JOURNAL OF COMPARATIVE RESEARCH IN ANTHROPOLOGY AND SOCIOLOGY Copyright © The Author, 2018 Volume 9, Number 2, Winter 2018 ISSN 2068 – 0317 http://compaso.eu The social construction of menopause as disease: A literature review Ilona Voicu1 Abstract Menopause is not only a natural biological aspect of women’s life, but, also, a social construct, mainly due to the contribution of the medical science. The article analyzes, in its first four parts, how this social construction has evolved, starting with the vision of the 19th century and the beginning of the 20th century medicine, that approached menopause as cause of multiple women’s diseases, continuing with the transformation of menopause, in the middle of the 20th century, in a specific disease (the oestrogen deficiency disease), due to the discovery of the synthetic oestrogen and, later, in a syndrome, and finishing with the potential role of the in-vitro fertilization in reconstructing the image of menopausal woman as “useless body”. The last part of the article aims to capture the main feminist critiques of these types of social construction and to stress out some gaps in the Romanian feminist approaches regarding this topic. Keywords Menopause, social construction, disease, feminist critique When you are a woman in your fifties, there are speeches that prepare you for a particular stage of your life: menopause. Most of the things I faced (from a few women I knew and who agreed to talk about it, from doctors, in online media) presented it as a kind of inevitable disease, not a deadly one, but one that is unpleasant enough to require serious preparations, a kind of forefront of strength to help you not become a danger to 1 Faculty of Sociology and Social Work, University of Bucharest, Romania, ilona.voicu@yahoo.com 11 Journal of Comparative Research in Anthropology and Sociology, Volume 9, Number 2, Winter 2018 yourself and to others (see, for example, the article “Be prepared: menopause danger!”, http://www.csid.ro/health/sanatate/fiti-pe-faza-pericol-de-menopauza-8320278/, were the menopause is presented as a phenomenon which affect not only the women, but the entire family). In addition, you are told, it is the equivalent of old age, so why not try to prolong the period you are young, beautiful (or, at least not disagreeable), and socially important? “I won’t become grey and invisible” is a phrase from Germaine Greer’s book, “The Change”2, told by her 50 years old best friend, when they were looking to a middleage woman trying to sneak as fast as possible among the people on the sidewalk. It is a phrase that synthesizes the anxiety of any woman who is preparing to be menopausal or who has already gone through this stage of her life, but, also, is a kind of promise that you will try to not “disappear” yourself, along with the disappearance of your reproductive abilities. Why has a natural biological aspect of our life, as women, become so scary, while others, like pregnancy or maternity, have not? This has always been the perspective on menopause or this is a recent way to represent it? In other words, is menopause only a biological phase in women’s life, or is, also, a socially constructed phenomenon. In order to respond to these questions, the present literature review has the following purposes: • to analyze the main approaches regarding menopause as disease, using historical and cultural differences in order to find out how the image of menopausal woman has evolved; • to find potential research themes regarding the social construction of menopause. Menopause as cause of disease – the vision of the 19th century and the beginning of the 20th century medicine In an article that examines the Victorian attitudes toward puberty and menopause in America, Caroll Smith-Rosenberg (1973) underlines the fact that the medicine of that époque was practiced under the conviction that women are “prisoners” of their reproductive functions. From puberty to menopause, almost all of women’s health issues were explained from this perspective, as consequence of bad function of their reproductive apparatus. According to this author, the consequences of menopause were, at that time, considered to be multiple and diverse, starting with flushes, and going through more serious problems such as paralysis, apoplexy, tumours, tuberculosis, diabetes, etc. Moreover, emotional problems such as hysteria, depression, and irritability, and, also, episodes of insanity were considered quite common for menopausal women, as direct consequence of their new state (Smith-Rosenberg, 1973) or as consequence of continuing to be sexual active at this age, when the sexual intercourse was considered as a “morbid impulse” (McPherson, 1981). 