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The meanings of menopause a
Patricia J. Estok RN, PhD, FAAN & Richard O'Toole PhD
b
a
Professor and Director, Parent Child Nursing, School of Nursing , Kent State University , Kent, Ohio, 44242 b
Department of Sociology , Kent State University , Kent, Ohio Published online: 14 Aug 2009.
To cite this article: Patricia J. Estok RN, PhD, FAAN & Richard O'Toole PhD (1991) The meanings of menopause, Health Care for Women International, 12:1, 27-39, DOI: 10.1080/07399339109515924 To link to this article: http://dx.doi.org/10.1080/07399339109515924
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THE MEANINGS OF MENOPAUSE Patricia J. Estok, RN, PhD, FAAN School of Nursing Kent State University Kent, Ohio
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Richard O'Toole, PhD Department of Sociology Kent State University Kent, Ohio
Multiple meanings have been assigned to menopause and to women experiencing menopause. Meanings are not inherent in reality but are assigned by humans in response to interaction. Once meanings are assigned to entities, they become coercive and influence interactions. Freidson's (1988) theoretical framework includes the imputation of responsibility, legitimacy, and seriousness to a deviance or illness and provides the basis for an analysis of the various meanings of menopause that are found in the literature. This analysis is concerned with the social, political, economic, and health care consequences of the assigned meanings of menopause for women.
Meanings are the "linguistic categories that make up a participant's view of reality and with which they define their own and others' actions" (Lofland & Lofland, 1984, p. 71). Meanings attached to menopause influence how women respond to menopause, how others respond to women they believe are experiencing menopause, and the kind of health care the women receive. Our purpose in writing this article is to describe and clarify some of the meanings that have been assigned to menopause and discuss how they influence health care provided to women. CONCEPTUAL FRAMEWORK Meanings are applied to objects and individuals on the basis of this interaction; therefore, meanings are different for persons with different sociocultural backgrounds and different life experiences. Health Care for Women International, 12:27-39, 1991 Copyright © 1991 by Hemisphere Publishing Corporation
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Basic assumptions concerning meanings are that they are (a) not inherent in reality; (b) basic to psychological functioning, communication, and social interaction; (c) constructed and used for social, political, and economic advantage; (d) a source of conflict when different meanings are ascribed to a single entity; (e) coercive and influence interactions and change in response to changing situations; and (f) determinants of illness behavior and health care provider responses. An important concept in symbolic interaction theory is W. I. Thomas's (Thomas & Thomas, 1928) famous statement illustrating the significance of the subjective in social interaction: "if men define situations as real, they are real in their consequences" (pp. 565-567). Thus, if menopause is assigned a certain meaning and behavior is enacted based on that meaning, the consequences are real regardless of whether the meaning is "right." Individuals will react to menopause and the women experiencing it in terms of the meaning they impute to it. We used Freidson's (1988) work to help us understand the meanings that may influence responses to menopause. Freidson analyzed the social construction of illness and explained the variable relationship between the "biological reality" and the "social reality" of the sick role. There may or may not be a close relationship between individuals' biological condition and the social meaning assigned to them, the sick role. As defined by the First International Conference on Menopause in 1976, menopause is the final menstrual period (Utian, 1977). Our analysis will indicate, however, that as with many biological events, social meanings of menopause have implications that range far beyond biological change. Freidson (1988) used the symbolic interaction concept of deviance, that there is nothing inherent in an act or attribute that leads it to be classed as deviant. Whether something is viewed as normal or deviant depends on the reaction of the perceiver. Thus, for many, menopause would be seen as "normal"; however, others may view it as deviant. Freidson isolated three concepts that he theorized would be useful in classifying types of deviance and then types of illness: (a) imputation of responsibility, (b) imputation of legitimacy, and (c) imputation of seriousness. The imputation of responsibility is a key concept in accounting for different reactions to individual attributes or behavior. When persons are perceived as sick, they are not held responsible for their behavior and they elicit a different response from others than if they are judged responsible for deviant behavior. Deviance for which the person is held responsible is shown in the second column of Table 1. If persons are judged responsible for their deviant behavior, they are subject to correction or punishment because the behavior is perceived to be under their
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Table 1. Freidson's Sociological Types of Deviance Individual not held responsible Imputed seriousness
Minor deviation (primary deviance)
Serious deviation (secondary deviance)
Individual held responsible
Illegitimate (stigmatized)
Conditionally legitimate
Unconditionally legitimate
Cell 1
Cell 2
Cell 3
Cell 4
Minor sanctioned offense
Minor stigmatized illness
Minor acute illness
Minor chronic illness
CellS
Cell 6
Cell 7
Cell 8
Serious sanctioned offense
Serious stigmatized illness
Serious acute illness
Serious chronic illness
Note. This table is a reorganization of Freidson's (19881, pp. 231-234) tables to provide theoretical types of deviance.
to
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control. Some attributes or behaviors imputed to menopause are thought to be under a woman's control; therefore, she may be subjected to ostracism, threat of punishment, or some other type of sanction to control her "deviance." As shown in Table 1 Freidson (1988) then distinguished three kinds of legitimacy: a) conditional legitimacy, the deviant being temporarily exempted from normal obligations and gaining some extra privileges on the condition that he seek the help necessary to rid himself of his deviance; b) unconditional legitimacy, the deviant being exempted permanently from normal obligations and obtaining additional privileges in view of the hopeless character imputed to his deviance; and c) illegitimacy, the deviant being exempted from some normal obligations by virtue of deviance for which he is not held technically responsible, but gaining few if any privileges and taking on some especially handicapping new obligations, (p. 238) In Freidson's (1988) words, imputed seriousness distinguishes the magnitude of societal reaction to deviance, the consequences of which are either to leave the offender in this "normal" role, somewhat tempered and qualified by nondeviant attributes (primary deviance) or to push him into a new, specifically deviant role (secondary deviance), (p. 232) There is a tendency for the identity and life patterns of the individual pushed into a deviant role to center around the deviance and for the person to become known largely in terms of this deviant master status. Individuals may become known in their deviant status of "murderer" or "heart attack victim," but it is unlikely that "parking violator" or "cold victim" will turn into a master status for the person (Freidson, 1988). It is important to recognize that the assigned master status of "heart attack victim" may result in coworkers and employers excluding a person from interaction or not considering the person for a promotion. Although the types of deviance in Freidson's (1988) model appear as static categories, he specifically recognized that health and illness are dynamic processes. Thus, the career of a problem can be traced as its meaning shifts from cell to cell in Table 1. The typology also explicitly incorporates conflict over meanings. Individuals, organizations, or professions hope to advance their meanings of menopause over others (McCrea, 1983; Connors, 1985). Thus, some meanings will have strong backing from groups such as the women's movement, sectors of organized medicine, or drug companies.
