The Right to Menstrual Hygiene: Period Poverty in Developing Countries

Across the globe, 1.8 billion individuals experience the biological process of menstruation.^[1] When menstruating individuals do not have “access to sanitary products, menstrual hygiene education, toilets, hand washing facilities, [or] waste management,” they experience period poverty, rather than a dignified biological process.^[2] Menstrual hygiene—or the lack thereof—impacts individuals’ dignity and self-worth regarding being clean and sanitary in part due to the stigma of shame surrounding menstruation.^[3] The lack of access to and the price of menstrual products force the use of unsafe and unsanitary products, such as old clothes, rags, and sawdust.^[4]

Running water and sanitation are necessary for washing hands after changing menstrual products, bathing while menstruating, washing materials stained with blood, safely disposing of used menstrual products, and preventing the transmission of HIV/AIDS and Hepatitis B.^[5] In 2017, four of five recommended menstrual hygiene services (e.g. sex-separate facilities, water supply, door with a lock, waste disposal bin) were met by less than 20% of schools in rural Ethiopia, Kenya, Mozambique, Rwanda, Uganda, and Zambia.^[6] Maintaining menstrual hygiene becomes more difficult in developing countries where only 27% of people possess adequate handwashing facilities in their homes.^[7] In fact, basic sanitation services are not available to 2.3 billion people worldwide.^[8] Individuals with disabilities and individuals living in either conflict or natural disaster-affected areas also possess an additional obstacle to menstrual hygiene.^[9]

Inadequate menstrual hygiene may result in physical health risks from “introduc[ing] or support[ing] the growth of unwanted bacteria” during menstruation, which increases the risk of infection, such as reproductive and urinary tract infections.^[10] Although, the health risks from inadequate menstrual hygiene in developing countries must be further researched to determine the severity; in India, about 14% of women self-reported menstrual infections.^[11] In addition, menstruation in developing countries is frequently accompanied by school absences.^[12] A lack of access to safe menstrual products and individual school bathrooms cause one in ten girls in Africa to miss school.^[13] In India, private, functional school toilets are not available to 54% of girls.^[14] Not to mention, school absences are often correlated with child marriage, early pregnancy, malnourishment, domestic violence, and pregnancy complications.^[15] Moreover, many cultures, in developing and developed countries alike, treat menstruation as shameful, resulting in a stigma that compounds the other obstacles to proper menstrual hygiene.^[16]

This article will argue for an explicit and enforced right to menstrual hygiene by first discussing the current international law supporting this right. Next, the management of menstrual health will be analyzed to determine the steps that developing countries must implement to recognize such a right. Lastly, an analysis of the exacerbating effects from COVID-19 on period poverty in developing countries will provide context for the immediate need to explicitly recognize and implement the right to menstrual hygiene.

A Right to Menstrual Hygiene

Given the consequences of inadequate menstrual hygiene, a global right must be recognized and implemented. The right to menstrual hygiene derives from the United Nations’ Sustainable Development Goals (“SDGs”) and the rights recognized by the United Nations (“UN”), an international organization. The SDGs lists more than three goals to achieve sustainable development relevant to a right to menstrual hygiene. First, countries should protect “the reproductive rights of women as a human rights issue” as demonstrated by multiple SDGs.^[17] Second, countries should ensure healthy lives and promote the wellbeing of all persons.^[18] Third, countries should manage water and sanitation to guarantee access to “safely managed drinking-water, sanitation and hygiene services.”^[19]

UN treaties also imply a right to menstrual hygiene. General Comment No. 36 (2019) to the International Covenant on Civil and Political Rights endorsed a right to an education on sexual and reproductive health, promoted access to quality prenatal and post-abortion health care, and affordable contraceptive methods.^[20] The Comment stated that individuals should be able to enjoy “their right to life with dignity.”^[21] A life with dignity requires access to adequate menstrual health and hygiene for individuals who experience this natural biological process.

In addition to the civil and political right to a life with dignity, the International Covenant on Economic, Social and Cultural Rights (“ICESCR,” 1976) recognized the right to “the highest attainable standard of mental and physical wellbeing” for all persons, reinforcing the second aforementioned SDG.^[22] According to the international treaty, in the context of women in prison, this right to wellbeing includes access to all preventative services available in the community for their age group, such as contraceptives to prevent painful menstruation.^[23] Within this right, a right to necessary menstrual hygiene exists for women in prison.^[24] Thus, a right to menstrual hygiene must also be interpreted from this treaty for all menstruating individuals, including individuals who are not incarcerated, to reach their highest attainable standard of wellbeing.

