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Shaming, Stigma, and Povery Surrounding Menstruation in Afghanistan
from PCR - Fall 2022
Shaming, Stigma, and Poverty Surrounding Menstruation in Afghanistan
by Sophia A. Odunsi (V), Dr. Sylvia Maier1
1Center for Global Studies, N ew York University; New York, NY
Abstract
How do menstrual stigmas, period shaming, and poverty affect Afghan girls? In this paper, I found that many misconceptions are formed since there is limited sex education before menarche, which often harms girls’ physical health. I also discovered that many girls leave school because essential period hygiene management products and toilet facilities are not in schools. Through further research, I found that Afghanistan’s poor healthcare system adversely affects women’s access to medical care. In addition, I also discovered that the Taliban’s women’s rights violations harm girls’ and women’s livelihoods. Lastly, I found that girls in rural communities have difficulty accessing period products stocked in city shops since they are scarce and expensive. Afghanistan has many cultural and economic struggles, making the menstruation experience for girls and women difficult. The following recommendations are to have more doctors practicing in rural communities, raise the consent age for women to 18 years old, have menstrual hygiene products accessible in all public restrooms, increase government spending on education, and allow women to leave their homes unaccompanied and without permission if they are doctors or seeking medical attention, and are meant to combat many of Afghanistan’s and the Afghan people’s problems. Women make up 18.2% of Afghanistan’s illiterate population, and this percentage will keep rising until Afghanistan implements the suggested modifications to make it so that girls feel safe attending school while on their periods.
In Afghanistan, more than fifty percent of girls have menarche without knowledge, expectations, or an understanding of menstruation [52]. An April 2021 cross-sectional study, which surveyed 768 girls between the ages of 11 and 18 in the city of Herat, Afghanistan, confirmed this, concluding that over 60.8% of girls did not know what menstruation was prior to menarche [42]. Furthermore, ten to thirty percent of Afghan girls are absent from class each day because schools do not have the proper hygiene facilities for menstruating, such as separate toilets for girls, toilet paper, or waste paper baskets [52]. These numbers show that menstruation hinders the education of young Afghan girls. In this paper, I seek to answer the question, how do period shaming, the stigmas around menstruation, and poverty directly harm Afghan girls? I argue that the unwillingness of parents and educators to provide pre-pubescent and menstruating girls and women with the proper education about human physiology, products for menstruation hygiene management, toilet facilities, and effective methods to manage pain when menstruating is among the principal causes of low literacy and severe gynecological conditions among Afghan females. With 7.2 million girls and women in Afghanistan, out of a total population of 39.6 million suffering from illiteracy, Afghan parents, doctors, and educators need to change their attitudes toward menstruation and make the appropriate changes, such as providing free menstrual products and sex education, to ensure menstruating girls are comfortable at school [58]. In Afghanistan, women must pay 4 USD for a single sanitary napkin, while the average salary of a teacher in Afghanistan is 672.81 USD a month [27]. Also, locating sanitary pads in city supermarkets is difficult since they are rarely seen and often hidden from patrons [20, 56]. These numbers reflect Afghanistan’s “period poverty,” meaning limited access to essential menstrual items, a lack of school hygienic facilities, and period shaming prevalence in society. One cause of period shaming, “period poverty,” and its stigmas is that sexual education is unacceptable in deeply conservative Afghanistan; in fact, the mere mention of genital parts or human reproduction is considered inappropriate. Unsurprisingly, young schoolgirls’ lack of knowledge of menstruation leads to poor hygiene practices and inaccurate beliefs about menstrual products. For instance, in Afghanistan, it is believed that washing oneself during menstruation can lead to infertility, but unbeknownst to them, the girls are in more danger of infection or skin irritation due to a lack of cleanliness [59]. Afghanistan’s cultural beliefs about female chastity and myths surrounding “virginity” also harm girls during their periods. Women and girls almost exclusively use pads as they believe tampons could potentially break their hymen, resulting in them not bleeding on their wedding night, which is a grave matter in conservative patriarchal cultures because it puts into question the woman’s sexual innocence [44]. Clearly, with the proper education about their bodies, the girls would be safe from falsehoods their parents, primarily their mothers passed on to them. In addition, many Afghan girls must be absent from or leave school entirely simply