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The goal of this analysis is not to describe current beliefs concerning menopause or to show the prevalence of one meaning of menopause over others. Our goal is to show the utility of Freidson's (1988) formulations in theoretically analyzing the types of meanings ascribed to menopause and to discuss the implications of the various ascriptions to the responses that are made to menopause and to the women who are experiencing it. Because the personal meanings of menopause influence health assessment and interventions received by women, it is important that health care providers understand the meanings of menopause and their consequences for women. Such understanding can assist women and their families in dealing with problems raised by competing definitions and can serve as a basis for advocating health care policy for women. MEANINGS OF MENOPAUSE Meanings of menopause were collected through an extensive review of the literature and personal research (Estok, 1981). The search revealed that the meanings Freidson (1988) identified have been widely used in different cultures, over historical time, and by different social groups within the same culture and time period, including the present. Meanings as they appeared in the literature were placed in the normal or nondeviant category or, if possible, assigned to one of the cells in Table 1. First, we describe meanings that portray menopause as natural and normal. Then we review meanings in which menopause is viewed as a breach of social norms or a crime and is subject to sanction. Finally, we consider meanings in which menopause is perceived according to various types of illness: stigmatized, conditionally legitimate, and unconditionally legitimate. Menopause as Natural and Normal Feminists in the United States have advocated that menopause is a natural process of aging and that most women pass through it with minimum difficulty (MacPherson, 1981; McCrea, 1983). Their position is a refutation of the disease model of menopause that they see as another example of menstrual and menopausal myths that have been used to control and exploit women. Meanings recorded by Estok (1981) reflect this view, for example, that it is "just a natural thing" and that it is "a natural stage of life." Researchers have presented cross-cultural data to support the generalization that cultures that give special privileges to the aged or to women beyond menopause do not have women reporting
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menopausal syndrome experiences (Bart, 1967; Griffin, 1977; Skultans, 1970). For example, Griffin (1977) reported a saying of the Marias about menopause—"as it appears, so it disappears"—an illustration of the normal, nondeviant point of view. Intrasocietal differences in menopause responses have also been recorded (Beyene, 1986; Estok, 1981; Jaszmann, vanLith, & Zoat, 1969). More recent research, however, calls these findings into question (Muhlenkamp, Waller, & Bourne, 1983). Thus, nonequivocal conclusions are impossible at this time because of the paucity of cross-cultural data on this complex biocultural phenomenon (Beyene, 1986). Data reflect neglect of menopause by anthropologists, sampling bias, and a number of measurement problems (Davis, 1986) that equivocate both the interpretation of specific research results and the comparison of different studies (Kaufert & Syrotuik, 1981; Lock, 1986). The results of research, then, are confusing to those searching for the "real" meaning of menopause. Menopause as Deviant If observers believe that a woman who is experiencing menopause has control over (is responsible for) the "impatience and irritability" that is attributed to "that age," the woman may be subject to sanction and loss of social interaction by coworkers and others if she continues such behavior. It is important to realize that a number of symptoms thought to be associated with menopause are believed by some to be subject to control (e.g., nervousness, irritability) or so minor that a person should "keep them to themselves and not bother others." As shown in Cell 1 of Table 1, the woman previously described would be placed in this category and would be held responsible for a minor deviation. Freidson's (1988) theory would have one understand that the strength of the reaction may result in the menopausal woman being pushed into a major deviant status (Cell 5). The mental illness that was called involutional melancholia was associated with women, particularly at menopause (Gallagher, 1980). Lay persons using the term crazy to characterize middle-aged women may feel that persons should be "sent away" as punishment for behavior that is basically under their control, for which they are held responsible, and thus be punished (Freidson, 1988). Some women still report being concerned about "losing their mind" at the time of menopause. Menopause as Illness Meanings of menopause are also influenced by the imputed legitimacy of it as an illness. As indicated in Table 1, menopause may be
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imputed to be conditionally legitimate, unconditionally legitimate, or illegitimate (stigmatized). Meanings of menopause are compared with the examples of illness that Freidson (1988) used to illustrate his conceptual distinctions. His examples are those that he judged would have been imputed by middle-class Americans around the time of his analysis. This is important to remember as imputation is considered to be a process; that is, changes or sequences in meanings of menopause develop as women and others attempt to organize and reorganize their perceptions of menopause and to manage it. Illegitimate (Stigmatized)—Cells 2 and 6
Goffman's (1963) notion of stigma—a societal reaction that "spoils" normal identity—is incorporated within this column of Table 1. Stigma is peculiar. Although persons are not held responsible for their behavior, they are treated somewhat like a responsible "bad" person. Many of the ordinary privileges of social life are denied to the stigmatized. There are many examples of stigmatized meanings of menopause: In 1977, Jane Byrne (Mayor of Chicago) came to the public's attention when she spoke out against political corruption in the city. It was reported in the press that some of her opponents explained the attack on the political machine as merely being due to the "change of life." (Perlmutter & Bart, 1980, p. 187) Thus, Mayor Byrne was a '"discreditable" person or one whose judgment was not to be trusted because she was menopausal. As a woman's behavior is viewed as more serious she may be shunted into deviant roles, that is, have barriers erected to her participation in some roles: If you had an investment in a bank, you wouldn't want the president of your bank making a loan under these raging hormonal influences at that particular period. Suppose we had a President in the White House, a menopausal woman President, who had to make the decision on the Bay of Pigs. . . . (Paige, 1973, p. 44) Further support for the stigmatization of menopause came from McKinlay and McKinlay (1973) in their influential review of the literature on menopause. They concluded that "menopause remains a stigma, a symbol of decrepitude and decay" (p. 181). In 1981, MacPherson concurred with earlier suggestions regarding the stigmatized meaning of menopause with the statement, "no female function has been so degraded, dreaded, and unmentionable as this final phase of the reproductive cycle" (p. 95).
