by Rose George
Surveys are not robust science. But they have to stand in for it because of an absence of data on women’s health and menstruation. Here are some things that science could stand to look at more closely: Premenstrual syndrome. Premenstrual disorder. Pain. Hormones. (I wrote this book while fighting menopausal depression, brain fog—a polite expression for temporary dementia—and other symptoms caused by hormonal fluctuations. When I asked the Society of Endocrinologists for an expert to discuss the effects of estrogen on the brain, it said the society didn’t have one.)
I did a short and definitely unscientific test by using two search terms on PubMed, a database containing 27 million citations from journals and books. “Premenstrual” had 5,496 citations. “Erectile dysfunction” had 21,672. Erectile dysfunction must be distressing. But does it debilitate 90 percent of men for at least two days a month? Does it damage their ability to work, think, live? Premenstrual syndrome is so poorly understood, its existence continues to be questioned, though not by me. When the psychologist Kathleen Lustyk made applications for grants to study PMS, they were refused “on the grounds that PMS does not actually exist.” The magazine writer Frank Bures wrote a book recently, claiming that PMS was a “culture-bound syndrome” created by the level of stigma around menstruation. He aligned it with other culture-bound syndromes such as one where men imagine their genitals have been sucked up into their bodies by voodoo; or the Indian affliction gilhari, “in which patients arrive at the hospital with swelling on the back of their necks, complaining that a gilhari (a kind of lizard) crawled under their skin.”47 His reasoning for this is that PMS is most likely to be reported by women in western Europe, Australia, and North America, and that “the more time that women of ethnic minorities spend living in the United States, the more likely they are to report PMDD.” Premenstrual dysmorphic disorder is a more severe version of PMS. The Diagnostic and Statistical Manual of Mental Disorders, the psychiatrists’ bible, now lists four main criteria for PMDD. First, you must have symptoms including marked depression, anxiety, persistent or marked anger, and marked affective lability (e.g., feeling suddenly sad or tearful or experiencing increased sensitivity to rejection). These must be bad enough to interfere with daily life, they must be related to the menstrual cycle (and be an exacerbation of symptoms relating to some other disorder), and occur during at least two consecutive menstrual cycles.48
I’d gladly switch places with Frank Bures on the several days a month when I have to avoid a nearby road bridge because I don’t have the defenses to stop myself from jumping off it, or when picking up a phone and speaking to a human seems the hardest thing in the world to do, and when I must breathe under the weight of invisible kettlebells sitting on my chest. Similar claims are routinely made about the menopause, such as that hot flashes are all in the mind. This is true, as that is where temperature is regulated, though the drivers are not thoughts but hormone fluctuations. Bures should know about this: men’s testosterone levels rise and fall on a monthly cycle. That’s probably well researched.
Isn’t this just the latest round of the wandering womb? Ancient gynecologists decided that hysteria was caused by a uterus moving around a woman’s body.49 How preposterous and old-fashioned. Except it is not. Katharine Switzer, the first woman to run the Boston Marathon, wrote in her memoir that her high school coach—a woman—told her that if women played basketball, an “excessive number of jump balls could displace the uterus.” In 2010, Gian-Franco Kasper, president of the International Ski Federation, said on television (publicly!) that a ski jump could cause a woman’s uterus to burst.50 Women were allowed a competitive ski-jumping event only in 2014. A post on the Public Library of Science (PLoS) blog was headlined, OLYMPIC SKI JUMPING COMPETITION COMPLETED WITHOUT A SINGLE UTERUS EXPLOSION. Unlike men, wrote Dr. Travis Saunders, women’s gynecology is safely contained inside the body.51
Perhaps claiming that any kind of premenstrual symptoms are akin to imaginary lizards or disappearing penises would be more difficult if research were better or better funded. Although talking of “symptoms” will get me accused of pathologizing a natural process. It didn’t feel natural when I was writhing on the floor in pain or when, once a month for several days, no thought was not a black or dangerous one. Last year, endocrinologists discovered that women who suffer from PMDD, which they described as “clinically distressing changes in mood and behavior,” may have genes that make them respond differently, and painfully, to hormonal changes or fluctuations.52
It wasn’t until 2013 that a comprehensive review was undertaken, by a team at the London School of Hygiene and Tropical Medicine, into the state of existing research about menstrual hygiene management.53 This is astonishing, when it has been understood for a while now that a worrying number of girls drop out of school when they get their period. Often it’s when their school lacks a toilet. Ankita and Khushi, the schoolgirls in Uttar Pradesh, used to go in an alleyway behind the school, or behind plants in the dusty yard. Now imagine doing that when you have your period. I’d drop out too.
