Considering that I had emigrated years before from the USA, I occupied a unique researcher's vantage point that enabled me to better understand the challenges that immigrants have when moving between countries. When the women were asked to talk about their experience at puberty, they often constructed their story related to their physical body development and integrated it within the context of the menarche experience. For the most part, women remembered the actual day, even when it was decades ago. To capture the types of knowledge that mothers passed on to their daughters, I developed a model of knowledge acquisition for learning about menstruation that articulated four types: traditional, embodied, technical, and authoritative. A central thread that runs in this model is that knowledge acquisition is different in an ethnically pluralistic context than in one more homogenous.

# The "Slap" Heard 'Round the World' and Other Menarcheal Traditions

One of the most interesting aspects of this research is the stories the women shared about their menarcheal (frst period) experiences. In many traditional cultures there were ceremonies, rituals, and traditions that were passed from one generation to another that may give either a positive or negative valence to the way women view menstruation. Traditional knowledge and rituals often provide strong emotional support for daughters allowing a comfortable transition through this key developmental stage. Several women whose origins were from Europe spoke about "the slap."  While the mother said the reason was "something about the blood coming back," the daughter said it was something about "the blood not going to your mind." The actual historical reasons for the slap are unknown. However different explanations include: the manner in which the act of slapping took place could determine the duration of menstruation; it was necessary for a girl when she becomes a woman as protection against disgrace; and the rush of blood will make the girl have a wonderful color in her cheeks throughout her life. The uncertainty surrounding this ritual exemplifes that even as traditions continue, their rationales are often lost.

Women who immigrated from North Africa and Ethiopia looked at the onset of menstruation as a milestone that symbolized fertility, therefore achieving status in the traditional society. Several of the women born in North Africa spoke with joy and excitement when they reminisced about getting their periods for the frst time and the celebrations that surrounded this event with mothers playing an integral role in this transition. Some of the traditions included mothers giving their daughters pieces of jewelry and preparing special foods and performing the ritual of putting three of the daughters' fngers in four so that they should only get their period for three days. Another tradition is the oil ceremony in which mothers told their daughters to look and smile at their refection in a bowl of olive oil, and then their faces were rubbed with oil. These girls were told that the image they saw on that day should continue and they should enjoy a happy life. The women noted that the oil would smooth a woman's passage into womanhood. This oil ceremony was accompanied by a festive meal with traditional foods including honey-dipped, oil-fried cakes. When these women, now elders, were asked if they continued this tradition with their daughters, they all answered an emphatic no, of course not. It appears that the change and adaptation to the new culture and environment took precedence over retaining certain cultural practices. But there were exceptions. For instance, I interviewed one daughter of American immigrants who grew up on a Kibbutz, a collective community. She spoke with excitement as she recalled when each girl in her age cohort got her period, they celebrated with gifts and a special party.

### Cultural and Religious Prohibitions

There are many religious customs and restrictions during menstruation related to the Jewish laws of family purity that include *niddah*, the time of separation; *teuma*, being unclean and untouchable; and *tahara*, the cleansing process following menstruating that religious Jewish women continue to observe today. An Ethiopian daughter told me that when you menstruate "you can't touch food for the Sabbath . . . my mother will not let me prepare food that is for the Sabbath." A North African mother shared, "it is forbidden to go into the Synagogue or hold the Torah Scrolls, or go to the cemetery since you are 'ritually impure', these were the things they always told us."

The older Ethiopian women talked about their experiences at menarche which included special foods that their mother's prepared, and then the young girl would go to the 'menstruation hut' where she would remain until the completion of her period.  They looked forward to this time to be taken care of and pampered by the other women of the community. As another mother noted "in Ethiopia there is no rest until you go to the hut, only during menstruation the women rests," and her daughter explained, "the week away from chores was fun and a brief vacation from everyday life and being with friends and not having to work so hard." However, the mothers did not continue traditions, such as preparing special foods or going to the menstruation hut after they immigrated to Israel.3

# Technical Knowledge—"There Weren't Pads, There Were Rags…"

Several mothers from Israel, North Africa, and Europe reported using rags when they frst got their periods. They told me "there weren't pads, there were rags, we just cut rags and we began with that, we would cut all sorts of strips of material and we would wash them and use them again . . ."  Another daughter from Ethiopia said she used cotton until she read in a magazine about pads. Many of the mothers and their daughters from almost all the countries reported using cotton and then over the years, they started to use pads and or tampons when they became more accessible. Often the daughters taught the mothers about products.4

The mothers from the former Soviet Union (FSU) immigrated either in the 1970s or late 1980s–1990s began menstruating before immigration and spoke about using cotton wool when they frst got their periods because "we didn't have other things." Mothers who immigrated in the 1970s also noted that "after immigration I used pads . . . I never heard about pads or tampons in Russia, only here [in Israel]," and another mother noted "back then there weren't any, when I came to Israel [in 1971] tampons were already here." It appears that pads and tampons were not available to the mass population in the FSU in the 1970s. On the other hand a mother from the FSU who only immigrated to Israel in 1994 spoke about using other products: "I knew about tampons when my daughter was about 14–15 [about 1990–1991], they were already in the stores [in the FSU], when there was something new, we started to experiment on ourselves." It appears that accessibility of menstrual products has a great infuence on what women use, and the methods of menstrual care have changed over the last several decades.5

There were some interesting differences based on country of origin. The more traditional the women, especially those from North Africa and Ethiopia, the less they used tampons. The reasons they gave included: not wanting to touch oneself; not putting foreign objects inside their bodies; perceived loss of virginity; and hearing in the media that tampons caused infections and cancer. All the mothers I interviewed from the United States and Canada, however, used pads and soon moved to tampons during their teenage years. Their daughters followed similar patterns. None of these women reported using cotton wool which led me to assume that since the mothers never used cotton wool, they did not recommend it to their daughters. These daughters began using tampons at a relatively early age, often younger than their Israeli contemporaries.

The use of products can have a profound effect on how women deal with menstruation in their daily lives. Many of the mothers spoke about restrictions and the inability to take part in certain activities that appear to be a direct result of how they handled menstruation. As an example, if one used cotton or pads it was almost impossible to swim or take part in certain sports activities. This may explain why women told me that it was not possible to swim while menstruating. However, the introduction of tampons enabled women greater mobility and therefore, freedom. For example, one daughter who immigrated from the FSU was a gymnast who never practiced or competed while menstruating. The frst time she even heard about tampons was in the late 1990s when an Israeli woman introduced her to tampons. She was so delighted to have access to tampons she exclaimed, "the person who invented the tampons should get the Nobel prize."

The model of knowledge acquisition of health has been applied to other aspects of women's health behaviors that include: family planning and birth control,6 informed decision making for breast cancer patients,7 and could be extended into further studies of learning about birth, breastfeeding, infant care, coping with marital confict, and mid-life or older age health challenges. Furthermore, the results should allow health professionals to tailor the educational programs to the ways in which women form their approaches to critical health behavior. These educational programs can be developed to focus on various target groups within the population and to include health education that takes into account the broad spectrum of cultural aspects of the attitudes of health behavior in ethnically pluralistic cultures.

My research was the frst undertaking of its kind that examined the intergenerational transfer of menstrual health knowledge and practices in Israel. Although the data was collected almost two decades ago, it remains relevant because it provides unique insight into the effects of mass immigration to a culturally diverse country. In addition, at the time of this study, the internet as a major source of information was not readily available in Israel to the general public, especially in the Hebrew language. Therefore, learning about menstruation was primarily based on verbal communication or written information. Today, as women are moving from one country to another, either by choice or through forced political or economic displacement, it becomes very important to understand the varied cultural beliefs and traditions of people on the move as they adjust to their new countries and home.

### Notes

**Open Access** This chapter is licensed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/ by/4.0/), which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license and indicate if changes were made.

The images or other third party material in this chapter are included in the chapter's Creative Commons license, unless indicated otherwise in a credit line to the material. If material is not included in the chapter's Creative Commons license and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder.

# Transnational Engagement: Designing an Ideal Menstrual Health (MH) Curriculum—Stories from the Field

*Breanne Fahs and Milena Bacalja Perianes*

# Introduction

How people learn about menstruation has a deep impact on the broader social justice implications of menstrual health, particularly as education becomes a force working against stigma, shame, and silence around menstruating bodies. The specifc tools people use to implement menstrual education also play a central role in shaping the public face of menstrual health. If menstrual education is fun and light-hearted, people learn that menstruation is "no big deal" and something that does not differ much from other bodily processes. If menstrual health education can be accessed more readily, more people learn about periods and reproductive health, including (and importantly) men and boys. We think together here about the specifc ways that menstrual health education works to undermine stigma, expand who learns about menstruation, and forge alliances between new organizations, partners, groups, and individuals.

The dialogues in this chapter on menstrual health education suggest that the world of teaching about menstruation is rapidly changing, expanding, and growing. Once confned to the narrow feld of the Water Sanitation and Hygiene (WASH) sector, menstrual education has evolved to encompass the varied and complex social, cultural, political, economic, and environmental determinants of health which facilitate or inhibit women and girl's wellbeing. Through diverse and holistic approaches to menstrual health, we are increasingly moving away from discursive practices that ground menstruation within a hygiene and cleanliness mindset and open up new possibilities for applying a menstrual lens to, and through a variety of sectoral approaches.

First and foremost, the dialogues in this chapter suggest that menstrual education has moved far beyond the confnes of schools, and as such, beyond the limitations of traditional models of a relatively limited, shortterm intervention given only to girls in a traditional educational setting. Instead, menstruators are taught about menstrual health and menstrual decision-making outside of school, with emphases on health literacy and education through a human-rights or justice-based learning experience. These dialogues explore just some of the integrated approaches to menstrual health that currently exist which draw upon new technologies, new modes of education, and new kinds of curriculum and learning.

With renewed attention to body literacy, menstrual health education has expanded to include more nuanced understandings of menstrual experiences paying particular attention to the connection between how education can, and does, impact health decision-making over a women or girls lifetime. In such a context, menstrual education is no longer simply focused on the need to "manage menstruation" hygienically and periodically, rather menstruation as an opportunity to increase bodily autonomy and as central to closing the gender gap. As a result, doctors work in tandem with public health offcials. Community organizers work in partnership with schools. WASH actors work together with menstrual activists. The public sector works together with the private sector. These fusions and overlaps have resulted in alliances and collaborations that refect exciting new models for social change that draw from the strengths of each of these entities while minimizing their weaknesses. For example, businesses get to innovate, while activists get to ensure access to those typically ignored or excluded. Doctors relay important health information and people in local communities have increased ownership over translating these messages to meet their needs and contexts. Most importantly, these new models of menstrual education ensure that we continue to see menstrual health as central to the ability of women and girls to exercise their human rights. We enlist the support of *all* genders in *all* parts of the world in these efforts.

# Shaping the Dialogue: Clue's Approach to Menstrual Health Education

#### – Anna Druet

*Clue is a menstrual health app that uses science and data to help users discover the unique patterns in their individual cycle. It reminds users about their period, PMS and fertile window.*

#### **Explain your approach and intervention toward menstrual health? How do you implement your menstrual health curriculum?**

The menstrual tracking app is, above all, a tool. It allows people to create a record of their menstrual cycles and periods, to track their health and identify cycle-related patterns. It facilitates connections with others and enables individualized healthcare. These are active elements of the tool itself, however it also has a variety of equally valuable passive elements, particularly education and learning. At Clue, we aim to enable learning as people use it, resulting in topics that are often taboo to become normalized, neutral, and reframed. Our approach to menstrual health is actually quite *zoomed*-*out* from the period. The period is viewed as a gateway into the rest of the cycle. Often, people start using our app as a period tracker alone however by interacting with the app and reading content, we aim to instill in our users an understanding of their cycle as much more than just the period. Promoting body literacy is an important value for us.