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Conditionally Legitimate—Cells 3 and 7
In Cell 3 of Table 1, Freidson (1988) used the example of a cold to show how middle-class Americans might respond to an illness of this theoretical type. Women who use this meaning of menopause might discuss their symptoms with a family member or a friend and try a treatment they suggest. One woman known to us described how she used an ice bag on her neck to relieve a headache she attributed to menopause because a friend had found this treatment effective. A trip to a physician for estrogen replacement therapy (ERT), in which the patient takes the prescribed medication and "gets well," may be viewed as a minor Cell 3 problem. The physician's reaction can be based on meanings that could be placed in either Cell 3 or Cell 7, depending on the degree of imputed seriousness. The physician may view menopausal symptomatology as a psychological problem that could be treated with brief counseling and perhaps a tranquilizer or as a biophysiological problem that estrogen can cure. Symptoms could also be disregarded or forgotten. There is also a possibility for the amplification of the deviance creation process to occur and for the meaning of menopause to move toward Cell 7 as a serious physical or psychological problem. Furthermore, a person who is being treated for a minor psychological problem may be reacted to in terms of a serious deviation by others who perceive any mental health therapy as an indicator of serious pathology. Some mental problems are stigmatized (Cell 2 or 6) by some individuals. The reaction to menopause as an example of a "deficiency disease," however, is the meaning that has caused the most controversy over menopause and its treatment in recent years (MacPherson, 1981; McCrea, 1983; Kaufert & Gilbert, 1986). Through research, menopause is traced as another example of the medicalization of deviance. The social construction of menopause as a deficiency disease is traced to Robert A. Wilson (1966), a gynecologist, who first promoted ERT. McCrea's (1983) analysis indicated that Wilson claimed that the "youth pill" could avert 26 symptoms "including hot flashes, osteoporosis, vaginal atrophy . . . , sagging and shrinking breasts, wrinkles, absentmindedness, irritability, frigidity, depression, alcoholism, and even suicide" (p. 113). Menopause has been described as threatening loss of the "feminine essence" and menopausal women have been described as "living decay" (Reuben, 1969). McCrea (1983) noted that "the disease label is not neutral. This label decreases the status and the autonomy of the patient while increasing the status and power of the physician" (p. 113). Reissman (1983) argued that both physicians and women have contributed to this process. She explained that women have collaborated in medicalization "because of
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their own needs and motives, which in turn grow out of the classspecific nature of their subordination" (pp. 3-4). Kaufert and Gilbert (1986) disputed the medicalization of menopause and stated that compared with childbirth menopause has not been medicalized to any great extent. In 1989, research findings on estrogen's ability to prevent osteoporosis made the deficiency label of menopause paramount. Controversy over ERT has social and economic overtones and has caused concern for many women (Cali, 1984; National Institute on Aging, 1983; Stampfer et al., 1985; Wingo, Layde, Lee, Rubin, & Ory, 1987). Although patient package inserts warning of cancer and other risks are now included with each estrogen and progestin prescription, the risks of not taking estrogen (osteoporosis) have altered the perceptions of many women and health care providers. Furthermore, the development of parenteral estrogen products and the use of progestins with ERT may alter the meaning ascribed to such products by women and others (Chetkowski et al., 1986; Judd, 1987; MacDonald, 1981; Nichols, Schenkel, & Benson, 1984). This may mean that medicalization of menopause will be accelerated. Unconditionally Legitimate—Cells 4 and 8
Meanings of menopause that include concepts of chronic illness or disability are in this column of Table 1. Freidson (1988) noted that "some attributes defined as illness, impairment, or deficiency remain merely that—an idiosyncrasy of the person, adjusted to by others without any special problems or expectation that he seek treatment" (p. 236237). In such instances the granting of legitimacy is unconditional. In the case of the minor type, Freidson used pockmarks as an example along with lumbago, rose fever, and the "sickly" woman. The sickly woman meaning needs little elaboration because of the extensive use of this typification. If it is a minor problem, a few minor privileges may be gained and a few obligations may be relinquished. If a woman was to make more serious demands, however, or if reactions become more serious, her rights and obligations would be changed. The sickly woman meaning would cease to be an idiosyncrasy and words like disabled or invalid might be used. Finally, when the condition is held to be so serious that nothing can be done, then chronically sick or dying roles may occur. Griffin (1977) reported that among the rural Irish "it is commonly believed that the menopause can induce insanity; in order to ward it off, some women have retired from life in their midforties and, in at least three contemporary cases, have confined themselves to bed until death years later" (p. 50).
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SIGNIFICANCE OF MEANINGS OF MENOPAUSE Two points deserve elaboration here: (a) menopause happens to women and (b) conflict may exist over meanings of menopause in the woman's social network and in society.
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It Happens to Women Meanings of menopause cannot be understood apart from the larger patterns of the gender system in our society. As Schur (1984) noted, recognition of deviance depends not so much on the specific act but on the basic kind of person the actor is assumed to be. The interpretation of acts and the attribution of psychological states, then, are as heavily influenced by gender as they are by social and ethnic stereotypes. Schur (1984) called attention to the fact that women are highly vulnerable to being judged "out of place" because there are so many restrictions on female behavior. The attribution of emotional disturbance is present in the background for women as a way of both devaluing what they say or do and as an implicit threat to control their behavior. Such attribution seems to center particularly around the female reproductive system: menstruation, pregnancy, childbirth, and menopause. McCrea (1983) isolated four themes included in medical definitions of menopause: "a) women's potential and function are biologically destined; b) women's worth is determined by fecundity and attractiveness; c) rejection of the feminine role will bring physical and emotional havoc; d) aging women are useless and repulsive" (p. 111). Conflict over Meaning Analysis of political and economic aspects of the social construction of meanings and conflict between meanings is basic to a holistic approach to the health care of women. Such analysis must be incorporated into decisions influencing social and health care policy. It is interesting to see how various constructors and champions of meanings have selected a particular biological, psychological, or social level of analysis to the neglect of the other levels of analysis that might be used to give meaning to menopause (Voda, Dinnerstein, & O'Donnell, 1982). For example, as noted, the deficiency disease model made biology destiny. Although biological factors cannot be denied, no one seems to have asked, "What aspects of the menopausal syndrome might be a realistic reaction to the situations in which middle-aged women seem to find themselves?" Instead, researchers gave exclusive focus to the psychological level and asked, "Where did the woman go wrong?" They de-
