High school student in eastern India, studies a leaflet on menstrual hygiene. Credit: Stella Paul/IPS

By Webster Mavhu
HARARE, Jun 12 2020 (IPS)

An all-male panel assembled to discuss menstrual health on International Menstrual Hygiene Day sparked outrage on social media and a flurry of memes of all-female panels discussing male issues.

But the social media spat should not divert attention from the issues the day tries to raise in order to break menstrual taboos and raise awareness about the importance of menstrual health and hygiene management for women and adolescent girls worldwide.

And if we truly want to do this, then we must include men not just in the conversation but also in the interventions being implemented.

Despite it being a natural biological process, menstruation is characterized by myths, stigma and taboos across the world.

Among both boys and girls, reproductive health knowledge is often acquired too late. For example, menstruation is often discussed only after it has happened, and begins with a feeling of fear.

As in many cultures, I grew up with menstruation taboos. For example, a menstruating woman is not supposed to slaughter a chicken, prepare certain foods, or brew beer for spiritual occasions.

Also, a menstruating woman is not supposed to verbally inform her sexual partner that she is menstruating. Instead, she will do so symbolically for example, by placing a piece of red cloth on their sleeping mat as there can be no discussion about the matter.

It is not just couples who do not discuss menstruation. Young girls are not able to talk about it openly with their mothers, grandmothers, aunts or fathers – all of whom are potential sources of reliable information.

My work over the past 15 years has included exploring sexual and reproductive health issues among adolescents in sub-Saharan Africa. A key finding has been that among both boys and girls, reproductive health knowledge is often acquired too late.

For example, menstruation is often discussed only after it has happened, and begins with a feeling of fear. In some of my research, an adolescent described her first experience: “Initially, I thought I had urinated without realizing it but I was shocked to see blood. When I informed my mother, she said I was supposed to use rags as sanitary pads and to wash myself three times a day so that I would not smell bad.” The discussion ended there.

Gaps in information are often filled by hearsay. Another girl described how, when she began menstruating, her elder sister advised her to use cotton wool as opposed to sanitary pads “as the latter make one lose virginity”. The elder sister said she had also been told this by her friend.

Myths around menstruation are also common among boys. For example, boys tell each other that unprotected sex with a menstruating girl has no risk of pregnancy or sexually transmitted infections. There is also the belief that potential health “effects” of having unprotected sex with a menstruating girl can be prevented by drinking a solution made from mature soot.

Clearly, efforts to tackle myths around menstruation must target both girls and boys to reduce menstrual-related stigma and ill-treatment, as well as improve sexual and reproductive health.

When I was in my sixth grade, a fellow classmate had her first period and bled on her school uniform. She tied her jersey around her waist. When the boys realized what had happened, they untied her jersey. She desperately tried to cover the stain with her hands, but the boys kicked away her hands to make sure the stain would remain exposed, jeering in the process. She missed the following week of school.

More than three decades later, girls continue to miss school during their menstrual period. Studies conducted across the whole world have highlighted full or part-day school absences as a result of menstruation.

Of course a range of measures are being introduced into schools to reduce girls’ absenteeism from school including: provision of sanitary products, access to socially acceptable disposal facilities, access to water for washing near toilets, and space for changing. However, very few seem to be targeting boys.

Targeting boys with menstrual health education will not only improve girls’ school attendance but will help address menstrual-related myths and stigma. 

A pilot study conducted in Uganda tested a multicomponent school-based menstrual health and hygiene intervention, and evaluated its impact on several issues including, secondary school attendance. The intervention targeted both boys and girls.

Study findings indicated a potential intervention impact on improving menstrual-related school absenteeism. Of note, a drama skit on menstruation was very popular with both boys and girls, and worked well to involve boys in this topic and de-stigmatize menstruation.

It is therefore critical for menstrual health and hygiene interventions to include boys not just for immediate benefits but also for influencing their future thought patterns and behaviors. 

Ultimately, men will be able to discuss menstruation with their wives and daughters, thereby significantly breaking taboos and reducing menstrual-related stigma.

