The new ‘Menstrual Health’ definition has paved a way that could redefine the ecosystem

Written by: Sakshi Srivastava & Dilip Pattubala

Authors’ special note:- Throughout this article, W.A.G.T.A. (Women, adolescent girls, trans, AFAB (assigned/observed female at birth) refers to the population that experiences/have experienced a menstrual cycle throughout their life. This is only for ease of reading and not to be taken as an absolute term.

We as an ecosystem( Ecosystem refers to all the stakeholders like W.A.G.T.A, Civil society organisations, Research and Advocacy Institutions, Product Markets, Governments etc, who work together on achieving better menstrual health ) are mindful of the diversity in the population and in the process of understanding the inclusive terms. Hence we are refraining from using either ‘menstruators’ or ‘women’ to address this diverse population.

Historically, menstruation has been understood as the function of the ‘female body’ and its representation in social, economic, political and cultural contexts. So, a large part of the identity of an individual is seen as the representation of the ability to reproduce. This has led to a range of norms of behaviour and expectations from the individual. The resultant stigma has had a huge effect on an individual’s life, access to opportunities, dignity and social identity.

COVID-19 and the subsequent lockdowns in the country have adversely affected the most vulnerable groups in the population. Restricted mobility and loss of employment widened the already existing fault lines such as widespread menstrual stigma, gender inequity and poverty, further decreasing access to information, resources and services crucial for menstrual health needs. Even when relief services were being provided, most of the focus was around product distribution, which also reflects the majoritarian default response to menstruation.

We, at Uninhibited, stayed connected to our beneficiaries throughout the pandemic to understand how their lives had been affected due to the pandemic and how we could still support them, despite being away from the field operationally. Building on their needs and insights around reduced access to healthcare and safe informational spaces, we designed a telemedicine and information helpline, Aarogya Saathi to serve the communities we were working with. One of the major learnings was that it is important to build collaborations with different spaces like organisations, government, corporates to keep the ecosystem from collapsing in wake of the disruption caused by the pandemic.

Carrying forward the same spirit, it is important that we look at the opportunities we have, as different stakeholders in the ecosystem, to rally behind one another and keep the momentum going. In that respect, broadening the scope of menstrual health will be supremely helpful.

A new definition of menstrual health was developed in consultation with 51 expert stakeholders from Europe, Asia, Africa, and the USA in this paper.

“This definition of menstrual health was developed through a multi-stage process, led by the Terminology Action Group of the Global Menstrual Collective (www.globalmenstrualcollective.org). The Terminology Action Group, which includes members reflecting research, practice, advocacy and funding perspectives, developed an initial draft definition drawing on past applications of terms such as “menstrual health” and “menstrual hygiene” in research and practice documentation, the World Health Organization’s definition of health, and the recent Lancet-Guttmacher Commission’s definition of Sexual and Reproductive Health and Rights (SRHR). This draft definition was shared with key stakeholders identified through membership of the Global Menstrual Collective, regional coalitions, and organisations with a history of funding or programming for menstrual health. Stakeholders completed a standardised form that requested feedback. An overwhelming majority endorsed the approach and provided feedback to refine the definition statement. Fifty-one experts provided detailed responses, representing academic institutions (18%), non-governmental organisations (27%), UN agencies (24%), funding organisations (8%), government (4%), regional coalitions focused on menstrual health (14%), and professional associations for gynaecological health (6%). Stakeholders were from organisations based in Europe (29%), the Americas (25%), Africa (25%) and South and South-East Asia (20%).”- Excerpt from the paper

According to the earlier definition of menstrual health- Menstrual hygiene management (MHM) or menstrual health and hygiene (MHH) refers to access to menstrual hygiene products to absorb or collect the flow of blood during menstruation, privacy to change the materials, and access to facilities to dispose of used menstrual management materials. This led to a mostly uninformed and unidimensional approach to the issue. Most governmental or civil society interventions were focused on product distribution, adoption and hygiene management during menstruation without addressing the stigma. It left out a lot of intersectionalities within the ecosystem.

The new definition is not just a change in the terminologies or language, but also indicative of the broadening of our understanding of menstrual health.

Then, what does this mean for the menstrual health ecosystem?

  1. Building holistic solutions and collaboration

Based on the earlier definition of menstrual health, the ecosystem’s scope was limited to designing interventions towards hygiene management spaces. Interventions mostly revolved around products and finding a market for the same amongst different age groups.

With the new definition, the scope of building holistic solutions which address issues like access to credible information around menstrual health, conducive WASH infrastructure, mental health etc is widened as they fall under the same category of interlinked issues.

In our experience with women on the ground, they would look at DSNs(disposable sanitary napkin) as add-on finance and would not pay much attention to having a fixed budget for it. We worked with them on building capacity to prioritize their menstrual needs (product choice based on context and hygiene practices, medicines, nutrition) as a part of their monthly budget and advocate for the same. The new definition allows the ecosystem to recognise the importance of this work, and understand how economics and menstrual health is connected beyond buying DSNs.

Since there is a lack of comprehensive policy on menstrual health, the State relies on prevalent understanding and notions of it. Our experience of working with the state in evolving a roadmap required us to collaborate with officials from WCD, WASH, line departments etc. One of our major learnings was that this lack of an expansive, recognised and workable definition, forced us to find ways to justify why these stakeholders need to be part of the solution. The new definition, if widely accepted, can bridge that gap by itself providing an inclusive roadmap, that makes collaboration between sectors easier to validate.

