Abstract

Government policies concerning access to menstrual hygiene primarily focus on adolescent girls and women, leaving out transgender individuals. Addressing access to menstrual hygiene for transgender persons will require two key steps: first, their inclusion in current policies, and second, framing additional policies to address specific needs. Due to the absence of specific studies on this subject, this commentary relies on personal narratives and international studies. Improving access to menstrual hygiene among transgender individuals will require the enhancing of the availability of menstrual hygiene products, mitigating of stigma and fear of harassment, sensitising of healthcare workers, and ensuring the availability of proper washrooms. In addition, addressing the menstrual injustice experienced by transgender persons involves addressing socioeconomic factors such as caste, poverty, and access to education. Using the lens of structural intersectionality, this article undertakes a review of oppressive systems causing menstrual injustice. This approach is intended to enable policymakers and researchers to consider the multifaceted identities of menstruators, fostering a holistic understanding that will inform their approach towards achieving menstrual equality.

Keywords: transgender persons, structural intersectionality, menstrual justice, access to menstrual hygiene

Introduction

Equality and justice in menstrual health intersect with several issues, including gender, poverty, environment, caste, access to education, and disability, among others. However, policies addressing menstrual health seldom consider these intersections. In India, the central and state governments have taken several measures to distribute sanitary napkins and increase general awareness of menstrual hygiene over the years [1]. In April 2023, the Supreme Court of India directed the central government to create a national policy to ensure availability of menstrual hygiene for girls in schools [2]. While awareness schemes such as Rashtriya Kishor Swasthya Karyakram seek to educate all, schemes for the distribution of menstrual hygiene products free or at subsidised rates, such as the Jan Aushadhi Suvidha Sanitary Napkin, are only aimed at menstruating women and girls.

A lacuna in such government schemes and policies is that they are directed at “adolescent girls and women”, leaving out menstruators who do not fall into those categories — such as transgender persons. Inclusive language becomes especially important, given that it directly affects the individuals whom the schemes and policies aim to benefit. The Supreme Court of India recently published a Handbook on Combating Gender Stereotypes in recognition of the harmful stereotypes in the language of the law that distort the application of the law and perpetuate discrimination and exclusion [3]. Without explicit recognition of the fact that transgender persons also menstruate, their unique problems in accessing menstrual hygiene cannot be addressed.

Gender identity, however, is just one aspect that affects menstrual equality. Caste, disability, and geographical location also intersect with gender identity, affecting how different people even within the same gender identity access menstrual hygiene. Therefore, menstrual equality for transgender individuals cannot be addressed without addressing the effects of all intersecting identities. This article uses a structural intersectionality framework to examine the identities and locations of menstruators that foreground the inequalities in accessing menstrual hygiene products. This framework proves the need to move beyond policy measures — such as providing free or subsidised sanitary napkins and conducting awareness programmes — and instead aim efforts towards addressing the specific issues faced by all menstruators due to their different identity locations.

This article uses the term “menstruators”, which is an inclusive term to refer to persons who menstruate, as it is inclusive of not just women, but also transgender, intersex, and non-binary persons.

The lens of structural intersectionality

Margaret E Johnson contended that menstrual injustice cannot be attributed exclusively to the structural oppression of women but to structural intersectionality, ie, overlapping forms of oppression, such as patriarchy, racism, transphobia, classism, and ableism. Employing the framework of structural intersectionality, she identified menstrual injustices and advocated for more comprehensive and egalitarian efforts to improve menstrual hygiene [4]. Without adopting an intersectional perspective on menstruation, we will lack the tools to dismantle the institutional frameworks that uphold oppressive practices of exclusion and inadequacy in India.

Menstrual taboos, for instance, present a significant barrier to achieving menstrual justice in India. Deepthi Sukumar posits that Dalit menstruators are not subject to menstrual taboos in the same way that dominant-caste menstruators are, as Dalits are already considered impure [5]. Similarly, T Sowjanya argues that Brahmanical patriarchy does not recognise menstrual taboos among Dalits and oppressed castes because they do not possess caste or sexual “purity”. Therefore, unlike the “untouchability practices” used to keep menstruating women at a distance in dominant-caste households, they touch crops, cook, and clean. The dominant perspective on menstrual taboos intersects with caste purity norms to create differential levels of menstrual justice [6]. Without adopting an intersectional lens, we will be unable to effectively address the barrier of menstrual taboos.

The following section shows how menstruators across various groups are affected differently due to their identity locations through a review of studies and reports on access to menstrual hygiene in India.

