Amhiv for
Arch. Gyn~k. 223, 9-18 (1977)
Gynfikologie 9
J. F. Bergmann-Verlag 1977
Ethnieity and Adaptation to Climaeterium B. Maoz 1' 4, A. Antonovsky 2, A. Apter 1, H. Wijsenbeck 1, and N. Datan a i Geha Psychiatric Hospital, Beilinson Medical Centre, Tel Aviv University Medical School and the William S. Schwarz Institute for Psychiatric Research and Treatment, P.O. Box 72, Petah-Tikwah, Israel z The Israel Institute of Applied Social Research and the Faculty of Health Sciences, Ben Gurion University of the Negev, Beersheba, Israel 3 Department of Psychology, West Virginia University, Morgantown, W. Va., USA
Summary. An investigation was made into the menopausal symptoms and attitudes of 1,148 Israeli women of five different ethnic origins. The results show that, while some of the somatic menopausal symptoms are independent of ethnic origin, psychic and psychosomatic symptoms are more closely associated with this variable. Similarly, the general health of menopausal women also varies with cultural origin. This variation is shown to correlate with the psychic and psychosomatic symptomatology of the climacterium. This study underlines the necessity of a multi-factorial, biological, sociological, psychological and anthropological approach to problems of menopause. Key words: Climacterium - Menopausal s y m p t o m s - Ethnic origin-- Psychic and psychosomatic symptoms.
Introduction A recent international congress has defined menopause (Utian) as: a) the phase in the aging process of women marking the transition from the reproductive to the nonreproductive stage of life -- the "climacteric"; b) the final menstrual period - "menopause" proper - this occurring during the climacteric. The climacteric is sometimes, but not necessarily, associated with symptomatology, which is designated "the climacteric syndrome". The symptoms can be divided into three main components: a) symptoms due to decreased ovarian function and hormonal insufficiency in the early stages, hot flushes, sweats, atrophic vaginitis, and later, symptoms due to metabolic changes in the end organs affected; b) symptoms reflecting the social and cultural components of the environment; c) symptoms reflecting the specific personality. The variability of the symptomatology is dependent on the interaction of these three components. Can we, however, be more precise than this general statement? 4
Offprint requests to:
B. Maoz (address see above)
10
B. Maoz et al.
On the one hand, it is possible that the component (a) is most significant; in this case, we would expect universalistic patterns of symptomatology. On the other hand, if personality factors are decisive, we would expect to find a substantial degree of individual variability even within relatively homogeneous cultural groups. Recent literature, however, (Neugarten, Dowty-Datan, van Keep, Flint, Hallstrom, Lauritzen, McKinley, Prill) has suggested that psycho-socialcultural factors may have a considerable role, pointing to large group differences. This might be the case, particularly if one considers the distinction between somatic, psychosomatic and psychological symptomatology. The first concern of this paper, then, is to clarify the relative roles of the three components of the climacteric syndrome, with a particular focus on the role of the socio-cultural environment. Adequacy of adaption to the challenge of the climacterium is a complex process. A pilot investigation (Maoz and Dowty) indicated four major foci for evaluation of this process: a) climacteric symptomatology per se; b) the "gains" versus "losses" balance experienced by the woman on reaching the climacterium; c) her "worries" and her "satisfactions" in each different area of living (her "degree of happiness", and d) her general state of physical health. These have been found to depend not only on objective somatic pathology, but also to be functions of psychosexual and social adaption as well as ethnocultural origins. These relationships and their importance for successful adjustment to the climacterium form the second concern of this paper. Our particular interest was in testing the hypothesis that women of Western ("modern") cultural origin would differ in their reaction to the climacterium from women from Oriental ("traditional") cultures 1. We did not commit ourselves in advance to the specific direction of such differences, since we felt that we could make a good case for prediction in either direction. On the one hand, one could postulate that the Western woman would regret the lack of full."use" of the reproductive period of her life, it now being "too late" to correct a "basic mistake". In contrast, the Oriental, traditional woman would feel relieved of the "yoke" of almost continuous pregnancy and childbearing, thus ensuring her a smoother passage over the climacterium. It would, however, be equally plausible to reason otherwise. The basis for the Western woman's self-identity is far broader than is that of the Oriental woman. The former has, long before climacterium, made peace with having few children, and has entered other meaningful roles in life than that of mother and housewife. She may even see menopause as liberating. The latter, by contrast, has for so long, in her own eyes and in those of her husband and others, been identified as primarily mother and housewife that climacterium may well come as a shock. (For an extended discussion of these issues, see Dowry, 1971, ch. 1.) The difficulties in adjusting to the climacterium may result in somatic manifestations. This, in turn, could lead to an increase in menopausal symptomatology and to deterioration of general health. 1 In Israel, "Western" is used to referto Jews of European origin, and "Oriental"to Jews originating in Moslem countries
Ethnicity and Adaptation to Climacterium
11
Population and Methods Owing to the multi-ethnic character of its population, Israel offers a rich opportunity for the study of the climacterium cross-culturally. Five population groups, four Jewish and one Arab, were assessed. The groups were chosen as reresenting the fullest possible range of the urbanised, modern woman through to the rural, traditional woman. The intra-group populations were largely homogeneous as to residential area and socio-economic status. All women were between ages 45 and 54 at the time of interview. The first group, of Central European origin, was drawn from an urban, middle class area near Tel Aviv. A second group, of Persian origin, and a third, of Turkish origin, were drawn from an urban, lower socio-economic area in Tel Aviv. The fourth group, of North African origin, came from two small cities in the Judean foothills, while the fifth group was taken from two all-Arab villages in central Israel. (The above coincides with the known demographic concentrations and socio-economic status of the ethnic groups studied.) All five samples were selected at random from the Population Register. (For sampling details, see Maoz and Antonovsky.) A total of 1148 women were interviewed in their homes: 287 Central Europeans, 176 Turks, 239 North Africans, 165 Persians and 286 Arabs. After the interview, 697 women were invited and came to a full medical examination. In order to see our investigation in perspective, we must review some of the socio-demographic variables involved. The five ethnic groups fall into three major types. At one extreme are the Jewish women of Central European origin. They are all literate, married after the age of 20 to partners of their own choice, and are most likely to have had at most three children. Though the children are probably no longer at home, only a third have grandchildren. Most are veteran Israelis, having immigrated before 1948. They are not religious, and most of their leisure time is spent with the husband. About a third of this group were in concentration camps during World War II (Antonovsky). The opposite extreme is typified by the Arab village women. They are most often illiterate, married before 20 (a third before 16) to a partner of parents' choice. They have more than five children living and histories of frequent miscarriages. By the time of climacterium, they are usually grandmothers but still have young children living at home. Leisure time is sex-specific. Most husbands are farmers or manual labourers. The other three groups can best be charaeterised as "transitional" between traditional and modern. The Turkish women tend, on the whole, to be somewhat closer in the above respects to the Central Europeans. The North Africans and Persians, on the other hand, are closer to the Arabs in marriage and childbearing patterns, literacy and education, religiosity, occupational status of husband and leisure time patterns. The socio-demographic data on the five samples completely supported our initial assumption regarding the relationship between ethnicity and traditionalism-modernity which led us to select these five groups. The five groups align as follows: Central European... Turkish... North African... Per-
sian... Arab. At least 80% in all groups were married at the time of the study, and less than I0% had undergone hysterectomy (surgical menopause). 30% of all the women were premenopausal (menstruating regularly), 17% were peri-menopausal (menstruating irregularly) and about 45% were completely postmenopausal (non-surgical). There were no significant differences among the five ethnic groups in regard to the above variables.
