Medina‑Perucha et al. International Journal for International Journal for Equity in Health (2023) 22:92 https://doi.org/10.1186/s12939-023-01904-8 Equity in Health RESEARCH Open Access Menstruation and social inequities in Spain: a cross‑sectional online survey‑based study Laura Medina‑Perucha1,2*, Tomàs López‑Jiménez1,2, Constanza Jacques‑Aviñó1,2, Anna Sofie Holst1,3, Carme Valls‑Llobet4, Jordina Munrós‑Feliu5,6, Cristina Martínez‑Bueno6,7,8, Diana Pinzón‑Sanabria9, Mª Mercedes Vicente‑Hernández6 and Anna Berenguera1,2,10 Abstract Background Available research suggests that menstrual inequity has an impact on (menstrual) health outcomes and emotional wellbeing. It is also a significant barrier to achieve social and gender equity and compromises human rights and social justice. The aim of this study was to describe menstrual inequities and their associations with soci‑ odemographic factors, among women and people who menstruate (PWM) aged 18–55 in Spain. Methods A cross-sectional survey-based study was conducted in Spain between March and July 2021. Descriptive statistical analyses and multivariate logistic regression models were performed. Results A total of 22,823 women and PWM were included in the analyses (Mean age = 33.2, SD = 8.7). Over half of the participants had accessed healthcare services for menstruation (61.9%). The odds for accessing menstrual-related ser‑ vices were significantly higher among participants with university education (aOR: 1.48, 95% CI, 1.13–1.95). Also, 57.8% reported having had partial or no menstrual education pre-menarche, with odds being higher among participants born in non-European or Latin American countries (aOR: 0.58, 95% CI, 0.36–0.93). Lifetime self-reported menstrual poverty was between 22.2–39.9%. Main risk factors for menstrual poverty were identifying as non-binary (aOR: 1.67, 95% CI, 1.32–2.11), being born in non-European or Latin American countries (aOR: 2.74, 95% CI, 1.77–4.24), and not having a permit to reside in Spain (aOR: 4.27, 95% CI, 1.94–9.38). Completed university education (aOR: 0.61, 95% CI, 0.44–0.84) and no financial hardship < 12 months (aOR: 0.06, 95% CI, 0.06–0.07) were protective factors for menstrual poverty. Besides, 75.2% reported having overused menstrual products due to lack of access to adequate menstrual management facilities. Menstrual-related discrimination was reported by 44.5% of the participants. Non-binary par‑ ticipants (aOR: 1.88, 95% CI, 1.52–2.33) and those who did not have a permit to reside in Spain (aOR: 2.11, 95% CI, 1.10- 4.03) had higher odds of reporting menstrual-related discrimination. Work and education absenteeism were reported by 20.3% and 62.7% of the participants, respectively. Conclusions Our study suggests that menstrual inequities affect a high number of women and PWM in Spain, espe‑ cially those more socioeconomically deprived, vulnerabilised migrant populations and non-binary and trans men‑ struators. Findings from this study can be valuable to inform future research and menstrual inequity policies. Keyword Menstrual inequity, Period poverty, Menstrual health, Menstrual hygiene management, Menstruation, Women’s health, Social inequities, Androcentrism *Correspondence: Laura Medina‑Perucha lmedina@idiapjgol.org Full list of author information is available at the end of the article © The Author(s) 2023. 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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. Medina‑Perucha et al. International Journal for Equity in Health (2023) 22:92 Page 2 of 25 Resumen Introducción Investigación previa disponible indica que la inequidad menstrual tiene un impacto en los resultados de salud (menstrual) y en el bienestar emocional. Es también una barrera para la equidad social y de género. El obje‑ tivo de este estudio es evaluar la inequidad menstrual y las asociaciones con factores sociodemográficos, en mujeres y personas que menstrúan entre 18-55 años en España. Métodos Este es un estudio transversal, basado en una encuesta, llevado a cabo en España entre marzo y julio de 2021. Se realizaron análisis descriptivos y modelos de regresión logística multivariados. Resultados Los análisis se realizaron con los datos de 22,823 mujeres y personas que menstrúan. Más de la mitad de las participantes habían accedido a servicios sanitarios para la menstruación (60.5%). La probabilidad de acceder a servicios sanitarios para la menstruación fue significativamente más alta en participantes con educación universi‑ taria (aOR: 1.48, 95% CI, 1.13-1.95). El 57.8% informó no haber tenido educación menstrual o que ésta fuera parcial, pre-menarquia; la probabilidad fue más alta en participantes que no habían nacido en países europeos o latinoameri‑ canos (aOR: 0.58, 95% CI, 0.36-0.93). La pobreza menstrual durante el ciclo vital se reportó en el 22.2-39.9% de las participantes. Los principales factores de riesgo fueron identificarse como persona no binaria (aOR: 1.67, 95% CI, 1.32- 2.11), nacer en países fuera de Europa o Latinoamérica (aOR: 2.74, 95% CI, 1.77-4.24), y no tener papeles para residir en España (aOR: 4.27, 95% CI, 1.94-9.38). Tener estudios universitarios (aOR: 0.61, 95% CI, 0.44-0.84) y no haber reportado problemas económicos en los últimos 12 meses (aOR: 0.06, 95% CI, 0.06-0.07) fueron factores protectores para la pobreza menstrual. Además, el 74.6% indicó haber sobreutilizado productos menstruales por no haber tenido acceso a espacios adecuados para el manejo menstrual. El 42.6% de las participantes comunicaron experiencias de discrimi‑ nación menstrual. Participantes no binarios (aOR: 1.88, 95% CI, 1.52-2.33) y aquellas que no tenían papeles (aOR: 2.11, 95% CI, 1.10-4.03) presentaron una mayor probabilidad de indicar discriminación menstrual. El absentismo laboral y escolar fue indicado por el 18.3% y el 56.6% de las participantes respectivamente. Conclusiones Nuestro estudio sugiere que la inequidad menstrual afecta a un número significativo de mujeres y personas que menstrúan en España y, especialmente, a aquellas en situaciones de mayor deprivación socioec‑ onómica, algunos colectivos vulnerabilizados de personas migradas, y a personas no binarias y trans que menstrúan. Los resultados de este estudio pueden ser útiles para investigación futura, así como para el desarrollo de políticas públicas de equidad menstrual. Palabras clave Inequidad menstrual, Pobreza menstrual, Salud menstrual, Manejo menstrual, Menstruación, Salud de las mujeres, Inequidades sociales, Androcentrismo Background We suggest that menstrual inequity is an umbrella term There is a growing attention towards the need to ensure that encompasses period poverty [9, 10], and menstrual menstrual health among women and people who men- hygiene management [11]. It also collates with definitions struate (PWM) worldwide [1–4]. This is a significant shift of menstrual health [12] as it refers to the social factors from the deeply ingrained neglect and invisibilisation of and conditions that may have an impact on menstrual menstruation and the menstrual cycle in social, political, and other health outcomes. Throughout this publica- economic and research spheres [5–7]. While there is an tion, we will use the terms “menstrual poverty” instead exponential increase of published research on menstrual of “period poverty” as “period” can be understood as an health and menstrual hygiene management, research on euphemism for “menstruation” [13]. The term “menstrual menstrual inequity is still soundly scarce. management” will be used, instead of “menstrual hygiene This study was framed based on a definition of men- management”, as referring to “hygiene” could contribute strual inequity developed by the authors, based on data to the prevailing menstrual taboo and stigma [14]. from the “Equity and Menstrual Health in Spain” project While evidence is limited, previous research has [8]. We understand menstrual inequity as “the system- already suggested that menstrual inequities are associ- atic and avoidable differences in the access to menstrual ated with worse (menstrual) health outcomes, includ- healthcare, education and knowledge, products, services ing the risk of bacterial infections [15]; barriers to and facilities for menstrual management, menstrual- diagnose menstruation-related health conditions related experiences of stigma and discrimination, and (e.g., endometriosis) [6, 16–19]; a negative impact on social, community, political and economic participation emotional health and wellbeing [9, 20–22]; menstrual based on having a menstrual cycle and menstruating”. taboo, stigma and discrimination [13, 23]; absenteeism Medina‑Perucha et al. International Journal for Equity in Health (2023) 22:92 Page 3 of 25 and presenteeism from schools, universities and Methods workplaces, and subsequently reduced productivity A cross-sectional study using an online survey was con- [24–26]; misinformation associated with worse health ducted among a non-nationally representative sample outcomes [27, 28]; barriers for social, community and of women and PWM living in Spain between 24th of economic participation [8, 9, 23, 29]. Menstrual ineq- March and 8th of July 2021. Inclusion criteria were being uity also poses a barrier to achieve the Sustainable 18–55 years old, having menstruated at least once in the Development Goals [4]. Moreover, available frame- last year, being able to understand and provide informed works [12] and recent literature reviews [30, 31] sug- consent, and understanding Spanish to complete the gest the access to education, healthcare, products, and questionnaire. Main exclusion criteria included having facilities (e.g., including water, sanitation and hygiene), entered menopause. STROBE guidelines for reporting as well as stigma, discrimination, and community cross-sectional studies have been followed. participation as main social inequities of menstrual health. Available evidence has not focused on menstrual Sampling, recruitment and data collection inequity as a comprehensive concept, but rather on A minimum of 1,535 women and PWM participants were disaggregated forms of menstrual inequity (e.g., men- required. The sample size, calculated for the “Equity and strual poverty). Research on menstrual management Menstrual Health in Spain” project, was based on power and menstrual poverty has also largely focused on calculations considering a “menstrual inequity” proxy. communities from the Global South and young people Sample size for the study was based on available evi- [2]. While research initiatives are starting to be echoed dence on menstrual hygiene management, given the lack in the Global North [8, 20, 21, 32–34], it is urgent to of published research on menstrual inequity. Maximum assess menstrual inequity comprehensively in our con- indetermination of the main variable (proportion of 50%) text. Doing so could remarkably contribute to make was assumed. These assumptions were in order to obtain menstrual inequities socially and politically visible, a precision of 2.5% in the confidence intervals. These and challenge the assumptions on menstrual inequity estimates have been calculated assuming an alfa risk of not being an issue in high-income countries. 