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nied that either social, structural, or biological variables were important. The feminists' position, in conflict with the medical biological model, according to Posner (1979, p. 189), has "been led into the ideological trap of denying their own hormones" and implying that menopause is only a socially constructed phenomenon. This seems to be another example of the all-or-nothing problem. At any rate, many proponents of meanings are guilty of treating women as a category. They believe that if some women have a particular menopausal symptom, then all women do. According to this view, all women have all problems. Or if some women have no problems with menopause, then all women have no problems or, at least, no problems of any real consequence. Science has, until recently, tended to wear the same blinders (Voda et al., 1982). Researchers have tended to use theories, research designs, and measurement techniques that focus on a particular level of analysis (Lock, 1986). Until recently, anthropologists did not see menopause as a problem worthy of scientific investigation, making cross-cultural analysis difficult (Griffin, 1977). Table 1 shows the potential conflict between meanings. Meanings include differences in etiology and in how the problem should be managed, by whom, and in which organizational setting. Medicine is not neutral but takes an explicit or implicit moral stand on such matters. The following questions deserve attention for both health care intervention and health care policy: What is the normalcy of menopause that can be documented (Voda & George, 1986)? When meanings are in conflict, who has the power to make their own interpretation dominant? What are the gains and losses for women encompassed by each meaning (Connors, 1985)? What are the uses of the meanings in terms of decision making in the family, business, political system, or religion? What are the implications of each meaning for the psychological functioning of women? CONCLUSION The meanings of objects influence responses to them. Meanings are socially constructed and have social, political, and economic consequences. In our society, menopause has been found to have a multiplicity of meanings. Professional health care providers need to consider the consequences of the various meanings of menopause for the health of individual women and for national health policy and health practices. Researchers must avoid a single level of analysis to the neglect of all other levels if the meaning of menopause to the health of women is to be adequately understood. The challenge is still here. Although some may lead us to believe that menopause is an insignificant issue in the lives of today's modern women, many women are asking questions that have
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serious consequences in their lives. The conceptual framework presented in this article can help health care providers to more clearly understand the importance of the meaning of menopause to the woman's response and to the health care she receives. There may be less public rhetoric regarding women's "raging hormones," however, the meaning that people attach to menstruation and menopause influences their actions and reactions, not only in private examining rooms but also on the national policy level. The more health care providers understand the importance of meaning, the more effective they can be. REFERENCES Bart, P. (1967). Post-maternal roles available to women: A cross-cultural study. Unpublished doctoral dissertation, University of California, Los Angeles. Beyene, Y. (1986). Cultural significance and physiological manifestations of menopause: A biocultural analysis. Culture Medicine and Psychiatry, 10, 47-72. Cali, R. W. (1984). Estrogen replacement therapy—boon or bane? Postgraduate Medicine, 75(4), 299-286. Chetkowski, R. J., Meldrum, D. R., Steingold, K. A., Randle, D., Lu, J. K., Eggena, P., Hershmen, J. M., Alkjaersig, N. K., Fletcher, A. P., & Judd, H. L. (1986). Biological effects of transdermal estradiol. New England Journal of Medicine, 314, 1615-1620. Connors, D. D. (1985). Women's "sickness": A case of secondary gains or primary losses. Advances in Nursing Science, 7, 1-17. Davis, D. L. (1986). The meaning of menopause in a Newfoundland fishing village. Culture, Medicine and Psychiatry, 10, 73-94. Estok, P. (1981). Menopause: A symbolic interactionist perspective. Unpublished doctoral dissertation, Kent State University, Kent, Ohio. Freidson, E. (1988). Profession of medicine: A study of the sociology of applied knowledge. Chicago, IL: University of Chicago Press. Gallagher, B. J. (1980). The sociology of mental illness. Englewood Cliffs, NJ: Prentice-Hall. Goffman, I. (1963). Stigma: Notes on the management of spoiled identity. Englewood Cliffs, NJ: Spectrum Books. Griffin, J. (1977). A cross-cultural investigation of behavioral changes at menopause. The Social Science Journal, 2, 49-55. Jaszmann, L., vanLith, N. S., & Zoat, J. C. A. (1969). Perimenopausal symptoms. Medical Gynecology and Sociology, 4, 268-277. Judd, H. L. (1987). Efficacy of transdermal estradiol. American Journal of Obstetrics and Gynecology, 156(5), 1326-1331. Kaufert, P. A., & Gilbert, P. (1986). Women, menopause, and aging. Culture, Medicine and Psychiatry, 10, 7-22. Kaufert, P., & Syrotuik, J. (1981). Symptom reporting at the menopause. Social Science and Medicine, 15, 173-184.
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Lock, M. (1986). Introduction to ambiguities of aging: Japanese experience and perceptions of menopause. Culture, Medicine and Psychiatry, 70(1), 23-46. Lofland, J., & Lofland, L. H. (1984). Analyzing social settings. Belmont, CA: Wadsworth. MacDonald, P. C. (1981). Estrogen plus progestin in postmenopausal women. New England Journal of Medicine, 305, 1644. MacKinlay, S. M., & McKinlay, J. B. (1973). Selected studies of the menopause. Journal of Biosocial Science, 5, 533-555. MacPherson, K. (1981). Menopause as disease: The social construction of a metaphor. Advances in Nursing Science, 2, 95-113. McCrea, F. B. (1983). The politics of menopause: The "discovery" of a deficiency disease. Social Problems, 31, 111-123. Muhlenkamp, A. F., Waller, M. M., & Bourne, A. E. (1983). Attitudes toward women in menopause: A vignette approach. Nursing Research, 32(1), 20-23. National Institute on Aging. (1983). Osteoporosis: The bone thinner (pp. 418-430). Washington, DC: United States Department of Health and Human Services and Public Health Service. Nichols, K. C., Schenkel, L., & Benson, H. (1984). 17B—Estradiol for postmenopausal estrogen replacement therapy. Obstetrical and Gynecological Survey, 39(4), 230-245. Paige, K. E. (1973, September). Women learn to sing the menstrual blues. Psychology Today, pp. 41-46. Perlmutter, E., & Bart, P. (1980). Changing views of "the change": A critical review and suggestions for an attributional approach. Unpublished manuscript. Posner, J. (1979). It's all in your head: Feminist and medical models of menopause (strange bedfellows). Sex Roles, 2(5), 179-190. Reissman, C. K. (1983). Women and medication: A new perspective. Social Policy, 14, 3-18. Reuben, D. (1969). Everything you always wanted to know about sex, but were afraid to ask. New York: David McKay. Schur, E. M. (1-984). Labeling women deviant. New York: Random House. Skultans, V. (1970). The symbolic significance of menstruation and menopause. Man, 5, 639-657. Stampfer, M. J., Willett, W. C., Colditz, G. A., Rosner, B., Speizer, F. E., & Hennekens, C. H. (1985). A prospective study of postmenopausal estrogen therapy and coronary heart disease. New England Journal of Medicine, 313, 1044-1049. Thomas, W. I., & Thomas, D. S. (1928). The child in America. New York: Knopf. Utian, W. H. (1977). Current status of menopause and postmenopausal estrogen therapy. Obstetrical and Gynecologic Survey, 32, 193-204. Voda, A. M., Dinnerstein, M., & O'Donnell, S. R. (Eds.). (1982). Changing perspectives on menopause. Austin, TX: University of Texas Press. Voda, A. M., & George, T. (1986). Menopause. In H. H. Werley & J. J. Fitzpatrick (Eds.), Annual review of nursing research (Vol. 4, pp. 55-75). New York: Springer. Wilson, R. (1966). Feminine forever. New York: M. Evans. Wingo, P. A., Layde, P. M., Lee, N. C., Rubin, G., & Ory, H. W. (1987). The risk of breast cancer in postmenopausal women who have used estrogen replacement therapy. Journal of the American Medical Association, 257(2), 209-215.
Requests for reprints should be sent to P. J. Estok, Professor and Director, Parent Child Nursing, School of Nursing, Kent State University, Kent, OH 44242.
