Written by: Advocate Neha Gurung
1 December 2021
#16daysofactivismagainstGBV
Period has been shunned and stigmatized for many centuries in most part of the world. In Nepal, we can see this stigma deriving its validity from religion, culture, social norms and even laws and policies to some extent. I am not a student of religion and culture and neither am I an anthropologist. But coming from the legal background, I find it absurd that Nepal Government until 2020 had been providing national holiday on Rishipanchami, despite our Constitution and Criminal Code clearly penalizing period-discrimination. RishiPanchami is a day when women seek forgiveness for making things impure by touching them when on menstruation in the past years. Thanks to organizations working on SRHR and human rights in Nepal who had an audacity to see through this age old practice and took it to the court in 2017 and achieve a positive judgment. Since 2017, this national holiday has been withdrawn.
Analyzing this legal episode in Nepal, I recall the discussion in international platform and among SRHR advocates who claim that one of the cause of menstrual discrimination, poverty and diseases faced by women, girls and people who menstruate is the basic yet significant ignorance about the linkage between menstrual health (MH) and Sexual and Reproductive Health (SRH). I find this claim legit!!
Culturally, people view MH as completely separate from SRHR. It is seen in isolation and thus linked instead with various stigma leading to multiple restrictions and barriers faced by menstruating individual. These barriers in most Nepali communities manifests as restriction to eat or sleep together or even in the same house with non-menstruating individuals, live in un-safe and un-hygienic sheds with inadequate living condition, having to bear additional financial burden to manage period materials, compromise on education and work due to unhygienic and lack of private/safe toilets and water in school or workplace. In short, universally agreed human rights that can be undermined by poor MH are the right to health, right to education, right to work, right to non-discrimination and gender equality and the right to water and sanitation, among others. The barriers faced by women, girls and people who menstruate has multidimensional impact on such person’s right to civil, economic, social, cultural, and political rights. These barriers can never be ended and the dignified menstrual health can never be achieved by viewing menstruation only from social and cultural perspective. The discussion is incomplete without keeping MH and SRH together on the same table.
Social Aspect: Social misconception and stigma around menstruation can influence the sexual and reproductive health decisions that women and girls take throughout their lives. Studies have established that there exists a lack of menstrual knowledge and widespread misconception about menstruation among menstruating individuals.
Girls often enter menarche with no or very little information about menstruation and other puberty related changes. Resultantly, menstruation is commonly experienced with shame, fear and embarrassment.
This same perspective is continued in sexual and reproductive health as well, because even those with some knowledge on menstruation generally lack an understanding of menstruation’s link with fertility. Furthermore, the huge knowledge gap about menstruation among boys and men contributes to the menstrual discrimination and stigma. In most household, women themselves, especially mothers, are the primary source of information for girls about menstruation. However, many adult women have insufficient knowledge or even hold deep misconception on menstruation and SRH. This lack of menstrual knowledge negatively impacts their menstrual experiences and also perpetuates the cycle of misinformation and misconceptions.
This stigma around menstruation means that women, girls and people who menstruate, become shy and apprehensive to share anything related to their sexual and reproductive health as well. Thus, it leads to their lack of bodily autonomy, limited ability to negotiate safe sex and limited capacity to seek health care for MH and SRHR concerns across different life stages. If we see from the lifecycle approach in the context of SRHR, which suggests providing health services, including SRHR services throughout the life, to ensure that a person’s sexual and reproductive health needs are addressed throughout, we can clearly see how MH is directly linked with SRHR. This intersection between MH and SRHR influence the experience and expression of sexuality, bodily autonomy and health related decision making.
Biological Aspect: Biologically, multiple research has shown that menstrual irregularities, including abnormal uterine bleeding and dysmenorrhea, are directly linked to aspects of SRH and can greatly affect the quality of life for menstruating people. Also, as such bleeding is linked with anemia, studies shows its contribution to maternal morbidity and is also associated with cervical cancer. MH is also directly linked with contraceptives where research indicate that hormonal contraceptives are among the primary treatment for symptoms of abnormal uterine bleeding and dysmenorrhea. Several research also suggest an association between poor MH and higher level of urogenital infections, including reproductive tract infections.
A study shows that overall 40.6% of women in Nepal have anemia, where 6.9% has moderate/severe anemia and 33.7% of all women had mild anemia. This is partly due to heavy menstrual bleeding which in turn has negative effects on fertility and maternal health. Anemic women are at higher risk of maternal mortality. Thus, the uterine bleeding associated with childbirth, abortion and pregnancy and the anemia due to heavy bleeding, which are de-facto an SRH issue, are important aspects of a life cycle approach to MH.
