By Bharti Kannan, Pratyusha V V
Menstrual hygiene management (MHM) refers to management of hygiene associated with the menstrual process [3]. WHO and UNICEF Joint Monitoring Programme (JMP) for drinking water, sanitation, and hygiene has used the following definition of MHM: ‘Women and adolescent girls are using a clean menstrual management material to absorb or collect menstrual blood, that can be changed in privacy as often as necessary for the duration of a menstrual period, using soap and water for washing the body as required, and having access to safe and convenient facilities to dispose of used menstrual management materials. They understand the basic facts linked to the menstrual cycle and how to manage it with dignity and without discomfort or fear [4].’
The struggle for accessible menstrual hygiene management becomes more challenging for prisons, where women often live away from the comfort of their homes and have to rely on authorities for access to basic water facilities and sanitary products. This problem needs to be addressed, as menstrual hygiene products are a necessity and should never be treated as a privilege.
The Model Prison Manual, 2016 [5] provides for basic minimum standards that must be maintained in prisons. The following series of recommendations are based on the provisions set out in the manual and are prepared to address some of the systemic issues [6] identified regarding menstrual health by the United Nations Educational, Scientific and Cultural Organisation (UNESCO). Further, these recommendations are also guided by visits by representatives of BOONDH and CHRI to women enclosures/prisons [7], interaction with prison personnel and awareness sessions with women prisoners [8].
The below mentioned measures are hereby recommended as the minimum standards that must be met with minimal investment and be adopted within prisons as a means to improve menstrual health and hygiene for women prisoners as well as women prison staff. These standards are also applicable for police stations, and for court lock-ups, as women often spend long durations in custody during arrest or court hearings.
I. Access to Clean Water and Basic Facilities
The Model Prison Manual 2016, provides that sufficient water shall be made available for the use of women prisoners and their children, and those prisoners, in particular, who are involved in cooking and those who are pregnant, breastfeeding or menstruating [9]. The United Nations Rules for the Treatment of Women Prisoners and Non-custodial Measures for Women Offenders (Bangkok Rules) provides that the accommodation of women prisoners shall have facilities and materials required to meet women’s specific hygiene needs, including a regular supply of water to be made available for the personal care of children and women [10].
Cleanliness of the prison toilets and washing areas of women enclosures/prisons are pre-requisites for maintaining good hygiene levels within prisons. Generally, women prisoners carry their own soap to the prison toilets . The landscape of the Water, Sanitation and Hygiene (WASH) infrastructure could evolve further with the following recommendations:
1. Water quality tests to be conducted periodically to assess compliance with minimum standards of water quality, especially water used for bathing and cleaning in toilets as it can have potential consequences to menstrual/sexual or reproductive health. Each source is to be tested twice a year for bacteriological parameters and once a year for chemical parameters with positive detects triggering clear pre-defined interventions [11]. Here it is important to acknowledge that since there is limited evidence to figure if/when/how chemicals have an effect in affecting health/reproductive health through bathing/washing, it is imperative to stick to quality standards described by Ministry of Drinking Water and Sanitation.
2. Adequate water supply must be ensured in prisons. It is recommended to peg this against the minimum standards of water required for basic WASH conditions (30 L per person)[12]. This would help in documenting the quantity of water in conjunction with quality, as a good practice.
3. Accessibility with respect to disabled/ pregnant/ post-natal menstruating women needs to be focussed upon. Based on the type of disability, special tools/modifications ought to be made with respect to water accessibility for the prisoners in order to be able to access, hold, wash toilets and themselves. This is fairly complex and requires contextualized responses within the limited resources [13].
4. A number of warder/s depending on the population of a women enclosure/ prison must be trained to effectively manage the menstrual needs of women prisoners.
5. It is imperative that prisoners are provided with measures for access to hot/cold/lukewarm water based on climatic conditions as that might also assist in managing period pain.