I sometimes think of the period as an (easily overlooked) black box. The contents of this box can go relatively unnoticed, or adversely perceived, until something happens that triggers a person to look deeper. Maybe they've had trouble becoming pregnant, or maybe they have symptoms of a reproductive health condition. By opening it, they learn what has been sitting there all along—a ffth vital sign, a signal of health, a process that can connect a person to their body, or to others. People suddenly learn that their cycle may infuence their acne, pain tolerance, headaches, or social lives. It may give them a better idea of their risk level for pregnancy if a condom breaks and they are considering emergency contraception. It may play into their muscle-building capacity and infuence their workout routine. It may infuence how a certain sex position feels on a given day. Learning about the cycle can go far beyond fertility and bleeding. At Clue, we have found people are surprised and excited to unleash the potential of this new information!

#### **What makes your approach unique?**

Our communication style is very important to our approach. We follow a carefully selected, ever evolving set of goals and rules to create the Clue tone and feel. Normalizing taboo topics is an overall goal, but the approach can shift from topic-to-topic. We aim to make things approachable and easily understandable, while also communicating the importance of complexity in some instances. We know that oversimplifed statements about health, a research fnding, treatment, or a little-understood disease, can be harmful. This approach is shaped by our research, academic collaborators, and the people who use our app. We receive hundreds of emails each month from people asking questions about their cycle, health concerns, and basic anatomy. These questions help us understand what is most concerning for people, and where gaps might be in our own materials.

#### **How did you develop your curriculum and who did you consult?**

Our menstrual curricula is designed collaboratively. We work directly with some of the world's top clinical researchers on menstrual health via our medical board and research partners. We use services like Uptodate, which incorporate new peer-reviewed research (when suffcient) into current clinical gold standards of practice. We do internal literary reviews, of varying depths, and have extensive research and fact-checking protocol to ensure rigor and accuracy.

#### **What kind of impact have you had?**

Our approach has resonated with people. Today we have over ten million active users in 190+countries. Our app has been translated into 15 languages and counting. We have seen shifts in the questions sent to our support team as we have incorporated certain educational goals into the app and content more broadly. Our dedicated users have led to the development of an unprecedented dataset on cycles and health, which we use in collaboration with academic partners for menstrual health research. We are conscious to choose research topics that can beneft the people who give access to their (amalgamated, anonymous) data for our carefully selected research collaborations. Our website, where we publish weekly content on menstrual and reproductive health topics, gets 2 million readers each month, most of whom are coming to the site after searching for health info in a search engine. We learned that people in areas with higher gender inequality are more likely to use their mobile devices to access sexual health information.

#### **What languages do you use and are there any tensions or conficts about the language you use for menstrual health education?**

Challenges for us have been in getting language right. Our app is not currently localized, meaning the same version of the app is being used globally (translated into different languages). The base and context of knowledge varies dramatically across Clue users, as does the status of evolving language around gender and health.

In terms of language, there are also differences in opinion in where the line sits between approachability and euphemisms—fuid vs. mucus, for example. We are grateful to have so many engaged Clue-users who give us a lot of feedback and have an ongoing process where we work with consultants to help in the development of our language.

Communicating on under-researched topics and bridging the gap between diverse menstrual-health spaces can also be challenging. We support access to comprehensive, reputable healthcare services, and information for all. However emerging dialogues on women's health have also brought voice to considerable and important disciplinary gaps. These include: the impact of female physiology being left out of research; the ignoring or minimization of female pain; the dearth of satisfactory answers on how to treat common but complex disorders like Polycystic Ovary Syndrome (PCOS) or endometriosis; the arguably disproportionate under-testing of gynecological medical devices, and undervaluing of female health issues. These facts have led to an important and necessary movement and conversation around women's health. On the other hand, they have also led to the creation of some resources and services using misinformation, a lack of credible research, or entities looking to proft from desperation. For us balancing clinical understanding with new research and evolving trends can be tricky. When writing on evolving health topics, we look out for newer fndings and examine the researchers conducting them, to see what recent contributions are being made to burgeoning bodies of knowledge. Sometimes this is all of what is out there. We make it clear when we share any fndings which are controversial, unreplicated, or require further validation. It is surprising how much research fts into this category. All sides of these emerging conversations need to take women's health seriously enough to vet and ethically portray the information they are offering to people in vulnerable positions.

#### **What does the future of MH education and curricula look like?**

In the future, I would like to see educational initiatives that focus on the cycle overall, cycle phases, and the cycle as a health indicator tool akin to a ffth vital sign. I would like to see boys and men included in menstrual educational initiatives. Like many, I would also like to see a shift in handling of the topic of premenstrual syndrome (PMS)—the 200+symptoms associated with an inconsistently defned syndrome cover a window of time in the cycle with several hormonal shifts, and diverse experiences. We also need more educational resources dedicated to perimenopause. Ultimately, I believe that more research into hormonal diversity, experiences around the ovulatory phase, and into positive (or perhaps not-only-negative) changes associated with the cycle would be incredibly valuable.

# Menstrupedia: Making Periods Fun and Accessible

#### – Carla Giacummo

*Menstrupedia is a comic which acts as guide to educate people around the world on menstruation.*

#### **Explain your approach and intervention toward menstrual health? How did you implement your menstrual health curriculum?**

I began working on menstrual health while running Eco-Ser in 2010, an NGO which increases women's knowledge of menstrual cups as a healthy product option for women. Within this project we worked with Mooncup Ltd., to educate and distribute cups to girls in rural areas or from disadvantaged backgrounds. After interacting with hundreds of women, I realized there was a clear lack of resources to talk about periods with girls aged 9 and up in the Latin America region, as well as tools for parents and educators to generate natural and easy interaction around the menstrual cycle. When I met Aditi Gupta, the Founder of Menstrupedia India, I realized that Menstrupedia was exactly the resource I was looking for to enable my own work in Latin America. Therefore I worked to translate Menstrupedia for a Spanish-speaking audience with sensitivity to the local context.

#### **What makes your approach unique?**

Within an Indian context, girls are often in a very vulnerable situation regarding the menstrual cycle and puberty related changes. The Menstrupedia comic contents captures different experiences to address all that a girl or a boy should understand regarding this time in a very easy, clear, and funny way. I recognized that cartoons are helpful to address complex concepts which through storytelling help young people grow up with positive messages around puberty and changes in their life. Within a Latin America context, there was no material available like this. Most sexual education focuses on contraceptive methods, abortion, and biological differences. Most resources I encountered either skipped the menstrual cycle or failed to acknowledge the importance of menstruation in little girls lives. The work of Menstrupedia in India and now the Spanish translation, connects the biological impact of puberty and menstruation with the emotional, social, and psychological aspects in order to help girls on their journey to womanhood.

#### **What kind of impact have you had?**

While working on the Spanish translation, I tested the English version at the biggest ecological event in our country. At this event a variety of different projects, alternative health workshops, and ecological products are presented to the public with approximately 15,000 people in attendance. I was able to sell several of the resources immediately and realized that mothers felt an incredible sense of relief to fnd a tool to help them start conversations with their daughters. However, there was clearly a need, and demand, for them to be readily available in Spanish. Teachers and midwives also showed interest in using the resource in educational and clinical settings. The frst edition in Spanish was available in October 2015.

### **How did you develop your curriculum and who did you consult?**

Menstrupedia's curriculum was developed with input from health and educational experts. The content has been carefully designed and created with expert input, therefore the Spanish version duplicated the content, with minor adjustments for a Latin American context. After the frst edition was produced with a positive response from Non-Government Organization's in Latin American countries (as well as Spanish speakers from across Spain, USA, and Europe) I collaborated with Daniel Goldman, CEO of Inmmentor, an expert in innovation. We both understood Menstrupedia as fundamentally an innovative educational tool, which supports an improved understanding of menstrual and reproductive health for girls in rural areas and indigenous communities in Latin America. With high rates of adolescent pregnancy in these populations we worked to increase distribution with the hope that in the long term we would see its impact on these pressing issues, among others. With strong interest from Mexico, Guatemala, Nicaragua, Colombia, Perú, Puerto Rico, Argentina, Chile, and Brazil we have worked to toward internationalization of Menstrupedia including adding several companion resources such as audiovisual, and trainers guide.

#### **What languages do you use and are there any tensions or conficts about the language you use for menstrual health education?**

While there are nuances across different Spanish-speaking countries, Menstrupedia was translated into *neutral* or the most common form of Spanish with minimal colloquialisms. We have found few tensions or conficts, as the content of the book is already culturally sensitive. Regardless of a readers beliefs or context, those who use the resource are not made to feel uncomfortable.

To ensure the accuracy of the translation we worked with Dana Riensi, Spanish Teacher, Library and Educational Technology Specialists (Oregon) as well as NGO partners from Guatemala, México, and Perú. This helped to translate and implement not only the text, but the audiovisual guides.

#### **What do you wish could be included in future curricula about menstrual health?**

After two years of working with different international and national organizations, as well as school teachers, social educators, and health professionals, I believe that there is a need for the development of a menstrual health workshop for adults. Menstrual health knowledge remains a gap in a variety of adult populations therefore those implementing our resources, also require capacity building regarding the importance of integrated menstruation health education. We have received many requests for further guidance beyond the audiovisual and trainers guide. This resource would need to be tailored to the needs of those working in rural areas, where populations are being affected by a broader lack of resources, hygienic products, and access to water, sanitation and hygiene. I also hope one day to be able to create a Portuguese and sign language (LSU) version of Menstrupedia

### **What does the future of MH education and curricula look like?**

I believe MH education and curricula should be simple and easily accessible by all. Governments seem unaware of the importance of MH education in spite of its social, economic, and cultural impact. There is a strong need for improved puberty-related education delivered at a younger age. It will enable girls to feel more confdent and help boys to understand what happens not only in their own bodies, but also those of girls. I hope to see plenty of information available that looks at the great biological and emotional changes that occur at this time.

I believe that early MH education is an opportunity for girls' interaction with their bodies and cycle. Menstrual dignity has to do with their own confdence, self-esteem, and healthy growth. However, it is also an opportunity for greater awareness and respect for human beings and their right to make decisions over the bodies and lives. We cannot express with words what we do not know. So, MH education is a great opportunity for adults and children to learn about their emotional and physical health and how they can talk about it.

# WoMena: Educating Around Innovative Products— Developing a Curriculum to Support Menstrual Cups Programming

– Marianne Tellier, Shamirah Nakalema, Siri Tellier, and Andisheh Jahangir

*WoMena is a Danish founded NGO that promotes the use of evidence*-*based, effective reproductive health technologies and solutions such as menstrual cups through research, advocacy, and project implementation in Uganda.*

# **Explain your approach (SRHR, WASH, gender), and intervention?**

WoMena has a broad view on menstrual health including physical, mental, social, and structural aspects, which we translate into a set of intervention activities:

To do this, we employ both paid local and international staff and volunteers, which contributes to a richness of perspectives and energy to implement our programs, and achieve social impact.

## **What makes your approach unique?**

WoMena's educational approach is unique in several ways. Our approach is context based, and our standard curriculum is usually tailored to the needs of the local population. We also use locally available materials, for easier accessibility and affordability of the menstrual management materials we distribute. We believe that when something is so new, like the menstrual cup, and knowledge is so low, you need to go into the fundamentals, personal stories, as well as a lot of honesty, to build people's trust, such as: how many holes women have, pros and cons of cups, and how diffcult it is when you take out your cup the frst time. Furthermore, we believe in a life-skills based educational approach. Such an approach recognizes that different people learn in different ways—therefore we like to make our trainings interactive, with lots of questions, physical props that people can touch, illustrations, energizers, learning through movement, friendly competitions and time for participant demonstrations.

We train trainers and educate many groups in the community, so that everyone feels included. We are conscious that men and communities have a role to play so that the new user has a supportive environment. We do preand post-training tests to see whether our training has had an impact and monitor how well we are doing. Last, but not least, we have also designed a whole training module with different training methods, as this is an essential part of quality training at WoMena.

