RESEARCH ARTICLES

Menopause and gender stereotypes: the importance of the approach from health education

Alicia Botello Hermosa^I; Rosa Casado Mejía^II

ABSTRACT: The aim of this research was to understand and analyze gender stereotypes that currently exist about menopause. A qualitative study, whose design was Grounded Theory, was performed in Seville (Spain), with 43 ​​women from rural and urban areas of different generations, young women (18-25 years, 26-35 years), middle aged (36-45 years, 46 -55 years, 56-65 years) and elderly (> 65 years). A semi - structured interview and 3 focus groups were used as a data collection technique. They were conducted between March 2008 and December 2011. The answers were subjected to content analysis and significant differences were found between the discourses of the different generations , the eldest being the ones who had a more physiological view while the younger had a more pathological idea of the same process. These results reflect the existing cultural bias and reinforce the importance of health education to eradicate it.

Keywords: Menopause; women's health; gender identity; community health nursing.

INTRODUCTION

Menopause is a physiological stage in the life of women bearing strong negative connotations nowadays that are mainly joined to ideas of deficit, deterioration and aging. In the late twentieth century, the interpretation and explanation of menopause became a topic of great interest, not only as an individual process, but also as a social fact, given the different positions that medicine and feminist thoughts have in respect to this and which are antagonistic positions¹.

The objective of this research was to understand and analyze gender stereotypes that currently exist about menopause in women from Seville (Spain) and verify the existence of cultural bias towards this physiological phenomenon.

LITERATURE REVIEW

The gynecologist Seara^2:251 illustrates the Old Testament : It should be taken into account that both, Abraham and Sarah were too old to have children and Sarah had lost the manners of women (Genesis 18:11) although the study of menopause as a health concept as the author goes back to the eighteenth century and reached a first peak at the beginning of the nineteenth century with the appearance of the first book devoted entirely to this topic, Avies aux femmes qui dans l'age entrent critique, by the French physician C.P.L. de Gardanne in 1816, which appeared four years after the author defended his doctoral thesis at the University of Paris on the same topic. It was Gardanne, 1821, who coined the term menespausie that was later shortened to, menopause in a second edition of his book2. Elle described it as the critical age and also as the woman’s hell¹.

Gender stereotype is defined as beliefs about the characteristics of the typical roles that men and women should have in an ethnic, culture or society. Similarities were established between puberty and menopause as they are transition states although opposite signs³; while menarche culturally represents the being a woman4 symbolically and menopause implies cultural biases associated to loss and old age. In fact, it represents an important cultural, psychological and physiological event for women. It means the end of breeding, which is equivalent to old age² in many Western societies since fertility is associated with beauty, health and femininity^5,6 due to its absence, for pathological or physiological reasons, women were less feminine = less woman.

METHODOLOGY

On beliefs about menopause being the subject of study, the research was qualitative⁷, since this type of research highlights the individual, holistic and dynamic aspect of human experience and seeks to capture the understanding of the whole. That is, it allows us to understand the world of subjective experience from the point of view of people who live it relating them to their environment. This paradigm does not focus on the prediction and control of a phenomenon (study of variables), but on the systematic description of daily experience⁸. It has been used as a technique for Grounded Theory analysis^9-11.

Targeting criteria are: age was established as a criterion for segmentation. Age groups were decided from the specific population, women: young (18-25 years, 26-35 years), middle aged (36-45 years, 46-55 years, 56-65 years) and elderly (> 65 years).

Another criterion was the location: rural or urban area. It was intended to compare the level of popular beliefs and consider whether they are more abundant in rural areas than in the urban environment. Two informants per profile were used.

Variability criteria are: level of education – no studies (no academic title), medium studies (non-university academic degrees), and university studies (bachelor and master degrees); mothers or childless women  - the approach was to study whether women live their life cycle differently being mothers or childless; profession - housewives or women working outside the home.
The categories of analysis were:
• Popular expressions and metaphors related to menopause.
• Menopause: Literally means cessation of menses. It is the period of life of women between 45 and 52 years, the average age at which a woman is no longer physiologically fertile. It must be followed by 12 months of amenorrhea.
• The control and knowledge about their own bodies: women who have been excluded by the sex-gender role of a social system, plead ignorance of their own bodies, sexuality and reproduction. Therefore it is a power device that they lack and tends to influence the relationship they establish with everything related to their reproductive life¹².
• Gender: Group of characteristics such as emotions, beliefs, personality traits, attitudes, that conform in each society an established form of relationship between men and women, determine what is male and female, how and what women and men should be and/or do¹³.

