The History of US Menstrual Health, School Nurses, and the Future of Menstrual Health Equity

Abstract

In the United States, adolescents suffer from inadequate menstrual health, meaning that adolescents are unprepared for menarche, lack the practical resources they need to comfortably and confidently manage menstruation, and receive inadequate health education and care for menstrual pain and disorders. In this article, we provide a historical analysis of the role of school nurses in addressing menstruation from the early 20th century up to the present day. We contextualize the current realities of school nursing and menstrual health education and clinical support. We argue that the decentralized US school system, a cultural aversion to open discussion about menstruation, and the outsized influence of commercial menstrual product manufacturers have hampered the ability of school nurses to deliver menstrual health education along with menstrual health support. Finally, we discuss implications for today’s schooling experiences as well as recommendations for how to support school nurses in aligning our national approach to menstrual health toward the public health perspective of menstrual equity. (Am J Public Health. 2024;114(9):903–908. https://doi.org/10.2105/AJPH.2024.307705)

In recent years, research and public advocacy have brought attention to disparities in menstrual health in the United States, particularly among adolescents. “Menstrual health” is a holistic term that includes access to menstrual education, menstrual products, adequate toilet facilities, health care for menstrual pain and menstrual disorders, and freedom from stigma and discrimination.¹ Globally, menstrual health has been incorporated into a public health paradigm, with research demonstrating that poor menstrual health and hygiene can negatively impact students’ educational experiences and their health and well-being.² The limited available evidence from the United States suggests that students here also suffer from inadequate menstrual health. Many are unprepared for menarche, lack the practical resources they need to comfortably and confidently manage menstruation, and receive inadequate health education and care for menstrual pain and disorders. For example, a 2017 systematic review of the pubertal experiences of low-income girls indicated that many girls felt that the menstruation information provided by schools was inaccurate, negative, and came too late.³ More recent research conducted with US adolescent girls and educators shores up these findings.^4–10

State-level legislative efforts have primarily focused on improving “menstrual equity” in US schools by mandating free menstrual products in public school bathrooms.^11,12 Such legislation aims to combat period poverty, which has been tied to missed school days and worse academic performance.⁴ To date, there has not been systematic evaluation of the implementation of these policies, and while menstrual product access is a crucial component of menstrual health, the effort to promote menstrual equity in schools must address all dimensions of menstrual health to truly impact population health. Addressing menstrual health comprehensively would encompass provision of menstrual education and the delivery of menstrual health care as needed in the school environment by adequately trained and resourced school nurses. In this essay, we aim to provide a historical analysis of the role of school nurses in addressing menstruation from the early 20th century up to the present day and discuss implications for today’s schooling experiences as well as recommendations for how to support school nurses in establishing an equity-focused national approach to menstrual health.

Timely, accurate, and appropriately delivered menstruation education has the potential to improve menstrual health literacy among all students, combat menstrual stigma, and direct adolescents to appropriate care when needed. School nurses have been identified as particularly well suited to provide menstrual health education and care.^5,6,13 They are trusted members of the school community and bring medical expertise to care for and refer students as needed. Yet a review of the history of school nurses and their relationship to menstrual health reveals how the decentralized US school system, a cultural aversion to open discussion about menstruation, and the outsized influence of commercial menstrual product manufacturers have hampered the ability of school nurses to deliver menstrual health education and menstrual health support.

HISTORY OF SCHOOL NURSES IN MENSTRUAL EDUCATION AND CARE

School nurses have been supporting and educating menstruating students since the early 20th century, when the profession was founded and US adolescents began attending school in large numbers.^14,15 The broad scope of early school nursing practice included physical examinations, care coordination, home visitation, and health education.¹⁴ According to a 1918 school nursing handbook, nurses were “constantly being called upon to give information” to girls about “matters of personal and social hygiene.”^16(p5) The handbook identified a lack of health literacy among the student population yet constrained nurses’ ability to take action, instructing them to share information only with the consent of the student’s mother, “who is the natural instructor of the girl in such intimate matters.”^16(p52) Menstruation, including guidance for those reaching menarche, was primarily relegated to the private sphere alongside other subjects related to sex and sexuality even as reformers argued vociferously about whether and how they should be incorporated into public school education.^17,18

In communicating a sense that menstruation was too “intimate” for school while not adequately addressing the gap in girls’ knowledge about menstrual health, the 1918 manual left a void that menstrual product companies such as Kimberly-Clark enthusiastically filled. In 1921, Kimberly-Clark created Kotex, the first disposable menstrual product. To convince women and girls that disposable pads were superior to homemade cloth pads and reusable sanitary belts, the company began producing educational pamphlets for female audiences, including young girls, mothers, and working women.¹⁷ This effort extended into classrooms, with Kimberly-Clark providing schools with materials (including menstrual products) that could be distributed directly to students by school nurses, professionals who were identified by Kimberly-Clark as important gatekeepers to the company’s joint educational and commercial mission.¹⁹