6. Prisons need to uphold the fundamental right to privacy and dignity, for prisoners to be able to use the toilet for ablutions/ bathing/ changing menstrual products with dignity. Each prison needs to take measures based on the current infrastructure, for example, raise the walls of toilets located inside the barracks, provide doors, etc. to ensure segregated enclosures.
7. A soap dispenser should be provided and filled in each wash area to enable better hygiene practices, as the prisoners have to currently carry their own soap to these areas.
8. Clothes lines for drying used and washed underwear/reusable menstrual cloth and other absorbents in sunlight are mandatory, in an area demarcated for the same, such that it also supports discretion. The area should be close to the wash areas yet secluded from line of sight of visitors/others as far as possible, keeping in mind possible fear/shame attributed to drying undergarments.
9. A dustbin with a lid to be provided in all female barracks for disposal of sanitary pads during lock up hours and night. It is observed that during lock up hours, prisoners are to store their soiled disposable pads with themselves and can only dispose the same post the barracks opening during the day time.
10. Provision of an option to procure hair removal cream for those who are habituated to, or those who would prefer in the prison context to groom their pubic hair. Practices around menstruation, comfort and cleanliness is varied and providing a range of menstrual products that assists ease of menstruating is imperative. Pubic hair has the potential to clog together and dry, when menstruating, if not frequently washed, and the option to remove the same is to be respected as one’s choice.
11. For female prison staff, a separate toilet with a lock/privacy enabler is to be provided in all prisons.
12. The change of colour for women convicts’ uniform, which are white sarees/salwar suits can be considered. It may be changed to more earthy/dark shades in a phased manner to ease management of stains.
13. Hot water bags for menstrual pain management are to be treated as a basic measure to help prisoners deal with menstrual cramps (a basic number of hot water bags can be allocated to a prison for prisoners to use on rotation).
14. A regular supply of used and old newspapers to be provided for disposal of pads.
II. Supply Chain of Menstrual Products [14]
One of the minimum standards specified by the Bangkok Rules is to prohibit financial burdening of prisoners for purchasing menstrual absorbents [15]. Ready access to sanitary and washing facilities, safe disposal arrangements for blood-stained articles, as well as provision of hygiene items, such as sanitary towels/pads, are of particular importance. These should be available to women under conditions in which they do not need to be embarrassed asking for them (for example either dispensed by other women or, better yet, accessible whenever needed). The European Committee for the Prevention of Torture and Inhuman or Degrading Treatment or Punishment (CPT) considers that the failure to provide such basic necessities can amount to degrading treatment [16]. This should be read along with the principle of informed choice of products for prisoners keeping in mind cultural, bodily and infrastructural factors that may enable menstrual equity in prisons, ensuring autonomy for the menstruator [17] over their own bodies.
Currently, menstrual products are available for free or at a cost to the prisoners. There is a lack of options. Products being used in prisons are predominantly disposable pads and cloth. The scope for these products is wider and includes cloth pads [18] which may or may not require underwear and menstrual cups [19]. It is imperative for the prison departments to streamline a process to ensure rights for menstruating population. The following are the recommendations with respect to products:
1. A fair and transparent system should be followed by all prisons in regard to procuring and supplying menstrual products.
2. According to the Model Prison Manual 2016, toilet articles and menstrual products including sanitary towels (procured through tenders issued by the Prison Department) are to be made available free of cost to the prisoner.
3. During admission, a menstrual kit including sanitary pads/a choice of preferred products, panties/underwear (of varying sizes for different body types: S, M, L, XL) must be immediately provided for new entrants as women prisoners may not have contact with family, to enable supply of these basic amenities..
4. Providing a range of product options that reduce the financial and environmental burden of disposable sanitary pads is a growing discourse in the menstrual health space. During discussions with prisoners and staff alike, adding menstrual cups, cloth pads, cloth pads that don’t necessitate panties emerged as suitable alternatives.
5. With respect to disposable pads, it is imperative that pads of varying sizes and absorbencies with options of wings be provided. This extends to other products as well, including cloth, where the roll of cloth can be cut according to needs/preference.
