I’m Jen Rubli, and I work as the Research and M&E Coordinator for Femme International, a role I’ve had since 2013. We’re a menstrual health NGO in East Africa. Our work focuses on community- and education-based strategies to expand access to menstrual resources whilst tackling gendered social norms. I could talk a lot more about our and my credentials, but that’s not what you’re here to read.

We’ve been working in the menstrual health sector almost since the beginning and have had the unique perspective of being a part of its evolution from a small, disparate number of little NGOs, one researcher (right here in Tanzania, where I’m based), and no money. Fast forward to today, where East Africa boasts numerous ground-breaking research projects, a research network, and is very much leading the way in terms of national-level policies and stakeholder groups, and regional-level coalitions, all in an effort to collaborate and coordinate. It’s dizzying, really.

The case for systems for menstruation

Systems-level thinking is so important. Especially in looking at the menstrual health sector’s roots: it was ‘young, scrappy, and hungry. And in many ways, it matured in a very ragtag way, through sheer force of will. But it also grew very much out of the water, sanitation and hygiene (WASH) sector, the first to address menstruation through supplying products (primarily disposable pads) and improving WASH facilities.

From the get-go, Femme never saw itself as WASH NGO. Instead, we started off with education and distribution of reusable products (menstrual cups and reusable pads). Our narrative followed that traditional ‘give a girl (disposable) pads and she’ll stay in school.’ PSA here: that stat about 1 in 10 girls missing school because of menstruation? Totally false.

We have learnt so much since those early days. School attendance and dropout is so much more complex than menstruation, and participation is a much better measure of programme success. Being in school or at work has nothing to do with what you actually get out of it.

Menstruation happens for 40 years, and far beyond just the school setting. It happens in workplaces and the streets and humanitarian settings. It happens to many people, not just those who identify as cis women and girls, or who do not have disabilities.

We know that products and WASH facilities, whilst vital components, are not nearly enough on their own, and a more holistic (and realistic?) approach is required. Whilst the onus is very much at the individual level, adolescent girls have no agency – giving them pads, improving access to water at school, teaching them healthy practices, these are absolutely unrelated to their ability to implement any sort of behaviour change. That comes at a community-based and systems-thinking level, and that’s where programming has to happen to see truly sustainable impact.

Those of you in humanitarian work are familiar with the cluster approach, where each expertise is siloed. But like gender, and because it is gendered, menstruation is a cross-cutting issue. It needs to be considered in WASH, in security, in lodging, in food, in healthcare. Moving beyond the humanitarian sector, it needs to be in policy, advocacy, social media, schools and workplaces, research. Like taking a gender lens to programming, menstrual considerations need to be at all levels. Which obviously isn’t to say that every menstrual health programme needs to do everything, that’s impossible. We all have our areas of expertise. This is about coordinating and collaborating to ensure we are collectively hitting all those targets.

That’s much more the approach we’re seeing today.

Pupils reacting to a menstrual cup.

Change is happening and more is on the horizon

Both the Integrated Model of Menstrual Experience (an evidence-based theoretical framework) and the newly-released definition of menstrual health (expanding upon the old ‘menstrual hygiene management that was completely WASH-focused), show this broader focus that takes into account the many intersecting factors that truly determine how somebody experiences and manages their period.

I’m part of two research projects in Tanzania that have done exactly this; one looking at the long-term impact on participation and health of menstrual cup users, and PASS-MHW, evaluating Femme’s school-based intervention with the London School of Hygiene and Tropical Medicine, and the Mwanza Intervention Trials Unit.

Our menstrual cup study, done in partnership with LUCSUS, Lunette Cup, Give a Heart to Africa, and the National Institute of Medical Research, used the framework to look at the link between menstrual cups and well-being, menstrual/reproductive health, and finances. We found that menstrual cup users suffered fewer menstrual/reproductive health symptoms and diagnoses like itching, rashes, UTIs, and bacterial vaginosis. They reported less anxiety. Why? They had increased financial security because cups result in fewer menstrual expenses. They felt safe and free during their periods, not constantly worried about leaking, smelling, or being somehow found out. They worried less about where and how they would safely change. And because anxiety and pain are part of the same feedback loop, less worry and fear meant they felt less menstrual pain. Cup users were at work more, lost less income, and had more robust social lives, missing out on fewer daily activities. Pretty powerful for a $20 piece of silicone, eh?

