"Comfortably, Safely, and Without Shame: Defining Menstrual Hygiene Management as a Public Health Issue" (2015), by Marni Sommer, Jennifer S. Hirsch, Constance Nathanson, and Richard G. Parker

In July 2015, Marni Sommer and colleagues published "Comfortably, Safely, and Without Shame: Defining Menstrual Hygiene Management as a Public Health Issue," hereafter "Defining MHM," in American Journal of Public Health. The authors discuss that growing interest in the gender gap in education raised awareness about girls’ obstacles to managing menstruation, especially in low-income countries. Increased focus on MHM pushed menstruation to be redefined as a public issue rather than a private one. That transition made MHM the responsibility of national governments instead of just the responsibility of young girls, because it became more widely recognized that girls could only appropriately manage menstruation if they had access to the necessary resources through public infrastructure. "Defining MHM" outlines how defining MHM as a public health issue brought much-needed attention to the obstacles to MHM young girls face and emphasizes that other underrepresented public health issues could use similar tactics as the MHM movement to gain global attention and funding.

Menstruation, also called a period, is a process in which endometrial tissue, or tissue lining the inside of the uterus, and blood are expelled from the uterus through the vagina every twenty-eight days, though every twenty-one to forty days is also normal. Menstrual hygiene management, or MHM, is especially important for menstruation. The World Health Organization, or WHO, and United Nations International Children’s Emergency Fund, or UNICEF, define MHM as women and girls having private access to clean sanitary pads, tampons, water, and sanitation and hygiene facilities, as well as knowledge of why and how menstruation happens. Women and girls in low income-countries have less access to MHM necessities due to factors like poor infrastructure and stigmatization of menstruation, or the societal viewing of menstruation as taboo, which can result in girls getting teased for discriminated against for menstruating.

Sommer and colleagues collaborated to write "Defining MHM" at Columbia University in New York City, New York. Sommer, the primary investigator, earned her Bachelor of Arts degree in history and French from the University of Pennsylvania in Philadelphia, Pennsylvania, in 1994. She became particularly interested in global health after a trip to Eritrea with the Peace Corps following her graduation from university in 1994. In Eritrea, she witnessed many girls drop out of school due to the shared difficulty of managing their periods without access to adequate resources. In 2001, Sommer received master’s degrees in public health and nursing from Johns Hopkins University in Baltimore, Maryland. Next, she pursued a Doctor of Public Health degree at Columbia University. As of 2021, Sommer is a public health researcher at the Mailman School of Public Health at Columbia University alongside her colleagues Jennifer Hirsch, Constance Nathanson, and Richard Parker, who helped author "Defining MHM." Hirsch and Parker both study constructions of gender and sexuality and how they affect health issues like the spread of human immunodeficiency virus, or HIV, a sexually transmitted, infectious disease. Nathanson’s expertise is in public health policy and politics, and she specifically researches social inequalities associated with public health.

"Defining MHM" is a review article that summarizes the history of how MHM became a public health issue and emphasizes the importance of it being viewed as a public health issue in improving menstrual health outcomes for women and girls in low-income countries. To analyze the transition from private to public, Sommer and colleagues utilize the former work of Joseph R. Gusfield, who researched sociology in the late twentieth century. In his 1981 book The Culture of Public Problems: Drinking-Driving and the Symbolic Order, Gusfield discusses the differences in outcomes for treating alcoholism when it is seen as a private versus a public issue. He explains that if society perceives alcoholism as a private issue, then the blame for it is placed on the individual. However, Gusfield argues that redefining alcoholism as a medical issue places responsibility on other actors such as medical institutions, the automobile industry, and governments to decrease its prevalence. Using Gusfield’s framework, Sommer and her colleagues explore how menstruation was once a private issue but started to be understood as a public health issue after public health researchers began to publish literature about obstacles to MHM in low-income countries in 2006. Those publications helped influence nongovernmental and grassroots organizations to promote better MHM outcomes in those countries. Sommer and colleagues explain that the interest of those stakeholders shifted MHM from a private to a public issue.