2 12 Germanine Greer (1992). The Change. Women, Ageing and the Menopause. London: Penguin Books, p. 11. Voicu / The social construction of menopause as disease: A literature review But not all medical specialists from this period saw menopause as a negative and critical phase in women’s life. For example, Tilt noted, in his book from 1882, “The Change of Life in Health and Disease” the fact that “the menopausal period could thus become the “Indian summer” of a woman's life - a period of increased vigour, optimism, and even of physical beauty (apud Smith-Rosenberg, 1973, p.65). The predominant vision of menopause as causing serious health problems continued in the beginning of the 20th century. For example, in a edition from 1928 of the Larousse Médical Illustré, menopause is called as “critical age”, and is described as a period in women’s life associated with numerous problems: “circulatory and nervous system disorders occur: hot flushes, congestive thrusts in the face, profuse sweating, feeling of suffocation, heartbeat, hearing disorders, heaviness in the lower abdomen, heartburn stomach, slow digestion, respiratory trouble.” (pp.1040-1041). If menopause had been considered such an important cause of disease for women, what kind of treatment would have been recommended, in order to prevent these associated diseases? The 19th century medicine doesn’t propose specific treatments, but some recommendations regarding the life style are frequently cited in papers and studies regarding this topic. McPherson (1983) underlines the fact that, in the 19th century, the physicians commonly recommended, for menopausal women, “a quiet life-style, avoidance of mental activities, and a commitment to domesticity” (p.101), and Smith-Rosenberg (1973), also, emphasizes that the common vision for that époque, between medical staff, was that women, at this age “should alter their style of life and retire from the world into the bosom of their family” (p.66). At the end of the 19th century, another approach, much more intrusive, became more and more popular in medicine: the gynaecological surgery. It was a perspective based on the theory that all women’s mental disorders have sexual origins. In consequence, these disorders could be prevented by destroying the source – the women’s genital organs (McPherson, 1981). Thus, clitoridectomy, female circumcisions and “castrations” (extirpations of the ovaries) became frequent treatments, inclusive at the age of menopause. In the USA, for example, there were gynaecologists from this period who “boasted that they had removed from 1,500 to 2,000 ovaries apiece” (McPherson, 1981, p.102), and some of them, who had experienced on poor women (most of them black or Irish immigrants) were gain medical rewards and public recognition for their medical contribution (McPherson, 1981). The beginning of the 20th century doesn’t come with remarkable discoveries in this curative approach, but it deserves to be mentioned the fact that the retirement and the isolation are no more the main recommendations. In Western Europe, they seemed to be replaced with a healthy life style: outdoor physical exercises and a diet with green vegetables and fresh fruits (Larousse Médical Illustré, 1928). However, gynaecological surgeries continued to be recommended and practiced, at least in the USA. According to Barker-Benfield (1975), American gynaecologists continue to perform clitoridectomy until 1925, female circumcision at all ages, up to menopause, until 1937, and female castrations until 1910. 13 Journal of Comparative Research in Anthropology and Sociology, Volume 9, Number 2, Winter 2018 For the beginning of the 20th century, an important contribution to the reinforcement of the gynaecology under the menopausal women’s life is represented by the psychoanalytical approach. Freud and his disciples sustained that the menopause is considered as cause of psychic wound. According to Bruck (1979), “Freud believed that previously undisturbed women could become neurotic at the menopause: he said they often get ‘quarrelsome and obstinate, petty and stingy, showing typical sadistic and analerotic features which, they did not show before’” (p.41). Also, one of Freud’s disciples, Helene Deutsch (apud McPherson, 1981) described menopause as a ‘narcissistic mortification’ and a very traumatic phase in women’s life, once fertility ended. Menopause as disease – the role of oestrogen / hormone replacement therapy The menopause started to be treated as a disease relatively recent (in the middle of the 20th century), and this new social perspective is related with a scientific discovery in medicine: the artificial oestrogen. In 1923, doctors discovered that ovaries produce oestrogen and progesterone, two hormones considered responsible for the good health state of women (McPherson, 1981, 1985). In 1938, according to McPherson (1981, p.105), “Diethylstilboestrol (DES), the first laboratory-produced oestrogen was synthesized […] and physicians began to explore the use of synthetic oestrogens in laboratory and clinical research. Menopause […] was investigated as a possible condition for synthetic oestrogen application”. After almost 30 years, mainly due to the work of dr. Wilson, menopause became a disease: the oestrogen deficiency disease, defined by the author of this new ideology regarding menopause, as a dangerous but curable one: “the transformation, within a few years, of a formerly pleasant, energic woman into a dullminded but sharp-tongued caricature of her former self is one of the saddest of human