Where is menstruation in global health policy?

Periods are a regular biological reality for millions around the world and a global public health issue. But when we discuss menstruation as a policy issue, what exactly are we talking about? Fran Amery, Melanie Channon, Josephine McAllister and Jennifer Thomson investigate. This blog was originally posted on the LSE Inequalities blog, which can be read here.

Menstruation is a fundamentally important issue for global health. Periods are a regular biological reality for millions around the globe – indeed, around 800 million people are menstruating every day. Reflecting this reality, over the past decade or so, periods have been the subject of public awareness campaigns and policy discourse: 28 May has been celebrated as Menstrual Hygiene Day since 2014; efforts around menstrual activism are increasing around the globe; and governments are finally taking action on period poverty, with many enacting changes to the so-called “tampon tax” and some now providing free period products in educational settings and elsewhere.

But when we talk about menstruation as a policy issue, what exactly are we talking about? Periods are an issue for health and medical science; but they’re also impacted by social stigma and have huge environmental consequences depending on what products we use.

Within the global public health arena, UN-level bodies and institutions, such as the World Health Organisation (WHO), the World Bank, and the United Nations Population Fund (UNFPA), hold significant sway. They often take the lead in deciding what goals are set, where money is allocated, and how issues are presented in wider policy settings. But for a complex and intersecting issue like menstruation, it can be difficult to know what measures to adopt and which populations to target. This can lead to siloed and counterproductive work.

In this context, our latest research looks at how menstruation is constructed and framed in UN-level global health policy. What we uncover is, at best, a patchy construction of menstruation as a policy issue…

How menstruation is framed in a public policy context

The attention paid to menstruation in research, policy and practice over the past decade has ignited various arguments about how it should be understood and framed.

In the early 2000s, menstruation first reached the international development agenda as an issue of hygiene management when the needs of adolescent girls at school began to be acknowledged, particularly from the water, sanitation & hygiene (WASH) sector. The concept of Menstrual Hygiene Management emerged. This largely focussed on physical infrastructure and products needed to “manage” menstruation safely and effectively, such as toilets and period pads. This approach gained a lot of criticism – does discussing menstruation as a hygiene issue implicitly suggest that it is something dirty?

Gradually, discussion moved beyond this narrow construction of menstruation as a hygiene issue to a more holistic health perspective. The concept of menstrual health recognises that mental and social wellbeing in relation to the menstrual cycle are important, too. In recent years, further arguments have been made for understanding menstruation as a matter of rights and justice, encompassing both menstrual hygiene management and menstrual health, and acknowledging its intersectionality.

Where is menstruation in global health policy today?

Despite these various arguments for how menstruation should be understood, little research has so far been done to explore how menstruation actually is talked about in global health policy.

To address this, we examined key policy documents, websites, press releases, statements and videos from six UN-level organisations (WHO, UNICEF, UNFPA, UN Women, UNCSW and the World Bank) in order to find out where menstruation features in global health policy today, how it is understood by these influential organisations and who their target populations are. By surveying a wide range of resources, we were able to understand how menstruation is constructed right across their discourse, rather than focusing solely on their final policy outputs.

We found various constructions of menstruation, demonstrating a need for greater clarity and cohesion across these organisations. In the resources we analysed, menstruation is predominantly still constructed as a hygiene issue that affects adolescent girls alone(!), demonstrating the ongoing influence of the WASH sector on menstrual policy discourse. We found that disposable period pads were emphasised as a “solution” over other menstrual products, with little consideration for their environmental impact or the value of being able to make an informed choice.

A life course perspective was absent from many of the resources, while issues relevant to older people (eg, the peri/menopause) and transgender and non-binary people who menstruate were largely neglected. In addition, we found that these policy organisations rarely address menstrual pain and menstrual-related illnesses (including conditions such as endometriosis) despite their prolific nature. In places where one might expect to find reference to menstruation, such as in the WHO’s webpages on health, menstruation was missing while other topics such as contraception or abortion were present.

Finally, we found a lack of ownership of menstruation as a key issue from the sexual and reproductive health and rights sector, including from the UNFPA, despite research advocating for understanding menstruation as an integral part of sexual and reproductive health.

The need for a more cohesive collective understanding of menstruation

Overall, our research shows how menstruation is still being understood in different ways by different policy actors. This reflects the fact that it is a complex issue, with lots of different problems that need to be addressed through various policy spaces.

However, a collective understanding of menstruation is needed at the international policy level to encourage collaboration across different sectors and to avoid siloed or counterproductive work. Greater consideration must be given to menstruation across the life course – it’s not just adolescent girls who menstruate! Future policies and communications materials should address the notable silences and gaps that we have found, specifically those on gender inclusivity, menstrual-related illnesses and conditions, and environmental justice. The sexual and reproductive health and rights sector, meanwhile, should take greater ownership of menstruation as an issue deserving of attention.

Does this mean that menstruation can no longer be constructed in multiple ways? No – menstruation is relevant to many different areas of policy and there is growing awareness that, as a multi-faceted area, it requires a multi-sectoral response. But a clear and cohesive understanding of menstruation could be advantageous, reducing the risk that policies skirt around or omit menstrual-related issues on the basis that the landscape is too confusing. Ultimately, this will make it easier to hold policymakers to account and advocate for clear goals. Period.