The perception of menarche and menstruation among Turkish married women: attitudes, experiences, and behaviors.
The perception of menstruation differs from society to society (Turan & Ceylan, 2007). For instance, in Brazil menstruation is regarded as a privilege a woman has from birth, a sign of being healthy, and a symbol for femininity and fertility (Estanislau do Amaral, Hardy, Hebling, & Faundes, 2005). In North India, it is considered as the woman's purification of the dirty blood in her body (Singh, 2006).
In Turkish society the attitudes towards menstruation differ on both a regional and a cultural basis and, according to these distinctions, women have different experiences concerning their menarche. In studies conducted in Denizli and Samsun, two developed cities in Turkey, (Kobya & Yazici, 1999; Turan & Ceylan, 2007), nearly one third of the participants stated that they perceived menstruation as the discharge of the dirty blood from the body. The physiology and hygiene of menstruation and the premenstrual syndrome constitute an important and widely studied area of women's health and health services. When many current issues, such as changes in lifestyle, the introduction of women to the business world, handicapped women, and health-services are considered, it can be accepted that behavior around, and attitudes towards, menstruation should be kept up-to-date. It is suggested that this update be done using a bio-psycho-social approach. Until recently, results of studies of menarche have shown that menstrual education and preparation for menarche are insufficient. The importance of the bio-psychosocial approach is emphasized both in the education process and in the solution of women's social and health problems. Public health research focusing on women can only be helpful in determining the causes of problems and in finding solutions when this research deals with the behaviors in the context of social and economic circumstances and when health status is interpreted alongside family circumstances and culture. Because of these complex requirements, the menstrual health of women is a difficult issue to address, but even so the topic attracts the attention of many public health researchers as an important and worthwhile subject (Anson, 1999; Chou, Lu, Pu, & Lan, 2008; McPherson & Korfine, 2004).
To this end the aim of this study was to determine the experiences of behaviors in regard to, and attitudes towards, menstruation of Turkish married women of fertility age.
Design and Sampling
The study was cross-sectional descriptive in design. It was conducted with 586 married women living in the city centre of Malatya, Eastern Anatolia, Turkey. These women were chosen from 30 groups selected by systematic sampling in proportion to the population of the city, which was 389,819 in 2008.
Collection of the Data
A data collection form which was prepared and configured according to the literature was used to collect the data for the research directly from the interviewees. The form consisted of two sections. In the first section, there were questions on the women's demographic information (age, education, family, social security, and occupation), and in the second section, on the women's perception of menstruation, their experience of menarche, their beliefs about, behaviors in regard to, and attitudes towards, menstruation. After getting the required permission, the women were interviewed in their homes between 14 February and 12 April 2007, and data were collected using face-to-face questionnaires. Before the questionnaires were completed, the aim of the survey was explained to the interviewees, verbal permission was obtained from each interviewee, and some information on how to fill in the forms was given to each of them. None of the women refused to take part.
SPSS 9.0 was used in the data analysis. The data were presented as a percentage distribution. Chi-square test was used in making comparisons between the women's attitudes. The significance level used was p < 0.05.
The mean age of the women included in the survey was 29.3 [+ or -] 0.2 and 96.4% were housewives. A total of 12.3% of them were illiterate, 54.9% were primaryschool graduates, and 32.8% were graduates of secondary school or higher. They lived in families with an average of 5.2 people. Of the total group, 64.2% perceived menarche as an unfavorable event and had a negative response and 93.3% of this group of women said that they had been frightened and surprised by menarche, while 2.7% stated that they had cried. A meaningful relationship was found between the experience of menarche, level of education, and age (p < 0.05). It was more common to perceive menarche as an unfavorable event among the women who were aged 30 or over and among those who had finished their education at either primary or secondary school (see Table 1).
Of the women in the survey 61.3% talked to nobody about their menarche (Table 2) and 37.4% of these stated that they did not need to talk to anybody because they had enough information about this subject. Of the 38.7% of the women who talked about their menarche with the people close to them, 55.5% of them talked to their mothers, 40.9% to sisters or sisters-in-law, and 3.6% to friends. They explained that they shared it in order to get some information or help. While there seemed to be no relationship between sharing of the event of menarche and the age of the women, there was a relationship between level of education and sharing (p < 0.05). The percentage of sharing among the illiterate women was 47.2%, whereas it was 62.0% among the group who had graduated from secondary school or had higher education. When the women were asked whether there were any rituals for a young girl who had her period for the first time, 98.6% of the women answered "No", and 1.4% answered "We are taught to perform full ablutions and we are made to take a bath".
