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What are the links between Menstrual Health Management & Gender-Based Violence?

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WoMena SUMMARY [1]

There is a growing understanding that gender-based violence (GBV) has many dimensions, both physical and psychological. It additionally includes both a deliberate deprival of dignity and access to basic services. This also applies to menstrual health management (MHM):

  • Physical violence: menstrual products can be expensive; this at times causes conflict since men are often the ones who pay.
  • WASH in schools: schools often have inadequate WASH facilities. This, coupled with a lack of products, leads to less participation (e.g. standing in class to answer questions), out of fear to have leaked. It also increases bullying and harassment by male peers.
  • WASH in general: poor access to toilet facilities due to distance (too far away, poor design (dimly lit) and going to the toilet at night for more privacy due to stigma, shame, and fear put girls and women at higher risk for sexual assault/harassment, exploitation, and rape.
  • Transactional sex: several studies indicate that girls resort to transactional sex to buy pads to remain in school.
  • Misconceptions and harmful traditional practices: misconceptions about menstruation exposes girls to sexual risks and violent gender problems. Examples of harmful practices are restrictions on girls to carry out activities and FGM/C.
  • Early marriage: it is often reported that parents marry off their daughters when they start menstruating as they think their daughters are ready or want to transfer the high cost of providing for their daughters, including the costs of menstrual products.
  • Humanitarian settings: Challenges such as crowding, lack of access to safe toilets and water facilities and poverty pose additional risks for GBV.
  • COVID-19: Around the world, there is repeated evidence that there has been a marked increase in GBV as people are confined to their homes. There are early signs that this generalized violence might also apply to issues related to MHM; withholding of products by men toward their partners or reluctance to pay for products.

This FAQ by WoMena explores the link between GBV and MHM. We write this FAQ while the COVID-19 pandemic is raging, and therefore a section is included about how lockdown measures are likely linked to GBV and MHM, although there is still limited empirical evidence. In addition, the results of the rapid assessment about the impact of the pandemic on MHM among girls and women in Uganda will be briefly discussed.

What is gender-based violence?

Attention to GBV has grown greatly over the last three decades. So has the understanding that it is multifaceted. According to the UNHCR (2019) Sexual and gender-based violence (SGBV) refers to ‘’any act that is perpetrated against a person’s will and is based on gender norms and unequal power relationships. It encompasses threats of violence and coercion. It can be physical, emotional, psychological, or sexual in nature, and can take the form of a denial of resources or access to services. It inflicts harm on women, girls, men and boys’’. Many use the term gender-based violence (GBV) and we will use that term in this FAQ.

What is the evidence for causal links between MHM and GBV?
30% of women globally have experienced sexual and/or physical violence by an intimate partner (RESPECT Women, 2019). A WoMena study reports that some married women are beaten by their husbands because they cut blankets to make pads to manage their periods (CARE International and WoMena Uganda, 2018)

 

  1. Water, Sanitation, and Hygiene (WASH) in schools

Studies in Sub-Saharan Africa have demonstrated that girls face challenges with managing menstruation in schools every day (Jewitt & Riley, 2014). Only 47% of schools in low-income countries have water coverage and only 46% have sanitation facilities (Cardoso et al., 2018). Lack of access to products, private toilets, and spare clothing in case of leaks create difficulties for female students. Girls are at risk of experiencing psychological abuse and ridicule from male classmates when attending school while menstruating, especially when they leak (Cardoso et al., 2018). A typical school day is long and increases the risk of leakage, resulting in repeated harassment by boys, enhancing shame and embarrassment amongst girls (Jewitt & Riley, 2014). Not being able to frequently change MHM products can increase infections and the smell of menstrual blood being detectable by others, causing suffering, discomfort, and stigmatization. Avoiding to stand in class to answer questions, insecurity, and problems concentrating in class are other consequences of poor WASH in schools (Hennegan et al., 2016).

 

  1. WASH accessibility, availability, and quality

The UN has reported that one in three women do not have access to safe and adequate toilets. A study in Kenya found a direct link between violence against women and inadequate sanitation; poor access to public toilet facilities due to distance/proximity (too far away or too few) and/or poor design (dimly lit or isolated) puts women at risk of sexual harassment, assault, and rape (Cardoso et al., 2018). Moreover, due to stigma, shame, and fear, girls and women go to the toilet at night for more privacy, even further increasing the risk for violence, harassment, sexual assault, and exploitation (The Case for Her, 2019 & Schmitt et al., 2017).