Unequal menstrual practices and their disproportionate effects

A 2010 study conducted by AC Nielsen and Plan India found that only 2–3% of menstruators in rural India used sanitary napkins. Further, the report found that 70% of menstruators faced financial constraints that prevented them from accessing sanitary napkins. Consequently, they resort to using homemade napkins or other available materials such as old fabrics, rags, sand, ash, and hay, which may pose sanitary risks [7]. A study by the United Nations Educational, Scientific and Cultural Organization (UNESCO) in Chhattisgarh found that none of the shops in the 65 villages studied stocked sanitary napkins. Additionally, due to a lack of toilet facilities, women in rural India bathe in ponds and do not bathe during their periods to avoid complications. They must also wait till dark to use common toilets [8].

Dasra’s report titled “Spot On!” provides insights into the causes and effects of the lack of sanitary napkins in rural areas. Insufficient access to proper menstrual hygiene leads to greater susceptibility to menstrual infections. Further, among the 88% of women who resort to unsanitary alternatives, 70% are likely to get reproductive tract infections [9]. Due to the non-availability of toilet facilities in schools, menstruators also stop attending school. According to a survey conducted by Plan India and Water Sanitation and Hygiene (WASH), in 556 schools in 3 rural districts, 23 million girls drop out of school annually due to a lack of period management facilities [10].

As socio-economic resources are significantly influenced by caste location, studies have found that oppressed castes have worse health and report lower socioeconomic development indicators, including access to facilities and awareness. Menstruators from these groups tend to be less informed about hygienic menstrual practices, leading to more health issues resulting from less hygienic menstrual practices [11]. National Family Health Survey 2019–2021 data revealed the role of caste in determining menstruators’ access to hygienic methods of menstrual management. While 86% of menstruators from dominant caste groups had access to hygienic methods, only 75% and 78% of menstruators from the Scheduled Castes and Scheduled Tribes categories and the Other Backward Classes category, respectively, could access hygienic methods of menstrual management [12].

A study conducted in Odisha found that 77% of menstruators with disabilities struggled to wear napkins properly. The study concluded that napkins must be designed better to address their specific needs. Further, for menstruators resorting to the use of cloth due to the non-affordability of napkins, managing menstrual hygiene becomes more challenging [13]. In fact, conventional practice endorses the use of forced hysterectomies and sterilisation to address menstrual issues among disabled menstruators [14]. Menstruators with intellectual disabilities often face verbal or physical abuse due to a lack of training and information [15]. This highlights that awareness campaigns about safe and healthy menstrual practices often focus on the experiences of neurotypical individuals, potentially overlooking the specific needs and challenges faced by those with disabilities.

Lack of awareness contributes to menstrual injustice at different levels across groups. In rural areas, schools are less likely to discuss menstruation. According to a 2015 survey by the Ministry of Education, 63% of schools in villages did not discuss menstruation at all [16]. A community study by the Indian Council of Medical Research in 50 villages found that 70.4% of mothers of adolescent girls considered menstruation “polluting” and “dirty” [17]. Additionally, several misconceptions exist about menstruation across different religious and socio-cultural groups, which lead to poor menstrual hygiene practices [18].

Further, current methods of disposing of sanitary napkins such as open dumping, burial or incineration, pose environmental and health hazards, which result in disproportionate harm to indigenous people and communities that rely on nature and forests for their livelihoods [19]. Improper waste disposal also affects the health of waste-pickers, which is a profession practised mostly by people from oppressed castes due to the institutionalised caste system. Finally, the voices of transgender persons are invisibilised in the discourse on menstruation. The next section delves deeper into the issues faced by transgender persons in accessing menstruation hygiene.

Transgender persons and menstruation

There is a glaring lack of research and policy regarding menstrual justice for transgender persons in India. Every study in this article addressed menstruation only in the context of “women” and “girls”. The 2011 Census counted upwards of 4,87,000 transgender people in India [20]. This number is widely believed to be an underestimation, given that transgender persons were accorded legal recognition only in 2014 [21]. Despite this, there is very little commercial or public recognition of the need to address the menstrual needs of transgender individuals. The persistent discrimination against marginalised communities is also closely linked to a lack of access to sanitation and health services [22].

In the absence of specific data, international studies and personal reports can provide a preliminary understanding of the issues faced by transgender persons in terms of menstrual hygiene access. A publication in The Lancet, Regional Health, Southeast Asia journal highlights issues such as a lack of sensitised healthcare workers, inadequate access to clean and safe washrooms, and difficulties in accessing menstrual hygiene products due to stigma and discrimination [23]. In India, transgender persons have reported challenges in accessing public bathrooms for changing menstrual products due to a fear of harassment and violence, accessing menstrual products at men’s shelters, accessing free menstrual products that are usually available for women, and overcoming stigmatisation while seeking healthcare [24, 25].

