Holst et al. Reproductive Health (2022) 19:45 https://doi.org/10.1186/s12978-022-01354-5 RESEARCH Open Access Experiences of menstrual inequity and menstrual health among women and people who menstruate in the Barcelona area (Spain): a qualitative study Anna Sofie Holst1,2, Constanza Jacques‑Aviñó1,3, Anna Berenguera1,3,4, Diana Pinzón‑Sanabria3,5, Carme Valls‑Llobet6, Jordina Munrós‑Feliu7, Cristina Martínez‑Bueno8,9, Tomàs López‑Jiménez1,3, Mª Mercedes Vicente‑Hernández9 and Laura Medina‑Perucha1,3* Abstract Introduction: Menstrual health and menstrual inequity have been neglected in social, economic, healthcare and political spheres. Although available evidence is scarce, it already suggests a link between experiencing menstrual inequity (which refers to the systematic disparities in accessing menstrual health and education, menstrual products and spaces for menstrual management, among other aspects) and menstrual health outcomes. The aim of this study was to explore experiences of menstrual health and menstrual inequity among women and people who menstruate aged 18–55 in Barcelona and surrounding areas (Spain). Methods: A qualitative study, using a critical feminist perspective, was conducted. Sampling was purposeful and selective. Recruitment was through sexual and reproductive health centres, social media and snowball sampling techniques. Thirty-four semi-structured photo-elicitation interviews were conducted between December 2020 and February 2021. Interviews took place in sexual and reproductive health centres, public spaces, and by telephone. Data were analysed using Reflexive Thematic Analysis. Results: Three themes were identified: “Systemic neglect of menstruation and the menstrual cycle”, “When “the private” becomes public: menstrual management” and “Navigating menstrual health: between medicalization and agency”. Experiences of menstrual inequity appeared to be widespread among participants. They referred to the impact of having to conceal menstruation and the barriers to managing menstruation in public spaces. Choosing menstrual products was often influenced by price and availability; several participants reported menstrual poverty. A general lack of menstrual education was described. Menstrual education was usually gained through personal experience and self-learnings, or through families and friends. Menstruation and the menstrual cycle had a significant impact on participants’ day-to-day. Accessing and navigating the healthcare system was challenging, as participants mostly reported feeling dismissed and almost exclusively offered hormonal contraception as a panacea to address menstrual health. *Correspondence: lmedina@idiapjgol.info 1 Fundació Institut Universitari per a la recerca a l’Atenció Primària de Salut Jordi Gol i Gurina (IDIAPJGol), Gran Via de les Corts Catalanes, 587 attic, 08007 Barcelona, Spain Full list of author information is available at the end of the article © The Author(s) 2022. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://​creat​iveco​mmons.​org/​licen​ses/​by/4.​0/. The Creative Commons Public Domain Dedication waiver (http://​creat​iveco​ mmons.​org/​publi​cdoma​in/​zero/1.​0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Holst et al. Reproductive Health (2022) 19:45 Page 2 of 16 Conclusions: The impact of menstrual inequity appears to be far-reaching. Multidimensional structural policies should promote agency in individuals and communities to enable opportunities for menstrual education, access to menstrual products, healthcare services and adequate menstrual-management facilities. Health professionals’ training is also nec‑ essary to improve access to and quality of menstrual healthcare. Policies need to be inclusive of non-binary and trans people, and vulnerable populations. Keywords: Menstrual health, Menstrual inequity, Menstrual equity, Period poverty, Menstrual hygiene management, Androcentrism, Menstruation, Social inequities of health Plain language summary There is a lack of research on menstrual health and menstrual inequity. However, we already know that menstrual inequities may have a negative effect on menstrual health. Yet, politicians, policymakers and healthcare professionals rarely pay attention to menstrual inequity and menstrual health. This study had the objective to collect experiences of menstrual inequity and menstrual health among women and people who menstruate (trans and non-binary people) between 18 and 55 in the Barcelona area (Spain). Thirty-four participants took part in interviews between December 2020 and February 2021. We used photographs during the interviews to deepen discussions with participants. We did the interviews in sexual and reproductive health centres, in public spaces and over the phone. Participants shared a variety of experiences of menstrual inequity and health. For instance, some participants explained that they had expe‑ rienced financial issues to buy menstrual products. Others, that it was often difficult to find adequate spaces to change menstrual products at schools, workplaces and public spaces. Participants told us that they mostly learned about men‑ struation through their own experiences and talking to family and friends. They had little information on menstruation. Also, when participants sought medical help they usually found that health professionals usually only offered hormonal contraception to treat menstrual issues. They felt frustrated and dismissed. In general, they thought that menstrua‑ tion affected their daily lives. Therefore, it is very important to train professionals, continue research and put policies for menstrual inequity and health in place. Resumen Introducción: La salud y la inequidad menstrual no han sido bien atendidas en las esferas social, económica, sanitaria y política. Aunque la evidencia disponible es escasa, ya sugiere un vínculo entre experiencias de inequidad menstrual (relativa a las dificultades sistemáticas para el acceso a la salud y educación menstrual, productos menstruales y espa‑ cios de manejo menstrual, entre otros aspectos) y la salud menstrual. El objetivo de este estudio fue explorar las experi‑ encias de salud e inequidad menstrual en mujeres y personas que menstrúan (18–55 años) en Barcelona y alrededores (España). Métodos: Estudio cualitativo desde una perspectiva feminista crítica. El muestreo fue intencionado y selectivo. El reclu‑ tamiento se realizó en centros de salud sexual y reproductiva, redes sociales y a través de técnicas de bola de nieve. Se realizaron 34 entrevistas semi-estructuradas utilizando foto-elicitación, entre diciembre de 2020 y febrero de 2021. Las entrevistas se llevaron a cabo en centros de salud sexual y reproductiva, espacios públicos y por teléfono. Los datos se analizaron mediante Análisis Temático Reflexivo. Resultados: Se identificaron tres categorías: “Descuido sistemático de la menstruation y el cycle menstrual”, “Candy “lo privacy” se vuelve public: manejo menstrual” y “Navegando la salad menstrual: entree la medicalización y la agencia”. Las participantes compartieron diversas experiencias de inequidad menstrual. Diversas participantes compartieron experiencias de pobreza menstrual, al no poder acceder o escoger productos menstruales debido a su precio y disponibilidad. Según las participantes, los aprendizajes menstruales son escasos. Estos suelen darse a través de la experiencia propia y el autoaprendizaje, o de familiares y amigas. La menstruación y el ciclo menstrual parecen tener un impacto significativo en el día a día, incluyendo el impacto de tener que ocultar la menstruación y las barreras para manejar la menstruación en los espacios públicos. Se identificaron barreras para acceder y utilizar el sistema sanitario. Las participantes también reportaron la prescripción sistemática de anticonceptivos hormonales como panacea para abordar la salud menstrual. Conclusiones: Es necesario desarrollar e implementar políticas estructurales y multidimensionales para promover la agencia de las mujeres y personas que menstrúan, así como de las comunidades, para generar oportunidades para Holst et al. Reproductive Health (2022) 19:45 Page 3 of 16 aprender sobre la menstruación, acceder a productos menstruales y servicios de atención sanitaria, así como a espa‑ cios adecuados para el manejo menstrual. Fomentar la formación de profesionales de la salud es también crucial para mejorar el acceso y la calidad de la servicios para la salud menstrual. Estas políticas deben incluir a las personas trans y no binarias, así como a poblaciones más vulnerables. Palabras clave: Salud