Williams syndrome

INTRODUCTION

Menstrual cycle changes consist of a variety of bodily manifestations that are perceived in dramatically different ways by women. In a Canadian study conducted on women's perceptions of menstruation and PMS, some women (3) responded to a question on the meaning of menstruation with the following statements:

Mary: I love it. I just love it because I feel it's like a cleansing.

Shelby: I hate it, I hate it. It's still embarrassing for me.

Holly: Blood (laughter). Strength, health, women.

Jody: Pain, cramps, premenstrual tension, anxiety, and I can hardly wait for menopause.

Rosemarie: It's very special to be able to have that cycle...it's all part of fertility and what it means to be a woman.

Claudia: I think of a really bad experience...pain would be one of the things that come to mind...I don't find it in the least bit pleasant or in any way healthy. It's just sort of a big bad part of the month.

Differences in the perception of menstruation are readily apparent in the discourse presented above. Some of this variation concerns bodily changes perceived as problematic and distressing, yet positive attitudes were also expressed. Nevertheless, the main focus of menstrual cycle research continues to concern changes that are commonly referred to as premenstrual syndrome, better known by its acronym PMS.

The label was first used by Greene and Dalton (1953) to represent distressing somatic and psychological changes prior to and during menstruation. (4) Since then researchers have documented a multiplicity of symptoms and suggested a variety of causal explanations that have led to considerable argument among researchers as to the nature of the disorder. Researchers have addressed PMS in terms of hormonal causes in clinical, biomedical studies (e.g., Dalton, 1984; Greene & Dalton, 1953; Mortola, 1998; Reid, 1989; Rubinow et al., 1988; Schmidt, Nieman, Danaceau, Adams, & Rubinow, 1998) and from the perspective that social and cultural factors underlie the perception of distressing, cyclic changes (e.g., Anson, 1999; Britton, 1996; Caplan & Caplan, 1994; Chrisler & Levy, 1990; Fausto-Sterling, 1985; Johnson, 1987; Laws, 1985; Markens, 1996; Martin, 1987, 1988; McFarlane & Williams, 1994; Parlee, 1974; Rodin, 1992; Ruble, 1977; Ruble & Brooks-Gunn, 1979; Scambler & Scambler, 1993; Slade, 1984; Taylor, Woods, Lentz , Mitchell, & Lee, 1991; Ussher, 1992; Woods, Mitchell, & Lentz, 1995).

Positive attitudes are not mentioned frequently in the literature on menstruation, although positive effects of menstruation have been discussed in a few papers (Alagna & Hamilton, 1986; Britton, 1996; Chrisler, Johnston, Champagne, & Preston, 1994; Delaney, Lupton, & Toth, 1988; Martin, 1987; Parlee, 1980; Ripper, 1991; Scambler & Scambler, 1985; Stewart, 1989; Sveinsdottir, 1998; Woods, Taylor, Mitchell, & Lentz, 1992). Some positive aspects of menstruation include feelings of increased energy and activity (Stewart, 1989; Sveinsdottir, 1998), heightened sexual interest and enjoyment, and increased creativity (Stewart, 1989). Affirmations of fertility, normalcy, health, and femininity (Britton, 1996; Scambler & Scambler, 1985; Woods et al., 1992) have also been reported, although Scambler and Scambler categorized these affirmations as acceptance, the closest women in their study came to displaying a positive attitude. Martin (1987) noted that menstruation was considered a positive factor for women in her st udy in that it defined them as women; however, negative factors tended to overshadow positive attitudes (also noted by Reilly and Kremer, 1999, who referred to this attitude as ambivalence). Positive effects were also found in a study by Ripper (1991) who stated that mood changes and perceptions of performance were reported as positive, rather than negative, aspects associated with the menstrual cycle.