because they are menstruating. A 2020 CARE study found that such disruptions in the young girls’ education cause approximately 30% of Afghan girls to develop depression or anxiety [12, 29]. This is made worse by the refusal of the Taliban, who are currently in charge of Afghanistan, to allow girls to attend secondary school [15]. In August of 2021, the United States evacuated Kabul, Afghanistan, ending twenty years of warfare [9]. The United States’ withdrawal from Afghanistan resulted in a catastrophic upheaval in the lives of Afghan women and girls, particularly in education, the workplace, and access to health care [60]. “Period poverty,” also, predictably, got worse. Companies like Safepad, which created “a reusable sanitary pad designed to provide a safe and infection-free experience;” the CDC’s WASH program, a global program that saves lives by improving access the adequate water, sanitation, and hygiene, through long-term prevention and control measures; and UNICEF, are striving to provide supplies, relief, and support. However, with the Taliban controlling Afghanistan, “period poverty” and stigmas can and will only worsen [11, 49, 60]. The Taliban, an Islamic fundamentalist group, first took control of Afghanistan in 2001 and has misogynistic behavior closely related to peri-
od stigmatization, period poverty, period shame, and general neglect of women’s health in Afghanistan. The group’s beliefs support the corrupt inferiority of women and girls, so girls and women in Taliban-controlled Afghanistan are subjected to unfair misogynistic treatment that is dangerous to their health and human dignity. With the Taliban currently in control, many new rules restrict women’s rights and access to healthcare. Generally, according to the UNFPA, Afghanistan does not get support from other countries, making life worse for Afghan girls and women under the Taliban regime [28]. II. MENSTRUATION STIGMAS AND PERIOD POVERTY ACROSS THE GLOBE
Women across the globe are facing period stigma and poverty due to archaic cultural b eliefs, a lack of education, and limited access to menstrual hygiene products. In this section, I will provide examples to show the prevalence of period stigmatization and its harmful consequences for girls and women. A particularly compelling example is India, a country with a long history of menstruation inequity. Sixty kilometers outside of New Delhi lies the Hapur District, and in Zehtabchi’s 2018 documentary, Period. End of Sentence, multiple Indian girls and women from the district were interviewed regarding their menstruation experiences. Many of the women interviewed had limited knowledge about menstruation. One older woman stated, “that is something only God knows,” when asked what occurs during menstruation [44, 01:22-01:33]. Cultural taboos that associate menstruation with impurity and evil also feed into India’s poor sex education. For instance, in India, it is believed that when a menstruating female touches a cow, it becomes infertile, which is, obviously, scientifically incorrect [4]. Likewise, with approximately 94% of the world’s Hindu population residing in India, Hinduism profoundly influences Indian culture and policies, including menstrual rights. Since it is “believed that menstruating women are unhygienic and unclean and hence …[everything they] handle can get contaminated,” Hinduism forbids women from participating in daily activities like praying or cooking while they are menstruating [4]. Likewise, women are also forbidden from taking a bath at the beginning of their period because menstrual blood would “pollute” the pure water [4]. Furthermore, Indian girls are also advised against exercising because exercise is thought to worsen period pain, which is medically incorrect [4]. Not surprisingly, most Indian schools lack proper private bathroom facilities, which causes many girls to drop out of school simply because they are menstruating [44, 02:41-03:28]. Like in many countries around the world, Indian women and girls are plagued by a lack of accessible and affordable menstrual products, so “girls see that they’re bleeding and use whatever cloth they can find;” but once entrepreneur Arunachalam Muruganantham discovered that menstruation was a key reason for women’s execution from full public participation in India, he built an inexpensive sanitary napkin machine [44, 06:34-07:21]. His “low-cost sanitary napkin machine” permitted women to make sanitary napkins using natural materials within their home, taught men and women about pads, and created jobs for women, granting them more respect within their households [44, 08:23-10:04]. Egypt is another country where shaming girls for their periods and misinformation about menstruation is a big problem. When menstrual hygiene products are purchased, convenience store clerks typically wrap sanitary napkins in newspapers because they are embarrassed to be seen with the product. Additionally, young Egyptian women are prevented from using tampons due to old myths and prejudices that it is thought to take a girl’s virginity or rupture the hymen, similar to Afghan beliefs [27]. Since sex education is the responsibility of parents and the subject is described as “shameful” in the Egyptian language, misinformation, like the idea that tampons soil virginity, can often spread [48]. Even in a progressive country like South Korea, discussing menstruation is usually avoided. For instance, when Women’s Health Magazine interviewed 31-year-old, Seungmee from South Korea, she stated that “we don’t see these things [like sex-ed videos] in Korea” [27]. She also shared that when she moved to Canada, she was surprised by the openness surrounding sexuality and tampon dispensers in public bathrooms, which influenced her mother to be more open to discussing the menstruation cycle [27]. Beyond Seungmee’s
