Illustration by Samiah Bilal
Illustration by Samiah Bilal

It was the third time in six months of my posting at the medical ward of a government hospital in Karachi that my clinical group was jotting down the medical history of Z. Khatoon*. The 21-year-old had come for consultation, complaining of almost the same symptoms she had had on her previous visits. Out of hundreds of patients we examined and diagnosed daily, we were most familiar with Z. Khatoon. Not as much because of her, but more so because of her father, who accompanied her on these visits. He had a distinct facial feature and was adamant in influencing the history-taking and the required physical examination of his daughter being conducted by my female colleagues.

Z. Khatoon was diagnosed with recurrent Urinary Tract Infection (UTI) because of improper hygiene maintenance during her menstrual cycle. However, she would not convey to her parents the counselling that she received from the doctors at the hospital at each visit, and so her problem persisted.

Cultural inhibitions, feelings of shame, ignorance or even monetary constraints continue to prevent awareness about female hygiene in general and menstruation in particular in South Asia. The hush factor associated with menstruation results in misinformation and baseless myths being transferred through generations and, in some cases, even today in the era of technology and information.

Instead of explaining the hygiene and cleansing protocols to the young girl, who is rather scared of the new physiological changes occurring in her body, she falls for her elders’ misconceptions. In extreme cases, these may result in infections, allergies and other unwanted urinary and reproductive issues.

This lack of awareness about a routine natural process paves the way for unsubstantiated, and sometimes even contradictory, beliefs. For instance, young women are advised to adopt certain traditional measures and “precautions” during menstruation that are nothing more than baseless practices and myths, such as consuming a specific quantity of water — be it more than normal, less than normal or even cold water in some cases — decreasing protein intake, lower consumption of foods like oranges, nuts and eggs, avoiding a bath in the first three days of having your period, or having a bath with hot or cold water.

Pakistani society can help promote better health and hygiene for our women only once it overcomes the taboo and shame associated with menstruation

Because of this ignorance, there is the conviction that not adhering to these beliefs will somehow negatively impact both the menstrual flow and the reproductive system of a future mother-to-be.

When peer, societal and cultural pressures discourage and sometimes even stop young girls from playing, jumping or even visiting their places of worship and going to schools when menstruating, the feeling of ‘something is wrong with me’ starts creeping in their subconscious. This results in a lack of confidence and the vicious cycle of guilt and shame overpowers her day-to-day life.

“The phase of menarche (beginning of menstruation) is tough for any girl. If she is not well-supported by her family, both morally and psychologically, the child is left in isolation, and this lowers her self-esteem,” explains consultant psychiatrist Dr Rahat Usman. “Existing societal and family concepts of shame and respect for females sometimes result in lack of communication within families and even among female family members, to discuss issues such as menstruation. Things, though, are improving as more information is shared on social forums and advertisements of hygiene products are on air regularly. This gap was not there half a century ago when families would live together in the same hall. The gap was created with the acceptance of the nuclear family system, separate rooms for family members and more women getting educated. These factors changed our scope of understanding and tagged taboo to the discussion on topics like menstruation and periods,” she says.

“Thankfully, many schools today are imparting education related to menstruation and its associated hygiene to young girls. The girls are becoming more confident, discussing the subject with their parents, unlike their previous generations, who may cry through the entire week to 10 days of their first period, fearing it to be a disease, a curse, God’s resentment or initiation of their possible death!” adds Dr Usman.

So what are the repercussions of not following the menstrual hygiene procedures?

Dr Sana Mustafa, a gynaecologist and member of the Royal College of Obstetricians and Gynaecologists (MRCOG), works as a senior registrar in a teaching hospital of Karachi. She explains, “Any from a multitude of issues may occur. However, most of these are not life-threatening. Broadly speaking, conditions like bacterial vaginosis, lower reproductive tract infection and UTI may result since, in the long run, contaminated menstruation hygiene products are the breeding grounds for infections causing bacteria, including E.coli, salmonella and staphylococcus. These infections can further affect the urinary and reproductive tract and, in rare cases, even enter the bloodstream which, if left untreated, may cause systemic infections, leading to death in worst case scenario,” she explains. 