menstrual, Inequidad menstrual, Equidad menstrual, Pobreza menstrual, Manejo menstrual, Androcentrismo, Menstruación, Inequidades sociales en salud Introduction and material barriers to accessing menstrual products. It Menstruation is a healthy biological event that has also includes menstrual hygiene management (or men- recently been considered a vital health sign [1, 2]. Men- strual management), which focuses on the need to ensure strual health (MH) can be defined as having menstrual safe menstrual management facilities (e.g., spaces that are cycles lasting 21–35 days, a menstrual cycle variation clean, where water is available and include a bin and can of 5–7 days yearly, menstrual flow during 2–7 days and be locked) [11, 13–18]. MI is argued to be the result of bleeding between 25–80 ml per menstruation [3, 4]. androcentric social, economic, political and research sys- Other authors also indicate that a healthy menstrual cycle tems. Besides, while the link between MI and MH has yet should be ovulatory [5]. Recently, MH has been defined not been established, we argue that addressing MI may from a more holistic perspective, as: “a state of complete have a positive impact on MH outcomes. physical, mental, and social well-being and not merely Barriers to address menstruation as a natural event the absence of disease or infirmity, in relation to the men- for half of the population leads to experiences of stigma strual cycle.” [6]. However, MH is often disregarded in and shame, and compromises community participation, healthcare and not included in public health strategies equity and free agency [19, 20]. Stigma, shame, taboo [7], despite experiencing MH issues (e.g., dysmenorrhea) and misconceptions around the menstrual cycle and could greatly compromise quality of life [8]. This struc- menstruation are prevalent in many cultures [14]. Men- tural neglect is explained by how ingrained androcentric struation is surrounded by negativity, mystery, and ideas values and norms (i.e., considering male’s needs, priori- of dirtiness [21] and embarrassment [31]. One of the ties, values and stereotypical physical characteristics as reasons for menstrual concealment and some taboos to “the gender-neutral standard”) are in social, political and prevail is because menstrual education is usually through research systems [9, 10]. Based on this, menstruation families [13, 21, 22]. Even if community-based education cannot be considered normative within the lens of andro- should be promoted, the population should have better centrism [10]. access to accurate menstruation-related information and Based on the current study, the authors have concep- knowledge. University curricula on healthcare, public tualized menstrual inequity (MI) as a two-fold concept health and education professions should also incorporate (Medina-Perucha et al., in prep). First, MI can be under- MH and MI as public health issues [18, 23]. stood in comparison to men and other non-menstruating Another consequence of prevailing MIs is the medicali- people (out-group MI), as “the systematic and avoidable zation of the menstrual cycle and menstruation [24, 25]. disparities in the access to healthcare, education and Hormonal contraception (HC), which generally stops a knowledge, experiences of stigma and discrimination, natural menstrual cycle and menstruation, is a common the lack of research on the menstrual cycle and men- strategy to manage menstruation-related issues such as struation, and the barriers to social, community, political menstrual pain or even acne [20, 26]. Women and PWM and economic participation based on having a menstrual experiencing menstrual problems rarely attend health- cycle and menstruating”. Second, we may consider MI care services, partly as some menstrual health problems within women and people who menstruate (PWM) (in- tend to be normalized and dismissed [22, 27, 28]. Delayed group MI) as “the systematic and avoidable disparities diagnoses (e.g., of endometriosis) and negative experi- between different populations in the access to menstrual ences are expected when seeking institutionalized health- healthcare, menstrual education and knowledge, prod- care for menstrual-related issues [27]. ucts, services and facilities for menstrual management, Previous evidence suggests that dysmenorrhea (pain- menstrual-related experiences of stigma and discrimi- ful menstruation) is widespread among women and nation and barriers to social, community, political and PWM [29] and may be related to absenteeism [22, 29] economic participation” (Medina-Perucha et al., in prep). and presenteeism in the workplace and schools [30] This conceptualization of MI encompasses period poverty (e.g., working while feeling unwell). On the other hand, (or menstrual poverty) [11, 12], which refers to financial community-based and policy actions are focusing on Holst et al. Reproductive Health (2022) 19:45 Page 4 of 16 reducing menstrual products’ price. Their cost has been and equity and exposing disparities [43, 48, 49]. Reflex- increasingly questioned, since they are rarely taxed as ivity, considered one of the pillars for critical qualitative necessity goods and some women and PWM cannot research [50], has been an integral part of the research afford them [31–34]. Despite the need to reduce men- process. The authors have continuously considered how strual products’ costs, partly as a matter of social justice, their own perceptions and experiences have influenced price reductions may not be enough to ensure affordabil- the research questions, data collection and analysis. ity [32, 33]. In fact, there have been various social move- Quality and rigor have been ensured by following the ments aiming at normalizing the conversation around Guba & Lincoln criteria [51], by ensuring the research’s menstruation [35], criticizing the cost of menstrual prod- (1) credibility (i.e., confidence in the truths apparent in ucts and the application of the “pink tax” in various coun- the findings), (2) transferability (i.e., findings are applica- tries [32–34]. The “pink tax” refers to products marketed ble to the context where the research has conducted and towards women being more expensive than “male prod- can inform other contexts), (3) dependability (i.e., find- ucts” (e.g., razors). ings are consistent and the research could be replicated), These social movements have also encouraged the pro- and (4) confirmability (i.e., findings are true to partici- motion of health literacy [22, 36], the “ability to interpret, pants’ accounts and researchers’ motivations, interests maintain, understand and use health decisions and fol- and perspectives have been clearly exposed). Research low treatment instructions” [27]. “Body literacy” may be quality has also been evaluated through the Critical a more appropriate concept when discussing menstrual Appraisal Skills Programme (CASP) tool [52] (see Addi- health. We define it as: (1) the ability to understand and tional file 1). The term PWM will be used to be inclu- observe how health and wellbeing are connected to the sive of people who menstruate that are trans, intersex or body’s natural functions and their environment, (2) the non-binary. knowledge to engage in meaningful discussions with health professionals and (3) the confidence to participate Participants in decisions regarding one’s health [36, 37]. If women Study participants were 34 women and PWM aged and PWM can understand and make decisions regarding 18–47 years old, living in Barcelona or surrounding their menstrual cycle and menstruation, they can better areas. Having entered menopause or have been 1 year monitor and self-manage their health [3]. or more without menstruating due to ovarian failure, Although half the population menstruates, MH and was the main exclusion criteria. One participant (P2) MI are largely ignored worldwide in social, economic was interviewed unknowingly that she had recently and political spheres. This has translated into a lack of entered early menopause. Her interview was included research and inclusion of MH and MI in public health, in the analysis for ethical reasons, as data were already healthcare and educational agendas [7]. This is inherently being collected when researchers knew that she was associated with the gender research (or data) gap and not menstruating regularly. See Table 1 for participants’ androcentric and patriarchal systems [7, 10, 24, 38, 39]. sociodemographic information and Additional file 2 for Most research on MH, menstrual poverty and menstrual participants’ self-reported menstrual cycle and