experiences surrounding period shaming and lack of education, South Korea also has a long history surrounding “period poverty.” As a result of companies like Yuhan-Kimberly raising their pad prices and creating the “insole girls1” in 2016, the South Korean government was forced to allow the sale of menstrual cups, which were previously prohibited, in 2017, and to provide free menstrual products in 10 public venues in 2018 [14]. Thus, charities and non-profits were encouraged to distribute free menstrual products for girls. In addition, South Korea started offering unpaid menstrual leave in 2001, allowing women to take one to two days off each month due to menstruation; however, the regulation was altered in 2003 [14, 36]. The altered law required women to request menstrual leave, ultimately leading to workplace inequity and discouragement of women from taking advantage of the law [14]. Like many countries in the Global South, women in the United States also suffer from “period poverty,” menstrual shaming, and stigmas. Incarcerated individuals, students, transgender and nonbinary individuals, as well as low-income and homeless women and girls, struggle with “period poverty” in the United States mainly because of the levying of sales tax on menstrual products, formally known as the “tampon tax” [53]. The “tampon tax” is controversial in the United States because other goods like groceries and medicines, which “are considered non-negotiable necessities,” are exempt from such a tax [53]. Since menstrual products are necessary, they should also be tax-exempt. Consequently, a 2019 study explored that two-thirds of low-income American girls and women were struggling to afford tampons or pads, and “more than one in five women said they had this problem every month” [10]. The same study confirmed that impoverished women and girls were forced to utilize cloth, diapers, or toilet paper from public facilities to maintain their dignity while menstruating, similar to women and girls in India. Lastly, beyond aggressive taxes on menstrual products and “period poverty,” American sex education gives girls a negative view of menstruation, contributing to body shaming, self-objectification, and other mental health illnesses [55]. Nonetheless, the United States is making significant progress in creating laws and policies protecting girls and women during menstruation. In the last ten years, the state and federal governments have passed 62 menstruation equity laws, with New York and Illinois passing the most. These laws include eradicating menstrual tax, making menstrual products more accessible in schools, prisons, and shelters, and transparency about the safety of menstruation products by disclosing ingredients [35].
III. WOMEN’S HEALTH CARE AND THE LATEST IN MENSTRUATION
A. Treatment of Women in Afghanistan
The Taliban is making Afghan women and girls’ lives worse. Secondary school girls are no longer permitted to attend school, and many other new rules restrict women’s rights and access to healthcare. For instance, under Taliban edicts, women and girls are forbidden from showering in public baths, even on women-only days, or attending social activities, like weddings, while menstruating [12]. Likewise, new guidelines state that male doctors are permitted to touch female patients only above clothing, and women are not educated on health care practices, keeping medicine a primarily male-dominated territory [34]. Women gynecologists are permitted to treat women, but their numbers are few, and pregnant women are often hesitant to leave their homes. It is predicted that more healthcare restrictions will be placed on women and girls, making it more difficult to receive proper medical care. According to the UNFPA, it is suspected that if Afghanistan does not get support from other countries, there could potentially be 4.8 million unplanned pregnancies, 51,000 maternal deaths, and two times as many people will not have access to family planning facilities between 2021 and 2025 [28]. Furthermore, the Taliban are also increasing child and forced marriages as militants marry young girls, leading to more child pregnancies and, eventually, a higher maternal mortality rate [28]. The Taliban is also making it difficult for female healthcare workers to work because those who are married are not allowed to leave their house without their husband’s permission or accompaniment, putting Afghanistan in a severe shortage of medical professionals, with 4.6 doctors per 10,000 Afghans [2, 7].
