2. GENDER AND HEALTH
• Health and illness vary according to social class,
geographical location, time and gender.
• In terms of gender, much research shows that
although women live longer than men, they are
more likely to be diagnosed and treated for a wide
range of health problems, from headaches and
constipation to depression, obesity and diabetes.
• Such gender differences can be understood in terms
of all the factors such as health beliefs and
behaviour, symptom perception, help-seeking,
coping, adherence to medication and behaviour
change.
3. • There are, however, a few health
problems which are gender-specific.
For example, while men suffer from
baldness, impotence and prostate
cancer, women get breast cancer,
endometriosis and uterine cancer.
They also suffer miscarriages, receive
terminations of pregnancy and
experience the menopause.
4. MISCARRIAGE
• Miscarriage is a common phenomenon occurring in 15–20 per cent of
known pregnancies, with 80 per cent of these occurring within the first
trimester.
• Miscarriage or ‘spontaneous abortion’ has been defined as the
unintended end of a pregnancy before a foetus can survive outside the
mother.
• Despite the frequency with which miscarriage occurs, it has only been
in the last 10 to 15 years that research has begun to identify and
explore the consequences of early pregnancy loss.
5. • This section explores the psychological consequences of miscarriage
in terms of the quantitative and qualitative research and then
examines the impact of how miscarriage is managed in terms of
women’s experiences of this event.
6. Quantitative research
This research has tended to conceptualize women’s
reactions to miscarriage in terms of :
1. Grief
2. Depression & anxiety
3. Coping
7. Grief:
One main area of research has conceptualized
miscarriage as a loss event, assuming that after
miscarriage women experience stages of grief
parallel to that of the death of a loved one.
The main symptoms identified are sadness,
yearning for the lost child, a desire to talk to
others about the loss and a search for
meaningful explanations.
Research has also highlighted grief reactions
that are unique to the miscarriage experience.
For example, women often perceive themselves
as failures for not being able to have a healthy
pregnancy.
8. Depression & Anxiety:
Other research has focused on depression and anxiety
following miscarriage.
Present State Examination (PSE) was used to assess
women four weeks post-miscarriage. They found that
48 per cent of the sample had sufficiently high scores
on the scale, which is over four times higher than that
in women in the general population. When analysed,
these women were all classified as having depressive
disorders.
In another study , it was found that women who had
miscarried had a significantly increased risk of
developing a minor depressive disorder in the six
months following their loss.
9. Coping:
A small number of studies have considered
the experience of miscarriage from a coping
viewpoint.
According to a study, they found that 86 per cent
of the sample had established their own set of
reasons as to why the miscarriage had occurred,
ranging from medical explanations to feelings of
punishment and judgement.
While working in terms of self-enhancement, 50
per cent of the sample made downward social
comparisons with women who had reproductive
problems.
By comparing themselves with women who were
worse off than themselves, they were able to
increase their own self-esteem.
10. •Qualitative Research:
In an early study, Hutti (1986) conducted in-depth interviews at two time
points with two women.
The results showed that although both women referred to a similar inventory
of events, the significance that they attached to these events was different and
dependent upon their previous experience.
For example, one woman had a previous miscarriage and was described as taking
more control over her medical treatment; she found her grief to be less severe than with
her first miscarriage.
In contrast, the woman who had experienced her first miscarriage represented the
miscarriage as a ‘severe threat to her perception of herself as a childbearing woman.
11. Bansen and Stevens (1992) focused on 10 women
who had experienced their first pregnancy loss of
a wanted pregnancy.
It was concluded that miscarriage was a ‘silent
event’ which was not discussed within the wider
community. The women were described as being
unable to share their experiences and felt isolated
as a result. When they did get the opportunity to
talk about their loss, they realized how common
miscarriage is and that was a source of comfort to
them.
Furthermore, it was also concluded that
miscarriage constituted a major life event that
changed the way in which women viewed their
lives in the present and affected the way in which
they planned for the future.
13. • With ultrasound, it's now much easier to determine whether an
embryo has died or was never formed. Either finding means that a
miscarriage will definitely occur. In this situation, you might have
several choices:
15. Expectant management.
• If you have no signs of infection, you might choose to let the
miscarriage progress naturally.
