In her 20 years of researching menstrual health, Chris Bobel has run across a lot of myths — that menstruation makes a girl unclean, that menstrual pain isn't as bad as women claim.
But she has also seen a lot of myths spread by the very people seeking to fight those misconceptions.
That is what she explores in her new book, The Managed Body: Developing Girls and Menstrual Health in the Global South. Bobel finds that a surprising amount of misinformation is fueling the work of charities and nonprofits in the menstrual health sector.
The goal for many of these organizations is to fight the stigma and negativity surrounding periods, especially in low- and middle-income countries, says Bobel. The idea is that if menstruation is seen as a neutral bodily function rather than something to be ashamed of, girls can be more confident and society will treat them more equitably.
"Stigma compromises healthy engagement with one's body. It undermines self-care, critical thinking and informed decision-making. It also hurts self-esteem and social status," says Bobel.
In recent years, Bobel, an associate professor of women's, gender and sexuality studies at the University of Massachusetts, Boston, says a major movement has emerged to support these girls.
But some of the activists' efforts have been misguided, says Bobel. "While these [groups] are busting [some] myths about menstruation, they're perpetuating other myths," she says.
Here are some of the misconceptions about menstrual health that Bobel investigates in her book.
Myth 1: Girls in Africa skip school during their periods
It's a popular claim that Bobel has seen used by nonprofits like Save the Children and Plan UK over and over in policy documents, advertising and fundraising materials: One in 10 girls in Africa doesn't go to school during her period because there's no safe place, like a clean bathroom, to change pads.
Menstrual health researchers are dubious, says Bobel. Africa is a huge continent with 54 countries. It would be hard to do a study at that scale. And to Bobel's knowledge, there has not been a continentwide assessment.
The misconception about skipping school has been attributed to a 2006 UNICEF document and is sometimes also attributed to UNESCO, Bobel writes in her book.
In 2016, the fact-checking group Africa Check investigated the statistic. A representative from UNESCO told Africa Check that "no one knows where this number comes from." Bobel herself tried to find the UNICEF document but could not locate it.
And how do the groups respond to her assertion? Jeanne L. Long, a senior specialist in school health and nutrition for Save the Children, told NPR: "We don't use that statistic anymore and discourage our country programs from using it in proposals because it undermines [the menstrual health movement's] legitimacy. However, it does crop up occasionally [in Save the Children literature] ... because it is a UNICEF citation."
When NPR asked Plan UK why it still uses the statistic, the group credited it to UNICEF.
"The citational practices revealed here, ranging from the total omission of a reference to an egregious misattribution, are fishy, though certainly not conspiratorial," writes Bobel.
She understands why: It seems to make sense, and [nonprofits] "do not feel compelled to dig beyond what 'feels right' or 'feels true,' " she writes.
Myth 2: Cloth pads are not good for menstrual hygiene
Bobel has observed that menstrual health advocates are pushing for girls in the developing world to use single-use menstrual products like disposable pads instead of cloth pads.
Some groups, for example, fund projects to give out free disposable pads. Some manufacture inexpensive pads using local materials. Others look for ways to distribute these pads more widely across the developing world.
Bobel doesn't doubt that disposable sanitary pads are more convenient and absorbent than cloth pads, which must be washed and dried between use. In some places, it can be hard to find clean water and soap to wash the cloth with or to find a private, sunny place to dry the cloths, writes Bobel.
But she questions the assertion by menstrual health advocates that unsterilized cloth pads can lead to infections.
For example, a 2008 document from UNICEF asserts: "One in three girls fail to change their cloths frequently or wash them with soap after use. ... Low standards of menstrual hygiene lead to widespread vaginal and urinary infections."
There is no causal link between using cloth that has not been properly washed and dried and these infections, writes Bobel. "We don't have data that verifies that assumption," she writes.
Bobel believes that the best strategy is to teach girls to properly clean and care for these cloth pads. That may make more sense than pushing them to rely on disposable pads, which may be expensive and hard to obtain.
"If cloth is changed when needed and properly washed and dried, it can be a suitable menstrual care option," Bobel writes.
What's more, says Bobel, the anti-cloth rhetoric is the opposite of what menstrual health activists in the West are championing: environmentally friendly and organic menstrual products like reusable cloth pads.
Myth 3: A great number of girls use primitive materials such as sand and ash to absorb their periods
A widely cited statistic comes from a 2010 study by the Nielsen Corp., a market research company. It says that 12 percent of India's 355 million menstruating women use sanitary napkins and 88 percent use cloth. "No other absorbent is mentioned," Bobel notes.
Yet when some advocacy groups refer to the report, they say that the women not using sanitary napkins are turning to such alternatives as rags, sand, ash and wood shavings.
"There are certainly anecdotes in dire poverty and emergencies where women need to use what they need to use," she says. That includes toilet paper and socks, which Bobel has used herself in a pinch. "But generally speaking, it's cloth," she says, referring to the most common alternative to disposable pads.
A lot of what's perpetuating these misquotations is the "shock and awe" factor, says Bobel. She believes that nonprofits like to share shocking anecdotes like these to make donors feel a sense of urgency and desperation to help.
Myth 4: Menstrual products are the answer to the menstrual crisis
Disposable and cloth pads, menstrual cups and tampons are not the solution to the menstrual crisis, argues Bobel in her book. "They manage the body, but they will not erase stigma," she says.
What's more, nonprofits that tout products as a solution are only "priming the pump" for manufacturers of commercial menstrual products to swoop in, she says.
"Eventually, [products] will let you down. Your flow will change; you'll leak and you'll be soaked in shame," she says. "Until we make menstruation neutral — something that doesn't challenge someone's respectability or likability — it doesn't matter what we provide people."