By the 1940s, menstrual education (and sex education in general) became more widespread in the school setting alongside a rising tide of interest in promoting healthy adolescent development in the United States.²⁰ These classes were often organized by the principal and school nurse and aimed to provide up-to-date scientific information about the physiology of menstruation as well as cultivate a positive attitude toward the social dimensions of growing up, including the normative heterosexual expectations around marriage, sex, and family life.²⁰

The decentralized nature of US education in the 1940s meant that menstrual health programs were implemented (as one component of sex education and family life curricula) at the district level through the efforts and cooperation of parents, educators, and health professionals.²⁰ Decentralization also fostered racial inequities across the school system by allowing educational resources, including health education and school health services, to fall along lines set by structural racism in its many forms, from legally segregated schools in the Jim Crow South to the neighborhood segregation and economic inequality of schools across the country.²¹

In the absence of Department of Education curricula for health educators or a mandate for school nurses, most menstrual education took the form of commercially produced materials. Commercial health education films were a phenomenon of the mid-20th century, covering subjects of public health concern from tuberculosis to venereal disease. In 1946, Kimberly-Clark expanded their educational offerings with the release of The Story of Menstruation, an educational film produced in collaboration with Disney. The film paired a truncated explanation of the science of menstruation alongside a sunny, animated narrative of a young, White girl for whom menarche inspired daydreams about a future of marriage and babies, thus setting a normative standard of Whiteness and heterosexuality shaped by the racialized social values of the time.^19,20 Notably absent from the film were details about the other dimensions of puberty, such as bodily changes and hormonal fluctuations. Rather, the ideology of the film seems to have been to infuse a “hygienic imperative” of menstrual self-care into an ideological framework of heteronormativity.^19,22 Outside of Kimberly-Clark and Disney representatives, the film had sign-off from the medical establishment: it was reviewed by a gynecologist before its release and received a positive reception from the American Medical Association.²³

School nurses served as a conduit between corporate menstrual education materials and their student audiences and provided direct clinical care for students experiencing menstruation in school. In both roles, their resources for providing education and care were shaped by the times they were living in. School nursing texts from the mid-20th century encouraged nurses to normalize menstruation and, as a 1949 manual put it, “avoid the formation of a mental attitude of invalidism in connection with the menstrual period,”^24(p61) advice that must be read with an awareness of the longer history of assumptions that menstruation made women weak and unsuited for equal educational opportunities to men. Guidance was also shaped by the normative gender roles of the mid-20th century: for instance, the nursing manual explained that menstrual pain may be an expression of “marital unhappiness in the home from which the pupil comes, an overly solicitous mother, or the rejection of the ‘woman role’ in life on the part of the pupil.”^24(p62) Educational materials were also a reflection of the limited biomedical understandings of menstruation and menstrual disorders at midcentury.²⁵ For example, a school nurse looking for guidance on how much physical activity to recommend for menstruating students in the 1940s or 1950s would have encountered conflicting information—from advice that girls “not ‘jiggle’ their uteri too much”^17(p92) to reassurances that activity during menstruation was “rarely contraindicated.”^24(p74)

School nurses have consistently been expected to deliver menstrual health education and clinical care without adequate preparation with which to do so independently. By the late 20th century, multiple paths to nursing qualification had opened up, and states implemented different models of school nurse certification, including a range of expectations and responsibilities for health education.^26,27 A 1960 article in Nursing Outlook reported that nursing school did not prepare future school nurses to teach adolescents about menstruation.²⁸ Thus, films like The Story of Menstruation were a pragmatic and popular tool that allowed school nurses to deal with the subject. Several school nurses are quoted in Kimberly-Clark’s Practical Guide for Teaching Menstrual Hygiene praising the quality of the company’s film and written materials. Voicing a perspective common at the time, one school nurse noted in the pamphlet that “our school system … believes that teaching on menstruation belongs in the home. Therefore, all I do is try to help mothers so that they can help their daughters.”^29(p10) The substance of these commercial materials was not necessarily inaccurate in their descriptions of menstrual cycle physiology,³⁰ but as feminist analyses of these materials began to point out in the 1970s, they were incomplete and biased toward a particular approach to menstrual hygiene that emphasized concealment and overlooked the embodied experience of menstruation for adolescents.³¹

In the 1980s, Kimberly-Clark replaced The Story of Menstruation with a new film, Julie’s Story, which reflected the influences of the feminist women’s health movement²² by centering the experience of menstruation for an individual girl. The film was developed with substantial input from an advisory board, including the executive director of the National Association of School Nurses (NASN) and three local school nurses. Julie’s Story and its accompanying educational materials were sent directly to school nurse offices and distributed to state health education officials around the country. At the same time, Procter & Gamble developed a menstrual education program that included a film, educational guides, and samples of the brand’s pads. The program was also evaluated and endorsed by the NASN. In fact, in 1989, program materials were sent to school nurses with an accompanying letter from the NASN president, citing it as an exemplar of puberty education.²³ According to historian Dan Guadagnolo, by the late 20th century, commercial menstrual education had become the norm in the United States, a trend that continues into the present day.¹⁹ Unfortunately we do not know how these materials were distributed around the country or to what extent they were incorporated into school curricula.

