http://www.jstor.org. Mon Apr 9 17:59:51 2007 ... were low in European countries, but varied dramatically else- where. F
Attitudes toward Menstruation Elizabeth M. Whelan Studies in Family Planning, Vol. 6, No. 4. (Apr., 1975), pp. 106-108. Stable URL: http://links.jstor.org/sici?sici=0039-3665%28197504%296%3A4%3C106%3AATM%3E2.0.CO%3B2-D Studies in Family Planning is currently published by Population Council.
Your use of the JSTOR archive indicates your acceptance of JSTOR's Terms and Conditions of Use, available at http://www.jstor.org/about/terms.html. JSTOR's Terms and Conditions of Use provides, in part, that unless you have obtained prior permission, you may not download an entire issue of a journal or multiple copies of articles, and you may use content in the JSTOR archive only for your personal, non-commercial use. Please contact the publisher regarding any further use of this work. Publisher contact information may be obtained at http://www.jstor.org/journals/popcouncil.html. Each copy of any part of a JSTOR transmission must contain the same copyright notice that appears on the screen or printed page of such transmission.
JSTOR is an independent not-for-profit organization dedicated to and preserving a digital archive of scholarly journals. For more information regarding JSTOR, please contact
[email protected].
http://www.jstor.org Mon Apr 9 17:59:51 2007
Attitudes toward Menstruation INTERNATIONAL COMMITTEE ON APPLIEDRESEARCH IN POPULATION prepared by Elizabeth M . Whelan
A number of the modern contraceptives cause intermenstrual bleeding and changes in regular menstrual patterns. The progestogen-only oral contraceptive often results in irregular, prolonged, or abundant bleeding, and, in some cases, amenorrhea. In the first few months of treatment, the injectable steroids are associated with heavy bleeding and frequent spotting and, as therapy proceeds, amenorrhea. Similarly, breakthrough bleeding and spotting have been reported with the use of the original estrogen-progesterone oral contraceptive, and increased menstrual flow and intermenstrual spotting have been a frequent complaint of IUD acceptors. There is reason to believe that cultural variables influence a woman's attitude about spotting, breakthrough bleeding, and menstruation and affect her willingness to accept contraceptive-induced bleeding changes. Bernard (1970), reporting international follow-up data on IUD use by some 14,000 women in 30 countries, notes that high discontinuation rates were predominantly due to bleeding and pain; dropout rates were low in European countries, but varied dramatically elsewhere. For instance, the IUD removal rate due to bleeding and pain in Ludhiana, India was six times higher than in Cabanatuan City, the Philippines. Interestingly, there were striking differences even within the same country. In Bombay, India, one study noted only one removal for "bleeding and pain" for each three in Ludhiana. In Ashqelon, Israel, Bernard reports, Orthodox Jewish women had an IUD removal rate five times that of nonOrthodox women. He states that in cultures where bleeding and spotting are considered basically "unclean," both IUD clients and physicians have a higher "removal readiness" than in cultures less dominated by orthodox religion. Not only changes in bleeding patterns lead to client discontinuance of a particular type of contraceptive method. Hornemann and Osler (1972), reporting on the experiences of 95 Danish women using medroxyprogesterone acetate, noted that a significant number after experiencing amenorrhea for several months expressed a wish for the return of menstrual bleeding. This wish, along with the disturbances of other medical side effects, usually explained their subsequent discontinuance of the method.
Historical Western Attitudes toward Menstruation Throughout much of history, menstrual bleeding was viewed as a supernatural event. The feeling that all blood, including the menstrual flow, carried some basic life principle led to the prevalent belief that contact with menstruating
women or menstrual blood could have serious consequencesboth evil and beneficial. The majority of these special powers, however, were evil. In early Western cultures, menstruation was believed to render a woman periodically dangerous, and numerous and varied social restrictions were created to limit her contact with her husband and with members of her community. During the nineteenth century, it was the opinion of some physicians that menstruation had no purpose whatsoever and that, indeed, it was a pathological condition, which did not exist in pre-Biblical times. They stated that menstruation ". . . has gradually become a fixed habit of the female sex in consequence of the vitiating influence of civilization (Studley, 1875). Some late 19th century and early 20th century reports continued to reflect historical beliefs about the malign influence of menstruating women. In 1878, the British Medical Journal carried a series of letters that claimed a menstruating woman could cause bacon to putrefy. And in 1915, the comments of the 1st century Roman, Pliny, on the harmful effects of menstruating women were recalled by a medical doctor who stated: With reference to Pliny's remark on the dulling of the sur-
face of a mirror, there may be an element of truth in it.
