The Journal of School Nursing2023, Vol. 39(6) 536–541© The Author(s) 2022Article reuse guidelines:sagepub.com/journals-permissionsDOI:10.1177/10598405221131012journals.sagepub.com/home/jsn
Access to menstrual products is important to support adolescent health. Advocacy to increase access to menstrual products in schools is growing; however, ideal access requires policies that will require schools to support the menstrual health of menstruating students. We conducted a legislative review on the existence and status of state legislation related to the provision of menstrual products in US schools and categorized by state’s political control (political party affiliation of governors and state legislature). Of 50 states and 6 territories, 21 had legislation to support menstrual products in schools, 7 had bills pending, 10 had bills failed, and 18 states had no policies introduced in the state legislature. States with Democrat control have significantly more menstrual product state laws compared to states with Republican control [z = 2.54, p = 0.01]. There is a need, especially in Republican states, to accelerate efforts to pass laws that will support menstrual product access in schools.
Keywordsmenstrual health, menstrual products, menstrual product legislation, schools
Pre- and peri-pubescent girls, ages 8–16, typically experience their first menstrual event in school (Rubinsky et al., 2020; Schmitt et al., 2021) and spend many days on their menstrual cycle in the school setting. However, this natural experience can become highly shameful due to US schools’ lack of preparedness and menstrual hygiene support (Sommer et al., 2016). The lack of menstrual products (i.e., tampons, pads) increases the likelihood of menstrual hygiene mismanagement, resulting in physical health effects such as reproductive tract infections (RTIs), urinary tract infections, and increased spread of sexually transmitted diseases (Phillips-Howard et al., 2016; Sumpter & Torondel, 2013). Disparities in access to menstrual products are heightened for students from low-income households or students experiencing homelessness (Michel et al., 2022). Consequently, at-risk menstruating students have the added burden of missing school days or leaving school early and can potentially suffer from mental health issues due to a lack of menstrual support and equipment in schools (Cardoso et al., 2021; Cotropia, 2019; Gouvernet et al., 2023; Kuhlmann et al., 2021; Oster & Thornton, 2011).
School nurses support menstrual hygiene management in schools; however, schools often lack menstrual products. In a recent national survey of US students, only 27% of students perceived being in school made it easier to access menstrual products (Thinx Inc. & PERIOD, 2021). To add, only 40% of elementary and secondary public schools in the US have a full-time school nurse, further likely diminishing access to menstrual products and hygiene support (Willgerodt et al., 2018). In a recent review examining school-based screening and care coordination programs, none of the studies highlighted care coordination activities to support menstrual hygiene (Francis et al., 2021).
Currently, no universal policies require US schools to provide free menstrual products to menstruating students. Several states have mobilized to introduce bills in their legislative bodies to require free menstrual products be available in schools; however, successful legislation usually requires political bipartisanship among state leaders (Curry & Lee, 2020). Several studies on the COVID-19 pandemic have shed some light on how gubernatorial political partisanship can significantly predict policy decisions to address COVID-19 prevention (Grossman et al., 2020; Hiserodt et al., 2022; Neelon et al., 2021) and the same may be true for menstrual products.
Regarding menstrual product legislation, some states have passed legislation, and others are either considering or have had bills fail. However, it is unclear whether the political affiliation of state leaders, including state governors, has any relationship with the status of state legislation regarding providing menstrual products in schools. This report provides an update on state legislation related to the provision of menstrual products to students attending US schools. This report also provides a cross-sectional view of the legislative status by the political party affiliation of the state governor (Mayor for DC) and state control via their partisan legislative compositions.
We reviewed state-specific policies on the provision of menstrual products in schools cross-sectionally (e.g., cases, statutes & court rules, bill tracking and activity documents, regulations, secondary sources, briefs, proposed, enacted, and adopted regulations) using Westlaw Next Campus Research from June 10, 2022-July 23, 2022. Westlaw Next Campus Research is an online legal research platform that houses federal and state legal data (WestLaw Next Campus Research, n.d.). Although frequently used by legal professionals, its user-friendly interface supports frequent use by those outside the legal profession. We used the search terms “menstrual hygiene, feminine hygiene, menstrual products, feminine products, OR period products, and schools.” We used these different search terms to capture state materials that may use various terminology to describe menstrual hygiene or products. Two independent reviewers (SM and DK) reviewed each state-specific policy and abstracted information on bill activities, proposed, enacted, and adopted regulations related to the provision of menstrual products in US Schools. As a final review and checking, DK searched other state-specific legal websites (legiscan.com, trackbill.com, openstates.org, fastdemocracy.com, and billtrack50.com) on August 1, 2022, to search for state-specific updates to ensure the latest documentation and information regarding whether a bill had been recently introduced, resolved/unresolved, passed, enacted, or vetoed. We developed a coding system to describe the status: 1. No available information, 2. Introduced in the legislative body, 3. Failed or Vetoed, and 4. Passed/Enacted/Governor signed into Law.