It was felt that the interview was the data collection technique that best fitted in with the objectives of the research, as it allowed women's beliefs, ideas, feelings and fears about their own experience of the life cycle to emerge.
An interview is a directed conversation that allows us to collect important information for a specific purpose. A structured outline of open questions related to the topic of the research, menopause and the subjective world of beliefs and attitudes that surround it was designed for the research. Twenty four semi-structured interviews were performed in different scenarios: the Faculty of Nursing, University of Seville, workplace and in the homes of some respondents. They had an average duration of 45 minutes.

Theoretical sampling is particularly appropriate when the primary purpose of data collection is to generate a substantive theory. It is continuous and gradual, guided by data collection, analysis and interpretation as the theory is established. It is particularly consistent with the objectives and techniques of grounded theory. This was the one that was used in the investigation. Interviews were conducted between March 2008 and December 2011.

The focus group is a planned discussion group in a non- directive and permissive environment in order to obtain information in a defined area of ​​interest¹⁴.

Three focus groups with minimal elements of homogeneity, so that situations were avoided which complicated the speech of the whole group (differences in knowledge, power, age)¹⁵ and take advantage of common experiences and also criteria of heterogeneity: age, rural or urban environment, education level and profession. Each group had seven participants except one which had five. The meetings lasted from 65:10 to 80 minutes in the afternoons. The same theme script was followed in all groups. To collect information, the sessions were recorded by video camera prior informed consent. The content of the groups was reflected in their transcripts. Transcripts were literal, respecting both the wording and the analogical language (laughter, silences, intonation ... ). To protect the anonymity we refer to the informants with the letter W for Women, followed by the number of respondents that was (1-24) or focus group (G1, G2, G3), if it was a Rural or Urban environment (R or U) and age (in years).

The data analysis was performed using the steps proposed by the Grounded Theory^16,17, widely used in the analysis of qualitative data.
After collecting empirical data, we proceeded to the coding or analysis of the data⁸. Preparation of qualitative data, segmentation of data, coding and grouping of codes in family was performed.

After analysis of these initial data, the researcher can encode them, thus ensuring constant movement back and forth in the text, which is defined as comparative analysis until theoretical saturation is reached and the substantive theory is obtained^8,17.

In this case it is important to point out that the use of a specific software of qualitative data analysis¹⁸ allowed us to sort out all the information, to codify, store categories, etc. , which greatly facilitated the analysis when working with large volumes of textual data. The content analysis of in-depth interviews was conducted by Atlas -Ti software Version 5.0 with license. A triangulation technique was performed, comparing the speech analysis from the semi -structured interviews and focus groups with the help of Atlas Ti software producing similarities in the categories.

All participants were informed and were asked for their informed consent to record the interviews. The research was conducted following the Declaration of Helsinki for research involving human subjects and ethical principles respecting the anonymity and confidentiality of informants.

RESULTS AND DISCUSSION

After content analysis of the semi -structured interviews and focus groups the following categories of results are obtained with respect to menopause:

Old age, loss and damage

Paradoxically, those with the worst view about menopause are the youngest respondents, who are the ones that reflect a pathological and less physiological view, perhaps because they are the most influenced by the view that is attempted to be given nowadays from various media such as, for example, the association between menopause and deficit. It is defined as the control of aging by the gender stereotypes¹⁹. References regarding menopause that are indicated are by their own mothers :

              My mother now has the menopause with many mood swings , suddenly it is okay, you say one thing and she starts screaming at you and sweats a lot. (W3, G2, U, 22).

Myths related to menopause are very broad and are presented as the antithesis of the ideal of the young beautiful woman from collective ideology²⁰.

             My mother is like that and has many hot flashes and joint pains, pains in her arms, cramps in her legs, and that getting up one day with an angry face and being fine the next day and telling you that nothing is wrong. (W7, G2, U, 22)

In young women from the study, the idea of ​​menopause associated to deficit and old age, osteoporosis and even virilization is appreciated.

