It's Only Blood_Shattering the Taboo of Menstruation

by Anna Dahlqvist

  For those who use pieces of cloth as menstrual protection and cannot afford to throw them away, there is no place to rinse them out. Those who throw away their menstrual protection can do so in the latrine – the hole in the floor – but at the risk of a subsequent visitor seeing the blood. On the other hand, it is difficult to store both new and used menstrual protection in school without the risk of being teased. Someone could see, or just understand. Just like someone could open the door. And what if you get blood on your hands? Are you supposed to walk across the yard to the tap?

  Phiona has short hair and wears a bright yellow T-shirt with the blue skirt, as smooth and clean as Saudah’s. When she got her first period she was 14 years old and had no idea what was happening.

  ‘First it felt wet, and then I saw blood in my panties. I thought I had injured myself.’

  Phiona looks away over the low rooftops of the school buildings when she speaks. Behind the roof, a mango tree reaches far higher.

  Phiona’s sister-in-law informed her that it was menses, gave her disposable pads, and explained how they work. That was the end of the conversation. Because she lived with her brother’s family and rarely saw her mother or other relatives, Phiona had no one else to ask.

  But disposable pads she got, and still does. In a country where a fifth of the population lives below the poverty line, that is unusual. Most use cloth – not least in a poor area such as Bwaise. Tampons are used very sparingly in Uganda and can only be bought in a few stores. Menstrual cups are even rarer.

  When Phiona says that she cannot afford to use more than one pad per day, the interpreters, both from the middle class, react with indignation. One single pad! But they are supposed to be changed at least every five hours! Phiona calmly notes that she has to stay as still as possible, not run, and preferably not walk ‘to not bleed as much’. She skips the dance class she otherwise attends after school. She explains that she gets anxious with the same calm and matter-of-fact tone. That’s just the way it is.

  ‘It actually starts several days before I get my period. I get nervous when I know that it’s coming and run in and out of the classroom to check.’

  Later, it continues with her fear that the pad might get too full.

  ‘I keep away from boys as best I can. So they won’t notice anything.’

  If she menstruates during one of the periods when they have a lot of exams in school it becomes difficult, she says. Her thoughts wander to the heavy pad and she has a hard time focusing on the questions. Most often the teachers are male, making it impossible to explain why her concentration falters.

  * * *

  One disposable pad per day is not a rarity. In a study from Tanzania, students explain that they do not have a choice; they cannot bring extra pads to school because the boys could find them. With long distances to cover, they are sometimes away from home until the evening.

  In both Uganda and Kenya, concerned staff members at organisations working with menstruation explain that disposable pads are used for as long as possible, sometimes more than 24 hours – which increases the risk of skin irritations and infection.

  At a children’s home in the Indian state of Karnataka, those who have had their first period say that they would never even think to change menstrual protection in school. For them, it is not a question of whether they can afford it; they receive menstrual pads from a non-governmental organisation. Nor is it about the risk of mockery and ridicule. No, the reason is that the toilets are too dirty and there is no water to wash with. In order to avoid visiting the bathroom at all, they refrain from drinking and hurry home around four o’clock. They laugh when describing how much they have to rush sometimes.

  The lack of clean school toilets with water, waste bins, doors, and locks is a gigantic threshold for the person who menstruates. These are missing in 30 per cent of the world’s schools, according to the UN children’s fund, UNICEF. In the poorest parts of the world, this number rises to more than 50 per cent. For many, it is simply not possible to go to the bathroom during the school day.

  Managing menstruation outdoors is more or less impossible – at least if you want to make sure to maintain the ‘menstrual etiquette’. For those with different types of disabilities, the lack of adequate toilets is even more catastrophic. Shrubs and trees are hardly an option. Many girls also request separate bathrooms, so as not to be disturbed by the boys. They want somewhere to throw away or wash their menstrual protection. They want lighting so that they can see if it is clean and longer breaks to give them time. They want teachers who understand.

  * * *

  The fear of being subjected to harassment and humiliation because of one’s gender – a gender that for most people involves the natural bodily function that menstruation is – can seem serious enough for politicians, non-governmental organisations, and the many UN bodies that promote human rights to react. When menstrual shame is combined with poverty, there are systemic violations of the right to dignity, the right to freedom from discrimination, the right to education, the right to health and to privacy – to name a few of the human rights that can be linked to menstruation. Power over the period is a necessity, a precondition for participation in public life.

  But it was not the many consonant studies about worry and stress among students in countries like Uganda, India, Sierra Leone, Afghanistan, Pakistan, and Kenya that triggered the interest in menstrua-tion at a higher level. During the same time, at the beginning of the twenty-first century, reports appeared that focused on another side of the prob-lem: girls who were absent from school several days per month or even dropped out of school entirely when they got their periods. With absences and dropouts, menstruation became possible to connect to economic development. Slowly, something that for a long time had been placed at the very back of the private closet began to become politics. Menstruation politics.