We examined the political party affiliation of governors for the US states and territories (Mayor for DC) since 2017. Since the state bills regarding menstrual products in schools were introduced to the state legislative body (i.e., House or Senate) as early as 2017, we searched the National Governor’s Association website to obtain and document state-specific governor affiliation since 2017 (National Governors Association, n.d.).
We also examined each state’s legislative partisan composition (2017-present) using the political control of the state’s legislative body (National Conference of State Legislatures, n.d.; Partisan Composition of State Legislatures, n.d.). At the time of the legislative status (i.e., the year bill was introduced or enacted), we defined Republican-led or Democrat-led states when the party affiliation of the governor/Mayor (DC) and state legislative body align or if any of the chambers of state legislative body is nonpartisan. A split was defined when the governor and state legislature’s party affiliation differed or if the state legislature was split politically.
We conducted a z-test of the equivalence of two proportions to examine if legislation status differed by political control with a significance of p ≤ 0.05.
The detailed results from this review are found in Supplemental Table 1. Of the fifty US states and six territories included in this review, 21 had state/territory laws regarding providing menstrual products in schools, 7 had a bill introduced in the state’s legislative body with no resolution or still in discussion, 10 had bills fail, and 18 had no available policy information on menstrual products in schools. Significantly more states and territories with Democrat control (Democrat Governor, Democrat legislature) have menstrual product state laws compared to those with Republican control (12 Democrat vs. 4 Republican) [z = 2.54, p = 0.01], and to those (5) split politically [z = 2.18, p = 0.03]. Significantly more states with Republican control have no bills introduced in the state legislature compared to states with Democrat control (13 Republican vs. 2 Democrat) [z = 3.71, p = 0.0002], and those (3) split politically [z = 3.32, p = 0.0009].
Of the 21 states/territories with menstrual product state laws, all but two states (Rhode Island and Michigan) specifically state that the products should be freely available to students. Still, only two states (Colorado and North Carolina) explicitly state a grant program to provide funds to enable the provision of free menstrual products in schools. We generated a heat map with MapChart using the information from our review (Figures 1 and 2).
The provision of menstrual products in schools is necessary to support menstrual hygiene and health outcomes and potentially reduce shame, embarrassment, and school absenteeism. Policy solutions are most promising since schools would be mandated to provide the support needed to promote student health and learning. Menstrual health and support are not only of national concern but also of global concern. The World Health Organization supports reframing menstrual hygiene as health that requires the same level of attention as any health issue, including providing the products needed to support health and doing so equitably (World Health Organization, 2022).
In this review, a little over a third of states had state laws to support menstrual product provision in schools, and most of these states had state leadership led by the Democratic Party. Of those with no bills in discussion, over threequarters had state leadership led by the Republican Party. Reproductive and women’s health issues have always been polarizing politically, and although Republican states are lagging in state laws on the provision of menstrual products in schools, members of both parties are leveraging activities from strong advocacy groups like the Alliance for Period Supplies (Alliance for Period Supplies, n.d.) and Period Equity (Period Equity, n.d.) to propose and support legislation around period equity. Other menstrual equity laws that appear to have bipartisan support are bills introduced to make tampons tax-free (reducing the so-called “pink tax”) (Pink Tax Facts, n.d.). At the federal level, Representative Grace Meng from New York introduced Bill H.R. 361 on May 28, 2021, to support menstrual equity for all by increasing the availability of menstrual products for those with limited access (Congress.gov, n.d.). Nonetheless, states, especially Republican-led states, need to accelerate their efforts in introducing bills to support menstrual health in schools.
Most states with menstrual product state laws stipulate that menstrual products should be available for free; however, it is unclear how states will financially support free menstrual product programs in schools. In this review, only two states explicitly stated a funding mechanism to support menstrual products in schools in the state law. There are some efforts to include menstrual products in state budgets, with estimates ranging from $5–7 per student per year, not including costs for potentially installing dispensers in the restrooms (Most Policy Initiative, 2022). Nonetheless, the true cost of state-by-state policy implementation is uncertain, and more studies are needed to examine anticipated implementation challenges.
