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Sociocultural aspects of menstrual attitudes and premenstrual experiences in India
0277-9536/91$3.00+ 0.00 Copyright C 1991Pergamon Press plc
Sot. Sci. Med. Vol. 32, No. 3, Pp. 349-351, 1991 Printed in Great Britain. All rights reserved
RESEARCH NOTE SOCIOCULTURAL ASPECTS AND PREMENSTRUAL SANTOSHK.
CIUTURVEDI*
OF MENSTRUAL ATTITUDES EXPERIENCES IN INDIA and PRABHA S. CHANDRA
Department of Psychiatry, National Institute of Mental Health and Neurosciences, Bangalore 560 029, India Abstract-Menstrual attitudes were studied in a group of 48 Indian women using the Menstrual Attitude Questionnaire, modified and adapted for Indian background. Attitudinal factors of menstruation being a natural, bothersome and debilitating event were studied, as also denial of the event and healthy/ unhealthy attitudes. High rating was seen in menstruation being perceived as a natural event and least as a debilitating one. Older women considered menstruation as a natural event. Relating premenstrual experiences to attitudes, it was observed that distressful symptoms correlated significantly with debilitating and unhealthy attitudes. Similarly, premenstrual well-being correlated highly with naturalness attitudes, thereby suggesting that the personal experiences are likely to influence the menstrual attitudes. Key words-menstrual
attitudes, premenstrual experiences, social factors, cultural variations
INTRODUCIION
Social and cultural factors influence the attitudes and beliefs regarding a multitude of natural events in women like childbirth, contraception, menarche and menstruation. The cultural differences might account for premenstrual tension being considered a culture bound syndrome in the west [l]. Women’s attitudes and expectations have been found to influence the reporting of menstrual symptoms (2-41. Attitudes and beliefs concerning menstruation are influenced by a woman’s immediate family environment and by the wider culture or society in which she is brought up (51. Studies have also demonstrated a relationship between religious beliefs [6], culture [A and menstrual cycle complaints [2-4, 81. Attitudes directly related to menstruation such as attitudes about sex, femininity or illness may also be important [6,9]. Previous work in this area has also highlighted attitudinal behaviour and its influence on perception of menstrual distress [IO, 111. Attitudes regarding menstruation differ widely in cultures and religions. American Catholic and Jewish women differ in their attitudes from Protestants [4,8]. Misconceptions regarding the role of uterus and menstruation were found more frequently among the French Canadian and women of European origin as compared to English Canadian women in a recent study [12]. Attitudes and beliefs (including misconceptions) are frequently observed in India, which are usually conveyed through ancestral transfer of practices and vary in subcultures [ 131.In India, beliefs regarding menstruation are reflected in rituals and customs practised across communities. In the Hindu and Muslim families, a girl who attains menarche is *Address correspondence to: Dr S. K. Chaturvedi, No. 8, Type IV, Nimhans Quarters, Byrasandra Campus, Bangalore 560 011, India.
conferred a special status. The event is considered auspicious and a religious function is held to announce puberty. At the same time a menstruating women is considered impure or unholy and is not allowed to participate in any religious or social function. She is expected to be away from the household, not enter the kitchen and for the duration of the period her role is taken over by other women or at times the men in the family. Hence, she enjoys a socially sanctioned respite from her daily duties. In certain communities menstruating women are not allowed to bathe or even look after their children [14]. The theme of contamination seems to be prominent in the rituals and practices. Such varying customs would necessarily influence attitudes towards menstruation. The measurement of attitudes in an Indian background is likely to reflect the cultural and social overtones. Premenstrual experiences are also known to be affected by the menstrual attitudes [2, 3,4,8]. We were interested in studying the menstrual attitudes in a sample of healthy Indian women and relate them with their premenstrual experiences. We wanted to know “How premenstrual experiences are influenced or affected by the menstrual attitudes?’ In fact, the cause-effect relationship between menstrual attitudes and premenstrual experience is complex, and the menstrual attitudes may be dependent upon the premenstrual experiences or vice versa. We have studied the inter-relationship between menstrual attitudes and premenstrual experiences in this study. METHOD
The subjects were 48 women nursing students, in the reproductive age group, who were posted at the National Institute of Mental Health and NeuroSciences, Bangalore, for training at various periods. The Menstrual Attitude Questionnaire, MAQ [lo] was abridged, adapted and modified by the authors 349
350
SANTOSH K. CHATWWEDI
and F’RASHA S.