5%. PASS software was used for the sample size calcula- One of the steps to understand menstrual inequities tions [PASS 15 Power Analysis and Sample Size Software is to assess how these social inequities may differ by (2017). NCSS, LLC. Kaysville, Utah, USA]. population groups. This could contribute to under- Sampling was non-probabilistic and purposive. Sev- stand how social inequities influence, not only men- eral recruitment strategies were used, including social strual, but other health outcomes associated with media platforms (e.g., Twitter), primary healthcare cen- menstrual access and management. Very importantly, tres, sexual and reproductive healthcare centres, non- it could inform policymaking to ensure menstrual governmental and other local organisations. Snowballing justice and social equity. The Spanish government techniques were widely used. Data were collected using has recently approved new menstrual leaves and a an online questionnaire that included questions on men- decrease in the taxes applied to menstrual products strual health, menstrual inequity and sociodemographic (from 10 to 4%, as it corresponds to essential goods). factors. The questionnaire was designed by the research Therefore, at a time when menstrual policies are being team, a group of interdisciplinary experts including psy- debated and approved in Spain, it is timely that we chologists, medical doctors, public health profession- can ensure and support evidence-based policymaking. als and midwives, among others. Several meetings were In this article, we aimed at responding to the follow- organised to devise the questionnaire, as guided by previ- ing questions: “How many women and PWM are esti- ous research and guidelines on questionnaire design [35]. mated to be affected by menstrual inequities in Spain? The questionnaire was piloted, took around 20 minutes What groups of women and PWM might be particu- to be completed, and was available in Spanish. The cur- larly at risk for these social inequities in Spain?”. The rent publication will only present menstrual inequity- aim of this study was to describe menstrual inequities related data. and their associations with sociodemographic factors, The LimeSurvey platform was used for online data among women and PWM aged 18–55 in Spain. This collection and management. LimeSurvey is considered research is part of a larger mixed-methods study, the a secure, web-based software designed to securely con- “Equity and Menstrual Health in Spain” project. To our duct online surveys (https://​www.​limes​urvey.​org). Even knowledge, this is the first study to explore menstrual though most data were collected online, researchers also inequities comprehensively in Spain. collected data face-to-face to ensure the participation of Medina‑Perucha et al. International Journal for Equity in Health (2023) 22:92 Page 4 of 25 hard-to-reach populations and those who may not have inequity variables. Statistical significance was set at 0.05 access to online platforms. This was done at sexual and and all tests were 2-tailed. Analyses were performed reproductive health centres, a service for sex workers, using SPSS 25.0 (SPSS Inc., Armonk, NY: IBM Corp), and and a food bank. Stata/MP 17.0 (StataCorp LLC, TX). Variables Conceptualisations of menstrual inequity changed Results throughout the study, based on the team’s experience A total of 22,823 women and PWM participated in the conducting the study and most recent evidence. For this study, most online and 78 face-to-face. Mean age was reason, variables’ operationalisation was modified from 33.2 (SD = 8.7), ranging between 18 and 55 years old. the projects’ original protocol. Variables were operation- Most identified their gender as women (96.8%) and 3.2% alised for data analysis as follows. as non-binary/other; 0.8% self-identified as trans. Most Sociodemographic variables included: age, gender and participants were born in Spain (93.4%) and held Spanish trans identification, country of birth, administrative situ- nationality (95.9%). Almost half were employed full-time ation, employment situation, completed education, and (47.5%), 17.1% were studying full-time, 8% were receiving financial problems in the last 12 months. unemployment benefits or COVID-19 unemployment Based on the concept of menstrual inequity devel- benefits, and 5% were unpaid homemakers or caregivers oped by the research team [8], menstrual inequities as their main occupation. More than half had completed were assessed based on the following variables: 1) previ- university education (69.4%). 32.9% identified as caregiv- ous access to menstrual health services [a) overall; b) for ers for someone else (e.g., children). Almost half had had symptoms associated with the use of menstrual prod- financial problems in the year preceding the study; 30.9% ucts]; 2) no menstruation and menstrual cycle knowl- sometimes or a few times and 11.9% always or many edge pre-menarche; 3) wanting more information on times (see Table 1). menstruation and the menstrual cycle; 4) normalisation Our study did not include a representative sample of of dysmenorrhea [based on a) considering not necessary women and PWM living in Spain. However, in order to to seek professional assistance when feeling menstrual support the contextualization of our findings, a compara- pain during the menstrual cycle; and b) believing severe tive between our study’s data and Spanish National Sta- dysmenorrhea is “normal”]; 5) menstrual poverty [con- tistics Institute (INE) representative data can be found sidering a) financial problems to buy menstrual products; in the Supplementary File 1. As s indicated in the sup- and b) financial problems to afford preferred menstrual plementary material, there was a higher proportion of products]; 6) prolonged menstrual products’ use due to younger women and PWM in our study, compared to no products available; 7) prolonged menstrual products’ women living in Spain in 2020. Besides, the inclusion of use due to no access to menstrual management facili- migrant communities was low in our study (6.6.%), com- ties; 8) menstruation-related experiences of stigma and pared to the population living in Spain (23.6%). Our sam- discrimination; 9) embarrassment to buy or ask for men- ple included a higher proportion of women and PWM strual products; 10) fear of menstrual staining in public; with completed university education, and significantly 11) menstruation concealment; 12) embarrassment to less participants who were unemployed, retired or receiv- talk about menstruation; 13) less able to pay attention ing pensions or other benefits. Data on self-reported or deal with day-to-day tasks during menstruation; 14) financial hardship in the preceding 12 months could be less productive during menstruation; 15) menstrual- compared with representative data on financial satisfac- related work absenteeism; 16) menstruation-related tion. When comparing these data, our data does not sig- school absenteeism; and 17) declining social plans when nificantly differ from the representative data available. menstruating. This information should be considered when interpreting the findings presented in this article. Data analysis Main findings are reported under distinct sections: Descriptive statistics were performed for each variable 1) access to healthcare services for menstrual health; 2) to identify asymmetric distributions. Categorical vari- access to menstrual education and knowledge; 3) use of ables were expressed as frequencies (percentage) and menstrual products, menstrual management and men- continuous variables as mean (SD) or median (inter- strual poverty; 4) taboo, embarrassment and experiences quartile range, IQR). We used the Chi-square test to of stigma and discrimination; and 5) social and commu- assess differences between groups. Multivariate logistic nity participation. Stratified descriptive analyses on men- regression models were constructed to evaluate associa- strual inequity by sociodemographic characteristics can tions between sociodemographic factors and menstrual be found in the Supplementary File 2. Medina‑Perucha et al. International Journal for Equity in Health (2023) 22:92 Page 5 of 25 Table 1 Sociodemographic characteristics (N = 22,823) medicine professionals (7.7%), social care professionals Variable N (22,823) % (4.8%), and teachers (1.6%). Consultations’ satisfaction (M = 3.3, SD = 1.2) was variable (range of 1–5). Age (18–55) M = 33.2 (SD = 8.7) The odds to access to healthcare services for menstrua- Gender identification tion significantly increased with age (e.g., for participants Women 22,100 96.8% aged 46–55: aOR: 1.74, 95% CI, 1.52–1.98), among par- Non-binary/Other 723 3.2% ticipants working full-time (aOR: 1.15, 95% CI, 1.04– Trans 1.28), those who were self-employed (aOR: 1.23, 95% CI, Yes 175 0.8% 1.09–1.39) or participants receiving a pension or retired Don’t know 155 0.7% (aOR: 1.41, 95% CI, 1.00–1.99). They were also signifi- No 22,493 98.6% cantly higher among participants who had completed Place of birth university education (aOR: 1.48, 95% CI, 1.13–1.95). On Spain 20,943 93.4% the other hand, the odds significantly decreased in par- Europe 841 3.8% ticipants with a permanent Spanish residency (aOR: 0.69, Latin America 501 2.2% 95% CI, 0.57–0.84), and among those who had never had Other 126 0.6% financial problems in the last 12 months (aOR: 0.75, 95% Administrative situation CI, 0.68–0.82) (see Table 2 and Figs. 1 and 2. Spanish Nationality 21,815 95.9% Permanent Residency 721 3.2% Access to menstrual education and knowledge Temporary Residency 174 0.8% Almost half (45.3%) reported having had partial infor- No permit/in process 49 0.2% mation on menstruation and the menstrual cycle at Employment situation menarche, and 12.5% did not know what menstruation Working full-time 10,834 47.5% was at that time. Around half (50.4%) did not feel pre- Working part-time 3,914 17.1% pared to menstruate at menarche. Most participants Self-employed 2,050 9.0% had initially learned about menstruation