ENTRAR            

ORIGINALS

Sociocultural representations of the menopause: Experiences of the menopause by women from Albacete (Spain)
Angélica Gómez Martínez,^1,2 Antonio Mateos Ramos,² Marca Lorenzo Díaz,³ Mercedes Simón Hernández,⁴ Llanos García Núñez,³ Benedicta Cutanda Carrión^3
1Anthropologist. University of Castilla-La Mancha. Department of Humanities. Social and Cultural Anthropology. Albacete, Spain. ²Doctor. Castilla-La Mancha Regional Health Department. Albacete Regional Council. Epidemiology Department. Albacete, Spain. ³Midwife. University Hospital of Albacete. Obstetrics and Gynecology Service. ⁴Psychologist. Albacete council. Youth Service. Albacete, Spain

Mail delivery: Angélica Gómez Martínez. Delegación Provincial de Sanidad, Sección Epidemiología. Avda. Guardia Civil 5, 02005 Albacete, España

Manuscript received by 25.9.07
Manuscript accepted by 15.1.08

Index de Enfermería [Index Enferm] 2008; 17(3): 159-163

How to cite this document

Abstract

Objective: Approach to the social representations constituent of a biological-biographical phenomenon denominated climacteric, by means of the meanings attributed through socio-cultural knowledge, attitudes and behaviours of the woman in this period of their life. Methodology: Qualitative study by means of seven focal groups (37 women). Population of study: women between 45-55 years, residents in the city of Albacete.
Results: Process identified with the biological age of the women, with negative attributes by its relation with the ageing. It is also related to the social image of the woman and the socio-cultural roles assigned classically to this group. This combination of factors leads them towards a period of their life labelled like "critical age", construction in which biographical elements prioritizes on biological. Conclusion: To recognize the "Variability" of the experience of the process. This would come into conflict with the present biomedical trend, of drawing up certain stages related to the vital cycle of people, trying to generate unitary ascriptions based on medical entities constructed with operative and instrumental aims. To recognize the "Vulnerability" that supposes the confluence between diverse circumstances, which lead them, not only to face physical, emotional and socio-cultural changes, peculiar of this stage, but to the accomplishment of a critical and deep retrospective evaluation of the life experience, of the autobiography.
Key-words: menopause, climacteric, women's health, social representation, qualitative, focus group.

Introduction

    The climacteric is a stage in a woman's life with imprecise limits that occurs between 45 and 65 years old.¹ It is a biological-biographic process^2-3 that characterizes the transition of a woman's reproductive to non-reproductive life. Although biological changes underlie this process, its biographical nature will help us to understand the real meaning for the individuals involved.
    The menopause in western biomedical discourse refers to the end of the menstrual cycle in women, resulting in the ovary losing follicular activity. It is, therefore, an isolated episode that takes place over the period of time that defines the menopause.
    In the scientific literature, the menopause appears as a conflictive stage, and there are two contrasting theories about it: one considers it as an "illness related to a deficiency" or a biological condition that requires special care⁴ and another as a natural age-related process that can take place without complications.⁴
    Although these theories appear to be contradictory, they can both be explained by the same underlying biomedical model based on gonad failure, upon which the recommendations that target this population sector are based, which reflect the hegemonic discourse of the traditional health service. Therefore, although not always with a solid epidemiological foundation, these processes have been associated with diverse symptoms and chronic processes, which has resulted in some women and professionals having a negative view of the menopause, which has tended to become over-medicalized.^5,6 However, neither of the approaches takes into account the experiences of the women themselves during this process.
    From a clinical perspective it is often forgotten that women's experience of the menopause does not necessarily correspond to this description, and how they live this period is often conditioned by the description of this model, rather than vice versa. Elements such as ageing, social and family relationships, their perception of themselves, their expectations, etc. that would all constitute part of subjectively acquired knowledge, and which have traditionally been ignored by medical systems in western societies, influence the different ways a phenomenon is perceived or reproduced in any social sphere.^5-8
    Women's health falls within the limits of social life, not only because women participate directly in all these areas, but also because the process of health-illness is basically constructed collectively and this development affects the activities of the people it involves and the relationships developing among them.⁹
    We propose a methodological debate that transcends simply comparing perspectives, but that does not deny or minimize the contribution made by biomedicine either.
    From this perspective, we hope to approach the social representations that constitute the biological-biographical phenomenon of the menopause, through the knowledge, attitudes and behavior of the women in this period of their lives.
    Of all the different possible approaches to social representations, we have opted to consider these as a discursive experience.¹⁰ In terms of the present research, the discourses of women were taken as a starting point to reconstruct a preliminary social representation of the object of study. Ultimately, the aim was to analyze "a way of social thinking" that is common and practical and that can be used to interpret the reality of the menopause for the group of women studied.
    We start with the idea that interventions to promote and/or protect an individual's health must follow approaches that take into account the discourses of the different groups of women about their health and about what, for them, is healthy, as well as professional and expert knowledge