Table 3 shows the attitudes of the women towards beliefs that are found in some sections of Turkish society, and whether or not the woman actually behaved in accordance with their stated beliefs.
It was found that women under 30 (86.1%) are more likely to believe that one shouldn't have sexual intercourse during menstruation compared to the older ones (74.5%) (p < 0.05). Attitude towards having sexual intercourse seemed to have no relation to level of education. When the attitudes were analyzed one by one according to age and level of education, it was found that attitudes about religious beliefs did not change in terms of age and education level, but the attitudes about daily activities such as pickling, kneading dough, and so on, did change in accordance with level of education. The women who had graduated from secondary school or had higher education did not mind performing daily activities other than religious observances (p < 0.05). Of the 2.2% of the women who stated that menstruating was a punishment given by God, there was a meaningful relationship between education level and attitude. There were 23.1% who believed this who had graduated from secondary school or had higher education, while the percentage of the women with the same belief who were less educated or had no education was 76.9% (p < 0.05).
There were 48.8% of the women who said that one had to hide one's periods from other people and 65.0% of these women said that it was shameful to reveal such a thing, while 34.6% said that it must be hidden especially from men. One of the women stated that it should be hidden because the other person would feel uncomfortable (0.3%). Of the secondary school or higher graduates 34.9% stated that one should hide one's periods and 70.8% of the illiterate women had this view (p < 0.05). There were 77.4% of the women who said that they felt uneasy and tired during their period and 74.5% said that they felt more nervous then.
From the whole group, 38.9% of the women stated that they put off some of their daily tasks (housework, handiwork) and social activities (religious activities, meeting friends) when they were menstruating. Putting off daily tasks was found to be related to age, but not level of education or conditions of work (p < 0.05). Younger women were more likely to put off tasks and activities (Table 4).
We found that many women living in the city center of Malatya have experienced menarche, the first step to womanhood, as a negative experience and many had been frightened and surprised by their first periods. Age and education were important factors in being informed about and prepared for menarche (Lee, 2009; Marvan, Morales, & Cortes-Iniestra, 2006). The fact that women in our survey recall menarche as a bad experience is serious because it shows that they had no knowledge about it before the event and were therefore not ready for it. We found that recalling the first period as a negative experience was more common among women who were aged over 30 and who were less educated (p < 0.05). This finding can be supported by the fact that more years of school attendance adds to the level of learning about reproductive healthcare which provides a preparation for menarche. The fact that younger women have a longer school attendance or a greater chance to access educational sources like the media may also have helped them to perceive menarche as a natural event. In Turkey, students are taught about the physiology of adolescence in biology and healthcare courses.
In other studies conducted in various parts of the world it has been shown that a significant number of women perceive menarche as a frightening, embarrassing, and disgusting event (McPherson & Korfine, 2004). In a study conducted in Zimbabwe (McMaster, Cormie, & Pitts, 1997), the first reaction to menarche was terror and anxiety among 44% of business women and 64% of housewives. Giroux (2008) reported that young French women had ambivalent feelings about menarche; both happiness due to the beginning of womanhood and guilt due to the probability of starting erotic activities with sexual maturity. Other researchers have also reported that younger women have positive feelings about menarche, as we found in our study. In their studies, Lee (2009) and Beausang and Razor (2000) reported that nearly half of the women younger than 21 perceived menarche as a positive and natural event. By contrast, in their study Marvan and his colleagues (2006) found that older women had more positive experiences of menarche.
In our study, only one-third of the women evaluated menarche as a natural event. It is also stated in the literature that there were women who perceived having periods as a sign of being healthy. Brazilian and Indian women are reported as considering menstruating as a symbol of femininity and productivity as well as a sign of freedom from pregnancy and a process that must be experienced (Bhatt & Bhatt, 2005; Estanislau do Amaral et al., 2005).
A great number of women included in our survey stated that they did not talk to anyone when they had their first periods, but the rest of the women shared this event with the people close to them. The rate of sharing was found to be higher among women who had an education level of secondary school or higher. Those who had less education were more likely to hide their menarche which shows that they are at risk in medical or socio-psychological terms and that they need more support. In many studies, it has been confirmed that women perceive menstruating as a private event and they share it with nobody, when they do, they share it first with mothers and then sisters and other relatives. In the United States, mothers, and in Iran, sisters, are preferred in the event of sharing (Logan, 1980; Tortumluoglu, Ozyazicioglu, Guducu Tufekci, & Sezgin, 2005; Uskul, 2004).
