An intersectional approach on menstrual inequity as lived by women in circumstances of socioeconomic vulnerability in an urban and rural setting in Spain: a qualitative study.

This is an explorative and interpretative qualitative study. A qualitative methodology 29 allowed us to apply an intersectional approach and understand the dynamic interaction of axes of oppression that develop and maintain menstrual and health inequities for study participants. 10 , 30 The complexity through which these axes operate and the need to provide a structural analysis supports our use of qualitative methods that steer away from a mere categorisation of identities. 30 The authors of this study believe menstrual health is a human right and that fulfilling this right means co-creating dynamics directed towards changing social structures. They hope that this research has a real impact in motivating menstrual equity and justice, which seeks to “identify, reduce, and repair oppression on (women and) PWM, as well as other forms of oppression that can intersect with menstrual oppression”. 31 Quality and rigour were assured by triangulation between research team members, reflexivity, verification, and theoretical-methodological adequacy. Guba and Lincoln’s criteria 32 and the COREQ Checklist were used (Supplementary File 1). 33 Credibility was reached by the detailed and exhaustive description of implemented phases in methodology and the revision of theoretical-methodological adequacy. To assure transferability, participant characteristics and their context are included in the results and Supplementary File 2, so these can be understood from other contexts. To comply with the consistency criterion, results were confirmed with our objectives and checked for inconsistencies or contradictions by team members. The authors’ subjectivities regarding the research phenomena were identified, reflected on, and declared for the confirmability criterion. Venue-based convenience sampling was used to find potential participants that fulfilled the inclusion criteria, while adapting sampling strategies to limitations in recruitment settings (e.g. limited time, or women’s inconsistent attendance). 34 At first, the research team had considered a theoretical sampling and pre-established sampling categories (e.g. age, country of birth, or housing situation) to achieve diversity of narratives. However, sampling was adapted to the challenges of recruiting hard-to-reach populations and convenience sampling was applied (with one participant recruited via snowball sampling). Inclusion criteria were: (1) age ≥18 years, (2) receiving aid from social services due to economic difficulties, and (3) having menstruated in the past 12 months. The exclusion criterion was not speaking English, Catalan, or Spanish. LMP approached two social service institutions in Catalonia, Spain to recruit participants facing circumstances of socioeconomic vulnerability. One was a non-governmental organisation (NGO) that provides services to people at risk of social exclusion in a neighbourhood in Barcelona whose socioeconomic indicators reflect the city’s average. 35 To decentralise action from Barcelona, where most research and programme implementations in Catalonia take place, we also collaborated with the community health team from the primary health care centre in a rural town near Lleida, with a population of around 7000 (2022), whose economy is based on the agricultural and food industry. 36 , 37 Participants were contacted by gatekeepers or telephoned by JPP. Eighteen individual semi-structured interviews took place between October 2022 and February 2023 with 15 participants (of whom one was recruited via snowball techniques) living in Barcelona and three in Lleida. With menstrual stigma and participants’ socioeconomic vulnerability in mind, individual interviews were used to create a space of intimacy and trust. This technique allowed us to adapt in time and space to each participant, especially with this being a hard-to-reach population. 38 , 39 The interviews took place in recruitment spaces (an NGO premise and a primary health care centre, as indicated above) (6), public spaces (e.g. park benches or coffee shops) (11) and participants’ homes (1). Interviews lasted 30–75 minutes using a topic guide (Supplementary File 3) developed and restructured on two occasions in light of objectives, research team discussions, scientific literature, and feedback from experienced researchers external to this study. 38 The topic guide composed: (1) open questions to understand the sociodemographic profile and the context of socioeconomic vulnerability (Supplementary File 2), and (2) questions to explore menstrual experiences – menstrual poverty, menstrual management, access to healthcare services for menstrual health, and menstrual discrimination. Data saturation were reached at the 15th interview due to data repetition and based on our research objectives. At that point, several patterns became clear among participants’ narratives as they were consistently shared, such as the link between experiences of housing insecurity and menstrual inequities. Although previously discussed on the phone before each interview, participants were given time to go through an information sheet explaining research objectives. Written and verbal consent was obtained from all participants prior to inclusion. It was made clear to all participants that their involvement in the study was voluntary, and that anonymity and confidentiality would be maintained. Confidentiality and anonymity were ensured in public spaces, as participants’ identities and their involvement in the research were never publicly disclosed. Additionally, participants chose locations that were sufficiently distanced from bystanders to prevent them from overhearing the conversations. Furthermore, snowball sampling did not compromise anonymity or confidentiality, as the referring participant was not informed of the participation status of the women contacted through this method. Given that JPP did not have previous qualitative research experience, she was mentored by LMP. Four interviews were led by LMP in the presence of JPP, two were led by JPP along with LMP and twelve were carried out by JPP. The interviews were audio recorded. As a token of thanks, a menstrual resource informational page and a €30 supermarket gift card were given. To mitigate the risk of creating any unintentional bias, the gift cards were not mentioned prior to the acceptance of participation. Field notes were also taken after each interview, and these helped contextualise and deepen data analysis. Some details from field notes can be found in Supplementary File 2. A thematic reflexive analysis took place following Braun and Clarke’s approach. 40 , 41 The interviews were manually transcribed and anonymised. The process included: (1) familiarisation with the dataset, (2) coding, (3) generating initial themes, (4) developing and reviewing themes, (5) refining, defining, and naming themes, and (6) writing up. 40 , 41 In the first phase of analysis this process took place for 11 interviews and the second phase integrated the remaining interviews. Transcription, reading and re-reading, and field notes allowed proximity to the data. In a second step, the interviews were coded and six were triangulated between JPP, LMP, AGE, and ABC to confirm findings as representative of the data. Initial and emerging themes were derived from the data and identified in a reflexive process based on the theoretical framework and team workshops on intersectionality. These themes were discussed over five team meetings and restructured until a consensus was reached. Some changes were made in the analysis while writing up; these were discussed in further meetings among team members. Atlas.ti software was used for data analysis. The analysis focused on exploring intersecting oppressions, both as perceived by participants and as identified by researchers. 42 It was especially considered how structural determinants permitted the development of certain pathways to shape the menstrual experience. 43 In addition, overall historic and geographic context, and strategies for coping with oppression were considered. 44 Ethical approval was obtained from IDIAPJGol Ethical Committee on July 1st, 2022, Ref 19/178-P.