.Participants and methods

    A comprehensive and interpretative examination of the processes studied, as well as their specific and detailed analysis, has led to the recommendation to develop an essentially qualitative approach.^11-12
    The technique used to collect information is that of focal groups. Given the semi-structured nature of the intervention, a matrix was designed of thematic dimensions-potential questions [figure 1], which was then tested in a pilot study.
    The study was carried out between October 2005 and December 2006. The target population consisted of women between 45 and 55 years old, who were all residents of Albacete. Access to the population was by social networks (neighborhood schemes).
    Sampling of the observation units was done by an exploratory poll, which provided general information about the participants, which helped to improve the selection process and obtain information about their willingness to collaborate or participate. Initially, all the units responded to expectations, but the final number was left to the criterion of the theoretical saturation of information.
    Participants were selected using intentional or convenience sampling, determined by the study objectives. In accordance with these, criteria of homogeneity (age, sex, residence in Albacete) and of heterogeneity basically socio-economic data (civil status, employment, etc) were looked for.
    Finally, a total of 37 women participated in the study (7 focal groups). Their mean age was 51 years old, with a predominance of "married women/couples" (84%). In relation to their working status, 92% referred to themselves as workers, and the majority worked at home.
    Sessions lasted around ninety minutes each. They were recorded on audiotapes with prior consent of the participants and after ensuring them of confidential treatment of their data (ethical considerations). These recording were later transcribed onto written records in natural language by members of the research team. Taking the subjects addressed as a starting point, a series of categories was developed [Figure 2], validating the information by triangulation of the researchers. Discrepancies with coding were resolved by discussion and by reviewing all the original accounts.
    The general analysis included all the mentioned categories although, for the purpose of this article we have only considered the first category. The information was complemented with data from category number four, as required, which records "processes that coincide in time with the appearance and development of the menopause": ageing, sexuality, changes in family environment, social understanding of the menopausal condition, self-esteem and body image.
    We would like to explain that the term used by the women in this study to refer to the study object was the menopause. The technical term "climacteric" does not appear spontaneously in any of the discourses. The linguistic expressions chosen were selected with the purpose of maintaining the meaning the women themselves gave to the term, for analytical purposes the phenomenon has been redefined as a menopausal process.

Results and discussion

    The category "menopausal process" includes a wide range of representations that we have classified into physical (symptoms, complications, etc.), psychological (feelings and sensations) and sociocultural (inherited concepts, family relations, partner, surroundings, etc.).