spectacles. The suffering is not hers alone – it involves her entire family, her business associates, her neighbourhood storekeepers, all others with whom she comes into contact. Multiply by millions, she is a focus of bitterness and discontent in the whole fabric of our civilization. And the supreme tragedy is that, in the light of present medical possibilities, all this is unnecessary” (Wilson, 1966, p.94). It’s an apocalyptical image with middle-age women with low levels of oestrogen and high levels of bitterness and anger, ready to destroy the entire humanity. This image of menopause as disease continued to be promoted for decades. More than that, there are authors who tried to convince the audience that the perception on menopause as natural event in women’s life could be more dangerous than they imagine. For example, in an article from 1989, W.H.Utian, the founder of the North American Menopause Society, wrote: “Many women perceive menopause – like menses and pregnancy – as just another physiologic event in the course of female reproduction, and do not seek medical help… We know now that menopausal symptoms must not be ignored. Even asymptomatic menopause may initiate silent, progressive and ultimately lethal sequelae” (p.2). Not only medical literature promoted this image of menopause as dangerous disease, but also the popular literature. Women’s magazines for example were used to create a “collective consciousness of the 14 Voicu / The social construction of menopause as disease: A literature review importance of menopause and the health risks following menopause” (Palmlund, 1997, p.90). Somehow, menopause represents a good example of a reverse medical step. Usually, a disease is discovered or defined, and after that, a cure is searched. For menopause, the treatment was first discovered (synthetic oestrogen), and, in consequence, menopause started to be considered as a disease which could be perfectly cured by using it. Thus, Oestrogen Replacement Therapy (ERT) / Hormone Replacement Therapy (HRT, the European name of the same therapy), became more and more popular between mid-life women from USA and West Europe, not only because seemed to prevent unpleasant symptoms of menopause, but also because it was presented as a possible “fountain of youth”, a panacea for another women’s socially constructed fear: the loss of youth and, implicitly, of beauty (Greer, 1992; Winterich & Umberson, 1999). The popularity of the ERT/HRT was so high, at least in the USA, that, according to Greer (1992), “between 1963 and 1973 sales of oestrogen preparations quadrupled; half of the post-menopausal female population was using HRT …” (p.185). Once the therapy was discovered and used, a lot of medical studies started to be conducted, in order to prove its benefices, but the results of these studies remained controversial. According to McKinlay and McKinlay (1973), there are, at least, two main methodological issues: a lot of them are general reports, based on observation or experience, “presented with no data or with data from vague or unevaluated sources” (p.535), and, also, a good part of them used only clinical trials, ignoring women who never see a doctor during their menopausal live. Another type of medical studies failed to demonstrate that some symptoms are strictly associated with menopause, and concluded that they are rather signs of aging (MacPhearson, 1981), or symptoms (such as depression, tiredness or headaches) which could be associated with various causes and phases of life (Kaufert, 1982). Others started to associate HRT with serious health issues, such as endometrial or mammal cancer (Greer, 1992; MacPherson, 1985). More and more, studies and articles emphasized the fact that HRT is far from being risk-free and is, in fact, a way to socially reconstruct, as a disease, a natural stage in women’s lives, in order to serve the interests of the pharmaceutical and medical fields (Palmlund, 1997). Menopause as syndrome – the role of HRT’s risks and alternative and complementary medicine In the ‘70s – ‘80s, due to the studies which related HRT with uterine and mammal cancer, as it is mentioned above, menopause started to be treated rather as a syndrome than a disease: it is no longer presented as an oestrogen deficiency disease, and more and more as a natural phenomenon, but associated with a lot of unpleasant signs and symptoms, such as osteoporosis, and cardiologic risks. The medical discourse changed, but the remedy remained the same: HRT. As MacPherson (1985, p.12) underlines, “now, that ERT had been implicated in the increase in uterine cancer, a new rationale was needed to promote its use. In the United States, the future of the metaphor of menopause as a treatable disorder was seen as lying in its transformation from disease to syndrome”. 