CHANGING BODIES, CHANGING LIVES: URBAN MIDDLE CLASS MALAY WOMEN‟S EXPERIENCES of MENOPAUSE Nurazzura Mohamad Diah B. Hsc. (Hon

CHANGING BODIES, CHANGING LIVES: URBAN MIDDLE CLASS MALAY WOMEN‟S EXPERIENCES OF MENOPAUSE

Nurazzura Mohamad Diah B. HSc. (Honours) & M. HSc in Sociology and Anthropology International Islamic University Malaysia

This thesis is presented for the degree of Doctor of Philosophy of The University of Western Australia School of Social and Cultural Studies Discipline of Anthropology & Sociology 2010

Dedication

I dedicate my noble work to Mbah, Nyai and Mak who have undergone the ‘silent passage’ with audacity

Abstract

Menopause is a time of life where women make the transition from a reproductive stage to a non-reproductive stage. Although it is biologically universal, menopausal experiences are not homogeneous in nature and there have been significant differences reported by women within and across cultures. The study of menopause is pertinent in anthropology because as Lock (1998) contended, how menopause is seen, experienced and managed, rests upon social and cultural factors. The purpose of this thesis is to gain an in-depth understanding of the menopausal experiences of urban middle class Malay women who, for the most part, are formally educated and work in professional paid jobs. The research addresses how these women manage their changing bodies and attribute meaning to the experience of menopause. By considering how families respond to the women during this time, as well as how menopause is cast within an increasingly medicalised and media oriented discourse, the thesis proposes that menopause in Malay society today creates specific challenges for ageing women. Using an ethnographic approach, the thesis investigates the various factors that contribute to Malay women‟s understanding of menopause. In-depth interviews and participant observation helped to unravel the complexity of this topic, which in Malay society is considered private and dealt with in silence. I argue that the increasingly pervasive influence of Western perceptions of youth, femininity and sexuality among urban Malay women, together with the increasing adoption of biomedical treatments have altered cultural understandings of menopause. It is apparent that medicalisation and the ageing female body have been discussed extensively in the Western academic community but to a lesser extent in non-Western settings so the thesis adds substantially to this discussion. My research shows that menopause is a problematic and chaotic life stage for most of the urban middle class Malay women in my study. In Malaysia today educated Malay women are most likely to stay in the paid workforce until their mid to late fifties so they experience menopause while still working full time. Their dual obligations to both family and work complicate their experience, particularly if they have typical menopausal symptoms such as „hot flushes‟ and fatigue. Pressures from work, as well as the desire to portray a youthful and attractive appearance, contribute to their acceptance of biomedical interventions. In order to maintain the social order, these women should transition easily and silently from one status to another. However, while those around them know little of the challenges faced by women undergoing

i menopause, the situation is not at all easy for them. There is no celebration to mark the coming of menopause as women move from middle to older age. By contrast to other life stage transitions, this experience is embarrassing, sometimes challenging to personal identity and generally unimportant to all, other than the women experiencing it. The Critical-Interpretive medical anthropological perspective provides the framework for this investigation as well as the personal narratives of the women. The study is implicitly linked to the experience of ageing in a contemporary Asian society which has taken up many of the values associated with Western lifestyles. The thesis highlights the encroachment of hegemonic Western attitudes upon traditional Malay perceptions of ageing and femininity. Although youth, beauty and sexual attractiveness are more often associated with Western values, they have increasingly influenced urban middle class educated Malay women. However, the picture is not straightforward as traditional Malay values are still abundantly evident in the women‟s daily lives, in their culture, religion and lifestyle. There are clearly competing values at play that create challenges for ageing women in urban Malay society as they navigate between traditional and Western approaches to femininity, ageing and health.

Table of Contents Abstract ...... i Table of Contents ...... iii Acknowledgements ...... vi Statement of Candidate Contribution ...... viii Translation Note ...... ix List of Abbreviations...... x List of Figures ...... xi List of Tables...... xii List of Plates ...... xiii List of Appendices ...... xiv Glossary of Malay Terms ...... xv CHAPTER ONE ...... 1 INTRODUCTION ...... 1 Background of the study ...... 1 An introduction to the researcher: the ethnographer as insider...... 3 Research questions ...... 11 Significance of the research ...... 12 Study setting ...... 14 Theoretical approach: combining the insights of interpretive and critical medical anthropology ...... 27 Connecting women and their bodies ...... 34 Organisation of the thesis ...... 36 Chapter Two ...... 36 Chapter Three ...... 37 Chapter Four ...... 37 Chapter Five ...... 38 Chapter Six ...... 38 Chapter Seven ...... 39 Chapter Eight ...... 39 CHAPTER TWO ...... 40 RESEARCHING A SENSITIVE ISSUE: METHODOLOGICAL ISSUES ...... 40 Introduction ...... 40 Researching a sensitive issue ...... 40 Methodological issues ...... 43 a) Research participants: urban middle class Malay women ...... 43 b) Research site ...... 49 Klinik Harapan: the menopause clinic ...... 50 Methodology ...... 53 Challenges in the research and strategies used ...... 65 Gaining access into the field ...... 66 Managing relationships in the field ...... 69 Building trust and rapport ...... 70 Supporting the self-disclosure of the participants ...... 72 Communication about menopause ...... 73 Conclusion ...... 76 CHAPTER THREE ...... 77 THE CHANGING ROLES OF MALAY WOMEN IN MALAYSIA ...... 77 Malay women of different eras ...... 77 My grandmothers ...... 78

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My mother ...... 80 Nura ...... 82 Women in Malaysia: a historical view ...... 87 Malay women in the pre-colonial age ...... 88 Malay women during the colonial age ...... 90 Malay women in the post-Independence age ...... 92 Women in the work force ...... 94 Women in education ...... 98 Women in politics ...... 100 Women’s health status ...... 103 Urban Malay women: maintaining Islam and re-working adat (customary law) ...... 105 The notion of femininity and beauty from the Malay perspective ...... 108 Perception of ageing...... 114 Conclusion ...... 116 CHAPTER FOUR ...... 118 MENOPAUSE: A CROSS-CULTURAL PERSPECTIVE ...... 118 Introduction ...... 118 Differing definitions of menopause ...... 120 Biomedical and psychological explanations of menopause ...... 125 The critique of biomedical and psychological literature ...... 128 Medicalisation in everyday life ...... 131 Critique of medicalisation ...... 133 Anthropological studies on women‟s experiences ...... 136 Comparative studies of the menopause ...... 140 Anthropological studies of menopause in Asia ...... 143 Malay women and menopause ...... 145 Conclusion ...... 148 CHAPTER FIVE...... 150 MENOPAUSE: AN OLDER WOMEN‟S PERSPECTIVE ...... 150 Introduction ...... 150 The informal way of learning about menopause ...... 153 The unexpected way to learn about menopause ...... 162 Variations of responses towards menopause ...... 164 Women with high anxiety towards menopause and ageing ...... 170 The mid-life crisis: physical appearance ...... 175 Grey hair: an interesting difference ...... 179 Decreased interest in sex ...... 181 Husbands‟ responses are not therapeutic ...... 184 Women with low anxiety towards menopause and ageing ...... 185 Respect the elders: the Malay traditional values ...... 190 Closer to Allah: the turning point in life ...... 193 Changing lifestyle: a happier ageing ...... 195 Conclusion ...... 198 CHAPTER SIX ...... 200 MENOPAUSE AND AGEING: DISCOURSE, MEDICINE AND THE MEDIA ...... 200 Introduction ...... 200 Understanding discourse ...... 201 The discourse of menopause: historical and social changes ...... 204 „Official‟ information about menopause ...... 208 The menopause pamphlets from the Ministry...... 209 Images of menopause in the print media ...... 212 Constructions of beauty in middle-age ...... 227

Doctors and nurses: the „influential‟ informers ...... 233 Women‟s acceptance of HRT ...... 246 HRT: „It‟s not for me‟ ...... 249 Conclusion ...... 252 CHAPTER SEVEN ...... 254 LIMINALITY AND THE MENOPAUSE EXPERIENCE: A SILENT AND OFTEN TROUBLING PASSAGE ...... 254 Introduction ...... 254 The Rites of Passage ...... 256 Rites of Passage and urban Malay women ...... 260 Menopause and the liminal life of urban Malay women...... 266 Urban Malay women creating a new sense of order in their lives ...... 276 Menopause: an opportunistic passage for others? ...... 279 Conclusion ...... 282 CHAPTER EIGHT ...... 285 CONCLUSION: A DIFFERENT LOOK AT MENOPAUSE...... 285 Introduction ...... 285 Anthropology and the study of sensitive issues ...... 286 Menopause and urban Malay women today...... 288 Malay women in a changing world ...... 290 The individual body: menopause as the unproductive state...... 292 The social body: continuity through adherence to Islam and adat ...... 294 The body politic: medicalisation in a non-Western context...... 294 Contribution to cross-cultural study on menopause ...... 297 REFERENCES ...... 300 APPENDICES ...... 330 Appendix I Research participants‟ demographic background ...... 330 Appendix II Greene Climacteric Scale ...... 331 Appendix III List of HRT in Klinik Harapan* ...... 332 Appendix IV Newspaper articles on menopause...... 333

Acknowledgements

Kalau tidak dipecahkan ruyung manakan dapat sagunya (you cannot get the precious sago without first breaking the bark) is best described my effort to unmask this sensitive issue which is normally best kept as a secret. My PhD journey is one of the most challenging experiences in my life. It was not always smooth. But, I must thank Allah for giving me the mental and emotional strength to persevere and endure such irregularity. Personally, completing this thesis is like what the Malay proverbs say muafakat membawa berkat which means consensus brings blessings and gotong royong which means joint-venture enterprise. Many people have invested their ideas and time towards the completion of this noble work. First of all, my biggest debt and gratitude goes to my principal supervisor Professor Beverley McNamara. Throughout this study, I have had the opportunity to be most appreciative of her critical appraisal, invaluable guidance and advice in facing problems in various stages of my study. If this study has any merit, the credit must then go to her conscientious supervision for many years. Any errors of judgment, observation and analysis however, remain my responsibility. In addition, I also dedicate my thankfulness to my secondary supervisor Professor Michael Pinches for his additional opinion and advice. I would have never completed this work without their help who read drafts of all chapters, made detailed comments and took great care to weed out errors. My sincere appreciation goes to the Economic Planning Unit (EPU), Ministry of Women, Family and Community Development as well as National Population and Family Development Board who granted the permission to conduct research in Malaysia. I am thankful to The International Islamic University Malaysia (IIUM) who sponsored my study and staff in the Department of Sociology and Anthropology of IIUM who gave their support to me. I felt indebted to my participants and their family members, the „HRT team‟ in Klinik Harapan, who provided me with all necessary information related to this research. In addition, my appreciation is also dedicated to my colleagues and former students who shared their own interesting stories related to this thesis. Technical assistance was very crucial during my fieldwork. Thanks to my former students: Khairulanuar Abdul Rahman, Helmi Afizal Zainal and Mohd. Shahrizan Abdul Razak for the photographs and recording of the events.

My heartfelt gratitude also goes to UWA who has accepted me as one of their post-graduate candidates. Many thanks go to the Graduate Research School and the School of Social and Cultural Studies who generously granted me some fund for my fieldwork in Malaysia and to attend conferences. I also would like to thank staff and postgraduate students in the Discipline of Anthropology & Sociology who provided me with a welcoming and friendly atmosphere. I offer my sincerest thanks to Mrs. Jill Woodman and Mrs. Emily Leaver who helped me with the administration problems. I am eternally grateful to Taz who spent hours re-checking this thesis. I thanked Dr Cheryl Lange for being a good listener and „counselor‟ during the ups and downs of my early intellectual journey. It is mandatory for me to mention and appreciate the undivided support, tolerance and prayers of my parents, siblings, in-laws and Puan Lailah Hussin and family. I am certainly grateful to my beloved husband Hafez who supported my career, patiently taking care of our two lovely sons Hakim and Naufal. To my sons, thank you for reminding me of the next life stage: „When you become a nenek (grandmother) later Mummy, you must know how to play PlayStation‟. Finally, words cannot accurately express my sense of gratitude and appreciation to each of you who have assisted me in one way or another in completing this challenging work.

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Statement of Candidate Contribution

This thesis is an account of my research undertaken in Kuala Lumpur, Malaysia during the period December 2005 to December 2006 while I was a full-time student in the Discipline of Anthropology & Sociology at The University of Western Australia. This thesis is important for several reasons. First, the theory that emerges from the data is original contribution to the study of menopause, particularly in Malaysia. In other words, this study is an attempt to develop a theory of Malay women‟s health issue in later life. My study offers some insights into the issue by detailed analysis of data collected through ethnographic research. To date, there is very little knowledge about how professional urban middle class Malay women working in organizations experience menopause. Secondly, the findings can be used by government agencies to understand the need of middle-aged women and how family members can understand menopausal women better.

Part of this thesis has been presented in two conferences:

Mohamad Diah, Nurazzura „Understanding menopause: what have we learnt?‟, National Conference on Sex Education, Theme: “The Implementation of Sex Education in Malaysia: Issues and Challenges” organized by Institute of Education (INSTED), International Islamic University Malaysia (IIUM), Kuala Lumpur, Malaysia 10-11 February 2007 (Chapter Five)

Mohamad Diah, Nurazzura „Exploring a sensitive issue: menopause experience among urban Malay women in Malaysia‟, 4 International Qualitative Research Convention. Theme: “Doing Qualitative Research: Processes, Issues and Challenges” organized by Qualitative Research Association of Malaysia (QRAM), PJ Hilton, Petaling Jaya, Malaysia 3-5 September 2007 (Chapter Two)

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Translation Note

Throughout this thesis, all translations from the Malay language sources are my own. All Malay words are translated or explained in the text where they appear for the first time. Example: Menopause bukan penyakit (not a disease). Frequently used Malay words are in the glossary.

List of Abbreviations

CMA Critical Medical Anthropology

HRT Hormone Replacement Therapy

KL Kuala Lumpur

MTM Menopause the Musical

UMNO United Malay National Organisation

List of Figures

Figure 1 ‘Three bodies’ as the theoretical framework of this thesis 33

Figure 2 Three stages of a Malay woman‟s life transition 260

List of Tables

Table 1 Research participants‟ demographic background 45

Table 2 Percentage distribution of female labour force by sector 96

Table 3 Percentage distribution of employment by occupation and 97 gender

Table 4 Male and female life expectancy (1991-2007) 103

Table 5 Local terminologies to describe menopause 122

Table 6 Variation of responses across cultures towards menopausal 166 symptoms

Table 7 Information on menopause reported in major newspapers in 216 Malaysia from 2000-2006

Table 8 Framing tools used to present menopause in either positive or 223 negative ways in various media

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List of Plates

Plate 1 Map of Malaysia 15

Plate 2 Klinik Harapan waiting area 51

Plate 3 Focus group interview in progress 62

Plate 4 Women made some jokes about menopause 64

Plate 5 Kay, her son, her new daughter-in-law and her husband 189

Plate 6 The word Era Mas on the clinic‟s glass wall 206

Plate 7 Celebrities selected for MIDI front page cover 214

Plate 8 Emotional expressions in menopause pamphlets 218

Plate 9 Menopaus hargai fasa emas (Menopause appreciate the golden 219 phase) in Mingguan Malaysia, 16 October 2005

Plate 10 Images of Western couples are used in Malaysian magazines 220

Plate 11 Showing-off their best look in their 50‟s 232

Plate 12 The researcher shaking hands with the bride during bersanding 258 ceremony

Plate 13 Salimah and her husband look after their grandsons during 263 weekends near their Koi fish pond

Plate 14 Salimah puts to sleep one of her grandsons in the endoi 264

Plate 15 Some herbal medicines available in Malaysian pharmacies to 281 reduce menopausal symptoms

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List of Appendices

Appendix I Research participants‟ demographic background 330

Appendix II The Greene Climacteric Scale 331

Appendix III HRT available in Klinik Harapan 332

Appendix IV Newspaper articles about menopause 333

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Glossary of Malay Terms

Allah God al-Qur’ān Muslim Holy Book abah father adat customary law bersanding ceremonial sitting on the dais bidan traditional midwives bomoh/dukun indigenous medical practitioner endoi cradle gatal itchy Hadīth Prophet Muhammad‟s saying hantu ghosts/evil spirits hormat respect ‘ibādat worship ilmu hitam black magic jamu herbal mixture kampung village lenggang perut rocking the belly mak mother mandi bunga floral bath mandi hadas ritual bath nenek/mbah/nyai grandmother padi rice pantang/pantang larang rules of behaviour petua old folk practices putus darah menopause putus haid menopause Sūrah chapters from al-Qur’ān surau praying room tempe(h) fermented soy tudung veil urut massage

CHAPTER ONE

INTRODUCTION

Background of the study

Menopause is a condition which occurs when women stop menstruating.1 It marks the end of a woman‟s child-bearing years. It is not a disease or a condition to be suffered through, but is a biological change women experience as one of the stages in her life.

Every woman‟s experience of, and attitude to, menopause is individual and unique, though there are some patterns that emerge when comparisons between groups of women are made. Studies have shown that women‟s experiences of menopause in Western cultures are different from those in non-Western cultures (Bart 1969; Boulet et al. 1994;

Lock 1994). Many women in Western societies see menopause as an unwelcoming and distressing change in their psychological and physical well-being (Gifford 1994; McCrea

1983) and most often it is considered a private or sensitive issue. It seems that Western women appear to have a potential vulnerability toward a more difficult menopausal transition than do non-Western women. Studies of non-Western women have revealed that they experienced fewer severe symptoms; they did not suffer from the „empty-nest‟ syndrome2, and enjoyed a higher status and received more privileges and freedom following menopause (Flint 1975; Mernissi 1987; Omar 1995; Chirawatkul, Patanasri &

Koochaiyasit 2002).

Using an ethnographic approach, my research examines the way in which a group of urban, predominantly professional Malay women in the city of Kuala Lumpur,

1 The World Health Organization (WHO) definition of natural menopause is used in this study. Natural menopause is defined as „the permanent cessation of menstruation resulting from the loss of ovarian follicular activity. Menopause is recognised to have occurred after twelve consecutive months of amenorrhea for which there is no other obvious pathological or physiological cause‟ (See Utian 2004, p. 135). 2 Empty-nest syndrome refers to the feeling of loneliness or emptiness as a result of grown up children leaving their parent‟s house due to marriage, employment or attending college or university (Harkins 1978; Krystal & Chiriboga 1979). 1

Malaysia, experience menopause. Thirty women were my main informants and while I interviewed other people, for example family members and health professionals, I call these women „my participants‟. Following the study of menopause by Lock (1994, 1998) who contended that how menopause is seen, experienced and managed rests upon social and cultural factors, my thesis explores how urban educated middle class Malay women3 experience and attach meaning to this new phase of life. With this in mind my study has three objectives. The first is to explore the women‟s personal attitudes to, and perceptions of, menopause. These attitudes and perceptions are interpreted in the light of changing values about femininity in Malay society. The research discussed throughout the thesis highlights the encroachment of hegemonic Western attitudes upon traditional Malay perceptions of ageing and femininity. Youth, beauty and sexual attractiveness are more often associated with Western cultural values, but my research demonstrates their increasing importance to urban middle class Malay women. The second objective of my research is to explore the diverse range of treatments the women in the study use to reduce their menopausal symptoms.4 These treatments range from Hormone Replacement

Therapy (HRT) to natural herbal treatments. Just as Western values surrounding femininity and ageing have taken some hold in Malay society, so too we see a tendency to adopt Western biomedical approaches in dealing with menopausal symptoms, often in an uncritical way. The third objective is to consider the influence of the family and the role of paid work in women‟s experience of menopause. During my fieldwork I was interested in finding how much the families knew of the women‟s day-to-day experience and how family dynamics and the demands of the paid workplace impacted upon the women as

3 I focus on urban women who are formally educated and who belong to a middle class. Later in this chapter and throughout the thesis I will discuss these ideas further, but for now it is important to note that these women, when compared to others in Malaysia and throughout other parts of Asia may be seen to some degree as privileged. 4 Women may experience unwelcome symptoms during menopause including hot flushes, bloating, tiredness, lack of sexual interest and so forth. 2 they faced the challenges of life change associated with the menopausal experience. In this thesis, I will argue that the increasingly pervasive influence of Western perceptions of youth and femininity among urban educated middle class5 professional Malay women has altered cultural understandings of menopause. There is increasing pressure for women to maintain a youthful appearance and outlook in their presentation of self and to participate actively in public life, particularly in the workplace. Many of the women, in approaching this time of their lives turn, somewhat uncritically, towards biomedicine as a way of coping with their changed circumstances. Biomedical intervention (in the form of HRT) is often used to treat their menopausal symptoms, indicating a level of medicalisation in this area.

An introduction to the researcher: the ethnographer as insider

In this section, I will explain my position as an insider within my own culture, a feature of the research and the method which has helped me to obtain the data I needed to address my research questions. Ethnography is defined as „a descriptive account of a community or culture, usually one located outside the West‟ (Hammersley & Atkinson

2007, p. 1) that is both a research technique and „a product‟ (Boyle 1994, p. 161).

Ethnography is an attempt by a researcher to understand the meaning of people‟s everyday lives within their own sociocultural and local context. Traditionally, anthropologists (also sometimes refers to ethnographers) have been „outsiders‟ immersing themselves in an entirely different culture. Mead (1981), Shostak (2000), Lock (1993) and Laderman (1983) are all well known anthropologists who have engaged in the process of describing people in a culture that is different from their own. They have indicated that being an „outsider‟, anthropologist/ethnographer has to deal with barriers,

5 When I refer to „educated‟, in this context I mean women who have undergone some form of formal schooling. On occasion I call these women „professional‟ as most are employed in the civil service or other professional jobs. 3 particularly in learning a new language and in understanding traditional practices.

However, through a reasoned dialogue with the „other‟ these ethnographers were able to achieve their main goal, which was to discover and interpret things they observed rather than looking for „pure data‟. Following Geertz (1973), who contended that cultural patterns are models of reality which create sets of symbols, and borrowing also from

Pike‟s work on emic and etic approaches I have sought to understand the urban middle class professional older Malay women‟s world view. Kenneth L. Pike (1967, p. 37) says of the emic and etic approaches:

The etic viewpoint studies behavior as from outside of a particular system, and as an essential initial approach to an alien system. The emic viewpoint results from studying behavior as from inside the system. (I coined the words etic and emic from the words phonetic and phonemic, following the conventional linguistic usage of these latter terms. The short terms are used in an analogous manner, but for more general purposes).

The emic viewpoint is important in allowing the ethnographer to understand the social and cultural practices of a particular society, whilst the etic viewpoint allows him or her to interpret how a community functions and how it is structured and how the people in that community connect to one another. Most importantly this approach enables the ethnographer to understand how a society goes about doing things. The ethnographer‟s task is to try to learn what it is like for a person living in that culture (emic perspective) through participant observation. This outsider status allows them to enter and withdraw later to take an etic perspective – a more objective way of analysing what is going on.

However, anthropologists living within a culture also study their own societies and their own native languages (McNamara 2001; Chirawatkul 1996; Omar 1994; Srinivas 1979).

They are already insiders. The challenge that this raises is that they already have an emic perspective and may not think to question taken for granted assumptions about their own culture. However, it also means that it is more difficult for them to withdraw to take an

4 etic perspective. The usage of etic and emic has spread into various disciplines and since then has generated debate in theory and research (Morton 1999; Fortier 1996; Voloder

2008). However, I am not engaging in this debate for now, but use the terms simply to explain how I have made connections between my participants‟ menopausal experiences and the society they live in, as well as to be better able to understand the „multiple and overlapping realities‟ (Danquah & Miller 2007, p. 72) of the information presented to me by my participants.

My choice of studying urban middle class Malay women as my research participants did not stem from pragmatic deliberations alone. Urban Malay women have experienced tremendous social and cultural change, over the past twenty to thirty years, and it struck me as something that would not only be interesting to study but also something not sufficiently researched before. In addition, I also felt it would be more appealing being an „insider‟ despite the unique challenges confronted by anthropologists who work within their own cultures (Danquah & Miller 2007; Colic-Peisker 2004). I agree with Baharudin (cited in Strathern 1987, p. 30) when he said that:

A Malay anthropologist should deliberately familiarize himself with Malay society. We cannot conclude that non-Western anthropologists will stand in the same relationship to their own society or culture as a Western anthropologist does to his/hers.

On a positive note, the advantages in researching women within my own society were that it did not take me too long to understand what was going on and I believe my research participants were more readily accepting of me. I consider myself as an insider within my own culture (see Chapter Two). However, while I had the privilege of insider status, I was sufficiently different from my research participants (older Malay women undergoing or having undergone menopause) to be able to provide me with some elements of the „outsider‟ perspective. These differences indeed have given me a particular kind of distance in order to question the women‟s experience and develop an

5 etic perspective for my own analysis. My position as an insider has helped to facilitate my research. As an insider to my own community, I am familiar with the adat 6that governs the life of Malay people.

In order to set the scene for the discussion of this thesis, it is essential to know something about my background and how that background relates to my topic of interest.

I am like many ethnographers who have worked in their own societies. This has provided me with a unique opportunity to study aspects of my own culture and to draw upon my own experiences. However, this situation also presents challenges as in order to embrace ethnography fully, the researcher needs to approach the subject matter with fresh eyes.

Certainly I am very familiar with Malay society, but as will become clear, the topic of menopause was very new to me.

I am a Javanese-Malay7 woman in my mid thirties, born, raised and formally educated in Kuala Lumpur. I have two sons of my own and have worked as an academic in a university in Kuala Lumpur for almost nine years. My research interests have always been about issues related to women‟s health. As a Malay woman, I was exposed to many pantang-larang (rules of behaviour), petua (old folk practices) and celebrations that marked important events in my life. It is for this reason that I am interested in issues pertaining to childbirth, pregnancy, post-partum, fertility and family planning.

Menopause is not a common topic of discussion in my family (nor most often in other

Malay families either) and prior to my research I had hardly ever heard stories about menopausal women or read about menopause in Malaysian publications.

6 Adat (customary law) is an accepted way of doing things. 7 Javanese-Malay or known as orang Jawa (Javanese people) is a sub-category of Malay people. It is define as „Malaysians with legal status as Malay-Malaysian but have retained a strong consciousness to their Javanese origins‟ (Miyazaki 2000, pp. 76-77) and cultural traditions. Miyazaki found that Malaysian citizenship has at least differentiated between Javanese-Malays and the Indonesian migrant workers. It is common in Malaysia to be identified as Malay rather than specifically identified a person as Javanese, Bugis or Achenese. Therefore, throughout my thesis, I will identify myself and my participants as Malay in general. 6

The absence of any public discussion about menopause in Malaysia is what prompted my interest in this topic. From my childhood until adulthood, I was exposed to several traditional practices of the Javanese community, which is slightly different from other branches of the Malay community (Banjarese, Minangkabau, Bugis and

Achehnese). When I was a small girl, I looked at my mother‟s experiences and listened to her stories about pregnancy, childbirth and the post-partum period. As the eldest in the family, I was there to assist her in performing small tasks like boiling hot water for her bath, making her jamu (traditional herbal mixture) and preparing the long cloth for berbengkung (wrapping part of the body from abdomen to buttock). In addition to these practices, I was also exposed to several celebrations centered on myself and other family members like berkhatan (male and female circumcision), lenggang perut8 (rocking the belly), cukur jambul (shaving the baby‟s hair) and khatam al-Qur’ān9 (completion of reciting the Holy Book). These ceremonies marked the importance of every stage in my life and the lives of those around me. I would like to quote from my fieldwork diary written on 1 January 2006 about some practices that I observed and performed, as well as some changes I noticed about my mother:

Fieldwork diary 1 January 2006

10 am: Today is New Year holiday. We had a family gathering at our parents’ place. I looked at Mak (mother) playing happily with her five grandchildren, while Mak’s six children and her two sons in-law were sitting nearby watching them. Abah (father) sat next to me and talked about how our children were behaving like us. We teased each other and laughed. Ever since Mbah

8 During the seventh month of pregnancy, the traditional midwife determines the gender and position of the baby by rolling a coconut or pomelo across the belly of the expectant mother. 9 Throughout this thesis, all notes that involve Qur‟anic citation are referred to Ali (1994). 7

(grandmother) passed away four years ago, my younger sister and I refer to Mak for many things, especially about women’s stuff. I remembered vividly that as the eldest child, I had to step on my five siblings’ uri (placenta). According to

Mbah and my parents, this is to avoid siblings from quarrelling with each other.

The placenta must be treated appropriately because it is the baby’s ‘friend’ while in the mother’s stomach. It must be washed and wrapped with a white cloth. It is then buried under a shady tree. Abah used to put the placenta in a clay pot, dig the soil and bury it. Abah would say ‘May all of you be good people’. There were also some Javanese songs Mak used to sing to her newborn child. She sang while she put adik (little brother/sister) to sleep, and bathed and massaged parts of the baby’s body. Two songs Sluku Sluku Bathok and Siram Bayem were the most popular ones taught to my younger sister and I. Interestingly, these practices were transmitted from my late grandparents generation to my parents and later to me. When my younger sister and I conceived our first children, Mak and Mbah were the busiest persons. There were many pantang larang and petua they prescribed for us. We called them the ‘unauthorised family doctors’. We had to observe food and behaviour taboos, attend a small feast and observe many other traditional requirements.10 Mak always reminded us, ‘as women we have to take care of our bodies because badan nak pakai lama (our body will be used for a long time). Every time a woman gives birth, banyak urat putus (many nerves break). If

10 Other traditional requirements of pregnant women practised in my family are: 1) need to wash the frying pan immediately after cooking to ease delivery 2) avoid putting cloth around the neck to prevent the umbilical cord from strangling the baby‟s neck and 3) in the eight or ninth month pregnancy, a mother-to-be has to drink air selusuh to ease delivery. Air selusuh is a drinking water that is incanted with verses from al- Qur’ān. A pregnant woman is required to drink this water once a week. The water is also wiped on the woman‟s belly seven times with the recitation of selawāt (praises to Prophet Muhammad peace be upon him). 8 you don’t observe the pantang now, you will suffer in your old-age’. We had to follow without hesitation though our husbands questioned the rationale of doing so. My husband once said ‘It’s modern today. Do you have to follow what Mak said?’ But after our children were born, my husband and my brother in-law buried the placenta like Abah used to do. My younger sister and I observed 44 days of confinement. After 44 days, Mak shared with us her family planning practices. It was very interesting to share with Mak her experiences of using some family planning devices, her concern and worries about taking contraceptive pills and inserting an IUD. Today, Mak is 55 years old. I have seen her taking lots of supplementary vitamins like calcium-magnesium, Vitamin C, fish oil and

Evening Primrose Oil (EPO). It is strange to compare these behaviours with not so long ago when she used to drink jamu and health tonic to boost her health.

Mak now is very sensitive and very quiet about being an ‘old’ woman. Nothing is said about menopause or what we ought to do when we reach middle-age. There is no advice like that we received when planning for children. It is strange to look at Mak today. She is not like the ‘unauthorised family doctor’ who is busy with her ‘prescriptions’. Or perhaps Mak is quieter today knowing her daughter is studying menopausal women and their experiences.

Another reason that inspired me to choose menopause as an area of study was when I came across statistics released by the Ministry of Health that indicated that 60 percent of Malaysian women are not aware of the menopausal symptoms (Subki 2004).11

In the New Straits Times (11 August 2002, p. 12) newspaper it was reported that women do not understand the connection between menopause and their own health. Therefore, in

11 It is not possible to tell from the article if this was 60 percent of all women regardless of age or 60 percent of women undergoing menopause. 9 the Fifth Malaysian Menopause Congress held on April 21, 2005 in Kuala Lumpur, the government called for more involvement of specialists and professionals to enhance the awareness of menopause among women (Utusan Malaysia, 22 April 2005, p. 1). The

President of the Malaysian Menopause Society (MMS) made the candid comment that menopausal women in Malaysia „….. prefer to suffer in silence. Even sadder, when there are husbands who feel that menopause is a woman issue‟ (Hassan 2005). Based on these reports which are dominated by a biomedical and professionalised perspective, I feel strongly that there is a need to study menopause from a sociocultural perspective. Indeed, the study of anthropology has emphasised the importance of adopting a meaning-centred interpretive approach in order to understand the cultural factors that shape menopausal experience among middle-aged women.

Finally, the amount of menopausal research in Malaysia based on ethnography is very limited. To date, I know of no ethnographic research on the menopausal experience of urban educated middle class Malay women apart from my own. There is only one instance of research conducted in Malaysia on menopausal women using ethnographic methods. The research which was carried out by Omar (1994) fifteen years ago inspired me to investigate menopause further. As menopause was only a small part of her study, her findings left me some room for further research. Omar conducted her research among rural Malay women in a village in Melaka.12 In her research, she claimed that „Malay women neither fear nor are affected by serious adverse symptoms of menopause‟ (Omar

1994, p. 48). Her study has been very useful in identifying some issues that relate to menopause and rural Malay women. However, it is now somewhat dated and there is also a need to study the urban Malay women as well. Researchers do not yet know how Malay women in the urban area see menopause, what their feelings are about menopause, what

12 Melaka which is also known as the historical state is situated in the southern part of Malaysia. 10 mechanisms they adopt to cope with the situation and the role of culture in protecting, reinforcing or challenging their emotional well-being. Omar (1995) proposed that further research about menopause in the Malaysian context should analyse the differences between menopausal women by age, exposure to modern life, exposure to media, education and other factors. Kaufert and colleagues (1986) proposed that future direction for cross-cultural research about menopause should focus on the menopausal experience of social and cultural change, particularly the impact of changing attitudes towards the status and role of women. Thus, my research focus, based on suggestions made by Omar

(1995) and Kaufert and colleagues (1986), explores the meaning of menopause among urban middle class Malay women in the context of contemporary urban Malay society. I have taken up the challenge issued by other researchers, particularly by examining the influence of social change and Westernisation in regards to the role of older women in urban Malay society.

Research questions

In this study, I am interested in investigating menopause as it is experienced by urban middle class Malay women in Kuala Lumpur. Specifically, I have asked the following questions as they relate in the day-to-day lives of the women:

1. How do urban Malay women attribute meaning to the experience of menopause in

the home, workplace and the menopause clinic?13

2. What are the differences and similarities in the thoughts (as expressed to me in

interviews) and actions of menopausal women in the above settings?

3. What role do family members play in women‟s experience of menopause?

4. How is menopause learnt about in the urban Malay family?

13 I spent some time observing in Klinik Harapan which is used as a specific case study in my thesis. 11

5. Which sources of information do the urban Malay women turn to for information

about menopause?

6. What role do the media, doctors and other health professionals play in providing

information and treatments about menopause?

7. Which forms of treatment do women choose to alleviate any symptoms they may

experience?

Given these particular questions I am also interested in using more of a macro perspective to question the role of older women in a changing urban society. How can the individual experiences of urban educated middle class Malay women undergoing a life transition like menopause tell us something further about the broader society? Unlike the women in Omar‟s (1995) study, the women in my study live in contemporary urban

Malay society where it is common for women to work through their forties and fifties.

Older women play an important part in the Malaysian economy. How do urban Malay women present themselves in this context and what kinds of factors lead to particular kinds of presentations of self?

Significance of the research

At the empirical level, the overriding interest is to document and analyse the experience, feelings, perceptions and beliefs of urban middle class Malay women in relation to the above issues. This topic is worth studying because it affects women‟s well- being in the later part of their lives. The relationship between health and well-being is important because women today play multiple roles in society. Indeed, women‟s life expectancy is longer and they will spend a significant proportion of their lives in a postmenopausal state so it is very important to understand how menopause both enriches and challenges their lives.

Women‟s involvement in income-generating activities this decade is accepted as a reality in today‟s life. The increased cost of living, especially in the urban areas, has led women to work outside of their homes and to join with their husbands in supporting their families. Furthermore, urbanisation and modernisation demands a change in women‟s role. Indirectly, women need to equip themselves with knowledge to face the challenges and address issues of globalisation. Despite Malay women‟s active involvement in education and the paid workforce today, their contribution in the domestic sphere as a

„dutiful wife‟ (Omar 2003, p. 118) remains important, and one might say paramount considering the obligations of the adat. In other words, women maintain a dual role: they nurture the future generation, and spend time managing their families and staying close to the kitchen, but at the same time they are also a source of economic development in many areas.

Women‟s role today, as I see it, is multi-functional – as wives, mothers, sisters, grandmothers and career women who contribute to nation building. No doubt, Malay women and other women elsewhere today have shown potential abilities in leadership, business and management. Therefore, their contribution is needed by the society.

Consequently, in having to maintain traditional roles while having to develop and improve their careers, women have had to face a great number of „obligations‟. In addition, women too, have to give serious attention to their own health and well-being in order to keep themselves active both at home and in the work place. All of this has complicated their lives. As such my thesis is noteworthy, particularly in understanding the conditions under which urban middle class Malay women face the challenges of growing older. This topic has not been fully explored by previous researchers.

Study setting

My research was conducted in my own country, Malaysia. For those not familiar with Malaysia it may be helpful to sketch a brief description in order to provide a context in which to understand the changing role of older women in Malay society and also to understand the multicultural nature of the country. Of course women from all kinds of ethnic backgrounds and social classes experience menopause, but my study focuses in particular on Malay women who, due to their educational status and participation in the paid workforce, belong to a middle class. Let me turn to the background of Malaysia.

Malaysia, a nation which is situated north of the equator in Southeast Asia, consists of 14 states, including three Federal Territories of Kuala Lumpur14, Putrajaya and

Labuan (see Plate 1). The total population of Malaysia today is 27 million (Department of

Statistics Malaysia 2008). Like the women I focus on in my study, most of the people live in urban areas. The urban population is 63 percent with 37 percent of people living in rural areas (Economic Planning Unit 2006). This indicates that more people are moving into the cities to find better jobs and urban residence. The life expectancy of Malaysian people has improved with the Malaysian male‟s expected age increasing from 70 years in

2000 to 70.6 years in 2005. The life expectancy of Malaysian women has risen from 75.1 years in 2000 to 76.4 years in 2005 (Economic Planning Unit 2006) which is of particular relevance to my study as we now find that women experience a longer period of life postmenopause. This scenario is also experienced in other countries, like Australia, where the life expectancy in 2005 for males was 79 years and 84 years for females. Similarly we see in Japan that the female life expectancy is higher than that of the male, 86 years and 79

14 Kuala Lumpur is the capital city of Malaysia. Affectionately known as KL, it is administered by a mayor. Historically speaking, KL was one of the most significant tin-mining areas in the mid-19th century. Today, KL has become the most important financial and business centre. In 2007, the total population of KL was 1.6 million people. 14 years respectively.15 This indicates that the living conditions which include the provision of medical technology, quality food and water supply have improved. As a result, there is a decline in the mortality rate not just in Malaysia, but in all the abovementioned countries.

Plate 1 Map of Malaysia. Source: http://www.maps.com [accessed 10 January 2007]

In general, Malaysia is a multicultural society which comprises three major ethnic groups, Malays, Chinese and Indians. In 2006, the Malays constituted 54.3 percent of the total population16, Chinese 25.1 percent, Indians 7.5 percent and other ethnic groups 1.3 percent (Department of Statistics Malaysia 2006a). These major ethnic groups are broadly different in their religion, culture, language, occupations and way of life. The Malays are known as Bumiputra (literally means „sons of the soil‟) (Nagata 1974; Kennedy 1962;

15 These figures were taken from the World Health Organization (WHO) website available from http://www.who.int/whosis/whostat/2007/en/index.html [accessed 26 November 2008]. 16 This figure does not include other Bumiputras which stood out at 11.8 percent of the total population. Other Bumiputras refers to Orang Asli (the indigenous people) of Peninsular Malaysia and the tribal people of Sabah and Sarawak. 15

Winstedt 1962) which means the indigenous people of Peninsular Malaysia. The Chinese and Indians are descendants of immigrants, who faced hardships in their country of origin. They came to Malaya17 in search of a better life (Hodder 1959; Gullick 1981).

From 1511 until Malaya gained its Independence on August 31, 1957, Malaya had been conquered by foreign powers which directly or indirectly ruled the country. The

Portuguese were the first to conquer Malaya, followed by the Dutch and then the British.

Today, Malaysia is considered as one of the most productive and developed nations compared to other Southeast Asian countries. Malaysia is also categorised as one of the most successful countries in the Southeast Asian region in terms of its economic growth. This growth is associated with significant changes in its economic structure with the economy now more internationalised mainly through the open economy approach

(Ariff 1991). Previously Malaysia relied heavily on primary commodities like tin, rubber and palm oil. In 1970s onward, there was a diminished importance placed on these commodities as a primary export concentration (Athukorala 2001; Ariff 1991). Today,

Malaysia exports other forms of goods like crude petroleum, electrical and electronic products. In other words, manufacturing of goods overtook the primary export commodities and agriculture products. As a result of urbanisation, the Malaysian economy has been more industrialised. In 1971, Malaysia started to venture into manufactured exports. Free Trade Zones (FTZs) were established in that year. The influx of multinational companies who helped expand the electronic and manufacturing sector in

Malaysia opened job opportunities for the population, particularly to women from the rural areas (Athukorala 2001; Ariffin 1992). The expansion of manufacturing sector led to the expansion of employment, the increase in the paid labour force and the reduction in

17 Malaya is a term used during the British colonial age. The name Malaysia was used in 1963 when the Persekutuan Tanah Melayu (Federation of Malaya), Singapore, Sabah and Sarawak formed a 14-state federation. In 1965, Singapore withdrew from Malaysia and became an independent country.

16 the incidence of poverty and unemployment in the country (Athukorala 2001; Yusof

2001).

In terms of Malaysian women‟s involvement in income-generating activities today, their contributions have been significant. Women‟s contribution and achievements have been acknowledged and appreciated nationally and internationally. The existence of the National Women‟s Policy and the Ministry of Women reflects the government‟s attitude to upgrade women‟s involvement in development in a more effective, systematic and meaningful way. Based on the Labour survey report in 2005 by the Department of

Statistics Malaysia, there are four million women working in various occupations. Their involvement has increased from 37 percent in 1970 to 46 percent in 2005. This clearly indicates that women‟s contribution to the society is very important. Women‟s achievement and development in the economy is measured based on the Gender-related

Development Index (GDI). This index is formulated by the United Nations (UN) under the Human Development Report (HDR).18 GDI is an index composite that measures women‟s achievement based on health, knowledge and quality of life. Based on the GDI reported in HDR in 2007/2008, Malaysia ranked 63 out of 177 countries.19

As noted, my study focuses specifically on urban educated middle class Malay women. They are part of the Malay group who constitute 54.2 percent of those living in

Malaysia (Economic Planning Unit 2006). Before I elaborate further about my research participants, it is important for my readers to have a general idea of the Malay social and cultural background. Though the information is only presented briefly in this chapter, I hope it will help readers to understand how the social and cultural background has had an impact upon the lives of my participants, and more generally upon Malay women. This information needs to be set within the broader context of the multicultural society itself.

18 GDI is available from http://hdrstats.undp.org/indicators 19 HDR Report 2007/2008 is available from http://hdrstats.undp.org/indicators/268.html [accessed 12 December 2008]. 17

In general, Malays are Muslim, both in their daily practices and more formally by definition. This is stated clearly in the Malaysian Federal Constitution which defines a

Malay as „a person who professes the religion of Islam, habitually speaks the Malay language, [and] conforms to Malay custom‟ (Kling 1995, p. 44). From the constitution, it is clear that religion and adat are very important to the Malays. They provide a framework which greatly influences their daily lives, customs and institutions (Kling

1995; Ackerman 1982; Karim 1992; Omar 1994). Adat which is etymologically an Arabic term is defined as „custom and tradition which include accepted ways of doing things by the Malays‟ (Omar 2003, p. 122).20 There are two types of adat: adat Pepatih and adat

Temenggong.21 Adat mainly deals with kinship and land tenure (Kling 1995; Ackerman

1982). Although some Malay cultures have been eroded by „modernisation‟, Malay conviction towards their religion remains strong (Leete 1996). The Malay society can be said to maintain their religion and adat while at the same time combining some elements of „Westernisation‟22 to some degree of their lives (Kling 1995; Karim 1992; Ong 1990).

The Western influence is principally the product of the media, which is one of the most important agents of socialisation in the Malay society. The role of the media in

Westernisation of Malay values is reflected in my own research where my participants still maintain their religion and adat in their daily lives but at the same time incorporate

20 I explain the meaning of adat in more detail later in this chapter. 21 Adat Pepatih is a matrilineal kinship system. It is only practised in Negri Sembilan and northern Malacca (Ackerman 1982) where the population are migrants of Minangkabau descendants from Sumatra. This adat gives more control to women over rights of land tenure and that particular kinship is strongly tied to the women‟s family. Adat Pepatih has been studied by scholars like Swift (1965), Banks (1983) as well as Stivens and colleagues (1994). On the other hand, Adat Temenggong is a bilateral system which is widely practised in most states except in Negri Sembilan and northern Malacca. Adat Temenggong which favours males over females however, gives equal opportunities to men and women to control and possess land as long as both actively cultivate the land for economic purpose (see Karim 1992). 22 Often in discussion about the changing nature of Malay society, both terms modernisation and Westernisation have been used. I appreciate that both terms are, to some extent, problematic and they have been debated in the literature (see Kahn 2001). For the most part, I use the term Westernisation as this seems more appropriate from a Malay perspective and I am a Malay scholar. However, it is also a term used frequently in the medical anthropology literature when discussion focuses on changing medical practices. 18 some Western ideas about youth and femininity, body image and treating their menopausal symptoms.

To describe the Malay society in Malaysia, one has to distinguish between rural and urban Malay areas and practices. Previously, the majority of Malay people resided in kampungs (villages) while very few lived in cities. They worked as farmers and engaged in agricultural work like planting padi (rice) or vegetables, fishing, cattle raising, and working as rubber smallholders or handicraft makers (Raybeck 1985; Rudie 1994;

Strange 1981; Firth 1966). Most of them had a low level of formal education and they lived within extended family networks. As rural Malay boys and girls grow up, they are trained according to gender roles. Girls learn to cook, wash the clothes, clean the house, look after younger siblings and boys help their father on the farm. From her childhood, a girl is trained to fit into the only socially acceptable role – that of wife and mother. Rural women married at an early age, typically through family arrangements and spent few years schooling.

Today, the overwhelming majority of rural Malay have migrated to big cities and now work in factories or offices. Rapid industrialisation has provided job opportunities to rural people and better access to education (Razali & Yusoff 2003; Ariffin 2000). In urban areas, most people appear to prefer the nuclear family size to that of the extended family. Urban Malay men and women have achieved a higher level of formal education than their rural counterparts and this has allowed them some level of career choice. Urban

Malay women live in two worlds - that of the family home and the work place. Family planning is practised mostly by working mothers. Nevertheless, urban women still adhere to pantang-larang (rules of behaviour) during pregnancy and after childbirth. Daughters will return to their parents‟ home to be taken care off during the post-partum period.

Others prefer to invite their mothers or mother in-law to stay together in their house

19 during this time. Both rural and urban Malay women still have to look after the home and maintain close rural ties.

I have mentioned that the women I have focused on for my study are „middle class‟. In Malaysia, one can generally determine to which particular social class a person belongs to through his or her occupation (Milne & Mauzy 1986; Stivens 1998). In relation to class, Malay society is stratified into three categories: upper, middle and lower class (Ali 1981). In the Malay traditional society, the kings and nobles belonged to the upper class, whereas village folk belonged to the lower class. Today, the royal families are still ranked in the upper class but other groups have emerged. The new groups are also categorised as upper class. Among them are politicians and senior officers who make up the upper crust of the bureaucracy (Ali 1981). Interestingly, middle class in traditional

Malay society did not exist. The middle class emerged as a result of British occupation in

Malaya and continued after independence (Stivens 1998; Ali 1981). Among the factors that lead to the emergence of middle class are economic growth, educational opportunities and political development which took place in the country at that time

(Stivens 1998; Ariffin 2000). The middle class now consists of professional, administrative and technical positions, as well as any job that is related to clerical work

(Stivens 1998). Most urban Malays who belong to the middle class are government servants:

The Malays were always given preference in recruitment to the civil service, and after independence the constitution fixed a quota of three Malays to one non-Malay in the service (Ali 1981, p. 70)

My research participants were mostly civil servants. Although none of them associated their work to a social class they belonged to, based on the demographic questionnaire they answered, I found their monthly salary, educational level, pattern of spending and the suburb they lived in indicated their middle-class status.

Another important aspect of Malay society can be seen in relation to marriage.

Marriage among the Malay is closely related to the adat (Karim 1992; Kling 1995).

Marriages are rarely arranged these days as most children meet their future spouses at university or in the workplace. With the spread of greater levels of education, arranged marriage has become less acceptable to younger people. They have become a phenomenon of the past (Arshat et al cited in Leete 1996). In Malaysia, polygamous marriage is practiced both by urban and rural men. However, only those wealthy men and rural elite Malays normally indulge in polygyny (Karim 1992).

Most urban Malays work and stay in big cities like KL, Petaling Jaya and Shah

Alam. The connection with their old folks or relatives in the kampung is still strong. This is evident based on my interviews with my research participants who return to their kampung to celebrate festive seasons or to spend holidays with their families. The continuation of maintaining family ties has been confirmed in earlier studies by Banks

(1983), Rudie (1994) and Kling (1995) who demonstrated that Malay people give overt emphasis to family and kinship.

Aside from this, Malay society has different health practices from the Westerners when it comes to health and illness. Malays believe that every illness comes from God and there are different ways to treat the differing illnesses. However, the Malays also commonly believe that „other illnesses‟ or „unusual illnesses‟ are the result of hantu

(ghosts/evil spirits) intervention or ilmu hitam (black magic). Even urban educated people, like my mother, and me for that matter, believe in hantu intervention and ilmu hitam. Malay people commonly combine modern medicine with traditional practices. In other words, the attitude of seeking help from a bomoh, or medicine man, is still practiced and strongly embedded in the Malay mind so that today it coexists with modern medicine.

In this sense, little has changed since Gimlette‟s (1971, p. 20)

observation that:

Malays of all classes still respect the „medicine-man‟: it is still his business to give advice in matters of sorcery; to propitiate devils, to chide or coax evil spirits as occasion seems to demand, and to prescribe taboo for everyday life.

Due to the bomoh‟s curative ability, he23 is honoured by Malay people. Studies by

Winstedt (1982), Laderman (1991), Osman (1998) and Karim (1984), to name a few, have confirmed that the institution of bomoh continues to flourish as modern medicine cannot treat all human illness, particularly those that involve bad spirits. For example, my own sister in-law who died eight years ago because of stroke was referred to a bomoh to identify the cause of her partly dysfunctional body. She was „prescribed‟ many things, among them were incanted water and a tangkal (talisman) to protect her from the evil spirit. In addition to the general health seeking behaviours, some Malay single women who have yet to find their life partners perform mandi bunga (floral bath) which is organised and conducted by a bomoh.24 On top of that, bomoh have a „special‟ ability called menurun (to go into a trance) which enables them to communicate with supernatural creatures (Laderman 1983; Karim 1984; Massard 1988). This, which modern medicine lacks, has motivated some Malays to seek a bomoh‟s service to treat their pain which they believed was caused by spirit intervention. Karim (1992) stated that a Malay

23 Mostly bomoh are males. Although there are female bomoh, the number is very few. In contrast, bidan is a female because she attends to pregnancy and childbirth matters. 24 Based on my personal communication with one of my former students on 16 December 2008, I found she had performed mandi bunga twice in a small suburb in Penang. The reason she performed this floral bath was to please her mother who wanted her to get married soon as she had not been dating anyone. She was accompanied by her mother who witnessed the ritual. According to her, the female bomoh prepared seven types of flowers though she remembered only five: rose, bougainvillea, jasmine, frangipani and chrysanthemum. The bomoh also incanted a pail of water for the bath. She then requested my student to change her clothes and wear a sarong (a long cloth wrapped round the body and tucked under the armpits). The bomoh pours the water from the head and simultaneously she requested my student to make her wish and trust that God will help her. After the ritual, the bomoh prevented her from touching the sarong. It is believed that if the maiden touches the cloth, bad luck cannot be dispelled. The bomoh removed the sarong for her. Later, my student was given seven betel leaves which had been folded into a triangle shape. She had to chew and swallow one leave per day. 22 husband will go to a bomoh for sex therapy or for trying out some local or Indonesian jamu which some men believe will increase their sexual potency.

Ostensibly, the Malays (also the Chinese and Indians) are reported to believe in the categorisation of food, diseases and treatments according to the reputed effect the food has (hot or cold) on a person‟s body (Manderson 1987; Laderman 1983). Laderman and Manderson found that the classification of hot-cold food is to prevent mothers from the reputed effect of the food and to restore their health after childbirth. Although medical doctors believed avoiding food that is rich in nutrients leads to deficiency (Mohd Ali

1985), this tradition remains strong, especially during pregnancy and after childbirth. It is also strictly imposed at other times like after circumcision and after surgery. My own experience after delivering both sons also confirmed this practice. After childbirth, my own mother prepared food for me. She avoided cooking vegetables like pumpkin and cabbages because they are „cold‟ and I can easily feel bloated if I consume them. Food which is prepared using chillies, curry powder or black pepper can be eaten as it is „hot‟ and can circulate the blood. I was not allowed to eat chicken because it is considered as gatal (itchy). This practice is passed from one generation to the other and is still practiced today among rural and urban Malays. Later in the thesis I will reflect on the treatments menopausal women seek in relation to the uncomfortable symptoms they experience, yet interestingly, the bomoh does not feature very strongly at all in these help seeking behaviours. With the emergence of an urban educated middle class group of women we see a corresponding shift to the use of Western biomedicine, at least in respect to problems associated with menopause.

The above description serves as a background to Malay social and cultural practices which have been in place for generations. These beliefs have, to some extent, shaped the behaviours of people within Malay society. Although some practices are

23 definitely becoming less popular due to modernisation and Westernisation25, people in

Malay society still adhere to their religion and adat. Adat has become subject to changes due to rapid industrialisation, urbanisation and Westernisation. In my thesis, I propose that urban middle class Malay women continue to value and respect adat, but they have re-worked adat in many ways. By re-working adat, I do not suggest that the customary law is changed, but that adjustments and negotiations have been made to allow people to live comfortably in modern Malaysia, while respecting and performing the obligations of their religious belief. With this in mind, readers can see that in the remaining chapters of my thesis the element of holding fast to Islam, adat, coupled with influences of westernisation are of prime importance in the lives of older women, and indeed in the society as a whole.

My research participants have revealed elements of change that took place in their lives which I have referred to as macro change (for example the change to working

„outside the home‟ for women). However, they also refer to elements of continuity

(maintaining religion, adat and domestic roles). This social process that sees a combination of change and continuity leads Malay women to express their ideas and desires in a new fashion, as will be demonstrated throughout my thesis. Based on my brief description about Malay society, we can see that no doubt it has undergone a process of tremendous social change. Some changes are visible whilst others are not. Factors like urbanisation, industrialisation and rural-urban migration have proven to contribute to significant social change among Malay people. However, other aspects of change are not so visible. For example how does one measure or observe easily the changes in the ways that women view their bodies and the ageing process?

25 While these concepts are important to the background of the thesis, there is insufficient scope within the thesis to discuss them in depth. Later in the thesis I will return again to these ideas and pay further attention to them in the context of discussion. 24

Interestingly, while my observations and conversations with my participants revealed that there are changes that took place in their daily lives, they have also maintained other things that I see as elements of continuity and the upholding of traditions within the society. According to Atchley (1983), continuity is created and maintained through repeating over and over again the same daily activities. Certainly the experience of menstruation throughout life provides the opportunity for repetition, but menopause provides some continuity as well. The word which is commonly uttered by my research participants during interviews to describe their lives at menopause: macam biasa (as usual), tak berubah (no changes) and macam dulu (like before). These words, as

I interpreted them meant there was still the repetition of and continuity of being a wife, mother and for some a grandmother. Life is as usual, although undeniably changes in their bodies have taken place.

Malay women have embraced the idea of being modern and Westernised and have no doubt been influenced by both education and the media. For instance, Malay women have sought Western medical support by delivering their babies in hospital and they prefer a nuclear family by adopting the family planning programme (Stivens 1998).

Similarly, Indonesian women studied by Brenner (1998) and Bennett (2005) have also experienced a similar scenario. In their own study, Brenner and Bennett found

Westernisation had influenced Indonesian women in terms of their dress, food and life style. Media has exposed them to different kinds of values and ideas through advertisements (see Chapter Six). Although Malay women have come to terms with the social change, it is not always smooth sailing. Conflict between old cultural experiences and modernity/Westernisation exist which complicates their everyday lives. In the paid workforce women‟s role has expanded from merely a worker to a decision-maker. Indeed,

25 there are multiple modern and traditional elements co-existing side by side especially in the Malay society.

Malay women have undergone tremendous change both in the private and public life. They have come a long way from their routine domain; that is from the home to their current position, which sees them working along with the men in the process of nation building (Abdullah, Mohd Noor & Wok 2008). Previous studies on Malay women by

Strange (1981), Omar (2003), Rudie (1994) and Manderson (1998) have shown that traditional and modern elements are not clearly separated. On the contrary, they are often combined or intertwined with each other. At the macro-level, the increasing percentage of women who are educated and who have joined the paid workforce represents significant and profound changes in the Malay society. In the mid of 1970s an attempt by the government to integrate women into the nation‟s development process was seen as a stepping stone into a less segregated division of labour (Ong 1987; Healey 1994; Hui

1996). This phenomenon later led to the „pluralization of life-styles‟ (Kiem 1994, p. 66) among Malay women. Malay women who worked in the electronics factory as reported by Ong (1987) were exposed to a different life and experiences such as working under the surveillance of supervisor, working with two shifts and doing repetitious work. Due to the pressure of working, the factory women expressed a form of mass hysteria as a symbol of resistance towards the authority. Similarly, my study also shows that while women are enjoying their position in the society, they too have conflicts in balancing their roles while managing their ageing and changing bodies. As I will demonstrate in

Chapter Three, the combination of traditional and modern elements of Malay life, coupled with specific influences from the colonial period, have contributed to the specific character of the Malay society.

Theoretical approach: combining the insights of interpretive and critical medical anthropology

In trying to make sense of the vast array of information I collected about the experiences of urban educated middle class Malay women undergoing the life transitional period of menopause, I have turned to a number of different sources in medical anthropology and its related areas. Rather than using one theoretical perspective I have drawn freely on a number of different approaches to inform my understanding and interpretation of my subject matter. However, I find that critical-interpretive medical anthropology most closely captures what I have tried to achieve in making the connection between the individual experiences of my participants and the workings of the broader society:

The task of a critical-interpretive medical anthropology is, first, to describe the variety of metaphorical conceptions (conscious and unconscious) about the body and associated narratives and then to show the social, political and individual uses to which these conceptions are applied in practice. When using such an approach, medical knowledge is not conceived of as an autonomous body but as rooted in and continually modified by practice and social and political change (Lock & Scheper-Hughes 1996, p. 44).

There are two components to this critical-interpretive approach. Let me start first by explaining something about the „critical‟ approach. Critical Medical Anthropology

(CMA) offers a unique way of thinking and analysing my research participants‟ individual experience of living with and through menopause because it goes beyond just their individual expressions of this experience. Many of the concepts employed by anthropologists using the CMA approach provide a way to examine the cultural and social conditions that have contributed to the present day urban Malay attitudes towards menopause. As Singer and Baer (2007, p. 33) note CMA has:

focused attention on understanding the origins of dominant cultural constructions in health, including which social class, gender, or ethnic group‟s interests particular health concepts express and under what set of historic conditions they arise.

In adopting this approach I have noted and analysed experiences that are particularly gendered, yet they also belong to women who are urban, educated, middle class and

Malay. While all women will have universal experiences, the specific location of my participants situates them in very specific ways.

The CMA approach has also shed light on explaining how and why some women choose to adopt HRT as a way of coping with menopausal symptoms. As Singer and Baer

(2007, p. 33) explain CMA „emphasizes structures of power and inequality in health systems and the contributions of health ideas and practices in reinforcing inequalities in wider society‟. It is not that women choose HRT because they willingly choose to be at the „mercy‟ of biomedical interventions or that they become „victims‟ of pharmaceutical companies. They make pragmatic decisions based upon their own circumstances, but their choices must be understood and analysed in the context of broader political and economic processes taking place in society. In addition, the CMA theoretical approach has contributed to an increased self-awareness of my own taken-for-granted attitudes and assumptions. A critical approach strips away the layers of my assumptions to reveal how one‟s own culture is so central to the way we think and act. Not only this, the social, economic and political circumstances we live in also become central to the way we think and act and to the kinds of limitations that are imposed upon us.

