In the past decade, significant progress has been made in India by government and non-governmental actors with regard to menstrual health and hygiene management (MHHM). Increased awareness about MHHM, enhanced access to female friendly/gender appropriate sanitation facilities and availability of menstrual products, in particular sanitary pads, are some of the visible outcomes of this progress. However, certain groups have been overlooked thus far, including girls and women with disabilities, who face an exceptional burden on account of the intersections between gender and disability.
Census data, Act’s ambit
According to Census 2011, nearly 27 million persons (or 2.2% of the Indian population) are disabled. The Rights of Persons with Disabilities Act, 2016 specifies that a person with disabilities has “long term physical, mental, intellectual or sensory impairment which, in interaction with barriers, hinders [her]/his full and effective participation in society equally with others”. Persons with disability are unable to fully participate in many areas of daily life or may be excluded from doing so as a consequence of impairments/societal barriers or socio-cultural attitudes.
Magnified vulnerabilities
The 2016 Act, while stipulating the rights and entitlements of persons with disability, recognised that women and children are particularly vulnerable, and that certain rights, such as reproductive rights, may be even more neglected or disregarded as compared to others. Despite the intent of the Act and its provisions, the realisation of rights and entitlements of persons with disability is poor, especially for those from socially and economically vulnerable groups. In India, girls and women with disabilities from poor households and marginalised communities, bear a triple burden that exacerbates their vulnerabilities.
Deeply embedded prejudices and misconceptions about the reproductive anatomy and abilities of persons with disability result in their being considered asexual, unsuitable for marriage, and incapable of having and raising children. Access to sexual and reproductive health information and services are in turn compromised because of these social and physical barriers. Several studies bear testimony to this, and reveal that persons with disability are more likely to be denied information about sexual and reproductive health as compared to those without disabilities. Field experiences reveal compromised menstrual health, a basic physiological aspect of sexual and reproductive health, among persons with disability.
For a vast majority of women and girls and persons with gender diverse identities, menstruation is more than a mere physiological process due to preconceived notions about menstruators and menstrual blood being impure or dirty. Economic and structural factors create additional hurdles to hygiene management, good health, and health-seeking behaviours. Constraints imposed by limited mobility, cognitive capacities and self-care pose even greater challenges for girls and women with disabilities.
Collaboration for solutions
The United Nations Population Fund and WaterAid India are working together to understand the key challenges and constraints faced by persons with disability with regard to menstrual health and hygiene. The aim is to identify simple and potentially scalable solutions based on insights from individuals and organisations working with persons with disability across the country. There are critical areas for improving the menstrual health of persons with disability that have emerged. These include: Accessible and adapted Information, education and communication on menstrual health and hygiene for persons with disability based on their differential needs and capacities, and an enabling socio-cultural environment. For example, while the core messages related to menstruation and menstrual hygiene are the same for all, the manner in which information is communicated will vary depending on the type of disability and extent of impairment. Tactile models accompanied by audio explanations can help people with visual impairment, whereas the same models accompanied by materials with clear step-by-step visuals are useful for people with hearing impairments.
The second is appropriate and safe menstrual products and hygiene promotion. Fewer than two-thirds of girls and women with disabilities aged between 15 to 24 years use hygienic menstrual protection methods (National Family Health Survey 2019-20). Thus, persons with disability and caregivers need to be educated on the diverse range of products available to enable them to choose the most appropriate product. Persons with intellectual impairments are highly sensitive to materials and may require those that are soft to touch and cause less irritation. Persons with mobility restrictions require products that can be worn for longer as changing them frequently poses a challenge.
The third is responsive and inclusive water, sanitation and hygiene (WASH) facilities, including disposal solutions in different settings. Accessible designs of WASH infrastructure for diverse needs exist and have been created in rural and urban contexts in India and particularly in schools, but need to be scaled up for wider coverage.
The fourth is caregivers, both from within the family and institutions are vital for disability focused interventions and must be included as both participants and partners. From a policy perspective, there is a need to incorporate a disability-inclusive approach within the menstrual health and hygiene work in the country and to implement specific disability focused interventions to facilitate inclusion.
It is a right
Every menstruating person has the right to menstrual health, irrespective of their gender identity, ability, or socio-economic status. While India has made significant progress busting stigmas around menstrual health and expanding access to hygiene products, let us not leave anyone behind. Let us raise the bar to ensure that all menstruating persons — abled or differently abled — enjoy the same dignity and rights every month of the year.
V.K. Madhavan is Chief Executive, WaterAid India. Andrea Wojnar is UNFPA India Representative and Country Director Bhutan