In accordance with the third relevant SDG, the right to water, sanitation, and hygiene (“WASH”) also supports a right to menstrual hygiene given the need for WASH services in maintaining individuals’ life with dignity and well-being during their menstrual cycles, as stated above. From the right to an adequate standard of living under the ICESCR, the UN General Assembly adopted a resolution that recognized the human right “to safe and clean drinking water and sanitation” as “essential for the full enjoyment of life and all human rights.”^[25] The Committee on Economic, Social and Cultural Rights explained that water and sanitation must be sufficient to cover personal hygiene as well as be physically and safely accessible, accounting for “the needs of particular groups, including…women.”^[26] Given the need for adequate running water and sanitation for a dignified menstrual cycle and proper menstrual hygiene, water and sanitation must be accessible. However, countries are only required to provide water and sanitation services when people cannot obtain access because of their uncontrollable circumstances, such as extreme poverty or natural disasters.^[27] This right does not require state ownership of these services, but states must adequately oversee and regulate the private control of the services to prevent human rights violations and maintain affordable prices.^[28] Regardless of the narrowing of state responsibilities, menstrual hygiene needs must be included in the right to safe drinking water and sanitation. Therefore, a right to menstrual hygiene is implicitly recognized by the UN SDGs and the international rights to a life with dignity, to the highest attainable standard of mental and physical wellbeing, and to safe drinking water and sanitation.

Menstrual Health Management: Steps Toward a Recognized Right

Despite this implicit right to menstrual hygiene, the SDGs are not binding on UN member states, and some countries have not ratified these international treaties recognizing the rights from which this implicit right derives. Many countries do not explicitly recognize a right to menstrual hygiene, but developing countries vary in their implicit recognition of such a right through their management of menstrual health. Menstrual health and hygiene (“MHH”) may be regulated through menstrual education in schools, the elimination of a tampon or pink tax, the free supply of menstrual products, the entitlement of menstrual or period leaves, and the improvement of water and sanitation services.

Developing countries do not mandate menstrual education. Although, international and non-governmental organizations increasingly disseminate guidance on MHH in schools in developing countries, creating minimum standards and strategies for implementing policy.^[29] Since 2014, organizations, such as UNESCO’s 2014 Puberty & Menstrual Hygiene Management guidelines, Save the Children’s 2016 Menstrual Hygiene Management Operational Guidelines and UNICEF’s Gender Action Plan for 2018-2021, continue to develop different guidelines on menstrual health and management in schools, yet one universal set of global guidelines has not been established.^[30] Some developing countries, like India, Zambia, Kenya, and the Philippines, provide their schools and teachers guidance.^[31] For example, Nepal’s National WASH in Schools Procedure (2018) explains the standards for proper menstrual health and management education and WASH facilities.^[32] Only a few governments, like Zambia, are implementing and monitoring MHH resources and services while other governments, such as Nepal, Indonesia, Madagascar, Somalia, and Gambia, initiated test programs to provide menstrual health and management packages in certain schools.^[33] Some countries also target menstruating individuals with disabilities, non-menstruating individuals, and menstruating individuals from minority tribal and ethnic groups in their conversations of MHH.^[34]

While menstrual education has developed more recently, almost all countries possess a tampon tax, which taxes menstrual products at a non-essential rate, despite being a necessary part of a natural biological process.^[35] Some countries even classify menstrual products as luxury items and tax them at the same rate as cigarettes and alcohol.^[36] In general, tampon taxes contribute to the added expense of menstrual hygiene in developing countries, and almost 13% of women and girls globally struggle in obtaining menstrual health and management resources.^[37] In fact, period products cost an average menstruating individual about $1,773 in their lifetime.^[38] The tampon tax rate also varies by country. For example, as of 2020, Hungary possessed a 27% tax rate on feminine hygiene products while Mexico possessed a rate of 16%, and Iran had a rate of 9%.^[39] Developing countries with tax-free feminine hygiene products in 2020 included India, Malaysia, Nicaragua, Uganda, Kenya, Tanzania, Nigeria, Jamaica, Lebanon, Colombia, and Rwanda.^[40] However, these states’ tax-free status does not necessarily equate to affordability because they may contain high import levies if they do not produce the products domestically.^[41]

