‘We do not know’: a qualitative study exploring boys perceptions of menstruation in India

In some poor regions of the world girls and women have difficulty looking after their menstrual hygiene. They resort to using items such as rags, cloths, foam from a mattress, or leaves and sometimes have nothing at all to soak up the blood. Those who use cloths may struggle to clean and dry them hygienically. When they have access to, and can afford pads, there may be issues with disposal. They are further disadvantaged because they lack knowledge around menstruation and menstrual hygiene management and it may be a taboo subject that they should not talk about. Because this is a gender issue, in societies where women are not empowered girls and women may need the help of boys and men to promote better access to suitable and affordable products, and sanitary support. However, little is known about male knowledge and attitudes towards menstruation, and whether they may be effective champions in helping to resolve menstrual issues alongside women. The present study was undertaken to explore knowledge and attitudes of adolescent boys across India. The study was undertaken across three states in India, chosen to represent a wide cultural and socio-economic range of the population. Qualitative data were gathered using focus group discussions with 85 boys aged 13-17 years, from 8 schools. Data were analysed using thematic analysis. We found there were three main themes: boys’ knowledge of menstruation, how they obtained their knowledge, and their thoughts about menstruation and menstruating girls. Specifically, the boys poorly understood menstruation in terms of the biology; however, they understood some of the cultural restrictions placed on girls during menstruation, and they also knew that menstruation affected girls in a negative way. Some boys learned about puberty and menstruation as part of the school programme, but they felt strongly that they were not given enough information. Most boys obtained their knowledge from listening to women and girls talking, or from watching them. Although a few boys thought that menstruation was a disease, most of them did not think negatively about menstruation, were kind to girls who were menstruating and wanted to support them. From our data, we are hopeful that boys and men can become involved in this gender issue, and help support menstrual issues for girls and women in the future.

Menstrual hygiene management (MHM) remains an issue of gender inequality [1], particularly for women and girls living in low- and middle- income countries (LMIC) who have limited information and few resources available for their basic menstrual hygiene needs. These include the need to access affordable and absorbent materials, privacy to change, adequate washing, cleaning and drying facilities, and appropriate and accessible disposal facilities. Menstruation is considered to be a contributing factor toward school drop-out, and exacerbates the struggles girls have in attending school and being able to function and participate fully [2, 3]. As a consequence, girls fall behind boys in their education, which prevents them from reaching their potential. An overview from the first ‘MHM in Ten’ global panel meeting reported that for girls in LMIC, lack of access to good MHM has some effect on school outcomes, with ‘repercussions for sexual, reproductive, and general health and well-being throughout the life course’ [4]. An agenda setting out future priority action areas for MHM was proposed to address the challenges facing schoolgirls (and women) in LMIC. This also recognised the need to involve men, and groups working to improve male involvement as stakeholders in these activities [5].

In countries such as India where the present study is set, cultural and societal taboos surrounding menstruation place restrictive practices upon menstruating females, compounding the difficulties faced by girls and widening the gender disparity further. Such taboos include restrictions in their diet, participation in cooking and visiting places of worship or involvement with social activities, as well as having to sleep or sit separately from the rest of the household [3, 6, 7]. In some settings, menstruating girls and women are considered unclean and untouchable during menstruation [2]. Furthermore, menstrual blood is taboo and so simple tasks such as washing and drying menstrual cloths becomes shameful for girls and women. This may result in damp cloths being stored or worn before adequately dry [3], which is potentially harmful to their health [8]. Even within families, menstruation is exclusively a female issue with males remaining ignorant of health and hygiene matters pertaining to their wives, mothers and children.

MHM is seen as a matter for women only, and one that should be kept private and not discussed, as to do so may bring shame. As a result, girls and women cannot express their needs and affect change within their homes, community or in society in general. It is suggested that male attitudes are one of the main factors driving the stigmatization and myths surrounding menstruation [9, 10]. Recognition and inclusion of the gendered nature of women’s reproductive health is weak, with low priority given to issues of gender equality and positive sexual and reproductive health outcomes resulting in MHM being a neglected issue as noted by Mahon et al. [1]. In the present study context lack of, or weak management responses for good menstrual health, coupled with negative social and gender norms surrounding menstruation and women’s sexual and reproductive health in general has hindered progress in reducing gender inequality within India. India, a patriarchal society has seen its ranking in the Gender Gap Index widen from 98th in 2006 when the Index was created, to 108th in 2015 [11], thus indicating little progress, if any at all in reducing inequality. In a patriarchal society, men hold power over women at all levels of society, women are traditionally seen as second class citizens with little power individually or collectively in relation to politics and finance, as well as health and education [12]. India has been described as a country of ‘contrasts’ with huge disparities of wealth, as well as gender inequity. A recent study reported that just 23% of women took part in family decision making in Rajasthan, compared to twice that (49%) in Tamil Nadu [13]. With little power in decision-making within the family setting, women will have minimal if any, impact on community or societal matters. Low literacy, lack of confidence and cultural norms prevent women from being innovators and it is therefore even more important that males assist in advocacy to affect change. There is a role for men to become involved in menstrual issues to help reduce the restrictive practices and negative view of menstruation, including in Indian and other societies, and to promote better menstrual hygiene management and critical investment in WASH (Water, Sanitation and Hygiene), through their roles as family members, policy makers, stakeholders and investors.