  ‘One could ask why those numbers are so important, when it’s such an obvious human right. Girls and women should be able to manage their periods in a dignified and comfortable way,’ Marni Sommer says, with an annoyed shrug of her shoulders.

  Marni Sommer is a researcher in global health and development based at Columbia University, New York. She is an authority, a constant point of reference when menstruation becomes the subject of research. Her doctoral thesis, which came out in 2009, investigated girls’ experiences of menstruation and puberty in Tanzania. Since then, she has been involved in a number of projects that approach menstruation as a global health issue.

  In the elevator up to her office I can finally exhale. It is a warm summer’s day and I have stepped off at the wrong subway station, 116th Street instead of 168th, on the long and narrow island of Manhattan in New York. The walk through almost all of Harlem up to Washington Heights and one of Columbia University’s many buildings was long and sweaty.

  Despite Marni Sommer’s irritation about the focus on absences and dropouts, the fact that menstruation has become an issue worthy of discussing at a higher political level during the last ten years is without a doubt a step in the right direction for someone who has long tried to shake up sluggish decision makers.

  ‘Schools are gender discriminatory environments for a number of reasons, but this was perhaps one that many hadn’t thought of before. With a growing body of academic data about girls’ experiences and the challenges they’re facing in relation to menstruation, this has become clearer.’

  For many – not least those who themselves lack any experience of menstruation – this was complete news. Menstruation is not just that which ‘the others’ deal with once a month. It can also have significance outside of the more intimate sphere.

  * * *

  There is no doubt that girls’ education is of great significance not just to themselves. In low- and middle-income countries, like Uganda, education leads to women giving birth later in life and to healthier mothers and children. For every year they stay in school, their future salary level also rises. And educated girls tend to share the
ir knowledge within the family. From an economic perspective, it is an upward spiral: girls’ education has a direct impact on the country’s economic development.

  The UN Millennium Development Goal for education was highly cherished, viewed by many as a precondition for the other goals. The Millennium Development Goals, which were about improving life for the world’s poorest, had 2015 as their end point. In many countries, the gap between girls and boys has been reduced, at the same time as the proportion of children in education has increased. These were both explicit objectives. But according to the UN body for gender equality, UN Women, only 2 out of 130 low- and middle-income countries have reached as far as accomplishing an equal gender balance in schools. More than 62 million girls who should be in school are not. Girls are more often absent; and the older they get, the more days they lose.

  Moreover, the positive trend has waned, which has made researchers, non-governmental organisations, politicians, and other important actors search high and low for the critical obstacles that prevent girls from staying in school. Menstruation became another piece of the puzzle.

  During the last ten years, menstruation has gone from being an issue that concerns individuals and families to becoming a public concern and a – however small – part of the global fight against poverty. The perspective has shifted. Now, national guidelines about menstrual management are being written in countries like Kenya and India; organisations within the water and sanitation sector are highlighting men-struation as a natural part of their work; and the same is true for a line of UN bodies, with the children’s fund UNICEF leading the way. Since 2014, organisations all over the world take part in an international Menstrual Hygiene Day on 28 May every year.

  The interest among those who fight for girls’ education is a central explanation – but it is not sufficient. Researcher Marni Sommer adds another four.

  ‘There were also assumptions that menstruation was being taken care of at the family level, that it’s a private issue. Given the limited resources, the global health community usually stays very focused on issues that are causing high rates of mortality. Menstruation didn’t seem like something that should be a priority.’

  But with the education perspective, mortality entered the picture. As we already know, if girls go to school both they and their children will be healthier. Maternal and infant mortality rates decline. The risk for HIV is also reduced, among both the girls and the children. The global health sector, which to a greater extent had focused on girls above the age of 15 in order to combat maternal mortality and HIV, began turning to the even younger girls.

  In parallel with the global health sector’s awakening, things began to happen among those who work for access to clean water, toilets, and other things related to sanitation and hygiene – the WASH sector.

  ‘One of the reasons was that more women engineers entered the industry. I don’t think the men intentionally overlooked the menstrual perspective, but it just didn’t occur to them. It’s not something they have to worry about.’

  The WASH sector became a driving force, allying itself with the education sector. Together, they focused on menstrual management in schools. At some point during this process, in the beginning of the twenty-first century, the acronym MHM for ‘Menstrual Hygiene Management’ was also invented, as a com-prehensive concept that made it easier to communicate menstruation as an issue. It became a way to say – in three words – that managing menstruation requires certain conditions and that the responsibility does not solely lie with the individual. Eventually, it was picked up by the World Health Organization and UNICEF, among others. They define the concept on the basis of a number of factors: access to effective menstrual hygiene products; water and soap; private spaces to change, wash, and dry menstrual products, as well as to throw them away; and education about menstruation. With time, the latter has proven far more crucial than many initially thought.

  In 2014, the United Nations Human Rights Council for the first time spelled out that the stigmatisation of menstruation and the scarcity of resources required to manage menstruation are an obstacle in the fight for gender equality, and that they affect the human rights of women and girls. A big step for an organisation that in its silence about menstruation all too often reflects the world in which it operates.