Table 2. Overall scores on attitudes (n = 48)
Table I. Characteristics of the sample Variable
n
Age: Under 25 yr Above 25 yr Marital status: Unmarried Married Religion: Hindu Christians Muslim Background: Rural Urban Children: Having children No children Age of menarche: &fore 14 yr After 14 yr Period of flow: Less than 4 days More than 5 days Interperiod interval: 28 days or less More than 28 davs
(“/.)
27 21
(56) (44)
30 18
(63) (37)
20 27
(42) (56)
I
(42) (58)
13 35
(27) (73)
26 22
(54) (46)
23 25
(48) (52)
31 17
(65) (35)
Factor
Mean
SD
Debilitating Natural Bothersome Denial Healthy Unhealthy
2.7384 3.9236 3.2292 2.8056 3.3494 2.9343
0.6045 0.7781 0.6916 0.6408 0.61 I2 0.5444
attitudinal items which could be included. Their suggestions were noted. Subjects rated their premenstrual experiences on premenstrual assessment forms which enquired about distressful as well as positive emotions during the premenstrual period. Menstrual attitudes were then correlated with the premenstrual positive as well as distressful experiences.
(2)
20 28
CHANDRA
RESULTS
so that it was easier to understand and could be used for Indian women. The modifications were mainly those involving the use of simpler language and alterations to suit local background. In fact, 11 out of the 33 items of MAQ were clearly not applicable for our subjects and hence were deleted. Items deleted were those relating to sports, intellectual tasks and work expectations. Items like “Menstruation provides a way for me to keep in touch with my body” were deleted as we felt this might not be well comprehended. The questionnaire which finally emerged had 22 items. Factors which were identified by BrooksGunn and Ruble [lo] in the original questionnaire were retained except those involving anticipation and prediction of the event, which were excluded as they were not a direct measure of attitudes. The four factors which were considered for analysis weremenstruation as a natural event, as a bothersome event, debilitating event and denial of the event. The other two dimensions measured were those of healthy and unhealthy attitudes towards menstruation. The rationale for selecting MAQ [lo] for our study was to have measurements which could be easily compared with those of other studies using same instrument. Moreover, MAQ has been standardized and found to be a reliable and valid measure of menstrual attitudes [lo]. Sociodemographic details of women like age, marital status, residence, occupation and religion and details about menstrual and obstetric history were also noted. Subjects were also encouraged to discuss other
The subjects were mainly under the age of 25 years (56%), unmarried (63%), Christians (56%) and students (63%). Other details of the sample are shown in Table 1. Table 2 shows the mean and standard deviation of the scores of the women on different factors. The mean scores on menstruation as a natural event are high (3.92 f 0.78), whereas those on debilitating event are quite low (2.74 _+0.60). Denial scores were moderate but the women did rate menstruation as a bothersome event (mean 3.23 k 0.692). Women above 25 years of age rated higher scores on menstruation as a natural event than women under 25 years (P < 0.05). No other statistically significant difference was noted in the demographic and menstrual variables. Attitudes did not differ between religious groups. Also, no significant differences were found between rural and urban women. The correlations between distressful premenstrual experiences and menstrual attitudes were not significant for three of the factors:viz. natural event, bothersome event, denial (Table 3). Menstruation as a debilitating event had significant correlations with affective, physical, behavioural and cognitive distressful premenstrual experiences. Similar correlation was also observed between unhealthy attitudes and premenstrual distress. Healthy attitudes and menstruation as a natural event had significant correlations with well-being during premenstrual period. Other premenstrual changes like excitement, feeling energetic, affectionate and well-being had significant correlations with the factor ‘denial’ of the menstrual attitude questionnaire. Unhealthy attitudes and factors ‘debilitating event’, ‘bothersome event’ had no significant correlation with any of the positive premenstrual experience item.