Further, transgender persons experience constant gender dysphoria because of such menstrual products being labelled and advertised as “feminine products” [26]. The gendered nature of the discourse and facilities leads to an increase in gender dysphoria, which is the psychological distress people face because of incongruences between their gender identity and assigned gender [27]. A 2022 report by the United Nations Population Fund (formerly the United Nations Fund for Population Activities, UNFPA) and WaterAid India recommends that the effects of hormone therapy on the menstrual cycle should be discussed during medical consultations and while providing treatment for transgender men when they transition from female to male. Additionally, the impact of menstruation on the gender dysphoria of transgender men should be addressed through mental health support and counselling [28]. Researchers studying transgender-inclusive sanitation in South Asia found that social stigma and fear of violence are still the biggest barriers for transgender individuals in terms of accessing public toilets. Securing funding for the creation of facilities for transgender persons is another barrier [29].

In the Palgrave Handbook of Critical Menstruation Studies, Shalini Vora explains that menstruation is not just a bodily reality but a negative, emotional, and expensive experience. Gender should be divorced from the menstrual experience [30]. Transgender men and intersex individuals can still menstruate. Alternatively, many women might not menstruate. Due to menopause and other external factors that can alter the menstrual cycle, such as stress, body weight, anaemia, and contraception, a large number of women do not menstruate. Therefore, even the assumption that menstrual health is a concern only for women is both socially and scientifically fallacious.

A transgender man who menstruates may face transphobia and sexism because of the belief that men do not menstruate. If this transgender man is from a rural area or an oppressed caste, their ability to afford and access menstrual hygiene products is further restricted. All barriers, and not just the barriers detailed in this section because of the transgender identity, have to be addressed for menstrual equality.

The way forward

There is growing recognition of the need to include transgender individuals in discussions on menstrual hygiene within civil society and the private sector. This recognition has resulted in diverse progressive initiatives that work towards different aspects of menstrual justice:

i. Inclusion of transgender persons in the creation of menstrual products: A Bihar-based NGO called Dostanasafar, in collaboration with the state government, announced the launch of a unit to manufacture menstrual cups that will be operated exclusively by transgender persons [31].

ii. Inclusivity in the language and symbols used for menstrual products: Bloody Good Period, an organisation that provides sanitary protection to asylum seekers in England, uses the term “menstruators” to be more inclusive [32]. Proctor and Gamble removed the Venus symbol from the packaging of their sanitary napkin product “Always” [33].

iii. Awareness and advocacy: Boondh, an organisation that works on menstrual advocacy, has called for media sensitivity to ensure that the language used in reporting on menstruation is not transphobic or discriminatory [34]. In 2021, Boondh, in collaboration with SchbangforGood, launched India’s first gender-inclusive menstrual campaign, #UngenderMenstruation [35].

iv. Inclusion in menstrual leave policies: Zomato, a leading food delivery company, introduced period leave for women and transgender employees to promote a more inclusive workplace [36].

Therefore, efforts to promote the inclusion of transgender persons in both commercial and public initiatives for menstrual hygiene and justice are urgently needed. However, without such inclusion being reflected in government policies and schemes, these measures will only be accessible to a small segment of the population.

There is an immediate need to undertake research and consult with members of the community to develop more safe, inclusive, and accessible menstrual care options. The literature review included in this commentary shows that the homogenisation of menstruators under the category of “women” by existing government policies and schemes overlooks the needs of several communities that are disproportionately affected because of their marginalisation. This article discusses specific policy changes required to accommodate the menstrual needs of transgender persons and further details why such policy changes need to address existing systemic differences such as caste, access to education, religion, geography, and disabilities to create true menstrual equality.

The lens of structural inequality enables us to appreciate the layers of differences and identity locations of menstruators, enhancing the effectiveness of solutions targeting menstrual justice. Our efforts may be inadequate if we construct toilets in rural areas for menstruators without including gender-neutral/transgender toilets. Similarly, eco-friendly menstrual products may not be designed in a way that is accessible to people living with disabilities.

As Martin Luther King Jr said, “It is not possible to be in favour of justice for some people and not be in favour of justice for all people.” True menstrual justice can only be achieved by employing tools like the lens of structural intersectionality, which considers the diverse variants and identity locations of individuals and includes all menstruators.

Acknowledgments: The author would like to thank the Neev Foundation for Legal Aid and particularly, Eklavya Vasudev, currently a Doctoral Researcher at FAU Erlangen-Nürnberg, for their comments and encouragement to write this in furtherance of the Represent All Menstruators in Sanitary Napkin Ads campaign. The author is also grateful to Sayantan Datta, queer-trans science journalist and Assistant Professor of Practice at the Centre for Writing and Pedagogy, Krea University for their suggestions.

Conflict of interest: No conflicts of interest to declare.