and the men- Studying full-time 3,896 17.1% strual cycle through their families (71.4%), school (40.9%) Studying part-time 1,934 8.5% or friends (37.6%). Menstrual education at the time of Unemployment /COVID-19 benefits 1,831 8.0% data collection was mostly through the internet (60%), Pension or retirement 163 0.7% health professionals (44.3%), friends (38.3%), social Unpaid carer/houseworker 1,134 5.0% media networks (35.1%), magazines or books (19.7%), Completed education and family members (13.9%). Most participants (73.9%) University education 15,811 69.4% reported being interested in having more information on Secondary education 6,728 29.5% menstruation and the menstrual cycle, while 3.1% were Primary education 217 1.0% not interested in this topic. In relation to participants’ No formal education completed 35 0.2% views on dysmenorrhea, 13.2% believed that dysmenor- Caregiving for someone else rhea was “normal”, and 4% did not think seeking medical Yes 7,518 33.1% assistance for dysmenorrhea was necessary. On the con- No 15,183 66,9% trary, 54.7% indicated that experiencing severe dysmen- Financial problems in the last year orrhea could be a sign of a health condition, and 47.6% Always/many times 2,707 11.9% believed that experiences of dysmenorrhea should be Sometimes/a few times 7,056 30.9% consulted with a health professional. Never 12,582 55.1% The odds for knowing what menstruation and the menstrual cycle were pre-menarche, were significantly reduced as age increased (ages 46–55: aOR: 0.72, 95% CI, Access to healthcare services for menstrual health 0.60–0.87), and among participants not born in Europe While over half of the participants (61.9%) had accessed or Latin America (aOR: 0.58, 95% CI, 0.36–0.93). Partici- healthcare services for menstrual-related consultations, pants working (aOR: 1.23, 95% CI, 1.06–1.43) or studying 15% did not think it was necessary to access health- full-time (aOR: 1.22, 95% CI, 1.02–1.45), and participants care services for menstruation and the menstrual cycle, with no financial problems in the 12 months preceding and 22.3% had not accessed but wanted to access. Par- the study (aOR: 1.28, 95% CI, 1.12–1.46) had higher odds ticipants sought professional assistance from healthcare of knowing about menstruation and the menstrual cycle professionals (59.3%), alternative and complementary before menarche (see Table 3) (Fig. 3). Medina‑Perucha et al. International Journal for Equity in Health (2023) 22:92 Page 6 of 25 Table 2 Associations between access to healthcare services for those working full-time (aOR: 0.87, 95% CI, 0.76–0.98). menstruation and sociodemographic characteristics (N = 21,418) In turn, odds for wanting to have more information were aOR (95%CI) p value higher in participants studying full-time (aOR: 1.21, 95% CI, 1.02–1.43), and participants with university education Age (aOR: 1.49, 95% CI, 1.09–2.02) (see Table 3). 18–25 1.00 26–35 1.41 (1.28–1.55) < 0.001 Menstrual poverty and menstrual management 36–45 1.51 (1.37–1.67) < 0.001 Lifetime experiences of menstrual poverty were dis- 46–55 1.74 (1.52–1.98) < 0.001 closed: 22.2% women and PWM reported having had Gender financial problems to afford menstrual products, and Women 1.00 39.9% had experienced difficulties affording preferred Non-binary/other 1.07 (0.87–1.30) 0.530 menstrual products. Trans The risk of reporting financial problems to access men- No 1.00 strual products increased with age (e.g., participants aged Yes 0.78 (0.54–1.13) 0.182 46–55: aOR: 1.35, 95% CI, 1.14–1.60), among non-binary I don’t know 0.95 (0.64–1.40) 0.789 participants (aOR: 1.67, 95% CI, 1.32–2.11), in those not Place of birth born in Spain, being the highest among participants born Spain 1.00 in non-European or Latin American countries (aOR: 2.74, Latin America 0.89 (0.75–1.05) 0.159 95% CI, 1.77–4.24), among participants with no permit Europe 1.01 (0.81–1.27) 0.912 to reside in Spain (aOR: 4.27, 95% CI, 1.94–9.38), and Other 0.96 (0.65–1.42) 0.837 in participants that were unemployed, receiving a pen- Administrative situation sion or were unpaid carers/houseworkers (e.g., receiv- Spanish nationality 1.00 ing a pension or retired: aOR: 1.59, 95% CI, 1.07–2.37). Permanent residency 0.69 (0.57–0.84) < 0.001 On the other hand, the risk for menstrual poverty was Temporal residency 0.77 (0.55–1.07) 0.120 lower among participants who were self-employed (aOR: No permit/in process 0.63 (0.35–1.13) 0.119 0.71, 95% CI, 0.61–0.83), studying full-time (aOR: 0.82, Employment situation 95% CI, 0.71-0.095) and had completed university edu- Working full-time 1.15 (1.04–1.28) 0.006 cation (aOR: 0.61, 95% CI, 0.44–0.84). Also, the risk for Working part-time 1.11 (1.00–1.23) 0.054 menstrual poverty significantly decreased as participants Self-employed 1.23 (1.09–1.39) 0.001 reported less financial problems in the last 12 months Studying full-time 1.02 (0.90–1.14) 0.786 (e.g., never financial problems < 12 months: aOR: 0.06, Studying part-time 1.10 (0.99–1.23) 0.073 95% CI, 0.06–0.07). These associations were similar for Unemployment or COVID19 benefits 1.04 (0.92–1.18) 0.541 the second form of menstrual poverty explored (i.e., Pension or retirement 1.41 (1.00–1.99) 0.048 hardship to afford preferred menstrual products) (see Unpaid carer/houseworker 1.07 (0.93–1.22) 0.352 Table 4 and Figs. 4 and 5). Completed education As for menstrual products’ cost, 73.5% believed that all Primary education 1.00 menstrual products were very expensive; 23.3% thought Secondary education 1.22 (0.93–1.60) 0.160 that the cost of some products cost was too high. In University education 1.48 (1.13–1.95) 0.004 order to reduce menstrual poverty, 84.6% of participants Financial problems < 12 months believed that menstrual products’ price had to be reduced Always/Many times 1.00 (e.g., through tax reduction), 62.4% thought that menstrual Some/A few times 0.93 (0.84–1.02) 0.128 products should be free or have a reduced price for most- Never 0.75 (0.68–0.82) < 0.001 in-need populations, and 34.3% believed that menstrual products should be delivered for free to all women and PWM. Only 0.3% declared that no policies were necessary. On the other hand, the odds for wanting to learn more Almost all participants (94.1%) had overused menstrual about menstruation and the menstrual cycle decreased products when they had no menstrual products available. as age increased (ages 46–55: aOR: 0.22, 95% CI, 0.19– Many participants (75.2%) had used menstrual products 0.26), and when participants reported less financial for a longer time than recommended when they could problems in the last 12 months (e.g., never had financial not find adequate menstrual management facilities. Vagi- problems < 12 months: aOR: 0.58, 95% CI, 0.51–0.66). nal/vulvar irritation, itchiness or abnormal vaginal dis- Besides, these odds were significantly lower in participants charge were experienced by 75.5% of participants in the who identified as trans (aOR: 0.36, 95% CI, 0.24–0.55) and 6 months prior to data collection. Among these, 64.4% Medina‑Perucha et al. International Journal for Equity in Health (2023) 22:92 Page 7 of 25 Fig. 1 Associations betweenaccess to healthcare service for menstruation and age Fig. 2 Associations betweenaccess to healthcare services for menstrual and completed education Medina‑Perucha et al. International Journal for Equity in Health (2023) 22:92 Page 8 of 25 Table 3 Associations between access to menstrual education, knowledge and sociodemographic characteristics (N = 21,459) Knowledge of menstruation and menstrual cycle Would like to have more information pre-menarche (N = 20,955) on menstruation and the menstrual cycle (N = 20,199) aOR (95%CI) p value aOR (95%CI) p value Age 18–25 1.00 1.00 26–35 0.89 (0.77–1.03) 0.112 0.71 (0.62–0.82) < 0.001 36–45 0.80 (0.69–0.93) 0.004 0.39 (0.34–0.45) < 0.001 46–55 0.72 (0.60–0.87) 0.001 0.22 (0.19–0.26) < 0.001 Gender Women 1.00 1.00 Non-binary/other 1.26 (0.92–1.71) 0.147 0.92 (0.72–1.17) 0.475 Trans No 1.00 1.00 Yes 0.69 (0.40–1.19) 0.182 0.36 (0.24–0.55) < 0.001 I don’t know 0.79 (0.45–1.38) 0.405 0.78 (0.48–1.27) 0.319 Place of birth Spain 1.00 1.00 Latin America 1.19 (0.92–1.52) 0.184 1.14 (0.92–1.41) 0.221 Europe 1.06 (0.76–1.48) 0.719 1.04 (0.79–1.38) 0.761 Other 0.58 (0.36–0.93) 0.024 0.80 (0.49–1.30) 0.359 Administrative situation Spanish nationality 1.00 1.00 Permanent residency 0.91 (0.68–1.21) 0.518 0.88 (0.69–1.13) 0.329 Temporal residency 1.08 (0.65–1.82) 0.761 0.69 (0.45–1.06) 0.091 No permit/in process 0.53 (0.25–1.10) 0.088 2.86 (0.86–9.48) 0.086 Employment situation Working full-time 1.23 (1.06–1.43) 0.006 0.87 (0.76–0.98) 0.029 Working part-time 1.22 (1.05–1.42) 0.010 1.08 (0.94–1.21) 0.285 Self-employed 1.17 (0.98–1.39) 0.085 1.04 (0.89–1.21) 0.613 Studying full-time 1.22 (1.02–1.45) 0.033 1.21 (1.02–1.43) 0.027 Studying part-time 0.95 (0.82–1.11) 0.548 1.36 (1.17–1.58) < 0.001 Unemployment or COVID19 benefits 1.17 (0.98–1.41) 0.090 1.04 (0.88–1.23) 0.639 Pension or retirement 1.76 (0.99–3.14) 0.054 0.97 (0.65–1.46) 0.894 Unpaid carer/houseworker 0.99 (0.82–1.19) 0.877 0.98 (0.83–1.16) 0.854 Completed education Primary education 1.00 1.00 Secondary education 1.09 (0.74–1.59) 0.671 1.19 (0.87–1.63) 0.273 University education 1.02 (0.70–1.48) 0.926 1.49 (1.09–2.02) 0.012 Financial problems < 12 months Always/Many times 1.00 1.00 Some/A few times 1.06 (0.93–1.22) 0.366 0.82 (0.72–0.94) 0.003 Never 1.28 (1.12–1.46) < 0.001 0.58 (0.51–0.66) < 0.001 had not treated the symptoms, 19.7% received treatment were unemployed or receiving COVID19 benefits (aOR: from a healthcare professional, and 15% self-treated. 