Physical representations. Most women recognize the end of menstruation and alterations in the female cycle as the main and defining symptoms of the menopause. Attitudes to the menopause encompass a wide range of feelings, in relation to more or less practical aspects, which can be identified in a physical plane as a relief, conditioned by disappearance of the annoying process of menstruation, or as a possible solution to other problems, when they have observed or heard about improvements in other health conditions that they associate with the menopause. On the other hand, a concern or fear is expressed for what may lie ahead, in the way of chronic illnesses. The presence of symptoms such as intense hemorrhaging, hot flushes, sweats, aching bones and joints, is interpreted as a prelude of other more important conditions, such as osteoporosis or osteoarthritis, in a cause/effect relationship, as an exacerbation of problems they already have. These fears are clearly associated with negative attitudes when these (physical or psychological) changes in health are important or are combined with other deficient social processes.
    Some women express their relief or an improvement with arrival of the menopause, since they lose the constant fear of becoming pregnant and can experience sexual freedom. However, this freedom does not imply an increase in sexual desire, since the latter tends to diminish.
    Regarding how women classify the menopause in relation to the theories mentioned above, the majority of the women consulted consider the menopause as a natural process associated with age that can develop without complications.¹³ This "naturalization" can imply self-acceptance and/or resignation.
    In spite of this, there is a clear identification with change. The feeling of "change" is the woman facing up to the conditioning factors traditionally considered to form part of this state. The background here is not the process in itself but, rather, an awareness of change, more in relation to sociocultural than physical situations: age understood as a social construction that discerns clearly defined periods in a woman's biology and culture: menarche, menopause and practices closely related to these, which are conditioned or impeded: "Where would you go at your age?".
    The negative associations of the age, appear to be related to getting older, the presence of which is associated with ideas of denial, a deterioration and loss of roles, functions, prestige etc.
    There is also the issue of body image, closely associated with ageing. An ageing woman has begun this life stage ten years earlier, when her body loses its reproductive capacity. Therefore, a woman passing through this process perceives these changes in her body as a biosocial process. The body takes on a symbolic dimension, full of cultural interpretations and responses to the changes, transitions and transformations she is experiencing. The body is not merely a natural concept but is also socially and culturally important. The body is something that changes in its function, configuration, in its interaction with itself and also in its self-perception. We can also see that the chronological age, or real age, may not coincide with the age a woman feels.¹⁴ This difference reflects the woman's positive perception of how she feels: they see themselves as "on great form", "I feel younger than I am... I even feel more enthusiasm for things than when I was younger"; "I feel better now than when I was 30 years old. Before I felt like a granny; and now, being a granny, I don't...".
    One problem associated with body changes is the social pressure related to image. With the increased weight and body changes, feelings appear that can damage self-esteem, cause worry and distress, not exactly because of the few extra kilos, but more for the approach to old age: "I'm getting a real old woman's body".
These fears materialize in one specific one, the possibility of putting on weight. Some opinions strengthen these situations still further. There is a need for a place that is almost absent in our society, a place that has been made to disappear by the social and cultural violence against older women; these women are not "young girls" nor are they "grannies", but they are forced to come closer to one of these two models as they have no place of their own.

Psychological representations. The psychological and emotional manifestations these women usually refer to include: depression, or feeling down, tiredness and mood changes.
    There is a psychosocial prototype that identifies the psychological disorders attributable to this stage, often combined with ironic attitudes that "make light of the situation": "leave her, she's like that because she's got the menopause"; "Mum you're senile", "Have you taken your brain irrigation tablet?"; "I forget something and they tell me I'm menopausal, I just ignore them".
    Most women experience emotional fluctuations or changes. For some women the end of the fertile life is seen as a sense of total loss and regarded with a pessimistic attitude; they think this is the beginning of the end: "the menopause is where youth's dreams end, you have to face the fact that your time is nearly up, that your dreams that have not yet come true now have little chance of doing so".
    The menopausal process makes a woman realize that as a person she has aged (not in years): it triggers in her the awareness of her vulnerability in all spheres of life.