In essence, CMA raises questions as to how political and economic structures have had an impact on health and disease. In other words, those employing this approach seek to understand health-related issues in the context of political-economic conditions that „pattern human relationships, shape social behaviours, condition collective experiences, re-order local ecologies, and situate cultural meanings, including forces of institutional, national and global scale‟ (Singer et al. 1992, pp. 78-79). This theoretical framework operates at multiple levels:

i) the individual level focusing on individual experience

ii) the micro-level which generally focuses on the doctor-patient relationship

iii) the intermediate level which concentrates on the local health care system

iv) the macro-level of global political-economic systems.

Each level shares a common goal, that is to understand how social relations structure or shape participants in the broader social system. As I have already noted, CMA positions health and disease as embedded within dominant social relations like class, gender, economic standing, social status and race/ethnicity. In my thesis I have sought at different times to present a multi-layered approach to make sense of both the experience of menopause, but also the role and place of older women in Malay society.

As a result of becoming modern and urban, coupled with the influence of

Westernisation in the Malay society, significant changes can be identified in various social and economic territories. These changes which are at the macro-level have affected women, particularly those in the paid workforce. Urban educated middle class Malay women are expected to play a productive role in the workplace and pressures from work and their aspiration to portray a youthful and attractive appearance contribute to their acceptance of biomedical interventions. Indeed, CMA is useful as a frame of inquiry that integrates the multiple layer of the metaphorical body which in some ways explains the conditions under which urban Malay women live.

My thesis has also employed ideas that are drawn from a more „interpretive‟ origin. Kleinman (1980) introduced the cultural interpretive model that focused on the patient experience. While I have used Kleinman‟s ideas, I have not focused on the

„patient‟ as such, but on the individual older female experience. The experiences disclosed to me by my research participants in KL have emphasised that personal

„suffering‟ is ultimately a social experience. Individual experiences of „suffering‟, such as

29 those related by my participants in this thesis, prompted me to reflect on the problem of collective suffering and led me to be of the same mind as Kleinman, Das and Lock (1997) when they pronounced that suffering is the result of various social conditions. As I will demonstrate in the chapters throughout the thesis the state, media, menopause clinics, workplace and the dynamics of home have all intensified the experience of menopause among my research participants, and indeed of women within Malaysia. These are the social conditions within which women must negotiate the life transition they undergo during menopause. As these social conditions change due to broader social, cultural, economic and political factors, so too does the experience of menopause. The same could be said about any life transition, for example from childhood to adolescence, from single to married life and from middle age to old age. We can also apply this same theoretical perspective to the illness experience or the experience of disability or trauma.

Scheper-Hughes and Lock (1987) developed the concept of sufferer experience and a metaphorical framework called the three bodies to facilitate the understanding of the multi-layered approach to health and illness. Although I do not view my participants as „sufferers‟, the idea that they embody a particular kind of experience and respond to it in particular kinds of ways is very relevant to my analysis. Scheper-Hughes (1992) in her work Death without Weeping drew upon some of these ideas. Hers was a study of poor women in an extremely underprivileged shanty town known as Alto do Cruzeiro in

Northeast Brazil. Her work, which described the relationship between mothers and their hungry babies, illustrated the concept of sufferer experience. The central insight this notion offers is not dissimilar to Mary Douglas‟s (1966) ideas about bodily experience.

Douglas described the body as a „natural symbol‟ for thinking about culture. The body in menopause is symbolic of older women‟s uncertain and problematic place in their own society. In studying middle-aged women in Japan and poor mothers in Brazil, both Lock

(1993) and Scheper-Hughes (1992) have demonstrated that the body is another way in which people can relate between nature, society and culture. I drew upon the notion of

„the three bodies‟ as a way of informing my study and relating it to the levels of nature, society and culture. I have tried to take into consideration the personal and bodily experience of my research participants as well as exploring ideas about the aging female body and the medicalised female body in the urban context of a Malay society.

The fundamental axiom of the „three bodies‟ concept states that health and illness takes place and is best understood in a multi-layered manner. There are three dimensions of bodies identified: the individual body, the body politic and the social body (see generally Scheper-Hughes & Lock 1987). According to Scheper-Hughes and Lock

(1987), the individual body refers to the living experience of an individual who is inflicted with pain or disease. Both reject explicitly the Cartesian mind-body dualism and, by contrast, adopt a holistic approach to the individual body. The social body includes the way in which the individual body is related or represented in nature, society and culture.

Thirdly, the body politic refers to „the regulation, surveillance and control of bodies

(individual or collective) in reproduction and sexuality, work, leisure and sickness‟

(Scheper-Hughes & Lock 1987, pp. 7-8).

Drawing upon these notions of the body within the context of a changing society my thesis is organised around several themes which emerged during ethnographic analysis: attitudes to and perceptions about menopause; changing values from traditional to Western; and the medicalisation of menopause. These themes broadly represent menopausal experiences of urban middle class Malay women and are schematised following the work of Scheper-Hughes and Lock (1987) in Figure 1. The figure I present encapsulates the whole idea of my thesis. Menopause as I see it, has a profound effect on women and this can be represented at various levels (therefore it begins from a personal

31 level and moves to a broader context). These levels are interconnected with one another.

The individual body is the body that is directly affected by menopause. My participants did not entirely accept their bodily changes and often complained that their bodies were ageing, and their bodies exhibited symptoms and could no longer function like they used to. In Chapter Five I demonstrate that the women have an array of feelings about their changing bodies and I show how this has affected their sense of self-worth and indeed their identities as worthy, attractive and productive women. Elements of continuity within the local cultural world are presented in the social body, which, following Scheper-

Hughes and Lock (1987), I consider as a symbolic body. Although my participants were slowly coming to terms with their bodily changes and responded by using Western means

(for example through use of HRT and beauty products), the adherence to Islam and adat is strong. Islam and adat helped my participants balance the changes they were going through physically, emotionally and socially. Most importantly, the women still upheld their obligation to being a dutiful wife and good mother. The body politic portrays both the political and economic power relationships domain that impacted on the menopause experience. Through this theoretical framework, menopausal women are seen as

„accepting‟ medical intervention and the dominant Westernised approach to dealing with menopause. They can also be seen to embrace a more Westernised view of femininity, principally through their exposure to the media. In addition, the demand from the workplace requires that women continue to be productive individuals. This has added to their pressure in dealing with their menopausal conditions. In short, the body metaphor in this figure can be understood as representing the experience of menopause in all its complexity from the individual experience to the context of the broader social, cultural, economic and political millieu.

[Topic]

Menopausal experience

[Themes]

Individual Body Social Body Body Politic

The ageing body Doctor/State/Media Relationships & Husband Children communication Work colleagues Women, femininity The assault to identity and the female body

Social roles Wife The asexual body Mother Women in the Work colleague workplace The symptomatic body Grandmother

Medicalisation The worried person Status in regards to religion & adat (customary law)

Figure 1 ‘Three bodies’ as theoretical framework of this thesis

Connecting women and their bodies

Apart from the interpretive and CMA approaches I have used in my analysis of my research participants‟ experiences with menopause, I have also incorporated other relevant theories that I found useful to situate my research findings. In Chapter Seven, I have incorporated ideas from van Gennep‟s (1960) influential book Rites of Passage.

Although van Gennep did not include menopause as an example of a rite of passage, I feel strongly that menopause is a life cycle process that takes a kind of passage which is in many ways similar to the other kinds of passages van Gennep explores. van Gennep‟s work provides a theoretical framework which can be applied to the lifestage (or lifecycle), thus allowing an understanding of how women undergo a process which sees them separating from one stage of their life (reproductive), transitioning (through menopause) to the next and will later see them being incorporated into a final stage

(older age). Nevertheless, my research findings have shown that while moving from one phase to the other, it is during the transition (liminal period) that women in my study are living, in what might be termed „betwixt and between‟ (Turner 1974).

The idea of liminality is further elucidated by Victor Turner (1974). In his early work with the Ndembu of Africa, Turner explained that through ritualised liminal phases the Ndembu „moved from one social status (with its attendant proprieties, moralities and identities) to another and to another throughout their lives, the moves sometimes involving great changes in behaviour, world view and expectation‟ (Rapport

& Overing 2000, p. 232). In a similar vein, Douglas (1966) wrote that during the liminal period, a person has no place or status in society - temporarily there is no sense of belonging. She argues that the individual between statuses is ambiguous, and it is this ambiguity during the liminal phase that one is susceptible to potential danger. In my thesis, I attempt to bring to the fore the importance of liminality as a concept which I found has rarely been used to help explain menopausal experiences among women.

34 Clearly losing youthful looks and vitality and losing the ability to reproduce, both of which are connected, have the potential to create discomfort, and can be seen as an assault to self identity which confirmed Douglas‟s idea that these kinds of responses to a physical transition indeed trigger potential harm and danger. I argue that my findings have shown that women with no menstruation blood (menopause) can also impose a danger by living betwixt and between as well as acting out of character (mood swings or feeling depressed). I will expand upon these ideas in Chapter Seven.

I have also used Mary Douglas‟s (1966) theory of pollution to flesh out my research findings. In her well-known book Purity and Danger, she identified two types of pollution: instrumental and expressive. I am more interested in the expressive pollution as it carries the idea of pollution through a symbolic expression and in a manner which „relates to social life‟ (Douglas 1966, p. 3). In this book, Douglas postulates that things become polluting or dangerous by the fact that it has been out of place, by not fitting in with a particular cultural order of things. Douglas further added that body fluids (particularly blood) are seen as polluting agents that can bring potential harm and danger. This is clearly manifested in the example of menstruating women where they are subjected to various taboos and other forms of restrictions (Martin

1987). Previous studies by Powers (1980) and Skultans (1970) have shown that menstruating women were isolated in huts or rooms away from their husbands, other family members and people around them who are „not polluted‟. Following Douglas‟s framework, in order to maintain order, societies must be guarded by pollution beliefs so that those who could dare to transgress can be controlled. This idea of pollution is embraced only in the non-Western societies. Interestingly, while both Douglas (1966) and Martin (1987) mentioned menstruation blood as agent of pollution that can lead to disorder, I found that somehow they did not identify that having „no blood‟

(menopause) may also impose different kinds of sanctions or, on the other hand, the

35 lifting of sanctions. The women in my study were in an interesting situation. On one hand the menopause has given them more agency and power, for according to the

Malay way they were no longer considered polluted. On the other hand, from a

Westernised perspective, they felt burdened and some felt unattractive, anxious and undervalued. As you will see in Chapters Five and Six, my research participants have more freedom to engage in religious activities after they stopped menstruating.

However, many also experienced the symptoms associated with menopause and responded in a „Western way‟. This is not a straightforward matter and no two women responded in exactly the same way. What I am attempting to argue is that the women in my study are caught between the old and new ways and I am illustrating this through the specific case study of menopause.

Organisation of the thesis

In general, my thesis provides an in-depth analysis of menopause among urban middle class Malay women in Malaysia. Chapter One provides background of the thesis which is based on Lock and Scheper-Hughes (1996) notion of the „three bodies‟. The thesis has eight chapters with each chapter introducing different topics, but with interconnected themes:

Chapter Two

This chapter started out as an exploration of how researchers approach issues of a sensitive nature which I first presented at the National Conference on Sex Education in Kuala Lumpur, Malaysia. The „taboo‟ nature of the topic in Malay society helped to shape the research approach and the methodology I eventually employed for the thesis.

In Chapter Two I describe the challenges I have encountered during my fieldwork and offer some reflections on these as well as the strategies I used to overcome them. I explore the use of ethnography, specifically in-depth interviews and participant observation and I include a description of my research participants and the research site.

36 Aside from that, I also elaborate on the extent to which I found humour as a useful tool to obtain sensitive data and to engage emotionally with the women in my study.

Chapter Three

This chapter provides the contextual background of Malay women‟s roles and their position in Malaysia towards the beginning of the 21st century. I start by discussing women‟s changing roles in Malaysia by providing the stories of my grandmothers, my mother and my mother in-law, as well as myself. The stories are pertinent to my argument and demonstrate that the experiences of menopause for urban Malay women today must be understood in the broader sociocultural and economic context of the time.

Indeed, as I show, the urban Malay women of today live in a very different situation compared to their mothers. To make this chapter more meaningful, I present the historical view of Malay women before and after Independence. Malay women‟s increasing involvement in various sectors like education, the paid labour force and politics is discussed and Malaysian women‟s changing health status is also described.

Equally important in this chapter is the discussion of the role of religion and adat

(customary law) in the lives of the urban middle class Malay women. I also describe how urban middle class Malay women re-work traditional ideas of femininity through which they have come to re-conceptualise the realities of their lives.

Chapter Four

This chapter provides a broad overview of the medical and anthropological literature on menopause and touches on other material pertinent to the discussion of how menopause is understood and managed in society. It has two parts. In the first part of this chapter, I review some previous studies which attempt to explain the origin of menopause as a disease among both Western and non-Western women. In addition, I explore Conrad‟s (1992) idea of medicalisation and how it enriches (and challenges) our

37 understanding of medicalisation within a non-Western context. The second part of this chapter highlights the work from anthropologists who have conducted research on non-

Western women. They have investigated how meaning and experience are formed as a result of specific cultural interpretations. Their findings have facilitated my research and allowed me to determine what is unique about the Malay experience and to understand patterns that are common to many groups of women.

Chapter Five

Chapter Five sets the ground for the transition to the second part of the thesis, by introducing the findings of my research. This chapter begins the analysis of women‟s responses towards menopausal issues. The principle aim of this chapter is to analyse the meaning of attitudes expressed by my participants towards menopause and its treatment.

I examine how their individual understandings of menopause are reflective of broad discourses surrounding both menopause and the role of older women in urban Malay society. In this chapter I use case studies to highlight attitudes towards menopause and to provide a context for understanding the factors that contribute to both high and low anxiety towards menopause and ageing. I describe how knowledge about menopause in urban Malay society is transmitted by the menopausal women through informal ways, particularly in the capacity to engage in prayer, fasting and the teaching of religion.

Chapter Six

In chapter six I examine the discourse of menopause as an entry point into a further analysis of urban middle class Malay women‟s conceptualisations of menopause and its treatment. It is useful in this context to examine the historical linguistic change, or the rise of common usage of the term „menopause‟, as compared to more localised

Malay terminology. This chapter also discusses the discourse of menopause and how this discourse has changed over a period of time in the urban Malay society. I argue in

38 this chapter that the acceptance of biomedical intervention to treat menopausal symptoms of women in my study is a clear manifestation of the impact of the discourse created by both the medical profession and the media.

Chapter Seven

This chapter examines the work of van Gennep (1960) – The Rites of Passage, predominantly by examining the concept of liminality and its relevance to menopausal experience. The importance of liminality as a concept is discussed here in order to help explain menopausal experiences among women either in rural or urban areas. In this chapter I show how women in my study accommodate and adapt themselves to an environment which is seen as imposing some threats and/or dangers. Furthermore, this chapter also describes the opportunistic and entrepreneurial enterprises that have emerged through taking advantage of the anxieties associated with menopause.

Chapter Eight

As a way of concluding, this chapter synthesises my findings and analysis of the data I presented in earlier chapters. The first part of this chapter reviews the key themes and findings of my thesis, while the second part briefly considers some of the implications of these findings. The chapter concludes the thesis by highlighting areas for future studies that are raised by this new understanding.

39 CHAPTER TWO

RESEARCHING A SENSITIVE ISSUE: METHODOLOGICAL ISSUES

Introduction

Researching a sensitive issue, like menopause, requires careful selection of methods and consideration of the approach needed. For my project, qualitative methodology was deemed more appropriate and is most often chosen by researchers

(Warr 2004; McNamara 2001; Chirawatkul & Manderson 1994) who undertake research on sensitive topics. This is principally because of its strength in providing rich textual description of people‟s experiences in a given situation. Qualitative methodology and ethnography in particular, may also help a researcher to identify the behaviours that contradict beliefs, opinions and emotions from the participant‟s perspective (Punch 1998; Hughes, J 1998). As I have explained in the previous chapter my research was designed to elicit the participant‟s perspective by exploring menopausal experiences among urban educated middle class Malay women in

Malaysia.

In this chapter, I will explore the use of ethnography, specifically in-depth interviews and participant observation and discuss these in relation to my chosen topic.

I include a description of my research participants, sampling technique and research site. Aside from that, I also offer some reflections on the challenges I encountered during my fieldwork as well as the strategies I used to overcome these challenges.

Researching a sensitive issue

Some research topics are more likely to be sensitive than others. For example studies on sexual health and deviance have frequently been regarded as having a sensitive character. Those people who participate in a sensitive study may be „identified, stigmatized or incriminated‟ (Lee 1993, p. 6). According to Lee (1993), all topics are

40 potentially sensitive depending on the context. Renzetti and Lee (1993, p. 5) suggest that:

a sensitive topic is one that potentially poses for those involved a substantial threat, the emergence of which renders problematic for the researcher and/or the researched the collection, hold, and/or dissemination of research data.

From the above definition, „sensitive‟ in research covers many areas which are believed to be potentially difficult or risky. In this sense, research into topics like pregnancy loss (Abboud & Liamputtong 2003), sexual education (Hirst 2004), deviance

(Romero-Daza, Weeks & Singer 2003), dying and death (McNamara 2001) and homelessness (Booth 1999) are typically regarded as „sensitive‟ in research terms.

Research that is sensitive often has elements of threat or controversy that impose problems to the researcher and/or the researched (Langford 2000; Peritore 1990). For example, Shahidian (2001, p. 59) contends that his research about Iranian refugees is sensitive as it involved „sensitive information regarding “subversive” activities, political imprisonment and “illegal” crossings of borders‟. On the other hand, McNamara (2001) claims that her research is sensitive as it involves discussing issues related to death, illness and dying that may generate a degree of emotion in the research. Renzetti and

Lee (1993) have identified four areas in which research is more likely to be sensitive than others:

a) research into the private sphere or personal experiences,

b) study on deviance and social control,

c) areas that invade the vested interests of powerful persons or the

exercise of coercion or domination and

d) research upon or “into” sacred things.

My research fits into the first identified area as it involves discussing women‟s personal experiences with menopause which may in part be unpleasant (hot flushes and other

41 uncomfortable symptoms), embarrassing (loss of libido) and even challenging to their identity (feelings about their changing bodies and issues around femininity and ageing).

Menopause is most definitely a challenging topic as it is not widely discussed in

Western societies and virtually never discussed in most non-Western societies. In

Chapter Four I demonstrate, through analysing the literature that very few anthropologists have focused on the study of menopause. Murdock (cited in Beyenne

1968, p. 48) claimed that ethnographic findings on menopause are „scanty, anecdotal, inconsistent or peripheral‟ compared to other topics of study. Of course since the late

1960s this research has increased somewhat (see Lock 1993). Nevertheless, the research area is neglected with social taboos contributing principally to the rareness of the research (Agee 2000; Im & Meleis 2000). This makes research in the area difficult. Rice and Manderson (1996, p. 2) highlighted that „issues about reproductive health, including menopause, are un-spoken mainly because women want to maintain discretion and privacy‟.

Similarly in Malaysia, menopause is a sensitive issue and is regarded as belonging in a private realm. Most women will disclose information about their menopausal status only to their doctors or among women of a similar age who may be experiencing similar symptoms and concerns. As I have pointed out in Chapter One, there is only one ethnographic study on menopause in Malaysia which investigated the experience of rural Malay women. The lack of attention to the issue in Malaysia confirms both the difficulty of conducting research in this area and the taboo nature of the topic. Menopause is simply not a topic discussed in Malaysia (Ismael 1994). Those studies that have been conducted in Malaysia have been medically and quantitatively oriented. From the outset, my study is sensitive because it intrudes into some deeply private and personal experiences of the women I interviewed and observed. My study involved obtaining information that could have been embarrassing to the menopausal

42 women in many ways. I learned for instance, about the uneasiness some of the women felt when engaging in intercourse with their husbands and how they experienced unwelcoming remarks and jokes about their bodily changes, as well as their concern that their husbands might look for younger women.

Methodological issues a) Research participants: urban middle class Malay women

In my study, thirty urban middle class women aged between 50 to 56 years of age were interviewed. They all worked outside their own homes in either the public or private sector as managers and administrators. My participants live in housing area which is in KL like Ampang, Wangsa Maju, Keramat, Setapak, Bangsar, Damansara and Kepong. The housing areas that I mentioned are nearby KL city center. It takes my participants twenty to thirty minutes to reach their offices. There are also others who live outside KL such as in Klang, Bangi, Serdang, Dengkil and Sg. Buloh. However, those who live outside KL will spent at least forty minutes driving to KL. Most of my participants drive their own cars to their offices. Some women are driven by their husbands to work. These women do not have a driving license or have stopped driving for many years. Only one participant rides a motorcycle to her office and one uses the train. My participants are not industry workers. They work in modern office blocks in

KL, Putrajaya whilst others in other suburb close to KL like Shah Alam and Subang

(see Table 1). Most of my participants engage in administrative work. Two of them are teaching in school and one in college.

The women were all in a relatively high socio-economic group, having obtained either a diploma or bachelor‟s degree mostly from a local university. One participant graduated from Adelaide, Australia. Their monthly income ranged from RM 2,500 to

RM 5,000. Most participants married late compared to their mothers. They get married

43 between twenty to twenty-five years of age. Out of thirty women, only one remained single, two women were divorced and one participant is a second wife. Most women had between one and five children with three of the women having had six children.

Thirteen women were grandmothers. Many had children who were married, but the majority of their children were still studying either in a secondary school or university.

Interestingly, most of their grown up children live with them in the same household.

Only their married children live separately. Their husbands aged between 50 and 60 years of age. Most husbands worked in government offices. Others ran their own businesses and a few had retired. In terms of their health condition, 11 women rated their health condition as good but the majority reported suffering from diabetes or high blood pressure.

44 Table 1. Research participants‟ demographic background Marital Spouse’s No. of No. of Health Taking No Pseudonym Age Education Occupation Workplace Residence status age children grandchildren status HRT 1 Aini 49 Certificate Constable KL Ampang M 52 3 1 H/B Yes 2 Rahmah 50 Bach. Deg. Lab officer KL Dengkil M 52 4 NIL H/B Yes 3 Siti 50 Diploma Deputy manager KL Kg. Baru Single NIL NIL NIL H/B Yes 4 Cempaka 50 Bach. Deg. Secretary KL Ampang M 54 3 NIL H/B Yes 5 Meenah 55 Certificate Public Relation officer Sg. Buloh Sg. Buloh M 57 6 6 Good No 6 Dahlia 56 Bach. Deg. Batik designer KL Keramat Divorce 56 4 2 H/B Yes 7 Zahira 54 Certificate Administrator KL Setapak M 58 4 NIL Good Yes 8 Diana 53 Diploma Staff nurse KL Kg. Pandan M 53 2 NIL H/B Yes 9 Sofiah 50 Certificate Administrator KL Gombak M 56 5 NIL H/B Yes 10 Rashida 55 Certificate Administrator KL Pantai Dalam M 60 5 6 H/B Yes 11 Rosmah 54 Certificate Asst. statistician KL Kg. Pandan M 55 2 NIL H/B Yes 12 Rafeah 51 Bach. Deg. School principal KL Wangsa Maju M 52 1 NIL Diabetes Yes 13 Salimah 53 Certificate UMNO Treasurer Subang Subang M 57 5 4 Good Yes 14 Habibah 51 Certificate Finance officer KL Keramat M 64 4 4 H/B Yes 15 Maisarah 49 Certificate Municipal council KL Setapak M 49 2 NIL Diabetes Yes officer 16 Zawiyah 50 Certificate Administrator KL Damansara M 53 3 NIL H/B Yes 17 Chombee 55 Bach. Deg. School principal Cheras, KL Cheras M 55 6 1 Good No 18 Rozana 50 Certificate Administrator Shah Alam Ijok M 54 2 NIL Good Yes 19 Mariam 51 Certificate Account officer KL Klang M 55 4 1 Good No 20 Lina 54 Certificate Dressmaker Subang Subang Divorce 56 4 2 H/B Yes 21 Balkis 54 Diploma Tax assessor Putrajaya Gombak M 54 5 1 H/B Yes 22 Zarina 53 Certificate Administrator KL Bangsar M 54 3 NIL Good Yes 23 Laili 50 Certificate Free-lance consultant KL Ampang M 51 5 NIL Good Yes 24 Sharifah 51 Diploma Hairstylist-cum- KL Ampang M 58 3 NIL H/B Yes lecturer (Monogamy) 25 Dalila 50 Certificate Administrator KL Bangi M 52 5 NIL Good Yes 26 Azaliah 50 Certificate Administrator Putrajaya Serdang M 50 6 NIL Good Yes 27 Asmah 49 Certificate Administrator KL Kepong M 61 3 3 H/B Yes 28 Halimah 50 Certificate Businesswoman Sg. Buloh Kapar M 55 4 1 Good No 29 Karima 52 Certificate Gas station operator KL Sg. Buloh M 52 1 NIL Diabetes No 30 Kay 55 Certificate Administrator KL Klang M 57 3 3 H/B No

Bach. Deg. = Bachelor Degree M = Married H/B = High blood pressure

Recruiting women to participate in my study was a challenging task. First, I advertised my research on notice boards of various agencies and second, I sent emails to women in the age group of 50-55 who worked in government offices asking them to participate. I waited for almost two months but no one replied to the advertisement, nor to my email. This situation confirms earlier accounts that menopause is a sensitive topic and Malay women are not willing to open-up about their menopausal experiences to a researcher like me. After my initial and disappointing failure at finding women for my study I tried other recruitment strategies including attending a menopause clinic and women‟s social gatherings. Through these methods I identified women who were willing to take part in my research. From then on I used the well known snowball sampling technique (O'Reilly 2005; Liamputtong & Ezzy 2005) which helped me to link up with other women. I agree with Taylor and Bogdan (1984, p. 85) who said

informants are seldom found; rather they emerge in the course of one‟s everyday activities. You just happen to stumble across someone who has an important story to tell and wants to tell it.

Each of the women was asked to describe their menopausal symptoms, feelings and cultural beliefs as well as how their family members responded to her changes in lifestyle. Most of the women who participated in my study were recruited from the menopause clinic. Women who attended the menopause clinic were more willing to disclose their menopausal experiences with me compared to those women who were recruited in a non-clinical setting. Of the thirty women26 in my study, twenty women were recruited from the menopause clinic whilst ten women were from elsewhere.

Women who attended the menopause clinic were introduced to me by one of my key

26 See Appendix I for a brief description of my research participants‟ demographic background. Only three women aged 49 participated in my study. They have stopped menstruating at the age of 48. Others are in their early, middle or late fifties. 46 participants (O'Reilly 2005) who was the head-nurse in the clinic.27 My intention was to have a balanced sample in which I had women who attended the menopause clinic and those who did not. However, it was impossible for me to achieve this as women who did not attend the menopause clinic tended to be more private towards their menopausal experience and were therefore far harder to access. Women who did not attend the menopause clinic were introduced to me by my family members, friends and former students.

The skewed sample, which consisted principally of women who attended the menopause clinic, may be considered to be a limitation of my study. However, my intention is not to claim that my findings can be generalised and as applying to all urban

Malay women. Rather I gathered data through the means that were available to me.

Nevertheless, through talking to women who identified their own menopausal symptoms and sought help from them I believe I gained a rare and valuable insight into the experience of possibly a much broader group of women who did not attend the clinic. My interviews with women who did not attend the clinic confirmed, as will be seen throughout the thesis, that many of these women shared similar concerns to those who attended the clinic.

The interviews I conducted took place in an environment where the participants were most comfortable, where it was easily accessible for the women and where they were able to respond freely. Some women chose to be interviewed in their homes and others in the menopause clinic. Other interviews took place in beauty salons, hospitals, community halls and business premises. Interviews were conducted in a conversational way, using open-ended questions. The interviews were conducted in English or the

Malay language, depending on the respondent‟s preference. However, the interviews conducted in Malay language were then translated into English.

27 My key informant was in her early 50s. She worked in the clinic for twelve years. It was through her that I was able to get women to participate in my study. She died while I was doing my fieldwork. 47

In addition, family members were also invited to participate in this study. I interviewed fourteen children aged between 25-42 years old to get their views about menopause in general and their perceptions about their mothers who were in the menopausal stage. Some children were my former students whilst others were my research participants‟ own children. These children have completed their tertiary education from local universities and work in KL. Some children stay with their parents and others prefer to rent a house with some friends. Most children have little knowledge about menopause and its treatment. The most common response from them was related to their mothers‟ behavioural changes. However, they were uncertain whether the changes were related to menopause or not.

I tried to interview men, or more specifically, the husbands, during my fieldwork but they declined. Several excuses were given to me; for instance one husband said „my wife knows better‟, while most men claimed that my topic „is woman‟s stuff‟.

Interviewing men was also difficult because some men who sent their wives to the menopause clinic did not accompany them into the doctor‟s room. Rather they left their wives at the door step of the clinic. Some men I saw stood outside the clinic smoking, reading the newspaper or talking to other men nearby, others went for a coffee at a café across the road. I also noticed one or two men sat in their car waiting for their wives.

Some men „disappeared‟ and only reappeared after they received a call from their wives that everything was done. Given the sensitivity of my topic and the situations that I have mentioned, I found as a young Malay woman I was not able to approach the men. This would have not been acceptable culturally.

I had the opportunity to interview six doctors and ten nurses. Two doctors worked at the menopause clinic and four doctors worked in the private hospital. These doctors have been practicing medicine for more than twenty years. The ten nurses were

48 mainly from the menopause clinic. These nurses managed patients‟ registration, appointments, prescriptions, counselling and check-ups.

Finally, I did not include women who had experienced surgical menopause28 in my study. It is reported that women who had surgical menopause have significant differences in their health and health behaviour (Williams & Clark 2000). However,

Dahlia aged 50, who I did happen to interview separately told me how she felt after she underwent a hysterectomy:

I had both ovaries removed in 2003. I was 47. I complained of stomach pain. I thought it was nothing. But, day by day the pain was intolerable. I went to see a doctor, went for check-ups. Later, doctor told me I had cancer in my womb and needed surgery. I was so sad. I lost my femininity because I have no womb. My womb has disease! Other women‟s wombs have no disease. I felt guilty to my husband. I ask him to marry another woman because I no longer can satisfy his sexual needs. But, he refused. Sometimes I think deeply „Why my fate is like this?‟ Well, there is no cure to my disease. It‟s cancer you see [sigh]. My worry now is not so much about menopausal symptoms but my condition. I have no womb!

Surgical menopause occurs very suddenly; that is after the surgery. In contrast, women who experience natural menopause have a gradual transition that can take many years. Women with surgical menopause are younger than women with natural menopause. They have to heal both physically, emotionally and mentally to adjust to what has happened. b) Research site

I used a multi-sited (Marcus 1995) approach in this research. My research was conducted in Kuala Lumpur, the capital city of Malaysia. I spoke to urban middle class women and observed them in the menopause clinic, in women‟s houses, their meeting

28 Surgical menopause is the removal of both ovaries in women who have not yet had natural menopause. Surgical menopause can be either hysterectomy or oophorectomy. Hysterectomy is the removal of the womb. The most frequent reason used to perform hysterectomy is to remove fibroid tumors. When the womb is removed, it will stop a woman from menstruating and having children. Oophorectomy is the surgical removal of one or both ovaries. If one ovary is removed, a woman may continue to menstruate and have children. If both ovaries are removed, menstruation stops and the woman lose the ability to have children. 49 places, business premises and beauty salons. Each of these places constituted the ethnographic setting for the study. These places have provided me with rich information about the women‟s daily activities either with their families or friends.

Klinik Harapan: the menopause clinic

Generally, most menopause clinics in Malaysia are based within hospitals as an out-patient clinic. These clinics are directly accessible to the public on a doctor-referred or self-referred basis. The Malaysian public is informed of the clinic by press articles, radio or television programmes, medical lectures, health exhibitions as well as seminars to women‟s groups. Menopause clinics in Malaysia are not in heavy demand, which I attribute in large part to the reluctance to discuss the issue and seek help for menopausal symptoms.

Menopause clinics were established in Malaysia to deal mainly with the menopausal symptoms experienced by women as they go through their menopausal period. These clinics are usually run by general practitioners and gynecologists. Since the Malaysian government has shown interest in women‟s health, in 1989, the Mature

Women‟s Clinic was established and in 1990, the Well-Women Clinic was set up to cater for menopausal women (Ismail 1997). However, Ismail reported not many women came to both clinics for menopausal consultancy. Following this, in July 1991 the first menopause clinic was opened for counselling and HRT29 (Ismail 1997). Again, Ismail reported very few women attended the clinic.

So, in 2004, Klinik Harapan (literally translated as Hope Clinic) was established to provide a range of reproductive services to both men and women so that they can lead a healthier and harmonious life. The clinic (Plate 2), officiated by the late Tun Endon

Mahmood, the wife of former Malaysia Prime Minister Tun Abdullah Ahmad Badawi is a modern concept clinic. The clinic which is situated at Jalan Raja Laut, Kuala Lumpur

29 HRT in Chapter One is described as Hormone Replacement Therapy. 50 is easily accessed by the public using their private vehicle or public transportation. The clinic is partly subsidised by the government. Thus, the charges for treatment and medication are affordable and much lower than those of the private clinics or hospitals.

The clinic operates on Mondays to Fridays from 7 am until 5 pm. The menopause consultation is on Mondays from 2 until 5pm.

Plate 2 Klinik Harapan waiting area. (Photo: Nurazzura Mohamad Diah)

One of the objectives of the clinic is to educate the community about menopause and women‟s mid-life health. The intention is that through continuous medical education programmes, seminars and health exhibitions, women are exposed to health information directly from the doctors and nurses. Educational strategies are used which include health information through brochures, electronic health notes, monthly lectures and websites to the public, free of charge. During the course of my fieldwork there were two female doctors (Dr. Zulaikha and Dr. Nirmala) in the clinic who handled menopausal problems, three nurses who assisted the doctors, two nurses in-charge of

51 the pharmacy and another two nurses who sat at the registration counter. Most of the nurses are in their early 50s. Only one nurse is 30 years old. At the same time, these doctors and nurses were also responsible for the fertility clinic which operates every

Monday from 7am until 1pm. During my fieldwork on the average, Klinik Harapan received seven patients per day who attended for help with menopausal symptoms.

Patients who visited the clinic were mainly from the main ethnic groups of Malaysia

(Malay, Chinese and Indian). I noted that most of them were from the middle-class group and very few women were from the upper-class group.30 As noted previously, the women worked mainly in the public sector. In the next chapter, I will go on to explain the role of women in the workforce in Malaysia. In a city like Kuala Lumpur it is not unusual for a Malay woman in her late 40s and early 50s to work in the full time paid workforce.

Based on my observation, most patients who attended the clinic were mainly

Malay and Chinese. Very few Indian women visited. According to a nurse, most Indian women preferred to go to the public hospitals because they believed the cost of treatment and medication were cheaper compared to the clinic. Most women came to the clinic unaccompanied by their husbands, though as noted previously some men did wait outside or returned to collect their wives at the conclusion of the visit. Some women came with their office-mates, friends or children. Others preferred to come alone. There were two types of women who attended the clinic during my fieldwork: i) patient baru (new) and ii) patient lama (previous). These terms were used by the nurses and doctors to refer to the different kinds of patient. The „new patients‟ were those women who came for the first time to the clinic whereas a „previous patient‟ refers to woman who previously sought fertility treatment in the fertility clinic during their reproductive years. Later, when they reached menopause, they were referred to the

30 Interestingly, there were no obviously poorer women who attended the clinic. 52 menopause clinic. So, the „previous patient‟ is well known to the doctors and nurses in the menopause clinic and an easier source of recruitment to the clinic.

Methodology According to Liamputtong and Ezzy (2005), the flexibility inherent in qualitative research helps the researcher to understand meanings, interpretations and subjective experiences of vulnerable groups. In addition, qualitative methods allow researchers to listen to „voices of the silenced, othered, [and those] marginalised by the social order‟ (Liamputtong 2007, p. 7). Since my method employed an open-ended approach, it allowed participants to speak about their feelings and experiences using their own words rather than to follow a set of pre-determined questions that are usually employed in a survey research. Warr (2004), who conducted her research on street sex workers, claimed qualitative methods provided her with „rich and complex data‟ that was unlikely to come to light using solely quantitative methods.

Strauss and Corbin (1990) noted that through qualitative methods, a researcher learns about person‟s lives, stories and behaviour. In addition, in order to learn about and understand people‟s behaviour, we need to understand the meaning and interpretations that people give to their behaviour (Punch 1998). Thus, qualitative methods can be used to discover the meanings people attach to their experiences of the social world and how they make sense of that world.

The strength of the ethnographic method lies in its holistic nature as it provides room to understand the interconnected nature and tensions between different dimensions. Following Denzin‟s triangulation method (Denzin & Lincoln 1998), I employed both in-depth interviews and participant observation in my research to elicit an understanding of urban middle class Malay women‟s menopausal experiences. In addition, I also analyzed magazines, advertisements, health brochures and other materials the women shared with me. The epistemological rationale for my approach is 53 the dearth of knowledge regarding the meaning and experience of menopause among urban Malay women in Malaysia.

In my study, I have chosen ethnography as the traditional way to observe people and their culture. On top of that, as I have mentioned earlier in this chapter, ethnography is the most suitable method to study sensitive topic. Ethnography is an approach which follows a cyclical pattern (Spradley 1980). Unlike other research which follows the linear model31, the ethnographic research cycle means that aspects of the research are repeated over and over again. This allows a researcher to move back and forth between the data and the theoretical framework to situate his/her findings, as well as to search for other emerging meanings. Interestingly, I was only able to find my own research focus towards the end of my analysis which was also ongoing during the process of data collection. Ethnographic fieldwork is the central process of getting data in anthropology where a researcher immerses himself/herself in the daily practises of the people that he/she observes. Ethnography as O‟Reilly (2005, p. 3) puts it is:

[an] iterative-inductive research (that evolves in design through the study), drawing on a family of methods, involving direct and sustained contact with human agents, within the context of their daily lives (and cultures), watching what happens, listening to what is said, asking questions and producing a richly written account, as well as the researcher‟s own roles.

The nature of my study follows O‟Reilly‟s above statement. This means I did not start with specific hypothesis; rather my method „begins with an open mind and as few preconceptions as possible, allowing theory to emerge from the data‟ (O'Reilly 2005, p.

26). I have drawn on a family of methods including participant observation, interviews and a focus group, but also textual analysis of various texts like magazines, newspapers, health brochures and flyers. Indeed, the innermost concern of ethnography is none other

31 Spradley (1980) explains that the linear model follows the sequence of the research process: beginning with defining the problem before data is collected; analysing after completing data collection process; the problem and research instrument remain the same throughout the research; and writing the final report does not spark new questions. Quantitative research commonly follows this model. 54 than to interpret research participants in a particular situation, either at the individual, local or societal level (Kleinman 1995). As I have indicated in Chapter One, I conducted my fieldwork in Kuala Lumpur from December 2005 until December 2006. My study was conducted principally with thirty urban middle class Malay women in Kuala

Lumpur who were in their menopausal stage, by which I mean these women had stopped menstruating for approximately a year. Most of these women worked in administrative jobs within larger organisations.

Like the topic of menopause itself, the ethnographic method was new to me at the beginning of my research. As an academic sociologist I was, in the first instance, used to the quantitative method. However, I was to find that conducting fieldwork gave me rich information in line with what Geertz (1973) called „thick description‟. In conducting participation observation I made, in total, forty visits of approximately three hours each to a menopause clinic. I attended monthly seminars organised by the menopause clinic, participated in their health campaigns and talked to doctors and nurses as well as women who attended the menopause clinic. I was also invited to deliver a talk about cross-cultural experiences regarding menopause based on my study to two women‟s groups. In addition, I also joined women‟s group activities like meetings, Tai-Chi class, religious events and family gatherings. These informal meetings allowed me to experience part of the daily lives of older women.

Since ethnography is about learning and understanding people‟s daily lives and culture from the emic perspective, the process of knowing about others involves participating and observing as well as talking (interviews). Participant observation has two purposes. First, it aims to engage in activities related to the situation, and secondly to observe the people, their daily activities and culture (Spradley 1980). In other words, participation observation is about immersing oneself in the culture. As Liamputtong and

Ezzy (2005, p. 169) puts it:

Immersion in ethnographic research is about being with other people; it is about learning about how people respond to situations, how they organize their lives; it is about learning what is meaningful in their lives. Through this immersion, the ethnographers themselves experience events in the same way as the local people. They then are able to see things from the people‟s perspectives and hence to have a deeper understanding of the people they are learning from.

My first day of participant observation seemed to be a disaster, though reading accounts of fieldwork and hearing from colleagues this may be the way we all start out. When I entered the field I was overwhelmed with what I saw before my eyes. I was uncertain of where to begin, what I should see or write. As a novice anthropologist, I took the

„vacuum cleaner approach‟ which catches and traps dirt on the floor. I swallowed all the information without filtering it. Even so, this approach has helped me to see in a wider spectrum of information about menopause and issues related to it. Since there are too many things being said and done while in the field, ethnographers have a unique way, or what Van Maanen (cited in Liamputtong and Ezzy 2005, p. 173) called as „peculiar practice‟, of recording the events – writing fieldnotes. By writing down notes and keeping my own personal diary while I was in the field, I found it later helped me to structure and develop what I have experienced. Most of the time a researcher writes the fieldnotes after the event. However, there were also times when writing fieldnotes at the time is not possible (the absence of pen and paper or writing at the time is not appropriate for some reasons). There were instances where I typed briefly some points and saved them on my mobile phone so that I could elaborate on the notes later. This helped me remember things I may have otherwise forgotten. For example, when I attended weddings and went shopping with my family I did not bring my note book. I just need to store the information somewhere in case I got carried away with the wedding ceremony or my shopping.

Prior to conducting research involving humans, higher degree candidates must submit a Human Ethics clearance form before proceeding with the research. I anticipated that my research may be uncomfortable for at least some of the participants, so I believed the topic had to be addressed with a high level of sensitivity and respect.

The nature of my study involved more than just eliciting people‟s co-operation in giving an interview, as they were invited to disclose their personal experience to a stranger and thus to outside scrutiny. My research has not specifically focused only on my participants‟ menopausal symptoms, but upon other experiences as well. For instance, I was interested in their relationships with their husbands, their feelings about their bodily changes, ageing, as well as the risks and benefits of taking Hormone Replacement

Therapy (HRT). Fortunately I was able to convey this as permission to conduct the study was granted by the University of Western Australia Human Ethics Committee.

In accordance with the university ethics requirement I asked my participants to read an information sheet and to sign a consent form. While most complied, surprisingly three participants refused to sign. From their point of view, their „task‟ was to share with me what I was interested in and that was all. One of them indicated that she thought signing the consent form was a kind of obligation towards me. She said:

„You must follow “my way” rather than I follow “your way” because you want my story‟. So, the signing of a form was obviously not appropriate for some of the women in my study. Other participants who signed the forms also said that they signed because it was a procedure that they (and me for that matter) must follow and they did not want to get me into trouble. For some participants, my student ID and a researcher pass that was provided by the Economic Planning Unit of Malaysia was already a sufficient identification as a researcher thus, they did not question too much about the information sheet or the consent form that I provided before the interview began. Most of my participants preferred to treat the conversation as sembang-sembang (casual talk) rather

57 than as a formal one. Ethnography is a complex and finely nuanced method that is, most often, informal and context specific. While ethics are of great importance and there are indeed many ethical dilemmas confronted throughout the research process, the signing of a form will never alleviate these.

In order for me to obtain ethically grounded and rich data for my research, I used in-depth interviews, which is another method frequently used by ethnographers. The ethnographic interview is often unstructured (Spradley 1980; O'Reilly 2005; Kvale

2007). It is designed in such a way as to give many opportunities and to allow some degree of flexibility for participants in expressing themselves about particular issues raised by the researcher. However, I also prepared a „theme list‟ (Liamputtong & Ezzy

2005, p. 62) or a set of main questions that guided my interview. As I talked to women,

I made sure that the main questions had been addressed by ticking a reminder box next to the questions. According to Kvale (2007) the researcher himself/herself is the tool to interview inquiry. He asserts that a good interviewer possesses some skills like knowing the subject matter, being adept in conversational skills and being critical without being judgemental. Most importantly, I avoided using technical terms in order to reduce the time spent in having to explain unnecessary terms. I asked questions using simple words that could be understood by my participants, and in return they responded using their own terms (the emic perspective). Liamputtong and Ezzy (2005) raise the issue of learning to keep silent while interviewing and not to interrupt while participants are talking. Before I entered the field, my supervisor suggested that I practised interviewing with some of my friends to identify some skills that I needed to develop. Surprisingly when I listened to the tapes, I found it was me who talked more than my friends.

Learning from my initial interviews, whenever I felt like interrupting my participants during my interviews, I quickly wrote down notes or simply uttered the word aha, ok,

58 yeah or yes. By doing this, I showed a sense of respect to my participants and gave them more opportunity to talk to me.

I hoped that my interviews would last for about one and a half to two hours but some women refused to be interviewed for that long. I had to respect the boundaries that my participants set for me. My research interviews varied in length, for example, after sixty minutes some participants felt they had given enough information or refused to elaborate further while others talked for longer. Kvale (2007, p. 79) stated that the length of interview depends on the researcher: „ If one knows what to ask for, why one is asking, and how to ask, one can conduct short interviews that are rich in meaning‟.

Some interviews that are straightforward can be very useful, rather than filled with irrelevant conversation. Hammersley and Atkinson (2007, p. 117) note:

Ethnographers do not usually decide beforehand the exact questions they want to ask, and do not ask each interviewee precisely the same questions, though they will usually enter the interviews with a list of issues to be covered. Nor do they seek to establish a fixed sequence in which relevant topics are covered; they adopt a more flexible approach, allowing the discussion to flow in a way that seems natural. Nor need ethnographers restrict themselves to a single mode of questioning.

I realised my research topic contained sensitive issues. Therefore, in order not to appear threatening or being pushy, I started my interview with less invasive questions about their families, work, hobbies and general health. By asking less invasive questions, it helped me to reduce my own anxiety about talking to older women and it was a good ice-breaking strategy. There were also times when my participants asked me questions of me. Most participants wanted to know if I was married, for how long and whether I had children. Disclosure about myself was important for me to gain their trust and to make them feel secure before telling me about their private experiences. I do believe my participants would have been more hesitant in sharing personal matters like their sexual problems with a single non-married researcher.

The interview is not merely a simple conversation with no agenda (Hammersley

& Atkinson 2007). I had to retain some control over the conversation so that my research questions were answered. Thus, for interviews of the kind I conducted I needed to be non-directive and an active listener in order to understand what the participants said and how the information given related to the research questions (Hammersley &

Atkinson 2007; O'Reilly 2005; Liamputtong & Ezzy 2005). Active listening is not only hearing what participants said but also getting the nuances of meaning described by them at a deeper level (Kvale 2007). These are often captured by observing an array of emotional expressions as well as non-verbal communications.

To understand how urban middle class Malay women conceptualise menopause, data analysis from the in-depth interviews was performed using a phenomenographic process (Dahlgren & Fallsberg cited in Lindh-Astrand et al 2007). There are seven steps that I took in reviewing the transcripts from the interviews:

Step 1: Familiarization: each interview transcript was read thoroughly and the digital recording listened to several times to understand the meaning of the content and to have a sense of the whole story.

Step 2: Condensation: significant and important statements made by the women were selected to give a short and representative version of the women‟s conception of menopause.

Step 3: Comparison: similarities and differences based on the significant and important statements from the women in relation to the aim of my research were identified.

Step 4: Grouping: statements were grouped according to their similarities and differences. Each quotation was assigned a specific code (in an alpha-numeric form) to make it possible to track them during further analyses.

Step 5: Articulating: the essence of each group was described in a preliminary category

Step 6: Labelling: each category was given a name to identify the main themes

Step 7: Contrasting: similarities and differences were compared to eliminate overlapping of data.

Although listing the steps that I have taken to analyse my data seems so straightforward, in reality it was far more complex and „messy‟. I took many months referring to my transcripts and fieldnotes in order to understand the meaning of my participants‟ responses and to put them into the context of the wider society and the role of older Malay women in Malaysia. The particular lengthy process that I have adopted has helped me identify specific sociocultural fields or practices. It is what most anthropologists do to help them understand how people in a given society define their world. The reason I used this form of analysis is to determine what categories are important to my participants, how they are arranged and what values are attached to their menopausal experience.

Apart from in-depth interviews and participant observation, I conducted one focus group (Plate 3). This method has been used to study sensitive issues and with sensitive populations (Hughes, J 1998). First, I believed it was particularly important for me to gain access to women who remained silent about issues pertaining to sexuality.

Second, I feel that women need somebody to listen to their stories and experiences. I found these women were never asked about their menopausal experiences except by their doctors. So this was an opportunity to listen to what they had to say about their concerns. Thirdly, women are often more flexible and ready to share their opinions or experiences in group discussion compared to the individual interview approach.

According to Morgan (1988), the main advantage of conducting focus groups is to be able to observe a large amount of interaction on a topic within a limited time. Like other researchers who employed this technique (Hughes, J 1988; Ruff, Alexander and

McKie 2005), I agree that the focus group is a form of collective testimony (Madriz

2000) where I was able to listen to their concerns, hopes and expectations about their menopausal experiences.

Plate 3 Focus group interview in progress. (Photo: Helmi Afizal Zainal)

My focus group was with women who never visited a menopause clinic. The group was more or less homogeneous. The women were urban educated middle class

Malays in their late forties and early fifties living in Kuala Lumpur and working as administrative officers in the same organisation. Prior to the focus group, I prepared two vignettes to probe the discussion. These vignettes were, for the purpose of the focus group, translated into Malay language:

Vignette 1:

When menopausal hot flushes caused sweat to run down Sofia‟s face during business meetings, she joked to concerned colleagues, „I‟m in the middle of a desert‟. But for an executive like Sofia, menopausal symptoms such as profuse sweating, nasty mood swings and memory lapses were not funny. She was a mess, and it started to affect her work. However, she did not seek medical assistance. Sofia, 54, felt self-conscious when she had to blot up sweat while giving presentations at a multi-national company in Kuala Lumpur, a company that does transportation work.

Vignette 2:

I'm Maria, 48 years old, middle-aged, and have two girls, 20 and 17 years of age. For the last year or so, I'd tend to wake up in the middle of the night and worry and not get back to sleep. It has, over the past week, developed into full-blown insomnia, where I simply cannot get to sleep at all. I have occasional night sweats, once a month or so. During the day my face will feel hot for no reason, although I don't necessarily sweat. My face also seems to have acquired a permanent blush, my cheeks are pink (I'm quite fair) and I never need blush (make-up). I'm nervous, irritable, and snap at my kids, have less sexual desire and burst into tears for no reason. I've always been in control of myself; sure I'd get nervous or anxious on occasion but always got over it in a day or so, and never had any trouble sleeping.

Vignettes are most often short stories about hypothetical individuals or scenarios in specific circumstances to which research participants are asked to respond (Finch

1987; Hughes & Huby 2002). Vignettes have been used to elicit sensitive information in other studies like induced abortion (Whittaker 2002), violence among children and young people in residential homes (Barter & Renold 2000), family care-givers of elderly people (Rahman 1996) and drug injecting and HIV (Hughes, R 1998). Vignettes are useful tools in my research because they act as a stimulus for the focus group discussion. In fact, data from vignettes are also regarded as „complement data‟ (Hughes,

R 1998, p. 384) to other data collected through other techniques. Hence, vignettes are useful „to enhance existing data or to generate data untapped by other research methods‟

(Barter & Renold 2000, p. 311). During the discussion, I acted as the moderator. The discussion lasted almost two hours. At the end of the discussion, a gift was given to the

63 participants as an appreciation for their involvement in the focus group interview

(Pham, Freeman & Grisso 1997; Liamputtong & Ezzy 2005; Ruff, Alexander & McKie

2005). I prepared six bags of souvenirs32 for the women in the focus group as a token of appreciation for participating in the discussion (Plate 4).

Plate 4 Women made some jokes about menopause. (Photo: Helmi Afizal Zainal)

To preserve the actual words of the participants, all interviews, including the individual and focus group were audio-taped with the participants‟ knowledge and consent. Following this, the interviews were transcribed. Permission to quote from the interviews to be used in this thesis was granted by the women. I have used pseudonyms throughout to protect the privacy of the women who participated. The pseudonyms also include the name of the menopause clinic where the main fieldwork was conducted, the

32 Each bag contains Australian souvenirs like koala key-ring, postcard, plastic coasters and tea-towel. 64 name of other relevant places, the informants, family members, the doctors and organisations that appear in this thesis. However, names of places that are outside my immediate fieldwork setting such as Kuala Lumpur, the capital city of Malaysia, the newspapers and magazines remain the same. I have permission to use photographs of the women in this thesis, provided they are not published elsewhere.

Challenges in the research and strategies used

As noted previously there are many challenges involved in researching sensitive issues. During my fieldwork, I certainly faced many challenges. First, most of my respondents questioned my interest in menopause as they had never come across a non- menopausal woman asking about menopause before. I am a young Malay woman, and though I have two sons of my own, I had not, at the commencement of my fieldwork, spoken about menopause to my own mother. My participants claimed their own daughters did not ask them about menopause and my own experience of not communicating with my own mother confirmed that the common approach was avoidance. I sensed that many of the women I interviewed were uneasy about talking about menopause with me - perhaps because of the age difference between us. I was asked questions like „why are you interested in menopause?‟ and „how did you end-up with this topic?‟ I answered these questions in-depth and in a polite manner and in time

I believed they opened up to me and spoke freely. Second, perhaps because I am an academic or at least non-medical, the women seemed to talk to me about their menopausal experiences differently from how they spoke to the doctors or nurses.

Most of the women who participated in my research told me that they had never before spoken about their menopausal experiences with a stranger and that never before had anyone ever listened to them for any length of time. The interviews I conducted were not therapy, but I did empathise with their situation and listened attentively to what they had to say. In fact, some women expressed their curiosity in regards to how 65 academics might help with menopausal problems. Over a period of time, I was able to answer their questions especially on issues to do with my own research which enabled me to build better relationships with the women, their family members, doctors and nurses and thus I was able to proceed more effectively with my data collection.

Overcoming these challenges took time, commitment, careful thought and deliberate strategies. I joined the women‟s group activities, delivered talks, joined family gatherings and helped the menopause clinic staff. Joining the women‟s group activities and keeping a good record of the fieldnotes facilitated my awareness of menopausal women and their problems as well as knowledge of the clinic, the doctors and the nurses.

Gaining access into the field

No doubt, negotiating access into the field can be difficult and sometimes frustrating. There are many challenges that researchers encountered to gain access into the field. These challenges are related to our own personal attributes like age, sex, colour and social status that hinder a researcher from gaining access (O'Reilly 2005).

Based on my own experience, there are some places that required me to write many letters, some had to organise a series of meetings to give me permission and a small number remained silent (an indication of not being interested). After waiting for many weeks, I had no luck and it was really frustrating. Nevertheless, Neuman (2003) said access to a particular group of people often depends on luck or personal network.

Similarly, other researchers like Ostrander (1993) claimed her opportunity to gain access to the field was based on her meeting with a prominent upper-class woman through one of her fellow graduate students. This prominent lady introduced her to three respected women (grande dames) who later suggested names for her to expand her network. Danziger (1979, p. 516) on the other hand, made this comment on her own experience: 66

One very special credential, however, served to minimize my threatening outsider status with respect to the medical profession. I had a personal connection in that my father is a practicing obstetrician gynecologist. Not only did I have my first opportunity to observe on labor and delivery units where he practiced or where he was a friend of the chief of staff, but I also had a letter of introduction from him, which proved to be a door opener. It meant that I was officially a member of the fraternal order of colleagues.

Interestingly, in some places gaining access to the field is based on a „who-you-know‟ approach or with some connection with the gatekeeper. Like Danziger, I also experienced a similar situation. My fieldwork diary illustrates this point:

17 December 2005 I have an appointment at 10am with Datin Maimunah, the chief nurse at the

Klinik Harapan. I prepared my ID’s, permission letters to conduct research, information sheet and consent form. I’m a little bit anxious today because I’m dealing with a mak Datin – a VIP. I knocked on the door and she greeted me with a ‘Garfield’ face. Not interested I guess or maybe she’s just like that. She offered me a seat and asked what my research is all about. She didn’t even bother to ask who I am. Maybe this is how bureaucrats work, no time for idle chatting, straight away jump into business. We had a very formal conversation.

I felt that I’ve swallowed my words while talking to her. Despite her facial expression, I managed to tell her about my research. When she is satisfied with my explanation, only then she had interest in me. It was when I told her I’m studying at UWA, she changed her tone of voice and her face. She became so lively and friendly – that Garfield face disappeared! She started to tell her own stories back in the 70s where she met her husband who studied at UWA while she worked as a nurse at Sir Charles Gairdner Hospital. She rented a unit in the same building where I lived. She then described Cottesloe beach, Freo fish and 67 chips restaurant and Matilda Bay where she used to have picnics and BBQs with her family as well as some other places that I’ve never heard of. She also delivered her triplets in Perth. I remembered the girls because they made a headline on one of the Malaysian newspapers many years ago. So, this is their mother! She started to talk about the triplets whom one of them went to USA to study with my younger sister. I listened to her stories for about 30 minutes compared to 15 minutes description of my research. When everything is said, she introduced me to her colleagues: ‘Meet my friend from Perth’. Before I left, she asked my mobile number and said: ‘If I need anything from Perth, I’ll call you’.

Datin Maimunah emerged „like a fairy-god mother to help the forlorn ethnographer‟ (Rock cited in O‟Reilly 2005, p. 90). I was lucky that she showed me around many places and I was able to meet her colleagues in the clinic. From that day onwards, she frequently e-mailed me about the clinic‟s upcoming seminars or health check-ups. At one time I was not able to attend a seminar and she rang to check why I was not there. Although it was unusual for a „stranger‟ like me to be introduced as a friend by a higher authority, it certainly advantaged for me greatly. Since we shared something in common, that is that both of us had lived in Perth, I encountered minimal problems in gaining access to the research field, particularly at the clinic. A senior officer once told me when I made enquiry about gaining access to particular offices, „If you know somebody, paper work is not really a big matter‟. With the recommendation of a higher authority whom you know or are related to (as exemplified in some studies I quoted earlier), you can get access to several places or documents for research purpose with minimal bureaucratic process. This is the common way of how things work in

Malaysia. However, it is not just who you know but also how you present yourself. On

68 one occasion I was not well accepted when I introduced myself as a researcher, but, when I introduced myself as a lecturer some of the officers and women were more willing to talk to me.

Managing relationships in the field

In the early days of my fieldwork, my presence in the menopause clinic was awkward. I was told by a senior nurse that the clinic had never had a researcher with them before, but only medical students who were doing their practical studies there. The nurses always mistakenly identified me as one of their patients. I remembered clearly my first day in the clinic a nurse said:

Yes Ma‟am. Please leave your appointment card here, take your number and have a seat. I will call your name later.

It was further confusing because the nurses had their duty roster changed every six months. I had to introduce myself again to the new nurses. It was amusing when another nurse once asked me:

So, when was your last period? What symptoms have you got?

In another situation, the nurses called me doctor. I jokingly told them „Please call me by my name. My DR is under construction!‟ I had to remind them repeatedly of who I was and my purpose of coming to the clinic. It was important for me to use humour and a friendly approach to establish trust and to differentiate my position from that of a patient. I needed to avoid the formality so that the nurses would confide in me and speak at length about their practices and their attitudes to their patients and to menopause in general.

Building trust and rapport

A study on menopause demands a close relationship between the researcher and the participants. I quickly realised I needed to develop trust and good rapport with the women. Flexibility was very important. I did not enter the research setting with a rigid plan of what I wanted to achieve. Rather, I entered with an open mind about what I could offer rather than what I could acquire. By projecting both personal and academic interests, I attempted to portray a particular image that this would enhance my acceptance among the menopausal women; for example, I was respectful and polite when talking to them. I realised that how I presented myself was an important process in establishing trust. At times my self-presentation was as much influenced by personal considerations and commitments as it was by academic ones. Building trust in the research is the key to creating a safe surrounding and to self-disclosure where respondents talk about private or emotional topics (Elam & Fenton 2003). Since confidentiality is a major ethical issue in sensitive research (Demi & Warren 1995;

Langford 2000), the re-assurance of confidentiality at the beginning and end of the interview was strongly emphasised. The respondents needed to trust that their feelings would be respected and their information kept confidential.

