The Role of Water, Sanitation, Hygiene, and Gender Norms on Women's Health A Conceptual Framework

Abstract

While the health impact of poor water, sanitation, and hygiene (WASH) conditions on children have been well documented, there has been less focus paid to its adverse impact on women's well-being and health. In this article, I highlight the health burden of water and sanitation insecurities for women by proposing a conceptual framework for understanding WASH-related diseases from a gender perspective, focused primarily on resource poor countries. The framework draws on feminist perspectives to examine how WASH insecure communities constrain women's functionings and capabilities. I identify eight different social–cultural pathways that fall into two synthetic constructs—gendered relations in the household and gendered presentation of the body—because they illustrate how social and cultural norms may burden women and put them at risk of exposure to a variety of WASH-related diseases. I use the critical interpretive synthesis methodology and draw on research from the fields of epidemiology, medicine, and social sciences to develop this conceptual framework that connects WASH-related diseases to gender norms that oppress women. The gender perspective proposed here has important implications for women living under poor water and sanitation conditions and for the WASH sector more broadly. It suggests providing women with direct financial assistance to purchase sanitary material, collecting sex-disaggregated data on sanitation access and on the health impact of gendered WASH-related tasks to improve women's health and quality of life.

Introduction: Water, Sanitation, and Hygiene Insecurities

Women's social roles (as caregivers) and bodies (when menstruating and pregnant) are intimately and critically dependent on adequate and safe water and sanitation access. However, their needs are often invisible in water, sanitation, and hygiene (WASH) policy making and programs (Caruso et al. 2015). This article shows that women's exposure to WASH-related diseases in many parts of the world is mediated through unequal power relations in the household and cultural scripts that enforce bodily comportment (see Figure 1).

Figure 1.

Gender Perspective on WASH-Related Diseases.

The framework proposed here ¹ broadly follows on the footsteps of other scholars who have focused on social processes and structures to understand the links between gender and health (Connell 2012 ; Lupton 2003).

It is estimated that 30% of people worldwide lack access to safe, readily available water at home, and 60% lack safely managed sanitation (WHO/UNICEF 2017). The public health model widely used to explain the role of WASH on health focuses on proximal factors such as water quality, sanitation, and hygiene that cause transmission of pathogens, while it often excludes the role of gender norms that determine health risks (Eisenberg, Bartram, and Hunter 2001; White et al. 1972). Assessments for the disease burden associated with poor WASH are also dominated by diarrheal disease mortality and acute morbidity (Langford, Bartram, and Roaf 2014; Langford and Winkler 2013). This article shows that infectious and noninfectious diseases that women are more vulnerable to because of their social roles and bodies are often missing from the models. ² When gender determinants are discussed, they typically only include the prevalence and impact of carrying water as a gendered activity in many cultures (WHO/UNICEF, JMP 2017).

In addition, when hygiene issues are addressed, the focus tends to be on hand hygiene (WHO/UNICEF, JMP 2017), and rarely includes menstrual and personal hygiene needs. The key international agency (WHO/UNICEF, Joint Monitoring Program for Water, Supply and Sanitation and Hygiene) that has been responsible since 1990 for developing global norms on WASH, collecting worldwide data, and monitoring global progress on WASH does not collect any data on the number of women and girls lacking access to menstrual hygiene or bathing facilities (Loughnan et al. 2016).

Methods

This article uses the critical interpretive synthesis (CIS) method in order to synthesize large multidisciplinary evidence to generate theory (Seers 2015; Tong et al. 2012; Barnett-Page and Thomas 2009; Dixon-Woods et al. 2006a). A conventional systematic review aims to test theories and summarize the data, whereas CIS aims to generate theories and concepts through an iterative process, grounded in the studies included in the review to interpret the data (Dixon-Woods et al. 2006b; Noblit and Hare 1988). The critical interpretive synthesis approach was chosen because this study is exploratory in nature with the objective of developing a conceptual framework that would explain how poor WASH conditions affect women's health. The CIS method enables the literature review to guide the development of a new conceptual framework ( Dixon-Woods et al. 2006b). In addition, the method is better suited for a large body of studies. I used 151 records in the final stage of the review process for this article (Dixon-Woods et al. 2006b; Seers 2015). CIS is recognized as being able to synthesize complex bodies of evidence from multiple disciplines (Dixon-Woods et al. 2006b), including both qualitative and quantitative evidence. For these reasons, CIS was chosen as an appropriate choice to achieve the goals of this article.

