KUALA LUMPUR: The Spanish cabinet's recent approval of a draft bill that grants menstrual leave for women suffering from severe period pain (or dysmenorrhea) reignited debates on period leave, casting a spotlight on the long-neglected issue of menstrual health and menstrual inequity across nations, including Australia, the United Kingdom, the United States and Malaysia.
The draft law, which still has to pass through Parliament, if approved would make Spain the first European country to advance such legislation.
Should Malaysia follow suit in adopting a menstrual leave policy?
Part 2: 'Menstrual leave, not an admission of weakness'
While proponents say it would be a progressive development to enhance women's health rights in the workplace, critics believe it would be detrimental to women's employment.
Gynaecologists, academicians, the Malaysian Employers Federation (MEF), the Malaysian Trades Union Congress (MTUC), and organisations weigh in on the hot-button issue.
DYSMENORRHEA: WHAT IS IT
Dysmenorrhea is caused by uterine contractions during menses and it may be either primary or secondary, said Professor Emeritus Datuk Dr Nik Nasri Ismail of the Obstetrics and Gynaecology department, Universiti Kebangsaan Malaysia.
Primary dysmenorrhea, he said could be normal and tolerable pain caused by an imbalance of chemicals in the body such as prostaglandins (a chemical that makes the uterus contract or tighten up).
It is distinguished from secondary dysmenorrhea which is due to disorders in the reproductive system such as endometriosis, adenomyosis, fibroids, pelvic infections, pelvic adhesions, and cervical stenosis (narrowing of the lower part of the uterus), he explained.
"In some women, the cramps can be severe causing social and physical disturbances, thus limiting activity. It can be very annoying," he told the New Straits Times.
Dr Nik Nasri added that dysmenorrhea is said to be abnormal when the painful uterine contractions are accompanied by a range of taxing side-effects - headache, diarrhoea, dizziness, vomiting, pain down the legs or even fainting spells.
"There are certain risk factors that can cause this problem such as smoking, drinking alcohol, being overweight and not being pregnant. In fact, for some women, the symptoms would disappear after the first pregnancy.
"To relieve the cramps, analgesics like aspirin, Panadol, and Ibuprofen are commonly used. These are non-steroidal anti-inflammatory drugs (NSAID). For those with known disorders like endometriosis, fibroids, or pelvic infections, surgical interventions may be needed."
Other relieving steps, he said include resting, placing a hot water bottle on the lower back or abdomen, massaging the lower back, consuming dietary supplements, exercising regularly, and avoiding caffeine, salt, alcohol and tobacco.
DYSMENORRHEA: PREVALENT YET UNRECOGNISED
Studies indicate that up to 95 per cent of women worldwide experience painful periods. The percentage varies depending on the country and the population studied.
In Malaysia, the most recently published research on dysmenorrhea and working women came from YouGov in 2017 where 86 per cent of women said they had period pain, and among those women who had period pain and had worked, 81 per cent said that it affected their ability to work.
Yet awareness about period pains remains woefully low, said Dr Hoo Mei Lin, president of the Obstetrical and Gynaecological Society of Malaysia.
Although period pain is subjective since it differs from one woman to another, she said a significant percentage of Malaysian women suffer painful periods but the prevalence and incidence are underreported for several reasons.
This, she said, included a relative lack of physician awareness of the high rates of prevalence, which often leads to inadequate treatment, women thinking period pain is normal, and lack of research.
"Menstrual pain is often unappreciated and unrecognised. Many women are told that it is normal to have menstrual pain and as such, do not seek treatment. Pain is not normal.
"It is estimated that it can take up to ten years for a woman to be diagnosed with endometriosis despite numerous presentations to doctors.
"Most of us experience some form of pain or discomfort during our menses. Because it is common, it becomes normalised and so, if a woman complains of period pain, it is often downplayed and this can lead to stigmatisation."
She said for some women, period pain is a monthly agony, severe enough to interfere with their daily activities.
"We are not talking about regular aches, discomfort or mood swings, but agony, severe pain.
"Typically, menstrual pain is described as an ache or cramp in the lower abdomen, sometimes extending towards the back and down the thigh. Anything else is not normal and requires medical attention.
"I have had young women in their 20s and 30s who have not had children come into my office begging for me to remove their uterus and ovaries just so they don't have to suffer every month.
"Endometriosis or adenomyosis are usually to blame for their pain, but not always. There is no one answer. You need to see a gynaecologist. Incidents of fibroids are also not uncommon."
A 2012 study published in the National Library of Medicine indicated that at least one in four women experiences distressing menstrual pain characterised by a need for medication and absenteeism from study or social activities.
A 2019 BMJ Open study found that menstrual symptoms has been linked to nearly nine days of lost productivity through presenteeism every year.