When you’re vacillating between cheap disposable pads that itch and burn, and cloth that leaks (so you stuff it with dried grass); when you’re choosing between a painkiller so you can be at work, or a ride to work because it hurts too much to walk; it’s easy to see the transformative power of anything that makes your period just a tiny bit easier. One less thing to worry about. So, imagine if, on top of having that menstrual cup, experiencing less pain, and being at work all day, you also didn’t feel shamed and contaminated, diminished by social norms and taboos, and restricted by sexist policies and myths.

That’s the power of using a holistic, comprehensive approach to tackling menstrual health.

If you’re interested in reading more about our menstrual cup study, follow this link: Health outcomes from using menstrual cups – A pilot study from Moshi, Tanzania

Addressing menstruation is a key component to achieving that gender balance, equality, and equity at every level of society. Why? Because menstruation is too often a barrier. It casts people as dirty or contaminated and places restrictions upon them which excludes them from fully participating in their daily lives. It is an extra financial burden (think: Tampon Tax) over something that cannot be controlled.

Femme’s Judith and Emma with students at Enkijape Primary School.

Pain is the number one reason globally that women and girls stay home during menstruation. First off, they’re missing school or work. Secondly, there is a worrying lack of research into what causes period pain, and how to treat it effectively. If more menstruators were making funding decisions or sitting on research ethics committees, there would probably be more money and more incentive to research this, as opposed to turning up at a clinic and being told to ‘deal with it’.

Ever heard of the tampon tax? Or on a broader level, the pink tax? Despite a growing movement in many countries, menstrual products are often still taxed as ‘luxury’ items, while things like wedding cakes, Viagra, or maraschino cherries are not taxed. I think most menstruators would agree that purchasing menstrual products is not a choice, it’s a necessity.

The gender pay gap is already well documented, where women make less than men for equal work. And then they have to pay more for their bodies – menstrual supplies each month, or are paying up to hundreds of dollars for some type of hormonal contraception. In family settings, it is also usually women who help to pay for other women’s menstrual costs. Bottom line: women earn less but pay more.

Hiding menstrual status is key. Women slip products up sleeves, into pockets, and once in the bathroom, wait for everyone else to leave so no one will hear the package crinkling. Product manufacturers boast smaller, more discreet, quieter packaging. In many countries, it’s even taboo to reveal menstrual status to men and boys. Women and girls fear the teasing or sexual abuse they will face if this is known. The non-menstruating body is what is considered status quo, and to deviate from that is an aberration that needs to be concealed and solved. In one study, a woman dropped either a tampon or a hair clip. Afterwards, participants rated women who had dropped a tampon as less competent and less likeable than those who had dropped a hair clip. Participants also tended to sit further away from tampon-droppers. All because it was a visible reminder of her menstrual status. Now extrapolate this scenario to every day in public, where a female applicant suddenly becomes less desirable for no reason other than she happens to reveal her menstrual status.

Women are judged much more harshly than men, and by different criteria. This is compounded when menstruation is added to the mix. A study on female entrepreneurs in Sweden, one of the most gender-equal countries globally, found that female entrepreneurs are, unsurprisingly, judged on very different criteria than their male counterparts. Women who pitched were more likely to be judged on their appearance, were often referred to as needing support (or somehow lacking it), were portrayed as anxious and worried about their success, and had their competency questioned. Male pitches were much less likely to be referred to negatively. Additionally, only the men were referred to as entrepreneurs. At the end of the day, men received 52% of the venture capital they’d requested; women received 26%.

This year’s theme for International Women’s Day (IWD) is #balanceforbetter. What does that mean? It is referencing the facts and statistics that demonstrate gender equality benefits everyone – it is not just about women.

“All of these inequalities add up – women are paid less, taken less seriously, judged based on their appearance as opposed to their ability, and generally considered a less capable aberration of the default male (non-menstruating) status quo. We live in a world designed by men, for men, and it takes its toll.”

Ironically, female is actually the biological default. Male feotal development requires that specific signals be sent and received in order to develop male internal and external reproductive organs, and gender identity. When those signals are not sent or received, the default female will develop. Furthermore, XX (female chromosomes) is viable, whilst YY is not. Males are XY chromosomes.

Addressing menstruation removes one of the barriers that women and girls face. Armed with accurate and practical information, an understanding of their bodies and how it works, and the tools they need, women and girls are better able to stand their ground. When they are not suffering from shame and anxiety of leaking, they can concentrate at school and work, and be present for key moments. Energy is instead directed to excelling professionally. Women and girls are empowered every day of the month.

Period.