Eighteen women aged between 23 and 55 years participated in the study ( Table 1 ). Fifteen of them lived in Barcelona and three in a town in the province of Lleida. Thirteen experienced some form of homelessness or housing exclusion. Six of the women were employed, while the rest were unemployed ( N  = 8) or worked sporadically ( N  = 4). Seven had completed secondary school and four had completed university studies; one woman had incomplete primary studies, and another had incomplete secondary school. Thirteen participants were born outside of Spain (four in Dominican Republic, three in Morocco, two in Ecuador, two in Romania, one in Honduras and one in Peru). One participant was in an irregular administrative situation at the time of the interview. Sixteen participants were mothers. Besides, nine women lived with different health problems; two were being treated for menstruation-related conditions. Table 1. Participant sociodemographic characteristics ( N  = 18) Participant identification Gender identity City of residence Age Housing Homelessness or housing exclusion* Current employment Education Country of birth Migration process Administrative status Children (number) 1 Woman Barcelona 55 Room/Roofless Yes No University Spain Yes Spanish nationality No 2 Woman Barcelona 45 Apartment Yes No University Ecuador Yes Temporary/permanent residency Yes (2) 3 Woman Barcelona 36 Apartment Yes No Secondary education Morocco Yes Spanish nationality Yes (5) 4 Woman Barcelona 37 Apartment Yes No Secondary education Romania Yes Spanish nationality Yes (3) 5 Woman City in province of Lleida 23 House (with parents) No No Professional education Spain No Spanish nationality No 6 Woman City in province of Lleida 43 Apartment Possible Farm work Secondary education Romania Yes Temporary/permanent residency Yes (2) 7 Woman Barcelona 37 Apartment No Sales Primary education (incomplete) Spain Yes Spanish nationality Yes (2) 8 Woman Barcelona 32 House Yes No Secondary education Spain No Spanish nationality Yes (2) 9 Woman Barcelona 42 Apartment Yes No, sporadic paid care work Secondary education Morocco Yes Temporary/permanent residency Yes (4) 10 Woman Barcelona 42 Apartment No Hospitality Primary education Dominican Republic Yes Spanish nationality Yes (5) 11 Woman Barcelona 42 Apartment Yes Cleaning University (incomplete) Dominican Republic Yes Spanish nationality Yes (1) 12 Woman Barcelona 24 Apartment Yes No University (incomplete) Honduras Yes Irregular Yes (1) 13 Woman Barcelona 47 Public housing Yes No, sporadic paid care work University (incomplete) Ecuador Yes Temporary/permanent residency Yes (at least 3) 14 Woman City in province of Lleida 43 House Yes No University (incomplete) Morocco Yes Temporary/permanent residency Yes (1) 15 Woman Barcelona 46 Public housing Yes No, sporadic paid care work Secondary education Dominican Republic Yes Spanish nationality Yes (2) 16 Woman Barcelona 41 Apartment No Cooking Secondary education Dominican Republic Yes Spanish nationality Yes (?) 17 Woman Barcelona 32 Studio Yes No, sporadic paid care work Secondary education (incomplete) Spain Yes Spanish nationality Yes (2) 18 Woman Barcelona 24 Room Yes Cleaning Professional education Perú Yes Temporary/permanent residence Yes (1) *The violation of certain basic housing necessities that may cause individuals to experience: rooflessness (living in the streets), houselessness (living in shelters), housing insecurity (unaffordability and legal insecurity), or housing inadequacy (inhabitability and overcrowding). 23 Participant sociodemographic characteristics ( N  = 18) *The violation of certain basic housing necessities that may cause individuals to experience: rooflessness (living in the streets), houselessness (living in shelters), housing insecurity (unaffordability and legal insecurity), or housing inadequacy (inhabitability and overcrowding). 23 Table 1 and Supplementary File 2 display participants’ sociodemographic and menstrual characteristics data respectively. Since only women participated in our study, we will use the terms “woman/women” to refer to our participants, and “PWM” or “women and PWM” where appropriate. Reflexive thematic analysis uncovered five themes: (1) “How you live … is transmitted in part to your period”: menstrual health and embodied menstrual experience, (2) “I felt like they were looking at me like I was crazy … they didn’t give me a solution” : handling menstruation within institutions, (3) “I can’t say, ‘today … I’ll buy a bag of rice and tomorrow I’ll buy pads’” : access to menstrual products and menstrual poverty, (4) “ At home you’re more comfortable … no one is going to bother you” : menstrual management inside and outside the home, and (5) “Especially when working (…) you’re thinking all the time, ‘and if I stain?’”: menstruating in the midst of productive and reproductive work. In general, while surrounded by financial burdens, experiences of gender violence, administrative difficulties, or daily hassles, menstrual experience was not a priority for the participants (except in cases of severe menstrual irregularities). Participants knew and noted that the socioeconomic context affected their lived menstruations: “How you feel, well it affects [menstruation] a lot. How you live … This is transmitted partly to your period, of course” (P9). Nevertheless, many participants expressed feelings of helplessness towards their socioeconomic difficulties, menstrual or otherwise: “I don’t let anything [general issues] affect me” (P6). In this way, despite causing worry or being acknowledged, when asked directly if affected by the menstrual experience, most women answered they were not: “ … it doesn’t cause me any stress, or shame, or ‘damn, I’m going to change [my pad], I have to hide it [changing the pad]’, that’s it” (P3). Most of the women considered menstruation to be “natural”, a sign of health and womanhood: “… that you get your menstruation every month, that’s a good thing” (P10). Several participants also thought it was “something they had to go through”, and that with age they had become less embarrassed and more knowledgeable. In general, they felt they did not hold menstrual taboos. However, narratives uncovered that exposing menstrual status publicly was avoided or feared because it could lead to discrimination, which often intersected with experiences of racial discrimination: “ … so they [people in public spaces] don’t see you stained, so it [her public image] doesn’t look bad” (P9). The same participant described in a similar manner what she felt while wearing the hijab: “ … they [people in public spaces] stay staring a bit, (…), they