Health & Place 66 (2020) 102431

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Health and Place

journal homepage: http://www.elsevier.com/locate/healthplace

Menstruation and homelessness: Challenges faced living in shelters and on

the street in New York City
Marni Sommer a, *, Caitlin Gruer a, Rachel Clark Smith a, Andrew Maroko b, Kim Hopper a
a
Columbia University, Mailman School of Public Health, Department of Sociomedical Sciences, 722 W. 168th Street, Room 537, New York, NY 10032, USA
b
Lehman College, CUNY School of Public Health, Department of Environmental, Occupational, and Geospatial Health Sciences, 55 W. 125th Street, Room 508, New
York, NY 10027, USA

A R T I C L E I N F O A B S T R A C T

Keywords: A growing literature attests to menstrual management difficulties of girls, women and other people who
Menstruation menstruate. Largely ignored are the menstruation-management needs of people experiencing homelessness. We
Homelessness explored these realities in New York City through in-depth interviews with individuals living on the street and in
Stigma
shelters (n = 22), key informant interviews with staff at government agencies, shelters and service provider
New York city
Sanitation
organizations (n = 15), and field audits of public toilets. This paper explores both pragmatic difficulties pre­
sented by inadequate access to toilets, bathing spaces, and laundering services, and pervasive menstrual stigma.
Amplifying the difficulties was near-constant pressure “to pass,” as someone who was not homeless in order to
enable increased access to toilets, and as someone who was not menstruating, in order to engage in the activities
of daily living. Our findings highlight the need for improved quality and accessibility of bathrooms for sheltered
and street-dwelling homeless, and expedited access to bathing and laundering. Such actions are essential given
the steady increase in homelessness in NYC and – under the long shadow of COVID – especially timely.

1. Introduction one group of low-income individuals in relation to menstruation – those

Increasing evidence attests to the challenges faced by girls, women,
and all people who menstruate to manage their monthly blood flow with
dignity, comfort and safety (VanLeeuwen and Torondel, 2018; MacRae
et al., 2019; Phillips-Howard et al., 2016). This includes barriers to
managing menstruation for girls and women in low- and middle-income
countries, such as stigma, inadequate access to toilets, water and men­
strual products, and insufficient information (McMahon et al., 2011;
Mason et al., 2013; Sommer et al., 2016; Hennegan et al., 2019); and
challenges and responses to the menstruation-related needs of the over
26 million displaced girls and women globally (Schmitt et al., 2017).
More recently, attention has focused on high-income countries, espe­
cially the discriminatory taxes placed on sanitary products (Crawford
and Spivack, 2017; Parrillo and Feller, 2017) and the affordability and
accessibility of menstrual products for low-income and vulnerable
populations (Kuhlmann et al., 2019). This has also included a bur­
geoning effort to better understand the menstruation experiences and
needs of gender non-binary, gender non-conforming, and others on the
transmasculine spectrum (Frank, 2020). Yet minimal evidence exists for
experiencing homelessness. In the US, the few studies exploring the
menstrual management needs of people experiencing homelessness have
primarily focused on access to menstrual products (Ensign, 2001; Levit,
2017; Kuhlmann et al., 2019), menstrual stigma (Mitchell et al., 2018),
ability to maintain personal hygiene (Durfor, 2015), and gynecological
challenges (Wenzel et al., 2019). This paper seeks to contribute to the
evidence on the day to day difficulties of managing menstrual blood flow
each month from a study conducted with street and sheltered in­
dividuals experiencing homelessness in New York City (NYC). In
particular, we highlight the difficulties posed by compromised access to
toilets, as well as to spaces for bathing and laundering.
In 2019, NYC homeless shelters held an average of 62,391 people per
night, with the shelter system serving 133,284 separate individuals in
2018, a 59% increase over the prior decade (Coalition for the Homeless,
2019). A point-in-time count in 2019 estimated 3588 more individuals
sleeping on the street, a number that may be a significant underestimate
due to the difficulties associated with locating this population (NYC
Department of Homeless Services, 2019). The primary cause of home­
lessness in NYC is lack of affordable housing, abetted and compounded

* Corresponding author. Columbia University, Mailman School of Public Health, Department of Sociomedical Sciences, 722 W. 168th Street, Room 537, New York,
NY 10032, USA.
E-mail addresses: ms2778@columbia.edu (M. Sommer), andrew.maroko@sph.cuny.edu (A. Maroko).

https://doi.org/10.1016/j.healthplace.2020.102431
Received 2 July 2020; Received in revised form 6 August 2020; Accepted 24 August 2020
Available online 25 September 2020
1353-8292/© 2020 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).