It’s well known that educated girls are better for just about everything: they have fewer, healthier, and better-educated children. The World Bank estimates that getting a higher education is equivalent to a 25 percent increase in wages in later life (compared to a rise of 7 percent for secondary).54 A UNESCO global report into education in 2014 found that Pakistani women with high literacy skills earned 95 percent more than women with weak or no literacy skills.55 Among men, the differential was only 33 percent. Overall, if female education rates rise by 1 percent, GDP increases by 0.3 percent. Educated girls are like yeast in the dough of sustainable, successful development (even dough kneaded by a menstruating woman). If girls can be persuaded to return to school because they have a toilet and good menstrual hygiene, then scholars of all ilks should be flocking to demonstrate this. The London School study found only sixty-five articles to review, a paltry number. It concluded that “menstruation is poorly understood and poorly researched” and that “there is a strong possibility that the best knowledge lies in the hands of those implementing programs.”
I wonder. If menstruation were better researched, would my endometriosis have been diagnosed sooner? The average time it takes to diagnose endometriosis is ten years. For twenty years, and by several doctors, I was given prescription-strength painkillers without question. The question should have been: Is there something wrong? Period pain, caused by prostaglandins making contractions in the uterus, is common. But extreme period pain is not. In a paper titled “The Girl Who Cried Pain,” the authors Diana Hoffmann and Anita Tarzian explored bias in how pain in men and women is acknowledged and treated.56 They had plenty of material. Children in postoperative pain: the boys were given codeine, while girls got paracetamol. One study found that male patients who had had a coronary artery bypass graft were given narcotics more often than female patients. The women were more often given sedative agents, “suggesting that female patients were more often perceived as anxious rather than in pain.” When researchers reviewed evidence from the American Medical Association’s Task Force on Gender Disparities in Clinical Decision Making, “physicians were found to consistently view women’s (but not men’s) symptom reports as caused by emotional factors, even in the presence of positive clinical tests.” Female chronic pain patients, in another study, were “more likely to be diagnosed with histrionic disorder (excessive emotionality and attention-seeking behavior) compared to male chronic pain patients.”
The hysterical woman and her wandering womb, her fragile mind. Same as it ever was.
* * *
Bihar is the poorest state in India, and despite a decent state government that has improved roads, it is the only place where our Yatra stalls and stage are erected by men who bring their equipment by buffalo. Today’s venue is a school that has one computer and only a generator for electricity. The Yatra’s MHM team has come to do outreach with teachers. Most are male. Education is the route out of menstrual stigma, but boys and
men must also be taught. The state government has insisted that the menstrual hygiene program be carried out even during the festival of Diwali. “I know,” says one of the program organizers. “I wouldn’t like me for that, either.” Perhaps that’s why an angry man comes up to me and yells that we are late and how dare we? I am there only as an observer and direct him to the program organizers, because he has confused my skin color for authority. I dislike him for that, and also that during the session he was asked about the menstrual cycle and said, “After twenty-one days, when the egg ruptures, there’s a lot of bacteria and it can make them ill and if they make food they can make everyone ill.”
In the classroom, men dominate in number and in their bullying. They shout down the women. Vaishalli, who leads the session, hands out a paper that holds three questions.