In this paper, I will discuss the results of an examination of women's perceptions of menstruation and PMS, which is part of a qualitative study on women's knowledge and understanding of menstruation and PMS conducted in Winnipeg, Manitoba, Canada. One of the primary goals was to analyze the meaning of menstruation and PMS from the perspective of women themselves or, in other words, the way women conceptualize and perceive their menstrual experiences (see Britton, 1996; Cumming, Urion, Cumming, & Fox, 1994; Gurevich, 1995; Hall, 1994; Jarvis & McCabe, 1991; Martin, 1987; Reilly & Kremer, 1999; Woods et al., 1992, for work in this area). This research, organized within a medical anthropological perspective, explores how women understand and frame their experiences of health and sickness and examines menstruation in terms of both positive and negative attitudes. Although a majority of women in my study stated that they considered menstruation to be healthy, feminine, a normal part of life, and important in ter ms of fertility, a small group of women exhibited an extremely positive attitude that reflected a reevaluation of menstrual cycle-related change as a valued part of their experience and refrained associations between self, identity, and menstruation.

Medical Anthropological Approaches to Sickness

Recent work in medical anthropology on the concept of sickness as an unwanted condition (Hahn, 1995) provides a theoretical framework for a discussion of menstrual cycle changes. Sickness has been defined as the social process involved in disease (Frankenberg, 1980; Kleinman, 1988; Young, 1982). Hahn defined sickness from the perspective of the individual who is experiencing an unwanted condition: "sicknesses are unwanted conditions of self, or substantial threats of unwanted conditions of self... Unwantedness comes in degrees, and individuals may have different thresholds regarding just how seriously unwanted a condition must be in order to qualify as sickness" (p. 22).

According to Hahn (1995), the concept of sickness is centred on an individual's perception of a disordered state that is considered a threat to the sense of self. Thus, an unwanted condition is one that is devalued according to certain elements a person has come to associate with a state of wellness or well-being. This definition of sickness is a particularly apt conception in terms of menstruation as it takes into account the individual's perceptions of changes associated with the menstrual cycle. Within this framework, menstruation can be viewed as an undesirable or unwanted state (perceived and labelled as PMS), or it may have a more positive connotation.

Hahn (1995) also stated that "societal accounts give names and explanations to sensations" (p. 29). These two factors, individual perception and societal accounts, affect the embodiment of menstruation. Women may perceive this process as unwanted due to the experiential component; societal and cultural attitudes and perceptions; medical knowledge and beliefs; and political issues, such as the position of women in society. According to Strathern (1996), embodiment is always derived from the sociocultural milieu.

METHOD

Participants

The research sample (see Table I) consisted of 43 women who volunteered for intensive, semistructured interviews. There were no specific inclusion criteria other than a willingness to discuss menstrual experiences in detail. Women ranged in age from 19 to 55 years of age with a mean of 34.4 years. The majority of women (48.8%) were single, and most women were highly educated: 27 women (62.8%) had completed a university education, and all women had achieved a high school degree. In terms of ethnicity, 35 women (81.4%) were born in Canada of European descent. Thirty-two women (74.4%) reported that they experienced PMS.

Procedure

Information was collected on menstrual attitudes, positive and negative aspects of menstruation, premenstrual changes and their impact on life, treatment and labelling issues, perceptions of PMS from those who did not experience it, recollections of menarche, and ideas concerning the body and the sell Women were also asked to rate their attitudes on a scale of 1 to 10 (1 = negative, 10 = positive), and this evaluation resulted in the construction of five categories: extremely positive, slightly positive, ambivalent, slightly negative, and extremely negative. Numerical choices were compared with women's descriptions of their attitudes in order to verify attitudinal classifications. Data were also compiled on demographic variables such as age, education, marital status, and ethnicity. Over 800 pages of text were derived from the 2-hr interviews, which were audiotaped and transcribed.