Health Care for Women International Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/uhcw20
The meanings of menopause a
Patricia J. Estok RN, PhD, FAAN & Richard O'Toole PhD
b
a
Professor and Director, Parent Child Nursing, School of Nursing , Kent State University , Kent, Ohio, 44242 b
Department of Sociology , Kent State University , Kent, Ohio Published online: 14 Aug 2009.
To cite this article: Patricia J. Estok RN, PhD, FAAN & Richard O'Toole PhD (1991) The meanings of menopause, Health Care for Women International, 12:1, 27-39, DOI: 10.1080/07399339109515924 To link to this article: http://dx.doi.org/10.1080/07399339109515924
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THE MEANINGS OF MENOPAUSE Patricia J. Estok, RN, PhD, FAAN School of Nursing Kent State University Kent, Ohio
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Richard O'Toole, PhD Department of Sociology Kent State University Kent, Ohio
Multiple meanings have been assigned to menopause and to women experiencing menopause. Meanings are not inherent in reality but are assigned by humans in response to interaction. Once meanings are assigned to entities, they become coercive and influence interactions. Freidson's (1988) theoretical framework includes the imputation of responsibility, legitimacy, and seriousness to a deviance or illness and provides the basis for an analysis of the various meanings of menopause that are found in the literature. This analysis is concerned with the social, political, economic, and health care consequences of the assigned meanings of menopause for women.
Meanings are the "linguistic categories that make up a participant's view of reality and with which they define their own and others' actions" (Lofland & Lofland, 1984, p. 71). Meanings attached to menopause influence how women respond to menopause, how others respond to women they believe are experiencing menopause, and the kind of health care the women receive. Our purpose in writing this article is to describe and clarify some of the meanings that have been assigned to menopause and discuss how they influence health care provided to women. CONCEPTUAL FRAMEWORK Meanings are applied to objects and individuals on the basis of this interaction; therefore, meanings are different for persons with different sociocultural backgrounds and different life experiences. Health Care for Women International, 12:27-39, 1991 Copyright © 1991 by Hemisphere Publishing Corporation
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Basic assumptions concerning meanings are that they are (a) not inherent in reality; (b) basic to psychological functioning, communication, and social interaction; (c) constructed and used for social, political, and economic advantage; (d) a source of conflict when different meanings are ascribed to a single entity; (e) coercive and influence interactions and change in response to changing situations; and (f) determinants of illness behavior and health care provider responses. An important concept in symbolic interaction theory is W. I. Thomas's (Thomas & Thomas, 1928) famous statement illustrating the significance of the subjective in social interaction: "if men define situations as real, they are real in their consequences" (pp. 565-567). Thus, if menopause is assigned a certain meaning and behavior is enacted based on that meaning, the consequences are real regardless of whether the meaning is "right." Individuals will react to menopause and the women experiencing it in terms of the meaning they impute to it. We used Freidson's (1988) work to help us understand the meanings that may influence responses to menopause. Freidson analyzed the social construction of illness and explained the variable relationship between the "biological reality" and the "social reality" of the sick role. There may or may not be a close relationship between individuals' biological condition and the social meaning assigned to them, the sick role. As defined by the First International Conference on Menopause in 1976, menopause is the final menstrual period (Utian, 1977). Our analysis will indicate, however, that as with many biological events, social meanings of menopause have implications that range far beyond biological change. Freidson (1988) used the symbolic interaction concept of deviance, that there is nothing inherent in an act or attribute that leads it to be classed as deviant. Whether something is viewed as normal or deviant depends on the reaction of the perceiver. Thus, for many, menopause would be seen as "normal"; however, others may view it as deviant. Freidson isolated three concepts that he theorized would be useful in classifying types of deviance and then types of illness: (a) imputation of responsibility, (b) imputation of legitimacy, and (c) imputation of seriousness. The imputation of responsibility is a key concept in accounting for different reactions to individual attributes or behavior. When persons are perceived as sick, they are not held responsible for their behavior and they elicit a different response from others than if they are judged responsible for deviant behavior. Deviance for which the person is held responsible is shown in the second column of Table 1. If persons are judged responsible for their deviant behavior, they are subject to correction or punishment because the behavior is perceived to be under their
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Table 1. Freidson's Sociological Types of Deviance Individual not held responsible Imputed seriousness
Minor deviation (primary deviance)
Serious deviation (secondary deviance)
Individual held responsible
Illegitimate (stigmatized)
Conditionally legitimate
Unconditionally legitimate
Cell 1
Cell 2
Cell 3
Cell 4
Minor sanctioned offense
Minor stigmatized illness
Minor acute illness
Minor chronic illness
CellS
Cell 6
Cell 7
Cell 8
Serious sanctioned offense
Serious stigmatized illness
Serious acute illness
Serious chronic illness
Note. This table is a reorganization of Freidson's (19881, pp. 231-234) tables to provide theoretical types of deviance.
to
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control. Some attributes or behaviors imputed to menopause are thought to be under a woman's control; therefore, she may be subjected to ostracism, threat of punishment, or some other type of sanction to control her "deviance." As shown in Table 1 Freidson (1988) then distinguished three kinds of legitimacy: a) conditional legitimacy, the deviant being temporarily exempted from normal obligations and gaining some extra privileges on the condition that he seek the help necessary to rid himself of his deviance; b) unconditional legitimacy, the deviant being exempted permanently from normal obligations and obtaining additional privileges in view of the hopeless character imputed to his deviance; and c) illegitimacy, the deviant being exempted from some normal obligations by virtue of deviance for which he is not held technically responsible, but gaining few if any privileges and taking on some especially handicapping new obligations, (p. 238) In Freidson's (1988) words, imputed seriousness distinguishes the magnitude of societal reaction to deviance, the consequences of which are either to leave the offender in this "normal" role, somewhat tempered and qualified by nondeviant attributes (primary deviance) or to push him into a new, specifically deviant role (secondary deviance), (p. 232) There is a tendency for the identity and life patterns of the individual pushed into a deviant role to center around the deviance and for the person to become known largely in terms of this deviant master status. Individuals may become known in their deviant status of "murderer" or "heart attack victim," but it is unlikely that "parking violator" or "cold victim" will turn into a master status for the person (Freidson, 1988). It is important to recognize that the assigned master status of "heart attack victim" may result in coworkers and employers excluding a person from interaction or not considering the person for a promotion. Although the types of deviance in Freidson's (1988) model appear as static categories, he specifically recognized that health and illness are dynamic processes. Thus, the career of a problem can be traced as its meaning shifts from cell to cell in Table 1. The typology also explicitly incorporates conflict over meanings. Individuals, organizations, or professions hope to advance their meanings of menopause over others (McCrea, 1983; Connors, 1985). Thus, some meanings will have strong backing from groups such as the women's movement, sectors of organized medicine, or drug companies.