To affect such change, it is necessary to understand the knowledge and attitudes that males currently hold so that appropriate actions can be taken to garner their support as advocates for women, or to contribute of their own accord in addressing these issues. A literature search suggests that male views on menstruation are largely unknown and under-researched globally. A small body of work undertaken in western culture, predominantly cited in feminist literature up to the 1990’s, suggests male perceptions of the menstruating woman are negative [14, 15]. However, little is known currently, nor within LMIC, where women are more likely to suffer disadvantage through lack of MHM. One study of male pupils in Taiwan found menstruation was taboo for boys despite their desire for information [16]. They found both families and teachers refused to talk about it or answer questions, going so far as to forbid boys to discuss the topic. As a result boys developed misconceptions, such as girls menstruated on a weekly basis, as well as negative attitudes. Further studies are necessary to elucidate male views and their understanding of menstruation, to facilitate development of educational packages to address this void [4, 5]. The present study aimed therefore to assess the knowledge and views of school-going boys across India on menstruation. The research questions were: What do boys understand about menstruation? Where have they obtained any knowledge about menstruation? What are their views on menstruation and menstruating girls?

The results were organised into three main themes to reflect on the key research questions: boys’ knowledge of menstruation, their source of knowledge and their attitudes towards menstruation and menstruating girls. Within these main themes, the following subthemes emerged: denial, misconceptions, curriculum gap, cues to acquire knowledge, loss of friendship / changing relationships, societal views, menstruation as a normal function, disease and isolation, and supporting girls. Interestingly, there were no differences in findings between the model school and the usual schools, however there were some differences in knowledge due to differences in the teaching of menstruation across the 3 states, which is indicated below where relevant.

Following introductions and warm-up, all focus group discussions began with a question exploring whether participants had heard of menstruation and what they understood it to be. The majority of boys denied all knowledge. For a minority this appeared to be true, although for many others it stemmed from reluctance to talk or embarrassment on this subject. This was evidenced across the groups by silence or self-conscious laughter when the moderator tried to initiate discussion. The following is an excerpt demonstrating boys’ reluctance to admit any knowledge:

Despite these strenuous denials, it emerged later in the discussion that these participants were taught about puberty and menstruation at school; with one pupil stating ‘It came as a lesson in the curriculum’ (P3 Tam S6).

Currently, there is a dearth of literature exploring male knowledge, and perspectives on menstrual hygiene mostly come secondhand through narratives of women and girls [17–19]. Even fewer studies have specifically explored MHM with males [4, 20, 21]. The current study adds to this small body of knowledge using primary data collected from adolescent schoolboys. Importantly, while there are study limitations that prevent the drawing of strong conclusions from the present study, the findings provide some optimism that males can become advocates in moving forward the MHM agenda. The reasons for this are twofold: boys were keen for more knowledge about menstruation, and were searching for information despite societal norms preferring them to remain ignorant. They were also largely sympathetic to their menstruating sisters and fellow classmates and understood the issues surrounding the need for good MHM. The findings, to some extent, echo the small body of literature to date, with some differences from previous studies, which are discussed in more detail below.

Although knowledge and understanding varied across the different discussion groups, we found that it was a challenge for most boys to understand menstruation because of the surrounding secrecy and the limited information they had access to, much of which was inaccurate, or was pieced together erroneously. Oftentimes they were discouraged to discuss menstruation at all. This has also been reported in studies conducted with adolescents in Taiwan and Rwanda [20–22], who similarly reported lack of knowledge on the link between menstruation and ovulation, and reported beliefs such as menstruation being a punishment from the gods, resulting from injury, or that it is a mental or physical ‘disease’. A consequence of this ignorance and secrecy is the maintenance of the stigma surrounding menstruation and menstrual issues. Ramifications include the improbability that they will become advocates for women in MHM issues as males and fathers, that they will fail to understand how menstruation and hygiene affects their wives and daughters and impacts on the community and society at large. Girls would thus continue to suffer the consequences of cultural and societal norms that impact on their health and education.