When our findings are assessed in terms of the people with whom this event is shared, it is evident that support from a family member is always looked for. However, the fact that the level of this sharing is lower when it comes to mothers indicates the necessity of looking at some factors in more detail, such as the relationship between mothers and daughters, interfamily relations, education, traditions, and their impact on these relationships as the daughter becomes a woman. As potential mothers, all girls need to be educated about reproductive health both medically and socially.
In some cultures there are some rituals for young girls having their menarche. Aborigines, for instance, first isolate their daughters during menarche, then they make them wear colorful clothes, put make-up on them, and wash them in the river. The family members and the elderly people eagerly attend this ceremony (Flood, 2007). In some parts of India the girls are dressed in nice clothes, they are adorned with jewelry, bathed in a private hut, and taught how to prepare and clean the cloths that will be used during the periods (Narayan, Srinivasa, Pelto, & Veerammal, 2009). In our study, almost all the women (98.6%) stated that they didn't know any traditional events or rituals for girls having their first periods. Some of the women said that they were taught to have a bath and also to perform a ritual full ablution. This ritual washing is mandatory for any adult Muslim after sexual intercourse, any sexual discharge, at completion of the menstrual cycle, after giving birth, and at the time of a death from a natural cause. In a study conducted in the South East of Turkey, Tumerdem (1995) said that girls were slapped in the face or pinched by their mothers at the time of their menarche, so they hid their first periods in order not to be beaten or pinched. Direk (2003) reported that girls hid their periods from the men in the family and when they shared news of it they were subjected to a traditional slap by the women of the family. Slapping in the face is also common among the people of the Jewish faith (Culpepper, 1991). It is obvious that passage from girlhood to womanhood is not welcomed warmly in Turkey.
Taboos regarding cooking, working, praying, and having sexual relationships while menstruating are common throughout the world (Buckley & Gottlieb, 1988). In Turkey, every 10-13 women out of 100 believe in taboos such as if a menstruating woman kneads dough, or pickles or cans food, it will spoil. Therefore, as a result of their beliefs in such things, women are observed to avoid doing these things. One-third of the women (30.4%) in our survey were found to believe that they shouldn't sit on the doorstep because it would bring bad luck and poverty with 30.2% of them acting according to this belief. In the Indian study done by Narayan et al. (2009) 70% girls of school age were found to believe that they should not sit on the doorstep. The results of our study have provided strong proof that beliefs have a great impact on behaviors. The attitudes about daily activities (pickling, kneading dough, and so on) were seen to be related to level of education. It is also reported in other studies conducted in Turkey that women are thought to be dirty or toxic during their periods and thus it is forbidden for them to touch any food or goods at home (Direk, 2003; Gulerhan, 2003; Okten, 2003; Yetkiner 2004). Similarly, it is still believed in Turkey that menstruating women cannot plant seedlings or sow seeds, because this would cause failure of crops (www.gullukdergisi.com).
In Islam, menstruating women are exempted from basic services such as performing the namaz, fasting, and going on the pilgrimage to Mecca. They are supposed to compensate by performing these duties when they are not menstruating. Almost every women included in the survey (more than 94%) reported believing that they should neither touch the Quran nor read it while menstruating; therefore, they behaved according to their beliefs. Moreover, the number who believe that women should not go to the mosque when they are having their periods was relatively big (82.6%). Our results show that the women in Malatya adopt the traditional limits and prohibitions of their religion about menstruation and obey them. However, there are no written directives in Islam religious writing prohibiting activities such as touching the Quran or going to the mosque when menstruating - these are just traditional taboos that have developed over time. We found that age and education had no effect on attitudes about religion. Drakshayani and Venkata (1994) stated in their studies that 50% of the women limited their religious activities, avoided touching holy texts and books, and visiting holy places during their periods. According to the Jewish religion, it is necessary for menstruating woman to stay away from temples, the holy belongings of the priest such as robe and turban, and food which requires ritual purity (Okten, 2003). Many religions include similar directives in their doctrine or ritual. The Quran for example, refers to menstruation as an illness, and under Hindu law menstruating women are required to keep apart from others for three days (Easteal, 1991; Spitz, 1987).
