Menstrual health is everybody’s business

Aakriti Pun was in the fifth grade when she got her first period. Pun was 11 and didn’t know what was happening. It wasn’t until her mother noticed the blood on her underwear that she was told she was menstruating. 

“My mother then handed me a piece of cloth to put on. I went to school, only to discover it didn’t prevent any leakage. When I stood up from my seat, I found out that it was stained,” said Pun, who is now 24 years old. 

Her mother never taught her how to use menstrual pads because she herself had never used one before, said Pun. She had to teach herself and it took her almost a year to get it right. The experience was so traumatic that it has been seared into her brain ever since. 

Pun’s experience is not hers alone; it is emblematic of the experiences of many menstruators in Nepal who are not prepared for their menarche. Young girls often look to their mothers for information on menstrual hygiene, which may be ineffective if mothers themselves are not well informed or comfortable sharing their experiences with their daughters. Emotional support is especially important during menarche but in the absence of information from family members, girls are often forced to figure things out for themselves. Lack of information, social and emotional support, and an enabling school environment for managing menstruation with dignity, safety, and comfort only contribute to feelings of helplessness and anxiety during the first period. 

“My sister showed me how to use sanitary pads a few months ago, but I’m not sure I still remember how to use them,” said 12-year-old Ritambhara Shrestha when asked if she felt ready for her menarche. “I’ll ask my mother or sister for help whenever I start getting my period. If they’re not around, I’ll just watch YouTube videos to figure things out.” 

While young people, especially in urban settings, are increasingly aware of menstruation, an element of fear persists. The lack of reliable information from a trusted source can mean the spread of misinformation and a failure to observe proper hygiene.

Teaching menstruation in school

Research has shown that a lack of education about menstruation is one of the many barriers to proper menstrual hygiene. Menstrual education through the standard Nepali school curriculum, starting from primary school itself, could prepare menstruators for their menarche. Each school in Nepal follows its own guidelines for menstrual health education which means that not all students have the same experience learning about menstruation in school.

In most Nepali schools, menstruation is briefly covered in the educational curriculum as part of the Health & Physical Education course. However, textbooks don’t discuss menstruation until the ninth grade, or in some cases, the eighth grade, which is fairly late considering that most menstruators begin menstruation at the age of 12 on average, and in some cases as early as eight. Ritambhara Shrestha is currently in the eighth grade and her school follows the Health & Physical Education Book published by Ratna Pustak Bhandar. There is nothing about menstruation mentioned in her textbook. 

The menstruating and non-menstruating individuals we spoke to as a part of a research project conducted by Pad2Go on menstrual health education in Nepal said that even when they did learn about periods in school, their education focused solely on the biology of the menstrual cycle. During our research, we found that lessons left out important information about anatomy and the use of sanitary products while continuing to present insufficient, ill-fitting, and misleading content.

While questionable advice exists throughout the books, here are three specific instances of information that are grossly inaccurate or misleading.

The above image is from the Health-Physical Education and Creative Art textbook for Grade 6, authored by Arjun K Baruwal (M.Ed. Health Education) and published by Aakar Publisher & Distributor. The recommendations to replace sanitary pads/soft cloths every 24 hours and to wash the vagina with anti-bacterial solutions such as Dettol/Savlon during menstruation are neglectful and even harmful.  

A similar recommendation to wash the vagina with Dettol/Savlon during menstruation can also be found in Shubharambha Publication’s Health, Physical and Creative Arts textbook for Grade 6, authorized by the Nepal government’s Curriculum Development Centre (CDC), which falls under the aegis of the Ministry of Education. 

“Health experts do not advise washing the vagina with soap or antibacterial products as they can disrupt the pH balance of the vagina and lead to infections,” said Dr. Madhurima Bhadra, a lecturer at Tribhuvan University’s Department of Gender Studies and an advocate for sexual and reproductive rights. 

The pH of the vagina must remain acidic as that naturally kills harmful bacteria in the vagina. Using Dettol or even products like VWash can end up destroying the pH balance and in turn, exposing the vagina to bacteria. 

Myths, misconceptions, and misinformation about periods feed into preexisting menstrual stigma, which can be hugely damaging for girls, women, and people who menstruate. The Grade 9 Health and Physical Education textbook, authored and published by the Curriculum Development Centre, continues to use words like ‘para sarnu’, ‘na chune hunu’, which loosely translate to ‘staying apart’ and ‘untouchable’ in English, to refer to menstruation. This propagates the perception that women are unclean or impure while menstruating and prolongs the negative stereotypes and cultural stigmas associated with menstruation, such as the practice of not entering the temple or kitchen, not touching the men or elders in the family, and restrictions regarding attending schools. 