Table 3. Inter-relationshio between menstrual attitudes and oremenstrual distress Premenstrual distressful symptoms MAQ factor Debilitating event Natural event Bothersome event Denial Healthy attitudes Unhealthv
Dysphoric 0.3937 0.221 0.139 0.176 0.147 0.429t
Physical
Behavioural
Cognitive
0.384t 0.062 0.073 -0.032 -0.086 0.319.
0.349’ -0.012 0.039 0.127 0.006 0.291.
0.4887 -0.061 -0.005 0.059 -0.162 0.325.
lP < 0.05; tP < 0.01. Other correlations are not significant.
Research Note DISCUSSION
Our findings indicate a clear relationship between menstrual attitudes and premenstrual changes. Those who reported a lot of premenstrual distress considered menstruation as a debilitating event and had unhealthy attitudes. Those who had premenstrual well-being considered menstruation as a natural event and had healthy attitudes. The cause-effect relationship between attitudes and premenstrual experiences, however, cannot be discerned. Brookes-Gunn and Ruble [lo] had also noted that attitudes about debilitation related to premenstrual and menstrual symptoms, and naturalness and bothersome attitudes not relating to these symptoms. Since there are no significant differences between religious groups or rural/urban background but clear and significant correlations between premenstrual experience and viewing menstruation as a debilitating event, it is likely that it is the personal experiences which mediate this relationship. Attitudes are known to be varying with religion [I 11, but no significant differences were noted in this study between religious groups. Women belonging to the Hindu religion have rigid social and religious restrictions imposed on them, though they are not followed universally [15]. The findings of this study are interesting when compared with those of another study with comparable material and methods but carried out in a culturally different set-up almost a decade earlier [I 11. On comparing the mean factor scores of this study with those of Brooks-Gunn and Ruble’s [ll] it was noted that the scores on menstruation as a ‘bothersome’ event and a ‘debilitating’ event were similar in the two samples, however ‘naturalness’ score were higher among the Indian women as compared to the American. Similarly, scores on denial of effects of menstruation were higher in the Indian women. These differences should be viewed with caution since the two studies were performed at different times and the scale had been modified and altered substantially. The differences indicate some differences in attitudes between the two cultures, which need confirmation. Certain cultures are more tolerant of biological events like childbirth and menstruation. These events are given special significance in some cultures which could cause attitudinal differences. Indian women are usually relieved of all duties and a number of aforementioned rituals are followed [IS] which, probably, may make them unaware of the negative aspects, and thus accept menstruation as a natural event. Menstrual symptoms are also experienced in a bipolar manner and many times as a positive phenomena [16, 171. Healthiness of attitudes may well depend on the amount of distress related to menstruation, as shown by the findings of the present study. The subjects suggested a number of other attitudinal items, which the modified scale did not explore. These were related to feelings of impurity or uncleanliness, participation in usual activities, participation in
351
religious activities (and visiting religious place) during their periods. Other items suggested were with regard to sex during menstrual periods and attitudes of men towards the menstruating women. Most of the subjects strongly urged the need for studying attitudes of men towards menstruation in the male dominated Indian society. These items have been incorporated in the subsequent revision of the Indianized menstrual attitude questionnaire, and is currently being used to measure attitudes in larger and different sections of general population in India.
REFERENCES
I. Johnson
M. T. Premenstrual syndrome as a Western culture specific disorder. Culr. Med. Psychiar. 11, 337-356, 1987. 2. Brush A. L. Attitudes, emotional and physical symptoms commonly associated with menstruation in 100 women. Am. J. Orrhopsychiat. 8, 286-306,
1938.
3. Parlee M. B. Stereotypic beliefs about menstruation: a methodological note on the MOOS Menstrual Distress Questionnaire and some new data. Psychosom. Med. 36, 229-240,
1974.
4. Ruble D. N. and Brooks-Gunn J. Menstrual symptoms: a social cognition analysis. J. behau. Med. 2, 171-194, 1979.
5. Fielding D. and Bosanko C. Psychological aspects of the menstruum and premenstruum. In Psychology and Gynaecological Problems (Edited by Broome A. and Wallace L.), pp. 21 l-242. Tavistock, New York, 1984. 6. Paige K. E. Woman learn to sing the menstrual blues. Psvchol. Todav 7. 41-46.