 

  1. Transactional sex

Lack of access to MHM products and understanding of women’s needs during their menstruation can lead to transactional sex (CARE International and WoMena Uganda, 2018). Lack of adequate WASH facilities in schools can lead to psychological and social abuse and suffering amongst girls. Combined with the limited availability and access to MHM products, many adolescent girls engage in (unprotected) transactional sex to get money for MHM products to remain in school (The Case for Her, 2019, Tellier & Hyttel, 2018, Jewitt & Riley, 2014).

 

  1. Misconceptions and harmful traditional practices

A study in Ghana found that misconceptions about menstruation is exposing girls to sexual risks and violent gender problems (Kotoh, 2008). Harmful traditional practices are putting females at a higher risk for early and unplanned sex, sexually transmitted infections, and teenage pregnancy (Kotoh, 2008; Jewitt and Riley, 2014). This becomes clear from the following quotes: ‘’My husband does not get close to me, he rather goes out with other women’’ and ‘’When men and boys get to know you have started menses, they start harassing you for sex’’. An example of the harmful traditional practice is prohibiting menstruators to enter the kitchen, cook or enter a place of worship (Cardoso et al., 2018); ‘’my father will kill me if he sees me near the kitchen during my menses’’. Touching men or children are also commonly forbidden or even touching items used by men (Kotoh, 2008). There are some extreme cases where a menstruator is put in isolation to a small outbuilding (Cardoso et al., 2018). Being burdened less during their menstruation with household chores is giving menstruators rest, but these practices are perpetuating gender discrimination (Kotoh, 2008). Another example of a harmful practice is Female Genital Mutilation/Cutting (FGM/C). Some research has shown that FGM/C can lead to menstruation issues later in life (Reisel et al., 2015; WHO, 2020b). Obstruction of the vaginal opening might result in painful menstruation (dysmenorrhea), difficulties passing menstrual blood, and irregular periods (WHO, 2020b).

 

  1. Early/forced/child marriage

In some societies, menarche is associated with being ready for marriage (Tellier & Hyttel, 2018). This especially holds true for girls from poorer households, as the financial responsibility of taking care of the girl shifts to the husband. Studies found that early menarche was associated with early marriage, early sexual debut, and early pregnancy (Glynn et al., 2010). The high costs of MHM products is another connection of early marriage to MHM, thus there is a higher risk of early marriage as parents want to pass on the financial burden associated with menstruation (Tellier & Hyttel, 2018).

  1. Humanitarian settings

At the end of 2018, an estimated 70.8 million people were displaced due to natural disasters or conflict (UNHCR, 2019) with half or more of them being women and girls (UNHCR, 2020; UNFPA, 2019). Challenges such as crowding, lack of access to safe toilets and water facilities, disruption of families, and poverty heighten the risks for GBV in humanitarian settings (Kayser et al., 2019; Sommer et al., 2016, UNHCR, 2015; UNFPA, 2019). Cultural attitudes and taboos towards menstruation might exacerbate these physical situations (Schmitt et al., 2017). In humanitarian settings, access to basic necessities may be provided, but access to MHM products may vary. In the 2015 earthquake in Nepal, women reported being too ashamed to leave their tents due to a lack of MHM products (Budhathoki et al., 2018). Despite the women placing priority on obtaining MHM products, supply proved a challenge for humanitarian actors (Tellier et al., 2020, Cardoso et al. 2018). Uganda provides a different setting: around one million refugees live in settlements, some having been there for over a decade. Women place a priority on MHM products (e.g. selling food rations to obtain pads) but many humanitarian actors only distribute products in the first three months after the refugees arrive (Tellier et al., 2020).