WoMena's fve training principles include:

#### **What kind of impact have you had?**

Our approach has had many layers of impact. The projects we support measure 75–94% uptake and 82% long-term continued use of menstrual cups among girls/women receiving our education and programming. Through our community involvement model we have seen considerable break down of taboos about menstrual health, opening up new avenues for important discussions in communities, while catalyzing change to male participants' perceptions of menstrual health (WoMena 2018a; Gade and Hytti 2017). Through our impact evaluations we know that thousands of women and girls have expressed increased feelings of freedom and comfort during their periods after starting to use the products, which research demonstrates can have a positive, trickle-down effect on girls' school performance (WoMena 2018b; Gade and Hytti 2017).

We also work at a systemic level to address menstrual equity issue including effectively advocating for the inclusion of menstrual cups in a Uganda's national menstrual hygiene management curriculum in 2018 training manual drafted by the Ministry of Education, as well as the waiver of value-added tax for menstrual cup importation. We have built the capacity of ten NGOs to deliver MHM trainings around cup-related projects. We have also partnered to develop training materials for AFRIpads, which led to us has a potential reach of 1 million girls and women. We are currently completing similar work and developing educational materials for Ruby Life. Lastly, we have built capacity and provided meaningful learning experiences for +100 volunteers from Denmark, Sweden, Iran, Finland, Uganda, US, UK, Lithuania, Germany, and Spain.

#### **How did you develop your curriculum and who did you consult?**

WoMena's training curriculum was developed in 2012 with the Red Cross and further improved upon through research and project testing in 2013 and 2014. However, our frst offcial comprehensive curriculum was produced and implemented in 2015 based on examples from organizations working with similar environments and target groups. This included resources produced or used by the Red Cross, school readers from Uganda, Kenya, and Tanzania, menstrual cup supplier user materials, group participation materials, as well as expert materials on specifc topics such as hymens from the Swedish Association for Sexuality Education. The initial draft was developed for an internal training of trainers by a group of six volunteers in consultation with actors in the feld of reproductive health, such as Ruby Life, Menstrual Cup Uganda, and Reproductive Health Uganda. As a relatively new area of research and programming, we consulted with our internal volunteer Medical Advisory Team on particular topics to ensure it met the highest quality standards. We ensured our educational materials were useful in a variety of settings, so we designed the material to be user friendly and fexible, with suggestions on how the content could be tailored for different contexts.

Later updates to our main curriculum included lessons learned and questions from the feld, brainstorms and curriculum development projects with partners such as AFRIpads, and updates based on new publications of relevant curriculum from the Uganda Ministry of Education and Sports. We also further developed our material on hymen and virginity with inputs from experts dedicated to this topic.

Now, when we implement new projects, our training curriculum is tailored to the specifc context by involving community health professionals and local leaders as part of the design process. Also, as education is not limited to training, our knowledge management team prepares FAQ sheets to answer in depth questions asked by implementers, women/girls, and community leaders on topics such as Toxic Shock Syndrome, hymens, menstrual irregularities, and infections.

#### **What languages do you use and are there any tensions or conficts about the language you use for menstrual health education?**

Our main curriculum is in English, although we have almost fnished developing a Danish curriculum for Danish contexts. We are also fnalizing the translation of our training tool designed for northern Uganda humanitarian contexts into Juba Arabic. In Uganda, we have different trainers who speak various local languages. In most cases they are able to deliver the training in the local language, though we sometimes use translators to deliver our trainings. Local trainers (such as teachers or other community members) are always trained to deliver the training and are also provided with menstrual products for their personal use so they are personally familiar with how the products work. WoMena's trainers then support the local trainers in teaching benefciaries with teachers sometimes translating the content of the training where necessary.

We rarely experience tensions related to the language we use, although people are often surprised to hear others speak so openly about menstruation and vaginas. Usually when we experience hesitancy around product use, we engage in open dialogue regarding the products (and any issues around its use) and ensure that all benefciaries understand that uptake is totally optional.

#### **What do you wish could be included in future curricula about menstrual health?**

There is a need to increase the focus of MH education on other parts of women's bodies especially myths around hymens, vaginal coronas, and virginity. This must frst focus on increased knowledge around basic female anatomy by health professionals as well as the social connotations surrounding it. All training curricula should ensure versatile activities and active participation of benefciaries, and move toward explanations through illustrative means, rather than simply text and words. Lastly, it would greatly improve implementation to have the best training curriculums translated into different local languages.

#### **What does the future of MH education and curricula look like?**

In Uganda and many other countries, the future for MHM education is bright. For example, MHM and menstrual cups are now included in the national curriculum in Uganda. There is more advocacy work being done by implementers of MHM with government and local leaders receiving more information regarding menstrual health issues. Male involvement in MHM education is also increasing, with the participation of men and boys in educational and advocacy initiatives at the grass root levels. Last but not least, WoMena is concentrating more on low-literacy populations in its curricula development which helps us to meet the needs of the most vulnerable populations. We can't wait!

# SRHR Africa Trust: Integration and Mainstreaming Menstruation into Health Programming

#### – Vicci Tallis

*SRHR Africa Trust (previously known as Southern African AIDS Trust) is an advocacy organization working around Sexual and Reproductive Health Rights (SRHR) and Gender Equality across Eastern and Southern Africa (ESA).*

#### **Explain your approach (SRHR, WASH, gender), and intervention?**

We work with communities, regional Non-Governmental Organizations (NGOs) and activists working for universal sexual and reproductive health and rights (SRHR) focused on girls, adolescents and young women to promote inclusive, equitable systems for health. We work in communities, districts, countries, and the region, while also having a global footprint in the policy and advocacy space.

Why menstrual health? We believe MH is a major concern for adolescent girls, and young women in the ESA region who lack access to adequate materials which restricts their choices and impacts negatively on their school attendance. We believe that contributing to the improved MH of girls and young women can reduce the risk of HIV infections. Evidence suggests that a lack of access to proper water and sanitation during menstruation and using non-appropriate materials for absorbing menstrual blood, can lead to vaginal imbalances and infections which have been associated with an increased risk of acquiring HIV, human papillomavirus as well as adverse pregnancy outcomes. At the SRHR Africa trust, we see MH as core to women and girl's health more broadly.

### **What makes your approach unique? How did you develop your curriculum and who did you consult?**

Our programming around menstrual health happens in different ways: (1) #TheGirlPlan; (2) Supporting local community based organizations; and (3) Youth hubs.

### #*TheGirlPlan*

We developed #TheGirlPlan to address the unmet needs of adolescent girls and young women and to improve the trajectory of their lives. #TheGirlPlan has six key, interlinked elements: keeping girls in safe schools, ending child marriage, addressing gender based violence, universal access to SRH services including modern contraception, comprehensive sexuality education and menstrual health.

We aim to promote adequate menstrual health through advocacy, capacity building and improvement of menstrual health facilities as critical parts of #TheGirlPlan. We have developed tools to equip learners and teachers to implement #TheGirlPlan in schools. These tools include booklets, posters and a YouTube video. The Menstrual health curriculum covers the following areas: (1) Education about girls' bodies and puberty; (2) Facilities and commodities needed for menstrual health—clean water, safe spaces et cetera; (3) Menstrual Products; and (4) Stigma and Discrimination.

As a result of this innovation, an increased number of schools now have emergency sanitary pads available and school attendance registers also report an increase of female school attendance. Girls also report that promoting menstrual hygiene has boosted their confdence and ability to participate in sports, despite having their period.

#### *Support for organizations*

Production of reusable sanitary pads is supported in three countries. SRHR Africa Trust (SAT) Zimbabwe was the pioneer, and designed and developed the reusable pad together with adolescent girls and young women through a participatory process. The reusable pad has passed scientifc tests of the Standards Association of Zimbabwe which checked for the safety of materials used and microbiological activity after use, washing and drying. Since then, Chiedza and SAT Zimbabwe have become part of the technical committee of the Standard Association of Zimbabwe.

It is important to support community partners with the provision of materials for making reusable sanitary pads in rural areas where levels of poverty contribute to a lack of access to menstrual products including pads. In Malawi, organizations have created mothers groups and identifed male champions to create an enabling environment for menstrual health. These groups are usually comprised of mothers, fathers, sisters and brothers of the girls who access the pads. Community based organizations are also involved in raising awareness regarding menstrual health through creative means. For example, Chiedza, our partner in Zimbabwe who is based in Manicaland, works with young people to express their menstrual concerns through drama, dance and music which provides a platform for young people to discuss different issues they encounter and create community-based solutions in response.

#### *Youth Hubs*

We develop programs for and with youth, paying particular attention to their voices and experiences. We are focused on growing, nurturing and supporting advocates across the continent in SRHR among the variety of projects and programs that SRHR Africa Trust runs. The primary purpose of our Youth Hubs is to bring together like-minded youth activists to convene, network and collaborate around SRHR advocacy issues in the region. The Hubs operate in Botswana, Malawi, Zambia and Zimbabwe. However, we also understand the need to include all youth and have virtual Hubs which attract young leaders from across the continent including Madagascar, South Sudan and Tanzania. Our Hubs carry out large-scale, out-of-the box thinking initiatives around SRHR and menstrual health issues. As they have grown and evolved their continued impact is seen at the grassroots level as well as in public policy as they advocate for change with their local governments.

#### **What kind of impact have you had?**

Young activists from the hubs have lobbied for increased and improved efforts of government and stakeholders to ensure that young girls have clean and safe toilets and washrooms with access to a range of menstrual products. Youth hubs have also engaged in media advocacy to address taboos associated with menstruation and starting conversations that de-mystify menstruation.

These conversations are driven by young people—whether they focus on advocacy around reducing sanitary pad tax, the implementation of hygienic washrooms in primary and secondary schools, inclusion of personal menstrual hygiene discussions in schools, or opening up discussions on the menstrual cycle to include management of menstrual cramps and the myths that the society creates pertaining to the management of menstrual cramps.

### **What languages do you use and are there any tensions or conficts about the language you use for menstrual health education?**

In most countries, the target audience determines our choice of language. Often discussions are held in multiple languages. Our materials are initially developed in English and then translated into local languages if needed with all materials tested in each country we work in. We also try and encourage discussions across the Southern African region—building regional movements that refect the diverse voices of young people who demand improved information and services.

### **What do you wish could be included in future curricula about menstrual health?**

The Youth Hubs play an active role in Menstrual Health day where we have adopted an inclusive, leave no-one behind approach. We actively work to reach out to, and raise issues affecting those often left behind—such as prisoners, women living with HIV, trans communities and refugees. We believe they are important to conversations around menstrual health and hope to see them included more in the future of menstrual health programming.

# The Cup: Education with <sup>a</sup> Special Focus on the Boy Methodology

#### – Steve Nganga Wambui, Camilla Wirseen

*The Cup Foundation is a California based non*-*proft organization founded in 2015 with a mission to empower underprivileged girls worldwide by providing them with sustainable menstrual cups and comprehensive education on sexuality and reproductive rights.*

The Cup runs a community empowerment program where underprivileged girls and their needs are at the center. The program is called The Cup Program and targets girls, boys, parents, teachers, elders and informal leaders. Girls are provided with three educational sessions and a menstrual cup while the boys are trained over the course of two sessions. The trainings usually take place in school settings with a focus on the trainers building a relationship with young people through role modelling. Teachers at the school are not allowed to participate in the trainings as they often have a complicated relationship with youths. It is instead young men and women who come from similar backgrounds who are facilitators. Our facilitators are often individuals who will have an easier time to connect with youths and who are able to provide an intimate and safe space.

## **Explain your approach (SRHR, WASH, gender), and intervention?**

The Cup believes there are three core issues facing adolescent girls growing up in challenging environments; poverty, cultural taboos around sex and menstruation, and gender inequality that often are inbedded in their culture. These challenges leave girls alone and with many gaps in basic knowledge putting them at risk for a variety of issues such as: teenage pregnancy, HIV, school dropout, sexual abuse, health infections, unsafe abortions, and low self-esteem. The Cup has developed a holistic manual which has a strong human rights perspective that targets many of the aforementioned challenges facing girls.