Data were gathered from electronic databases (Scopus, PUBMED, and Google Scholar) by using a combination of key and free text terms, such as gender or woman and water, toilet, latrine, sanitation, bathroom, menstrual hygiene and health or disease; gender inequality and health; and gender in combination with numerous diseases caused by poor water and sanitation. Organizational websites (such as Sustainable Sanitation Alliance or SuSaNa, World Bank, WHO-UNICEF Joint Monitoring Program, WaterAid) were also searched for publications and reports using the same terms. Germane papers were also retrieved through hand searching bibliographies of significant articles.

The material extracted was in English, from all geographic regions, and included journal articles, reviews, documents, books, and the gray literature (such as theses and organizational reports). The objective was not to conduct a comprehensive search of all relevant literature but instead to search for potentially significant materials to develop and refine the framework.

Four hundred twenty-three records initially qualified for inclusion and were then grouped into three different areas: gender determinants of health; women's interactions with water, sanitation, and hygiene; and problems and diseases related to poor and inadequate access to WASH. All records were included regardless of study design or quality to capture concepts and regions often overlooked in mainstream WASH literature.

As the framework was refined, based on the evidence from the materials reviewed, 151 records were finally included if they focused (1) on the sociocultural and behavioral practices of women and girls in their interaction with water, sanitation, and hygiene, including menstrual hygiene (but not food or hand hygiene), and (2) on studies of WASH-related diseases that focused on women or on sex differences in prevalence, exposure, and outcome. Also, preference was given to peer-reviewed studies; other material was included only when such evidence was lacking (such as when a study focused on a region not covered by peer-reviewed studies). Many studies were also excluded if they focused only on the disease without reference to gender differences. However, studies on WASH-related diseases were included if they mentioned exposure pathways that are known to be gendered (such as child fecal disposal practices). In the final selection, besides conceptual papers and organizational reports, there were 80 empirical studies (13 qualitative and five mixed methods) and 22 reviews (including five systematic reviews). Most were in peer-reviewed journals. 43 empirical studies were from the Asia region (mostly from India), 38 from Africa (some studies covered countries in Asia and Africa), four from Latin America, two from North America, and one from Europe.

The draft of the framework was presented at a public health seminar. The feedback from experts (in the fields of water and sanitation; public health; gender and development; and social determinants of health) who attended the seminar was incorporated into the framework. This feedback shifted the framework away from a disease-based framework to one that emphasized the social–cultural determinants of WASH-related diseases. This shift sharpened the report and its focus on the impact of social norms on women's health in communities with poor water and sanitation conditions.

The final framework, presented here, identified multiple ways that shape women's interaction with WASH. These pathways generated two synthetic constructs, "gendered relations in the household" and "gendered presentation of the body," using the grounded theory approach (Tie et al. 2019). The first construct captured two distinct categories of gender relations within the household (gender division of household labor and gender differences in power) and six different pathways that expose women to health risks. The second construct (gendered presentation of the body) encompassed two categories of social norms that affect health. The categories and subcategories derived from these constructs are summarized next (also see Figure 1):

1. A. Gendered Relations in the Household

   1. 1. Gender Division of the Household

      1. a. Caregiver

      2. b. Washing Utensils and Laundry in Contaminated Water

      3. c. Water Colletion

   2. 2. Gender and Power in the Household

      1. a. Level of Control over Household Budget

      2. b. Care and Treatment in Son-Preference Households

      3. c. Health Care Seeking Behavior

2. B. Gendered Presentation of the Body

   1. a. Gendered Use of Public Space

   2. b. Menstruation and Cultural Taboos about Menstrual Blood

These categories were developed through an iterative process by repeatedly comparing them to the evidence in the literature, filing studies into the preexisting categories, and constructing new categories when needed. In total, the CIS method generated eight different social–cultural pathways that increase women's risk of exposure to a variety of infectious and noninfectious diseases related to WASH.