1.17, 95% CI, 1.00–1.37). This risk was lowered as age The risk of overusing menstrual products when not increased (e.g., participants aged 46–55: aOR: 0.35, 95% having products available was significantly higher in non- CI, 0.30–0.40) and financial problems in the last year binary participants (aOR: 1.25, 95% CI, 0.97–1.59), and decreased (e.g., never financial problems < 12 months: those working full-time (aOR: 1.18, 95% CI, 1.04–1.32) or aOR: 0.57, 95% CI, 0.50–0.64). As for the risk of overusing Medina‑Perucha et al. International Journal for Equity in Health (2023) 22:92 Page 9 of 25 Fig. 3 Associations betweenknowledge of menstruation and menstrual cycle pre-menarche and age menstrual products when adequate menstrual manage- non-European countries (aOR: 2.19, 95% CI, 1.41–3.40), ment facilities were unavailable, findings were similar, did not have Spanish nationality (e.g., no permit/in pro- except for the heightened risk among non-binary partici- cess: aOR: 3.65, 95% CI, 1.88–7.07), were full-time stu- pants, and those unemployed or on COVID19 benefits. dents (aOR: 1.21, 95% CI, 1.03–1.43), or had completed Besides, the risk increased as educational attainment university education (aOR: 1.70, 95% CI, 1.01–2.86). In was higher (e.g., university education: aOR: 1.87, 95% CI, turn, these reports were lower as age increased (e.g., par- 1.18–2.99). See Table 4 for further details. ticipants aged 46–55: aOR: 0.37, 95% CI, 0.30–0.45), and among participants with no reported financial difficulties Taboo, embarrassment and experiences of stigma in the year preceding the study (aOR: 0.82, 95% CI, 0.71– and discrimination 0.93) (Table 5). Emotional experiences related to menstruation were The report of taboo, stigma and experiences of discrim- mostly “negative” or inferring distress, with participants ination also decreased with age and as financial problems reporting feeling tired (59.1%), sensitive (58.7%), sad lessened. However, it increased in full-time students and (24.2%), angry (22.7%), dirty (16.5%) and embarrassed participants with completed university education (see (1.8%). It is also important to acknowledge that 14.2% Table 5). Non-binary participants were at higher risk to felt happy, 19% calm, 8.4% relieved, and 8.4% felt indif- report having concealed menstruation (aOR: 1.38, 95% ferent when menstruating. Experiences of taboo, embar- CI, 1.11–1.71) and having experienced discrimination rassment, stigma and discrimination were common. or judgment due to menstruating (aOR: 1.88, 95% CI, Most women and PWM (83.3%) disclosed feeling scared 1.52–2.33). Trans people were also at a heightened risk of of staining their clothes with menstrual blood in public, reporting shame to discuss menstruation (aOR: 2.37, 95% 58.5% had concealed menstruation, 44.5% had felt dis- CI, 1.59–3.54). This was also higher among women and criminated or judged for menstruating, and 19.2% were PWM born in non-European or Latin American coun- embarrassed to discuss menstruation. tries (aOR: 2.17, 95% CI, 1.44–3.28) (Figs. 6 and 7 ). Participants with higher odds of reporting feeling The odds for reporting experiences of menstrual dis- ashamed of buying or asking menstrual products identi- crimination/judgment were higher among participants fied as trans (aOR: 2.51, 95% CI, 1.64–3.83), were born in born in European countries other than Spain (aOR: 1.30, Latin American (aOR: 1.28, 95% CI, 1.02–1.61) or other 95% CI, 1.02–1.66). Also, in participants with a more Medina‑Perucha et al. International Journal for Equity in Health (2023) 22:92 Page 10 of 25 Table 4 Associations between access to menstrual poverty, menstrual management and sociodemographic characteristics (N = 20,622) Lifetime financial Lifetime financial Overuse menstrual Overuse menstrual problems to access problems to choose products when no products when no menstrual products menstrual products products available adequate menstrual (N = 20,518) used (N = 20,467) (N = 20,543) management space available (N = 20,622) aOR (95%CI) p value aOR (95%CI) p value aOR (95%CI) p value aOR (95%CI) p value Age 18–25 1.00 1.00 1.00 1.00 26–35 1.34 (1.18–1.51) < 0.001 1.11 (1.00–1.23) 0.044 0.71 (0.63–0.80) < 0.001 0.84 (0.66–1.05) 0.122 36–45 1.28 (1.12–1.46) < 0.001 0.97 (0.87 (1.08) 0.561 0.47 (0.41–0.53) < 0.001 0.67 (0.53–0.84) 0.001 46–55 1.35 (1.14–1.60) < 0.001 0.99 (0.86–1.14) 0.893 0.35 (0.30–0.41) < 0.001 0.48 (0.36–0.62) < 0.001 Gender Women 1.00 1.00 1.00 1.00 Non-binary/other 1.67 (1.32–2.11) < 0.001 1.49 (1.21–1.84) < 0.001 1.25 (0.97–1.59) 0.080 0.77 (0.52–1.13) 0.182 Trans No 1.00 1.00 1.00 1.00 Yes 0.91 (0.59–1.41) 0.669 1.10 (0.74–1.64) 0.632 1.30 (0.77–2.18) 0.326 2.57 (0.89–7.45) 0.082 I don’t know 1.03 (0.65–1.63) 0.886 1.08 (0.71–1.64) 0.708 1.18 (0.70–1.97) 0.540 1.92 (0.68–5.43) 0.221 Place of birth Spain 1.00 1.00 1.00 1.00 Latin America 1.48 (1.22–1.79) < 0.001 1.14 (0.96–1.37) 0.142 0.82 (0.68–0.99) 0.044 0.64 (0.46–0.87) 0.005 Europe 1.36 (1.03–1.80) 0.032 1.08 (0.84–1.38) 0.554 0.97 (0.74–1.26) 0.795 1.03 (0.63–1.67) 0.908 Other 2.74 (1.77–4.24) < 0.001 1.45 (0.96–2.20) 0.079 0.93 (0.58–1.49) 0.765 0.66 (0.31–1.38) 0.270 Administrative situation Spanish nationality 1.00 1.00 1.00 1.00 Permanent residency 0.94 (0.74–1.20) 0.625 1.20 (0.97–1.48) 0.098 1.08 (0.86–1.37) 0.500 1.02 (0.68–1.54) 0.912 Temporal residency 1.05 (0.71–1.56) 0.793 1.38 (0.96–1.99) 0.084 1.30 (0.84–2.00) 0.236 1.00 (0.50–2.00) 1.000 No permit/in process 4.27 (1.94–9.38) < 0.001 2.95 (1.35–6.49) 0.007 0.95 (0.46–1.94) 0.883 0.46 (0.18–1.16) 0.099 Employment situation Working full-time 1.07 (0.94–1.22) 0.287 1.06 (0.95–1.18) 0.294 1.18 (1.04–1.32) 0.008 1.36 (1.09–1.69) 0.007 Working part-time 1.00 (0.88–1.14) 0.994 1.08 (0.97–1.21) 0.146 1.18 (1.05–1.34) 0.007 1.42 (1.12–1.79) 0.003 Self-employed 0.71 (0.61–0.83) < 0.001 0.78 (0.69–0.89) < 0.001 0.97 (0.84–1.11) 0.626 1.00 (0.77–1.29) 0.997 Studying full-time 0.82 (0.71–0.95) 0.010 0.97 (0.85–1.10) 0.589 0.96 (0.82–1.11) 0.552 0.93 (0.71–1.22) 0.585 Studying part-time 1.09 (0.95–1.24) 0.208 1.04 (0.93–1.17) 0.491 1.07 (0.94–1.22) 0.321 1.06 (0.82–1.37) 0.651 Unemployment or COVID19 benefits 1.20 (1.04–1.40) 0.015 1.22 (1.06–1.39) 0.004 1.17 (1.00–1.37) 0.040 1.08 (0.82–1.42) 0.589 Pension or retirement 1.59 (1.07–2.37) 0.021 1.15 (0.81–1.63) 0.441 0.78 (0.54–1.13) 0.193 1.62 (0.71.-3.73) 0.255 Unpaid carer/houseworker 1.19 (1.02–1.40) 0.029 1.23 (1.06–1.41) 0.005 1.04 (0.89–1.22) 0.595 0.98 (0.74–1.29) 0.871 Completed education Primary education 1.00 1.00 1.00 1.00 Secondary education 0.84 (0.61–1.16) 0.304 0.88 (0.65–1.18) 0.383 1.29 (0.95–1.76) 0.106 1.86 (1.16–2.98) 0.010 University education 0.61 (0.44–0.84) 0.002 0.70 (0.52–0.94) 0.017 1.20 (0.88–1.63) 0.249 1.87 (1.18–2.99) 0.008 Financial problems < 12 months Always/Many times 1.00 1.00 1.00 1.00 Some/A few times 0.29 (0.27–0.33) < 0.001 0.44 (0.40–0.49) < 0.001 0.72 (0.64–0.82) < 0.001 0.67 (0.52–0.86) 0.001 Never 0.06 (0.06–0.07) < 0.001 0.15 (0.14–0.17) < 0.001 0.57 (0.50–0.64) < 0.001 0.48 (0.38–0.61) < 0.001 vulnerable administrative situation (e.g., no residency 1.00–1.31) and concealing menstruation (aOR: 1.11, permit: aOR: 2.11, 95% CI, 1.10–4.03). Working full- 95% CI, 1.00–1.23). On the other hand, the risk of fear- time was associated with a higher risk of fearing stain- ing staining was significantly lower in women and PWM ing in public with menstrual blood (aOR: 1.15, 95% CI, who were self-employed (aOR: 0.74, 95% CI, 0.64–0.87), Medina‑Perucha et al. International Journal for Equity in Health (2023) 22:92 Page 11 of 25 Fig. 4 Associations betweenlifetime financial problems to access menstrual products and completededucation Fig. 5 Associations betweenlifetime financial problems to access menstrual products and self-reportedfinancial problems Table 5 Associations between menstrual-related taboo, stigma, discrimination and sociodemographic characteristics (N = 20,619) Shame buying or asking Fear of staining in public Has concealed Shame discussing Experiences of for menstrual products (N = 20,196) menstruation (N = 19,944) menstruation (N = 20,159) discrimination (N = 20,619) or judgment due to menstruating (N = 19,602) aOR (95%CI) p value aOR (95%CI) p value aOR (95%CI) p value aOR (95%CI) p value aOR (95%CI) p value Age 18–25 1.00 1.00 1.00 1.00 1.00 26–35 0.59 (0.52–0.67) < 0.001 0.62 (0.54–0.71) < 0.001 0.83 (0.75–0.92) < 0.001 0.81 (0.72–0.91) < 0.001 1.02 (0.92–1.12) 0.738 36–45 0.46 (0.40–0.53) < 0.001 0.54 (0.46–0.62) < 0.001 0.80 (0.72–0.89) < 0.001 0.82 (0.72–0.93) 0.002 0.83 (0.75–0.92) < 0.001 46–55 0.37 (0.30–0.45) < 0.001 0.56 (0.47–0.67) < 0.001 0.71 (0.63–0.82) < 0.001 0.75 (0.63–0.88) < 0.001 0.54 (0.47–0.62) < 0.001 Gender Women 1.00 1.00 1.00 1.00 1.00 Non-binary/other 1.21 (0.91–1.59) 0.180 0.88 (0.68–1.15) 0.346 1.38 (1.11–1.71) 0.003 1.08 (0.85–1.37) 0.542 1.88 (1.52–2.33) < 0.001 Medina‑Perucha et al. International Journal for Equity in Health Trans No 1.00 1.00 1.00 1.00 1.00 Yes 2.51 (1.64–3.83) < 0.001 1.18 (0.67–2.06) 0.565 1.48 (0.96–2.27) 0.076 2.37 (1.59–3.54) < 0.001 1.10 (0.73–1.66) 0.653 I don’t know 1.19 (0.71–1.98) 0.507 1.18 (0.67–2.07) 0.576 1.08 (0.71–1.65) 0.708 1.38 (0.89–2.14) 0.156 1.50 (0.97–2.32) 0.070 Place of birth (2023) 22:92 Spain 1.00 1.00 1.00 1.00 1.00 Latin America 1.28 (1.02–1.61) 0.036 1.05 (0.83–1.32) 0.695 1.10 (0.92–1.31) 0.283 1.18 (0.97–1.44) 0.103 0.95 (0.80–1.13) 0.535 Europe 1.28 (0.94–1.74) 0.120 1.08 (0.79–1.48) 0.636 1.08 (0.85–1.37) 0.543 1.48 (1.14–1.93) 0.003 1.30 (1.02–1.66) 0.033 Other 2.19 (1.41–3.40) 0.001 1.00 (0.57–1.77) 0.993 1.41 (0.92–2.16) 0.111 2.17 (1.44–3.28) < 0.001 1.31 (0.87–1.98) 0.195 Administrative situation Spanish nationality 1.00 1.00 1.00 1.00 1.00 Permanent residency 1.42 (1.09–1.86) 0.010 0.97 (0.74–1.27) 0.818 0.94 (0.77–1.16) 0.577 1.10 (0.87–1.39) 0.446 0.78 (0.63–0.96) 0.019 Temporal residency 1.69 (1.13–2.53) 0.011 1.44 (0.83–2.50) 0.201 1.29 (0.88–1.88) 0.189 1.48 (1.01–2.14) 0.042 0.89 (0.62–1.27) 0.514 No permit/in process 3.65 (1.88–7.07) < 0.001 2.67 (0.81–8.82) 0.107 2.04 (1.01–4.13) 0.047 2.11 (1.10–4.03) 0.024 0.62 (0.32–1.17) 0.140 Employment situation Working full-time 0.93 (0.80–1.07) 0.306 1.15 (1.00–1.31) 0.046 1.11 (1.00–1.23) 0.048 1.07 (0.94–1.21) 0.303 0.98 (0.88–1.09) 0.748 Working part-time 0.93 (0.80–1.07) 0.302 0.98 (0.85–1.13) 0.797 1.07 (0.96–1.19) 0.208 0.91 (0.80–1.03) 0.156 1.07 (0.96–1.19) 0.194 Self-employed 0.89 (0.73–1.07) 0.207 0.74 (0.64–0.87) < 0.001 0.90 (0.79–1.01) 0.077 0.94 (0.81–1.09) 0.428 1.06 (0.93–1.20) 0.381 Studying full-time 1.21 (1.03–1.43) 0.019 1.45 (1.21–1.74) < 0.001 1.25 (1.11–1.42) < 0.001 1.29 (1.12–1.49) < 0.001 1.31 (1.16–1.48) < 0.001 Studying part-time 1.01 (0.86–1.18) 0.920 0.87 (0.76–1.00) 0.054 0.99 (0.89–1.11) 0.858 1.06 (0.93–1.20) 0.419 1.28 (1.14–1.43) < 0.001 Unemployment or COVID19 benefits 0.99 (0.83–1.20) 0.951 1.07 (0.90–1.27) 0.462 1.17 (1.03–1.34) 0.017 0.99 (0.85–1.16) 0.907 1.21 (1.06–1.38) 0.004 Pension or retirement 0.91 (0.56–1.49) 0.713 0.90 (0.58–1.42) 0.660 1.07 (0.76–1.51) 0.700 1.05 (0.70–1.57) 0.825 1.18 (0.84–1.67) 0.346 Unpaid carer/houseworker 0.90 (0.73–1.11) 0.311 0.85 (0.72–1.01) 0.057 0.88 (0.76–1.00) 0.054 1.02 (0.86–1.20) 0.813 1.30 (1.13–1.49) < 0.001 Page 12 of 25 Table 5 (continued) Shame buying or asking Fear of staining in public Has concealed Shame discussing Experiences of for menstrual products (N = 20,196) menstruation (N = 19,944) menstruation (N = 20,159) discrimination (N = 20,619) or judgment due to menstruating Medina‑Perucha et al. International Journal for Equity in Health (N = 19,602) aOR (95%CI) p value aOR (95%CI) p