We believe that the only way to break down menstrual and sex related taboos taboo is by talking and including boys and men in the conversations around menstruation in order to break the stigma surrounding the issue. Closing girls off into one room and only educating them about menstruation will not challenge cultural taboos which are ingrained in society. During our boy focused sessions, the trainers engage in conversations about puberty and menstruation. We examine how reproduction is a natural part of human development with menstruation as natural, healthy and a normal part of girls and women's lives. We have found that boys are usually very curious, not shy and ask many questions.

We work toward building empathy and greater understanding among boys regarding period pain, discomfort, lack of solutions, leakages, shame, transactional sex, relationships, and parenting. We touch upon other important issues such as human rights, sex education, gender roles, hygiene, abuse, and HIV. We focus on empowering boys to be important allies to the women in their lives as brothers, boyfriends, husbands, and fathers. The boy curriculum also targets challenges that are specifc to boys own development and other issues such as drugs and crime.

#### **What makes your approach unique?**

The Cup Life Education Program is unique because it provides comprehensive education to adolescent boys and girls that goes beyond menstruation in order to tackle challenges that arise from cultural taboos and gender inequality more broadly. The program does not only have a comprehensive curriculum but is also holistic in its nature by including; informational meetings with the parents, teachers, and elders; a youth helpline to provide long-term support; and the links to access medical services and counseling sessions if needed. Our trainers play an important role within our educational program and are trained to communicate sensitively regarding these complex subjects and perform peer counseling. They are often selected based on their similar backgrounds and experiences as the youths they educate which improves the effcacy of the trainings. The manual and methodology is developed so it can be adapted to a variety of cultural contexts.

#### **What kind of impact have you had?**

The Cup has trained 20,000 girls and over 10,000 boys in Nairobi slums as well as other parts of Kenya since 2015. The decision to include boys in the training was seen as a necessary step to reach a healthier social environment among girls and boys and a way to challenge gender inequality. The cup has a general user acceptance of 80% and girls who are users express that they feel more comfortable, happy, relaxed and are able to concentrate in school. The female trainers are almost in every session able to identify girls who are in need of counseling or medical attention and the team supports them to get help whenever they can. We have also found that starting a conversation with the menstrual cup makes it is easier to speak about taboo topics that are usually avoided as the cup helps with entering into diffcult conversations with parents, teachers, and elders. Lastly, the number of girls missing classes due to lack of proper menstrual solution has gone down with the introduction of menstrual cup program in our intervention areas.

#### **What languages do you use and are there any tensions or conficts about the language you use for menstrual health education?**

Our trainers usually use Swahili and English depending on the context. However, they often make a point of talking the local slang called 'sheng' which makes the boys and girls feel relaxed and at home. The trainers are often dressed in a casual and relatable manner with jeans and sneakers. This casual dress code and use of local language helps to encourage the youths and create a safe space.

#### **How did you develop curriculum and whom did you consult?**

The Founder of the Cup, Camilla Wirseen, developed the curriculum after having read several health manuals and books on different topics aimed at youths from different origins and after having worked in the feld in Kibera for over 8 years with Peepoople, a sanitation solution of which she is the co-founder. Most ideas for the methodology came from interviewing the trainers and women who grew up in similar environments to identify the key relevant problems facing different groups as well as reading and analyzing the many anonymous questions that have been gathered since start of program from the girls and boys that have participated in the program. The manual was developed over a one-year period and is regularly revised and updated to refect any new learning from the feld. The curriculum is leaning on the International technical guidance on sexuality education by UNESCO.

#### **What do you think could be included in future curriculum about menstrual health?**

We believe that in the future most menstrual health curriculums and programs will become more holistic as menstruation cannot be separated from sexuality education. We see menstrual knowledge as central to health more broadly. For example, a lack of period is one of the signs of pregnancy. By only giving girls a basic menstrual education and solution, girls are left vulnerable to HIV and teenage pregnancy. Comprehensive and holistic menstrual health education can help to combat these related issues. At The Cup, we hope to men and boys as a central part of the menstrual conversation, and their involvement as key tackling taboos.

#### **What does the future of menstrual education and curriculum look like?**

As the founder of The Cup my hope for the future is that all adolescents, whether rich or poor, male or female will be reached with similar programs that provide comprehensive sexuality education with a human rights approach where the MHM is only one of the topics. I would also like to see programs that could be connected to health clinics so children and parents also have access to health care services in their communities. I don't believe that teachers are best equipped to talk to youths about such sensitive subjects wherever they are. Communication and trust is key in this regard. Much like people who are in need of counseling, require support from someone outside their circle and environment where there is no dependency, power relationship, or risk of abuse. I hope all young people have access to networks who can support them through puberty.

### References

**Open Access** This chapter is licensed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/ by/4.0/), which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license and indicate if changes were made.

The images or other third party material in this chapter are included in the chapter's Creative Commons license, unless indicated otherwise in a credit line to the material. If material is not included in the chapter's Creative Commons license and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder.

# Menstruation as Structural

# Introduction: Menstruation as Structural

# *Inga T. Winkler*

To recognize menstruation as structural, we must tune into the very political dimensions that undergird our institutions, laws, policies, budgets, guidelines, taxation, programs, and data collection. Historically, decision-makers have paid limited attention to menstruation—either due to oversight and neglect or due to deliberate exclusion. Yet, the last decade has seen enormous developments; at various levels, menstruation is rising to the level of global awareness. This might be what most distinguishes the current state of the menstrual movement from its past. Menstruation is gaining traction.

Examples of this shift abound. We see an emerging feld of 'menstrual hygiene management' as development practice. Policy advocacy is burgeoning, for example addressing 'period poverty' in the United Kingdom and 'menstrual equity' in the United States. Efforts to improve menstrual hygiene and health range from innovating and distributing products, building girl-friendly facilities in schools, raising awareness through broad-based campaigns such as establishing May 28 as Menstrual Hygiene Day, campaigning to lift the 'tampon tax,' developing national menstrual health policies in India, Kenya, Senegal, and many other countries, to embedding menstrual health in the Sustainable Development Goals.

Against this background, this section offers an overview and early assessment of these developments at various levels including those driven by practitioners, policy-makers, activists, and civil society actors. It seeks to capture these trends and initiatives through a combination of practice-based and research-based chapters that bring together different perspectives, voices, and experiences. This diversity is essential to engage different types of emerging knowledge in this feld and to combine practical experience with critical refection.

The section starts with a refection by Catarina de Albuquerque and Virginia Roaf on the origins of raising awareness on menstrual hygiene in the context of human rights. The account demonstrates that the water, sanitation and hygiene (WASH) sector has played a critical role in the early development of these efforts as it provided an entry point. However, they also acknowledge that there are obvious, but underutilized linkages with other felds including health, education, work, sexual and reproductive health and rights, culture, religion, among many others.

While these global developments have played a vital role in raising the profle of menstruation, governments and other actors at the *national* level have been instrumental in developing policies, programs, tax reforms, and advocacy campaigns. Archana Patkar traces the development of such efforts in multiple countries, exploring the pathways, challenges, and successes of embedding menstrual health in formalized national agendas. Swatija Manorama and Radhika Desai complement this policy analysis by taking a critical look at the gaps in Indian health policies, while Rockaya Aidara and Mbarou Gassama Mbaye offer insights into a menstrual hygiene management program in West Africa. Jennifer Weiss-Wolf offers an account of her involvement with the 'menstrual equity' movement in the United States, including her refections on the elimination of the 'tampon tax' as a gateway for activism. The strongest testament to the deeply political nature of menstruation is revealed by Stella Nyanzi's essay in which she details her bold efforts to hold the Ugandan government accountable for its promise to provide menstrual products to girls leading to her imprisonment for her critique of the Ugandan President, Yoweri Museveni.

Another key policy debate is about menstrual leave, which Rachel Levitt and Jessica Barnack-Tavlaris address in their chapter. This debate, possibly more than any other, shows that policies and other structural changes must not be developed in isolation, but accompanied by sociocultural resistance to menstrual stigma and gendered stereotypes. Introducing a menstrual leave policy in a particular context that is not yet equipped for it might have unintended negative repercussions for menstruators. On the other hand, the introduction of menstrual leave policies and other legislative, policy, and judicial developments serve to normalize menstruation and, in that way, can be very powerful.

In the subsequent two chapters, Libbet Loughnan et al. turn to exploring menstruation specifcally in the context of the Sustainable Development Goals and the monitoring frameworks they provide, and Siri Tellier et al. address humanitarian responses that point to the challenges that arise in the immediate aftermath of disasters as well as long-term protracted crises.

While menstrual hygiene and health programming is a rapidly developing and dynamic feld, this section seeks to provide an overview of the current state of knowledge, which also prompts us to ask 'where do we go from here?'. Venkrataman Chandra-Mouli and Sheila Vipul Patel map the knowledge of menarche and menstrual health among adolescent girls and generally fnd low levels of knowledge in many low- and middle-income countries, and the same holds true for many girls living in the Global North. Just as importantly, the section also acknowledges and draws attention to the fact that there is a lot we still do *not* know, while program and policy responses are moving at a rapid pace. Julie Hennegan provides a critical analysis of the evidence for menstrual health interventions in low- and middle-income countries, discussing the approaches which have been trialed to date and highlighting key gaps and new potential pathways. The "Transnational Engagements" edited by Victoria Miller and Inga T. Winkler on the emergence of the feld of menstrual health and hygiene conclude this section and similarly raise important questions about the status, development, and future directions of the feld, which warrant further exploration. The rapid momentum around menstruation as focus of intervention brings signifcant opportunities, but it also poses risks.

First, several of the chapters highlight the centrality of WASH in spiraling attention to menstrual hygiene. WASH is a largely technical sector focused on facilities and infrastructure. Moreover, many of the initiatives described in this section are focused on products: their distribution, use, regulation, safety, and taxation. While these initiatives can make valuable contributions (and surely most menstruators assert the need for something to bleed on or into), we observe a narrow focus on the provision of menstrual products as 'quick fxes,' losing sight of structural injustices, which can be addressed through the lens of menstruation. This narrowed focus risks obscuring broader questions of gender justice and body politics which underlie sociocultural perceptions of menstruation. Too few programs tackle the embarrassment and shame associated with menstruation at a deeper level and instead often reiterate (sometimes inadvertently) that menstruation is best kept concealed. We often hear that, for instance, initiatives in the WASH sector or the elimination of the 'tampon tax' can provide *entry points* for tackling the broader, structural challenges. It is time to honor that promise and to move from the entrance into the deeper structure. Only then will we be able to normalize menstruation.

Second, there is a risk of rushing toward poorly conceived policies that are developed on the basis of sensationalized accounts instead of reliable evidence. The widely cited claim that one in ten 'African' girls allegedly miss school because of menstruation, is one recent example of a claim without backing. The contributions in this section caution us to develop a solid evidence base for policy and program development. While many (in particular qualitative) studies detail the challenges women and girls face with regard to inadequate facilities, infrastructure, products, education, and other means of support, we must acknowledge that experiences of menstruation are very context-specifc and be careful not to overgeneralize from existing (small-scale) studies.

Third, there is a need to challenge the underlying assumptions of some interventions. As is often the case in global development, we must avoid the imposition of Western ideas, perceptions, or products without adequate regard for local contexts, such as the wholesale dismissal of menstrual cloth as a viable option. Such assumptions lose sight of the aim to enable empowered and informed decision-making, a move that can patronize menstruators. Because participation of the people concerned is key for something as personal as menstruation, many programs would beneft from devoting more time to understanding menstruators' priorities and preferences. Acknowledging the agency of women and girls and any menstruators requires that *they* must be able to decide how they want to cope on the days they menstruate, what activities and cultural practices they want to engage or avoid, and what materials they want to use to catch the fow (if at all).