Interview Schedules T h e d a t a t o b e c o n s i d e r e d in this p a p e r , in line w i t h o u r t w o m a j o r a r e a s o f c o n c e r n , w e r e o b t a i n e d as f o l l o w s :
9 a) Menopausal Symptoms T h e 25 m e n o p a u s a l s y m p t o m s d i s c u s s e d b y N e u g a r t e n w e r e p r e s e n t e d t o e a c h subj e c t , o n c e in the c o u r s e o f the i n t e r v i e w , a n d a g a i n at the m e d i c a l e x a m i n a t i o n , as " p r o b l e m s w o m e n s o m e t i m e s h a v e " (see T a b l e 1), in r a n d o m o r d e r .
B. Maoz et al.
12 Table !. Menopausal Symptom List Somatic symptoms 1. 2. 3. 4. 5. 6. 7. 8. 9. 10.
Diarrhoea Constipation Pains in back of head or neck Breast pain Cold sweats Numbness and tingling in hands and feet Cold hands and feet Hot flushes Rheumatic pains Weight gain
Psychosomatic symptoms 1. 2. 3. 4. 5.
Pounding heart Dizziness Tired feeling Black spots in front of eyes Headaches
Psychic symptoms 1. Nervousness 2. Inability to concentrate 3. Crying spells 4. Feeling depressed 5. Instability 6. Forgetfulness 7. Sleeping badly 8. Fear 9. Worry about going insane 10. Feeling of suffocation
Each w o m a n was asked to say whether "during the past year you were troubled by the problem often, infrequently, or not at all". These responses were scored 1, 2 or 3 respectively, so that the lower the score the greater the symptomatology. In addition to the overall raw score, three subscores were calculated, relating to the 10 psychic, 10 somatic and 5 psychosomatic symptoms.
b) Physical Health Status Both subjective self assessment and an objective physician's evaluation were obtained - the latter after a thorough medical examination. Self assessment was made in terms of overall health, the taking of medication and painful sensations of mild and/or moderate severity. The physician was asked to comment on: 1. the overall impression of good or bad health; 2. limitation of activity in everyday life; 3. the presence of a severe chronic medical condition; 4. the need for medical attention; 5. the presence or absence of physical and emotional symptoms (see Table 4).
Results
Menopausal Symptoms. The data are presented in Table 2. It will be recalled that the higher the score, the lower the symptomatology. Total menopausal symptom scores by ethnic group ranged from 53.0--57.7 (the maximum being at the interview, and from 5 4 . 1 - 6 0 . 9 at the medical examination). Although the overall differences
13
Ethnicity and Adaptation to Climacterium Table 2. Menopausal symptom scores by ethnic group
Overall menopausal symptom score a) Interview (n = 1148) b) Examination (n = 697) Psychic symptom score (interview) Psychosomatic symptom score (interview) Somatic symptom score (interview)
Europeans
Turks
N o r t h Persians Arabs Africans
57.7 59.2 23.2 10.9 23.9
55.2 56.6 21.5 10.2 23.7
55.2 56.6 21.6 9.8 23.0
53.0 54.1 20.8 9.4 22.9
54.7 60.9 21.9 10.5 22.8
among the ethnic groups are not statistically significant, it is clear that the Persian women had the greatest degree of symptomatology on both occasions. The European women are found at the other extreme: they report having the least symptomatology, apart from the Arabs, on examination. The score was given on the basis of 1, 2 or 3 for the response to each question. Though, the theoretical range was: Psychic 1 0 - 3 0 - 10 items, Psychosomatic 5 - 1 5 - 5 items, Somatic 1 0 - 3 0 - 10 items. The higher the score, the fewer the symptoms. Note: There are minor discrepancies between the sums of the sub-scores and the overall score which derive from the coding instructions of not including women who failed to answer a given number of items on a given sub-scale. The sub-scale symptom mean scores by ethnic group appear in the lower part of Table 2. The results of the statistical comparisons of paired ethnic groups on each of the three sub-scales appear in Table 3. On all three, the Europeans report least symptomatology. The difference between them and the other four ethnic groups is statistically significant on the psychic and psychosomatic items (except, on the latter, between Europeans and Arabs). The Persians report significantly more psychosomatic symptoms than do the other groups; on the psychic items, the trend is in the same direction, but falls short of significance. On both the psychic and psychosomatic items, the Arabs are the second most "healthy" group. This is not, however, the case on the somatic symptom score. As a matter of fact, the somatic symptom sub-group, comprising "real" or "hard" symptoms, including the classic hot flushes and sweats, showed no significant differences at all among the five ethnic groups. In summary, it seems as if Jews from Persia and, to a lesser extent, North Africa, complain more about psychic and psychosomatic symptoms than do Central European Jews and Arabs, but there are no real somatic symptom differences among the groups.
