|
| A) | Gender is based on reproductive organs. | ||
| B) | There are no differences between the two terms. | ||
| C) | Gender is defined by existing institutions and ideologies. | ||
| D) | Sex is a social construct, while gender is a biologic construct. |
When exploring women's health experiences, gender is yet another central variable that must be taken into account. First, it is important to differentiate between sex and gender. Sex is the biologic classification based on reproductive organs and chromosomes (i.e., male and female), while gender is a social construct influenced by societal, institutional, historical, and cultural norms [17]. Gender affects patterns of societal, community, familial, and individual expectations; processes of daily life; intrapsychic processes; and social interactions [18]. Gender is also defined by existing institutions and ideologies and is imbued with views about power differentials. Therefore, when attempting to understand the experience of menopause, some scholars emphasize the impact of meanings attached to reproduction, fertility, sexuality, aging, and social and gender roles [149]. These dimensions are contingent upon the attitudes and belief systems perpetuated and reinforced by social and cultural structures and institutions [19]. It is also important for healthcare and mental health professionals to examine their own biases about women within the context of health, reproduction, and psychological well-being. In general, helping professionals have a proclivity to focus on the negative aspects of women's lives, referred to as the "women-as-problem bias" [104].
| A) | Menopause was closely linked to insanity. | ||
| B) | Menopause was portrayed as having "evil" consequences. | ||
| C) | Menopause was considered a normal transition that all women go through. | ||
| D) | Menopause was referred to as "hysterick fits," implying it was a psychological condition. |
Throughout history, menopause has had negative connotations. Hippocrates described a climacteric syndrome, which was attributed to a weak uterus causing women to lose power [150]. In 1701, a physician argued that women 45 to 50 years of age develop a condition known as "hysterick fits" [8]. As the label implies, the underlying premise was that menopause affects women on a psychological level. Others believed that menstruation was a biologic way for the female body to eliminate poisonous chemicals, and lack of menstruation resulted in toxic accumulation. This has been the historical case throughout different cultures and religions [181]. Menstruation was a social mechanism for restricting and controlling women's sexuality, social identities, and movements.
| A) | Increased femininity | ||
| B) | The shriveling or deadening of ovaries | ||
| C) | Positive improvements to women's character | ||
| D) | An opportunity to experience new things as they enter a new chapter of life |
In the late 1960s, an era of defining menopause as a disease or deficiency began, which is first evidenced by the publication of Feminine Forever, a book by Robert Wilson, an American gynecologist [25]. Wilson maintained that menopause, as an estrogen deficiency, symbolized the end of femininity for women [25]. In essence, menopausal women were a form of living decay [21]. He argued that the effects were not only physiologic (i.e., the shriveling or deadening of ovaries) but also psychological (i.e., resulted in adverse consequences on women's character). His book suggested to women that the only way to deal with the negative effects of menopause was estrogen replacement therapy [26]. The concept of menopause being caused by a reduction of endogenous estrogen led to the use of replacement therapy, which continued into the 1980s [150; 183].
| A) | It was one of many options to manage the negative effects of menopause. | ||
| B) | Estrogen replacement therapy was prescribed as a solution to maintain one's youth and beauty. | ||
| C) | Women were cautioned to look at the potential adverse side effects of estrogen replacement therapy. | ||
| D) | Estrogen replacement therapy was not depicted as a prevention for other conditions that might result from menopause. |
Furthermore, during this time, menopause was believed to be an instigator of other illnesses, and consequently, estrogen replacement therapy was viewed as a preventive intervention for other diseases that might follow [25]. Estrogen replacement therapy was also sold to women as a way to maintain their youth [27]. By 1975, 28 million prescriptions for estrogen replacement were reported [129]. Interestingly, the use of estrogen itself was not a novel intervention, as it was being used in a limited manner in the 1930s to treat hot flashes. However, Dr. Wilson's book popularized this medical intervention, and the pharmaceutical companies disseminated advertisements that showed all the catastrophic, negative effects of women experiencing menopause [27]. Hormone replacement therapy became a common solution in contemporary medicine [183]. With this popularization, menopause was no longer a private issue but was transformed into a medicalized process [28]. (The term "medicalization" has been coined to describe the process by which non-medical phenomena is transformed and treated as a medical problem [105].)