• Usually this happens within a couple of weeks of determining that the
embryo has died. Unfortunately, it might take up to three or four
weeks.
• This can be an emotionally difficult time. If expulsion doesn't happen
on its own, medical or surgical treatment will be needed.
16. Medical treatment.
• If, after a diagnosis of certain pregnancy loss, you'd prefer to speed the
process, medication can cause your body to expel the pregnancy tissue and
placenta.
• The medication can be taken by mouth or by insertion in the vagina. Your
health care provider might recommend inserting the medication vaginally
to increase its effectiveness and minimize side effects such as nausea and
diarrhea.
• For about 70 to 90 percent of women, this treatment works within 24
hours.
17. Surgical treatment.
• Another option is a minor
surgical procedure called suction
dilation and curettage (D&C).
• During this procedure, your
health care provider dilates your
cervix and removes tissue from
the inside of your uterus.
• Complications are rare, but they
might include damage to the
connective tissue of your cervix
or the uterine wall.
• Surgical treatment is needed if
you have a miscarriage
accompanied by heavy bleeding
or signs of an infection.
18. Impact of Miscarriage:
• The results indicate that miscarriage can result in feelings of grief,
anxiety and depression.
• In addition, women experience their miscarriage as a process,
involving a series of stages which can result in women reassessing
both their past and future experiences.
• medical management of miscarriage brings with it the risks associated
with surgery, a more 'natural' approach can leave women feeling
misinformed and unprepared.
19. Termination of Pregnancy
An abortion (or termination) is the medical process of ending a pregnancy so
it does not result in the birth of a baby.
In 1967 the Abortion Act was passed in the UK
and abortions were made legal. The Act was
welcomed by many women who could
subsequently gain access to a legal abortion on
the grounds that it was considered to be less
physically and mentally harmful than childbirth.
Nowadays, abortions can be obtained through
the National Health Service (NHS) and also
through private for-profit services.
20. Abortion is also legal in the USA and most European countries. In England and
Wales one in three women is likely to have an abortion in their lifetime
(calculated from The Abortion Statistics England and Wales 2001)
Ways of Abortions
The type of abortion procedure depends upon the gestation of the
pregnancy, the preference of the woman and the methods preferred
by the clinic involved. In the UK an abortion is legal up until the 24th
week of gestation although abortions occur within the first trimester.
Nowadays, women can choose to have their abortion using either
the D&C with a general or local anaesthetic
A suction technique which can involve general or local
anaesthetic or no anaesthetic
The abortion pill which induces a miscarriage (later miscarriages
may be managed through inducing labour)
21. Abortion is illegal in a number of countries in all circumstances except
to save a woman’s life.
These include Brazil, Chile, Mexico, Venezuela, Angola,
Congo, Mali, Niger, Nigeria, Uganda, Afghanistan, Iran,
Egypt, Libya, Syria, Bangladesh, Ireland and Malta. In
addition, many countries only allow abortion to
protect a woman’s health. These include Argentina,
Peru, Cameroon, Ethiopia, Malawi, Zimbabwe, Kuwait,
Saudi Arabia, Pakistan, Thailand, Poland and Portugal.
Research focusing on abortions has addressed a range of issues including deciding to have
an abortion, the provision of services, women’s experiences of such services, their
experiences of having an abortion, the longer-term consequences of having an abortion
and the impact of the mode of intervention used.
22. Deciding to Have an Abortion
Freeman and Rickels Study (1993)
Using quantitative data, the results illustrated that those who opted for an abortion had more
Employment in their households
1
Were more likely to still be in school
2
Showed better course grades at school
3
4 Reported having friends and family who
did not approve of early childbearing.
believing that their mother did not approve
of having a child while still a teenager.
5
Highlights
23. Deciding to Have an Abortion
01
02
03
04
The decision to have an abortion was related to social
deprivation.
05
06
Lee et al. Study (2004)
In a similar vein, Lee et al. (2004) carried out a qualitative
study involving in-depth interviews.
In addition, those who believed that their future life would
include higher education and a career,
Who had higher expectations of their life in the present,
Who felt that they lacked the stable relationships to support them if
they became a mother were more likely to have an abortion
Who had a lack of financial independence
In contrast, those who went on to have an abortion described how their parents saw
abortion in a pragmatic way, regarding young motherhood as a more negative event.