Whereas some countries have lifted or reduced the tampon tax recently, Scotland remains the only country that provides free menstrual products.^[42] For instance, New Zealand and England provide free menstrual products in schools, but developing countries do not mandate the provision of these necessities to students for free.^[43] Some schools in developing countries may voluntarily provide free products if their budget allows. Aside from schools, free menstrual products are provided for refugees and women prisoners. Since 2001, the UN Refugee Agency has allocated funds to its offices worldwide to provide refugees with sanitary products to prevent an infringement on dignity, rights, and health.^[44] According to the Bangkok Rules, a resolution adopted by the UN General Assembly, correctional facilities must meet women prisoners’ “hygiene needs,” which includes free sanitary towels and a regular water supply for menstruating individuals.^[45]

Surprisingly, Japan, South Korea, Indonesia, and Taiwan, as well as some provinces and companies in China and India, offer an entitlement to menstrual or period leave, which provides individuals with (paid or unpaid) time off work while they are menstruating.^[46] Although, the policy has declined in use; in 2017, only 0.9% of female employees in Japan and 19.7% of women in South Korea claimed menstrual leave.^[47] Despite being a natural biological process, the issue of non-use is grounded on the stigma of menstruation being labeled as ‘shameful’ or ‘dirty,’ resulting in the avoidance of requesting menstrual leave from supervisors, especially if they are male, which indirectly informs them of their menstrual cycles.^[48] In addition, to access menstrual leave, some policies require a doctor’s note, and Indonesian policy requires the passing of “an invasive physical examination.”^[49] Opponents of menstrual leave argue that menstruating individuals should continue to work during menstruation to avoid undermining their ability to work and the potential backlash of employment discrimination.^[50] However, menstrual pain and inadequate menstrual products may contribute to a loss of productivity which may be resolved with menstrual leave, the inclusion of menstruation under medical leave, or teleworking—provided the individual is privileged with the necessary infrastructure.

Besides the necessary employment reform and a cultural shift away from stigmas to implement menstrual leave, developing countries must also improve their WASH services for a dignified biological process. For instance, the World Bank aims to remedy the lack of access to WASH infrastructure through its various projects, such as the WASH-in-School program in Tajikistan. In Tajikistan, the World Bank’s 150-school program maintains WASH facilities, finances the delivery of supplies (e.g. soap, toilet paper), constructs safe, gender-separated sanitation facilities, and creates menstrual education materials.^[51] The World Bank also provides clean water sources to homes in underserved areas, and campaigns behavior changes for sanitation, menstrual hygiene management and solid waste management in the Solomon Islands.^[52] The World Bank and other organizations continue to fund projects to provide and improve access to water and sanitation services within developing countries.^[53] The improvement of WASH services as well as the other policies must be implemented in developing countries to explicitly recognize a right to menstrual hygiene—a necessity for a natural biological process.

Worsened Effects of Period Poverty from COVID-19

Recently, COVID-19 highlighted the importance of recognizing and implementing a right to menstrual hygiene by worsening the negative impact of period poverty in developing countries. Women healthcare workers compose 70% of the global healthcare workforce, and these menstruating individuals must overcome the obstacles of menstrual hygiene while working on the frontlines of the global pandemic response.^[54] Menstruating healthcare workers face challenges involving managers who are unaware of MHH needs, a lack of MHH supplies, the difficulty quickly changing menstrual products while wearing personal protective equipment, a lack of access to water and sanitation facilities, and menstrual pain.^[55] The importance of caring for these workers is highlighted by the limited number of healthcare workers during the pandemic; Sub-Saharan Africa only retained ten nurses and midwives per ten thousand people.^[56] Nonetheless, the menstruating individuals who are hospitalized or quarantined for COVID-19 may also lack MHH and WASH services.^[57] In addition, the pandemic increased menstrual abnormalities, which are not recognized or supported for COVID-19 patients.^[58]

On the other hand, most—if not all—people experienced disrupted production and distribution of MHH products (e.g. toilet paper), reduced accessibility to MHH products, suspended basic social services, and inadequate MHH facilities and products to privately manage menstruation.^[59] For example, countries, like Fiji, offset their revenue losses from trade and tourism by increasing the prices of menstrual products.^[60] Even water and sanitation services experienced increased costs from the scarce supply.^[61] Menstruating individuals who quarantine at home may face an increased lack of access to adequate clean water and sanitation supplies.^[62]

Furthermore, school closures and budget reallocations interrupted access to MHH supplies. When schools closed, the millions of menstruating individuals who relied on schools for menstrual products were forced to find alternatives that were likely unsafe, such as old clothes, rags, and sawdust.^[63] Schools did not continue providing MHH products, social support, or MHH education through school closures.^[64] When schools reopened, the limited resources for a safe reopening during COVID-19 did not prioritize MHH services.^[65] Likewise, funding for women’s health, including information on menstruation, was reallocated to other issues and mischaracterized as non-essential or elective.^[66] A lack of access to technology, school closures, suspended community programming, and low literacy levels also contributed to further limited access to menstrual information.^[67] These exacerbated effects of period poverty in developing countries from COVID-19 demand the explicit recognition of the right to menstrual hygiene.