| A) | menopause. | ||
| B) | dysmenorrhea. | ||
| C) | premenstrual syndrome. | ||
| D) | premenstrual dysphoria disorder. |
In the 1980s, premenstrual syndrome (PMS) was introduced as a disorder. Although this course focuses on menopause, it is impossible to not briefly discuss the medicalization of PMS, as the two concepts are interrelated. Late luteal phase dysphoric disorder (LLPDD) was introduced in the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III) in 1987 in the Unspecified Mental Disorder section as a topic for further research. LLPDD was not necessarily meant to replace PMS but was considered a more severe disorder with recurring episodes of dysphoria during the menstrual cycle [30]. In 1994, LLPDD was replaced by premenstrual dysphoria disorder (PMDD) in the DSM-IV and was also placed in the section in the DSM that warranted further research. The DSM descriptions of the two disorders were not very different. Basically, the DSM-IV reordered the listing of symptoms and added a new symptom (feeling out of control) [30]. In 2013, following decades of research, PMDD was recognized as an official depressive disorder in the DSM-5 [125]. Precise diagnostic guidelines are now available.
| A) | Older people are constantly sick. | ||
| B) | Elderly people lack mental acuity. | ||
| C) | Older adults seek and are amenable to change. | ||
| D) | Older people tend to be sad, lonely, and grouchy. |
Krajewski asserts that menopause is a satellite taboo, or a taboo related to a larger social taboo [154]. In this case, the taboo of menopause is related to the greater issue of aging [154]. Therefore, in order to better understand attitudes about menopause, it is essential to have an appreciation for societal stereotypes regarding aging. Thornton has identified six prevalent myths about aging in Western cultures [33,111]:
Older people are constantly sick and experience serious physical conditions.
Not only are elderly people physically debilitated, they lack mental acuity.
Older people tend to be sad, lonely, and grouchy.
The elderly are sexless, and discussion of sex among older individuals is "dirty."
Elderly people lack vigor and vitality.
The aged are not productive citizens and are not amenable to change.
| A) | Asian elders are viewed as burden to society. | ||
| B) | Asian elders are believed to be a spiritual vehicle to dead ancestors. | ||
| C) | The aging process in Asian culture is invisible because it is viewed as a stigma. | ||
| D) | As Asians grow older, they hold respected and venerable positions within the family and community. |
It has been said that Western culture values self-sufficiency, control, uniqueness, and individuality, all characteristics associated with youth. Because older people are viewed as dependent, the process of aging is not respected [186]. In Western culture, where societal norms value youth, with aging comes invisibility [112]. This invisibility and marginalization is in contrast to traditional Asian cultural norms, in which old age signifies wisdom, status, and power in the family and the community [34,155,186]. Kao and Lam maintain that when Asian immigrants age in the United States, their experience of aging is very different from how they were socialized [35]. It is a more demanding task to age in a society in which contributions of the elderly are devalued, compared to a society in which elders are treated with deference. Similarly, in Native American culture, the aged are believed to be a repository of wisdom and their role is to teach the young the traditions, customs, legends, and myths of the tribe [36]. Consequently, elders are taken care of by the tribe. This is also the case in traditional African religions, as the oldest family members are believed to have special status and an ability to communicate with God [37]. Again, these cultural values are quite divergent from Western norms about the aging process and the elderly.
| A) | African American women are typically depicted as a matriarch of the family. | ||
| B) | The concept of motherhood is solely biologic for African American women. | ||
| C) | African American women play a large role in contributing to their household's financial stability. | ||
| D) | Gender roles in African American families have traditionally been more flexible, adapting to the environment. |
The socialization process of African American women is not reflective of White, middle-class norms. For example, African American women are not necessarily socialized to expect that marriage will help them achieve financial stability. Because of economic hardships, African American women have traditionally played an integral role in maintaining their families' economic well-being—the common social portrayal of the "strong Black woman" [135]. Furthermore, while motherhood is a crucial role for African American women, the concept of motherhood is not solely biologic. The extended kinship and communal system meant that multiple African American women played key roles in raising children. In a 2007 study with African American adolescents, African American women were defined as matriarchal figures, typically mothers and/or grandmothers who were economically independent and contributed to the economic vitality of the family. Being a woman also meant being emotionally strong and keeping the family together during difficult times [48].