             [ ... ] I've also heard that, that women are useless, now I'm getting older [ ... ] that she is getting old (W16, R, 23)

The idea of ​​growing old when reaching menopause is discovered in many of the testimonies; with the menopause the woman becomes old, with the negative connotations that surround this word in our culture; related to ageism as defined by Professor Anna Freixas and Beauty Shop cult¹.

And directly related to the previous idea of ​​old age, is the view that implies the lack of sex appeal.

Your bones hurt a lot and you are very hot. I swear, she takes no medication. (W23 , U, 19)

Anthropological research indicates that there is no universal menopausal syndrome, showing a great variety and social, cultural and personal differences in the presentation of what menopause is and how it has been lived throughout time and history¹.

Anxiety, depression and fears

In scientific reductionist models, menopause is a deviation from the rules of health and good inner workings (rather than the gender per se) and once more is described as a dysfunctional state that requires medical intervention generally Hormone Replacement Therapy (HRT)²⁰.

           Overall I think that nowadays menopause is very medical and this is a source of problems for many women [ ... ] It is associated with old age and neglect , and wearing a track suit and go for short walks by the river and take a lot of calcium. (W5, G3, R, 35)

The provision of hormones to replace those that are lost after menopause embodies the same medication, domination of the female body. As such, it is directly related to the social construction of gender and proper conduct. As such beliefs are full of ideas of biological essentialism, relevance of age and assumptions that fuel sexism, the image of menopause such as estrogen deficiency syndrome and images of femininity that are used to promote their use have consequences for women of all ages²³.

          Yes , it was as she had already spent one part of her life and was almost in another, shall we say, older one [ ... ] As if she had lost sexuality; that they are "dry" (W6, R, 46)

In this sense, we observed in the middle-aged women’s speech how menopause they associate the menopause with going to the doctor’s, and even the psychologist’s, because you can "fall into a depression."

         With the menopause you are given pills, and some were sent to the psychologist because had a depression [ ...] . (W2, R, 31)

These results are consistent with research performed in Mexico, in 2005, on the psychological meaning of menopause in adult women, obtaining associations between menopause depression and anxiety²⁴ at this range of ages.

taboo

Older women have lived it as something natural, physiological, casually in most cases, very quietly; This is a different image to what is currently promoted as menopause associated to estrogen deficiency and old age.

             Nothing was said about menopause, if you hot flashes it was because the weather was hot.  (W11, R, 84)

The idea of ​​taboo associated with menopause was repeated in the older informants.

              When the menopause started it was natural, I took my fan, fanned myself and that was all.  There was no talk of menopause or anything like that. (W1, G3, R, 82)

According to a 1991 study by Professor Anna Freixas²⁵, menopause is not considered a significant event in a woman’s life. Despite the strong campaign that laboratories and the medical establishment conducted to medicalize menopause, charging numerous fears, women who have lived and have been there, even define it as a liberating experience. Currently there are many studies that increasingly support this affirmation²⁶, so it highlights the importance of Nursing in community health²⁷ to try to deconstruct gender stereotypes associated with menopause.

CONCLUSIONS

The main beliefs and gender stereotypes that exist about menopause are those associated with aging and loss, present in the younger informants, a source of anxiety, depression and fear in middle-aged women and taboo in the elder women. Likewise, no differences were observed if the environment in which they live is rural or urban.

As limitations of the study we have to point out the difficulties in moving on subjective and personal grounds and the shame of discussing these aspects by some informants, although the researcher managed to overcome this by creating a climate of trust.

It is necessary to create specific health education programs about menopause for women's groups because of the confusion they feel about this stage; whose view as a deficit is increasingly being imposed rather than treated as a natural physiological process as women themselves are demanding. It is the idea of loss that is associated to menopause, loss of beauty and loss of sexuality; to sum up, loss of youth and therefore loss of fertility and reproductive capacity in the negative sense, as if the centrality and the intention of  women had to be the reproduction.

We highlight, due to the testimonies collected and after analysis and interpretation, that a lot of Health Education of healthy women focused on their life cycles is still needed nowadays. Understanding Health Education as the process that informs, motivates and helps the population to adopt and maintain healthy practices and lifestyles; that advocates the necessary environmental changes to facilitate these objectives, and directs training and research towards the same goals.

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