Conclusion

In sum, a right to menstrual hygiene must be recognized and implemented to satisfy the needs of a natural biological process. Countries should require menstrual education for all genders, increase access to menstrual products by providing state-wide free products or at least remove additional taxes and import rates, provide accessible menstrual leave, and improve access to WASH infrastructure. By explicitly recognizing and enforcing this right to a dignified menstrual cycle, the stigma of shame around menstruating will be diminished. Considering COVID-19 and its worsened effects on period poverty, awareness of menstrual hygiene management is immediately necessary to remedy these negative consequences and ensure the well-being of all individuals—regardless of their menstruation status.

1. Brooke Yamakoshi, Mitigating the Impacts of COVID-19 and Menstrual Health and Hygiene, UNICEF, 1 (2020), https://www.unicef.org/media/95496/file/UNICEF-Brief-Mitigating-the-impacts-of-COVID-19-on-menstrual-health-and-hygiene.pdf. ↑
2. Erica Sȧnchez & Leah Rodriguez, Period Poverty: Everything You Need to Know, Global Citizen (Feb. 5, 2019), https://www.globalcitizen.org/en/content/period-poverty-everything-you-need-to-know/. ↑
3. Id.; see Sarah House, Thérèse Mahon, & Sue Cavill, Menstrual Hygiene Matters: A Resource for Improving Menstrual Hygiene Around the World 28, 31 (2012), https://www.susana.org/_resources/documents/default/3-2210-21-1426498269.pdf. ↑
4. Sȧnchez & Rodriguez, supra note 2. ↑
5. House et al., supra note 3, at 90-92. ↑
6. Marni Sommer et al., Menstrual Hygiene Management in Schools: Midway Progress Update on the “MHM in Ten” 2014-2024 Global Agenda, 19 Health Rsch. Pol’y and Sys. 1, 9 (2021), https://doi.org/10.1186/s12961-020-00669-8. ↑
7. Sȧnchez & Rodriguez, supra note 2; see House et al., supra note 3, at 29. ↑
8. Sȧnchez & Rodriguez, supra note 2. ↑
9. Id. ↑
10. Id.; House et al., supra note 3, at 33. ↑
11. House et al., supra note 3, at 37; see also id. at 32-37. ↑
12. Sȧnchez & Rodriguez, supra note 2. ↑
13. Grace Ganz, The Struggle to Access Feminine Products During COVID-19, Borgen Magazine (Dec. 2, 2020), https://www.borgenmagazine.com/the-struggle-to-access-feminine-products-during-covid-19/. ↑
14. Id. ↑
15. Sȧnchez & Rodriguez, supra note 2. ↑
16. Id. ↑
17. Republic of Kenya Ministry of Health, Menstrual Hygiene Management Policy 2019-2030, at 6-7 (2020), https://www.health.go.ke/wp-content/uploads/2020/05/MHM-Policy-11-May-2020.pdf; See Department of Economic and Social Affairs, The 17 Goals, U.N. Sustainable Development Goals, https://sdgs.un.org/goals. ↑
18. Department of Economic and Social Affairs, Goal 3: Ensure Healthy Lives and Promote Well-being for All at All Ages, U.N. Sustainable Development Goals (2021), https://sdgs.un.org/goals/goal3. ↑
19. Department of Economic and Social Affairs, Goal 6: Ensure Availability and Sustainable Management of Water and Sanitation for All, U.N. Sustainable Dev. Goals (2021), https://sdgs.un.org/goals/goal6. ↑
20. International Covenant on Civil and Political Rights, art. 6, general comment No. 36, ¶ 8, Sept. 3, 2019, CCPR/C/GC/36. ↑
21. Id. at ¶ 3. ↑
22. G.A. Res. 65/229, U.N. Rules for the Treatment of Women Prisoners and Non-custodial Measures for Women Offenders (the Bangkok Rules), 31 (Mar. 16, 2011), https://www.unodc.org/documents/justice-and-prison-reform/Bangkok_Rules_ENG_22032015.pdf; International Covenant on Economic, Social and Cultural Rights, art. 12, Dec. 16, 1966, G.A. Res. 2200 (XXI). ↑