24. The Provision of Services
Research has highlighted that, despite increasing provision for abortion in the UK within the NHS,
there remains wide variation in the level of NHS provision in different health authorities (Abortion
Law Reform Association 1997). In particular, figures revealed that, while on average 70.5 per cent of
abortions are funded by the NHS in England and Wales.
Clarke et al. (1983) examined why half the women in
their study had their abortion in a private or charitable
clinic despite generous provision of NHS abortion
services. The study showed that an important reason
for women bypassing the NHS was that they either
thought or had been actually told by their GP or
another doctor that it was difficult to get an abortion on
the NHS. Other reasons for not having an abortion on
the NHS included not wanting to delay the abortion,
expectation of better personal treatment in a private
clinic and wanting to ensure anonymity.
25. Harden and Ogden (1999a) interviewed 54
women aged between 16 and 24 up to three
hours after their abortion about their
experiences. They reported that, overall,
having an unwanted pregnancy was
experienced as a rare event which was
accompanied by feelings of lack of control
and loss of status.
26. Psychological Impact
Zolese and Blacker (1992) argued that approximately 10
percent of women experience depression or anxiety that
is severe or persistent after an abortion.
In contrast, although Major et al. (2000) found that 20
per cent of their sample experienced clinical depression
within two years of an abortion
some research has also considered what type of
psychological reactions occur after an abortion.
Söderberg et al. (1998) conducted interviews with a
large sample of Swedish women (n = 845) a year after
their abortion and found that 55 per cent experienced
some form of emotional distress.
Similarly, Alex and Hammarström (2004) conducted a
study in Sweden of five women’s experiences and
concluded that the women reported gaining a sense of
maturity and experience.
27. In a similar vein, Major et al. (2000) explored the variation in
emotional reactions over time and reported that negative
emotions increased between the time of the abortion and two
years.
Kumar and Robson (1987) found that neurotic disturbances
during pregnancy were significantly higher in those who had
had a previous termination than those who had not
immediate distress has been reported as being higher in those
women who belong to a society that is antagonistic towards
abortion (Major and Gramzow 1999), in those who
experienced difficulty making the decision (Lyndon et al. 1996),
and in those who are younger, unmarried, have the abortion
later in pregnancy (which may be due to the features of women
who delay), show low self-esteem, have had multiple
abortions, and self-blame for the pregnancy or abortion.
Longer-Term Impact
Russo and Zierk (1992) followed up women eight years after their abortion and compared them to those who
had kept the child. They found that having an abortion was related to higher global self-esteem than having
an unwanted birth, suggesting that any initial negative reactions decay over time.
28. Impact of Mode of Intervention
An abortion can be carried out using a D&C (surgical), vacuum aspiration (suction) or the abortion pill (medical)
and may or may not involve a general or local anaesthetic. Some research has explored the relative impact of t
ype of procedure on women’s experiences. For example,
01
Slade et al. (1998) examined the
impact of having either a medical or
surgical abortion. After the abortion,
however, the medical procedure
was seen as more stressful
and was associated with more
post-termination problems. It was
also seen as more disruptive to life.
Further, seeing the fetus was
associated with more intrusive
events such as nightmares,
flashbacks and unwanted thoughts.
Goodwin and Ogden (2006)
suggest from their study that
the abortion pill technique
may result in a more
negative experience for
several women than other
methods, as some women
described seeing the fetus
as it was expelled from their
bodies.
02
03
29. Problems with termination Research
Research exploring the impact of termination
is therefore problematic because the
researcher’s own views and experiences are
highly likely to influence the research process.
For example, an ideological position either for
or against termination could affect the choice
of research design, the selection of
participants, the ways the data are analysed
or the ways the data are interpreted and the
results presented.
30. The pre-menopause refers to the whole of the
woman’s reproductive life up until the end of the last
menstrual period.
The peri-menopause is the time prior to the final
menstrual period when hormonal changes are taking
place and continues until a year after the last
menstrual period.
The post-menopause stage refers to any time after
the last menstrual period but has to be defined
retrospectively after 12 months of no menstruation.