What are the problems faced by girls when they get periods during school hours?
What problems do female teachers face when they get periods in school?
What problems do male teachers face when they realize female students have periods?
There is confusion. The girls can take two days off school. No, not the girls, the teachers. No, the teachers can’t. No, the girls can’t. There is no facility in the school to change pads, a man says, so if they need to do that, they definitely need to leave. A male teacher said, “They get very irritable.” A female teacher, allowed to speak for once, says, “We help them by giving them permission to leave the school. That’s all we can do.” Missing education is sad, but period leave sounds better than what happened at my school, when the only concession to periods and pain was a code whereby the games mistress asked, “Who isn’t showering?” and I wondered how often you could say “me” and whether Miss Applewhite kept records.
A report by Plan India dating from 2010 claimed that 23 percent of Indian schoolgirls miss school or drop out altogether because they are menstruating.57 This statistic is cited by almost anyone writing about menstrual hygiene management, even though the report can’t be found anywhere. Here is another widely repeated fact: that one in ten schoolgirls in Africa do not attend school during menstruation. This is so striking and large—how do they know?—that I investigate it, finding the original quotation in a UNESCO document quoting the source as a UNICEF study that doesn’t actually contain the figure or anything like it. It is one of those shimmering figures that dot authoritative reports (a “zombie statistic,” in the words of a WaterAid analyst58) that are built only on expectation and belief that it makes sense. I find another zombie figure repeated: that a 2013 study by the University of Nottingham found that 61 percent of girls worldwide had missed some school each month because of periods.59 The study found no such thing. Believable figures are not global and more guarded: that Nepali schoolgirls missed only 0.8 percent of school days in a year, but half of them missed school at some point while menstruating. In Ghana, 95 percent of schoolgirls reported missing school, and 53 percent in Nairobi, Kenya.60A UNICEF survey found that 35 percent of girls in Niger and 21 percent in Burkina Faso “sometimes” missed school because they were menstruating.61
I’ve visited dozens of schools in the developing world, and even when they had toilets, they were filthy and ramshackle and I wouldn’t have used them. In Liberia, I once met a young woman who wore two pairs of underwear, a pair of trousers, and two skirts. All at once. She was terrified of staining her clothing, and although her school had just been decently renovated by a Liberian NGO, it had somehow forgotten to build a toilet block. Grace had to go to the bush to change her sanitary cloths, and so she either stayed home or wore her uniform of period-protective clothing.
SHARE, a research initiative at the London School of Hygiene, thinks a link between school absenteeism and periods is plausible but unproven. In sober development language: “Although there was good evidence that educational interventions can improve MHM practices and reduce social restrictions there was no quantitative evidence that improvements in [menstrual] management methods reduce school absenteeism.”62 I’m not sure what’s more infuriating: that Grace and other girls are missing or leaving school because they are bleeding or that the reason we can’t be sure that’s connected to poor menstrual hygiene is because there isn’t enough research or science, because there never is, when it comes to women’s health.