15 Journal of Comparative Research in Anthropology and Sociology, Volume 9, Number 2, Winter 2018 Consequently, hormone pills continued to be prescribed, using, often, the argument that the cancer risks are limited, but the unpleasant and painful associated symptoms are much more frequent (Callahan, 1993). This approach is, also, valued by the alternative and complementary medicine (ACM), which seems, nowadays, to be more and more preferred by menopausal women, as a safer alternative to HRT. But is ACM more efficient and safer? In an extensive study, using three databases from January 1980 to April 2002, Kang, Ashbacher and Hammoud (2002) had been studied the effects of some complementary and alternative therapies, such as phytoestrogens (soy compounds relatively similar with oestradiol), ginseng, and acupuncture on symptoms usually associated with menopause: hot flashes, night sweats, and osteoporosis. Their conclusions underline that “there are insufficient data at this time to make any conclusions on their potential efficacy and safety for the treatment of symptoms in menopausal women” (p.204). In another study, Hill-Sakurai, Muller and Thom (2008), based on semi-structured interviews conducted on 44 women recruited from primary care clinics, concluded that the decision to use ACM is based, in almost all cases, on the belief that is “natural”, but the mean of “natural” vary from being gentler and safer than classical medication to the continuity of familial tradition according to whom their mothers and grandmothers used this kind of therapy in order to diminish their menopausal symptoms such as hot flashes or sweats. The potential role of the in vitro fertilization (IFV) and its potential impact on the social perspective of menopause Starting with the last century, medical science created and encouraged an entire industry of maternity, helping women (or, at least, rich or middleclass women) to decide when and how to give birth to their healthy, perfect children. According to Franklin (1995), for example, the human reproduction, due to the medical and scientific progresses, loss its natural character and became, more and more, a professional procedure. An important part of this medical and technological progress is represented by the in-vitro fertilization (IFV) which made reproduction possible for some persons who couldn’t become parents otherwise. Menopausal women perfectly feet with this category, because the “death” of their ovaries, as barrier to maternity, seems to be seriously challenged by IFV, as alternative that could change the image of menopausal woman as non-reproductive one. IFV allows them to become mothers, even after their reproductive capacities failed. But, despite this appearance of opportunity, IFV has ethical and social implications that deserved to be taking into consideration. Firstly, the main objection consists in the fact that is not a “natural” or “normal” process. As Cutas and Smajor (2015) underlined in their article, “what causes controversy is ‘motherhood after the normal age of menopause’, because what the objectors are concerned about is not the presence or absence of menstruation itself, but advanced age and questions of normality” (p.388). Secondly, the argument of the ‘abnormality’ often takes the concrete form of ethical objections which question the reasons why women of a certain age want to become mothers, as well as the medical teams’ motivation. For example, starting to the case of 16 Voicu / The social construction of menopause as disease: A literature review Adriana Iliescu, the oldest woman who gave birth at that date, Cutas (2007) analyzed the three most common objections against post-menopausal motherhood: “(1) the age of the mother; (2) the fact that she was single, and (3) the fact that her motivations and those of the medical team were based on selfishness, and the desire for fame respectively” (p. 459). But, according to her analyze, there are arguments which make these objections seem hypocritical: there are different other categories of parents who put their children in risk to become prematurely orphans (such as military personnel), as well as younger single parents and there is no ethical debate to question their rights to procreate. In fact, debate consists in a confrontation between the right to autonomy and the medical/societal right to control this autonomy (Cutas & Smajor, 2015). The feminist critique of the construction of menopause as disease One of the most consistent critiques regarding the medicalisation of the menopause is represented by the feminist approach. This critique, mainly initiated as a reaction to the more virulent marketing of menopause from the ‘60s – ‘70s, following the discovery of artificial oestrogen, has few important directions. Firstly, the feminist authors who analyzed the role of the 19th century and the beginning of the 20th century medicine in this process underlined the fact that in that stage, medicine encouraged the social image of women as “defective” versions of men: their physical experiences, such as menstruation, pregnancy, birth and menopause are considered as pathological and treated in consequence (Berger, 1999). Thus, the process of medicalisation of menopause is viewed as part of a patriarchal society, in which gender represent a power relationship, a relationship of social control of the women’s bodies: “the history of how the body, and in particular the female body has been brought under