6. There is to be no limit on the quantum of products one can access to ensure menstrual equity. Sterilised sanitary pads should be issued to women prisoners as per their requirements [20]. The quantity of menstrual pads (Disposable Sanitary Pads) must be medically accepted as a minimum standard of change. Every menstruator should have access to at least 4-6 pads per day of their cycle (varying cycle lengths), making it a healthy practice to change pad/cloth once in 4-6 hours. The same applies to quantum of supply of cloth pieces, 4-6 cloth pieces of a minimum 40 cm X 25 cm of absorbent flannel/jersey cloth preferably sourced in rolls/bales. This should particularly account for the access to washing/drying facilities apart from humidity/rain conditions to enable proper sun-drying of the cloth used as a menstrual discharge absorbent.
7. Regarding standard of products, there is no concurrence internationally, as well as in India, on minimum standards to be met for sanitary pads. There exist no standards for cloth as it isn’t classified as a consumer product. Consensus is that India being an LMIC (Low and Middle Income Countries), the standards for pads need to be higher considering usage patterns, hygiene needs, resources needs, etc. Standards to consider are safety of raw materials, absorbency, retention, bio compatibility, microbial testing, toxicology among others apart from disposal means. Pads are essentially categorized as Grade I Medical Devices and hence vendors who can provide minimum certifications for the same is recommended. Compliance and reference for the same can be the Bureau of Indian Standards (BIS) Standards for Disposable Sanitary Pads in India (IS 5404 : 2019)[21], which lays down the standards for reusable pads (IS 14922) in development, as well as menstrual cups.
8. Consultations with a menstrual product expert to build in a supply chain to pre-qualify a basket of vendors to ensure smooth supply with various options of price point is recommended. Both cloth pads and cups have their own standards of reference for procurement and supply chain.
III. Waste Management of Used Menstrual Products
Safe disposal arrangements for blood-stained articles must be made available to women prisoners [22]. However, the disposal of menstrual hygiene materials is often overlooked, to the detriment of both women and the facilities. Where there are not alternative disposal options, women often dispose of used menstrual materials in toilets. This may stop toilets from functioning, for example, or clog vacuum hoses during de-sludging of septic tanks [23]. Therefore, there is a need to have a regular, sustainable and safe disposal plan, which ensure the following standards:
1. Disposal mechanisms can include incineration or another safe method on-site, or safe storage and collection via a municipal waste system, as appropriate.
2. It is imperative that pads are collected in separate waste disposal bins by covering with newspaper and marking with a red dot also if possible, to enable ease in segregation, and if possible sent to a central incinerating facility/hospital that has the capacity to handle the waste.
3. It is equally important to have a dignified disposal space especially during lock up hours in the barracks for menstruating prisoners to discard their pads which is generally absent. For that, a dustbin with a lid should be provided in all toilets in the female barracks.
4. Complaints of pads being discarded into latrines have to be dealt with by sharing informative material on disposal methods as posters/videos.
5. Incineration Standards are to be prescribed in accordance with WHO standards. Incinerators ought to operate at a functional temperature of over 800 degree C in order to not add toxins that can release as a result of low temperature burning [24], as is not the case with the existent incinerator that is non-functional/semi functional in the prison. Maintenance and upkeep of such a facility in terms of human/monetary resources to be factored in during product procurement.
A menstrual health expert could be consulted for determining the specifics regarding the standards mentioned above.