don’t see you integrated in society” (P9). Another participant explained worry after staining in front of a coworker: “ … that he saw me, (…), not the girl, no, but that any man saw me stained [with menstrual blood]” (P16). Additionally, two participants noted they probably would not have shared as much if the interviewer had been a man, feeling embarrassed or uncomfortable. Feeling clean during menstruation was also essential for most participants, either by washing the genitals or changing products frequently. Although genital washing was usually carried out with water and soap, one participant explained how she cleaned herself with lavender infusions: “And I clean myself with lavender water and it’s really good. I don’t know if people like it here, but for us, in, in Morocco … I remember my mom always advised me to do it [clean herself with lavender infusions]” (P14). According to some participants, not washing was particular to some marginalised groups “like gypsies” (P13), inferring racial and classist stereotypes. The participant who had recently lived in a situation of rooflessness explained how “people that are just laying out on the street, dirty, with boxed alcohol in their hand” (P1) and those perceived as sex workers or stained during menstruation had a “street profile” (P1) and could be discriminated against. In this way, the uncontrollability of menstruations was frustrating for a few participants when they could not display such cleanliness, and especially when associated with being roofless and concurrently experiencing homelessness- and sex work-related stigma. Menstrual discomfort was frequent and considered “normal”, but some women also experienced intense menstrual pain: “Well, sometimes it [menstruation] hurts a lot and … and well I can’t” (P5). The perception of menstrual pain seemed to be influenced by societal normalisation and other women’s experiences. A woman living with endometriosis explained that before diagnosis she lived with pain and infertility issues, leading to depression and suicidal ideation: “Because it [living with constant menstrual pain] wasn’t living. At least five, six years not living. That it hurt when I ovulated, when I was about to get it, I mean … All the time” (P11). A few women associated reduced menstrual pain to pregnancies, and many recalled worse menstrual pain in their youth. A participant with very abundant, undiagnosed abnormal uterine bleeding felt discriminated against by acquaintances for not participating in social events: “You can’t go around giving explanations to everyone [about missing events or rescheduling due to bleeding], (…). But you still feel bad” (P15). Women also had other symptoms during their menstrual cycle or experienced how other pains heightened during menstruation. A woman in perimenopause showed concern regarding menopause’s effects on sexual-affective health and body image: “I’m worried about the postmenstrual care, [like] how to buy collagen pills” (P1). She shared her worries about how factors like age, the COVID-19 pandemic, malnourishment while being homeless, and the stress of living in the streets had affected her menstruations. Her narrative inferred an intersection of class, age and gender-related concerns, based on how climacteric experiences are socially portrayed. Women accessed medications to manage menstrual symptoms and menstrual pain through the public healthcare system or had them prescribed for other diagnoses. This was not possible when women were undocumented or when prescriptions were not included in public services. Thus, based on participants’ narratives, structural racism could deepen financial vulnerability. Participants resorted to asking friends or paying out-of-pocket. In parallel, the regular prescription of contraceptive methods influenced menstrual cycle characteristics and tied menstrual experience to reproductivity. Two participants explained increased menstrual flow with copper IUDs. For one, this caused symptomatic anaemia, but she settled for these complications to avoid pregnancy. On the other hand, for some, contraception had helped regulate pain, like for the participant with endometriosis: “That’s why I adore the [contraceptive] pill” (P11). Menstrual experience and discourse did not appear often in women’s narratives when discussing their encounters in institutions. In fact, a few participants said they preferred asking friends, pharmacists or online search engines when they had doubts regarding menstruation: “No because … they [doctors], they’re going to give me what I have [anti-inflammatory medication], or … you go to the pharmacist, you say, ‘my period hurts a lot’, and they give you the same thing [anti-inflammatory medication]” (P10). However, most of the women had contacted healthcare services regarding their menstrual cycles. Socioeconomic vulnerability appeared to be deepened by discrimination and institutional violence. Most of the women had felt judged at some point, through racism or xenophobia, intertwined with classism: “ … I have brown skin, I have really dark hair. I break a bit, to say, the stereotype of the Spanish, Catalan woman. (…) I’ve always been judged for that [having darker skin and hair]” (P8). Another told the story of her first time in social services: “A social worker told me, ‘But, you’re very well dressed’, I said, ‘it’s because I wasn’t in this situation [need of economic aid]!’” (P17). For a few, however, discrimination or judgment was not something they felt personally exposed to. Women signalled healthcare services and NGOs that provided “hygiene products” (only the women from Barcelona had received menstrual products from the latter) as institutions where menstruation was to some extent discussed and verbally acknowledged. When interacting in both institutions, women generally communicated positive experiences. Within an NGO, women felt thankful for the provision of menstrual products, explaining that these products were generally offered with other “hygiene products”. A participant who recently experienced rooflessness claimed access to products through social services was easy, but possibly not well communicated: “Because I went to ask the specific person I knew would have (menstrual products), ‘Do you have pads?’” (P1). The inability to choose menstrual products could lead to the use of uncomfortable products: “They [menstrual products from NGO] aren’t comfortable, but I have to use them because I don’t have the means to go and buy something [better]” (P18). Some felt shame in general over having to ask for any product due to financial necessity, inferring class-related