menstru- management has been conducted in the Global South, ation characteristics. investigating menstrual health and menstrual inequity in the Global North is also imperative [31, 40]. This study Sampling and recruitment aimed at exploring experiences of menstrual health and Sampling was purposive and selective. Participants were menstrual inequity among women and PWM aged 18–55 recruited through social media (Instagram, Twitter and in the Barcelona Metropolitan area. It is part of a larger WhatsApp) and relevant key persons and organizations mixed-methods project, the “Equity and Menstrual in the Barcelona area such as public sexual and repro- Health in Spain” study. ductive health centers (ASSIRs). Discourse diversity was ensured by recruiting participants with different charac- Methods teristics, such as age, socio-economic context, country This is an explorative qualitative study, using photo- of birth, gender and being from the Roma community (a elicitation techniques [41, 42]. This work takes a critical distinctive and widespread cultural group in Spain). Spe- and feminist perspective [43–45], to critically examine cial attention was paid to recruiting women and PWM systemic neglects and structural violence embedded in who had limited access to social media, people living in institutions and social structures, and how power rela- socio-economic deprived areas, participants from the tions have an impact on society [45–47]. Taking a femi- Roma community and migrant populations. Snowball nist perspective means considering social inequities from sampling techniques were also used. a gender perspective, working to attain freedom, justice Table 1 Participants’ sociodemographic characteristics (N = 34) ID Age Residence (city) Birthplace Administrative Employment Economic Completed Gender Identifies as Roma Interview location status status issues in the education trans community last year P1 27 Sant Adrià del Spain Spanish national‑ No employment/ Yes, sometimes Primary educa‑ Woman No Yes ASSIR Besos ity income tion P2 40 Barcelona Spain Spanish national‑ Works full-time No Secondary educa‑ Woman No No ASSIR ity tion Holst et al. Reproductive Health P3 23 Barcelona Spain Spanish national‑ Maternity leave Yes, sometimes Professional Woman No Yes ASSIR ity education P4 24 Barcelona Spain Spanish national‑ Works full-time No University studies Woman No No Telephone ity P5 25 Barcelona Spain Spanish national‑ Works full-time No University studies Woman No No Telephone ity (2022) 19:45 P6 29 Barcelona Spain Spanish national‑ Self-employed No University studies Not sure Not sure No Telephone ity P7 33 Sant Cugat del Spain Spanish national‑ Works full-time No University studies Woman No No Telephone Vallès ity P8 35 Sant Feliu de Spain Spanish national‑ Works full-time No University studies Woman No No Telephone Llobregat ity P9 24 Barcelona Spain Spanish national‑ Works full-time Yes, always University studies Woman No No Telephone ity P10 33 Barcelona Spain Spanish national‑ Works full-time No University studies Woman No No Telephone ity P11 33 Barcelona Spain Spanish national‑ Works full-time No University studies Woman No No Telephone ity P12 25 Barcelona Spain Spanish national‑ Work full-time; No University studies Woman No No Public space ity Studies part-time P13 25 Barcelona Spain Spanish national‑ Works full-time No University studies Woman No No Public space ity P14 26 Barcelona Spain Spanish national‑ Studies full-time No University studies Woman No No Public space ity P15 25 Sabadell Spain Spanish national‑ Works part-time No University studies Woman No No Telephone ity P16 47 Tarragona Spain Spanish national‑ Works full-time No Professional Woman No No Telephone ity education P17 34 La Torre de Clara‑ Spain Spanish national‑ Works full-time No University educa‑ Woman No No Telephone munt ity tion P18 23 L´Hospitalet de Spain Spanish national‑ Medical leave; Yes, sometimes Professional Woman and non- Not sure No Telephone Llobregat ity Studies part-time education binary P19 25 Barcelona Spain Spanish national‑ Works part- Yes, sometimes Secondary educa‑ Woman No No Telephone ity time; Studies tion full-time Page 5 of 16 Table 1 (continued) ID Age Residence (city) Birthplace Administrative Employment Economic Completed Gender Identifies as Roma Interview location status status issues in the education trans community last year Holst et al. Reproductive Health P20 20 Barcelona Spain Spanish national‑ Studies full-time Not sure Secondary educa‑ Woman No No Telephone ity tion P21 35 Badalona Spain Spanish national‑ Self-employed; No University studies Woman No No Telephone ity Studies part- time;Unpaid houseworker (2022) 19:45 P22 18 Barcelona Spain Spanish national‑ Studies full-time; Yes, sometimes Secondary educa‑ Woman No No Public space ity Unpaid house‑ tion worker P23 28 Sabadell Spain Spanish national‑ Works full-time No University educa‑ Woman No No Telephone ity tion P24 20 Sabadell Spain Spanish national‑ Studies full-time No Secondary educa‑ Non-binary Yes No Telephone ity tion P25 37 Badalona Morocco Permanent resi‑ Works full-time No Professional Woman No No Telephone dence education P26 24 Manresa Spain Spanish national‑ Works part-time Yes, sometimes Professional Woman No No Telephone ity education P27 35 Sabadell Columbia Spanish national‑ Unemployed Yes, sometimes University studies Woman No No Telephone ity P28 37 Cardedeu Spain Spanish national‑ Works full-time No University studies Woman No No Telephone ity P29 23 Barcelona Argentina Refugee status No income Yes, sometimes Secondary educa‑ Woman No No ASSIR tion P30 22 Barcelona Spain Permanent resi‑ Works full-time Yes, sometimes Professional Woman No No ASSIR dence education P31 25 Badalona Pakistan Permanent resi‑ Works full-time Yes, sometimes Professional Woman No No Public space dence education P32 29 Terrassa Spain Spanish residence Works full-time No University studies Woman No No Telephone P33 28 Esplugues del Spain Spanish national‑ Works full-time Yes, sometimes University studies Woman No No Telephone Llobregat ity P34 38 Sant Adria del Brazil Spanish national‑ Unemployed Yes, sometimes Professional Woman No No ASSIR Besòs ity education ASSIR: sexual and reproductive healthcare centre Page 6 of 16 Holst et al. Reproductive Health (2022) 19:45 Page 7 of 16 Data collection inductively, through deep analysis and reflection, as well Thirty-four semi-structured photo-elicitation interviews as discussions between ASH and LMP [56]. A meeting were conducted between December 2020 and February with the whole research team was organized to have an 2021. Individual interviews were considered most appro- in-depth discussion on the preliminary findings. A pre- priate since menstruation is often considered a taboo and liminary conceptual framework with themes and sub- could be a sensitive topic [53, 54]. Photo-elicitation tech- themes was developed. The remaining 22 interviews were niques were chosen to facilitate conversations around then coded and analyzed based on the conceptual frame- menstruation and elicit participants’ responses and par- work developed by LMP and ASH. While new themes did ticipation [41, 42, 46], and allow to reinforce the themes not emerge on this second round of analysis, themes and discussed throughout the interviews [55]. A topic guide sub-themes were re-organized. The final thematic frame- was developed by the research team (see Additional work was finally developed based on team discussions. file 3). Data on participants’ conceptualizations on men- struation and menstrual health, identified opportunities Results to improve menstrual health and menstrual equity, per- Data analysis identified three themes: “Systemic neglect ceptions on menstrual products, and perceived impact of of menstruation and the menstrual cycle”, “When “the COVID-19 on their menstrual cycles and menstruation, private” becomes public: menstrual management” and will be explored in future publications. Two photographs, “Navigating menstrual health: between medicalization chosen by the research team, were used during the inter- and agency”. views (see Additional file 4). Photographs were shown to participants, who were asked to discuss the photographs Systemic neglect of menstruation and the menstrual cycle based on how would they describe them and what did There were two sub-themes regarding the systemic they feel about the images portrayed. neglect of menstruation and the menstrual cycle: “Being Participants were given the option of doing the inter- “othered”: the invisibilization of menstruation and the view