Sociocultural representations. Some women experience a sense of loss in relation to their condition as "a woman" when they reach the menopause, because this entails the end to their fertility. They regard menstruation as an important part of being a woman. When it stops they feel they have lost part of themselves, a part that defines and identifies them.
    The experience of the menopause is influenced by the concept of being a woman. Traditionally, in our society, a woman's reproductive capacity has been considered to be more important than other distinguishing attributes. This social construction of the condition of womanhood will ultimately brand her, creating an almost tragic view of the menopause, crushing the feminine identity, and producing "one more thing to cope with": "As if you didn't have enough already... it's the last thing you need".
    The menopause is also viewed from past and related experiences in their immediate environment: "when I had my tubes tied, my father said: well daughter you're not a woman any more". A series of questions are, therefore, reproduced repeatedly in our culture today in relation to this identification and are passed on through the generations (woman = children/woman = ability to have children/woman = periods).
    The family environment is the closest one to her, and the attitudes to a woman in this environment can affect her experience. The most important role is that held by her partner. Most women feel supported by their partners' response to practices directly related to the menopause, such as medical assistance, or the physical changes produced. However, the emotional side is the one paid the least attention and for which it is the hardest to find solutions. Other people tend to be excused for not understanding and the woman themselves may be blamed for what is happening. Personal experiences are regarded as a problem for the people around you: "we are awkward, harassed, stressed, negative or sad etc".
    In general, they feel slightly more supported by their partner than by the rest of the family, although this does not affect the previously established domestic roles.
    An interesting issue, is that of feeling overloaded, associated with the woman's role as a carer. The classical "empty nest" syndrome is replaced by the "full nest" syndrome or rather her role as "replaced", since the occupants tend to be from a different generation. The "wonder woman" is faced with a situation that, at least potentially, can produce a great socio-family stress, which can even lead to a personal crisis or breakdown. This is also accompanied by the woman's own work situation and how this work project combines with her family project.
    The syndrome described takes importance away from the traditional sexually stereotyped explanation of the empty nest, where the woman experiences anxiety as she sees her children grow up and leave home, as her "self as a needed person" is undermined. This classical and stereotyped female image was not observed in our participants, and less importance was given to this sense of loss as a mother, or the social bereavement described as explaining this period of female crisis in this stage of a woman's life.
    Regarding their attitudes to sex, most of the women said they felt almost no desire. Although the menopause is given as a reason for this, they describe this lack of sexual desire as having increased over some time. This attitude seems to result in the application of sexual practices to produce gratification that they do not really feel like, an imbalance between the partners. Men are identified with the social concept of male sexuality, hyperactivity and virility. However, women see these matters as merely anecdotal since they consider the idea of love and tenderness as much more important than that of sex and desire. This corroborates the stereotyped image of women in our society as: being calmer, less passionate, less impulsive, with not as much physical desire, more tiredness associated with children, and guilt at not producing gratification. In general, "our things": excuses, tiredness and all that.
    Other aspects lead to a degree of subordination of women to men in relation to sexual activities. However, the discourses do not reflect that women feel particularly uncomfortable about these distinguishing practices of sex/gender, but rather tend to use accommodating practices to satisfy female interests.
    Others show a clear lack of sexual satisfaction because of routine and monotonous sexual relationships: "some times is as the saying goes, making the effort for nothing". Lack of desire because of sexual dissatisfaction: "if you don't enjoy sex in your relationship and you don't have a good time then it's normal that you don't want to do it".
    Finally, it is worth noting that, in this study, the taboos about sex don't seem to refer to sex in itself (the concept or the contents) but instead to the women's enjoyment of it (social practice). This is talked about freely and openly and the women express their lack of sexual desire and dissatisfaction as protagonists. The discourse takes place easily and naturally and disagreement only appears in situations which deal with the quality of the sexual relations.