The word menopause means the end of monthly
menstruation and for the average woman this occurs at
the age of 51 years, with 80 per cent of women reaching
the menopause by age 54. the menopause is considered
to be a transition which has been classified according to
three stages.
31. Symptoms
The most common symptoms are as following:
Change in pattern and heaviness of
periods.
Hot flushes.
Night sweats.
Tiredness.
Poor concentration.
Aches and pains in joints.
Vaginal dryness.
Changes in the frequency of passing urine.
32. Conti..
As part of a large-scale survey, 413
women completed a questionnaire
about their experiences of
menopausal symptoms and their
perceptions of severity.
And the results showed that the most
common symptoms were hot flushes,
night sweats and tiredness, and of
these, night sweats seemed to cause
the most distress with over a third
describing their night sweats as
severe.
33. Physical changes
Women also experience a range of physical
changes which persist after the menopause has
passed. In particular they show changes in their
breasts and it is suggested that older women
should have regular mammograms to check for
breast cancer.
There is a post-menopausal increase in cholesterol
in the blood which places women more at risk of
heart disease; bone loss becomes more rapid,
increasing the chance of osteoporosis; the urinary
organs can become less elastic and pliable,
resulting in many women suffering from
incontinence; and finally women experience
vaginal dryness, making sexual intercourse
uncomfortable.
34.
35. The menopause therefore signifies the end of a
woman’s reproductive capacity and brings with it
a wide range of symptoms and physical changes.
Ballard (2003) describes how the menopause
experience is influenced by a range of social,
cultural and biological factors which in turn have
a psychological impact upon the individual.
This reflects why the menopause is also referred
to as ‘the change of life’. This is illustrated in
Figure 16.6. Research exploring the impact of the
menopause has highlighted the experience as a
life transition and the social and psychological
factors that affect this transition.
36.
37. Menopause as a transition
The women completed questions about their
symptoms and health in general and then 65 per cent
also completed a ‘free comments’ section. These data
were then analyzed using both quantitative and
qualitative methods. From this study the authors
conclude that women experience the menopause as a
‘status passage’ which involves five stages.
Expectations of symptoms: The results illustrate that,
prior to the menopause onset, women are searching
for symptoms and looking for signs of any biological
changes. At this point some women seek help from the
doctor and start to find further information.
Experience of symptoms and loss of control: Women
then start to experience symptoms such as night
sweats, hot flushes and mood swings, which for some
interfere with their sense of well-being and can make
them feel out of control.
38. Conti..
Confirmation of the menopause: Once women sense a
loss of control, they then try to confirm the onset of the
menopause by visiting their doctor as a means to regain
control. The doctor can use blood tests to measure
hormone levels to confirm the onset of the menopause
and at this stage many women are offered hormone
replacement therapy (HRT).
Regaining control: Women try to regain control in
several ways. Some try to minimize the impact of their
symptoms by taking HRT while others try a range of
methods such as wearing different clothes to cope with
hot flushes or taking alternative medicines.
Freedom from menstruation: The end of menstruation
is often welcomed by women as, for the majority,
decisions about family size have been made long ago.
Women therefore feel relieved that they do not have to
experience the pain and bleeding from periods any more
and the inconvenience that this can cause.
39. Social factors
The menopause happens at a time in a woman’s life when she is
probably also experiencing a range of other changes. Whether or
not such changes have a direct or indirect effect upon the
menopausal experience, research indicates that the menopause
needs to be understood in the context of these changes and
describes them and their effect upon the menopause as follows :
Elderly relatives: At the time of the menopause women often
find that they are also increasingly responsible for caring for
elderly relatives. Further, this may come at a time when women
are just starting to enjoy a newfound freedom from the children
leaving home. The added pressure of elderly relatives can make
women feel under stress and guilty and can affect their physical
health, all of which may exacerbate their menopausal symptoms.
Changes in employment and finance: In middle life many
women increase their hours of work as the children leave home.
This may bring with it new opportunities and a sense of rebirth.
40. Conti…
Changing relationships: At the time of the
menopause women often experience changes in their
role as a mother as this is the time when children
leave home, and a change in their relationship with
their partner as they renegotiate a new life without
children. Such changes can make the menopause
seem more pertinent as it reflects the end of an era.