M. Sommer et al.
by unemployment, domestic violence, institutional discharge, addiction,
and serious mental and physical illness. Notably for a study of menstrual
hygiene, the number of women in NYC’s shelter system has steadily
increased for the last 18 years, and by an average of 8.6% per year since
2015 (NYC Department of Homeless Services, n. d.; Coalition for the
Homeless, 2003, 2004, 2005, 2011).
Concerns about the difficulties individuals experiencing homeless­
ness confront in managing menstrual hygiene are not new. Researchers
noted in the early 1990s that women experiencing homelessness were
more likely to be seen in local health clinics for gynecological problems
than their non-homeless counterparts, and that menstrual-related issues
accounted for the majority of diagnoses (Ferenchick, 1991; Wenzel
et al., 2019). Urinary tract infections, yeast infections, and vulvar con­
tact dermatitis, the most commonly reported gynecological symptoms
among this population, may be caused or worsened by an inability to
maintain genital hygiene, especially during menstruation (Parrillo and
Feller, 2017). Still, aside from clinical reports, focused attention to
menstrual hygiene has been noticeably sparse in a literature that now
spans four decades.
In general, obstacles to personal hygiene for people experiencing
homelessness increase their vulnerability to disease and are com­
pounded by other risk factors, including sleeping outside (Leibler et al.,
2017). Housed friends and family, rather than government or social
service providers, play a significant role in providing hygiene resources
such as showers and laundry. Notably, those with the most risk factors,
such as those with mental illness, are often also more difficult to reach
for intervention. In a study of chronically unsheltered women in
Southern California, attention to personal hygiene self-management
(including menstrual hygiene management or MHM) was described as
a way to blend in with the general public and improve overall quality of
life, rather than prevent or reduce the severity of health problems
(Durfor, 2015). Other reported or hypothesized challenges of menstru­
ating while homeless include difficulty procuring tampons and pads,
lack of access to bathrooms for washing and changing menstrual prod­
ucts, keeping underwear and clothing clean, and managing irregular,
unexpected periods (Ensign, 2001).
Managing monthly blood flow presents a classic instance of gendered
stigma: a potentially “discreditable” condition, occasioning shame and
avoidance, but one ordinarily managed in ways that allow one to “pass”
as a person who is not menstruating (barring the occasional – and
mortifying – “accident”) (Goffman, 1963). For the destitute, dealing
with both the practical and symbolic aspects of menstruation interferes
with help-seeking, strains time and resource management, and compli­
cates survival strategies. Like routine harassment on the street and in
shelters, the distinctive challenges posed by menstruation while expe­
riencing homelessness are conspicuous by their near-absence in the
literature to date. That absence is itself telling, a point to which we will
return in conclusion.
The study described here was conducted in NYC (May–August 2019)
in partnership with the Coalition for the Homeless. Given the sensitivity
of conducting research with the vulnerable population of people expe­
riencing homelessness, it was vital to partner with an institution that has
deep roots and knowledge about this community. Founded in 1981, the
Coalition is one of key service organizations providing services to and
advocating for the needs of this population in NYC. This partnership also
facilitated our entrée into the community of service providers. Impor­
tant to note are the unique and diverse gendered aspects of the popu­
lation as described in this paper. Not all women menstruate, and not all
people who menstruate are women. In addition, a large number of youth
experiencing homelessness are those identifying as transgender or
gender non-conforming, creating distinctive vulnerabilities in relation
to managing menstruation. For all of these reasons, utilizing more in­
clusive gendered language is essential.
The study aim was to understand the menstrual management expe­
riences of people experiencing homelessness in dealing with their pe­
riods while living on the streets or in shelters in New York City. We
2
Health and Place 66 (2020) 102431
sought to explore how well they were able to manage their periods,
including accessing sanitation facilities (toilets, water) and menstrual
products, as well as how their needs could more effectively be addressed,
aside from the possibility of gaining more stable housing.
2. Methods
We conducted a mixed-methods study that sought to capture at both
individual and institutional levels the voiced realities re menstrual
management on the part of those experiencing homelessness, and how
the local context shapes those experiences. This included: 1) key infor­
mant interviews with staff of government agencies and homeless service
organizations; 2) in-depth interviews with people experiencing home­
lessness who menstruate; and 3) field-based audits of public toilet fa­
cilities in a select number of sites across the city. The last included the
use of an observational checklist assessing the design and characteristics
(e.g. cleanliness, safety, accessibility, availability of resources) of the
facilities, as assessed through a systematic mapping of toilets located
near clusters, or “hot spots,” of individuals experiencing homelessness in
NYC. All of the methods were conducted in parallel, although the initial
set of qualitative interviews helped to guide the observations to be
conducted during the audits. The findings described in this paper draw
on the key informant interviews and in-depth interviews; findings from
public toilet audits will be described in a subsequent article.