A majority of women in our study (80.9%) believed that they shouldn't have sexual intercourse when menstruating. In the literature it has been stated that women generally avoid having sex when they are having periods (Garg, Sharma, & Sahay, 2001). Hensel, Fortenberry, Marezlak, Anderson, and Orr (2004) also reported that 87.4% of the adolescent women in their study avoided having sex when they had vaginal bleeding. Sexual intercourse during bleeding is a risk factor in terms of sexually transmitted infections. The incidence of contracting pelvic inflammatory diseases is higher during menstruation (Hensel et al.). Therefore, this kind of attitude would be considered as a favorable one. We found that, compared to older women, more of those under 30 (86.1%) believe more strongly that one should not have intercourse during menstruation (p < 0.05). This may be an indicator that young women are more aware of the risk of infection during this time.
Nearly half of the women in our study said that one should conceal menstruation. In many other studies carried out in different parts of Turkey, menstrual bleeding was found to be considered as something shameful, dirty, and disgusting that must be hidden (Gulerhan, 2008; Yetkiner, 2004). Women used some codes such as "I'm ill", "I'm dirty", "I'm in my private days" in order not to say that they have their period (Celebi, 2008; Gulerhan, 2008; Tortumluoglu et al., 2005; Yetkiner, 2004). Similar statements occur in other studies (Garg et al., 2001; Stubbs, 2008). In line with our findings, Marvan and his colleagues (2005), in their surveys carried out among young and middle-aged Mexican women reported that younger women think that it is not necessary to hide menstruation so strictly.
A quarter of the women in our study declared that they felt tired and aggressive when menstruating, and 38.9% said that their social activities and housework were interrupted during their periods. In her study, Lu (2001) reported that women felt tired and weak, felt pain, anxiety, depression, and nervousness respectively. Chamay-Weber and Narring (2008) reported in their studies that 20% of the women could not attend their schools or jobs or carry out social activities, and 35% of them could not perform sports activities. Lu also found that 3.3% of the women could not carry out their social activities. In our study, putting off daily activities was found to be related to age, but the level of education and working conditions were irrelevant.
Nearly half of the women included in our survey believed that women should rest during their periods. The number who believed that menstruating women should rest was higher among the younger group with a higher level of education. Drakshayani and Venkata (1994) reported that 38% of the women in their study rested more when they were menstruating. In a system that limits the right to leave of absence for women from paid employment before and after giving birth, it can cause a significant discussion to talk about rights to rest during periods. However, in some studies it has been shown that women have asked for such a right. In some societies there are taboos such as that menstruating women should be isolated from society and from men and they should perform lighter activities like weaving baskets or chatting with friends and resting during menstruation.
It is said that taboos of this kind aim to glorify women, not to restrain them (Buckley & Gottlieb, 1988). However, these authors also point out that taboos against women working, cooking, having sex, and so on may, on the other hand, be considered as effective means of suppressing women.
In this study we found that, for the Turkish women we surveyed with the beginning of womanhood and throughout the fertile period of their lives, their beliefs about menstruation were negative, and consequently their physical, social, and emotional health is affected by this. The findings cannot be generalized to all Turkish women. Nevertheless, it is clear that more research should be conducted on this subject together with other disciplines in order to meet the needs of women. It is suggested that menstruation should not be considered as just a matter of women's physical health, but also as a social and emotional issue. Necessary arrangements should be made for education to be given.