Our laws and policies also have not been able to see that MH as an integral part of SRHR.
Now that we have seen how MH, socially and biologically, intersects with SRHR, let us search the legal terrain. Human rights treaties such as Convention on the Rights of the Child (CRC), Convention on the Elimination of all forms of Discrimination Against Women (CEDAW), Convention on the Rights of Persons with Disabilities (CRPD) and the international Covenant on Economic, Social and Cultural Rights (ICESCR) all articulate a vast area of human rights that are particularly relevant to MH and SRH. UNFPA has even provided the definition of menstruation linking it directly with reproductive health – as “menstruation being any natural and hygienic process that women and girls of reproductive age go through”. Furthermore, in 2018, the Human Rights Council explicitly acknowledged menstruation and menstrual hygiene as integral to the right to water and sanitation.
However, MH was excluded from previous international norm-setting agendas, including the ICPD Programme of Action (1994), the Beijing Declaration and Platform for Action (1995) and the Millennium Development Goals. The current Sustainable Development Goals (SDG) does not directly mention menstruation. However, a reference to ‘the needs of women and girls and those in vulnerable situations’ in SDG target 6.2 on access to adequate and equitable sanitation and hygiene is commonly understood to include MH. In addition, MH is viewed critical for the attainment of several other SDGs such as SDG 3 – Ensure healthy lives and promote well-being at all ages, SDG 4 – Ensure inclusive and equitable quality education and promote lifelong learning opportunities for all, SDG 5 – Achieve gender equality and empower all women and girls, SDG 6 – Ensure availability and sustainable management of water and sanitation for all and SDG 8 – Promote sustained, inclusive and sustainable economic growth, full and productive employment and decent work for all.
In Nepal, Article 38 (2) of the Constitution ensures that every woman shall have the right to safe motherhood and reproductive health. From our above establishment, that MH is an integral part of RH, it can be naturally assumed that the subsequent laws have taken a life cycle approach on SRHR and have included MH as a part of such cycle. However, the Safe Motherhood and Reproductive Health Rights Act, 2018 and Regulation, 2020 have both ignored MH. This further provides validation to the belief that MH is indeed separate from SRH!
These laws does not envision that healthy reproductive health also constitute a healthy monthly period with absence of any infection in reproductive tract or urogenital that may occur as a result of poor menstrual health. The current laws does not foresee that a women or girl’s inability to access proper information on menstruation and menstrual health, inability to access menstrual products, clean water and toilet that is also safe and private with doors and locks is a violation of right to dignified MH and SRHR.
The Criminal Code, 2074 in Section 168 (3) penalizes Chhaupadi and discrimination related to menstruation and delivery. The fact that menstruation and delivery has been mentioned together in the same sentence, can be used to infer that Criminal Code also views MH and SRHR as integral to each other.
There are also several policies, strategies and programs of Nepal Government that ensures women and girl’s right to menstrual hygiene and right to education in this area. For instance, the National Health Policy 2014, states that adolescent and youth-friendly health services shall be incorporated into all health facilities throughout the country (policy 1.21). This policy has kept MH under the broader area of adolescent SRHR. However, it is essential that MH be seen as an independent issue within SRHR.
Furthermore, the Government also has National Adolescent Health and Development Strategy, 2015 that dedicates menstrual hygiene as separate priority area under SRHR. Government has also initiated various programs in local schools for distributing sanitary pads, installing WASH, toilets and discouraging Chhaupadi practice. While this maybe commendable, distribution of pads may not be enough. It is imperative that Government make it tax free, easily accessible, and affordable and also encourage the use of menstrual cups by conducting its own research in this area and spreading awareness through different medium.
In light of these national policies, strategies and programs and Nepal’s obligation under international instruments, it is essential we fully recognize and integrate MH into SRHR and ensure a lifecycle approach within the Safe Motherhood and Reproductive Health Rights Act and Regulations itself. Such lifecycle approach should include the right to dignified experience of pre-menarche, menarche, menopausal and post-menopausal periods along with the women/girl’s right to information related to menstruation, right to access free or affordable and accessible menstrual products, right to seek service in cases of menstrual complications or infections due to issues related with menstruation. I believe that such inclusion of MH into SRHR is essential in order to ensure qualitative, accessible, affordable and safe menstrual health for all those who menstruate.