stigma. Three women verbalised experiences of violence and trauma within healthcare institutions during their pregnancies. One had recently been judged for not breastfeeding and, as a teenager, suffered obstetric violence. Another participant identified racism as the cause of discrimination while in labour: “She threw me on my back. You know the belly crushes you [when you’re pregnant] (…). I stand like this, and I tell her, ‘Man, I’m suffocating’. And she tells me, ‘Should've thought of that [before getting pregnant]’” (P11). Another participant explained mental health treatment due to “trauma during labour” (P12). In general, weak communication, depersonalised attention, cultural differences, and long wait times were considered an issue: “[There needs to be] At least a … a gynaecologist in urgent care or something. Because something happens to me, and I don’t have an appointment for three months” (P8). This participant referred to the long waiting lists to access gynaecological care in public healthcare services, as these were the services she could afford and access, having experienced this firsthand. Many women also mentioned negative situations where menstrual problems were normalised, pathologised, or not thoroughly investigated and treated with contraceptives or pain medication. For example, a woman who went to the emergency room due to menstrual pain after her IUD implantation had been quickly discharged without explanation. Another explained how her condition was treated as “unreasonable”, also in an emergency room: “I felt like they were looking at me like I was crazy, you understand? I mean, no … because they didn’t give me a solution” (P15). Other examples included waiting years for menstrual diagnoses (in one case still unresolved). When discussing “ideal health care” for women, narratives revealed it was important for healthcare professionals to be trusting and take an integral approach. A couple of participants mentioned that their menstrual worries were calmed after tests ordered by physicians: “They've [healthcare professionals] done everything [all possible tests and scans], they’ve done (that) I’m very thankful because they’ve done everything” (P15). Several participants preferred institutional interactions to take place with women. Within healthcare services, receiving care from male gynaecologists for their menstrual health could be uncomfortable, or even feel violent: “I always get women gynaecologists. I feel better. I feel more comfortable. And (…) I did have a male gynaecologist, but … I didn’t feel good … ” (P8). Similarly, within an NGO, there could be embarrassment or lack of menstrual knowledge from male staff when women picked up menstrual products, which could signal menstrual stigma and taboo at the intersection of gender and class. All the participants used non-reusable menstrual products, usually preferring menstrual pads over tampons. Both a pad and tampon, multiple pads, or diapers were used in cases of heavy menstrual flow. In a similar manner, being in public spaces influenced menstrual product choice: “When I’m at home, I use the pads that I told you about [large pads from NGO]. I don’t care because I’m home and no one can see the lump or anything” (P2). Menstrual abundance, irregularity and staining increased menstrual expenses. Despite their costs, these products were considered essential for everyday life: “Exactly, part of your health, yes, really it’s [buying pads] like buying ibuprofen when your head hurts” (P3). Four participants mentioned that, at some point, they had used toilet paper, or cut diapers or cloth, as alternative methods to manage menstruation due to economic difficulties. In addition, one of the participants in Lleida received menstrual products from her boss, to minimise the cost of purchasing menstrual products and to be able to access them. Women mentioned the need for the provision of quality menstrual products firsthand. One participant thought prices were accessible and alternatives could be used: “I don’t think pads are worth much because I think the price is right … You find a way and that’s it. To clean yourself there’s no excuse” (P14). All but four participants did not use menstrual products of their choice regularly. Several women used store brands, and while some women expressed a preference for these products, others indicated that they were the only available option due to cost considerations. Economic constraints led to numerous saving strategies like buying cheaper products, prolonging use, stocking up on sales and planning to avoid staining: “You can’t go out. [If] you don’t put on a pad … [you] Don’t leave, you don’t leave [the house]. Because you stain” (P4). Store brands could cause vulvovaginal irritation, were “smelly” or uncomfortable, and were less absorbent or moved, increasing chances of staining: “Store brands … make … make me itch sometimes … But, since there’s no choice, right? It is what it is. Then, you get used to it” (P3). Most participants had to prioritise between menstrual products and other products and services. In general, this meant deferring food necessities and deepening the impact of socioeconomic vulnerability: “It’s [buying menstrual products over other goods] happened um … it’s … it’s something we can’t avoid, I mean, I can’t say ‘today … I’ll buy a bag of rice and tomorrow I’ll buy pads’” (P2). Some also had to buy menstrual products or medication for their daughters, employing additional tactics. In this case, large families and single mothers signalled further difficulties: “Pads, that almost everyone can afford. But well, in my case, being a special[ly] large family, everything is harder” (P3). Socioeconomic vulnerability was accompanied by stress and feelings of shame, embarrassment, or frustration for most participants: “You feel impotent (…) that there’s nothing you can do, that you can’t acquire, that you can’t, that not being able to … well … it eats away at you” (P9). Another participant explained unrest due to marital economic dependence that restrained access to these products: “Of the fact that I’m depending a lot on, on the work of (just) my husband. So, of course, getting to the point of saying, ‘oh, well I can’t even buy pads with my money, I mean from my job and my things’” (P12). In contrast, many participants, when asked directly, explained menstrual poverty did not affect them emotionally, as they integrated this strain into the socioeconomic vulnerability they already experienced: “Well, it [difficulties in access to menstrual products] doesn’t really affect me. It’s survival” (P18). In the context of socioeconomic