The interplay of culture and symptoms: menstrual symptoms among Samoans.

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The interplay of culture and symptoms: Menstrual symptoms among Samoans Maureen H. Fitzgerald

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Assistant Professor in the Department of Anthropology , University of Hawaii , Honolulu, HI, 96822 Published online: 12 May 2010.

To cite this article: Maureen H. Fitzgerald (1990) The interplay of culture and symptoms: Menstrual symptoms among Samoans, Medical Anthropology: Cross-Cultural Studies in Health and Illness, 12:2, 145-167, DOI: 10.1080/01459740.1990.9966019 To link to this article: http://dx.doi.org/10.1080/01459740.1990.9966019

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The Interplay of Culture and Symptoms: Menstrual Symptoms Among Samoans


Maureen H. Fitzgerald Menstrual symptomatology has received much attention in recent years but little attention has been given to the interplay of culture with these symptoms. Interview data from male and female Samoans in rural Western Samoa, rapidly modernizing American Samoa, and modem Hawaii are used to explore the role of culture and culture change in explaining variations in reports of menstrual symptomatology and menstrual distress. I suggest that culture plays a significant role in the recognition, evaluation, and expression of menstrual symptoms, and thus culture must be considered along with biological and psychosocial variables in the evaluation of symptomatological differences, including differences in number and kind.

INTRODUCTION

In the last three decades menstrual distress, especially Premenstrual Syndrome (PMS), has been a sodal, political, and medical issue in Western societies. Discussions of this phenomenon are common in both the popular and professional sectors. But, although there is a large and rapidly growing literature on menstrual distress, anthropologists have only rarely contributed (e.g., Paige 1973; Johnson 1987; Martin 1987,1988; Colligan and Ethier 1988; Siegel 1986), despite the fact the •anthropological approach is particularly well suited for addressing many of the questions associated with menstrual distress.1 The fact that anthropologists are only now turning their attention to menstrual distress is interesting in view of anthropology's long tradition of attention to other menses-associated issues (menarche and menarche rites, menstrual beliefs and practices, family planning, and more recently menopause). As Buckley and Gottlieb's (1988) excellent review suggests (see also Fitzgerald 1984), much of the anthropological literature on menstruation emphasizes its symbolic aspects. At least since Douglas (1966), menstruation has been the focal point for discussions of pollution.2 But, the cultural aspects of menstruation go beyond menstrual symbolism, restrictive menstrual practices, menarche rites, and menopause. Culture must also be viewed as part of the interactive system which influences the menstrual experience on all levels, including its symptomatology. One of the most common, and perhaps most critical, questions for understanding menstrual distress is why there are such large variations in the prevalence of menstrual symptoms, particularly those regarded as distressful, from one population to another (Woods 1985:145). Researchers have generally approached such MAUREEN H. FITZGERALD is an Assistant Professor in the Department of Anthropology, University of Hawaii, Honolulu, HI 96822. Her interests include contemporary health issues, culture change and health, and women's health.

145


146

M. H. Fitzgerald

questions from a strictly biological, psychological, or sociological perspective (Fitzgerald 1984,1989). Others have tried to explain the differences from one study to another and from one population to another by citing methodological problems (Parlee 1973,1982; Koeske 1983; Asso 1983; Rubinow and Roy-Byrne 1984). While methodological problems are certainly an important issue and biological, psychological, and social factors are dearly involved, none of these factors alone fully addresses the question of why we find such differences. One issue which is rarely induded in these analyses is: What role does culture play? Is it not possible, as Zola (1966,1979) and Woods (1985; Woods, Most, and Longenecker 1985) suggest, that many of the differences can be explained by the "interplay of culture and 'symptoms'" (Zola 1966:617)?3 The assumption of such an interplay is a basic tenet of medical anthropology. Discussions of the interplay between culture and symptoms are found in the literature on illness behavior (e.g., Good and Good 1981; Waxier 1981; Mechanic 1963,1969,1972,1978; Stoeckle and Barsky 1981; Zola 1966,1979). This literature (which is relevant even though menstruation is not universally considered an illness) makes several interrelated points. First, common or widespread conditions can be perceived as normal rather than aberrant or symptomatic of illness. Second, each sodety has its own definitions of what behaviors, dysfunctions, and feelings will be called and treated as symptoms or illness. Sodocultural factors can lead to different definitions, interpretations, and responses to essentially the same experience. Explanations are bound to a sodety's cosmology, epistomology, and values. Third, what conditions and even whether or not a particular condition will be called "illness," "disease," or "symptom" may depend on medical practices, in particular whether or not there is an "effective" treatment. Fourth, illness concepts and symptoms are "bound to the medium of language and signification" (Good and Good 1981:175). Fifth, attribution processes are also shaped by individual personality, characteristic defense mechanisms, and prior knowledge and experience. In other words, the same state can be labeled in many ways. Symptoms which may in some cases be regarded as normal or of no consequence can be "reconceptualized within the context of newly acquired knowledge" (Mechanic 1972). New knowledge and experiences may even provide new "frames of reference" for identifying and giving meaning to symptoms (Zola 1979; Mechanic 1972). Social learning can affect the vocabularies people use to define and talk about symptoms or feeling states and may even determine whether or not people talk about their symptoms (Mechanic 1972). As Mechanic points out: It is reasonable to expect that persons from origins where the expression of symptoms and seeking help is permissible and encouraged will be more likely to do so, particularly under stressful circumstances. In contrast, in cultural contexts where complaining is discouraged, persons experiencing distress may seek a variety of alternative means for dealing with their difficulties. [Mechanic 1972:1136]

Mechanic (1972), Kleinman (1980,1982), and others note that some people express all manner of distress in somatic terms while others utilize and are more receptive to "psychological vocabularies." In other cases illness is expressed in the vocabulary of sodal relationships (e.g., Turner 1968; Janzen 1978). Exposure to different medical systems can be, and often is, accompanied by the acquisition of a new symptom or illness vocabulary. Assimilation of these new vocabularies can also be accompanied by new ways of conceptualizing feeling states. What was once ex-

Menstrual Symptoms among Samoans 147


pressed exclusively in somatic terms may come to be expressed in more diverse ways. The same menstrual symptoms seem to occur in all populations (Snowden and Christian 1983; Janiger, Riffenburg, and Kersch 1972), but cultural factors affect: 1) the number and kinds of symptoms reported; 2) what symptoms will be attributed to menstruation; 3) whether menstrual symptoms "will be recognized and given attention; and 4) whether or not menstrual symptoms are perceived as distressful. Karen Paige (1973) may have been right when she wrote: "Women learn to sing the menstrual blues." But unlike Paige (and others), who believes menstrual symptoms have their origins in social and cultural beliefs and attitudes—that menstrual distress is a social response to menstruation—I believe the symptoms occur universally and women just learn to "sing" with new words or new interpretations. Many women know the tune, but they leam new versions. Such an interpretation not only accounts for differences across space (i.e., extant populations) but also across time. THE SAMOAN MENSTRUATION STUDY

The purpose of the Samoan Menstruation Study, which was conducted as a part of the University of Hawaii Samoan Stress and Health Project, was to see if culture change, in this case exposure to modernization, results in a change in the menstrual experience towards that seen in modem Western societies. Particular attention was given to reports and descriptions of menstrual feelings and behaviors. As I have discussed elsewhere (Fitzgerald 1989:9-13), like most terms used to denote the processes of culture change, the term "modernization" is problematical. In spite of the criticisms and definitional problems associated with the term, it does have some utility. Traditional and modem are relative terms; modernization occurs in all societies—even those considered the most advanced. Modernization is used here . . . to refer to the processes of change initiated by contact with recently developed techniques, methods, or ideas, especially those associated with modem Western societies. It includes the idea that modernization involves the accumulation of both instrumental and cognitive knowledge. It assumes that the processes of change affect, albeit to varying degrees, all aspects of human life. It further assumes that modernization occurs at both the conscious and unconscious level. [Fitzgerald 1989:13]