IV. Reproductive Health of Women Prisoners
During admission, it is important that the reproductive health history of women must be recorded in their medical files to assist with determining any future treatment. Current reproductive health complications should receive the appropriate medical responses without delay. For example, women who have recently undergone abortions, experienced miscarriages or complications during delivery may need urgent medical attention. Those who have recently given birth require post-natal care and, often, counselling related to this circumstance [25]. International standards guarantee the right to medical confidentiality for all individuals, including prisoners. Women may have particular safety and security concerns in relation to their reproductive health history, and therefore should never be coerced into giving information, which they feel may put them at risk. In this context women should have the right to refuse vaginal screening/hymen examination [26]. All women are entitled to treatment and care equivalent to that of community standards for their gender specific health-care needs [27] and therefore the following must be ensured:
1. Only lady doctors shall look after the medical care of women prisoners during their stay in prison. As far as possible a female medical officer must be appointed for women enclosures. If not appointed, efforts must be made to collaborate with the government hospital to ensure weekly visit by a gynaecologist. In case a male medical officer is treating women prisoners, he should be accompanied by a female nurse/pharmacist to not impede menstruating prisoners from accessing medical care for such needs.
2. During admission, every woman prisoner shall be examined by a lady Medical Officer [28]. Part-time lady medical officers of the District Government Hospital can be engaged for medical examination of female prisoners on admission [29]. If a female medical practitioner is not available and a male medical practitioner undertakes the examination, a woman staff member shall be present during the examination [30].
3. Admission forms including NHRC’s Proforma for Health Screening of Prisoners on Admission to Jail [31] must be completed with the medical needs of menstruators in mind. They may be amended to include gender/menstruation specific questions such as:
a. Period regularity
b. Hormonal disorders related to menstrual health
c. Menstrual disorders
d. Anaemia
e. Preference of menstrual product
4. During regular check-ups of women prisoners, the Medical Officer should specifically include checks and redressal/treatment related to the following:
a. Anaemia
b. Sexual Tract Infections (STIs) or Reproductive Tract Infections (RTIs)
c. Yeast/Bacterial Infections
d. Chronic Menstrual Disorders: Dysmennorhea, Ammenorhea, Endometrisosis, Pre Menstrual Dysphoric Disorder (PMDD), Pre Menstrual Syndrome (PMS), Poly Cystic Ovarian Syndrome (PCOS), etc
e. Specific Needs of Disabled Menstruating Populations, more particularly with accessing products, seeking information (tactile/visual/audi-visual)
f. Hormonal disorders
V. Period Tracking and Monitoring
The right of women prisoners to medical confidentiality, including specifically the right not to share information and not to undergo screening in relation to their reproductive health history, shall be respected at all times [32]. In principle, though it is healthy to monitor one’s period cycle and keep a track of when they are to get their next period, in order to be prepared for managing the same with respect to products, medication, travel, etc., one can safely argue that institutional tracking of period cycle can lead to a fundamental violation of dignity and privacy in the name of a voluntary surveillance with implications on how the data can be used/interpreted/relayed with potential consequences to the prisoners’ bodily autonomy. Tracking of periods under any pretext should be stalled with immediate effect. Medical data is sensitive with confidentiality being a tenet to any practice of medicine and this role ought to be taken only by the Medical Officer who visits with the premise of menstrual and reproductive health, more on a case to case basis as part of a regular check-up.
VI. Awareness of Prisoners and Prison Staff
Improving the knowledge, attitude and practice parameters related to menstrual health of prisoners and prison staff is imperative. Women prisoners, typically from economically and socially disadvantaged backgrounds, and often uneducated and illiterate, will generally have received minimal education or awareness-raising about prevention from STDs and reproductive health conditions. It is therefore important to raise the level of knowledge and awareness among women in prison, in order to prevent the development of such diseases. Volunteers, health services from outside and NGOs may be constructively involved in providing such awareness raising and education. It should be undertaken in the following ways:
1. Awareness Camps on various aspects of sexual, reproductive and menstrual health needs of women prisoners to be periodically done once in 6 months. This is to include screenings for cervical cancer and other reproductive tract related infections to be undertaken by a medical practitioner.