The mistreatment of Afghan girls during their adolescent years goes beyond stifling their education. Girls that leave school because of the inability to manage menstruation will face issues with employment later in life; regardless, girls who do complete schooling with bachelor’s and master’s degrees still find employment difficult. In Afghanistan, many educated women are unemployed, in irrelevant jobs, or working part-time jobs [1, 51]. High unemployment, especially among educated women, has worsened since the Taliban regained control. For example, 900,000 Afghans lost their jobs, mostly women, because the Taliban forced women out of work [43]. Due to the Taliban’s enforcement of strict policies, such as mandating the burqa in public and requiring women to be accompanied by a male when going outside, many women are highly discouraged from working [39]. These new mandates are damaging the livelihood of many women, mainly because after many years of war, many women have been left widowed and must be their family’s “sole breadwinner” [39]. These new mandates enforced by the Taliban are blatant attacks on Afghan women’s rights, and, besides restricting their education, it also threatens the future livelihood of Afghan girls. B. Life Expectancy, Health Care, and Infant Mortality
As of 2020, Afghan women have an average life expectancy of 67 years compared to a life expectancy of 80 years in the United States and 78 years in Iran [30, 57]. Due to the lack of medical care provided to Afghan women and girls as a result of the renewed Taliban takeover, they often have fatal reproductive lives. Female adolescents, children ages 10-19, which make up approximately forty percent of the Afghanistan population, face significant struggles in their sexual reproductive health needs and elevated levels of reproductive health inequality, contributing to the high maternal death ratio of 638 deaths per 10,000 births, making Afghanistan the country with the tenth worst maternal mortality rate [26]. This lack of health care for adolescent girls is paired with Afghanistan’s fertility rate of 58 births per 1,000 girls between the ages of 15 and 19 [2]. When young girls enter labor, they are at the highest risk of death and other health complications. Obstetric fistula, for example, is a result of prolonged unassisted labor that causes incontinence and community alienation and is a condition that 1 in 4 Afghan girls and women suffer from [41, 62]. The inadequate healthcare system is the primary reason conditions like fistulas have a higher prevalence in Afghanistan than in countries like the United States. Luckily, when the United States defeated the Taliban-led Afghan government in late 2001, international donor countries prioritized the weak healthcare system. Such efforts led to an impressive decline in maternal deaths, an increase in modern contraceptives and midwives, but some women and girls continue to struggle to access basic health information, contraceptives, pre- and post-natal care, and modern cancer and fertility treatment [7]. The care the girls and women receive is also often poor quality, and they must travel far distances to access mediocre care [2, 7]. Fortunately, organizations like UNICEF, which is training healthcare professionals in Afghanistan and sharing sexual health impositions in “youth-friendly, gender-sensitive services,” are combatting healthcare inequity and providing girls and women with the best available healthcare [26]. Another health risk in Afghanistan comes from normalizing child marriages and closely-spaced pregnancies, which can cause death for the young girl and her baby [7, 8]. Child marriage is a union where one or more parties are under 18, and in 2021, approximately twenty-eight percent of girls and women aged 15-49 had been married before they turned 18 [1, 19, 22]. Child marriages often occur when lower-income families sell their daughters for significant funds to wealthy, much older husbands or as a way to settle rivalries between families [13]. The main reason for the popularity of child marriage in Afghanistan is extreme poverty and gender inequality or inferiority of girls, which are also the leading causes of period poverty, stigmas, and shaming [1]. “The traditional society in the country considers a girl who … [experiences] ‘menarche’ as being ready for marriage and child bearing,” a misconception fueled by a lack of sexual education and gender disparity, linking the horrors of child marriages to menstruation [54]. With an increase in child marriages in Afghanistan, a third of girls between the ages of 15-19 give birth each year, and the country has one of the highest infant mortality rates, with 45 deaths