2.1. The study received internal review board (IRB) approval from the
[blinded institution]
2.1.1. Sample and recruitment
Our sample for the key informant interviews (n = 15) included staff
of government agencies and organizations providing services to people
experiencing homelessness, including shelters. We used purposive
sampling to identify a range of participants who would represent the key
agencies and organizations (e.g. Department of Transportation, Parks
and Recreation, food pantries, youth shelters) expected to be most
knowledgeable about the issue and/or relevant to identifying potential
solutions for existing challenges. We recruited participants through
initial email communications explaining the proposed study, and
expressing our interest in conducting a short interview. When partici­
pants could not be reached through email, we reached out by phone to
contact and recruit them. The participants included staff from relevant
government agencies (n = 3), as well as staff (n = 12) from across ten
direct service organizations. The service organizations ranged from
those focused on vulnerable youth, to those providing temporary and
transitional housing, to those providing basic necessities such as food
and water. One organization was focused specifically on providing
menstrual products to individuals living on the street and in shelters.
Respondents’ positions ranged from the president and director-level, to
medical providers, and frontline services coordinators.
Our sample for the in-depth interviews (n = 22) included street and
sheltered individuals experiencing homelessness ages 18 years old and
older. We sought to identify 4–5 individuals in each of the following age
groups: 18–25; 26–35; 36–45; and 46 and above in order to capture a
range of menstruation-related experiences. We used convenience sam­
pling to identify a range of participants from among those seeking ser­
vices at the Coalition, as well as from organizations specifically serving
youth. We recruited participants in collaboration with our organiza­
tional partner, who made announcements to those coming in for ser­
vices, provided brief details on the study, and mentioned the incentive of
a metro card ($10 or $15) for those who participated. A flyer was also
placed on the front desk where clients signed in upon arriving for ser­
vices. For those who expressed interest in participating, the Coalition
and/or service provider introduced them to the research team.
The participants all presented as female, although we did not ask for
gender identification. Similarly, while we did not ask for age—beyond
confirming that they were above the age of 18—many of the participants
M. Sommer et al.
shared their age during the course of the interview and the researchers
estimated age for the others based on appearance and life story. Based
on these methods, we approximate that the ages of the participants
ranged from 18 to 62, including 8 in the 18–25 category, 5 in the 26–35
category, 4 in the 36–45 category, and 5 in the 46 and above category. A
number of the participants (n = 7) had experienced both street and
shelter living, shuttling between them at various points during their time
homeless.
2.2. No one approached refused to participate, and all those recruited
completed the interview
2.2.1. Data collection
During the period of June–August 2019, the research team worked in
two-person teams to conduct all of the key informant and in-depth in­
terviews in NYC. The two-person teams consisted of the Principal
Investigator (PI) and the research assistant (RA), or the RA and a
member of the PI’s staff research team. All members of the interview
team were females, with two members having conducted previous work
or research with individuals experiencing homelessness. Prior to the
data collection, the team conducted exercises in reflexivity, considering
our positionality in relation to the power dynamics of the exchange, and
reviewed our own experience as city-dwellers who menstruate. The
larger research team included a Co–I with decades of experience
engaging in research, practice and policy with individuals experiencing
homelessness, a second Co–I with spatial analysis expertise, and grad­
uate assistants supporting the data collection. Informed consent was
provided by all participants prior to each interview.
2.2.1.1. Key informant Interview (KII). The KIIs were conducted either
in person or online, depending on the preference of the interviewee.
When online, we utilized the service freeconferencecall.com. When in
person, the interviews took place in a confidential space (a room with a
closed door) at the participant’s office. We utilized a semi-structured
interview guide that explored the organization’s work and mission,
their history of interaction with people experiencing homelessness,
specific needs they have encountered (related to menstruation and
otherwise) and successes or challenges in meeting those needs. We also
asked about ways around the barriers to managing menstruation that
they had observed in their work. Interviews ranged from 30 to 60 min,
and were all tape-recorded with the consent of the participants.
2.2.1.2. The In-depth Interviews (IDI). The IDIs were conducted at the
respective community-partnership organizations, in a confidential space
(a private room with a closed door). Our semi-structured interview
guide began with general questions about the participant’s recent
housing status, personal history and daily routine, and then turned to the
experience of managing their menstrual hygiene, including where par­
ticipants regularly use the bathroom, bathe and launder their clothing;
challenges faced in terms of keeping clean and finding privacy; and how
they felt about dealing with the different dimensions of managing
menstruation. Interviews ranged from 30 to 60 min, and were recorded
with the consent of the participants.
2.2.2. Data analysis
Two researchers, consisting of the PI’s staff research team member
and a RA, reviewed all of the qualitative data transcripts (KIIs and IDIs)
using Malterud’s ‘systematic text condensation’ for thematic cross-case
analysis. This approach includes the following steps: 1) identification
of preliminary themes; 2) creative development of qualitative codes; 3)
condensation of coded text; 4) synthesis and reconceptualization (Mal­
terud, 2012). The PI and Co-Investigator (Co–I) reviewed and helped
revise the final codebook, with the team using Dedoose software to
support the analysis. The key themes identified from the data were then
shared with the full research team for discussion, refinement, and
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Health and Place 66 (2020) 102431
validation. The section below presents the key analytical themes that
were identified during analysis, along with excerpts that demonstrate
the recurrent descriptive codes under each theme.