Themes and patterns were uncovered in the data using domain analysis (Borgatti, 1994; Spradley, 1980). Four primary domains were constructed in terms of menstruation: conceptual, functional, experiential, and attitudinal. Camponential analysis was undertaken in order to assess attributes associated with the designated cultural domains (Spradley, 1980). Another method of analysis was free listing terms from the domains to compile frequency data (Borgatti, 1994; Weller & Romney, 1988).

Women also agreed to complete a consensus questionnaire, which consisted of 66 statements derived from their interviews, during a follow-up session scheduled approximately 6 months after the initial interviews. Consensus analysis (5) is a technique derived from cognitive anthropology to assess shared knowledge in a particular cultural domain (Romney et al., 1986). This technique, although not the primary focus of this paper, was important as a complementary method in conjunction with the analysis of women's narratives and was useful in terms of verifying information provided by women in the study.

Narrative Analysis

The transcripts provided detailed narratives of women's conceptualizations and understandings of menstruation and PMS. These individual or personal stories that are used to explain behavior are part of a growing field of analysis in which experience is viewed as "an integrated construction, produced by the realm of meaning, which interpretively links recollections, perceptions and expectations" (Polkinghorne, 1988, p. 16). This analysis provides a way for the lives and stories of individuals to be understood not only in terms of subjective meaning, but also within the context of "larger human and social phenomena" (Hatch & Wisniewski, 1995, p. 113). Kirkman and Rosenthal (1999) summarized four typical features of narrative research: (1) the recognition of the individual person; (2) the recognition of the subjective dimension of lives and the importance of meaning; (3) the recognition of the contribution of context to meaning; and (4) the recognition of the collaborative construction of autobiographical accou nts.

Narrative analysis within medical anthropology is a useful method to understand how individuals perceive their worlds of health and sickness (Farmer & Good, 1991; Garro, 1994; Good, 1994; Hahn, 1995; Kleinman, 1988; Lang, 1989). Although specific case studies are used primarily to illustrate complex narratives, the aggregation of women's responses within negative and positive attitudinal groupings provides a similar way to focus on fundamental narratives underlying menstrual cycle experience.

RESULTS AND DISCUSSION

Attitudes Toward Menstruation

Attitudes ranged across a broad spectrum from extremely negative to extremely positive, although 57.1% of women were positive in attitude. The average response on the self-rating scale was 6.5, which reinforced the positive rating (see Table II).

A small group of women were identified who were extremely positive in attitude. This subset comprised 23.8% or 10 of the women interviewed. (6) The extremely positive women rated themselves 8 or higher on the self-rating scale (the mean value on the scale for this group was 9.6), and their discourse reflected an intense valuation of their menstrual experiences, which were essential to their identity as women. The extremely positive attitude was quite different from slightly positive (n = 14) and ambivalent (n = 3) attitudes, which could be described as acceptance, in which women regard menstruation as healthy, feminine, and a normal part of life (Scambler & Scambler, 1985). In contrast, the difference between the extremely negative (n = 6) and slightly negative (n = 9) groups was one of degree, with the extremely negative group exhibiting a more intense negative experience and dislike of menstruation. On the basis of women's narratives and consensus analysis, two groups were singled out for discussion: a neg ative group that combined the extremely negative and slightly negative women (n = 15) and the extremely positive group (n = 10). See Table III for consensus scores that validate the attitudinal groupings and Table IV for a list of statements that reflect differences between the groups.

Subgroup Demographics

The women in both groups exhibited little variability in terms of demographic variables (Table V). The mean age was similar, although the range in age was greater in the negative group. There were 4 women above age 42 in the negative group: 1 woman was 45 years of age, 2 women were 49 years old, and another woman was 55 years of age. One might expect older women to exhibit more negative attitudes particularly if their menstrual experience has consisted of severe changes over a long period of time; however, younger women in the negative sample related similar experiences and attitudes. The majority of women in both samples were single. In terms of marital status, 5 women in the negative group were married, whereas in the extremely positive group, only 1 woman was living with a partner.