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The goal of this analysis is not to describe current beliefs concerning menopause or to show the prevalence of one meaning of menopause over others. Our goal is to show the utility of Freidson's (1988) formulations in theoretically analyzing the types of meanings ascribed to menopause and to discuss the implications of the various ascriptions to the responses that are made to menopause and to the women who are experiencing it. Because the personal meanings of menopause influence health assessment and interventions received by women, it is important that health care providers understand the meanings of menopause and their consequences for women. Such understanding can assist women and their families in dealing with problems raised by competing definitions and can serve as a basis for advocating health care policy for women. MEANINGS OF MENOPAUSE Meanings of menopause were collected through an extensive review of the literature and personal research (Estok, 1981). The search revealed that the meanings Freidson (1988) identified have been widely used in different cultures, over historical time, and by different social groups within the same culture and time period, including the present. Meanings as they appeared in the literature were placed in the normal or nondeviant category or, if possible, assigned to one of the cells in Table 1. First, we describe meanings that portray menopause as natural and normal. Then we review meanings in which menopause is viewed as a breach of social norms or a crime and is subject to sanction. Finally, we consider meanings in which menopause is perceived according to various types of illness: stigmatized, conditionally legitimate, and unconditionally legitimate. Menopause as Natural and Normal Feminists in the United States have advocated that menopause is a natural process of aging and that most women pass through it with minimum difficulty (MacPherson, 1981; McCrea, 1983). Their position is a refutation of the disease model of menopause that they see as another example of menstrual and menopausal myths that have been used to control and exploit women. Meanings recorded by Estok (1981) reflect this view, for example, that it is "just a natural thing" and that it is "a natural stage of life." Researchers have presented cross-cultural data to support the generalization that cultures that give special privileges to the aged or to women beyond menopause do not have women reporting
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menopausal syndrome experiences (Bart, 1967; Griffin, 1977; Skultans, 1970). For example, Griffin (1977) reported a saying of the Marias about menopause—"as it appears, so it disappears"—an illustration of the normal, nondeviant point of view. Intrasocietal differences in menopause responses have also been recorded (Beyene, 1986; Estok, 1981; Jaszmann, vanLith, & Zoat, 1969). More recent research, however, calls these findings into question (Muhlenkamp, Waller, & Bourne, 1983). Thus, nonequivocal conclusions are impossible at this time because of the paucity of cross-cultural data on this complex biocultural phenomenon (Beyene, 1986). Data reflect neglect of menopause by anthropologists, sampling bias, and a number of measurement problems (Davis, 1986) that equivocate both the interpretation of specific research results and the comparison of different studies (Kaufert & Syrotuik, 1981; Lock, 1986). The results of research, then, are confusing to those searching for the "real" meaning of menopause. Menopause as Deviant If observers believe that a woman who is experiencing menopause has control over (is responsible for) the "impatience and irritability" that is attributed to "that age," the woman may be subject to sanction and loss of social interaction by coworkers and others if she continues such behavior. It is important to realize that a number of symptoms thought to be associated with menopause are believed by some to be subject to control (e.g., nervousness, irritability) or so minor that a person should "keep them to themselves and not bother others." As shown in Cell 1 of Table 1, the woman previously described would be placed in this category and would be held responsible for a minor deviation. Freidson's (1988) theory would have one understand that the strength of the reaction may result in the menopausal woman being pushed into a major deviant status (Cell 5). The mental illness that was called involutional melancholia was associated with women, particularly at menopause (Gallagher, 1980). Lay persons using the term crazy to characterize middle-aged women may feel that persons should be "sent away" as punishment for behavior that is basically under their control, for which they are held responsible, and thus be punished (Freidson, 1988). Some women still report being concerned about "losing their mind" at the time of menopause. Menopause as Illness Meanings of menopause are also influenced by the imputed legitimacy of it as an illness. As indicated in Table 1, menopause may be
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imputed to be conditionally legitimate, unconditionally legitimate, or illegitimate (stigmatized). Meanings of menopause are compared with the examples of illness that Freidson (1988) used to illustrate his conceptual distinctions. His examples are those that he judged would have been imputed by middle-class Americans around the time of his analysis. This is important to remember as imputation is considered to be a process; that is, changes or sequences in meanings of menopause develop as women and others attempt to organize and reorganize their perceptions of menopause and to manage it. Illegitimate (Stigmatized)—Cells 2 and 6
Goffman's (1963) notion of stigma—a societal reaction that "spoils" normal identity—is incorporated within this column of Table 1. Stigma is peculiar. Although persons are not held responsible for their behavior, they are treated somewhat like a responsible "bad" person. Many of the ordinary privileges of social life are denied to the stigmatized. There are many examples of stigmatized meanings of menopause: In 1977, Jane Byrne (Mayor of Chicago) came to the public's attention when she spoke out against political corruption in the city. It was reported in the press that some of her opponents explained the attack on the political machine as merely being due to the "change of life." (Perlmutter & Bart, 1980, p. 187) Thus, Mayor Byrne was a '"discreditable" person or one whose judgment was not to be trusted because she was menopausal. As a woman's behavior is viewed as more serious she may be shunted into deviant roles, that is, have barriers erected to her participation in some roles: If you had an investment in a bank, you wouldn't want the president of your bank making a loan under these raging hormonal influences at that particular period. Suppose we had a President in the White House, a menopausal woman President, who had to make the decision on the Bay of Pigs. . . . (Paige, 1973, p. 44) Further support for the stigmatization of menopause came from McKinlay and McKinlay (1973) in their influential review of the literature on menopause. They concluded that "menopause remains a stigma, a symbol of decrepitude and decay" (p. 181). In 1981, MacPherson concurred with earlier suggestions regarding the stigmatized meaning of menopause with the statement, "no female function has been so degraded, dreaded, and unmentionable as this final phase of the reproductive cycle" (p. 95).
