In Her Hands: Normalizing Menstruation in Nepal

In Nepal, approximately 290,000 women and girls menstruate every day. However, 82% of those living in rural Nepal use unhygienic and potentially dangerous menstrual hygiene management methods. A study from UNICEF revealed that 1 out of 3 girls in South Asia knew nothing about menstruation prior to getting their first period.

Based on societal ignominy, menstruation’s direct barrier to girls’ health and education remains a hushed conversation. As a result, both household dialogue and policy making discussions often leave menstrual hygiene management (MHM) off the table.

Menstruation signals a girl’s entry into womanhood and reproduction. It is a crucial time for adolescent girls to learn about their bodies and their health. Silence and stigma surrounding menstruation impinge on girls’ lives, as the inability to manage menstrual hygiene affects education, physical health, psychological and emotional well-being, as well as overall quality of life.

Old taboos surrounding menstruation die hard in rural Nepal. One extreme example is the customary practice of ostracizing women and girls from their own homes during their periods, known as ‘Chhaupadi pratha’. Chhaupadi – which is based upon the belief that menstruating women are impure – prohibits menstruating women and girls from inhabiting any public space and socializing with others.

The effects of Chhaupadi are extremely dehumanizing and psychologically stressful, with young girls being told that they will bring bad luck on their families if they enter their own homes during menstruation. In addition to being emotionally degrading, Chhaupadi places women and girls at risk of rape, abduction, snakebites, animal attacks, and malnourishment. Forced to sleep in rickety huts without adequate insulation or ventilation, women and girls face illness exacerbated by the cold and unhygienic conditions or in extreme cases, even death due to asphyxiation from improperly ventilated heat sources.

Despite being outlawed by the Nepalese Supreme Court in 2017, Chhaupadi retains a foothold in the country’s western region and continues to put constraints on the potential, action and participation of women. Even in regions where Chhaupadi is not practiced, taboos surrounding menstruation still severely affect Nepalese women and girls. Many modern households in Kathmandu still prohibit menstruating women from entering kitchens or temples, eating with the family or sleeping on their own beds.

Managing menstruation in resource-poor settings is often challenging. Buying a sanitary napkin is a luxury most rural women can’t afford, and so many end up using cloths, rags and – in extreme cases – straw, sand or even ash as menstrual absorbents. Such challenges are further increased by societal taboos, ignorance and embarrassment around menstruation.

The plight of women in Nepal deeply motivated me to break the silence around menstruation by starting a dialogue, and so I founded a Project called ‘In Her Hands’. It aims to destigmatize menstruation and encourage conversation through…

  • Advocacy campaigns on menstrual hygiene management
  • Focus group discussions
  • Facilitating access to sanitary materials and physical infrastructures like female friendly toilets and safe water sources
  • Capacity building activities for adolescent girls

The goal of our initiative is to start a dialogue around menstrual hygiene and liberate girls and women from silent suffering. We are working towards ensuring that girls have a voice in their communities so that their menstrual hygiene needs are taken into account. We also want to make sure that they have full control over their bodies, and that they are part of a world in which every woman and girl can manage her menstruation in privacy, safety and dignity.

The pilot project was conducted in the village of Ramdaiya Bhawadi in Janakpur, Nepal. Since beginning in early 2017, our work has benefitted more than 500 women and we are looking forward to expanding to other areas of need in the near future. The initiative has sparked conversation about a topic that many people previously felt uncomfortable talking about. It has also helped facilitate policy change at the local level while catalyzing action and commitment towards securing the basic human rights of girls and women.

Despite increasing evidence for taking urgent action, menstruation remains a neglected public health, social and educational issue that requires prioritization, investment and concentrated effort at national and local level. I believe that girls and their individual stories should be at the forefront of development and if menstrual hygiene management is included as a part of the conversation surrounding policy changes, we will be able to spark change.

Project ‘In her hands’ has recently been awarded the ‘Student Project for Health Competition 2018’ by Foundation for Advancement of International Medical Education and  Research (FAIMER). It was also recognized as one of the Top 12 finalist projects in the Opportunity Desk Impact Challenge 2017 by the Opportunity Desk.