Death of family or friends: As women reach their
fifties they may experience the death of similar-age
family or friends. The menopause may represent a
sense of mortality which can be exacerbated by a
sense of loss.
41. Psychological Effects
Psychological factors influence the menopause in terms of
symptom perception because symptoms such as hot flushes,
night sweats, lack of concentration and tiredness are all
influenced by processes such as distraction, focus, mood,
meaning and the environment . In addition, the menopause
has more direct effects upon the individual’s psychological
state.
Changes in body image: The menopause brings with it
physical changes such as dryer skin, changing fat distribution
and softer breasts, which can all impact upon a woman’s
body image. In addition, becoming 50 is also seen as a
milestone, particularly within a society that associates
getting older with being less attractive. Ballard provides
interesting descriptions of how women can suddenly catch
themselves in a mirror and think ‘it’s my mum’ or ‘you are
getting old’.
42. Conti..
Mood changes: Some women report experiencing
moods such as anxiety and depression and some
report having panic attacks. Given the many life
changes that co-occur with the menopause, it is
not surprising that women experience changes in
their mood. However, many women view their
emotional shifts as directly linked to their
changing hormone levels.
Self-esteem and self-confidence: Some women
also report decreases in their self-esteem and
self-confidence. They describe not feeling
confident in everyday tasks such as cooking or
work, and feeling less able to manage
relationships
43. Conti…
Lack of concentration:
Several surveys report that women describe how
the menopause disrupts their cognitive function
in terms of concentration and memory.
Experimental studies in controlled conditions,
however, show no evidence for any cognitive
decline that could be attributed to the
menopause above and beyond standard age
effects.
45. Some women simply carry on with their lives and wait for
the symptoms to pass.
For example:
They may manage these symptoms using ‘tricks of the
trade’ − such as wearing layered clothes rather than thick
jumpers to make removing clothes easier, sleeping with
the window open to cope with night sweats and buying
lubricants to manage vaginal dryness.
But they do not necessarily present their symptoms
to the doctor.
Others try alternative medicines for symptom relief
including herbal remedies, homeopathy and preferring
a more natural approach.
Ways to Manage
46. Hormone Replacement Therapy (HRT) consists of treatment with estrogen or a combination of estrogen
plus progestin.
HRT was originally developed to reduce menopausal symptoms but has subsequently been shown to
treat and prevent osteoporosis, Alzheimer’s disease, cardiovascular disease and depression. It also has
its own risks, however, and has been associated with breast and endometrial cancer, heart attack,
cerebrovascular disease and thromboembolic Disease.
Hormone Replacement
Therapy (HRT)
47. According to a survey,
“The numbers of women taking HRT increased
threefold between 1981 and 1990, up to 19 per
cent, and increased to a rate of 60 per cent by
2000.”
(Moorhead et al. 1997; Kuh et al. 2000; Ballard 2002)
Use of HRT in Pakistan
Use of HRT in West
According to a survey,
“Out of 102, only 02 (1.96%) respondents were
aware of HRT. Most of respondents (94%) did not
consider menopause to be a medical condition but
a normal transition.”
(Jinnah Medical College Hospital Karachi)
48. HRT may help to alleviate menopausal symptoms and can protect against menopause-related diseases, but at the
same time evidence indicates that it can increase the risk of longer-term health problems. Women therefore have
to weigh up the pros and cons of HRT if they are to decide how to manage their menopause.
Deciding how to manage..
Research has explored how women decide whether or not to take
HRT:
Ballard (2002) studied why women take HRT. The results showed that the main reason was for the relief of
symptoms, particularly hot flushes, tiredness and irritability. Similarly, Welton et al. (2004) study showed that, for
those taking HRT, the main reason was perceived improvement in quality of life regardless of either the costs or
benefits in the longer term. In addition, however, Ballard (2002) also reported that 58 per cent also took HRT to
prevent osteoporosis. Symptom relief would therefore be the main factor influencing the decision-making
process.