Gendered Relations in the Household

Scholars argue that the division of labor in the household is a central process through which gender inequality is created. For some sociologists and economists (England and Folbre 2005; England and Folbre 2003; Williams 2001; Greenstein 2004 ; England 2000; Folbre and Nelson 2000; Ilahi 2000; Folbre 1997; Agarwal 1997; Lorber 1994; Brines 1994; Hochschild 1989), social norms play an important role in determining sex segregation of housework. In the developing world, social norms may also lead to unequal allocation of resources (Ilahi 2000; Agarwal 1997) by systematically undervaluing women's contributions or needs and thus their access to resources. "Women and girls … receive less because their contributions to the household are seen as being less valuable than that of men or boys… and/or because they are seen as needing less" (Agarwal 1997, 15).

These feminist perspectives provide insights linking household allocation of labor and resources to women's health risks under poor water and sanitary conditions. Housework that women are primarily tasked with—from caring for children to collecting water—is closely intertwined with WASH and its effect on health (as described in the following under gender division of household labor). In addition, unequal allocation of resources for care and treatment of women and girls can also put them at risk, as the later section on gender and power in the household shows.

Gender Division of Household Labor

Caregiver

Women in most societies have the responsibility to take care of children, the elderly, and the sick. As caregivers, they handle their children's feces and, in households lacking latrines, even the feces of sick adults. It has been estimated that one gram of fresh human excreta from an infected person contains many viral and bacterial pathogens and helminth eggs (Mara et al. 2010, 1). Therefore, caregivers who handle feces may be at risk of exposure to infectious diseases. However, studies that examine such links are very few and results are not definitive. Also, most studies (Aluko et al. 2017; Majorin et al. 2017 ; Morita, Godfrey, and George 2016) that examine child feces disposal practices focus on the health risks to children but not to the caregivers, who are primarily women.

Rotavirus is a virus that causes diarrhea and spreads from person to person, mainly by fecal–oral transmission. It can spread if hands are not washed after changing a child's diaper or helping a child to use the toilet. Evan and Weber (2004), in a literature review on rotavirus infection, report on several studies that found transmission of rotavirus to be a common event within families from children to parents (gender of parent was not mentioned) and in pediatric wards from sick children to nurses.

Gendered relations within the household determine some of the risk of exposure to trachoma (a leading cause of infectious blindness due to lack of water and poor hygiene practices). Women are affected more than men with trachoma-induced blindness because of close contact with their infected children, who infect their mothers (West 2003). Due to repeated infection, women are blinded more often than men (Cromwell et al. 2009).

Washing Utensils and Laundry in Contaminated Water

Nine percent of the world's population relies on water of poor quality for all household needs ( WHO/UNICEF, JMP 2015). In rural communities, women doing domestic chores (laundry or cleaning cooking utensils) in infested water may thus be at risk for schistosomiasis (Gabr et al. 2000; Michelson 1992). However, a recent systematic review (Sevilimedu et al. 2016) found a higher prevalence among males, who may be at increased risk of exposure to outdoor contaminated surface waters and soils that harbor parasitic worms. Men are more likely to work in occupations like fishing and farming or to bathe in canals, occupations and bathing/swimming practices that are prohibited for females in many cultures (Sevilimedu et al. 2016). However, it is not clear whether the studies reviewed examined women's exposure risks due to these domestic chores.

Water Collection

Globally, 263 million people spent more than 30 minutes per round trip to collect water from an improved source outside their house (WHO/UNICE,F JMP 2017 ), and in seven out of 10 households (in 45 developing countries) the physical and time burden of water hauling fell primarily on women and girls ( WHO/UNICEF, JMP 2015; Hope 2006; White et al. 1972). These heavy containers of water are carried on the head over long distances (Graham, Hirai, and Kim 2016; Crow, Davis, Paterson, and Miles 2013; Geere, Hunter, and Jagals 2010).