Most women in both groups were highly educated: all of the extremely positive women were either attending university or had received a university degree. Among the negative group, all but 2 women had higher education. Socioeconomic status was not assessed. Nevertheless, based on their family background and university experience, the overall sample could be described as representing middle-class women. Most women were born in Canada and were of European descent. In the extremely positive group, 3 women were born elsewhere (England, Switzerland, and Brazil). However, these women had been living in Canada since they were very young: 1, 2, and 4 years of age respectively, whereas only 1 woman in the negative group had entered the country as an adult from the Caribbean.

PMS Experience

A majority of women in the study tended to characterize PMS as an unwanted condition, and most women placed changes associated with the menstrual cycle within the PMS label. Thirty-two women or 74.4% of the sample experienced PMS: in the extremely positive group, 70% reported PMS, whereas the figure for the negative group was 80%. When asked to define PMS, the most common response was that it consisted of negative, emotional symptoms occurring prior to the period.

The extremely positive group differed from the negative group in their views of the PMS construct. In general, they perceived changes associated with menstruation as positive, and they were also critical of changes being placed within the PMS label. These women valued their menstrual experience, and their narratives revealed that they had, in effect, transformed "unwantedness" into "wantedness." This transformation is important to highlight as it may provide some insight into the reason changes associated with the menstrual cycle are perceived by this group as valued changes rather than as part of sickness.

Women's Narratives

Menstruation: Valued or Unwanted

When the extremely positive women were asked to describe their attitudes toward menstruation, they responded with strongly worded sentiments about their sense of self, sense of being a woman, and the spiritual aspect of cyclic change.

Leslie: I think it's a wondrous event, how the body can collect nutrition for a potentially growing egg and then just let it go.. . I find it a time for introspection and reflection and being more in touch with my own body. I feel positive about it.

Jane: It's pretty cool that we can do that, like we can bleed without hurting and without it challenging our health.., it's a pretty cool process what our bodies can do I feel more creative and more in touch with myself.., it's like a reaffirmation of my womanhood.

Aset: It's a part of being a woman it's who I am, it's what I am so I love it. I think it's fantastic; it actually feels like a relief now when I do menstruate.

Within the group of women classified as negative, the major themes identified were inconvenience, pain, and disturbing changes identified as PMS. Women in the negative group expressed their feelings in the following ways:

Shelby: I hate it... I have a really heavy blood flow, and it's uncomfortable, embarrassing.

Sarah: Actually, since I've had my period, I've had lots of problems... it's so-regular... it's really annoying I find. I hate having my period.

Celeste: I find it a real inconvenience. Well, it's kind of a nuisance, and sometimes it gets in the way of my living cause of the problems it creates.

Joan: I see it only as an inconvenience and an expense. I mean, let's face it, it's dirty, it's smelly.

Myra: Will it ever end?

Inconvenience was a frequent theme associated with heavy bleeding, irregular periods, and the anxiety of having to deal with the flow of blood over a period of many years. Myra, a 55-year-old woman who asked "Will it ever end?," experienced a heavy and lengthy flow and was looking forward to menopause. Women who experienced heavy blood flow and irregular periods said that menstruation was an inconvenience and a nuisance. Reilly and Kremer (1999, p. 784) referred to this perception as disempowering because timing and symptoms are "perceived as uncontrollable."

Nevertheless, women in the negative group thought that there were some positive attributes (e.g., procreation and cleansing) associated with menstruation.

Jody: That's what menstruation is, that one is physically able to bear children or conceive. . . I associate womanhood with motherhood. It means I can be a mother.

Women in the extremely positive group did not agree with the idea that motherhood was an essential part of being a woman. This does not mean that they did not value their fertility; it was the merging of two distinct qualities, motherhood and womanhood, with which they disagreed.

Aset: I was not put on this earth to reproduce. That annoys me. Associating women with reproduction only. We don't do it alone, and I mean, if men could carry them, go ahead. It's a wonderful thing.. . but I don't think we all have to endure it simply because we're women.