in person or over the phone, depending on their menstrual cycle”, and “Why am I bleeding from down preferences and COVID-19 public health recommen- there?”: learnings on menstruation and the menstrual dations. Face-to-face interviews (N = 11) were either cycle”. conducted in ASSIRs (N = 6) or public spaces (N = 5) that allowed enough intimacy for the interviews while Being “othered”: the invisibilization of menstruation COVID-19 prevention measures could be ensured. The and the menstrual cycle rest were telephone interviews (N = 23). For telephone Participants treated menstruation as a taboo topic. It interviews, photographs were sent by email just at the was socially considered “dirty” and against “women’s start of the interview. The interviews were conducted by purity”: “It (menstruation) reminds you that it is an ani- LMP (N = 11) and ASH (N = 11). Some interviews were mal body, so then all this idea of an idyllic and virginal conducted by both LMP and ASH (N = 12), as ASH was woman, so Virgin Mary does not exist (…), this stereotypi- training as a qualitative researcher. cal idea of a woman as all purity (…), so the period breaks The interviews lasted between 40 min and 1 h and that (image), because suddenly it is dirty and it bleeds 25 min. All interviews were audio recorded with partici- and this is all opposite to the image of the clean and pure pants’ consent. Participants received a debrief form with woman”-P27. Some participants mentioned how they resources on the menstrual cycle and menstruation, and were expected to conceal menstruation, especially in a 10€ voucher as a token of thanks for participating. public as it was “something intimate”. Participants often refer to physical discomfort or illness instead of disclos- Data analysis ing menstrual pain or other menstrual-related issues, as a Reflexive inductive thematic analysis [46, 56] was used way to conceal menstruation. Interestingly, many partici- for data analyses. First, all interviews were transcribed pants mentioned that they did not perceive menstruation verbatim, anonymized, and prepared for analysis by ASH to be a taboo for themselves and the same time, words and external transcribers. Secondly, a preliminary analy- like: “menstruation” “vagina” or “vulva” were often omit- sis was carried out by ASH and LMP by reading, reflect- ted. The words used instead were “period”, “down there”, ing, and discussing the data, to formulate preliminary “there” or simply paused for a moment to ensure the reflections and themes using data from 12 interviews. interviewer understood what they meant. Talking about These interviews were coded by ASH, and triangu- “women-things” in front of men was uncomfortable for lated with LMP and CJA by comparing and discussing some and it was mostly avoided. In general, menstrua- codes and potential themes and sub-themes resulting tion was perceived shameful when they were younger from them. Themes and sub-themes were identified and more acceptable to talk about during adulthood, Holst et al. Reproductive Health (2022) 19:45 Page 8 of 16 although most women and PWM still feared staining in Participants also indirectly referred to the stigmatiza- public: “There was a girl in my school that had her period tion of “the menstruating woman”, seen as hysterical and quite early and had very abundant periods and so she irrational beings unable “to control themselves”: “Men- stained the chair with blood very often and all that (…) struating woman equals hysteria and hormonal lack of and so she told us to help her hide it, giving her a jacket, control. (…) there might be a hormonal dysregulation (…) waiting for the boys to go to the playground so that we but that doesn’t mean that I do not know how to control could later clean the chair before they saw it (the chair) myself (…) I think this is all a structural problem”-P23. In like that”-P18. line with this, a few participants referred to their part- When discussing the first photograph, as part of the ners as more reliable sources than themselves, to deter- photo-elicitation, participants thought it was “brave” to mine whether or not they experienced emotional changes menstruate in public. This act was seen as undefeated throughout the menstrual cycle: “No, I don’t experience and empowering: “I think it’s wonderful. And well, in (emotional) changes, this is something that my husband fact, I see it as a vindictive act, right? (…) Very interest- can answer, he will say yes. No, no, I don’t experience ing, that she feels free. Of course, why would she stop run- them… (…) No, because look, I’ve just had my period and ning simply because her period has started”-P14. At the he hasn’t said anything to me… right now… he hasn’t said same time, some participants assumed that menstruating anything to me. No, my period just ended and he hasn’t in public could only be an accident, implying that no one said anything, so no, no… I don’t think I experience could actively decide to display menstrual blood in public changes.”-P33. spaces. They expressed empathy and compassion for “this incident”, while they thought public displays of menstrua- “Why am I bleeding from down there?”: learnings tion were socially seen as unhygienic and dirty; “She is a on menstruation and the menstrual cycle pig, not wearing anything (menstrual products)”-P1. Menstrual education were generally depicted to be insuf- Some participants explained that menstrual taboo was ficient and often late. Participants learned about men- related to women being historically seen and treated struation mainly through informal education (family, as an object for social reproduction (i.e., self-care and friends, and others). Even if participants appeared to have care for others, including maintaining physical spaces had access to positive learnings on menstruation, they and organising required resources to care, and human described how they still held negative perspectives on reproduction). Blood had negative associations with menstruation when they were young: “I still don’t under- death, pain, hurt and satanic rituals. A few participants stand very well… I remember that my mum had not had mentioned that bodily fluids had different connotations many period problems and so… that’s why I’m telling you depending on where they come from. Those that came that I don’t know where this idea that “periods are shit” from the vagina were stigmatized: “It’s as if I’m sweaty came from, you know?”-P21. Most participants cited their and there’s a mark in my armpit, it is ok, but if it is a family members as their first and most accessible source blood stain from the vagina, it’s not (ok)…”-P12. Partici- for menstrual education: “I know more or less what it is, pants also mentioned the role of religion, politics, gender menstruation, because in my house…. My grandmother roles and patriarchy to contribute to the invisibilization had talked about it… or my mother had explained it to of menstruation: “As I said, religion (…) and I guess that me. If I had to ask, I would ask and they would explain they are things that have been perpetuated in society. it to me”-P26. Menstruation was almost exclusively dis- Also, seeing women as something that has to be at home, cussed with other women and PWM. really pulled away (…) it (menstruation) turns into some- Not all participants had access to formal menstrual thing that has to be there, behind closed doors”-P19. Fur- education. The formal education encountered was mainly thermore, one participant, who identified as non-binary, at school, where the focus was on reproductive and sex- explained how what is not considered “normative” in an ual health more than menstrual health. Participants men- androcentric society is relegated to the private sphere, tioned that boys were rarely included or participated in mentioning the invisibilization of people who menstruate menstrual education, which was criticized by some who who identify as men: “The androcentric society is sexist,… demanded menstrual education regardless of sex/gen- it is created based on androcentrism around the idea of der. Menstrual education should be adapted to each per- the cis man, normative body, and everything else is rele- son and include all options for menstrual management gated to the private sphere and also (…) bodies that can (including free bleeding). Although most participants did menstruate, for instance, (…) men who menstruate are not consider school an important source of information, totally invisibilised, and for example if they gestate they it was for one participant: “Luckily at school they