2. Shifting narratives

The earlier definition of menstruation also looked at it as a phenomenon that happens only for 3–7 days and hence the focus is on taking care of self only during that period. That is only part of the experience of that individual’s life. Broadening the definition also communicates the relevance towards other parts of a menstrual cycle which should also be prioritized. It is important to build an understanding of how different parts of the cycle like PMS (Pre-menstrual Syndrome), Ovulation is experienced by individuals and what are the challenges that need to be addressed. It would help validate holistic solutions and make way for resources and investments in programmes and policies that are aimed towards addressing the entire life cycle of primary stakeholders.

3. Policymaking and the need for evidence-based approaches

When civil society organizations advocate for a shift in laws and policies by governments, we ensure that persistent structural issues can be resolved at scale. But, menstrual health has largely been absent from the landscape with few public health policies covering only distribution of menstrual products under reproductive health. But, with the new definition, we can broaden the lens and the advocacy asks from governments. This is a mammoth step towards building integrated policies around MHH.

The Indian state’s health policies fail women and adolescent girls (the only target audience) because they do not recognize that the marking of them as ‘impure’ is a cause of gender inequity, and only concentrate on product distribution.

The Menstrual Hygiene Scheme, under the Swacch Bharat Abhiyan, provides free DSNs to adolescent girls in government schools and supports building WASH infrastructure in the same space. While the policy is intentioned to promote better education and menstrual hygiene, it lacks in major aspects. Like how important a safe, harassment-free environment in a school is for an adolescent girl to not only confidently access services like product and WASH, but also be able to understand and absorb critical information around normalizing periods, hygiene and health management. Other stakeholders like teachers, adolescent boys are not included in the solution, but instead, made gatekeepers of these services, which invariably widens the power differential.

Most of these policies, do not account for the diversity in the population, contextual differences in the healthcare infrastructure, age-based needs of the stakeholders, existing structural oppression, the gendered experience of the menstrual cycle etc. Also, a lot of these policies are built by people who have little to no understanding of the manifestation and intersectionalities of the issue.

There is a lot of debate happening around the Menstrual Leave Policy in the organised workspace (which is not inclusive of the populations working in the informal workspaces with little legal or social security). For individuals who have distressing and extreme experiences during their menstrual cycle, the policy could serve to address the need for a safe and dignified space. The new definition could put this under self-care essential to that individual’s right to life and dignified work as well as communicate that menstrual discrimination is indeed real.

Evidence-based research is an excellent way to influence advocacy and policy changes.

This is an incredible opportunity to research and build evidence on how menstrual health, WASH, SRHR, Gender and Body Politics, Violence, Caste, Employment opportunities, Migration, Economics, Mental Health, affect W.A.G.T.A. lives. How can menstrual health become part of the national curriculum in schools, and so on? Since different aspects of social development impacts menstrual health and allied issues, the new definition opens up the opportunity for different departments like Education, Labour, Family Welfare etc, to collaborate as they do with several other programmes.

4. Stakeholder diversity and language of inclusion

Language, apart from helping with communication, is a powerful tool to shift perceptions and develop empathy. Currently, words with feminine connotations like ‘women’s health’, ‘menstruating women’ are used, and it is discriminatory in nature. A lot of women menstruate, but not all who menstruate identify as a woman. It is important to use language that is not exclusionary in nature. Attaching negative connotations to mood changes, mental health struggles borne out of changes in the cycle etc dehumanises the experience and dilutes the dignity of an individual.

The majority of interventions around MHH are focused on serving only the cis-het women’s category of the population. Products are termed within this binary. This leaves out a range of identities who also experience menstrual cycles, like trans and AFAB (assigned/observed female at birth). A difficult relationship with menstrual cycles can escalate body dysphoria and social inclusion.

A trans man, who might be experiencing a menstrual cycle faces challenges while accessing a hygiene product labelled as “feminine hygiene product” He would have to bear the burden of justifying the need for such a product or face the assumption that it is not for him.

Exclusion from the menstrual health narrative also means that trans and AFAB persons have a harder time accessing credible information, and healthcare interactions can be a huge source of humiliation and violation of personal boundaries, which can result in reduced access to safe toilets, water and hygiene products etc. The constant ‘othering’ of non-binary identities reinforces stigma and discrimination.

Many people find themselves missing from the narrative. For example, for individuals who do not menstruate regularly, people living with disabilities, amenorrhea, PCOD, PMDD and other menstrual disorders, this exclusion can be a source of distress. Vulnerable stakeholder groups like people in prisons/detention facilities, refugees/affected by violence, sex workers face this stigma even more.

With the new definition, inclusion at the policy level is also recommended.

If a cishet woman faced rude comments, salary cut, other forms of harassment for taking measures to address her menstrual needs in the workplace, it can be addressed under the POSH act. The same isn’t true if someone who identifies as a non-binary person experiences something similar.

Or if an individual work as a daily wage labourer, who in most cases, do not have a structured workplace, taking leave would mean loss of income.

The new definition could be a way for us to broaden the scope of such anti-discriminatory policies to include different lived realities.

With the ongoing COVID-19 crisis disproportionately impacting certain sections of the population, and likely to leave long-term adverse impacts going forward, the need to build holistic and relevant interventions becomes paramount ever more than before. The crumbling public healthcare system is already widening the gap in accessing a better quality of life and might reinforce a lot of stigmas. It is, therefore, incumbent upon the ecosystem to lead the way in building innovative collaborations and solutions to address the issue.

We, at Uninhibited, are looking at this definition as a cornerstone of the work which would help us further the menstrual agenda, by scaling our programmes to new regions, working with more diverse communities like trans persons, sex workers etc, and building collaboration which will help us further the menstrual agenda. We simultaneously invite the stakeholders in the ecosystem to explore opportunities and together make better menstrual health a reality.

This article neither covers the issue from all angles nor is it representative of all the relevant identities.

Written by : Sakshi Srivastava & Dilip Pattubala (With inputs from Narendra Pai, Bhuvana Balaji and Rucha Satoor)

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