1973.
7. Janiger 0. R, Riffenburgh R. and Kersh R. Crosscultural study of premenstrual symptoms. Pspchosomatics 13, 226-235, 1972. 8. Brooks J., Ruble D. N. and Clark A. College women’s attitudes and expectations concerning menstrual related changes. Psychosom. Med. 39, 118-130, 1977. 9. Slade P. D. and Jenner F. A. Attitudes to female roles, aspects of menstruation and complaining of menstrual symptoms. Br. J. Sot. Clin. Psychol. 19, 109-I 13, 1980. IO. Brooks-Gunn J. and Ruble D. N. The menstrual attitude questionnaire. Psychosom. Med. 42, 503-S 12, 1980. 11. Brooks-Gunn J. and Ruble D. N. The development of menstrual related beliefs and behaviour during early adolescence. Child Devl. 36, 229-240, 1986. 12. Lalinec-Michud M. and Engelsmann F. Cultural factors and reaction to hysterectomy. Sot. Psychiar. Psychiar. Epidem. 24, 165-171,
1989.
13. Mazumdar D. N. Races and Cultures of India, pp. 238-239. Asia Publishing House, Bombay, 1958. 14. Chandra P. S., Chaturvedi S. K. and Isaac M. K. Measurement of menstrual attitudes in Indian women: a cultural perspective. J. Psychosom. Obsfer. Gynec. 10, 247-253, 1989. 15. Varma V. K. Toward a theory of cultural defenses. In Readings in Transcultural Psychiatry (Edited by Kiev A. and Rao V.). pp. 31-46. Higginbothams, Madras 1982. 16. Chaturvedi S. K. and Chandra P. S. Letter to the Editor. J. psychosom. Res. 33, 383, 1989. 17. Logue C. M. and Moos R. H. Positive perimenstural changes: toward a new perspective on the menstrual cycle. J. psychosom. Res. 32, 31-40, 1988.
Sot. Sci. Med. Vol. 32, No. 3, Pp. 349-351, 1991 Printed in Great Britain. All rights reserved
RESEARCH NOTE SOCIOCULTURAL ASPECTS AND PREMENSTRUAL SANTOSHK.
CIUTURVEDI*
OF MENSTRUAL ATTITUDES EXPERIENCES IN INDIA and PRABHA S. CHANDRA
Department of Psychiatry, National Institute of Mental Health and Neurosciences, Bangalore 560 029, India Abstract-Menstrual attitudes were studied in a group of 48 Indian women using the Menstrual Attitude Questionnaire, modified and adapted for Indian background. Attitudinal factors of menstruation being a natural, bothersome and debilitating event were studied, as also denial of the event and healthy/ unhealthy attitudes. High rating was seen in menstruation being perceived as a natural event and least as a debilitating one. Older women considered menstruation as a natural event. Relating premenstrual experiences to attitudes, it was observed that distressful symptoms correlated significantly with debilitating and unhealthy attitudes. Similarly, premenstrual well-being correlated highly with naturalness attitudes, thereby suggesting that the personal experiences are likely to influence the menstrual attitudes. Key words-menstrual
attitudes, premenstrual experiences, social factors, cultural variations
INTRODUCIION
Social and cultural factors influence the attitudes and beliefs regarding a multitude of natural events in women like childbirth, contraception, menarche and menstruation. The cultural differences might account for premenstrual tension being considered a culture bound syndrome in the west [l]. Women’s attitudes and expectations have been found to influence the reporting of menstrual symptoms (2-41. Attitudes and beliefs concerning menstruation are influenced by a woman’s immediate family environment and by the wider culture or society in which she is brought up (51. Studies have also demonstrated a relationship between religious beliefs [6], culture [A and menstrual cycle complaints [2-4, 81. Attitudes directly related to menstruation such as attitudes about sex, femininity or illness may also be important [6,9]. Previous work in this area has also highlighted attitudinal behaviour and its influence on perception of menstrual distress [IO, 111. Attitudes regarding menstruation differ widely in cultures and religions. American Catholic and Jewish women differ in their attitudes from Protestants [4,8]. Misconceptions regarding the role of uterus and menstruation were found more frequently among the French Canadian and women of European origin as compared to English Canadian women in a recent study [12]. Attitudes and beliefs (including misconceptions) are frequently observed in India, which are usually conveyed through ancestral transfer of practices and vary in subcultures [ 131.In India, beliefs regarding menstruation are reflected in rituals and customs practised across communities. In the Hindu and Muslim families, a girl who attains menarche is *Address correspondence to: Dr S. K. Chaturvedi, No. 8, Type IV, Nimhans Quarters, Byrasandra Campus, Bangalore 560 011, India.