  Marni Sommer continues her analysis of what became a kind of international ‘menstrual momentum’: ‘We shouldn’t underestimate the role that big companies like Procter & Gamble have played through their global push for puberty and menstrual education in schools, usually coupled with product information, outside of the established markets in Europe and the US.’

  No, commercial interests should not be underestimated. For those who sell menstrual pads, tampons, and to some extent menstrual cups, many countries in Africa, Asia, and South America are markets with huge potential. Several companies have funded menstruation studies in low- and middle-income countries, provided free information, and at the same time expanded. For better or worse, they are powerful players in the global arena. In schools in Uganda, for example, I hear the American company Procter & Gamble’s brand Always used synonymously with disposable pads several times.

  But their efforts have also been met with a backlash from those who emphasise the environmental unsustainability of disposable products. There are a number of social entrepreneurs who instead produce pads that can be reused, as well as menstrual cups on a smaller scale. Embedded in the backlash is also a criticism of how the companies that showcase their own social justice initiatives through marketing reinforce the shame and stigma around menstruation. A criticism of the focus on the commercial aspect, in which those who menstruate are only of interest as profit potential for companies.

  One explanation remains for Marni Sommer, who seems to have all the time and energy in the world to go through ‘the global menstrual awakening’. The idle pace in the sunshine outside has not reached her cool office. The final explanation is about those billions of people who menstruate or have menstruated. We who remember the teenage fear of blood stains on our clothes; we who looked in vain for waste bins for bloody tampons and instead shoved them down our pockets on the way out of the bathroom; we who find it hard to say the word ‘period’ without – during a moment’s hesitation – feeling ashamed.

  ‘There is something universal about periods. Almost half the world’s population experiences them and can relate to difficulties connected to menstruation,’ says Marni Sommer.

  It creates an emotional investment among a significant amount of people, who want to know more, spread information, and get involved – all over the world. The Swedish ‘menstrual trend’ with books, podcasts, films, and art exhibitions is no isolated phenomenon, but rather part of a larger, worldwide conversation. A menstrual movement.

  * * *

  Traffic flows in a steady stream below Marni Sommer’s small office. On the other side of the Hudson River, New Jersey begins. We are almost as far westward as one gets on Manhattan. Once again, we are talking about how school absences and dropouts in low- and middle-income countries are taken as the only justification for why menstruation matters.

  ‘It bothers me incredibly that we should have to show an impact on girls’ academic performance in order for them to get access to toilets and information about their bodies. As if it wasn’t worth anything otherwise.’

  Marni Sommer feels – as she says – ‘uncomfortable’ with that reasoning. It is a diplomatic researcher’s way of being deeply annoyed at the fact that the girls’ worth is measured against the welfare of others. Those who do not menstruate must also have something to gain.

  But regardless of what she thinks of this reasoning, Marni Sommer agrees that absences due to menstruation are a real problem. And that this problem grows out of the reality that it is more or less ‘not possible’ to have one’s period in school. At least not without a struggle that is too demanding, with only ineffective and uncomfortable solutions.

  The link between dropouts
and menstruation is more complex than when it comes to absences. It may be well documented that more girls drop out of school when they get their periods, but there are several explanations for this. In some cases, menstruation is seen as proof that they are ready to shoulder more responsibility at home and sometimes also marry and start a family. The great majority of the 16 million people between the ages of 15 and 19 who give birth every year live in low- and middle-income countries. Menstruation carries strong symbolic ties to sexual maturity with highly practical implications. Many parents justifiably fear that their daughters will be subjected to sexual abuse. They are afraid that their daughters will get pregnant or simply that they will have sex. That too becomes a reason to keep them at home.

  But menstrual issues can also become critical when boys’ and girls’ education are forced into competition. With minimal margins, the families’ investments in education – especially for girls ­– are vulnerable. When absences affect performance, it becomes harder to argue for the value of an education in the long run. The connection with menstruation is there, but the dropouts are caused by a range of factors.

  ‘One thing, we know for sure,’ Marni Sommer says, and this she wants to impress. If she has one main message, I think to myself, this is it.

  ‘We know that it’s a big problem that the girls are very uncomfortable being in school when they have their periods. And those of us who’ve been doing this research for a while would like to talk about it more. About stress, concentration, and self-esteem.’

  That which a schoolgirl from a study in Zambia sums up as: ‘You will make yourself very small.’ The one who menstruates diminishes themselves.

  * * *

  In the schoolyard in Bwaise, Kampala, Phiona is starting to get restless. She has talked enough about menstruation and wants to go back to the classroom. I hurry to ask if she knows what she wants to be when she is done with school. She knows. A hairdresser or clothing designer.

  Phiona would never stay home from school because of her period, however difficult it may be to last a whole school day on just one pad. She already missed too much when her family did not have enough money to pay for her education. Now she is several years behind the other students.