Roman mirrors were made of silver or silvered bronze, and
I have known a patient . . . to leave off wearing silver orna-
ments during menstruation on account of the rapid tarnish-
ing which occurred at that time. (Crawfurd, 1915)
More recent medical research also provided an updated version of Pliny's observations. In 1920, Dr. Bella Schick (principal developer of the test for susceptibility to diphtheria) claimed to have isolated a "menotoxin" in the perspiration, saliva, and blood of menstruating women (Ford, 1945). Dr. David I. Macht of the Johns Hopkins School of Medicine followed up Dr. Schick's observations and concluded that these menotoxins ". . . contaminate by contact to such an extent that they retard development and even kill plants" (Baumberg, 1929). The experimental designs of Schick and Macht, however, made no allowance for a control fluid-for instance, nonmenstrual blood. This concern about the dangers of menstrual blood prevailed until as late as 1945. In that year, Ford, in a review of cross-cultural attitudes toward menstruation, cited data confirming the presence of a toxic rcaterial in menstrual blood that could lead to contamination of the penis if sexual intercourse took place during menstruation. After 1945, no published reports either confirmed or denied the existence of such a menotoxin.
-
Orthodox Jewish and Muslim Attitudes toward Menstruation Historical attitudes toward menstruation and adherence to strict ritualistic behavior coordinated with the menstrual cycle are reflected &I a number of cultures. For instance, during the first few days of her menstrual period a Hindu woman may not mount a horse, an ox, or an elephant, or drive a vehicle (David, 1972); and many peasants of Central and Eastern Europe persist in the belief that a menstruating woman should not bake bread, churn butter, or spin thread. The Orthodox Jewish and Muslim cultures will serve here as further examples of this phenomenon. It should be remembered, however, that the formal dogma is not necessarily synonymous with the practice of the majority of Orthodox Jews and Muslims.
By far the most important regulation of the marital relationship of Orthodox Jews revolves around the practice of niddah-literally, a separation-which includes the proscription of sexual intercourse during what is termed the wife's "unclean" period. Generally speaking, a woman is considered "unclean" just prior to the beginning of her menstrual flow, during the bleeding itself, and for seven full days following the termination of the flow at which point she must undergo a ritual bath to reinstate her marital cleanliness. During her "unclean" phase a woman may have no sexual relations or any other contact . . the husband may not come in conwith her husband-". tact with his wife's body . . . not even with her little finger; he is not allowed to hand anything to her" (Goldin, 1941). Two important aspects of the niddah regulations should be noted: First, the ban on male-female contact is enforced prior to the beginning of the menstrual flow itself. Second, the proscription on coitus and male-female interaction of any type is related not only to bleeding that is the result of the normal menstrual cycle but to any type of vaginal bleeding. If a woman finds a stain that she is uncertain about, she is advised to consult a religious source for an evaluation. Whatever the cause of the uterine or vaginal bleeding, there must be a sevenday period of abstinence after the last day of the flow.
In Muslim cultures, it is recommended that the men avoid women during menstruation and do not approach them until they are "pure" (Seklani, 1967). The regulations placed on menstruating women are derived from Koranic law: They question thee ( 0 Muhammad) concerning menstruation. Say it is an illness so let women alone at such times and go not into them ti1 they are cleansed. And when they have purified themselves, then go in unto them as Allah hath enjoined upon you. (Koran 2:222) Two specific restrictions are placed on the menstruating Muslim woman. First, because she is considered a threat to holiness, a menstruating woman may not visit any shrine or mosque and is forbidden to pray or fast in the month of
Ramadan. Second, she is forbidden sexual intercourse for at least seven full days after the flow begins and is considered "unclean" until she completes a ritual washing (Westermarck, 1926).
Attitudes of US Women toward Menstruation Although relatively few published reports present data on contemporary US women's attitudes toward menstruation, studies in the United States suggest that either "neutral" feelings or slightly negative feelings about the menses prevail. McHugh and Wasser (1959) reported that college students had a neutral attitude about menstruation and a general understanding of its physiological purpose. Larsen (1963, 1965) noted that among 260 college women, 26 percent reported feeling pride or happiness at menarche; 28 percent reported negative feelings; and 46 percent said they were confused or had no negative or positive feelings about menarche. Dunham (1970), Brush (1938), and Henton (1961) studying reported attitudes of college women and adolescents toward menarche and menstruation found predominantly neutral attitudes, although all three researchers noted either overt or latent negative feelings in some respondents.
