Hi Froggi,

It has been a while since this post and discussion on the sensitivity of the inclusion discussion in conservative cultures. I think the research team went about things the right way and your response really got me thinking... Are we doing enough for the WASH and Menstrual Health Management needs of minority LGBTQ groups within culturally conservative contexts? 

I wonder whether there are interventions out there that are looking into this and taking action. Would be glad to hear from them, what these interventions look like and what challenges they face.

Best,
Chaiwe

Hi Chaiwe,
Thank you for asking for more details!
I was impressed by the approach the team settled on for the final survey instrument: they thought carefully about their respondents and how to leave room for this possibility without confusing or alienating the respondent.  The questionnaire was delivered orally by the field team and followed a specific order:
"Can you tell me the number of each of the following in your house?:
Men over the age of 18 ___
Women over the age of 18 ___
Boys age 5-17 ___
Girls age 5-17 ___
Boys under 5 years ___
Girls under five years ___
Is there anyone else in the household not covered in this list? ___"
That gave people the opportunity to add an "other" response if applicable, without creating awkwardness for folks who aren't familiar with the concept, with a universal script.

Thank you Elisabeth for starting a very thought-provoking discussion. 

As someone coming from the Global South, Zambia, Sub-saharan Africa to be exact it would be an injustice not to add my thoughts and opinion to this discussion. I particularly want to address the following comments and i quote: 

Elisabeth wrote:

My question to people from around the globe is: how does this conversation sit with people in other cultures, such as developing countries, predominantly Muslim countries and so forth. I'm wondering if you might feel that we (Britta and I) are in a bubble of American liberal Western speech and are dealing with "luxury problems"? 

For most countries within Sub-saharan Africa, It is deeply engraved in the culture, religion, and law that only Male and Female are recognised as appropriate pronouns to describe one's sex and homosexuality or other non-heterosexual orientations are illegal and punishable. Therefore, even though pockets of people are adapting to what is termed the 'western agenda' to redefine the current laws and norms, it is certainly something that is still very much frowned upon.  The term Menturating Person in itself sounds quite harmless and does not immediately raise any eyebrows unless someone explicitly mentions the connotation and intention behind it, which is of course inclusiveness. Without a doubt, this is then bound to raise dust in this part of the globe.

Froggi Wrote:

After building a template for a household survey, the original drafting team (investigators and project manager of Northern origins, one of whom was living in the Southern area of research) debated whether to include an "other" category for gender.  For fear of confusion and/or alienating the respondent population, we left it off.  When our Southern collaborators began editing the draft, one of the first comments was that we needed an "Other" category.  I was grateful for this learning experience, which challenged my North/South assumptions.  

I think you were right in assuming that adding the category 'other' would confuse/ alienate some of the respondent population that are aware of what this category really represents.  Especially for those that take notice and understand the intention behind adding that particular response. If you had maybe probed your Southern collaborators a bit more with respect to the respondent's awareness and understanding/ acceptance of the category 'other', I can imagine you would have probably gotten a very different response depending also on who the target respondents were. I would love to learn and I am quite curious... during the delivery of the questionnaire, did the translators/ enumerators explain clearly what they meant by 'other' and what was the general reaction of the population? 
It sounds somewhat 'sneaky' to me... adding 'Other' to that question to unsuspecting respondents can go undetected if not elaborated/ explained, considering many of the questions within the questionnaire probably have the option 'Other' and this is often open-ended. However, it could also be as strategic as asking someone who is suspected to have been abducted to give a signal in a subtle way if they need your help.  

Regards,
Chaiwe

There's a new publication out that is relevant for this thread. It cautions against pushing for terms such as "menstruators", "people with a vagina" and alike in the context of menstrual hygiene management in the Global South:

Effective Communication About Pregnancy, Birth, Lactation, Breastfeeding and Newborn Care: The Importance of Sexed Language
www.frontiersin.org/articles/10.3389/fgwh.2022.818856/full

I copy a paragraph from the paper which I think is interesting in our discussions about decolonising the WASH sector, as it argues that desexed language (i.e. terms like "menstruators" instead of menstruating women) can be seen as "cultural and linguistic imperialism":

Cultural Imperialism in Global Public Health
As previously explained, the impetus to desex language in relation to female reproduction flows from a philosophy developed in the USA and within which American understandings and priorities predominate ( 147 ). In the context of global public health, an increasing encouragement, or requirement, to desex language by international organizations or funders based in the USA/the West may be experienced not only as confusing but also as cultural and linguistic imperialism ( 148 ,  149 ). This view was recently expressed by over 250 breastfeeding counselors from 45 countries to the Board of the USA-based breastfeeding support organization La Leche League who stated that changes in language requirements were being experienced as “colonialist” and “oppressive” ( 150 ). Organizations and individuals have a responsibility to avoid imposition of Western ideas that may cause harm to those with whom they work 4 . In addition, the risks associated with desexing language should be carefully considered with an impact assessment undertaken, even where the concept of gender identity holds cultural salience.

Regards,
Elisabeth

Thank you to everyone here for your insights!  