Procedure 1. Chi square test used for significance. 2. The frequency distribution of the total population was examined for each of the three symptom scores separately. Cells were collapsed in order to arrive at a
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B. Maoz et al.
Table 3. Tests of significance on three menopausal symptom scores, between pairs of ethnic groups Psychic
Psychosomatic
Somatic
x2
Significance level
x2
Significance level
X2
Significance level
27.84 17.92
p < 0.001 p < 0.01
30.77 9.67
p < 0.001 p < 0.05
N.S. N.S.
European-N. African 19.73 European-Arab 13.36 Persian-Turkish 6.82 Arab-Turkish 2.2 Turkish-N. African by inspection Persian-N. African 5.17
p < 0.001 p < 0.01 N.S. N.S. N.S.
25.47 3.88 24.55 6.07 9.49
p < 0.001 N.S. p < 0.001 N.S. p < 0.05
8.3 by inspection 8.14 14.74 6.79 5.31 5.86
Persian-Arab
5.4
N.S.
10.9
p < 0.02
N. African-Arab
5.88
N.S.
10.91
p < 0.02
European-Persian European-Turkish
N.S.
7.45
p < 0.05
by inspection by inspecfion by inspecfion
N.S. p < 0.01 N.S. N.S. N.S. N.S. N.S. N.S.
quintile or quartile distribution, in such a way as to equalize, as much as possible, then in each cell for the total population. Distributions of the ethnic groups were disregarded at this point. 3. Each pair of ethnic groups was then compared, on each symptom score to see if the distribution differed significantly. Original score given on basis of score of 1, 2 or 3 for the response to each question. Thus theoretical range was: Psychic ( 1 0 - 3 0 -- 10 items), Psychosomatic ( 5 - 1 5 -- 5 items), Somatic ( 1 0 - 3 0 - 10 items). Coded scores entered and punched in 9 categories, which meant collapsing at most two adjacent categories.
Physical Health Status The results of the physical health state evaluation are summarised in Table 4. The following points are of special note: 1. There were highly significant differences between the various ethnic groups as to the quantity of medication consumed - from 70% of regular medication amongst Persian women through 66% of the other Jewish women to 20% of Arab women. Also, an enquiry was made into the nature of the medicines taken. In this respect, it was found that very few were receiving sex hormone therapy (6% of European women to none of the Arab women). 2. The overall subjective evaluation referred a) to painful sensations, and b) to general feelings of being in good health.
15
Ethnicity and Adaptation to Climacterium Table 4. Selected responses (percentage) to medical examination. - Items in ethnic groups Item
% taking medication regularly % reporting mild pain % reporting moderate or severe pain % with quite good or excellent overall health: Self assessed Physician rating % with poor or very poor overall health: Self assessed Physician rating % with moderate or severe activity [imitation % with serious chronic condition % not requiring medical attention % with moderate somatic symptoms % with none or mild somatic symptoms interfering with function % with no evidence of emotional symptoms
Area of birth Europe
Turkey
North Africa
Persia
Palestine (Arabs)
Chi square test (df = 4) of significance
58
64
64
70
22
p < 0.01
20 33
25 30
27 27
90 43
31 41
p < 0.01 N.S. p < 0.05
61 55
40 37
47 62
22 24
56 59
p < 0.01 p < 0.01
9 3 12
11 4 13
13 4 10
20 9 21
16 4 31
N.S. p > 0.05 N.S. p > 0.05 p < 0.01
21
18
14
31
17
21
21
23
14
33
p > 0.05 (just) p < 0.05
18
13
13
26
30
p < 0.01
58
42
71
37
57
p < 0.01
46
34
49
24
52
p < 0.01
Milder painful symptoms were reported by 90% of the Persian group as opposed to 2 0 - 3 0 % of the other groups. They also had a tendency to report moderate or severe pain more frequently than the other women - a tendency shared by the A r a b sample. Only one-fifth of the Persians were prepared to admit to subjective feelings of good overall health. This contrasts dramatically with the 56% of A r a b women who felt well despite an almost equal prevalence of painful sensations of more than moderate severity. 3. The physician's rating of overall health was based on a thorough medical examination, and took into account specific disease entities, functional limitations, the need for medical treatment and physical and emotional symptoms. Once again, the Persians have a significantly lower degree of good health and axiomatically, a tendency to have poorer health. The groups at the extreme ends of the moderntraditional spectrum (Arabs and Europeans) had the best health, though not necessarily the least severe ill health. It is interesting.that subjective self evaluation and objective physician rating of good health correlated closely, except in the case of the
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B. Maoz et al.
North Africans who assessed themselves as far less healthy than they really were. All groups tended to overestimate their overall poor health: the Persians and the Arabs tended to do this more frequently. However, this tendency does not reach significance between groups. 4. Limitation of activity was defined as any interference, because of ill health, with the normal daily activities of women at this age. The Arabs and Persians show relatively more significant limitations than the other groups. 5. The presence of a serious medical disorder was based on the finding of either a definite and severe chronic condition or an acute illness of lifethreatening dimensions. Here, too, the Persians tended to be prominent - the other groups being very close together in this respect. An important feature, not noted in the Table, was that very few women were given a clean bill of health (only 4% of the Persians and 7% of the Turks!). 6. At least two-thirds of the subjects were considered to require medical attention. Only 14% of the Persian women at the age of menopause were found not to require treatment! 7. Arab women either had more moderate physical symptoms than other groups or no physical symptoms at all. Though, it seems as if the physicians tended to see this group as either in very good or very poor health. Persian women were more consistently seen to have more subjects with moderate somatic symptoms and the least number of symptom-free individuals. Conversely, the North Africans were the most symptom-free of the whole sample. 8. Emotional symptoms followed a similar pattern, Persians having considerably more suffering than all the other groups in this respect.