There are a few basic rules that underlie the rapport-building process: first, obtaining information is a two-way communication of gathering and giving information

(Booth & Booth 1994). Both the women and I exchanged personal questions, telephone numbers and home addresses. Second, observing so-called common sense rules (Reid et al. 1998) like observing punctuality, keeping appointments, returning phone calls and attending family gatherings. Third, being friendly and practicing a non-threatening approach and openness (Booth 1999), such as providing participants time to think about the research questions and not being pushy.

Conducting research on sensitive topics demands creativity from the researcher

(Lee 1993). According to Frijda (1986), humour helps to emotionally disengage those involved in intense situations. In fact, laughing together with some women in my study indicated a positive value that a „mutually supportive relationships‟ (Wennerstrom

2000, p. 316) had developed between us. I found this to be the case on more than one occasion, for example:

Salimah: I remember my husband jokingly said that I‟m just like a car which has an expired road tax! It can‟t be used on the road. You know what I mean? [Laugh] Nura: But you still can renew the road-tax Salimah: Not when the engine is 50 years old! Not sure if there‟s a mechanic who can fix it. Nura & Salimah: [Laugh]

In summing the situation up, I used the women‟s responses as a guide, if they laughed, I laughed. At this point, I think theories of humour provide a useful understanding. Wennerstrom‟s (2000) research in the United States (US) found that taboo topics like menopause can be discussed openly through the use of humour. She employed Victor Raskin‟s (1985) theories of humour, summarising his three major approaches to humour as hostility-based theories, release theories and incongruity theories. The release theory is relevant to my own research with women more freely discussing menopause in situations where humour was used. Wennerstrom (2000, p.

315) noted:

The second category, termed release theories, posits humor as an attempt to escape from social restrictions and taboos. Obvious examples are sexual, political or religious humor. The physical release of energy which laughter allows is noted in justification of this category. To the extent that menopause is still a social taboo; these theories hold relevance for the current study since the element of release in humorous talk about this restricted topic would not be unexpected.

I found humour was used by the women in my study as a form of resilience along the life cycle (Gibson 2003) and as an adaptation strategy (Sullivan, Weinert & Cudney

2003) to deal with emotional ups and down resulting from menopausal experiences. In her study among rural women in Nova Scotia, Canada, Price and colleagues (2007) discovered that humour was used among the women as a coping strategy, as well as to facilitate the exchange of menopausal experiences and information in the focus group.

Their research participants claimed that humour reflects a new-found freedom and permission to discuss menopause, a topic which they regarded as taboo. Another study which sees humour as a means to disengage people from an intense situation is by

Sullivan and colleagues (2003). They conducted research among women in a rural state in the US on individual perceptions of chronic illness-management experiences. One of the findings was that humour helps those managing challenges of everyday life living with chronic illness. Humour was used as an adaptation strategy through poems, jokes, funny stories and anecdotes to reduce stress and tensions. Not only did the women in my study use humour to deal with their emotions, I found humour helped me to release my own tensions while engaging in a sensitive discussion with the women. Since my research is not specifically on identifying coping mechanisms among menopausal women I do not have the liberty to discuss this issue further. However, I feel the use of humour and menopause (as well as other taboo topics) requires further investigation.

Supporting the self-disclosure of the participants

Self-disclosure is referred to as „the act of revealing personal information to others‟ (Gilbert 1976). The following quotes are examples of sensitive topics which were discussed with me during interviews. Rozana, aged 50, confessed that:

Following menopause, my vagina is dry. I feel painful when I have sex with my husband. He doesn‟t understand. I feel trauma whenever we have sex.

I did not expect such honest self-disclosure, especially as I had not asked specifically about her sex life. I was, in fact, shocked by her candid admission. However, I felt it was important that I did not act shocked but accepted what she had to say. If I had acted shocked, she might have felt embarrassed or not continued to disclose her other menopausal experiences. Another woman, Diana, 53, found it was easy to talk about her sexual experiences after menopause:

I use KY gel. It‟s easy. I have no problem. I can still fulfill my husband‟s sexual needs.

The above quotes show the extent to which I was able to develop trust and rapport with the women I interviewed. Indeed, some participants reported that they did not disclose their sexual problems even to doctors unless they were asked.

Communication about menopause

From my observation, urban middle class Malay women in my study are experiencing a communication change from high-context communication to low-context communication. Samovar and Porter (1991) refer to high-context communication as information that is not told explicitly while low-context communication information is shared in an explicit way. Asian and Middle-Easterners are regarded as using high- context communication techniques whereas Westerners are regarded as being low- context communicators. According to Hall (1976), high-context communication is characterised by indirectness. However, as I illustrate below, the women in my study are moving from high-context to low-context communication; that is, they use both forms to some extent. While they are being more explicit, they continue to use some techniques which also allow them to avoid being entirely explicit. For example, in my study, some women talked about their menopausal experiences expecting me to be able to pick up the cues. In other words, they provided part of the information and I was expected to fill in the rest. For instance Rosmah, 54, said: 73

This [menopause] is a husband‟s problem too. Menopause happens to women at a later age. Husbands, when their wives are menopausal and lack this and that, men don‟t understand. Just like me, my husband couldn‟t care less. If he wants it, I have to give.

In this case lack this and that means decreased sexual interest or vaginal dryness that makes sexual activity uncomfortable. The word it refers to „to have sex‟. However,

I had to infer this meaning from her implication. If Rosmah had had to say directly what her experiences were and what her husband wants, she would have found it difficult.

Thus, she talked around what she experienced, and as the researcher I was expected to understand the cues. Another woman, Aini, 49, shyly explained:

I came to see the doctor to get treatment. Doctors and friends said HRT is good. They said it will make your that life [sexual life] better. When your that [vagina] thing dried, it is very uncomfortable to anu33 [have sex] with your husband. When we grow old our that life [sexual life] is not like in the twenties or thirties.

In this situation, members in a high-context culture are expected to know what is disturbing a group member (Hall 1976). In other words, details of the story are not provided by the women, but problems they experienced are considered to be known by the researcher. I found this kind of communication a challenging experience because I have not experienced menopause and was not previously aware of the problems and concerns facing women experiencing menopause. However, my interviews earlier with doctors and nurses and the reading I had done on the topic had given me the necessary information about the kinds of menopausal symptoms some women experienced that may affect their lives. The doctors and nurses also cited some cases that gave me a general idea of how menopausal symptoms affected some patients in the clinic.

As already noted in general, when a Malay woman experiences menopause, she tells nobody what she is going through. She feels there is no need to expose her private

33 The word anu refers to a person, behaviour or any other thing that is not directly mentioned or is forgotten. For example: „Please switch on that anu for me‟ or „Anu is coming tomorrow for lunch‟. Anu is widely used in Malay conversation.

74 life. In contrast, Western women tend to discuss their biological changes so they can share with others and inform them about their experience (Breheny & Stephens 2003).

However, I found that some Malaysian women (for example Rozana and Diana quoted in the earlier section) have some low-context characteristics. This is probably partly due to their exposure to Western culture and to their level of education. Conversely so, I am also told that not all Western women wish to discuss the menopausal symptoms openly either. Nevertheless, in all likelihood if they did they would be more likely to say „sex life‟ and possibly „vagina‟.

To obtain information on intimate and sensitive topics, a researcher must be sensitive, gently steer the conversation and be a willing listener for the participants involved in the study. I was able to access intimate and sensitive information from menopausal women because of my status as an academic researcher and an insider of the Malay culture, an aspect I discussed in Chapter One. In this context according to

Barrett‟s study (cited in Bruenjes 1998, p. 67) there are three ways that an anthropological researcher can identify themselves: a) as an insider; that is a researcher from a dominant ethnic group conducting research at home, b) as a native anthropologist; that is a researcher from minority group studying their own people and c) as an indigenous anthropologist that is, one who conducts research in his or her own society. The insider category fits me best. I come from the dominant ethnic group in

Malaysia and I returned to Kuala Lumpur from my place of study in Western Australia to do my research. It is essential for me to consider my social location in the context of how the research participants may be influenced by it and how this may affect our relationship (Liamputtong 2007). In other words, it is relatively easier for a woman like me to study menopausal experience rather than a male researcher. My personal background as a Malay woman born and raised in an urban society helped facilitate my research. Being a well educated, married woman working on a women‟s health issue

75 and belonging to the dominant religious group in Malaysia were all factors that helped minimize the problem of communication with the women in my study. Indeed, the strategies that I have mentioned above used during my fieldwork were paramount in helping me to obtain rich information from the women who participated in my study.

Conclusion

Conducting research on a sensitive topic is taxing and in the course of my own research was at times overwhelming. I used several strategies to overcome the challenges I faced in the field including immersing myself in the environment.

Flexibility, patience, being respectful and humorous helped me gain the information I required. In this chapter, I have shown the advantages of using ethnography to explore delicate issues among women and their family members. I argue that ethnography is an effective method to gain understanding about the range of attitudes that urban middle class Malay women have about menopause. I believed the depth and complexity of the issues I explored would not have come to light using solely quantitative methods, particularly the survey methods I had used previously as a sociologist. I cannot imagine women divulging information about their sex lives through the survey, or talking about the anxieties associated with ageing, all issues which I explore further in the coming chapters.

CHAPTER THREE

THE CHANGING ROLES OF MALAY WOMEN IN MALAYSIA

Malay women of different eras

Having outlined my thesis argument and methodology, I set out in this chapter to give an overview of the changing roles of Malay women in Malaysia. This chapter contextualises the topic and gives a background to how older women have established an important place in the changing face of urban Malaysia, while at the same time maintaining aspects of their traditional roles as wives and mothers. As a preface to discussing these changing roles I recount the stories of my grandmothers, my mother and my mother in-law (as well as myself) to give a firsthand account of the everyday lives of Malay women in Malaysia over three generations. On a personal note I have chosen to include the stories of women from my family because I have detailed knowledge of their life-experience and, of course, they have played a very significant role in my life from childhood until adulthood. From an analytical point of view these stories are relevant to the thesis because they reflect the different living circumstances of women from different historical periods. The contrasts between the women are strong when we take into consideration the change from rural to urban living and the different levels of education, both of which have helped to shape the changing nature of Malay femininity and Malay women‟s place in the world of work. The stories are relevant to my thesis and demonstrate that the experience of menopause for urban middle class

Malay women today must be understood in the broader sociocultural and economic context of the time. Educated urban middle class Malay women live a very different life from that of their mothers.

My grandmothers

Mbah (my father‟s mother) (born 1930, died 2003) lived in a wooden house in the middle of a padi (rice) field in Selangor, one hour‟s drive from Kuala Lumpur (KL).

Mbah the fourth child out of nine siblings, was a housewife while her husband worked in a one acre padi field. At the age of twelve Mbah‟s marriage was arranged by family members. She gave birth to three sons at home with the help of Moyang (Mbah‟s mother) who was a bidan (traditional birth attendant and healer). Mbah strictly adhered to the pantangs34 (rules of behaviour) after childbirth. Mbah and my grandfather worked hard to allow their three sons to complete schooling. As both Mbah and my grandfather were illiterate, educating their children was seen as a priority. Abah (my father) was the eldest of her children and the only one to attend boarding school in KL and university.

Mbah‟s life was very „traditional‟. Getting up every morning at six o‟clock to gather coconut fibres for the fire, she cooked rice and fish on a wooden stove, looked after her children, washed and sewed, tidied the house and fed the chickens. Her life was physically hard as she had to fetch water from the well and work in the padi field during planting and winnowing seasons. She and my grandfather would not allow their sons to help in the fields as they wanted them to concentrate on their studies. In the evening Mbah taught her children to recite al-Qur’ān and supervised their school work.

During her leisure time, she invited friends for tea and they talked about their families and women‟s business of various kinds. On the weekends, Mbah attended religious classes in a nearby mosque with her friends.

My grandfather accompanied Mbah wherever she went, transporting her on the back of his bicycle. Mbah was widowed early at 40 years of age when my grandfather

34 After childbirth, Mbah observed pantangs for forty-four days. Mbah avoided food which is considered harmful to her body. She drank jamu, and took part in berurut (massaging), bersalai (roasting/smoking) and berbengkung (binding). In addition, Mbah tied her hair and formed a bun to avoid masuk angin (wind entering the body/catching a cold). She smeared herbal mixture called pilis on her forehead to avoid getting headache. Mbah also performed dzikr (remembrance of God) to prevent herself and the newborn from supernatural danger. Carol Laderman‟s (1983) ethnography, Wives and Midwives: Childbirth and Nutrition in Rural Malaysia, Berkeley: University of California Press deals with these issues in depth. 78 died. She remained alone in Selangor for several years with her sons working in KL and sending her money every month. In the 1980s my father, Abah, persuaded her to migrate to KL to live with him and she became part of my life as I grew up. She passed away at the age of 70 years.

Similarly, my mother‟s mother, Nyai (born 1931), now 78 years old, is also a typically „traditional‟ Malay woman. She lives in a palm oil plantation in Perak (a northern state of Malaysia) with her husband and her youngest daughter. Her story is much like Mbah‟s. As a housewife she cooks, washes, cleans and feeds chickens. As

Nyai has always lived far from KL, she has seldom come to visit us, although she usually visited us after my mother delivered her babies. Nyai has nine children, the youngest of whom is disabled. Unlike Mbah who only looked after her family‟s needs,

Nyai also makes jamu (a traditional herbal mixture) and bahulu (a Malay traditional cake for special occasions) for other people. This work provides her with additional income to the money she receives from her children every month. Normally, Nyai sells her jamu and bahulu to her friends and acquaintances, making on average between

RM100 and RM150 per month. Nyai learned to make jamu from her mother. Although in Nyai‟s family, jamu making has been transmitted from one generation to the next she did not teach this skill to her daughters. Most of her daughters now prefer to use doctor‟s prescriptions and other forms of medications that are available in pharmacies.

With her daughters following the modern way, Nyai taught her close friend Mak Jah, who lives ten minutes from her home, in order to continue the jamu legacy. Like Mbah who helped her husband in the padi field, Nyai helps her husband in their ten acre palm oil plantation. However, today, Nyai‟s deteriorating health does not allow her to be as active as she once was. Nevertheless she still always attends religious classes every weekend in the mosque.

Both grandmothers have devoted their time to taking care of their family‟s needs. Their stories are an indication of a clear division of labour between husband and wife. Both my grandfathers were considered the breadwinners of the family and guardians of their wives while both Mbah and Nyai were expected to nurture their families. However, Nyai due to her work in a small-scale business from home had more financial independence than Mbah and she has been able to accrue some savings and buy jewellery for herself.

My mother

My mother (Mak) (born 1953) is 56 years old this year. She migrated to KL with

Abah (my father) in the 1970s and works in the Federal Land Development Authority

(FELDA)35 in KL. Mak is an accounts officer and has worked continually since completing high school. By Western standards Mak might be considered a „super woman‟. The pattern I became familiar with as a child continues today. She wakes up at six o‟clock to prepare breakfast for the family and drives to her office during the weekdays. She works from eight to five o‟clock, returning home at six o‟clock to cook dinner for the family. Before she goes to bed, she irons her clothes and my father‟s clothes as well. On Saturdays, she does the laundry for the family. Like my grandparents before them Mak and Abah practice a clear gendered division of labour. In other words, Abah participates less in duties at home while Mak maintains the total responsibility for the home and family. However, unlike my grandmothers, Mak takes on the „double burden‟ of paid and unpaid work. It is true that my grandmothers helped in the fields, but they did not participate in the world of paid work in the way that Mak has done for many years.

35 FELDA is under the Ministry of Land and Cooperative Development. It was established in July 1956 as a Federal Statutory Body that channel financial assistance into the development of remote areas in Malaysia. FELDA is responsible to clear lands for planting crops particularly rubber and oil palm, selection and emplacement of settlers, managing projects, providing credits, marketing service as well as facilitating the settlers social and community development. 80

Mak has six children, three boys and three girls. All of them were born in a private hospital in KL with the assistance of an Irish male gynaecologist. Mbah and

Moyang (Mbah‟s mother) took turns in looking after Mak after childbirth. Nyai visited during the weekends to supply jamu for Mak. My brothers, sisters and I attended boarding schools from the age of thirteen. Mak is proud because her children have completed their tertiary education and now all have good jobs. Mak‟s job demands that she has often had to travel inter-state. When we were in school, Mak sometimes left us with maids who cared for us.

As a working woman, Mak is financially independent. She bought her own car, earned extra income from the multi-level business scheme she joined and bought some shares offered by her office. In contrast, my mother in-law who lives in Penang stays at home and is financially dependent on my husband, her eldest child, as she is widowed.

The contrast between my mother and mother-in-law demonstrates that there is no one way of depicting the roles of women in this age range. Many women, like Mak, particularly those living in urban areas, work both inside and outside of the home, while others maintain a more traditional life in the home.

Mak is concerned with her appearance, health and well being.36 On pay day she spends hours shopping for her clothes, shoes and jewellery. She also frequently visits the beauty parlour for facial treatments and buys cosmetics as well. Mak takes vitamins to boost her health. Unlike Nyai who takes jamu regularly, Mak only used it during her confinement period. Once in a while, Mak and her friends attend an aerobic class after office hours. Once a month, she undergoes a medical check-up to ensure her health is

36 I am grateful to Abah, Mak, Nyai, my mother in-law as well as other family members whom I have quoted in this chapter and elsewhere in my thesis who granted me the permission to share their stories and personal circumstances. 81 not being threatened. In her younger years she also adopted the family planning programme.37

In the office, Mak participates enthusiastically in the women‟s society activities.

She has organised charity programmes with her friends, and has attended seminars, family days and represented her department in several netball tournaments. Every

Friday, Mak and her friends attend religious classes or talks. Unlike Mbah and Nyai who attended religious classes in a mosque on the weekend, Mak‟s religious classes are in the office. The office management organises such classes every Friday in the auditorium for an hour for their Muslim staff. At the end of every year, Mak is normally busy studying for her job appraisal exam. Now that Mak has five grandchildren her

Sundays are devoted to visiting or taking care of them. Sometimes she takes her grandchildren to Kentucky Fried Chicken or McDonalds and she buys them toys and books.

Nura I was born in 1973, the eldest of six children. I have two sons of my own aged eight and six years old. I work as an academic in a public university and my husband works in the national oil and gas company better known as PETRONAS as a manager.

We met each other while studying at the same university.

I have been teaching in the university where I graduated for almost seven years.

My work entails having to prepare reading materials and examination questions, giving lectures and attending meetings, seminars and training organised by the university.

Other work like conducting research and organising educational trips for students are also on my long list of duties. Sometimes during a long lunch break on Friday (from

37 Contraceptive pills, condoms, intrauterine device (IUD) and Implanon (a matchstick size rod which is inserted under the skin of a woman‟s arm) are the common family planning programme in Malaysia that is adopted by Malay women. 82

12.30pm until 2.45pm) my friends and I will go shopping or have lunch in a nearby mall. This is the time where we get together and tell our own stories about work, family and other issues of interest. If I need to communicate with my family members while at work, I will text message them on my mobile phone or send an e-mail.

I am a dual-career and financially independent woman, combining motherhood and work at home with an academic job. In making decisions on small matters pertaining to the family I do not feel the need to consult with my husband. I bought my own car and like my mother, I drive to my office. Due to the expense, we do not have a maid at home so the house-chores are carried out together with my husband. Together we clean the house, water the garden, feed the children and do the laundry. My day starts every morning at six o‟clock just like Mak. I take my sons to Cik Lela who is a relative, to take care of them while I am working. We have to leave early to avoid the traffic jam that normally starts around seven o‟clock. I have to be in my office by eight thirty at the latest because most of my lectures begin at nine o‟clock. Either my husband or I will collect the children from Cik Lela at six o‟clock. By then she will have fed them and spent time teaching them to read.

During the week days, I rarely cook. Cik Lela prepares some food for us to be eaten at home. Once in a while, my husband will buy pre-packed foods and bring them home. On Saturdays and Sundays, my husband and I normally spend our time visiting other family members. We also play computer games and go to the movies with the children. I also spend time doing e-mails, chatting on the computer and surfing the internet at home while the children are sleeping.

Like Mak, I also adopted the family-planning programme.38 As a working woman, I have to juggle my roles of wife and worker simultaneously. This is not an easy task and I find in many circumstances it is stressful. Therefore, I prefer to have a

38 My mother and I adopted different contraceptive methods. My mother took the contraceptive pills whilst I preferred IUD. 83 small family so that I can spend more quality time with the children. In addition, both my husband and I frequently travel outside KL to attend meetings, training or conferences. My husband is very supportive in regards to the family-planning. He accompanied me to the hospital and helped me to decide on the best methods to use.

During my confinement periods, my husband looked after me and the babies with the supervision of Mbah and Mak. The adherence of pantangs after childbirth is strongly observed in my family. Although I used the doctor‟s prescribed medicine I also took jamu in the form of capsules and I had my body massaged to boost my health after childbirth.

I decided to study for my PhD away from my home with my husband‟s permission and full support. He voluntarily stays with the children and takes care of all of their needs with the help of Mak, my mother in-law and Cik Lela. On the school holidays, my husband and children have visited me. My husband has given me the freedom to pursue my career in a way that is quite different from the traditional patriarchal approach to gender relations in Malaysia.

My story and that of my mother and grandmothers illustrates to some extent how

Malay women‟s roles have changed across the different eras. My family‟s stories are not typical of all Malay families, but they are used to illustrate the manner in which women‟s lives remain central to the social and economic production of the family unit, while changing from more manual work to more specialised work. These changes were influenced by increased urbanisation, educational attainment, economic status and media exposure and I will these points further in the chapter and throughout the thesis.

My mother and I, like most of the women who participated in my study, work in either the public or private sectors. At the time of my study most of the women I interviewed held important positions in their offices. However, as my study illustrates, Malay women‟s changing roles and achievement have generally altered women‟s role in the

84 domestic realm.39 Women‟s role, especially in the post-Independence era, has not been confined to managing the needs of the family. Rather it has moved to help generate the economy of the family as well as the nation, and women have worked alongside their husbands in creating the Malaysia that exists today (Abdullah, Mohd Noor & Wok

2008; Mohd Noor 2006). The changing roles of urban Malay women indicate that the ways they perceive themselves, their identity and place in the larger society has changed as well. With regards to my thesis, these changes reflect the increasing acceptance of

Western influences. This discussion is particularly pertinent to the ways that urban middle class Malay women approach menopause, ageing and femininity.

In general, Malaysian women have experienced a tremendous change over the past 50 years. They have made significant progress and participated actively in all aspects of development programmes available to them in the country. Increasing urbanisation and industrialisation, wider access to education, employment opportunities and better health-care facilities have a profound effect on contemporary Malay women‟s status and roles. These aspects are elaborated later in the chapter under the headings women in the workforce and women in education. Changes that have taken place in the sociocultural environment reflect changing societal views of women. In addition, there are also several laws that have been enacted to protect women‟s rights and improved status. Indeed, Malay women, together with the Chinese and Indian women in Malaysia, have made a major contribution to many aspects of nation building, particularly in key areas like education, economics, politics and health.

Malay women have traditionally been economically dependent on their husbands and they were entirely responsible for looking after the family needs

(Laderman 1982; Strange 1981; Swift 1965). However, this was and is not always the

39 My husband and I are an example of this scenario. Both of us work together to manage the children and domestic chores. Spousal role sharing of domestic work is more of a generational phenomenon. Some young working couples in Malaysia that I know today have taken the responsibility to send and fetch their children from school or the day care centre as well as doing some cleaning and cooking. Nevertheless, others prefer to hire maids to help them with the house chores. 85 case especially for women in Kelantan and Negeri Sembilan. Raybeck (1985) found that women in Kelantan were actively participating in small businesses selling agricultural products in the markets. Additionally, in the Minangkabau society of Negeri Sembilan, padi planting was women‟s responsibility (Manderson 1980; Stivens 1994). So the situation is more complex than what it would seem. Women in various places were required to work inside and outside of the home. In the period 1400 to 1970s women, together with their husbands and families, mainly lived in kampungs (villages) and were involved in agricultural work (Ariffin 1992; 2000). Currently, the scenario has changed dramatically due to the increasing formal education of women which means they are increasingly able to earn more in more recent times than from working in the agricultural sector. Among the factors that have influenced women to migrate to urban areas are greater employment opportunities particularly in the manufacturing sector, the potential for a higher income, improved communication and infrastructure and better quality of health care (Ariffin 2000). They are found actively participating in more formal roles; occupying higher positions and are involved in decision-making in large organisations and institutions (Sim & Ling 2003). Sim and Ling (2003) reported that women‟s participation as professionals and managers in accredited or licensed professions had increased. This can be seen where women accounted for more than half

(52.1%) the number of professional lawyers and managers in legal work in 1994 compared to 36.8% in 1983. There was also an increase in the percentage of women in the engineering sector. In 1983, women engineers constituted only 4.3%. The percentage had increased to 10.9% by 1994. Interestingly, while they have changed in many ways, Malay women still adhere to their traditional religion and the traditional values of adat. I will discuss this in more depth later in the chapter where I argue that urban middle class Malay women have reworked adat in an adaptive way that makes it more relevant to today‟s society and their own needs.

The remainder of this chapter is divided into four sections. The first two sections are devoted to a historical overview; in the first section, I will describe something of what it was like for Malaysian women in the colonial age. During this period,

Malaysian women in general worked in jobs that were created according to their ethnic group. In the second section, I will highlight some changes experienced by Malay women after Independence as well as giving an overview of the current scenario, with particular emphasis on women‟s changing roles and status in Malaysia in the early

2000s. Thirdly, the issue of beauty and femininity, religious belief and customary law as they relate to Malay women will be discussed. Lastly, I will consider how historical changes have led urban Malay women to a particular point in time when they are challenged by increasing demands which include combining work in the home and office and maintaining traditional values while taking on Western standards of beauty and femininity. Overall, this chapter serves as a contextual background for the thesis by focussing on the changing roles of Malay women over different periods of time.

Women in Malaysia: a historical view

In general, Malay women have experienced a significant change especially in their roles in the past few decades. Nowadays, Malay women have to balance between their typical role as a mother and wife, and at the same time maintain their position in the workforce. Although women in general have multiple roles, Duxbury and Higgins

(1991) have indicated that many women have accepted the fact that the mother role is still the primary role because the traditional role expectations toward women are still strong. I believe this general finding could also be applied to Malaysia where the emphasis upon motherhood is strong (Stivens 1998; Whittaker 2000). In the following section, I break the discussion into three periods; the pre-colonial, colonial and the time after independence to reflect women‟s changing roles in three periods of time. These periods, to some degree have reflected my previous account of my maternal and 87 paternal grandmothers, my own mother and me. While my thesis principally considers urban middle class Malay women, some of the following discussion relates more generally to women in Malaysia. At times, I use statistics for Malaysian women as there are none available for Malay women alone. However, the statistics that I have chosen to illustrate my points in this chapter will give some indication of the general trends and will be relevant to the discussion of Malay women.

Malay women in the pre-colonial age

The exact date of what is known as the pre-colonial age is not known. The abundance of historical records about Malay society indicate that the time is likely to start around 1400 where Parameswara was said to be the founder and first ruler of the

Malay Empire of Malacca until the fall of the empire to Portuguese in 1511 (Kennedy

1962).

At that time class was a major issue in Malaysian society. The society differentiated between the ruling class and the commoners. Class also defined the roles of men and women as well as determining their position in the society. In a traditional

Malay society, there was no „recognizable entrepreneurial class with a specific ideological bent or an existential style‟ (Chee 1983, p. 28) and the existence of the middle class came much later in time. The Malay traditional community was divided into two; the raja (ruling class) and the rakyat (commoner class) (Swettenham 1942;

Winstedt 1961). The ruling class consisted of the royal and noble families while the commoners were the village folks who worked as traders, orang berhutang (debt- bondage serfs) and hamba (slaves) (Ariffin 1992). The distinction between the two classes was based on „birth and clearly demarcated by custom and belief‟ (Roff 1967, p.

4). Women in the various class groups played different roles in the social, political and economic sector. Women in the ruling class were confined to domestic tasks like looking after the children in order to socialise them to fit into the social structure of the 88 society (Ariffin 1992). They were segregated and did not appear in public; unlike the commoner class of women who mixed around in markets, fishing villages and padi fields (Winstedt 1961). Women from the ruling class functioned as „adornment or source of entertainment‟ (Ali 1975, p. 62). Some women in the royal court were presented to other rulers as a gift or symbol of friendship. For example, Tun Teja the princess of Pahang was given to Sultan Mahmud Shah (1488-1528) to be his consort. In contrast, women in the commoner class actively participated in the economic sphere, in addition to their roles as wives and mothers. Peasant women, who worked in the padi fields for instance would weed, winnow and harvest the crop, while women in the fishing village, dried and processed the fish and mended the fishing nets.

Women‟s participation in political life was very limited. However, it was women in the ruling class that indirectly „foster[ed] better political connections with other kingdoms through marriages‟ (Ariffin 1992, p. 2) around the Malay-Archipelago.

In the Malaccan Empire for example, only Tun Fatimah the consort of Sultan Mahmud

Shah (1488-1528) was known as a warrior who helped to fight against the Portuguese invasion in 1511 together with her husband. After the war, she created an alliance with other kingdoms in the Malay-Archipelago by marrying her children to the rulers.

Since the peasant women did not have any access to the political sphere, their main participation was within the peasant economy. The peasant women who were economically dependent on their husbands worked together with them in the padi fields whereas the women in the fishing village helped their husbands to dry and process the fish. Indeed, peasant women‟s position at this stage was to complement their husband‟s job rather than simply being subjugated to them. During this period, the peasant women juggled their roles in the domestic sphere and in economic activities. Summing up the situation, it is apparent that the role and status of Malay women during this period was

89 clearly marked by social stratification. The types of job and social status they had were factors which differentiated them as belonging to one class or another.

Malay women during the colonial age

The colonial age in Malaysia begins in 1511 and continues through to 1957. The main interest of the Portuguese and Dutch at that time was trading (Winstedt 1962;

Kennedy 1962). The Dutch made treaties in trading with the local rulers. In general, they were not interested in interfering with the social and cultural lives of the people

(Abdullah 2003). Perhaps the most significant change for women during this time was the introduction of formal education for women, which happened during the British occupation in Malaya from 1874-1946.

The British occupation in the 1870s brought „a real change in the lives of the community‟ (Ariffin 1992, p. 5). Colonial rule was one of the most powerful agents of change in Malaysia. It has left its mark on Malaysia in many aspects – in its economic development, its multi-racial communities, educational and legal system, constitutional and administrative structure and individual culture (Gullick 1981; Ryan 1971). The influx of Chinese mining workers brought into the country by the British, and the

Indians in the rubber estates, has dramatically changed the socio-economic and political structure of the Malayan society (Ariffin 1992; Kim 1991). During the British occupation, they successfully implemented the „Divide and Rule‟ policy in order to segregate the three main ethnic groups from one another (Ariffin 1992). As a result of the segregation, Chinese immigrants were largely working in the tin mines and lived in the cities, the Indians in rubber estates, and the Malays in their kampungs were engaged in subsistence agriculture, firmly tied to padi production and the fishing sector (Firth

1966; Hodder 1959; Milne & Mauzy 1986).

Again, Malay women from the commoner class were more integrated into the economic life of the village and engaged equally with men in the economic activities. 90

Other studies among the Malays have shown that Malay women from the commoner class still played a fundamental role in the traditional agricultural economy (Milne &

Mauzy 1986; Manderson 1979). Studies by Strange (1981) and Raybeck (1985) found that Malay women on the east-coast were traders and agriculturists; selling foodstuffs and other goods produced by them or purchased from other traders in a larger city to be resold locally. The Chinese women who migrated to seek a living, worked as dulang

(tray) washers in the tin mines while the Indian women were recruited as tappers, weeders or factory workers in the rubber processing factories (Kaur 1986; Ariffin

1992). Malay women who largely lived in kampungs were employed in the agricultural sector. Based on the above description, the British policy has successfully divided women‟s work along lines of their ethnic affiliation.

The British political and social policies at the time stimulated various activities and programmes which were alien to the Malaysian inhabitants. Lady Peggy Templer, the wife of a British officer, initiated the Women‟s Institute in Malaya to attract women to expand their activities while at the same maintaining their domestic roles (Raja

Mamat 1991). Through this institution and the assistance of some Malay women who graduated from the Malay Women‟s Training College the awareness of getting women educated was promoted. The political movement initiated by men who struggled for

Independence from the British led some women to form the Kaum Ibu (literally

Mother‟s Group) movement to assist the men. The significant role of Kaum Ibu will be elaborated further in the following section. Indeed, women‟s participation in Kaum Ibu has indicated a degree of readiness to perform non-domestic jobs outside their homes and to gain some influence within the society.

Malay women in the post-Independence age

After Malaysia gained its Independence in 1957, there was an attempt by the government to involve women in many sectors. From my observations of their efforts and achievements, women have been recognised, now as a potential source for development within the nation. Malaysian women today are widely acknowledged as having pioneered many initiatives that have addressed issues, with specific emphasis on the legal, social, political, religious, economic, educational, health and cultural areas of public society.

In Malaysia, prior to 1980 little attention, in regards to policy making or legislation40 was devoted specifically to women (Mohamad Diah 2001). The only important statement that I noticed that reflected the Government‟s view on women vis-

à-vis the development process during this period is found in the Third Malaysia Plan

(1976-1980), which reads as follows:

the role of women in society has become an increasingly important factor in both the developed and developing countries. The active participation and contribution of women in development outside the family circle is no longer saddled by prejudice and traditional conservatism… The contribution of women to the evolution of a strong and self-reliant society in Malaysia needs to be appreciated and taken into consideration in the agenda for rapid development progress (Economic Planning Unit 1976, p. 105).

40 Previously, there was no definite policy which addressed women‟s need in the national agenda of development. Women were involved previously but most often in informal and „officially unrecognised‟ ways. In the First Malaysia Plan (1966-1969) the National Population and Family Development Board (NPFDB) was responsible for co-ordinating all aspects of the Family Planning Programme. Apart from this, the pro-natalist policy of the Malaysian government to ensure five children in each family was also implemented. The aim of this policy was to increase the population up to 70 million. This policy has created incentives like income tax rebates and longer maternity leave for women. It was in 1989 the NPW was formulated to fully integrate women into development programmes. Apart from NPW, the National Social Policy (NSP) was also another attempt to incorporate women in development agenda. The objective of NSP was to ensure every Malaysian, man and woman regardless of ethnic background, culture, religion and economic status was able to participate and contribute in national development and enjoy gratification in life. Recently, the government has agreed to implement a policy requiring 30 percent of women at decision-making positions in the public sector. The government is hoping the same policy will be implemented in the private sector too. 92

This statement was insufficient to project the government‟s attempt to integrate women into development process. Therefore, in 1989 the National Women Policy was formulated by the government with two objectives (Secretariat for Women Affairs

1995) in mind:

1. To ensure equality in obtaining resources, information, opportunities in participation and development for both men and women. Equality objectives and equity must be made based on a development policy that is people-oriented, so that women (whose composition is about half of the total population) can contribute and achieve their highest potential.

2. To integrate women in all sectors of national development in line with the ability and needs of women to improve the quality of life, to eradicate poverty, abolish ignorance, illiteracy and to achieve a peaceful, prosperous and happy nation.

The crux of the policy was to guarantee that every woman in Malaysia would be able to contribute actively and equally in the society as well as benefit from the national development. Following the formulation of NPW, it was in the Sixth Malaysia Plan

(1991-1995) that the „Women in Development‟ chapter was included:

The Government has long acknowledged the significant contribution by women to overall national development. As such it has actively and consistently promoted the participation of women through facilitating their access to social, economic and political opportunities. The formulation of the National Policy for Women (NPW) reflects the Government‟s commitment towards optimizing the potential of women in the social and economic development of the nation (Economic Planning Unit 1991, p. 413).

The inclusion of this chapter seemed to be in line with the Government‟s earlier move to formulate National Policy for Women (NPW) in 1989. Since then, various government and non-government agencies have devised more development programmes for women ranging from macro plans to action-oriented programmes for women.41 The

41 Poverty eradication is one of the government‟s programmes to help women to earn more income through various micro-credit schemes, for example Amanah Ikhtiar Malaysia (AIM), Majlis Amanah Rakyat (MARA) and Small-Medium Enterprises (SMEs). These income-generating schemes not only assist women in self-employment, but also give them a feeling of self-confidence, respect and elevation in their status as well as the ability to make decisions. 93 following sections will elaborate the scenario of women in key areas: economic, education, politics and health.

Women in the work force

Malaysian women have undoubtedly always contributed substantially to the economic sector, but this has become more obvious in recent times. Since the 1970s, the changes brought about by industrialisation have resulted in many rural Malay women migrating to work in the urban areas (Ong 1987). From 1970 to 1995, the manufacturing sector recorded the highest growth of 39 percent of employment rate in general. Between 1990 and 1994 the manufacturing sector has created about 0.6 million jobs and in 1994 alone it has provided employment to 1.9 million people (Ministry of

International Trade and Industry 1995). The growth of the manufacturing sector has indeed led to the mobilisation of female labour and increased in employment with about

46.4 percent in 1990 and 43.4 percent in 1995 of female workers.42

One of the most significant reasons that contributed to the increase in the workforce participation has been the government policy known as the Investment

Incentive Act which focuses on the export-oriented industries (Ariffin 1992). This act has encouraged foreign investor to come to Malaysia to expand their businesses and at the same time to provide employment opportunities for the people. There are two Free

Trade Zones operating at that time – one at Bayan Lepas, Penang and another at Sungei

Way, Petaling Jaya. The export-oriented industries particularly in electronics, food processing, plastics, textiles and garment have generated many job opportunities for the

Malaysian people (Raja Mamat 1991; Ariffin 1992). There was an influx of multi-

42 The inclusion of women in such numbers in the manufacturing sector is quite different from countries like Australia, where there are very few women employed in this sector. Based on the Australia Yearbook 2001 availbale from http://www.abs.gov.au/AUSSTATS/[email protected] [accessed 17 April 2007] data has shown that only 27 percent of Australian women are involved in the manufacturing sector. 94 national companies into Malaysia in the 1970s (Kean 1986). This scenario has linked the Malaysian market to international markets, thus expanding the demand for a domestic labour force in the industrial sector (Ariffin 1980). The scenario of young rural female Malay women migrating to urban areas in the 1970s and 1980s indicates a change in the previous established societal norms against the movement of unaccompanied young women (Karim 1987; Ong 1990). These women migrated to improve their standard of living, achieve individual freedom and remit money home

(O'Brien 1983; Strange 1981). By contrast, the Chinese women were employed in factories or worked in their family small businesses (Gullick 1981).

Due to the employment opportunities created by industrialisation, the role of women has undergone some changes. In a typical urban Malaysian family today, a mother has to juggle between paid work and managing the family. A grandmother is often a child-care provider and provides social support for her daughter‟s family and unmarried daughters are expected to work outside the home (Mohd Noor 2006; Nagaraj

1995). However, the number of women working in the agricultural and manufacturing sector has decreased dramatically (see Table 2).43 As more Malaysian women become educated, they prefer to work in the professional and services sectors due to better remuneration and added benefits (Sim & Ling 2003). It is evident from the table that there has been also an increase in the business and public administrative sector.

43 Data from Table 2 shows the percentage for Malaysian women in general. Due to government policy and ethnic sensitivity, some statistics did not report specifically on a particular ethnic group. I found some statistics are not comprehensive and may be biased therefore they were not included. 95

Table 2 Percentage distribution of female labour force by sector.

Sector 1970 1980 1991 2000 2005 Agriculture, Forestry, Livestock and Fishing 58.9 49.3 28.2 11.9 9.0 Mining and Quarrying 0.8 0.3 0.2 0.2 0.1 Manufacturing 8.5 16.3 24.3 33.5 31.7 Construction 0.5 1.0 0.7 1.5 1.4 Electricity, Gas and Water 0.1 0.1 0.1 0.2 0.3 Transport, Storage and Communications 0.5 0.7 1.5 1.8 2.4 Wholesale and Retail Trade, Hotels and Restaurants 5.3 11.2 19.7 22.1 25.0 Finance, Insurance, Real Estate and Business Services 0.5 1.6 3.9 6.1 7.8 Community, Social and Personal Services; Public Administration; Other Services 16.4 19.5 21.4 25.8 28.6 Source: Census of Population and Housing 1970, 1980, 1991, Labour Force Survey 2000 and Ninth Malaysia Plan (2006-2010).

Since Malaysia gained its independence in 1957, women‟s entry to the paid labour force has been dramatic, from 30.8 percent in 1957 to 46.7 percent in 2000

(Economic Planning Unit 2001). However, men are still principally the participants in the paid labour force. Similarly in Australia, data from 2006-2007 showed that the employment population percentage was higher for men than women (72.2 percent compared with 57.6 percent).44 There are three factors that help explain the increase in women‟s participation in the paid workforce in Malaysia: (i) greater educational opportunities for women, (ii) implementation of the New Economic Policy (NEP)45 in

1970 by the government and (iii) the rapid economic development and industrialisation which provided jobs for women especially in the electronics and textile industries

(Kementerian Pembangunan Wanita Keluarga & Masyarakat 2003).

In the past few years, Malaysian women have made significant progress in securing jobs in higher paying occupations. To illustrate my point, I am using data from the various sources (see Table 3) that gives a clearer breakdown of women‟s

44 Data available from http://www.abs.gov.au/AUSSTATS/[email protected] [accessed 18 April 2007]. 45 The NEP was formulated in 1971 after the 13 May 1969 racial riot in Kampung Baru, KL. The main objective of NEP was to reduce the economic disparity among the Malays, Chinese and Indians. This policy is also regarded as a tool to unite the three major ethnic groups thus creating unity and harmony among them. 96 involvement in various occupational categories. Examining the percentages in Table 3, although in some occupational category men outnumbered women, it is interesting to see that there is an increase of percentage of women in the professional and technical, clerical workers as well as services and sales workers categories.

Table 3 Percentage distribution of employment by occupation and gender.

Occupational 1957 1970 1980 2000 Category Males Females Males Females Males Females Males Females % % % % % % % % Professional & 71.8 28.2 66.1 33.9 61.8 38.2 55.4 44.6 Technical

Administrative 98.0 2.0 96.9 3.1 91.7 8.3 79.8 20.2 & Managerial

Clerical 92.6 7.4 74.7 25.3 56.7 43.3 42.3 57.7

Sales Workers 90.1 9.9 81.8 18.2 75.2 24.8 62.3 37.7

Service 79.2 20.8 68.2 31.8 67.9 32.1 50.5 49.5 Workers

Agricultural 66.9 33.1 61.5 38.5 62.6 37.8 73.7 26.3 Workers

Production 88.9 11.1 83.4 16.6 78.4 21.6 76.0 24.0 Workers

Total 75.5 24.5 67.4 32.6 68.0 32.0 65.3 34.7 Sources: Census of Population and Housing 1957, 1970, 1980 and Labour Force Survey 2000

The number of senior officials and managers has increased from 4.8 percent in

2000 to 5.4 percent in 2005. The growth of women in the professional occupational categories remained slow from 7.2% in 2000 to 7.5% in 2005. Nevertheless, there has been a reduction of percentage in the skilled agricultural and fishery, plant and machine operators and assemblers as well as in the elementary occupations. Women in the services occupation category have increased from 13.3 percent to 17.7 percent in 2005.

One of the reasons that explains this occurrence is that more Malaysian women have now obtained higher-level skills from their education and training, and as a result, they prefer to avoid jobs that require little formal training (Sim & Ling 2003). Unfortunately, 97

I was not able to find data on women‟s income distribution in the work force. But, from the available data in Table 3 it can be deduced that the income earned by women has also improved significantly with the increased involvement of women in higher paying occupations. On the average, the women participating in my study who I interviewed earned an income between RM2,500 to RM3,500 per month.46

In urban Malaysia, most women work on a full-time basis either in the public and private sector until their retirement age which is 55 years old. This situation is different from Australian women, for example, who work either on a full-time or part- time basis. Interestingly, in the age category of 45-55, I found 41 percent of Australian women worked in a part-time job.47 Women who participated in my study were in the workforce on a full-time basis. They mainly worked in the public sector as senior officials and administrators. As I will elaborate in the next section, the women in my study who entered the labour force had completed Certificate, Diploma or Bachelor

Degree. While most of my participants obtained their degrees from local universities, only one participant graduated from an external university (Adelaide, Australia).

Women in education

There are two important factors that improved Malaysian women‟s social status: level of education attainment and increased participation in the work force (Raja Mamat

1991; Mohd Noor 2006). Agreeably, education has provided women with access to jobs

46 In Malaysia, there is a difference in the distribution of monthly wages between males and females who perform the same tasks especially in the private sector. Ahmad (1999) found that males earn more than female particularly in the agriculture and manufacturing industries. However, in some jobs, women earn more than men. For example, in the manufacturing sector, a male accountant is paid RM3342.35 and female RM2861.37 monthly. A male marketing manager earns RM3247.22 whilst female earns RM2372.21. In other jobs like system analyst, female earns more than men RM2563.00 and RM2402.00 respectively. Similarly, female material planning officer receives RM891.02 compare to male who only receives RM751.02 per month. For those who work in the public sector, monthly income is based on the wage grade scale (for example Grade D for teaching and Grade N for administration/clerical). The majority of my participants are in Grade N. However, some participants earn lesser income than their husbands (some husbands are businessmen and others are directors in the organizations) and some participants receive similar income because they are in the same wage grade scale. 47 This figure is available from http://www.abs.gov.au/AUSSTATS/[email protected] - Labour Force, Australia (cat 6291.0.55.001) [accessed 17 May 2008]. 98 outside the house and consequently to economic independence (Ong 1990; Kaur 1986).

The higher the educational level, the better work options and the status of women will be. In the past, Malay peasants generally did not send their children to school. Children were expected to help their parents in the padi fields and fishing villages. Girls were taught household skills and crafts which helped them fulfil their traditional roles in the domestic domain. Only the aristocratic class and the emerging middle class had the opportunity to receive an education. Even in schools these girls were taught subjects related to the traditional roles of women, mainly crafts and domestic skills (Mohd Noor

2006; Ariffin 1992). It was only after World War II that parents realised the importance of education, and the need to get their children educated has brought significant change to the number of students attending schools (Raja Mamat 1991). The importance of education was seen in both my grandparents‟ and my parents‟ generation. When the

British came to Malaya and introduced English Schools, it was viewed negatively as parents feared the teachers who were missionaries would convert their children to

Christianity (Razali & Yusoff 2003). Malay parents sent their children either to religious or Malay schools. Parents preferred Islamic education particularly for their daughters. Religious education is seen by Malay parents as an opportunity to become a respected individual. Most important, being educated through religious education is one of the characteristics that make a woman a desirable wife in Malay society (Razali &

Yusoff 2003; Omar 1994). I will elaborate on this point later in this chapter and throughout the thesis as the fulfilment of religious duty forms a Malay view of femininity. This is important in relation to my study as Malay women now receive conflicting views about femininity. On one hand they are socialised to believe in the importance of religious education and obligation, and on the other hand they are exposed to Westernised media oriented views of femininity and sexuality.

Since 1980, there has been substantial expansion in educational opportunities in

Malaysia. More women are found to be participating actively in the educational sectors as teachers. For instance, the number of female teachers in secondary schools increased from 74,753 in 2001 to 87,989 in 2005 (Department of Statistics Malaysia 2006a). In

2005, there were 33,271 female graduates in universities compared to 17,718 male graduates (Department of Statistics Malaysia 2006a). UNESCO reported that the literacy rate for Malaysia which stood at 80 percent for men and 64 percent for women in 1980 has increased to 93.9 percent and 89.1 percent respectively in 2006.48

The women in my study each spent time in pursuing education for more than twelve years. They received the necessary training and skill to undertake various kinds of jobs that previously were not suitable for them, for example in finance, management, engineering and the legal sector. As consumers and providers of education, Malay women, at least those in the urban areas, have successfully penetrated the so-called male-dominated occupations due to their achievement in education.

Women in politics

Previously, for most Malaysian women, participation in politics was not seen as a duty or an option. There was little effort made to inspire in them the need to do so.

Five factors have been noted (Wan Ismail 2002, p. 2) that hinder women from becoming actively involved in politics. They are (i) subliminal discrimination against women, (ii) time constraints, (iii) the notion that „a woman‟s place is at home‟, (iv) less motivation and aversion to political involvement; and (v) lack of adequate resources.

According to Kim (1994), World War II was an important turning point in the politicising of women in Malaysia. However, it was not the war that opened up new

48 Available from UNESCO Institute of Statistics website at http://stats.uis.unesco.org/unesco/TableViewer/document.aspx?ReportId=124&IF_Language=eng&BR_C ountry=4580&BR_Region=40515 [accessed 17 February 2007]. 100 values, but rather that „men found it necessary to mobilise the support from the women in order to achieve their political goals‟ (Kim 1994, p. 4).

In the political arena, Malay women‟s actual participation has been more prominent than Chinese and Indian women (Ariffin 1992; Pathmanathan & Partiban

1994; Chu 1994). Malay women who have been actively involved in politics come from the educated Malay elite group. The educated Malay elite group of women studied in

English schools and were exposed to Western ideas of female emancipation (Ariffin

1992; Roose 1963). They began to play a vital role in the public domain. The English- educated women like Kontik Kamariah, Ibu Zain and Salmah Ismail (the first female

Malay doctor) were among the few Malay women who were previously involved in politics. Though the Malay women play a small role in the policy-making at the level of political parties, they participate by attending meetings and gatherings, though they

„provide minimal input‟ (Milne & Mauzy 1986, p. 114). Despite their minimal involvement in politics, women are responsible for organising meetings and distributing pamphlets in the villages to generate political awareness among other women and work actively as fund-raisers to support their political campaigns (Manderson 1980). At the national level, Manderson49 reported that Pergerakan Kaum Ibu UMNO (literally

Mothers Group Movement) was established to „serve as a support section to the men‟s organization‟ (Manderson 1980, p. 56). This group which was formed in late 1945, expressed opposition as well as assisting the men in anti-Malayan Union rallies (Dancz

1987). The formation of Kaum Ibu is:

1. to encourage its members in the fields of politics, education, particularly domestic science, culture, tradition, sports, social activities and religion 2. to encourage its members to work actively for social progress 3. to co-operate with any recognized women‟s organization (UMNO Constitution 1960 Article XXV: Women’s Movement quoted in Manderson, 1980)

49 Lenore Manderson‟s book entitled Women, politics and change: The Kaum Ibu UMNO, Malaysia 1945-1972 was written based on her Doctoral dissertation. She discussed in detail how social, economic and political participation of Malay women have affected their lives. 101

Many housewives who were in their middle-age joined Kaum Ibu. They were not among those with high education. Within Kaum Ibu, these Malay women had the opportunity to act as leaders which was not open to them elsewhere. Malaysian women who participate in politics today have several reasons that help explain their motivations for becoming involved in politics. These differ from the traditional male motivations.

They have a broader view of their role and attempt to redress inequalities in the power structure (Nagaraj 1995). Today, the number of Malay women who participate in politics is still low. Hence, in 2000 Puteri UMNO (another woman‟s wing of UMNO) was established to attract more young Malay women between 18 to 40 years old to become involved in political debate. The 2008 general election has yielded interesting results. The number of women ministers in the cabinet line-up is only two and there are only four women deputy ministers.50 To describe women‟s political apathy, Kim (1994) said:

For most Malaysian women, overt and active participation in public affairs was not seen as a duty. Little had been done to instil in them the need to do so. At any rate, mingling with sexes was largely frowned upon. There were of course, a small number of women who were less prone to submit to social decorum. Their behaviour was disapproved by both men and women.

It is evident from my participants‟ demographic profile (see Appendix I) that most of them work in professions that are apolitical. There are various reasons to explain this situation. Like Wan Ismail (2002), Kew (1994) found that factors such as women‟s negative perception about politics, heavy workload and lack of incentives have de- motivated women and prevented them from joining political parties. Perception that politics is the „men‟s affair‟ is still strong (Kew 1994) and this is evident from

50 The 2008 general election yielded only one Malay woman and one Chinese woman appointed as ministers. There are four Malay women and one Chinese woman who occupy the deputy minister positions, whereas there is no Indian woman representative in the new cabinet line-up. 102

Malaysian data where women only occupy a small percentage of the Parliamentary seats.

Women’s health status

Malaysia has made an impressive improvement in the standard of living accrued to women following Independence in 1957. The health condition of women is a good indicator of women‟s status and it helps in explaining their active participation in the economic and social development of Malaysia. Malaysian women today are healthier, live longer and enjoy a better quality of life as compared to women who lived in the

1950s. Based on the 2004 Population Census, the average life expectancy of Malaysian women continued to improve from 75.2 years in 2000 to 76.5 years in 2007, compared with 70.3 years and 71.8 years, respectively, for men (see Table 4).51

Table. 4 Male and female life expectancy, Malaysia (1991-2007).

1991 1993 1995 1998 2000 2002 2003 2004 2007

Male 69.2 69.4 69.4 69.7 70.3 70.4 70.6 71.7 71.8

Female 73.4 73.8 74.2 74.7 75.2 75.3 75.5 76.1 76.5

Sources: Vital Statistics Time Series Malaysia (1963-1998) and Statistics Handbook Malaysia 2002, 2003, 2006.

The increase in life expectancy at birth in developed and many developing countries is because of the low death rate at all ages. Improvement in living conditions like better sanitation and water supply, increase in nutrient intake, access to quality health services, health education and advances in medical technologies have contributed to the reduction of the mortality rate.

51 In 2008, Australia male life expectancy at birth is 78.7 and 83.5 for female. Data derived from Year Book Australia 2008 available from http://www.abs.gov.au/AUSSTATS/[email protected] [accessed 17 May 2008]. 103

In the early 1950s, mortality was high and diseases like malaria, cholera and rabies were rampant in the society. The health condition among the Malays, Chinese and Indians was very poor at that time. Manderson (1992) reported the health care condition in Malaya was poor due to lack of access to medical services and inadequate maternal knowledge rather than environmental and sanitary conditions. Thus, these conditions have contributed significantly to high mortality and morbidity rates at the time. One of the direct indicators of reproductive health of woman is the maternal mortality. After 50 years of Independence, the maternal mortality rate has decreased significantly - more than tenfold to 0.3 per 1,000 live births (Kementerian

Pembangunan Wanita Keluarga & Masyarakat 2003). The expansion of reproductive health services to the rural areas and the introduction of health-care programmes were pivotal in decreasing the maternal mortality rate. In addition, better control over infectious disease was also seen as a contributing factor to the reduction of maternal mortality rate (Ministry of Women and Family Development 2003). Likewise the Total

Fertility Rate (TFR) has dropped from 2.6 in 2002 to 2.4 in 2006 (Department of

Statistics Malaysia 2006b).52 The decline in TFR has been linked to increasing participation of women in education and the paid labour force, preference towards smaller family size, lifestyle choices and greater access to contraceptive measures.

The Family Health Programme which was introduced by the government in

1996 emphasised two aspects of women‟s health: namely the health of the family which comprise maternal and child health, immunization, family planning, the early detection of cancer, and nutrition; and secondly, diseases affecting women particularly HIV/AIDS

(Economic Planning Unit 2001). Since the initiation of a „family planning programme‟, the number of new family planning users from 2001-2005 has increased from 42 to 48

52 Australia TFR has dropped from 2.9 babies in 1966 to 1.79 in 2005. Again, I obtained these figures from Year Book Australia 2008 available from http://www.abs.gov.au/AUSSTATS/[email protected] [accessed 17 May 2008].

104 thousand in the rural areas and 30 to 42 thousand for the urban areas (Department of

Statistics Malaysia 2006a). In view of the fact that women have a longer life expectancy than men, and to ensure that women remain healthy throughout their middle-age, specific health education programmes, including the promotion of healthy lifestyles and nutrition, continue to be one of the main agendas of the Malaysian government. In a later chapter I will discuss women‟s health in relation to menopause in detail and will discuss the Malaysian government‟s efforts to educate women and the general public about the health and well being of older women.

Urban Malay women: maintaining Islam and re-working adat (customary law)

In the previous section of the chapter I focused on the changing roles of women, especially as they relate to participation in work-force, education and politics. I have also tried to give some indicators of what life is like for urban Malay women today. In this next section, I consider how urban Malay women combine the challenges of work and family in urban society while maintaining their religious beliefs. Islam has always been meshed into Malay life and personhood to a great extent. As I have indicated in

Chapter One, the importance of adat can be illustrated in the old adage „Biar mati anak, jangan mati adat’ (It is better to let your children die than allow adat to lapse). This old adage refers to the importance of adat in the Malay society. Roff (1967, p. 69) stated that:

For the Malay peasant as for his overlord, custom and religion - adat and ugama (religion) were related parts of the one whole, together ensuring the proper functioning of society and preventing its disintegration.

Islam and adat are the fundamental basis that governs the values and behaviour of the

Malay society. It encapsulates the qualities of wisdom, character, correctness and procedure. The concept of shyness, tolerance, good moral character and sincerity have their roots in Islam (Zamani 2002). Islam and adat further define the socialisation of 105 children which includes the everyday skills they should necessarily learn. Traditionally,

Malay girls learned domestic chores to assist their mothers at home and as a preparation for when they were married. For generations the Malay cultural socialisation within the family, kin groups and villages has substantially shaped the „value perception and value consciousness‟ of Malay people (Chee 1983, p. 7).

In the modern context of a Malay society, I believe, as a Malay woman and anthropological observer of Malay society,53 that adat has become the subject of changes due to rapid industrialisation, urbanisation and Westernisation. One important change is that women are no longer confined to staying at home. This is a practice that no longer holds currency in modern Malay society. More women leave their homes to seek employment to contribute to the household economy and work together with their husbands to provide for the family. Most women no longer restrict their activities at home. Other than that, women today are also doing traditional men‟s jobs, which is further evidence that gender socialization has also changed. Malay women today are working in the male-dominated jobs as engineers, architects, businesswomen and managers. On the other hand, Malay women too are seen frequently going out from home without being accompanied by family members either to work, study or shopping.

Form my personal observation, Malay women too has changed in terms of their attire.

Although they still maintain wearing the traditional attire to certain events like weddings and other formal ceremonies, Malay women too are comfortable wearing pants, jeans and t-shirts. It appears Malay women are gradually embracing the youth and beauty culture which is far more common in the West. In other words, Malay women today exercise a degree of independence and freedom to suit their modern lifestyle. In my thesis, I propose that urban Malay women continue to value and respect

53 My position as an insider anthropologist (as I have emphasized both in Chapter One and Two) has helped to facilitate my research. As an insider to my own community, I am familiar with the adat that governs the life of Malay people. This is an advantage for a researcher like me who undertakes issues relating to adat. 106 adat, but they have re-worked adat in many ways. By re-working adat, I do not suggest that the law is changed but that adjustments and negotiations have been made to allow people to live comfortably in modern Malaysia while respecting and performing the obligations of their religious belief (Ong 1990; Omar 1994; Karim 1992). For instance, more women work in male-dominated jobs, they have become financially independent, delay their marriage, prefer smaller families and are increasingly career-oriented. Due to educational attainment, women‟s attitudes have changed significantly especially towards the importance of education, women‟s changing roles and their ability to contribute significantly to the nation‟s development. These attitudes are the result of the increasing contacts women have with other nationalities and the outside world through various kinds of media. It is through education and employment that women get to know other people from different cultural backgrounds and expand their own aspirations and interests in life outside of the narrow confines of the home. Apart from that, the electronic and printed media have provided much information about what is going on in other parts of the world and at the same time they bring in elements which are new to the people. Internet is one of the strongest tools that connect women all over the world. They can express their views and write comments on their blogs, chat rooms or e-mails. In addition, due to the influence of Western ideas particularly on gender equality, men are nowadays „no longer anxious to exercise their superiority‟ (Roose

1963, p. 292). In other words men are changing too, and for this reason I used the example of my own relationship with my husband to illustrate an increasing gender balance in younger educated Malay people. Urban middle class Malay women in my study claimed that their husbands are more open-minded and have acknowledged the importance of having their wives working outside the house. Thus, today it is not surprising to see Malay women working outside their homes but still maintaining adat

107 and their domestic roles as a „dutiful wife‟54 (Omar 2003, p. 128). The concept of

„dutiful wife‟ will be discussed in detail in Chapter Seven.