2. By means of period awareness sessions (at least 2 times a year) by experts (different from medical camps)
3. By means of Information, Education and Communication (IEC) Material related to various aspects of menstruation which would be put up in strategic places in vernacular languages
4. By means of movie screenings/discussions
An institutional policy to ensure staff awareness and training to recognize symptoms of mental distress must be adopted. This would enable administrators to respond to needs in an appropriate manner, through an increased understanding of women’s need and referring them to specialised support, as necessary (e.g. psycho-social support services, including those provided by specialised organisations of civil society, non-governmental organisations, etc).
VII. Menstrual Enterprises
There have been many instances of pads/cloth pads being manufactured in prisons by prisoners. Building and scaling a sustainable micro enterprise model as a livelihood option is strongly recommended.
In conclusion, it is recommended that the Board of Visitors [33], comprising Official (judicial officers, district administrators, police officers, health officials etc) and Non-official visitors (public spirited individuals including social workers, teachers, doctors etc) as well as Special Rapporteurs from the National Human Rights Commissions, and any other government officials who are mandated to regularly visit prisons, should ensure that facilities for menstrual hygiene are available in all women prisons and enclosures. They must in their reports document the facilities available, any grievances aired by women prisoners in this regard, and suggestions for improvement.
References
[1] Boondh is a social enterprise and non-profit that works on Menstrual Literacy, Policy, Advocacy, Programming, Activism and Sustainable Products. Boondh strives to work towards better gender, health and environmental outcomes, at the intersection of science and society, growing into an organization that can combine research and practicum on interdisciplinary aspects of Menstruation.- http://www.boondh.co/index.php
[2] The Commonwealth Human Rights Initiative (CHRI) is an independent, non-profit, non-partisan, international non-governmental organisation working in the area of human rights, focussing on the themes of Access to Information and Access to Justice, which includes Prison Reforms, Police Reforms and media rights. - https://www.humanrightsinitiative.org/
[3] Menstrual process includes the entire menstrual cycle, from the intial stages of bleeding, luteal, follicular and ovulating phases, accounting for a 28 days cycle (A global average) every year, from menarche to menopause.
[4] WHO/UNICEF (2012) Consultation on draft long list of goal, target and indicator options for future global monitoring of water, sanitation and hygiene. Available at https://washdata.org/file/122/download (last accessed on 18.05.2020) [As cited in Guidance on Menstrual Health and Hygiene, UNICEF. Available at - https://www.unicef.org/wash/files/UNICEF-Guidance-menstrual-health-hygiene-2019.pdf (last accessed on 18.05.2020)]
[5] The Model Prison Manual was approved by the Ministry of Home Affairs in 2016 and sent to all states and union territories for guidance – Available at https://www.mha.gov.in/sites/default/files/PrisonManual2016.pdf (last accessed on 22.05.2020)
[6] The key issues are – accurate and timely knowledge; available, safe, and affordable materials; informed and comfortable professionals; referral and access to health services; sanitation and washing facilities; positive social norms; safe and hygienic disposal; and advocacy and policy.
[7] In India, women prisoners are either confined in women prisons, or in women enclosures situated within male prisons.
[8] This was undertaken in Karnataka and Punjab for catalysing the development of discourse for menstrual needs of women prisoners and women staff in prisons.
[9] Para 26.85, Model Prison Manual 2016
[10] Rule 5, United Nations Rules for the Treatment of Women Prisoners and Non-custodial Measures for Women Offenders
[11] Uniform Drinking Water Quality Monitoring Protocol, Ministry of Drinking Water and Sanitation (February, 2013) – Available at https://phedharyana.gov.in/Documents/UniformDrinkingWaterQualityMonitoringProtocol.pdf (last accessed on 12.05.2020)
[12] The volume specified corresponds to the survival figures for in-patients in therapeutic feeding centres and has been used a reference in this context. Source: The Sphere Handbook. Available at - https://spherestandards.org/wp-content/uploads/Sphere-Handbook-2018-EN.pdf (last accessed on 18.05.2020)
[13] For a compendium of accessible WASH technologies,kindly refer to - https://wedc-knowledge.lboro.ac.uk/resources/learning/EI_Compendium_of_accessible_WASH_Technologies.pdf (last accessed on 12.05.2020)
[14] Menstrual products are those that aid in absorbing or collecting menstrual discharge such as pads, cloths, tampons or cups.
