Cambodian girls are sometimes shocked by their first period, known as mokrodou – “the coming season”. Young women often don’t learn about menstruation in school, and the topic remains taboo.

Yet even those who are expecting it have little more than traditional knowledge about their own health. Kunthea*, a high school student in Sihanoukville province, has received information about her period only from her mother. So the 14-year-old abides by cultural – not medical – norms. Sometimes, they are restrictive.

“When I first had my period, I went straight to ask my mother about the situation,” Kunthea says. “My mother told me not to eat ice, cold water or sour things whenever I have my period, and I follow what she told me.”

To describe a girl’s first period, Khmer speakers also use the phrase choulmlob, which means “into the shade”. The phrase might also be applied to the perceptions surrounding menstruation, which remain cloudy. As students and experts have pointed out to Post Weekend, it could be more beneficial to women and their health if these perceptions changed.

A gap in education

Until now, sexual health education, including menstrual hygiene management (or "MHM"), has been quite limited in Cambodian public schools. It is integrated into other subjects if it’s mentioned at all, says Dr Yung Kunthearith, the deputy director of the Ministry of Education’s department of school health.

But this academic year, the ministry aims to pilot health studies as a compulsory project in 10 provinces. “Youth knowledge about MHM and sexual education is very low,” Kunthearith says.

Kunthea, who attends Sandach Ouv High School in Sihanoukville province, says she has never studied health education, let alone menstrual hygiene, in school. She admits that she would be shy about asking questions, but a single-sex classroom would help. “I think it’s really important,” she says. “We need to know more than the traditional ways.”

Srey Mao, 24, says she never learned about menstruation in school. Photo supplied

Although the Ministry of Education syllabus is not yet complete, it is likely that 35 hours of classroom time will be dedicated to health education per year by 2019. Of that total, says Kunthearith, one or two hours will be spent on menstrual hygiene education.

But it remains to be seen if two hours per year will be enough: educators could come up against embedded traditions and stigmas about periods. This knowledge gap is not unusual in the developing world, says UNICEF communications specialist Meas Bunly. Evidence shows that in low-income countries, girls lack information when they menstruate for the first time.

Samuel Desalegn Tumdedo, the water, sanitation and hygiene (WASH) program manager for NGO Samaritan’s Purse, describes this knowledge gap as “menstrual poverty”. Menstrual poverty, he explains, includes not only practical poverty (lack of sanitary facilities, for example), but also psychological challenges.

Women and experts who spoke to Post Weekend say the idea that periods are dirty continues to restrict women’s behaviour in Cambodia. Women are not permitted to shower regularly during their period, as it is believed to affect the beauty of their skin.

Sex is off the cards during menstruation because periods are thought to carry sexually transmitted diseases. Swimming is also taboo, either to avoid infections or because doing so might dirty the water.

There are dietary restrictions, too: no sour foods and fermented fish (to limit the smell), and no ice water or coconut juice, as they are believed to block menstruation.

One lingering practice is that of saving the “material”, or cloth, from a girl’s first period. Girls are told to keep it on their body as protection from evil. The material is even believed to work as anti-venom for snake bites.

These sorts of taboos remain despite their lack of scientific basis, says Saron Srey Mao, a designer. “Typically girls are taught to keep it a secret and hide it, but if they’re empowered and told it’s a natural thing, that’s where the menstrual education will begin to sink in,” Srey Mao says.

Srey Mao, who is 24 years old, was only recently educated about menstruation – in her workplace, a foreign-run social enterprise for women. At school she says she was given an anatomy textbook, but her teacher was shy. Changes that accompanied puberty were glossed over, with no mention of their meaning.

The book Growth and Changes was written for the Cambodian context. Photo supplied

“We knew we would get our periods, but we didn’t know what it meant or why it happened,” she says.

Srey Mao thinks that if menstruation issues were taught better, pupils would be less embarrassed. “A lot of the problem comes from women and girls not feeling empowered,” she says.

Sharing knowledge

To combat the period knowledge gap, UNICEF worked alongside the Ministry of Education to distribute 120,000 of the puberty book Growth and Changes across five provinces in 2014 and 2015. The book was developed specifically for the Cambodian context. It has since been introduced to 19 provinces, and Kunthearith says it will be included in the new national health education syllabus.

Bunly, of UNICEF, says the book was distributed to educate students on hygienic practices. But it’s harder to do when facilities are lacking – as is the case in many Cambodian schools. About half of schools nationwide lack a reliable water supply, and one third don’t have latrines, according to a Ministry of Education report.