value aOR (95%CI) p value aOR (95%CI) p value aOR (95%CI) p value Completed education Primary education 1.00 1.00 1.00 1.00 1.00 (2023) 22:92 Secondary education 1.38 (0.82–2.32) 0.231 1.15 (0.80–1.65) 0.443 1.56 (1.16–2.08) 0.003 1.09 (0.74–1.63) 0.656 1.58 (1.15–2.17) 0.005 University education 1.70 (1.01–2.86) 0.045 1.19 (0.83–1.71) 0.335 2.22 (1.67–2.97) < 0.001 1.65 (1.11–2.44) 0.013 2.10 (1.53–2.88) < 0.001 Financial problems < 12 months Always/Many times 1.00 1.00 1.00 1.00 1.00 Some/A few times 0.92 (0.80–1.05) 0.207 0.98 (0.86–1.12) 0.765 1.03 (0.94–1.14) 0.518 0.96 (0.86–1.08) 0.531 0.70 (0.63–0.77) < 0.001 Never 0.82 (0.71–0.93) 0.003 0.78 (0.69–0.89) < 0.001 0.85 (0.77–0.93) 0.001 0.85 (0.76–0.95) 0.006 0.46 (0.42–0.51) < 0.001 Page 13 of 25 Medina‑Perucha et al. International Journal for Equity in Health (2023) 22:92 Page 14 of 25 Fig. 6 Associations betweenshame discussing menstruation and age Fig. 7 Associations betweenshame discussing menstruation and place of birth Medina‑Perucha et al. International Journal for Equity in Health (2023) 22:92 Page 15 of 25 or were unpaid carers or houseworkers (aOR: 0.85, 95% CI, 0.49–0.61) financial problems in the previous year CI, 0.72–1.01). See Table 5 for more details. (see Table 6) (Fig. 8). The risk for education absenteeism during menstrua- Social, community and economic participation tion was significantly higher in non-binary participants Feeling less able to pay attention or cope with day-to- (aOR: 1.57, 95% CI, 1.23–2.00) and participants with day issues (73.1%) and perceiving oneself as less produc- completed university education (aOR: 1.74, 95% CI, tive (70.1%) when menstruating was common among 1.23–2.46). The odds of education absenteeism were sig- participants. Interestingly, 13.1% reported not hav- nificantly lower as age increased (e.g., participants aged ing paid attention to their levels of productivity while 46–55: aOR: 0.33, 95% CI, 0.29–0.38) and financial prob- menstruating. lems lessened (e.g., no financial problems < 12 months: The risk for reporting feeling less able to cope with aOR: 0.51, 95% CI, 0.46–0.57) (see Table 6). day-to-day activities and decreased productivity was sig- The odds for declining social meetings during menstru- nificantly lower as age increased [e.g., participants aged ation were significantly higher among participants who 46–55: aOR: 0.32, 95% CI, 0.28–0.37; aOR: 0.25, 95% identified as non-binary (aOR: 1.70, 95% CI, 1.37–2.11), CI, 0.21–0.30] and financial problems lessened [e.g., and born in non-European or Latin American countries no financial problems < 12 months: aOR: 0.47, 95% CI, (aOR: 1.64, 95% CI, 1.07–2.52). Also, among full-time 0.42–0.53; aOR: 0.53, 95% CI, 0.46–0.62]. The odds were students (aOR: 1.17, 95% CI, 1.03–1.32) and women also lower among participants working full-time [aOR: and PWM with university education (aOR: 1.39, 95% 0.74, 95% CI, 0.65–0.84; aOR: 0.66, 95% CI, 0.57–0.77]. CI, 1.04–1.85). The odds were significantly lower as age Instead, the odds were significantly higher among women increased (e.g., participants aged 46–55: aOR: 0.48, 95% and PWM with university education [aOR: 1.63, 95% CI, CI, 0.48–0.55) and participants reported fewer financial 1.19–2.21; aOR: 1.59, 95% CI, 1.10–2.28]. Furthermore, problems (e.g., no financial issues < 12 months: aOR: 0.51, the risk for feeling less able to cope with day-to-day tasks 95% CI, 0.46–0.56). See Table 6 for more information. was significantly higher among non-binary participants (aOR: 1.36, 95% CI, 1.05–1.77), and participants study- Discussion ing full-time (aOR: 1.44, 95% CI, 1.23–1.68). Participants This study aimed to describe menstrual inequities and with no permit to reside in Spain presented significantly their associations with sociodemographic factors, among lower odds to report decreased productivity when men- women and PWM aged 18–55 in Spain. Menstrual ineq- struating (aOR: 0.41, 95% CI, 0.19–0.86) (see Table 6). uities were widespread in our sample, having a more Work absenteeism was disclosed by 20.3% of women profound impact on some groups of women and PWM, and PWM who were working at the time of data collec- such as those with less socioeconomic resources. Other tion. Among students, 62.7% did not attend their school/ main associations were between menstrual inequities university when menstruating. Just over half (53.8%) and completed education, employment and administra- reported declining social plans, 79.7% did not prac- tive status, and non-binary or trans identification. Main tice physical activity, and 72.3% did not go to the pool/ findings are discussed below. beach when menstruating. The reasons to stop doing these activities were: dysmenorrhea (68.6%), tiredness Access to healthcare services for menstrual health (65.3%), emotional status (48.2%), abundant bleeding Access to menstrual-related healthcare services is a (32.4%) and the need to conceal menstruation (0.9%). core element for menstrual equity, also considering that Participants reported teleworking or timetable flexibility women have been reported to have more difficulties in (76.4%) and the menstrual leave (49.9%) as preferred pol- accessing healthcare compared to men [36]. Although icies to improve menstrual management in workplaces. more than half of the participants had sought profes- These measures were not deemed necessary by 11.4% of sional assistance for menstruation, a significant number the participants. of them did not think it was necessary to access health- The odds for work absenteeism were significantly care services for menstruation. As expected, lifetime higher among non-binary menstruators (aOR: 1.65, 95% access to healthcare services was higher in older partici- CI, 1.30–2.08), participants with no residency permit pants as they had had more time to access and potentially (aOR: 3.30, 95% CI, 1.66–6.55), and women and PWM more opportunities for consultations. The fact that par- who were self-employed (aOR: 1.40, 95% CI, 1.22–1.61). ticipants receiving a pension or those who were retired On the other hand, the risk for work absenteeism was also had higher odds of accessing healthcare services significantly lower among participant working full-time for menstruation might be explained by the potentially (aOR: 0.62, 95% CI, 0.55–0.71) and those having some/a higher age of this participant group, or due to experienc- few (aOR: 0.80, 95% CI, 0.72–0.90) or no (aOR: 0.55, 95% ing less time poverty [37]. Participants on health benefits Table 6 Associations between social, community and economic participation, and sociodemographic characteristics (N = 20,622) Feel less able to cope with Feels less productive during Work absenteeism during Education absenteeism Decline social meetings day-to-day activities during menstruation (N = 17,330) menstruation (N = 18,463) during menstruation during menstruating menstruation (N = 19,997) (N = 18,271) (N = 20,182) aOR (95%CI) p value aOR (95%CI) p value aOR (95%CI) p value aOR (95%CI) p value aOR (95%CI) p value Age 18–25 1.00 1.00 1.00 1.00 1.00 26–35 0.78 (0.68.0.88) < 0.001 0.76 (0.65–0.89) 0.001 1.06 (0.93–1.20) 0.375 0.88 (0.79–0.98) 0.024 0.99 (0.90–1.09) 0.846 36–45 0.56 (0.49–0.63) < 0.001 0.50 (0.42–0.58) < 0.001 0.93 (0.82–1.07) 0.307 0.51 (0.45–0.57) < 0.001 0.73 (0.66–0.82) < 0.001 46–55 0.32 (0.28–0.37) < 0.001 0.25 (0.21–0.30) < 0.001 0.91 (0.76–1.07) 0.254 0.33 (0.29–0.38) < 0.001 0.48 (0.48–0.55) < 0.001 Gender Women 1.00 1.00 1.00 1.00 1.00 Non-binary/other 1.36 (1.05–1.77) 0.020 1.06 (0.78–1.43) 0.711 1.65 (1.30–2.08) < 0.001 1.57 (1.23–2.00) < 0.001 1.70 (1.37–2.11) < 0.001 Trans No 1.00 1.00 1.00 1.00 1.00 Medina‑Perucha et al. International Journal for Equity in Health Yes 1.51 (0.82–2.79) 0.184 1.46 (0.72–2.98) 0.294 1.01 (0.62–1.66) 0.970 0.88 (0.54–1.41) 0.588 0.87 (0.57–1.30) 0.490 I don’t know 1.15 (0.67–1.99) 0.611 0.82 (0.45–1.50) 0.513 1.25 (0.78–2.03) 0.355 0.71 (0.45–1.13) 0.153 0.78 (0.51–1.17) 0.230 Place of birth Spain 1.00 1.00 1.00 1.00 1.00 (2023) 22:92 Latin America 0.98 (0.81–1.20) 0.880 0.95 (0.74–1.21) 0.655 1.24 (1.01–1.53) 0.037 0.75 (0.62–0.90) 0.002 0.96 (0.81–1.15) 0.675 Europe 1.55 (1.16–2.06) 0.003 1.34 (0.94–1.90) 0.100 1.19 (0.90–1.59) 0.223 1.32 (1.01–1.73) 0.039 1.22 (0.96–1.55) 0.098 Other 1.04 (0.63–1.71) 0.877 0.98 (0.52–1.85) 0.958 1.40 (0.85–2.30) 0.184 1.13 (0.71–1.80) 0.602 1.64 (1.07–2.52) 0.023 Administrative situation Spanish nationality 1.00 1.00 1.00 1.00 1.00 Permanent residency 0.92 (0.72–1.18) 0.520 1.05 (0.77–1.42) 0.771 0.99 (0.77–1.27) 0.957 0.76 (0.61–0.95) 0.016 0.82 (0.67–1.01) 0.064 Temporal residency 0.88 (0.56–1.38) 0.575 0.82 (0.48–1.40) 0.465 1.34 (0.89–2.03) 0.160 0.82 (0.55–1.20) 0.303 0.75 (0.52–1.06) 0.106 No permit/in process 1.56 (0.64–3.81) 0.330 0.41 (0.19–0.86) 0.019 3.30 (1.66–6.55) 0.001 1.34 (0.63–2.85) 0.450 1.09 (0.56–2.13) 0.791 Employment situation Working full-time 0.74 (0.65–0.84) < 0.001 0.66 (0.57–0.77) < 0.001 0.62 (0.55–0.71) < 0.001 0.75 (0.66–0.84) < 0.001 0.81 (0.73–0.89) < 0.001 Working part-time 0.83 (0.73–0.94) 0.004 0.74 (0.63–0.87) < 0.001 0.58 (0.51–0.66) < 0.001 0.85 (0.76–0.96) 0.006 0.81 (0.73–0.91) < 0.001 Self-employed 0.89 (0.77–1.02) 0.094 0.84 (0.70–1.00) 0.046 1.40 (1.22–1.61) < 0.001 0.88 (0.77–1.00) 0.057 0.87 (0.77–0.98) 0.021 Studying full-time 1.44 (1.23–1.68) < 0.001 1.20 (0.98–1.46) 0.073 1.15 (0.99–1.35) 0.070 1.55 (1.35–1.78) < 0.001 1.17 (1.03–1.32) 0.013 Studying part-time 1.29 (1.12–1.48) < 0.001 1.11 (0.94–1.31) 0.214 1.11 (0.97–1.27) 0.114 1.68 (1.49–1.91) < 0.001 1.18 (1.05–1.31) 0.004 Unemployment or COVID19 benefits 0.97 (0.83–1.14) 0.697 0.86 (0.71–1.04) 0.121 0.77 (0.66–0.90) 0.001 1.05 (0.90–1.21) 0.553 1.08 (0.95–1.23) 0.232 Pension or retirement 0.91 (0.61–1.36) 0.648 0.92 (0.57–1.48) 0.720 1.13 (0.71–1.79) 0.616 1.28 (0.86–1.91) 0.227 1.26 (0.88–1.78) 0.202 Unpaid carer/houseworker 0.93 (0.79–1.09) 0.355 0.89 (0.73–1.08) 0.226 0.97 (0.82–1.14) 0.685 0.92 (0.78–1.07) 0.259 0.94 (0.82–1.08) 0.402 Completed education Primary education 1.00 1.00 1.00 1.00 1.00 Page 16 of 25 Table 6 (continued) Feel less able to cope with Feels less productive during Work absenteeism during Education absenteeism Decline social meetings day-to-day activities during menstruation (N = 17,330) menstruation (N = 18,463) during menstruation during menstruating Medina‑Perucha et al. International Journal for Equity in Health menstruation (N = 19,997) (N = 18,271) (N = 20,182) aOR (95%CI) p value aOR (95%CI) p value aOR (95%CI) p value aOR (95%CI) p value aOR (95%CI) p value Secondary education 1.22 (0.89–1.66) 0.213 1.35 (0.94–1.95) 0.108 0.88 (0.61–1.27) 