Not enough attention has been addressed to women's health status or quality of life due to the burden of carrying water (Geere et al. 2010). Water loading can lead to musculoskeletal disorders, physical injuries, exhaustion, and dehydration ( Geere et al. 2018; Sorenson, Morssink, and Campos 2011; Scott, Charteris, and Bridger 1998). The energy expended in water collection can have a negative impact on people with poor nutritional intake and in pregnant women can reduce weight gain (Mehretu and Mutambirwa 1992). Regular heavy physical work, including lifting, among other risk factors, is also associated with pelvic floor dysfunction that includes conditions such as pelvic organ prolapse (POP), urinary incontinence (UI), and fecal incontinence (Walker and Gunasekera 2011 ; Kuncharapu, Majeroni, and Johnson 2010). During pregnancy and immediately after delivery, extensive physical labor also can lead to UI (Bodner-Adler, Bodner, and Shrivastava 2007), increase the risk of miscarriages, exacerbate malnourishment, and also affect the quantity and quality of milk produced by lactating women (Dufault 1988). Water insecurity also is significantly associated with psychosocial distress (Boateng et al. 2018; Stevenson et al. 2012 ; Wutich and Ragsdale 2008) and can lead to women economizing on water used for hand washing, clothes washing, dish washing, bathing, cooking, and even drinking, with some women going to sleep thirsty, thereby affecting their hygiene and health (Boateng et al. 2018; Stevenson et al. 2012; Cairncross and Cuff 1987). In addition to the direct health effects, the time spent collecting water significantly impacts women's employment opportunities, other home-based income-generating activities, and the health and care of children (Crow et al. 2012; Stevenson et al. 2012; Pickering and Davis 2012; Cairncross and Cuff 1987).

Gender and Power in the Household

Level of Control Over Household Budget

Where women have less or no economic and decision-making power over the spending priorities of a household, their preferences for some market goods may not be met, including on sanitation, hygiene, and preventive care. For example, women have greater preference for constructing toilets on the premises, but less decision-making authority to do so (Routray et al. 2017; Hirai, Graham, and Sandberg 2016; Khanna and Das 2015; Coffey et al. 2014; O'Reilly 2010). This puts women at risk (from physical to mental health risks, as discussed later). However, women are eager to use government subsidies for toilet construction when available (Clasen et al. 2014). Women also may have less access to financial resources to pay for travel expenses, health care, and medicine (Sen and Iyer 2012; Raj 2011; Roy and Chaudhuri 2008).

In addition, women who do not have control over household income may not be able to engage in preventive care such as the purchasing of treated bed nets to protect them from diseases like malaria (Bonilla and Rodriguez 1993; also see Rashed et al.1999), or buying soap or sanitary napkins ( Mason et al. 2013; Joshi, Fawcett, and Mannan 2011). Women's lack of autonomy may even explain why households spend more on men's consumption items such as tobacco and alcohol and less on personal care and the toiletries women need (Jalali 2019a; Vaughn 2013; Subramaniam and Deaton 1991).

Unable to buy market napkins, poor women use unsanitary material to manage their monthly periods. Among Indian women 15–24 years of age, only 37% are known to use hygienic methods of protection during their menstrual periods (Ram et al. 2020). Use of unhygienic material can lead to chafing (Mason et al. 2013 ; Shah et al. 2013) and can become a risk factor for urogenital infection (Das et al. 2015; Torondel et al. 2018) and human papillomavirus infection ( Bayo et al. 2002; Peng et al. 1991; Zhang et al. 1989; Chaouki et al. 1998). Further research is required to understand the role of gender inequality in hygiene practices under poor WASH conditions.

Care and Treatment in Son-Preference Families

In some societies, the unequal treatment of women starts early and carries through to adulthood ( Sen and Iyer 2012). This is especially true in South Asian countries, where there is a strong preference for boys and where abortion rates for female fetuses are high (Jayachandran and Pande 2017).

