Written by: Abigail Goh
Edited by: Jesie Randhawa
Illustrations by: Davida Eyam-Ozung
Design by: Angelina Gan
Globally, 4.2 billion people still do not have basic sanitation facilities such as toilets or latrines, and nearly 60% of the world’s Open Defecation (OD) occurs in India alone. Other developing countries also face similar challenges when tackling the problems surrounding clean water, sanitation and hygiene which can be referred to as WASH. Cities in India and other countries such as China, Indonesia, Nigeria continue to grapple with the task of expanding basic sanitation services to their rapidly growing population, whilst concurrently building a sustainable service delivery model. Lack of sanitation availability has widespread consequences, but it is clear that men and women have specific sanitation needs, access and utilisation patterns as well as experiences. Whilst both genders are badly affected by poor sanitation facilities, women and girls are found to be particularly more vulnerable.
The 19th of November is World Toilet Day. To raise awareness, representatives from Women Unbounded (WU) learnt more about how women are disproportionately affected by WASH issues from the founder of the World Toilet Organisation (WTO), Mr. Jack Sim. The WTO has worked long and hard to bring awareness to WASH, and WU wants to promote their work as they take intersectionality into account when providing solutions/advice to communities, governments and transnational entities such as the United Nations (UN). WTO’s Rainbow School Toilet Initiative (2015) in China is one of many projects that have impacted young girls to stay in school, in a hygienic and safe environment. This year marks the WTO’s 20th anniversary, and their work towards WASH accessibility is extremely encouraging (please find out more here).
The following blog-piece and interview will elucidate how specific gender-based WASH problems impact women and girls making them vulnerable to: dropping out of school early, loss of dignity, the increase of health concerns, and risk of safety (i.e. rape and harassment).
The consequences of poor sanitation have devastating effects on human health, the environment, education and the economy as a whole. When waste travels into open sewers and public areas/water bodies, the spread of diseases such as diarrhoea, cholera, tropical enteropathy becomes more likely. CDC (Centres for Disease Control) reports the shocking fact that diarrhoea kills approximately 2,195 children daily, which is more than AIDS, malaria and measles combined. Alongside the waterborne diseases that are inflicted upon developing countries, gender-based sanitation problems surrounding menstruation, education, nutrition, gender-based violence and psychosocial wellbeing needs to be confronted.
Menstrual hygiene management (MHM) stands for equity, human rights, health, and environmental issues which is closely linked to sanitation. Poor sanitation facilities undermine girls’ and women’s ability to manage their menses, which leads to poor maintenance of personal hygiene. This entails inadequate privacy, water, toilet, hygiene amenities to change, as well as to wash, dry and dispose of used menstrual absorbents.
Moreover, MHM is a factor in school enrolment and retention, specifically in secondary and higher education. The difficulty for girls to manage their menses in school discourages attendance, causing education schemes to decline. According to the Speaker of the Andhra Pradesh Legislative Assembly, Dr Kodela Rao, 'health expenditure due to poor sanitation wipes off 2-3% of the State Domestic Product and 7 out of 10 girls drop out of schools with no toilets’.
Organisational reports and anecdotal evidence suggest that sanitation has major nutritional impacts, causing women and girls to control food and water intake in order to minimise defecation and urination in a day. Intake is limited to certain times in a day so that OD and urination can occur at night or early morning when toilet facilities are unavailable. These practices harm female nutritional status and increase the likelihood of urinary tract infections (UTIs), constipation, and further urogenital and gastric problems. Given the nutritional needs during pregnancy and adolescence, such problems are particularly important to these stages of life.
Gender-based violence, occurs more often when there is poor sanitation access, due to physical vulnerability with a lack of privacy and protection. OD practices increase the risk of harassment, rape, attack and murder for many women in developing countries. Other security measures are lacking with poorly made facilities, making them unsafe due to lack of locks on doors and adequate lighting.
'Other marginalised groups, such as transgender or disabled people, also experience harassment or assault when using toilets – their specific needs must also be taken into consideration.'
According to a senior police official in Bihar (India), approximately 400 women would have escaped rape in 2013 if they had toilets in their homes. Lastly, the psychosocial effects and induced trauma correlated with OD creates a negative experience of toilet use which is extremely damaging. Women and girls in these circumstances express concern over stigma and discrimination, due to their experiences of violence, harassment or being seen openly defecating or urinating. Such incidences lead to post-traumatic stress disorder (PTSD), stress, anxiety, fear, low self-esteem, and disgust. Given the social and cultural context in India, women and girls have the fear of blame for being assaulted or accused of being unfaithful and consequently disowned by their husband and/or families.