already are directly seen as monsters and aberrant”-P18. tell you about these things, so I was not caught off guard (at menarche)”-P11. Holst et al. Reproductive Health (2022) 19:45 Page 9 of 16 Interestingly, most participants considered having Managing menstruation in public learned more about menstruation and the menstrual Overall, menstrual management was perceived as cycle through their own experiences and being autodi- “uncomfortable” and “annoying”, and to create a mental dactic: “Like everything (…) One learns to walk by walk- load women and PWM had to endure. In general, par- ing… so… every month I learnt something, mainly to ticipants shared that managing menstruation at home understand your body (…) But I’m not conscious of it was easier: “I know that I am comfortable at home (…), until… relatively until recently”-P33. Social media was I change it (menstrual product) much more often, but if I used as a platform for menstrual education during adult- am at work instead, I know that I cannot get up every now hood by some participants. However, access to men- and then to go to the bathroom and such”-P29. In fact, strual education was mentioned to be unequal, as it was managing menstruation in public spaces was deemed dif- dependent on one’s family, the school they attended, and ficult by participants, mostly due to the lack of adequate their access to self-learning. Some women explained how facilities. Consequently, managing menstruation in pub- it was more difficult for them to access to menstrual edu- lic was generally seen as unhygienic, associated with cation pre- and post-menarche in their countries of birth. health problems (especially if menstrual products could Some participants did not know what menstruation not be changed timely and hygienically), and avoided was at menarche. Some learned about menstruation over by some. In order to be considered adequate, menstrual time through friends or other sources (e.g., the internet management spaces had to be clean, contain a sink, a bin or TV): “Yes, the period (…), they have not explained it and a hanger for clothes within the bathroom stall, and well (…). Until I searched for “why is blood coming out have a door that could be properly locked. from me down there”, nobody ever explained this to me”- These struggles were also common in workplaces P30. Menarche was symbolically perceived as a transition and schools, not just because of the lack of appropri- into womanhood and adulthood. This was often per- ate menstrual management facilities but social barriers. ceived to be distressing (and even traumatic), especially if P26 shared how she was questioned about her reasons menarche was at an early age and they were the first ones for using the bathroom, a basic need, in school: “So you in their friend groups to menstruate. had to tell them, please, I need to go to the bathroom Participants generally had no information on how a because I’m on my period, and I need to go to change well, healthy menstruation and menstrual cycle looked like, it’s like… you have to explain everything that happens so so participants appeared to construct their perceptions that they let you go… and of course you had to say it in the and believes comparing their experiences to women and middle of the whole class, like they were like “wow, she has PWM around them:” I don’t have the ideal menstrual her period, she’s going to change” … it was like … pf … you cycle that everyone dreams of, but I have also seen other know, some uncomfortable moments”-P26. realities that are worse”-P11. If participants had ques- tions or concerns, they usually turned to friends, family, Menstrual products are necessity goods: menstrual poverty and the internet before asking a healthcare professional. All participants considered menstrual products as neces- Overall, participants agreed that menstrual education sity goods, although one participant (P9) mentioned how should be fully available and accessible, to promote posi- they were only perceived to be necessary since men- tive views on menstruation and the menstrual cycle; men struating in public was socially unacceptable. Most con- should be included. Those participants who were moth- sidered menstrual products unjustly expensive. They ers reflected on how they would educate their children thought that taxes on menstrual products, and/or their on menstruation: “Well me with my child (male child), I price, should be lowered: “They have super high taxes, want to speak with him mainly like this, an open conver- when it is a basic need’s product”-P24. While some partic- sation and all and explain things not to repeat mistakes… ipants advocated for the need of free menstrual products, (referring to her parents)”-P34. at least for more vulnerable people, a few claimed that menstrual products should not be free as other essential When “the private” becomes public: menstrual products are not. Two participants (P33, P34) expressed management their concerns if menstrual products were free; they said Three sub-themes were identified, related to menstrual that this measure would need to be implemented care- management and its impact on participants’ lives: “Man- fully, implying that some people might re-sell menstrual aging menstruation in public”, “Menstrual products are products: “That is a complicated topic because everything necessity goods: menstrual poverty”, and “Menstruation’s that is for free I believe that in some way people try to take impact on daily life: social participation and paid labour”. advantage (…) There would need to be a lot of control. Too much control to start giving out things for free and that they do not escape to the “black market””-P34. Holst et al. Reproductive Health (2022) 19:45 Page 10 of 16 Some participants had experienced menstrual poverty Jordan, Brazil and Philippines), especially tampons, (P1, P3, P9, P18, P19, P25, P26, P29, P30, P31) at some organic and reusable products (except for cotton cloths point in their lives. P1 shared that she had struggled to or self-made menstrual pads). This was negatively linked afford menstrual products sometimes if menstruation to menstrual health: “Unfortunately there are many came before her salary, or if the usual cheap pads were women in other parts of the world, we are not talking sold out. In these cases, she would use toilet paper or only in Europe where we have everything in our reach. borrow menstrual products from friends. Menstrual But in other areas (…) then, of course, they can’t feel the products’ price seemed to be the main reason for partici- menstrual health”-P25. The idea that reusable products pants not being able to buy the products they preferred, have to be promoted was shared by some participants, even if they caused discomfort and health issues: I do not although personal choice needed to be respected and buy the pads non-branded. But I do buy the tampons non- free-will ensured. Others mentioned the importance of branded. Maybe that’s why it hurts (laughing) (…). Tam- men being involved in promoting menstrual products’ pons (branded) are more expensive than pads (branded). accessibility. Buying the two things (branded) is not feasible for me to be honest.”-P30. Other participants used menstrual products Menstruation’s impact on daily life: social participation for a longer time than recommended when they could and paid labour not afford menstrual products, or to save money. When Menstrual pain appeared to have the biggest impact on having more financial issues, other participants decided participants’ lives, but also heavy bleeding, low energy to use the cheapest products available. However, a few levels, difficulty concentrating, premenstrual symp- participants attributed using cheap products to vaginal toms and emotional changes throughout the menstrual infections. Still, a few participants chose the cheapest cycle. Even if participants mostly referred to the impact products that did not cause them health issues. of menstruation on paid work, social participation was On the other hand, a few participants had been forced also mentioned. The latter were mostly adapted, but to prioritize purchasing menstrual products over other sometimes cancelled. Avoiding hard physical activities, goods or activities. Menstrual products were prioritized sex, swimming, praying, going to the beach, exercis- as they were considered necessity goods: “So I knew that, ing, and driving due to pain and/or heavy bleeding was (…) I am a woman and that it (menstruation) came every common. Feeling unwell during menstruation or at any month. So, I knew that