Finally, there is a risk of rushing decisions and entrenching existing patterns of exclusion and marginalization. In our efforts to move menstruation from the margins to the center, do we leave some individuals behind? For instance, by framing menstrual health as an 'adolescent girls' issue,' do we ignore other women's health issues across the life course? Do we acknowledge women who do not menstruate as well as the needs and experiences of menstruators who do not identify as female? By focusing interventions on girls in schools, do we reinforce the marginalization of girls who are out of school? To respond to these challenges, future initiatives should consider how to most productively support, inform, and normalize the menstrual health of marginalized populations including people who are trans or gender nonconforming, live in poverty, experience homelessness, and/or are deprived of their liberty. We must tune into the experiences of people who are on the move or live with a disability, as well as others living in various conditions of precarity (see "Part I: Menstruation as Fundamental" of this Handbook). We need more emphasis on the lived realities and experiences of *all* menstruators to inform policy-making, programming, innovation, and data collection to ensure that no menstruators are excluded.

Policies and other instruments can be a powerful normalizer that recognize menstruation as requiring political attention, but such normalization and structural change can only be achieved when policy-making and programming include initiatives to challenge sociocultural norms and menstrual stigma. In order to bring about such structural change we need to think about menstruation in a comprehensive way and use it as a lens to identify and address injustices at the intersection of gender and a range of other identities.

**Open Access** This chapter is licensed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/ by/4.0/), which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license and indicate if changes were made.

The images or other third party material in this chapter are included in the chapter's Creative Commons license, unless indicated otherwise in a credit line to the material. If material is not included in the chapter's Creative Commons license and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder.

# Practice Note: Why We Started Talking About Menstruation—Looking Back (and Looking Forward) with the UN Special Rapporteur on the Human Rights to Water and Sanitation

*Virginia Roaf and Catarina de Albuquerque*

**Virginia Roaf:** Catarina, we have been asked to refect on your work as Special Rapporteur on the human rights to water and sanitation,1 and how it was that we started to work on menstruation as a human rights issue over a decade ago. What do you remember of that time?

**Catarina de Albuquerque:** It is a great opportunity to look back and see how far we have come! It is already over a decade since I became Special Rapporteur—and so much has moved on since then in terms of discussions on menstruation and menstrual health and the importance of this for achieving gender equality. I started my mandate on human rights, water, and sanitation with a consultation on sanitation, as this was the aspect that needed the most attention. At that time, the right to sanitation was very much the poor cousin of the right to water. Further, 2008 was the frst UN International Year of Sanitation, and as such, sanitation was being recognized as a 'problem child' of the Millennium Development Goals, always relegated to second place in comparison to water.

Virginia Roaf, specialist in the human rights to water and sanitation, was an advisor to Catarina de Albuquerque from 2010 to 2014.

Catarina de Albuquerque was the UN Special Rapporteur on the human rights to water and sanitation from 2008 to 2014.

**Virginia Roaf:** I remember that your focus on sanitation, both in your frst report to the Human Rights Council on sanitation in 2009, as well as during your country visits to Costa Rica, Egypt, and Bangladesh of that year started you thinking about the need for better access to sanitation in schools, in particular for girls.

**Catarina de Albuquerque:** During those visits, I was particularly looking at girls' sanitation needs and, in visiting schools in Bangladesh, I learnt that girls' needs for privacy, adequate sanitation, clean water, and somewhere to change and wash themselves and menstrual products was preventing some adolescent girls from attending school. I also visited several community initiatives to raise awareness about menstrual hygiene, especially among adolescent girls. Menstruation was in Bangladesh, as elsewhere, taboo, and so I was impressed by the efforts of the communities I visited to ensure that girls are aware of adequate menstrual hygiene and that they have access to appropriate facilities. In my report to the Human Rights Council, I recommended that the government should ensure that women and girls have access to information about menstrual hygiene, and that sanitation facilities enable them to practice good menstrual hygiene (de Albuquerque 2009, Paras. 18, 69, 125).

**Virginia Roaf:** I remember that this was a pretty fertile time for those of us working with you on your mandate—we started working on menstruation at a broader level in response to what we learnt from women and girls following your country visits.

**Catarina de Albuquerque:** Absolutely, my visit to Bangladesh informed the rest of my mandate in terms of the needs of menstruating girls and women, not just in schools but across all aspects of their lives, at home, in the workplace and beyond. Menstrual hygiene and health became an additional consideration to be included within the requirements of the human right to sanitation, and all subsequent visits and most thematic reports included a consideration of the needs of women and girls due to their menstrual cycle as a matter of course.

**Virginia Roaf:** As I remember, one of the messages you wanted to convey over the course of your mandate was that human rights are universal and are to be applied equally all around the globe. People working within the development discourse often imagine that human rights are more likely to be violated in developing countries. What did you fnd with respect to menstruation in this regard?

**Catarina de Albuquerque:** While many may consider the taboos and stigma of menstruation to be something to be concerned about in developing countries, I found the same stories of discrimination when I visited Slovenia in 2010, when visiting a Roma community. One Roma woman told me about the shame she felt about the conditions in which she had to practice her menstrual hygiene. Even when the women were able to wash in the river in the spring and summer months, they risked being chased away by the local police, which they considered humiliating. This lack of adequate hygiene perpetuated discriminatory stereotypes about Roma among Slovenians, and I was keen to shine a light on that (de Albuquerque 2010, Para. 36).

The toll of poor menstrual hygiene and the stigma associated with menstruation on women and girls was also apparent in my mission to the Pacifc Islands of Tuvalu adolescent girls told me that they sometimes skipped school during their periods because they could not afford to buy menstrual pads, and that families sometimes had to compromise on other daily necessities in order to provide their daughters with menstrual pads (de Albuquerque 2013b, Para. 32). Moreover, on the Pacifc Islands (and I also visited Kiribati), disposal of all waste, including menstrual pads is a problem in atoll islands; Kiribati has no land on which to dump waste and does not recycle its waste (de Albuquerque 2013c, Paras. 35–36).

**Virginia Roaf:** What other experiences do you remember that women have shared about how they managed their menstruation?

**Catarina de Albuquerque:** On mission in Thailand, I remember asking one migrant worker how she bathed at the open bathing point especially during menstruation, and she told me: "I just shut my eyes and wash myself as quickly as possible, so that it is done" (de Albuquerque 2013a, Para. 25).

But the lack of attention to menstruation is something I recall everywhere I went. When I visited refugee camps in Jordan in 2014, one girl told me that the menstrual pads are such poor quality that she could not leave home for fear of leakage. I believe that this issue has since been addressed, and the menstrual pads provided by the humanitarian services have improved (de Albuquerque 2014a, Para. 53; see also Tellier et al. [Chapter 45] in this volume).

But the problem is the same whether among people in so-called developed or developing nations, refugees or nationals. On my visit to Kenya, women and girls shared their stories of how diffcult it is to reconcile their menstruation days with attending school or working. A small pack of menstrual pads in Kenya costs KSh.80 on average; women in informal settlements and girls in communities living in poverty all said they could not afford them and therefore use a piece of cloth instead that can be diffcult to wash out due to scarcity of water.

I was impressed by the courage of one girl in a remote area in Kanyadhiang who openly said, after being asked what she wanted most to have a better life "I want one more pair of panties because I only have one and I need to wash them daily and I want sanitary napkins" (de Albuquerque 2014b).

**Virginia Roaf:** Would you say that you had moments of hope, where women's and girls' needs were being considered?

**Catarina de Albuquerque:** Absolutely, yes. In Turkana, the poorest county in Kenya, I learnt that the county government was providing menstrual pads to secondary school girls. This has since been expanded to cover all 4.2 million school girls in Kenya. I would love to see all countries in the world adopt similar measures, to give menstrual hygiene greater political and budgetary visibility for menstrual hygiene (de Albuquerque 2014a, Paras. 61, 80–81).

**Virginia Roaf:** I visited Kenya in late 2018, and the people you traveled with then are still talking of your visit and the recommendations that you made. Impressively, they have been incorporated into the work of the Human Rights Commission in Kenya, which now has a unit dedicated to the human rights to water and sanitation, and on an even better note, a menstrual hygiene policy is going through the fnal stages of approval in Kenya, and as you mentioned, free menstrual pads are now available in schools (Global Citizen 2018). Things do indeed change for the better (see Patkar [Chapter 38] in this volume)!

**Catarina de Albuquerque:** Meeting with girls and women and talking about menstruation on country visits was always a highlight. The discussions we had elicited much laughter, but also embarrassment. The stories that girls were telling about their experience of getting their frst period, the lack of information on how their bodies were developing, what this meant for their lives, their worries about attending school, their lack of medical or social support with their periods rang true with me, and I think with all of us in the team. Perhaps because we were mostly (sometimes exclusively) female, we could relate to what women and girls were experiencing.

**Virginia Roaf:** I think that in our sector, we often focus on the material solutions, better construction, the technologies, even better menstrual products. But within these stories, it became clear that the problem also contained an enormous need for education, understanding, and for acceptance—not just for girls, but for boys, for women and men, for the whole of society to be better informed on menstruation.

**Catarina de Albuquerque:** Absolutely, it was through these discussions with girls and women on country visits, that I identifed the stigmatization of women due to their periods as a signifcant barrier to resolving a whole host of other issues related to menstruation, such as reproductive health, education, and gender equality. And since the unique mandate of a Special Rapporteur is listening, I was able to experience the lived experiences of women and girls and then take these to the level of the UN in an attempt to infuence policy-making and programming.

**Virginia Roaf:** I remember that one of the most signifcant issues was a lack of data—and the information that existed was full of assumptions and anecdotal evidence. Considering women and girls' needs relating to menstruation, and their negative experiences relating to menstruation, all over the world, certainly not limited to developing countries, we identifed the need for more research, as data on women and girls' menstrual needs was, and continues to be extremely limited. We also identifed taboos suggesting that people consider menstrual blood to be 'dirtier' than other blood. Specifcally, I remember working with you to prepare your keynote at a session at the World Water Forum in Marseille, in 2012, and that was one of the frst times that menstruation had a dedicated session. What do you remember of that event?

**Catarina de Albuquerque:** I was invited by the UN Water Supply and Sanitation Collaborative Council to give the keynote at their session on menstruation, in recognition of the work that I had already done to popularize menstrual hygiene as a signifcant barrier to the realization of the human rights to water and sanitation. In my address, I identifed the taboo of menstruation preventing progress on the achievement of gender equality. In fact, I remember starting that keynote stating that I, too, menstruate, and it was seen as a brave intervention!

**Virginia Roaf:** I believe it was partly in response to these discussions that we decided to dedicate your 2012 report to the Human Rights Council to the impact of stigma on the realization of the human rights to water and sanitation.

**Catarina de Albuquerque:** Yes, it was clear to me that we needed to look at discrimination in a more nuanced way, and we decided to focus on stigma as one of the key underlying factors that infuences so many of our perceptions of women and girls. Of course, menstruation had to be part of that. At the time, I wrote:

The silence and stigma surrounding menstruation makes fnding solutions for menstrual hygiene management a low priority. Menstruating women and girls often lack a private place to change or wash the rags used. Menstruation has many negative cultural attitudes associated with it, including the idea that menstruating women and girls are contaminated, dirty, impure or polluted. These manifest in practices such as the seclusion of women and girls, reduced mobility, dietary restrictions, and/or women and girls being required to use different water sources or prohibited from preparing food for others during menstruation practices that are often deeply rooted in sociocultural and patriarchal interpretations of religious prescriptions. Even where such restrictions are not followed, women and girls may continue to harbour internalized stigma and are embarrassed to discuss menstruation. The lack of privacy for cleaning and washing, the fear of staining and smelling, and the lack of hygiene in school toilets are major reasons for being absent from school during menstruation, and have an education. (de Albuquerque 2012, Para. 25)

**Virginia Roaf:** As I remember, it was about this time that we started engaging with discussions on the post-2015 agenda (which became the Sustainable Development Goals or SDGs). Our goal was to integrate attention to menstrual hygiene at yet another level. Your team was represented in all the water, sanitation, and hygiene preparatory technical working groups, including the sanitation and hygiene working groups in particular. At the end of the process, in November 2012, we recommended that menstrual hygiene to be included in the future post-2015 goals, targets, and indicators (UNICEF/ WHO Joint Monitoring Programme 2013, 2–3, 6). While this recommendation was not included in the Sustainable Developments Goals themselves, different UN agencies, including the UNICEF/WHO Joint Monitoring Programme, have emîbarked on signifcant efforts to improve monitoring of menstrual hygiene and to collect more comprehensive data on menstruation (see Loughnan et al. [Chapter 44] in this volume).