Webster Mavhu is a linguist-turned social scientist and global health practitioner who has been conducting research to inform programming for the past 15 years. He is a 2020 @aspennewvoices fellow.

By Webster Mavhu
HARARE, Mar 5 2020 (IPS)

Women are the face of HIV in Africa, yet four of every 10 persons living with HIV in East and Southern Africa are men. Despite higher rates of HIV infection among women, more men living with HIV are dying.

Men are often left behind by programs that aim to reduce HIV rates as well as those providing HIV treatment.

Global HIV targets are that by December 2020, 90% of all people living with HIV will know their status, 90% of those HIV positive are on treatment and, 90% of those on treatment have reduced replication of the virus in their body.

Some African countries are on track to achieve these targets because programs for women are doing so well. Unfortunately, men in many settings are far from achieving these targets.

The Joint United Nations Programme on HIV and AIDS (UNAIDS) report shows that globally, less than half of men living with HIV are on treatment, compared to 60% of women. Data from 30 African countries also show that, across all age groups except 45-49 years, men are much less likely than women to have ever taken an HIV test.

In response to HIV testing and treatment gaps between men and women, the U.S. President’s Emergency Plan for AIDS Relief emphasizes the need for an acceleration of strategies to reach men under 35 years.

Webster Mavhu. Credit: Natasha Sweeney.

For more than a decade, I have been researching why men in sub-Saharan Africa do not take up HIV services even though they are aware that they need to take the necessary steps to either prevent HIV or ensure it does not eventually kill them. I recently visited four African countries – Lesotho, Malawi, Tanzania, Zimbabwe – to explore why men act against their own best interests.

One issue that came out in all countries is that men believe that the body and mind ought to be resilient. They consider ‘submission’ to the healthcare system as necessary only when the body can no longer hold out, or when men are certain they are no longer in control of their health and fate. A fisherman in Tanzania summed it up as: “A man is like a car which only goes to the garage when it has broken down.”

Men want to be seen as being in control, but HIV – considered a serious, life-long condition – undermines this image, with the result that men want to avoid knowing they have it.

HIV programs therefore need to change the narrative around HIV for example by repositioning HIV testing and treatment as acts that allow men to regain control of their health and fate more broadly.

Another concern voiced by men is that programs are largely based at clinics, but men rarely visit clinics. Programs need to take services to where men are.

We implemented HIV self-testing in three African countries and found that it increased HIV testing among men. Men liked that they were in ‘control’ of the testing process and that they were the first to know the result, which is different from when a health worker does the testing.

Global HIV targets are that by December 2020, 90% of all people living with HIV will know their status, 90% of those HIV positive are on treatment and, 90% of those on treatment have reduced replication of the virus in their body

But self-testing requires a second test to confirm a possible positive result, so programs need to consider how to make confirmatory testing easily accessible for men who self-test positive. 

It is also important to ensure that men who test HIV-positive access treatment. Large numbers of HIV-positive men choose not to seek treatment nor stick to treatment plans once started. An innovative way to address barriers to treatment access has been the use of community medication refill groups, where groups of individuals who are doing well on HIV treatment take turns to collect medication for each other, reducing the need to go to the clinic regularly.

Another barrier for some men is fear that others may learn their HIV status, which can mean they prefer to collect medication from male community health workers, and in secret. 

While some argue that too many resources have been channeled to HIV and it is now time to focus on other conditions, HIV has provided huge learning which can be adapted by other programs. Better still, health systems (including community-based approaches) developed for HIV prevention and care can be combined with those for non-communicable diseases (e.g. diabetes, hypertension) and implemented alongside each other.

I am not arguing for less focus on women. But all that focus and hard work will be undone if we do not also focus on men. To do that, we need to use targeted approaches that take into account men’s particular concerns about privacy, self-determination (control) and need for flexibility.

At stake is more than simply reaching global goals. At stake is the health and well-being of millions of African men.

Webster Mavhu is a linguist-turned social scientist and public health practitioner who has been conducting research to inform programming for the past 15 years. He is an @aspennewvoices fellow. Follow him on twitter @webstermavhu