conferred a special status. The event is considered auspicious and a religious function is held to announce puberty. At the same time a menstruating women is considered impure or unholy and is not allowed to participate in any religious or social function. She is expected to be away from the household, not enter the kitchen and for the duration of the period her role is taken over by other women or at times the men in the family. Hence, she enjoys a socially sanctioned respite from her daily duties. In certain communities menstruating women are not allowed to bathe or even look after their children [14]. The theme of contamination seems to be prominent in the rituals and practices. Such varying customs would necessarily influence attitudes towards menstruation. The measurement of attitudes in an Indian background is likely to reflect the cultural and social overtones. Premenstrual experiences are also known to be affected by the menstrual attitudes [2, 3,4,8]. We were interested in studying the menstrual attitudes in a sample of healthy Indian women and relate them with their premenstrual experiences. We wanted to know “How premenstrual experiences are influenced or affected by the menstrual attitudes?’ In fact, the cause-effect relationship between menstrual attitudes and premenstrual experience is complex, and the menstrual attitudes may be dependent upon the premenstrual experiences or vice versa. We have studied the inter-relationship between menstrual attitudes and premenstrual experiences in this study. METHOD
The subjects were 48 women nursing students, in the reproductive age group, who were posted at the National Institute of Mental Health and NeuroSciences, Bangalore, for training at various periods. The Menstrual Attitude Questionnaire, MAQ [lo] was abridged, adapted and modified by the authors 349
350
SANTOSH K. CHATWWEDI
and F’RASHA S.
Table 2. Overall scores on attitudes (n = 48)
Table I. Characteristics of the sample Variable
n
Age: Under 25 yr Above 25 yr Marital status: Unmarried Married Religion: Hindu Christians Muslim Background: Rural Urban Children: Having children No children Age of menarche: &fore 14 yr After 14 yr Period of flow: Less than 4 days More than 5 days Interperiod interval: 28 days or less More than 28 davs
(“/.)
27 21
(56) (44)
30 18
(63) (37)
20 27
(42) (56)
I
(42) (58)
13 35
(27) (73)
26 22
(54) (46)
23 25
(48) (52)
31 17
(65) (35)
Factor
Mean
SD
Debilitating Natural Bothersome Denial Healthy Unhealthy
2.7384 3.9236 3.2292 2.8056 3.3494 2.9343
0.6045 0.7781 0.6916 0.6408 0.61 I2 0.5444
attitudinal items which could be included. Their suggestions were noted. Subjects rated their premenstrual experiences on premenstrual assessment forms which enquired about distressful as well as positive emotions during the premenstrual period. Menstrual attitudes were then correlated with the premenstrual positive as well as distressful experiences.