Conclusions

    In general, we have found a differential concept of the menopause among women participating in our focal groups where the menopause is perceived as a change, a transformation linked with the woman's biological age. This quantitative identification confers it negative attributes because of its association with the process of ageing. The process is clearly associated with the woman's social image, or even with a decrease in her "femininity" and sociocultural roles. The combination of these factors leads the woman to a period of her life often called the "critical age", which is paradoxical since the only factor not present in the crisis is the woman's biological age, for which the determining factors of the social and culture environment are constant.
    First of all, we find a clear recognition of the great "variability" of how women experience this process. This diversity goes against the current tendency in healthcare spheres to classify and protocolize certain stages related with people's life cycle in an attempt to standardize them and to produce single assignations based on medical institutions with operative and instrumental purposes. The narrow vision of only one biomedical option conceals the diverse meanings the protagonists themselves assign to this stage, and the different pathways that their concerns about it can follow. In spite of the overall consideration of the menopause as something natural and not related to illness, the mention of symptoms, that can be present, absent or yet to come, gives the idea of an ideal assimilation of the medical prototype of an illness. This can produce an important distortion and conflict between what a woman feels and what she should feel, what's happening to me and what they say should happen to me.
    Therefore, in spite of it being true that some characteristics can be used to define women in this stage, or the group of women as a whole, this group is not as homogeneous as is generally portrayed.
    Secondly, "vulnerability", is a key factor that emerges in this context as an explanatory principle to help explain the sensations experienced in this stage of a woman's life. The average age at which women go through the menopause, not only finds women faced with the physical, emotional and sociocultural changes typical of this stage, but also requires a critical and in-depth retrospective study of their life experience, or autobiography. During this process, women are often faced with contradictions that arise from confronting their own requirements of independence and personal identity with the demands of the family and work.
    The menopause represents a change in lifestyle that marks the end of the dreams of youth. It is the entry into old age, there is not much of a future and family burdens and demands often making it difficult to do the things they really want to. Many of these factors generate insecurity and fear.
    The physical, psychological and social changes attributed to this stage acquire through the term "menopausal" a special niche with a series of standardized and stereotypical elements, to which the menopause, as a sociocultural reference, relates. The scientific concept from which it is derived, based upon the biological view of the phenomenon, has gone through these limits to construct a new significance for one of women's life stages in which physical factors are of secondary importance.

Acknowledgements

    This study has been partially funded by a research grant from the Castilla-La Mancha Regional Council.
    The authors would like to thank all the participants of the different focal groups.

References

1. Goberna, Josefina. Promoción de la salud en el climaterio. Matronas Prof. 2002; 4: 4-14.
2. Lolas, Fernando. Las ciencias sociales como discurso de la salud reproductiva. El ejemplo del climaterio femenino. Cad. Saude Pública 1998; 14: 131-134.
3. Dupeyago, Jodse. Menopausia ¿Lo sabemos todo? Matronas Prof. 2000; 4: 23-25.
4. Pelcastre-Villafuerte B, Garrido-Latorre F, de León-Reyes V. Menopausia: representaciones sociales y prácticas. Salud Pública Mex. 2001; 43: 408-414.
5. Freixas, Anna. Mujer y envejecimiento: aspectos psicosociales. Barcelona: Fundación La Caixa, 1993.
6. Capilla P. Mujer y Menopausia. Un problema social y sanitario. Sesenta y Más (IMSERSO). 1996; 132: 48-53.
7. Amedillo MS, Pozo F, Zaragoza MC. Grado de información y actitudes de las mujeres premenopáusicas sobre el climaterio. Matronas Prof. 2001; 5: 35-39.
8. Giraudo, Nancy; Dreyer, Claudia; Bakalar, Karina; Discacciati, Vilda. ¿Qué les pasa a las mujeres en la menopausia? Nexo Rev. Hosp. Ital. Buenos Aires. 2003; 23(1): 3-9.
9. Domm JA, Parker EE, Reed GW, German DC, Eisenberg E. Factors affecting access to menopause information. Menopause. 2000; 7: 62-67.
10. Jodelet D. La representación social: fenómenos, concepto y teoría. En: Moscovici, S, editor. Psicología Social II. Barcelona: Paidós, 1984: 469-494.
11. Denzin NK, Lincoln YS. Handbook of qualitative research. London: Sage, 2000 (2ª ed.).
12. Iñiguez L. Investigación y evaluación cualitativa: bases teóricas y conceptuales. Aten Primaria 1999; 23(8): 496-502.
13. Lostao L, Regidor E, Calle E, Navarro P, Domínguez V. Evolución de las diferencias socioeconómicas en la utilización y accesibilidad de los servicios sanitarios en España entre 1687 y 1995/97. Rev. Esp. Salud Pública. 2001; 75(2): 115-128.
14. Beauvoir, Simone de. La vejez. Editorial Sudamericana, Buenos Aires, 1980.

RECURSOS CUIDEN

RECURSOS CIBERINDEX

FUNDACION INDEX

GRUPOS DE INVESTIGACION

¿Quiénes somos?
RICO Red de Centros Colaboradores
Convenios
Casa de Mágina
MINERVA Jóvenes investigadores
Publicaciones
Consultoría