**Virginia Roaf:** It is now nearly ten years later and it is interesting to refect how far the conversation has come. A flm on menstruation has even won an Oscar this year—what should we take from this?

**Catarina de Albuquerque:** It's true, and gratifying that this issue has been taken up so widely and with such enthusiasm across the globe. Menstrual hygiene and health have become part of mainstream policy-making, programming, and advocacy efforts. Organizations and governments are working on a range of aspects related to menstrual health including sexual and reproductive rights. There is a marked difference to when we started talking about menstruation. The menstrual health agenda is starting to reach far beyond the Water, Sanitation and Hygiene (WASH) sector which is essential to address the full range of human rights issues related to menstruation.

**Virginia Roaf:** Yes. And yet, over a decade ago, the WASH sector was an ideal entry point for starting the conversation on menstrual health. What prompted us to consider menstruation as part of your mandate on water and sanitation were the stories women and girls told you. They mentioned their very real needs in terms of access to facilities and materials. The predominantly male engineers working in water and sanitation were surprised to hear that menstrual hygiene was something that also lay within their remit, but once the initial surprise was overcome and the silence around menstruation was broken, most WASH sector professionals were open and eager to address the issue and to start fnding solutions for the immediate needs by women and girls. This focus on tangible and concrete measures is a huge part of what triggered the increasing efforts on menstrual hygiene management.

Frustrating as it remains that many women have the primary role as homemakers and as caregivers, water and sanitation are still particularly critical issues for women. Therefore, I do feel that considering menstrual health through the lens of the human rights to water and sanitation still makes sense, although I think it is not the only lens that we should be using. Through access to adequate water and sanitation services, which include consideration of privacy and dignity, and which comply with the standards of the human rights to water and sanitation, many issues relating to menstrual hygiene and health will be addressed. Adequate water for washing ourselves and our menstrual pads, a place to safely dispose of used menstrual materials, sanitation facilities available at school, at the workplace, and elsewhere, these services address requirements for menstrual hygiene. And precisely because the WASH sector is perceived as rather technical, it provided an 'innocuous cover' to start addressing issues that are ultimately about deeply entrenched gender norms.

**Catarina de Albuquerque:** I absolutely agree. But at the same time these benefts point to the risks associated with addressing menstruation exclusively through the lens of WASH due to the heavy focus on tangible outputs, facilities, and the provision of materials. While the WASH sector proved to be an excellent entry point, we must get past this narrow understanding of menstrual hygiene to fully embrace menstrual health. The World Health Organization defnes health as "a state of complete physical, mental and social well-being and not merely the absence of disease or infrmity" (WHO 1946) and we must embrace all these dimensions in relation to menstruation. This entails education, reproductive and mental health, working conditions, as well as sociocultural taboos. To manage our periods and menstrual health more generally, it is essential that we understand how our bodies work and are able to fuently express what we need in terms of help or support when things go wrong. The taboos regarding menstruation, for example, extend to the lack of attention that the medical profession pays to poor menstrual health. For example, the symptoms of endometriosis are not well understood and too often dismissed by health care providers. Women and girls need better education about their bodies. Men and boys must also be educated on the menstrual cycle and women and girls' needs to manage their menstruation, so that they can respond with understanding and not fear. Menstruation is also deeply enmeshed with cultural and religious traditions, and we need to approach the discussion of such practices with more nuance. I am emboldened by the efforts of women and girls across the globe to treat menstruation as a fact of life and to resist attempts to restrict them, for instance from accessing cultural or religious sites.

Refecting on where we began over a decade ago and how far we have come, I think we are truly beginning to realize that menstruation is a gender equality issue that affects the realization of all human rights. Menstruation is about so much more than blood and the materials and services (in the context of WASH) that we need to deal with it. I am glad that we were able to identify this entry point in the WASH sector and that I could contribute to normalizing menstruation all over the world, beginning with my discussions with the girls in Bangladesh to the Palais de Nations in Geneva.

### Note

1. An independent expert mandated by the UN to promote compliance with and examine violations of the human rights to water and sanitation.

### References

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# Policy and Practice Pathways to Addressing Menstrual Stigma and Discrimination

*Archana Patkar*

### Introduction

I vividly remember being shushed at any mention of menstruation as a potential factor in absenteeism and poor learning achievements among adolescent girls in school in India. As recently as 1994, menstruation was the ultimate unmentionable, shrouded in multiple veils of forbidden sexuality and silent patriarchy. It did not help that there were no national policies that included menstruation, and none of the international human rights instruments explicitly mentioned it (Winkler and Roaf 2014). Working on education, adolescent health, and water and sanitation, I was struck by the systematic neglect of the human life course in the design of the built-up environment and seized every opportunity to understand and address menstrual stigma in policy and practice.

People at home, school, in the felds, offces, while traveling or playing a sport all ached with silent resentment at the ignominy of the monthly period because they were forced to suffer it in shame and silence. Adolescent girls were often uninformed and unprepared for menarche. Exclusion and shame led to misconceptions and unhygienic practices during menstruation (Chandra-Mouli and Patel 2017). The pattern repeated itself when conversations expanded to include persons with disabilities or HIV; those who had been genitally cut or who suffered from fstula; or those negotiating questions of gender and sexual identity. Discussing menstrual fows with the transgender community revealed a complex web of intersecting stigma around identity, occupation, class, age, caste, and ethnicity. With every conversation I engaged in, people of all ages poured out their thoughts, ideas, fears, hopes, and demands around menstruation.

It was evident early on that, freed of stigma and mysticism, menstruation and its practical challenges might actually be nonthreatening and universal enough to stride across geographical context and sector silos as a powerful, positive disruptor for gender equality. Engineers, administrators, medical practitioners, nurse-midwives, hygiene promoters, educators, adolescent girls and boys, women and men from all walks of life and at different stages of life shared, listened, learned, and took a pledge to break the silence and walk without shame. Across national boundaries, from village, ward, county, province, and state, these voices rose to a crescendo that could not be ignored.

This chapter seeks to share a transformative policy pathway to gender equality using noncontroversial and pragmatic yet universal entry points, such as water, sanitation, and hygiene (WASH), to make explicit women's silent and neglected needs around menarche and menstruation. It draws on my professional experiences: frst, from 1994 to 2010, as an independent adviser on education, health, WASH, and urban poverty projects to many governments and development partners; then, from 2010 to 2018, as head of policy at the Water Supply and Sanitation Collaborative Council (WSSCC), a small organization within the United Nations working on sanitation and hygiene, with national governments in Asia and Africa.

The approaches employed in this work included a judicious mix of advocacy related to policy, systems behavior change, and the media (see Naeve et al. 2017). They often operated simultaneously and at different levels to build critical mass and reach tipping points for change. The process relied on making the voices of thousands of women and girls in Asia and Africa heard. These voices rang clear and true; they changed the perceptions, understanding, attitudes, and openness of diverse populations and their policy makers, who cast away age-old taboos to ask questions, learn, and embrace the universal truth of menstruation.

As a result, between December 2013 and 2019, India and Senegal published and Kenya approved menstrual hygiene/health policies and guidelines that broke the silence on menstruation and recognized menstruators' needs for basic services. Afghanistan, Bangladesh, Bhutan, Cameroon, Maldives, Nepal, Niger, Sri Lanka, and Tanzania followed suit, initiating trainings and institutional changes to health, education, and WASH government guidelines, budgets, and projects. A corpus of facilitators1 trained in gender equality and menstrual hygiene management (MHM), built a cadre of government offcers who championed a carefully thought-through policy advocacy and practice agenda.

# Sanitation and Hygiene Are Powerful Entry Points for Change

The language of WASH has long been one of taps, toilets, and soap, with people absent from the conversation. The recognition of the right to water and sanitation in 2010 (UNGA 2010) and the subsequent distinction and separation of the right to sanitation in 2015 were crucial milestones to move the sector forward (UNGA 2015; Winkler 2016). However, there remains a wide gulf between the rudimentary sanitation infrastructure available to those living in poverty and the obligations enshrined in these rights (Patkar 2016).

Far from being a pleasant experience, toilets, hand-washing facilities, and water points are often wet, damp, ill-smelling, dimly lit, unhygienic spaces where one can slip, fall, hurt oneself, or fall ill. Worse, sanitation services are heavily gendered, and women across the world report a fear of being followed, seen, touched, or violated (Kulkarni, Bhat, and O'Reilly 2017). Several studies have shown the intimate connection between the sanitation environment and the physical and mental well-being of women and girls (O'Reilly 2016; Sahoo et al. 2015). Furthermore, trans men and women feel unwelcome in single-sex toilets worldwide and are at risk of violence in these spaces (Boyce et al. 2018).

Urination, defecation, bathing, changing, and washing are basic, everyday needs that require privacy, comfort, and dignity. Women's and girls' sanitation behaviors are more expansive than urination and defecation (Sahoo et al. 2015), but these are often overlooked in policy, investments, and initiatives (WaterAid 2013). There has been surprisingly little analysis when it comes to the question of whether toilet access, design, or programs satisfy female needs around menstruation, menopause, and infant or elder care (Burt, Nelson, and Ray 2016). More generally, Phadke, Khan, and Ranade (2011) present a powerful refection of women's experiences, encounters, and negotiations in urban public spaces in India. They eloquently illustrate that public spaces streets, parks, playing felds, and courts—have been designed without women in mind and are therefore primarily frequented by men, excluding women and restricting their presence, visibility, and voices.

But it is just as possible to imagine a reversal of these gendered environments. Reimagine, if you will, public spaces redesigned to accommodate women and men of all ages, including menstruators, pregnant women, elderly persons, and caregivers with babies or young children. Imagine spaces where menstruators are able to change their menstrual materials, wash their cloths freely without being ashamed or ridiculed, dry them in the sun, and inhabit public spaces with confdence because they are sure of fnding facilities to wash and change wherever they go. Imagine the breaking down of unconscious biases so that one day we can think of unisex washrooms that all genders can use without fear.

This simple yet inclusive reimagining of the world around us provided the underlying principles for the policy and practice change I sought. Because sanitation and hygiene require spaces that come with a certain conceptualization of use, toilets, washbasins, and their surroundings have the potential to help us think differently about human needs. There is something about the very basic human need to relieve oneself that is indisputably universal.

### Proof of Concept: From Listening to Policy Development

#### *Embarking on the Journey*

The journey began in India in 1994, when I worked with the state government on the District Primary Education Programme of Madhya Pradesh. The program was launched to achieve the objective of universalization of primary education. In the 1990s, Madhya Pradesh was a state plagued with a deteriorating male-to-female ratio, high maternal mortality, large gender gaps in education, and poor female participation in the workforce (Prabhu, Rampal, and Shukla 1995). Endowed with visionary leadership in the Ministries of Education and Finance,2 the powerful combination of human and fnancial resources and political will, positioned Madhya Pradesh to be a fagship state for achieving parity in primary education.