Karim (cited in Omar 2003, p. 123) described educated Malay women as

„wanita Melayu moden tetapi beragama dan beradat’ (the modern Malay women who is religious and strongly holds to tradition). Islam allows women to work outside their homes provided they comply with the basic guidelines like maintaining their modesty and chastity (Maududi 1975; Othman 1989). It is evident today based on the urban middle class Malay women whom I interviewed that they still practise Islam as a way of life but at the same time these women have made several changes in their life to meet the challenges brought about by modernisation and Westernisation (I will discuss this later in the thesis). In the remaining chapters of my thesis, I will show the changes that have taken place among urban Malay educated women which have affected their response to menopause. One of these reasons is that many have come to accept biomedical intervention to treat their menopausal symptoms. In this context the medicalisation of menopause must be analysed in the context of the relationship of biomedicine to the processes of colonisation, modernisation and Westernisation. More will be said about this in later chapters in the thesis.

The notion of femininity and beauty from the Malay perspective

As has happened with adat, Malay women have also re-worked traditional ideas of femininity through which they have come to reconceptualise the realities of their lives. There are very few studies on Malay beauty and femininity. I rely on the works of

Omar (1994), Swami and Tovée (2005) and McDowell and Bond (2006) who conducted research on the perception of beauty, physical attractiveness and body image among

Malay women. Omar (1994) emphasized that the concept of femininity in the Malay

54 The concept of „dutiful wife‟ refers to women who fulfil their traditional roles (supervising the running of the household, looking after the well-being of the husband, managing the children, cooking and cleaning) and simultaneously they carry out their religious duties. 108 culture includes both proper attire and deportment. Malay women are expected to dress and behave modestly according to religion and adat. Omar‟s respondents in her study55 defined femininity in terms of being well-groomed, lemah-lembut (graceful), sopan

(modest) and tidak bising (not loud). Using this perspective the character of an ideal

Malay woman is that she fulfils her religious duties, is modest in her behaviour and is fertile.

It is important for the majority of Malay women to look attractive. To enhance their good looks and attractiveness, Ong (1990) found that Malay adat emphasised preserving sexual attractiveness to retain the husbands‟ interest. Previously, many

Malay women drank jamu to boost their health and to appear young and vital. Drinking jamu is strongly recommended especially during the post-partum period to restore the women‟s health, physical beauty and sexual urges (Omar 1994; Laderman 1983; Karim

1992). Today, drinking jamu is very rare except during the post-partum period. None of my participants took jamu to preserve their sexual attractiveness. They claimed that they took jamu only during the post-partum period but not as daily routine. In a later chapter,

I will discuss the kinds of things women do to maintain physical attractiveness and the importance they place on this attractiveness during the menopausal period of their lives.

Swami and Tovée (2005) conducted a study on perceived physical attractiveness among females in Britain and Malaysia. They recruited 682 participants from both countries and women were asked to rate a set of preferred images of women. The study discovered both British and Malaysian women preferred a low Body Mass Index (BMI) of about 20-21kg/m2.56 Malaysian women who resided in the urban areas of Malaysia preferred images of women with lower BMIs compared to Malaysian women who live

55 Omar conducted an ethnographic study among rural women in a small village in Malacca. Her study focuses on women‟s perception and experience about their reproductive cycle from menarche until menopause. 56 BMI is a formula to assess an individual‟s body-weight relative to height. It is also a way to measure fatness. According to WHO categorization, a BMI of less than 18.5 is considered underweight, healthy weight is a BMI of 18.5-24.9, overweight is 25-29.9 and obese is 30 and above. Available from http://www.who.int/bmi/index.jsp?introPage=intro_3.html [accessed 12 May 2008]. 109 in rural areas. Swami and Tovée postulated that the preference of lower BMI by

Malaysian women is influenced by the media who portray images of slim physique, an image which is also preferred by most Western women.

Similarly, McDowell and Bond (2006) who focused on the study of negative body image found that the impact of Western messages of thinness has influenced

Malay women‟ and that these messages have been disseminated largely through the media. McDowell and Bond compared body images of three cultural groups, Malay,

Samoan and Australian. Their findings showed that Malay women preferred the slim physique similar to the Australian women who participated in the study. Samoan women on the other hand, showed little preference towards slim physique because their culture prefers the endomorphic body type. Both researchers also studied the weight- related behaviours of diet and exercise as a means of maintaining their desired body shape. In terms of losing weight and maintaining a slim physique, Malay, Samoan and

Australian women adopt either dieting or exercising as a strategy. However, the Malays and Samoans are very flexible in choosing their strategy. They can go for either exercising or dieting, but rarely combine both. The Malays prefer dieting to exercising, which is yet to become a behaviour that is associated with cutting down weight.

Conversely, Australian women were found to combine both dieting and exercising for weight loss purposes. McDowell and Bond concluded that the culture of thinness which has been perpetuated by the West has made a great impact on other cultures too.

„Beauty is in the eye of the beholder‟. This famous proverb indicates that beauty is a subjective matter. However, judging by Western standards this would not seem to be the case. As Wolf (1991) notes beauty, in the Western context is treated like a

„currency system‟ (p. 12). It can depreciate or otherwise depending on political or economic factors. If the commodity is highly demanded, then the need to maintain its market value is high. Similarly, if a woman is beautiful, they are regarded as sexually

110 attractive and vice-versa. Notions of femininity and beauty in the Malay culture have been influenced by the Western beauty standards due to the exposure by the media. This has had a negative impact upon women‟s experience through menopause. Chapter Six will cover, in part, the issue of femininity and beauty as they are perceived by urban

Malay women experiencing menopause. While adat requires women to maintain their sexual attractiveness for the purpose of satisfying their husbands, further emphasis is placed upon femininity and sexual attractiveness through messages in Western media.

Life for women in the period just before, during and after menopause in Malay society is complex and challenging.

Islam and adat, have, for many decades been, and still remain a dominant factor in the lives of the Malay community. However, they have also been perceived as something totally opposed to development and change (Banks 1976). Contrary to this belief, anthropological researchers who studied the Malay society like Laderman

(1983), Karim (1987), Strange (1981) and Swift (1965) have shown that tradition and modernity are not in conflict. Rather they may be mutually reinforcing. Particularly in the Malay context, treating traditions and modernity as separate entities or opposite pairs tends to overlook the mixtures and blends which reality displays. As I have elaborated earlier in this chapter and elsewhere later in my thesis, Islam and adat are the central factors that guide the Malay society in many facets of their lives. As I have stated the condition of Malay women in different eras has changed and with this their roles have also shifted. In the pre-colonial and colonial age, Malay women‟s participation in activities that took place outside the house was very minimal. Those activities that did take place were usually in the economic sector (Raybeck 1985). I do not embrace Rosaldo‟s (1974) view which suggested that whatever the actual distribution of the labour between male and female, it is the male who controls both the public sphere and the specialised activities considered as socially significant. In a

111 patriarchal society, like the Malay society, asymmetry in the cultural evaluations of male and female is not commonly upheld. As I have illustrated earlier in this chapter, the division of labour among Malay males and females in different eras are not rigid.

Malay women are not secluded and based on previous studies (Strange 1981; Ariffin

2000) they have actively participated in various income-generating activities.

The transition from rural to urban life is indeed an important turning point in

Malay women‟s life (Karim 1987; Ariffin 1992). Malay women‟s participation in the national market economy since 1970s has occurred at increasing speed and has challenged the functioning of the traditional household economy. Today, agricultural work has actually shrunk. Although there is still agricultural work in many parts of

Malaysia, most young generations were attracted to migrate to big cities to work

(Ariffin 2000; Karim 1987). With the influx of multi-national companies in Malaysia, rural women have turned to paid labour. As a result, massive migration to urban dwellings is rampant. In addition, this scenario has created friction in the Malay traditional society. By changing the nature of traditional work, rural women have greatly changed the authority relation within the male domain. More women aspire to being educated, are able to make decisions without male consultation and many more are financially independent.

In Kuala Lumpur specifically, there is a whole range of very different lifestyles available to women – where orientations in terms of education, work aspirations, healthcare, beauty and leisure have become considerably influenced by the Western cultural back-drop. One of the examples is the youth and beauty culture which gradually is being accepted by most Malaysian women. The advertisements that promote slim physique, youthful features are rampant in magazines and on television these days. The chances of having a greater access to education and of entering a wider variety of jobs are obviously enhanced in the urban areas. As can be expected, Malay women today are

112 subject to more pressure and thus they have changed to a considerable degree, particularly in respect to how they perceive themselves and their positions in the wider society. In terms of their health acceptance of biomedicine among Malay women today is another indicator of their desire to participate in modernity. Malay women‟s high acceptance of biomedical intervention has reduced their dependency on the bidan and home birthing. Instead, Malay women have expressed clear preferences towards trained healthcare providers, delivering their children in hospital and have adopted family planning. Bennett (2005) who studied Muslim women in Mataram, Indonesia found a contrasting phenomenon. Unlike the women in neighbouring countries, Indonesian women are reported to under-utilise the modern primary health programmes like vaccination, nutrition and prefer home birthing. In similar vein, Grace‟s (1996) study on the Sasak women of East Lombok, Indonesia has shown that the preference of traditional health services over modern health facilities is still strong. Most women during their pregnancy and childbirth did not seek modern medical aid. They trusted the belian nganak (traditional birth attendant) who played a significant role as a healer in the women‟s lives.

In her article Modernizing the Malay mother, Stivens (1998) has identified that urban Malay women have opted for „modern motherhood‟ (nuclear family, family planning) compared to their mothers who have many children. Having a smaller family means that the chances of having a better educated family is higher; more quality time is spent with the children; and the mother is allowed more time and space to venture into activities outside the home. Stiven‟s work has been useful in this thesis as it provides the reader with a picture of how Malay traditional women have changed due to the government‟s interventions in its attempt to develop the country coupled with the medical authorities who promote better and modern healthcare. Stivens demonstrates

113 that traditional practices of birthing have lost their prominence among the Malays (there is more discussion on Stiven‟s work in the next chapter).

Perception of ageing

Malaysia‟s ageing population has increased from 5.9 percent in 1991 to 6.3 percent in 2000 (Mohamed 2000). The ageing population defined by the United Nation

World Assembly on Ageing held in Vienna in 1982, as those over 60 years of age (Mat

& Md Taha 2003) has now begun to move inevitably upward as the life expectancy at birth has increased for both males and females. In Malaysia in 2000, the percentage of the elderly population in rural areas was 7.5, compared with 6.5 in 1991 whilst the urban ageing population recorded only 5.4 percent in 2000 (Sim 2001). The slow growth rate of the Malaysian ageing population in urban areas is due partly to the migration of the young rural population to the urban areas in search of employment and education opportunities, as well as the influx of foreign labour into Malaysia.

Like other Asian countries, ageing and respecting elders in Malaysia are perceived in a positive light. Both Malay ageing males and females deserve to be respected by the younger ones because they are regarded as persons of wisdom and experience (Sheikh Al-Hadi 1986). In the Malay society, strong emphasis is laid on the need to give due respect and care for parents in their old age. This emphasis is derived mainly from al-Qur’ān and Hadīth57 and the Malay adat. Respecting the elders is central to Islam as well as to the Malay adat and these values are propagated by parents in the home and by teachers in the school and the mosque. As a Muslim country, where

Islam is the official religion, respect for the elders is strongly emphasised more than it is in the Western societies. Islam condemns children who fail to look after their parents

57 See al-Qur’ān Sūrah al-Isrā’ 17:23-24 and Sūrah Luqmān 31:41. The importance of respecting and caring for the elderly as stated in al-Qur’ān and Hadīth is perceived as a benchmark of the Islamic observance. Malay children are reminded of the punishment for neglecting and showing disrespect to parents and the elderly people. In fact, if a child ignores his or her religious obligations towards the parents, it means that they are jeopardizing the chances of a place in heaven for themselves. 114 who are in their old age. In the Malay society, most elderly parents will stay with their children, daughter or son-in-laws and grandchildren. For the Malays, placing parents or elderly members of the families in nursing homes is regarded as unacceptable.

Malay adat relating to family and religious values have remained as constant as they were several decades ago. Respecting the elders is seen as an important value

(Karim 1992; Omar 1994). This statement is supported by Strange (1987) in her study among the Malay elderly of Rusila, Terengganu. Strange found old-age is recognised among people of Rusila. They accepted positively the status of being an elderly person.

The young ones were expected to treat the elderly with respect. In fact, an elderly person not only earns respect from their family members and young ones but strangers too. Strange has made an observation that an elderly person can do what she or he feels like doing, for example the refusal to do heavy jobs. Furthermore, elderly women are free from many modesty rules imposed before menopause like hanging around with young men or lying on the porch in full view of anyone wearing only a sarong tied under her armpits. Ali (quoted in Strange 1987) points out that elders in the Malay society are people who are educated about Islam, wealthy, occuping other statuses and knowledgeable about the adat. These criteria are used to determine whether an elderly man or woman is considered wise among the family members.

I realised that almost every conversation that I had with the women who participated in my study as well as with their children, circled around the topic of hormat orang tua (respect the elders). During my research into the meaning of becoming old in the Malay society, I learnt that hormat (respect) measures the value of people. The Malay proverb sudah makan garam dulu (have tasted the salt first) justifies the wisdom and experience of the elders. This proverb is elaborated in Chapter Six when I discuss the issue of ageing among urban Malay women. At this point of the thesis I have simply attempted to give some general indication of the value in which

115 older people are held in Malay society. However, as will be seen later in the thesis, older women, particularly those experiencing the menopause, express anxiety about ageing despite the values they have learned through Islam and adat.

To sum up, although there have been changes in the Malay family structure in which most people prefer the nuclear family and where we see more women are participating in the paid labour force, Islam and Malay adat remain strong and are being reinforced by the Malaysian government in its pronouncement - Vision 2020.58

Conclusion

Malay women‟s participation in key areas of the national development, particularly in the economy, education and politics have increased markedly post-

Independence. The idea of keeping women at home and limiting their potential roles as productive members of the broader society seems no longer a common characteristic of urban Malaysian society. Malay women, as well as the Chinese and Indian women, are given the opportunity to play their active roles in the public domain. Today, many

Malay women are financially independent due to their advancement in education.

Nevertheless, their roles as wife and mother are still significant. Indeed, Malay women have encountered several challenges brought about by forces of modernisation in their lives and have reworked adat in order to accommodate these.

As noted previously, this chapter has served to contextualise the thesis and to help position the women in my study into the broader context of a changing Malay society. In order to understand the role and place of the older woman in Malay society

58 Vision 2020 was introduced by the former Prime Minister, Tun Dr. Mahathir Mohamad in 1991. The aim of this vision is to make Malaysia a fully developed nation by the year 2020. This vision outlines nine challenges which need to be achieved by the Malaysians by the year 2020: 1) establishing a united Malaysian nation with a sense of common and shared destiny, 2) creating a psychologically liberated, secure and developed Malaysian society with faith and confidence in itself, 3) fostering and developing a mature, democratic society, 4) establishing a fully moral and ethical society, 5) establishing a matured, liberal and tolerant society, 6) establishing a scientific and progressive society, 7) establishing a fully caring society and a caring culture, 8) ensuring an economically just society and 9) establishing a prosperous society. Available from http://www.pmo.gov.my [accessed 10 April 2008]. 116 and to appreciate the challenges faced by women undergoing menopause, it has been necessary to firstly give a broad picture of a changing Malaysia, and then to focus more closely on the changing role of women in Malaysia. With this in mind I have also discussed a particular view of Malay femininity and beauty. My discussion of ageing in

Malay society was intended to give some background to how older women are likely to view ageing in regards to their traditional beliefs and religious values. However, none of this is straightforward, as I have already indicated and the forces of Westernisation and modernisation have also influenced how the older woman views herself and indeed is perceived in the wider society. In the next chapter I turn to discuss the issue of menopause more fully as this experience provides the specific case-study through which

I examine how older women in Malay society view their bodies, their health, their family relationships and their place in the workforce. Literature from cross-cultural studies is used to draw out some comparative views and to illustrate the socioculturally constructed nature of the menopause.

117

CHAPTER FOUR

MENOPAUSE: A CROSS-CULTURAL PERSPECTIVE

Introduction

Whereas in the last chapter I focused on women‟s changing roles in Malay society, in this chapter I turn my attention to the major topic of this thesis – menopause.

In order to understand how urban Malay women‟s perceptions of menopause have been influenced by their position in society, it is necessary to spend some time examining cross-cultural approaches to menopause. With this kind of background, we are better able to understand how a biological process associated with ageing comes to be understood in a specific social and cultural context.

For a number of years many studies have been proposed and many theories have been conducted in the Western world to explain various menopausal symptoms and experiences. These explanations have varied dramatically according to areas of study and how these areas or disciplines view menopause. In a Western context, currently menopause is often, but not always, seen by doctors as a medical problem that needs medical attention. Psychologists are interested in examining how menopause influences the emotional and psychological well-being; while anthropologists are concerned with how social and cultural factors shape menopausal experiences. Although previous studies have covered a wide variety of areas, this chapter will focus on two major issues which have emerged through the literature reviewed.

In the first part of this chapter, I will review some previous studies which attempt to explain the origin of the concept of menopause as a disease. Most of the literature on this issue has focused on the medical and biological findings that emphasise the pathogenic image of menopause. In the past, and to some extent in contemporary times, for many in the medical community like physicians, epidemiologists and biologists, menopause is viewed as a disease that needs a cure. 118

Therefore, the support in the medical literature for taking Hormone Replacement

Therapy (HRT) as a treatment modality to alleviate menopausal symptoms is consistent.

Integrated into this overview is a discussion on the medicalisation of menopause as this is now widely discussed in the context of Western society. To date, this discussion has not extended to any great extent to non-Western societies and I hope that my thesis may go some way toward contributing to this area of research by focusing on Malay women.

An exception to this discussion is, of course, Margaret Lock‟s work (1993) on menopause as it is experienced in Japan.

The second part of this chapter will highlight the work from anthropologists who have conducted research on non-Western women as this is most pertinent to my research. While there is a vast literature on menopause from various disciplines and a fair amount from anthropologists and sociologists about Western womens‟ experience of menopause, it is not within the scope of the thesis and is therefore not dealt with in any detail. Anthropologists have investigated how meaning is made of the menopause experience as a result of specific cultural interpretations. Their findings have facilitated my research and allowed me to determine what is unique about the Malay experience and to understand patterns that are common to many groups of women. Since I have employed ethnographic methods in my study, my findings are unique, for although there were several studies conducted about menopause on Malaysian women (Arshat,

Tey & Ramli 1989; Ismael 1994; Mohd Zulkefli & Mohd Sidik 2003), to date no published qualitative studies exist on the menopausal experience of urban Malay women. The voluminous literature on menopause from medical, biological and psychological research concentrates either on symptoms or the negative feelings which women have towards menopause. This research, however, rarely addresses the private experience of these women, the changes in their traditional values, the range of treatment selected by menopausal women, and how family members respond to the

119 women‟s changes and needs. This gap in the literature has encouraged me to think more about the social and cultural life of urban middle class Malay women who endeavour to balance mothering, working and health.

In the following section, I will discuss the differing definitions of menopause based on the medical and local perspectives. Next, the medical, biological and psychological explanations on menopause as well as its critique are also presented.

Discussion on medicalisation and the critique of medicalisation are also highlighted.

Differing definitions of menopause

As stated in previous chapters, my study deals with menopausal women who have experienced, or are experiencing, menopause naturally. These women have stopped menstruating for twelve consecutive months. This definition of menopause is adopted from the World Health Organization (WHO). As a result of a series of meetings59 by medical professionals, menopause has been defined according to stages and types. The terms listed below depict a clinical and scientific definition of menopause:

Climacteric: Transition from reproductive stage to a non-reproductive stage of an ageing woman.

Menopause (natural menopause): The permanent cessation of menstruation from the loss of ovarian follicular activity. It occurs for twelve consecutive months of amenorrhea and has no other obvious pathological or physiological cause.

Induced menopause: Cessation of menstruation resulting from the removal of ovaries or iatrogenic ablation of ovarian function (by chemotherapy or radiation).

59 In various workshops and meetings (see Utian 2004), the term menopause has been defined according to menopausal stages by the medical professionals. Among the workshops that discuss the definitions of menopause were: 1) First international menopause society definitions 1976 2) WHO scientific group definitions 1980, 1996 3) Korpilampi definitions 1986 4) Ovarian function/therapy-oriented definition 1991, 1994 5) The international menopause society definitions 1999 6) Stages of Reproductive Ageing (STRAW) Workshop, park City, UT, 2001 120

Menopause is not clinically or scientifically defined by some women. Studies have shown that the term menopause is not known or not popularly used to refer to menopause (refer to Table 5 on page 122). The term used by women in the lay community derives from the local context of what menopause is understood to be.

Davis (1986) contended that in order to understand menopause, we need to understand the meaning of menopause from the emic perspective60. This idea has been supported by others (Omar 1995; Rice 1996; Chirawatkul, Patanasri & Koochaiyasit 2002) who studied menopausal women in their own communities. I agree with Davis on three important points about why the emic perspective is important: First, menopause is impossible to explain through the medical model alone as menopausal experiences exist on a continuum from „normal‟ to „abnormal‟. For the majority of women, menopause is normal whereas, a minority of women feel that it is abnormal. In other words menopause is a subjective experience. Second, an etic or so called „objective‟ perspective conceals the differing and complex nature of menopause. Every menopausal woman‟s experiences are unique and therefore different factors may exist that can be incorporated into the cultural realm. Third, women‟s experiences of menopause should be understood holistically. So, factors like the personal understanding of menopause as well as the role of the community in negotiating the meaning of ageing in the local and social context should be taken into consideration. In contrast, the etic perspective aims at developing a standardised or grouped instrument to assess symptoms and perceptions about menopause (Davis 1986). The etic perspective (in the form of a standardised instrument) is only useful in measuring particular sociocultural variables in the form of statistics; an approach used by quantitative and medical researchers.

Cross-cultural studies on menopause have shown the different and highly nuanced local meanings of menopause (see Table 5). The terms and meanings listed in

60 Emic means „what the people themselves perceive as reality and etic refers to views from those outside looking in‟ (Harris cited in Flint 1982, p. 174). 121 the table have been taken from various cross-cultural studies of the menopause which I discuss below.

Table 5 Local terminologies to describe menopause. ______Women Local terms Meaning ______Japanese konenki the change of life

Newfoundland the change menopause

Malay putus haid or break from menstruation putus darah break from bleeding

Isan sud lyad, sud luuk no menstruation, no baby

Hmong tsis coj khaub ncaws lawn no more menstruation

Peruvian la edad critica the critical state

Thai leod cha pai-lom cha ma the blood will go, the wind will come

Italian cambiento di vita change of life; life dries up; time of loss or sorrow; life becomes heavier

Korean pekyung closing of menstruation ______

In her study of women in a Newfoundland fishing village, Davis (1986) found that the women she spoke to were unfamiliar with the term menopause. Instead they used the term „the change‟61 which is synonymous with menopause. The emic perspective as emphasised by Davis is consistent with Omar‟s (1995) findings. In the rural Malay society she studied for instance, menopause was putus haid.62 Putus means break; haid means menstruation. So, menopause means a break from menstruation.

According to Omar, rural Malay women believed the occurrence of menopause resulted

61 „The change‟ according to Davis can be in many forms: a) menarche, b) any stage in the menstrual cycle, c) irregularities in menses, d) Pre Menstrual Symptom complaints, e) vagina secretions, f) time of ovulation, g) pregnancy and childbirth, h) post-partum bleeding, i) menopause and j) post-menopausal mood changes. A person has to identify which „change‟ she/he refers to. 62 Omar‟s (1995) study among the rural Malay women in Malacca used this term to refer to menopause. Some of them also used the term putus darah (break from bleeding). 122 from having many children throughout their lives. Having children had dried up all the blood during pregnancies and childbirth. In other words, women have used up all of their menstrual blood. Malay women in Omar‟s study believed that menopause occurs for women who have many children and for those who menstruated early. Women who have fewer children or do not have children at all are considered stronger due to the fact they experience less stress in pregnancy, childbirth and child-rearing. Nevertheless, the women in my urban study did not use the term putus haid. Instead, they used the word menopause. Words borrowed from English appear in many places in Malaysia as can be seen in business, agriculture, politics and medical matters. The word menopause, for instance, is spelled either menopos or menopaus in Malay language.

Chirawatkul and Manderson (1994) identified within the local idiom sud lyad, sud luuk (no menstruation, no baby) as being used by women in Thailand to describe their understanding of menopause. Like Thai women, Hmong women studied by Rice

(1996) also used their own terminology to describe menopause. Menopause was referred to as tsis coj khaub ncaws lawn which means no more menstruation.

Correspondingly, Punyahotra and Dennerstein (1997) discovered there was no specific term for menopause used by the Thai women in their study. Women generally understood menopause as leod cha pai-lom cha ma. Literally this means „the blood will go – the wind will come‟. The term refers to behavioural and emotional changes that were believed to take place during and after menopause. In a study on Korean women

(Im & Meleis 2000), menopause was understood as pekyung which means the closing of menstruation. On the other hand, Lock (1993) in her study among Japanese women did not come across the term „menopause‟ but konenki which simultaneously described the term menopause and the „change of life‟.

According to Lock, the term konenki translated into English as menopause does not have a similar meaning to menopause as it is understood in North America. Neither

123 the Japanese women nor the doctors she spoke to in her study considered menopause an important marker of middle-age in women. Instead, menopause for Japanese women is thought of as the last part of their reproductive stage. Lock found that most Japanese women were in better health compared to North American women of the same age.

However, unlike North American women, Japanese women reported they experienced headaches, shoulder stiffness, dizziness and ringing in the ears which formed part of the konenki experience. Symptoms like hot flushes, which arecommon among Western women, as well as women in my study, were reported infrequently. One of Lock‟s finding was that the Japanese diet which is soy bean based contributed to the lower symptoms like hot flushes.

From the local definitions I have pointed out, menopause in general indicates the end of childbearing years but it can also mark the end of the „bad blood‟63 in a woman‟s body. However, the interpretations of menopause are diverse and some cultures view menopause quite differently. While most non-Western women mentioned in the above studies defined menopause as a fact of life and a change from menstruation and pregnancy that took place in their later life, Gifford (1994) found Italian women who migrated to Australia and lived in Melbourne offered a different definition of menopause. The term cambiento di vita was used by these women who described menopause as a time of „sorrow‟ or a time of „loss‟. These women associated menopause with deteriorating health where they were vulnerable to a number of related symptoms and illnesses after their menstruation stopped. Indeed, while local terminology for menopause is clearly evident in the anthropological literature it does

63 The concept of bad blood is associated with menstruation. When a woman is menstruating, the menstrual blood is regarded as „dirty‟ or „polluted‟. Women are prohibited in having sex with their husbands. They are not allowed to perform some religious duties and are subjected to food and social taboos and restrictions. In some societies, menstruating women are secluded from the rest of the societies. Contrary to this belief and practices, menstrual blood is also regarded as a sign of good health and fertility (Chirawatkul 1996; Whittaker 2000; Skultans 1970). 124 not exist in the medical literature. We sometimes see that the lay language has been transposed into medical terminology.

Biomedical and psychological explanations of menopause

Menopause is an area that has occupied the attention of medical professionals for a number of years. The subject matter is widely researched: my Google search for

„menopause‟ in 2007 yielded more than 13,300,000 results and in 2008 there were

15,800,000 results. Medical journals specifically related to menopause have also been published. Among the most popular menopause journals are Maturitas, Menopause

International, Climacteric and Menopause Management. Due to the extensive medical research on menopause, medical professionals have established menopause societies to educate women in all matters related to menopause. Again, a Google search for menopause societies in 2008 found 363,000 hits. For instance, The British Menopause

Society, North American Menopause Society (NAMS), Australasian Menopause

Society, International Menopause Society (IMS), Malaysian Menopause Society

(MMS)64 and European Menopause and Andropause Society (EMAS), to name a few. I performed another Google search in the same year and found more than one million conferences and seminars on menopause organised worldwide. In addition, many books on menopause were published and many pharmaceutical products were available to the wider society to address menopause issues.

As may appear obvious, there are thousands of articles and many discussions on and about menopause. In the MEDLINE database in The University of Western

Australia alone, I found 25,897 articles on menopause. These articles have taken many years to discuss a number of different menopause-related issues like management of vasomotor symptoms, risks and benefits of HRT, cognitive function, sleep disorders,

64 Malaysian Menopause Society (MMS) is a non-profit organisation that manage menopause and andropause related problems. Further information about MMS can be obtained from its official website at http://www.menopause.org.com 125 diagnostic and therapy issues related to osteoporosis, treatment of depression, HRT and cardio-protection, risk of breast cancer, musculoskeletal pain, trial of alternative medicines for menopausal symptoms, sexual function in menopausal women, association with menopause and overweight and so forth. From a different perspective, menopause in psychology is also widely researched.65 Most of the areas covered were on emotion for example health care needs (Defey et al. 1996), sexual and psychological symptoms in the menopausal years (Wylie et al. 2007), depression and anxieties in women (Labriola & Vene 2006), well-being (Deeks & McCabe 2004) and self-concept

(Shu et al. 2007). While psychology is interested in the study of the emotion of menopausal women, the field of biology emphasises the biological aspects of the woman‟s body (Leidy 1994), somatic changes (Hunter 1990) and age at menopause

(Goodman 1980). Many of these studies, particularly in psychology, were focussed to women‟s current health and lifestyle factors as well as emotional disorders. Biomedical studies are more inclined to look into the changes that take place in the body. Little attention has been given to other factors like the social and cultural factors which may influence women‟s bodily changes, well-being and emotion or the meaning they attach to their changing biological and social status.

Historically menopause was „discovered‟ by Charles de Gardanne a French physician in 1821 (Spitzer 2003; Watkins 2007). Of course women have always experienced the transition from being biologically reproductive to non-reproductive provided they lived long enough. However, de Gardanne coined the term menopause and described the life transition and the symptoms thereof. Over the next 100 years, many scientists, particularly in the West were interested in searching for a „cure‟ for the symptoms associated with menopause. It was in the early 1930s that doctors developed an estrogen extract from the urine of pregnant mares that later was manufactured under

65 Menopause articles in the psychology database of UWA library found 28,881 results. The search was performed on 12 August 2007. 126 the name of Premarin. In the 1960s, estrogen only was given to treat menopausal symptoms. It was known as Estrogen Replacement Therapy (ERT). Premarin usage was very popular from 1963 to 1966 and became the number one „wonder drug‟ for women in America (McCrea 1983). However, in the 1970s, doctors realised that estrogen–only therapy increased the number of women suffering from uterine cancer. Therefore, scientists produced a combination of estrogen and progestin (a synthetic form of progesterone) to help reduce the risk of uterine cancer. The new hormone which is claimed to be much safer is known as Hormone Replacement Therapy (HRT). HRT is clinically proven to alleviate hot flushes (called hot „flashes‟ in America), combat insomnia, reduce vaginal dryness, and help with mood swings (Palmer 1998; Wallis

1995). Several studies in the 1980s showed that HRT reduced the risk of heart disease as well as hip and wrist fractures, Alzheimer Disease and colon cancer (Palmer 1998).

Moreover, it has been seen as helping to prevent osteoporosis and neutralises the risk of uterine cancer (Wright 2005; Palmer 1998).

However, despite the benefits of HRT as a preventive agent to menopausal symptoms there have been challenges from studies that claim HRT is risk-laden. For instance, studies by the Heart Estrogen/Progestin Replacement Therapy (HERS) group in 1998 and 2002 revealed that there was no heart benefit and no cardiovascular benefit to women who took HRT (Machens & Schmidt-Gollwitzer 2003; Naessen 2000). In

2002 and 2003, a similar study was conducted by the Women Health Initiative (WHI) to identify HRT benefits. Like HERS, WHI found there was an increase of cardiovascular and stroke risk and breast cancer in women who took HRT (Cockey 2004). The use of

HRT and indeed the continuing medicalisation of menopause are contentious issues, both within and outside of the medical community. It is sufficient to say that there is no one clear direction for menopausal women to take when it comes to addressing menopausal symptoms.

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The critique of biomedical and psychological literature

For the past few decades, the medical literature on menopause has been subject to criticism by scholars from various fields of study (Daniluk 1998; Deeks & McCabe

2004). Among the criticisms are the definition of menopause as a „disease‟, and the methodological factors associated with determining and treating menopause

(particularly in relation to HRT). In the past, the image of menopause has been described overwhelmingly in a negative way by both doctors and women (Mitteness

1983; Engel 1987; Winterich 2003). For instance, menopausal women in the Victorian area were regarded as having a sinful mind and a decaying body (McCrea 1983). In

Freudian psychology menopausal women were described as having neuroses (Mitteness

1983) and menopause has been seen as leading to physical and psychological diseases

(MacPherson 1990). It has been seen by some to be a time of diminished health (Gifford

1994). I found that these highly Westernised depictions contradicted the portrayals of women in non-Western countries who appear to have fewer severe symptoms; do not suffer from the empty-nest syndrome; enjoy a higher status and receive more privileges and freedom following menopause (Boulet et al. 1994; Mernissi 1987; Lock 1993; Rice

1996; Omar 1995).

Although menopause is a natural biological change, the medical view has been for some time that menopause is an estrogen deficiency disease (MacPherson 1990;

Frey 1981; Cate & Corbin 1992). Due to the negative connotations associated with menopause, women have found themselves being portrayed as vulnerable to the symptoms. In addition they are seen to have a greater reliance on doctors to „fix‟ their problems with HRT which in turn increases the power of the doctors to treat menopause medically (McKinlay & McKinlay 1973). In 1960, when the synthetic estrogen was made widely available to women, doctors agreed on two things; menopause is the prerogative of medical practitioners and Hormone Replacement Therapy was to be the

128 therapy of choice given to menopausal women (MacPherson 1990; Kaufert & Gilbert

1986). It is medicine in the form of HRT that defines menopause as a disease. Thus, menopause is regarded as prescriptive (Kaufert & Gilbert 1986) in nature.

The notion of menopause as a disease has been re-defined by Robert Wilson who wrote Feminine Forever in 1966. He was responsible for igniting the controversy that menopause is equated to other types of disease:

…You might think of menopause as a deficiency disease…similar to diabetes. Both are caused by a lack of certain substances in the body chemistry. To cure diabetes, we supply the lacking [insulin]. A similar logic can be applied to menopause - the missing hormones can be replaced (Wilson cited in MacPherson 1990, p. 181).

Like other „diseases‟, menopause can be described as a malfunctioning condition that threatens women (McCrea 1983). Therefore, to save women from this „disease‟ Wilson argued persuasively that HRT is the remedy to slow down the ageing phenomenon, thus securing a narrowly defined womanhood associated with youth and the illusion, at least, of reproductivity. Wilson‟s pronouncement has influenced medical attitudes towards menopause and the use of HRT for many years. Although Wilson‟s idea gained attention particularly from the doctors and media his idea of deficiency appeared problematic to feminist groups. Greer (1991), in her book The Change, proposed that menopause should be seen as a normal or natural event. In terms of treating menopausal women, the feminists favoured a more natural approach rather than the use of medication in the form of HRT (Voda & Eliasson 1983). Other studies by Lewis (1993), and Dickson (1990) were in agreement with Greer. The feminist perspective seeks to clarify the connection between women‟s menopausal experiences and the social, biological and political variables that affect their lives.

Furthermore, feminist scholars have suggested that women should retain control of their bodies and participate fully in the decision making about their health (Murtagh

& Hepworth 2003). By controlling their bodies, women could ultimately seize greater 129 control of their lives. Feminists also are of the view point that the traditional doctor- patient relationship weakens women‟s autonomy and control over their own bodies. In other words, women have placed their decision making rights in the hands of the medical experts. Thus, it is the doctor who controls their bodies by prescribing HRT.

This is the main focus of feminist studies with regards to menopause and the consumption of HRT. They believe women are the ultimate decision makers when it comes to their bodies (Guillemin 1999; Murtagh & Hepworth 2003). Indeed, the feminist view has had an impact on how women perceived themselves as consumers of medical products and it has encouraged them to take a different perspective of the doctor-patient relationship by proposing that it should be negotiable rather than static.

Generally, most biomedical studies on menopause have adopted a survey technique (Uncu et al. 2007; Khademi & Cooke 2003; Huffman et al. 2005; Malacara et al. 2002). This data collection technique has failed to delve into a deeper experience of menopause. Studies which employed the quantitative approach have been criticised from a methodological perspective because the results were based on a tested assumption66 and later they were assumed to have a similar value (Neugarten 1963).

Such studies were often limited to identifying symptoms that bother women and failed to investigate women‟s view about the changes and how these changes have affected their lives (Winterich 2003). Studies have shown that most researchers are drawn to investigate more negative changes like declining sexual function, depression, and feeling less attractive (Dhillon, Singh & Abdul Ghaffar 2005; Gifford 1994; Hunter

1990; Koch et al. 2005) as compared to the positive ones. More important, this technique, as I have discovered in my discussions with urban middle class Malay

66 Most of the medical studies adopted various different scales to identify menopausal symptoms. Women were required to identify their menopausal symptoms according to the prepared list. Some popular scales used in medical researches were the Attitudes-Toward-Menopause-Checklist known as ATM (Neugarten 1963), the Kupperman Menopause Index (Fu et al 2003), Menopause Attitude Scale (Bowles 1986) known as MAS and Greene Climacteric Scale (Sierra et al 2005). In general, these scales yielded mainly vasomotor, psychological and somatic symptoms. The menopause clinic in my study adopted the Greene Climacteric Scale (see Appendix II). 130 women have limited women‟s vocabularies to explain their personal experiences about menopause. The methodological deficiencies of the quantitative methods used in these studies, in part motivated me to explore the issue from an ethnographic perspective. I discussed some of the justifications and practicalities of employing ethnographic methods in my study earlier in Chapter Two.

Studies about menopause that depict women as physically and psychologically unstable have been proven false (Skultans 1970; Flint 1975; Barnett 1988) and I find that they are generally unhelpful. In many non-Western societies, women gained higher social status as they aged. The role of grandmother or old women is still highly valued in many societies. The old women are granted the status of being a wise person. They are invited to teach and lead the young ones. Since their responsibilities towards children are lessened, they occupy new roles in the society, becoming important people in the religious realm, in medicine and in politics (Mead 1981; Omar 1994). The older woman‟s contribution changed as she experienced a new transition in life.

Medicalisation in everyday life

The issue of medicalisation in relation to menopause has already been introduced in this chapter and it is pertinent to my thesis proposition that menopause for urban middle class Malay women has, to some extent, become medicalised. For this reason it is useful to consider some background to the topic. The term medicalisation came into use in the social scientific literature in the 1970s (Conrad 1992).

Medicalisation has been defined as „a process whereby more and more of everyday life have come under medical dominion, influence and supervision‟ (Zola cited in Kaufert &

Gilbert 1986, p. 7). Conrad (1992, p. 210) sees medicalisation as a „medical problem or illness and [the] mandating or licensing [of] the medical profession to provide some type of treatment for it‟. This definition focuses on the service factor, and emphasises the giving of treatment to the „problem‟ with jurisdiction of the problem placed in the 131 hands of medical practitioners. In addition, the term medicalisation has co-opted other conditions that might not otherwise involve medical intervention. Problems among the

Malays like latah67 (Kenny 1990; Winzeler 1995) and spirit possession (Skeat 1965) did not in the past require medical intervention. Overall, we see that some conditions

(pregnancy and childbirth) are highly medicalised, some are partially medicalised

(menopause, stress) while others are minimally medicalised (menstruation, child abuse).

Conrad and Scheider (1992) have expanded the medicalisation definition into three main levels; the conceptual, the institutional, and the interactional level. On the conceptual level, the uses of medical terms or models have been used to define a particular problem. Once a condition has been defined as a medical problem, then a medical approach is considered the solution to that problem. On the institutional level, medicalisation exists when a medical body legitimises medical practitioners to have the exclusive right (Bell 1990) to treat the problem. The doctors are said to have an:

exclusive license to practice medicine, prescribed controlled drugs, and [to] admit patients to hospitals, and perform other critical gate keeping functions (Friedson cited in Bell 1990, p. 174)

At the level of interaction between doctor and patient, medicalisation exists when patients‟ complaints are treated as medical problems. Neither Conrad nor Schneider claimed that all doctors behave in this way (Bell 1990). In the study of menopausal women by Martin (1987), she found that menopausal women were not obliged to take

HRT by their doctors nor was menopause an issue for them. Martin‟s study was supported by Kaufert and Gilbert (1986) who found Canadian women are not subjected to doctors‟ prescription of HRT. Instead, these women consulted their doctors to obtain information about menopause. Similarly, Lock (1982) who studied doctors patterns of approaching menopause found that there is a range of responses in their clinical practices. Lock explained that there were multiple factors like age, medical training, and

67 Latah is an act of shock or hyper startle. 132 area of specialisation that determine doctors‟ approaches to diagnosing and treating their patients‟ problems. In sum, these studies have noted that medicalisation on the conceptual level is visible but that this is not always the case in practice. These observations will be pertinent when I discuss practices in the menopause clinic later in the thesis. It can certainly be the case that practices vary in different settings. So for example, it may be the case that individual medical practitioners have an array of approaches which they apply to different women who present differently to them, but that a clinic which is mandated to „treat‟ menopause as a medical problem takes on a highly medicalised approach. We will see later in the thesis that the menopause clinic I observed adopted this kind of medicalised approach.

It has been noted that Conrad and Schneider overlooked the changing roles of women from „passive victims‟ (Metzl & Herzig 2007) of medicalisation to active agents of change. As reported in Kaufert and Gilbert (1986) as well as Lock‟s (1994; 1993) studies, women have a choice either to accept or reject the treatment. This kind of approach not only describes medicalisation beyond doctor-treatment territory but it has also taken into consideration interactional and organisational factors. However, the notion of medicalisation also is associated with the kinds of perceptions held within different cultures and by groups and individuals. Each culture is unique and the people within that culture are entrenched within their own practices and interpretation of everyday life (Kleinman 1980).

Critique of medicalisation

It is apparent that medicalisation has been discussed extensively in the Western context. However, though medicalisation is usually elaborated upon within a narrowly defined Western context, I found this idea has emerged within the urban Malay society as well, especially when we consider the condition of menopause. Very few researches working on cross-cultural studies of menopause have focused on this issue. Lock‟s 133

(1993) comparative study between the Japanese and North American women is an exception. Lock reported that menopause in Japan is less medicalised than in North

America. She also found that the Japanese women in her study rarely sought medical help when they reached the menopausal stage. My approach is in agreement with

Conrad‟s idea of medicalisation and enriches an understanding of medicalisation within a non-Western context. Conrad (1992) proposed two approaches that are useful in studying medicalisation cross-culturally: i) indigenous definitions of problems that are medicalised in the West and ii) the diffusion and exportation of medicalised conceptions and treatments to non-Western societies. Little is known about how menopause is treated in the Malay society (also in other non-western societies elsewhere). In addition we know very little about and how the process of medicalisation has been played out within the Malay society and under what conditions the medicalisation of a life stages or conditions is accepted or rejected. The best example that has been elaborated in some detail is that of childbirth. Before the advent of medical technology childbirth in

Malaysia took place at home with the assistance of the bidan and bomoh. Laderman

(1983) and Karim (1984) reported that the use of the bidan and bomoh among pregnant mothers is very instrumental in the rural areas. Nevertheless, the traditional practice gradually eroded due to the intervention of government, medical practitioners, as well as policy-makers. to Although there was a sense of uneasiness between the traditional midwives and the government trained midwives, the idea of medicalizing childbirth was principally seen by the researcher as regulating people‟s behaviour (Karim 1984) as well as safe-guarding the well-being of expectant mothers and their babies. Indeed, childbirth nowadays tends to take place in hospitals with the assistance of medical experts. There is also a need to investigate the differences between women who seek medical assistance from women who do not. I will address these issues in the chapters to come.

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Based on the literature, I found there is an inconsistency between what is reported as a „treatable disease‟ (McKinlay & McKinlay 1974) and the experiences of menopause as just another phase of life that is experienced by women in all societies.

The medical literature has proven unjust to the life-experiences of menopausal women.

It „has been used as a convenient scapegoat to explain problems of menopause‟

(Lammert 1962, p. 56). Indeed, there are other possible factors (e.g. work pressures) that may influence menopausal experiences. Diverse cultural factors, ethnic background and the social meanings attached to menopause and ageing may influence women‟s views about menopause and their experiences of menopause. I am interested as well in whether aspects of urban living as opposed to rural living affect the manner in which women understand and approach menopause. I might well ask the same question about women‟s socio-economic status (including their level of education). Nevertheless, there have been opposing views to those evident in medical and psychological literature. The medical view on menopause as an estrogen deficiency condition needing medical intervention has been challenged in the anthropological literature.

Within this context the term medicalisation is indeed complex. Medical authorities tend to shift one‟s view of what is known as „illness‟ to that of „disease‟.

Conrad (2007) explained there are two serious implications due to the heavy emphasis upon medicalisation. First, there is the pathologising of everyday problems. This pathologising turns our everyday problems into something medical so that they are seen as serious problems, ones which require both moral treatments as well as medical ones.

If our everyday life is being medicalised, it will benefit not only the pharmaceutical companies but also the insurance companies more than ever because people have to buy insurance and pay more for the services.

Secondly, medicalisation turns the focus to individual problems with clinical solutions instead of problems that may require social solutions. In my study for

135 example, although menopause is the result of the depletion of estrogen, other related problems like receiving minimal support from husbands and family members as well as the pressure from the media have no relationship with the medical field, yet they are relevant to the responses women have to menopause. The fact that my participants have to juggle between their roles as wife, mother and worker also contributed to the problem. So, medication is a limited solution and may be inappropriate where the problems associated with menopause are based not just on physical symptoms but also upon moral, ethical, social and cultural factors.

I support Conrad‟s ideas in which using medical treatment is seen as inappropriate in conditions where problems are the result of ethical, moral, political or economic. Medicine although it has proven to cure diseases, nevertheless it also involves the social meaning and contexts of the person who take the medicine. Too much emphasis on medicalisation will undermine personal meanings and social contexts which must be recognized as well as it can also trigger to inappropriate diagnose or treatment of people‟s condition. In the following section, I will illustrate findings from the anthropological literature to support my stand that menopause is an experience influenced by sociocultural factors.

Anthropological studies on women’s experiences

As stated earlier in Chapter Two, menopause is a subject which gains relatively little attention in anthropology (Agee 2000; Beyenne 1986; Kaufert 1982). I found that the rareness of anthropological research on menopause is best explained through the relative importance placed of menstruation and pregnancy as significant events in the life cycle of a woman as compared to menopause. Menstruation and pregnancy are positive signs of womanhood and reproductivity compared to menopause. The onset of menstruation in many societies marks the reproductive ability and maturation of a woman, whereas menopause is often seen as a symbol of „old age and desexualization‟ 136

(Posner 1979, p. 180). Since menstruation is a physical transition associated with being a woman, it is discussed among women more openly than is the case with menopause.68

In some traditional societies, puberty or transition from childhood into female adolescence is celebrated with an assortment of menstrual rituals like Kinaalda (Wright

1982) and Isnati Awicalowanpi (Powers 1980).

According to Wright, Kinaalda is a ceremony that provides Navajo girls with necessary knowledge before entering the society as an adult. The ceremony too is a place where proper adult behaviour is taught with a mythical figure known as the

Changing Woman operating as a model. In this ceremony, which lasted for four days, a huge corn cake was baked during the final night and Blessingway songs were sung over the girl. On the other hand, Isnati Awicalowanpi which means they sing over her [first] menses took place for ten days after the young girl‟s first menstrual period at the request of the girl‟s father. This rite was headed by a shaman who performed the Buffalo ceremony to invoke the spirit of the buffalo69 and secure the virtues of chastity, fecundity, industry and hospitality desired by the Oglala women of Native America (a tribe of North-American Indians). At the end of the ceremony, the shaman will announce to the people that the girl has become a woman. Such celebrations that mark the life cycle of a woman, particularly the menarche, are unusual within Western societies.

While menstruation is celebrated in some societies, interestingly van Gennep

(1960) in his work The Rites of Passage stated that there were no known specific ceremonies or rituals to mark the new phase of life of aged women in the society:

68 This also applies in the Malay society where mothers and daughters speak about menstruation in a casual manner. 69 Buffalo is the most important animal to the Oglala people. Buffalos provide them with food, clothing shelter and fuel for making fires. The Oglala believe that there is a relationship between woman and the buffalo myth and ritual. One of them is reflected in the Isnati Awicalowanpi rites. The preparation of the ceremony has been fully described by Powers (1980).

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There do not seem to be any rites of menopause, or of the graying of hair, though these both mark the beginning of a new phase of life which is very important among the semi civilized (p. 145).

Menopause, in other words, is a different kind of rite of passage in the sense that it does not attract certain rituals or celebration like menstruation or childbirth. Although there is no celebration that marks menopause, in many non-Western societies women gain more respect, occupy higher status and are free from social taboos and restrictions.

Kaufert (1982) summarised three important points pertaining to van Gennep‟s observation: first, there is no specific rite associated with menopause; second, menopause indicates a beginning of a new phase of life; and third, women‟s former status is often reversed at the onset of menopause. van Gennep‟s observations served as a ground to conceptualise menopause as an important event that has implications towards the changing status and roles of middle-aged women in their own societies.

Although van Gennep demonstrated there is no specific rite for menopause, I found it is helpful to explain this situation through the status passage advocated by

Glaser and Strauss (1971). This classical work explains that there is a movement in our life from one stage to the other with an alteration in status. In my study specifically, the movement is from pre-menopause to the menopause stage. Status passage has two important features: the first is an objective status that is associated with achieving a publicly recognisable status (example a grandmother) and second, the subjective status where individual experiences a change in their sense of self. I will return to a further discussion of rites of passage in Chapter Seven where I apply the status passage to the experiences of my research participants.

For many decades, the world has witnessed extraordinary changes in the lives of men and women. This is clearly seen in the number of women who are now educated and who have joined the workforce. There is also the increase in the number of dual- income earners, single parents, the high divorce rate, childcare problems, changing of 138 roles as well as changing attitudes and values towards men and women (Mohd. Noor

2006; Bahry 1982). According to some in a modern society like Malaysia, the general perception of women‟s roles has not changed a great deal (Abdullah, Mohd. Noor &

Wok 2008). So despite women‟s level of education and their place in the workforce, women still believe that their prime role is to support their husbands and nurture their children. Women are still committed to their families although they have to juggle between roles as a wife, mother and worker. This idea is also supported by women in

Saudi Arabia studied by Bahry (1982), in China (Edwards 2000) and Bangladesh (Todd

1996). The researchers reported that although women are working, they still maintain their duties as wife and mother. Although women have to make sacrifices and often encounter role conflicts in order to achieve their ambitions in life, they are fully committed to family obligations.

Traditionally, women have been valued in most societies for their ability to reproduce and for their role as mothers. This value has been reflected in the notable work of anthropologists like Margaret Mead (1981) and Marjorie Shostak (2000). Mead and Shostak spent many years examining the various aspects of everyday life in different societies. Both made observations about the role of older women and their positions in society. Mead (1981) who studied the Samoan people found that old women were more powerful in the household than men were. Old women acquired a special position by becoming midwives and herbalists and by heading certain ceremonies in the community. Like Samoan women, !Kung women of north-western

Botswana who reached old age were very influential, highly respected and enjoyed a certain degree of privilege that was not experienced by the younger people (Shostak

2000). Like the older men, !Kung older women played an important role in spiritual matters because at that age they were free from social taboos and restrictions that normally bound younger adults. Both Mead‟s and Shostak‟s findings confirmed that

139 women‟s position is highly recognised as they enter old age. Samoan and !Kung women described menopause as an event of no great importance. Although Mead and Shostak reported that women in their studies experienced some slight temperamental instability, these women did not associate menopause with the physical symptoms as reported by many women in Western cultures. Their findings do, however, reflect similarities with other studies of women in non-Western societies where the importance of the older woman in society is clearly evident.

Comparative studies of the menopause

In the anthropological literature on menopause, there has been a general agreement that social and cultural factors have strongly shaped women‟s menopausal experience (Lock 1994; Chirawatkul & Manderson 1994; Rice 1996). My study adds further weight to the argument that menopausal experiences are multi-determined

(Theisen et al. 1995). Menopause is a process of ageing that comes with emotional, psychological and physiological changes similar to menstruation and pregnancy

(Daniluk 1998). These events are associated with hormonal and bodily changes coupled with a range of emotional and psychological factors that vary across cultures. I am also of the view that menopausal experiences have to be examined within a local context of specific practice and with sufficient attention to the cultural norms expressed within that context. These themes are to be further developed in this thesis.

Interestingly some anthropologists have investigated the issue of menopause through a wider lens of cross-cultural study. For example, Bart (1969), who conducted a study among eight cultures, found that women‟s status and activities during their childbearing years reversed at menopause. She also found that women in these cultures enjoyed an increased social status. Bart argued that this happens mostly in traditional societies which protect older women from being the subject of negative remarks. In addition, Bart has outlined a model that she believed governed middle-aged women in 140 non-Western societies. The model has six important traits: strong ties to the family of origin, an extended family system, emphasis on reproduction, strong mother-child relationships, institutionalised grandmother roles and institutionalised mother-in-law roles. In this model, Bart identified that the institutionalised mother-in-law role does not exist in Western societies which results in the decreased social status amongst Western mother-in-laws.

Beyenne (1986) conducted anthropological research on the reproductive lives of

Mayan and Greek women. In her research, she categorised women according to their menstrual status and found that Mayan women like those women reported in Rajput

(Flint 1975), perceived menopause as a positive event that marks the end of their childbearing years. Interestingly, Beyenne found that Mayan women did not complain of having hot flushes or cold sweats. By contrast the Greek women in her study had similar menopausal complaints to those of Northern European women, mainly discomfort and uneasiness. Beyenne suggested that menopause should be interpreted as a biocultural event taking into consideration other variables like diet and reproductive history which influence the experience of menopause. However, Beyenne did not suggest any physiological explanations which supported the attitudes expressed by the

Mayan women. Although Beyenne has argued for the importance of studying diet and reproductive history of menopausal women, there is little evidence that anthropologists have taken these issues into account (see Lock). This may be, to some extent, a reflection on the methodological and theoretical limitations associated with working within a single disciplinary frame.

Davis (1986), in her study of women living in a Newfoundland fishing village, has challenged the relationship between improved high social status and a positive attitude towards menopause. She found that middle-aged women who enjoyed high social status experienced the negative consequences of menopause more so than women

141 in lower socio-economic groups. In contrast, a study among Iranian women by Khademi and Cooke (2003) found that urban Iranian women of upper socioeconomic standing accepted positively the changes brought about by menopause compared to Semiromian rural women. Urban Iranian women‟s positive reaction towards menopause is due to broader social identity and they are less defined by their reproductive ability. One of the reasons is that occupying professional jobs and degrees contributes to the women feeling independent and to their greater high self-esteem. The researchers postulated that both of these have a modulating effect on the way urban Iranian women adapt to menopause. By contrast the Semiromian women are of the opinion that menopause summons a status drop for women. Most importantly, they are considered as family- oriented individuals, socially and financially dependent on their husbands. Thus, menopause does not occur easily for them. These findings are of relevance to my study as I focus specifically on women in urban areas of a higher socio-economic status and compare, where I can, these findings with a previous study of women in a Malay village

(discussed later in this chapter).

Gifford (1994) provided further research which contradicts the findings that women‟s status improves with age. She focused upon middle-age Italian women who migrated to Australia who have expressed ambivalent feelings about menopause and associated menopause with deteriorating health. Although the women in her study accepted menopause as a biological change, they described menopause as a time of vulnerability, fear and insecurity. The women believed that they were more susceptible to illness than men as they aged. The results of the studies outlined above tell us something of the study participants‟ social status (gender, social class and ethnicity) and their cultural values in relation to their menopausal status. However, I believe that the question of why older women‟s status has shifted over time and across different forms of social organisation still needs to be addressed. This is of particular interest when we

142 consider a country like Malaysia where, as I have already noted, the majority of people now live in urban locations and where older women are expected to fulfil the dual roles of dutiful wife and full time paid worker. Within this context it is useful to consider the kinds of anthropological studies conducted within Asian settings.

Anthropological studies of menopause in Asia

In general, there have been relatively few anthropological studies on menopause conducted in Asia (Punyahotra & Dennerstein 1997). The existing literature shows heterogeneous data on menopause due to geographical location, health care systems and women‟s conditions (Punyahotra & Limpaphayom 1996; Boulet et al. 1994). One of the earliest and most famous anthropological studies about menopause in Asia was by

Marcha Flint (1975) who studied women in Rajput, India. Flint studied menopause and status change at mid-life. She found that menopause marked the end of purdah (veil and social isolation) and that women were given the freedom to participate in activities previously denied to them. Flint explained that women of Rajput considered menopause as a reward that entitled them to greater freedom. In reality, she noted, Rajput women hardly had any menopausal symptoms. By contrast, it has been shown that Western women who suffer from role loss and empty-nest syndrome regard menopause as a punishment. Two studies by Beyenne (1986) and Rice (1996) record similar findings.

Nonetheless, Sharma and Saxena (1981) who studied Indian women in Varanasi City,

India found that 61 percent of women were having hot flushes, 58 percent had night sweats and 67 percent complained of insomnia. This finding disagrees with the statement above by Flint, that women of Rajput are barely affected by the symptoms.

The high percentage of Varanasi women inflicted by hot flushes is similar to most

Western women who are disturbed by menopausal symptoms.

Like Flint, Chirawatkul and Manderson (1994) found similar results with Thai women who did not regard menopause as an upsetting event. Culturally, Thai women 143 were highly valued and they regarded menopause as a biological event associated with ageing. Nevertheless, the researchers indicated that this perception has gradually changed among some modern Thai women. These women experienced menopause negatively and thus they resorted to medical treatment. One of the reasons offered was that the women were confident with biomedical treatments which they saw as controlling infectious diseases. In addition, since pregnancy and childbirth were under the surveillance of medical treatment, this was viewed as appropriate for other women‟s health treatments as well. Although modern women seek medical treatment,

Chirawatkul and Manderson found there were no available studies specifically on HRT among Thai women.

A study among Hmong women who migrated to Melbourne, Australia, by Rice

(1996) has also associated menopause with ageing. In Rice‟s study, Hmong women welcomed menopause and perceived it as a positive event with few symptoms. Rice reported that Hmong women who lived in Melbourne experienced a process of cultural adaptation to the Western society. However, she had not, at that time, explored the possibility of younger generation Hmong women adopting different attitudes towards menopause as a result of exposure to Western ideas.

Lock‟s (1993) well known study focused on Japanese and North American women. She explored the divergent sociocultural factors of ageing women which range from the physiological changes and cultural understanding of menopause. She found

Japanese women reported fewer menopausal symptoms compared to Western women.

Lock‟s interesting findings outline a number of contributing factors that influence menopausal experience like women‟s social status, gender roles, personality, life history and state of health. All of these have an effect that, in part, determines their menopausal experiences and position in the society. In comparison with Kauferts‟s (1985) study on women in Manitoba, Lock found Japanese women reported low menopausal symptoms.

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Malay women and menopause

Little baseline information exists from which to understand what constitutes menopausal experience among Malay women in Malaysia. As already noted, menopause is not a topic that is generally discussed in Malaysia (Ismael 1994). Even though there have been medical studies done in Malaysia (Ismael 1994; Mohd Zulkefli

& Mohd Sidik 2003) these have largely reported menopausal symptoms. In terms of methodology, these studies used surveys to obtain data from the women. Although the above-mentioned studies discussed menopause, the findings focused on categorising menopausal symptoms as being either positive or negative. Furthermore, the findings were based on clinical practice studies that have not incorporated sociocultural factors that may account for certain attitudes or experiences. There still remains very little information on the social and cultural experiences of urban middle class Malay women.

According to Omar (1994), the anthropological literature that deals with health issues of Malay women in Malaysia is limited. Specific anthropological studies on

Malay women‟s health are best illustrated in Laderman‟s (1983) work on childbirth and post-partum care among rural Malay in Terengganu, and Manderson‟s (1981; 1987) works which address post-partum rituals and classification of foods among Malay women. While these were rich ethnographic studies that provided in-depth appraisals of women‟s reproductive health experience Laderman and Manderson, however did not include the experience, beliefs and attitudes toward menopause among Malay women in their studies.

A study conducted by Omar (1995) unravelled the meanings, attitudes and experiences of menopause among rural Malay women in a way that was absent in other studies in Malaysia. This is the only study conducted on menopause in Malaysia which uses a qualitative approach. A Malay scholar, Omar focused on the menopausal experiences of rural Malay women in Malacca. One of Omar‟s main claims is that

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„Malay women neither fear, nor are affected by, serious adverse symptoms of menopause‟ (p. 480). Omar reported that most women in her study only complained of having irregular menstruation. The women in her study did not mention any menopause-related symptoms such as hot flushes, empty-nest syndrome, depression or mood swings. Indeed, rural Malay women in her study are contented with their life at the onset and throughout menopause. Omar‟s study conformed to Bart‟s model of changes in roles and status theory. Like Bart, Omar also found that most women had strong ties to their family of origin and that they were part of an extended family system in which the mother has power and control; there were strong reciprocal ties between parents and children, institutionalised grandmother roles and institutionalized mother- in-law roles; and for most women age was valued over youth. All of the above factors were seen as contributing to people viewing menopause more positively (Bart 1969).