To build on the above posts, I will share a small anecdote from my 2019 field research in a country in the global South:
After building a template for a household survey, the original drafting team (investigators and project manager of Northern origins, one of whom was living in the Southern area of research) debated whether to include an "other" category for gender.  For fear of confusion and/or alienating the respondent population, we left it off.  When our Southern collaborators began editing the draft, one of the first comments was that we needed an "Other" category.  I was grateful for this learning experience, which challenged my North/South assumptions.  

Among my acquaintances in the North are numerous people who identify as male or nonbinary, and who menstruate.  I appreciate seeing increasing use of the terms "people who menstruate" or "people with a uterus", as clear alternatives to gender-specific language for menstruation.  I find that both terms translate easily across languages and cultures; while one might consider them awkwardly wordy, nobody finds them confusing.  

Hi Elisabeth, 

In response to your comment: 'A lot of our members in the SuSanA Discussion Forum are from developing countries / Global South (about two thirds, see  here  ). I fear they don’t speak up about this but might silently find it very strange?' I wanted to raise the point that we know many countries have groups who identify using terms loosely translated as 'third gender', including India, Nepal, Bangladesh, Pakistan and Indonesia. While taboo in many countries (and illegal in some countries), perhaps the conversation is more familiar than we might assume.

Water for Women and Edge Effect produced a Guidance Note  (PDF) last year explaining how sexual and gender minorities were more likely to be left behind in COVID-19 WASH responses and recommend more inclusive messaging. 

For the Sanitation Learning Hub, we have recently committed to using the phrase 'people who menstruate' in an effort to be more inclusive of groups who may be marginalised. You can read more about it in my blog .

Thanks,

Alice

Thank you, Britta, for these very informative blog posts that challenge our traditional thinking.

My question to people from around the globe is: how does this conversation sit with people in other cultures, such as developing countries, predominantly Muslim countries and so forth. I'm wondering if you might feel that we (Britta and I) are in a bubble of American liberal Western speech and are dealing with "luxury problems"? 
 
A lot of our members in the SuSanA Discussion Forum are from developing countries / Global South (about two thirds, see here ). I fear they don’t speak up about this but might silently find it very strange?
 
Secondly, I wonder what percentage of trans men do menstruate. Is there an estimate for that in the literature? It might be regarded as an insensitive question. Like saying if it’s only 1 person per 1 million then why bother. But I don’t mean it like that. I am just curious. It might be more people than ordinary people realise (or it might be less). I’ve also written about that on the Wikipedia article’s talk page for “trans men”, see here .

Regards,
Elisabeth
 

We at Vulvani try to be as inclusive and gender-sensitive with our language as possible and thus prefer using terms like menstruators, menstruating people or depending on the context people with vulva / uterus. From our perspective, inclusion is important for everyone, but above all for people who find themselves outside the binary gender system. Our vision at Vulvani is to create a safe space for everyone who is experiencing menstruation at some point in their life and to learn about their own body - independent of gender identities. 
Here are two articles we've published on Vulvani about the topic, if you want to learn more about our perspective: 
-  Why are we using the term ‘menstruating people’?
-  Including the Men in Menstruation: Trans Periods & Branding 

Have you also noticed that the term "menstruator" is popping up more and more in publications about menstrual health and hygiene? How do you feel about that? Well, I was a bit confused so I did a bit of reading and thinking. Once I felt that I have figured it out (more or less), I put it in Wikipedia to summarise my learnings and to help others in their journey.

See here: en.wikipedia.org/wiki/Menstruation#Menstruator

Menstruator
A publication in 2020 makes the case for using the term "menstruator" instead of "menstruating women", stating that this term has been in use at least since 2010. ^{[21] :950} The term menstruator is used by activists in order to “express solidarity with women who do not menstruate, transgender men who do, and intersexual and genderqueer individuals”. ^{[21] :950} However, referring to people who menstruate as "menstruators" has also been criticized, and this is related to a more general debate within  feminism . ^{[21] :950}

Further up on the article we now also have this information:

Who menstruates
In general, women may menstruate after they have started menarche and until the time of menopause. Women who do not menstruate include:  trans women ,  postmenopausal  women,  pregnant  women, and those experiencing  amenorrhea . ^{[21] :950} During  pregnancy  and for some time  after childbirth , menstruation does not occur. The average length of postpartum  amenorrhoea  is longer when  breastfeeding ; this is termed  lactational amenorrhoea .

I'd be happy if others could add to that by suggesting other references which explain the concept even better. The way I understand it now is that "not all women menstruate (all the time in their lives)" and not all people who menstruate are women.

I am wondering how this discussion sits with you? Would you say "fair enough" or do you find it liberal & PC talk? Also I am wondering how menstruator could be translated into other languages. For example in German we don't have an equivalent term, and would probably say "menstruierende Person" (= menstruating person) which seems a bit of a mouthful. 

Is this important or unimportant for your work on menstrual health? What are your thoughts?

Regards,
Elisabeth


P.S. We also had a previous short discussion about it here (with Daphne): forum.susana.org/24-menstrual-hygiene-ma...amps-in-greece#31899