3. Results
Informed by our provisional understanding of likely areas of diffi­
culties encountered in managing menstruation while homeless, we
perused the interview transcripts for instantiations and elaborations of,
variations upon, and additions to those difficulties and their manage­
ment. These were then grouped into three key categories or themes: 1)
uncertain access to safe, clean, private spaces for changing period
products; 2) bathing and laundering difficulties; and 3) dealing with
menstrual stigma. Within each thematic area, there were reported dif­
ferences in the way that menstruation was experienced for those living
primarily on the street versus those in shelters.
3.1. Uncertain access to safe, clean, private spaces for changing menstrual
products
An overarching finding from both street and sheltered homeless
participants was the challenges faced in accessing safe, clean private
spaces – preferably toilets – for changing period products while
menstruating. Barriers were described by those living in shelters that
offered limited access to safe, clean spaces, and as they sought out ser­
vices away from the shelters. Additional challenges existed for those
living primarily (or entirely) on the street.
For the many people experiencing homelessness rotating in and out
of the municipal shelter system, the shelter provides access to bathroom
facilities, but not without a host of problems with respect to meeting
menstrual management needs. These varied depending on the type of
shelter. The most common concern raised was the lack of a sufficient
number of clean, functioning, privacy-safeguarding toilets. Many par­
ticipants, particularly those living in single adult or couples’ shelters,
both of which generally have communal facilities, reported that the
bathrooms in their shelter were often dirty or flooded, making them
unpleasant or even, in some cases, impossible to use. As two women
described:
… all of them are communal bathrooms, um, they’re nasty. Toilets
are clogged. They have
roaches. They’re just nasty.
–IDI002
Um, me personally, I don’t even use the bathrooms … because when
you go, all the toilets are either flooded with feces and urine … so
when you’re walking in, if you do have sneakers or anything, most,
your socks will be covered with feces or urine. And, um, or blood
everywhere, pads stuck everywhere to the wall, tampons just
thrown, um blood everywhere.
–IDI020
Inadequate stocking of bathroom necessities, which are of particular
importance when managing blood flow, was also frequently mentioned,
especially toilet paper. Many people wrap used products in tissue or
toilet paper before disposing of them in a trash can, a part of unspoken
‘menstrual etiquette’ (Houppert, 2000). Supply problems were particu­
larly flagrant in communal facilities, which were described by some
women as lacking trash cans, necessitating carrying used products
elsewhere in a shelter building for disposal. Notably, none of the bath­
room facilities in shelters had disposal units within the actual stalls; a
design feature that enables hiding menstruating status more easily. This
also led to cleanliness and flooding challenges as some women opted to
flush their products, sometimes causing clogged toilets, or left their used
products out in the stalls rather than taking them from the privacy of the
M. Sommer et al.
stall to one of the external trashcans.
At least one participant described an additional challenge posed by
shared living with strangers – specifically, how the mental well-being of
some in the shared space created tensions around time spent in the
toilet, the duration of which is frequently lengthened when
menstruating.
Yeah, one bathroom for eight … And we always fighting. Um, I just
get in a fight about that, physical fight … Because they, like, think
they own [the toilet]! And I don’t want to say nothing, but they like
[snaps fingers] go out from the bathroom now!
–IDI001
Compounding the challenges of managing menstrual blood flow each
month, some shelters have policies that do not allow residents to remain
on the premises, or near their living/sleeping spaces, during the daytime
hours. Although this policy enables the shelter to clean the living spaces,
and was often described informally as an approach aimed at encour­
aging people to engage in job seeking efforts, it was also found to create
challenges for some participants as they are unable to access their
“home” bathroom facilities for many hours during the day. Substitute
facilities proved difficult to find – especially given the limited avail­
ability and poor quality of public toilet facilities in NYC (to be discussed
in a separate publication). Thus, a number of women reported having to
make do in desperate ways, either when out of the shelter or when living
on the street – “I’ve still multiple times … had to go pee in a corner of the
subway and then put a tampon in” (IDI002)– or, preferably, scheming to
use private sector toilets given their improved quality, accessibility, and
safety. “McDonalds is always good for French fries and restrooms.”
(IDI011) Still, gaining access to a private sector toilet, such as those
located in fast food restaurants or those in clothing stores, is predicated
on ability to “pass” (Goffman, 1963) as someone who is not homeless.