Discussion At the outset, we must state that we are compelled to reject our preliminary hypothesis. We anticipated, it will be recalled, a linear relationship between responses to the climacterium and the traditionalism-modernity continuum. It appears that the matter is far more complex. The first striking feature of our results is the stability of the somatic or "hard" symptoms independent of the ethnic variable. This confirms Novack's original opinion that only the vasometer symptoms are definitely hormone-related and are "objective". The second point to be noted is the relatively low level of psychic and psychosomatic complaints in the Central European and Arab groups. This finding, with regard to the former, confirms Jaszmann's findings that higher income and education are correlated with an easier menopause, and could be thought to result from the "liberation" of women from traditional female stereotypic roles (Dowty). However, the fact that the most traditional of the five ethnic groups, the Arabs, also showed the least symptomatology, while the transitional groups showed the most symptoms, in spite of the fact that they are more modern than the Arabs, points to the involvement of other factors. We would suggest that the crucial factor is the relative cultural stability of the group and its degree of adaptation to its present surroundings. The Arabs have, of course, been resident in their villages for genera-
Ethnicity and Adaptation to Climacterium
17
tions, while the Central Europeans constituted one of the early waves of immigration to Israel. In socio-economic terms, they have achieved the highest standard of all ethnic groups, and are clearly part of the dominant sub-culture of Israefi society. In this respect, it should be stated that the Persians are, of the five groups, in the least stable situation, culturally and economically. The most consistent finding to emerge from the physical health assessment, was the poor physical health of the Persian Jewish group. It is obvious that the eight assessment categories are not independent of each other, yet the other four groups varied significantly in the different items. In contradistinction, the Persian sample is to be found consistently at the "sick" end of the spectrum. Physician bias may be discounted on the grounds that the other ethnic groups of Eastern origin who resemble the Persians, North Africans and Turkish Jews, showed completely different patterns of physical health. Two other less definite tendencies emerge from this part of the investigation: 1. The relative good health of the North African group (despite a subjective bias towards denying this). 2. The position of the Arab group at the extreme ends of the health spectrum, i.e. they are either very healthy or very sick and rarely "in-between". There is a clear-cut cluster of findings regarding the Persian Jewish sample, viz. more psychic and psychosomatic symptoms in the climacterium, in addition to a poor general health status. Therefore, it can be stated that an increase in psychic and psychosomatic symptoms (but no "hard" somatic symptoms) is associated with poor general health. The common denominator in this instance probably is the relative unstable socio-economic and psychosocial condition of Persian Jews compared with the other ethnic groups investigated (Maoz).
Conclusion
This study demonstrates the importance of ethno-cultural considerations in the shaping of the psychic and psychosomatic symptoms of the climacterium. Both these factors are, in turn, interrelated with the general health status of the population at risk. The fact that Arab and European women suffer least from such symptomatology and Persians the most is probably related to basic socio-economic and psychosocial integration into and stability within Israeli society at large. The modern-traditional spectrum is probably less important than first hypothesised. It is clear that Jaszmann (1973) is correct in stating that further research into the symptoms and treatment of menopausal symptoms must take into account ethnocultural backgrounds. The importance of general health is also fundamental. Acknowledgements. The project on which this paper is based was supported by a grant from the U.S. National Institute of Mental Health (AgreementNo. 8 MH-43-01) to the Israel Institute of Ap~ plied Social Research, Jerusalem.
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References 1. Antonovsky, A., Maoz, B., Dowty, N., Wijsenbeek, H.: Twenty-five years later: A limited study of the sequelae of the concentration camp experience. Social Psychiatry 6, 186-193 (1971) 2. Dowty, N., Maoz, B., Antonovsky, A., Wijsenbeek, H.: Climacteric in three cultural contexts. Trop. and Geograph. Medicine 22, 77--86 (1970) 3. Dowty, N.: Women's attitudes toward the climacterium in five Israeli subcultures. The University of Chicago: Ph.D. Thesis 1971 4. Flint, M.: Menarche and menopause of rayput women. Dissertation. New York: City University Graduate Centre 1974 5. Hallstrom, T.: Mental disorder and sexuality in the climacteric. Scandinavian University Books 1973 6. Jaszmann, L.: Op weg naar een nieuwe levensfaze. Voorlichting over de overgangsjaren. Van Loghum Slaterns Deventer 1973 7. Van Keep, P., Kellerhals, J. M.: The impact of socio-cultural factors on symptom formation. Psychother. Psychosom. 23, 251--263 (1974) 8. Van Keep, P. A., Kellerhals, J. M.: The aging woman. About the influence of some social and cultural factors on the changes in attitude and behaviour that occur during and after menopause. Acta Obs. Gynec. Scandinavia Suppl. 51 (1975) 9. Lauritzen, C.: The female climacteric syndrome: Significance problems, treatment. Acta Obs. Gynec. Scandinavia Suppl. 51 (1975) 10. McKinley, S. M., Jeffers, M.: The menopausal syndrome. British J. of Preventive and Social Medicine 28, 108 (1974) 11. Manz, B., Dowty, N., Antonovsky, A., Wijsenbeek, H.: Female attitudes to menopause. Social Psychiatry 5, 35--40 (1970) 12. Maoz, B.: The perception of menopause in five ethnic groups in Israel. University of Leyden, Holland: Thesis 1973 13. Maoz, B.: Menopausal symptoms in five ethnic groups in Israel. Paper. 4th International Congress of Psychosomatic Obstetrics and Gynaecology. Tel Aviv, 1974. (Published by S. Karger 1975) 14. Neugarten, B., Wood, V., Kraines, R. J., Loomis, B.: Women's attitude towards menopause. Vita Humana 6, 140 (1963) 15. Neugarten, B. L., Kraines, R. J.: Menopausal symptoms in women of various ages. J. Psychosomatic Medicine 27, 266-273 (1968) 16. Prill, H. J., Lanritzen, C.: Das Klimakterium. Klinik der Frauenheilkunde und Geburtshilfe, pp. 341-417. Mfinchen-Berlin-Wien: Urban and Schwarzenberg 1970 17. Rennie, T. A. C., Srole, F.: Social class prevalence and distribution of psychosomatic conditions in an urban population. Psychosomatic Med. 18, 449 (1956) 18. Utian, W. H.: Summary and conclusion of a workshop on the climacteric syndrome. Held at the 1st World Congress of Menopause. Montpellier, 1976
Received March 7, 1977
Arch. Gyn~k. 223, 9-18 (1977)
Gynfikologie 9
J. F. Bergmann-Verlag 1977
Ethnieity and Adaptation to Climaeterium B. Maoz 1' 4, A. Antonovsky 2, A. Apter 1, H. Wijsenbeck 1, and N. Datan a i Geha Psychiatric Hospital, Beilinson Medical Centre, Tel Aviv University Medical School and the William S. Schwarz Institute for Psychiatric Research and Treatment, P.O. Box 72, Petah-Tikwah, Israel z The Israel Institute of Applied Social Research and the Faculty of Health Sciences, Ben Gurion University of the Negev, Beersheba, Israel 3 Department of Psychology, West Virginia University, Morgantown, W. Va., USA
Summary. An investigation was made into the menopausal symptoms and attitudes of 1,148 Israeli women of five different ethnic origins. The results show that, while some of the somatic menopausal symptoms are independent of ethnic origin, psychic and psychosomatic symptoms are more closely associated with this variable. Similarly, the general health of menopausal women also varies with cultural origin. This variation is shown to correlate with the psychic and psychosomatic symptomatology of the climacterium. This study underlines the necessity of a multi-factorial, biological, sociological, psychological and anthropological approach to problems of menopause. Key words: Climacterium - Menopausal s y m p t o m s - Ethnic origin-- Psychic and psychosomatic symptoms.