In 1995, a small survey of 39 school nurses found that the majority (85%) were responsible for teaching about menstruation in their schools. However, this responsibility was only sporadically supported by dedicated financial or pedagogical resources. As the survey authors wrote in their conclusion, “more attention needs to be paid to the resources [nurses] have available.”^32(p682) In 2022, a survey of elementary school nurses found that the majority of them taught menstrual health and were interested in learning about the best way to impart this critical information to their students.²⁴ A range of educators, including physical education teachers and science teachers, has historically been assigned the role of educating young people about menstruation and puberty. But even if they are not the primary health education instructors, health education falls within the school nurse’s scope of practice, and the role is uniquely positioned to provide one-on-one education to students.³³ The lack of consistent school nurses at some schools because of resource limitations can negatively impact the ability of teachers to collaborate with them on imparting menstrual health and management guidance to students.⁵

CURRENT REALITIES OF SCHOOL NURSES AND MENSTRUAL EQUITY

Constraints on school nursing resources, the decentralization of US schools, and the association of menstrual health education with sex education—the latter of which may be restricted in some schools—pose significant barriers to the delivery of comprehensive menstrual health education and care in schools. A key challenge today is that school nurses across the country are underfunded and underresourced to deliver the care they have been trained to provide.³⁴ The inadequate fiscal prioritization for school nurses has meant that, for many years, public school districts around the country, particularly those in low-resource communities, lack sufficient school nursing staff.^34,35 Menstrual periods do not only show up one day per week, and so support and care for young people who may be managing excessive menstruation- or endometriosis-related pain or bleeding is difficult to provide without more regular school nurse staff.³⁶ In addition, the ability of school nurses to provide menstrual education is challenged by the more complex health needs of the US school-going population from elementary to high school: rates of diabetes mellitus, attention-deficit/hyperactivity disorder, asthma, and mental health concerns have all increased over time.³⁷ In recent years, the demands of the COVID-19 pandemic have further swelled the weekly work burden on school nurses.³⁸ These dynamics severely hinder the ability of school nurses to build the trusting relationships with students needed to provide menstrual care or to deliver menstrual health education.

While the growing global menstrual health agenda within public health has brought recognition that menstrual health should not be relegated to the private sphere, there is no shared national mandate for menstrual education in the United States. While state standards for health education about topics like nutrition and body systems are common, only a handful of states have standards for menstrual health.⁸ A recent hearing on menstrual equity in New York City schools revealed that a protocol does not exist for a girl’s first period happening in school, despite protocols existing for nosebleeds and stomach aches.³⁹ This absence of guidance at every level contributes both to the profound neglect of menstrual health literacy as central to population health and to the underuse of adequately trained and resourced school nurses to meet this need. The Title IX legislation released for public comment by the federal Department of Education in 2022 did not have a single mention of the word “menstruation,” which would suggest that this gap may persist if not addressed by strong advocacy to make the connections between menstrual health and gender equity in schools.⁴⁰ School nurses do not provide classroom health education in every state or district because of the heterogeneity of health education standards and certifications, a status quo that only reinforces the need for strong federal guidelines about the provision of menstrual health education and support that could be adapted by school nurses for their local conditions.

A final challenge is that social and political influences continue to shape what is taught in US schools, as in many countries around the world. Parents and caregivers have an important role to play in supporting and educating their children as they develop into young adults, including having a trust in the educational system. However, this also means that menstruation education is often coupled with the delivery of sex education, which in most states can be opted out of upon parental request (sex education requires “opt-in” parental consent in four states).⁴¹ Something as fundamental and basic as menstruation, a natural part of the child developmental experience for half the population of young people in our schools today, is central to the health-related education that should be provided. The stakes of such education are high: research from across the United States indicates that many girls are not prepared for their first period, and experience fear, shame, and anxiety when they bleed for the first time.⁴ Yet parents and caregivers are often uncomfortable talking to their children about menstruation.⁵ School nurses, armed with menstrual health standards in schools and working in collaboration with health educators, could fundamentally address this challenge. They are also positioned to provide the menstrual health care that young people need for both normal menstrual experiences and menstrual disorders throughout their schooling experiences. As the average age of menarche in the United States is now 11.9 years, school nurses prepared and resourced for supporting menstrual health education and care are essential from elementary school onward through high school.⁴²