Conclusions From studying Orthodox Jewish and Muslim interpretations and practices related to the menses, it is clear that the tolerance of contraceptive-induced bleeding changes may be culturally determined. For instance, because of the niddah regulations, a contraceptive that induces irregular bleeding is not acceptable to the Orthodox Jewish culture. According to Rabbi David M. Feldman (1968), the author of Birth Control in Jewish Law, the original low-dose birth control pills presented difficulties for Orthodox women because of the high probability of breakthrough bleeding associated with their use. El-Mahgoub et al. (1972), reporting on Muslim women using a three-month contraceptive injection, state that ". . . spotting and irregular bleeding (associated with the drug) are troublesome as they compel our women to prohibit coitus due to religious habits. . . ." Additionally, the observation that traditional Western attitudes toward menstruation have reflected misinformation about the physiological purpose of periodic bleeding suggests that contraceptives that alter the menstrual cycle could raise anxieties among US women as well. Some basic questions-all critical to the acceptability of contraceptive methods that induce bleeding changes-remain unanswered. For instance, ( a ) what type of variation exists in cross-cultural attitudes toward menstruation in general; ( b ) among women using IUDs, progestogen-only pills, traditional oral contraceptives, or injectable steroids, what has been the reaction to the bleeding changes; and (c) is there a gap between the formal religious or social mores related to menstruation and the actual practice. Although little is known about client perception of menstruation and contraceptive-induced bleeding, it appears obvious that these perceptions play an important role in the acceptability and successful use of modern methods of fertility control. Research is needed to provide answers for some basic attitudinal and behavioral questions in this area.
References Baumberg, S. 1929. T h e Golden Chain: T h e Treatment o f the Religious Laws of W o m e n and Purification f r o m a Scientific Point o f View. London: Williams, Lea and Company. Bernard, R. R. 1970. "IUD performance patterns-A 1970 world view." International Journal o f Gynaecology and Obstetrics 8, no. 6:926-940. British Medical Journal. 1878. Volume 1, pages 324, 353, 590, 633. Volume 2, pages 544, 654, 714. Brush, A L. 1938. "Attitudes, emotional and physical symptoms commonly associated with menstruation in 100 women." American Journal o f Orthopsychiatry 8, no. 2:286-301. Crawfurd, R. 1915. "Of superstitions concerning menstruation." Proceedings o f the Royal Society o f Medicine 9, no. 2:49. David, H. P. 1972. "Psychosocial Aspects of Menstrual Cycles and Menses Regulation." Paper presented at Workshop on Menstruation, International Health Foundation, Geneva, Switzerland. Dunham, F. Y. 1970 "Timing and sources of information about, and attitudes towards, menstruation among college females." T h e Jozrrnal of Genetic Psychology 117, no. 2:205-217. El-Mahgoub, S., et al. 1972. "Long term use of Depot-Medroxyprogesterone Acetate as a contraceptive." Acta Obstetricia et Gynecologica Scandinavica 5 1, no. 3 :25 1-255. Feldman, D. M. 1968. Birth Control in Jewish Law. New York: New York University Press. Ford, C. S. 1945. A Comparative Study o f Human Reproduction. New Haven, Ct.: Yale University Press. Goldin, H. E. 1941. T h e Jewish W o m a n and Her Home. New York: Hebrew Publishing Company.
.
Henton, C. 1961. "The effect of socio-economic and emotional factors on the onset of menarche among Negro and white girls." Journal of Genetic Psychology 98, no. 1:255-264. Hornemann, B., and M. Osler. 1972. "Medroxyprogesterone Acetate as a contraceptive." International Journal o f Fertility 17, no. 4:210-216. Larsen, V. L. 1963. "A psychological study of colloquial menstrual expressions." Northwest Medicine 62, no. 11:874-877. -. 1965. "College students and menstrual facts." Journal of American Medical Woman's Association 20, no. 6 : 557-559. McHugh, G., and J. Wasser. 1959. "Application of the ThurstoneChave attitude rating technique to attitudes towards menstruation." Psychological Reports 5:677-682. Seklani, M. 1967. "Fecundity in Arab nations: Attitudes." In Muslim Attitr~destoward Family Planning. Edited by Olivia Schieffelin. New York: The Population Council. Studley, W. H. 1875. "Is menstruation a disease?" American Journal of Obstetrics and Diseases o f W o m e n and Children 8, no. 5:487-3 12. Westermarck, E. 1926. Ritual and Belief in Morocco. New York: Macmillan and Company.
ABOUTTHE AUTHOR Elizabeth M. Whelan, Sc.D., is executive director of Demographic Materials, Inc., and a consultant with the Population Council.
,
. A
I