Madhya Pradesh was not alone in grappling with girls' frequent absenteeism, low motivation, and eventual dropping out of school. The links with menarche were unmistakable: restricted interaction, play, and mobility; reduced confdence; withdrawal and other behavioral changes; and low motivation to continue secondary school (Sommer et al. 2016). In my own state of Maharashtra, I witnessed frst-hand the immense water and sanitation burden that women and girls experienced every day as water collectors, carriers, managers, and household and street cleaners. Sanitation duties were reserved for women and 'lower-caste' men, bringing with them distaste, discrimination, and exclusion. Menstrual blood—the mere mention of it—triggered the same reactions (see Sukumar [Chapter 13] in this volume). No one wanted to talk about it. Menstruation was socially, politically, and culturally unmentionable. Anyone articulating it was politely ignored. This complete denial meant that parents and teachers alike could not show interest in the topic. The 'menstrual lag' was systematic and seemed to persist even in schools with decent infrastructure. Teachers simply skipped over the reproductive health chapter or asked students to read it at home (Singh 2019). The human body and how it reproduced was a mystery to be magically unlocked once a couple tied the knot. Concepts of sexual attraction were entirely absent from the conversation, as was the link to reproductive anatomy and function (Thirunavukarasu and Simkiss 2013).

I came up against the same silence, reticence, and opposition when seeking answers in other sectors. Specialists in reproductive health, life skills, and WASH had never really thought about menstrual health (Bharadwaj and Patkar 2004). Privately, policy makers acknowledged that the issue 'may' be important but complained about the lack of data, social mores, and worries about 'corrupting' our girls if we talk about 'it'—'it' being closely related to sexuality. While everyone I spoke to agreed in principle,3 many enlightened health and WASH professionals at the time simply felt that there were so many other important issues, this one could wait (Bharadwaj and Patkar 2004).

But women could wait no longer. They wanted to talk about menstruation. They wanted to learn about their bodies. They wanted to have information and make choices. In focus group after focus group over the next ten years across India, and later in Cambodia, Senegal, Kenya, Niger, Nigeria, Tanzania, Bangladesh, Bhutan, Nepal, and Sri Lanka, women and girls opened up after the initial silence and embarrassment. Young girls and older married women alike, bombarded us with questions that they had never been allowed to ask. So did men and boys.

#### *Listening: The Menstrual Hygiene Management Lab*

The Nirmal Bharat Yatra, also called the Great WASH Yatra, a traveling carnival organized by the Government of India in partnership with WASH United, was a golden opportunity to make this silent demand heard (Desai 2012; Chanam 2012; Fernandez 2012). Conceived originally to deliver two important messages—stop defecating in the open and wash your hands at critical times with soap and water—we added a third: Manage your menstruation hygienically and with safety and dignity (Patkar 2012). This was a never-before-heard message in the government's health and WASH arsenal and a critical frst step in breaking the silence. Neither cautious nor careful, it was broadcast with fanfare and the endorsement of Bollywood celebrities who talked about menstruation and sanitation in the same breath, with the blessings of the then-minister for Drinking Water and Sanitation, Jairam Ramesh (Gottipati 2012; YouTube 2012).

In 2012, a small team4 designed the Menstrual Hygiene Management Lab (MHM Lab) as part of the Great WASH Yatra that journeyed through fve Indian states and 2000 km over 51 days (WaterAid, WSSCC, and Unilever 2013). Some 12,000 girls and women took part in focus group discussions, and the Yatra team collected preliminary data from 747 participants. Women, girls, men, and boys—everyone wanted to know about their bodies, learn to express and manage their secret fears and worries, feel clean, smell good, understand their sexual needs better, and be in control of their body and mind. The original MHM Lab design was conceived as a safe space for women, but we realized at our frst stop, in Wardha, Maharashtra, that we had to include men and boys.

The questions did not stop at menstruation, as grandmothers, young men, and boys focked to the MHM Lab to participate in focus groups and individual interviews conducted by our volunteers and partners.5 The results showed that 70.9% of the girls had no idea what was happening when they began to bleed and boys could not understand why girls suddenly stopped talking to them or playing with them (WaterAid, WSSCC, and Unilever 2013). All Lab participants, male and female, understood the menstrual cycle, made and wore a 28-bead sparkling saffron-and-red bracelet that represented the menstrual cycle and took the pledge to break the silence (Chanam 2012; George 2012).

Thus, the MHM Lab served two interlinked objectives: It was a safe space to talk about menstruation at a time when this was still unthinkable and, it allowed us to build the evidence for policy change and refne the prototype training toolkit. The methodology of the MHM Lab was later refned and published as *The MHM Lab Manual*, endorsed by the Government of India as a training methodology for raising awareness and replacing stigma around menstruation with practical information and pride in one's own body (WSSCC 2013c). National, state, and district offcials witnessed the evidence in action, which paved the way for policy reform.

#### *Evidence for Policy and Capacity Development*

The Union Minister, H.E. Jairam Ramesh, visited the MHM Lab and experienced frst-hand the intensity of discussions and the massive queues before the tent (Gupta 2013). The news traveled quickly. Everywhere the Great Wash Yatra pitched its tents, the facilitators and managers of the MHM Lab met with state and district offcials, principals, school teachers, and opinion leaders in addition to thousands of men, women, boys, and girls to talk about the issue and seek joint solutions to destroy the stigma and neglect that menstruators faced (Patkar and Deschaine 2014). This laid the groundwork for policy discussions at the state and national level.

Campaigns to build awareness and advocacy by powerful politicians and celebrities are important in initiating change. Certainly, they create a buzz, prod the media, and bring unmentionables to the agenda (Ma 2016). But as a long-term skeptic of advocacy's unfnished business and largely unmeasured effectiveness (see Puri 2016), I was determined to hitch the learning outcomes of the Yatra, impressive in terms of diversity and scale, to the readiness of the Ministry of Water and Sanitation to break the silence on menstruation in national policy.

On my next visit to the Ministry of Drinking Water and Sanitation in New Delhi in early 2013, Joint Secretary Jitendra Mathur, Directors Vijay Kumar and later Sujoy Mojumdar, and their colleagues were fully aware of the success of the MHM Lab. The conversation with the ministry moved rapidly: What would the integration of MHM into the national policy on water and sanitation look like? What were the budgetary implications? What capacity to implement change was needed, and how would this be built within the government system? How could the change on the ground be monitored for uptake, learning, and improvement?

Working with slim resources and the existing normative mandate of the Government of India, government partners and my team, we sought opportunities within existing government schemes to break the silence on menstruation. Putting together an amendment to the Nirmal Bharat Abhiyan (Total Sanitation Campaign) (Indian National Congress 2018) was a straightforward solution: Simple, easily understandable language that could immediately be translated into budgets and local plans across the country's 29 states, 725 districts, and 7 union territories. The three paragraphs deliberately contained no human rights language and almost erred on the side of brevity. They simply stated that existing funds may be used "to raise awareness, information and skills on menstrual hygiene management" and to "implement safe disposal solutions for menstrual waste" (Ministry of Drinking Water and Sanitation 2013). The language used matched that of the existing water and sanitation policy and was therefore practical, output-oriented, and designed for use by planners and engineers. The aim was to get this off the ground—and it worked.

In September 2013 Pankaj Jain, the secretary in the Ministry of Drinking Water and Sanitation, Government of India, endorsed and launched the MHM toolkit at the frst national MHM training for government offcials from health, WASH, social welfare, and public administration held in New Delhi (WSSCC 2013a, 2013b, 2013c). Sixty-two participants from the states of Uttar Pradesh, Jharkhand, Bihar, Madhya Pradesh, Chhattisgarh, Uttarakhand, and Delhi attended the four-day training. The response was tremendous, resulting in demand and follow-up trainings in southern and western India.

In 2014, under the Modi government, menstrual hygiene was maintained under the national Clean India Mission (Swachh Bharat Mission)6 guidelines, which state, "Issues relating to women's personal hygiene namely menstrual hygiene are to be focused under the Swachh Bharat Mission (SBM). Girls and women have hygiene and sanitation needs linked to their menstrual cycle. Women suffer in the absence of knowledge about safe practices on Menstrual Hygiene Management (MHM)" (MDWS 2017). The guidelines provided funds to conduct information, education, and communication activities to raise awareness among all stakeholders about MHM, including why menstruation occurs and how to manage it safely (washing, cleaning, using, and changing clean absorbents regularly) and menstrual waste management (safe disposal solutions for used cloths and pads).

### Extrapolating a Pathway and <sup>a</sup> Methodology

With MHM now frmly in national policy, a mammoth task lay ahead. Developing a pathway for menstrual health involved (1) deepening the engagement in India with a strategy to percolate the change holistically to local levels; (2) leveraging the momentum to expand menstrual health policy development to other countries and regions; (3) expanding the agenda to address other taboo topics; and (4) addressing the diversity of menstruators' needs.

#### *Deepening the Engagement in India*

Breaking the silence in policy was seen as a real victory by the ministry staff, who became passionate advocates for MHM. The language of the policy amendment was deliberately short and sharp, but it prioritized the frst prong of increased information, education, and communication through sequencing of activities and funding. However, the tangible quickly takes precedence over slower, deep-rooted changes. The proxies that proliferated were menstrual absorbents, subsidies, handouts, unsustainable projects, and the endless rounds of training that poor women in communities often undergo to learn about their own stark realities. Despite the publication of MHM Guidelines with a focus on girls (MDWS 2015), MHM remained on the periphery of the Swachh Bharat Mission, whose primary aim was to make India open-defecation-free by October 2019 (MDWS 2018). As it became easier to talk about menstrual hygiene, sanitary pad distribution schemes became the favor of the moment. Without complementary information, counseling, and support mechanisms in place, adolescent girls were unable to or chose not to use them (Chandra Sharma 2018). These schemes did little to change the narrative or to recognize and value the diverse experiences of menstruators across the life course. As Chris Bobel argues, "the largely product-based solutions that often follow fail to challenge the social construction of the menstrual body as dirty and in need of concealment" (2019).

The persistence of menstrual stigma points to the challenges of using the WASH sector, with its focus on hygiene and tangible solutions, as an entry point. Working with policy makers, it was prudent to couch activist actions for example, breaking the silence on menarche and menstruation—within the instrumentalist language linked to budgets and measurable outputs. The water and sanitation sector, ever pragmatic and action oriented, offered the ideal launch pad. However, without parallel mechanisms and advocacy stressing participation, voice, and choice, there was always a risk that change would be limited to physical design around taps and toilets, pads and cups. This would ignore the crucial need for refection, spaces for dialogue, learning and sharing between men and women, and the myriad expressions of gender and sexual identity that are needed to replace body stigma and shame with knowledge and pride. MHM can too easily be co-opted by a training, pad-manufacturing, and distribution army, leaving notions of voice and agency far behind. Once the initial euphoria linked to a holistic approach dies down, champions leave and the dust settles, policies intended to be transformational are often narrowly interpreted. The menstrual hygiene movement seems to have settled on WASH facilities, tax-free pads, and incinerators as key indicators of action and success. Encompassing broader questions of menstrual health has thus far proved challenging in India, but the policy change can only be applauded as progressing a transformative agenda in a complex and diverse country of 1.4 billion people—a country in which the right to reproduction is traditionally seen as a family health and well-being issue (Kosgi et al. 2011) and menstruation, especially for young girls, means that marriage and childbirth are the next rites of passage into adulthood (CREA 2005). The developments to date are important early steps that have unleashed language, conversations, and demands that have been suppressed for centuries. And with them come a furry of innovative strategies, resources, and programs to make up for lost time in India and beyond.