| A) | head of the household. | ||
| B) | caregiver of the children. | ||
| C) | primary breadwinner and decision maker. | ||
| D) | All of the above |
This conceptualization of an African American woman is a departure from the depiction of Asian women. Chinese culture, for example, endorses the view that the husband is the head of the household, the caretaker of the finances, the primary breadwinner, and the decision-maker [49]. Meanwhile, a wife is expected to be devoted to her husband and her husband's family. She is also viewed as the nurturer and caregiver of the children [50]. According to Watson and Ebrey, "a daughter [is] just passing through, waiting presumably to assume her true role as wife and mother" [51]. A popular contemporary Chinese saying is, "There exist three genders in the world: man, woman, and woman who has earned a doctoral degree" [188]. This saying reflects the idea that academic or career advancement is not feminine [135]. In contemporary China, women who remain single into their 30s and who are well-educated are called "leftover women" [188].
| A) | Feminist perspective | ||
| B) | Sociologic perspective | ||
| C) | Biomedical perspective | ||
| D) | Psychoanalytic perspective |
The biomedical model generally focuses on biologic disease or illness symptoms, and the goal of this model is to identify the cause of disease symptoms [54,149,189]. Using this theoretical lens, menopause would be defined as an illness or endocrine deficiency that results in decreased levels of hormones [2]. Menopause has also been portrayed as a "malfunction" of an aging reproductive system [54].
| A) | Small sample sizes | ||
| B) | Overly diverse study samples | ||
| C) | Lack of control groups in the design | ||
| D) | Poor baseline data to provide a benchmark or point of comparison |
In Rostosky and Travis's study, they argue that much of the medical literature written between 1984 and 1994 had serious methodologic flaws, including poor baseline data, failure to take into account diversity, lack of control groups, and overgeneralizations despite small sample sizes and nondiverse study samples [56]. Furthermore, the articles were not written in an objective manner; pejorative language was often used to describe women's bodies. Examples included "atrophic genital changes," "ovarian dysfunction," "total ovarian failure," and "problem women." It is within this medical backdrop that women ultimately seek information and assistance, which can lead to distorted constructions of menopause. The biomedical model is the most common model used to explain menopause in the United States and serves as the guidepost or truth for many women [113].
| A) | It eradicates any form of gender discrimination. | ||
| B) | It shifts the focus away from women's bodies and the biologic process. | ||
| C) | It places the problem within the medical field and seeks medical solutions. | ||
| D) | It takes into account the context of race, ethnicity, culture, gender, class, and other social factors. |
When applied to the study of menopause, the feminist model asserts that menopause is a natural event that marks a transition for women [158]. It is a biologic process, but with distinct sociocultural factors that interact with biologic processes in a complex manner. Menopause is not considered a disease or a disorder in this model. In fact, identifying this life event as a disorder reinforces societal attitudes regarding reproduction, fertility, sexuality, aging, and social and gender roles [19,150]. When menopause is framed as a deficiency disease, it assumes that aging women's bodies are flawed, which ultimately perpetuates gender inequality [57]. Feminists in the 1960s maintained that misogyny was woven into the fabric of the medical establishment, reinforcing social control and the oppression of women [128]. Feminist scholars argue that the proponents of the biomedical perspective have taken a normal phenomenon and medicalized it (e.g., hormone replacement therapy as first-line therapy) [61,159]. Instead, these scholars emphasize the importance of exploring menopausal experiences within the context of race, ethnicity, culture, gender, class, and other social locations in order to better understand the complexities of the biologic and social phenomenon, particularly in light of how these social factors lead to oppression and marginalization [62]. The feminist model has taken a very critical stance on the biomedical model in explaining menopause, but it is important not to completely renounce the involvement of biologic factors [113]. Focusing exclusively on sociocultural factors does not provide a comprehensive picture. Critics of the feminist perspective argue that the approach inadvertently dichotomizes women as either victims or empowered agents [158].