medical control is a history of social control, where professionals trained in scientific medicine have repeatedly asserted their dominance against other groups engaged in health care and where they also often acted in the interests of the dominant groups in society” (Palmlund, 1997, p.91). And thinks seems that doesn’t change very much until now. For example, as an aspect subsumed to the previous, there are feminist authors who reproached 20th century medical literature dedicated to menopause that is mainly produced by men, even though is an exclusively feminine experience, and, often, the image and expectancies of women regarding their own menopause are shaped in consequence: “through the literature on menopause is vast, almost none of it has been written by women. Most of it has been written by men for the eyes of other men; thousands of middle-aged women troop meekly through the pages of hundreds of studies assessing their health, their well-being, their status, their needs, their opportunities, and their problems and we hear hardly one word in their own voices” (Greer, 1992, p.13). Even though, from the moment Greer wrote her book, things went through a few changes, and women began to write more about their own experiences on topics previously considered taboo, those experiences continued to be considered as less socially and politically important, directly connected with nature and the private sphere, meanwhile the public domain is a male dominated one. Feminists consider this dichotomy 17 Journal of Comparative Research in Anthropology and Sociology, Volume 9, Number 2, Winter 2018 as politically relevant and as expression of the patriarchy: “Women are equipped to carry and give life. This fact is politically relevant, even if, for example, politics, like theorists of politics, seem to have given more importance to wars than to birth. […] The political control over the female reproductive faculties is a constant in the history of the patriarchy” (Miroiu, 2004, pp.44-45). In this process of transformation of women’s experiences in natural, private, and, in consequence, socially irrelevant ones, the medicalisation of menopause perfectly feet, from a feminist perspective: “The medicalisation of the natural ending of the reproductive cycle was a political achievement rather than part of the inevitable process of medical science […] Public and political institutions contributed to the creation of menopause as disease” (MacPherson, 1985, p.12). Secondly, there are feminist researchers or, at least, researchers inspired by the feminist approach, who dedicated their work to the cross-cultural and generational differences of the menopausal experiences of women, started to the main hypothesis that it represents a social and cultural mediated experience. In an article which examines the differences of menopausal experiences between different categories of middle-aged women (rural and urban women, women with non-English speaking backgrounds, etc.), based on a research conducted on 140 women, using the focus-group technique, Daly (1995) concluded that the interpretation of menopausal ‘symptoms’ is socially mediated, and both gender and age contribute to the negative cultural stereotypes regarding the social importance of middle-aged women. In another articles, regarding the menopausal experiences of women from specific countries, Lock (1995) and Chirawatkul & Manderson (1994) dedicated their studies to mythologies of menopause in Japan and North America, respectively to the perceptions of menopause in Thailand. Their conclusions are similar, underlined the importance of the cultural context in the auto-perception of menopause. The importance of the birth cohort differences in the understanding subjective menopausal experiences of the American women from different generations is, also, underlined in a qualitative study conducted on 24 middle-aged women, interviewed in their homes (Utz, 2011). All these study results contradict the universality of the image of menopause as disease, and reinforce the idea that, in fact, this social construction of the menopause can be seen, for example, as part of a public discourse that attempts to control the effects of the aging of the female body, which loses its social significance with the loose of the reproductive capacity (Lupton, 1996). Thirdly, there are studies which emphasize the fact that, beyond signs and symptoms, for middle-aged women, there are stressful life events (such as loss of their jobs, the fact that their children leave home, or another health issues) that marked their perception about life. Additionally, some research findings underlined the pressure of medical specialists on menopausal women, in order to make them subjects of the HRT, even they don’t need or don’t want to: “The medicalization of menopause by doctors may profoundly affect a woman’s menopausal experience. The three women in this study who did not know perimenopause had begun until their doctors examined them all received recommendations to begin HRT, even though two of them continued menstruating. A fourth woman reports that her doctor frightened her