Indeed, Omar‟s study as well as Bart‟s is still relevant to the context of my study on urban middle class Malay women. Bart‟s model identifies core symbols in the life of urban Malay women which are relevant to my study. Family relationships are still at the heart of the urban Malay woman‟s life, but as we will see these women are beginning to think about the values associated with ageing in different kinds of ways.

Omar‟s study also agrees with the status-gain hypothesis used by Barnett (1988).

Rural Malay women in Malacca enjoyed a higher status and received more privileges and freedom when they reached menopause. Likewise, as I will show in the chapters to come, the urban middle class Malay women in my study still gain respect, being considered as wise and experienced persons and they are given the honour of taking care of their grandchildren. However, in comparison with the rural Malay women, urban

Malay women have less responsibility in looking after their grandchildren now, as many of their grandchildren are sent to day-care centres, or are taken care of by foreign maids.

I found it was also very unlikely for the women in my study to take up another role

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(healer, masseuse, religious teacher as mentioned by Omar in her study) as they still continued working and the demand for them to stay in the workforce was compelling.

The other aspect of Omar‟s study which was novel and does not appear to have been noted by other researchers studying menopause was that rural women consulted a bidan to determine whether or not they had reached menopause. In the Malay urut

(body massage) system, the bidan is consulted because of „her knowledge about the anatomical and physiological aspects of the body‟ (Omar 1995, p. 481). On this particular point, my data shows that urban middle class Malay women no longer go to the bidan but prefer to see a doctor to discuss their health conditions and to get treatments. According to most of the women in my study, they consulted with a bidan only after childbirth or to get their bodies massaged for body aches. The bidan was not consulted for issues regarding menopause.

Omar noted that the Malay adat extended child-raising duties to grandparents.

The grandparenting role, together with the strong religious beliefs expressed by the women gave them a feeling of accomplishment and satisfaction. This finding is similar to other studies conducted in Thailand (Punyahotra & Dennerstein 1997; Chirawatkul,

Patanasri & Koochaiyasit 2002) where menopausal women stated that they meditated and listened to Buddhist teachings which were regarded as tools allowing them to become „calm‟ and „cool‟ during menopause. In other words, in these traditional religious settings religious teachings provided a structure whereby women could find strategies to manage their menopausal experience.

Omar‟s findings showed that women were not the „victims‟ of their biology and that they did not experience menopause in a stereotypically Western manner. Omar‟s study has been useful in identifying some issues to do with menopause and Malay women. However, it is now somewhat dated and there is also a need to study urban

Malay women as well. We do not know how Malay women in the urban area see

147 menopause, what their feelings are about menopause, what mechanisms they adopt to cope with the situation and the role of culture in protecting or reinforcing their emotional well-being.

In my assessment, it may be that Omar tended to over-simplify the issue. She insisted that rural Malay women welcomed menopause and did not see any of the physical symptoms of menopause as problems. Furthermore, she ignored the more private experience of Malay women. As I will show in the remaining chapters of my thesis, my research discovered that not all Malay women were experiencing menopause

„easily‟, nor were they particularly happy with menopause. While I agree with Omar that women are not „victims‟ of their bodies, I do not take a deliberate feminist standpoint. In some ways, I believe it may be counter-productive to adopt this stance, by insisting upon women‟s agency. I may not do justice to the stories of my participants who at times felt bereft of agency. This is not to say that the women I spoke with were not competent and active members of society. Indeed, as will become evident, many were particularly productive, combining work in both the domestic and the public spheres. It is notable that the working lives of married women in their middle-aged years have not received a great deal of attention in Malaysian research. Yet this is a period when many changes typically occur in women‟s personal, domestic and family lives. This is one reason, among many, why I have chosen to focus on the menopausal experience of urban middle class Malay women in Malaysia.

Conclusion

It is clear that menopausal experiences and symptoms vary across and within cultures. It appears that some women exhibit severe symptoms, others encounter only mild symptoms and some women report no symptoms at all. The existing anthropological literature that I have reviewed does not discuss how urban professional women experience menopause at home and in their workplace. Issues like the role of 148 the family members in women‟s experience of menopause, women‟s perception of their doctors and of treatment have not been studied, at least not within the Malaysian context. Earlier anthropological studies have focused on women in the agricultural sector, mostly in a rural setting and among women of low socio-economic status. In my study, I attempt to examine menopause experience within a different setting and to focus on women from a higher socio-economic background. While the abovementioned anthropological studies have successfully shown the link between menopause and sociocultural factors, I found little attention has been given to addressing the issue of medicalisation. In addition, there has been little, if any, attention paid in a non-Western setting of how older women experiencing menopause may think about femininity, sexuality and beauty in relation to becoming older. Being able to uncover some of these issues through talking with menopausal urban middle class

Malay women in Malaysia has certainly been enlightening to me and will, I hope, begin to fill some gaps in the knowledge of this subject area.

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CHAPTER FIVE

MENOPAUSE: AN OLDER WOMEN’S PERSPECTIVE

Introduction

The principal aim of this chapter is to consider the cultural understandings of menopause through examining the manner in which the women in my study spoke about menopause and the treatments they chose to deal with the symptoms of menopause. I have also sought to understand how the way they spoke about menopause is reflective of broader discourses surrounding both menopause and the role of older women in urban middle class Malay society. As noted in earlier chapters, the women in my study are in many ways typical of urban Malay women in KL and as such my findings are likely to reflect the experience of many middle-aged Malay women in cosmopolitan Malaysian cities. However, I do not claim that the views of the women are truly „representative‟, as my study is qualitative in nature. This kind of methodology allows me to explore the world views of a group of women who are combining work in the home and the paid workforce while simultaneously undergoing a significant biological change. My findings indicate that in general, Malay women accepted menopause as part of the biological process and acknowledged that menopause untied them from menstruation, pregnancy and childbirth. Despite this resolution to change, many of them kept their condition (and all that it entailed in terms of symptoms and discomfort) secret and did not tell family members about their experiences. Many of the women I spoke with viewed menopause as a distressing time of their lives.

Indeed, there is a compelling theme that emerges from the women‟s stories that suggests that menopause is experienced very differently by the urban middle class

Malay women today compared to their mothers. On one hand Malay women, especially those living in rural areas were very private about their menopausal condition and this level of secrecy may not be that different from urban Malay women today. However,

150 urban Malay women today, unlike their mothers, are more likely to seek medical advice for unwelcome symptoms and complaints. They are also more likely to feel the pressure of maintaining a certain appearance and level of performance in the paid workforce, which is an important aspect of my study as most urban educated middle class Malay women work in the government or non-government sector, so their workplace is the

„office‟. Women must learn about menopause in some ways, and this is not solely through going to a doctor to help alleviate unwelcome symptoms. Consequently, women (and men for that matter), learn about menopause in a very informal way, often through observation and what is not said and done, rather than by explicit education about the matter.

What urban middle class Malay women undergoing menopause say about this inevitable biological change cannot be disentangled from what they say and think about ageing in general. Menopause is a very real biological marker of the ageing process. I am interested in understanding what middle-aged women think and feel about their physical and emotional changes after they have stopped menstruating and how this is linked to what it might mean to be an older Malay woman in urban society. Women are exposed to conflicting messages and take these up differently. On one hand, the women

I spent time with still adhere to traditional Malay culture, religion and lifestyle. This cultural view accommodates respect for both older people and for women. Yet on the other hand, urban middle class Malay menopausal women are now exposed to a

Western youth and beauty culture mostly through media portrayals. The experience of menopause for these women is „betwixt and between‟. Not only is this stage of their life a transitional rite of passage (van Gennep 1960), but it is further complicated by the conflicting cultural values associated with tradition, and with modernity and

Westernisation.

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In this chapter I use case studies to highlight attitudes towards menopause and to provide a context for understanding the factors that contribute to both high and low anxiety towards menopause and ageing. In the first instance I examine the complexity of every day life for twenty-seven of the women in my research study. Due to many factors which I will elucidate in the course of the chapter I have considered these women as having a high level of anxiety towards menopause and ageing. I will focus particularly on two women, Sharifah and Balkis, who were affected markedly by the experience of menopause. Their stories and those of others allow me to explore several key issues that influence the menopausal experiences of Malay middle-aged women like body image, sexual relations and the influence of media on the emerging youth and beauty culture in

Malay society.

In the second section of this chapter, I will introduce readers to Meenah,

Chombee and Kay, their families and their occupations. These women were selected because they exhibited a low level of anxiety towards menopause and ageing. Unlike the other twenty-seven women who participated in the study, they did not exhibit the same negative attitude towards menopause. This has enabled them to lead rich and meaningful lives; they reported that their lives were gratifying and that they see this time of life as a period of self-evaluation and reflection. My choice of these case studies indicates my strong belief that women cannot all be categorised into „menopausal‟ as if their biological status defines them in a particular way. While I will identify and analyse significant trends and commonalities, each woman has her own story embedded within a rich local culture.

Part of this rich local culture is the importance of Malay traditional values and the strong influence of Islamic teachings that have conditioned the lives of Malay people in general and their attitudes towards middle-aged and older people. In addition,

I include a discussion about religiosity and the adherence to the Malay adat because it

152 will be impossible to understand everyday life for my informants without appreciating this central aspect of their lives. In this chapter, I will report on different responses to both the experience of menopause and ageing in general. While I discuss these aspects in relation to the stories of the three women who have low anxiety to menopause, it is important to note that all women in the study respect traditional values. First of all, in this chapter I consider how Malay people actually come to understand what menopause is. I will examine this mainly by using the reflections of the menopausal women themselves, but I will also draw upon some of the comments made by the children of the menopausal women I interviewed during my fieldwork in KL.

The informal way of learning about menopause

Malaysian society, because of cultural and religious mores, has a very restricted notion about sex education. Even if sex is discussed in a formal way, such as in the academic curricula of sex education, many aspects of sexuality are omitted from the learning process to conform to the cultural and religious restrictions. Discussion about sex is taboo and is generally regarded as kotor (dirty) (Mohd Ali 1985). Furthermore, any issues regarding sexuality are considered lucah (obscene). In many ways menstruation and menopause are associated with discussions of sex because they signal the ability or non-ability to conceive. Similarly in the Korean culture, talking openly about menstruation, pregnancy, sexual relationships and menopause is also regarded as taboo (Kim cited in Im & Meleis 2000). Among the Malays, religious teachers are responsible for conducting sex education with children (Mohd Ali 1985) though this is limited to issues pertaining to puberty, prohibition of sex before marriage and its

153 consequences, menstruation and mandi hadas.70 Mandi hadas, or ritual bath, is performed immediately after menstruation ends, and after sexual intercourse and also at the end of the confinement period; which are Islamic requirements specified in Hadīth.

Malay parents in general do not talk openly about sex in front of their children or discuss with their children the issues relating to sex or bodily functions, for example as a preparation for puberty, the teenage years or marriage. Children are expected to experience these transitions for themselves, but of course while these things are not spoken of in an overt way, children must learn about sex and bodily processes in some fashion. In most instances, information about sex and issues related to it (in the case of my study, menopause) is passed on by friends who are older or the nearest kin, other than the parents. As Zila, one of my participants (a child of one of my participants) aged

42 said:

I guess we come from a different generation… my mum and I. My mum‟s generation is not very open on certain subjects like sexuality. It is a sensitive topic to be discussed. She told me about menstruation, but other topics are told in a very general manner. A lot of the time, middle-aged people don‟t discuss this [menopause] openly. We heard other people‟s cases, but not our own mum. Previously when I was at school or currently at the office, my friends and I used to compare stories with one another. That is how I found out some things that my mum didn‟t tell me.

This scenario is also true - based on my own experience. Like Zila, my own mother also spoke very little about sexuality. In the month before I was due to marry; my mother and my grandmothers were responsible for explaining married life to me.

Tips on maintaining a happy marriage were transmitted to me from one generation to the other. They advised me endlessly on how to become an obedient and responsible

70 Mandi hadas, sometimes also known as mandi wajib (compulsory bath), is obligatory after fluid is emitted as a result of marital intercourse, having a wet dream, after the end of menstruation and postpartum bleeding. The steps of performing mandi hadas outlined by Abu (2000) are as follows: i) make the niyyat (intention) to perform the bath. A person has to be specific in regards to the particular bath he/she wants to perform, ii) wash the private parts to remove any secretion, iii) perform wudhū’ (ablution), iv) wash the entire body beginning from the head preferably three times, v) pour water over the right side of the body and clean all the parts; repeat the same action on the left body. Having completed the steps, men and women are considered clean and they can perform their prayers, fasting and recitation of al-Qur’ān. 154 wife. I was told to take care of my husband, prepare good meals for him, manage the household and comply with anything else that is related to marriage. There was no discussion about how a woman becomes pregnant. They were more interested in explaining the signs of pregnancy like the delay in the period, morning sickness and the cravings for sour food. When I conceived my first child both my mother and grandmothers talked about the pantangs during pregnancy and after childbirth, family planning as well as teaching me some parenting skills. However, despite the gap in my sex education I still managed to have two children.

Discussions about menopause have been the subject of similar limitations. In

Malaysia, menopause as a topic is not included in the sex education curricula; it is also not well explained in science subjects as part of the biological process which affects women‟s reproductive capacity. As I explained earlier, it is notable that overt discussion about sex, even something that is more oriented to bodily changes such as menopause, is avoided, even between mothers and daughters. Thus, much information about menopause is learned in a very covert way. Another way of explaining knowledge about menopause is to say that it becomes a kind of tacit knowledge that is not openly acknowledged, but nevertheless, is understood in a very informal way. Interestingly, some women in my study obtained information about menopause from me as a researcher. This is somewhat ironic given that I am much younger than the women I spoke with. During my fieldwork in KL where my mother lives, she spent some time asking me questions about menopause with full enthusiasm every time I returned from the menopause clinic. I brought back health information brochures from the menopause clinic and bought her a magazine for middle-aged woman entitled MIDI for her own education.

In this next section, I will discuss how knowledge about menopause is obtained by women and their children, namely, the observation of elder members of the family,

155 listening to stories told „around‟ rather than „about‟ the topic and information from the printed media are some of the ways Malaysians learn about menopause. Before I do that, I would like to quote from my fieldwork diary on this issue.

Fieldwork diary 7 January 2007

It is a sad day today. I have to say goodbye to my husband and two sons. I have to return to Perth to continue my unfinished business – PhD! We arrived very early at the Kuala Lumpur International Airport (KLIA) to avoid the traffic jam on the road and the long queue at the check-in counter. After I obtained my boarding pass, we had breakfast together at a nearby café. I hardly ate or talked because tears kept falling down my cheeks. After breakfast, I spent a few minutes talking with my family. At 9.00am, it was time for me to go. I always hate this part. My family and I exchanged hugs and kisses as well as good wishes. While I waited for my flight MH125 to Perth, I decided to grab something to read; perhaps a newspaper or magazine to keep my mind busy thinking about something else, not my family. I went to a bookstore. After fifteen minutes of looking for something nice to read, my eyes were attracted to a book that bore the title of my research topic, MENOPAUSE from the ‘Chicken

Soup for the Soul’ series. I’d been searching for this book for months! I had read other books from this series during my university days. It was jam-packed with enlightening stories. I waited no longer, grabbed the book and paid for it. I looked at my watch, it’s 9.20am. I have twenty minutes before I board the plane to read the book. I read a few pages from the book with enthusiasm hoping to

156 get some ideas for my next journey - writing the thesis. I came across a very interesting story. It reads:

My son, Graig, discovered Dr. Ruth when he was ten years old. He sat riveted to the television while I was preparing his favourite breakfast - French toast. As I was whipping up the eggs, I was half listening as Dr. Ruth and a gynaecologist were explaining menopause to the viewing audience. Suddenly, I was aware of a pair of eyes looking at me longingly. My son said nothing but continued to watch as I cooked. Finally, I asked if something was wrong. Wistfully, my son answered, ‘Did you know, Mommy, that after menopause, you can’t make eggs anymore? (Hendrix, Canfield & Hansen 2005, p. 1)

This amusing story gives a clue to the complex understandings of menopause held by Malay people, and perhaps people from other cultural groups as well. My interviews with some of the family members of the women in my study, particularly with their adult children, have shown that menopause is a topic that often creates confusion. Most women in my study mentioned that their mothers had not taught them openly about menopause when they were younger. Instead, they were advised to deal with menopause when „their time came‟ or to consult a doctor. Similarly, even though I found myself talking to women who were in my own mother‟s age group, I had somewhat paradoxically never spoken with my own mother about this topic, until of course she showed curiosity in my research and I responded willingly with useful information.

Like other daughters in my study, I had observed my own mother praying five times a day without fail indicating that she was not menstruating.71 At times, I heard from my younger sisters that she had complained about hot flushes and tiredness but she has never admitted that these experiences were linked to menopause.72 In other words

71 According to Fiqh (Islamic jurisprudence), women who are menstruating or having postpartum bleeding are exempted from both prayer and fasting. The law regulates menstruation as a time of ritual impurity. Once they are rid of it, they can resume praying and fasting. In my mother‟s case she was able to continue praying as she had ceased menstruating. 72 My younger sister always kept me updated about our parents, especially Mak, throughout my study time in Perth. We exchanged stories about our own families, parents and siblings through the Yahoo Messenger every week. It was through her I knew that Mak complained about her hot flushes. 157 stories were told „around‟ the topic through reference to the symptoms, but the word menopause was not mentioned so the story was not literally „about‟ menopause.

Interestingly among Malay women, topics like menstruation, pregnancy and the post-partum period are discussed at length, but not menopause. The women I spoke to, felt that their mothers regarded menopause as either private or too insignificant to discuss even with their daughters. Many recalled the secrecy that surrounded the subject when they were young. Zawiyah, aged 50, told me:

After I got married, I stayed with my mum for five years. We shared a lot of things. But this problem [menopause] she never told me a word about it. Not at all! Never! I guess it‟s her way of doing things. She was hiding it from us, I don‟t know. I don‟t know how she feels. Now, I‟m experiencing it, I know how it feels.

Balkis, 54 years old, recalled a similar situation with her mother:

My mum‟s menopause was in her early 40‟s. I was a small girl. I saw her bleeds heavily and sometimes she couldn‟t walk. She stayed at home. There was no medicine at that time. But, she never told me she was in the process of [starting] menopause.

In my study, as I have explained, I found my participants learned about their mother‟s menopause through observation – by noting her daily practices like praying five times a day, fasting 30 days and no more pregnancies. The majority of the women I interviewed who were undergoing menopause admitted that they sought information from friends by listening to stories, reading women‟s magazines and books and other media. Family members, especially sons and daughters, tended to know very little about their mother‟s experiences of menopause. Many were uncertain when their mothers acted out of character whether the behaviour was associated with menopause or not. In fact, most of them had no idea about menopausal symptoms.

Some children I interviewed recalled the effect that menopause had on their mothers. Dewi, who works as a personal assistant in a private company has ten siblings aged between 5 and 29 years old. As the eldest, she helps her mother to cook, wash and

158 clean the house. Sometimes she also helps get her siblings ready for school. Dewi‟s mother, Mariam, is a 53 year old housewife. When asked about her mother‟s menopausal experience, Dewi was uncertain whether Mariam‟s change of behaviour was related to the symptoms or because of the pressure of managing a big family. Dewi recalled that Mariam frequently complained of joint pain, numbness and wrinkled skin.

At one time, Dewi bought some anti-wrinkle cream for her mother but Mariam continued complaining. Dewi recalled how Mariam vomited for a week and became quite alarmed when she could not get off her bed. Mariam spat, could not cook, had a fever and a cough. Was she pregnant again thought Dewi and why did she sleep in a room with two of Dewi‟s younger siblings for several nights? Why had she left Dewi‟s father to sleep alone? Surprisingly, Dewi‟s father did not complain. Instead he said that

Mariam had many children and she could choose to sleep with any one of them she liked. One thing that Dewi could not comprehend was her mother‟s unpredictable mood. She noticed her mother easily „snapped‟ over small reasons and sometimes there was no reason at all for Mariam to get angry. When Mariam „snapped‟, she would break the glasses in the kitchen or scold her children. Dewi explained how Mariam appeared to urinate frequently and suspected that her mother was suffering from a disease, or was it simply menopause?

Like Dewi, Sabrina, a bank officer in her late twenties, noticed some behavioural changes in her mother‟s physical appearance and mood. Sabrina is the eldest of two siblings with her younger brother having just completed high school. Her father, aged 58, retired from the army and now spent his time running a small business in the city. Sabrina‟s 55 year old mother, who worked in a government office, started to be very grumpy. Sabrina recalled that her parents had an argument. She overheard her mother saying that her father was an „old man but still wanted to have sex!‟ Sabrina claimed she was not interested in the argument as it was „a personal matter‟, but clearly

159 she was confused about what was going on. One night, she noticed that her mother had slept in the guest room and her father complained. It was during breakfast that her mother provided further clues for Sabrina to work out what was going on. She remembered her mother said she was very hot last night and she has no interest in sleeping with her father. At this point Sabrina was still uncertain and it did not occur to her that her mother exhibited menopausal symptoms. To her, it was an adult issue and something that was quite clearly awkward. The following week, to her surprise, she recollected that her mother came home from her office with blonde hair. Sabrina was speechless. Her mother said she felt good with her new hair colour and believed it gave her new confidence.

Some sons noticed behavioural changes in their mothers as well. Azman, aged 29, for example, is the second child in his family and is a primary school teacher. Like

Dewi and Sabrina his mother also exhibited some behavioural changes:

Nura: Tell me what do you know about menopause? Azman: Not much. What I know is that women stop menstruating around the age of 50. They don‟t have babies. Nura: How do you know that your mother is going through menopause? Azman: I have hunches as she never tells me or my sisters. I realized when she never misses teaching the children to recite al-Qur’ān. Previously, once a month she must postpone the class because she‟s having her off day [menstruation]. She will not teach for about six to seven days. Then, she will not pray. When her off day ended, the class resumes. She will also pray as usual. Nura: Did you notice any behavioural changes? Azman: Certainly! I guess my mother has entered another world. A world of tiredness and inefficiency. Just like my late grandmother who had entered the same world. Previously my mother was very active and energetic. She cooked and cleaned very fast. She participated in women‟s activities in the neighbourhood. Now she seems very tired, rarely wants to go shopping or travelling and she is forgetful. She prefers to stay at home or to visit her grandchildren who live nearby. Lately my mother is becoming very sensitive. We have to be very careful of what we say or do at home. I try to minimize speaking to my mother. I fear my words will hurt her even though I didn‟t mean it. Nura: Did your mother seek any treatment for her symptoms? Azman: Not that I know. I brought her to see a doctor not long ago but it was about her muscle pain. Not specifically on menopause. But one day, she shouted at me „Buy me menopause pill, buy me menopause 160

pill!‟ Menopause pill? I have no idea what it looks like or where to buy it. If she asked me to buy Panadol, I know where to get it. That was the first time I heard she mentioned the word menopause.

Like Azman, Kamal, a senior executive at the Central Bank of Malaysia, also raised the same issue. His own mother, Sofiah, has bad mood swings. Kamal recounted the following:

I don‟t understand why lately my mother is grumpy. I noticed she has a fluctuating mood. Sometimes she‟s OK, she‟s nice to us. Sometimes she‟s not stable, always pissed off. We are all the prime target of her anger. My father advised us not to argue with our mother as it will make her more „unstable‟. I guess the older you grow, it‟s like that.

Dewi, Sabrina, Azman and Kamal noticed some behavioural changes in their mothers but were not completely sure whether the changes were associated with work or pressure of managing the family. All of them agreed that their mothers had never spoken about menopause as it was a topic that most mothers did not openly discuss with their adult children. They all expressed their concern about their mothers acting out of character outside the house. With regards to mood swings and sensitiveness, these symptoms have to some degree altered their communication with their mothers. All of these children expressed concern for their mothers and would do their best to please them in words and behaviour. Nevertheless, they remained confused about what was really happening and how best to respond.

Through my interviews, I found that not only had menopausal women desisted from questioning their mothers, their children were not encouraged to make enquiries of them. Even Malays who are urban and educated are not encouraged to ask too many questions about issues of sexuality. Those who ask questions regardless are regarded as

„showing disrespect‟ (Zamani 2002, p. 172). In addition, parents impose sanctions upon their children to make them fearful of asking questions, thus discouraging them from asking again in the future. Hence, most Malay children‟s experience of asking about

161 sexuality is shadowed by the fear of punishment and is seen as pointless because they would be unlikely to be given a „straight‟ answer. My study is similar to Agee (2000) who studied the transmission of menopausal knowledge among African-American and

Euro-American women. The African-American women‟s main reference for learning about menopause was through looking at women who fanned themselves in church due to hot flushes. In other words, knowledge about menopause among the African

American women is transmitted in the public space of the church and not in the privacy of the home. Similarly, knowledge about menopause in urban Malay society is transmitted by the menopausal woman‟s capacity to engage in prayer, fasting and the teaching of religion. However, though in one sense while they are „pure‟ and free from the pollution of menstruation, they are subject to misunderstanding by their families and many are burdened by the discomforts of menopausal symptoms.

The unexpected way to learn about menopause

As part of my research, I conducted a focus group which I organised with the help of my aunt Zubaidah who is the Chair of women‟s group for the Water Corporation agency in KL. As I stated in Chapter Two, the reason for the focus group was to listen to women‟s concerns, hopes and expectations about their menopausal experiences. With the consent of six women (none of whom had ever attended a menopause clinic) I organised the group which took place in Zubaidah‟s home. I brought along some copies of MIDI magazines73 , brochures on Klinik Harapan74 and Hormone Replacement

Therapy, as well as health flyers about menopause to help the discussion along. Unlike most of the other women I discuss in this chapter, the women who attended the focus group did not seek medical assistance to help them cope with their conditions. One of

73 A magazine published especially for middle-aged Malay women, which I will describe in more detail in the following chapter. 74 The menopause clinic where I conducted observation and from where I recruited many of the women I interviewed. 162 the women was still menstruating, but irregularly and she had exhibited symptoms associated with peri-menopause75 like insomnia and less sexual desire. When I asked about their menopausal symptoms, all of them were unsure what the „symptoms‟ were but, they noticed some changes had taken place in their bodies or in their social interactions and memory:

Salbiah: Not sure whether this is the symptom that you are looking for. First thing I noticed I had a bad PMS (pre-menstrual syndrome). I hate to have my period because every time I bleed I have to take six tablets of Panadol to reduce the pain. I can‟t work. My period is irregular. Sometimes it overflowed. I feel hot, sweating profusely at night, cannot sleep and yes my sexual desire has slowed down. I have mood swings. But then I guess my „typhoon‟ [mood swing] is all the time, not specifically at this stage. I‟m glad I have no crying spells or anxiety.

Norakma: My husband told me I‟m sensitive now. I easily get offended when my husband makes jokes about me. Last time, we didn‟t speak for three days just because of his stupid joke. Other than that, my sexual desire too has decreased. Previously, when my husband hugged me, I said, „Let‟s do it!‟ Now, when my husband caresses me or even „shakes‟ me, I don‟t feel the impulse to do it. Is this what you meant by menopausal symptoms?

Mazwin: Lately I realized I can hardly focus on what I read. I repeat twice, sometimes thrice to read a page of a magazine. After repeating over and over again what I‟ve read, only then I understand the content. It was not like this before. What do you think? Do I have the symptoms?

The above interview excerpts indicated that the women were uncertain about what was going on with their own bodies by expecting me to translate their bodily changes and experiences into menopausal symptoms or not. Although my role was not as a doctor to confirm that they were going through menopause, I responded that the changes did appear to be associated with menopause and ageing in general. After they heard my explanation and I showed them the brochures, Salbiah said, „so, this is it. It‟s menopause symptoms‟. Norakma added, „now I understand why this happens. You age,

75 The period before menstruation actually stops, but when menstruation may be sporadic and menopausal symptoms may begin. 163 you have all sorts of unbelievable problems‟ and Mazwin exclaimed „oh my God, I‟m there!‟ Other women in the group thanked me for bringing up the issue. Most information, particularly information about symptoms, HRT and the menopause clinic were introduced by me during the discussion. Interestingly, women in the focus group had never come across any of the materials that I brought to show them. Instead of using the material to probe the discussion, I ended up using the material as a source of information about menopause for them. While these women exhibited similar symptoms to the women who I had interviewed in the menopause clinic, the difference was that they learned about menopause through the most unexpected way – from me!

Variations of responses towards menopause

All symptoms of menopause are the result of the depletion of the estrogen hormones. The symptoms include vasomotor symptoms, psychological symptoms, aches and joint pains, urinary and genital changes and other visible effects.76 Earlier in

Chapter Four I explained that every woman‟s experience of, and attitude to, menopause is individual and unique. Studies have shown that women‟s experiences of menopause in Western cultures are different from that of non-Western cultures (Bart 1969; Boulet et al. 1994; Lock 1994). Many women in Western societies see menopause as an unwelcoming and distressing change in their psychological and physical well-being

(Gifford 1994; McCrea 1983). In other words, Western women appear to have a potential vulnerability toward a more difficult menopausal transition than non-Western

76 A menopausal woman may experience any or all of the following symptoms: A. Vasomotor symptoms: hot flushes, night sweats, anxious sleeplessness, headaches, palpitations B. Psychological symptoms: depression, anxiety, mood swings, crying spells, forgetfulness, loss of concentration, irritability C. Aches and pains: backache, joint paints, muscle aches, osteoporosis D. Urinary and genital changes: dry vagina, painful sexual intercourse, recurrent urinary tract infection (UTI), bladder problems E. Other effects: thin and dry skin, hair loss or growth in facial hair, sagging breasts, lost of skin elasticity, vulnerable to skin rashes, accumulation of abdominal fat 164 women. Studies on non-Western women revealed that they experienced fewer severe symptoms; they did not suffer from the empty-nest syndrome, enjoyed a higher status and received more privileges and freedom following menopause (Flint 1975; Mernissi

1987; Omar 1995; Chirawatkul, Patanasri & Koochaiyasit 2002). As I illustrate in Table

6, there are broad variations of prevalence in menopausal symptoms among women in different societies or within the societies. The variations of reported symptoms are influenced by socio-economic as well as cultural conditions of any particular group of women. No doubt they vary for physiological reasons as well; those have not been thoroughly explored. It is unclear whether variation is due to women reporting or not reporting symptoms. It is more likely to be a complex interaction of social, cultural, political, biological and environmental factors that influence menopause.

Based on the literature that I have discussed in Chapter Four, various factors, particularly social, economic and cultural factors, in each society have a substantial impact on the lives of women from the day they are born until they reach their older years. Studies by Lock (1993), Davis (1986), Im & Meleis (2000) and Gifford (1994) to name a few, have shown that women‟s health including their menopausal experiences are impacted by several factors like the environment they lived in, pressures from both home and workplace, childbirth, food intake, migration experiences, cultural practices and insufficient healthcare.

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Table 6 Variation of responses across cultures towards menopausal symptoms. ______Researcher Study sample Reported menopausal symptoms ______McKinlay & Jeffreys (1974) American women hot flushes Flint (1975) Rajput women absence of any menopausal symptoms Sharma & Saxena (1981) Indian women hot flushes, insomnia, night sweats Davis (1986) Newfoundland women problems of „nerves‟ Beyenne (1986) Mayan women absence of any menopausal symptoms Lock (1986) Japanese women shoulder stiffness Chirawatkul & Manderson (1994) Isan women headache and dizziness Omar (1995) Malay women irregular menses Rice (1996) Hmong women irregular menses Punyahotra & Dennerstein (1997) Thai women joints pain, backache, dizziness and headaches Damodaran et. al (2000) Malaysian women fatigue, hot flushes Im (2000) Korean women nervousness, pain in arms and legs, fatigue al-Qutob (2001) Jordanian women urinary incontinence, UTI Fu et. al (2003) Taiwanese women tiredness, backache, dry skin Sierra et. al (2005) Ecuadorean women difficulty in concentrating, headaches, hot flushes, distress Discigil et. al (2006) Turkish women urine leakage, decreased libido, lack of energy, memory loss Lu et. al (2007) Arab women feeling tired/worn out, night sweats, hot flushes ______

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Thus, the health of women during menopause is the accumulation of physical and emotional experiences extending over their entire life span (al-Qutob 2001) and each is embedded within a specific sociocultural context. Narratives by urban middle class Malay women in this particular chapter and elsewhere in my thesis reflect this point.

My study also illustrates a degree of variation towards menopause among the urban educated middle class Malay women. In comparison with Omar‟s (1995) study which indicated that rural

Malay women pass through menopause without even noticing it or being affected by the symptoms, I found that most of the urban middle class Malay women in my study experienced unpleasant symptoms which, during the early stages, may have included irregular periods, night sweats and hot flushes and vaginal dryness.77 It has been reported that the number of Malaysian women with really severe symptoms could be less than 10 percent (Murugesan 2003); however, we cannot be sure if this is a correct estimation. I suspect, due to the lack of acknowledgement about menopausal symptoms and the difficulty in acknowledging them openly, the problems of discomfort may be under-reported. In my study, most women associated the beginning of menopause with irregular periods and other symptoms which would become distressingly apparent like having hot flushes, sleep disturbances, vaginal dryness, joint pains and fatigue. The women in my study consider that the menopausal symptoms have caused some problems in their lives and they described them as „inconvenient‟ or „bothersome‟. For example, some of them have to change their nightgown every night through sweating profusely, even in an air- conditioned room; they may cry for no reason; they may get angry easily and many experience memory loss.

77 I acknowledge here, as I have done in my methodology chapter, that many of the women I interviewed were recruited from the menopause clinic and were therefore perhaps more likely to be aware of and inconvenienced by menopausal symptoms. However, many other women who I spoke with did not attend the clinic and they too reported unpleasant symptoms. 167

Hot flushes78 and night sweats are the most commonly reported of the classical menopausal symptoms as described in a number of studies (Hunter 1990; Kowalcek et al. 2005; Malacara et al. 2002). These studies have shown that menopausal women will experience sudden unpleasant sensations of heat spreading over the face, neck and chest and sometimes over the whole body.

These attacks may occur at any time of the day or at night. My study indicates that urban middle class Malay women experience hot flushes similar to those experienced by Western women as reported in a number of studies. Hot flushes were the most apparent symptoms experienced by most women in my study.79 Zahira, a 51 year old administrative officer, described to me how her hot flushes irritated her husband:

I feel one kind of „hot‟. Not on my face. Only my legs feel hot. Normally it is at night. Every night I wrap my legs with wet towel and go to sleep. My husband complains because he is uncomfortable with that wet towel on my legs. Sometimes I didn‟t realize that wet towel was on his legs. Later he brings me to see the doctor.

Another woman Zaitun, aged 50, described her hot flushes:

My hot flushes is like… when you hold a pounded cili padi (birds eye chilli), it‟s pijar (hot). It‟s always hot on my back. Sometimes I can‟t sleep at night. I‟ll find a fan, though I‟ve already switched on the air-conditioner.

Apart from hot flushes, women in my study reported having experienced less sexual desire and reduced sexual activity. This situation occurs during menopause partially because of the thinning and shrinking of the vaginal tissue (Beckham 2002, Stoppard 1997). Since the vagina is thinner and drier, it will lead to unpleasant love-making. Some women described the situation as tak ada mood (no mood), kurang keinginan (less desire) or kurang minat (less interest) in having sex with their husbands. These responses were supported by a study conducted by an anonymous

78 A hot flush is „a sudden sensation of heat in the skin, especially in the face, neck and upper trunk, experienced by many women at the time of menopause‟. In Brewer’s Dictionary of Modern Phrase and Fable available from http://www.xreferplus.com/entry/2133356Hot flushes [accessed 27 March 2007]. The American equivalent is „hot flashes‟. 79 It is important to note that I spoke with most women about their symptoms in interviews conducted at the menopause clinic. Therefore, it is likely that the setting influenced their answers. They were more likely to focus on negative aspects even though I asked them general questions about their lives. 168 company in July 2006 among 300 menopausal women in Malaysia. Findings from the study have shown that 75 percent of the women experienced vaginal dryness and felt uncomfortable having sexual activity with their husbands (Ibrahim 2006). The study further reported that only 9 percent of the women reported that they had no problem during sexual intercourse when they reached the menopausal stage. However, because of religious obligations these women felt it was their responsibility to fulfil their husbands‟ needs, though not as frequently as before they reached menopause. I will return to this issue later in this chapter, when I discuss the women‟s concern about menopausal symptoms, especially hot flushes, which have created discomfort for most women as well as declining sexual desire.

On examining my interview transcripts and notes I found that there is no indication of the so-called empty-nest syndrome that has been reported elsewhere (described in Chapter Four).

Despite what has been said before by Harkins (1978) that when the children leave home the mothers will feel lonely, this was not really the case among women in my study. It is sometimes said that menopausal women have a bad time when their children leave home, get married or gain employment. Instead women‟s responses suggest that they are very satisfied with having less duties and more time to develop their own interests and careers. This situation can be explained in part because in Malaysia today more women between the ages of 50 and 56 are employed, thus the empty-nest syndrome seems to be an irrelevant issue and an outdated concept. Most women in my study married on the average in their mid 20s. Therefore, many of the children of the women I interviewed were still in school. So, they were still living together in the same households. Although some women had their children in boarding school or university

(living in hostels), their children would frequently return home or the women themselves would pay visits to their children. Very few women had children who were married. Only some of

169 them had at least two grandchildren who visited them during weekends. As mentioned before I do not claim that my study groups are representative of all Malay women, but they do give a fairly good insight into the kind of lives that urban educated Malay women aged in their fifties have. As noted in Malaysia, this group of women stay in the workforce. It is common practice for them to maintain a home and a paid job while undergoing the experience of menopause.

Women with high anxiety towards menopause and ageing

In this section I will discuss the twenty-seven urban Malay women in my study who I believe have high levels of anxiety80 towards menopause and ageing. I have analysed their responses to my questions and treated them as one group based on their similar responses towards menopause and ageing. In general, the women have four things in common: they are concerned with their declining physical appearance and how their bodies are ageing; they have, to varying degrees, problems with their sex lives; they experience distressing menopausal symptoms; and they mostly attended the menopause clinic to get treatment from the doctor for their menopausal symptoms, particularly hot-flushes, lack of sexual desire, vaginal dryness and tiredness. With regards to how my respondents look at the issue of fertility and infertility, they have indicated that although menopause signifies infertility, they are more concerned if reaching infertility stage without having children. In other words, becoming infertile women at this stage is a non-issue since most of them have children. Later in this chapter I will discuss three women

80 In order to determine high and low anxiety I adapted questions from quantitative scales – Beck Depression Inventory (Bromberger & Matthews 1996) to design questions which could be included in the interview. These were not used in a statistical manner but were simple guidelines to get women to discuss their level of anxiety, not to rate them per se. The kinds of questions I asked were feelings like worthlessness, self-dislike, concentration difficulty, tiredness, loss of pleasure, sadness, changes in sleping patterns, irritability to name a few and women usually answered 'never, sometimes, very little, frequently' and so forth. I then analysed these short responses as well as their open-ended discussion to determine whether or not they presented as having low or high anxiety about their menopausal changes. 170 who had very different experiences and who did not attend the menopause clinic. This will help to illustrate the variation in responses to menopause held by women in urban Malay society.

The level of anxiety for women in the group with high anxiety is of course varied and while there are similarities there are also differences. Some women have a very high level of anxiety related to their menopausal experience and ageing in general, while others have moderate to mild anxiety. This may be because of some internal factors that I will bring to fore later in the chapter. There are a wide range of responses regarding how menopause influences their sense of self-worth physically, emotionally and socially. However, there is no significant difference in response between married and unmarried women. I will share the story of one unmarried women name Siti in Chapter Seven. Before I do that, I will first present the story of two women,

Sharifah and Balkis, who told me stories of how they were greatly affected by adverse menopausal symptoms.

Sharifah, aged 51, operates a beauty salon in KL and is also a part-time lecturer in a private beauty school. Her husband, aged 58, works as an administrator in a government office.

Sharifah is her husband‟s second wife and married him when she was 40, an age considerably older than when Malay women generally marry. Sharifah desperately wanted to have children and felt time was running out because of her age. Although in the first place her husband was reluctant to have children because he already had five children with his first wife, Sharifah‟s strong determination made him change his mind and support her intention to have children.

Sharifah knew that it was potentially risky for women of her age to get pregnant but she decided it was worth the risk and went to a fertility clinic to get some advice and treatment. After a series of consultations with her gynecologist, Sharifah conceived but her happiness was short lived.

She experienced two miscarriages both at about four months. Sharifah told me how the

171 experience was unbearable. Later, she and her husband decided to adopt a child, a little girl who, at the time of my interview with Sharifah, was three years old. After obtaining a diploma in one of the universities in Adelaide, Sharifah returned to Malaysia and opened her own beauty salon which had been operating for ten years. Her salon provides services like cutting and trimming hair and facial treatments.

Sharifah spends a lot of time cleaning and decorating her house. She keeps herself fit by taking several supplementary vitamins and exercising. She also enjoys dancing and singing with her husband. She told me that unfortunately her „road to 50 was clouded with doom and gloom‟.

Sharifah says that she was very upset with her husband‟s reaction towards her when she stopped menstruating a year ago. After ten years of marriage, her husband wrote her a letter saying „sorry

I have to say this. This is for our own good. The bed is nicely made, the house is nicely arranged, you take care of your body well and your dresses are nice to look at. But what is there „in-bed‟?

(meaning there is a lack of love-making). You‟re cold!‟ She cried after reading the letter and her self-esteem fell very low. To add further to her hurt feelings and low mood, she suffered particularly from hot flushes which came on frequently while she was at work. They became yet another predicament she had to deal with:

Sharifah: I cannot tolerate hot flushes. One day when I was trimming my customer‟s hair, my hot flushes came. The heat came from my tummy and zupp goes straight to my brain. It was very hot that I felt my brain was burning! I can‟t think. It really upsets me! I cannot work. It is hot inside me! I took a deep breath and pretend nothing happened in front of my customer. I can‟t. Another day, I accidentally cut my fingers. It was too hot! Every time I had this hot flush, I stop doing my work because the heat is intolerable. This situation happens several times. Every time it occurs, I apologised to my customers. I would rest for five minutes until the heat subsides. Then, I continued my work. There are also times when I can‟t do my work at all. I have to ask my assistant to help with my work. Nura: Do your customers know why you acted this way? Sharifah: Some customers understand and some did not. Customers who are in my age know about this. They said it is part of growing old. Sometimes while

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cutting their hair, we talked about this, had a good laugh. Younger customers rarely understand. Nura: What about during your lectures? Sharifah: Similar situations also happen while I am lecturing my students in the college. Since most of my students are between 20-30 years of age, many express their concerns about my condition. I didn‟t tell them it was hot flushes. I told them I‟m not well. Sometimes I have to dismiss the class early or I will postpone the class if my condition is worse. Nura: Do you think menopause influences your work performance? Sharifah: Yes. I felt weak and tired. I have to manage my business, giving lectures, taking care of the family as well as managing my body. It‟s too much. I hate giving excuses and apologising to people because of my condition. Not once, but many times! I felt my body has worn out lah!

Sharifah explained that she was devastated about how her husband sees her at this stage of her life. While she is affected by menopausal symptoms, particularly the hot flushes, it was most hurtful that her husband was complaining of her inability to perform sexually. Sharifah says that this has created a lot of stress in her life.

Balkis also told me of her difficulties with menopause. She is 54 years old, an income-tax assessor and is a mother to her five children and a grandmother to a twelve month old baby girl.

Her husband Samad, who is the same age, works in the same office. They met each other in the office and have been married for 29 years though they have been working together in the same office for 34 years. Balkis has four children who live at home with her but her eldest son has his own family and he lives in a nearby suburb. Her health problems began at the age of 40. Twelve months after delivering her youngest child, she noticed irregularities in her menses. She had long periods and sometimes she hemorrhaged and fainted. She described how her situation prevented her from performing her job adequately as both a worker and as a mother. She was hospitalised for a month or so and most of the household chores had to be managed by her husband, children, in-laws and relatives. In the office she skipped important meetings and had to take medical leave several times. Her husband, Samad, too was affected by her condition. He frequently took

173 emergency leave to take Balkis to the hospital when she fainted in the office. Sometimes Samad had to stay at home to look after her.

One day, Balkis bled so heavily that the blood trickled down into her shoes. It was a nerve-racking experience for Balkis to go to work. She became nervous and stressed every time she prepared herself for work. Eventually she went to see doctors and traditional healers to treat her problem. After some treatment, her condition improved for several months but later it started again and in 2004 a doctor diagnosed her with fibroids which resulted in the removal of her womb. After the surgery the episode of heavy bleeding was over and she started a new life – that of menopause. However, this new life brought other episodes of awkwardness and trouble.

Balkis81 realised that she easily got tired and sometimes snapped for small reasons, both at home and in the workplace. She told me how her children and her co-workers were the targets of her fluctuating moods. She scolded her children for not helping her in the kitchen, for not keeping the house tidy and for not appreciating her. In the office for example, Balkis once snapped at co- workers who stared at her. Some co-workers who talked loudly even made her feel irritated. As a result her younger co-workers minimised their communication with her. She became furious when a co-worker labeled her as a kondem (a colloquial expression which means useless) woman. Balkis was seen as less productive and less professional in her work. She took longer time to prepare paper work, was unable to meet deadlines, and once in a while she misplaced important documents. Balkis felt that her co-workers felt negatively towards her and other colleagues who were also menopausal. According to Balkis they were seen to be not as efficient as the more youthful members of staff. Balkis also felt that both her children and co-workers

81 Although I have generally excluded women in my study who have menopause induced because of surgery, I have chosen to include Balkis as she is in the general age range of the other women in the study. I do acknowledge that her case is extreme, but it gives me the advantage of highlighting a case that appears to be at one particular end of the spectrum of experience. Her stories of the workplace are also illustrative of the negativity that can be experienced by some women trying to maintain their professional lives while managing menopausal symptoms. 174 were scrutinising her appearance. This made her feel self conscious and she decided to change her old style and try to be more fashionable in order to keep up appearances in the office.

The stories of both Sharifah and Balkis have illustrated that some women did not sail through menopause smoothly. It is very unfortunate that women like Sharifah and Balkis have to undergo these kinds of ordeals in their middle-age. It is also concerning that they find so little support from the people around them as they struggle with the biological changes that are really a common experience. Sharifah and Balkis are not alone. There were other women in my study who also encountered similar problems, but to a lesser degree. Nevertheless, they have reported how menopause has a debilitating effect on their emotional and social lives and their work performance.

The mid-life crisis: physical appearance

One apprehension that many women have as they approach menopause is the changing shape and tone of their bodies. In other words, the women‟s perceptions of their own body image changes. It is common to evaluate one‟s own body image based on physical attractiveness and overall appearance (Koch et al. 2005; Kelson, Kearney-Cooke & Lansky 1990). Most of the women described the clear indications of their bodily changes, like wrinkled skin, excess abdominal fat, weight gain and sagging breasts. In general, they described their bodies as tak sedap badan (body don‟t feel comfortable), badan rasa lain (body feels different) and badan dah tak macam dulu (body is no longer like before). In reality, throughout menopause there are obvious physiological changes that are associated with ageing and this is universal, although this does not mean that women accept and are happy with the physiological markers of decline. One of the women‟s main concerns was the changes to their skin. Medical studies have indicated that

175 the skin undergoes many changes during menopause, including dehydration, thinning and loss of elastic tissue (Cosgrove 2007; Quatresooz 2006; Rousseau 1998). This condition is due to the depletion of estrogen which results in the declining collagen content and decreased capacity for tissue repair (Wines & Willsteed 2001).

Dalila, aged 50, who works in a government office said:

I feel old, look old. I feel my skin on both hands is different. You see… the skin has lost its elasticity [showing both hands]. My face, neck, eyes have wrinkles. I‟m worried if I look old.

The same feeling has been expressed by Sharifah, aged 51:

When you reach 50, your skin is „out‟ [not firm] no matter how much anti- ageing cream you put on your face. I don‟t believe in Botox injections. I took other products to make my skin look firmer and younger. I think HRT helps. In fact, operating a beauty salon demands me to look presentable most of the time in front of my customers.

Some women, around the time of menopause, express concern about their changing body shape and weight. This was the case for women in my study who were of varying weights. It was not just the overweight women who were worried, but women of „normal‟ weight and those who were underweight had anxiety about their body shapes too. Interestingly, all the women described their weight and body shape as a problem or something that they particularly disliked about their appearance. Some women believed that there is a need to maintain their body shape to look and feel good in their midlife. One of the women I interviewed told me that when she reached her menopausal stage, her 34-26-34 figure82 increased in size. As a result, she had to rely

82 It is known as the curvaceous hourglass shape. This shape is popular in the Western culture compared to other non-Western cultures. The bust and hip have the same measurement while the waist is smaller. It is said that a woman who has this shape appears sexy and attractive. Other shapes like the pear-shape, inverted-triangular and rectangular shape are regarded as disproportionate shapes for the female figure. Thus, the hourglass shape is regarded as an ideal proportionate shape and seems to be the most valued shape among women. Both men and women pursue this shape and use it to evaluate physical attractiveness. 176 upon beauty work interventions including slimming tablets, slimming gel and weight loss programs. Despite the dissatisfaction with body shape none of the women I interviewed used cosmetic surgery or liposuction fat reduction as they claimed it was too expensive. The cost appeared to be the major deterrent to using surgery to enhance the body, though I am not sure if presented with the money to do this the women would have taken this option. The increase in body weight or waist-hip ratio (WHR) is related to decreased fertility, menopause and can be related to polycystic ovary syndrome (Streeter & McBurney 2003). The size of WHR83 is another reliable indicator of women‟s general reproductive status (pre- or post-pubertal to menopause) and youthfulness (Singh 2006) and therefore this shape change would appear to be physiologically normal for menopausal women. Nevertheless, the majority of women in my study were not happy about this change. It can therefore be argued that dissatisfaction with physical appearance in midlife is not confined to Western women alone.

Studies conducted in the Western societies have demonstrated that what is beautiful is good (Dion, Berscheid & Walster 1972). This perspective focuses heavily on the physical appearance, particularly the body shape. Davies and Furnham (1986) postulated that women whose bodies do not comply with current ideals are likely to express dissatisfaction with their body weight. Cempaka, aged 50, who worked as a secretary in a private firm, illustrated how body image can be complex:

Ever since I stopped menstruating, I feel that I have gained a lot of weight. I put on five kilos. My doctor advised me to observe my diet. Doctor prescribed me Xenical a slimming tablet to cut down weight. Look at my arms, it‟s flabby and my tummy too. I put on make-up, wear contact lenses and buy new clothes so that I feel good about myself. If people want to take my photos, I refused. I‟m just too big!

83 Women have a lower WHR than men. On the average, women‟s WHR is 0.7, while male is 0.9. However, when women reached their menopausal stage, their WHR increased to that of men‟s WHR (see Singh 2006). 177

It is interesting that in Cempaka‟s case her doctor supported her quest for an ideal body by prescribing slimming tablets. Cempaka also turns to the fashion and cosmetics industry to help turn around the normal physiological process of ageing. She also indicates a certain shame associated with her changed body by not allowing photographic images to be taken of her body because it is „too big‟. All of the accounts I have relayed indicate that women experienced some feeling of uneasiness regarding how they appear, especially with regards to her skin, body shape and weight. This has undoubtedly affected their emotions and cognitive reactions. Some of the women have low self-esteem and this is linked to their appearance which makes them feel inadequate. They try on new fashions or try to mix with and emulate younger colleagues in their offices.

My observations are supported by Swami and Tovée (2005) who studied female attractiveness in both Britain and Malaysia. As I recounted in Chapter Three, their findings revealed that social and cultural contexts have influenced women‟s preferences for body sizes. In their study, Malaysian women in the urban areas associated attractiveness with slim physique whereas women in the rural areas preferred a rounder body size which symbolises fertility.

Factors like media, education, employment opportunities, mate choice, birth control and legal rights have influenced the condition of Malaysian women (Raja Mamat 1991; Nagaraj 1995;

Hamzah 2003; Karim & Abdullah 2003). Thus, these conditions have created a conflicting scenario in the lives of the women who strive simultaneously for career accomplishment while maintaining their physical attractiveness. This is true for the women in my study who are very much concerned about their body weight and shape. Since these women are still working within large organisations, I found that physical appearance or attractiveness, particularly their body shape and weight, has imparted „an emblematic credence into the social and work-related sphere‟

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(Lee cited in Swami & Tovée 2005, p. 125). This has contributed to an understanding of the commonalities and differences accepted by people from different age groups, opposite genders or different statuses.

Grey hair: an interesting difference

Interestingly, regardless of whether the women in my study put on their tudung (veil)84 or not, none of them felt concerned about their uban or rambut putih which in Malay language means grey hair. In fact, none of them said they dyed their hair. Unlike many women in Australia and other Western countries, they did not associate grey hair with negativity and it seemed a more acceptable symbol of ageing than ageing skin and sagging bodies. Instead, the women indicated that grey hair is a sign that they are „no longer young‟. While their responses towards their skin and bodies (weight and shape) reflect a compliance with the dominant Western culture of youth and beauty, they greying hair did not fit the typology of youthful beauty. According to the women in my study, grey hair symbolises respect and wisdom. While they were unimpressed by their changing body shape and the appearance of their skin, hair colour did not appear to worry them. Glazier (1983) made the following observation among Trinidadian men: canes, glasses, hearing aids and grey hair serve as symbols of respectability, though these kinds of symbols are often more respectable for males than for females. Previous studies, particularly among Western women, have shown that greying hair is not an acceptable sign of ageing. Grey hair is associated with looking old (Koppelman 1996) or a manifestation of mortality (Synnott

84 Only three women who have yet to wear tudung participated in my study. The act of covering the awrat (nakedness) which includes the hair is compulsory in Islam (see al-Qur’ān in Sūrah al-Nūr 24:31). Wearing tudung is common among Malay women in Malaysia. However, some Malay women consider wearing tudung as an individual choice (Omar 1998, 2003). Some women wear tudung because they want to fulfil what is compulsory in Islam that is being a good Muslim; this is to ensure they will be granted by God a better life in the hereafter; whilst other women find age (particularly those in their forties) is another factor that motivates them to cover their awrat (Omar 2003). 179

1987). In today‟s youth and beauty fixated society where grey hair is seen not as a sign of wisdom but an indication that one is approaching old age, women are often motivated to hide their grey hair with the use of dye to camouflage this particular sign of ageing. Therefore, today the hair care industry is actively introducing hair products in the form of dye, spray, gel, shampoo, conditioner and so forth to meet the consumer demand. Even though grey hair, or the need to dye their hair, is not a focus of concern for the women in my study, they do put on make- up to look attractive and presentable in the workplace. Like Cempaka, Diana, a 53-year-old nurse, explained that she must put on her make-up because she needed to look „fresh‟, by which she meant she wished to appear youthful, energetic and vibrant which was of particular importance to her in the workplace as well as the home. In her own words, Diana told me:

I always put on make-up to work. I make sure I put on lipstick and my favourite blue-black eye shadow. Even if I‟m at home, I must put on at least my eye shadow. My make-up is a necessary thing for me. It‟s like makanan jiwa (food for the soul). If I don‟t put on my make-up, I feel uncomfortable or incomplete. My make-up and I can‟t be separated.

Although many people say that beauty is within, it seems that what people view on the outside is important to many of the women in my study. It is what they have to deal with on a daily basis. However, though women, even older women in Malay society, may feel pressured to look a certain way, this does not apply in regards to hair colour. This interesting paradox serves as a metaphor for the way that menopause and ageing are viewed in Malay society. There is a degree of Westernisation, but many of the older values in regards to the respect associated with ageing still hold true.

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Decreased interest in sex

Another factor that contributed to the high level of anxiety among women in this group is their decreased interest in sex. This situation was seen to be even more problematic when the women reported that they feared their husbands would find younger women to satisfy their sexual needs.85 Studies have shown that menopause contributes to significant reduction in sexual activity (Bertero 2003; Koch et al. 2005). From the biomedical point of view, sexual functioning during menopause is affected by the urogenital ageing and musculo-skeletal changes which occur before and after menopause (Dhillon, Singh & Abdul Ghaffar 2005). Due to the low level of estrogen, the vagina becomes dry and this makes sexual intercourse unpleasant. For Rozana, aged 50, her sexual experience was described as „traumatic‟ because of the pain and feeling of discomfort. She explained:

Following menopause, my vagina is dry. I feel painful whenever I have sex with my husband. He doesn‟t understand.

There are five basic menopause-related changes in sexual function based on medical and psychological literature: diminished sexual responsiveness, dyspareunia, decreased frequency of sexual activity, decline in sexual desire and a dysfunctional male partner (Sarrel

1990). As a result of menopause, many women in my study confided that they had problems with their sex life. This also agrees with some studies among menopausal women in other countries which contend that menopausal women experienced a loss in sexual interest

(Gruszecki, Forchuk & Fisher 2005; Bertero 2003; Malacara et al. 2002).

85 In Islam, polygamous marriage is allowed (refer to al-Qur’ān in Sūrah al-Nisā’ 4:3). However, Islam has warned men if they cannot be just or are unable to give fair treatment to their wives, it is better to have only one (see al- Qur’ān in Sūrah al-Nisā’ 4:129). Polygamous marriage is possible only if a woman consents to this kind of life. Polygamy is allowed based on strict conditions. For instance, when the wife is terminally ill and becoming incapable of doing the household work or the wife is infertile and most importantly the husband can be just to his wives. 181

While Sharifah and Balkis had upsetting experiences, which I relayed earlier in this chapter, other women in this group told me they still have sex with their husbands, but less frequently compared to when they were in their thirties and forties. The main reason given to me was sakit (pain) or the vagina dah kering (has dried) during intercourse. From the medical point of view, poor lubrication or decreased vaginal secretion contributes to pain during coitus. Some women admitted to having sex only once a week or perhaps even once or twice a month. Indeed, women in this group felt very much less interested in sex at that point of their lives. Generally they did not feel motivated to have sex and they expected their husbands to understand and respect their feelings. Sexual difficulties that arise as a result of menopause have affected the women‟s mood as well and emotional and physical issues do impact upon the intimate relationship between the women and their husbands. Indeed, vaginal dryness and the length of time the women take to experience orgasm have influenced their sexual activity with their husbands. Furthermore, hot flushes and the absence of a supporting spouse have contributed to the decline of sexual interest of menopausal women.

Although the women in my study felt less desire themselves they still fulfilled their husbands‟ sexual needs as they considered it as part of their religious duty. In Islam, the primary purpose of marriage is procreation. However, Islam does not put an end to sexual relations in a

Muslim marriage if the wife reaches the menopausal stage (al-Ghazali 1977). At menopause sexual activity is regarded as a secondary purpose in a marriage. It is performed as an act of companionship and enjoyment as women are no longer able to reproduce. Islam encourages older couples to carry on their sexual activity well into old age as it is a form of ibādah

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(worship).86 Worship in Islam is very comprehensive. It includes rituals like praying, fasting, zakāt (alms-giving) and pilgrimage as well as social and personal activities including personal contributions to the betterment of fellow human beings. In the case of sexual activity, it is a form of worship if it is accompanied by the proper intention. The Prophet Muhammad (peace be upon him) told his companions that they will be rewarded by God even for having sexual intercourse with their wives.87 Thus, Islam does not prohibit sex at certain life stages but it considers sexual activity sinful only when it is satisfied outside marital life.

I found there was a connection between how particular women perceived their bodies and their sexual responses. One woman claimed that she was no „longer sexy‟ and felt that her sexual activity was less enjoyable. Anderson and LeGrand (1991) found that women with negative evaluations about their bodies engaged in a limited range of sexual activities compared to those who had a positive evaluation. This study is also supported by Koch and colleagues

(2005) who found that American women who perceived themselves as less attractive were likely to report a decline in their sexual activity. Conversely, women who perceived themselves as attractive were reported to increase their sexual activity.