 

  1. COVID-19 pandemic

At the time of writing this FAQ, COVID-19 is raging. There are several reports from various countries (e.g. France, China, Argentina, Turkey and the United States) that domestic violence cases have increased markedly during the lockdown, attributed to stress due to cramped situations and uncertainty (UN Women, 2020; WHO, 2020a). The cost and thereby stress, associated with purchasing products may contribute to tensions. Panic buying has been widely reported, leading to shortages of not only toilet paper but also MHM products (Knoll, 2020). WoMena’s rapid assessment indicated that prices of disposable pads in Uganda have increased by 17-33% since the beginning of the pandemic (WoMenaUganda & WoMena, 2020). One way COVID-19 affects survivors are that abusive partners might withhold items such as hand sanitizers, but also health insurance cards to keep them from searching for medical care (The Hotline, 2020). Another way is that abusive partners can share misinformation to scare or control the survivors (The Hotline, 2020). Abusers do this because abuse is about power and control, therefore, if survivors have to stay at home or be closer to their abuser more often, an abuser could use anything to control the victim (The Hotline, 2020). In the rapid assessment conducted by WoMena Uganda between 19th and 24th of May, 2020, it also became clear that 14% of the respondents (65) experienced or knew someone who experienced violence because they used household finances to get MHM products and 12% experienced or knew someone who experienced restrictions of using household finances to get MHM products.

 

What are some examples of interventions?

One early intervention in humanitarian assistance came from the UNFPA. In 2000, UNFPA introduced ‘dignity’ kits. These kits include basic hygiene items such as soap, but also panties and menstrual pads, to meet the specific needs of women and girls, facilitating their mobility and helping restore their dignity during the crisis (Abbott et al., 2011). They were seen as part of the ‘protection’ efforts in humanitarian response, including the prevention of GBV. Some also contain flashlights in recognition of the risks menstruators face when they need to access toilets in the dark. They have since been widely adopted and adapted by humanitarian actors, e.g. finding opportunities for local women and girls to assemble the kits, providing opportunities for income and awareness-raising discussions.

WoMena has worked in about 100 sites in Uganda, including refugee settlements, introducing MHM. A strong part of WoMena’s theory of change is a recognition that, with a sensitive and taboo issue such as MHM, there is a need to address the knowledge and shame, not only of the individual girl/woman but of the community, not least males (Dahlberg LL et al, 2002). ‘Male involvement’ is often mentioned in development projects, but what this means in concrete actions is less often described and tested. The strategy is to involve men and boys as key stakeholders, with training and other involvement actions, to help change from a negative male role to one of advocacy and protection. Some of the main findings are that many males felt left out, are keen to know more, and grasp the opportunity given by the projects to advocate for improvements. Girls feel less ashamed to mention (e.g. school girls feel free to state they need to use toilet facilities). Notably, males in refugee settings often have more time and are more open to change, compared to more settled populations. Men are often the ones paying for products. Menstrual cups are cost-saving in the long run and findings from WoMena’s projects indicate very positive feedback from males about this aspect (Tellier et al., 2020).

Conclusion

GBV is widely acknowledged to go beyond physical to not only psychological but also restricting activities or access to basic services. Males are often the breadwinners, and withholding cash can be a means of control. This is also the case in MHM. Many dimensions were found to have an association with GBV: early/child/forced marriage, transactional sex, poor access to WASH in schools, and in life in general, education, and misconceptions. Many of these associations are or can be expected to be exacerbated in crisis situations e.g. in humanitarian settings and in the COVID-19 pandemic. WoMena’s approach of facilitating access to low-cost reusable products (pads or MCs), providing education for both males and females e.g. on basic facts of menstruation, how to manage pain, or hygiene education, have proven to provide new confidence and feelings of freedom for menstruators and to strengthen roles as protectors for males. There are many studies of low knowledge among girls and women, but even less among men and boys, and this would be important for future studies. However, meanwhile, WoMena studies indicate higher levels of knowledge among both males and females, less stigmatizing attitudes, more openness in the discussion (e.g. girls feeling comfortable talking to both male teachers and family). There is a need for further investigation of male knowledge and attitudes, as well as further evidence of the impact on violence. WoMena will continue to explore these linkages.