0.492 1.31 (0.92–1.85) 0.133 1.30 (0.97–1.74) 0.077 University education 1.63 (1.19–2.21) 0.002 1.59 (1.10–2.28) 0.013 0.89 (0.62–1.27) 0.518 1.74 (1.23–2.46) 0.002 1.39 (1.04–1.85) 0.025 (2023) 22:92 Financial problems < 12 months Always/Many times 1.00 1.00 1.00 1.00 1.00 Some/A few times 0.73 (0.64–0.83) < 0.001 0.78 (0.67–0.92) 0.002 0.80 (0.72–0.90) < 0.001 0.79 (0.70–0.88) < 0.001 0.78 (0.71–0.87) < 0.001 Never 0.47 (0.42–0.53) < 0.001 0.53 (0.46–0.62) < 0.001 0.55 (0.49–0.61) < 0.001 0.51 (0.46–0.57) < 0.001 0.51 (0.46–0.56) < 0.001 Page 17 of 25 Medina‑Perucha et al. International Journal for Equity in Health (2023) 22:92 Page 18 of 25 Fig. 8 Associations betweenwork absenteeism and self-reported financial problems could have reported more access to healthcare services socioeconomically deprived populations [36]. The link due to poorer health. The odds of healthcare access were with administrative status is not clear, although our higher in employed and self-employed participants. This data suggests that not having the Spanish nationality can be potentially related to the age of women and PWM may be associated with a decreased access to health- in these groups (e.g., they may be at the time of trying to care services for menstruation. This is coherent with get pregnant). This association could also be explained by previous evidence on, not only the legislative, financial poorer menstrual health outcomes of workers and self- and economic barriers that migrant populations face to employed women and PWM, as their access to the labor access healthcare services [36, 44], but also institution- force may increase stress and burden of care [38]. alized racism and the lack of cultural safety in health- Education is an important social determinant of care systems [45, 46]. Especially migrant women and health [39, 40]. Consistently with previous evidence PWM with no access to a public health insurance card on the link between education, health outcomes and may face significant barriers to healthcare access. health equity [41, 42], completing university educa- tion was a protective factor for healthcare access. Access to menstrual education and knowledge Women and PWM with higher education may be more The number of women and PWM that did not have informed, given their increased access to educational enough information on the menstrual cycle and menstru- resources. At the same time, participants with a higher ation before menarche was reasonably high (45.3%), with educational attainment might have been more empow- 12.5% not knowing what menstruation was at menarche. ered, less impacted by time poverty [37] and have a Furthermore, around half were not feeling ready to men- higher health and body literacy. The latter has been struate at the time of menarche. Not only menstrual previously linked to positive health outcomes [43]. Our education is essential [47, 48], but how girls and young findings also reveal a link between financial constraints PWM feel about menstruating, and the resources they and an increased access to healthcare services, possibly are equipped with to manage menstruation and the social due to poorer menstrual health [10]. However, special changes that commonly come with menarche [29, 49]. attention should be paid to women and PWM with a As apparent in our study, most participants learnt from lower socioeconomic status, as previous reports report their families, school or friends at the time of menarche. the increased barriers for healthcare access among Instead, the internet and social media appear to become Medina‑Perucha et al. International Journal for Equity in Health (2023) 22:92 Page 19 of 25 main sources of menstrual information during adult- scarce, these estimates are higher than those reported hood. This points to the role of social media and online in previous studies. Menstrual poverty in young people networks on public health strategies [50, 51]. Also, to its has been calculated to be around 10% in the UK [32] potential drawbacks of being sources of “infodemics” [52] and between 10–14.2% in the US [21] in young popu- and generating further social inequities as a result of the lations. Spanish national statistics indicate that 10.9% digital divide [53], among other challenges [54]. However, of employed women, 31.2% of unemployed women and these data can serve to support and inform the use of 42.6% of women receiving unemployment benefits lived online networks and platforms in strategies that promote in a situation of relative poverty in 2020 [60]. These menstrual education and equity. reports are consistent with our estimates of menstrual Being older was a risk factor for not having had access poverty. However, the prevalence of menstrual poverty to menstrual education pre-menarche. This is expected in Spain may be higher as our sample was fairly soci- given that reproductive and sexual health curricula oeconomically privileged. This is a limitation in our (where menstrual education is usually included) has research that may have led to underestimate, not only started to be particularly present in young people’s edu- realities of menstrual poverty but menstrual inequity. cation in the last few years [55]. Although this could be However, our study suggests that menstrual poverty attributed to recall biases, the access to information may not only affect women and PWM living in situa- through information and communication technology, tions of poverty, but other women that may experi- and the influence the feminist movement has had in the ence occasional financial hardship. This point leads us last few years may have also led to an increased access to mention how common precarious work is in Spain, to menstrual education amongst. Spain has experienced with poorly paid, insecure and temporary jobs having some profound socio-political changes in the last dec- particularly increased since the 2008 economic crisis, ades, which can also explain our findings. Spain was and during the COVID19 syndemic. Also, to highlight under a dictatorship from 1939 until 1975, which led, that poverty and precariousness are gendered, highly not only a systematic violation of human rights, but a affecting women and gender non-conforming people profound regression in the educational system. The Fran- [61, 62]. In fact, our study shows that non-binary peo- coist dictatorship was characterized for being an authori- ple are more at risk of menstrual poverty. Besides, men- tarian regime that enforced Catholicism. Women lost strual poverty risk was higher in migrant populations, many human and civil rights that they had been granted potentially those more socioeconomically deprived. to at the start of the twentieth century, which included As for the relationship between menstrual poverty and the prohibition of the use of contraception, abortion, and age, increased age was another risk factor for menstrual divorce by law. The post-dictatorship decades have led to poverty in our study. However, this should be inter- a slow restructuring of our political and societal systems, preted with caution as data were collected for lifetime which have also led to including sexual and reproductive experiences of menstrual poverty. However, there may education in the school curricula. Considering that many be generational differences that are worth exploring in of our participants grew up in the last decade of Franco’s future research. dictatorship, and during the transition to democracy, it is On the other hand, menstrual management is plausible that they received limited to no menstrual edu- imperative for women and PWM’s health and wellbe- cation pre-menarche. ing [11, 12, 63–66]. Unsafe management of menstrua- Participants born in non-European or Latin American tion and overusing menstrual products may lead to countries were also found to have had less access to men- several health problems, such as lower reproductive strual education pre-menarche. This indicates disparities tract infections [67, 68]. Most of the participants in our in the access to menstrual education across countries study had overused menstrual products, with 75.5% and world regions. On the other hand, trans people in experiencing symptoms related to the use of men- our study appeared to be less interested in learning about strual products in the six months preceding the study. menstruation and the menstrual cycle, possibly given the Product overuse may be one of the reasons for such a potential distress and gender dysphoria that some trans high prevalence of menstrual product-related symp- people may experience related to menstruation [56–59]. toms identified in our research, together with the lack of access to adequate menstrual management facilities. Menstrual poverty and menstrual management The odds for overusing menstrual products were higher Women and PWM in our study reported a lifetime in non-binary participants, although not related to the prevalence of menstrual poverty between 22.2% (to lack of access to menstrual management facilities. It afford any menstrual product) and 39.9% (to afford pre- also affected employed participants more, particularly ferred menstrual products). Although evidence is still as the challenges to manage menstruation are greater if Medina‑Perucha et al. International Journal for Equity in Health (2023) 22:92 Page 20 of 25 working away from home due to gender discrimination discrimination. Prevailing experiences of stigma and in urban and built environments [69]. Besides, a link discrimination can have a profound impact on social, between financial hardship and the overuse of men- psychological [75] and physical wellbeing [76, 77], thus strual products was found. This suggests that socioeco- research and sociopolitical actions on menstrual inequity nomically deprived women and PWM are at higher risk should pay particular attention to the structural violence for using menstrual products for longer than recom- that migrant populations experience. mended, which may be accompanied with an increase in (menstrual) health risks. At the same time, higher Social, community and economic participation educational attainment was a risk factor for menstrual It was common for women and PWM in our study to product overuse. As already discussed, participants report feeling less able to cope with day-to-day activities with university studies may be more empowered and and be productive when menstruating. Although this is have less restrictions (e.g., time poverty) to identify and not problematic per se, it leads us to question whether report some menstrual inequity-related experiences. women and PWM count with