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Conditionally Legitimate—Cells 3 and 7
In Cell 3 of Table 1, Freidson (1988) used the example of a cold to show how middle-class Americans might respond to an illness of this theoretical type. Women who use this meaning of menopause might discuss their symptoms with a family member or a friend and try a treatment they suggest. One woman known to us described how she used an ice bag on her neck to relieve a headache she attributed to menopause because a friend had found this treatment effective. A trip to a physician for estrogen replacement therapy (ERT), in which the patient takes the prescribed medication and "gets well," may be viewed as a minor Cell 3 problem. The physician's reaction can be based on meanings that could be placed in either Cell 3 or Cell 7, depending on the degree of imputed seriousness. The physician may view menopausal symptomatology as a psychological problem that could be treated with brief counseling and perhaps a tranquilizer or as a biophysiological problem that estrogen can cure. Symptoms could also be disregarded or forgotten. There is also a possibility for the amplification of the deviance creation process to occur and for the meaning of menopause to move toward Cell 7 as a serious physical or psychological problem. Furthermore, a person who is being treated for a minor psychological problem may be reacted to in terms of a serious deviation by others who perceive any mental health therapy as an indicator of serious pathology. Some mental problems are stigmatized (Cell 2 or 6) by some individuals. The reaction to menopause as an example of a "deficiency disease," however, is the meaning that has caused the most controversy over menopause and its treatment in recent years (MacPherson, 1981; McCrea, 1983; Kaufert & Gilbert, 1986). Through research, menopause is traced as another example of the medicalization of deviance. The social construction of menopause as a deficiency disease is traced to Robert A. Wilson (1966), a gynecologist, who first promoted ERT. McCrea's (1983) analysis indicated that Wilson claimed that the "youth pill" could avert 26 symptoms "including hot flashes, osteoporosis, vaginal atrophy . . . , sagging and shrinking breasts, wrinkles, absentmindedness, irritability, frigidity, depression, alcoholism, and even suicide" (p. 113). Menopause has been described as threatening loss of the "feminine essence" and menopausal women have been described as "living decay" (Reuben, 1969). McCrea (1983) noted that "the disease label is not neutral. This label decreases the status and the autonomy of the patient while increasing the status and power of the physician" (p. 113). Reissman (1983) argued that both physicians and women have contributed to this process. She explained that women have collaborated in medicalization "because of
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their own needs and motives, which in turn grow out of the classspecific nature of their subordination" (pp. 3-4). Kaufert and Gilbert (1986) disputed the medicalization of menopause and stated that compared with childbirth menopause has not been medicalized to any great extent. In 1989, research findings on estrogen's ability to prevent osteoporosis made the deficiency label of menopause paramount. Controversy over ERT has social and economic overtones and has caused concern for many women (Cali, 1984; National Institute on Aging, 1983; Stampfer et al., 1985; Wingo, Layde, Lee, Rubin, & Ory, 1987). Although patient package inserts warning of cancer and other risks are now included with each estrogen and progestin prescription, the risks of not taking estrogen (osteoporosis) have altered the perceptions of many women and health care providers. Furthermore, the development of parenteral estrogen products and the use of progestins with ERT may alter the meaning ascribed to such products by women and others (Chetkowski et al., 1986; Judd, 1987; MacDonald, 1981; Nichols, Schenkel, & Benson, 1984). This may mean that medicalization of menopause will be accelerated. Unconditionally Legitimate—Cells 4 and 8
Meanings of menopause that include concepts of chronic illness or disability are in this column of Table 1. Freidson (1988) noted that "some attributes defined as illness, impairment, or deficiency remain merely that—an idiosyncrasy of the person, adjusted to by others without any special problems or expectation that he seek treatment" (p. 236237). In such instances the granting of legitimacy is unconditional. In the case of the minor type, Freidson used pockmarks as an example along with lumbago, rose fever, and the "sickly" woman. The sickly woman meaning needs little elaboration because of the extensive use of this typification. If it is a minor problem, a few minor privileges may be gained and a few obligations may be relinquished. If a woman was to make more serious demands, however, or if reactions become more serious, her rights and obligations would be changed. The sickly woman meaning would cease to be an idiosyncrasy and words like disabled or invalid might be used. Finally, when the condition is held to be so serious that nothing can be done, then chronically sick or dying roles may occur. Griffin (1977) reported that among the rural Irish "it is commonly believed that the menopause can induce insanity; in order to ward it off, some women have retired from life in their midforties and, in at least three contemporary cases, have confined themselves to bed until death years later" (p. 50).
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SIGNIFICANCE OF MEANINGS OF MENOPAUSE Two points deserve elaboration here: (a) menopause happens to women and (b) conflict may exist over meanings of menopause in the woman's social network and in society.
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It Happens to Women Meanings of menopause cannot be understood apart from the larger patterns of the gender system in our society. As Schur (1984) noted, recognition of deviance depends not so much on the specific act but on the basic kind of person the actor is assumed to be. The interpretation of acts and the attribution of psychological states, then, are as heavily influenced by gender as they are by social and ethnic stereotypes. Schur (1984) called attention to the fact that women are highly vulnerable to being judged "out of place" because there are so many restrictions on female behavior. The attribution of emotional disturbance is present in the background for women as a way of both devaluing what they say or do and as an implicit threat to control their behavior. Such attribution seems to center particularly around the female reproductive system: menstruation, pregnancy, childbirth, and menopause. McCrea (1983) isolated four themes included in medical definitions of menopause: "a) women's potential and function are biologically destined; b) women's worth is determined by fecundity and attractiveness; c) rejection of the feminine role will bring physical and emotional havoc; d) aging women are useless and repulsive" (p. 111). Conflict over Meaning Analysis of political and economic aspects of the social construction of meanings and conflict between meanings is basic to a holistic approach to the health care of women. Such analysis must be incorporated into decisions influencing social and health care policy. It is interesting to see how various constructors and champions of meanings have selected a particular biological, psychological, or social level of analysis to the neglect of the other levels of analysis that might be used to give meaning to menopause (Voda, Dinnerstein, & O'Donnell, 1982). For example, as noted, the deficiency disease model made biology destiny. Although biological factors cannot be denied, no one seems to have asked, "What aspects of the menopausal syndrome might be a realistic reaction to the situations in which middle-aged women seem to find themselves?" Instead, researchers gave exclusive focus to the psychological level and asked, "Where did the woman go wrong?" They de-