Boys in our study were mostly curious about menstruation, evidenced not just by their request for it to be taught in the curriculum but also by the questions they asked our moderators. In another Indian study based in West Bengal, boys also requested menstruation to be included in the school curriculum [23]. Chang and colleagues (2013) reported that boys in Taiwan resorted to going online to investigate this topic [20], as did some of our participants. We wonder therefore, why boys are poorly informed when they could be provided with information that they request, which would serve for their future role as husbands, partners and fathers.

Provision of education within the school curriculum to boys in their formative years, when they are eager to learn, and where the content can be managed, would appear to be key. The present study raises concern on the apparent lack of education that boys received. Although part of the curriculum via the Adolescence Education Programme (MHRD 2017), it was seemingly ignored or skipped over by teachers. This phenomena has been reported in studies from Kenya, Bolivia and the Philippines [18, 24, 25], which have similarly described teachers’ discomfort in teaching ‘sensitive’ topics, or who feel ill- equipped to adequately cover topics due to a lack of knowledge [26]. Most often teachers do not possess any formal training or guidelines to teach such sensitive information, and may need specific capacity building to correctly impart information. This is particularly important in coeducational schools where girls and boys are present in the same class and when gender of the students and teachers differ.

Studies also suggest that health information and education in schools may be best taught by those trained specifically for that purpose [27], rather than being covered within the curriculum by class teachers. Other authors contend that school (or general) nurses may be particularly effective in providing sex and relationship education in schools [28].

It was interesting that boys in one of the FGDs strenuously denied that girls were teased, a finding contradictory to a large body of international literature suggesting that girls suffer humiliation from being teased. Although most of this evidence has been collected from girls’ narratives [17–19, 29] boys’ studies have also confirmed this [21]. However similar to our study, in Rwanda Penakalapati (2009) also mentioned instances where boys themselves prevented the girls being teased and assisted them in hiding staining [21]. We have no way of knowing whether the participants in our group were genuine in their denial, or concerned about ramifications if admitting to this. Importantly though, evidence from Ghana suggests that taking part in an MHM initiative, which included an educative element, had a positive effect in boys no longer teasing girls [30]. Given the effects of being teased on girls’ confidence and school attendance, the importance of including boys in MHM initiatives cannot be stressed enough.

In our study it was also noted that boys appear to recognize but are saddened by, the resulting change in the nature of their friendships with girls once they reach menarche. In effect they lose friendships. Chang and colleagues (2012) [16] and Penakalapati (2009) [21] similarly reported loss of friendship was remarked on by their participants, and this is further described by Allen and colleagues studying undergraduates in the US (2011) as a ‘gender wedge’ [31]. This phenomenon may stem from the girls’ own change in attitude on reaching puberty and withdrawing from boys generally, but particularly during menstruation. However, it is also likely to be perpetuated in societies where male/female relationships are restricted, as well as in cultures where girls reaching menarche are seen as ready for marriage. Other authors refer to this as the ‘sexualising of menstruation’ [16].

We acknowledge some limitations in the present study including the disadvantage of using FGDs as the key method of soliciting opinion. Because of peer pressure, individuals may not have felt comfortable in voicing opposing views to the group norm. Whilst some contradictory points of view emerged, mostly narratives showed a high level of agreement, which may indicate acquiescence. However, as there were similarities across the FGDs we are confident that our findings represent an overview of the boys’ perspectives even if not every individual view.

We only included boys who attended non-residential schools. It is possible that boys attending residential schools have a different, possibly greater understanding, of menstruation depending on the curriculum teaching. On the other hand, boys who have dropped out of school, and those who have not attended school were not represented in our study. It is likely that their knowledge and understanding was even poorer than those boys attending school routinely.

We are also aware that the series of FGDs were short in length. We believe that this reflects the lack of knowledge boys had about the subject, which coupled with the sensitivity of the topic, meant that they were not verbose in their responses to the moderator, nor stimulated to converse as a group easily. However, boys did appear to give their perspectives and opinions freely, providing useful insights allowing us to answer the research questions posed.

We conclude that in order to help drive forward the changes needed in MHM, the male perspective should not be ignored or forgotten. Boys need to be educated and involved in MHM whilst at school, something they appear to desire for themselves. MHM should be included as a critical component of comprehensive sexuality and life skills education, not just as a paper exercise but provided to each and every boy so that they grow up informed. Consideration of the education role needs to be taken seriously, with training provided to those teachers, counselors or school nurses responsible for passing on knowledge to the current and future generations. There is need to promote inclusive, learner-centered, participatory and gender transformative teaching and learning on menstruation, which is based on core principles of human rights and gender equality. Rather than a stand-alone education, menstrual teaching should be considered as an important component of comprehensive education on life skills, development and sexuality. Without such education to challenge social norms, negative perceptions of menstruation will remain, and the desired change will not be effected. However, there is hope that with inclusive education boys can become ambassadors in promoting MHM requirements, particularly in cultures where women and girls do not yet have a voice to do this.