Methodology Data were collected in three Samoan communities. They represent "a rough continuum of increasing 'modernization'" (Hecht, Orans, and Janes 1986:39). At one end of the continuum is a rural coastal village on the island of Savai'i in Western Samoa. This village is identified by the villagers and Samoan officials as one of the most traditional villages in Samoa today. The second community represents an area of rapid modernization. Respondents in this sample come from seven villages on the southern coast of the island of Tutuila in American Samoa. The community at the most modern end of the continuum is urban Honolulu, Hawaii. Data were collected in 1986 and 1987. Menstrual symptomatological data come primarily from two sources: a structured health interview and a semi-structured menstrual experience interview. Although the menstruation study took place in the


148 M. H. Fitzgerald context of the Health Project, the menstruation interview was additional and voluntary. All interviews were done in the respondent's language of choice.4 The health interview contains a list of ninety-one feelings, symptoms, and diseases. This is an expanded version of the symptom list used by Woods and her colleagues in their study of menstrual symptoms (Woods nd). Respondents were asked if they ever experience the item; if yes—how often does it occur and is it related to anything else. Menstruation was discussed during the health interview only if it was brought up by the respondent. The menstruation experience interview does not include a symptom list, but does deal with a wide variety of menstrual experiences and menses-related topics, including feelings and behaviors associated with menstruation, menarche, menstrual beliefs and practices, and menstrual expressions. This interview is similar in style to the ethnographic interview described by Spradley (1979), and focuses on domains rather than formalized questions. Respondents were specifically asked at one point to relate the feelings and behaviors they associate with menstruation, but symptomatology data are found throughout the interview. Data from these interviews are supplemented with information from other Health Project interviews, a set of weekly physical measurements, observations, and interviews with health care providers and people knowledgeable about Samoans and Samoa. The Research Samples

A total of ninety-three Health Project subjects agreed to a menstruation interview (Fitzgerald [1989] describes subject selection in detail). The Western Samoan sample includes eight males and 20 females, the American Samoan sample includes 14 males and 15 females, and the Hawaii sample includes 12 males and 24 females. All respondents are between 18 and 37 years of age. Unlike many other comparative studies, members of these communities share a genetic and cultural heritage; the major distinguishing variable is the degree of exposure to modernization and Western models of menstruation (Fitzgerald 1989). Males were included for several reasons. First, a more accurate and complete picture of the menstrual experience requires obtaining both the female and male perspective (Fitzgerald 1984,1985; Buckley and Gottlieb 1988). Male data supplement and expand upon female data. Second, males were used as a kind of control sample. Their role as controls is clearest for the weekly measurements, which were an attempt to explore objective symptoms, but they also functioned as controls for knowledge of menstrual symptoms. Male data is especially important for considering the influence of culture. If data from males and females are similar, this suggests that something more than just biology is involved. POTENTIAL FOR EXPOSURE TO MODERNIZATION AND WESTERN MODELS OF MENSTRUATION

The research sites were specifically chosen to represent three distinctively different portions of the "modernization continuum." Background data from Health Project


Menstrual Symptoms among Samoans

149

questionnaires, which were used to create an index suggesting potential for exposure to modernization, offer additional support that there are significant differences between the three sites (Table I). The index combines information on level and place of education, employment experiences, place of residence, amount of time outside of Samoa, and language ability (information on construction of the index is presented in Fitzgerald [1989]). The lowest scores, representing the lowest potential for exposure, are found in Western Samoa and the highest scores are found in Hawaii. Scores in American Samoa overlap those of the other two sites. Menstruation interview data present evidence that the modernization continuum is associated with a difference in exposure to modern, Western models of menstruation (Fitzgerald 1989). The number of sources (and potential sources) of menstrual information clearly increase across the continuum with two exceptions. Western Samoans get almost all of their information from personal experiences. Females learn about menstruation from having it. Males learn from friends, wives, and lovers. School (i.e., sex and health education courses and sessions on menstruation) and mass media (i.e., books, magazines, television) increasingly become important sources of information as one moves towards the modem end of the continuum. The exceptions are access to menstrual information from pregnancy-associated experiences and family planning educational efforts. Western Samoans and Samoans in Hawaii have a similar level of opportunity to obtain menstrual information from these sources, while American Samoans are the least likely. This is explained in part by the fact that fewer respondents in American Samoa are biological parents (Western Samoa=*67.9%, American Samoa=34.5%, Hawaii=69.4%). Most Samoans, especially in the Samoas, are introduced to family planning only after the first pregnancy. In Western Samoa family planning is an important part of the Public Health program, especially in the area where this research took place. Family planning information and devices are routinely offered as part of the monthly wellbaby clinic held in the village. Samoans in Hawaii are generally introduced to family planning both in school and after childbirth. Family planning information is. not readily available in American Samoan schools and the family planning clinic at the hospital is not well utilized. As a result, many American Samoans are exposed to family planning information only during the period of hospitalization immediately following childbirth. Females at the more modem end of the continuum are more likely to know

TABLE I. Potential exposure to modernization index scores by site and sex. Female

Male WS N Mean SD Range

8 11.3 1.75 8-13

AS 14 12.5 1.51 10-14

ANOVA by: site P - 0.000 Sex P- 0 . 3 1 site/sex interaction P - 0 . 0 3 Adapted from Fitzgerald (1989:83)

HI 12 14.2 1.27 ' 13-17

WS

AS

HI

20 9.8 1.29 7-12

15 12.3 1.29 11-16

24 14.8 1.71 12-18


150 M.H.Fitzgerald

something about menstruation before menarche (Western Samoa=50%, American Samoa=66.7%, Hawaii=79.2%) and males in this group are more likely to know something before they develop intimate heterosexual relationships. With exposure to modernization, Samoans have increased potential for access to information about menstruation and menses-related topics, and they are more likely to be aware of a Western biological model and other popular menses-related issues. One very distinctive difference across the sites is the awareness of the concept of PMS. In fact, no evidence of the concept of PMS, even by another name, exists in traditional Samoa. On the other hand, both male and female respondents in Hawaii have heard of PMS and can discuss it. In many cases, the respondents introduced the subject of PMS before I did. Casual conversations about menstruation are generally uncommon among Samoans but do occur among intimates and are more likely to occur at the modern end of the continuum than at the more traditional. There are no taboos about talking about menstruation, but because of Samoan attitudes towards menstruation, people feel there are few reasons to talk about it.

SAMOAN ATTITUDES TOWARDS MENSTRUATION

Samoans view menstruation as a normal, natural, and private part of female life which is necessary for individual and reproductive health but over which humans have little control. It is often described as something given to women by God. Evidence of this attitude can be seen in sample statements from the menstruation interviews. It's just part of nature for women. (American Samoan female) It's good it's coming out. You know if it doesn't come out you are probably going to be dead. (American Samoan female) 1 It's God. It's God that, you know, he's the one who provide that for us. So we cannot deny it. It's our thing. (American Samoan female) It's up to God. Ifs God's planning. (Western Samoan female) People who have irregular periods . . . I heard that some people say that they will have a hard time getting a child or staying with child, (female in Hawaii)

In spite of the fact that a common Samoan word for menstruation is ma'imasina (literal translation—monthly illness), it is dear from the interviews that Samoans do not view menstruation as an illness.5 Females are not considered more or less healthy than males because they menstruate. Samoans who know anything at all about menstruation know that menstruation normally ceases during pregnancy, but some believe that females who never menstruate (primary amenorrhea) become sick and may die, and females with irregular menses (secondary amenorrhea) may have difficulty conceiving. Because Table II is based only on statements from the menstruation interview, and people frequently confounded primary and secondary amenorrhea, it underrepresents the number of people who associate the cessation of menses with pregnancy and the lack of menses with a potentially life threatening situation. It is interesting that although females generally associate menstruation with some kind of pain, males frequently do not. Males often told me that when they first learned about menstruation they were concerned about pain, but males claim that

Menstrual Symptoms among Samoans 151 TABLE II. Reasons women do not menstruate. Male WS N-6 Woman is pregnant Either pregnant or sick Woman will die Woman will get sick Either pregnant or will die Other

.