Menstrual Pain is a Public Health Matter

Menstrual health is a topic that is often neglected and ignored. In particular, issues pertaining to menstrual pain can be overlooked because of the silence that surrounds it. However, I recently read an article in Cosmopolitan magazine about period pain. It mentioned Professor John Guillebaud, of University College London, who has described the severity in pain as being “almost as bad as a heart attack”.

However, it remains true that many doctors dismiss menstrual pain as irrelevant when brought up by a patient. As a practicing doctor, I have come across patients in casualty complaining of period pain. Shamefully, I admit that I have trivialized these women and their pain or regarded them as ‘hysterical’ because my internalized sexism chooses not to believe them or expects them to deal with the pain (it’s all part of womanhood, isn’t it?). I believe many other doctors, both male and female, have harboured similar thoughts. As a result, women to wait longer for medical attention and sometimes receive inadequate pain management.

Menstrual pain interferes with the daily life of one in five women. The two main causes of menstrual pain have been found to be primary dysmenorrhoea or endometriosis. It is often difficult to differentiate the two because they can present with similar symptoms. Endometriosis can be difficult to diagnose – in some instances the process can take up to a decade. Doctors have struggled to find the specific medical causes for primary dysmenorrhoea. This may be related to the poor quality or low volume of sufficient scientific and medical research into menstrual pain.

I believe that the society and culture we’re in chooses to ignore menstrual pain or completely disregard it. At times males cannot relate because they cannot share the experience. As women, we are not taught not to discuss menstruation openly and to keep the great physical and emotional distress we may have to go through to ourselves.

In the workforce, menstrual pain is seen as a hindrance – yet another reason to deny women equality in the workplace. In schools, girls and young women are shamed for their pain and as a result, many choose to stay at home if the intensity increases.

There are changes that need to take place regarding menstrual pain:

  • Increased awareness around menstrual pain and its causes
  • Open discussions about menstrual health in the media, schools, offices and GP rooms
  • Consideration of period leave for girls and women
  • Working to removing the stigma around menstruation more widely
  • Increased scientific research into menstrual pain, including causes & management
  • Access to adequate and safe pain management for women
  • Recognition of menstrual pain as a public health matter

Menstruation is a normal biological process and we should not shame women for it. We must not neglect menstrual pain or matters surrounding it. We need to open dialogue and provide more medical information on menstrual pain to help the many women who suffer silently.

Evidence for Effective Sex Ed

Where did you first learn about sex? From a parent? From a teacher in school? From friends? On the internet? Was the information you learned accurate?

I think most of us would agree that the best time to learn about sex is before you start having it, but millions of adolescents and young people – especially those in low-resource environments – don’t have access to quality, comprehensive sexual and reproductive health information and services. Many of them are pressured into sex before they are ready, putting them at risk of sexually transmitted infections and unplanned pregnancy.

To help prevent this, public health experts recommend offering comprehensive sexuality education (sex ed) in schools. But people have a lot of questions.

At what age should children start learning about sex?

What do they need to know and when?

Does teaching kids about sex encourage them to start having sex earlier than they might otherwise?

Fortunately, there is evidence about what effective sex ed programs look like, and we can now answer many of these questions.

Back in 2009, the United Nations released its first guidance document on comprehensive sex ed. The purpose of this guide was to help government officials to develop and implement effective school-based programs by providing them with the best available evidence about what young people should know about their sexual and reproductive health and rights.

Recently, a revised and updated version of the International Technical Guidance on Sexuality Education was released. The new addition is more inclusive than the original, covering a wide variety of concepts and topics from relationships, gender, social norms, and values, to sexual behavior and reproductive health. The information is broken down by age groups, starting with age 5 and continuing to late teens.