"Defining MHM" is divided into seven sections. In the introductory section, the research team states that their purpose for writing "Defining MHM" was to review the history of how the public began to see MHM as a public health issue in low-income countries. Next, in "The Historical Dimensions of the MHM Agenda," Sommer and colleagues describe MHM’s rise as a public health issue, noting that attention to the gender gap in education brought attention to MHM. In "Cultural and Structural Dimensions of Attributions of Responsibility for MHM," the authors adopt Gusfield’s framework to understand the implications of perceiving menstruation as a private issue. Then, in "Evidence and Advocacy for Bringing MHM into Focus as A Public Problem," the authors describe how MHM has become a public health issue in recent years. The fifth section, "Cognitive Beliefs, Moral Judgments, and Alternate Framings of MHM," explores how grassroots organization and social media in high-income countries helped to shift social and cultural views of menstruation and bring attention to MHM in low-income countries. Next, in "Political Responsibility and Ownership of the Menstruation and MHM Issue," the authors refer to Gusfield again to explore how framing MHM as a public health issue has placed responsibility on governments to play an increased role in implementing MHM in low-income countries. In the conclusion section, Sommer and colleagues express that continued partnerships between stakeholders and aid from political entities are important for implementing and maintaining proper MHM in low-income countries.

In the introduction, Sommer and colleagues state that in the ten years before the article’s publication, researchers, nongovernmental organizations, and large institutions began to see MHM as a prevalent public health issue. During that time, public health researchers, nongovernmental organizations, feminine hygiene companies, and other stakeholders had been raising awareness about lack of resources and menstrual-related stigma, particularly in low-income countries. Given that trend, the research team states that the purpose of "Defining MHM" is to establish how MHM became widely recognized as a public health issue in order to gain useful insights that public health professionals could use to draw attention to other under-recognized health concerns.

Next, in "The Historical Dimensions of the MHM Agenda," Sommer and colleagues acknowledge that menstruation is often stigmatized or ignored in many contexts, but highlight how women and girls in low-income countries face added difficulties in managing menstruation. The authors point out that menstrual etiquette, which encourages girls to keep menstruation a private matter, is a shared experience between girls in high- and low-income countries. However, the authors recognize a discrepancy between the ability of girls in high- and low-income countries to practice proper MHM. In high-income countries, girls generally have access to the resources they need to manage their menstrual cycles in private and education to learn about menstruation. However, in low-income countries, those resources are not readily available. Specifically, Sommer and colleagues point out that low-income countries often lack clean water, private sanitation and hygiene facilities, affordable feminine hygiene products, and menstrual education. The authors explain that MHM was not considered a public health priority in part because public health researchers often perceived inadequate MHM in low-income countries as unavoidable. Additionally, according to the authors, policymakers in low-income countries often overlooked the unique needs of menstruating women and girls. However, beginning in 2004, the authors note that a global movement became interested in addressing the gender gap in education. As a result of that movement, several nongovernmental organizations began to focus on the menstrual-related challenges that hindered girls from attending school.

Continuing in "The Historical Dimensions of the MHM Agenda," Sommer and colleagues note that attention to the gender gap in education began to draw attention to MHM as a public health issue. The research team draws attention to draw a number of early examples of nongovernmental organizations and large institutions like the Rockefeller Foundation’s interventions to address MHM in low-income countries. For example, in 2006, Procter & Gamble, a company that makes various personal hygiene products, supported puberty training sessions for girls in low-income countries. Those sessions were often the only source of information regarding menstruation for those girls. However, despite early interventions like Procter & Gamble’s, the authors point out that the public health sector still paid minimal attention to MHM until several years later.

In "Cultural and Structural Dimensions of Attributions of Responsibility for MHM," the authors adopt Gusfield’s framework to understand the causes and consequences of perceiving menstruation as a purely private issue. The authors explain that because many schools in low-income countries were built at a time when girls could not pursue an education, they are rarely constructed to accommodate girls during menstruation as the schools were not designed with girls in mind. Likewise, the authors point out that there are few women in positions of political power in low-income countries to advocate for MHM. The authors note that those two factors have reinforced the sentiment put forth by cultural stigmas that menstruation is a private matter. Sommer and colleagues explain that because menstruation has often been viewed as a private matter rather than one that should be publicly addressed, public health researchers have tended to ignore inadequate MHM in low-income countries.