83.3 0 0 0 0 16.7 •

AS N

%6

50.0 33.3 0 0 0 16.7

Female

HI N = 11 100.0 0 0 0 0 0

WS N-12 41.7 25.0 16.7 8.3 8.3 0

AS N - 10

HI N = 18

20.0 10.0 50.0 10.0 10.0 0

72.2 16.7 0 0 0 11.1


Adapted from Fitzgerald (1989:186)

when they asked whether or not menstruation was painful their female informants often told them it was not. There would seem to be a paradox here. Most females associate menstruation with pain but males are told it is not painful. Maybe by chance these males questioned the few females who do not experience pain, but a more reasonable explanation is that the denial is an example of Samoan stoicism, especially as this case involves a natural, but private, aspect of female life. Samoans generally express a fatalistic acceptance of menstruation and a stoic attitude towards all that it entails. Menstruation is considered a fuss and a bother but as there is little that can be done about it, one must simply endure. It will all go away in a few days. When Samoan females, especially in Western Samoa, are asked if they do anything to make themselves feel better during menses, they shrug their shoulders and say something like: "Wait until it goes away" (Western Samoan female) or "No. Because I know I am going to have my period" (Western Samoan female). They feel there is little that can be done other than to wait it out. One Western Samoan female once tried massage for backpain during menses but as it only provided momentary relief she no longer bothers with it. Females are more likely to seek medical attention for a prolong unexplained absence of menses than for menstrual symptomatology. The Samoan attitude towards menstrual symptoms is consistent with the general Samoan attitude towards all manner of discomfort and is similar to the attitude of females in many other societies. Samoans are recognized as stoic. Markoff and Bond (1974:87) associate Samoan stoicism towards pain and illness with "the cultural value of resignation in the face of uncontrollable aspects of the man-nature interaction". According to Ablon: Samoans speak of themselves as being strong and knowing that one has to take hardships without complaint. They exhibit a great tolerance for pain, death, and calamities, regarding these as aspects of life that one must beat, sanctioned by a Christianity that dictates an acceptance of God's will as nonreversible fate. Many informants offhandedly stated that despite painful events of whatever magnitude, the mechanics of life must, after all, go on. [1971:332]

Mackenzie adds that when Samoans feel they can not overcome a situation they tend to withdraw and remain quiet. "Strong pressure is exerted not to complain" (1978:111). Snowden and Christian note that although reports of physical discomfort are

152

M. H. Fitzgerald

widespread among the women in their cross-cultural study, few "claim to take action to relieve pain before or during menstruation" (1983:67). Snowden and Christian hypothesize that:


. . . most •women accept the physical discomforts associated with menstruation as natural or inevitable and rather than try to alleviate the pain itself, prefer instead to minimize the overall discomfort through a reduction in strenuous or tiring activity or by taking short periods of rest. [1983:67]

In White and Wildman's (1986:473) study, "women who reported believing that their health was controlled by chance or fate were less likely to seek medical help than women who placed responsibility for their health in other sources." Scambler and Scambler (1985:1066-1067) found that women who accept menstruation as a normal life process and women with a fatalistic attitude towards menstruation are less likely to seek medical consultation for their symptoms than "women showing antipathy towards their periods." In the West, the belief that menstrual symptoms are natural and inevitable has a long history and has only recently been seriously challenged. In the case of menstruation, Samoans are not necessarily just being stoic. Many do not consider menstrual symptoms as disturbing or distressful, but those who do, especially in Western Samoa, feel they have little alternative but to endure. Only in the modern setting, where people learn that options beyond fatalistic endurance exist, do they begin to address their menstrual symptoms and enter into menstrual symptom help-seeking behavior. Help-seeking rarely involves Western medical specialists and is generally confined to self-help, home remedies, and advice from family and friends. There is no evidence of a traditional pharmacopoeia for menstrual discomfort, and fofo (massage) is only rarely used for menses-related back or head pain. Both males and females in American Samoa and Hawaii mention television, including television advertising, as sources of information on menstruation and treatments for menstrual discomfort. Over-the-counter remedies, such as aspirin, Tylenol, and Pamprin, are commonly used in Hawaii, only occasionally used in American Samoa, and almost never used in Western Samoa. Two females in Western Samoa asked if there were any medications for menstrual cramps. One female in Hawaii use to take pills her mother gave her for cramps but now that she is "use to them" (the cramps) she just waits them out. The only respondent who has ever sought a physician's advice for menstrual symptoms has always lived in Hawaii.

MENSES-ASSOCIATED BEHAVIOR

Samoans have no explicit rules governing behavior during menses. Unlike other areas of Polynesia (Hanson 1982), there is no evidence Samoa ever had an elaborate menstrua] belief system (Mead 1949). Menstruation is not, and apparently never was, surrounded by elaborated concepts of taboo or pollution or the restrictions such belief systems generally entail. Respondents are quite adamant that any change in behavior during menses is an individual decision. There is, however, an implicit expectation that menstruating females will give extra attention to their personal hygiene and the proper disposal of menstrual


Menstrual

Symptoms among Samoans

153

materials. Hygienic expectations are consistent with Samoan values concerning hygiene and proper respect for the sensibilities of others. As a result, females generally bathe more often than usual, take care to hide evidence of their menses, and discretely dispose of soiled materials. Females, especially if they are unmarried, also hide evidence of their menses for another reason. Some Samoans, particularly males, believe coitus is a necessary prerequisite for menarche and the resumption of menses postpartum. For these Samoans, menstruation is evidence of a sexually active status. Public evidence of sexual behavior, especially for the unmarried, causes individual and family shame. In spite of the lack of rules about menses behavior, 64% of all the females feel females do change their behavior during menses. Twenty-five percent of the Western Samoan females, 40% of the American Samoan, and 75% of the females in Hawaii change their own behavior. The kind and amount of change varies from one individual to another. Over 20% of the females change their behavior because they are concerned about being able to properly contain the menstrual flow, but according to most respondents, both male and female, behavioral changes are more often associated with the female's affective and physical state. Although females in all three sites do all their essential daily tasks, the most commonly reported behavioral change, aside from bathing more, is resting more. Females also report other decreases in activity. Many avoid extra or strenuous activities and a few decrease their social activities. When I have it I don't do heavy work because my body feels weak. (Western Samoan female) Well from my own experience it does affect my life. Every time I have it, ah it interferes with my daily activities because when I have it I don't feel like doing much. And I'm always sleeping. . . Like sometimes when there are some things you have to go to, like social gatherings and things, I just don't feel like going because I have it. (American Samoan female) I just stay home unless I have to go work. That's the only way I will go but going out like that [to social gatherings]. I never like go anywhere because. I mean I will go if you like getting to the ending of it. But if I just started I won't want to go anywhere. I feel lazy, (female in Hawaii) Most of the girls they really sick when they make the period. They really sick. One of my girlfriends she no show up [at work] the whole week she make a period, (female in Hawaii) Oh at times I'm really uncomfortable when I'm on it. I don't like to go anywhere. I don't like to do much. You know I don't like to do cooking either, (female in Hawaii)

Some females, especially in the Samoas, claim they do not change their activities in any distinctive way even though information provided by husbands and friends suggests they do. Husbands say things like: She lazy when she start her period. Not really lazy, but she don't [do] what she suppose to do. (male in Hawaii) Sometimes she don't tell me but I will know by the way she acts. She'll be a little bit grouchy, (male in Hawaii) My wife has always sleep, sleep, sleep. No work. (Western Samoan male) • She doesn't tell me about the ma'imasina [does not tell him she is menstruating], but she looks like a lazy woman. Acts tired. (Western Samoan male)

Although the changes may in fact be menses-related, the female may not associate the changes with menses. Alternative explanations are available and some changes do not require an explanation. In fact, changes in behavior are often so subtle and so consistent with normal variations in behavior that Western Samoan respondents often claim that behavior does not provide a clue about menstrual

254 M. H. Fitzgerald status. On the other hand, respondents in American Samoa and Hawaii often cite behavioral changes as evidence that a female is menstruating or is about to begin.