Our research found that teachers often do not teach sexual and reproductive health in school and regularly ask students to study the topic on their own. This is in part because teachers are rarely trained in menstrual health education and management or are stymied by cultural and social stigmas. 

Instruction on menstrual health is often also given to girls separately during guidance and counselling sessions or promotional campaigns and workshops by menstrual product brands that are not open to male participation. Hence, boys and men tend to remain ignorant of what menstruation is and how it functions. By excluding male pupils from the discussion, schools socialize boys into thinking that periods are ‘gross’ and nothing to do with them while also teaching girls that they need to be discreet and keep their periods hidden. 

“While many boys are curious about the developmental changes that girls are experiencing, they are often left out of conversations about menstruation, both at school and at home, which may contribute to misconceptions and teasing of female peers,” said Bhadra, the TU lecturer.

By educating both boys and girls about menstruation and menstrual hygiene, girls can feel more confident managing their periods in school. Stigmas also begin to break down when boys encourage and support their female peers rather than mocking and ostracizing them. 

“The taboo around periods is a form of misogyny and patriarchy. Boys and men can be agents of change when it comes to breaking taboos around menstruation. Engaging and educating them is critical to achieving the social change we need in families, schools, and society at large,” said Tapas Khatri, who works at Pad2Go Nepal, a social enterprise that promotes menstrual health.  

Expanding menstrual education

After asking both menstruators and non-menstruators about what they remember learning in health class about menstruation, as well as going through textbooks, our research found that menstrual education is limited and substandard. It consists of an overview of biology followed by an introduction to pads, missing out on important subjects like an understanding of what to expect; the practicalities of managing periods; an explanation of what is normal and crucially, what isn’t normal and when to go to the doctor; how periods change over the course of life; menopause; recognition that products other than pads exist; and an acknowledgment that trans and non-binary people experience periods too.

Most conversations about menstruation are heavily gendered. The education system assumes that all of those who menstruate identify as women and have typically ‘female’ experiences of their periods. Another population, which is often neglected, is the disabled community, which needs to be taken into account when thinking about how to design menstrual education programmes. 

“Issues on menstruation in individuals with Down Syndrome are often understudied. Difficulty in handling menstrual hygiene, premenstrual disorders, and the risk of sexual abuse are often of major fear to caregivers,” said Shila Thapa, founder of the Down Syndrome Society of Nepal.  

It is also important that menstruators learn about products such as sanitary pads, cloth pads, menstrual cups, tampons, and period underwear. Learning about the pros and cons of menstrual products, the ways of disposal, and their effect on the environment can help menstruators make an informed choice about what product to use given the socio-economic contexts in which they live. 

“Menstrual education is so much more than just knowing what a sanitary pad is and how to wear one,” said gender researcher Bisheshta Shrestha. “Our menstrual education should have included how to track our cycle, reduce premenstrual symptoms, and regulate our emotions while on our cycle.”

Eliminating stigma through education

Providing young people with comprehensive menstrual education will not solve all the problems related to menstruation. It won’t, for example, address issues such as lack of access to sanitary products due to financial difficulties. It is, however, a good place to begin. 

Schools are a microcosm of society, so it’s important that they are part of the movement to end menstrual stigma and empower young people to feel comfortable about their bodies. Free, high quality menstrual products available in school restrooms would eliminate the need to ask your teacher, friend, or go to the school nurse. 

“Menstrual hygiene requires clean and proper toilet facilities and appropriate methods of disposing of used sanitary pads, and availability of water and soap,” said Babu Kaji Shrestha, founder and director of Global Action Nepal, a social organization that provides primary education and health services for children in Nepal. “Unfortunately, these facilities are hard to come by in public schools in remote areas of Nepal. The absence of sanitary products or proper girls’ toilets still results in girls missing school during their menstrual periods.” 

A comfortable experience at school is especially important for major reasons like not skipping school, having access to period products they might not be able to get outside on their own (whether it be a financial problem or a home problem), and staying safe and clean throughout that week.

Menstruators need information, education and an enabling environment to cope with menstruation issues. But currently, menstrual education in Nepal is not integrated deeply into school curriculums; they survive and grow through independent initiatives, like Global Action Nepal and the Nepal Fertility Care Center. 