food and my (menstrual) product other time during the menstrual cycle had also an impact could not be missing. Then I would see about the rest”-P29. on other responsibilities such as those related to social Another participant shared a similar story: “It was either reproduction: “Obviously our health is dynamic and our pads or going for a bite? The pad goes first”-P30. emotional state. And our responsibilities outside of the Accessibility to menstrual products was also mentioned workplace”-P10. to be compromised depending on the type of prod- Especially menstrual pain, but also emotional fluctua- uct used and whether women and PWM lived in rural tions related to the menstrual cycle and premenstrual or urban areas. For instance, reusable, organic (with- symptoms, had an impact on paid labour. Many said it out endocrine disruptors) and non-reusable products was more complicated to work while menstruating, due were more difficult to access, especially in small shops to the unavailability of spaces to change menstrual prod- and rural areas. Assuming that women and PWM could ucts and because of menstrual pain impacting their abil- always freely choose menstrual products was actually ity to focus. Presenteeism was common as absenteeism challenged by P14. She critically argued that the energy due to menstruation and was perceived as embarrassing and time to look for less available products compromised and even unacceptable. This was due feeling that men- the use of less mainstream (but healthier) options: “It is struation was not a “good enough reason” to stop work- not so much of a choice because I…, if all products were ing. In order to avoid absenteeism, participants either on the shelfs (…) And you really have them equally acces- took painkillers (“When I feel the slightest bit of pain, sible, you are deciding more freely indeed. But if they are I take something (painkillers), because if not, I already offering you a particular product that has a way higher know that I will not be able to work, you know? (…) I cost. Well you have to find the time to do these things know I should not do it like this. But if I don’t do it… Every (find menstrual products), but in the end you don’t have month I would miss two days of work, you know”?-P12) it (time), to be honest. And you go and look for the quick or used HC to continue being productive at work, or to solution”-P14. avoid managing menstruation in the workplace (“I cheat, Migrant and second-generation migrant participants because my period comes on Friday night, (…) because at also described how it was harder to access menstrual the beginning I did have a little bit of a painful menstrua- products in their countries of origin (Morocco, Pakistan, tion and I believe that it came in the middle of the week Holst et al. Reproductive Health (2022) 19:45 Page 11 of 16 (…) and work-wise (…) that day I was useless”-P6). How- Experiences and access to health services for menstrual ever, some mentioned having to take days off from work. health For all, there was more presenteeism at work, while dur- Overall, participants had previously sought medical help ing their time at educational institutions there was more for menstrual-related issues, although some sought pro- educational absenteeism. They had also experienced fessional assistance only if they had issues getting preg- presenteeism at school/university when responsibilities nant. Despite a few participants mentioning that they (e.g., an exam) were unavoidable. One participant (P25) had very good experiences accessing healthcare services, gave her daughter painkillers for menstrual pain to pre- most shared negative experiences. They felt that they vent her daughters’ school absenteeism. She explained were not listened to and their concerns were easily disre- that if her daughter could not attend school due to men- garded and unattended. For instance, menstrual pain was strual pain, she would not go to work. normalized and dismissed within the healthcare system As P8 explained, menstruation is wrongly perceived (as it was socially). Besides, health professionals often did to be a burden as it does not fit into the current socio- not give enough information for women and PWM to economic system based on continuous productivity. She make informed decisions: “Gynecologists, and my mum suggests the need of systemic changes towards a more is one of them, do not always explain well how hormonal cyclic productivity model based on the menstrual cycle: contraception works in the body, right? And the truth is “Because you are as if you were ill, and ill people do not that it is important that this is explained, and once you produce, and those who do not produce are less valued know how it works, you decide”-P21. in society, and consequently in the working area it (men- A participant, who was born in Pakistan and worked struation) is seen as a burden (…) there is much that can as a cultural mediator in healthcare services, mentioned (menstrual cycle) can contribute to qualitatively”-P8. One that disclosing vaginal pain or amenorrhea was difficult woman (P34) told the researchers how some work col- for some Pakistani women to share with healthcare pro- leagues had been fired due to menstruation supposedly fessionals (P31). This was aggravated if the healthcare impacting their work performance. Most participants professional was a man. Another participant stated that stated for the need for menstrual policies at workplaces. not all women and PWM have the same access to health- Working from home during menstruation was seemingly care services, and thus to have a good menstrual health: perceived ideal by most participants. Menstrual leave “I’ve you’ve got money you can afford it (…) economic dif- was mentioned too, for those who may need it “without ferences can lead to differences in health, so, you can care having to feel bad, guilty, or that I’m a bad worker, or for yourself more or less (…) You can attend to a doctor lazy”-P14. because you have less worries in relation to obtaining food When asked if they thought menstruating created a or proper housing and so, and at the same time you can disadvantage compared to men and non-menstruating buy better-quality products or that better adapt to your people, some participants perceived it as uncomfort- menstruation”-P23. able more than a disadvantage. Other women and PWM Participants reported to have been diagnosed with thought menstruating was a disadvantage if they expe- several menstrual-related issues or health conditions: rienced dysmenorrhea, because of the mental load of endometriosis, polycystic ovary syndrome, amenorrhea, managing pain, or if their partners did not support them. adenomyosis, dyspareunia, anemia or acne. Many par- Others said that society had created the disadvantage, ticipants experienced dysmenorrhea and heavy bleeding. rather than it being originated from menstruating itself: Menstrual pain, already mentioned as the most inva- “Maybe we have to take a step back and see that the prob- sive menstrual issue in participants’ lives, was managed lem is not menstruation. Maybe it’s what we do with it… either by trying to relax and use natural methods for ”-P12. The lack of research was also mentioned by one pain management (e.g. hot water bottles or teas), by tak- participant as contributing to the invisibilisation, lack ing painkillers or HC, or by disregarding it: “It depends if of knowledge on menstruation and the menstrual cycle I’m at home or I’m out of home doing things, obligations and subsequently resulting in a perceived disadvantage of that I cannot say no to. If I can I always try to rest (…) menstruating. at home I can allow myself to be lying down (…) I use a hot water bottle or maybe I drink teas or hot things and I Navigating menstrual health: between medicalization try to manage pain mentally. When it’s not possible (…) I and agency would need to take a pill, some sort of painkiller, to do my This theme includes data on participants’ accounts of two tasks, otherwise it is impossible for me”-P8. Interestingly, these two sub-themes: “Experiences and access to health both menstrual pain and abundant bleeding were often services for menstrual health” and “Systemic medicaliza- considered normal and “part of being a woman” for most tion of menstruation and the menstrual cycle”. participants. Holst et al. Reproductive Health (2022) 19:45 Page 12 of 16 The perceived lack of answers from the healthcare a woman to have to suffer these pains for menstruation… system appeared to leave participants to navigate MH but as the