| A) | menopause and issues of loss are intertwined. | ||
| B) | menopause represents a neurosis (castration anxiety). | ||
| C) | all women experience penis envy, and menopause is a reflection of this. | ||
| D) | All of the above |
Psychoanalysis focuses on how the unconscious influences behaviors. In terms of women's sexuality, Freud maintained that a young girl's psychosexual development revolves around penis envy; that is, she realizes her genitals are not like her male counterpart's, and she concludes she has been castrated (i.e., castration anxiety). Ultimately, she desires a penis, which results in penis envy [63]. Some psychoanalytic theorists have argued menopause is a revisit of castration anxiety. In other words, a woman's castration anxiety has been dormant as she has been busy as a wife and mother, and it then resurfaces when her role as a wife and mother is no longer the dominant theme. According to this model, menopause will then trigger depression and other psychological issues revolving around loss.
| A) | A universal menopausal syndrome exists. | ||
| B) | There are no differences in menopausal symptoms between racial/ethnic groups. | ||
| C) | Asian American women reported more menopausal symptoms overall compared to women in other groups. | ||
| D) | The onset of menopause started earlier for African American and Hispanic women compared to women in the other groups. |
In 1996, one of the larger studies on menopause involving Western women from diverse racial/ethnic groups, the Study of Women's Health Across the Nation (SWAN), was conducted to examine White, African American, Hispanic, Japanese American, and Chinese American women's menopausal experiences [70]. The study found that less than 1% of the participants experienced early menopause (i.e., before 40 years of age). African American and Hispanic women were more likely to experience early menopause, and the Asian American women were less likely to go through early menopause. In addition, the SWAN study found differences in menopausal symptoms across groups. For example, after controlling for age, educational level, general health status, and economic stressors, White women were more likely to disclose symptoms of depression, irritability, forgetfulness, and headaches compared to women in the other racial/ethnic groups [71]. African American women appeared to experience more night sweats, but this varied across research sites. Finally, Chinese American and Japanese American women reported fewer menopausal symptoms overall compared to the women in the other groups [70]. These findings replicated those of a study comparing the menopausal experience of 105 Taiwanese and 450 Australian women, which reported that Taiwanese menopausal women reported less irritability, headaches, anxiety, hot flashes, depression, and mood changes compared to Australian women [72]. In a 2019 study, researchers found that Asian women experienced fewer cognitive symptoms related to menopause compared with other racial/ethnic minority groups [161]. In a study of 725 midlife Indian women, only 17.1% of the women reported experiencing hot flashes and 94% stated they welcomed menopause [116]. In India, aging women gain status and prestige and no longer have to go through self-imposed menstrual restrictions, which may contribute to women's experiences.
| A) | In Mayan culture, there is no word for "hot flashes." | ||
| B) | Menopause is a traumatic experience for all women. | ||
| C) | For some women, menopause symbolizes a time when they can focus on themselves. | ||
| D) | For some immigrant women, the realities of discrimination, immigration, and unemployment overshadow experiences of menopause. |
The presence of language or terminology to describe menopause in various languages and cultures can also provide clues about whether menopausal experiences are universal. For example, in Western culture, the term menopause tends to be linked to a malfunction in women's bodies (e.g., deficiency, failure) [117]. In Arab cultures, women in midlife and menopausal stages are referred to as being in a "desperate age" or "age of despair" [117,152,197]. In Lebanon, the term used for menopause literally translates to "hopeless age" [156]. As noted earlier, in the Mayan culture there was no word for "hot flashes," and Mayan women indicated that they did not experience these symptoms [16]. In another cross-cultural study examining menopausal experiences of Hmong tribal women living in Australia, the researcher found that there was no word for menopause [77]. When asked about physical changes during menopause, the Hmong women reported lighter or no periods. When asked about emotional symptoms, the women reported none and found the concept of emotional difficulties caused by menopause amusing [77]. Similarly, a 2010 study with First Nation women in Canada found there was no single word for "menopause" in the Oji-Cree or Ojibway languages, with women referring to the phenomenon only as "that time when periods stop" [118]. In interviews with 185 racially/ethnically diverse women 45 to 55 years of age living in Hawaii, the pre-menopausal women expressed fears about becoming emotionally unstable [140]. In Japan, the term konenki is used, which connotes a natural transition [168]. In Iran, there is no specific word for menopause; some women simply say bashdan dushmak, which means "cessation of menses" [147]. Likewise, there is not a direct translation for the word menopause in China, although juejingmeans permanent cessation of menstrual periods andgengnianqimeans losing one's temper during midlife [182].