They really change. You know 'cause I can tell. They just sit still and never do nothing. They're always tired so they just sit there for days. (American Samoa female) My friend. I'm close to her. Usually we talkative. When she has her's she's a quiet one. A quiet. So when I see her quiet I kind of have a feeling either she's mad at somebody or she has her period, (female in Hawaii)

The lifestyle and customary work practices of traditional Samoa make it unnecessary to consider menses as an explanation for some changes in behavior. Other socially acceptable explanations for resting are available and everyone takes an occasional rest day. Samoans are traditionally task oriented (Franco 1985). When a task is completed, or a person has been working very diligently, a rest period is socially acceptable—and no explanation is required. Furthermore, in traditional Samoa there is some flexibility and individual control over daily activities. Work orders are given out on a daily or weekly basis by the mdtai (chief) or highest ranking female, but the individual decides how to fill the order within the allotted time frame. Within the context of the hierarchical structure of Samoan society a person can often pass all or part of a task on to a lower ranking person. Households in Western Samoa tend to be larger than in the other sites (Fitzgerald and Howard in press) so others are always available to share the work. Thus, a female can often redistribute or adjust her workload for a few days without explaining why she is doing this to herself or to others. Many females, again especially in Western Samoa, do not report menses-related changes in affect. The evidence suggests such changes probably do occur but women may not recognize the changes in themselves, they may not associate them with menstruation, or they may be unwilling to admit to socially disapproved behaviors. Some changes in affect are probably more obvious to husbands and dose friends. Samoans, particularly husbands, describe menstruating females as more likely to get angry with little provocation, to cry easily, and to strike out verbally and physically, especially towards children.

MENSTRUAL SYMPTOMATOLOGY

Females may not be able to identify all the changes associated with menses, but all females are aware of changes. Samoan females have no difficulty with questions such as: Can you tell by the way you feel or the way you act when your menstruation is going to begin?. They are also able to describe how menstrual feelings and behaviors change over the course of the cycle and if they have changed over time. This information is frequently offered without solicitation. There are, however, distinctive across-site differences in the number and kind of symptoms reported as known and personally experienced (Tables HI and IV). Although males report knowledge of fewer symptoms than females, the across-site differences among males parallel the differences among females. In general, Western Samoans offer fewer kinds of symptoms and fewer symptoms per individual and Samoans in Hawaii offer the greatest number. Western Samoan descriptions of

MENSTRUAL SYMPTOMS AMONG SAMOANS 155 TABLE m. Symptoms known. Western Samoa


Male N - 8 Cramps Backache Headache Leg pain Sore breasts Chest pain Pimples Pale Diarrhea Change in stool Bloating Weight gain Weight loss < Appetite > Appetite Food Craving (Crave Sweets) > Activity Clumsy Dizziness Nausea Fatigue Uncomfortable Grouchy < Desire to move Sad Weepy Total symptoms

12.5

American Samoa

Hawaii

Female N • 20

Male N = 14

Female N = 15

Male N = 12

Female N = 24

100.0 75.0 30.0 5.0

14.3 14.3

73.3 60.0 20.0

8.3

100.0 75.0

8.3

4.2 8.3

16.7 14.3

6.7 46.7

8.3

6.7

54.2 4.2 8.3

5.0 26.7 6.7

5.0 5.0

14.3 7.1 7.1

5.0

50.0

10.0 10.0 75.0 100.0 5.0

13

16.7 16.7 8.3 8.3

20.0 28.6 28.6 21.4 21.4

2

26.7 20.0 20.0 13.3 26.7

25.0 4.2 4.2 37.5 20.8 41.737.5 12.5 4.2

9

93.3 100.0 20.0 20.0 13.3 6.7 19

58.3 25.0 50.0 16.7 8.3 11

91.7 100.0 58.3 41.7 12.5 4.2 22

Note: Symptoms at the top of the list are primarily somatic; those at the bottom are primarily affective. Adapted from Fitzgerald (1989:221. 222)

symptoms are also less likely to be as elaborate or as extensive as those offered by more modernized Samoans. Superimposed over the modernization continuum is a somatic/affective continuum. This continuum ranges from symptoms that appear to be primarily somatic to those which are primarily affective. Somatic symptoms are the most commonly offered symptoms in all three sites and are usually the first symptoms offered. Affective symptoms are offered progressively more often as we move towards the modern end of the continuum. Some of the emphasis on somatic symptoms seen in Western Samoa is the result of a difference in vocabulary, but somatization and a modernization-associated difference in the ability to psychologize and express internal states are also involved. Some of the difference must also be explained by differential exposure to the idea that menses can be associated with changes in affect.

256

M. H. Fitzgerald TABLE IV. Mean number of symptoms known and experienced by site and sex. Male

N Mean Number Known* Mean

SD


Range Mean Number Experienced* Mean

Female

WS

AS

HI

WS

AS

HI

8

14

12

20

15

24

0.6 0.5 0-1

1.6 1.9 0-5

2.3 1.8 0-6

4.3 1.3 2-6

6.1 2.0 2-9

7.3 2.4 3-13

4.0

4.5 2.03 0-8

5.9 1.62 3-10

SD

1.26

Range

2-6

'ANOVA site P < 0.001, sex P < 0.001, site/sex interaction ns 'ANOVA site P < 0.001 Adapted from Fitzgerald (1989:243, 249)

The somatization of menses-related affect is seen in the meaning of some of the terms people use. Females in all three places report menses-associated headache, but, like many somatic symptoms, headache is more commonly offered by Western Samoans. When Samoans talk about headache they refer to more than pain or discomfort brought on by physical causes (i.e., being in the sun too long). Headache is also used to talk about cognitive or psycholpgical strain and/or emotional pain. Samoans daim headaches can be caused by thinking too much, worry, and strong emotions. Samoans also use terms like headache as metaphor for all kinds of distressing conditions. Fatigue, a primary explanation for decreases in activity level, is one of the most frequently reported symptoms in all three sites. Both males and females associate menstruation with fatigue. Two common terms from this category are relevant to the discussion of the somatic/affective elements of Samoan symptom terms, for while they both clearly refer to fatigue, they suggest that more than physical tiredness is involved. These terms are "lazy" and "iva." English speakers often use the term lazy" when they talk about mensesassociated fatigue and behavior. Gerber (1985:130) considers one Samoan term for lazy (augata) as an emotional term, and identifies it as a low-level expression of pique" often connected to situations having to do with work.6 According to my informants, lazy is also a fatigue term and includes any or all of the following: a desire for less activity, a decrease in activity level, increased sleeping, and avoidance of all but the most essential of life's events, tasks, and interactions. Although lazy also includes a fatigue-initiated decreased desire to talk or move, I have treated "decreased desire to talk or move" as a separate category because it is not always associated with fatigue. "Decreased desire to talk or move," which is only offered in American Samoa and Hawaii, is used to refer to a decreased desire for social interaction or a desire to be left alone. In terms of menstruation, the "lowered desire to talk and move" element of lazy emphasizes the somatic but includes an affective element whereas "lowered desire to talk and move" (as a separate, distinctive category) is primarily psychological.


MENSTRUAL SYMPTOMS AMONG SAMOANS

157

Iva is similar to lazy. During the interviews my research assistant always translated iva as tired. The Samoan in Hawaii who helped transcribe interview tapes pointed out that iva means something more than tired. He compares iva to the way people feel when they have a hang-over. Milner (1976) makes a similar association in his example of the verb form—fa'a'iva (make listless, exhaust): "E fa'a'iva tagata k inu pia: Beer-drinking makes people listless." Other consultants in Hawaii describe iva as feeling "sleepy, tired, weak, lazy. The brain is too tired to work." (The latter part shows great similarity to explanations associated with headache.) So iva, like lazy, involves physical feelings, including those associated with fatigue, but it also implies a change in affect and the ability or desire to engage in any activity. Lethargy, the term used by Snowden and Christian (1983), might be a useful synonym for these terms but malaise is even better. These terms mean more than just the kind of tiredness one might associate with physical exertion or drowsiness. Both terms also imply an indefinite feeling of debility or vague sense of a lack of health or mental well-being, a sense of uneasiness or indisposition (Webster's New Collegiate Dictionary 1977; Tabe^s Cyclopedic Medical Dictionary 1963). In fact, many of the terms I have included in the fatigue category carry these additional connotations. With words like lazy and iva (and headache) we see that terms which initially appear to address primarily physical feelings also in many cases address affect as well. However, such an analysis is dearly etic in nature. While many of the respondents in American Samoa and most in the Hawaii group identify, recognize, and talk about affective symptomatology, Western Samoans rarely mention affective symptoms or the affective component of such feelings as those I have identified with iva. Thus, the etic analysis provides evidence for the existence of affective symptomatology in all three locations but such symptomatology is generally only identified in the more modernized settings (see Fitzgerald [1989] for additional evidence). In her study of emotions among Samoans, Gerber notes that, in contrast to Americans, Samoans offer few descriptions of internal sensation (1985:137). She suggests that: "In cultures like the Samoan, where attention is turned outward to social and interactional cues, informants may not be able to express inner experiences directly" (1985:159). "Some affects may be left completely undefined and unclassified by a culture" and in such a situation people might "have some difficulty in expressing these feelings, if indeed they are conscious of them at all" (1985:130). Furthermore, as Gerber and other Samoan specialists have noted, it may be difficult for Samoans to express or even to admit to feelings which may be culturally disapproved. They may hypocognize them. Levy (1973) states that: "Feeling becomes associated with cultural understandings which designate the cause of the feeling and what should be done about it. Feelings are halfway stations to action and are amendable to considerable cultural manipulation." In a discussion of Tahitian emotion, knowing and culture, Levy (1984) points out that there are two kinds of "knowing"—covert (or primary) and overt (or secondary). Covert knowing is the recognition of a feeling while overt knowledge "is associated with a culturally patterned evaluation of, and response to, the feeling" (1984:220). Levy (1984:219) describes "underschematized emotional domains" as "hypocognized" while "hypercognized" refers to situations where