#### *Broadening: Testing the Proof of Concept for Universality and Scale in Africa*

If senior, male government policy makers could talk about menstruation in the patriarchal states of Northern India, could the same be achieved in other geographies using the same methodology? Building on the success in India and momentum created at the international level through a series of advocacy events (ANEW 2013; Naafs and Brewer 2013), it was time to test the waters in Africa. In September 2013, a small team,7 in partnership with UNICEF WCARO in Dakar, Senegal, organized the frst-ever multicountry training workshop on menstruation for government offcers from 22 countries in West and Central Africa (ANEW 2013). Regional Sanitation Adviser for UNICEF WCARO, Jane Bevan, brought critical commitment and resources to break the silence in the region. We invited offcers from health, education, WASH, and environment ministries, as well as teachers, trainers, practitioners, and activists. Participants shared personal stories of shame and stigma and forged a strong commitment, and the movement was born. Several meetings and discussions later, the Government of Senegal launched The Joint Programme on Gender, Sanitation and Hygiene, cofnanced by WSSCC and UN Women in Louga, Senegal, on March 8, 2014, to listen and respond to the needs of women and girls regarding sanitation and hygiene in policies, laws and regulations, and related budgets in Senegal, Niger, and Cameroon (see Aïdara and Gassama Mbaye [Chapter 40] in this volume).

The policy pathway was similar to India and yet different. Senegal, with a population of 14 million, of which 60% were under age 25, was rattled by the raw novelty of the term 'MHM.' From ward to village to ministry to agency, I was told that this would need to be handled extremely sensitively. However, a mix of essential ingredients—in this case, action research in urban and rural areas to fll the baseline and evidence gap, rapidly adapted tools following local interviews and focus groups, advocacy with parliamentarians and an interministerial committee—unleashed tremendous support for MHM (WSSCC and UN Women 2016).

Leading the charge were champions from the Health, Education, Environment, and WASH8 ministries, with the able support of the UN Women team in Dakar.9 For example, Amadou Diallo from the Ministry of Water and Sanitation in Senegal spoke eloquently about how the work on MHM had opened the eyes of the ministry to a new way of working—one that made complete sense within the ethos and culture of fairness, respect, and dignity innate in Senegalese tradition. MHM was able to weave a common thread across health, education, gender, environment, and WASH within government as well as development agencies—refecting realities that are not confned to one sector and therefore must be solved through convergence. The Joint Programme has successfully integrated MHM in the national strategy of the Ministry of Water and Sanitation, which now mandates that investments in WASH take into consideration women's needs, particularly menstrual management (Ministère de l'Hydraulique et de l'Assainissement, République du Sénégal 2016).

English and Swahili-speaking Kenya presented an interesting contrast. In 2016, Kenya was already a hotbed of MHM activity, with large UN agencies and a plethora of national NGOs working on raising awareness and producing pads. However, it had yet to articulate a coherent approach to menstrual health and hygiene, as the focus was largely on keeping girls in school. Girls who had dropped out of school, HIV-positive women and girls, and female refugees were not yet a focus of the discussion (Geertz et al. 2016).

The frst national MHM training was organized with the Ministry of Health in 2016 for 70 offcers working in health, environment, water, and sanitation. It served to galvanize latent champions into action (Okwaro et al. 2016). 12 County frst ladies were crowned MHM champions. An initially skeptical Ministry of Health was convinced about the relevance of the issue and the need to train all 47 counties and move to the logical next step: a coherent national policy. Building a cadre of trainers to work across East Africa was an important investment and critical link in the policy pathway.10

Kenya's—and the world's—frst dedicated MHM policy, approved in November 2019, is a bold statement of recognition of its approximately 25 million menstruators and their needs. A series of multi-stakeholder consultations were convened by an impressive cast of characters: Director of Public Health Kepha Ombacho; his deputy, Jackson Muriithi; WASH Alliance and WSSCC national coordinator, Tobias Omufwoko; Knowledge and M&E offcer, Neville Okwaro from the Ministry of Health WASH Hub; and WSSCC.11 The meetings involved a range of NGOs, researchers, development partners, manufacturers, and county governments, and they were marked by numerous power plays: between national control and newly decentralized counties fghting for fscal control; institutional fragmentation and confusion between which government authority would manage which aspect of MHM; competing interests on generating funds for particular pet projects or research; and lots of excitement around disposable and reusable pad innovation. However, the meetings were largely positive, with a shared desire for coherence in policy and practice. Translating the policy into meaningful budgets, actions, and monitoring across 47 districts is the next step, along with urgently needed product regulation, an area of concern for the Ministry of Health.

The Kenyan Cabinet, chaired by President Uhuru Kenyatta, approved the National Menstrual Hygiene Management (MHM) Policy highlighting MHM as a rights issue and bringing it into the mainstream of the country's health and development agenda (Government of Kenya 2019). The policy intends to highlight MHM as a rights issue and bring it into the mainstream of health and development. It examines the social, economic, cultural, and demographic context of MHM, including its implications for menstruators' health. Menstruation is a critical indicator of female health and vitality, and a healthy menstrual cycle indicates overall well-being. This policy aims to break the silence around the biological phenomenon of menstruation and menstrual blood to enable Kenya's women and girls to access information, make informed choices, and participate fully in all walks of life, every day of the month.

#### *Regional Declarations and Benchmarking*

Creating regional MHM hubs of activity on policy and practice was intended to engage neighbors, catalyze innovation and action, and break the silence on the ground and within WASH and health policy. The frst countries chosen—India, Senegal, and Kenya—were also regionally recognized infuencers, innovators, and leaders well placed to drive transformation beyond their borders. They then found regional counterparts for sharing, benchmarking, learning, and dialogue: Niger and Cameroon in West and Central Africa; Tanzania and Uganda in East Africa; and Afghanistan, Bangladesh, Bhutan, the Maldives, Nepal, Pakistan, and Sri Lanka in South Asia.

Regional sanitation conferences and their declarations were an essential part of this policy advocacy, as all countries report on their achievements regionally every two years (Naafs and Brewer 2013; Narayan et al. 2011). Bringing MHM into regional declarations was therefore crucial for advocacy, action, benchmarking, regional learning, and sharing. The ffth South Asian Conference on Sanitation (SACOSAN V) in Kathmandu, Nepal, in October 2013 ended with a declaration urging compliance measures on MHM facilities and explicitly calling for an end to discrimination across its eight member states (Kathmandu Declaration 2013). At SACOSAN VI in Dhaka, ministers and government offcials from the Maldives, Sri Lanka, and Bhutan—as well as Sri Lanka's Minister of City Planning and Water Supply, Rauff Hakeem, and Member of the Legislative Assembly in India, Prem Lata Singh responded to the concerns and demands expressed by adolescent girls, transgender persons, and persons with visual and hearing impairments. These were then refected as commitments in the Dhaka Declaration (2016). Similarly, at AfricaSan V, Ministers Mansour Faye from Senegal and Wassalke Boukhari from Niger co-chaired a powerful session on MHM and spoke about their countries' commitments to breaking the taboo in policy and providing MHM-friendly public facilities and awareness programs (WSSCC and UN Women 2015a).

In addition, building capacity and equipping policy makers and practitioners with information and tools were essential. To deliver the SACOSAN commitments on MHM, WSSCC pledged to train government staff of key national ministries in all eight countries in the South Asian Association for Regional Cooperation (Theseira 2016). National trainings were complemented by regional trainings that brought together offcials from several countries to listen, share, and learn in neighboring host countries (Okwaro and Davis 2017; Theseira 2016). Expanding regionally and providing opportunities for mutual sharing, learning, and benchmarking was crucial to reach a critical mass of champions and believers.

Regional voices were important not just for sharing and learning but to validate global advocacy and policy. These same ministers, researchers, and practitioners from Africa and Asia brought commitments and demands to sessions at the Commission on the Status of Women in New York, the Water and Health Conference in North Carolina, International Women's Day, the World Health Assembly in Geneva, and other global platforms. They helped break the silence from the bottom up (George 2013; Patkar et al. 2017; WaterAid 2013; WSSCC and UN Women 2015b; WSSCC 2016a, 2016b, 2017a, 2017b; UNC 2017; Essity 2017b).

#### *Expanding the Conversation to Other 'Unmentionables'*

As ministers and senior bureaucrats, village chiefs, parliamentarians, and the media started openly discussing menstrual health and hygiene, would they also be more open to conversations on other hitherto taboo topics? In Senegal, Cameroon, and Niger, menstruators who talked about their frst period went on to describe menstrual experiences across their lives (WSSCC and ONU Femmes 2015), including stories of genital cutting and injuries during childbirth (Mimche et al. 2017). These were taboo topics, shameful for perpetrators, accomplices, and victims alike, that commanded humble listening.

These conversations—across different countries and cultures and often initiated around health-seeking behaviors, child spacing, and contraception—provided a natural space to disrupt notions of voice, control, choice, and even gender identity and expression. Most important was the discussion around fertility, especially in countries in West Africa, where women themselves perceived that a woman's fecundity made them more attractive to men. Surrounded by myths, perceptions, and social stigma, women's information, support, and health-seeking behavior around menopause is not that different from menarche (Wambua 1997; see also Bacalja Perianes and Ndaferankhande [Chapter 33]; Dillaway [Chapter 21]; and Singh and Sivakami [Chapter 70] in this volume), as is the subject of female urinary incontinence (Aoki et al. 2017). The burden on individuals at these life stages is disproportionate to the limited attention in policy, research, fnancing, and care.

#### *Catering to the Diversity of Menstruators: Work in Progress*

Globally, menstruators suffer in silence, but many experience stigma and discrimination on multiple grounds: socioeconomic status, choice of occupation, gender identity, caste, class, ethnicity, and many other factors (see McCarthy and Lahiri-Dutt [Chapter 3]; Bozelko [Chapter 5]; Roberts [Chapter 6]; Vora [Chapter 4]; Sukumar [Chapter 13]; Steele and Goldblatt [Chapter 8]; Hawkey, Ussher, and Perz [Chapter 10]; Persdotter [Chapter 29]; Steward et al. [Chapter 55]; Frank and Dellaria [Chapter 7]; and Rydström [Chapter 68] in this volume). Disability, gender, and sexual identity were almost entirely absent from the emerging MHM conversation, as was the intersection of multiple stigmas throughout life, with particular vulnerabilities at puberty, pregnancy, childbirth, and menopause.

The Sanitation Action Summit organized by WSSCC in Mumbai in November 2016 created a platform for listening, learning, and joint action (Sanitation Action Summit 2016). The summit brought together citizens from across India who are often silenced and/or made invisible—sanitation workers, adolescent girls and boys, transgender persons, older persons, and persons with hearing and/or visual impairments. It concluded: "The challenge is not just to build infrastructure like toilets but to fght stigma and prejudice that discriminate against women, girls, transgender persons, sanitation workers and many more" (WSSCC 2016b). The summit was followed by the publication of transformative national *Guidelines on gender issues in sanitation* (MDWS 2017), marking an important departure from narrow WASH messaging to explicit acknowledgment of the dangers of instrumentalist, stereotypical messages for behavior change. The guidelines state:

It is noted that behaviour-change messaging [in Swachh Bharat Mission (Gramin)] often includes subjects like 'shame and dignity of women.' While these may be useful for entry-point messaging they carry risks of lack of ownership by men and the reinforcing of gender stereotypes (like women should not step out of the house, men as custodians of women's dignity, etc.) The … messaging should therefore be gender sensitive and targeted at both men and women, particularly focusing on men, who are often the primary decision makers in rural households where household expenditure is involved.

These guidelines are fairly radical in a culture that places women at two ends of a complex spectrum: the frst, as the stereotypical goddess to be revered—a wife, daughter, or sister to be protected from the male gaze; and the second, a workhorse without agency. Signifcant in these guidelines is the emphasis on dignity versus patriarchal messaging that reinforces widely accepted perceptions of a woman's modesty, dignity, and therefore place in society (MDWS 2017). The guidelines go on to advocate for inclusion and adaptation to ensure that the third gender,12 elderly persons, children, and persons with disabilities have unfettered access to facilities. They end with detailed guidance to address MHM-related taboos and superstitions and specifcally acknowledge women's sanitation stress and insecurity and call for better siting, ventilation, and consideration of age and disability in facilities design and management.

#### *Persons with Disabilities*