specialists I have seen, told me the same thing, on their own, while some had sought help from naturo- it has been well, so… whatever, I guess I will have to accept paths and other non-medical professionals: “In reality, if it (…) It is as if they don’t give importance to your pain, I can avoid it I prefer no to go to traditional doctors (…) and (…) it makes you a bit angry, right? “-P12. I would try to look for something like Chinese medicine, acupuncture, things like that”-P18. Managing stress and Discussion emotional distress, factors that a few participants associ- Through participants’ experiences, we have explored the ated with changes in menstrual patterns (e.g., intensified complex, structural and multi-dimensional nature of MH menstrual pain), was an approach for some participants. and MI. Menstrual inequities are an unacceptable conse- Making nutritional changes had also helped one partici- quence of androcentrism [9, 10]. They appear to be wide- pant (P8) to manage menstrual pain. For the same par- spread among women and PWM and to take a variety of ticipant, having to manage pain on her own had led her forms. Our findings suggest that MI does not only com- to feel guilty for feeling pain at times. promise MH but it may also impact emotional health and wellbeing [11]. While it was not as evident in our data, Systemic medicalization of menstruation and the menstrual MI may also be a barrier to self-care and social repro- cycle duction [57]. As one participant explained, menstrua- Participants generally expressed frustration over treat- tion and the menstrual cycle are expected to remain in ment options offered in healthcare services. Medicaliz- the shadows, hidden and managed in intimate and there- ing with HC appeared to be the only option given: “It’s fore private spaces. The parallelism with women’s histori- like the only thing (HC) that they give, the alternative to cal relegation to the “private life” becomes conspicuous. everything that happens to you with your menstruation is While menstruation remains invisible, we argue that the “antibabies”-P12. HC was often prescribed as a “solu- menstrual management in public spaces (including tion” for menstrual-related issues such as menstrual pain, schools and workplaces) is challenging [58]. In turn, the irregular menstrual cycles, heavy bleeding, amenorrhea, lack of adequate menstrual management facilities in pub- and acne. Most participants distrusted the generalized lic spaces contributes to the invisibilization and taboo of prescribing of HC as an actual treatment for their health menstruation. Besides, not being able to manage men- concerns, especially when they had no medical exams or struation reinforces and perpetuates MI and may lead to tests to explore the reasons for menstrual-related issues. health risks [18, 59–61]. There was a general perception of HC being “harmful” With menstruation being socially stigmatized [11, 53, and some participants expressed resistance to taking HC 62] and menstruation socially-constructed and expected for reasons other than contraception: “If I will have a ter- to be invisible and hidden, controlling menstruation, rible acne breakout again… Uhm, I’d be looking for other for example through medicalization, becomes a moral ways to treat it”-P5. Still, many perceived HC as an “easy” imperative [19]. The medicalization of women has and accessible option to manage MH. Many participants already been discussed in the literature [24, 25, 38, 63, disclosed negative experiences with HC due to the sec- 64]. Unsurprisingly, menstruation has for a long time ondary effects, which were often overlooked by health- been constructed as a “health issue” in need of medi- care professionals. P31 shared not being aware of the calization [64] and has been critically under-addressed risks of taking HC until they told her to stop taking HC in public health [23]. This points to the importance of due to a blood clot: “it was a small blood clot, right? (…) reframing menstruation as a vital sign of health [1], which Nobody had ever explained this (risk) to me”-P31. does not seem implemented in clinical practice based on At the same time, medicalization was sometimes per- our results. There is a need to address the medicaliza- ceived as a means to gain control over their menstrual tion, not only of menstruation but of the menstrual cycle. cycle, or to have a “normal” menstrual cycle. Some par- Also, it is important to de-normalize menstrual pain and ticipants perceived HC to “regulate” their menstrual other menstrual-health related issues, to ensure timely cycle. P3, who used the vaginal ring, said the following: diagnoses and respectful approaches to menstruation “That caught my attention, “wow, my period (cycle) was and MH. Working on shifting power dynamics in health- very controlled”-P3. care [24, 27] is also necessary to ensure women’s and Similarly, there was resistance to taking painkillers for PWM’s agency to care for their MH and overcome MI. menstrual pain, although these were often considered Overall, the dismissive and often paternalistic approach indispensable to continue daily life. Seeking professional towards MH could result in self-medicating, as seen in help for menstrual pain was sometimes perceived as dif- our results, and have a profound impact on general phys- ficult and frustrating: “I think it shouldn’t be normal for ical, emotional and community health. Inequities among Holst et al. Reproductive Health (2022) 19:45 Page 13 of 16 different populations (e.g., vulnerable migrants, refugees, attainment, social and economic participation, and ulti- people from the LGTBIQ+ and Roma communities, mately health outcomes [71, 72]. Other studies have those living in a situation of homelessness or functional assessed productivity loss in the workplace due to diversity groups) to access healthcare services should also menstrual-related issues [30]. However, it is important be acknowledged and tackled. to shift the narrative from attempting for women and Among our participants, menstrual education appear PWM to fit into androcentric socio-economic systems, to be gained mostly through social networks and self- towards adapting social and economic productivity sys- learning. Although social learnings can strengthen tems to those who have a menstrual cycle and menstru- agency among women and PWM, they could also lead ate. Workplace menstrual policies, such as flexible hours, to misconceptions around the menstrual cycle and men- menstrual leave or the creation of well-being spaces, struation [21]. It thus appears necessary to promote men- are suggested as measures to support menstrual man- strual education in formal, such as schools or healthcare agement in the workplace [73]. While it is important to services, and informal settings. Both formal and informal acknowledge some women and PWM prefer to work education could equip individuals and communities with from home or take a day off while menstruating, men- enough informational resources, to ensure good-quality strual leave comes with the risk of being a band-aid for a community learning and development [65]. Implement- structural problems in healthcare access. Besides, work- ing menstrual education in schools equally will be key to place menstrual policies should be adapted to the charac- prevent deepening in-group MI [66]. We further suggest teristics of each occupation and individual context. focusing on improving body literacy [27, 37]. However, it Further attention should also be placed on the impor- is also critical that social, economic and political systems tance of self-care and social reproduction when it comes do not ignore their responsibility in ensuring good-qual- to MH and MI, challenging the generalized prioritization ity education and healthcare [67]. Boys, men and people of monetized powers and markets [74]. As discussed in who do no menstruate should also be included in educa- “Results” section, presenteeism and absenteeism from tional strategies, as they could actively support women’s educational and productivity systems may not only come and PWM’s MH and become reliable partners in fighting from one’s own menstrual experiences but the experi- MI. ences of those one cares for. This is one of the reasons Based on our findings, we propose three main types why MI should concern us all, regardless of whether of menstrual poverty: (1) not being able to afford men- we menstruate or not. Increasing community aware- strual products, (2) not being able to choose preferred ness and engagement for MH and MI could help ensure products, and (3) having to prioritize menstrual prod- (self-)care among women and PWM. It could also sup- ucts over other products or activities. While menstrual port the establishment of informal and community care policies have been implemented in some countries, these networks to guarantee social reproduction. Not only eco- policies solely focus on menstrual products price reduc- nomic but public and social participation (e.g., engaging tion and availability. These strategies come with the risk in social activities) appears to be compromised due to of being tokenistic and not necessarily ensuring afford- MI and MH issues, so policies need to ensure women’s ability [33] or addressing other aspects of MI. Even if pro- and PWM’ social, economic and political participation. moting reusable menstrual products can be a sustainable Further research is needed, particularly on the potential and convenient option to reduce menstrual poverty and relationship between MI, MH and social and community support MH [68], these products are not acceptable for participation. all [69]. Furthermore, our findings suggest that acces- While policy interventions are necessary, these need to sibility to products may not just be related to price but be multi-dimensional and aimed at structural determi- availability. Women and PWM in a situation of financial nants of MI and MH. Although ensuring accessibility to and/or social vulnerability, or those living in rural areas, menstrual products and menstrual management in work- may have decreased opportunities to access less con- places are necessary to reach menstrual equity, stand- ventional products due to a lack of resources, including alone strategies can be rather paternalistic and become time poverty [70]. In turn, time poverty may limit educa- a barrier for individual agency and social capital [73]. tional opportunities, engaging with healthcare services, Together with ensuring equal access to menstrual prod- the ability to earn money and is associated with poorer ucts, strategies to address MI and MH should ensure com- health outcomes [10]. Thus, lack of time can be a barrier munity-based menstrual education and formal education for MH and sustain MI among those already more vul- on menstruation and the menstrual cycle. Biological and nerable to experience it. reproduction-based education should be accompanied by School presenteeism and absenteeism may have a curricula centered in promoting positive views on men- long-lasting impact on women’s and PWM’s educational struation, body literacy and women’s and PWM’s agency. Holst et al. Reproductive Health (2022) 19:45 Page 14 of 16 They should strengthen healthcare professionals’ training Supplementary Information and healthcare services to approach menstruation and the The online version contains supplementary material available at https://​doi.​ menstrual cycle as vital health signs. Community and pop- org/​10.​1186/​s12978-​022-​01354-5. ulation-level strategies would also need to be implemented to de-stigmatize and debunk taboos surrounding menstru- Additional file 1. Critical Appraisal Skills Programme (CASP) criteria. ation, at the same time that public spaces are progressively Additional file 2. Participants’ menstrual cycle and menstruation re-structured to allow for healthy menstrual management. characteristics. Any strategies need to be inclusive to vulnerable popula- Additional file 3. Interview topic guide. tions and non-binary and trans people [75–77]. Resources Additional file 4. Photographs used for the photo-elicitation interviews. for intersectional, gender-based and feminist research on MH and MI are also required to continue working towards Acknowledgements reaching menstrual equity and ensuring MH. We would like to thank all participants taking part in the “Equity and Menstrual Health in Spain” study. Also to Ramona Ortiz López, Rosa Turbau Valls, Car‑ men Revuelta Lisa, Mónica Albaladejo Isidro, Paula Briales Canseco and Lola Limitations Hernández for their contributions in the development and recruitment for the There were a few limitations to the sample. Participants study. who were interviewed in ASSIRs may have felt restrained Authors’ contributions to share negative healthcare experiences. Also, while we ASH supported the conceptualisation of the study, collected and analysed intended to include participants with different educa- data. She also co-wrote the manuscript; CJA supported the conceptualisation of the study and was involved in the data analysis and interpretation process; tional backgrounds, many participants had completed AB contributed to the conceptualisation of the study, data interpretation university education. Another limitation is related to and supported the funding acquisition; DPS, CVL, JMF, CMB, TLJ and MMVH the inclusion of trans, intersex and non-binary peo- contributed to the conceptualisation of the study and data interpretation; LMP conceptualised the study, led the collection, analysis and interpretation ple. Despite the team’s efforts to recruit a more diverse of the data. She obtained the funding, coordinated the study and co-wrote sample, only a few non-binary people participated. the manuscript. All authors read and approved the final manuscript. Functional diversity could have been considered during Funding recruitment. Although actions were taken to lessen the The study was funded by the European Society of Contraception and Repro‑ impact of the digital divide, recruitment and data collec- ductive Health (P-2019-A-01). Funding was obtained by LMP and AB. tion were mainly done online due to COVID-19 restric- Availability of data and materials tions. This could have compromised participation. The datasets generated and analysed during the current study are not publicly available to maintain participants’ anonymity and confidentiality, but are avail‑ Conclusion able from the corresponding author on reasonable request. Our study suggests that MI is a multifaceted phenome- non that needs to be addressed as a public health issue, Declarations through research, to ensure social equity and MH. Ethics approval and consent to participate The link between MI and MH, that should be further Ethical approval was obtained from IDIAPJGol Ethical Committee on 21st explored. It is essential to develop multidimensional Nov 2020, Ref 19/178-P. Written and verbal consent were obtained prior to participation and audio recordings All participants were made aware of their structural policies and interventions that focus on pro- participation being anonymous, confidential, and voluntary, along with their moting women’s and PWM’s agency and community right to withdraw consent to participate until data analysis. care networks. Community-based actions should be Consent for publication encouraged, to promote MH and reduce MI. Health pro- All participants gave their consent to share anonymised data for publication. fessionals’ training is also imperative. Future research could focus on assessing MI among different popula- Competing interests The authors declare that they have no competing interests. tions and communities, using gender and intersection- ality approaches. Research could also aim at developing, Author details 1 implementing and evaluating interventions and policy Fundació Institut Universitari per a la recerca a l’Atenció Primària de Salut Jordi Gol i Gurina (IDIAPJGol), Gran Via de les Corts Catalanes, 587 attic, strategies. Research and actions addressing MH and MI 08007 Barcelona, Spain. 2 Universitat Pompeu Fabra, Barcelona, Spain. need to be inclusive to non-binary and trans people who 3 Universitat Autònoma de Barcelona, Bellaterra (Cerdanyola del Vallès), Spain. 4 menstruate and vulnerable populations, and account for Departament d’Infermeria, Universitat de Girona, Girona, Spain. 5 SomiArte Taller, Barcelona, Spain. 6 Centro de Análisis y Programas Sanitarios (CAPS), social determinants of health. Barcelona, Spain. 7 Atenció a la Salut Sexual i Reproductiva (ASSIR) Muntanya/ La Mina, Institut Català de la Salut, Barcelona, Spain. 8 Servei d’Atenció a la Salut Sexual i Reproductiva (ASSIR). 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Inserting informed choice into global menstrual product • maximum visibility for your research: over 100M website views per year use and provision. Lancet Public Health. 2019;4(8):e361–2. 70. Hyde E, Greene ME, Darmstadt GL. Time poverty: Obstacle to women’s At BMC, research is always in progress. human rights, health and sustainable development. J Glob Health. 2020;10(2):020313. Learn more biomedcentral.com/submissions