The authors of this document reviewed the best available research and compiled some key findings on effective, comprehensive sex ed programs. We encourage you to read the whole thing for yourself, but if you’re short on time, here are some highlights (see p. 29-30):

  1. Sex ed “does not increase sexual activity, sexual risk-taking behavior or STI/HIV infection rates.
  2. Sex ed “has positive effects” on young people. It increases knowledge about sexual and reproductive health, sexuality, and risk of pregnancy and sexually transmitted infections (including HIV).
  3. Abstinence-only sex ed is ineffective at reducing or delaying sexual activity among students.
  4. Programs that encourage students to reflect on, question, and challenge social and cultural norms related to gender, and to adopt more equitable attitudes about gender, are more effective than those that don’t.
  5. Sex ed is most effective when community-based services are available and tailored to youth, such as condom distribution, training health providers to offer youth-friendly services, and involving parents and teachers.

Although not all policymakers find this evidence convincing, one small African country is leading the charge for comprehensive sex ed. The Government of Burundi, concerned about high rates of teenage pregnancy and the spread of HIV and other sexually transmitted infections, is taking steps to improve access to sexual and reproductive health information and services for in-school and out-of-school young people.

They partnered with CARE, Cordaid, Rutgers, and UNFPA, and received funding from the Embassy of the Kingdom of the Netherlands in Burundi to implement the Menyumenyeshe program (translation: “be informed and inform others”), designed to provide comprehensive sex ed, to make sexual and reproductive health services more accessible and friendly to youth, and to promote supportive attitudes toward youth accessing these services in their communities.

Adolescents and youth represent about one-third of the population of Burundi, and their education and health status will impact their country and communities for years – and decades – to come.

Comprehensive sex ed programs help to equip young people with the knowledge and skills to make responsible choices in their lives, but too often the needs of youth are neglected by those with the power to implement these programs. Fortunately, young people around the world are speaking up, advocating for themselves, and claiming their rights to comprehensive sexual and reproductive health information and services. Adults would do well to support them in these efforts. Youth, after all, are not just the future; they are the present.

Cervical Cancer: a Threat to Women in Developing Countries

More than half a million women develop cancer of the cervix every year. It is the fourth most frequent cancer type worldwide and the global mortality rate remains high at 52%.

Of the estimated 270 000 deaths each year, more than 85% occur in less developed regions. This makes cervical cancer one of the greatest threats to women’s lives in these countries.

The high toll of cervical cancer in developing countries is due to the fact that the majority of cases are detected in late stages as a result of lack of access to health care and resources. Patients often report for treatment at a very advanced stage when their pain and symptoms have become extreme.

In most instances, cervical cancer can be prevented, and yet it is still killing millions of women worldwide. There is sufficient scientific evidence to conclude that screening for cervical cancer would result in significant reductions in incidence, mortality and morbidity.

Screening tests can help prevent cervical cancer or to find it early. The first is the Pap test (or Pap smear), which detects precancerous or cancerous cells. The Pap test is one of the most reliable and effective cancer screening tests available. In many countries, it is recommended to women between the ages of 21 and 65 years old, and can be done in a doctor’s office or clinic.

Another screening test is the HPV test, which looks for the virus (Human Papilloma Virus) that can cause cell changes leading to cervical cancer. HPV infection is the most common sexually transmitted infection among sexually active women. At least 12 types of HPV have been linked to cervical cancer.

Most sexually active people have been exposed to HPV at some point in their lives. All sexually active women are at risk of contracting it, therefore, it is highly recommended that all women visit a medical professional to discuss cervical cancer screening. Screening aims to prevent the development of cancer by identifying high-grade, pre-cancerous cervical lesions. When screening detects pre-cancerous lesions, these can be treated easily.

Screening can also detect cancer at an early stage when treatment has a much higher rate of success. Because pre-cancerous lesions take many years to develop, the World Health Organization recommends screening for women aged between 30 and 49 at least once in her lifetime and ideally more frequently.

There are preventive vaccines which have been used for decades in developed countries to protect against the most high-risk HPV groups. HPV vaccine efficiency in preventing cervical dysplasia and cancer has been recommended globally on population-based studies. Vaccination is recommended for all girls aged 9-13.

A global prevention strategy, starting with vaccination programmes and backed up by proper screening on a regular basis, would do a huge amount to fight the cancer that takes a heavy toll on women’s health and lives around the world.