(2)
20 28
CHANDRA
RESULTS
so that it was easier to understand and could be used for Indian women. The modifications were mainly those involving the use of simpler language and alterations to suit local background. In fact, 11 out of the 33 items of MAQ were clearly not applicable for our subjects and hence were deleted. Items deleted were those relating to sports, intellectual tasks and work expectations. Items like “Menstruation provides a way for me to keep in touch with my body” were deleted as we felt this might not be well comprehended. The questionnaire which finally emerged had 22 items. Factors which were identified by BrooksGunn and Ruble [lo] in the original questionnaire were retained except those involving anticipation and prediction of the event, which were excluded as they were not a direct measure of attitudes. The four factors which were considered for analysis weremenstruation as a natural event, as a bothersome event, debilitating event and denial of the event. The other two dimensions measured were those of healthy and unhealthy attitudes towards menstruation. The rationale for selecting MAQ [lo] for our study was to have measurements which could be easily compared with those of other studies using same instrument. Moreover, MAQ has been standardized and found to be a reliable and valid measure of menstrual attitudes [lo]. Sociodemographic details of women like age, marital status, residence, occupation and religion and details about menstrual and obstetric history were also noted. Subjects were also encouraged to discuss other
The subjects were mainly under the age of 25 years (56%), unmarried (63%), Christians (56%) and students (63%). Other details of the sample are shown in Table 1. Table 2 shows the mean and standard deviation of the scores of the women on different factors. The mean scores on menstruation as a natural event are high (3.92 f 0.78), whereas those on debilitating event are quite low (2.74 _+0.60). Denial scores were moderate but the women did rate menstruation as a bothersome event (mean 3.23 k 0.692). Women above 25 years of age rated higher scores on menstruation as a natural event than women under 25 years (P < 0.05). No other statistically significant difference was noted in the demographic and menstrual variables. Attitudes did not differ between religious groups. Also, no significant differences were found between rural and urban women. The correlations between distressful premenstrual experiences and menstrual attitudes were not significant for three of the factors:viz. natural event, bothersome event, denial (Table 3). Menstruation as a debilitating event had significant correlations with affective, physical, behavioural and cognitive distressful premenstrual experiences. Similar correlation was also observed between unhealthy attitudes and premenstrual distress. Healthy attitudes and menstruation as a natural event had significant correlations with well-being during premenstrual period. Other premenstrual changes like excitement, feeling energetic, affectionate and well-being had significant correlations with the factor ‘denial’ of the menstrual attitude questionnaire. Unhealthy attitudes and factors ‘debilitating event’, ‘bothersome event’ had no significant correlation with any of the positive premenstrual experience item.
Table 3. Inter-relationshio between menstrual attitudes and oremenstrual distress Premenstrual distressful symptoms MAQ factor Debilitating event Natural event Bothersome event Denial Healthy attitudes Unhealthv
Dysphoric 0.3937 0.221 0.139 0.176 0.147 0.429t
Physical
Behavioural
Cognitive
0.384t 0.062 0.073 -0.032 -0.086 0.319.
0.349’ -0.012 0.039 0.127 0.006 0.291.
0.4887 -0.061 -0.005 0.059 -0.162 0.325.
lP < 0.05; tP < 0.01. Other correlations are not significant.
Research Note DISCUSSION
Our findings indicate a clear relationship between menstrual attitudes and premenstrual changes. Those who reported a lot of premenstrual distress considered menstruation as a debilitating event and had unhealthy attitudes. Those who had premenstrual well-being considered menstruation as a natural event and had healthy attitudes. The cause-effect relationship between attitudes and premenstrual experiences, however, cannot be discerned. Brookes-Gunn and Ruble [lo] had also noted that attitudes about debilitation related to premenstrual and menstrual symptoms, and naturalness and bothersome attitudes not relating to these symptoms. Since there are no significant differences between religious groups or rural/urban background but clear and significant correlations between premenstrual experience and viewing menstruation as a debilitating event, it is likely that it is the personal experiences which mediate this relationship. Attitudes are known to be varying with religion [I 11, but no significant differences were noted in this study between religious groups. Women belonging to the Hindu religion have rigid social and religious restrictions imposed on them, though they are not followed universally [15]. The findings of this study are interesting when compared with those of another study with comparable material and methods but carried out in a culturally different set-up almost a decade earlier [I 11. On comparing the mean factor scores of this study with those of Brooks-Gunn and Ruble’s [ll] it was noted that the scores on menstruation as a ‘bothersome’ event and a ‘debilitating’ event were similar in the two samples, however ‘naturalness’ score were higher among the Indian women as compared to the American. Similarly, scores on denial of effects of menstruation were higher in the Indian women. These differences should be viewed with caution since the two studies were performed at different times and the scale had been modified and altered substantially. The differences indicate some differences in attitudes between the two cultures, which need confirmation. Certain cultures are more tolerant of biological events like childbirth and menstruation. These events are given special significance in some cultures which could cause attitudinal differences. Indian women are usually relieved of all duties and a number of aforementioned rituals are followed [IS] which, probably, may make them unaware of the negative aspects, and thus accept menstruation as a natural event. Menstrual symptoms are also experienced in a bipolar manner and many times as a positive phenomena [16, 171. Healthiness of attitudes may well depend on the amount of distress related to menstruation, as shown by the findings of the present study. The subjects suggested a number of other attitudinal items, which the modified scale did not explore. These were related to feelings of impurity or uncleanliness, participation in usual activities, participation in
351
religious activities (and visiting religious place) during their periods. Other items suggested were with regard to sex during menstrual periods and attitudes of men towards the menstruating women. Most of the subjects strongly urged the need for studying attitudes of men towards menstruation in the male dominated Indian society. These items have been incorporated in the subsequent revision of the Indianized menstrual attitude questionnaire, and is currently being used to measure attitudes in larger and different sections of general population in India.