23. G.A. Res. 65/229, supra note 22, at 31-32. ↑
24. See id. ↑
25. G.A. Res. 64/292, The Human Right to Water and Sanitation, 2 (Aug. 3, 2010); U.N. Human Rights Office of the High Commissioner, About Water and Sanitation (2021), https://www.ohchr.org/EN/Issues/ESCR/Pages/AboutWater.aspx. ↑
26. U.N. Human Rights Office of the High Commissioner, supra note 25. ↑
27. Special Rapporteur on the Human Right to Safe Drinking Water and Sanitation, Frequently Asked Questions, 2, https://www.ohchr.org/Documents/Issues/Water/FAQWater_en.pdf. ↑
28. Id. ↑
29. Marni Sommer et al., supra note 6, at 3-5. ↑
30. Id. at 5-6. ↑
31. Id. at 6. ↑
32. Id. at 5. ↑
33. Id. at 9. ↑
34. Id. at 10. ↑
35. Leah Rodriguez, The Tampon Tax: Everything You Need to Know, Global Citizen, (June 28, 2021), https://www.globalcitizen.org/en/content/tampon-tax-explained-definition-facts-statistics/. ↑
36. Katharina Buchholz, Women Pay High Tax Rates for Period Supplies, Statista, (May 28, 2020), https://www.statista.com/chart/18194/sales-tax-rate-on-feminine-hygiene-products-in-selected-countries/. ↑
37. Leah Rodriguez, supra note 35. ↑
38. Id. ↑
39. Katharina Buchholz, supra note 36. ↑
40. Id. ↑
41. Id. ↑
42. Scotland Becomes First Country in the World to Offer Free Menstrual Hygiene Products, The Economic Times: Panache, (Nov. 25, 2020), https://economictimes.indiatimes.com/magazines/panache/scotland-becomes-first-country-in-the-world-to-offer-free-menstrual-hygiene-products/articleshow/79408113.cms?from=mdr. ↑
43. Helen Regan, New Zealand to Provide Free Sanitary Products in Schools to Fight Period Poverty, CNN World, (June 4, 2020), https://www.cnn.com/2020/06/04/asia/new-zealand-period-poverty-schools-intl-hnk/index.html. ↑
44. Milllicent Mutuli, Refugee Women Must Receive Sanitary Supplies on Regular Basis, UNHCR, (Oct. 22, 2001), https://www.unhcr.org/en-us/news/latest/2001/10/3bd435574/refugee-women-must-receive-sanitary-supplies-regular-basis-unhcr.html. ↑
45. G.A. Res. 65/229, supra note 22, at 9. ↑
46. Stephanie Leguichard, Why Do Some Countries Give Women Paid Period Leave?, An Injustice Mag, (June 4, 2021), https://aninjusticemag.com/why-do-some-countries-give-women-paid-period-leave-f29bf6778502; Danielle Ong, South Korea Airline’s Ex-CEO Refused to Give Menstrual Leave to Female Staff, IBT, (Apr. 25, 2021), https://www.ibtimes.com/south-korea-airlines-ex-ceo-refused-give-menstrual-leave-female-staff-3187536. ↑
47. Julia Hollingsworth, Should Women Be Entitled to Period Leave? These Countries Think So, CNN Business, (Nov. 20, 2020), https://www.cnn.com/2020/11/20/business/period-leave-asia-intl-hnk-dst/index.html. ↑
48. Id. ↑
49. Stephanie Leguichard, supra note 46. ↑
50. Julia Hollingsworth, supra note 47. ↑
51. Periods Don’t Stop for Pandemics – Neither Will Our Efforts to Bring Safe Menstrual Hygiene to Women and Girls, The World Bank, https://www.worldbank.org/en/news/feature/2020/05/28/menstrual-hygiene-day-2020. ↑
52. Id. ↑
53. Id. ↑
54. Brooke Yamakoshi, supra note 1, at 3. ↑
55. Id. ↑
56. Department of Economic and Social Affairs, supra note 16. ↑
57. Brooke Yamakoshi, supra note 1, at 4. ↑
58. Id. at 2, 4. ↑
59. Id. at 2. ↑
60. Grace Ganz, supra note 11. ↑
61. Brooke Yamakoshi, supra note 1, at 4. ↑
62. Id. ↑
63. Grace Ganz, supra note 13. ↑
64. Brooke Yamakoshi, supra note 1, at 6. ↑
65. Id. ↑
66. Id. at 5. ↑
67. Id. ↑