Menstruation was also considered to be a cleansing process, a positive attribute in terms of the negative group. Cleansing was connected to reproductive function, as the system was "cleaned out" to allow the reproductive cycle to begin all over again. For the extremely positive women, cleansing was not associated with the reproductive aspect. Cleansing was a way to maintain health (also noted by Jurgens & Powers, 1991; Woods et al., 1992).

Emily: It feels like a cleansing in some ways. It just implies that if your cycle is regular, you know, a regular cycle, it gives a message of being in good health.

Jane: I've heard this theory that the idea of menstruation is that when women have sex with men, men introduce bacteria or different organisms that might not be healthy to women, and so shedding is a way for them to clean out their systems.

Menstruation was a time for the extremely positive women to address the issue of self-care; for example, they recognized the need to slow down, to isolate themselves from people, in effect, to treat themselves differently at this time. Extremely positive women perceived their changes as a necessary part of their cycles so they were not more critical of themselves prior to and during menstruation. They did not express feelings of self-hatred, nor did they feel more self-conscious about body image (see consensus statements in Table IV).

Holly: I like the fact that it reminds me to take care of myself and to take time out. It sort of reminds me to indulge myself sometimes... I like the fact that it gives me a chance to get to know how my body works. That really interests me (laughter).

Some women in the negative group also felt the need to treat themselves differently, but their approach to self-care was not as evident as that of the extremely positive group. Women with negative attitudes were also more critical of themselves in terms of conceptions of self and body image. PMS was associated with self-consciousness and feeling less attractive, and some women expressed extreme reactions in terms of self-hatred and low self-esteem.

Jody: I hate myself. I have low self-esteem, I feel fat, I feel ugly, I feel unloved. That about sums it up.

Brenda: I hate myself. I do not feel comfortable in my own skin. I just feel like I'm a complete failure.

Gwen: I think, in that 10 days, 10 to 14 days before... I can sometimes have, sort of, a self-loathing... I mentally feel blue, depressed. It's just sort of like a horror show. It's just ugly. It's an ugly sort of mood.

These negative perceptions seem to impact significantly on a woman's sense of self and identity and appear to have an enormous impact on conceptualizations of normal menstrual cycle functioning as sickness.

The Labelling of PMS

Women with negative attitudes also considered PMS to be an appropriate label for premenstrual changes, and most women in this group thought that the identification of PMS was important as symptoms were not taken seriously unless they were part of a biomedical explanation.

Ula: I think it's important it has a name because if it doesn't have a name it tends to lack validity with people... but I don't think it's very well understood.

Although 7 of the 10 extremely positive women responded affirmatively when asked whether they experienced PMS, their discourse about PMS differed from the ideas expressed by women in the negative group. They were much more critical about the labelling of changes as PMS and indeed about the concept of PMS itself

Zena: I think that the changes came before the label, and I think that it's a very medicalized term... it bothers me that it legitimates it, you know, it makes it a medical thing... I think the other thing that bothers me about the PMS label is that it negates a lot. I think it tends to be viewed as an excuse almost, now, to negate women's feelings.

However, some women who experienced changes prior to and during menstruation refused to label these changes PMS, and they expressed strong views about labelling as well.

Mary: I don't like things called syndrome... I have this very positive kind of feeling about your period and that your womanhood--to put all these negative connotations around it--I'm not too pleased with that, you know.

Leslie: I sure don't want a label... It's stagnant. Our health is dynamic, our body is always changing.

Some of the women noted that, even though their experiences could be problematic, these changes were positive factors in their lives.

Marg: It does impact on my life, and I change my lifestyle to accommodate it... I don't see PMS as something that's outside of me or that impacts me from the outside... It's me, it's just me and my hormones. It's me.

Rosemarie: My biggest wish would be that on the day that I have my period that I'm absolved from anything outerworldly, that I could just sit around and have a bath and read and not have to take care of a child and make meals... my body is doing its thing.