There are relevant warning signs associated with improper menstruation hygiene. “Most commonly occurring signs of infections caused by using hygiene products for longer duration than recommended, re-using or not maintaining proper hygiene may include, but are not limited to, itching, rashes, allergic reactions, lower back pain, lower abdominal pain, pustules over genitalia, abnormal genital discharge, painful sexual intercourse and even a cyst, namely Bartholin’s cyst, which may lead to Bartholin’s abscess,” warns Dr Mustafa. “Discomfort because of local skin irritation leading to dermatitis, a skin condition characterised by swelling and redness of the skin and sometimes even tender blisters may also occur. Infertility, secondary to genital tract infections, in rare occurrences may also occur because of the adoption of unhygienic sanitary practices.”

“Opportunistic fungal and yeast infections because of moisture retention over a longer period of time, and poor menstrual hygiene may also occur,” she concludes.

Social phobias, psychological distress and low self-esteem are the predominant traits for women experiencing any of the above-mentioned symptoms.

The improper application of hygiene protocol is not related to economic strata or educational level of the family only. One solution is to open up, as a society, to discussions on women’s health. Generally, other than the female elders, the father also knows about menstrual cycle information. Awareness about the process of menstruation is also necessary among all male members of the society, so that they can have a more understanding attitude towards their peers or young family members who are going through the physiological change. This depends on the upbringing of boys with relevant awareness, in addition to their formal education. Male siblings should be schooled on such topics so that, instead of abhorring or bullying their fellow siblings or students, they know how to respect their space.

But are these the only problems? “We regularly come across female patients, being consulted for different medical issues, who are using just one tampon daily during their periods, instead of the recommended 4 to 6 tampons in a day, and patients coming here are generally from well-off families,” shares Dr Shafaq, medical officer at a high-end hospital in a relatively posh area of Karachi. “But yes, overall, as a society money matters and its absence plays a significant role!” she gives in quickly.

Being part of the Subcontinent, where many families hardly earn enough to feed themselves, it is difficult to assume that people will be willing to keep aside a major chunk of their monthly income to buy products to ensure menstrual hygiene. This lack of means to get access to sanitary products, washing facilities and relevant awareness is significantly augmented by the economic strata and the wealth of the society as a whole. This concept is known as ‘Period Poverty’, which is deeply rooted in South Asian societies because of the fact that the majority of the population here can hardly make both ends meet. Even in the developed societies and Western countries, ‘Period Poverty’ is prevalent in low-income groups.

In 2018, Scotland became the first nation to make menstrual hygiene products absolutely free for school, college and university students. The country is currently in a process to pass the bill which will make all menstruation hygiene relevant products free for all female citizens of the country. The Period Products (Free Provision) Scotland Bill will make the ruling government of Scotland responsible for ensuring provision of free-of-charge menstruation-related hygiene products “for anyone who needs them” which will encompass females from all age groups.

The bill’s first stage was passed with 112 votes in favour and none against the legislation proposed by Monica Lennon, a Scottish Labour Party politician. The legislation also suggests that the free sanitary products be made easily accessible at different pharmacies, community centres and youth clubs. This will not only generate awareness but also rules out any chances of ‘Period Poverty’ or lack of sanitary products for any individual hailing from a low-income group. Other countries should follow suit.

With respect to Pakistan, a lot more is required on the governmental level. We proudly belong to that society which firmly believes in teachings of Islam. We equate and accept cleanliness and hygiene as fundamentally being half of our belief system. Introducing a bill or law on the same lines as is being done in Scotland will help develop Pakistan as a healthy nation. It will also automatically change the perception and mindset of the society as a whole and may even remove the stigma associated with menstruation. No girl needs to miss out on her school due to ‘Period Poverty’ in Pakistan.

** Name changed to protect privacy
The writer is a physician and a healthcare leader working with a pharmaceutical organisation. He tweets @Ali_Shahid82.*

Published in Dawn, EOS, September 13th, 2020