Given this situation, women in my study have taken what they believe is the necessary action to improve their sexual function. The commonest action taken by the women was in consuming HRT followed by applying lubricant or gel before coitus. Traditional medicine or alternative therapies were not used for this particular symptom. They also made behavioural adjustments like making sure they took regular exercise and controlled their diet. However, the

86 Al-Qur’ān has indicated in Sūrah Maryam 19:9 the story of Prophet Zakariyyā who had fathered a child (the great Sufi Abdul Qadir Gilani r. a) well into his old age: „He [Zakariyyā] said: „O my Lord! How shall I have a son, when my wife is old and I have grown quite decrepit in old age?‟ Gilani was born when his mother was 60 years of age. Another meaningful example is the Prophet Muhammad‟s (peace be upon him) life. He married Khadījah when she was 40 years old. They were blessed with four children throughout their entire 26 years of marriage. 87 Hadīth reported by Muslim. 183 women did not observe the hot-cold food regime which is practiced by other Malay women

(particularly Meenah and Chombee) who exhibit low anxiety towards menopause and ageing. A little later in the chapter I will present the stories of Meenah, Chombee and Kay who did not go through a debilitating phase in their middle-age. They found menopause as a liberating event and rejoiced in the new phase in their lives.

Husbands’ responses are not therapeutic

As women are undergoing significant changes in their bodies and having to contend with physical and emotional symptoms of menopause, it is not surprising that their relationships with close family members also change. I have already indicated some of the irritabilities women express towards their children. However, perhaps most insight can be gained from what the women say about their husband‟s responses to the menopause experience. Some of these examples illustrate that many men are not sympathetic to what their wives are going through. For example, some husbands referred to their wives as having a badan kembang (expanded body) and suggested that they tak boleh pakai (cannot be used). Earlier in Chapter Two, I recounted how Salimah told me that her husband jokingly equated her with a car which had an expired road-tax. Although she took it lightly at the time her husband‟s remark was unacceptable. The comment, though offered in jest, evoked in Salimah a range of emotions like sadness, disappointment, anger and feelings of unworthiness. Like Salimah, other women in the study felt disappointed with their husbands‟ comments, while others were sad that their husbands‟ did not understand and accept their bodily changes. For example, Rahmah aged 50 said:

My husband couldn‟t be bothered whether I have problem with menopause or not. He didn‟t even know I go to this clinic and take HRT. As long as I‟m alive and healthy, it‟s fine with him.

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Rahmah‟s experience is similar to that of participants in Walter‟s (2000) study. In Walter‟s group of African American women many reported that their husbands were not interested in discussing issues related to menopause and were often critical rather than sympathetic when responding to their wives‟ menopausal symptoms. Some of the women in Walter‟s study decided to separate from their husbands due to their husbands‟ inability to understand their conditions.

One of my participants, Azaliah aged 50, was very frustrated about the way her husband responded to her menopausal symptoms:

I have a bad crying spell. Sometimes for no reason, I feel sad and started to cry. This usually happens at home or in my office. When I cried at home, I lock myself in my room and spend at least 15 minutes crying. In my office, I usually go to the surau (praying room) and cry. One day, my husband said, „Look at you. Just like our youngest daughter, a cry-baby in your fifties‟.

Interestingly, despite some unkind remarks from their husbands, only three women in the group of twenty seven reported a decrease in their spouse‟s sexual interest in them. For these three women, whose husbands had erectile dysfunction due to old age and diabetes, the issue of changed patterns of sexual relations was associated more with their husbands than it was with the women themselves. I found the women did not make jokes or unpleasant remarks and did not complain about their husbands‟ condition. Instead, they accepted the situation and encouraged their husband‟s to seek medical treatment for their condition.

Women with low anxiety towards menopause and ageing

It is important to note that Meenah, Chombee and Kay did not report experiencing symptoms associated with menopause and their experiences illustrates that there is no „one fit‟ in terms of the menopause . „Age is just a number!‟ This is a phrase that explains Meenah‟s feeling about her age. I was introduced to Meenah by her daughter Nani, who was my former student.

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Nani visited me in my office when I returned to Malaysia for my fieldwork in 2005. I told her about my research, and asked her if she could introduce me to some women who were in their menopausal stage. She later rang me and told me that her mother had agreed to be interviewed.

„Mak was very happy because she has lots of stories and tips to share with you‟. Meenah turned out to be quite a contrast to the majority of women I interviewed because she was so positive and open about the subject of menopause. In fact, the subject of menopause was not really an issue in this interview and in the other two I am about to relate, because it did not intrude upon the women‟s lives as it did in the lives of the other twenty-seven women I interviewed in the course of my study. What the following illustrates is a positive view of ageing in Malay society and it serves as a contrast to the many difficulties that women can experience when undergoing this stage of their lives.

I went to meet Meenah one Saturday morning. When I arrived at her house, I saw her feeding the chickens and ducks with her husband in the backyard. Meenah has lived in a big bungalow ten kilometres from KL for almost twenty years. The bungalow has five rooms with a big backyard where she grows vegetables and rears some chickens and ducks. When she greeted me Meenah explained that it was a busy time for them because they were expecting their grandchildren to visit. Meenah, aged 55, told me that she worked as a Public Relations Officer in a research institute where she had been for almost thirty years. Meenah explained that she was extremely satisfied with her work at the institute where she was in-charge of organising special events, such as press conferences, exhibitions, open days and tours. Her work has enabled her to meet people from many walks of life.

Sharing her stories about her family with me, she noted how thankful she was to have a supportive husband who provided emotional support and companionship. Their relationship was

186 in stark contrast to the stories I had heard from other women at the clinic and it was comforting to know that some older Malay men were of some comfort to their wives. For example,

Meenah‟s husband would cook for the family if she was not feeling well or when Meenah had to leave town for a couple of days for work purposes. She expressed her relief that her six children were university educated and now occupying good jobs in and around KL. This did give me cause for thought about how education and social class may influence people‟s attitudes to biological processes like menopause. It was clear to me that from her stories, Meenah was happy with both her work life and family life. Her husband, children and grandchildren were the source of her strength and satisfaction with her life and her story illustrated to me that Malay women at this stage of life could lead fulfilling and happy lives.

This feeling of satisfaction with life was also found in the stories of Chombee and Kay, both of whom, like Meenah, were around 55 years of age. Chombee worked as a school principal and taught English whilst Kay told me her job was as a senior operation clerical officer at a leading university in KL. Like Meenah, Chombee and her six children had completed their tertiary education. Chombee reported that she found a great deal of satisfaction in teaching and helping students in school. Chombee told me that her work day began at 7am and continued until

10pm. If she was not working teaching, she would be attending to the needs of her family. In addition to this daily work routine, Chombee woke at 5.30am every morning to prepare cookies for her students and breakfast for the family. The cookies and cakes she made were to be given to the poor students and at 6.40am she arrived at the school to help the students to sell English newspapers in the school as part of a charity. „My students are my children. They need to be given attention academically and socially. I want them to excel in their studies and be a good person‟. It is this attitude that led Chombee to be named the winner of Best Teacher in her school

187 in 2005. „I‟m not that old to do things that I like. I spend a great deal of time with families and friends doing the things we like. Sometimes I forget that I‟m 55!‟

Kay who told me she had three sons, all engineers, and three grandchildren, said that her age does not prevent her from enjoying activities she used to do previously, but perhaps to a lesser degree. „You shouldn‟t feel old in your 50s. If you do, you will not be happy. I still regard myself as being young, but I act according to my age‟, she advised me. Working at the university since 1974, Kay was responsible for developing and managing training programs for clerical staff, modifying clerical operations and procedures and improving efficiency, updating computerised files using software applications and sometimes processing information for billing purposes.

On top of her busy schedule at the office, Kay told me she made dresses for friends and family. A very skilled tailor, Kay has made Kebaya (a traditional Malay blouse) and Baju

Kurung (traditional Malay dress) for women and girls as well as Baju Melayu (traditional Malay outfit for man) for boys. She told me that during Īd al-Fitri88, she makes at least RM 2,000 from the dress-making. Once in a while, some boutiques in KL will send her some Baju Kurung to be sewn. This is because Kay is well-known for her jahitan sembat89 and jahitan tulang belut.90 In addition, Kay told me she also liked to cook for her family and sometimes volunteers to take care of her grandchildren while their parents are out of the country. I was invited by Kay to attend her second son‟s wedding, and turned up early to help organise the food. I noticed that Kay meticulously put on her make-up and dressed up nicely. She said, „women my age should put

88 A Muslim festival celebrated after completing Ramadhān (fasting month). 89 Jahitan sembat is a traditional Malay hand stitching. It is a method to keep the ends or joints of the fabric neat. Jahitan sembat holds the fabric stronger compared to the serger machine. Jahitan sembat is more expensive than the serger machine because it is done manually. 90 Jahitan tulang belut is a stiff stitching known as eel spine. The stitching is done around the simple hemmed round collar of the Baju Kurung. 188 make-up on just like we used to do when we were young. It is not that I want to look young. But, it makes you look good and feel better at 55. Sometimes I look younger than my friends‟ she laughed.

Plate 5 Kay, her son, her new daughter in-law and her husband. (Photo: Nurazzura Mohamad Diah)

The stories of Meenah, Chombee and Kay clearly illustrate my argument that there are complex issues at play when we come to look at the lives of middle-aged and older women in urban Malay society. Not all women are immersing themselves in the youth and beauty culture of the West, though others are more absorbed with these issues and some look to Westernised practices to help them deal with menopause. Interestingly Kay liked to use make-up but did not use it as a prop to make her feel better. Meenah, Chombee and Kay had very busy lives, and like

189 most of the other women in my study they combined paid work with work in the home.

However, their lives did not appear to be dominated by the symptoms and anxieties associated with a difficult menopausal transition. This freedom of concern allowed me the opportunity to explore some of the other issues related to ageing for urban Malay women in their fifties.91

Respect the elders: the Malay traditional values

Bart‟s model (1969) as I discussed in Chapter Four outlined six cultural traits that appear to reduce the anxiety of ageing, these include: strong ties to the family of origin, an extended family system, an emphasis on reproduction, a strong mother-child reciprocal relationship in later life, institutionalised grandmother roles and institutionalised mother in-law roles. As I have experienced myself and observed in Meenah, Chombee and Kay, close ties with family members are important and can be maintained from near or far. Some adult children and grandchildren will visit their parents frequently, accompany their mothers and some even prefer to stay in the same household in an extended family.

In addition, the institutionalised grandmother role provides a continuous maternal role for her grandchildren and self-satisfaction beyond her child-bearing years (Barnett 1988; Omar

1995; Rice 1996). Although Bart‟s model resonates with other findings (Lock 1986; Boulet et al.

1994) on how menopausal women have improved their status in middle-age; and how age is valued over youth, there are also studies which did not reflect the same view about ageing. For example, Korean immigrant women believed that ageing brings an ugly physical appearance, deteriorating body and mental functions as well as few opportunities and possibilities for them to venture into economic and social activities (Im & Meleis 2000). Similarly, a negative perception

91 I asked all of the women the same questions regardless whether they had interviews in the menopause clinic or in other places. Meenah, Chombee and Kay all answered in very different ways from the other women who attended the clinic for their problems. 190 is also reported among Greek women (Beyenne 1986) as well as Thai women (Chirawatkul &

Manderson 1994). Since ageing is viewed negatively by these women, the approach of middle- age appears to increase their level of anxiety.

In my study, I found Meenah, Chombee and Kay who are in their middle-age, enjoyed an improved status and privilege. This is a similar observation made by Omar (1995) in her study among rural Malay women in Melaka. In her study Omar shows that rural women neither fear nor are affected by menopausal symptoms. In fact, they did not associate menopause with the termination of the best time in their lives. For the rural women, reaching menopause as well as growing old meant being respected and having prestige and freedom. Middle-age brings with it respect, as the Malay culture considers middle-aged and older women as wiser and more experienced (Omar 1995). In Malay culture, middle-aged and older people tend to claim: Saya sudah makan garam dulu (I had tasted the salt first) or sudah masak (already cooked) to justify their wisdom and experience. They tend to justify knowledge by age as they believe that wisdom comes with age (Lim 2003). As such, the Malays believe that they should take the counsel of elders when it is necessary for relevant matters. For instance, if a daughter has difficulties in raising her children, she must consult her mother for advice because her mother has more experience in raising children. Therefore, middle-aged and older people deserve to be respected and consulted in any matters pertaining to the family. As Meenah said, „I‟m old now. I don‟t want money or anything. I want my children to respect me. That‟s all. And syukur (thank God), they do‟. Kay put it in a different way, „No matter how rich or clever you are, never forget the elders. I reminded my sons and daughters in-law. You must respect them‟. Chombee expresses her concern „If I don‟t teach them how to respect elders, people will blame me. I fear my children will not be respected by their own children when they grow old‟.

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The attitude that Meenah, Chombee and Kay hold towards respecting elders indicates that

Islamic teachings92 and the Malay adat (customary laws) have a strong influence in their attitudes towards middle-aged and older people.93 Omar (1995) highlighted two important behaviours that were signalled by her participants and that are still relevant today: mesti hormat orang tua (must respect the elders) and mesti ingat jasa orang tua (must remember the elders‟ sacrifices). These behaviours have been taught to Malay families as guidance to act appropriately and to be grateful to their parents and grandparents. In addition, the Islamic concept of anak yang soleh (a loyal child) is important to maintain a strong relationship between the children and parents.

I asked the three women what makes their life content. They spoke about how their children act towards them. Indeed, they did not focus on material gain, but are more thankful that their children respect them. Thus, adherence to tradition and strong religious teachings, as I will discuss in the following section, are paramount in maintaining family relations in the urban

Malay society. Furthermore, Moen, Dempster-McClain and Williams (1992) depicted that healthy and successful ageing can be characterised by the ability to adapt to the changes that come with age. How a person adapts to the changes has a strong impact on their mental, physical and/or emotional health. As illustrated clearly through the stories from these women, their low anxiety towards ageing lies in the fact that they themselves view ageing positively. Also, they

92 In Islam it is obligatory for Muslims to show kindness, respect and obedience to their parents. Al- Qur’ān in Sūrah al-Isrā’ 17:17 emphasised: „If either or both of them reach middle-age age with you, say not to them a word of contempt, nor repel them, but address them in terms of honor‟. In fact, God orders us in al-Qur’ān to pray for our parents, in these terms: „My Lord, have mercy on them (my parents) as they have brought me up when I was young‟. Thus, respecting and remembering parents‟ kindness and love when we were young become intertwined with worship. In one authentic Hadīth (the Prophet‟s saying), narrated „Abdullah: I asked the Prophet (peace be upon him) „Which deed is the dearest to God?‟ He replied, „To offer the prayers at their early stated fixed times‟. I asked, „What is the next (in goodness)?‟ He replied: „To be good and dutiful to your parents‟ (Sahīh Bukhārī). 93 I am not suggesting that the other women I interviewed did not hold these same values. They preferred to use the interview as an opportunity to discuss menopause specifically. 192 have no familial issues creating stress. Perhaps even more important, they are not affected by the media which reinforces the images of youthful women.

To summarise, factors such as strong family relationships, strong adherence to religion and Malay tradition, healthy lifestyle and work satisfaction have helped Meenah, Chombee and

Kay to cope with ageing. Consequently, the prevalent myths of ageing, like youth-obsession and depression and alienation in old women, have proven untrue in the case of Meenah, Chombee and Kay. More important, the positive view of middle-aged people and ageing is strongly emphasised within the wider community through the media, advertisements and government campaigns like „Family First-Bring Your Family Home‟94 and in our television dramas and movies. However, for women like Sharifah, Balkis and the other women from the menopause clinic, their debilitating symptoms and associated anxiety have taken a prominent place in their lives. This is not to say they do not value Malay traditions nor have work satisfactions or strong family relationship. Nevertheless, menopause overshadows their lives.

Closer to Allah: the turning point in life

Islam is a religion or ad-Dīn (a way of life) which establishes the relationship between man and God, man and man and man and other creations (al-Banna 2003). In Islam, men and women are asked to live their worldly life and fulfil their religious duties and obligations. Any human activity which satisfies men‟s and women‟s physical needs and yields pleasures become acts of ibādat (worship) when they are performed with true religious motives (al-Zarqa 2003).

„It‟s now time to focus more on your ibādat. Praying and reciting al-Qur’ān‟ Meenah

94 This campaign was launched in 2002 by the former Malaysian Prime Minister Tun Dr. Mahathir Mohamad at the Ministry of Women, Family and Community Development. With this message, he is hoping that every Malaysian will instill and practice the spirit of awareness that the family must be given priority and uphold the good values that have proven to enrich Malaysian society. 193 commented to me. My study revealed religious convictions in women grew more intense with increasing age. In other words, it appears that the older you are, the more religious you will become. Meenah, Chombee and Kay told me that middle-age is a time when you assess your life and, come closer to Allah (God). This point of view was also emphasised by other women in my study. As the women recognised they were growing older, spirituality became increasingly important to them. At this stage of their lives, Meenah, Chombee and Kay spent their leisure time attending religious classes and religious talks with their husbands and friends so as to deepen their knowledge of akhīrat (the other world). They normally went to the local mosque on

Saturday or Sunday to learn more about religion. „As an old person, what else do you have in mind? Continue accumulating pahala (rewards from God through good deeds)‟. On the average the women would spend two hours a week studying religion. Meenah and Chombee had performed their Hajj95 and were glad that they had completed this important Pillar of Islam; whereas Kay was looking forward to performing her Hajj the following year. Chombee confessed to me:

Alhamdulillah (Praise to God Almighty) my husband and I have performed our Hajj in 1991. Our fifth Pillar of Islam has been completed. In fact, I conceived my youngest child when I was there [in Makkah]. Though shocking, I considered that as rezeki (bounty) from Him. I‟m satisfied with what I have now. I think God has answered my prayers there. My life is now more peaceful and meaningful. I‟ve raised my children well, completed my duty as a Muslim. When I was young I focused more on raising my children, work and work. Now that I‟m 55, I focus more on my ibādat, helping others and doing charity for the school. I‟m happy about doing that at this age and I have no grudges about life.

Indeed, for these three women, attending religious classes means that they are able to participate in social activities that enable them to meet other people of their same age, as well as

95 Hajj is a pilgrimage made by Muslims throughout the world to the Ka’bah in Makkah, Saudi Arabia. It is the last Pillar of Islam which is performed once in a lifetime (if it is economically feasible). 194 obtain new knowledge and provide them with an opportunity to discuss issues related to family and community. To Meenah, Chombee and Kay, religious instruction is important for their spiritual and emotional needs. It guides them in everyday life.

Based on their stories, it is clear that religion plays an important part in the lives of these three women and gives them a feeling of well-being, both in terms of personal spirituality and communal solidarity. In a nutshell, the spiritual dimension in the life of a middle-aged woman is important because religion acts as a resource for well-being in later life, helping to shape a meaningful and fulfilling existence (Hill & Pargament 2003). In addition, spiritual resources may also help middle-aged women (particularly in the case of Meenah, Chombee and Kay) to adjust themselves successfully to some of the changes associated with growing old.

Changing lifestyle: a happier ageing

The purpose of this section is to try and understand the lifestyle96 of Meenah, Chombee and Kay after they have reached menopause. There are three important things that I observed about the three women which were not always apparent in the other women who were involved in my study. They had a very healthy diet, took regular exercise and engaged in positive thinking. Each of these factors appeared to contribute to a more accepting attitude towards the process of ageing and towards menopause itself. As mentioned earlier, the three women were in good physical condition. It was clear that none of them appeared to be suffering from major or significant health problems or to have adverse menopausal symptoms or to display what is termed the empty-nest syndrome.

96 Lifestyle in this study is referred to as eating the right food, plenty of exercise, having regular health check-ups, no smoking, no drug prescriptions and positive thinking. 195

Meenah, Chombee and Kay all placed an emphasis on healthy diet and lifestyle. They frequently visited their doctors to get advice to maintain their health. Since these women did not suffer from adverse menopausal symptoms, they only took healthy food and vitamins to boost their health. Interestingly, although they all consumed vitamins to boost their health, they still believed in the humoral concept (Manderson 1981; Laderman 1987). The humoral concept has been well-entrenched in the thoughts of the Malays. It is strongly emphasised during pregnancy and the forty days after childbirth.97 The principle idea of humoral concept is to categorise food as „hot‟ or „cold‟. According to Manderson (1981), the classification is made because of the reputed effect of the food on the body, not because of its temperature, spiciness or raw or cooked state.98 Hot food like curry, chilli or pepper is said to improve blood circulation, whereas cold food such as ice-cream, cabbage, pumpkin, watermelon, cucumber and ice if taken in a large amounts may result in weakness and lethargy (Laderman 1987; Manderson 1981). Interestingly, most women in my study no longer adhered to this food classification. Instead, they preferred a more balanced diet of food consumption.99

As Meenah strongly emphasised „I observe pantang when I take my food. Not only have

I avoided taking oily food but cold food too. It‟ll make me feel uncomfortable. I prefer to eat ulam-ulam (vegetable shoots). I planted a lot of ulam-ulam in my garden‟. Although this humoral

97 The confinement period varies according to states. Most women observe 40-44 days. Only some women observe 60 days. Based on my confinement period experiences, I observed 100 days (44 days prescribed by my mother‟s culture, 100 from my mother in-law). I added another 56 days to complete the 100 days. The food that was prescribed by my mother in-law was slightly different from my own mother. According to my mother in-law, food like assam laksa (sour fish-based soup) must be avoided because it can cause stomach complaints. Fish like bawal (Silver Pomfret) is considered as bisa (sharp), while seafood is gatal (itchy); both must be avoided during the confinement period. 98 A list of „hot-cold‟ food has been identified, see Manderson, L. 1981. Traditional food classifications and humoral medicine theory in Peninsular Malaysia. Ecology of Food and Nutrition. Vol. 11, pp. 81-93 99 Based on the medical view, the pantangs observed by Malay mothers after childbirth with regards to hot-cold food rules is strongly discouraged (Mohd Ali 1985). An unbalanced diet during postpartum period will make mothers „unhealthy, very weak, the milk produce is of low quality and chances to get peripheral neuritis is high‟ (Mohd Ali 1985, p. 120). Meenah, Chombee and Kay observed the humoral approach to eating. Some, though not all women in the focus group, observed this approach. However, none of the women who attended the menopause clinic used the hot-cold rules of food consumption. 196 concept is highly practised during and after pregnancy among Malay women, Meenah and

Chombee have both continued to adhere to it into their middle-age. However, Kay prefers to eat oats and milk every morning for breakfast, noodles for lunch and salad and fruit for dinner. In addition to food, regular exercise is also their priority since they have reached middle-age.

Meenah and Kay preferred to join aerobic classes while Chombee was happy with gardening and strolling in a nearby park. Indeed, eating good food, regular check-ups and exercise have helped them to maintain their healthy condition and have lowered their anxiety about ageing.

Unlike other menopausal women, particularly in the West, who have been reported as suffering from empty-nest syndrome (Gifford 1994; Defey et al. 1996), it seems empty-nest syndrome is not a problem to Meenah, Chombee and Kay as well as other women that I have interviewed in my study. Interestingly, most of their grown up children live with them in the same household. Only their married children live separately. „I have no objection if my children want to stay with me or with their friends. But I prefer them to stay with me as it can reduce their living expenses, plus they can eat good food at home‟ said Meenah. In fact, three of Meenah‟s children were at home during my interview with her. Her son was helping his father in the backyard, while his younger sisters were busy cooking in the kitchen. The same scenario I observed in Chombee‟s and Kay‟s house, whereby they were surrounded by their grown up children. As I have pointed out earlier in this chapter, empty-nest syndrome is an irrelevant issue and an outdated concept. Urban middle class Malay women in my study having to juggle family life and work have more activities to engage in rather than thinking about their grown up children leaving home.

197

Conclusion

Menopause, no doubt, is an important passage in a woman‟s life as it brings a lot of changes in her body that can affect her social life, feelings, relationships with her husband and other people as well as her work performance. As I have presented in this chapter, women across cultures and within cultures have their own unique journey through menopause. As the body makes its own transition out of the reproductive years, some women find menopause is liberating, whilst others find it tiring and a time of crisis. In terms of its symptoms, it may vary from one person to another. Generally, urban middle class Malay women in my study acknowledged menopause as part of the biological process. However, due to pressures from home and outside of home, particularly in the paid workforce, most women found the menopause experience a distressing one. Though most women find it is relatively easier to speak to their doctors, family members remain confused or unsure of what is happening and find they only learn about menopause through informal ways, particularly through observation.

My findings highlighted the significance of culture and lifestyle that shapes the understanding of ageing among menopausal urban Malay women. No doubt as women grow old, there are many similar changes they encounter related to physical health, transition of roles, sexual activity, meaning and purpose of life and emotional well-being. In Malay society, strong family ties and spiritual factors appear to be more prominent than immersing oneself in the youth, beauty and femininity culture. Nevertheless, many urban Malay women today have succumbed to the notion of the Western youth and femininity culture transmitted predominantly through the media. Other women have also reported that age-related changes were distressing because women were „pressured‟ by the demands of society that promote attractiveness. Thus, women felt unhappy about their outward appearance which they perceived had become less

198 attractive as they aged. In the following chapter I will extend this discussion to show how the media and the broader discourses in Malay society have contributed to the changing face of the older woman in Malay society.

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CHAPTER SIX

MENOPAUSE AND AGEING: DISCOURSE, MEDICINE AND THE MEDIA

Introduction

In this chapter I examine the discourse of menopause as an entry point into a further analysis of urban middle class Malay women‟s conceptualisations of menopause and its treatment. It is useful in this context to examine the historical linguistic change, or the rise of common usage of the term „menopause‟, as compared to more localised Malay terminology. As may have already become apparent from the last chapter, this usage is fairly recent. In addition, as was evident from my focus group, it appears that some women do not associate menopausal symptoms with the actual cessation of menstruation. Yet, as will be illustrated in this chapter, this lack of knowledge is somewhat surprising given the amount of educational material that is now available in the printed media and Ministry of Women, Family and Community

Development brochures. Doctors also now more commonly prescribe remedies like Hormone

Replacement Therapy (HRT) to help alleviate unwanted symptoms associated with menopause.

So it appears „menopause‟, as it is now commonly understood, is a fairly recent phenomenon in urban Malay society.

I found magazines and newspapers were the main source of information about menopause for women. HRT is depicted as a beneficial treatment to improve menopausal symptoms in most printed media. By presenting narratives from women and statistics, reporters proclaimed that a remarkable number of women could be helped by HRT. Interestingly these sources employed the biomedical point of view in presenting a particular view to the public and have significantly influenced many women‟s perception about menopause and its treatment. It appears that many women have adopted the medical language in their conversation as well. This

200 process of adoption goes beyond language; as I will demonstrate - HRT has become a preferred treatment by a number of women resulting in a level of medicalisation of the biological process.

This is not to say that all, or even most, women use HRT, but rather that the increasing and relatively unquestioned use of HRT indicates a growing acceptance of medicine as an appropriate response to biological change.

Understanding discourse

In Chapter Four, I explained that „menopause‟, as many people in contemporary society have come to understand it, is a medical discourse in which menopause is an estrogen-deficiency disease that requires medical treatment. However, the discourse surrounding menopause varies from one culture to another, just as the lives of women‟s themselves are different and multi- faceted. There is no need for me to account for all aspects of discourse in its fullest sense here, but I will attempt to provide a concise introductory explanation of the concept as it relates to issues that arise in my discussion.

Discourse is an important concept in the social sciences that has for decades been the subject of debate. Originally derived from the field of linguistics, „discourse‟ in its most elementary sense refers to speech or conversation. The term discourse is defined in The Compact

Macquarie Dictionary (1994) as communication or conversation of thought by words, but in addition to the spoken language, it also includes written and signed language and other forms of communication, for example visual communication. Although early linguistic approaches judged the unit of discourse to be larger than the sentence (Thompson 1981), discourse ranges from silence, single utterance, a novel, newspaper articles or a conversation (Strega 2005). Post- modern theorist Michel Foucault (1972) has applied the concept of discourse to the social

201 sciences from its linguistic formation. His definition of discourse is referred to as a system of thoughts that are composed of ideas, attitudes, beliefs and practices that create the world of which they speak.

There are many factors that contribute to how people use and interpret meanings, for example they will be affected by the social class to which they belong, their ethnicity, gender, age, educational level and their place of residence; each will affect their world view.

Consequently these factors indicate that meanings are the result of „who talks to whom, when and where‟ (Rosenberger 1992, p. 238). Therefore, discourse emphasises the power and knowledge of the speaker, what can be spoken, as well as where and how a person speaks. I will elaborate this point later in this chapter by providing an example based on the doctor-patient relationship. In addition, discourse is also understood as a conversation which has a certain agenda (Singer & Hunter 1999). Since discourse has a certain agenda, it is tailored to establish a particular view which will be accepted by the society or a particular group of people. For example, in Foucault‟s work Madness and civilization: a history of insanity in the Age of Reason

(1989), he argues that the discourse of madness produced by psychiatrists and psychologists is the way we have come to think and talk about it over time. It determines what we believe is madness and how a „mad‟ person behaves. Consequently, madness is a shameful condition and therefore „mad‟ people must be hidden or isolated (in prison or hospitals) from „normal‟ people.

In addition, not only does discourse have an agenda, it also exhibits to some extent, the power relationships within society and influences how individuals make sense of their experiences.

Discourse is an avenue to the exercise of power. Discourse, Foucault argued, goes beyond words whereby it is seen as a mechanism where people exercise their power at all levels through individual interaction, or from the government to the people (Foucault 2000). Doctor-

202 patient interaction is a good example which can be used to illustrate the exercise of power as it reflects a kind of hierarchical arrangement. Since doctors and nurses can be expected to have sound knowledge about menopause and its treatment, menopausal women normally see them as the experts. Therefore, HRT is considered as part of their „expert talk‟ (Linell et al. 2002, p.

215). One view may be that these experts have encouraged women to subjugate themselves to a particular medical decision. In this manner women may defer to the doctor or the nurse because they are perceived as having greater knowledge about menopause and therefore, because of this perception, they have greater power of influence. People‟s preferences towards healing practices give an insight into how they are led to accept a particular kind of treatment. These preferences are motivated by factors like cultural practices and the presence of scientific evidence which is often seen as having an aura of factuality.

In general, most people in Western societies, when presented with a range of options will turn to Western medicine, although there are other forms of treating illness available including traditional practices like acupuncture and Ayurvedic, and other healing systems like reiki, reflexology, kinesiology, thought field therapy and homeopathy (Easthope 2005). In a Western society like Australia, most people will seek Western medicine to treat various kinds of illness.

This is because Western medicine, with its emphasis on scientific evidence and objective measurement, supports the belief that it is objectively proven and therefore supposedly not influenced by cultural beliefs. Thus, Western medicine sees non-Western medicine as less credible. In the Malay healing practices some forms of treating illness are still popular like urut

(massage), consulting bomoh/dukun (indigenous medical practitioners) as well as bidan

(traditional midwives) and herbalists. Moreover, seeking help from orang ‘alim (religious people) to treat illnesses is commonly practiced amongst Malays. The healing practices that I

203 have mentioned are connected to a belief system that rationalises its continuation. Nevertheless, in Malay culture today, traditional and Western medical practices do not carry a similar weight of importance. There is most definitely one dominant practice that overshadows the others. In other words, it is the scientific and medically proven practices which are given the support of other institutions like education, law and the media.

Most of the women who attended the menopause clinic accepted the doctor‟s dominance, because doctors talk to them about their problems and the women tend to accept their expertise.

As one woman stated:

I trust what my doctor said. They go to medical school and learn what I don‟t know. I feel comfortable with the medicine she gave me.

In short, discourse can be an institutionalised way of speaking about matters of the body, health and medicine, in which the discourse establishes what we say, what we do not say and how we say it. In the realm of medicine, medical professionals have gained more credibility and authority than non-medical people through the discourse that is used and this is translated into power that they can use in different kinds of ways.

The discourse of menopause: historical and social changes

As I have discussed earlier in the thesis - menopause is a silent discourse. Menopause is not discussed as extensively in Malay society as it appears to be discussed in Western society.

Menopause, like other private and personal experiences is regarded as taboo.100 It is discussed predominantly in the medical context and the private sphere, between the doctor and the woman.

100 Menopause is considered a taboo topic because it involves a degree of embarrassment and humiliation to women who experience it. Thus, it is undesirable and offensive to discuss menopause openly. Other topics which are considered as taboos in some societies are death, discussion of genitalia, exposure of the body (pornography and nudity) and sexual activities (incest and paedophilia). 204

Most participants in my study agreed that their mothers never spoke about menopause with them.

Today many urban Malay women feel constrained by the silence that is imposed about menopause. As it is a natural human process that women will undergo in their later life, some women feel it should be discussed more openly. After being interviewed by me most women said they „needed to open up‟, especially with family members and friends about the issue of menopause and how it affects them. As will become apparent throughout this chapter, menopause is not discussed directly between close family members. By contrast, friends may discuss one another‟s mother‟s menopause, but they will not discuss this with their own mothers.

It is not an easy matter to „open up‟ about menopause and there is a level of ignorance and naivety, not just amongst women experiencing, or having experienced menopause, but also amongst the general community.

In Chapter Four, I noted that the closest term that can be used to describe menopause in the Malay language is putus haid or putus darah. Based on Omar‟s (1994, 1995) findings, the rural Malay women used the term putus haid or putus darah to describe the experience of menopausal symptoms. A term like „menopause‟ would have been completely foreign to them.

Similarly, as I described earlier in Chapter Four, research by Davis (1986) in a Newfoundland fishing village showed that local women were not familiar with the term menopause. Rather, the local term „the change‟ was used to describe menopause and its symptoms. In contrast, the urban middle class Malay women in my study used the word „menopause‟ rather than the common

Malay terms. Menopause is an English word but I found that in Malay newspapers, magazines and health brochures the word has been spelled the Malay way, which is menopaus or menopos.

In the urban context I would argue the term menopause has gained popularity above any of the localised Malay terms that I mentioned earlier. Most of the women I spoke to said that they

205 learned of, or heard, the term from doctors, nurses and health magazines. The medical language has been used in the clinic as well as in the media. In 2003, the former Minister of Women,

Family and Community Development instigated a new term Era Mas (Golden Era) supposedly to replace putus haid. Interestingly the term has not been used widely. I found it was not used in daily communications and was only seen on the Ministry of Women, Family and Community

Development health brochures and its bulletin, on the health package flyer and on the glass wall at the menopause clinic (Plate 6).

Plate 6 The word Era Mas on the clinic’s glass wall. (Photo: Nurazzura Mohamad Diah)

The rationale of replacing the term putus haid with Era Mas, as reported by Dain (2003) in

Utusan Malaysia newspaper was to signify women‟s dignity and to show the importance of women‟s role in the society and thus it was supposed to change the perception of older women in the society. This may well have been the intention, but a more critical view may be that the 206 euphemistic term continues to keep the topic secret to some extent as it does not explicitly state what is happening. For example the pregnancy or ante-natal clinic would not be called the

„budding times‟ clinic.

Terminology can be used in many different ways. For example, Chirawatkul and

Manderson (1994) who studied women in Thailand found that local terms or idioms were used when the women were talking to their husbands or friends about menstruation and menopause. In a similar vein, women who participated in my focus group discussion used the word dah off

(already stopped menstruating) to describe the cessation of menses. Women whom I interviewed separately also used the term. Some women indicated to me that their husbands used particular words and phrases to describe their menopausal condition, for example umur meragam

(problematic age) and dah pencen (already retired). While most of my participants used the term menopause or its Malay variants, they continued to use Malay terms to describe menopausal symptoms. For example, a hot flush is referred to as panas-panas (hot-hot) and mood swing as marah-marah (angry-angry). In a similar manner, Lock (1993) found that Japanese women used particular terminology to describe „the change‟ (konenki).

In general, the urban middle class Malay women in my study realised that menopause is a biological event which occurs in all women. Like the rural Malay women reported in Omar‟s study (1995), the urban middle class Malay women in my study also described menopause as dah semulajadi (it is natural), dah sampai masa (it is time), perubahan dalaman (inner change) and bukan penyakit (not a disease). Nevertheless, there are differences in the approaches taken by women in rural and urban Malay settings which I will describe further along in this chapter.

In the following sections of this chapter, I will discuss the discourse of menopause as presented in the Ministry of Women pamphlets, through the media and by doctors and nurses. This section

207 is not an attempt to provide a detailed content analysis of the subject, but rather, to show the variety of information about menopause presented to urban Malay women.

‘Official’ information about menopause

Information about menopause has been very limited, but this has recently changed, at least in urban parts of Malaysia. In trying to get a sense of what happened in the past I asked women about their mothers‟ experiences. Most women who I spoke with said that their mothers obtained information about menopause, not from printed or electronic media, but from the village clinic, bidan, tukang urut (masseuse), their closest friends or their relatives. But again, the information received was very minimal. The focus of medical health in Malaysia from 1960s to 1990s was on family planning, fertility and childcare (Manderson 1998). From what I can gather, menopause appears to have been a marginal or non-existent issue in terms of women‟s health or health policy. In recent times in KL, as experienced through my recent fieldwork, I found that there were some potential sources where women could obtain information about menopause. The main source of information was derived from doctors who treated women in the menopause clinic, obstetrician and gynaecologists, friends, family members and seminars as well as printed material like health brochures, newspapers and women‟s magazines. These sources have supplemented women‟s information about menopausal symptoms, their treatment and management. Other studies like George (2002), Mohd Zulkefli and Mohd Sidik (2003),

Chirawatkul, Patanasri and Koochaiyasit (2002) have also reported similar findings in which television, magazines, newspapers, and advertisements have helped to shape women‟s attitudes towards menopause. As I mentioned in Chapter Five, most women did not rely on their mothers for clarification because menopause was rarely, if ever, discussed with them nor did they recall

208 their mothers‟ experiences in any depth. The children of women in my study, though taking a somewhat more „modern‟ view, still had to learn from observation, rather than from open discussion. From what I have gathered, women have easier access to information about menopause from printed material and from their doctors and this appears to be more influential in terms of giving them some kind of direction in how they may deal with unwelcome symptoms and concerns.

The menopause pamphlets from the Ministry

When I made enquiries about women‟s health in general and menopause in particular from the Ministry of Women, Family and Community Development in 2005, they gave me several health brochures, pamphlets and flyers. They included information about cancer of the cervix, the pap-smear test, breast cancer, reproductive health and weight management. These materials were published by the Ministry and were circulated in government offices, public and private hospitals as well as clinics. The pamphlets, with two pages of condensed information were colourful and printed on glossy paper. They included a number of pictures, for example some had parts of the human anatomy, while others had the medicine they were promoting and others had pictures of women depicting various moods and facial expression to help explain specific issues. The pamphlets were prepared by the Ministry in collaboration with a panel of doctors. Of all the materials I have received, only two are dedicated to the menopause. Although the brochures were circulated in the government agencies, some women in my study claimed they did not receive or see the brochures I showed to them during my interviews and the focus group. Some women indicated that they had seen or received other pamphlets, but not pamphlets about the menopause. The majority only saw the menopause pamphlets for the first time during

209 my interview though a few claimed they saw the brochures in government hospitals or clinics.

This finding tends to reflect the particular prominence given to information about menopause by the Ministry. Compared with other aspects of women‟s health (for example cervix and breast cancer, reproductive health, diabetes) it does not appear to gain attention, but this may be because it is seen as less of a health issue and more of a life stage issue.

The menopause pamphlets I received were in the Malay language. Both pamphlets have similar information about menopause. One pamphlet has an encouraging title: Menopaus: Suatu

Kehidupan Baru (Menopause: A New Life). It described the process of menopause and its relationship with hormonal changes. It is reported in the pamphlet that on average Malaysian women reach menopause at the age of 50.7 years. This indicates that women will reach menopause somewhere between 45 to 55 years of age. In addition, the pamphlet also highlighted that only 30 percent of Malaysian women are affected by adverse menopausal symptoms, although it is not clear where this information is derived from. According to the pamphlets the most prevailing symptom is the hot flush. Among the prevalent symptoms listed on the pamphlet are: night sweats, less sexual desire, memory loss, mood swings, vaginal dryness, sleep disturbance and palpitations. In relation to the treatment of menopausal symptoms, the pamphlet suggests three possible ways. First, a woman is advised to practice a healthy diet with a greater intake of soy food. She should include regular exercise in her daily routine, get plenty of rest and remain calm when she encounters any problems. Next, women who have mild symptoms are encouraged to consume herbal therapies for a short period of time only. However, the pamphlets do not recommend any herbalist or identify which herbal remedies to consume. Finally, HRT is recommended for severe symptoms. The length of time a woman may need to take HRT is either

210 less than or, in particularly severe cases, more than five years. For osteoporosis prevention HRT is taken between five to ten years.

There are four sections about HRT in the pamphlet: i) what is HRT; ii) its advantages and disadvantages; iii) duration of taking HRT; and iv) steps taken before taking HRT. The pamphlet clearly shows that HRT is recommended to women who have severe symptoms. The pamphlet further elaborates that HRT comes in two synthetic forms: estrogen and progesterone. However, it does not indicate the various selections of HRT available in Malaysia.101 The advantages of taking HRT listed in the pamphlets are: prevention of osteoporosis and heart disease, increasing reduced sexual desire and reducing urinary problems, whilst the disadvantages are headache, problematic bleeding, gaining weight and feeling bloated.

The other available pamphlet had similar information but an additional recommendation of sharing and discussing women‟s menopausal conditions with family members and friends. It also recommended to menopausal women that they must ensure their family members understood their condition and bodily changes. It also suggested that menopausal women should attend religious and social activities to fulfil their leisure time. Despite the suggestions for changes to lifestyles, the pamphlets show predominantly that the Ministry of Women, Family and Community Development, with strong support from the doctors, recommend a direct biomedical treatment and management of menopause among Malaysian women. There is no information included that would help women to understand how their symptoms may be manageable or not. In other words, the clinic is promoted but women would not necessarily know if they should attend. It is evident the Ministry of Women, Family and Community

101 Based on my interviews with doctors and nurses in the menopause clinic, I found only oral HRT is available and commonly prescribed by doctors in Malaysia (see Appendix III). Other forms of HRT like implants, spray, skin patches and gel are not available in Malaysia. 211

Development supports and sees a role for biomedical intervention as they initiated and financially support the clinic.

Images of menopause in the print media

Another way of obtaining information about menopause in Malaysia is through the printed media. Media is one of the most powerful tools in disseminating information to society about health-related issues. Among the kinds of health-related issues dealt with by the media are

HIV/AIDS, various cancer diseases, obesity, diabetes and heart attack. In general, the media reports on the symptoms and treatment of the diseases as well as preventative measures that need to be taken into consideration by the public. However, menopause is a „relatively minor topic of interest to the media‟ (Gannon & Stevens 1998, p. 10) compared to issues like cancer,

HIV/AIDS and heart disease. Gannon and Stevens‟s (1998) have noted that the media primarily disseminate information about menopause based on the biomedical paradigm in which menopausal women are seen as declining in their condition and in need of a drug to fix the problem. Gannon and Stevens‟ study, which is set in America, reflects the practice in Malaysia where the media also rely on the medical model to explain the issue to women and society at large. Media presentations of issues related to the menopause in Malaysia are to some degree unhelpful and do not portray menopause in a positive light.

Some years ago Wright (1975) confirmed that mass media was the source of medical information for particular people who wanted to know about symptoms, illnesses or treatments.

His study showed that, at that time, magazines and newspapers were the most used media while radio was the least used medium to obtain health-related information. I found a similar kind of reliance on the print media for health related information among the women I spent time with. It

212 appears it is really only the print media that have taken this issue up, and it would be difficult for women to find much information on television, for example, though the internet is another viable source of information. However, the women in my study did not use the internet as a source of information. Although they used the internet, it was not to find out health-related information; the contents of the relevant websites about menopause are generally in English and are quite technical.

In December 2005, I visited Malaysia for my fieldwork and was very interested to see that a publishing group called Karangkraf started to publish a magazine specifically for the middle-aged women. This is unusual because most women‟s magazines in Malaysia are published either for women in general (regardless of age) or for teenagers. The magazine entitled

MIDI is a Malay language magazine dedicated to women aged forty and above. Its slogan is

Aspirasi Wanita (Women‟s Aspiration) and it highlights issues about health, business opportunities, cosmetics, fashion, food, and the relationships and families of middle-aged women. The magazine is published twice a month and priced at RM 4.20 per copy. Interestingly,

I noticed that some of the information about middle-age and the menopause are reported inconsistently and often in a contradictory manner.102 For example, it is evident in its first edition in 2006 the headline was „Sex crisis in the 40s‟, in 2007 it was „Reaching 50 with confidence‟ and in 2008, „The apprehensions of reaching 40‟. These headlines appeal to women who are often confused themselves about their transitional status from younger to more mature woman.

102 It is common that the media often project inconsistent and contradictory messages in their reporting on particular issues. Gannon and Stevens (1998) explained that the inconsistent and contradictory information reported in the media is not just due to the journalists‟ inability to understand and interpret the complex medical situation as there are similar contradictions that appear in the medical literature. Furthermore, Gandy‟s study (cited in Gannon & Stevens 1998, p. 12) stated that „the journalists generally were subsidised by pharmaceutical companies to write about health-related information‟. They normally did this by supplying a short summary of the topic, colourful brochures and presenting statistics. Thus, the journalists report information which is in favour of the pharmaceutical companies‟ perspectives. An example of inconsistency reported by the media can be derived from the newspaper articles I have reviewed. For example, „HRT has no risk of breast cancer‟ (Utusan Malaysia, 26 January 2003). In the next seven days, Utusan Malaysia on 2 February 2003 reported „HRT has low risk of getting breast cancer‟. 213

In general, magazines, as well as newspapers, make their headlines or stories more appealing through using catchy phrases and reporting the stories of celebrities. This is also evident in the

MIDI magazine where middle-aged celebrities were selected for the front cover of the magazines

(Plate 7) and their tips about how to maintain youthful looks and femininity were also highlighted throughout the pages of the magazine.

Plate 7 Celebrities selected for MIDI front page cover.

Initially, not much was written about menopause in MIDI‟s first year of publication in

2006. In that year, a more positive report about menopause, ageing, healthy lifestyle and diet were presented to the reader. On top of that, the emphasis of youth and beauty through fashion, cosmetics and accessories was strongly emphasised. I found only a small fraction of articles in

2006 had negative overtones. MIDI also promoted alternative medicine and petua orang tua (old

214 folk practices) to treat menopause. However, the emphasis on these treatments was not the highlight of the magazine. Only more recently between 2007 and 2008 MIDI began to promote a biomedically approved approach to menopause.

Throughout the past two years the emphasis on youth and beauty in the magazine has been even stronger and bolder than before. More and more beauty products, fashions and the latest technologies were introduced in the magazine, supposedly to boost women‟s level of confidence in their middle-age. A more proactive approach to the menopause was also advocated; for example, in MIDI 1 July 2008 edition: Terapi gantian hormone bantu atasi vagina kering (HRT helps to overcome dry vagina) was printed on the magazine front page cover. The two pages article, which is based upon an interview with a gynaecologist, supports the need for women to take HRT to overcome their sexual problems, prevent osteoporosis and other menopause-related symptoms. New technologies were also introduced in this magazine like anti-ageing treatment through mesotherapy, Botox, Serdev, collagen, placenta and Vitamin

C injections to revitalize ageing skin, associated with menopause and ageing in general.

The reporting of menopause in the four major newspapers in Malaysia indicates that there are both positive and negative representations of menopause. To identify what kind of information was being disseminated to the Malaysian women about menopause and its treatment,

I reviewed articles in the four major Malay and English newspapers published in Malaysia from

2000-2006. As can be seen from Table 7, Malaysian reporters have presented diverse opinions on the prevalence of menopausal symptoms; the various perceptions of menopause and the use of

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HRT (see Appendix IV for a detail list of the newspaper articles reviewed).103 In general, all newspapers reported hot flushes as the most frequent symptoms. There were also other symptoms reported in the newspapers like insomnia, mood swings and vaginal dryness. I found two articles reported on medical studies conducted in Malaysia. Some reporters were inclined to report findings from America and Britain.

Table 7 Information on menopause reported in major newspapers in Malaysia from 2000-2006.

Newspaper Symptoms reported Perception about On HRT menopause Berita Harian wrinkle, dry skin, biological change, warning about (Malay) insomnia, hot flushes physical and mental breast cancer effects, reduces femininity, it is a „dark age‟

Utusan Malaysia hot flushes, mood New phase in life, uplifting, quality (Malay) swings uncomfortable experience of life, how to reduce symptoms

New Straits Times depression, vaginal bodily changes, difficult prevents heart dryness, insomnia, time, a disease disease and hot flushes, breast osteoporosis tenderness, mood swings

New Sunday hot flushes, mood natural change, still a alleviates Times swings mystery, ends the „health menopausal shield‟, double the symptoms anxiety, double the health risks, emotional upheavals, physical disturbances

103 I reviewed eighty-two newspaper articles from thirteen newspapers in Malaysia. However, out of thirteen newspapers, I found only four newspapers (see Table 7) which reported extensively about menopause. Most newspapers are in English and the Malay language. However, Tamil and Mandarin newspapers were not reviewed due to my inadequacy in understanding both languages. I also did not feel they were particularly relevant given my study focuses on Malay women. 216

Several newspapers have used captivating headlines to sell their stories about menopause, for example: „There‟s life after menopause‟ (Kaur 2001); „Preparing for the golden years‟ (De

Lima 2001); „Celebrating menopause‟ (Vela 2004); „Menopaus hargai fasa emas’ (Menopause appreciating the golden phase) (Hassan 2005); „Wanita menopaus perlu dibantu’ (Menopause women must be helped) (Ibrahim 2006). With regards to treating menopausal symptoms, HRT was clearly the most commonly mentioned treatment for menopause, but reporters also have suggested a balanced diet, regular exercise and alternative treatments. The conflicting opinions and medical findings on HRT were evident in the newspaper articles. I have selected some newspaper headlines that contained strong messages about the potential dangers of HRT to illustrate the changing medical opinions that have occurred regarding the issue: „Cancer scare‟

(Malay Mail 26 July 2002, p. 46); „Stark warning on HRT‟ (Malay Mail 9 August 2003, p. 17) and „Possible link between cancer and use of HRT‟ (Abdul Razak 2003). By contrast, I found very few, if any, headlines reflecting a positive view of HRT. For example, „Staying fit with

HRT‟ (De Lima 2002). In short, some reporters said HRT was beneficial to reduce the symptoms and others said it was not. While some reporters chose to report issues related to HRT, others presented material on alternative treatments to menopause. Some reporters proclaimed that menopause could be treated with herbal remedies: „Lignans104 and their role in menopause‟

(NST-LTimes 1 February 2001); „Menopause relief with Remifemin‟105 (Veera 2001);

„Alternatives for menopausal women available‟ (NST-LTimes 1 August 2002, p. 6); „Alternative options to HRT‟ (Seng 2005) and „Easing menopause naturally‟ (New Sunday Times 10 April

2005, p. 24). Since the effectiveness of products of pharmaceuticals and medical findings were

104 Lignans is one of the most common types of phytoestrogens. Flaxseed oil is known to have an excellent source of lignans. Lignans have shown positive results in relieving menopausal symptoms particularly hot flushes. 105 Remifemin is a herbal remedy product which contains extract from Black cohosh (Cimicifuga racemosa). Black cohosh is believed to reduce hot flushes, sweating and restlessness associated with menopause. 217 given more emphasis by the media, I found non-medical treatments were given insufficient attention within the media reports. However there was always some lingering doubt about the safety of HRT due to the conflicting medical reports over time.

While women were presented with information through the text (words), images depicting menopausal or middle-aged women also have a significant influence upon women as they enter another phase of their lives. Some images I found in newspapers or magazines were very positively portrayed and interesting, yet others were unappealing. Interestingly, Malaysian magazines and newspapers mostly presented pictures of Western women. Some pictures portrayed unhappy faces showing emotional states like anxiety or sadness (Plate 8) and others portrayed slightly ambiguous figures like one older woman who, because of the angles used by the camera, has a large nose and prominent hands and to me she appears somewhat „witch like‟, which may not have been the intention of those preparing the publication (Plate 9).

Plate 8 Emotional expressions shown in menopause pamphlets.

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Plate 9 Menopaus hargai fasa emas (Menopause appreciating the golden phase) in Mingguan Malaysia 16 October 2005.

I interpreted the picture of the woman (see Plate 9) as witch-like because she uses a cane, there are herbs in the photograph and these are associated with witches in Malaysia and the clawish fingers depicted an elderly woman who is known as nenek kebayan. Nenek kebayan is a powerful elderly lady in the Malay folklore. She is said to possess magical powers and can materialize or disappear into thin air. Moreover, nenek kebayan walks with a cane and uses herbs to make good medicine. I showed this picture to friends, particularly Malaysians (Malay, Chinese and Indians) to see what they thought. Similarly, they too interpreted the picture as portraying nenek kebayan.

I then showed the picture to other friends who are mainly Australian and they commented that the picture showed a „normal‟ older women and felt there was „nothing wrong‟ about the photograph. Indeed, images do not necessarily translate cross-culturally which is interesting in view of the practice in Malaysia of using images of Western people when topics considered sensitive, inappropriate or difficult are being depicted.

It is not considered culturally appropriate or respectful to use images of Malay people when depicting private or sensitive information. Images of couples embracing or even touching

219 are considered too explicit. Images of a Western couple may be used to convey a particular message, for example the idea that it is possible and even desirable to have an intimate relationship during and after menopause (Plate 10). Western images are used to avoid offending any individual and to avoid transgressing a taboo. Some women in my study claimed that they were intimidated by the images they came across in magazines and newspapers and others said it was a wake-up call for them to update their style as they were still working outside of the home and had husbands that they needed to keep interested in them. The media, to some degree, must be seen as responsible for creating a climate of pressure upon urban Malay women to look good and feel good about their bodies. However, as is the case in Western societies the images portrayed are not always realistic.

Plate 10 Images of Western couples are used in Malaysian magazines.

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When, I asked the women in my study why they rely on magazines and newspapers for information about menopause, they said that some doctors spent very little time during appointments and there were times when the doctor had many patients and they had to consider others who were waiting. They did not have the confidence to ask the doctor questions about their condition or to seek further information from them. Laili, a 50 year-old consultant, told me:

What is written in the newspaper is also from the doctors. Some doctors they [the reporters] interviewed are well-known in our country like Dr X and Dr Y.

Rafeah, aged 51, shared a similar view. She obtained most information from her favourite women‟s magazine - Her World:

I like to read this magazine because the things that I wanted to know were all here. I am confident that those people who wrote the articles consulted the specialists first before getting it published.

It is clear that Laili and Rafeah have used the printed media as their source of reference. They are not dissimilar to many other women in my study who have a high level of trust in the sources of information provided in printed media. These sources inform their perceptions and understandings and confirm or deny their own personal experience of menopause. They lead them to adopt positive or negative ways of thinking about menopause and ageing in general.

Through the study of communication we see that the way in which the news is transmitted to the public and the frame through which the news is presented, is a choice made by journalists

(Vainionpää & Topo 2006). In other words, media draws public attention to certain topics through their reporters who select the topics.

According to Goffman (1974), mass media have a role in framing issues either to be seen as something positive or negative. Framing will make a particular issue look more appealing; just as I framed my wedding and children‟s pictures and place them on a table next to my bed, the

221 media choose certain aspects of news to report in a particularly positive light. Framing leads others to accept a particular issue over the other. It is a process by which an individual or the society perceives a particular issue as a political, security, medical or public controversy. For

Entman (1993, p. 52):

To frame is to select some aspects of a perceived reality and make them more salient in a communicating text, in such a way as to promote a particular problem definition, causal interpretation, moral evaluation and/or treatment recommendation.

Indeed, frames influence the perception of the audience about the issues presented. This process is a form of agenda-setting; it not only tells us what to think about, but also how to think about the issue. In Table 8, I borrow a technique employed by Fairhurst and Sarr (1996) to examine how issues can be framed in ways to make them more appealing and outstanding. In the table I use some examples from my review of the newspaper articles to illustrate how issues are framed through use of metaphor, stories, slogans and contrasts. However, I argue that the framing is not always positive; it is in fact quite ambiguous and there are conflicting meanings presented to the women who use the media as a principal source of information.

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Table 8 Framing tools (adopted from Fairhurst and Sarr 1996, p. 101) used to present menopause in either positive or negative ways in various media.

Framing Purpose Example Metaphor To offer a new meaning by Menopause is entering the comparing it to something else golden years or the twilight of your life. (positive and negative)

Stories To frame a subject by selecting One woman who swears by stories that can attract attention HRT is Ruby. She turned to and be remembered by people HRT and claimed it helps her to live life to the fullest. (positive)

HRT links to cancer researchers say. (negative)

Slogans and To frame a subject through HRT - a pill a day will keep catchphrases106 unforgettable and familiar your troubling symptoms expressions away. (positive)

Contrast To describe a subject in terms of Some women take herbal what it is not remedies but there is no guarantee it helps prevent osteoporosis.

By using stories of women who have taken HRT and combining catchy slogans produced by pharmaceutical companies a particular frame can influence the manner in which women make decisions about using HRT or other remedies for symptoms associated with menopause. During my fieldwork I found a booklet produced by a pharmaceutical company, Organon, based in

Malaysia which used the slogan „Discover a new zest for life with Livial‟. The pharmaceutical company Wyeth‟s slogans are even bolder: „HT (Hormone Therapy) 60 years of confidence‟ and

„60 years of proven benefits‟. In addition, Wyeth has also used quite a fanciful poem in their booklet to convince readers that HRT has had a great impact on a particular woman‟s life:

106 While framing can be either positive or negative, slogans and catchphrases are likely to be positive. Normally negative slogans do not sell. 223

The Crowning Glory of HRT

I used to fret and fight, Nothing was ever quite right. I felt dull and dry, Trivialities made me cry.

I tossed and turned at night, My insidious insomnia was a blight. Hot flushes, sweating and palpitations, I dread those aberrations.

Despair and despondency were rife, My health took a dive. There was no respite, Who could shed some light?

Then trusty HRT came along, And I broke into a song. Magical moments are here to stay, And HRT is leading all the way.

I‟m fresh as a daisy, The world is pink and rosy. Mercurial Menopause is contained, Sublime Sensations reign.

The idea of framing menopause as a biomedical issue by medical scientists and professionals gives some insight into the issue of the power difference between experts and the lay person, as suggested by Foucault (2000). Thus, connecting what is framed as being within the biomedical domain together with other powerful political and economic factors such as the commercial side of drug production, presents HRT as being the answer to the problem. However, in the example given above of the poem, the information is broken down in a rather patronising manner to paint a picture of a woman out of control who is saved by the „trusty‟ HRT that „leads‟ the way to a future life of „rosy‟ bliss. The medical framing of the issue has a striking impact on

224 women‟s overall thinking about menopause. Doctors attempt to promote HRT by encouraging patients to think about its benefits along particular lines. This is accomplished by highlighting certain benefits of HRT, such as alleviating menopausal symptoms as well as providing protection for their bones and hearts. My interviews with doctors which I will discuss later in this chapter confirm these observations.

Menopause as a non-spoken topic shrouded in embarrassment can therefore potentially be transformed into a spoken topic by re-framing the issue in terms of a medical problem needing medical intervention. In my review of the media reports in the year 2000 for example, reporters were only informing the Malaysian public about menopause as a biological process, with some reference to the possible symptoms that a woman may encounter during that period and some discussion of the treatments that were available at that time. By 2002, menopause had become an issue that needed to be addressed urgently when the Former Health Minister, Datuk Chua Jui

Meng said:

…only 30% of Malaysians consulted doctors for advice on menopause. Some 60% of the 2 million women aged between 45 and 55 do not understand the link between menopause and their health (New Sunday Times 1 August 2002, p. 12).107

Due to what was thought of as alarming statistics, the Ministry of Women, Family and

Community Development launched Klinik Harapan in March, 2004 to provide women with health screening packages which included the ability to consult a clinic doctor about menopause.