Emily: I think my body experiences changes throughout the course of a cycle, but those changes are necessary, normal, and healthy.

The extremely positive women expressed concerns about the use of the term syndrome as it medicalized the changes and designated menstrual cycle variations as sickness, although it is important to note that this awareness was also present, to some extent, among women with negative attitudes. Referring to "changes" rather than "syndrome" may be an important step in the dismantling of the concept of PMS (Bancroft, 1995; Richardson, 1995), as many women have mentioned that the label is loaded with contradictory meanings (7) and ultimately serves to disempower women (Choi, 1995). According to Stoppard (1992), "new ways of naming women's experiences in relation to menstruation that are free of the negative connotations of PMS" (p. 127) are needed.

Resistance to the Concept of Sickness

Is menstruation sickness? As Rosemarie stated, when asked whether she would describe changes experienced prior to menstruation as PMS:

No, no, no. It's a sickness? It's absolutely ridiculous. Yeah, the world's gone insane calling all these natural, special things that have to do with womanhood a sickness. The world's nuts, crazy. And any chance I get, I'll let people know (laughter).

The refusal to accept a natural process as sickness, and the desire to vocalize that dissent, were common issues expressed by the extremely positive women. Martin (1987) has referred to this critical stance as resistance, and she defined resistance as "refusing to accept a definition of oneself and saying so, refusing to act as requested or required. This can be done as an individual or in concert with a group" (p. 187). Although Martin's analysis focused on class differences in resistance to the medical model of menstruation, which emphasized the concept of failed reproduction, I believe that resistance also applies to the extremely positive women in my study who had transformed their perceptions of menstruation from an "unwanted" condition of self to a "valued" state of being. This transformation involves reclaiming the body, which includes redefining what it means to be a woman and developing a more positive self-image (Currie & Raoul, 1992; Stoppard, 1992). "Taking action" is also a way in which self-este em can be increased (Rome, 1986).

Jane expressed her thoughts this way:

I think... that the changing of my perceptions has come from looking inside and sharing with other women... I was ready to start questioning what the culture says about me and my body as a woman. And I think they're very connected... And I think something that was key for me was an awareness of my own sexuality. And right now I'm in a same sex relationship, and you have to let go of that stuff to love a woman.

The idea that cultural conceptions of the female body should be reevaluated is an important part of "reclaiming the body." This conviction was voiced by all of the extremely positive women. Another example of transformation involved Mary, an artist who used menstrual blood in some of her pieces. She liked the visual quality of blood; to Mary, blood was a positive phenomenon, a desirable body secretion rather than simply an inconvenient by-product of the menstrual cycle.

Furthermore, the perception of menstruation as positive appears to be closely associated in this study with a feminist perspective. The importance of feminism in the lives and backgrounds of the extremely positive women provides a crucial component in the process of unravelling their attitudes toward menstruation and understanding its transformation from an "unwanted" to a "valued and wanted" condition. Women in the extremely positive group acknowledged that a feminist orientation had helped them deal with difficult issues in their lives. Women in the negative group were more ambivalent about the importance of feminism.

CONCLUSION

A primary goal of this study was to examine the meaning of menstruation and PMS from the perspective of women themselves. Although the use of a volunteer sample was a limitation of this study in that the sample could not be considered representative of Canadian (or even Manitoban) women in general, this methodology was appropriate in terms of the goals of the research. Results illustrated that the study was successful in that it provided additional information on women's experiences of menstruation and PMS and contributed new data on a more positive reorientation toward menstrual cycle changes.

One of the most important results of the study was the identification of a group of women who were extremely positive. These women had refrained their menstrual cycle experiences and reevaluated negative, cultural attitudes toward menstruation. They acknowledged that change was an integral part of menstruation (change that, in some cases, caused the individual to engage in proactive self-care measures), and their awareness served to distance these fluctuations from PMS, a label that medicalized a normal, female, biological process.

