More than a ‘woman’s issue’: male advocacy for menstrual health

We speak with Georgia Hales, lead author of the recent PLOS Water publication “Influencing non-menstruator attitudes and behaviours towards menstrual health among rohingya refugees in Bangladesh: A realist evaluation“, part of the ongoing UNC Water and Health Conference Collection with PLOS.

What is a ‘woman’?

‘Woman’ is a gender identity. We recognise that not all women menstruate (e.g. trans women), and that not all who menstruate are women (e.g. trans men or non-binary persons). In this blogpost, we use a mixture of gender-neutral and gendered terms.

Why is this topic important?

Poor access to menstrual health is fuelled by misogyny. The shame, secrecy, and desire to control female bodies mean that many people that menstruate don’t get what they need to manage their periods with comfort and dignity across the world. This works to further subordinate menstruators. In a male-dominated world, we need to start looking more at how patriarchal structures – and the role of men within this – work as a barrier to menstrual health.

Why this context?

The issue is exacerbated in humanitarian contexts where there is limited access to water and sanitation facilities, decreased privacy, and a lack of prioritisation within responses. The Rohingya refugee community living in Bangladesh offer a good example of how patriarchal norms influence access to menstrual health. For example, it is often the male head of household who controls finances and receives information from outside the house. When menstruation is seen as only a ‘woman’s issue’, period products may not be bought and important menstrual education and information may not be passed on. Additionally, they have more influencing power to uphold stigmas, taboos, and cultural practises such as those who menstruate not leaving the house whilst menstruating. Though this may raise issues such as girls missing out on their education, we wish to tread carefully in commenting on the nuances and complexities of cultural practises that are not our own for fear of misunderstandings or veering into paternalism.

What are humanitarian organisations doing to address it?

UNICEF and World Vision who have worked with the Rohingya since their largest exodus into Bangladesh in 2017 noticed this barrier. They addressed it by carrying out a programme aiming to encourage male Rohingya to become advocates of menstrual health for their families. This was done through selecting influential ‘Menstrual Health facilitators’ from the community to change negative and uniformed misconceptions, education on the risks associated with poor menstrual health led by World Vision, and talks from the Imam on the nobility of supporting family members in this way.

Why did you choose your research methods?

Since behaviour change programmes – especially ones related to stigmatised and silenced topics – work on a deep and personal level we needed a form of evaluation that would allow us to uncover how and why any changes in attitude and behaviour were occurring. Realist evaluation asks how a programme works, for whom, and under what circumstances. It is a theory-based approach that explores how a programme’s inputs interact with specific contextual factors to produce the underlying causal mechanisms that lead to its outcomes.

To give us a lead on which factors may have been important to look into we conducted surveys that allowed us to divide people into those with ‘positive’ attitudes and behaviours and those with ‘negative’. We statistically analysed their responses to understand which contextual (e.g. marital status) and psychosocial (e.g. understanding of menstrual health) factors may determine whether someone possesses positive or negative traits. We also conducted interviews with programme staff to understand how they think the programme might be working.

Using the significant factors that came to light in the analysis plus initial programme theories from interviews with staff, we conducted in-depth interviews with the participants. This allowed us to unearth what was causing the mechanisms that led to positive changes in their attitudes and behaviours.

What were your most interesting results?

It was not surprising that becoming aware of and empathetic to the health risks of poor menstrual health was a big influencing factor for changing attitudes and behaviours. What we found interesting was the role that the constructs of masculinity played. For example, when we reframed menstruation from being a ‘woman’s issue’ to the responsibility of the male head of household to protect his family’s health, participants were much more encouraged to see it as their duty as a husband or father to support their families in this way. What was touching were the remarks of participants who would glow from seeing their wife or their mother happy and healthy as a result of their support. Some even said it had improved their relationship and made them feel closer. In a community as devoutly Muslim as the Rohingya it was not unexpected that the Imam had a big influential role – especially in removing the misconception that menstruation was something dirty or devilish to it being seen as a gift from Allah allowing for conception. Feeling comfortable and trusting of staff and other participants was also important to allow everyone to share and learn together – this was something that was strengthened increasingly over time.

What would you like to see in practise going forwards?

We would like to see more humanitarian organisations looking at the role that men and patriarchal structures play in influencing access to menstrual health within different contexts. Through understanding the community’s dynamics, beliefs around menstruation, and ideas of gender roles and masculinity, they can tailor programmes to effectively transform people’s perception of menstruation from a ‘woman’s issue’ to something that concerns us all.

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