Interestingly, in July 2004 the American Broadway smash-hit comedy, Menopause the Musical

(MTM) was shown in KL and menopause was made more public through humour and

107 My own findings amongst women who did not go to the menopause clinic, that is those within the focus group, confirmed this as many did not associate their symptoms with the cessation of menstruation. 225 music.108 Once again, MTM was invited to perform in KL in conjunction with the Arts Festival from 27 July until 5 August 2007. I was interested to know how MTM was perceived by people in Malaysian society. I reviewed the content of a number of newspapers and found only English newspapers reported information, in the manner of reviews, of MTM. An English newspaper reported:

It was the second night of the show last Thursday, and it played to a full house. The audience, educated and urban, laughed at the right points, clapped enthusiastically and obviously relating to the storyline. Menopause the Musical touched a chord with the audience – mainly women, just turning the corner if not already there. Many brought along their partners: boyfriends, husbands and significant others. The 20% male audience looked like they have been brought kicking and screaming. Most looked unimpressed. (Aznam 2004)

A similar remark was noted in another English newspaper:

Even the men, albeit a handful, in the audience simply burst out laughing at the hijinks on stage, be it about mood swings or sex drives (Devan 2007)

Although the newspapers reported that MTM was hilarious and the audience had a good laugh, there was no reference to socio-demographics other than gender. In other words we were not given information about the audience‟s ethnic background. I browsed through some

Malaysian blogs to find more answers (if any) to this question and came across one blog109 written by a Malay male which said: „the theatre was almost full and the crowd seemed mainly

30-somethings and above and with a lot of Mat Salehs [a colloquial which indicates Western people] there as well‟. Although this man was present at the show for one night only, this

108 The musical comedy was written by Jeanie Linders and directed by Kathryn Conte. The musical was staged at the Actors Studio Bangsar (Bangsar Shopping Centre) in KL from 6-25 July, 2004. The musical show is about four women who are middle-aged and known as Iowa Housewife, Power Woman, Soap Star and Earth Mother. They met during a sale at a shopping mall. They all came from various backgrounds and shared their concerns and thoughts about their „new life‟ through familiar pop and disco songs. This musical comedy is an educational play of sorts as it conveys information about menopause in an amusing manner. 109 This personal blog is available from http://amirfuadh.blogspot.com/2007_07_01_archive.html [accessed 13 July 2008]. 226 audience demographic was likely to have been similar on other nights; namely, that the audience was predominantly Western and most people were in their thirties.

In October 2004, the Ministry held a special women‟s health programme110 known as

Wanita Health and Lifestyle 2004 (WHL 2004) to discuss women‟s health issues such as menopause, nutrition, weight management, dental and mental health as well as maintaining a healthy heart. Thus, WHL 2004 was seen as a platform for women to get the right information about women‟s health-related issues. As I have pointed out in Chapter One, in the Fifth

Malaysian Menopause Congress held on April 21, 2005 in Kuala Lumpur, the government called for more involvement of specialists and other health professionals to enhance the awareness of menopause amongst women (Utusan Malaysia 22 April 2005, p. 1). The effort made by the

Ministry indicates that officially, at least, menopause was no longer a topic that was kept in the closet but was to be viewed as an important issue. Today, women‟s life expectancy in Malaysia, as elsewhere, has increased. Women live longer and will spend approximately one third of their lives post-menopausal. Moreover, Malaysian women today are engaging in multi-task jobs and it would seem that they need to be healthy in middle-age. The government are no doubt aware of the important labour force issues and middle-aged women are not only encouraged to stay in the workforce, they are needed there, particularly those who are educated and living in urban areas, like the women in my study.

Constructions of beauty in middle-age

Discussions of how media representations of the menopause affect middle-aged women cannot be separated from representation of middle-aged and older women in general. As I

110 The health programme includes talks and seminars, health exhibition, slide shows, free medical check-ups and a cooking competition for women. 227 discussed in Chapter Five, much of the anxiety surrounding menopause is not just about the biological symptoms associated with the cessation of menstruation, they are also connected very closely to what this means to a woman‟s identity. The symptoms of menopause also mean that the biological markers of ageing become more obvious and menopause is itself symbolic of a transition to another stage of life, where the notion of beauty is less clearly associated with ideas about feminine and youthful looks. As I explained in Chapter Three, studies about Malay beauty are very limited. Malay beauty focuses on the principles of beautifying from the inside and the outside of a woman‟s body (Ahmad 2005). According to Omar (1994), to enhance a woman‟s health and attractiveness, the Malay women in her study consumed jamu. Jamu is usually taken after childbirth to maintain physical beauty, health and sexual urges (Omar 1994; Laderman

1983; Karim 1992). Apart from that, wearing gold jewellery is another way to look attractive and beautiful. Jewellery plays an important role in the Malay culture, not only for beautification purposes but gender differentiation as well (Omar 1994). On the other hand, it is also a possibility of some attempt to indicate degrees of financial success and status.

Studies have shown that the association of youth with beauty is in part a product of

Western media, which portrays feminine beauty in a particularly idealistic manner. As a result, many non-Western societies have imitated the Western ideal of youth and beauty (Frith, Shaw &

Cheng 2005; Swami & Tovée 2005). The women in my study who expressed dissatisfaction with their bodies and „looks‟ have no doubt been influenced by the media in Malaysia which has started to portray Western ideals of beauty and youth. Cusumano and Thompson (1997) indicated that media portrayals of women create negative influences over the way they feel about their bodies. Most of the women I spoke with said they were influenced by women‟s magazines and beauty product catalogues, as well as friends who visited spas and beauty parlours.

228

In addition, my study suggests that the majority of the urban middle class Malay women I spoke with have internalised the „culture of youth and beauty‟ and think that the signs of ageing on their bodies are undesirable. This is also evident from women in my focus group who, after looking at MIDI magazines that I showed them during the discussion, expressed their feelings about needing to appear „young‟ and beautiful in their middle-age. Below is the excerpt of two women from the focus group:

Salbiah: We must take care of our bodies. Look young - in and out. On the outside, we put on make-up and wear beautiful clothes. Inside, we must strengthen „that thing‟ [vagina]. We please the husband with our looks and our „that thing‟. There‟s no point if you look good outside, but „nothing‟ inside. We have money, so buy good clothes, make-up and eat good food. Don‟t keep it in the bank. Many beauty products are available now. Just pick one. Mind you, don‟t overdo it like some women in this magazine. We must appear beautiful according to our age. I don‟t see why we need to colour our hair, go for plastic surgery or get the Botox injections. There are only two ways to appear beautiful - the natural way and the fake way! Tepuk dada, tanya selera.111

Dina: No matter how old we are, we must appear young. Wear clothes nicely, put on make-up. Not for anybody else but our husbands. Don‟t blame the husbands if they turn to younger women. To look beautiful costs you a lot of money. I think it is worth it to look beautiful. Why not spent some cash? After all, there are discounts and sales, here and there in KL. Plus we have bonus end of the year. Don‟t wait too long to look beautiful. Get started ladies!

According to Martin (1992), the emphasis upon the beautiful body reflects the social and cultural context in which women are socialised to view their bodies as parts or fragments of the self.

Bordo (1993, p. 35) stated that „the body we experience and conceptualise is always mediated by constructs, associations, images of a cultural nature‟. Although I agree with Bordo in principle, I also believe that the attitudes to, or meanings associated with, the body may be meaningful in different ways for different groups. Some groups and individuals may view the body more as functional to the ability to perform, while others may pay more attention to the body as symbolic

111 Tepuk dada, tanya selera (literally means tap your chest, ask your taste) is a Malay proverb which means you should know what you really want. 229 of some value such as beauty. In other words although the majority of woman in my study, who I referred to in Chapter Five as women with high anxiety about menopause and ageing, adhere to the youth and beauty culture, Meenah, Chombee and Kay did not draw on notions of youth and beauty to make meaning of their ageing bodies in their everyday lives. Each and every woman had a body which was visibly starting to show the biological processes of ageing, but to some this was distressing, while to others it was of no particular concern.

The emphasis on youth and beauty is overwhelmingly noticeable in advertisements, movies, television and print media. Women, regardless of age, are frequently exposed to visual images of young women and advertisements promising youthful looks through beauty interventions like anti-ageing and anti-wrinkle creams, Botox injections, weight loss products, breast implants, skin lightening or tanning, liposuction and cosmetic surgery. Immersing themselves into this culture of youth and beauty has resulted in devastating problems for women as they age, ranging from low self-esteem to depression, anxiety, anorexia nervosa and bulimia

(Becker & Hamburg 1996; Wolf 1991). I agree with Patton (2006) who argues that the pervasive influence of hegemonically defined standards of beauty in Western societies and the marginalisation of certain types of beauty that deviate from the „norm‟ are devastating to all women. In addition, the media is also responsible for reflecting images of slimness and link this image to other symbols of prestige, happiness, love and success for women (Bordo 1993; Wolf

1991). Because the images in the media have been repeatedly viewed over a lifetime, the

Western beauty standard becomes internalised and thus leads many women to feel fulfilled and satisfied only when they are working toward, or succeeding in, the achievement of that beauty standard. What is particularly notable from my study is that this pervasive influence does not happen in Western countries alone and it is becoming increasingly obvious amongst urban

230 middle class Malay women in Malaysia. It is notable that this is not limited to young women, but middle-aged and older women increasingly feel the pressure to conform to the idealistic standards portrayed through the media.

Regardless of age (see Plate 11), women look forward to meeting the Western beauty standard which is supposedly acceptable to the majority of people and therefore is the ideal norm. Adherence to Western standards of beauty can be exported to other countries [including

Malaysia] with, in this case, very concerning consequences. In my study for example, women who no longer conform to the ideal beauty image of youthful appearance report that they are subjected to their husbands‟ criticism and jokes. Women in my study have spent a lot of money to look and feel good, although they acknowledged their bodies are ageing. For instance,

Rashida, aged 55, who works as a finance officer told me that she normally spent between RM

400-RM 600 per month on clothes, accessories, shoes and beauty creams. Rashida, who earned

RM 2,500 per month, explained that she is sometimes influenced by friends of her age to look younger. Rashida went to her favourite boutique First Lady in Ampang, KL to get new clothes, tudung and brooches. It is important to her that she matches the colour of her clothes, tudung and brooch. She told me that she buys at least three baju kurung every month and at least one pair of shoes. Rashida was very concerned about some freckles on her cheeks and bought foundation makeup from Maybelline which cost her almost RM 100.112

112 RM100 is equal to AUD31.75 (conversion rate on 19 July 2008). 231

Plate 11 Showing-off their best look in their 50’s. Source: MIDI magazine

It appears that in contemporary society much of a woman‟s self-worth is tied to her physical appearance, and ageing represents declining social value (Grimes 2003). Women are fearful and worried about ageing and many buy beauty products which promise them ways to maintain a youthful look throughout their middle-age. As a by-product of this culture of youth and beauty,

232 reaching the menopausal stage means that women are likely to be perceived as unattractive, asexual and undesirable. Ballinger (1990) argues that this is true in the Western culture, where the media tends to put a high value upon youth, and the menopause is a clear reminder of increasing age. I would argue that this is increasingly the case also in urban Malaysia. It appears that the media contributes to a discourse of menopause which construes menopause and the role of middle-aged and older women by valuing what they are not. This confirms my argument of

Chapter Five where I illustrated how people learn about menopause through observation and what is not said, or what is done that was not done before (as in the case of continual prayer, fasting and religious instruction). Menopause, like death (McNamara 2001), is discussed in a particular manner; the discourse is shaped by the medical gaze (Foucault 1973), through cultural portrayals of the body and through defensive actions carried out to avoid explicit discussion. In this section I have focused particularly on the media and the ideal youthful body. I now turn to a discussion of how doctors and nurses contribute to the biomedical aspects of the discourse of menopause.

Doctors and nurses: the ‘influential’ informers

Aside from obtaining information about menopause through the Ministry of Women pamphlets, magazines and newspapers, I had the opportunity to interview five gynaecologists who treated women who had sought help with menopausal symptoms.113 I also interviewed four nurses who worked in the menopause clinic. Generally the health professionals described menopause as an avenue for a range of personal interruptions. By personal interruptions they mean mostly problems with spouses and their family relationships. They claimed that these interruptions should be curbed with biomedical treatments, in this case, HRT. They told me that

113 Out of five gynaecologists, two were from the menopause clinic and three were from the private hospitals. 233 the most commonly reported symptoms were hot flushes, joint pain, fatigue, insomnia, body aches and pains and decreased libido. Only two doctors said they had encountered a depressed patient. None of the doctors mentioned the empty-nest syndrome. Due to the dominant biomedical practice, all of the doctors prescribed HRT to women who sought treatment for menopausal symptoms, arguing that if a woman came to the clinic or their medical practice it was because she was not managing with her symptoms. Although the doctors said that HRT was not a compulsory treatment, they believed that alternative medicine was less effective in preventing women from osteoporosis and other health-related problems. Like the doctors, the nurses themselves also viewed HRT as reliably able to alleviate menopausal symptoms. Some nurses who used HRT themselves were happy with the outcome. When comparing their conditions before and after taking HRT, they said they had a tough time managing their own bodies before HRT. One nurse described her condition as rimas (uncomfortable) when her hot flushes interrupted her while she was at work. Another nurse said that she frequently took a half day medical leave due to her erratic mood. Interestingly, younger nurses looked forward to taking HRT when they reached a similar stage to their senior colleagues because they believed it would help them to work comfortably and effectively.

In Chapter Two, I mentioned that women who visited the clinic were mainly from the main ethnic groups of Malaysia; Malay, Chinese and Indian. However, Malay women outnumbered the Chinese and Indians. I noted that most of them were from the middle class group and that there were very few women from the upper-class group.114 The middle class women worked mainly in the public sector as I have explained previously. Most had been using

HRT for approximately two years. The women who used the clinic commented that they came

114 In Chapter Two I explained that I classified women as being in the middle class if they earned between RM 2,500 to RM 5,000 whilst upper class group earned more that RM 5, 000. 234 because of its location which is easily accessible with public transport. In addition some were conscious that the price of HRT was cheaper when purchased from this clinic compared to other clinics and medical practices.115 Most women have some idea about HRT based on their readings and participation in seminars, whilst a minority have no knowledge at all and simply use it because their doctor has prescribed it.

In order to obtain medical opinions about menopause, I interviewed Dr Aliza who is a gynaecologist in a private hospital in KL. She stated that Malaysian women did not understand the importance of taking HRT and their awareness about HRT is mainly influenced by scary stories from friends and families. Below is the excerpt from my interview:

Nura: What is your perception about HRT? Dr Aliza: I prescribe HRT to my patients because it improves their conditions. They are much better after taking HRT. HRT is good from my point of view. We have to check how many women around the globe who were on HRT have breast cancer. I‟m against Women‟s Health Initiative (WHI) findings. The study was conducted in the US and their sample is women in their 60s. What I‟m trying to say is that there are many factors involved in the study like age, socio-economic factors, culture, lifestyle and diet that influence our menopausal experience. Our lifestyle and diet is good because we take plenty of isoflavone or phytoestrogen. I‟m very open if my patients refuse to take HRT. They can eat kilos of tempe or tofu that is not a problem. But they must understand that there are other options which are far better than what they eat. Nura: How about its benefit? Dr Aliza: Plenty. Our role now is to get them to realise that it is ok to get treatment for the betterment of oneself in order to be able to go daily to the surau or mosque etc. without any backache, joint pain and without walking sticks. Thus, life is more independent. Not only has that healthy life meant more independence, but not relying on the children or especially so those single women. Today Malaysian women are working and actively contributing to the society. Life is different than our mothers. I usually emphasise about the need to be physically fit to perform the daily routine of spiritual needs and in fact that it is better if they‟re without ailments. Plus, I want my patients to enjoy their sexual life although they are ageing. There are several unhappy voices from women about how worried they are thinking their husbands will find non-menopausal women you know. You see what I mean…

115 Women who registered with Klinik Harapan purchase HRT at the pharmacy inside the clinic at a cheaper price compared to other pharmacies. This is because Klinik Harapan is subsidised by the government. However, for other women who see their GPs normally purchase HRT at the pharmacies with doctor‟s prescription. The price difference between HRT in Klinik Harapan and other pharmacies is between RM 3-RM 5 per tablet. 235

Nura: And how many women are on HRT? Dr Aliza: Generally, women who seek such advice range from 10 percent to 20 percent. It is a small percentage. I hope more of them, especially the Malay women, come and see me. Don‟t listen to other people. Our Malay women said menopause is terima pemberian Tuhan (accept what God has given) or having dah takdir (already fated) attitude.116 Or in the kampung they don‟t know that there is such a treatment that exists or rather they ikut orang-orang tua dulu-dulu (follow old folk practices). Nura: What should women know about HRT? Dr Aliza: A lot of things. They have a little bit of information about HRT but nothing formal. Most of them said they rely on the media plus it‟s cheaper than seeing a doctor. But, information about HRT in the media and magazines is poorly done. This makes our women more confused. There must be an intensive educational thing through the responsible agencies that goes to the remote areas plus the Ministry of Women should make a full initiative to educate people about this matter. They need counselling and education about this whole issue – menopause and its options of treatment. Taking HRT is not merely consuming it without doctors close monitoring [of it]. Our women don‟t understand that HRT is not needed for women who have no symptoms. For those who have, we will closely monitor them. Meaning, we advise them to do regular medical check-ups, breast-self examination and mammogram. They can stop taking HRT if they want.

I have also interviewed two doctors from the menopause clinic - Dr Zulaikha and Dr Nirmala.

Both doctors said menopause is a transition from a reproductive to a non-reproductive stage and women must prepare themselves to encounter the challenges that may come with it, as more women are working in the paid labour force. Like Dr Aliza, Dr Zulaikha also made some important remarks about women‟s changing roles and the importance of sexual function in middle-age:

Dr Zulaikha: Women must understand that they are multi-tasking today. They have to work in the office and at home. They are ordinary women. But you see… my concern is more than that. They deserve to have a happy life in their golden years, keep their marriage alive and don‟t let their husbands run away! [Laugh]

Unfortunately, Dr Zulaikha said the route that some women take did not bring them any benefit; instead it has led them to a more confused situation.

116 In my interviews with doctors, they mainly spoke in English but occasionally they used Malay terms. By contrast, the women I interviewed spoke Malay and used English terms for medical language. 236

Dr Zulaikha: I don‟t‟ understand why our women always consult other people and „other doctors‟ [bomoh] who are not in the medical field. Their first doctor is always bomoh! There are also some women who prefer to listen more to stories from friends and relatives. „My friend said I can‟t take this, my relative said I should eat that‟… and the story goes on and on. Surprisingly, these women listened to them more than us. Why? Please trust us! We have spent years to study medicine and we want to help our women. Plus, don‟t swallow what the newspaper and magazines write. Sometimes they reported wrongly, they wrongly spelled the words, they show us ugly pictures of women. These people only want to sell their newspapers; they don‟t care what‟s going on with these women.

Dr Zulaikha agreed that some ailments, particularly illnesses which are caused by evil spirits, are not curable through modern medicine. She further elaborated that illnesses which are clearly under the „medical lens‟ must be cured accordingly. In my fieldwork, I had the opportunity to talk to a participant about the use of the bomoh. She told me about her friend‟s mother who consulted a bomoh to cure her hot flushes and insomnia:

A friend of mine took her mother to see a bomoh to check why her mother couldn‟t sleep at night, always complaining that her whole body was hot. Sometimes her mother was OK and sometimes she was not. My friend believed it was caused by the menopause. But, her mother suspected that she had terkena buatan orang (spirit attack from human witchcraft) because somebody was jealous or hated her so much. Her mother was at that time 55 years old. My friend told her mother that it was normal to feel that way because she‟s in her mid-50s. However, her mother insisted on seeing the bomoh. They went to a remote village. The bomoh told them that „Yes, a bad spirit has caused her to feel hot and restless‟. The bomoh gave her mother a bottle of air penawar (soothing water) which had been given a jampi (incantation) to help ease the problem. It didn‟t work. Her mother asked for more air penawar from the bomoh. After many times of visiting the bomoh and after consuming many bottles of water there had been no sign of improvement, so my friend decided to take her mother to see a medical doctor. The doctor gave her some medicines and her mother now no longer insists on seeing the bomoh nor has she mentioned the air penawar.

All of the doctors I spoke with shared the same feelings about menopause and agreed that Malaysian women lack an awareness of HRT and do not understand how it can be used to help relieve unwanted symptoms. Based on the doctors‟ narratives, I was given the impression that, women were to be blamed for not getting the right treatment or for rejecting HRT without

237 first understanding its benefits. All doctors agreed that some women who took HRT were motivated by trying to keep their sexual relationship active. Their patients were mostly women who were employed in the paid workforce and many were very much concerned about their appearances and they wanted to remain healthy in their middle-age. What is evident from the doctors‟ responses is that menopause had become a territory of personal disruption that needed to be cured through biomedical intervention. One can see that without specifically intending to, the doctors were reading the women‟s anxieties and projecting menopause as a barrier to performing well at work, or as a risk factor that may contribute to a husband seeking sexual gratification outside of the marriage. They confirmed to the women their feelings of insecurity and saw this as a wake-up call for Malaysian women to take up the necessary precautions in order to enjoy life in the later years of their lives. While their emphasis was upon the quality of the women‟s lives this quality was to be ensured by a process of medicalisation. It is interesting to see how the doctors made comments about women‟s changing roles in the society, the role of the media and how people learn about menopause. The doctors have brought values beyond medicine to the way they manage menopause. The female doctors, like their patients and the women who participated in my study play important roles; as mothers, wives and employees in the paid force.

As Malaysian women today (and other women around the globe) are multi-tasking, maintaining their health is the utmost priority to keep them managing the problems of working inside and outside their homes.

In a similar vein, the anxieties experienced by the women were being fed by other forces; for example the former Minister of Women, Family and Community Development quoted in a

Malay newspaper stated: „Divorce among couples in their middle-age has reached an alarming stage following the recent trend showing that husbands prefer younger women as their new

238 wives‟ (Dr Suraya Arshad 2000). Consequently, menopause can contribute to tensions experienced by middle-aged couples.

While most doctors prescribed HRT, only one doctor expressed the need to seek other forms of treatment for menopausal symptoms. Dr Kamal, who was no longer involved in clinical work, said that previously only one out of ten patients came to see him for advice about menopause. In his email to me sent in May 2005, Dr Kamal said he promoted natural menopause management. In Malaysia, Dr Kamal is well-known for popularising Qigong117 exercise. Like other doctors, Dr Kamal emphasised that there is no need to take HRT if a woman is not affected by the symptoms. However, he advised women to subscribe to alternative treatments like Qigong which he believed helps to reduce the symptoms in a more natural way.

In Chapter Four, I noted that medicalisation occurs on three levels – the conceptual, institutional and interactional (Conrad 1992). At the interactional level, medicalisation occurs when doctors define or treat patients‟ complaints as medical problems (Bell 1990). Nevertheless, studies have shown that there are many kinds of interactions between doctors and patients; for instance, patients who comply or do not comply with their doctor‟s prescriptions and advice.

There are doctors who prescribe medication readily and there are those who take a more cautious approach to prescribing. This will mean that there are very different dynamics in the respective resultant interaction. This of course means that both doctors and patients have choices. For example Lock (1993), who studied Japanese doctors, has revealed several factors that influenced doctors‟ decisions to prescribe HRT or otherwise. These factors included the kind of training the doctors undertook; their socio-demographic background, their experience, their personality, as well as the type and location of the medical practice. Similarly, Kaufert and Gilbert (1986) who

117 Qigong (pronounce chi‟kung) is a Chinese art of mind and body exercise. This exercise requires a person to focus on the mental awareness, relaxation and co-ordinated breathing. 239 studied women between the ages of 40 and 59 years in the Province of Manitoba, Canada, revealed that there were a range of interaction patterns that took place between the patients and doctors. In Kaufert and Gilbert‟s study some women agreed with the biomedical model and shared the doctor‟s view that menopause is a medical event. As a result, they took HRT. Other women did not take HRT, but acknowledged that the doctor was their main source of information.

I noticed patterns of miscommunication between the doctors and patients at the menopause clinic where I conducted observation and interviews. Most of the doctors claimed that Malay women needed to be informed and counselled about menopause. They felt that most women preferred to listen to stories from friends or relatives who were not educated in the medical field, and were therefore likely to be an unreliable source of information. However, while doctors claimed they had tried their best to help the women to get the appropriate treatment, many of the women in my study were disappointed that the doctors and the menopause clinic in general did not go to enough trouble to communicate the information they needed to hear. They felt the operating hours of the menopause clinic very short and that the doctors spent too little time with them. They felt they needed longer operating hours and more time where they could discuss their problems with the doctors without the need to rush from their workplace to the clinic. Treatment for menopause became another activity to fit into their busy schedules. The women in my focus group were, as I have already mentioned, unfamiliar with menopause and knew virtually nothing about the menopause clinic or HRT. I introduced the topic to them in my discussion and although they identified with the scenarios I presented and recognised similar experiences and symptoms, all were unsure about these symptoms and experiences and did not associate them with menopause. So, in many ways the doctors were

240 right, at least for this group of women who really knew nothing about the „medical‟ side of menopause.

Through my observations in the menopause clinic I discovered that a verbal communication problem existed, not just between the doctors and patients, but also in a general sense between the patients and the health professionals. The women attending did not understand the medical jargon that was used regularly and this was evident when they asked the nurse to explain the medical terms in words that they could understand. At times they even sought my help in translating terms they did not understand. As I was not permitted to enter the doctor‟s rooms when patients were with them, my observations were confined to the registration counter and waiting room where sometimes I was called to assist the nurses during peak hours, usually from 2pm until 3.30pm. Some of the women who came to the clinic found it difficult to convey their problems to the nurses at the registration counter. Among the problems that I noted were that some: i) had never heard of the symptoms, particularly in medical terms, and this was especially true for women who came to the clinic for the first time; ii) were unable to remember the names of medicines if they were using medication; iii) were unable to describe their condition in such a way that it showed that it was meaningful to them; and iv) did not appear to take the situation seriously, though clearly there was a reason for them attending the clinic.118

The following excerpt from my fieldnotes serves to highlight some of the communication problems in the menopause clinic, particularly the challenges in understanding some of the medical terminology, as well as describing symptoms in medical terms. The nurses expected the patients to describe their symptoms by using specific medical terms. However, on the other hand,

118 Women were not embarrassed to speak about their conditions at the registration counter. The nurses who are in- charged at the counter are in the same age group as the women. Other women who sat in the waiting room could not hear them talking because the counter and the waiting room were quite a distance apart so a level of privacy was ensured. 241 patients had to struggle to describe their conditions in a way that made sense to the nurses and they expected the nurses to pick up the meanings they were trying to convey. This is not surprising, as I have already noted that Malay women do not generally talk openly about menopause and tend to use euphemistic language to convey ideas about menopause.

Fieldwork diary 27 March 2006

2pm: Today is my first day at the menopause clinic. I was instructed by Nurse Rubiah to sit at the registration counter to help her call patients’ names and give them their numbers. Dr Zulaikha came to the registration counter and said, ‘We now have a new assistant working in HRT’.119 Nurse Rubiah smiled, ‘Yes from Perth. And today Dr

Nirmala is in-charge of HRT. She’s a little bit late’. Dr Zulaikha nodded and wished me a happy time working at the clinic. I went to the shelf near the entrance to re-fill some brochures with Nurse Salmah where I heard another nurse ask her, ‘Where is Dr

Nirmala?’ ‘She’s in HRT’ replied Nurse Salmah. I asked Nurse Salmah what is HRT?

HRT is the nickname of this clinic and it is only used among doctors and nurses.

2.30pm: Two Chinese ladies and a Malay lady came towards the counter to place their appointment cards and to get their numbers from me. While waiting for Nurse Chong to check their details, one Chinese lady asked her about menopause treatment. Nurse

119 HRT is the nickname of the menopause clinic. I was told by Nurse Salmah that only doctors and nurses in the clinic use this name. The reasons: it is shorter and easier to remember. Personally, I found the nickname was intimidating. For a person like me who had yet to reach this stage, it occurred to me that HRT was the only solution to the many menopause-related problems. In addition, it is also an indication that doctors and/or nurses are promoting biomedical interventions in treating menopausal women. In other words, the clinic was HRT because that is what they prescribed – attending the clinic meant that the doctors would be prescribing the medication and the patients would accept it. 242

Chong straight away answered: ‘The best is HRT. You should take it’. Then the Malay lady interrupted saying that she heard it triggers breast cancer. Nurse Chong replied:

‘Don’t listen to people. You take HRT, you’ll be fine’. The ladies nodded their heads.

They looked at each other, frowning and whispering. I gave them a number each and asked them to be seated.

3.30pm: Nurse Salmah sat next to me while Nurse Rubiah went to the pantry to make herself a cup of tea. Another Malay lady came for her appointment. As she walked towards the registration counter, I could see from her facial expression that she was confused and unhappy. She frowned a little bit. Nurse Salmah told me she is a new patient. The nurse asked, ‘Do you have hot flushes or insomnia?’ the patient replied,

‘What is that?’ Instead of explaining the meaning of the words, Nurse Salmah asked her to describe her symptoms. She said ‘I feel hot, very hot. Lately I cannot sleep at night’.

Nurse Salmah nodded and wrote the symptoms on the lady’s medical record. She then told her: ‘We call that ‘hot thing’ hot flushes and your sleeping problem insomnia’. The lady said, ‘Oh I don’t know. What was that again? Hot flushes…. insomnia’. She repeated the terms many times fearing that she would forget the words. She took the number I gave her and remained seated.

3.45pm: A Malay lady in her early 50s who was also new to the clinic came to see the doctor regarding her condition. She told Nurse Salmah she had hyper-tension and was on medication. Nurse Salmah asked the name of the medicine, she replied ‘Don’t know the name but it is yellow in colour and small like an M&M chocolate’. When asked about her menopausal symptoms, the lady said, ‘I’m not sure about that. But my period

243 sometimes is long, sometimes short. The blood sometimes is like dot, dot, dot [she means spotting] and sometimes berekor-ekor [literally means tail; it shows the blood is elongated and has a tail-like structure]. Once, my period is like a flood [menorrhagia]’

4.30pm: There are no more patients. Dr Nirmala spoke to Nurse Chong in her room. I arranged the magazines at the lounge and at the same time flipped some pages of a magazine. The phone at the registration counter rang. I heard Nurse Rubiah arrange an appointment for a lady next week. She explained to the women, ‘HRT is OK. It is safe.

Don’t worry too much because the doctors in this clinic will monitor your health’. Then,

I heard she said, ‘We have also herbal remedies here. You can also take it if you refuse to take HRT’.

Apart from the problems reported by the patients in regards to their communication with the doctors, there also appeared to be communication barriers in the patient-nurse interaction.

The women who came to the clinic did not know about clinical trials, treatment modalities and even had trouble understanding what would appear fairly basic terminology like „hot flushes‟ and „insomnia‟. The most frequent communication problem in clinical settings is medical vocabulary deficiency amongst patients, or rather the inability of health professionals to make this meaningful (Houle et al. 2007; Levy 1985; Plaja, Cohen & Samora 1968). If patients have little knowledge of medical jargon, the probability of their misunderstanding increases. From my observation, other problems included insufficient knowledge about HRT and its possible side effects, little or no knowledge of alternative treatments and receiving conflicting information about medical findings. One woman in the clinic mentioned to me: „Some doctors say HRT is good, other doctors say it is not good. Which one should I believe?‟ I was also somewhat surprised to see that nurses were giving their own opinions about HRT and actively encouraging

244 women to use it, before the women themselves had met with the doctors to discuss treatment options. I realised very quickly that both the nurses and doctors in the clinic were completely focused on what they believed was their responsibility to come up with a treatment decision for the women. In an earlier chapter, I indicated that from information gathered in interviews, which is when the women were questioned separately, most of them reported being satisfied with the doctors‟ prescription and advice.120 Yet, it was also clear to me that in the clinic many were dissatisfied and felt they were not given enough time. It appears that women display a fair amount of confusion and a significant gap in awareness about menopause and its treatment.

Health professionals in the clinic, in the interests of efficiency and possibly to avoid the lengthy process of outlining detailed information about menopause, tend to act on the women‟s behalf.

Undeniably, it is a one way communication between the doctor and patient. Most women in my study refer more to the doctor than themselves. For example, „The doctor knows what is best for me‟; „The doctor said…‟; „The doctor advises me…‟ and „The doctor gives…‟ I did not find anything in my interview transcripts or fieldnotes of observation to support the shared decision making model121 (Charles, Gafni & Whelan 1997). The traditional paternalistic approach of medical decision-making is still exercised and relevant in the menopause clinic. Doctors [and often the nurses] make decisions on behalf of their patient by selecting the treatment they consider to be best for the women who attend the clinic, and this is invariably HRT. The situation demonstrates the dominance of medical power as it is played out in the menopause clinic. It is interesting that the doctors and nurses refer to the clinic as the HRT clinic, so there is

120 This may appear contradictory but it is common for people to say contradictory things especially when questioned in different settings and at different times. 121 This model has similarities with that of patient-centred medicine. There are four important characteristics of the shared decision making model: i) the decision making process involved both parties; the doctor and the patient, ii) doctors and patients share information, iii) doctor and patient agree to the selected treatment and iv) both agree to implement the treatment. Charles and colleagues (1997) argued that the shared decision making between doctor and patient is possible if only the four characteristics exist. 245 an obvious awareness that this is the treatment modality that they subscribe to – they are all on the HRT team.

Women’s acceptance of HRT

There are many forms of treatment available to menopausal women ranging from HRT to herbal remedies. In this section I will illustrate the various treatments and the reasons why some urban middle class Malay women may prefer one treatment over the others. The women in my study who attended the menopause clinic told me that they had sought advice outside their family on how to reduce their menopausal symptoms as their mothers had not given them any information. Like the African American women in Agee‟s (2000) study, the urban middle class

Malay women too had no examples to use as a frame of reference regarding HRT or other kinds of treatments. Some women in the study visited their doctors to get treatment and were prescribed HRT to reduce their menopausal symptoms. Women in my study have revealed a variety of experiences and responses related to HRT so there are no clear patterns of preference.

However, I can detect two primary reasons why the women took HRT. The first reason was to reduce their menopausal symptoms, particularly hot flushes. The second reason was to help maintain their sexual relationship with their husbands. Some women feared that if they did not do something about their condition, particularly those who experienced vaginal dryness, they would find their husbands turning to younger women for sexual gratification. Zahira, aged 54, told me:

I take HRT because I still have a husband. And I must fulfil his needs. I want to maintain our relationship.

Most women who take HRT expressed satisfaction with it as it reduced their menopause- related problems. They dismissed the belief that HRT may have a potential association with

246 cancer and if they were aware of this, they were prepared to take the risk. They also displayed an overwhelming degree of trust in what the doctors had said to them. Two women who used HRT reported:

Of course, I heard people say it will cause cancer. For me, I take things like… everything you eat has its own side-effect. I believe what my doctor said. Normally of course my doctor will advise the best for me. Sometimes we don‟t take it [HRT], we get one [cancer] right? (Sharifah, aged 51)

HRT is good for woman like me. Memang bagus! (Absolutely good). If you talk about cancer, my late mother had cancer without taking HRT. (Habibah, aged 51)

Other women in my study who felt generally well while on oral HRT said the following:

I took HRT for my well-being. HRT doesn‟t turn me into a Superwoman. It saves my life! I can do things I like. My life turns out normal again. (Rahmah, 50 years)

We, as an employer, we must have keceriaan (bubbly character). We must take something because we are modern, there‟s medicine out there that helps. We must take that [HRT]. I‟m confident Allah (God) helps. And He asks us to improve our lives. If there‟s a medicine that helps, take it! That‟s why I take it. I believe what my doctor said. (Balkis, 53 years)

The women who took HRT expressed strong beliefs in their doctor‟s ability to help them to gain control of their bodies. Clearly, my findings show that women who lost control over their bodies are more likely to comply with medical intervention and therefore are likely to place their faith in their doctor and the doctor‟s ability to deal with their symptoms. Equally so, from what I have shown from the doctors they assume this position of control. During my interviews, many women told me they preferred „modern‟ medicine compared to the traditional approaches like jamu. Most women said they take jamu after childbirth and now they avoid taking it because it is

„hot‟. Some of them said they had diarrhoea and felt bloated when using jamu. Others worried about the effects of taking jamu as it is traditionally prepared and does not undergo pharmaceutical testing. In short, the urban middle class Malay women who took HRT have

247 negotiated menopausal treatment in a different social environment compared to their mothers who were very silent about their condition. It is difficult to know if their mothers actually had symptoms because this was not discussed, whereas for many urban Malay women of today, they believe they need to exist within a „modern‟ world which demands that they perform in the workplace and in the private spaces of the bedroom.

What transpire from this section is that adat, as I have mentioned in Chapter Three has become the subject of changes due to media exposure and the level of education among the

Malays. However, adat continues to be a significant element in the Malay society. It is important to differentiate ethnic identity and serves as guidance in a wide diversity of contexts in the life of Malay people (Nagata 1974). Its continuing importance can be seen not only among the rural Malays but the urban Malays too. This is because adat governs one‟s behaviour as the

Malay proverb says ‘hidup dikandung adat, mati dikandung tanah’ (one‟s life is bound by adat, one‟s death is bound by the earth). Nowadays adat is practice according to circumstances.

Meaning, those elements that is beneficial is taken whilst those that can hinder progress or harmful are discarded. For example, the use of bomoh and incantations during childbirth, male and female circumcision is conducted by tok mudim (a person who performed circumcision traditionally) using special knife. These services nowadays are performed by doctors either in the clinics or hospitals. Malay women today have been reported to give up traditional practices of childbirth (Stivens 1998). Stivens supported Manderson (1992, 1998) who reported that the intervention of the government, medical authorities and advise-givers have promoted the encroachment of medicalization in the health care sector in Malaysia. Nevertheless, Laderman

(2004) who mentioned that „American women are delivered by obstetricians; Malay women give

248 birth‟ (p. 244) is outdated. Today, like the American women, Malay women too delivered their babies with the assistance of obstetricians.

In the case of my study, it can be said that adat has no significance in womens‟ action to seek medical assistance to alleviate menopausal symptoms. In fact, as I have mentioned earlier, meeting bidan to determine menopause or to get their bodies massage and complying with food taboos are no longer the practice of most respondents. My respondents are of the opinion that menopause must be manage by the experts like they treat their childbirth experiences. Although my respondents‟ actions can be seen as reducing their autonomy, again the emphasis is to make adjustments and negotiations in order for them to live comfortably in modern Malaysia (Stivens

1998; Omar 2003; Mohd. Noor 2006). I agreed with Nagata (1974) who witnessed that adat is not declining in terms of its significance in modern Malay society. Adat still exist to strengthen

Malay identity, regulate people‟s behaviour and applies in rites of passage ceremonies.

HRT: ‘It’s not for me’

While most women in my study took HRT to reduce their menopausal symptoms,122 there were a small number who did not take HRT, particularly those from the focus group. Based on a research report in July 2006, 23 percent of Malaysian women were reported to express fear of the effects of HRT (Ibrahim 2006). They claimed HRT could lead to breast cancer; moreover a further 45 percent of the women who participated in this study claimed that they feared discussing the issue of HRT. Some women I interviewed who were suspicious of HRT had taken the „herbal route‟ to naturally replace the estrogen hormones as well as to reduce their menopausal discomfort. Among the reasons offered when asked why they avoided taking HRT were „not sure whether it is safe‟, „you can get breast cancer‟ and „not a natural remedy‟. In my

122 This is because most were recruited from the menopause clinic and had decided to seek treatment. They were already open to the idea of receiving help of some kind. 249 study, I used Taylor‟s definition of herbal (cited in Gingrich & Fogel 2003, p. 183) which refers to „any food or supplement made from seeds, flowers, fruits and roots‟. Herbs like Black

Cohosh, Red Clover and Evening Primrose Oil (EPO) are commonly preferred by women who fear the effects of HRT, particularly breast cancer. These herbal remedies are easily found in pharmacies around KL. The price of each herbal remedy is more expensive than HRT because these herbal products123 were imported mainly from America and Australia. Women who preferred herbal remedies obtained information about herbs from their friends, women‟s magazines and salespersons at the pharmacies, but very few obtained them from the doctors or from a certified herbalist.

In addition, alternative treatments like Ayurvedic124 are also preferred for treating menopausal symptoms. Although Ayurvedic health care is rarely a woman‟s choice of treatment for menopausal symptoms, particularly in Malaysia, one of the women who participated in this study asserted that the Ayurvedic tablet called Menotab125 she consumed for one year had helped reduce her menopausal symptoms. Studies on Menotab by Devi and Swarup (2001) and Misra,

Kumari and Gupta (2000) have shown that the tablets help to give women relief from their menopausal symptoms.

123 The herbal products are sold for between RM 60 to RM 110. The price variation also depends on the brand, type of herbs, number of tablets and pharmacies. For example, a bottle of Evening Primrose Oil (EPO) which contains 60 tablets is sold at RM 80. Based on my interviews, most women who opted for herbal remedies have taken EPO. Whether consuming EPO has little or many therapeutic effects does not seem to matter as most women said it did not really matter as long as it was not HRT. 124 Ayurvedic is an alternative form of health care which is popular in India. 125 I visited a leading Ayurvedic outlet in KL. I was given a flyer about Menotab, a tablet one of my participants told me about. According to the sales person, Menotab tablets contain a combination of various herbs that relieve menopausal symptoms more effectively. Among the active ingredients as stated on the flyer are: Canscora decussate (Kambumalinee), a nervine tonic which stabilises mood and helps to promote sleep. Glycyrrhiza glabra (Licorice, Yashtimadhu) soothes the mucus membrane of genital organs and prevents vaginal dryness. Asparagus racemosus (Asparagus, Shatavari) relieves anxiety and controls irritability. Withania somnifera (Winter Cherry, Ashwagandha) removes fluid retention. Adhatoda vasica (Malabar nut, Vasaka) controls uterine discharge. Saraca asoca (Ashoka tree, Ashoka) controls uterine hyper reactivity and prevents leucorrhea. 250

The literature that is based on alternative remedies to help menopause has emphasised consumption of soy, which has tested to have positive effects in reducing menopausal symptoms. Soy is a plant that is rich in phyto-estrogen. It has been part of a popular diet for many Asian countries for centuries (Astuti et al. 2000; Hasler & Finn 1998; Messina 2002).

Biomedical researchers have found that Soy is rich in phyto-estrogen and has provided some benefits to human physical and psychological health, especially among menopausal women

(Cheng et al. 2007; Geller & Studee 2006). Some of the benefits reported in the biomedical studies about Soy are: i) reduced hot flushes; decreased menopausal anxiety, irritability and mood swing; ii) reduced LDL (bad) cholesterol and heart disease risk; iii) increased bone density; iv) lower risk of breast cancer; and v) ability to fight fat cells. These benefits were also reported in Lock‟s (1993) study among Japanese women. Japanese women consume Soy in large quantity and they are reported to have comparatively higher longevity, lower rates of breast cancer, heart disease and osteoporosis, as well as rarely complaining of hot flushes. During my fieldwork, I had the opportunity to interview a group of women who run a small-scale tempe126 business near my parent‟s home. These women made tempe in the traditional way. Tempe is popularly known in the diet of the Malays in particular and among the Indonesians (Astuti et al.

2000) in general. Normally, tempe is regarded as a cottage industry and the production of tempe in the business I visited was about 10 to 20 kg per day. Making tempe varies from one country to the other. I observed the women making tempe which involved soaking, boiling, inoculating with dry yeast and incubating the soy at room temperature.127 However, the traditional inoculum is prepared in banana leaves and dry yeast is used. In some places in Malaysia where the supply of banana leaves is very few, thick brown paper is used to inoculate the microbia. Tempe making

126 Tempe, sometimes is spelled tempeh is a fermented soy. 127 The same process of making tempe is also reported in Indonesia. Astuti and colleagues (2000) have described the process and nutrition of tempe. 251 among the Malays involves some pantangs128 that must be observed in order to produce a good quality tempe. If a tempe maker fails to observe the pantangs, the tempe will be rotten and smelly.

Interestingly, while Western women have turned to consuming food that is believed to reduce menopausal symptoms like soy, none of the women in my study associated eating soy based food, particularly tofu, tempe or soy milk with having any significant effect on relieving their menopausal symptoms. While the tempe makers, believed including soy in the diet improved their general well–being, none of the women I spoke to associated taking soy or tempe with relieving menopausal symptoms. To them, eating tempe or soy improves their appearance and gives them awet muda (a youthful look). This was also reported by women who I interviewed in the menopause clinic and elsewhere. They did not believe that taking soy could reduce their menopausal symptoms, but they did think it would improve appearance and well- being. My findings corroborate with Sievert and colleagues (2007) who reported that the women they studied who consumed high amounts of soy did not associate the consumption of soy with fewer vasomotor symptoms. Indeed, the study on soy and menopausal symptoms is not conclusive.

Conclusion

It is evident from my findings that the discourse of menopause and that associated with ageing, youth and beauty is by and large shaped by the media and medical practitioners.

128 The pantangs a person has to observe while making tempe are: i) A person must be in a good mood to make tempe. If a person is not happy, she will be dismissed from making tempe, ii) A person must avoid her/his hands from touching oil or/and salt. These substances will make the tempe rotten. In other words, a person must come with hati dan badan yang bersih (clean heart and body) to make tempe. These pantangs were told to me two days before I was scheduled to interview the tempe makers. This is to make sure that I understood and observed the rules and thus did not mess up their business that day. Since this was my opportunity to talk with the women and to participate in tempe making, I made sure that day I was in my best mood. 252

Reaching middle-age in contemporary Malaysia today is treated ambivalently. While conforming to religious teachings and adat, the women in my study are at the same time struggling to meet the standard of youth and beauty culture propagated by the Western media. Hence, the acceptance of biomedical intervention to treat menopausal symptoms by the women in my study is a clear manifestation of the impact of the discourse created by both the medical profession and the media. The discourse also influences the manner in which decisions about treating menopausal symptoms are made – this is for both doctors and middle-age women undergoing menopause. Indeed, menopause, particularly when it is associated with difficult symptoms, is seen by people in the medical arena as well as in a more public sense as a condition that needs urgent treatment in order to live life to the fullest. Of course, while there is still a kind of silence around menopause, there have been changes made at the level of policy to educate women more about menopause. Nevertheless, most of this effort is translated in terms of biomedical discourse.

However, it is also important for the government to keep middle-aged and older women healthy and productive because they are important members of the workforce as noted in Chapter Three.

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CHAPTER SEVEN

LIMINALITY AND THE MENOPAUSE EXPERIENCE: A SILENT AND OFTEN TROUBLING PASSAGE

Introduction

In the previous chapter I discussed the discourse of menopause with topics of interest particularly surrounding ageing, youth and beauty. While many traditional Malay values still hold true, more modern and Western influences, like the media and the institution of biomedicine, have begun to influence Malay thinking about the place of older women in society.

What should women look like? How should they manage a changing and older body? How should they behave in society? These are all questions needing answers for the older woman in

Malay society. While conforming to religious teachings and adat, the women in my study are simultaneously struggling to meet the standard of a youth and beauty culture propagated by the

Western media. It follows that the acceptance of biomedical intervention to treat menopausal symptoms by women in my study is a clear manifestation of the impact of the discourse which is, in part, created by both the medical profession and the media. The discourse also influences the manner in which decisions about treating menopausal symptoms are made – this is for both doctors and middle-age women undergoing menopause. For most of the urban middle class

Malay women in my study who had a great concern about their declining physical appearance, sexual attractiveness and productivity, menopause is seen as a threat to their work performance, self worth and general well-being.

This chapter begins with a discussion of van Gennep‟s (1960) work on Rites of Passage.

In Chapter One I indicated that this important anthropological work, and the ideas generated from the Rites of Passage, has contributed to my thinking around Malay womens‟ transition

254 through menopause. van Gennep‟s work provides a theoretical framework which can be applied to the lifestage (or lifecycle), thus allowing an understanding of how women undergo a process which sees them separating from one stage of their life, transitioning to the next and will later see them being incorporated into a final stage (old age). While moving from one phase to the other involves changes in roles and status, it is during the transition (liminal phase) that women in my study are living, in what might be termed a „limbo‟. As with any liminal phase there is a degree of uncertainty and this will already have become obvious to my readers. Needless to say, the majority of the women in my study have negotiated this liminal phase by turning to methods that helped them retain aspects of their youthful and healthy selves. The strategies used by the women provide everyday examples supporting my argument that the increasingly pervasive influence of Western perceptions of youth and femininity among the urban middle class Malay women has altered cultural understandings of the menopause. As a result, many urban middle class professional Malay women are uncritically accepting biomedical intervention (in the form of HRT) to treat their menopausal symptoms; indicating an increasing level of medicalisation in this area.

Therefore, in this chapter, I attempt to bring to the fore the importance of liminality as a concept which I found has rarely been used to help explain menopausal experiences among women, either in rural or urban areas. The notion of liminality sheds some light on how women accommodate and adapt themselves to an environment which is seen as imposing some threat and/or danger. Clearly loosing youthful looks and vitality and losing the ability to reproduce, both of which are connected, have the potential to create discomfort, and can be seen as an assault to self identity. In addition, a previously healthy person may become „unwell‟ by virtue of the symptoms associated with a „normal‟ phase of the lifespan. This chapter also addresses the

255 opportunistic and entrepreneurial enterprises that have emerged through taking advantage of the anxieties associated with menopause. Certain groups capitalise on the risk associated with menopause and are thus able to expand their businesses and as such, the „business of menopause‟. Whether women realise it or not, entrepreneurs, knowingly or otherwise, have used their products as a deceptive means to further silence an already awkward and sensitive issue.

Menopause in urban Malaysia is a silent passage.

The Rites of Passage

Earlier in Chapters One and Four, I touched on van Gennep‟s (1960) important work on

Rites of Passage. van Gennep indicated that there were no known specific ceremonies or rituals to mark the new phase of life for aged women in the society as compared to other life events like childbirth, coming of age, marriage and death. Menopause, in other words, is a different kind of rite of passage in the sense that it does not require certain rituals or celebrations like menstruation or childbirth. It has been noted that although there is no celebration that marks menopause, women generally gain more respect, occupy higher status and are free from social taboos and restrictions. Kaufert (1982) summarised three important points pertaining to van

Gennep‟s observation: first, there is no specific rite associated with menopause; second, menopause indicates a beginning of a new phase of life; and third, women‟s former status is often reversed at the onset of menopause. van Gennep‟s observations served as a ground to conceptualise menopause as an important event that has implications towards the changing status and roles of middle-aged women in their own societies.

Although van Gennep demonstrated there is no specific rite for menopause, I find it is helpful to explain this situation through the status passage advocated by Glaser and Strauss

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(1971). This classic work focuses on alterations in status that may accompany the movement of one life stage to another. In my study the movement is from pre-menopause (youth) through the menopause to the post-menopause (old) stage (see Figure 2, p. 274). The status passage has two important features: first, it is an objective status that is associated with achieving a publicly recognisable status (for example, becoming a grandmother); and second, it is a subjective status where an individual experiences a change in their sense of self. So, while there are no rituals or ceremonies, as are evident in many of the examples van Gennep uses, aspects of status, like being a grandmother, or freedom from some obligations or sanctions, like the inability to continue praying while menstruating, are symbolic markers of a woman‟s change in status.

van Gennep‟s (1960) work on The Rites of Passage has provided a model to analyse life crises according to certain recurring patterns. The central idea of van Gennep‟s work is to identify the process of acquiring a new status that is the movement from one status to the other.

He is not focusing on the nature of the position (being a wife, mother or grandmother) or role in society (Draper 2003). He found that the process involves three stages: rites of separation, transition rites and rites of incorporation all of which transform social identity.

During rites of separation, a person is detaching his or her former status into a new one.

For example, marriage which is a common rite of passage in every society is religiously sanctioned and performed to achieve the distinction between the world of staying single and moving into the realm of becoming a family person. My own personal experience of childbirth is another indication of shifting to a new status – becoming a mother. The four „standard‟ rites of passage - coming of age, childbirth, marriage and death are perceived as the most intimate and distinctly family affairs in the history of human life (Cole 1962). These rites of passage are normally marked by various ritual attentions that differ from one culture to the other. In the

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Malay wedding for instance, several steps have to be fulfilled by a couple before they are pronounced as husband and wife. The first step is merisik (investigation), bertunang

(engagement), berinai (putting henna of fingers), aqad nikāh (solemnisation of marriage) and finally bersanding (ceremonial sitting on the dais) (see Plate 12).

Plate 12 The researcher shaking hands with the bride during bersanding ceremony. (Photo: Mohd. Shahrizan Abd. Razak)

Nevertheless, in other societies, the period of moving from one status to the other is very brief. In the ethnography Death without Weeping, Scheper-Hughes (1992) described how

Brazilian women in Alto de Cruzeiro rarely expressed their sadness following their infants‟ deaths. Scheper-Hughes reported that the incidence of infant mortality in Brazil is extremely high. The maternal bonding between Brazilian mothers‟ and their infants is, according to

Scheper-Hughes, weak. The mother‟s grief on her infants‟ death is „attenuated as her attachment to a baby who never demonstrated more than a fragile hold on life‟ (Scheper-Hughes 1998, p.

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382) is necessarily lessened. Mothers are expected to express joy on their babies‟ death rather than expressing grief. They believed that the angel babies (the velorio de anjinhos) will have a happy future in heaven. In Bom Jesus da Mata, Scheper-Hughes found that there were no songs and prayers and no ritual performances that marked the death of the angel babies. In other words, ritual practice no longer had any significance in Bom Jesus da Mata where the death of infants is frequently experienced by the people. However, it is not just that this was a common experience, but one which people would rather not acknowledge due to a number of factors ranging from unacknowledged shame and grief to unimportance. In the same way menopause may well be a transition that people would rather not acknowledge; in some circumstances it may not rate as important enough to warrant attention, particularly as it involves a transition in older women from reproductivity to being unable to reproduce. Ironically, while older urban Malay women may no longer be able to reproduce they are still extremely productive members of society.

In the transition rites, van Gennep described this stage as one in which a person may have been detached from the old status, however not yet attached to the new status. Draper

(2003) described this stage as one in which the individual occupies a non-status, a kind of no- man‟s land seen as potentially harmful. The stage is seen as being betwixt and between the former status and an uncertain future. Transitional rites are puzzling periods. Allan (2007) uses the concept to explore the liminal period in her study which focuses on the experiences of infertile women in a British fertility clinic. The women in her study found they were betwixt and between as there was no certainty as to whether they would become pregnant and there was a high risk they may fail to conceive. In some societies, often during the liminal stage, the human body is itself the object of ritual process. A young person, for example, may be required to undergo procedures like circumcision among the males (Bloch 1986) or scarification (Little

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1951). The healed wounds permanently signify the status change from boyhood to manhood.

Having completed the initiation rites, a person can now move into the next stage – incorporation.

The last stage, incorporation is when the passage from one status to another is perfected. This phase involves the reintegration of the transformed individual into the social group to which the person previously belonged. The individual is once again in a stable stage and is expected to comply with the customary rules that bind the new status.

Rites of Passage and urban Malay women

I shall now turn to illustrate how van Gennep‟s three stages of passage operate in the lives of urban middle class Malay women. The model below gives a simplified overview. It would appear that Malay women undergo separation, transition and incorporation at two major junctures of their lives. First at menarche, the first menstrual bleeding, which typically is the time when a girl leaves childhood and enters adulthood; second, when a woman stops menstruating and she moves, less obviously from middle-age to old age. In reality, both of these transitions do not happen overnight and there is a period of transition.

Phase 1 Phase 2 Phase 3

Transition Separation Transition Incorporation (Liminal) Childhood (Liminal) Adulthood Old age Adolescence Menopause

Figure 2 Three stages of a Malay woman‟s life transition. (Model developed for this study)

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In the case of adolescence, during phase one, separation, we see the end of the urban

Malay female‟s period of childhood. Here they begin the transition into the adult world. In general, their socialisation begins through imitating their mothers. During their childhood the

Malay girls are taught feminine tasks like cooking, washing, looking after the younger siblings and cleaning the house. In addition, Malay girls are also taught to behave softly and politely

(Omar 1994). When Malay girls reached puberty and become adolescent, they are trained to be a

„proper Malay woman‟ (Omar 1994, p. 28). There are three things that are emphasised in order to become a proper Malay woman: learning household tasks; refining appropriate female behaviour; and the inculcation of adat and religious belief.

According to Omar (2003), the ideal characteristics of Malay women are fulfilling her duties to Allah, good behaviour and modesty, fertility [ability to procreate] and femininity. The emphasis of good behaviour is crucial in a Malay woman as „it will ensure happiness and a stable marriage‟ (Omar 1994, p. 29). When a Malay girl experiences menstruation, it is viewed positively. Since fertility is emphasised, becoming a mother is a source of gratification to Malay women. This is because during pregnancy a Malay woman gets the greatest comfort and attention from her husband as well as her extended families. The Malays believe that children are pengikat kasih (love ties) between the husband and in-laws. It is this stage of a Malay woman‟s life that separates her from childhood; the period of adolescence in transition is a liminal phase.

This separation is clearly identified within the culture and is accepted by the Malay women themselves. Adolescence, like menopause, can be a time of challenge, but while the former holds the promise of great things to come – marriage and motherhood, the menopause is less salutary. I will turn to the menopausal period later.

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The incorporation phase clearly marks the transition to a confirmed status – following adolescence this is adulthood and following menopause this is old age. The new status brings new identity either as an adult woman or as an old woman (a grandmother and an infertile woman). In most Asian countries, grandmothers deserve and expect respect from their children and grandchildren; they are also regarded as wise and experienced persons (Omar 1995; Rice

1996; Lock 1993; Bart 1969). Old age is regarded as a phase when old woman are free from their many daily responsibilities and the woman turns herself into a consultant on all matters, particularly women‟s health and childrearing practices. The story of Salimah aged 53 (Plate 13) who works as a treasurer for the Wanita UMNO129 political party which has a branch in Subang

(a suburb near KL) illustrates the „older age‟ phase.

129 In 1947, Kaum Ibu was formed as the Malay woman political organisation. The main objective of Kaum Ibu was to bring Malay women to the forefront of politics (see Chapter Three). However, in 1947 Kaum Ibu has changed its name to Ahli-ahli Perempuan UMNO and later renamed to Pergerakan Wanita UMNO (popularly known as Wanita UMNO) in 1969 to reflect the dynamism of more younger and educated women who participated in the political party (Manderson 1980). To ensure Malay women has the opportunity to participate in politics, Wanita UMNO has opened its branch in all states in Malaysia. Although the main agenda is to generate awareness about politics, there are also other activities ranging from sports, cultural, religious, educational, charity to community programmes conducted by Wanita UMNO either at the national, state or local council level. 262

Plate 13 Salimah and her husband look after their grandsons during weekends near their Koi fish pond. (Photo: Nurazzura Mohamad Diah)

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Plate 14 Salimah puts to sleep one of her grandsons in the endoi. (Photo: Nurazzura Mohamad Diah)

Salimah has been married for 35 years. She and her husband have five children and four- grandchildren. All her children are married except the youngest who is still studying at university completing her Master‟s degree. Salimah is a busy person; her schedule is full of meetings, organising charity work, business trips in the country or outside the country with Wanita UMNO.

When I conducted my interview with her on a Saturday, Salimah had just finished her Tai-chi lesson at a nearby park. She invited me to see her newly built Koi fish pond at the backyard.

Salimah told me that she was expecting her three grandchildren that day. Her son in-law had to attend two-days of training organised by his company outside KL and her daughter was to accompany him. Since no one was able to look after the children, Salimah volunteered to look after them with Hasan‟s (her husband) assistance. While waiting for her grandchildren to arrive, I

264 saw Hasan prepare the meal for their grandchildren while Salimah pulled out a box of toys and placed it in the living room. Then, she pulled out the endoi (cradle) for her grandson to sleep in.

It was easy to baby sit her grandchildren as Salimah‟s husband, a retiree, helped her with the cooking and cleaning the dishes. Salimah said she found the experience of looking after her grandchildren a rewarding experience. I heard Salimah say to her daughter before she left „I will take care of them like I used to do when you were small‟. Salimah told me ‘Masa muda jaga anak, masa tua jaga cucu’ (When you are young you take care of your children, when you are old you take care of your grandchildren).

Both Salimah and Meenah, whose story I recounted in Chapter Six, have come to terms with being grandmothers, viewing this status as a sign of becoming old in an appropriate manner.

Looking after their grandchildren is seen as an acceptable act that reflects their age and status.

Grandmothers have been exceptionally educated in term of their experience (Meleis & Im 2002).

Thus, family members; young and old will pay attention to their advice and wisdom as well as accepting their authority (Omar 1994; Mernissi 1987). These changes in practices serve to indicate symbolically that these women are transitioning to a new stage; however there is a level of ambiguity. In some ways, the women in my study have lost the ability to reproduce, but in other ways they continue to nurture in the role of grandmother. This of course only applies to those who have this status. Urban Malay women, like women in many other countries, do not always have their children when they are young so being a grandmother for some may not happen in the early stages of menopause but may happen in later years. On the average, it is reported that the mean age of Malaysian women having their first child is 23 years old in 1994 and is projected to increase to 25 in 2004 (Ministry of Unity and Social Development 1999).