vulnerability, housing inadequacy and housing insecurity were common for the participants in the study: “Our contract ended, the owner didn’t want to renew, which is what’s happening to all tenants in the neighbourhood, that rent is always higher and higher” (P3). Another participant had shared a room with her husband and four children during their migratory process, while yet another slept in the living room, leaving the bedroom available for her four children. One participant rented out additional bedrooms in times of financial strain, although she worried this would affect her son: “It’s not a very safe neighbourhood, that’s why I can afford it, (…), when I see myself in situations of, (…), bad financially, what I do sometimes is rent a room … ” (P11). Despite these circumstances, menstrual management in the home was considered comfortable and almost always preferred by housed participants: “I feel more comfortable there [her house], I have my things, you know? (…) it’s my house (…) it’s simply for, for comfort … ” (P8). A woman in a situation of rooflessness expressed daily uncertainty and discrimination (she mentioned there was an “immense prejudice” towards rooflessness): “The fear of being completely unsafe, vulnerable (…). Not vulnerable, you’re literally in constant danger” (P1). She explained how men on the streets had warned her, “a woman in the streets alone is dead” (P1), enacting the violence that especially women who are roofless (intersected by axes of gender and class) are exposed to. This participant, in contrast, emphasised that using bathrooms in public spaces had been “horrible” (P1), a moment of discomfort and insecurity, especially at night and even more so during menstruation: “You can’t [use public restrooms], there’s no wa(y)-, not even think about it. (…). With or without your period, imagine with [your period]” (P1). In many cases, menstrual management outside the home meant asking to use restrooms or buying products in exchange for use in private establishments, which could become limited by financial strains. The participant who had been living in homelessness explained that she had “places of trust” that allowed her to use the bathroom: “Luckily there are cafes that let you in. Only a few have been, ‘no, no we don’t serve this … minority … [people in situation of homelessness]’ I’m also not a street profile and I’ve had that in my favor” (P1). Furthermore, participants mentioned that bathroom uncleanliness (and fear of urinary infections), visibility of used products in bins, small spaces, lack of menstrual products, toilet paper and/or washing facilities, feeling insecure, and time pressure were some of the negative characteristics of menstrual management outside the home: “In public places you have to do it [change menstrual products] fast, fast and that’s it. At home, you’re more comfortable, and … and you take your time (…) no one is going to bother you” (P9). Three women explained that these time limitations for bathroom use also existed within the home, especially when living with others besides family due to housing insecurity. Another woman expressed the emotional impact of forgetting menstrual products and not having any available. In addition, when outside the home, two participants mentioned that they did not like leaving their used menstrual products in bins for others to see: “I take off the pad, wrap it, put it in a bag. I always try to use containers, to not leave it there, I’m embarrassed” (P13). Although the workplace was also used and comfortable for menstrual management, women preferred their homes because of the lack of washing facilities, space, or time: “Sometimes what I do is try to wait the eight hours of work with just one (tampon)” (P16). On the other hand, using bathrooms outside the home could mean exposing menstrual status. Since several participants had been exposed to or seen others suffer menstrual discrimination, such as pointing and laughing, in public spaces, some prepared beforehand, extended menstrual product use, or avoided menstrual management outside the home, especially with heavy periods: “When I’m menstruating like that, that a lot comes out, I try not to go out, except for an important reason” (P2). They also coordinated with and relied on other women if they forgot menstrual products, or these were unavailable. However, most participants did not perceive an impact from barriers to menstrual management and focused on adapting to them. For example, of two participants from Lleida who brought up changing menstrual products in open fields, one explained: “I’m used to it [changing menstrual products outside], always working on the fields … It’s the same to me, house or field” (P6). Hence, women adjusted to open fields and natural spaces for menstrual management in this rural context. The intersections between gender, class and race-related oppressions were apparent when women discussed productive and reproductive work, and in relation to their menstrual experiences. Sixteen women were mothers, and many explained how they performed unpaid care work like cleaning, caring for children and protecting them from worries of personal socioeconomic difficulties, among other tasks that generally increased mental load. Unpaid care work even extended beyond borders, as migrant women were sometimes responsible for family members in their countries of origin. Only six women participating in our study worked in paid conditions, which made socioeconomic vulnerability apparent in the women interviewed. Productive work – mostly manual labour – could prove to be difficult during menstruation due to additional physical burdens, menstrual symptoms or irregularities, or fear of staining interfering with work: “Sometimes I’ve bought bad quality pads that move. And sometimes this has been uncomfortable (…) especially when working (…) you’re thinking all the time, ‘and if I stain?’” (P8). In contrast, a participant working in farm work indicated she could lower her workload or sometimes take time off work due to menstrual pain. During reproductive work, women commonly reduced their personal menstrual care, by limiting medication use during lactation, conceding product choice, or worrying about exposing menstrual status to children: “Because sometimes my son has to see things [menstrual blood] I don’t want him to see because he’s a small boy” (P11). A woman remarked that when her children were young, she prioritised using diapers instead of menstrual pads, since these had to be bought for children. A participant also explained how she organised menstrual care around productive and reproductive work with