enough resources to practice self-care to manage menstruation. Participants Taboo, embarrassment and experiences of stigma who reported being more burdened by menstruation in and discrimination their day-to-day were non-binary participants, younger Consistently with previous evidence [13, 70, 71], men- people, and women and PWM with more financial prob- strual-related taboo, embarrassment and experiences of lems. As already discussed, this points towards the need stigma and discrimination were significantly common to particularly address menstrual inequities among gen- among women and PWM in our sample. Being employed der non-conformity individuals and those more socioec- or studying were risk factors to report menstrual-related onomically deprived. Further, being employed was found taboo and embarrassment, which links to the challenges to be a protective factor, which could be explained by the of managing menstruation in workplaces [26] and educa- fact that, often, employees cannot avoid productive work. tional [72] settings. Another risk factor was having com- This may particularly affect women and PWM with pre- pleted university education. In order to understand this carious working conditions or experiencing higher eco- finding, first we need to consider that most participants nomic hardship [62]. had completed higher education. Also, that the relation- Menstruation-related work and education absenteeism ship between education and the report of taboo, embar- were high. Based on participants’ responses and previous rassment, stigma and discrimination may be mediated by research [25], it is urgent to support menstrual manage- having more resources to identify and report such expe- ment policies in work and educational environments. riences. It may also be that women and PWM with higher Future research should further investigate the strategies education attainment are less burdened with day-to-day that may be most relevant to women and PWM, and hardships, allowing them to pay more attention to expe- those most feasible to implement, to then inform poli- riences of menstrual taboo, stigma and discrimination. cymaking processes. Also, to further evaluate the impact On the contrary and coherently with other findings from of education absenteeism on women and PWM. Policies our research, having less or no financial problems was a should not only focus on supporting self-care and men- protective factor for menstrual-related taboo, embarrass- strual management [26] but also address the reasons why ment and experiences of stigma and discrimination. women and PWM might need to be absent from work or The odds to report menstrual-related embarrassment their studies during menstruation. Non-binary people were higher among trans people. Likewise, the odds for and some migrant groups were again found to be more concealing menstruation and experiencing menstrual- affected. It is however imperative that these findings related stigma and discrimination increased in non- are not used to discriminate against these groups, but binary participants. This may be associated with the rather promote policies that can be adapted to the needs prevalent stigma and discrimination that gender non- of different populations. Understandably, experiencing conformity people experience, including related to men- financial hardship was a protective factor for work absen- struation [56–59] and in healthcare settings [73, 74]. teeism, as the socioeconomic costs of absenteeism could There was also a tendency for some migrant popula- be certainly greater. tions to be more at risk of reporting taboo, stigma and Lastly, social and community participation must not be discrimination. While this may be related to sociocul- disregarded, as our study revealed that it can be greatly tural conceptualisations of menstruation, it is essential to compromised during menstruation. The benefits of social highlight that migrant populations, and especially racial- and community participation have already been exam- ised individuals or those in a situation of socioeconomic ined in previous research [78, 79], being fundamental ele- deprivation, are already a target of structural stigma and ments to attain social and health equity [80]. Encouraging Medina‑Perucha et al. International Journal for Equity in Health (2023) 22:92 Page 21 of 25 women and PWM’s social and community participation, a first approximation to describing menstrual inequities while promoting self-care and menstrual management, in Spain. The team is committed to continuing this line can be core pillars towards menstrual equity. of research to offer an overview of menstrual inequities that is representative, considers diversities and reaches Strengths, limitations and reflections out to those most vulnerable to experiencing menstrual The main strength of this study is that it provides, to inequities. our knowledge, the first comprehensive description of Moreover, the use of self-reported data entails further menstrual inequities in Spain. A second strength is the challenges to interpret our findings. One of the limita- inclusion of a large number of women and PWM across tions of self-reported data is the inability to understand the Spanish territory. There were also limitations. First, participants’ experiential knowledge and subjective expe- the questionnaire used for data collection took around rience. Thus, the research team cannot be sure of how 20 minutes to complete. This may have led to drop- participants have understood and answered some ques- outs and the refusal to participate. Despite the efforts to tions (e.g., regarding “feeling less productive”). Although design an accessible questionnaire, the team is also aware this could have had an impact on our results, as these that the complexity of some questions may have also had may have not accounted for subjective diversity, the team a negative impact on participation. Besides, based on its assumes this challenge and calls for a mindful interpre- methodological nature, this study cannot be representa- tation of our results. The research team has conducted tive to the whole menstruating population in Spain, as qualitative research, which complements and expands we used an online questionnaire and sampling was non- the findings provided in this manuscript; this could par- probabilistic. As already presented in the Results section, tially address the limitations of quantitative self-reported our sample differs from available representative data in methods. The use of self-reported data in inequity Spain in age distribution, completed education, the pro- research presents another challenge. As other research- portion of migrant populations, and people who were ers have previously identified and discussed [81], we are unemployed and those receiving pensions/benefits. Our limited to understand how the response to certain vari- sample included a higher proportion of younger peo- ables (e.g., menstrual poverty) may differ by socioeco- ple who had completed university studies, were born in nomic proxies (e.g., completed education). This presents Spain and were not unemployed or receiving a pension or challenges to describe and estimate menstrual inequities, State benefits. However, representative data on employed entailing a potential under or overestimation of these populations and financial satisfaction were similar to the inequities. Further research is required to improve data data in our study. Thus, overall, we can conclude that collection and interpreting methods that account for our participants were in a relatively socioeconomically social inequities, such as for differences in self-report privileged situation. This suggests that our study may reporting by educational level [81]. be underestimating menstrual inequities. Besides, it is As a final point, data were collected at a time when important to consider this information when interpreting tax reductions for menstrual products and a new (and the data from our study. Although results should be inter- polemic) law on Trans Rights were being discussed at the preted with caution, the sample size is large and repre- Spanish Congress. We believe that collecting data in this sentative enough to present a good estimate of menstrual context has had a two-fold impact on recruitment and inequity in Spain. Moreover, we need to acknowledge the data collection. While the study was highly disseminated potential detrimental impact of the digital divide on the given the public discussions around menstrual health recruitment process and representation of the sample. and equity at the time of data collection, we are aware As noticeable from our results, over 60% of participants that some women refused to participate in the study as had completed university studies and over half were it was also welcoming non-binary and trans people who employed. Thus, our findings may not be representative menstruate to participate. Additionally, using gender- of populations with less access to social and economic neutral/inclusive language in Spanish is difficult given resources. Acknowledging this limitation is important that grammatical gender is pervasive and there is no as this study may have underestimated menstrual ineq- neutral grammatical gender in common language use. In uities in Spain. We may have also missed understanding order to make the questionnaire accessible to most par- the profound impact of menstrual inequity among socio- ticipants, the questionnaire’s language was mostly using economically vulnerable and hard-to-reach populations “feminine” language structures in places where gender- (e.g., those living in situations of homelessness). Despite neutral/inclusive language could not be used. Some non- this limitation may challenge the interpretation of our binary and trans people may have refused to participate findings, the data presented in this publication present for this reason, as they may have not felt represented. Medina‑Perucha et al. International Journal for Equity in Health (2023) 22:92 Page 22 of 25 In spite of this limitation, the sample of non-binary and Conclusions trans people represented 4% of the total sample (3.4% and Our study presents an overview of menstrual inequi- 0.8% respectively). There are no estimates of how many ties in Spain, which are widespread and affect a high non-binary and trans people live in Spain. However, number of women and PWM, especially those with a estimates in the United States indicate that 0.3–4.5% of lower socioeconomic status, some migrant popula- adults identify as trans and/or gender diverse [82, 83]. tions and non-binary