The risk of contracting COVID-19 during the current global pandemic increases with poor sanitation and access to a toilet. Hand-washing and clean drinking water are essential to stop the virus from spreading. Amar Habib (a community leader) explains the part of the reason COVID-19 has badly affected rural India is that there isn’t ‘...enough water to keep washing their hands throughout the day’. Moreover, women and young girls are the primary caretakers of the sick in the household and in medical facilities, which puts them at a greater risk for contracting the virus.
Gender-responsive Policy (macro-level)
Using India as a case-study, the following is an example of how gender-neutral policy can be extremely harmful. Additionally, policymakers have been called upon to revise their resolutions specifically regarding sanitation policy with India’s SBA, but also the World Bank-funded ‘Slum Sanitation Program’ (SSP).
RTI International states the setbacks of SBA, as the policy does not make mention of sanitation needs specific to women and girls. This means the policy does not even make mention of MHM especially in the context of sanitation infrastructure and solid waste management for urban areas.
The RTI policy brief also recommends the following:
Policy documents to advocate for gender-related research on sanitation practices and preferences at an urban/rural level to inform policy and program initiatives
Include the disposal of menstrual waste products in solid waste management plans
Spread awareness about actions that respond to women’s sanitation needs and gender-responsive sanitation solutions through public awareness campaigns
Ensure women’s participation in the design of the community, public and household toilets
Implement monitoring and evaluation plans to evaluate facilitates, use patterns, and educational impacts for men and women
Monitor frameworks in policy documents to include gender-responsive indicators disaggregate data by sex
Gender-based Power Dynamics (at the micro/household level)
Alongside gender-responsive policy awareness in government, the reshaping of power dynamics at the household level would aid in the solution to this global health issue in India. Women’s participation at the household level would encourage and improve the need for privacy in order to avoid gender-based violence and psychological effects on mental health.
For example, budget/subsidy toilets built under SBA should ensure privacy needs with a proper door, roof and enclosures. The lighting and location of these toilets should also meet the bathing, cleaning and menstruation needs of women and girls. Lack of ‘voice’ and decision is a powerful influence in toilet construction and usage in households by women. A study in Nepal emphasised the significance of including both men and women and addressing gender relations in decision making. This caused sanitation coverage to increase by two times in poor households in villages where men and women were both involved, in the health intervention training programme. This is a key factor which if implemented in the SBA effectively can improve access to and consistent utilisation of toilet facilities.
In an article by Tina Khanna, ‘Why gender matters in the solution towards safe sanitation?’, Khanna explains that the perceived gender gap for safe toilets did not have an economic constraint. Women’s lack of control over the household budget does influence spending on toilet construction, as toilet construction is not a large priority for men as they have fewer restrictions and household sanitation responsibilities. The article expands that men have easier access to open fields and do not have to deal with many of the same issues, and therefore were less responsive towards the challenges women face while going out for OD. Khanna argues that it is important to reaffirm the need for a review of sanitation programmes and policies from a gendered lens in order to address the differential sanitation needs of women and girls. Her research, therefore, illuminates certain directions for further action between policy, practice.
The adverse effects of poor sanitation facilities which target women and girls in particular need to be tackled through sanitation policy and programming. Successful policy must ensure that effective sanitation facilities and services are designed to account for the gender-specific needs addressed above. Challenges which governments and organisations continue to face in 2020 stem mainly from three structural constraints: poverty, inadequate sanitation policy and its implementation, and gender-based power dynamics at both the policy/societal and household level. These structural constraints are the key factors that are limiting toilet construction and use.
This piece and interview emphasises the relevance of engendering sanitation policy and programs, as the involvement of women and girls in processes will lead to sanitation solutions across the board. Although the proposals require a larger budget to strengthen sanitation infrastructure effectively, solutions to the gendered issues simply begin with awareness. Awareness of the difference in the experience of men and women with toilet use is where the solutions begin, through movements such as #WeCantWait and World Toilet Day. By addressing gender power relations, health, education, and environmental crises can be avoided, saving millions of lives.