medication: “Paracetamol, or an ibuprofen, or something. Because, yeah, with routine, work, kids, well of course you need to take something [medication] because if not you have no pull” (P7). A couple of participants mentioned lower care workload during menstruation because of help from their partners: “Sometimes I’m lucky that my menstruation arrives on the weekend that (son’s name)’s dad is here, so I rest” (P12). However, this was particularly difficult for single mothers, migrant women, or mothers of children with health issues. One of them recounted her experiences of financial strain and lack of social/emotional support when managing menstrual pain: “Beyond a financial [problem] (…) when I’m in pain, I’m alone. I have a bad time. I don’t have medicine at home, I don’t have anyone to help me” (P18). Another woman expressed guilt for taking her menstrual needs into consideration, especially because her son needed constant care: “But when I see I’m about to explode [while outside with my son], I say [to my son], ‘(…) remember that I said that I couldn’t, that I’m on my period’. ‘Okay, okay’, he understands, and we go up [to the apartment]. I mean I’m there to please him because I don’t want to drag him with my frustration” (P15). Another participant explained how both unsolved menstrual irregularities and childcare left her without leisure time. General childcare also extended to menstrual care for their daughters. Women with daughters not only provided menstrual products but also emotional support and menstrual education. For one of the participants, it was a great concern how and when she would bring about menstrual education to her daughter with autism: “Because right now I feel very lost [on how to talk about menstruation with her daughter]. I’m trembling my daughter is going to get her period” (P8). A couple of women also protected their daughters from menstrual discrimination, making sure that they always had menstrual products with them at school: “When my daughters have their periods, well, they always have to have, have pads in their backpacks. Always ” (P10).

Beyond a hegemonic biomedical perspective, 1 menstruation is a sociocultural and political experience. 2 Menstrual health 3 has recently been identified as a human right and public health issue 4 and included in the 2030 Agenda’s Sustainable Development Goals. 5 Community and policy actions have also focused on addressing menstrual inequity: “the systematic, unjust and avoidable differences in access to health care for menstrual health, access to menstrual education and knowledge, access to products, services and spaces for menstrual management, and barriers for social, community and political participation for having a menstrual cycle and menstruating” that affect women and people who menstruate (PWM). 6–8 We refer to women and PWM (e.g. trans men, non-binary individuals who menstruate) since the menstrual cycle is not exclusive to a particular gender identity, and to avoid the normalisation of a morally superior, ideal subjectivity, juxtaposed against diverse menstrual experiences. 9 Menstrual norms can be examined through intersectionality, originally developed to analyse the structures of oppression and power dynamics in the lives of black women through the intersection of sexism and racism in the United States. 10 An intersectional perspective can be applied to (re)identify mechanisms of power that underlie menstrual inequities and paths for social transformation. For example, research worldwide has identified situations of menstrual poverty; 11 , 12 in fact, 22.2% of study participants in Spain had not been able to access menstrual products and 39.9% had not been able to access those of their choice for economic reasons at some point during their life. 7 Applying an intersectional perspective to these findings, we can analyse that the commodification (i.e. social practice and attitude of treating something as a property that can be sold, bought, or rented) 13 of menstrual products impacts on menstrual poverty through the intersection of sexism and classism, maintaining menstrual inequities. 14 Some situations of socioeconomic vulnerability, and their relation to menstrual inequity, have been explored, especially in the Global South. We understand this vulnerability as the elevated risk of harm due to the hierarchy of social groups that emerge from social structures of power. 15 , 16 Studies in informal settlements in India and Kenya have found challenges in menstrual management 17 due to lack of facilities, inadequate disposal options, menstrual poverty, and menstrual stigma. 18–20 These studies concluded that socioeconomic inequities and contextual factors have an impact on menstrual experience. It is also noted that menstrual interventions (usually led by Global North researchers) may not consider pre-established menstrual knowledge, culture and context, or underlying mechanisms that affect menstrual experience. 19 For some time, menstrual inequities may have been thought of as an issue of “uncivilised” regions, and only in recent years made visible in the Global North. 21 A study in the United States exploring menstrual challenges for low-income women, displayed the obstacles to access good-quality menstrual products and menstrual management. 22 Most other studies explore situations of homelessness and housing exclusion, conceptualised as the violation of certain basic housing necessities that may cause individuals to experience: rooflessness (living in the streets), houselessness (living in shelters), housing insecurity (unaffordability and legal insecurity), or housing inadequacy (inhabitability and overcrowding). 23 Menstrual management has been identified as a challenge amongst women and PWM experiencing homelessness in the United States and England. 22 , 24–26 These studies have pointed out that menstruation during homelessness is excluded from policy and public health action. Nevertheless, they have generally failed to name systemic structures as responsible for homelessness. 27 , 28 This further justifies the need for intersectionality in critical menstrual research. To our knowledge, there is virtually no evidence regarding menstrual inequities of women and PWM in socioeconomic vulnerability in the Catalan context. Hence, the aim of this study was to analyse, from an intersectional perspective, the experiences of menstrual inequity of women and PWM (≥18 years) under circumstances of socioeconomic vulnerability in an urban and rural setting in Catalonia (Spain), focusing on menstrual poverty, menstrual management and access to health care for menstrual health.