REFERENCES
I. Johnson
M. T. Premenstrual syndrome as a Western culture specific disorder. Culr. Med. Psychiar. 11, 337-356, 1987. 2. Brush A. L. Attitudes, emotional and physical symptoms commonly associated with menstruation in 100 women. Am. J. Orrhopsychiat. 8, 286-306,
1938.
3. Parlee M. B. Stereotypic beliefs about menstruation: a methodological note on the MOOS Menstrual Distress Questionnaire and some new data. Psychosom. Med. 36, 229-240,
1974.
4. Ruble D. N. and Brooks-Gunn J. Menstrual symptoms: a social cognition analysis. J. behau. Med. 2, 171-194, 1979.
5. Fielding D. and Bosanko C. Psychological aspects of the menstruum and premenstruum. In Psychology and Gynaecological Problems (Edited by Broome A. and Wallace L.), pp. 21 l-242. Tavistock, New York, 1984. 6. Paige K. E. Woman learn to sing the menstrual blues. Psvchol. Todav 7. 41-46.
1973.
7. Janiger 0. R, Riffenburgh R. and Kersh R. Crosscultural study of premenstrual symptoms. Pspchosomatics 13, 226-235, 1972. 8. Brooks J., Ruble D. N. and Clark A. College women’s attitudes and expectations concerning menstrual related changes. Psychosom. Med. 39, 118-130, 1977. 9. Slade P. D. and Jenner F. A. Attitudes to female roles, aspects of menstruation and complaining of menstrual symptoms. Br. J. Sot. Clin. Psychol. 19, 109-I 13, 1980. IO. Brooks-Gunn J. and Ruble D. N. The menstrual attitude questionnaire. Psychosom. Med. 42, 503-S 12, 1980. 11. Brooks-Gunn J. and Ruble D. N. The development of menstrual related beliefs and behaviour during early adolescence. Child Devl. 36, 229-240, 1986. 12. Lalinec-Michud M. and Engelsmann F. Cultural factors and reaction to hysterectomy. Sot. Psychiar. Psychiar. Epidem. 24, 165-171,
1989.
13. Mazumdar D. N. Races and Cultures of India, pp. 238-239. Asia Publishing House, Bombay, 1958. 14. Chandra P. S., Chaturvedi S. K. and Isaac M. K. Measurement of menstrual attitudes in Indian women: a cultural perspective. J. Psychosom. Obsfer. Gynec. 10, 247-253, 1989. 15. Varma V. K. Toward a theory of cultural defenses. In Readings in Transcultural Psychiatry (Edited by Kiev A. and Rao V.). pp. 31-46. Higginbothams, Madras 1982. 16. Chaturvedi S. K. and Chandra P. S. Letter to the Editor. J. psychosom. Res. 33, 383, 1989. 17. Logue C. M. and Moos R. H. Positive perimenstural changes: toward a new perspective on the menstrual cycle. J. psychosom. Res. 32, 31-40, 1988.