258 M. H. Fitzgerald' "there are a large number of culturally provided schemata for interpreting and dealing* with the emotion. Other across-site differences in the kinds of symptoms reported can be explained by different points of reference. For example, the series of physical measurements provides evidence for small weight increases among females around the time menses begins (Fitzgerald 1989) but "bloating" is only offered by females in American Samoa and Hawaii.7 Females who report bloating indicate they notice the bloating by the way clothing fits or feels in terms of comfort. ("I don't fit in my clothes, like my pants" [female in American Samoa].) Unlike more modernized females, females in rural Western Samoa rarely wear fitted clothing or clothing with stationary waistbands (e.g., shorts or slacks); they usually wear lavalava (a loose wrap-around skirt held in place with a twist at the waist). Females who wear lavalava most of the time may be less likely to notice bloating. Points of reference may also explain differences in reports of things like gastrointestinal symptoms and facial blemishes. In populations where diarrhea and skin lesions are common they may either go unnoticed or they can be attributed to other causes. Stool changes from parasites and traditional foods, such as palusami and breadfruit, and skin lesions from insect bites and infected minor cuts are common in rural Western Samoan villages.8 Differences in lifestyle may also find females using different explanations for some symptoms. Backaches are commonly reported during the health history, but only a small number of females associated backaches with menstruation. Hard physical labor and sitting for long periods (e.g., weaving mats) are more common explanations. DISCUSSION

As the increase in the number of symptoms reported as experienced coincides with increased exposure to modernization, it appears that some aspect of the moderniz- • ation process may be a significant factor. My data suggest that culture change and exposure to modernization processes and Western models of menstruation are important considerations. An exclusively biological explanation is inadequate for it can not explain the concomitant increases in the number and kind of symptoms and menstrual expressions known (Fitzgerald 1989). Nor can it account for the parallel differences seen among males. Biological and individual psychological differences might explain some of the differences in symptoms experienced, but they can not fully explain all of the across-site differences in general knowledge about menstruation or knowledge about modern topics like FMS. It appears then that while we are dealing with a biological process, the explanation for the across-site and sex differences is most likely in the realm of modernization-initiated psychological and cultural differences. Differences in lifestyle and activities of daily living which accompany modernization, including the nature of work, may be important. Not because they are associated with a change in status or level of satisfaction with life as proposed by some researchers (e.g., Martin 1988), but because they require new coping styles— different forms of adjustment and adaptation. Granted menstrual symptoms.


MENSTRUAL SYMPTOMS AMONG SAMOANS 159

whether or not they are considered signs of illness, can provide a sanctioned, if not acceptable, excuse for cultural time out. And, they can be used as "idioms of distress" (Nichter 1981). But, as I have suggested elsewhere (Fitzgerald 1984,1989), using menstrual symptoms in this way appears to be necessary primarily in societies which do not have other culturally available, acceptable, and sanctioned ways of dealing with the psychological and physical symptoms of menstruation (i.e., menstrual houses or behavioral restrictions). The structured, inflexible work week in Western societies, and the perpetual repetition of daily chores imposed by a modern lifestyle, do not offer the flexibility to step away from daily tasks, without undo attention, to address the needs imposed by menstruation. Voluntary social institutions like "menstrual leave," which is found in places like Japan, clearly do not resolve the situation (Dan 1986). In many non-Western societies the need for menstrual time out is resolved in one of two ways. Either all females, even those without menstrual distress, are restricted during menstruation or there is enough flexibility in the lifestyle so females can step away from the day-to-day world without interrupting the daily work flow or having to provide a reason to herself or to others. As I have already pointed out, this kind of flexibility is still present in rural Western Samoa. It is less often the case in more modern settings when Samoans adopt a focus on the nuclear family and live in relative isolation from extended family. Furthermore, the scarcely furnished Samoan/ale requires considerably less daily attention than a palagi (Western style) house or apartment filled with furniture and other goods. With modernization and increased employment outside the household, Samoan women begin to encounter the same restrictions of the worka-day world as other modern women. In the modern setting, the use of menstrual symptomatology as a way to gain mastery over an impersonal, inflexible environment is a viable option. There are secondary gains. I therefore suggest that differences in symptom reports are more apparent than real. The behavioral data and analysis of the menstrual symptoms indicate that most of the same symptoms occur in all three places. Modernization is accompanied, not by an increase in symptoms, but by an increase in the ability to recognize and express such symptomatology, especially affective symptoms. Exposure to modernization and modern, Western ideas about menstruation is accompanied by the acquisition of a new menstrual lexicon or vocabulary, a new set of words for talking about menstruation and menstrual feelings. It is accompanied by an increase in the knowledge of and ability to talk about internal states—an increase in the tendency and ability to "psychologize." Modernization is accompanied by a breakdown in the restraint of talking about one's self and menstruation. The girls from Samoa I know, we hardly talk about it. They kind of like back away when they hear us talk about it. But us, the girls I hang around with say: 'Oh my Gad! I got my rag today. So don't bother me today. I'm not in the mood.' (female in Hawaii)

Furthermore, with modernization there is a change towards a less stoic attitude towards menstrual feelings, especially distressful or unpleasant feelings. People learn from educational efforts, the media, and interaction with other people that it is acceptable to talk about and admit to menstrual feelings and discomforts. Rather


160 M. H. Fitzgerald than being socialized to experience menstrual symptoms as some researchers have suggested, people are socialized to recognize and express them. New medical and menstrual knowledge provide new models for dissecting feelings. Feelings which in the past may have been glossed with a single term (a term which may have subsumed much) now get expressed in many ways..What was once "tired* now becomes 'tired, irritable, lazy, etc." Both approaches describe the same entity, but one explicates the details while the other assumes or subsumes the details. One woman says she feels iva. Another says she feels lazy. And yet another says she feels tired, weak, uncomfortable, out of sorts, and doesn't want to work. The words are different—but are the feelings different? I think not. Evidence of this expanded vocabulary is also found in the across-site increase in the number and kind of menstrual expressions (Fitzgerald 1989: Chapter 6). But the differences go beyond just number and kind; there is also an increase in the use of English language terms and American expressions, and a progressive decrease in the use of Samoan terms for menstruation and menstrual symptoms. It was quite easy to categorize Samoan menstrual symptoms into a small number of categories. Many words were offered but I only needed twenty-two to describe the range of symptoms. In fact, this list can be condensed even further by using broader categories such as: pain, changes in appetite, and gastrointestinal disturbances. A review of symptoms attributed to menstruation among Western populations suggests they too can be condensed. Statements such as: "over 150 symptoms have been connected to menstruation" (Johnson 1987) are therefore misleading. One person uses the term "depressed," another uses "sad," and still another says she feels "blue." The essence of fatigue, lethargy, and tired is very much the same. Just as words like: nervous, anxious, and tense; or edema and swelling of hands and feet; are similar Sometimes words to describe menstrual feelings, while not exactly the same in meaning, grade into one another or overlap in the essence of what they are trying to convey. The terms: confusion, distractible, and forgetful are of this type. Other terms are related in other ways. Nausea, vomiting, diarrhea, and possibly abdominal cramps and decreased appetite, are all gastrointestinal symptoms which can be related as a syndrome. When several terms are available, the one that will be used depends on personal preference, context, and knowledge of vocabulary. When I speak to a professional or in a formal setting I use terms like "lethargy"; when I talk with my friends or do menstruation interviews I say "tired." Some people would never think of using a word like lethargy; for some it is not even in their vocabulary. Most of the Englishspeaking respondents know the word "menstruation" but most of them rarely use it. They more commonly use "period" or some other colloquialism. At the beginning of the menstruation interviews, the most formal part, people use menstruation and ma'imasina; when the interview became more relaxed they used period and palapala.9 Culture change also offers new frames of reference for identifying symptoms. These frames of reference include those associated with changes in the nature of work and lifestyle. The woman who is accustomed to backaches throughout the month from lifting, carrying, bending, and sitting for extended periods weaving mats is less likely to consider one backache as any different from the others,