“Nepal Fertility Care Center (NFCC) has collaborated with the government of Nepal and other partners to design a menstrual health training curriculum to ensure that teachers and health workers are equipped with the necessary information and skills to assist students with menstruation- related challenges and questions,” said Pema Lhaki, executive director of NFCC. “We’re also developing a menstrual health curriculum that will be integrated into the national educational curriculum and implemented in all public schools in Nepal.”

Global Action Nepal too trains teachers in proper hygiene education so that they are able to provide psychosocial support to adolescent girls and boys, and regular hygiene classes in their own community, according to Shrestha. 

But educating girls alone is not enough; these are deep-rooted cultural issues and girls cannot make the necessary changes by themselves. Society at large, including shopkeepers who sell menstrual products wrapped up in newspapers, also needs to be gender sensitized. Educational interventions are also most effective when tailored to cultural norms, delivered in local languages, and constructed in a variety of ways to empower communities to advocate for themselves.

“After interacting with women in Nepal, I realized there was a clear lack of resources to talk about periods as well as tools for parents and educators to generate natural and easy interactions around the menstrual cycle in the local context,” said Sophie Maliphant, a UK-based graphic designer and curator of the book, Kumari’s Adventures with Her Moon Cycle, which will soon be available in local languages. “I worked with a network of activists and aid workers on our soon-to-be launched book. The story of Kumari seeks to empower Nepali women to voice their discomfort with practices that should be critiqued.”

Cultural and religious taboos make it challenging to teach and talk about menstrual health. If parents support girls during menstruation, they may face fewer obstacles to continue attending school. Initiating conversations about the menstrual cycle early and arming children with information so they can make informed decisions may be the most effective way to keep them safe. 

Amidst all the restrictions, girls in both rural and urban areas are challenging these prescriptions in their own way. 

“I grew up being told what to do and what not to do. It was unimaginable for me to enter a temple during my period. However, during a recent family trip to Kalinchowk, I chose not to notify anyone that I was on my period and went into the temple. Nothing happened, but the fear is so deeply ingrained in our minds that I’ve been linking every unpleasant incident with my act of defiance,” said 24-year-old Neha Agrawal.

The government of Nepal announced on May 28, 2020, that all Nepali schoolgirls would have access to free sanitary pads at school. But while some schools have received pads, not everyone has been reached and the sustainability of the program remains a major issue. As supplies are limited, distribution is not equitable. In some schools, students are required to personally request pads from the staff room or the school director’s office, which can be embarrassing. 

“Even female teachers tend to discriminate against girls who have their periods, and if girls ask for a sanitary pad, they sometimes get yelled at. Girls may thus prefer to sneak out of school or stay home, missing out on lessons,” said Sona Khatik, a journalist from Kapilvastu.

Khatik, who is from a Madhesi Dalit community, said that in many parts of Far Western Nepal, many people don’t even have underwear. If a family does have underwear, they often have to share it. In such instances, free sanitary pads will be of little use. These women will need access to underwear and an understanding that regular use will result in proper hygiene and cleanliness. In the future, once they begin using underwear, then cloth pads can be introduced.

“We hope that as more people join the menstrual equity movement, we can accomplish more long-term goals, such as removal of the 13 percent VAT on all menstrual products, through our #RaatokarMaafGar campaign, implementing sex and menstrual health education tailored to the needs of the local population, and providing menstrual products to those in great need,” said Pad2Go Nepal’s co-founder, Shubhangi Rana. 

Pad2Go is currently working on a survey on the status of menstrual health education in Nepal to understand what is included in the current curriculum and where improvements can be made, in both English and Nepali languages. Pad2Go is known primarily for introducing sanitary napkin vending machines in Nepal. They plan to begin the survey with Province 3 and work their way through other provinces. 

For many young people, there’s a strong interest in menstrual education, especially since they are unable to hold open and frank conversations about menstruation. Cultures are often ingrained inside the confines of school walls or households with the self-conceptualizations that are fostered and then carried into adulthood about menstruation. 

“Why did I leave middle school knowing how to discreetly get a pad from my backpack into the sleeve of my sweater instead of gossiping about the benefits and drawbacks of wings vs. no wings?” said 25-year-old Deepsana Shrestha. “Menstruation can be a painful experience and the first time can be extremely frightening. Proper education is necessary so that no young person feels scared of dying when they have their first period.”