Although we cannot make any inferences regarding the status of menstrual product legislation and school attendance, addressing access to menstrual products in schools may support school attendance, especially for students from lowincome households, and is an objective of Healthy People 2030 (Healthy People 2030, n.d.). Further research is needed to assess the relationship between school absenteeism and other impacts and menstrual product provision legislation.
Although this review has several strengths, including using a legal data source to review the status of legislation, there are some limitations. Due to the cross-sectional nature of this review, we cannot make any inferences about the relationships between political party affiliation and the status of legislation. Additionally, because bills are introduced regularly at any time, this review will need to be updated periodically to get the most up-to-date information on menstrual product legislation. We provide the most up-to-date information to support current advocacy efforts around menstrual product equity in schools.
School nurses and researchers are well positioned to provide the evidence-base needed to fuel advocacy and policy on menstrual products in school. The Framework for 21st Century School Nursing Practice considers leadership a fundamental principle in evidence-based nursing practice (National Association of School Nurses [NASN], 2016). Within leadership are advocacy, policy development and implementation, and systems-level leadership. We provide some recommendations for future research and school nurse advocacy to inform policy work on menstrual products in schools:
Research to Inform Menstrual Product Policy
(1) Robust studies are needed to fill significant research gaps in understanding and examining:
(a) Unmet menstrual needs of school-aged individuals
(b) Relationships between menstrual products in schools and school attendance, school success, and physical and mental health outcomes
(c) Cost and dissemination concerns of free menstrual product policy implementation
(d) Effectiveness of free menstrual product initiatives and programs in schools
(e) Role of school nurses in achieving menstrual product equity
(f) Role of healthcare, administrative, legislative, and community actors in achieving menstrual product equity
Nurse Advocacy to Promote Menstrual Product Justice
(1) School nurses should consider calling or writing a letter of support to their state representatives, especially in states that do not have any bills introduced in the state legislative body, have bills currently being discussed, or have state law but no concrete plans for financial support to make products freely available to menstruating students.
(2) School nurses should leverage the National Association of School Nurses’ advocacy tools to support leadership in menstrual justice (National Association of School Nurses, n.d.).
(3) School nurses should also consider using the Toolkit for Menstrual Sustainability created by Period.org (The Launch Pad Education, n.d.) and the Menstrual Equity Legislative Toolkit created by Period Equity to guide advocacy efforts (ACLU National Prison Project, 2019).
(4) In the interim, all stakeholders should explore creative ways to meet the needs of menstruating students while waiting for policy to promote equity (Parmar, n.d.). School nurses should also leverage the attention placed on menstrual products to advocate for support for general hygiene management and healthy habits for students identifying as male, female or gender non-binary.
(5) School nurses should continue to promote efforts to reduce the stigmatization of school-age menstruation and incorporate initiatives to advance the education and awareness of reproductive health and menstrual equity for students, schools, community members, and administrative and legislative stakeholders.
We would like to thank Christopher John and Emily Louie, M.S.N. students, for their guidance on Westlake Law Nexus. We would also like to thank Lucas Johnson for his helpful input on a finalized draft of the manuscript.
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
The author(s) received no financial support for the research, authorship, and/or publication of this article.
Lucine Francis https://orcid.org/0000-0002-0063-9934
Supplemental material for this article is available online.
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Lucine Francis, PhD, RN, is an Assistant Professor at Johns Hopkins School of Nursing. She is also a Steering Committee Faculty Member of the Johns Hopkins Consortium for School-Based Health Solutions.
Shafkat Meraj is a BA student at Johns Hopkins University Homewood Campus.
Divya Konduru is a BA student at Johns Hopkins University Homewood Campus.
Eliana M. Perrin, MD, MPH, is a Bloomberg Distinguished Professor with appointments at the Johns Hopkins Schools of Nursing and Medicine (Department of Pediatrics).
1 Johns Hopkins University School of Nursing, Baltimore, MD 21205, USA
2 Center for Community Programs, Innovation, and Scholarship, Johns Hopkins School of Nursing, Baltimore, MD 21205, USA
3 Johns Hopkins Consortium for School-Based Health Solutions, Baltimore, MD, USA
4 Johns Hopkins University Homewood Campus, Baltimore, MD, USA
5 Johns Hopkins University School of Medicine, Baltimore, MD, USA
Corresponding Author:Lucine Francis, PhD, RN, Johns Hopkins University School of Nursing, Baltimore, MD 21205, USA.Email: Lfranc12@jhu.edu
Correction (November 2022): Article updated to correct legend for “Not Resolved” and “Failed/Dead/Vetoed” in Figure 2.