I read an angry piece objecting to the phrase “menstrual hygiene management,” because it perpetuates the belief that period blood is dirty and smelly. But sometimes what pushes girls out of the classroom is because they are terrified that they are dirty and smelly. They don’t stand up to answer the teacher for fear their clothes are stained, and many live in hot countries where school uniforms are light-colored. Good for sunshine, bad for period confidence. In Malawi, girls interviewed by WaterAid, who almost all wore sanitary cloths, reported boys taunting them when the cloths fell out of underwear, saying, for example, that they “looked like they had killed a chicken.” (This is surely the politer version of what they said.) The cloths they used were so uncomfortable they would make the sanitary pads that my school secretary dispensed—so bulky, we called them bricks—seem like gossamer. The cloths were easily soaked and became visible through uniforms. School toilets had no doors and no water, so they may as well not have been toilets. “We go to the toilet,” one girl said, “then we eat with shit or blood on our hands.”63
Period pain was another reason for absenteeism and dropping out: girls can’t afford painkillers and will rarely dare to tell the teacher they are in pain from menstruating. Also, when girls start menstruating, it means that they are sexual beings and can be married. Studies have shown success, though limited, with the provision of sanitary pads and menstrual cups (plastic devices that gather blood and are thought sustainable, including by everyone who writes to me after I publish anything on periods and urges me to try one). When schoolgirls in Uganda were given a combination of puberty education alone, puberty education and sanitary pads, or sanitary pads alone, it was puberty education that kept them in school.64
In the Bihar classroom, a male teacher stands up at the end of the session. He is pouring water on the day, in a way, because he said, “It’s very easy to talk about menstruation but the social conditions are this: if a male teacher starts to do this, he is going to go through hell. Social conditions don’t allow us to talk to girls, and they have problems already talking to female teachers, so forget about us.” A female teacher agrees. “If a male teacher tries to talk to girls about periods, he will get beaten up.”
Teachers matter when it comes to dissolving stigma. But the girls matter most, the ones like Ankita and Neelam and Radha and her schoolmates, who have the confidence to protest injustice to me, and one day may have more, and spread it further.
I think about Radha sometimes, after I leave Nepal. She wasn’t particularly chatty or communicative, not even when we walked together for four hours back to the river where the road arrived, while she carried some of our luggage because she wanted the portering fee. I don’t know if she was smart or had hopes. But I knew that her opportunities, as a young woman in rural Nepal, were constricted. Child marriage rates in Nepal are disturbingly high, and with absent parents there was a good chance that her family would think the safest state for Radha to be in was a married one. In 2017, our photographer Poulomi returned to Jamu on assignment and found her. She e-mailed me a picture. Look, she wrote. Here is Radha, nineteen now, and married. She has to endure only three days of chaupadi now, not five. That is her pickle, her progress.
Arunachalam Muruganantham at home
SEVEN
NASTY CLOTHS
To change his sanitary napkin and clean himself up, Muruga thought the public well near the burial ground was the best option. People avoided the well as they avoided the dead; he could remove his pad, rinse his stained clothing, and be safe. But Muruga was wrong. People saw, and they talked. This strange man, washing blood from his clothes, wearing a sanitary pad like a woman: What was he doing? The shame of it. The
disgrace.
He was doing something revolutionary. It counted as revolutionary in his village, but also in his state, his country, and worldwide. Arunachalam Muruganantham, a poorly educated workshop helper and son of a handloom weaver, was on his way to becoming Menstrual Man.
* * *
In the predawn hours, Delhi Airport is packed. Heaving packed. Small children everywhere. The city has been hotter than a heat wave, with temperatures of 50 degrees Celsius (122 degrees Fahrenheit). To stand outside for more than a few seconds is dreadful. One newspaper is running a regular column called Death by Breath, because the temperatures are making the city’s air pollution worse than ever. Most people are going north to the cool of the hills, but I’m going south, to a town I’d never heard of a year before. To Coimbatore, Tamil Nadu. When the plane lands, a woman behind me says to her daughter: Look! Red soil and coconut trees.
The air is fresher than I am. I’m tired and traveled and smell like it. But I have a meeting, and I have to wake up: I make a phone call and am told to come for one o’clock, for lunch. (In fact, he tells me later, he never eats before three. He was trying to be considerate of a Westerner’s lunchtime and didn’t realize this was a Westerner in desperate need of a nap.) His home is only a half-hour drive from Coimbatore center, but the taxi driver gets lost: narrow lanes, no house numbers. I’m sulky-tired and slumping in the taxi when I see him. He stands in the street, looking for his guest, his posture erect, his skin the darker one of South Indians, his clothes white like his house, a smile beneath his mustache. Suddenly I am alert, because I’m about to meet a celebrity. This is Muruga, as he shortens his name, friend of presidents and Bill Gates and Bill Clinton, and a sanitary pad superstar.