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Ayse Sayan Cevirme
Sakarya University, Sakarya, Turkey
Kocaeli University, Kocaeli, Turkey
Rize University, Rize, Turkey
Mugla University, Mugla, Turkey
Poturge State Hospital, Malatya, Turkey
Ayse Sayan Cevirme, PhD, RN, Assistant Professor, School of Health, Sakarya University, Sakarya, Turkey; Hulya Cevirme, PhD, RN, Assistant Professor, Department of Turkish Teaching, Faculty of Education, Kocaeli University, Kocaeli, Turkey; Leyla Karaoglu, PhD, Assistant Professor, Department of Public Health, Faculty of Medicine, Rize University, Rize, Turkey; Nezihe Ugurlu, PhD, RN, Assistant Professor, School of Health, Mugla University, Mugla, Turkey; Yasemin Korkmaz, MSc, Research Assistant, Public Health Nurse, Poturge State Hospital, Malatya, Turkey. Appreciation is due to anonymous reviewers. Please address correspondence and reprint requests to: Ays.e Sayan Cevirme, Sakarya University, School of Health, Sakarya, Turkey. Phone: (+90) 0 264 295 66 08; Fax: (+90) 0 264 295 66 02; Email: firstname.lastname@example.org or email@example.com
TABLE 1 AGE AND EDUCATION LEVELS OF WOMEN AND THEIR PERCEPTIONS OF MENARCHE Sociodemographic features The perception of menarche Age * natural unfavorable n event % event % [less than or equal to] 24 40.8 59.2 98 25-29 42.7 57.3 225 30-34 36.8 63.2 125 [greater than or equal to] 35 20.3 79.7 138 Level of education * Illiterate 23.6 76.4 72 Literate + primary school graduate 27.0 73.0 322 Graduated from secondary school 55.2 44.8 192 or higher n 210 376 586 % 35.8 64.2 100.0 * p = 0.001, [chi square] test Table 2 WOMEN WHO TALKED TO OTHER PEOPLE ABOUT THEIR MENARCHE ACCORDING TO AGE AND EDUCATION LEVEL Sociodemographic features Sharing their Total menarche with other people Age Not shared Shared [less than or equal to] 24 35.7 64.3 98 25-29 39.6 60.4 225 30-34 44.8 55.2 125 [greater than or equal to] 35 34.1 65.9 138 Level of education * Illiterate 52.8 47.2 72 Literate + primary school graduate 36.0 64.0 322 Graduated from secondary school or higher 38.0 62.0 192 n 227 359 586 % 38.7 61.3 * p = 0.001, [chi square] test TABLE 3 THE ATTITUDES OF THE WOMEN TOWARDS MENSTRUATING Attitudes towards menstruating Beliefs number % One should not pickle during menstruation 78 13.3 One should not make tinned food during menstruation 67 11.4 One should not knead dough during menstruation 80 13.7 One should not dye one's hair during menstruation 92 15.7 One should not henna during menstruation 78 13.3 One should not sit on the doorstep during 178 30.4 menstruation One should not go into the mosque during menstruation 484 82.6 One should not listen to "mevlut" during menstruation 244 41.6 One should not touch the Holy Quran during 551 94.0 menstruation One should not read the Quran during menstruation 555 94.7 One should not listen to the Quran during 256 43.7 menstruation One should not visit graves during menstruation 389 66.4 One should not have sexual intercourse during 474 80.9 Attitudes towards menstruating Behaviors in accordance with beliefs number % One should not pickle during menstruation 76 13.0 One should not make tinned food during menstruation 66 11.3 One should not knead dough during menstruation 77 13.1 One should not dye one's hair during menstruation 90 15.4 One should not henna during menstruation 76 13.0 One should not sit on the doorstep during 177 30.2 menstruation One should not go into the mosque during menstruation 484 100.0 One should not listen to "mevlut" during menstruation 242 41.3 One should not touch the Holy Quran during 549 93.7 menstruation One should not read the Quran during menstruation 554 94.5 One should not listen to the Quran during 255 43.5 menstruation One should not visit graves during menstruation 388 66.2 One should not have sexual intercourse during 471 80.4 menstruation N = 586, percentages are calculated over total N. TABLE 4 DAILY ACTIVITY DEFERRALS ACCORDING TO SOCIODEMOGRAPHIC FEATURES OF THE WOMEN Sociodemographic features Deferrals in daily activities yes no n % n % Age * [less than or equal to] 24 54 55.1 44 44.9 25-29 99 44.0 126 56.0 30-34 45 36.0 80 64.0 [greater than or equal to] 35 30 21.7 108 78.3 Education levels Illiterate 20 16.7 52 72.2 Literate + primary school graduate 114 19.6 208 64.6 Graduated from secondary school or higher 94 19.3 98 51.0 Occupation Housewife 218 38.7 346 61.3 Paid employment 10 45.5 12 54.5 Total 228 38.9 358 61.1 Sociodemographic features Total n % Age * [less than or equal to] 24 98 16.7 25-29 225 38.4 30-34 125 21.3 [greater than or equal to] 35 138 23.5 Education levels Illiterate 72 12.3 Literate + primary school graduate 322 54.9 Graduated from secondary school or higher 192 32.8 Occupation Housewife 564 96.2 Paid employment 22 3.8 Total 586 100.0 * p < 0.05, [chi square] test
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|Author:||Cevirme, Ayse Sayan; Cevirme, Hulya; Karaoglu, Leyla; Ugurlu, Nezihe; Korkmaz, Yasemin|
|Publication:||Social Behavior and Personality: An International Journal|
|Date:||Apr 1, 2010|
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