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nied that either social, structural, or biological variables were important. The feminists' position, in conflict with the medical biological model, according to Posner (1979, p. 189), has "been led into the ideological trap of denying their own hormones" and implying that menopause is only a socially constructed phenomenon. This seems to be another example of the all-or-nothing problem. At any rate, many proponents of meanings are guilty of treating women as a category. They believe that if some women have a particular menopausal symptom, then all women do. According to this view, all women have all problems. Or if some women have no problems with menopause, then all women have no problems or, at least, no problems of any real consequence. Science has, until recently, tended to wear the same blinders (Voda et al., 1982). Researchers have tended to use theories, research designs, and measurement techniques that focus on a particular level of analysis (Lock, 1986). Until recently, anthropologists did not see menopause as a problem worthy of scientific investigation, making cross-cultural analysis difficult (Griffin, 1977). Table 1 shows the potential conflict between meanings. Meanings include differences in etiology and in how the problem should be managed, by whom, and in which organizational setting. Medicine is not neutral but takes an explicit or implicit moral stand on such matters. The following questions deserve attention for both health care intervention and health care policy: What is the normalcy of menopause that can be documented (Voda & George, 1986)? When meanings are in conflict, who has the power to make their own interpretation dominant? What are the gains and losses for women encompassed by each meaning (Connors, 1985)? What are the uses of the meanings in terms of decision making in the family, business, political system, or religion? What are the implications of each meaning for the psychological functioning of women? CONCLUSION The meanings of objects influence responses to them. Meanings are socially constructed and have social, political, and economic consequences. In our society, menopause has been found to have a multiplicity of meanings. Professional health care providers need to consider the consequences of the various meanings of menopause for the health of individual women and for national health policy and health practices. Researchers must avoid a single level of analysis to the neglect of all other levels if the meaning of menopause to the health of women is to be adequately understood. The challenge is still here. Although some may lead us to believe that menopause is an insignificant issue in the lives of today's modern women, many women are asking questions that have
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serious consequences in their lives. The conceptual framework presented in this article can help health care providers to more clearly understand the importance of the meaning of menopause to the woman's response and to the health care she receives. There may be less public rhetoric regarding women's "raging hormones," however, the meaning that people attach to menstruation and menopause influences their actions and reactions, not only in private examining rooms but also on the national policy level. The more health care providers understand the importance of meaning, the more effective they can be. REFERENCES Bart, P. (1967). Post-maternal roles available to women: A cross-cultural study. Unpublished doctoral dissertation, University of California, Los Angeles. Beyene, Y. (1986). Cultural significance and physiological manifestations of menopause: A biocultural analysis. Culture Medicine and Psychiatry, 10, 47-72. Cali, R. W. (1984). Estrogen replacement therapy—boon or bane? Postgraduate Medicine, 75(4), 299-286. Chetkowski, R. J., Meldrum, D. R., Steingold, K. A., Randle, D., Lu, J. K., Eggena, P., Hershmen, J. M., Alkjaersig, N. K., Fletcher, A. P., & Judd, H. L. (1986). Biological effects of transdermal estradiol. New England Journal of Medicine, 314, 1615-1620. Connors, D. D. (1985). Women's "sickness": A case of secondary gains or primary losses. Advances in Nursing Science, 7, 1-17. Davis, D. L. (1986). The meaning of menopause in a Newfoundland fishing village. Culture, Medicine and Psychiatry, 10, 73-94. Estok, P. (1981). Menopause: A symbolic interactionist perspective. Unpublished doctoral dissertation, Kent State University, Kent, Ohio. Freidson, E. (1988). Profession of medicine: A study of the sociology of applied knowledge. Chicago, IL: University of Chicago Press. Gallagher, B. J. (1980). The sociology of mental illness. Englewood Cliffs, NJ: Prentice-Hall. Goffman, I. (1963). Stigma: Notes on the management of spoiled identity. Englewood Cliffs, NJ: Spectrum Books. Griffin, J. (1977). A cross-cultural investigation of behavioral changes at menopause. The Social Science Journal, 2, 49-55. Jaszmann, L., vanLith, N. S., & Zoat, J. C. A. (1969). Perimenopausal symptoms. Medical Gynecology and Sociology, 4, 268-277. Judd, H. L. (1987). Efficacy of transdermal estradiol. American Journal of Obstetrics and Gynecology, 156(5), 1326-1331. Kaufert, P. A., & Gilbert, P. (1986). Women, menopause, and aging. Culture, Medicine and Psychiatry, 10, 7-22. Kaufert, P., & Syrotuik, J. (1981). Symptom reporting at the menopause. Social Science and Medicine, 15, 173-184.
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Lock, M. (1986). Introduction to ambiguities of aging: Japanese experience and perceptions of menopause. Culture, Medicine and Psychiatry, 70(1), 23-46. Lofland, J., & Lofland, L. H. (1984). Analyzing social settings. Belmont, CA: Wadsworth. MacDonald, P. C. (1981). Estrogen plus progestin in postmenopausal women. New England Journal of Medicine, 305, 1644. MacKinlay, S. M., & McKinlay, J. B. (1973). Selected studies of the menopause. Journal of Biosocial Science, 5, 533-555. MacPherson, K. (1981). Menopause as disease: The social construction of a metaphor. Advances in Nursing Science, 2, 95-113. McCrea, F. B. (1983). The politics of menopause: The "discovery" of a deficiency disease. Social Problems, 31, 111-123. Muhlenkamp, A. F., Waller, M. M., & Bourne, A. E. (1983). Attitudes toward women in menopause: A vignette approach. Nursing Research, 32(1), 20-23. National Institute on Aging. (1983). Osteoporosis: The bone thinner (pp. 418-430). Washington, DC: United States Department of Health and Human Services and Public Health Service. Nichols, K. C., Schenkel, L., & Benson, H. (1984). 17B—Estradiol for postmenopausal estrogen replacement therapy. Obstetrical and Gynecological Survey, 39(4), 230-245. Paige, K. E. (1973, September). Women learn to sing the menstrual blues. Psychology Today, pp. 41-46. Perlmutter, E., & Bart, P. (1980). Changing views of "the change": A critical review and suggestions for an attributional approach. Unpublished manuscript. Posner, J. (1979). It's all in your head: Feminist and medical models of menopause (strange bedfellows). Sex Roles, 2(5), 179-190. Reissman, C. K. (1983). Women and medication: A new perspective. Social Policy, 14, 3-18. Reuben, D. (1969). Everything you always wanted to know about sex, but were afraid to ask. New York: David McKay. Schur, E. M. (1-984). Labeling women deviant. New York: Random House. Skultans, V. (1970). The symbolic significance of menstruation and menopause. Man, 5, 639-657. Stampfer, M. J., Willett, W. C., Colditz, G. A., Rosner, B., Speizer, F. E., & Hennekens, C. H. (1985). A prospective study of postmenopausal estrogen therapy and coronary heart disease. New England Journal of Medicine, 313, 1044-1049. Thomas, W. I., & Thomas, D. S. (1928). The child in America. New York: Knopf. Utian, W. H. (1977). Current status of menopause and postmenopausal estrogen therapy. Obstetrical and Gynecologic Survey, 32, 193-204. Voda, A. M., Dinnerstein, M., & O'Donnell, S. R. (Eds.). (1982). Changing perspectives on menopause. Austin, TX: University of Texas Press. Voda, A. M., & George, T. (1986). Menopause. In H. H. Werley & J. J. Fitzpatrick (Eds.), Annual review of nursing research (Vol. 4, pp. 55-75). New York: Springer. Wilson, R. (1966). Feminine forever. New York: M. Evans. Wingo, P. A., Layde, P. M., Lee, N. C., Rubin, G., & Ory, H. W. (1987). The risk of breast cancer in postmenopausal women who have used estrogen replacement therapy. Journal of the American Medical Association, 257(2), 209-215.
Requests for reprints should be sent to P. J. Estok, Professor and Director, Parent Child Nursing, School of Nursing, Kent State University, Kent, OH 44242.