Menstruation has been described as a process to be managed "as though menstruation is an illness and disables women" (Britton, 1996, p. 652). This medicalization of reproductive physiology portrays normal experiences and processes (e.g., menstruation, childbirth, and menopause) as medical problems (Conrad, 1992; Kaufert & Gilbert, 1986; Lock, 1993; Martin, 1987; Miles, 1991; Reissman, 1983; Sherwin, 1992; Stoppard, 1992; Zita, 1988). The emphasis on more positive aspects of menstruation as described in the narratives of the extremely positive women has implications in terms of questioning the medicalization of women's health and the labelling of menstrual cycle-related changes as PMS. The rejection of accepted cultural values along with a proactive stance associated with reclaiming the body appear to be effective strategies for change. This suggests that more attention should be placed on women's subjective experience of menstrual cycle change (Gurevich, 1995; Jarvis & McCabe, 1991; Koeske, 1985). The sharin g of women's stories can be a powerful element in the resistance of negative concepts of menstruation in society.

APPENDIX: EXAMPLES OF INTERVIEW QUESTIONS

Questions on menstruation

What do you think of when you hear the word menstruation? List anything that comes to mind.

What is your first recollection of menstruation?

Describe how you feel about menstruation at this time in your life.

Please list some positive and negative aspects of menstruation.

On a scale of 1 to 10 (1 = negative; 10 = positive), which number best represents your feelings about menstruation at this time?

What do the following terms or phrases mean to you: femininity; being a woman; the female role or roles; feminism?

Questions on PMS

Do you personally have experience with premenstrual syndrome or PMS?

What is the first thing you think of when you hear premenstrual syndrome mentioned?

Can you give me a definition of PMS?

What changes do you experience?

What effect do these changes have on your life? Which changes have the most effect: emotional or physical?

What do you think PMS is caused by?

On a scale of 1 to 10 (1 = mild; 10 = severe), what number best represents the severity of your PMS in terms of its impact on your life?

ACKNOWLEDGMENT

I thank the women who so willingly participated in my study.

(1.) An earlier version of this paper was presented at the June 2001 meeting of the Society for Menstrual Cycle Research in Avon, CT. This paper is based on a portion of the data from the author's doctoral dissertation: A Study of the Knowledge and Understanding of Menstruation and Premenstrual Syndrome (PMS) among Women in Manitoba.

(3.) All names used in reference to the participants in the study are pseudonyms.

(4.) Premenstrual syndrome (coined in 1953) was not the first labelling of premenstrual symptoms. As early as 1931, Frank referred to these symptoms as premenstrual tension.

(5.) Consensus analysis was originally formulated as "a way of describing and measuring the amount and distribution of cultural knowledge among a group of informants in an objective way" (Romney, Weller, & Batchelder, 1986, p. 313). Informants are offered two choices on a consensus questionnaire: to agree or to disagree with a series of statements. The responses are factor analyzed (using the Anthropac computer program for consensus data) based on a correlation matrix of matches among the respondents. As there are no correct answers to form an answer key, the program estimates the correct answer in terms of the matches within the group. If there is a high level of agreement, the first eigenvalue must be three times as large as the second value, and other factors must be relatively small. The use of small samples is a component of the consensus technique.

(6.) One woman was excluded from the attitude classification as she did not experience bleeding (due to a hysterectomy), although she still had ovarian function. She was included in the PMS sample as she reported experiencing PMS symptoms.

(7.) This stance does not in any way minimize the severe changes that a small group of women experience in connection with their cycles. It is the labelling of the changes as PMS that is important to explore critically.

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Shirley Lee (2)

(2.) To whom correspondence should be addressed at Department of Anthropology, University of Manitoba, Winnipeg, Manitoba, Canada R3T 2N2; e-mail: lees0@cc.umanitoba.ca.

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