[15] Rule 5, The Bangkok Rules
[16] CPT Standards, European Committee for the Prevention of Torture and Inhuman or Degrading Treatment or Punishment (CPT). Available at - https://www.refworld.org/pdfid/4d7882092.pdf (last accessed on 18.05.2020)
[17] The term ‘menstruator’ is defined in UNICEF’s Guidance on Menstrual Health and Hygiene – “A menstruator is a person who menstruates and therefore has menstrual health and hygiene needs – including young girls, women, transgender and non-binary persons.” Throughout this document, the term ‘women’ is used as a shorthand term to increase readability and refers to all menstruators regardless of gender identity. [Guidance on Menstrual Health and Hygiene, UNICEF. Available at - https://www.unicef.org/wash/files/UNICEF-Guidance-menstrual-health-hygiene-2019.pdf (last accessed on 18.05.2020)]
[18] Cloth pads are pads made of cloth with a single PUL layer at the base to make it leak proof (as disposable pads are made of more than 90% plastic). 3-4 cloth pads per menstruator can be used for 4-5 years, upon careful reuse. It also requires minimum standards of water, Soap, and private space. It produces negligible waste and is a one-time cost in 4-5 years (500-2000 INR).
[19] Menstrual cups are a bell-shaped medical device that fits snugly into the vagina to collect menstrual discharge. A cup can last up to 10 years with a learning curve to usage and proper protocol that requires resources for minimum sterilization, quality and quantity of water, Soap, private space. It produces negligible waste and is a one-time cost (500-2000 INR).
[20] Para 26.67, Model Prison Manual 2016.
[21] Published by BIS for internal use catalyzed by the consultative and policy work undertaken by Menstrual Health Alliance of India (MHAI). Reusable pads and menstrual cups are not currently regulated in India and pioneering work on regulation and in turn standard setting will further assist in decision making of products. Products are currently compliant with standards set by relevant international agencies based on the discretion of companies that sell/manufacture them.
[22] Rule 5, The Bangkok Rules
[23] Guidance on Menstrual Health and Hygiene, UNICEF. Available at - https://www.unicef.org/wash/files/UNICEF-Guidance-menstrual-health-hygiene-2019.pdf (last accessed on 18.05.2020)]
[24] For information on the WHO best practices for incinerations, kindly refer to https://www.who.int/water_sanitation_health/medicalwaste/en/smincinerators3.pdf (last accessed on 12.05.2020)
[25] Rule 6(3), The Bangkok Rules
[26] Rule 8, The Bangkok Rules
[27] Rule 10(1), The Bangkok Rules
[28] Para 26.26, Model Prison Manual 2016
[29] Para 26.25, Model Prison Manual 2016
[30] Rule 10(2), The Bangkok Rules
[31] Proforma for Health Screening of Prisoners on Admission to Jail, NHRC - https://nhrc.nic.in/sites/default/files/Medical%20Examination%20of%20Prisoners%20on%20Admission%20to%20Jail.pdf (last accessed on 18.05.2020)
[32] Rule 8, The Bangkok Rules
[33] Section 59 of the Prisons Act (1894), the State Governments have the powers to make rules for the appointment and guidance of official visitors of prisons. Further, Chapter XXIX of the Model Prison Manual 2016 discusses the composition and duties of the Board of Visitors (BOV). The BOV has the duty to meet periodically and assess the state of the prison, its inmates and management and make recommendations and reports to the administration and higher authority. To know more on the functioning of the BOV in Indian prisons, read our latest report, Looking into the Haze (2019) – https://www.humanrightsinitiative.org/publication/looking-into-the-haze-2019-second-national-report-on-prison-monitoring-in-india (last accessed on 23.05.2020)