This may be further complicated by commercial establishments’ expe­
riences with misuse of such facilities as one individual experiencing
homeless explained: “… a lot of times they’re skeptical about letting people
in the bathrooms because people in there, go and get high and stuff, so they
don’t let anybody use the bathroom.” –IDI010.
Those living on the street face real difficulties in maintaining
appearance, and so were found generally to opt for public facilities
(meaning those that are municipally run) for managing menstruation.
The latter reliably proved to be in short supply and in poor upkeep (with
specific findings to be discussed in a subsequent publication). As two
individuals experiencing homelessness explained:
I mean, Christ, there are not a lot of clean bathrooms or easy access to
bathrooms, you see signs more and more now of “No Bathrooms” or
“Customers Only. … It’s horrid! They don’t clean the bathrooms. You
see, that have a sign, we’re cleaning the bathrooms, you don’t wipe,
nobody wipes the seats down, nobody cleans the floors …
–IDI006
[Using the bathrooms while living on the subway] was … just
terrible, like, like, like the bathrooms in the city are like disgusting,
like I’m a bit of like a germaphobe but like, it’s just like, I, I couldn’t
like really do much like there, I would always have to like go to like
[public-private space in NYC] or like [grocery store] or like some­
where that like I know has like a clean bathroom
–IDI012
In addition, there are temporal barriers encountered, as another in­
dividual experiencing homeless described, “Subway bathrooms are closed
midnight to 5 a.m. … They’re, um, they don’t even always open them at 5 a.
m. My husband had to use the bathroom at 7 a.m. once and it was closed.”
Our efforts to locate a map of the subway system showing all available
toilets, and their hours of opening, were unavailing, limiting our ability
to describe the scope of subway toilet access more generally.
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Health and Place 66 (2020) 102431
3.2. Bathing and laundering difficulties
A related set of challenges centered around staying clean, including
being able to bathe oneself and launder underwear and clothes. Monthly
blood flow can lead to an increased need for bathing and laundering due
to potential odor, menstrual leaks and stains, and general increased
hygiene needs. Again, differences were found depending upon shelter
type or street locus.
Few concerns arose from those living in family shelters with private
bathrooms in their apartments. But those living in shelters with shared
bathing facilities faced a number of concerns. Some had to do with the
lack of privacy common to congregate settings; others related to low
standards of cleanliness as maintained by staff and residents alike,
although other residents received far more critiques than those of staff
who were indicated to be under-resourced. Others were concerned with
the lack of locks on shower doors or the use of shower curtains to
separate shower stalls. However, the absence of locks may be a security
measure implemented by shelters.
Along with privacy and safety concerns, a lack of cleanliness also
arose in some descriptions, such as this one, by a woman who described
her experiences in shelter bathrooms:
The showers, women are using number one, number two, and then
pushing it down in the drain, pads, tampons, blood, everything, so it’s to
the point where I don’t even do that. I’ll go to a public
place or a hospital, ask to use the bathroom. And, um, bird shower,
pretty much.
–IDI020
Maintaining personal hygiene on the street is a monumental chal­
lenge, and managing menstrual blood flow each month compounds it.
Many participants described the challenges of finding showers or places
to bathe, and as one key informant (NYC official) described, there can be
a gendered difference in resorting to public toilets as impromptu bathing
spaces:
We had some instances where people have been using comfort sta­
tions [park bathrooms] for
bathing … mostly it’s men … I did ask … how often they come upon
homeless women [bathing], and um, it’s a lot smaller than the men.
–KII002
This may simply be related to fewer women living on the street than
men, or could reflect the observation made by many service providers
that women on the street tend to stay hidden for safety reasons.
Regardless, such “misuse” was described as adding to the maintenance
challenges of public comfort stations, and thus deterring others seeking
a clean toilet.
Showering facilities were available at select service providers around
the city, especially for homeless youth, but were few in number, difficult
to get to, and with limited hours and days of operation. And, as with the
shelters, users report variable levels of cleanliness and security. Some
service providers provide lists of places to shower across the different
boroughs of NYC, given their scarcity; however, this did not seem to be a
common practice.
As a result, participants often do without showers for long stretches
of time, resorting to makeshifts instead: taking sink showers in park
bathrooms, or using public recreational equipment, such as the sprin­
klers in a children’s playground for bathing (and risking arrest or cita­
tion in the process). Repurposing commercial facilities has its own
problems:
When you’re like, in a McDonald’s or something, people are coming
in and out, they’re seeing me change, they know what the hell was
going on in there, you know what I mean? Yeah, I mean, they know
I’m homeless and I have to wash myself type of shit, so it’s
M. Sommer et al.
embarrassing, and then the workers come in, telling me to leave and
shit, you know, shit like that, but I’m like, I bought a fucking sand­
wich …
–IDI016
This exemplifies well the challenge of maintaining dignity while
living on the street, with cleanliness during menstruation exacerbating
the situation. Excepting the few providers offering the service, laun­
dering clothes presented issues of both availability and affordability.