This trend shows that later marriage implies that women tend to have their first birth at a later

265 age. Most women in my study had their first child in their early twenties and a few of them in their mid-twenties. Most women told me that they adopted the family planning program in order to balance work life and nurturing children. By contrast, my participants‟ own mothers had their first child in their teens. The women in my study came from large families, consisting of seven or eight siblings. Only thirteen of the women in my study had grandchildren. Most of their grandchildren are still at kindergarten or primary school. All of them felt that their grandchildren were a source of happiness. Again, this is because of religious teachings and adat which uphold the value of respecting the elders that makes my participants feel they are valued and appreciated by their grandchildren. Although their grandchildren visited them only during the weekends or on public holidays, some grandmothers voluntarily took one or two days off from their annual leave to look after their grandchildren while their parents attended meetings or had to work outside KL. No doubt, the grandmother role is still relevant in the life of a Malay woman and signifies a successful old age phase.

Menopause and the liminal life of urban Malay women

Although van Gennep highlighted the idea of „liminality‟, it was anthropologist Victor

Turner (1974) who was most interested in the liminal phase. Liminality is defined as a stage in the transition when an individual moves from one status to the other, but is not fully secure in the other status (Draper 2003; MacNeil 1997). Turner (1974, pp. 231-232) wrote:

… margin (or limen – the Latin for threshold, signifying the great importance of real or symbolic thresholds at the middle period of the rites, though cunicular, “being in a tunnel”, would better describe the quality of this phase in many cases, its hidden nature, its sometimes mysterious darkness).

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The concept of liminality is normally used to explain ritual and performance (Turner 1974).

However, I found this concept is useful to clarify the condition of my participants who are caught in between – so on one hand there is the desire to look young, beautiful and sexually attractive as they used to, but at the same time their bodies are no longer as they were in youth.

Liminality has also been used to explore other social contexts, for instance in the area of health and illness. Liminality has been applied to help explain the condition of sick people, particularly those suffering from chronic or serious illnesses like cancer (Little et al. 1998; Luxford 2003), disabled people (Murphy et al. 1988), schizophrenia (Barett 1988), stroke (Becker 1993) and infertility (Allan 2007). In the study of advanced prostate cancer among fifteen men in Israel,

Navon and Morag (2004) found that men who had undergone hormonal treatment reported themselves as „neither or nor beings‟ (p. 2345). The men also indicated that they were neither ill nor fully recovered. In other words they felt „betwixt and between‟. Similarly Luxford (2003) who investigated the experience of older women with breast cancer in Australia reported that liminality occurs when women were uncertain as to whether they had benign breast disease or not. They were uncertain about whether their health status was „healthy‟ or „sick‟. Luxford argued that the liminal experience of her participants has created a sense of uneasiness between the women and their bodies. In other words, the previously predictable and familiar relationship between the women‟s selves and their bodies has been disrupted.

Douglas (1966) wrote that during the liminal period, a person has no place or status in society - temporarily there is no sense of belonging. She argues that the individual between statuses is ambiguous, and it is this ambiguity during the liminal phase that is susceptible to

267 potential danger:

Danger lies in transitional states, simply because transition is neither one state nor the next, it is undefinable. The person who must pass from one to another is himself in danger and emanates danger to others. The danger is controlled by ritual, which precisely separates him from his old status, segregates him for a time and then publicly declares his entry to his new status. Not only is transition itself dangerous, but also the rituals of segregation are the most dangerous phase of the rites (Douglas 1966, p. 97).

Bloch and Parry (1982) have characterised the liminal phase as disorder, chaos and pollution which turn the social order upside down; the danger also means the matter is out of place

(Douglas 1966). People who are living in a liminal state are regarded as living „outside‟ the normal boundary because „they have been declassified but are not yet classified: they have died in their old status and are not yet reborn in a new one‟ (Murphy et al. 1988, p. 237). Thus, interacting with them is seen as problematic or/and unpredictable. This was evident in some of the stories told by the children of women undergoing menopause in Chapter Five where the children were clearly confused about what was going on and why their mothers acted outside the realms of their normal behaviour. Since the Malay culture (and other cultures as well) do not embrace menopause as a rite of passage, women‟s productivity has been suppressed.

Reproductivity has come to an end and there is no cause for celebration. Although men may not live as long as women, they are still seen as sexually active and productive as they age, at least throughout their fifties and sixties. In other words, the ageing process is not as detrimental for them. Women who live longer are the opposite – supposedly asexual and weak (Wolf 1991). The stories of Sharifah and Balkis that I presented earlier in Chapter Five are indicative of the kinds of chaotic lives that may be experienced in the menopausal stage. The „danger‟ that is triggered by menopause for the individual presents predominantly as a threat to mental health and well- being. This form of danger is also clearly illustrated from two other studies. One study focuses

268 on suicide among the Gisu women of Uganda. Here we see an example of an ultimate „danger‟ with women feeling so worthless at this stage of life that they take their own lives. La Fontaine

(1960) discovered that the suicidal rate among Gisu women increased when they reached the end of childbearing years. Woman‟s position in Gisu society clearly depended on their ability to fulfil maternal roles. A woman in that society is an asset to the community only while she is capable of reproducing. However, when women stop reproducing, they are regarded as a liability to the community and subjected to rejection by both husbands and families.

Correspondingly, menopausal experience has entailed personal, physical and emotional changes among Italo-Australian working class women studied by Gifford (1994). The women in

Gifford‟s study described menopause as a time of vulnerability, fear and insecurity. The women were depressed, sad and nervous and this was linked to the stress associated with becoming an

„old‟ woman. Retirement meant women had to leave their jobs and this event meant they were isolated from their co-workers and friends. The role as an „old‟ woman that they were expected to undertake in Italy was not possible in Australia because their children lived far away and they were no longer consulted about childrearing practices. They also encountered difficulties when their adult children left home, gained employment or got married.

What makes menopause impose a kind of „danger‟ to society though? In the previous examples we see a threat to the integrity of the self and this has been evident in the stories recounted throughout my thesis and through the words of the women themselves. The topic of menopause is surrounded by taboo and secrecy (Agee 2000; Im & Meleis 2000). Sheehy (1998) called menopause a „silent passage‟. I believe it is a passage of ignorance. Some of the participants in my study had no idea what was really happening to them. They were not aware of the symptoms which had been with them for many years and some wondered what all the fuss

269 was about with menopause. The symptoms of menopause were considered a part of „women‟s lot in life‟ – a woman must accept the so called „deficiencies‟ of her female body. In this context for a woman to claim special status would be to threaten the integrity of men‟s privileged position in society. The freedom of not having the possibility of having to reproduce may potentially allow a woman to take a more prominent position in society.

In the context of Malay society for example, although menopause has never been associated directly as an issue that contributes to divorce rate, it may be associated with changing relationships between men and women. Women may no longer be interested in sex; they may focus more on their children and on being a grandmother. One suggestion may be that this might lead husbands to find other ways (particularly marrying younger woman) to fulfil their needs.

This scenario has been expressed by Mr. Mohd Shauki Abd Majid, the assistant director from the

Islamic Da‟wah Foundation Malaysia (YADIM) in a Malay newspaper:

Based on my experiences handling divorce cases among middle-aged couples, 80% of the divorce factors were caused by the wives. Normally, when women reached their middle-age, they no longer appear presentable; have reduced their time to beautify themselves for their husbands and did not fulfil husbands‟ sexual needs. Most women are more concerned to take care of their children, grandchildren and daughter or son in-law rather than their own husbands. It is not surprising if husbands seek for younger women in their middle-ages because husbands felt they are being ignored or are not well-treated by their own wives at this age (Mohamad 2000, p. 1).

Responding to Mr. Mohd Shauki‟s statement, the former Ministry of Women, Family and

Community Development emphasised that if this phenomenon was not addressed by women themselves, it would trigger to a more serious problem in the future among the Malay families

(Mohamad 2000). This sentiment has also been expressed by the women in my study as well as the doctors that I have interviewed. The story of Sharifah in Chapter Five gives a picture of how bodily changes may affect a husband‟s expectation of a woman‟s sexual activity. Although none

270 of my participants talked about their husbands‟ intention of marrying younger women because of their condition, some of them did say that their husbands once in a while jokingly said they wanted to marry another woman. Nevertheless, most of them did express the fear of their husbands marrying someone else:

Maisarah: When I reached this age now, if I don‟t do anything or deal with my menopause symptoms, my heart sometimes says „What if my husband finds another one [wife]?‟ I‟ve heard… stories from friends at the office, on TV, magazines and newspapers this thing can happen to a woman like me, at this age. Because my husband is a building contractor, he always goes to the site and there are many young Indonesian girls there working. When I think about this, takut jugak! (I‟m scared too).

Like Maisarah, Rozana warned me:

Better do something before it is too late! I want my marriage to last long like my own parents. Takut jugak kalau suami lari (I‟m afraid too if my husband run away) because of me!

Both Maisarah and Rozana described how takut (scared/afraid) they were thinking their husbands would look for younger women. They saw that it was important for them to keep their marriage in tact, particularly at this stage of their lives. They were concerned that serious symptoms associated with the menopause could affect the marital relationship. This was a prominent issue of concern for the majority of women in my study. They had become „worried‟ people thinking about their marital lives. Although, none of my participants experienced divorce in their middle-age, the feeling of insecurity regarding their marriage for those who had husbands, was definitely an issue. I am aware that there are many factors that contribute to divorce, and I am not suggesting that menopause contributes to divorce per se. However, the symptoms of menopause can contribute to stress within the marital relationship and this was related to me by the women I spoke with, many of whom feared the possibility of their husbands divorcing them.

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Menopause can be a source of problems in the women‟s work as well. Today, women‟s life expectancy has increased and they will spend a significant proportion of their lives postmenopausal. On top of that, they are expected to be a productive member in the paid work force. As I have indicated in Chapter One, 60 percent of Malaysian women are not aware of the menopausal symptoms and they do not understand the connection between menopause and their health. This indicates that Malaysian women may have neglected their health and do not make it a priority. I would like to emphasise that urban Malay women today, as compared to their mothers, are experiencing changes in their roles; demands from the workplace have pressured them to be energetic and efficient employees. Several studies have shown that menopause can disrupt the working environment. A study by High and Marcellino (1994) among women who worked as managers and non-managers in Long Island, New York indicated that 47 percent reported their lives have been disturbed by their menopausal symptoms. Another 30 percent of the women reported having been affected by menopausal symptoms such as hot flushes, mood swings and irritability while working. These symptoms resulted in poor performance in their workplace. Similarly, Im and Meleis (2001) findings among immigrant Korean women revealed that the adverse affects of menopausal symptoms made them feel unfit to work and that depression made them not want to work at all. Interestingly, women reacted differently when encountering either psychological as opposed to physiological symptoms. When the Korean women encountered psychological symptoms, they worked harder than before. By working harder, this group of women occupied their time and minds thinking about work rather than worrying or thinking about their menopausal symptoms. On the other hand, if physiological symptoms persisted, some women went to clinic to get hormone replacement therapy; others either quit or changed their jobs.

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In reality, it is stressful having combine home and work demands with efficiency for women as they age. The women in my study admitted that they experienced fatigue and memory loss which was seen in an unfavourable light by some younger and male co-workers. The story of Balkis in Chapter Five illustrates this observation. She took a long time to prepare paper work, was unable to meet deadlines and once in a while she misplaced important documents. Her story shows how she struggled to manage the kinds of ordeals she faced in her work place where she was seen as less productive and less professional in her work.

As I have reported in Chapter Four, menopause has the potential to modify women's lives in many ways; mentally, emotionally, physically, and spiritually. Unfortunately, many women move through this profound life passage alone and this includes the majority of the participants in my study. Menopause is not widely acknowledged compared to other life events like childbirth, pregnancy, marriage and death. Unlike pregnancy, which is publicly visible, menopause is a hidden process. Menopause is a hidden process because women have a degree of choice over whether or not to disclose their condition, when to disclose it and for what reason

(Kaufert & Gilbert 1986). On the other hand, pregnancy can usually be concealed only to a certain point. Once visible, women are vulnerable to the pressure on them to do whatever is culturally expected of the pregnant woman, for instance consulting the gynaecologists, attending ante-natal check-ups/classes, scanning, purchasing maternity wear and shopping for new born needs as well as organising a baby shower party. Another contributing factor which differentiates menopause from pregnancy (and other events as well) is the social attachments displayed within the context of these processes. Childbirth and pregnancy are matters of concern not only for the pregnant mothers, but gynaecologists, the family and the larger society. In a traditional Malay society, as reported by Laderman (1983), a pregnant mother has to undergo ceremonies like

273 lenggang perut130(rocking the belly) during the seventh month of the first pregnancy. This is to ensure ease of labour and safety of delivery. However, menopause is a far more of private and personal matter as menopausal women are at the end of their reproductive lives. What happens to them at menopause, particularly in regards to what they feel or how they treat menopause, has not been the subject of community concern, but neither has it been the subject of community pressure on menopausal women (Kaufert & Gilbert 1986). This observation was made by Siti, aged 50, who worked as a deputy manager in a Japanese company:

Nobody knows I‟m menopause. Maybe they don‟t bother if I‟m menopause. Why should I tell them? I‟m more comfortable talking to my doctors. I have my own way to deal with the problem.

While Kaufert and Gilbert suggest that women undergoing menopause are not subject to community pressure, I believe this is only to a certain extent. As it is a silent transition they are not obliged to share the information with those around them, as Siti suggests. It is no one else‟s business. However, I argue that reaching menopause through a transitional phase in the life course has disorientated women and throughout this time they are expected to orient themselves to encroaching old age. There is a community expectation that they should reorient themselves; however urban educated Malay women are also expected to continue in much the same way as they always have. That is to say they must continue in the workplace and they should also appear as they once did. It is clear from the stories and the accounts of the women in Chapter Five and

Chapter Six that the majority of my research participants have apprehensions and experience a lack of control when faced with menopause and ageing more generally. This experience has a

130 Lenggang perut is a pregnancy rites performed previously in the Malay society. It is performed by a bidan during the seventh month of the first pregnancy. Laderman (1983) reported that this act is only performed for a first pregnancy because a woman is seen as not yet adept at carrying and delivering her babies. Currently, lenggang perut is not practised as it used to be due to advancement of technology in the medical field and it is seen as against the Islamic teachings. 274 serious impact upon their lives. Therefore, most of my research participants who live betwixt and between have searched for a way out of the uncertainty experienced in their everyday lives through the help received from doctors and the menopause clinic in particular. As I have reported in my earlier chapters, women in my study have also sought to regain control over their bodies by engaging in an outward attempt to maintain a youthful appearance. Although their bodies are changing, they have „fixed‟ their bodies to work the same way with the help of HRT and cosmetic products. Maisarah told me how during menopause she was uncertain about her bodily changes:

Previously I had problems with my period. About four to five months. I had long periods and it bothers me a lot! I‟m not sure what‟s going on with my body. Am I sick? I remember my late mother was having the same problem. Long periods, then it stops. She‟s ok for a month and again that long period comes. I had this feeling you see… am I sick? As far as I‟m concerned, I‟m just fine. I never had big problem with my health. I went for a check-up in a clinic near my house to confirm my condition and the doctor said „it‟s nothing serious‟. I can‟t take nothing serious as an answer. I return home feeling uncomfortable. I came here last year to see Dr Zulaikha. She said she needs to take some blood sample to check first. Nobody tells me exactly what went wrong with me. Am I sick? Has this something to do with my age? I wanted to know whether I‟m like this or like that. It‟s really scary.

While Maisarah was unsure about reaching menopause at that time, Halimah expressed a different opinion:

Apa masalah aku? (What is my problem?) I‟m not like this before. I‟m not like myself! Moody, sensitive, forgetful… My friends told me I got to do something before it‟s too late. It sounds like… I am sakit (sick) and I have penyakit (disease)…. I asked myself, what will happen if I don‟t so something? What should I do? It took me a while to come to my sense and be able to see a doctor. I thought it was just this stress thing – work, family, traffic jams in KL and meetings. You know what? This whole thing is becoming worse each day.

This particular experience has disrupted Maisarah‟s normal life with the symptoms coming on unexpectedly. During this period of „disruption‟, the women in my study were uncertain about

275 why their bodies and behaviours had changed. As a result, some of them visited the menopause clinic to find a way out of uncertainty. In other words, they are finding a way to create an orderly life. Equally so, they are expected to find a way to create an orderly life. The community expectation is that whatever kind of personal disruption they may experience this should not inconvenience anyone else. They should continue on in their workplaces and homes in much the same way.

Urban Malay women creating a new sense of order in their lives

One thing that I realised as I reviewed my transcripts and notes was that most of the women in my study approached the liminal stage with a particular kind of attitude – to „put up a good fight‟ (Little et al. 1998, p. 1491) in approaching the uncertainty of menopause:

Putting up a good fight is socially endorsed. Patients will often say, when someone explains that there is nothing that can be done to cure the disease, “I can't simply give up. There must be something I can do to fight this thing”. Relatives and friends will say in hushed (and often slightly disapproving) voices “He's given up. He just doesn't seem to want to fight it any more”, as though the effort of will could indefinitely prolong life.

The culture of putting up a good fight is endorsed not only by the women in my study but also by others who have suffered from cancer and AIDS (Sontag 1990). In order to create a new sense of order in their lives, many of my participants have chosen to follow the medical path to fight against this uncertainty. Again, at this particular point, I wish to emphasise that the increasing influence of Westernisation and medicalisation in the lives of urban middle class Malay women is very clear. From the earlier interview excerpts that I have quoted, it is apparent that urban middle class Malay women did not succumb to the problems associated with menopause but turned to medical help.

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As Habibah said:

There are lots of medicine out there to help us with menopausal symptoms, why fret? Go and get one. Don‟t sit down and cry because we have all these things [menopausal symptoms].

There is an urgent need for urban middle class Malay women to overcome uncertainty as they (as I have discussed in Chapter Three) are juggling between two roles simultaneously. My participants feel they have to work through the liminal phase, both metaphorically and literally, as they have to move on with their lives and participate in the paid work force. The story of Siti, the only participant who was single, illustrates the case of a woman who has worked through the uncertainty and has lived life to the fullest. Like Sharifah and Balkis, Siti is a woman who never gave up or became dejected with her menopausal condition. At 50 years of age Siti lives with her elderly parents in Kampung Baru, KL. She has worked as a deputy manager for 24 years in a

Japanese company in KL. Siti comes from a big family of ten siblings, five boys and five girls, all of whom were married. Since she was the only unmarried child, she volunteered to look after her parents. Siti earned her successful position at her paid employment through her hard work.

She joined the company after completing her high school and worked as a clerk. With her strong will and determination she took night classes to learn computer skills. Later, she enrolled in a college and studied business management. After obtaining her diploma in business management, her company raised her salary and appointed her as chief clerk in the Human Resource

Department. Two years later Siti registered in the same college and studied part-time for her bachelor‟s degree in Human Resource Management. It was after obtaining her bachelor‟s degree, that Siti was appointed as the deputy manager in –charge of the human resource department in the company.

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I met Siti at the menopause clinic through her best friend Cempaka whom I interviewed earlier. Cempaka introduced Siti to the menopause clinic. At first Siti refused to go because the clinic is well-known for its family planning program and it seemed inappropriate for her to attend. It did not cross her mind that the clinic also managed menopause-related problems. When

I asked why she finally made up her mind to come to the menopause clinic, she answered „ I came here to get an opinion about HRT and I wanted to grow old gracefully‟ Siti told me she had mild hot flushes and a weight problem which she felt had changed her perceptions about her body and her self. She wanted to „find something to cure her hot flushes‟ and to cut down her weight. I asked her opinion about ageing and specifically about being single as she got older. She responded with confidence „Growing old, you have to face it. I don‟t feel old. I want to be happy until the end of my life‟. Interestingly, she shared her tips about staying happy and single at her age. First, you must be happy with what you do especially your work, second do things sincerely, third find out about yourself first and only then venture to find out about others, and fourth do what you should do as instructed by the culture and the religion. With these in mind you will be happy no matter what challenges come to you.

While women like Sharifah, Balkis and Siti are participating actively outside the house to improve their living conditions, I have argued more generally that the workplace has become

„the site of tension and anxiety‟ (Morris & Symonds 2004, p. 314). The workplace has become the ground where women undergoing menopause are scrutinised by other women who judge the other‟s capacity to work adequately. Some women felt uncomfortable, inferior and inadequate when menopausal symptoms, particularly hot flushes or mood swings, came on suddenly in the office. The lack of support the women felt they received both at home and in their workplace added to the pressure of juggling their maternal roles and worker roles. Based on the selected

278 narratives of Balkis and Sharifah I have illustrated what Kittel and colleagues (1998, p. 621) term „keeping up [the] appearances‟ in terms of managing their menopausal bodies. Because menopause is an emotionally draining experience and women need to feel good about themselves, most women in my study have decided to get treatment in the form of HRT in order to reclaim control of their bodies as well as to overcome the symptoms so that they can perform their motherly duties at home and work in the office with the least amount of disruption.

No doubt, my participants‟ adherence to religious teachings and adat, as I have explained in the case of Meenah, Chombee and Kay, has helped them in the liminal phase. Religious teachings and adat have acted as a „stabilizer‟ during this period of uncertainty and thus enhanced the social order of my participants‟ lives. Both religious teachings and adat have helped them to keep up appearances, maintain peace as well as giving them a sense of meaning in their lives.

Menopause: an opportunistic passage for others?

Menopause is indeed a passage that is kept secret by most women and indeed within the wider community as well. Sheehy (1998) called upon women to embrace and understand menopausal changes and to allow this issue to be discussed openly. Like Sheehy, Greer (1991, p.

61) in her book The Change said:

Women need to devise their rites of passage, a celebration of what could be regarded as a restoration of a woman to herself.

Although menopause is not enacted by the religious institution as one of the celebrated rites of passage, other institutions have taken advantage of this life transition. I argue that this passage has been subtly commercialised by entrepreneurs who take advantage of the „silence‟, the

279 uncertainty and the anxiety expressed by women who must deal with symptoms while maintaining a pretence of normality. Menopause is not a passage that is celebrated like the passage from adolescence to adulthood, or the passage from being single to being married.

Menopause is an awkward process that must be disguised and for this women need to look much the same as they did before and act in much the same way as well. It is not just menopause that has been commercialised; even rites that are celebratory suffer from this approach. For instance in many societies today wedding rituals have generated an industry of wedding planners, caterers, hoteliers, media, photographers and printing companies. As Grimes (2003, p. 307) has noted:

The difference between using ritual to abuse and using it to serve or heal is not always clear, especially when money is involved. And money is involved as soon as we shift from enacting rites for ourselves and families to providing them to others for a fee. When talking about ritual creativity and criticism, it is easy to conceive of rites as transpiring in a protected zone much in the same way that art and research are imagined as insulated from the struggle for economic survival.

This situation also works similarly for menopause. Menopause as a biological process has provided an opportunity for entrepreneurs in various industries. It has been commercialised extensively in the West. When menopause is constructed in such a way that people believe it is

„a disease‟ suffered by all middle-age women the field is then open to entrepreneurs to play upon the vulnerabilities of the „diseased‟ women. It was Wilson‟s (cited in McCrea 1983) widely read book Feminine Forever that escalated the acceptance of HRT in USA. It has been reported that in 1975 HRT was ranked the fifth most prescribed drug in USA (McCrea 1983). Aside from that, the cosmetic industry too has been quick to take advantage of the anxieties associated with growing old by selling their anti-wrinkle and anti-ageing creams and Botox injections.

Alternative medicines have also entered the domain of big business by busily promoting herbal

280 remedies (black cohosh, wild yam, red clover and evening primrose oil - see Plate 15),

Ayurvedic, reflexology to alleviate menopausal symptoms and other non-mainstream methods are unlikely to be offered for free.

Plate 15 Some herbal medicines available in Malaysian pharmacies to reduce menopausal symptoms. Source: MIDI magazine (January-February 2006 edition, p. 49)

Moreover, people in the fashion industry have come up with ideas or products that are deemed suitable for middle-aged women who face particular „challenges‟ like weight gain and changing body shapes. In a recent television programme in Australia, the UK style queens

Trinny and Susannah131 urged women to love their shape and dress well regardless of age.

Clothing industries have advertised their products on the internet like www.coolfemme.ca and www.menowear.com showing their latest range of clothes and providing some useful advice to menopausal women who find they can no longer wear their „normal‟ clothes. In Malaysia the situation is somewhat different. The products, like alternative therapies, have been in the market for a long time but they have not been heavily advertised by pharmaceutical companies. I noted

131 Trinny and Susannah: Undress The Nation is a fashion programme shown every Thursday on Channel 7 in Perth from 9.30-10.30pm. The hosts Trinny and Susannah advise audiences on what not to wear, tips to stay young, learning your body shape, bra fitting advice and many more. In their television programme dated 15 May 2008, Trinny and Susannah suggested women who had an apple-shaped body (a shape that is common among postmenopausal women) should select flat-fronted skirts to avoid the extra fat at the abdomen and hips. Furthermore, they find tailored, wide-legged denim pants are the perfect choice for apple-shaped bodies. 281 earlier that according to government reports 60 percent of Malaysian women are supposedly not aware of the link between menopause and their health. It was the medical community, alongside the media and entrepreneurs who have inserted the idea of menopause „as a problem‟ through images, reports and products. Things are beginning to change in urban Malaysia and more older women are subjected to ideas about the role of the older woman in Malay society.

Modernisation has had the deepest impact of all on the practice of traditional rites of passage in many societies either in the Western or non-Western world. Most traditional rites were characterized by strong family and community ties (van Gennep 1960; Cole 1962). In modern societies it is evident that family and community members have become increasingly mobile and transient. Similarly, as I have mentioned in Chapter Three, industrialisation has shifted the work life from home to the factory and office. Most of the jobs which have been carried out previously by family members or old folks are now being performed by specialists, such as doctors, obstetricians and gynaecologists, pharmacists, financial planners, childcare centers and caterers outside the home. With time at a premium in modern societies, most ritual observances have been shortened, invented and negotiated while commercialisation has allowed entrepreneurs of different backgrounds to trade rites of passage as commodities (Grimes 2000).

Finally, the encroachment of scientific discoveries has led many people to reconsider some rituals which are necessary or otherwise in their lives.

Conclusion

In sum, while women undergo rites of passage from one phase to the other with societal acknowledgement and rituals particularly coming of age, birth, marriage and death, menopause is a process for women where there is no formal or specific way of acknowledging this

282 transition. Like other transitions, particularly from adolescence to adulthood, which involve elements of liminality, menopause is also similar. As I have described in this chapter, the menopause process is characterised by liminality or uncertainty. This situation has been described by many of my participants as problematic and chaotic. There is, as Douglas notes, a danger to the individual and the social order – this danger relates to how women‟s identities are challenged. In terms of the social order we see that women should supposedly transition easily and silently from one status to another. However, in modern societies this is not always the case

– women are expected to maintain their previous roles as productive members of society.

Interestingly, menopause as a passage is silent in order to support the social order. No one is interested in celebrating as in the case of the wedding or childbirth, or in ensuring the respected passage to the next world in the case of the funeral. The passage of menopause is also now commercialised, particularly by pharmaceutical and cosmetic industries, not for the purpose of celebration, but for the purpose of silencing the passage and keeping the social order. Thus, the experience of liminality throughout the time of menopause has led most of my participants to seek help from the medical professionals to create a new sense of order in their lives. In addition the control of their menopausal symptoms allows them to maintain their place within the social order as productive and uncomplaining women.

For urban middle class Malay women the passage or transition is about the challenge to the individual body (the lived and literal body is changing with age, with the cessation of menstruation as the real sign of this change); the social body ignores what is happening during this transition and there is no open acknowledgement or celebration. Instead husbands, children, work colleagues and health professionals try to „deal‟ with the issue as best they can. Women, as they age are still central to the social body – their place is necessary to the functioning of society

283 and yet they have a triple burden – the burden of work in the home, work outside of the home

(that is paid work), and they are often challenged by a changing body that does not function in the same way. Indeed, the urban middle class Malay women in my study had to work things out by relying on the medical assistance that has helped them to cope with their changing bodies.

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CHAPTER EIGHT

CONCLUSION: A DIFFERENT LOOK AT MENOPAUSE

Introduction

Throughout this thesis I have argued that life for urban educated middle class Malay women in Malaysia is very different from the lived experience of their mothers and grandmothers. As these urban educated Malay women age, they encounter menopause in a very different way from the way menopause was experienced by women in earlier generations and in rural areas. There are many ways of explaining this change, but using an anthropological perspective I suggest that a holistic view allows us to consider the situation at many levels. In this final chapter, I will review my thesis research findings by considering a macro perspective, which includes an overview of the changes that Malaysia has undergone and how these changes have impacted upon the lives of older women. In addition, I will also take a more micro and localised perspective by reflecting upon the experiences, thoughts and challenges conveyed by the women in my study.

Studies by Lock (1993), Rice (1996), Chirawatkul and Manderson (1994), Gifford (1994) and La Fontaine (1960), to name a few of the scholars who have worked in this area, have demonstrated convincingly that menopausal experiences are mediated by social and cultural factors. This was also true for the research participants whom I spoke with during my fieldwork.

However, I also show in my study that urban educated and middle class women in Malaysia are likely to experience menopause in a very different way to women from rural areas and from

Malay women who lived in earlier times. They are exposed to modern Western values which privilege youth and beauty, and they are obliged to work in the world of dual roles, in the home as a good wife and mother, and in the paid workforce.

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Anthropology and the study of sensitive issues

Ethnography allows for findings to be captured in a more detailed way compared to other methods of inquiry (particularly quantitative) and this is essential in studying a sensitive topic like menopause. As an anthropologist, I was interested in this study in knowing how things happen and to observe the details of women‟s daily lived experience. As Scheper-Hughes (1997, p. 218) puts it: „at the heart of anthropological method is the practise of witnessing which requires an engaged immersion, as far as possible, in the lived phenomenological world of anthropology‟s subjects‟. By adopting this approach, I allowed for an emic interpretation of my research participants‟ own menopausal experiences.

I have taken the interpretive approach (Kleinman 1980; Scheper-Hughes & Lock 1987) to explore this issue and I now believe this approach was the right choice as it allowed me to understand how the women in my study attached meaning to their menopausal experiences.

Experience, as Bruner (cited in Jansen & Davis 1998, p. 293) noted, is „more personal as it refers to an active self, to a human being who not only engages in, but shapes an action and feelings, but also reflections about those actions and feelings‟. In my thesis I have tried to translate my participants‟ menopausal experiences and place them within the broader context of a changing

Asian society.

Reflecting now upon the anthropological enterprise, I see that my sociological training could not have led me to uncover the intimate experiences of my research participants. I cannot imagine older Malay women divulging information about their sex lives or communicating their anxieties about their changing bodies and ageing through a survey. I believe I have tapped into an area of older Malay womens‟ lives which was not previously explored in a Malaysian context.

The lack of attention to the issue in Malaysia and elsewhere confirms both the difficulty of

286 conducting research in this area and the highly sensitive nature of the topic. As I explained in

Chapter Two, my research involved discussing women‟s personal experiences with menopause which may be unpleasant, embarrassing, frightening, uncertain and even challenging to personal identity.

By focusing specifically on medical anthropology I have learned that issues of individual suffering like pain, chronic ill-health, ambiguous status (liminality) and crisis (Janzen 2002) have much in common with women‟s experience of menopause, particularly when it is complicated by severe symptoms. My participants, many of whom have had difficult menopausal experiences, have demonstrated various responses, which are not straightforward but, rather, ambiguous. For the majority, menopause was a relief from the possibility of pregnancy and the regularity of menstruation, but it was also a signal that their lives as females were changing. Menopause was seen as an entry into old age. It became very clear to me, in talking with these women that the majority were not willing to let go of the kind of „femininity‟ that once defined their lives.

Menopause was not just about the cessation of menstruation, it was about their changing status.

Due to its taboo nature, menopause in Malay culture, as in most other settings, is kept private and is seen as a personal matter. My thesis shows that women only discuss their condition with their doctors, perhaps jokingly with their close female friends, but not at all seriously with family members.

I am grateful to the women in my study who have opened-up their „secret path‟ (Apter

1995) to make my fieldwork journey a memorable and interesting one. I can understand why the women in my study, and perhaps all women who are going through menopause, keep it as a secret. I understand now that menopause is personal and uncertain terrain. Each woman has to work out what is happening to her own body, how she can best manage her changing condition

287 and how she can best meet the expectations of husbands, children and work colleagues.

However, older women together are confronted with expectations from a society which increasingly values a particular look, a capacity to contribute to society and a „normally‟ functioning person. There is little room for uncertainty, vulnerability, mood changes and unpredictable bodies.

Menopause and urban Malay women today

Urban middle class Malay women today have experienced a variety of living circumstances, including formal education, which require them to be active and productive in the private and public realm. Their lives are filled with various challenges and pressures like managing the household, being a productive employee and, at the same time, managing their own health. These triple burdens, to some extent, have contributed to uncomfortable conditions like fatigue, depression and stress. Tiredness, depression and being stressed become part of the normal way of life as older women try to keep up with the expectations placed upon them.

In Chapter Four, after reviewing the available literature from a variety of disciplines, I argued that the differential presentations of physical and/or psychological symptoms are, at least in part, the result of the social expectations of a particular sociocultural group. Thus, a particular culture could contribute to the label of dysfunctionality that might be linked to menopause

(Gifford 1994; La Fontaine 1960; Sharma & Saxena 1981). Dysfunctionality is linked closely to a medicalisation of the menopausal experience. My thesis shows that this is slowly but increasingly becoming the case for women who perceive their symptoms to be unbearable or difficult. In the Malay culture, however, part of the raft of coping strategies includes an adherence to religion and adat. I have demonstrated that this, in part, can keep many women grounded as they work through the liminal phase between middle and old age. So it appears that

288 urban middle class Malay women simultaneously draw upon modern Western technologies and traditional values to help them deal with their changing bodies as well as their changing lives.

However, as I have presented in this thesis, traditional values and ways of life, which now co-exist with modern Western values and practices, perpetuated mainly through the media, have contributed to a conflicting atmosphere. I can now speculate quite confidently that there will be more complaints about „symptoms‟ of menopause in youth-oriented cultures where fertility is valued and ageing is feared. This has become the case in urban Malay society for women who are formally educated and who belong to a professional middle class. Indeed, the media has to take a great deal of responsibility for the negativity associated with ageing. Yet the media also reflect predominant values within the society and they also act in tandem with industries, like the cosmetic industry, that have played upon fears of ageing and being unattractive.

As menopause is the biological marker of old age, losing youthful looks and femininity is not something that women look forward to, nor embrace willingly. Judging by my participants‟ actions in attempting to retain their youthful appearances through medical intervention and the purchase of beauty products, I have argued that urban middle class Malay women view menopause and ageing ambivalently. Fear of ageing and loss of femininity is one element of what makes menopause difficult in today‟s society, but what other elements contribute to this growing ambivalence so evident in the women I observed and spoke with? Many women around the globe and in Malaysia have entered the paid workforce. The gendered nature of the paid work environment has impacted greatly on women‟s work experience (Itzin & Newman cited in

Morris & Symonds 2004, p. 314). Women are exposed to a new working environment; working long hours, working with younger colleagues and facing constant work pressure (Ong 1990).

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Urban middle class Malay women have to adjust their bodies to a so-called male-dominated organisational arrangement. Most women in my study who were affected by menopausal symptoms in the workplace voiced their dissatisfaction that their „condition‟ could not be taken into consideration by management in the way that pregnancy and childbirth were.

Urban middle class Malay women are expected to maintain their dual roles; that of dutiful wife and good mother, and that of efficient, productive and uncomplaining worker. At the same time the ageing women are also expected to maintain their youthful femininity and ensure they maintain their husbands‟ sexual satisfaction. Unfortunately, unlike the rural Malay women reported in Omar‟s (1995) study who received considerable attention from their husbands, the urban middle class Malay women in my research reported that they received only minimal attention from family members (particularly their husbands), friends and employees.

Embarrassment is the key factor that makes most women disclose their problems only to their doctors to get the support and help they need.

Malay women in a changing world

As I have argued throughout the thesis, the individual stories of women undergoing menopause need to be seen in a broader context in order to understand how these women have come to think about their bodies and their lives in a particular way. Elsewhere in the thesis I have written about how Malaysia has grown from a small nation, well-known for its tin-mining and rubber industry, to an industrialised nation reliant upon the contributions of women.

Industrialisation together with rural-urban migration both impacted tremendously upon women, seeing them exposed to modern lifestyles and able to take advantage of educational opportunities which changed their position in society. Due to „the revolution of rising expectations‟ (Ariffin

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2000, p. 37) among educated women, large numbers joined the paid work force and consequently this altered their traditional roles.

Despite Malaysia having comparative success in its economic endeavours and despite women being more able to participate in the public realm, there are repercussions, most often felt on the „home front‟ and in the personal lives of women. I have attempted in the thesis to bring this sense of the personal repercussion to life through giving insights into the lives of older women. The strain of having to cope with traditional wifely duty and paid work plus managing their health in their middle and older age leads to a particular kind of discord. Compared to their younger work colleagues, older women can be disadvantaged or not fully supported in terms of managing their health. The issue of menopause, for example, has been recently raised in

Malaysia, but not in a helpful way. Menopause is still a marginalised area of discussion in

Malaysia. Although relevant parties, including the Ministry of Women, claim that they have attempted to create awareness about the importance of menopause through public health seminars and exhibitions, the information, particularly on HRT, appears confusing to some women. Unlike breast cancer, which appears more relevant and pressing as a topic of discussion, menopause is often misunderstood. As women can have a variety of responses to this time in their life, and these responses can be physical, psychological and emotional, menopause falls into an area that is difficult to discuss in a meaningful manner. Women find it difficult to talk about it and others simply just do not talk about it at all. As I have presented in my earlier chapters, I would like to emphasise again that menopause was indeed not an easy process for my research participants and it was not always easy for them to talk about it.

In many ways my thesis has given voice to these urban middle class Malay women who otherwise would not have their stories told. While the women were urban and predominantly

291 professional Malay women in the city of Kuala Lumpur, many of their experiences may ring true for women the world over. However, in summary, I can say that their experiences of their symptoms, treatments and apprehensions about reaching this stage of their lives most clearly provide a picture of how menopause is dealt with today in urban Malay society. Compared to their own mothers who lived in the rural areas of Malaysia, this experience is different and unique, thereby giving weight to the place historical, economic, social and cultural factors play in the experience and understanding of bodily change. I have argued that the increasingly pervasive influence of Western perceptions of youth and femininity among the urban middle class Malay women has altered cultural understandings of menopause. These changing notions of femininity and ageing, together with increased use of biomedical approaches to health and healing within the general society, have resulted in most of the women in my study turning somewhat uncritically to biomedical forms of intervention to treat their menopausal symptoms.

There are three important findings that I wish to revisit in this conclusion. These findings are schematised following CMA and the notion of three bodies proposed by Lock and Scheper-

Hughes (1996). First: coming to terms with an individual body that is an ageing body or a symptomatic body, second: maintaining the elements of continuity through the adherence to religion and adat, (the social body) and third: acceptance of biomedical intervention and the dominant Westernised approach to deal with menopause as well as the media portrayal of the youthful and feminine look (the body politic).

The individual body: menopause as the unproductive state

The real sign of the changing body can be seen through the cessation of menstruation. In

Chapters Five, Six and Seven, I demonstrated that most of the women in my study were

292 dissatisfied with their changing bodies. I argued that losing the ability to reproduce and the growing realisation of their diminished youthful appearance was clearly an assault to the women‟s self-identity. What followed was that my participants used not just beauty products, but also medical interventions to recapture aspects of their youthful appearance and vitality.

Interestingly, unlike pregnancy and childbirth (and other life stages), menopause is neither subject to any particular rituals, privileges and celebrations; nor is it discussed openly with other people. In other words, menopause is a life stage which is not rated as important enough to warrant the attention of society, most probably due to its transitional nature, that is from being a reproductive to a non-reproductive person. No doubt pregnancy causes some temporary inconvenience to the organisational aspects of the society, but because societal emphasis on reproduction is strong, less sociocultural pressure is placed upon pregnant women. Menopause, however, is quite different.

Menopause is a life stage that is closer to that of illness. For this reason it has a profound impact on women‟s lives. During menopause a woman‟s womb is regarded as drying up; metaphorically it is finished and no longer useful. Pregnancy on the other hand, is associated with productivity (fertile ground), procreation and the increasing population. A pregnant woman is entitled to maternity leave and expected to return to work after she has had a considered time of leave, but this is not the case with menopause. There is no time off and no ceremony marks the coming of menopause – it is undefined, ambiguous and unknown. However, being a grandmother is considered as badge of honour in Malay society so the role of the ageing woman in society is not all bleak. The task of caring for their grandchildren and passing down family traditions is seen as a continuation of the woman‟s domestic role. Another advantage of menopause in Malay society is that it has freed my participants from cultural and religious

293 sanctions and obligations such as not being allowed to pray while menstruating as discussed in

Chapter Five. Menopause has provided the opportunity for them to become more involved in spiritual activities. Again we see the interesting combination of the modern and the traditional which coexist side by side and in many ways contribute to the ambivalence that surrounds the menopausal stage for Malay women.

The social body: continuity through adherence to Islam and adat

When considering the social body I have referred to how female bodies undergoing menopause are represented within a particular social context and within a particular social network. Women undergoing menopause must manage their bodies; the problems associated with their condition are ever present, but to others they are to a large extent ignored.

Consequently, urban middle class Malay women experiencing menopause find themselves living in a kind of limbo. While managing their changing bodily status they continue to take on the primary household tasks. Their responsibility for household management is expected regardless of whether or not they have careers and responsibilities outside of the home. For all of my female participants the family was central, with the strong Malay values associated with female virtue ever present. According to these values a good mother and dutiful wife should be conversant with her esteemed and „natural‟ role which is to nurture her children and to be a considerate companion to her husband – a view that my participants embraced.

The body politic: medicalisation in a non-Western context

As Malay women age they are still central within the community and the social networks.

Their place is necessary to the functioning of society and yet they have a triple burden – the burden of the work in the home, work outside of the home (that is paid work) and they are often

294 challenged by a changing body that does not function in a manageable or „attractive‟ way. This is not to say that younger women do not have bodily challenges associated with menstruation, pregnancy and childbirth. However, while menstruation is usually a regular bodily function, there is relief between cycles; moreover, pregnancies and childbirth are generally causes for celebration and extra attention. To overcome the challenges that have been brought about by menopause, the women in my study relied heavily upon medical assistance that has, in the most part, helped them to cope with their changing bodies.

In most Asian countries social and cultural changes have occurred rapidly and, in this context, the management of women‟s bodies is often located between tradition and modern medicine. In most developing countries, childbirth, for instance, has come progressively under the surveillance of modern/Western medicine. Hence, today home birthing and the use of traditional midwives have gradually become unpopular. The adoption of biomedical therapies and treatments goes hand in hand with the process of modernity and, as I explained in Chapter

Four, within the medical discourse menopause is treated very much like a „disease‟. The symptoms that women experience during menopause are viewed within a medical model and are seen as imposing a danger to their well-being. Within the biomedical framework the „disease‟ needs to be fixed by HRT to restore women to normality. So, women‟s bodies are like machines that need to be regulated, controlled and managed by medical intervention. The idea of medicalisation has not generally been explored in a non-Western setting. In this thesis I have argued that, like pregnancy, menopause is slowly but surely becoming medicalised in Malaysia.

The Malaysian media draw upon much of the medical discourse to promulgate various ideas about menopause. Unfortunately, as I have shown in Chapter Six, many of these ideas are reported in an uneven and haphazard fashion. So while a great deal of health care is informal

295

(that is in the home), increasingly Malay women are turning to a form of formal „medical‟ management when dealing with menopause. Information reported in the media is more often than not less than helpful. In addition, it is also saturated with images of youth and beauty that popularise a particular view of womanhood that devalues the older woman.

Eventually our bodies will decay and die. However, throughout adult life they can, under some circumstances, be shaped and moulded according to the intention of the owners. This can be done through plastic surgery, bodybuilding or consuming health products (which includes

HRT). The body is for women, as for all humans, a significant symbol of their identity and self worth. When women experience bodily changes which may make them feel they have lost control of their bodies it will inevitably also affect their sense of self worth and their identity.

The changing female body, through the process of menopause, has potential to challenge women‟s sense of control and their ability to feel at ease with the way their body is at that stage of life. Women‟s bodies today have become an essential social issue in the society. Women‟s bodies are subjected to the scrutiny of medical experts, entrepreneurs and the media. In addition, males notion of beauty also contributes to women‟s understandings of how their bodies should look. My study has illustrated how many Malay women, encountering menopause, have cause to feel dissatisfied with their ageing bodies. They have placed an increasing emphasis on their bodies and many have taken steps to change the way their bodies function, respond sexually or look through the use of HRT and beauty products of various sorts. Investing in their bodies

(through HRT and beauty products) signifies a degree of self management and increased control over their own bodies as well as introducing an element of pleasure in maintaining and beautifying their bodies. Although their investment might fail, the emphasis on youth and beauty

296 would appear to override other issues. Thus, it is not surprising if women continue to seek various means to maintain their body shape, size and function.

Contribution to cross-cultural study on menopause

The critical interpretive approach proposed by Lock and Scheper-Hughes (1996) has provided me with a framework for approaching the study of menopausal experiences with a critical yet empathetic view. The value of this framework is that it has invited me to focus on women‟s changing roles and position in society as they age and experience bodily change. I believe the approach has made my research somewhat different from previous studies about menopause in a Malaysian context. The research was also enriched by my chosen method of enquiry. Ethnography goes beyond reporting what is seen. It emphasises the search for meaning and the detailed description of the lived experience. Using an interpretive approach I have attempted to explicate the various meanings associated with menopause in a Malay context. In doing this I have tried to remain true to my participants‟ experiences, their apprehensions, anxieties, expectations and feelings about their ageing bodies.

My thesis is, as far as I know, the first detailed study of how urban middle class Malay women experience menopause. The study is also one of relatively few ethnographies that focus on women‟s changing roles during menopause and later life. Most anthropological works on menopause derive from cross-cultural analyses and commonly report the experience of women of a lower economic status. Although previous studies have given a number of accounts of menopausal women in both Western and non-Western countries, these studies do not necessarily cover the myriad of factors which contribute to the whole experience of menopause. These factors include the manner in which spouses and families respond to women as they go through

297 menopause; media reports about the menopause; biomedical interventions and control of menopause; government polices regarding older women‟s health; and the manner in which menopause is dealt with in work settings. My analysis of menopausal experiences among urban middle class Malay women has focused on considering the issue at three levels – individual, social and political. Together a consideration of the three levels provides a meaningful picture of how urban middle class Malay women experience a significant time in their lives.

There is still a lot of contradictory evidence that shows that the experience of menopause is not straightforward. Some women have severe menopausal symptoms and others do not. Some cultural groups report few problems with the menopause, yet modern society finds many women finding menopause unbearable. Some anthropological studies have also shown that menopause heralds a higher status for women as they grow into old age with older women considered wiser and deserving of respect (Bart 1969; Mernissi 1987; Omar 1995). Others have taken a different stand and contend that menopause is either a rewarding experience or a punishment to some women (Flint 1975; Gifford 1994; La Fontaine 1960). These studies have been too simplistic. In other words, there is no one-dimensional way of looking at menopause. I have argued that menopause is not an event but a process that must be understood along a continuum. There are variations in responses to menopause and it is not solely a physical experience. Individual women experience menopause differently. However, as my study shows, there are social patterns within particular societies which indicate that how women, and those around them, approach this life change is contingent upon social, cultural, economic and political factors. Perhaps it is time that more anthropologists shifted their attention to studying the social, emotional and psychological outcomes of menopause and ageing, particularly among women of higher economic status in other Asian countries. It may also be interesting to look in-depth at how

298 menopause has affected decision making in families and marital relationships. There are also other under-researched areas like the menopausal experience among middle-age single and childless women. Studies of menopause show much more than how women respond to inconvenient biological symptoms; they offer insights into how we as members of society manage our ageing bodies.

299

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APPENDICES

Appendix I Research participants’ demographic background

Marital Spouse’s No. No. of No Pseudonym Age Education Occupation Status Age of grand child child 1 Aini 49 Certificate Constable M 52 3 1 2 Rahmah 50 Bach. Deg. Lab officer M 52 4 NIL 3 Siti 50 Diploma Deputy manager Single NIL NIL NIL 4 Cempaka 50 Bach. Deg. Secretary M 54 3 NIL 5 Meenah 55 Certificate PR officer M 57 6 6 6 Dahlia 56 Bach. Deg. Batik designer Divorce 56 4 2 7 Zahira 54 Certificate Administrator M 58 4 NIL 8 Diana 53 Diploma Staff nurse M 53 2 NIL 9 Sofiah 50 Certificate Administrator M 56 5 NIL 10 Rashida 55 Certificate Administrator M 60 5 6 11 Rosmah 54 Certificate Asst. statistician M 55 2 NIL 12 Rafeah 51 Bach. Deg. School principal M 52 1 NIL 13 Salimah 53 Certificate UMNO Treasurer M 57 5 4 14 Habibah 51 Certificate Finance officer M 64 4 4 15 Maisarah 49 Certificate Municipal council M 49 2 NIL officer 16 Zawiyah 50 Certificate Administrator M 53 3 NIL 17 Chombee 55 Bach. Deg. School principal M 55 6 1 18 Rozana 50 Certificate Administrator M 54 2 NIL 19 Mariam 51 Certificate Account officer M 55 4 1 20 Lina 54 Certificate Dressmaker Divorce 56 4 2 21 Balkis 54 Diploma Tax assessor M 54 5 1 22 Zarina 53 Certificate Administrator M 54 3 NIL 23 Laili 50 Certificate Free-lance M 51 5 NIL consultant 24 Sharifah 51 Diploma Hairstylist-cum- M 58 3 NIL lecturer 25 Dalila 50 Certificate Administrator M 52 5 NIL 26 Azaliah 50 Certificate Administrator M 50 6 NIL 27 Asmah 49 Certificate Administrator M 61 3 3 28 Halimah 50 Certificate Businesswoman M 55 4 1 29 Karima 52 Certificate Gas station M 52 1 NIL operator 30 Kay 55 Certificate Administrator M 57 3 3

Bach. Deg. = Bachelor‟s Degree M = Married

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Appendix II Greene Climacteric Scale

No SYMPTOMS Not at A Quite Extremely all little a bit 1 Heart beating quickly or strongly 2 Feeling tense or nervous 3 Difficulty in sleeping 4 Excitable 5 Attacks of pain 6 Difficulty in concentrating 7 Feeling tired or lacking in energy 8 Loss of interest in most things 9 Feeling unhappy or depressed 10 Crying spells 11 Irritability 12 Feeling dizzy or faint 13 Pressure of tightness in head or body 14 Parts of body feel numb or tingling 15 Headaches 16 Muscle and joint pains 17 Loss of feeling in hands or feet 18 Breathing difficulties 19 Hot flushes 20 Sweating at night 21 Loss of interest in sex

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Appendix III List of HRT in Klinik Harapan*

No Name Price (RM)

1 Livial 75.00

2 Femostan 35.00

3 Femostan Conti 54.40

4 Fosamax 137.00

5 Premelle 40.00

6 Progyluton 29.00

7 Premarin 20.00

8 Progynova 24.00

9 Remifemin (herbal) 33.20

10 Fem-E (herbal) 2.00

* Courtesy of Klinik Harapan

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Appendix IV Newspaper articles on menopause

English newspapers Reporters/Doctors Date Title Section Sunday Mail Meera Murugesan 21-Sep-03 Putting the risk in perspective (SUM) Mary Chen 21-Sep-03 HRT and breast cancer Mary Chen 30-May-04 Specialist with gland solutions

Business Times Dr Sivamohan 2-Feb-01 HRT for women facing menopause Health watch

Malaysian Business Chai Choi Wei 16-Oct-02 Making sense of menopause

New Straits Times 2-Apr-01 Women facing menopause advised to seek ERT (NST) 4-May-04 Bio-identical HRT the safer course Dr H. C. Ong 11-May-04 Tact needed in handling menopause cases 25-Jan-05 What menopause means 13-Apr-05 Reproductive health takes centre stage Body Yam Cher Seng 31-May-05 Alternative options to HRT David Mattin 11-Sep-07 Facial reflexology for menopause Life & Times

Malay Mail (MM) 26-Jul-02 Cancer scare Info Health Jan-03 No cancer risk in HRT treatment 9-Aug-03 Stark warning on HRT Sharmila Vela 24-May-04 Celebrating menopause Amir Hafizi 5-Jul-04 The funny side of menopause

The Star Oct-02 Menopause and estrogen loss Jan-03 Flawed HRT study Jul-04 Facing menopause without fear

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The New Sunday R. V. Veera 30-Sep-01 Menopause relief with Remifemin Times (NSUNT) Jul-02 Is HRT doing more harm? 11-Aug-02 Most women unaware of link between menopause and health Dzulkifli Abdul Razak 17-Aug-03 Possible link between cancer and use of HRT 17-Oct-04 Living with menopause 5-Dec-04 Coping with menopause 6-Mar-05 Coping with menopause 20-Mar-05 Life after menopause 10-Apr-05 Easing menopause naturally 24-Apr-05 Weight loss and menopause 15-May-05 Eat right, live right NST-LTIMES 20-Mar-01 Lignans and their role in menopause 27-Mar-01 Alleviating symptoms of menopause 23-Jun-01 Public talk on menopause 7-Aug-01 Hormonal balance vital during menopause Anthea De Lima 30-Aug-01 Preparing for the golden years Manveet Kaur 4-Dec-01 There‟s life after menopause 11-Jul-02 Lend sympathetic ear to menopausal wife Loretta Ann Soosayraj 1-Aug-02 The HRT dilemma 1-Aug-02 Alternatives for menopausal women available Anthea De Lima 20-Aug-02 Staying fit with HRT Sofianni Subki 24-May-04 A wake-up call for women on health Gerald Chuah 26-Jun-04 Brassy, bawdy „Menopause‟ Hafidah Samat 8-Jul-04 Humorous ride on hot flashes Anthea De Lima 14-Feb-05 Help for mature skin

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Malay newspapers Reporters/Doctors Date Title Section

Berita Harian Rosniza Mohd Taha 1-Oct-01 Kesan buruk rawatan menopause (BH) Aug-03 HRT – Dos sesuai kurangkan risiko penyakit Kesihatan Halina Mohd Noor 6-Apr-05 Penjagaan kulit penting ketika menopause Halina Mohd Noor 14-Apr-05 Terapi hormon ketika menopaus Wanita & Keluarga Nor Affizar Ibrahim 28-Dec-06 Wanita menopaus perlu dibantu Citra

Harian Metro 24-Apr-01 Episod menopaus harus ditempuhi (HM) Mohd Amin Jalil 23-May-01 Kikis rasa takut periksa kesihatan Feminin & Famili

Mingguan Feb-03 HRT – Risiko hidap kanser buah dada rendah Malaysia Najibah Hassan 16-Oct-05 Menopaus hargai fasa emas 27-Nov-05 Legakan simptom menopaus Kesihatan

Berita Harian - Halina Mohd Noor 26-Oct-04 Wanita perlu bijak hadapi menopause Edisi Sentral 26-Oct-04 Jangan takut hadapi putus haid

Utusan Malaysia Rosniza Mohamad 19-Jun-99 Menopaus penggunaan hormone hak individu Gaya hidup (UM) Hapizah Aziz 11-Mar-00 Rawatan HRT di kalangan wanita menopaus meningkat Gaya hidup Saifulizam Mohamad 14-Nov-00 Wanita punca utama perceraian pasangan tua Muka hadapan Dr Suraya Arshad 10-Feb-02 Menghadapi menopaus Kesihatan

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Najibah Hassan 7-Jul-02 Hormon pengaruhi emosi wanita Kesihatan Sarjit Singh 23-Oct-02 Nasihat umum mengenai terapi penggantian hormon Rencana 23-Nov-02 Risiko wanita ambil hormon Rencana 22-Dec-02 Suami perlu memahami perubahan biologi dan fizikal isteri – Kesihatan Tekanan emosi menopaus 26-Jan-03 Terapi hormon menopaus tiada risiko barah buah dada Muka hadapan Najibah Hassan 2-Feb-03 HRT: Risiko hidap kanser buah dada rendah Kesihatan Rosmah Dain 31-Jul-03 „Era Mas‟ – Ubah persepsi wanita menopaus Keluarga Shafinaz Sheikh Maznan 11-Aug-03 Black cohosh redakan menopaus Kesihatan Roslah Othman 17-Jun-04 Tulang rapuh – mudah dialami wanita menopaus Keluarga Rahana MD 27-Feb-05 Menopaus: Wanita perlu rawat wajah Keluarga 22-Apr-05 Menopaus: Ramai pakar diperlukan Muka hadapan Siti Zaleha Jorimai 6-May-05 Menopaus: Berakhirnya kesuburan wanita Keluarga 30-Jun-05 Menangani menopaus secara semulajadi Keluarga Tajaiyah Ihsan 10-Jul-05 Terapi herba menopaus Kesihatan 10-Jul-05 Apa itu menopaus? Kesihatan Siti Zaleha Jorimai 19-Jul-05 Gejala menopaus – sangat berbeza Keluarga Shafinaz Sheikh Maznan 21-Aug-05 Herba penawar menopaus Kesihatan 3-Oct-05 Budaya menebal halang wanita fahami menopaus Dalam negeri 27-Nov-05 Legakan symptom menopaus Dr Sudha Kumari 31-Dec-06 Kesihatan optimum wanita menopaus Kesihatan Rosmah Dain 6-Feb-07 Menstruktur semula vagina dengan kaedah laser LVR Keluarga Rabiatul Adawiyah Koh 1-May-07 Merawat gejala menopaus melalui TPH Keluarga Abdullah 17-Jul-07 Tips menghadapi menopaus Keluarga

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Translated version

Malay newspapers Reporters/Doctors Date Title Section

Berita Harian Rosniza Mohd Taha 1-Oct-01 Bad effect of menopausal treatment (BH) Aug-03 HRT – Suitable dose lessen the risk of disease Health Halina Mohd. Noor 6-Apr-05 Skin care is importance during menopause Halina Mohd. Noor 14-Apr-05 HRT during menopause Woman & Family Nor Affizar Ibrahim 28-Dec-06 Menopausal women must be helped Citra

Harian Metro 24-Apr-01 Menopausal episode must be encountered (HM) Mohd Amin Jalil 23-May-01 Put aside fear to get health check-ups Feminine & Family

Mingguan Feb-03 HRT – Low risk of getting breast cancer Malaysia Najibah Hassan 16-Oct-05 Menopause - appreciating golden phase 27-Nov-05 Alleviate menopausal symptoms Health

Berita Harian - Halina Mohd. Noor 26-Oct-04 Women must be wise facing menopause Edisi Sentral 26-Oct-04 Don‟t be afraid to face menopause

Utusan Malaysia Rosniza Mohamad 19-Jun-99 Menopause – Hormone usage is individual rights Lifestyle (UM) Hapizah Aziz 11-Mar-00 HRT treatment among women increased Lifestyle Saifulizam Mohamad 14-Nov-00 Wanita punca utama perceraian pasangan tua Front page Dr Suraya Arshad 10-Feb-02 Facing menopause Health

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Najibah Hassan 7-Jul-02 Hormone influences women‟s emotion Health

Sarjit Singh 23-Oct-02 General advise on HRT Article 23-Nov-02 Risk for women taking hormones Article 22-Dec-02 Husbands must understand wives biological and physical – Health menopausal emotional pressure 26-Jan-03 HRT no risk of breast cancer Front page Najibah Hassan 2-Feb-03 HRT: Low risk of breast cancer Health Rosmah Dain 31-Jul-03 „Golden Era‟ – Changes women‟s perception about menopause Family Shafinaz Sheikh Maznan 11-Aug-03 Black cohosh relief menopausal symptoms Health Roslah Othman 17-Jun-04 Osteoporosis – menopause women is easily affected Family Rahana MD 27-Feb-05 Menopause: Women need to treat the face Family 22-Apr-05 Menopause: More professionals needed Front page Siti Zaleha Jorimai 6-May-05 Menopause: The end of women fertility Family 30-Jun-05 Overcome menopause the natural way Family Tajaiyah Ihsan 10-Jul-05 Menopausal herbal therapy Health 10-Jul-05 What is menopause? Health Siti Zaleha Jorimai 19-Jul-05 Menopausal symptoms – extremely different Family Shafinaz Sheikh Maznan 21-Aug-05 Herbs menopausal remedy Health 3-Oct-05 Culture prevent women to understand menopause Local news 27-Nov-05 Alleviate menopausal symptoms Dr Sudha Kumari 31-Dec-06 Optimum health for menopause women Health Rosmah Dain 6-Feb-07 Restructuring vagina with LVR technique Family Rabiatul Adawiyah Koh 1-May-07 Treating menopausal symptoms with HRT Family Abdullah 17-Jul-07 Tips facing menopause Family

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