per 1,000 births [13, 38]. Since two in three deliveries in Afghanistan happen at home without an attendant, pregnancies for these young girls are significantly more dangerous [23]. Child marriages and early pregnancies also lead to girls being removed from school, contributing to Afghanistan’s low literacy rate. Alternatively, the Taliban banning girls aged 12 and older from going to school increases child marriages. Another misconception in Afghan culture is that after each menstruation cycle, a girl supposedly loses an opportunity to get pregnant; thus, once a girl reaches menarche, she is often rushed into marriage [5]. Generally, Afghanistan’s poor healthcare system impacts child marriages, infant mortality, menstruation, and life expectancy. IV. RECOMMENDATIONS FOR CHANGE
A. Improving the Situation of Women’s Rights with International Aid
Being a woman in Afghanistan is beyond difficult. From the Taliban’s intensely misogynistic views to women’s lack of freedom to leave home without male permission, Afghanistan consistently violates women’s and girls’ rights. Examples of Afghanistan’s women’s rights violations as of September of 2021 include forcing girls to wear hijabs, banning women from complaining about or suing “their husbands or the men of the family,” and banning girls in grades six and above from attending school [7]. The effects of women’s rights violations on Afghan women are exhibited in a 1998 JAMA research journal about “Women’s Health and Human Rights in Afghanistan.” The journal shared that 97 percent showed signs of depression, 68 percent expressed that they had tightly restricted social activities, and 71 percent sensed a decline in physical health [9, 44, 47]. In a July 2022 interview, Afghan-born journalist Rukhsar Azamee provided a personal view regarding the Taliban’s infringement on women’s rights. Azamee shared how devastated she was about the Taliban’s re-gain of control in Afghanistan, primarily because the work she and her colleagues completed to provide Afghan girls and women with a better life was being tarnished by the Taliban’s oppressive policies. A highlight of how Azamee helped trailblaze more rights for women includes her bravery in being one of the first women to drive, ultimately leading to her being “[literally] thrown out of the country.” Azamee also presented her thoughts about why the Taliban is adamant about stifling young girls’ education, as she assumes that educated women with substantial careers hold more authority, threatening Afghanistan’s patriarchy. Despite the desperate situation in Afghanistan, are international countries obligated to help Afghan citizens, especially women and girls? America, for example, has a history of not supporting international women’s rights, especially during President George W. Bush’s administration when he scaled back on “women’s rights at home and abroad through a slew of executive orders, judicial appointments, and administrative rules” [21]. More recently, the United States’ departure from Afghanistan was also an attack on Afghan women’s rights and a violation of their freedom and dignity. Despite warnings about the fragility of women’s rights if the United States’ troops were to leave Afghanistan, President Biden, nonetheless, made the final decision to evacuate [24]. In the July 2022 interview, Azamee highlighted that she believes international countries must be accountable; she stated, “if they say they want to protect girls’ rights to go to school…[international governments should] make sure they can go to school” [5]. Despite the world’s awareness of Afghanistan’s situation, Afghan people believe international attention has “horrifically moved away from Afghanistan” [5]. The situation of women’s rights in Afghanistan will not get better on its own. It will take assistance from other international powers to overthrow the Taliban’s rule and restore the rights of Afghan girls and women. Thus, it can be inferred that international powers must be involved in Afghanistan to protect women’s rights. For example, Afghanistan’s healthcare system initially relied on the help of Western countries, which funded ninety percent of Afghan health clinics [37]. This international support ended, however, because most of those countries are boycotting a Taliban-led country. In regards to the healthcare system, the lack of funds has prohibited ambulances from affording fuel, and thus, physicians advise many patients to take taxis, find other modes of transportation, or ultimately forgo treatment [28].