Again, necessity frequently made for inventiveness – “and if I have an
accident, I will take my bucket, mop bucket, and I will soak them.” However,
some participants described having positive experiences with respect to
the ability to access free laundry facilities at various service providers
around the city, usually at particular shelters.
Those living on the street, and also many of those living in shelters,
reported that they tended simply to dispose of items that were blood­
stained or heavily soiled, necessitating frequent replenishment of un­
derwear, clothing, or pad surrogates (t-shirts used to manage menstrual
blood flow). Some were able to rely on service organizations, particu­
larly those serving youth in the city, that provide supplies of free
clothing to their clients.
A number of participants had recommendations in terms of making
bathing and laundering more accessible, to improve their menstrual
management experiences. In relation to bathing options, one woman
proposed how to improve accessibility to showering even within the
context of limited beds in shelters:
… in certain, um, shelters, after dinner, uh, I would say can I take a
shower, and some would say no, some would say yes, but if they
could say oh, you’re in a job training program, you know, uh, we’ll
take your name, you just take a shower, uh, we’ll give you a kit, and
after the, and then you go, because we’re not going to give you a bed,
or we don’t have a bed for you, but at least we can do for you.
–IDI022
A frequent suggestion was also to have free laundering services
within shelters and other service providers. Such solutions emerging
from individuals experiencing homelessness serve as a reminder of the
ingenuity of this population, and also their role as a resource for solving
the challenges experienced around menstruation in the absence of being
able to provide adequate housing for all.
3.3. Menstrual stigma
Menstrual stigma complicates matters further, contributing to feel­
ings of shame by participants, eroding their sense of confidence and
impeding their ability to engage in their daily round of activities.
Pointedly, it intensified isolation:
“… when you can’t clean yourself, you don’t want to be out, you
don’t want to be seen, because you feel like everybody else can smell
and see you.
–IDI020
“I was on the subway or like brief bouts on the street or a car, it was
… a big problem, not having the money and … worrying that you’re
gonna, that it’s gonna show …. embarrassment, on top of all your
other problems.”
–IDI015
Both the possibility of menstrual blood leakage and odor, strongly
tied to one’s ability to change and bathe as needed, intersects with
longstanding stigma within society for the perceived polluting nature of
menstrual blood. Fundamental to many people experiencing homeless is
being able to escape notice in everyday social settings, an ability that
may profoundly influence the ability to work, to ride the subway
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Health and Place 66 (2020) 102431
unmolested, or even to access and be able to utilize private sector toilets.
Menstruation’s “potentially discrediting” status is far more precarious
for those experiencing homelessness, if for no other reason than
frequently lacking the desiderata of concealment. Being able to “pass”
while homeless requires artfulness and resources:
… as far as the period, it’s the thing that saved me was I was able to
blend in. Once 6 am hit, everything opens, 7am, everything’s open, I
just blend in. So I can go into a public place and I always, it’s an
honor thing, that I would always just buy something and use the
restroom and just make it seem like I was just, whatever.
–IDI003
Our informants frequently mentioned buying things in order to ac­
cess private sector facilities, a move given added urgency because blood
flow cannot be ‘held in’ until a toilet can be accessed. Even so, some
were denied a key or keycode, or simply informed that toilets were not
available by employees.
The embarrassment and shame around managing menstruation were
intensified for those living on the street, given the limited access to
supplies and facilities:
I feel like the most annoying thing when being, like living outside,
and getting your periods is leaking
through your clothes. It’s embarrassing. And it shouldn’t have to
necessarily be embarrassing, but
it is, um, and then in my situation, having to go either walk to
[service provider], get on the train
to the [service provider] hope they will let me in,..and then I can
hope to be first in line for the
shower, so that I can fix this …
–IDI013
This woman’s desire to “fix” her irregularity, along with her
resentment of gendered injustice stigma, underscore the profound
“othering” effect of menstrual-related shame. Although not specific to
periods, the decision to provide free laundry services was described by
one service provider as an important way to enable the clients to be able
to “pass” within society:
Our clients have access to free laundry services so their clothing is, is,
um, you know, clean, and, um, they have access to toiletries and, and
um, so their, their physical appearance is rarely indicative of their …
status as homeless.
–KII009
Although not specific to toilets, bathing or laundering, the ongoing
presence of menstrual stigma hinders women’s abilities to be comfort­
able during their periods in a range of ways. Individuals experiencing
homelessness in NYC access menstrual products through a variety of
ways including personal purchases, distributions by shelters and other
service providers, theft, and use of makeshift materials; many of these
processes are complicated by the embarrassment and shame of having to
disclose one’s menstruating status in order to meet one’s basic needs (to
be discussed in-depth in a subsequent publication). When male staff are
responsible for distributing menstrual-related products within shelters,
the embarrassment around requests was found to be compounded. Thus,
not only the provision of improved toilet, bathing and laundering spaces
is essential, but also tackling the ongoing stigma around menstruation is
essential.