A UNICEF study conducted in East Asia and the Pacific shows that a lack of facilities could increase absenteeism. Missing school was common when girls had their period, and they preferred to use toilets at home, especially if they didn't have sanitary materials or suffered from pain.

Whether that translates to higher dropout rates is unclear.

Jan Jaap Kleinrensink, the country director of Plan International Cambodia, says that he is particularly interested in gender rates, especially if more girls than boys of a certain age are staying home. A Plan project found an increased dropout rate for girls during lower secondary education. “It is hard to make sure it is one specific factor [causing absenteeism],” Kleinrensink adds.

For her part, Ros Sopheap, the executive director of Gender and Development for Cambodia (G/DC), draws a direct link between menstrual poverty and the barriers it puts on girls’ education.

“Hygiene throughout girls’ periods is particularly difficult in rural Cambodia, and girls continue to drop out of school if there are no facilities and if it’s too far from home,” Sopheap says, explaining that it is common for girls to be bullied, and there are few facilities to dispose of sanitary napkins.

Many NGOs, like Restore One, conduct village health-education sessions with primarily women present. Photo supplied

While she welcomes the ministry’s new curriculum, she adds that teachers must be properly trained in the topic.

Mixed messaging

Among the programs run by the Reproductive Health Association of Cambodia (RHAC), an NGO providing family planning and sexual health information, is one that trains teachers in Kampot so that they can advise students properly.

Var Chivorn, RHAC’s executive director, echoes Sopheap in support for the government curriculum. But he adds that the subject still isn’t talked about enough.

“We need to train teachers on how to discuss sensitive issues and improve their confidence,” he says. “And it’s not just confidence. It’s about the environment: for some, they feel uncomfortable because of what other teachers will say.”

Chivorn explains some teachers won’t delve into sensitive details, and worries that devoting classroom time to discuss sexual health won’t necessarily increase education on periods – unless there is a societal shift in attitude.

And attitudes remain a challenge, as Restore One, an NGO, found when it introduced menstrual cups to communities in Kampong Thom province. Manager Sopheavy Chea says there is a common misconception that talking about sexual health, including MHM, is to talk about sex. It limits discussion, Chea says, including information girls receive from their mothers.

When Restore One introduced the alien product – named the Restore One Rose – women reacted with shock. “‘How does that work? Will it be stuck in there?’” Chea recalls. “They were freaking out – saying: ‘Absolutely no!’”

“Women who don’t have husbands or haven’t had sex believe that using the cup will mean losing their virginity,” she adds. “So parents won’t let the girls use them, and the girls won’t do it because virginity is really important for them.”

Traditions hold strong, Chea says, and women often won’t use the cups until they need to save money. Pads are most commonly used, but at 75 cents per box, women need to spend at least $1.50 per period – an expense many families can’t afford.

These women are the mothers of, and remain the primary educators for, the new generation of girls reaching choulmlob, Chea adds. If they are reluctant to alter their own practices, it is likely they are continuing to educate girls in the traditional fashion.

While many that Post Weekend spoke to agreed that educating the educators is the most effective method to change the message, little work is being done to educate mothers.

Organisations like Clear Cambodia, Splash, Samaritan’s Purse and Plan have implemented education programs and are involved in distributing Growth and Changes nationwide. But with no governing body reviewing the menstrual education available in schools and communities, approaches vary – especially with regards to boys in the classroom.

Splash’s hygiene manager, Phally Meas, says the program provides a one-day training session on sanitation, with MHM just one topic covered. All facilitators are male, and the girls are hesitant to talk at the beginning.

Meanwhile, Clear Cambodia’s program focuses specifically on girls in Grades 5 and 6 – the average age of puberty. “If [they] added boys into the training, girls may feel uncomfortable and wouldn’t participate well,” says Vann Chhorvy Vanny, the project manager.

Clear Cambodia is also one of the few NGOs working to dispel some myths, informing girls about the importance of washing during their periods instead of avoiding bathing as is traditionally passed down.

“In general, I would say education is the best medicine against superstition, but of course that is culturally biased,” says Plan International’s Kleinrensink. “There is definitely more of a role for the ministry to play.”

Srey Mao, the designer, says there has been no change “because there’s been no education”. So for now, most girls continue to get most of their information about mokrodou from female family members. With only specific communities currently receiving training, most parents are still unable to educate their children about menstrual hygiene.

And, as Srey Mao says: “The parents can be pretty stubborn on traditions.”

*Names have been changed to protect identities.

Additional reporting by Vandy Muong.