Abstract
Menarche is one of the most important transitions for women. Perceptions of menarche play an important role in this transition process and appear to be influenced strongly by culture. The purpose of this study was to examine perceptions of menarche among female adolescents in South Korea. Fifty-three female students’ essays and drawings representing their own perceptions of menarche were qualitatively analyzed. Five themes emerged from the data: something unfamiliar, lack of welcome, reaching maturity, pain and discomfort in my body, and changes in my daily life. When we quantitatively compared the themes, fifth-grade students and students who had not yet experienced menarche tended to focus more on the theme of reaching maturity, whereas students who had experienced menarche regardless of grade tended to focus on the theme of pain and discomfort in my body.
Introduction
All human beings experience diverse transitions as part of the developmental process. According to Schlossberg (1981), transition can be defined as any event or nonevent resulting in changes in relationships, routines, and roles. Moreover, all individuals continuously experience various forms of transition throughout their lives. In women, one such transition is menstruation, a natural physiological and developmental process that signals a women’s fertility (Erbil, Boyaci, Kurt, Akdoğan, & Kaya, 2012). A woman’s first menstruation is called menarche, and most females consider it a significant event. This is because, unlike other signs of puberty, menarche occurs suddenly and unexpectedly, and is often accompanied by various unpleasant feelings such as pain and cramping (Al Omari, Abdel Razeq, & Fooladi, 2016; Uskul, 2004). All women begin this transition by experiencing menarche and must adapt to a life with periodical menstruation.
According to Schlossberg (1981), however, not all people show the same reactions or adapt to transitions in a similar manner. Individuals have different abilities to adapt to changes, and the same person might react differently to the changes that occur at different times in his or her life. Thus, Schlossberg conceived the Transition Theory to explain the complicated process of adaptation to transition. In her model, there are three crucial factors that influence adaptation to transition: perception of the transition, characteristics of pre- and post-transition environments, and characteristics of the individual. The interaction of these factors produces one of two outcomes: adaptation or failure to adapt.
Applying this theory specifically to menarche, females might perceive this transition either negatively or positively; examples of the emotions accompanying the former perceptions are shame, embarrassment, and misery, whereas those accompanying the latter perceptions are happiness, pride, and excitement (Uskul, 2004). Interestingly, females’ attitude and perception of menarche seem to play an important role in women’s future health. According to previous studies, these perceptions and attitudes not only influence girls’ health behaviors and body image but also their subsequent menstruation experiences and even their attitudes toward menopause (Al Omari et al., 2016; Erbil et al., 2012; McPherson & Korfine, 2004). Unfortunately, the majority of women tend to hold negative attitudes and perceptions regarding menarche, which are associated with factors such as inadequate preparation for menarche, lack of support, and lack of knowledge and education (J. Lee, 2008; McPherson & Korfine, 2004; Tang, Yeung, & Lee, 2003; Uskul, 2004).
Ethnicity (cultural norms) is one factor noted to have a particularly strong influence on participants’ attitude and perception toward menarche and menstruation. Women’s menstruation and menarche are perceived rather differently across different societies and cultures. For instance, Zambia and Sri Lanka are representative of countries where women’s menstruation is perceived as a beautiful and joyful event (Uskul, 2004). Conversely, several countries consider menstruation as taboo and stigmatize menstruating women. Crawford, Menger, and Kaufman (2014) explored the stigmatization of menstruation in South Asia by interviewing 19 Nepali women. The women detailed their experiences of being stigmatized for menstruation: for instance, they were occasionally prohibited from approaching sacred places, from touching food, and even from touching their husbands. This phenomenon caused these Nepali women to develop negative feelings toward menstruation, such as fear, anxiety, and shame. In addition, in Hong Kong, the attitude toward menstruation aligns with traditional Chinese culture and beliefs—namely, that menstruation symptoms are considered almost pathological, the result of an imbalance between blood and Qi (body energy). Such beliefs make girls exhibit more negative perceptions toward menstruation and its accompanying symptoms (Wong et al., 2013; Yeung, Tang, & Lee, 2005).