4. Discussion
Numerous challenges emerged from this exploration of managing
M. Sommer et al.
menstruation among street and sheltered individuals experiencing
homelessness in NYC. These included three particular barriers: access to
private, safe spaces for changing menstrual products (and procuring
products); availability of bathing and laundering facilities; and ongoing
menstrual stigma, which creates feelings of shame and embarrassment
and impacts confidence in being able to “pass” as someone who is
housed. Differences emerged in terms of the experiences of those who
are living in shelters or on the street, with those in shelters having
increased access to toilet, bathing and laundering facilities, and those
living on the street more apt to seek out public facilities for changing
menstrual products, and often going without bathing or laundering for
long stretches of time, augmenting their challenges of managing
menstruation. In addition, even individuals living in shelters described
struggling when moving around NYC to access places to change their
menstrual products, and to afford laundering when not provided freely
within shelters. In addition, the type of shelter, particularly those with
communal versus private bathroom facilities, also appeared to influence
the ability to manage menstruation with dignity and comfort. There was
a galling sense amongst our respondents of frequently failing to keep
themselves clean. This constant threat of feeling “dirty” or unclean,
combined with pervasive menstrual stigma, took a toll on their self-
esteem, their confidence, and their sense that they can be respected in
the world around them.
People experiencing homelessness in the US, as well as other high-
income countries, have described difficulty locating accessible rest­
rooms not only for changing menstrual products, but also for bathing
and washing blood out of underwear and other clothing (Ensign, 2001;
Kuhlmann et al., 2019; Mitchell et al., 2018). During monthly
menstruation, there is an increased need to bathe and to launder (e.g.
stained clothing). This proved similarly challenging to our study par­
ticipants, with many shelters having showers described as unclean and
unsafe. In addition, not all shelters were found to have laundry services,
and if they existed, many required payment. Although showering and
laundering spaces exist at various service providers across the city, these
proved to be insufficient in location, hours and cost, particularly for
those living on the street. Importantly, the absence of the ability to
manage one’s menstrual blood flow creates feelings of shame per
ongoing menstrual stigma, and can hinder the ability to access services,
and take care of the daily activities of living. For those living in a type of
shelter with inadequate bathing and laundering facilities, or for those
living on the street, the lack of provisions for bathing and laundering
poses particular challenges that may hinder their abilities to acquire
food, housing and work.
In a review of the interactions between menstrual management and
sanitation systems in low-income countries, the authors describe the
basic components necessary to meet the sanitary needs of people who
menstruate (Sommer et al., 2013). Components include “privacy and
space for changing, cleaning, drying or discarding materials,” as well as
adequate water for washing and a way to dispose of products without
interfering with plumbing or other parts of a sanitation system. Pro­
fessionals in the field of water, sanitation and hygiene (WASH) further
argue that “female-friendly” toilets, specifically in dense urban areas,
should consider the unique safety and sanitation needs of individuals
who menstruate, providing adequate doors and locks, waste disposal,
water, soap, accessibility and lighting (Sommer et al., 2016; Schmitt
et al., 2018). These requirements mirror the concerns documented for
people experiencing homelessness who menstruate in the US: bathrooms
that could be safely accessed 24 h a day, laundry facilities, and spaces for
private bathing (Ensign, 2001; Kuhlmann et al., 2019; Mitchell et al.,
2018). As many of the individuals in our study described, being able to
command privacy when managing their menstruation was deeply
prized. This includes sufficient time – not feeling rushed to manage their
periods because they were in a public or commercial toilet, or because
they shared a poorly equipped living space. In addition, there existed the
constant underlying need to ask for things as a person experiencing
homelessness. The asking related to menstruation can be even harder
6
Health and Place 66 (2020) 102431
because of existing stigma, and that reality is not seemingly being taken
into account as often as it should be; as exemplified by having to ask
male gatekeepers for menstrual supplies, or the necessity of seeking out
accessible toilets.
Our findings from NYC support the need for improved female-
friendly toilets within shelters, toilets that are regularly cleaned, feel
safe, are adequately stocked with soap, and have built-in design fea­
tures, such as disposal units in stalls, to enable discreet management of
menstrual blood flow. Ideally toilets in shelters would also provide a
stock of free menstrual products, thus reducing the shame that is
frequently experienced in asking for materials; this will be further dis­
cussed in a subsequent publication. There is in addition an urgent need
for improved access to safe, clean spaces for managing menstruation –
not just for those experiencing homelessness, but for anyone moving
about the city. Although the quality of commercial toilets, such as those
located within fast food restaurants, made them preferable to our re­
spondents, such facilities are not always easily accessible to those
experiencing homelessness. These facilities, which might require a
purchase to gain access to the bathroom or refuse access to those who
were more “visibly” homeless, were not accessible to those without extra
money or whose hygiene had already deteriorated past the point of so­
cial acceptability. This underscores the importance of the ability to
‘pass’ when experiencing homelessness, a point noted by many of our
study participants. Plainly, the private sector currently bears much of
the burden of people needing toilets outside of shelters. A circumstance
that naturally raises the question of government’s role, whether it be
contracting with businesses specializing in this service, or in the shoring
up of the public toilet infrastructure across NYC.