 

References

Abbott, L., Bailey, B., Karasawa, Y., Louis, D., McNab, S., Patel, D., Posada Lopéz, C., Sharma Rani, R., Saba, C., Vaval, L. (2011). Evaluation of UNFPA’s Provision of Dignity Kits in Humanitarian and Post-Crisis Settings. Final Report, May 9th 2011. https://www.alnap.org/help-library/evaluation-of-unfpas-provision-of-dignity-kits-in-humanitarian-and-post-crisis-settings

Budhathoki SS, Bhattachan M, Castro-Sanchez E, Sagtani RA, Rayamajhi RB, Rai P, et al. Menstrual hygiene management among women and adolescent girls in the aftermath of the earthquake in Nepal. BMC Womens Health. 2018;18(1):33. https://bmcwomenshealth.biomedcentral.com/track/pdf/10.1186/s12905-018-0527-y

Cardoso L.F. Clark C.J. Rivers K. Ferguson G. Shrestha B. & Gupta J.. (2018). Menstrual restriction prevalence and association with intimate partner violence among Nepali women. BMJ Sexual and Reproductive Health, 45: 38–43. https://srh.bmj.com/content/familyplanning/45/1/38.full.pdf

CARE International and WoMena (2018). Ruby Cups: Girls in Imvepi Refugee Settlement Taking Control. CARE International, Kampala, Uganda. Available from: https://womena.dk/wp-content/uploads/2018/12/Ruby-Cups-Girls-in-Imvepi-Refugee-Settlement-Taking-Control-03.12.18-Final-report.pdf

Dahlberg L.L. & Krug E.G. Violence – a global public health problem. In Dahlberg LL, Krug EG, Mercy JA, Zwi Ab, Lozano R, editors. World Report on Violence and Health: World Health Organization; 2002. p. 1-56.

Glynn, J.R., Kayuni, N., Floyd, S., Banda, E., Francis-Chizororo, M., Tanton, C., Molesworth, A., Hemmings, J., Crampin, A.C. and French, N. (2010). Age at menarche, schooling, and sexual debut in northern Malawi. PloS one, 5(12), p.e15334.

Hennegan J., Dolan C., Wu, M., Scott, L., Montgomery, P. (2016). Measuring the prevalence and impact of poor menstrual hygiene management: a quantitative survey

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Jewitt, S & Ryley, H. (2014). It’s a girl thing: Menstruation, school attendance, spatial mobility and wider gender inequalities in Kenya. Geoforum, 56, 2014: 137-147. https://www.sciencedirect.com/science/article/pii/S0016718514001638

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New York Times, 13 March 2020 https://www.nytimes.com/2020/03/13/nyregion/coronavirus-panic-buying.html

Kotoh A.M. (2008). Traditional Menstrual Practices: Sexual and Reproductive Health and Gender Implications for adolescent girls. Institute of African Studies Research Review, 24, 1: 37-51. https://journals.co.za/content/inafstud/24/1/EJC45998

Reisel, D., Creighton, S.M. (2015). Long term health consequences of Female Genital Mutilation (FGM). Maturitas, 80, 1: 48-51. https://www.sciencedirect.com/science/article/abs/pii/S0378512214003260

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Schmitt et al. (2017). Understanding the menstrual hygiene management challenges facing displaced girls and women: findings from qualitative assessments in Myanmar and Lebanon. Conflict and Health, 11, 19: 1-11. https://conflictandhealth.biomedcentral.com/track/pdf/10.1186/s13031-017-0121-1

Sommer, M., Schmitt, M., Clatworthy D., Bramucci, G., Wheeler, E., & Ratnayake, R. (2016). What is the scope for addressing menstrual hygiene management in complex humanitarian emergencies? A global review. Waterlines, 35(3), 245-264. www.jstor.org/stable/26600764

Tellier, M; Farely, A; Jahangir, A; Nalunga, D; Nakalema,Sh; & Tellier, S. (2020). ‘Practice Note: Menstrual Hygiene Management in Humanitarian Settings’ The Palgrave Handbook of Critical Menstruation Studies. https://www.palgrave.com/us/book/9789811506130

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Available from: https://share-netinternational.org/events-list/menstrual-health-missing-piece-srhr/

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WoMena and WoMena Uganda (2020). “Impact of COVID-19 pandemic on menstruating women and girls in Uganda: Preliminary findings.” Infographic Report.

This is the best evidence we could find. Comments are warmly welcome! (please write demi.cheng@womena.dk)

[1] The FAQ was developed by WoMena (researcher Demi Cheng and reviewers Andisheh Jahangir and Siri Tellier)

This is the best evidence we could find. Comments are warmly welcome! (please write demi.cheng@womena.dk)

[1] The FAQ was developed by WoMena (researcher Demi Cheng and reviewers Andisheh Jahangir and Siri Tellier)