Malnutrition poses very serious health risk from waterborne disease (Griffiths 1998). Where WASH conditions are poor, gender discrimination in care and treatment (from being breastfed less, to receiving less nutrition and less access to treatment—see Degefa et al. 2018; Fledderjohann et al. 2014; Jayachandran and Kuziemko 2010; Corsi et al. 2009; Borooah 2004) puts girls at greater risk for waterborne diseases. In son-preference cultures, the biological advantage that girls enjoy disappears after 1 month, when social discrimination puts them at a disadvantage. For example, beyond the neonatal period (0–1 month), mortality rate in India due to diarrheal disease, including that attributable to rotavirus, is higher for girls than for boys for every age group under 5 years ( Morris et al. 2012), suggesting inequities in access to care as a plausible explanation, rather than biological or genetic factors (Million Death Study Collaborators et al. 2010). In such son-preference cultures, investments in sanitation coverage were found to improve girls' health more than boys' (Augsburg and Rodríguez-Lesme 2018).

The social biases continue into adulthood, affecting nutritional outcomes (India, Ministry of Health and Family Welfare 2009; Vlassoff 2007). Under poor WASH conditions, such biases can have intergenerational health effects and set off a vicious cycle of chronic malnutrition, anemia, and stunted growth that impacts the health of a woman and her offspring, including poor pregnancy outcomes and neonatal health (fetal growth retardation, low birth weight—see Osmania and Sen 2003; also see Coffey et al. 2015).

Health Care Seeking Behavior

Unequal gender relations in the household may disadvantage women further when it affects their health care seeking behavior, especially in son-preference cultures. While better off households can afford health care, women in many such households may internalize biased beliefs about their worth (Sen and Iyer 2012) or may have no power to make decisions about their own health care and limited freedom to travel (Raj 2011; India, Ministry of Health and Family Welfare 2009; Nikièma et al. 2008; Roy and Chaudhury 2008; Buor 2004) ³ because of the control of husbands and elders. Using a nationally representative survey of 41,554 Indian households, a study (Saikia, Moradhvaj, and Bora 2016) on gender differences in health care expenditure found that expenditure on females was systematically lower than on males across all demographic and socioeconomic groups, although both short-term and major morbidity rates were significantly higher among females even after controlling for male–female differences in demographic, socioeconomic, and health care-related factors. The authors argue that families spend less on female health because they believe that female health is not as important as male health. Other studies from Asia also report similar findings (Song and Bian 2014; Fikree and Pasha 2004).

Gendered Presentation of the Body

Feminist theories of embodiment help us understand how cultural norms governing male and female bodily comportment undermine women's hygiene and health in communities lacking water, toilets, and bathing spaces, but privilege men who also live in these communities. At the center of the embodiment perspective is the idea of an embodied self that is embedded within an environment—that is, the experience of embodiment is a product of situation (De Beauvoir 1953 ), and unequal power relations shape the disciplinary practices of the body, and specifically, the female body. Women actively police their own bodies to comply with social norms (Butler 1988; 1990; Young 2005).

In Gender Trouble, Butler (1990) argues that gender is an act constructed through repeated performances. As a performative act, gendered bodies are governed by punitive conventions when the cultural scripts are not followed. For Young (2005), too, women's embodiment is shaped by social norms that determine female bodily comportment, from throwing like a girl to concealing the signs of menstruation. The rules of menstrual etiquette and in traditional societies of menstrual taboos "govern the comportment of menstruating women" to ensure their confinement in the "menstrual closet" (Young 2005, 106). From early on, girls bear the burden of personal shame as they learn to follow the imperative that the menstrual process should be hidden because menstruation is dirty, disgusting, and defiling (106).

An embodiment perspective gives a deeper understanding of the gendered nature of WASH deprivation. In a society with rigid cultural scripts and poor infrastructural conditions, where modesty is especially valued, the female body is hidden from public view, and menstruating women are considered impure, a lack of private toilets and bathing facilities does not allow for these scripts to be followed. By one conservative estimate, nearly half a billion women and girls globally lack adequate facilities for menstrual hygiene management (Loughnan et al. 2016; WHO/UNICEF, JMP 2015). While no global data exist for access to bathing facilities, Indian Census data (Census of India 2011) show that 42% of households do not have such a facility in the premises of their house.