Our results revealed that the embodied menstrual experiences of the women in our study were determined not only by gendered norms and institutionalised menstrual discourses but also by the context of socioeconomic vulnerability. In this way, menstrual health and inequities were a distant – but present – preoccupation embedded within socioeconomic problems, housing difficulties, and productive/reproductive work; these had an impact on menstrual management, menstrual care, and menstrual poverty. Menstrual health and its related inequities are recognised globally, 3 , 21 but variations in menstrual injustices influenced by intersecting social oppressions and privileges are less explored. 31 Our results indicate that menstrual experiences are shaped by power structures of gender, race, and class, which are complex and intertwined. For example, most participants viewed menstruation as a “normal/natural” aspect of their identity yet felt compelled to hide it. Studies highlight internalised shame and self-surveillance regarding menstrual status, 45 reflecting patriarchal norms – which situate men in a position of power and privilege over women 46 – that associate menstruation with dirtiness and moral inferiority. 47 , 48 Narratives from our study evidenced not only this but also that revealing menstruation in contexts of other oppressions, like homelessness, intensified discrimination and limited access to menstrual management resources. Furthermore, the difficulty in accessing quality menstrual products in situations of socioeconomic vulnerability increased the risk of staining, reinforcing ideas of menstruation as “monstrous” or “dirty”. 47 , 49 Economic disparities between those who hold the means of production and those who do not 46 exacerbate these challenges. Moreover, colonialism further dehumanises marginalised groups, 50 like the participant who explained feeling judged for wearing the hijab, and in a similar way when stained with menstrual blood (P9). In this way, the integration of patriarchal, capitalist, and colonial systems – though divisible in academic jargon – shapes menstrual health experiences, privileging some over others. 51 , 52 The systematic exposure to othering , based on norms of power-oppression regarding gender, class, and race, and the generalised inaccessibility of products and services, placed menstrual care as “secondary” for our participants living in circumstances of socioeconomic vulnerability. Participants expressed discourses of powerlessness and system justification (that is, rationalising existing system norms), 53 while situated in positions of negotiating power within rigid, oppressive, intersecting structures. As such, participants’ agency was navigated by resolving and reconciling daily difficulties. 44 The actions to prioritise and organise needs, rights, and coping strategies (e.g. planning ahead for sales or to confront difficulties in menstrual management), can be pointed out as forms of individual, covert, and everyday organised resistance. 54 In our results, menstrual discourse was confined to health institutions and those that provide “hygiene” products, making menstruation institutionally visible only when it falls outside societal norms or is a reproductive health issue. 55 , 56 For instance, a participant seeking a menstrual diagnosis mentioned how she felt she was seen as “crazy” in emergency care. In fact, the association of “madness” and “menstruation” is a deep-rooted one, 57 and it has been legitimised through institutional practices and the psychiatrisation of menstrual experience. This is demonstrated by the suppression or minimisation of menstrual experience (e.g. pain, symptoms, or impact) in our results. 47 , 56 , 58 This is especially so in situations of disability, menopause, or menstrual diagnoses like endometriosis. 59–61 Currently, health care is being increasingly privatised in Spain, 62 due to cuts in funding to the public healthcare system and an increased demand for private healthcare insurance (for those who can afford it). Privatisation reduces access to public health care for those in socioeconomic vulnerability, as it has meant a reduction in the number of healthcare professionals (e.g. gynaecologists) working in the public sector and increased waiting times, as some participants shared. It should also be noted that public health care in Spain is not accessible to those with an irregular administrative situation. 63 Contextual factors that placed women in socioeconomic vulnerability in the first place, like unemployment due to racial and religious discrimination, further limited access, along with lack of access to medications to manage menstrual symptoms. Once care is accessed, women are pushed towards “civilised” conceptions of menstrual health and experience through knowledge produced from the perspective of Global North researchers, including ours. 19 In this way, there is a trickle-down effect from the marginalisation of these populations to menstrual inequities. As shown in other contexts 22 , 25 and in ours, 6 , 7 socioeconomic inequities perpetuate menstrual inequities. In this way, menstrual poverty does not exist in isolation but is one more manifestation of deprivation lived by participants. 14 Participants in our study depended on NGO provision, economic aid from others (e.g. husband or boss), supermarket sales, and availability of cheaper (but worse quality) menstrual products for access, which distanced them from empowerment over their menstrual experience. Menstrual product commodification creates additional economic needs for women and PWM, influences menstrual conceptualisation, and dehumanises those who undergo menstrual poverty. 14 If menstruation should be clean and concealed, by restricting access to menstrual products, women and PWM who cannot access those products break a social rule, putting them in a position of immorality, 9 as suggested by a participant who said, “To clean yourself there’s no excuse” (P14). Participants obtained menstrual products from social services at the same time as they obtained food, cleaning supplies and economic aid for rent, as part of survival supplies, and felt shamed by this. In this way, genderisation and racialisation drive both menstrual poverty and poverty in general and reinforce each other. As apparent in our study, and especially important given the current health impacts of the housing crisis in Spain, 64 housing exclusion and homelessness seemed to put menstrual care at risk. The contrast between participants’ experiences managing menstruation within and outside the home uncovered how the menstrual experience is homogenised by menstrual taboo and stigma, which force menstrual experience to the private sphere. 49 Participants from our study described avoiding menstrual management outside the home in order to avoid menstrual stigma and discrimination, and the home became a place of safety, 26 not because menstruation should be private, but because taboo requires it to be individually and socially conceptualised as such. 47 Consistent with our results, women and PWM living in socioeconomic vulnerability in previous studies have been found to be more exposed to menstrual injustices and inequities, as suggested by a study that showed neighbourhoods with higher socioeconomic status or a higher proportion of the white population having more access to resources for menstrual management. 