particularly if there is no need to make a distinction (i.e., there is no reason to suspect it is a threat to her life). On the other hand, the woman who is unaccustomed to postural backaches (or headaches from working in the sun, etc.) may feel the need to search for an explanation. One of the major purposes of medicine and etiological theories—traditional or otherwise, is to explain the seemingly inexplicable (e.g., Hallowell 1963; Kleinman 1973, 1980; Foster 1976; Young 1976). Why these symptoms, these feelings, this illness? Why me? Why now? If the idea that backache and headache can be associated with menstruation is within a particular person's cultural repertoire, menstruation may be considered as an explanation. Sometimes, even without this knowledge, the experience (e.g., backache) and the event (menstruation) are so closely spaced in time that the connection is easily made, especially when the pattern is repeated time and tune again. At other times the two appear discrete, but over time, and with the knowledge that in other people they are related, a pattern is discerned. If, however, there has never been anything in the person's experience to suggest the two might be associated, the connection might never be made. If the person has never heard anyone talk about such a relationship, never read about it, the connection may never be made. There are always alternative explanations. It is even less likely that a connection will be made if the person is not inclined towards introspection. Cassara's (1987) story is not uncommon even in middle America where introspection and psychologizing are part of the cultural paradigm. For years Cassara experienced a disturbing recurring symptom complex. At first, each time the symptoms appeared she attributed them to "externals" in her life— her job, her husband. Then she began to feel she was personally responsible. She must be doing something wrong. Finally, she began to keep a journal. "I then saw the tendency to ascribe them [the symptoms] to outside events and, at the same time, the dramatic relief in both the emotional and physical symptoms the day I started menstruating'' (1987:207). Traditionally, Samoans do not focus on the "self (Shore 1982) or internal sensations (Gerber 1975,1985). They tend to be more context, situation, and relationship oriented. But, this is changing to varying degrees with the exposure to modernization. There are respondents in all three places who are very self-reflective, but this dissecting of internal states, emotions, and motivations is more common among those with greater exposure to and assimilation of American culture (i.e., lived in the U.S. or lived a more American lifestyle). I suggest that symptoms do not increase with modernization but an increase in the options to deal with them increases the tendency to give them notice. Exposure to the Western model may even be accompanied by a change in worldview, or at the very least a change in menstrual worldview. For example, stoicism is likely to occur when people feel they have no option but to endure. Until recently stoicism also dominated Western female attitudes towards menstruation. It was only when Western medicine began to offer acceptable alternatives to enduring menstrual pain (e.g., birth control pills and antiprostaglandins rather than surgery, especially surgery than would render them permanently infertile) or acquiring the stigma of a psychiatric diagnosis that women began to feel that menstrual discomfort was no longer a natural, necessary, and unavoidable part of being female. The change in attitude was further enhanced by efforts associated

162 M. H. Fitzgerald with the modem women's movement where efforts were made, especially via the media, to inform women that there were options. One result of these efforts was that menstruation went public. What was once a private, personal, female affair in the United States became a public, social and medical issue. The taboo of silence was broken. It became acceptable to talk about menstruation. It became acceptable to seek help for menstrual symptoms.


CONCLUSION This does not mean that all menstrual symptoms are universal or necessarily biological in origin. Nor does it mean that even if all females shared the same menstrual worldview that they would all have the same perception of the experience. Perceptions of menstruation and its associated symptomatology are the result of an interaction between cultural knowledge, personal experiences, biology, and personality. No two females are exactly alike on each and every one of these dimensions, and no two females will ever have exactly the same experiences. Therefore, there will always be some variation in menstrual symptom reports. Samoans themselves recognize that the menstrual experience varies from one female to another. Some of this variation must be attributed to individual psychological, biological, and environmental factors. But, while these factors help explain individual and within-site variations, they do not fully explain all of the across-site trends. As I have already noted, the across-site increase in the number of symptoms reported as experienced is accompanied by an increase in symptoms known, menstrual expressions, preparation for menarche, access to menstrual information, and the ability to identify and discuss menstrual issues. Furthermore, the same trend towards increased knowledge and ability to talk about menstruation is seen among males. While biological and psychological differences may account for some of the variation within a population, we must go beyond individual differences to account for the kinds of trends we see among Samoans. The effect of modernization, or better the exposure to modern ideas and concepts and the need to adapt to new circumstances, results, not in critical biological changes in menstruation, but changes in the psychological and cultural experience. This is not, however, a total change. The Samoan menstrual experience becomes, with modernization, more like that seen in the West, but it is not necessarily exactly the same. It is more an assimilation and/or an incorporation of the modern with the traditional, similar to that seen when different medical systems are juxtaposed. People learn, and even accept, Western biological explanations of menstruation and menarche but they do not always discard all of the old beliefs, such as the importance of coitus for initiating and maintaining menstrual cycles. For example, based on a school-associated exposure to a biological model of menstruation, one male in Hawaii believes all females begin to menstruate as teenagers irregardless of whether or not they have ever had coitus, but he also believes that menarche will happen earlier than it would naturally if she has sex. People accept and use new ways to talk about the feelings and behaviors associated with menstruation without necessarily changing their attitude towards men-



struation. Few Samoans have adopted what American writers have called a "negative" attitude towards menstruation. At its worst, menstruation is a "fuss and bother"; at its best, it is a welcomed event which signifies the woman is healthy, normal, not pregnant but able to become pregnant. We cannot make the assumption that menstrual symptoms are grounded in disease, illness, or sickness, or that.they represent real or perceived pathology. Samoans rarely view menstruation or its symptoms as disease or illness. On the other hand, we also cannot assume that all menstrual symptoms are nonpathological. Nor can we assume that even if menstrual symptoms are normal and natural that they are not distressful. Menstrual cycle research into the etiology, distribution, and evaluations of whether or not menstrual symptoms constitute pathology must take into account cultural differences in the evaluation, recognition, and expression of such symptoms. This includes not only the differences among different ethnic groups, but cultural differences within Western, Caucasian populations. Too often researchers assume that all white, middle-class, Caucasian Americans share exactly the same culture. Differences within these populations go beyond differences in religious affiliation and socioeconomic class. We must not forget the lesson in works of people like Zborowski (1952,1969) and Zola (1966,1979). There are, even among Caucasian Americans, cultural differences in what constitutes a symptom; how it is identified, evaluated, and expressed; and whether or not it will be associated with some kind of help-seeking behavior. The information presented here, and covered in more detail in Fitzgerald (1989), suggest that culture plays a significant role in the differences in the distribution and reports of menstrual symptoms. Clearly, explanations of menstrual symptomatology must go beyond the bibgenic, psychogenic, or sociogenic. I am not advocating that such explanations simply be replaced with cultural explanations. Rather, explanations, even explanations for white, middle-class American populations, must consider the interaction of all of these.

ACKNOWLEDGMENTS This paper is based on my Ph.D. dissertation: Modernization and the Menstrual Experience Among Samoans (Fitzgerald 1989). Research was conducted while I was a research associate with the Samoan Stress and Health Project directed by Joel M. Hanna and funded by NIMH (Grant number MH40675). I would like to express my appreciation to Joel M. Hanna and Jay and Christina Pearson for all their assistance and support. I would also like to thank Richard Lieban, Alan Howard, Lawrence Greene and the three anonymous reviewers who were gracious enough to read and offer helpful comments on earlier drafts of the manuscript. Most of all I would like to say fa'afetai tele lava to all the respondents, research assistants, and others associated with the three Samoan communities for sharing so much with me.