into trying HRT 18 Voicu / The social construction of menopause as disease: A literature review even though she repeatedly told him she was not interested” (Winterich & Umberson, 1999, p.64). Finally, another feminist perspective questions the entire idea of “maternal instincts” and the role of the medical science in glorifying pregnancy, and underlines that the whole debate about postmenopausal motherhood due to IFV should be translated from menopausal women’s and medical teams’ responsibilities to the social structure. This social structure is viewed as patriarchal in essence, “forcing” women to socially legitimate themselves mainly as caretakers of their own children: “the trouble with prevalent social attitudes today is that they carry unreflectively the old patriarchal glorification of the ‘seed’ that incorporates a notion of children as property, women as caretakers and biology as destiny” (Smith, 1993, p.102). The Romanian feminist approaches regarding menopause are a very few. The mention of menopause as exclusive female experience (like pregnancy, birth, and abortion) in the Mihaela Miroiu’s book, “The way to autonomy” (1994), permits the author to mention, also, the cultural differences between the mainstream perception and the way in which menopausal Roma women are perceived in their communities (as gifted with wisdom, due to the fact they are no longer sexually attractive, and, in consequence, ‘purified’). Also, “The Feminist Lexicon” (2002) contains a short description of menopause, but, despite the fact that some prejudges regarding the association between attractiveness and women’s age are mentioned, most of the content of this description is basically centred on the description of the signs and symptoms of menopause, including non-specific ones, such as insomnia, loss of memory and of concentration, urinary issues, etc. That is, in fact, a reinforcement of the medical perspective on menopause, far away from another feminist approaches, such those mentioned above. Consequently, there are a lot of opportunities to investigate, for a gender sensitive perspective, which are the main subjective ways to percept menopause for the Romanian women, and which are the most important social aspects (such as economical or marital status, ethnicity, etc.) that mediate the construction of this perceptions. REFERENCES Barker-Benfield, B. 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Dragomir, O., Miroiu, M. (2002). Lexicon Feminist. Iași: Polirom. Franklin, S. (1995). “Postmodern Procreation: A Cultural Account of Assisted Reproduction” in Faye D. Ginsburg & Rayna Rapp (Eds.). Conceiving the new world order: the global politics of reproduction. Berkeley, California, University of California Press: 323-345. Greer, G. (1992). The Change. Women, Ageing and the Menopause. London: Penguin Books. Hill-Sakurai, L.E., Muller, J.,Thom, D.H. (2008). “Complementary and Alternative Medicine for Menopause: A Qualitative Analysis of Women’s Decision Making”. Journal of Internal Medicine, 23(5): 619 – 622. Kang, H.J., Ansbacher, R., Hammoud, M.M. (2002). “Use of alternative and complementary medicine in menopause”. International Journal of Gynaecology and Obstetrics, 79: 195 – 207. Kaufert, P.A. (1982). “Myth and menopause”. Sociology of Health and Illness. 4(2): 141 – 166. Lock, M. (1995). “Encounters with aging: Mythologies of menopause in Japan and North America”. 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Indiana University Press: 92 - 119. Smith-Rosenberg, C. (1973). “Puberty to Menopause: The Cycle of Femininity in Nineteenth-Century America”. Feminist Studies. 1(3,4): 58 -72. Utian, W.H. (1989). “Renewing Our Commitment to the Remaining 85%”. Menopause Management. 2(1,2): 1 – 6. Utz, R.L. (2011) “Like mother (not) like daughter: The social construction of menopause and aging”, Journal of Aging Studies, 25(2), 143 – 154. Wilson, R.A. (1966). Feminine Forever. New York: M. Evans. 20 Voicu / The social construction of menopause as disease: A literature review Winterich, J.A., Umberson, D. (1999). “How Women Experience Menopause: The Importance of Social Context”. Journal of Women and Aging. 11(4): 57 – 73. Larousse Médical Illustré (1928). Paris: Librairie Larousse. Ilona Voicu graduated, in 1992, undergraduate studies at the University of Bucharest, Faculty of Sociology, Psychology and Pedagogy (specializing in Psychology). Between 2009 and 2011, she attended the Master's degree “Policies, Gender and Minorities” at the Faculty of Political Science of the National School of Political and Administrative Studies (SNSPA). Starting with 2018, she is a PhD Student at the School of Sociology and Social Work/University of Bucharest, with a thesis regarding the social construction of menopause of Romanian women. She is working as researcher at the Romanian National Military Centre of Psychology and Behavioural Health/Romanian Ministry of National Defence. She has a 20 years’ experience in the social research, in areas such as military families support, soldier’s reintegration after missions abroad, gender and sexual violence in the military, and cross-cultural studies. 21