Introduction A recent international congress has defined menopause (Utian) as: a) the phase in the aging process of women marking the transition from the reproductive to the nonreproductive stage of life -- the "climacteric"; b) the final menstrual period - "menopause" proper - this occurring during the climacteric. The climacteric is sometimes, but not necessarily, associated with symptomatology, which is designated "the climacteric syndrome". The symptoms can be divided into three main components: a) symptoms due to decreased ovarian function and hormonal insufficiency in the early stages, hot flushes, sweats, atrophic vaginitis, and later, symptoms due to metabolic changes in the end organs affected; b) symptoms reflecting the social and cultural components of the environment; c) symptoms reflecting the specific personality. The variability of the symptomatology is dependent on the interaction of these three components. Can we, however, be more precise than this general statement? 4
Offprint requests to:
B. Maoz (address see above)
10
B. Maoz et al.
On the one hand, it is possible that the component (a) is most significant; in this case, we would expect universalistic patterns of symptomatology. On the other hand, if personality factors are decisive, we would expect to find a substantial degree of individual variability even within relatively homogeneous cultural groups. Recent literature, however, (Neugarten, Dowty-Datan, van Keep, Flint, Hallstrom, Lauritzen, McKinley, Prill) has suggested that psycho-socialcultural factors may have a considerable role, pointing to large group differences. This might be the case, particularly if one considers the distinction between somatic, psychosomatic and psychological symptomatology. The first concern of this paper, then, is to clarify the relative roles of the three components of the climacteric syndrome, with a particular focus on the role of the socio-cultural environment. Adequacy of adaption to the challenge of the climacterium is a complex process. A pilot investigation (Maoz and Dowty) indicated four major foci for evaluation of this process: a) climacteric symptomatology per se; b) the "gains" versus "losses" balance experienced by the woman on reaching the climacterium; c) her "worries" and her "satisfactions" in each different area of living (her "degree of happiness", and d) her general state of physical health. These have been found to depend not only on objective somatic pathology, but also to be functions of psychosexual and social adaption as well as ethnocultural origins. These relationships and their importance for successful adjustment to the climacterium form the second concern of this paper. Our particular interest was in testing the hypothesis that women of Western ("modern") cultural origin would differ in their reaction to the climacterium from women from Oriental ("traditional") cultures 1. We did not commit ourselves in advance to the specific direction of such differences, since we felt that we could make a good case for prediction in either direction. On the one hand, one could postulate that the Western woman would regret the lack of full."use" of the reproductive period of her life, it now being "too late" to correct a "basic mistake". In contrast, the Oriental, traditional woman would feel relieved of the "yoke" of almost continuous pregnancy and childbearing, thus ensuring her a smoother passage over the climacterium. It would, however, be equally plausible to reason otherwise. The basis for the Western woman's self-identity is far broader than is that of the Oriental woman. The former has, long before climacterium, made peace with having few children, and has entered other meaningful roles in life than that of mother and housewife. She may even see menopause as liberating. The latter, by contrast, has for so long, in her own eyes and in those of her husband and others, been identified as primarily mother and housewife that climacterium may well come as a shock. (For an extended discussion of these issues, see Dowry, 1971, ch. 1.) The difficulties in adjusting to the climacterium may result in somatic manifestations. This, in turn, could lead to an increase in menopausal symptomatology and to deterioration of general health. 1 In Israel, "Western" is used to referto Jews of European origin, and "Oriental"to Jews originating in Moslem countries
Ethnicity and Adaptation to Climacterium
11
Population and Methods Owing to the multi-ethnic character of its population, Israel offers a rich opportunity for the study of the climacterium cross-culturally. Five population groups, four Jewish and one Arab, were assessed. The groups were chosen as reresenting the fullest possible range of the urbanised, modern woman through to the rural, traditional woman. The intra-group populations were largely homogeneous as to residential area and socio-economic status. All women were between ages 45 and 54 at the time of interview. The first group, of Central European origin, was drawn from an urban, middle class area near Tel Aviv. A second group, of Persian origin, and a third, of Turkish origin, were drawn from an urban, lower socio-economic area in Tel Aviv. The fourth group, of North African origin, came from two small cities in the Judean foothills, while the fifth group was taken from two all-Arab villages in central Israel. (The above coincides with the known demographic concentrations and socio-economic status of the ethnic groups studied.) All five samples were selected at random from the Population Register. (For sampling details, see Maoz and Antonovsky.) A total of 1148 women were interviewed in their homes: 287 Central Europeans, 176 Turks, 239 North Africans, 165 Persians and 286 Arabs. After the interview, 697 women were invited and came to a full medical examination. In order to see our investigation in perspective, we must review some of the socio-demographic variables involved. The five ethnic groups fall into three major types. At one extreme are the Jewish women of Central European origin. They are all literate, married after the age of 20 to partners of their own choice, and are most likely to have had at most three children. Though the children are probably no longer at home, only a third have grandchildren. Most are veteran Israelis, having immigrated before 1948. They are not religious, and most of their leisure time is spent with the husband. About a third of this group were in concentration camps during World War II (Antonovsky). The opposite extreme is typified by the Arab village women. They are most often illiterate, married before 20 (a third before 16) to a partner of parents' choice. They have more than five children living and histories of frequent miscarriages. By the time of climacterium, they are usually grandmothers but still have young children living at home. Leisure time is sex-specific. Most husbands are farmers or manual labourers. The other three groups can best be charaeterised as "transitional" between traditional and modern. The Turkish women tend, on the whole, to be somewhat closer in the above respects to the Central Europeans. The North Africans and Persians, on the other hand, are closer to the Arabs in marriage and childbearing patterns, literacy and education, religiosity, occupational status of husband and leisure time patterns. The socio-demographic data on the five samples completely supported our initial assumption regarding the relationship between ethnicity and traditionalism-modernity which led us to select these five groups. The five groups align as follows: Central European... Turkish... North African... Per-
sian... Arab. At least 80% in all groups were married at the time of the study, and less than I0% had undergone hysterectomy (surgical menopause). 30% of all the women were premenopausal (menstruating regularly), 17% were peri-menopausal (menstruating irregularly) and about 45% were completely postmenopausal (non-surgical). There were no significant differences among the five ethnic groups in regard to the above variables.