NOTES 1. Menstrual distress is generally divided into that which occurs before the onset of menstrual flow (premenstrual tension or syndrome) and that which occurs after the onset of flow (dysmenorrhea). Dysmenorrhea is generally used to refer to painful menses, but can include an array of symptoms


164

M. H. Fitzgerald

including: pelvic cramps, backache, headache, irritability, malaise, depression, fatigue, etc. In other words, much the same symptomatology as that associated with premenstrual syndrome (PMS). As these two phases: 1) are etic categories or culture specific (Johnson 1987), 2) share symptomatology which often does not demonstrate any significant qualitative or quantitative change with the onset of flow, and 3) may not be recognized by all women, menstrual distress tends to be the more salient term and allows discussions of symptomatology to utilize information from a wider variety of studies. 2. See Social Science and Medicine, volume 21, number 6 (1985) for some of the latest contributions to the menstrual pollution literature. 3. The term symptomatology carries a less heavy implication of pathology. It is used here to mean any change in a person's physical or mental state, whether or not it is recognized by others, and whether or not it represents real or perceived pathology. 4. Most of the interviews in Western Samoa were conducted primarily in Samoan while all of the rest were primarily in English. All Samoan language interviews were done with the assistance of two Samoan research assistants. One female assisted with all female interviews and one male helped with all male interviews. 5. John Mayer, a Samoan language specialist who has spent many years working with Samoans, and I have discusssed the apparent paradox in the use of ma'i to refer to both menstruation and pregnancy. Kinloch (1985) claims Samoans think of pregnancy as illness, but our experiences suggest Samoans consider neither menstruation nor pregnancy as illness. Both situations are considered natural and normal and as signs of health—but both are also associated with changes or differences from the usual state. Ma'i appears to be used in these and other situations (e.g., ma'imanatu [lovesickness, homesickness]) only to mark a difference—a difference which may include (and may even emphasize) emotional changes. Detailed discussions of Samoan menstrual expressions can be found in Fitzgerald (1989) and Shore (1981). 6. An anonymous reviewer pointed out that paie (lazy, sloth, sluggish [Milner 1976]), better describes lazy as a character trait. I think both terms illustrate the point that lazy refers to something more than physical tiredness. 7. Weekly measurements included: weight, hemoglobin and hematocrit, blood pressure, and circumference of chest, waist, hips, and ankles. There were no other noteworthy differences in the physical measurements over the menstrual cycle or between males and females for a one month period (Fitzgerald 1989). 8. Palusami, a dish usually served on Sundays and holidays, is made from taro leaves, coconut milk, and seawater. 9. Shore (1981:198) reports that palapala (dirt or mud) and ele'ele (dirt) are used in chiefly respectful address to refer to blood, "but only when it flows uncontrolled from the body." According to Shore, menstrual blood represents pollution because it is not subject to social control. My informants in both Western and American Samoa insist that palapala as "dirt" and palapala as "menses" are: "Different words. Same spelling but different meanings." This is a reasonable explanation because the Samoan language has many homonyms. In my experience, palapala is clearly used as a "common" word for menstruation much as Americans and Samoans in American Samoa and Hawaii use the word "period" (Fitzgerald 1989). The long held assumption that in Polynesia menstruation represents pollution has recently been challenged (Hanson 1982; Thomas 1987; Fitzgerald 1989) and is inconsistent with my data from Samoa.

REFERENCES CITED Ablon, J. 1971 Bereavement in a Samoan Community. British Journal of Medical Psychology 44:329-337. Asso, D. 1983 The Real Menstrual Cycle. New York: John Wiley & Sons. Buckley, T., and A. Gottlieb 1988 A Critical Appraisal of Theories of Menstrual Symbolism, in Blood Magic The Anthropology of Menstruation. T. Buckley and A. Gottlieb, eds. Pp. 1-50. Berkeley: University of California Press.


MENSTRUAL SYMPTOMS AMONG SAMOANS 165 Cassara, V. 1987 A View from the Top of a Consumer Organization. In Premenstrual Syndrome: Ethical and Legal Implications in a Biomedical Perspective. B. E. Ginsburg and B. E Carter; eds. Pp. 207221. New York: Plenum Press. Colligan, S.,and M. Ethier 1988 PMS: Medical or Cultural Anomaly? Paper presented at the Annual Meetings of the American Anthropological Association, Phoenix, AZ, November 16-20. Dan, A. 1986 The Law and Women's Bodies: The Case of Menstruation Leave in Japan. In Culture, Society, and Menstruation. V. L. Olesen and N. E Woods, eds. Pp. 1-14. Washington: Hemisphere Publishing Corp. Douglas, M. 1966 Purity and Danger. An Analysis of Concepts of Pollution and Taboo. Boston: Routledge & Kegan Paul. Fitzgerald, M. H. 1984 A Review and Critique of the Literature on Menstrual Beliefs. Master's Thesis, Department of Anthropology, University of Hawaii, Honolulu, HI. 1985 Is Menstruation Inherently Sexual? Paper presented at the 6th Conference of the Society for Menstrual Cycle Research, Galveston, TX. 1989 Modernization and the Menstrual Experience Among Samoans, Ph.D. dissertation. Department of Anthropology, University of Hawaii, Honolulu. Fitzgerald, M. H., and A. Howard in press Aspects of Social Organization in Three Samoan Communities. Pacific Studies. Foster, G. M. 1976 Disease Etiologies in Non-Western Medical Systems. American Anthropologist 78:773-781. Franco, R. W. 1985 Samoan Perceptions of Work: Moving Up and Moving Around. Ph.D. dissertation, Department of Anthropology, University of Hawaii, Honolulu. Gerber, E. R. 1975 The Cultural Patterning of Emotions in Samoa. Ph.D. dissertation. Department of Anthropology, University of California at San Diego. 1985 Rage and Obligation: Samoan Emotion in Conflict. In Person, Self, and Experience: Exploring Pacific Ethopsychologies. G. M. White and J. Kirkpatrick, eds. Pp. 121-182. Berkeley: University of California Press. Good, B. and M-J. Delvecchio Good 1981 The Meaning of Symptoms: A Cultural Hermeneutic Model for Clinical Practice. In The Relevance of Social Science for Medicine. L. Eisenberg and A. Kleinman, eds. Pp. 165-96. Dordrecht, Holland: D. Reidel Publishing Co. Hallowell, A. I. 1963 Ojibwa World View and Disease. In Man's Image in Medicine and Anthropology. I. Gladston, ed. Pp. 258-315. New York: International Universities Press. Hanson, F. A. 1982 Female Pollution in Polynesia? Journal of the Polynesian Society 91(3):335-381. Hecht, J. A., M. Orans, and C. R. Janes 1986 Social Settings of Contemporary Samoans. In The Changing Samoans: Behavior and Health in Transition. P. T. Baker, J. M. Hanna, and T. S. Baker, eds. Pp. 39-62. New York: Oxford University Press. Janiger, O., R. Riffenburg, and R. Kersch 1972 Cross Cultural Study of Premenstrual Symptoms. Psychosomatics 13(4):221-235. Janzen, J. M. 1978 The Quest for Therapy. Medical Pluralism in Lower Zaire. Berkeley: University of California Press. Johnson, T. M. 1987 Premenstrual Syndrome as a Western Culture-Specific Disorder. Culture, Medicine and Psychiatry 11:337-356.


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M. H.