65 In addition, our research acknowledged that homelessness operates differently depending on gender. Our results point to the previously unresearched difficulties for housed women living with strangers and time limitations for menstrual management. Though women are less often roofless, they are affected by other forms of housing insecurity resolved within individual social spheres (e. g. unstable housing with acquaintances), 66 but there is a lack of evidence concerning women in situations of housing insecurity and homelessness that fall outside rooflessness. Thus, assuring quality menstrual management facilities 17 , 67 should not replace measures to tackle racist, sexist and classist mechanisms that place individuals in homelessness. 27 In our study, menstrual care was deprioritised and revolved around unpaid care work for almost all the women. As a result of the genderisation of public and private spheres, menstrual care and unpaid care work are both characterised as reproductive, exploited for the (re)production of the labour force and to sustain daily life, and devalued in respect to what is deemed productive. 68 This became apparent in our results, as women were mostly engaged in informal and precarious productive work alongside reproductive responsibilities. To sustain this, woman self-medicated or endured pain and symptoms. In addition, although measures have been taken to provide the possibility of menstrual leave for women in Spain, these measures may not only reproduce the concealment of the menstrual cycle, hiding structural lags within health care, 69 but also reinforce patriarchal-capitalist notions of women’s bodies as unfit for productive work. On the other hand, this right is available for those that have jobs within a formalised, productive setting but makes unpaid care work invisible. Also, in our results, menstrual care work – that which women do to care for girls and children who menstruate, like providing menstrual products, menstrual education, etc. – was also inconspicuous and unpaid, especially in situations of disability. 70 , 71 Although the legislation of menstrual leave can provide huge relief, it should not distract from underlying structures and intersecting mechanisms. 69 Finally, the emotional and mental health impact of the intersections explored with the menstrual experience need to be acknowledged. For instance, some participants signalled the emotional repercussions of menstrual poverty and managing menstruation when living in situations of homelessness and housing exclusion. 26 These emotional experiences should be mainly understood as consequences of socioeconomic vulnerability and structural dynamics, instead of merely being reduced to menstrual experience. 11 , 72 Moreover, the need for emotional and social support narrated by some women in our study is highly significant and directs us to analyse how the disintegration of social networks and communities is intertwined with menstrual experience (e.g. recurrent and severe menstrual pain). 73 This analysis needs to consider how this may be particularly relevant for migrant women and PWM, and other communities that may struggle with social exclusion and isolation. Our research points towards attaining menstrual equity through contextualising the menstrual cycle as intersected with axes of inequities. Key policy actions include ensuring access to quality menstrual products, safe spaces for menstrual management, time for menstrual care and its integration into workplaces, and health care for menstrual health free of institutional violence. Our study shows the importance of tackling these issues through their underlying mechanisms. For instance, menstrual poverty should be approached by considering how women and PWM fall into positions of socioeconomic vulnerability, for example, through migration laws that form barriers to employment. Our findings may contribute to create programmes and policies from an intersectional perspective, such as rethinking menstrual leave to consider care work and situations of informal employment. Our research also highlights that the recognition of menstrual health rights and perpetuated menstrual inequities and injustice is imperative. Menstrual experiences need to be heard and menstrual needs should be met at an institutional and community level. Moreover, the emotional and mental health implications should be recognised as a potential consequence of socioeconomic vulnerability (i.e. when living amid intersecting oppressions). Healthcare systems and professionals should review and develop their protocols and practices from an intersectional perspective, to promote menstrual health and equity, also understanding their relationship with emotional and mental health. On the other hand, individual and community agency for menstrual equity should be promoted. However, these actions should avoid neglecting the needs of women and PWM or putting responsibility on individuals to change menstrual conceptualisations that have been socially structured and imposed. Critical community-based and participatory research is imperative so that power on knowledge production can be redistributed. Critical menstrual research should also continue to advance social theory and its implementation within policymaking processes and practices in health care and social institutions. This research should not only focus on those who are oppressed but must analyse how power systems operate. One of the main limitations of this study was difficulties in achieving discourse diversity, by recruiting participants in circumstances of homelessness, from rural settings, gender-diverse individuals or other identities. Nevertheless, given the exploratory nature of the study, the remaining gaps provide areas for future research. Regarding our interview topic guide, questions regarding housing and discrimination were restructured later in the data collection process, which may have limited information collected in the first interviews. Furthermore, the spaces of recruitment could have influenced our results by contacting participants with more access and more aligned to gatekeepers, or not reaching circumstances of greater (menstrual) inequity. Finally, interview spaces could have influenced our intent to create a trusting environment due to cold temperatures, or the presence of children and/or strangers in public spaces. The time allowed for interviews could have also been too short for building sufficient trust to discuss difficult topics like racism more exhaustively and limited the depth of some of our results. Briefly, we reflect that further work must be taken to shift power in knowledge production within critical menstrual studies as part of attempts towards social transformation, considering community-based participatory research as key. Unfortunately, in not being participatory, our work was also limited by the reduced involvement of participants and the fact that the authors do not live the same experiences of menstrual inequity.

Our study revealed that situations of menstrual poverty, difficulties in menstrual management and menstrual self-care, barriers accessing healthcare institutions for menstrual health, and menstrual taboo, stigma and discrimination were commonplace and deepened by socioeconomic vulnerability. Menstrual inequities were modulated by lived intersecting axes of oppression (based on gender, race and class), that placed women in positions of vulnerability, and root menstrual experiences in social structures of power-oppression. Our research highlights the need to co-construct knowledge and enable heterogeneous counter mechanisms to promote social and institutional transformation within communities. It also aims to support incorporating intersectionality perspectives in policymaking and in practice in healthcare and social institutions.