Even pre-COVID, or the global pandemic highlighting the impor­
tance of handwashing and hygiene, some American cities were currently
falling short of basic sanitation facility standards for people experi­
encing homelessness. Seattle, WA, for example, had just six municipally
owned and operated toilets to serve a homeless population of more than
11,000 (McNamara, 2019). The United Nations recommends one latrine
per 50 people in the period immediately following a humanitarian
emergency, meaning the city of Seattle has met less than 3% of that
standard for its homeless residents (United Nations High Commissioner
for Refugees, 2011). Lack of basic sanitation has a negative effect on the
health and hygiene of people experiencing homelessness, and especially
those who menstruate. Such global standards for maintaining public
health are convenient parameters by which to measure toilet accessi­
bility within a large urban context such as NYC, including considerations
of how much of the population – both those who do and do not
menstruate – should be able to easily access public or private toilet fa­
cilities. NYC code requires that toilet facilities be provided for staff and
customers or patrons of all business establishments, with exceptions
made for “food service establishments with a seating capacity of less
than 20 people” and those which are “less than 10,000 square feet” (N.Y.
C. Plumbing Code, 2014). But tasking commercial establishments does
little for those who cannot afford to use them. Access to decent sanita­
tion and clean water was recognized as a human right in 2010 (United
Nations General Assembly, 2010). One would think that the provision of
decent, clean, safe, easily and temporally accessible public toilets across
NYC would be a natural extension of that right in an urban environs.
5. Limitations
There are three limitations of importance to note in relation to this
study. First, the sample was small, and although the participants rep­
resented both street and sheltered homeless, a larger sample would
likely have captured a broader range of both challenges encountered
along with improved responses in relation to toilets, bathing and laun­
dering needs during menstruation. In addition, the sample skewed to­
wards those who are currently sheltered, even if many had previously
lived on the street. Second, our sample only included those individuals
experiencing homelessness who were able to provide informed consent.
M. Sommer et al.
This means that we were unable to include individuals experiencing
homelessness who struggle with mental health conditions, and also are
likely less able to ‘pass.’ Their ability to manage menstruation with
dignity, comfort and safety may be even more compromised. Lastly,
although the recruitment sought to be inclusive, ultimately everyone
who was available for and interested in participating in an interview
identified as a woman, and thus we were unable to capture the experi­
ence of transmasculine people, for whom adequate menstrual manage­
ment can be a serious safety issue.
6. Conclusion
Overall our study highlighted that both sheltered and street in­
dividuals experiencing homelessness struggle to manage their
menstruation with dignity and comfort in the absence of adequate
spaces for changing menstrual products, bathing, and laundering stained
clothing and underwear. Ongoing menstrual stigma exacerbates their
difficulties, creating feels of shame, embarrassment and hindering the
ability to attend to the daily activities of living, including seeking out
services and participating in job training opportunities. A 2016 NYC
government policy required the improved provision of menstrual
products in shelters and by service providers (N.Y.C. Office of the Mayor,
2016). However, there remains inadequate attention to the other key
components necessary for managing menstruation – access to toilets,
bathing, and laundering facilities. Although additional research is
important for capturing a broader range of experiences around man­
aging menstruation while homeless, our findings demonstrate the need
for improved quality and accessibility of bathrooms for both sheltered
individuals and those on the street, as well as expedited access to
bathing and laundering resources. Such actions are essential given the
increase in homelessness in NYC. In the time of COVID, a clarion call for
clean and accessible public toilets is especially timely.
A final note: as the paucity and recency of citations in this paper
suggest, this topic has received little attention in the literature of
homelessness that now spans four decades, and we might well ask why.
The simplest answer is that this is how misogyny works: to so naturalize
a state of gendered deprivation that it becomes beneath notice and
beyond question (Manne, 2017). That this erasure requires our collec­
tive go-along is also conveniently masked.
Declaration of interest
The authors have no conflict of interest.
Funding
This study was funded by the Sid and Helaine MHM Faculty Support
Fund and the Osprey Foundation.
Acknowledgements
We would like to thank the Coalition for the Homeless, the Door, the
Midtown Outreach Project (CUCS) and all of the service providers in
NYC and individuals experiencing homelessness who so generously
provided their insights.
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