Fitzgerald

Kinloch, E J. 1985 Midwives and Midwifery in Western Samoa. In Healing Practices in the South Pacific. C. D. F. Parsons, ed. Honolulu: The Institute for Polynesian Studies. Weinman, A. 1973 Medicine's Symbolic Reality: On a Central Problem in the Philosophy of Medicine. Inquiry 16:206-213. 1980 Patients and Healers in the Context of Culture: An Exploration of the Borderland between Anthropology, Medicine, and Psychiatry. Berkeley: University of California Press. 1982 Neurasthenia and Depression: A Study of Somatization arid Culture in China. Culture, Medicine and Psychiatry 6:117-190. Koeske, R. D. 1983 Lifting the Curse of Menstruation: Toward a Feminist Perspective on the Menstrual Cycle. Women & Health 8(2/3):l-16. Levy, R. I. 1973 Tahitians: Mind and Experience in the Society Islands. Chicago: University of Chicago Press. 1984 Emotion, Knowing, and Culture. In Culture Theory: Essays on Mind, Self, and Emotion. R. A. Shweder and R. A. Levine, eds. Pp. 214-239. Cambridge: Cambridge University Press. Mackenzie, M. 1978 More North American than the North Americans: Medical Consequences of Migrant Enthusiasm, Willing and Unwilled. Modem Medicine and Medical Anthropology 359:109-115. Markoff, R. A., and J. R. Bond 1974 The Samoans of Hawaii. In People and Cultures in Hawaii. W.-S. Tseng, J. F. McDermott, Jr., and T. W. Maretzki, eds. Pp. 81-89. Honolulu: Department of Psychiatry, University of Hawaii School of Medicine. Martin, E. 1987 The Woman in the Body: A Cultural Analysis of Reproduction. Boston: Beacon Press. 1988 Premenstrual Syndrome: Discipline, Work, and Anger in Late Industrial Societies. In Blood Magic: The Anthropology of Menstruation. T. Buckley and A. Gottlieb, eds. Pp. 161-185. Berkeley: University of California Press. Mead, M. 1949 Coming of Age in Samoa. New York: Mentor Books. (1st edition William Morrow 1928) Mechanic, D. 1963 Religion, Religiosity, and Illness Behavior: The Special Case of the Jews. Human Organization 22(3):202-208. 1969 Illness and Cure. In Poverty and Health: A Sociological Analysis. J. Kosa, A. Antonovsky, and I. K. Zola, eds. Pp. 191-214. Cambridge, MA: Harvard University Press. 1972 Social Psychological Factors Affecting the Presentation of Bodily Complaints. New England Journal of Medicine 286(21):1132-1139. 1978 Effects of Psychological Distress on Perceptions of Physical Health and Use of Medical and Psychiatric Facilities. Journal of Human Stress December:26-32. Milner, G. B. 1976 Samoan Dictionary. Oxford: Oxford University Press. (1st edition 1966) Nichter, M. 1981 Idioms of Distress: Alternatives in the Expression of Psychological Distress: A Case Study for South India. Culture, Medicine and Psychiatry 5(4):378-408. Paige, K. E. 1973 Women Learn to Sing the Menstrual Blues. Psychology Today September:41-46. Parlee, M. B. 1973 The Premenstrual Syndrome. Psychological Bulletin 83(6):454-465. 1982 The Psychology of the Menstrual Cycle: Biological and Psychological Perspectives. In Behavior and the Menstrual Cycle. R. C. Friedman, ed. Pp. 77-99. New York: Marcel Dekker. Rubinow, D. R., and P. Roy-Byrne 1984 Premenstrual Syndrome: Overview From a Methodological Perspective. American Journal of Psychiatry 141(2):163-172.


MENSTRUAL SYMPTOMS AMONG SAMOANS 167 Scambler, A. and G. Scambler 1985 Menstrual Symptoms, Attitudes and Consulting Behavior. Social Science and Medicine 20(1):1065-1068. Shore, B. 1981 Sexuality and Gender in Samoa: Conceptions and Missed Conceptions. In Sexual Meanings: The Cultural Construction of Gender and Sexuality. S. B. Ortner and H. Whitehead, eds. Pp. 192-215. Cambridge: Cambridge University Press. 1982 Sala'ilua: A Samoan Mystery. Cambridge: Cambridge University Press. Siegel, J. 1986 The Effect of Culture on How Women Experience Menstruation: Jewish Women and the Mikvah. Women & Health 10(4):63-74. Sriowden, R., and B. Christian 1983 Patterns and Perceptions of Menstruation: A World Health Organization International Collaborative Study in Egypt, Pakistan, Philippines, Republic of Korea, United Kingdom and Yugoslavia. New York: St. Martin's Press. Spradley, J. P. 1979 The Ethnographic Interview. New York: Holt, Rinehart and Winston. Stoeckle, J. D., and A. J. Barsky 1981 Attributions: Uses of Social Science Knowledge in the 'Doctoring' of Primary Care. In The Relevance of Social Science for Medicine. L. Eisenberg and A. Kleinman, eds. Pp. 223-40. Dordrecht, Holland: D. Reidel Publishing Co. Taber, C. W. 1963 Taker's Cyclopedic Medical Dictionary. 9th Edition. Philadelphia: E A. Davis Company. Thomas, N. 1987 Unstable Categories: Tapu and Gender in the Marquesas. Journal of Pacific History 22(3):123138. Turner, V. 1968 The Drums of Affliction. Oxford: Claredon Press and the International African Institute. Waxier, N. E. 1981 The Social Labeling Perspective on Illness and Medical Practice. In The Relevance of Social Science for Medicine. L. Eisenberg and A. Kleinman, eds. Pp. 283-306. Dordrecht, Holland: D. Reidel Publishing Co. Webster's New Collegiate Dictionary 1977 Springfield, MA: G. & C. Merriam Company. White, P. A., and B. G. Wildman 1986 Factors Related to Medical Help-Seeking in Women with Menstrual Discomfort. Behavior Research and Therapy 24(4):471-474. Woods, N. F. 1985 Relationship of Socialization and Stress to Perimenstrual Symptoms, Disability, and Menstrual Attitudes. Nursing Research 34(3):145-149. nd Women's Health Survey: Daily Health Diary. Seattle: School of Nursing, University of Washington. Woods, N. F., A. Most, and G. D. Longenecker 1985 Major Life Events, Daily Stressors, and Perimenstrual Symptoms. Nursing Research 34:263267. Young, A. 1976 Some Implications of Medical Beliefs and Practices for Social Anthropology. American Anthropologist 78(1):5-24. Zborowski, M. 1952 Cultural Components in Responses to Pain. Journal of Sodal Issues 8:16-30. 1969 People in Pain. San Francisco: Jossey-Bass. Zola, I. K. 1966 Culture and Symptoms: An Analysis of Patients' Presenting Complaints. American Sociological Review 3:615-630. 1979 Culture and Symptoms—An Analysis of Patients Presenting Complaints. In Cultural Diversity in Health and Illness. R. E. Spector, ed. Pp. 84-105. New York: Appleton-Century-Crofts.

Religious influence on menstrual attitudes and symptoms.

Menstrual symptoms in women with pelvic endometriosis.

Acute intermittent porphyria symptoms during the menstrual cycle.

Amenorrhoea and other menstrual symptoms in student nurses.

Physical symptoms and depressive symptoms among individuals with HIV infection.

Smoking- and menstrual-related symptomatology during short-term smoking abstinence by menstrual phase and depressive symptoms.

Menstrual cycle effects on psychological symptoms in women with PTSD.

A study of minor psychiatric and physical symptoms during the menstrual cycle.

The effect of cinnamon on menstrual bleeding and systemic symptoms with primary dysmenorrhea.

The Relationship of Premenstrual Syndrome Symptoms with Menstrual Attitude and Sleep Quality in Turkish Nursing Student.

Acute Pain and Depressive Symptoms: Independent Predictors of Insomnia Symptoms among Adults with Sickle Cell Disease.

Burnout in psychiatric nursing: examining the interplay of autonomy, leadership style, and depressive symptoms.

Characterizing the longitudinal relations between depressive and menstrual symptoms in adolescent girls.

Relief of menstrual symptoms and migraine with a single-tablet formulation of sumatriptan and naproxen sodium.

Depressive symptoms and cardiovascular burden-related mortality among the aged.

Borderline Personality Disorder Symptoms in College Students: The Complex Interplay between Alexithymia, Emotional Dysregulation and Rumination.

The interplay between individual social behavior and clinical symptoms in small clustered groups.

Anxiety and Depression Symptoms Among Farmers: The HUNT Study, Norway.

Subjective depressive symptoms and metabolic syndrome among the general population.

Predicting psychiatric symptoms among homeless people.

mGlu₅-GABAB interplay in animal models of positive, negative and cognitive symptoms of schizophrenia.

Acute Stress Symptoms Among US Ocean Lifeguards.

Stress-related symptoms among dental hygienists.

Primary Dysmenorrhea and Menstrual Symptoms in Indian Female Students: Prevalence, Impact and Management.