This section illustrates how lack of water and lack of safe, private access to bathing spaces and toilets affect women's ability to maintain hygiene in a manner that does not impact men who also live in these poor WASH communities. The extra burden on women's health and well-being results from social constructions of the body that affect norms about the use of public space for hygiene, the sexual behavior of men, and even the perception of women's bodily fluids.

Gendered Use of Public Space

Historically, in the Western world public toilets were not provided for women because "sanctioning the women's lavatory effectively sanctioned the female presence in the streets, thus violating middle-class decorum and ideals of women as static and domestic" ( Gershenson and Penner 2009, 45). By making women's bodies and their "private" functions publicly visible, the lavatory threatened to transform its users into "public women" (Gershenson and Penner 2009).

In many resource-poor settings in South Asia, gendered norms continue to dictate the use of public space for toileting or bathing. Men face no social strictures when they urinate, defecate, or bathe in the sight of others and whenever the need arises, but cultural norms dictate that women should not be seen nor their bodies exposed while urinating, defecating, or bathing. Poor women thus face a double burden—inadequate infrastructure, and social opprobrium for performing acts that are basic to human health. Women are forced to bathe at dawn and hold the urge to urinate or defecate until dark (Jalali 2019b; Routray et al. 2015; Reddy and Snehalatha 2011), or to walk long distances to seek a safe place, inducing high levels of stress (Caruso et al 2017; Hulland et al. 2015). Women also learn to control their diet (avoiding drinking water or food, especially at night) and patrol their bodies (bathe with clothes) while practicing personal hygiene in public under the gaze of predatory men (Jalali 2019b; Sahoo et al. 2015; O'Reilly 2010), a hardship borne on a daily basis.

In crowded urban spaces, women face similar challenges (Desai et al. 2015; Corburn and Hildebrand 2015; Sommer et al. 2015; Joshi et al. 2011; Reddy and Snehalatha 2011; UNICEF, WaterAid, and WSUP 2018) and are even willing to work in low-paying domestic jobs because it offers "privacy for bathing and defecating" (see Joshi et al. 2011, 104, on Dhaka, Bangladesh). In the slums of Hyderabad, India, Reddy and Snehalatha (2011, 393) report, women bathe with their petticoat on and ask someone to look out as "men move around on some pretext or the other & try to watch [women bathing]" said Neenavati Nanu of Banjara Colony. The women are thus very tense while bathing [and] "have to bathe hurriedly."

While the burden women face due to lack of access to safe, private toilets is now recognized within the WASH sector, there is no mention of the need for bathing facilities to maintain bodily hygiene, especially for women, nor are there efforts to measure its availability (the WHO/UNICEF Joint Monitoring Program designated to monitor the WASH sector does not collect this information). Recent attempts by researchers to develop gender-sensitive sanitation security indicators also failed to include a measure for bathing ( Caruso et al. 2017; Loughnan et al. 2016; Sahoo et al. 2015).

Menstruation and Cultural Taboos About Menstrual Blood

Women's menstruating bodies require access to clean absorbent material, facilities to dispose used material, a private toilet, and a bathroom with water and soap to manage special cleansing needs, but these facilities are lacking for poor women and girls in parts of Africa and South Asia (Jalali 2019b; Loughnan et al. 2016; Das et al. 2015; Sommer et al. 2014; Mason et al. 2013; Vaughn 2013) and in some Western countries (Ensign 2001). Lack of access not only is a major barrier preventing hygiene but also is deeply humiliating since there are strict norms against washing and drying menstrual cloth in the sight of others.

Besides prohibitions that restrict menstruating women from many social and religious activities, cultural taboos about menstrual blood also require women to follow washing and drying practices that may be unhygienic, such as where and how the menstrual cloth is stored, washed, and dried (Jalali 2019b; Das et al. 2015 ; Sahoo et al. 2015; Vaughn 2013). Taboos about menstrual blood also inhibit menstruating women from bathing in communal spaces (Jalali 2019b; Caruso et al. 2017). Many of the same taboos apply to postpartum bleeding (Jalali 2019b; Coffey and Spears 2017). Given these social restrictions, women and girls report high levels of stress managing menstruation (Benshaul-Tolonen et al. 2020; Hennegan et al. 2016; Hulland et al. 2015; Oruko et al. 2015; Jewitt and Ryley 2014). Women also complained of the smell of stale blood from their bodies, hands, and poorly washed rags (Jalali 2019b; Hennegan et al. 2016; Oruko et al. 2015; Sahoo et al. 2015; Joshi et al. 2011) because of lack of private facilities to manage menstrual hygiene.