Interview Schedules T h e d a t a t o b e c o n s i d e r e d in this p a p e r , in line w i t h o u r t w o m a j o r a r e a s o f c o n c e r n , w e r e o b t a i n e d as f o l l o w s :
9 a) Menopausal Symptoms T h e 25 m e n o p a u s a l s y m p t o m s d i s c u s s e d b y N e u g a r t e n w e r e p r e s e n t e d t o e a c h subj e c t , o n c e in the c o u r s e o f the i n t e r v i e w , a n d a g a i n at the m e d i c a l e x a m i n a t i o n , as " p r o b l e m s w o m e n s o m e t i m e s h a v e " (see T a b l e 1), in r a n d o m o r d e r .
B. Maoz et al.
12 Table !. Menopausal Symptom List Somatic symptoms 1. 2. 3. 4. 5. 6. 7. 8. 9. 10.
Diarrhoea Constipation Pains in back of head or neck Breast pain Cold sweats Numbness and tingling in hands and feet Cold hands and feet Hot flushes Rheumatic pains Weight gain
Psychosomatic symptoms 1. 2. 3. 4. 5.
Pounding heart Dizziness Tired feeling Black spots in front of eyes Headaches
Psychic symptoms 1. Nervousness 2. Inability to concentrate 3. Crying spells 4. Feeling depressed 5. Instability 6. Forgetfulness 7. Sleeping badly 8. Fear 9. Worry about going insane 10. Feeling of suffocation
Each w o m a n was asked to say whether "during the past year you were troubled by the problem often, infrequently, or not at all". These responses were scored 1, 2 or 3 respectively, so that the lower the score the greater the symptomatology. In addition to the overall raw score, three subscores were calculated, relating to the 10 psychic, 10 somatic and 5 psychosomatic symptoms.
b) Physical Health Status Both subjective self assessment and an objective physician's evaluation were obtained - the latter after a thorough medical examination. Self assessment was made in terms of overall health, the taking of medication and painful sensations of mild and/or moderate severity. The physician was asked to comment on: 1. the overall impression of good or bad health; 2. limitation of activity in everyday life; 3. the presence of a severe chronic medical condition; 4. the need for medical attention; 5. the presence or absence of physical and emotional symptoms (see Table 4).
Results
Menopausal Symptoms. The data are presented in Table 2. It will be recalled that the higher the score, the lower the symptomatology. Total menopausal symptom scores by ethnic group ranged from 53.0--57.7 (the maximum being at the interview, and from 5 4 . 1 - 6 0 . 9 at the medical examination). Although the overall differences
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Ethnicity and Adaptation to Climacterium Table 2. Menopausal symptom scores by ethnic group
Overall menopausal symptom score a) Interview (n = 1148) b) Examination (n = 697) Psychic symptom score (interview) Psychosomatic symptom score (interview) Somatic symptom score (interview)
Europeans
Turks
N o r t h Persians Arabs Africans
57.7 59.2 23.2 10.9 23.9
55.2 56.6 21.5 10.2 23.7
55.2 56.6 21.6 9.8 23.0
53.0 54.1 20.8 9.4 22.9
54.7 60.9 21.9 10.5 22.8
among the ethnic groups are not statistically significant, it is clear that the Persian women had the greatest degree of symptomatology on both occasions. The European women are found at the other extreme: they report having the least symptomatology, apart from the Arabs, on examination. The score was given on the basis of 1, 2 or 3 for the response to each question. Though, the theoretical range was: Psychic 1 0 - 3 0 - 10 items, Psychosomatic 5 - 1 5 - 5 items, Somatic 1 0 - 3 0 - 10 items. The higher the score, the fewer the symptoms. Note: There are minor discrepancies between the sums of the sub-scores and the overall score which derive from the coding instructions of not including women who failed to answer a given number of items on a given sub-scale. The sub-scale symptom mean scores by ethnic group appear in the lower part of Table 2. The results of the statistical comparisons of paired ethnic groups on each of the three sub-scales appear in Table 3. On all three, the Europeans report least symptomatology. The difference between them and the other four ethnic groups is statistically significant on the psychic and psychosomatic items (except, on the latter, between Europeans and Arabs). The Persians report significantly more psychosomatic symptoms than do the other groups; on the psychic items, the trend is in the same direction, but falls short of significance. On both the psychic and psychosomatic items, the Arabs are the second most "healthy" group. This is not, however, the case on the somatic symptom score. As a matter of fact, the somatic symptom sub-group, comprising "real" or "hard" symptoms, including the classic hot flushes and sweats, showed no significant differences at all among the five ethnic groups. In summary, it seems as if Jews from Persia and, to a lesser extent, North Africa, complain more about psychic and psychosomatic symptoms than do Central European Jews and Arabs, but there are no real somatic symptom differences among the groups.