and trans PWM. Working women Based on this, we could have an acceptable representa- and PWM also face increased challenges, particularly tion of non-binary and trans people in our study. to manage menstruation in workplaces. Those with a higher educational attainment and socioeconomic Implications for research and policy status may have increased resources that serve as pro- Recommendations for future research and policy devel- tective factors for menstrual inequities. Given that the opment can be drawn from this study. First, research study mostly assessed lifetime experiences of menstrual actions could examine the impact of menstrual inequities inequities, older participants seemed to be marginally on women and PWM’s emotional and physical health, more at risk for these social inequities. To our knowl- including the potential associations between menstrual edge, this study presents the first data describing men- inequities and (menstrual) health outcomes. Future strual inequities in Spain. Its findings can have a great studies could also focus on younger populations, and social impact and translate into policy, future research, on particular forms of menstrual inequities (e.g., access practice and advocacy recommendations to tackle to healthcare services for menstruation). Developing a menstrual inequities. Very importantly, this study could menstrual inequity index could be another significant aid addressing menstruation-related social inequities contribution to the current body of research. Second, (of health). policy strategies should be multifaceted and multidimen- sional, addressing menstrual inequities comprehensively Abbreviations rather than only focusing on, for instance, tackling men- PWM People who menstruate strual poverty. As for menstrual poverty, it should not only be considered as not being able to afford menstrual Supplementary Information products, but also as not being able to choose preferred The online version contains supplementary material available at https://​doi.​ menstrual product(s) due to financial constraints. Taxes org/​10.​1186/​s12939-​023-​01904-8. on menstrual products need to be reduced, not just to improve affordability but as a matter of social justice. Additional file 1: Supplementary Table 1. Comparative between Equity and Menstrual Health in Spain Study Data (N=22,823) and Spanish Given that tax reduction will not be sufficient to tackle National Statistics Institute Data. menstrual poverty, policies should be far-reaching and Additional file 2: Supplementary Table 2. Access to healthcare intersectoral. Policies to ensure affordability and avail- services stratified by sociodemographic characteristics (N=22,313). ability among socioeconomically deprived women and Supplementary Table 3. Access to menstrual education and knowl‑ edge stratified by sociodemographic characteristics (N=21839). PWM could have a positive impact. Together with men- Supplementary Table 4. Menstrual management and menstrual strual poverty strategies, policies should ensure formal poverty stratified by sociodemographic characteristics. Supplemen- and community-based menstrual education aimed at tary Table 5. Tabboo, embarrassement and experiences of stigma and discrimination stratified by sociodemographic characteristics. Sup- younger and older generations. Access to menstrual plementary Table 6a. Barriers to social, community and economic health services should also be ensured, particularly participation stratified by sociodemographic characteristics. Supplemen- through educating the population and healthcare pro- tary Table 6b. Barriers to social, community and economic participa‑ tion stratified by sociodemographic characteristics. fessionals on menstrual health. Healthcare services also need to be structured mindfully around the needs and barriers faced by non-binary, trans, and migrant women Acknowledgements and PWM. Adequate facilities for menstrual manage- We would like to thank all participants, for dedicating their time and energy to ment in public spaces, workplaces and educational cent- take part in the study. Thank you to Carmen Revuelta, Ramona Ortiz, Rosa Tur‑ bau Valls, Mònica Isidro Albaladejo, Enara Solana Lizarza, Paula Briales Canseco, ers are also required to address menstrual inequities. Lola Hernández for their contributions to the study. Also, to the following peo‑ Besides, menstrual workplace policies can greatly aid ple and organisations for disseminating the questionnaire and contributing to menstrual management among working women and the recruitment process: Institut Català de la Salut, Centre Jove d’Atenció a les Sexualitats (CJAS), DIM Protect, Joventut Barcelona, La Caravana Roja, Somi‑ PWM. Overall, menstrual inequity policies must con- Arte Taller, Centro de Análisis y Programas Sanitarios (CAPS), La Vida en Rojo sider and be adapted to the needs of most affected popu- Asociación de Cultura Menstrual, CYCLO Menstruación Sostenible, Aguas de lations, such as those more socioeconomically deprived, Luna, Xusa Sanz, Cristina Luna, Sylvia de Bejar, Laia Casadevall, Irene Aterido, Celia Cuenca, EndoFem, Judit Pelegrí Alvárez, Blanca Albillos Mingorance, Julia non-binary and trans PWM and vulnerabilised migrant Arquillos Jimenez, Gala Montenegro Nadal, Sílvia Martin Egido, Cristina Morote populations. Muñoz, Marta Boqué Ramon, Anna Solé Valls, Anna Sánchez Benedet, Irene Medina‑Perucha et al. International Journal for Equity in Health (2023) 22:92 Page 23 of 25 Blanco Alcántara, Frater Nadal, Abel Renuncio, Emilia Bailón, Tania Cedeño, Author details 1 Sociedad Española de Medicina Familiar y Comunitaria (semFYC), Banc Fundació Institut Universitari Per a La Recerca a L’Atenció Primària de Salut Farmacèutic, La Nau and Ajuntament de Cornellà. Last but not least, to Anna Jordi Gol I Gurina (IDIAPJGol), Gran Via de Les Corts Catalanes 587 Attic, Moleras Serra for her valuable technical assistance and management to devise 08007 Barcelona, Spain. 2 Universitat Autònoma de Barcelona, Cerdanyola del the online questionnaire on LimeSurvey and during data collection. Vallès, Spain. 3 Universitat Pompeu Fabra, Barcelona, Spain. 4 Centro de Análisis Y Programas Sanitarios (CAPS), Barcelona, Spain. 5 Atenció a La Salut Sexual I Authors’ contributions Reproductiva (ASSIR) Muntanya/La Mina, Institut Català de La Salut, Barcelona, Conceptualization, LMP, AB, CJA, TLJ, JMF, CMB, CVLl, DPS; methodology, LMP, Spain. 6 Sexual and Reproductive Health Care Research Group (GRASSIR), TLJ, AB, CJA, JMF, CMB; validation, LMP and TLJ; formal analysis, TLJ, LMP; inves‑ Barcelona, Spain. 7 Servei d’Atenció a La Salut Sexual I Reproductiva (ASSIR). tigation, LMP, TLJ, ASH, CJA, JMF, CMB, CVLl, BPS, MMVH, AB; resources, LMP, Direcció Assistencial d’Atenció Primària. Institut Català de La Salut, Barcelona, AB, JMF, CMB, CVLl; data curation, TLJ, LMP; writing—original draft preparation, Spain. 8 University of Barcelona, Barcelona, Spain. 9 SomiArte Taller, Barcelona, LMP; writing—review and editing, LMP, TLJ, ASH, CJA, JMF, CMB, CVLl, BPS, Spain. 10 Departament d’Infermeria, Universitat de Girona, Girona, Spain. MMVH, AB; visualization, LMP; supervision, LMP; project administration, LMP; funding acquisition, LMP and AB. All authors have read and agreed to the pub‑ Received: 15 February 2022 Accepted: 30 April 2023 lished version of the manuscript. Funding The study was funded by the European Society of Contraception and Repro‑ ductive Health (P-2019-A-01). The funders had no role in the development References of the study and the preparation of this manuscript. The project received 1. Barrington DJ, Robinson HJ, Wilson E, Hennegan J. 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Available from: (2005); the Helsinki Declaration (2013) and relevant EU laws (European https://​www.​scopus.​com/​inward/​record.​uri?​eid=2-​s2.0-​85125​02060​2&​ Parliament and Council Directive 2001/20/EC); the Spanish Law on Biomedical doi=​10.​1186%​2fs12​978-​022-​01354-​5&​partn​erID=​40&​md5=​fa34b​97249​ Research (14/2007) and the LOPD (Spanish Law on Personal Data Protection) d3af8​cebcd​ffc1c​83d0b​4f. (3/2018). An information sheet was available to all participants prior to taking 9. Crichton J, Okal J, Kabiru CW, Zulu EM. Emotional and psychosocial part. All participants were requested to consent through the online platform. aspects of menstrual poverty in resource-poor settings: a qualitative The research team’s contact details were also available for any queries. study of the experiences of adolescent girls in an informal settlement COVID-19 prevention strategies were put into place at all times when recruit‑ in Nairobi. Health care women Int. 2013;34(10):891–916. Available from: ment and data collection were face-to-face. The researchers were guided at all https://​www.​scopus.​com/​inward/​record.​uri?​eid=2-​s2.0-​84884​35702​4&​ times by the IDIAPJGol Research Ethics Committee and the Internal Scientific doi=​10.​1080%​2f073​99332.​2012.​74011​2&​partn​erID=​40&​md5=​92363​ Committee of the European Society of Contraception and Reproductive Health. 98b4a​43ea0​c0938​39d15​bd950​cd. All participants received enough information about the study to make an 10. Rossouw L, Ross H. Understanding period poverty: Socio-economic informed decision on their participation. Written consent was requested to inequalities in menstrual hygiene management in eight low-and middle- all participants prior to taking part in the study (both online and in person). income countries. Int J Environ Res Public Health. 2021;18(5):1–15. Avail‑ Confidentiality and anonymity have been carefully ensured. Physical identifi‑ able from: https://​www.​scopus.​com/​inward/​record.​uri?​eid=2-​s2.0-​85101​ able data were securely stored. Digital information was securely stored at the 89728​3&​doi=​10.​3390%​2fije​rph18​05257​1&​partn​erID=​40&​md5=​b7e38​ IDIAPJGol’ secure portal. 7f062​6a791​87682​093cc​4c420​bd. 11. Sommer M, Hirsch JS, Nathanson C, Parker RG. Comfortably, safely, and Consent for publication without shame: defining menstrual hygiene management as a public All participants gave their consent to share anonymised data for publication. health issue. Am J Public Health. 2015;105(7):1302–11. Available from: https://​www.​scopus.​com/​inward/​record.​uri?​eid=2-​s2.0-​84930​83045​5&​ Competing interests doi=​10.​2105%​2fAJPH.​2014.​30252​5&​partn​erID=​40&​md5=​f5176​e60a1​ The authors declare having received funds from DIM Protect to support a285e​19ddd​a4a68​0c51b​9a. the team’s future research on equity and menstrual health. DIM Protect 12. 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