Without international aid, Afghan citizens’ access to adequate medical care will continue to worsen. B.Giving Afghan Women Menstruation Support
Afghanistan has many areas that need to be fixed to create a higher quality menstruation experience, and general livelihood, for girls and women. Nevertheless, before changes to how Afghans approach menstruation and female healthcare begins, Afghans must change how it approaches women’s rights. Presently, the legal age of consent is 16 years for females and 18 years for males [3]. However, if the legal age of consent for females were also raised to be 18, there would be a decrease in child pregnancies that result from child marriages and misogynistic beliefs. Such change would protect the lives of young Afghan girls and act as a precedent to further shifts to improve the lives of Afghan females. For instance, another prominent issue in Afghanistan is a lack of affordable menstruation products and accessible places to acquire such products. However, if public venues like libraries and hospitals stocked themselves with menstruation products, impoverished girls and women could better access such products. Next, another problem that affects Afghan girls is the inappropriate toilet facilities in schools due to a lack of clean running water, custodial services, and separate-gendered bathrooms. To decrease the prevalence of this issue, the Afghanistan government will need to put more funding toward education. Afghanistan has total spending of approximately $11 billion, but only about $17 per capita is used for education [25]. If Afghanistan starts to spend more money on its education sector, schools will be able to afford more sanitation efforts and can work on improving access to clean water. Lastly, Afghanistan needs more physicians, male and female, in rural areas. A 2018 World Health Organization study found that “Afghanistan has the second lowest health workforce density and the highest level of rural residing population in the Eastern Mediterranean Region” [1, 50]. In 2016, Afghanistan had a total of 0.3 physicians per 1,000 people and only 0.1 midwives and nurses per 1,000 people [40, 46]. Such alarmingly small numbers prove that Afghan citizens living in rural communities lack appropriate healthcare. Therefore, to improve Afghanistan’s healthcare system in rural areas, female doctors should be legally permitted to work without male permission, and the government should increase its spending on healthcare. sMoreover, along with enhancing the healthcare system in rural areas, Afghanistan needs to improve girls’ and women’s ability to access medical care. An Afghan doctor working in Balkh, Afghanistan, realized quickly in his career that many of his patients walked seven hours to the closest medical facility; he also noticed that many female patients who had deteriorated health conditions often sought treatment “too late” because they needed permission and accompaniment from a maharam2 [17]. Since women are required to get male permission before going out, many women forgo getting medical assistance or receive care at home. So to relieve this terrible problem, women should be permitted to go out without permission if they seek medical care.
IV. CONCLUSION
This paper reviewed poverty, stigmas associated with menstruation, and period shame affect Afghan girls. The prominent issue addressed in the paper was the evident lack of sex education in Afghanistan, resulting in over 50% of girls having limited knowledge about periods before menarche [52]. Since Afghan culture believes sex education is inappropriate, many misconceptions about menstruation have formed, like that washing oneself while menstruating can cause barrenness [59]. Another problem discussed in the paper is that the lack of toilet facilities in schools forces schoolgirls to miss school and eventually drop out, contributing to Afghanistan’s high illiteracy rates and high unemployment rates for women. “Period poverty,” due to the lack of accessible period products, especially in rural areas, is another problem addressed in the paper. Other issues addressed include the flawed healthcare system, its adverse effects on women’s ability to receive medical care, and the Taliban’s violation of women’s rights. Afghan girls have limited access to pre-pubescent and menstrual education, menstrual hygiene management products, and effective pain relievers, putting them at greater risk of gynecological conditions and higher rates of maternal mortality.
I recommended there be more physicians in rural communities, women should be permitted to leave the house without male permission if they are doctors or are seeking medical care, menstrual hygiene products should be available in all public restrooms, and more government spending on the education sector and the age of consent for females should be raised to 18 years old, to improve the menstruation experience for Afghan girls and women. However, this is very difficult to enforce given the current political climate of Afghanistan, which is under control by the extremist Taliban group. The topics discussed in this paper are of great significance because 29.2% of Afghanistan’s population are illiterate females, and this number will continue to increase unless Afghanistan makes the recommended changes and international countries continue to support Afghan women’s rights to ensure girls feel comfortable going to school while menstruating [58]. IV. END NOTES
1 The term was first used after many South Korean girls were found using shoe insoles as sanitary napkins because they could not afford actual pads. These girls inspired a Lunapads documentary and marked the beginning of a new age, where the South Korean government began actively combatting “period poverty.” 2A male companion, such as a husband or an in-law. Under the latest rules set by the Taliban, such male companions must accompany women whenever they travel outdoors.