Procedure 1. Chi square test used for significance. 2. The frequency distribution of the total population was examined for each of the three symptom scores separately. Cells were collapsed in order to arrive at a
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Table 3. Tests of significance on three menopausal symptom scores, between pairs of ethnic groups Psychic
Psychosomatic
Somatic
x2
Significance level
x2
Significance level
X2
Significance level
27.84 17.92
p < 0.001 p < 0.01
30.77 9.67
p < 0.001 p < 0.05
N.S. N.S.
European-N. African 19.73 European-Arab 13.36 Persian-Turkish 6.82 Arab-Turkish 2.2 Turkish-N. African by inspection Persian-N. African 5.17
p < 0.001 p < 0.01 N.S. N.S. N.S.
25.47 3.88 24.55 6.07 9.49
p < 0.001 N.S. p < 0.001 N.S. p < 0.05
8.3 by inspection 8.14 14.74 6.79 5.31 5.86
Persian-Arab
5.4
N.S.
10.9
p < 0.02
N. African-Arab
5.88
N.S.
10.91
p < 0.02
European-Persian European-Turkish
N.S.
7.45
p < 0.05
by inspection by inspecfion by inspecfion
N.S. p < 0.01 N.S. N.S. N.S. N.S. N.S. N.S.
quintile or quartile distribution, in such a way as to equalize, as much as possible, then in each cell for the total population. Distributions of the ethnic groups were disregarded at this point. 3. Each pair of ethnic groups was then compared, on each symptom score to see if the distribution differed significantly. Original score given on basis of score of 1, 2 or 3 for the response to each question. Thus theoretical range was: Psychic ( 1 0 - 3 0 -- 10 items), Psychosomatic ( 5 - 1 5 -- 5 items), Somatic ( 1 0 - 3 0 - 10 items). Coded scores entered and punched in 9 categories, which meant collapsing at most two adjacent categories.
Physical Health Status The results of the physical health state evaluation are summarised in Table 4. The following points are of special note: 1. There were highly significant differences between the various ethnic groups as to the quantity of medication consumed - from 70% of regular medication amongst Persian women through 66% of the other Jewish women to 20% of Arab women. Also, an enquiry was made into the nature of the medicines taken. In this respect, it was found that very few were receiving sex hormone therapy (6% of European women to none of the Arab women). 2. The overall subjective evaluation referred a) to painful sensations, and b) to general feelings of being in good health.
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Ethnicity and Adaptation to Climacterium Table 4. Selected responses (percentage) to medical examination. - Items in ethnic groups Item
% taking medication regularly % reporting mild pain % reporting moderate or severe pain % with quite good or excellent overall health: Self assessed Physician rating % with poor or very poor overall health: Self assessed Physician rating % with moderate or severe activity [imitation % with serious chronic condition % not requiring medical attention % with moderate somatic symptoms % with none or mild somatic symptoms interfering with function % with no evidence of emotional symptoms
Area of birth Europe
Turkey
North Africa
Persia
Palestine (Arabs)
Chi square test (df = 4) of significance
58
64
64
70
22
p < 0.01
20 33
25 30
27 27
90 43
31 41
p < 0.01 N.S. p < 0.05
61 55
40 37
47 62
22 24
56 59
p < 0.01 p < 0.01
9 3 12
11 4 13
13 4 10
20 9 21
16 4 31
N.S. p > 0.05 N.S. p > 0.05 p < 0.01
21
18
14
31
17
21
21
23
14
33
p > 0.05 (just) p < 0.05
18
13
13
26
30
p < 0.01
58
42
71
37
57
p < 0.01
46
34
49
24
52
p < 0.01
Milder painful symptoms were reported by 90% of the Persian group as opposed to 2 0 - 3 0 % of the other groups. They also had a tendency to report moderate or severe pain more frequently than the other women - a tendency shared by the A r a b sample. Only one-fifth of the Persians were prepared to admit to subjective feelings of good overall health. This contrasts dramatically with the 56% of A r a b women who felt well despite an almost equal prevalence of painful sensations of more than moderate severity. 3. The physician's rating of overall health was based on a thorough medical examination, and took into account specific disease entities, functional limitations, the need for medical treatment and physical and emotional symptoms. Once again, the Persians have a significantly lower degree of good health and axiomatically, a tendency to have poorer health. The groups at the extreme ends of the moderntraditional spectrum (Arabs and Europeans) had the best health, though not necessarily the least severe ill health. It is interesting.that subjective self evaluation and objective physician rating of good health correlated closely, except in the case of the
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North Africans who assessed themselves as far less healthy than they really were. All groups tended to overestimate their overall poor health: the Persians and the Arabs tended to do this more frequently. However, this tendency does not reach significance between groups. 4. Limitation of activity was defined as any interference, because of ill health, with the normal daily activities of women at this age. The Arabs and Persians show relatively more significant limitations than the other groups. 5. The presence of a serious medical disorder was based on the finding of either a definite and severe chronic condition or an acute illness of lifethreatening dimensions. Here, too, the Persians tended to be prominent - the other groups being very close together in this respect. An important feature, not noted in the Table, was that very few women were given a clean bill of health (only 4% of the Persians and 7% of the Turks!). 6. At least two-thirds of the subjects were considered to require medical attention. Only 14% of the Persian women at the age of menopause were found not to require treatment! 7. Arab women either had more moderate physical symptoms than other groups or no physical symptoms at all. Though, it seems as if the physicians tended to see this group as either in very good or very poor health. Persian women were more consistently seen to have more subjects with moderate somatic symptoms and the least number of symptom-free individuals. Conversely, the North Africans were the most symptom-free of the whole sample. 8. Emotional symptoms followed a similar pattern, Persians having considerably more suffering than all the other groups in this respect.