Thus, lack of access to WASH services, including menstrual hygiene facilities, together with gendered social norms may dictate women's sanitation behavior. Women may bathe infrequently, may be unable to perform vulvar and perineal hygiene on a daily basis and during the menstrual cycle, and may be unable to adequately wash and dry underclothes and menstrual material, especially in the rainy season (Jalali 2019b; Hulland et al. 2015; Sahoo et al. 2015; Mason et al. 2013; Reddy and Snehalatha 2011). All these factors increase the risk of various genital infections. There is limited research on how gendered body norms under poor WASH conditions affect women's hygiene behavior and infections to the female genital system and affect the conditions of chronic constipation and dehydration. Some of the potential health risks are discussed next.

Human papillomavirus (HPV) infection and reproductive-tract infection (RTI)

Poor genital hygiene has been suggested as a risk factor for the development of cervical cancer as well as reproductive-tract infections (RTIs). For example, a few studies suggest genital hygiene practices as an independent risk factor for HPV infection (the major etiological agent for the development of cervical cancer), practices such as absence of daily genital washing ( Zhang et al. 1989; Schmauz et al. 1989; Peng et al. 1991; Varghese et al. 1999) or washing infrequently during menstruation (Herrero et al. 1990). Washing the genital area before and after sexual intercourse is a protective factor against HPV infection (Kataja, Syrjanen, and Merja Yliskoski 1993). Other studies have found that menstruating women who had to change outdoors were more prone to have bacterial vaginosis than those who had a private room or toilet (Das et al. 2015; Torondel et al. 2018), and those who washed their bodies regularly during menstruation also had a lower risk (Torondel et al. 2018 ).

The exact biological pathways between poor WASH conditions and RTIs or HPV infections remain unknown. Also not known are how factors such as the quality of water and absorbent material used (the quality of even reusable material varies; see Jalali 2019b and Smith et al. 2020) or perineum hygiene practices after defecation may increase exposure risks to RTI/HPV.

Gender-based violence

Studies from many poor countries have reported that a lack of safe toilets and bathrooms puts women and girls at risk for sexual harassment and rape (Winter and Barchi 2016; Jadhav, Weitzman, and Smith-Greenway 2016; Khanna and Das 2015; for a review of this literature see Sommer et al. 2015) and induces high levels of stress, especially among adolescent girls (Bisung and Elliot 2017; Caruso et al. 2017; Hulland et al. 2015; Sahoo et al. 2015; Routray et al. 2015; Corburn and Hildebrand 2015) who have no privacy when performing the necessary rituals of ablution and hygiene. There is very little evidence on how the fear and experience of sexual harassment affect women's hygiene practices.

Hygiene for maternal health

Burdened by gendered social norms, how do poor women manage genital hygiene during pregnancy and in the postpartum period when lacking clean water or private toilets or bathrooms? Access to water and sanitation is essential for the healing of perineum ruptures and episiotomy after deliveries. In one study, 77% of rural and urban respondents found sanitation management in the postnatal period to be stressful (Hulland et al. 2015). For a pregnant woman, good hygiene practices are important to prevent genital-tract infections ( Sinha and Motify 2012) or neonatal sepsis. Poor perineal hygiene and bathing also can predispose pregnant women to puerperal sepsis (Bako et al. 2012; Winani et al. 2007). Better sanitation facilities may improve undernutrition in adult and pregnant women (Radhika et al. 2018; Janmohamed 2016) and lack of access to toilets may also lead to adverse pregnancy outcomes because of psychosocial stress due to poor facilities or because women may limit intake of food and water to avoid using inadequate toilet facilities ( Padhi et al. 2015; Baker et al. 2018).