Some research with menopausal women has indicated that women may feel liberated in not having to experience a period and not having to plan their lives around their periods [61,136]. In one study of 21 women in midlife, the participants reported feeling more sexually confident, being more "in tune" with their body, and experiencing this time period as a "happy window" [136]. In some cultures, aging women are venerated and elevated to a higher social order [171]. For example, Muslim and Hindu women who are menstruating are not allowed to perform certain religious functions or rituals, but this changes with menopause, opening new religious opportunities [171,172].
A study with Chinese American and immigrant women during their midlife stages revealed that the women understood that menopause is a natural order of life, and while they would prefer youth to the aging process, they accepted menopause as inevitable [86]. Furthermore, they identified menopause as a time of liberation during which they could care for themselves and their inner needs, without being tied down to family and professional responsibilities. This was also expressed in several other studies, including a qualitative study with 65 Korean women from Seoul and a study with 42 aboriginal Mi'kmaq women from First Nation communities in Canada [87,88]. In the former study, the Korean women did not deny initial feelings of loss and sadness, but eventually they progressed to feeling liberated. The women expressed an ability to enjoy life with more light-heartedness, free from responsibilities of husbands and children [87]. Participants in the study of aboriginal women echoed these themes of freedom—being liberated from having children and childrearing and being free to search for activities outside their roles as mothers and caregivers or even leave unhappy relationships [88,193]. Similar themes surfaced in Dare's qualitative study with 40 Australian women in their midlife [108]. Most of the women in the study experienced symptoms in varying degrees and described them as irritating and uncomfortable, but they did not view them as debilitating or distressing. Many did view menopause as liberating. It is important to acknowledge that for those who experienced greater distress during menopause, there were also concurrent stressors in their lives that augmented their distress [108]. No longer having to live up to culturally defined ideals of femininity and beauty have also been reported as freeing by menopausal women [112]. Liberation from the responsibilities and inconveniences of infertility was likewise reported in studies of southeast Asian women [170].
It is often automatically assumed that women will view menopause as "traumatic" or "significant," attaching considerable meaning to this event. In a quantitative study with 140 first-generation Korean American and Korean women from low-income households, one of the major themes was that they gave the menopausal experience far less attention than their current life situations, which were marked by stressors and demands related to immigration and employment [89]. Consequently, less emotional investment was focused on menopause and its associated symptoms, all of which were viewed as a normal part of life [89]. Similarly, in a qualitative study with a total of 61 women from diverse racial/ethnic groups, women from all groups expressed frustrations with the symptoms related to the physical bodily changes [62]. However, the attitudes toward menopause itself differed. African American and Hispanic women had more positive attitudes compared to their White counterparts. For example, there was less anxiety regarding menopause as a life transition, and African American and Hispanic women expressed feeling too busy dealing with day-to-day realities to be burdened with the worries about what menopause means. Similar results were found with Taiwanese women from Taiwan and White women from Australia. In a large survey study, Taiwanese women were found to have neutral feelings about menopause and more Australian women were relieved not to have to deal with menses [72].
| A) | Loss of freedom | ||
| B) | Loss of bad blood | ||
| C) | Loss of youth and physical attractiveness | ||
| D) | All of the above |
Among middle-class White women, menopause often symbolizes the loss of youth. It is "the change," the transitional marker to aging. This was demonstrated in a focus group study with White and African American women. White women in the study were more likely to link menopause with fears about the physical components of aging compared to their African American counterparts. The African American women were more likely to view it as a normal phase of life [78]. This was also true in interviews conducted by Dillaway and Burton [113]. In this study, African American women were more likely to take their menopausal symptoms in stride while the White women were more negative about the experience and were also more likely to seek medical treatment for menopause. In another qualitative study involving 17 White, middle-class women, participants were asked to discuss perceived changes in physical appearance as a result of menopause [64]. The women viewed these physical changes, such as wrinkles, sagging arms, drooping breasts, and dry skin, with sadness and a sense of loss [198].