Discussion At the outset, we must state that we are compelled to reject our preliminary hypothesis. We anticipated, it will be recalled, a linear relationship between responses to the climacterium and the traditionalism-modernity continuum. It appears that the matter is far more complex. The first striking feature of our results is the stability of the somatic or "hard" symptoms independent of the ethnic variable. This confirms Novack's original opinion that only the vasometer symptoms are definitely hormone-related and are "objective". The second point to be noted is the relatively low level of psychic and psychosomatic complaints in the Central European and Arab groups. This finding, with regard to the former, confirms Jaszmann's findings that higher income and education are correlated with an easier menopause, and could be thought to result from the "liberation" of women from traditional female stereotypic roles (Dowty). However, the fact that the most traditional of the five ethnic groups, the Arabs, also showed the least symptomatology, while the transitional groups showed the most symptoms, in spite of the fact that they are more modern than the Arabs, points to the involvement of other factors. We would suggest that the crucial factor is the relative cultural stability of the group and its degree of adaptation to its present surroundings. The Arabs have, of course, been resident in their villages for genera-
Ethnicity and Adaptation to Climacterium
17
tions, while the Central Europeans constituted one of the early waves of immigration to Israel. In socio-economic terms, they have achieved the highest standard of all ethnic groups, and are clearly part of the dominant sub-culture of Israefi society. In this respect, it should be stated that the Persians are, of the five groups, in the least stable situation, culturally and economically. The most consistent finding to emerge from the physical health assessment, was the poor physical health of the Persian Jewish group. It is obvious that the eight assessment categories are not independent of each other, yet the other four groups varied significantly in the different items. In contradistinction, the Persian sample is to be found consistently at the "sick" end of the spectrum. Physician bias may be discounted on the grounds that the other ethnic groups of Eastern origin who resemble the Persians, North Africans and Turkish Jews, showed completely different patterns of physical health. Two other less definite tendencies emerge from this part of the investigation: 1. The relative good health of the North African group (despite a subjective bias towards denying this). 2. The position of the Arab group at the extreme ends of the health spectrum, i.e. they are either very healthy or very sick and rarely "in-between". There is a clear-cut cluster of findings regarding the Persian Jewish sample, viz. more psychic and psychosomatic symptoms in the climacterium, in addition to a poor general health status. Therefore, it can be stated that an increase in psychic and psychosomatic symptoms (but no "hard" somatic symptoms) is associated with poor general health. The common denominator in this instance probably is the relative unstable socio-economic and psychosocial condition of Persian Jews compared with the other ethnic groups investigated (Maoz).
Conclusion
This study demonstrates the importance of ethno-cultural considerations in the shaping of the psychic and psychosomatic symptoms of the climacterium. Both these factors are, in turn, interrelated with the general health status of the population at risk. The fact that Arab and European women suffer least from such symptomatology and Persians the most is probably related to basic socio-economic and psychosocial integration into and stability within Israeli society at large. The modern-traditional spectrum is probably less important than first hypothesised. It is clear that Jaszmann (1973) is correct in stating that further research into the symptoms and treatment of menopausal symptoms must take into account ethnocultural backgrounds. The importance of general health is also fundamental. Acknowledgements. The project on which this paper is based was supported by a grant from the U.S. National Institute of Mental Health (AgreementNo. 8 MH-43-01) to the Israel Institute of Ap~ plied Social Research, Jerusalem.
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References 1. Antonovsky, A., Maoz, B., Dowty, N., Wijsenbeek, H.: Twenty-five years later: A limited study of the sequelae of the concentration camp experience. Social Psychiatry 6, 186-193 (1971) 2. Dowty, N., Maoz, B., Antonovsky, A., Wijsenbeek, H.: Climacteric in three cultural contexts. Trop. and Geograph. Medicine 22, 77--86 (1970) 3. Dowty, N.: Women's attitudes toward the climacterium in five Israeli subcultures. The University of Chicago: Ph.D. Thesis 1971 4. Flint, M.: Menarche and menopause of rayput women. Dissertation. New York: City University Graduate Centre 1974 5. Hallstrom, T.: Mental disorder and sexuality in the climacteric. Scandinavian University Books 1973 6. Jaszmann, L.: Op weg naar een nieuwe levensfaze. Voorlichting over de overgangsjaren. Van Loghum Slaterns Deventer 1973 7. Van Keep, P., Kellerhals, J. M.: The impact of socio-cultural factors on symptom formation. Psychother. Psychosom. 23, 251--263 (1974) 8. Van Keep, P. A., Kellerhals, J. M.: The aging woman. About the influence of some social and cultural factors on the changes in attitude and behaviour that occur during and after menopause. Acta Obs. Gynec. Scandinavia Suppl. 51 (1975) 9. Lauritzen, C.: The female climacteric syndrome: Significance problems, treatment. Acta Obs. Gynec. Scandinavia Suppl. 51 (1975) 10. McKinley, S. M., Jeffers, M.: The menopausal syndrome. British J. of Preventive and Social Medicine 28, 108 (1974) 11. Manz, B., Dowty, N., Antonovsky, A., Wijsenbeek, H.: Female attitudes to menopause. Social Psychiatry 5, 35--40 (1970) 12. Maoz, B.: The perception of menopause in five ethnic groups in Israel. University of Leyden, Holland: Thesis 1973 13. Maoz, B.: Menopausal symptoms in five ethnic groups in Israel. Paper. 4th International Congress of Psychosomatic Obstetrics and Gynaecology. Tel Aviv, 1974. (Published by S. Karger 1975) 14. Neugarten, B., Wood, V., Kraines, R. J., Loomis, B.: Women's attitude towards menopause. Vita Humana 6, 140 (1963) 15. Neugarten, B. L., Kraines, R. J.: Menopausal symptoms in women of various ages. J. Psychosomatic Medicine 27, 266-273 (1968) 16. Prill, H. J., Lanritzen, C.: Das Klimakterium. Klinik der Frauenheilkunde und Geburtshilfe, pp. 341-417. Mfinchen-Berlin-Wien: Urban and Schwarzenberg 1970 17. Rennie, T. A. C., Srole, F.: Social class prevalence and distribution of psychosomatic conditions in an urban population. Psychosomatic Med. 18, 449 (1956) 18. Utian, W. H.: Summary and conclusion of a workshop on the climacteric syndrome. Held at the 1st World Congress of Menopause. Montpellier, 1976
Received March 7, 1977