Then, in "Evidence and Advocacy for Bringing MHM into Focus as A Public Problem," the authors describe that as attention to the number of girls dropping out of school increased, so did attention to MHM in low-income countries, which helped redefine menstruation from a private matter to one of public concern. Sommer and colleagues indicate that in 2006, public health researchers increasingly began to study obstacles to achieving adequate MHM in low-income countries. Specifically, those researchers were concerned with addressing how obstacles to MHM affected girls in schools. Sommer and her colleagues state that the publication of those studies in academic journals began to draw more attention to MHM among researchers and organizations.

Moreover, Sommer and colleagues note that growing partnerships between stakeholders helped redefine menstruation as a public issue. Institutions like Procter & Gamble sponsored studies about girls’ obstacles to managing menstruation in schools. Procter & Gamble also partnered with Save the Children, a nongovernmental organization that works to improve children’s quality of life across the world, to provide education related to menstruation and sanitary pads to girls in Nepal and Ethiopia. Partnerships between institutions and nongovernmental organizations like that one brought needed resources and attention that helped frame MHM as a public issue. By 2010, MHM became a widely utilized term. The authors indicate that the specific inclusion of the word "hygiene" brought more attention to the issue among public health officials because it linked MHM to larger public health issues of clean water and sanitation. Due to that increased attention to girls’ struggles with MHM in schools, according to Sommer and colleagues, people began to advocate that it was the responsibility of schools to provide education and resources to menstruating girls.

The fifth section, titled "Cognitive Beliefs, Moral Judgments, and Alternate Framings of MHM," explains that, in high-income countries, grassroots organizations and social media have help to shift social and cultural views of menstruation and increase attention to poor MHM in low-income countries. Sommer and colleagues discuss how grassroots organizations, such as Days for Girls, an organization that provides girls with reusable sanitary pads, intervened to provide sanitary pads for girls in low-income countries. According to the authors, the use of social media to spread stories about grassroots projects along with girls’ menstrual stories helped bring attention to menstrual issues and mobilize support for improved MHM. Specifically, Sommer and colleagues claim that girls’ stories of being shamed because of their periods or lacking access to feminine hygiene products invoke an emotional response from people in high-income countries. The authors argue that because menstruation is a shared experience between women and girls, news articles that share the struggles of menstruating girls could increase discussion about MHM.

Next, in "Political Responsibility and Ownership of the Menstruation and MHM Issue," the authors explain that as attention on MHM as a public health issue grew, governments were increasingly seen as responsible for providing access to puberty education, private and clean water, sanitation and hygiene facilities, and feminine hygiene products necessary for MHM. Sommer and colleagues cite WHO and UNICEF’s decision to include MHM as a global advocacy issue in 2015 as an important event that built support for public responsibility of MHM. Additionally, Sommer and colleagues discuss a set of guidelines for puberty education for governments around the world to implement published by the United Nations Educational, Scientific, and Cultural Organization, or UNESCO. The authors explain that those guidelines pressured the global education sector and national governments to address MHM. However, the research team maintains that governments cannot be the only entities responsible for public health issues. Especially in the case of MHM, Sommer and colleagues acknowledge that social and cultural views of menstruation that perpetuate stigma pose obstacles that may be beyond governmental control.

Finally, in the "Conclusions" section, Sommer and colleagues conclude that partnerships between stakeholders and aid from political entities, including the United Nations and national governments, were integral in mobilizing action to address inadequate MHM in low-income countries. However, the authors maintain that there is still much work to be done to fully address barriers to MHM. At the time of the article’s publication, fifty percent of schools in low-income countries lacked access to clean water, sanitation, and hygiene facilities. The authors argue that the continued lack of resources in low-income countries demonstrates that MHM continues to be an issue despite increased recognition.

As of 2021, "Defining MHM" has been cited one hundred and fifty-seven times, often in the context of specific MHM-related interventions in low-income countries. In 2017, Sommer went on to create the "MHM in Emergencies Toolkit," or the Toolkit, for humanitarian organizations to utilize in emergency settings like refugee camps. During that year, Sommer piloted the Toolkit in refugee camps in Tanzania. The Toolkit served as a guideline for humanitarian organizations to identify the specific needs of the refugee camps and implement adequate MHM.

"Defining MHM" shows how reframing MHM as a public health issue helped bring global attention to the challenges young girls in low-income countries face in managing their menstrual cycle. The authors emphasize that the lessons learned from the transition of MHM being considered a private to a public issue could be vital in getting other underrepresented issues to a global stage.