Researchers have noted patients describing period pain as "almost as bad as having a heart attack" to "killer cramps" and "sharp, stabbing pain."
There are several related studies in Malaysia on adolescents and young adults aged up to 25 years, which showed a high prevalence of dysmenorrhea in the population. The prevalence rate in three studies conducted in the Klang Valley and Negri Sembilan ranges between 58 per cent and 78 per cent, where the presence of dysmenorrhea was significantly associated with the Malay population.
University Malaya Medical Centre's Professor Dr Mukhri Hamdan, head and consultant of the obstetrics and gynaecology department said up to 80 per cent of women can have dysmenorrhoea at varying degrees and severity, with the pain being described as tearing and ripping in nature.
"Severe menstrual cramps and heavy bleeding are both abnormal and require medical attention," he said.
WHAT'S THE FUSS IF TREATMENTS ARE APLENTY
There are cases where women have to live with the pain until they reach menopause, Dr Hoo said.
"Discussing menstrual leave would shed light on period pain and available treatments. But there are also women who despite the best of medical treatments, continue to have excruciating pain, such as in patients with endometriosis.
"In those circumstances, menstrual leave is a good thing. It's a way of taking care of our female counterparts at work."
Dr Hoo, with over 20 years of experience in the field, therefore said menstrual leave could be viewed in a positive light but it requires plenty of background work before it could be implemented.
Dr Mukhri said apart from pain killers, there are hormonal treatments that could help but in some cases, period pain could not be stopped forever.
He further said persistent pain, extending beyond the menstrual period could have an unidentifiable cause, which makes it tricky.
Dr Mukhri added that in severe cases, even working from home would not help women with dysmenorrhea as the patient would not be able to concentrate and perform her job well.
"As a gynaecologist, we see a lot of more severe pain usually referred after seeing GPs that have not able to resolve their problems.
"Therefore, we will definitely support the call for a menstrual leave policy particularly in secondary dysmenorrhoea. But primary dysmenorrhoea (without any cause) can be quite painful and thus need to be handled non-judgmentally."
Dr Mukhri, a sub-specialist in Infertility and Reproductive Medicine, however, said menstrual leave should be granted in genuine cases and not be generalisable to all as it will leave the door open to abuse.
"The definition needs to be explicitly defined. Menstrual leave should only be issued by a specialist. However, it should be given non-judgmentally."
WHAT IS MENSTRUAL LEAVE
Menstrual leave is an employment policy that allows women the option to take paid or unpaid leave from work during menstruation due to associated health issues.
The policy, however, is an old idea that dates back to the early days of the Soviet Union in the 1920s, initially introduced to protect women's ability to be mothers.
Since then, only a handful of countries have national policy frameworks that grant some form of menstrual leave ranging from a day to an unlimited number of days off, with Asian countries taking the lead - Japan introduced it in 1947, Indonesia in 1948, South Korea in 2001, Taiwan in 2002, and Zambia in 2017.
In other parts of the world, private companies have introduced menstrual leave as in the case of India - Culture Machine, Zomato and Byju's. Bihar is the only state in India which has granted two days of special period leave to women since 1992.
Prior to the draft bill in Spain, in December 2021, a handful of local administrations in the country had offered employees menstrual leave to strike a better balance between workplace demands and period pains.
According to the Spanish Gynaecological and Obstetric Society, a third of women suffer from dysmenorrhea.
Women in these countries contribute significantly to the labour force. According to the International Labour Organisation modelled estimates, ILOSTAT database on labour force participation rate (female), in 2022, women make up 69.5 per cent of the workforce in Zambia, 53.5 per cent in South Korea, 53.1 per cent in Japan, 52.2 per cent in Spain, 50.7 per cent in Taiwan, and 19.9 per cent in India.
Comparatively, Malaysia where 47.7 per cent of the 32.5 million population are women has seen an increase in women in the labour market, surpassing men.
In 2007, the women's labour force participation rate was 46.4 per cent and in 2021, it rose to 55.4 per cent (over six million).
CURRENT PRACTICE
At present, women employees in Malaysia who experience acute menstrual pain could visit a doctor for treatment who would decide based on a case-by-case basis whether to grant sick leave.
"Menstrual leave is not offered in Malaysia. Women employees may, at her discretion apply for paid or unpaid sick leave during menstruation," said MEF president Datuk Dr Syed Hussain Syed Husman.
Syed Hussain opined that the current practice should be continued rather than making menstrual leave compulsory as not all women experience period pain.
"Menstruation is a normal occurrence for females at a certain age while they are still fertile. It is part of normal female life.
"It is also clear that in some rare cases they experience severe pain. The medical fraternity has provided medication for these patients.
"At the same time, many employers at the advice of the doctors treat this as medical leave. This has worked well all these years. Menstruation that happens every month cannot be treated as an illness or serious medical problem that is linked to normal leave."