49. Cont...
Research has also used the theory of planned behaviour (TPB) to predict the use of HRT, showing a role
for attitudes to HRT and self-efficacy (Huston et al. 2010). Not all women, however, take HRT and Wathen
(2006) explored women’s use of complementary and alternative medicines. This study used a mixed method
approach and reported that 57 per cent of the Canadian sample had either considered or used alternative
medicines as an alternative to HRT and that these women tended to be younger and had experienced worse
symptoms than those who had not tried such remedies.
Protection from illness, however, also seems to have a role to play. As a means to further understand the
decision-making process, Buick et al. (2005) carried out a systematic study to explore women’s beliefs about
HRT. The results support those described earlier and indicate that use and discontinuation of HRT are more
related to symptom relief than considerations of long-term benefits. Further, the results indicate that those women
who refuse HRT often believe that the menopause is a natural event that does not require chemical intervention
and that women’s beliefs about the benefits of HRT are often countered by their concerns about potential adverse
events.
50. Impact of HRT on symptoms
Women report a wide range of menopausal symptoms which vary in their severity and the impact they have on their quality of life.
Much research has explored the extent to which HRT does actually relieve menopausal symptoms. From the perspective of the
patient, research indicates that women feel better when taking HRT and report improvements in their symptoms and quality of life.
Researches showed that the majority of the women believed that HRT helped hot flushes, non-specific emotional changes,
vaginal dryness, insomnia and loss of muscle tone.
In contrast, however, a large randomized trial, which explored the effectiveness of HRT compared to a placebo, suggested that HRT
may not be as effective as believed (Utian et al. 1999). In particular this double-blind placebo-controlled study showed that HRT was
only effective at relieving vasomotor symptoms such as hot flushes and night sweats. Similarly, another placebo-controlled trial
showed that HRT only improved vaginal dryness, increased frequency of passing urine and the tendency to get urinary
infections (Eriksen and Rasmussen 1992). These data suggest no effect for insomnia and mood.
Further, they were placebo controlled, suggesting that such changes cannot simply be attributed to women wanting
to feel better. Rymer et al. (2003) explored the effectiveness of HRT and suggested that this discrepancy between
perceived effectiveness and actual effectiveness may illustrate a domino effect. In particular, while HRT may
only relieve hot flushes and vaginal dryness, which can be directly explained by oestrogen deficiency, such changes
may in turn improve mood, sleep and general quality of life.
51. 1.
The menopause happens to all women
regardless of class, culture or time.
Most research to date, however, has
explored the experiences of western
women for whom the menopause is
often seen as an event that needs to
be managed medically. It is likely that
other cultures have very different
beliefs and experiences of the
menopause and that this influences
their management strategies.
2.
New research is constantly being
published about the risks and benefits
of HRT. Studies exploring women’s
beliefs and use of HRT must therefore
be located within the time that the
data were collected and the current
state of evidence at this time. This
means that aggregating studies is
problematic and drawing conclusions
across time is difficult.
Problems with Menopause Research
52. 4.
3.
The menopause and HRT generate strong
beliefs in researchers, clinicians and patients
according to the need for any medical
intervention, the dangers of HRT and the
dangers of menopause-related disease.
Interpreting research is therefore problematic
as results and the ways in which results are
presented may well reflect the beliefs of the
people involved.
Conti…
Research on the menopause and HRT
illustrates the complex problem of risk
analysis and risk communication because
symptoms, side-effects and longer-term costs
and benefits will have different meanings to
all the parties involved. There is a tendency
within the literature to attempt to find the state
of ‘truth’ within all these risks and
probabilities. Future psychological research
could focus on how different risks are
managed and communicated without
attempting to synthesize them.
54. • There are
many areas
of health that
are specific
to women.
This chapter
has explored
three of
these which
were chosen
because
they
seemed to
have
generated
the most
research
and most
closely
reflect the
interests of
the health
psychology
community.
56. The results
from the
studies
described
indicate that,
although
these are
difficult and
often
unpleasant
times for
women,
many
women
report how
they can
also see the
benefit in
these
experiences.
57. • In particular,
miscarriage is
sometimes
seen as a
pivotal point in
a woman’s
life, enabling
her to re-
evaluate her
past and
future self.
• termination is
often
accompanied
by feelings of
relief and a
return to
normality.
• the
menopause
introduces a
new period of
life and a
sense of
liberation.