| A) | India. | ||
| B) | Nigeria. | ||
| C) | urban Thailand. | ||
| D) | the United States. |
In some cultures, there is an emphasis on the vitality of blood. Therefore when menopause occurs and blood is no longer being lost, women may believe that they are retaining "bad blood." This concept emerged in a survey study with 676 Nigerian women. Many participants expressed worry that lack of menstrual flow would lead to illness, as menstrual blood flow was believed to drain away impurities [85]. This cultural explanation is also shared among some women in Iran and in rural parts of Thailand. A qualitative study found that some Thai women did not want to go through menopause because they feared how their body would eliminate "bad blood" after menstruation ceased [91]. The drainage of this "bad blood" was linked to good health and youth. This culture-bound relationship between health and blood is consistent with beliefs regarding the importance of blood in shaping not only health but personality and emotional states [91]. Muslim Iranian women expressed the same anxiety about no longer being able to excrete "polluted" blood from their bodies [198].
| A) | attractiveness. | ||
| B) | children and family. | ||
| C) | Both A and B | ||
| D) | None of the above |
Women during their midlife years may perceive that their youth, attractiveness, and productivity have been lost. Other women may feel that they are losing their children as they become adults and achieve greater independence. The changing dynamics of relationships may be more pronounced during mid-life. These shifts and perceived losses may trigger great introspection about value conflicts and dissolutions of dreams and expectations [202]. Women in midlife experience uncertainties in an array of physical, social, cultural, familial, and psychological dimensions [202]. The notion of loss will inevitably emerge in the clinical encounter. Indeed, in a longitudinal study, psychosocial loss was a crucial predictor in how women experienced menopause [144].
| A) | refrain from acting as a family educator. | ||
| B) | direct women to embrace their new family roles. | ||
| C) | examine the interaction of a women's experience with menopause and her family. | ||
| D) | encourage women to share their experiences with other women, but not with men, in their families. |
Practitioners should examine the interaction of a woman's experience with menopause and her family. It is important to keep in mind that a woman's menopausal experience is not removed from her family's developmental life cycle; rather, it is embedded within it [97]. For example, is the woman going through menopause during a time of divorce, raising children, providing caregiving to elderly parents, widowhood, or while her husband or partner is going through a midlife issue as well [97]? Practitioners can then serve as family educators and facilitators, providing family members with information about the biopsychosocial dynamics of menopause. This is particularly important because menopause is not frequently openly discussed among family members, and it may help ease tensions that can ensue if family members perceive the menopausal woman as being irrational or irresponsible [202]. For example, a husband may not understand his wife's changing sexual responsiveness or may not understand the symptoms associated with menopause [97]. In a qualitative study examining women's discussions about menopause with their spouses, many women reported negative interactions [98]. One woman in the study related that her husband continually urged her to see her physician so she could "control" her symptoms. In an in-depth study with 12 Aboriginal women, many of the participants expressed a desire for their spouses to have a better understanding of the symptoms and physical changes (including the effect on sexuality and libido) caused by menopause [145]. In a small study of male partners of menopausal women, the men related feeling that their partners' emotional instability was due to "raging hormones" [13]. As facilitators, practitioners can serve to open the communication and dialogue process between family members about the perimenopausal and menopausal experience as well as the meanings of transition and aging. Providing husbands and partners training and information about the menopausal experience can be a crucial element in building a support system for women [203]. Peer support groups, participatory lectures, and group therapies for men with the goal of sharing information and experiences are also recommended [204]. Educating men and women about menopause has been found effective in increasing marital satisfaction and in fostering communication within a couple [174].
| A) | Vasomotor symptoms | ||
| B) | Fear revolving around castration anxiety | ||
| C) | Fear about aging and losing his/her youth | ||
| D) | Concern that family togetherness will decrease |
Countertransference is defined as a practitioner's reactions to a client's feelings and responses in the clinical encounter that stem from his/her past reactions (i.e., transference). In working with any group, there will be unique countertransference issues associated with the specific clinical issues relevant to that population. This remains true for practitioners working with women in their mid-life who are going through perimenopause and menopause. Three primary countertransference issues may arise when working with women in their midlife developmental stage [101]:
Fear of aging and death
Anxiety regarding loss of femininity and role status
Competition with younger women