MENSTRUAL LEAVE, A BETTER POLICY
MTUC acting president Mohd Effendy Abdul Ghani, however, said menstrual leave should be given separately and not included in the sick leave as a whole.
"As opposed to other sick leaves where we can avoid illnesses through regular health care and nutrition, menstrual cramps to some women occur monthly," he said, adding that women might exhaust their eligible sick leave.
Effendy said there is a need to qualify women workers for menstrual leave with 81 per cent of women surveyed by YouGov saying that menstruation has affected their ability to work.
The qualifications and details of its implementation need to be discussed in more depth and holistically, he noted.
This, he said was to ensure its implementation has a positive impact on the part of employees and employers, besides discussing if this should be a paid or unpaid leave.
"If this implementation requires policy changes in terms of employment legislation, then an effective tripartite discussion between stakeholders, the government, MTUC and MEF needs to be held," Effendy said.
Women of Will secretary Ruku Subramaniam said it is about time that women employees in Malaysia be given a day off instead of having them to visit a doctor for a medical leave certificate.
This, Ruku said also incurs medical costs, which might not be reimbursed by employers.
"A day of paid leave should suffice and if a woman needs more than a day, a medical leave can be obtained.
"This is a basic right. Women should not be discriminated against for their natural biological changes.
"An employer who accords menstrual leave to women will be viewed as compassionate and respecting a woman and the changes her body undergoes. This may even earn her loyalty and commitment to her employer.
"As it is, women in Malaysia are generally considered weaker and discriminated against when it comes to promotions. A dedicated woman employee will not abuse this right."
Women of Will is a non-governmental, non-profit organisation registered with the Registrar of Societies since March 2016 that seeks to empower disadvantaged women from the B40 communities to be self-sufficient and financially independent instead of depending on handouts.
MENSTRUAL LEAVE: AMPLIFYING STEREOTYPES
MEF's Syed Hussain argued that menstrual leave casts women as less able than men and could lead to further discrimination against female employees in the workplace, potentially threatening their employment.
Therefore, he said Malaysia should not adopt a policy for special menstrual leave.
"Menstrual leave may be seen as a sign of weakness. It will worsen the stereotypes women currently face at the workplace that female employees are too emotional, unreliable or expensive for employers. All of these may make employers less likely to hire women."
Syed Hussain said businesses that wish to introduce menstrual leave should consult with their employees to design a suitable policy.
Pertubuhan Wanita Industri Binaan Malaysia (Women in Construction Malaysia) (WIBM) secretary-general Azmiah Rahman shared a similar sentiment noting that granting menstrual leave could lead to unhealthy implications for working women.
"Menstrual leave is unnecessary. If the pain is unbearable, medical leave can be obtained.
"Members of WIBM work in a man's world. We have no issue with this. It is unfair for employees who do not have monthly menstrual pain and unfair to employers in terms of productivity and work efficiency.
"Menstrual leave is not a way forward as it has several unfavourable implications for the women working in the construction industry since we are always fighting for a level playing field," she said.
A 2003 International Labour Organisation report warned granting women 24 days of menstrual leave on top of their 12 days of annual leave represented a "significant cost" for many employers, causing them to discriminate against women in their hiring policy.
In Japan, there was a relatively high take-up when period leave was first introduced - around 26 per cent of women workers claimed the leave in 1965, however, a 2017 Japanese government survey found that only 0.9 per cent claimed the leave.
Usage also dropped in South Korea, where a survey showed that 23.6 per cent of women applied for menstrual leave in 2013 and the figure dropped to 19.7 per cent in 2017.
The issue has been said to be predominantly cultural as it widens the gender equality gaps where women who take leave due to period pain were perceived to be inferior to men.
MTUC's Effendy, however, said there is no need to make a difference whether these women workers will be more burdensome if hired and no need for employers to look down on female workers.
"Workers' rights are human rights. All human beings regardless of gender have their respective weaknesses and strengths. This is where gender equality plays an instrumental role.
"And if what is mentioned above is a problem that can affect the productivity or economy of an organisation, then action and efforts from all stakeholders must be held in terms of changes in legal policy holistically and comprehensively," Effendy said.
MOVING FORWARD
While the MTUC had discussed menstrual leave over the years, no in-depth study was conducted, Effendy said.
"Some have also suggested at an early stage that unions should include these menstrual leave benefits into their respective Collective Agreements.
"The benchmark that can be set is by looking at the implementation in Indonesia. This menstrual leave regulation already exists in the first labour regulation in Indonesia, namely through Law No.12 of 1948 on Work.
"Perhaps following this issue, the MTUC through its Women's Wing will take this agenda to the next stage so that women's rights will be improved in the area of menstrual leave," he added.