Dehydration and chronic constipation

Women who have restricted access to toilets and cannot urinate or defecate in public as men do avoid fluid intake, causing dehydration (Sahoo et al. 2015 ) and increasing the risk of kidney stones, gallstones, and urinary-tract infections (UTIs) (Rudaitis et al. 2009; Institute of Medicine 2005). Higher fluid intake is important for those women engaged in heavy physical activity, living in warm climatic regions, and lactating (Institute of Medicine 2005). Higher fluid intake may also reduce the risk of bladder and colon cancer (Institute of Medicine 2005).

In pregnant women, UTIs can increase the risk of preterm labor, preterm birth, pregnancy-induced hypertension, preeclampsia, and anemia (August and De Rosa 2012 ). The symptoms of UTIs are harder to manage for those without easy access to toilets. Restricted toilet opportunities also are known to increase the risk for chronic constipation ( Human Development Report 2006). Furthermore, for women, straining with constipation (among other factors) may contribute to pelvic organ prolapse (Kuncharapu et al. 2010). The link between diet and toilet access has not been studied, especially whether the diet of women and girls (controlling what they eat and when they eat) is affected by lack of access to safe toilets (Sahoo et al. 2015).

The two sites of injustices (gendered nature of intrahousehold relations and body norms) are closely interlinked, for they both constrain women's functioning and capabilities in WASH-insecure communities (Sen 1993). As Sen's capability approach (1993) has shown, it is important not only to give value to measures of women's good physical health, education, and paid work, but also to place equal emphasis on women's mental well-being, bodily integrity and safety, the choice to do domestic work and care, mobility, leisure activities, time autonomy, and the respect women receive in the family and community as a way to measure women's well-being (Robeyns 2003 ).

Conclusion

This article has illustrated that there is a need for policymakers, public health specialists, and others in the WASH sector to address how gender norms and the needs of women's bodies impact the health and quality of life of women and girls living under poor water and sanitation conditions. As has been suggested, "an integrated public health perspective for water-related diseases should account not only for the disease transmission perspective addressing the proximal causalities, but also the distal causalities that may impact on those proximal factors" (Eisenberg et al. 2001, 231).

A critical interpretation of the studies mentioned here indicates that while many acknowledge the role of gendered social norms on women's health under poor WASH conditions, only a few successfully study the detrimental health effects of these social norms. A good example is the set of studies that document the burden of water collection on women. The burden of this gendered task has been widely accepted, but only a limited number of studies examine the type and severity of health risks women experience (Geere et al. 2018; Graham et al. 2016). The same can be said for studies of fecal disposal practices where the focus is on the health impact on children but not on the caregiver. In fact, of the eight social–cultural pathways examined in this study, only one has begun to receive some attention by numerous scholars—the link between gendered use of public space and psychological stress and violence (although the links between hygiene behavior and gendered body norms have yet to be studied).

The framework proposed here places women's bodies at the center of a WASH agenda so that the "H" in WASH is expanded beyond hand hygiene and even monthly menstrual hygiene to include the ability to practice daily bodily and perineal hygiene. Collection of global data on menstrual hygiene prevalence rates would be a beginning (Loughnan et al. 2016), privacy and other concerns notwithstanding (e.g., data on contraceptive prevalence rates have been collected for decades now). Also, direct financial assistance to poor women to purchase menstrual products would also ease their burden. In addition, there is a need to gather sex-disaggregated data on differences in sanitation access (toilets and bathrooms); differential exposure risks due to differences in gender roles, norms, and bodily needs; and gender differences in hygiene practices and privileges. WASH programs should target men and boys to sensitize them to the burden of menstruation for women and girls. In addition, menstrual health education should not only provide biomedical information but also include programs that change social norms and stigma about menstruation (Benshaul-Tolonen et al. 2020 ). Further research is also needed to understand how women's exposure to WASH-related diseases may differ by region, ethnicity, caste, and class. The costs and benefits of safe water and sanitation cannot be accurately estimated if such evidence that affects the health and well-being of millions of poor women and girls is not collected. Finally, as this article has shown, providing women access to adequate and safe water and sanitation is critical to reducing gender inequalities in functioning and capabilities and removing a major source of unfreedoms for women.