Available online at
http://www.bridge.ids.ac.uk/sites/bridge.ids.ac.uk/files/reports/re40c.pdf (Accessed on 5
Patkar, A. (2011) Preparatory Input on MHM for End Group, WSSCC. Pp. 1-7. Available online at http://bestcommunionideas.com/en/menstrual-hygiene-management-wsscc/ (Accessed on 28 November 2016)
Roberts, T. A., Goldenberg, J.L., Power, C., Pyszczynski, T. (2002) ‘Femine Protection’: The Effects of Menstruation on Attitudes towards Women. Psychology of Women Quarterly, 26, 131–139.
Roy, S. (2014) ‘Growing up with Rishta’. Civil Society 12: 2 Available online at http://www.civilsocietyonline.com/pages/Details.aspx?625 (Accessed on 15 January 2016).
Santina, T., Wehbe, N., Ziade, F.M., Nehme, M. (2013) Assessment of Beliefs and Practices Relating to Menstrual Hygiene of Adolescent Girls in Lebanon. International Journal of Health Sciences & Research Vol.3; Issue: 12, 75-88.
Scott, L., Dopson, S., Montgomery, P., Dolan, C. and Ryus, C. (2009) Impact of Providing Sanitary Pads To Poor Girls in Africa. Working Paper. SAID Business School, University of Oxford.
Shukla, S. (2005). Working on menstruation with girls in Mumbai, India: Vacha Women’s Resource Centre. EQUALS, (15) p. 5 Available online at http://k1.ioe.ac.uk/schools/efps/GenderEducDev/Equals%20Issue%20No.%2015.pdf (Accessed on 18 December 2015).
Sommer, M., 2010. Where the education system and women’s bodies collide: the social and health impact of girls’ experiences of menstruation and schooling in Tanzania. J. Adolescence 33 (4), 521–529.
Sommer, M., Hirsch, J. S., Parker, R.G. (2015) Comfortably, Safely, and without Shame: Defining Menstrual Hygiene Management as a Public Health Issue. American Journal of Public Health. Vol 105, No. 7, 1302- 1311.
Sommer, M., Sahin, M. (2013) Advancing the Global Agenda for Menstrual Hygiene Management for Schoolgirls. American Journal of Public Health. Vol 103, No. 9, 1556-1559. Sumpter, C. & Torondel, B. (2013). A Systematic Review of the Health and Social Effects of Menstrual Hygiene Management. PLoS ONE, 8, 1-14.
Tearfund (2009), Gender and Sanitation: Breaking Taboos, Improving Lives’, Tearfund,
Teddington. Available online at
Gender%20and%20Sanitation.pdf (Accessed on 10 January 2016).
Tegegne, T. & Sisay, M. (2014). Menstrual hygiene management and school absenteeism among female adolescent students in Northeast Ethiopia. BM Public Health 14. Available online at http://www.biomedcentral.com/1471-2458/14/1118 (Accessed on 18 December 2015).
United Nations Educational, Scientific and Cultural Organization (UNESCO). 2014. Puberty, Education and Menstrual Hygiene Management. Booklet 9 Availabe online at http://unesdoc.unesco.org/images/0022/002267/226792e.pdf (Accessed on 6 January 2016).
WHO/UNICEF. (2014) WASH POST-2015: proposed targets and indicators for drinking-water, sanitation and hygiene. Joint Monitoring Programme (JMP) for Water Supply and Sanitation. Available online at http://wsp.org/sites/wsp.org/files/publications/Post-2015-WASH-Targets-Factsheet.pdf (Accessed on 13 January 2016)