In this study, we examined the perception of menarche among members of a particular ethnicity (Korean). Attitudes toward and perceptions of menarche or menstruation have been extensively documented across diverse cultural backgrounds—researchers have examined not only females in Zambia, Nepal, and Hong Kong but also those in Kenya (Secor-Turner, Schmitz, & Benson, 2016), Canada (Rempel & Baumgartner, 2003), Brazil (Makuch, Osis, Petta, De Pádua, & Bahamondes, 2011), Mexico (Marván & Molina-Abolnik, 2012), India (Yagnik, 2012), Taiwan (Chang & Lin, 2013), Jordan (Al Omari et al., 2016), and so on. However, these attitudes and perceptions have not yet been studied in South Korea. Moreover, globally, the age of menarche is gradually decreasing (Cho et al., 2009; Parent et al., 2003; Woo, 2016). In South Korea, in particular, the mean age of menarche was around 16.9 years old in 1920; by 1985, this had decreased to 13.8 years old, after which it further decreased to about 12 years old in 2011 (Korea Centers for Disease Control and Prevention, 2015). In 2015, the mean age of menarche was reported to be 11.7 years old (Korea Centers for Disease Control and Prevention, 2015). Considering that the age of menarche is decreasing among female adolescents, adequate preparation for menarche through evidence-based education and support is needed. However, there has been a lack of research in this area.
Therefore, in the current study, we used a qualitative approach to understand the perception of menarche among female South Korean adolescents; as noted above, perception of the transition is one of the three most important factors influencing adaptation to a transition according to Schlossberg’s (1981) Transition Theory. In this study, we focused on females between 11 and 12 years old (fifth and sixth grade in elementary school), as this accords with the mean age (11.7) of experiencing menarche in South Korea. We assumed that these female adolescents would either be about to experience or had just experienced menarche. The specific aims of this study were (a) to qualitatively explore the meaning of menarche among Korean female adolescents and (b) to quantitatively compare the meaning of menarche according to grade and experience of menarche. There are two reasons we used the term menarche rather than menstruation: first, we thought that “menarche” (first menstruation) is a better term to explore the symbolic meaning of the transition for female adolescents. In addition, according to Schlossberg’s (1981) Transition Theory, transitions are caused by “an event” that leads or requires one to change one’s behaviors, routines, or relationships. To that end, we thought the term menarche was more suitable as “an event,” as it results in changes in the routine once it begins. Second, this study used existing data on students’ knowledge about puberty prior to education. Normally, during the education for elementary school students, school nurses teach the term menarche. Although menstruation is a more common term in daily life, the first author (who is a school nurse) wanted to determine students’ current knowledge of puberty by asking about the meaning of menarche.
Method
Design
This study used existing data collected during health education classes in Bucheon elementary school in South Korea. The data were collected by the first author as part of a pre-investigation to determine current knowledge about menstruation and menarche in students prior to their education about puberty. The data comprised essays written about their thoughts and perceptions of menarche, as well as drawings depicting their own meaning of menarche. Both male and female students completed the class tasks; however, only female students’ materials were analyzed, as the purpose of this study was to explore the meaning of menarche in female adolescents. This study was approved by the Inha University Institutional Review Board in South Korea.
Sample
The study sample comprised 79 female adolescents who were attending Bucheon elementary school in the Bu-Cheon city area of South Korea. Among them, 32 students were in fifth grade (11-year-olds) and 47 were in sixth grade (12-year-olds). None of the students in fifth grade had yet experienced menarche, whereas 26 students (55% of sixth grade) in sixth grade had experienced it.
Data Collection
Before the class began, male and female students were asked to sit separately, so that they could not see each other’s activity materials. The materials prepared for this class were then distributed. The materials asked students to write an essay about menarche by answering two questions (written in Korean): (a) What do you think a menarche is? and (b) How does it feel when to think about menarche? The students were informed that the essays should be more than six sentences. After completing the essay, they were asked to draw a picture representing their own meaning of menarche and to write descriptions of these pictures. Because the original purpose of this activity was to investigate students’ experiences prior to education, anonymity was guaranteed; in fact, there was no place to put their names in the materials. However, students were asked to identify their age, gender, grade, and whether they had experienced menstruation or not (only if they were female). None of the students declined to participate in this activity or left any of the materials incomplete.
Data Analysis
The data analysis comprised three phases: (a) calculating the proportion of students who knew the word menarche, (b) analyzing and interpreting the pictures that the students drew, and (c) analyzing the essay texts by using summative content analysis.
First, two authors in this study selected the essays of students who gave an explanation of “menarche” based on their answers to the first question “What do you think a menarche is?” Most students described menarche as “first menstruation.” However, essays were also selected if the definitions that described menarche used metaphorical or symbolical expressions, such as “first bleeding,” “being an adult,” and “menstruation begins.” We carefully read each of the essays and selected those who indicated knowledge about menarche. In particular, we conducted this process separately, after which we matched the results. Ultimately, of the 79 essays, we selected 53. We initially achieved 92.4% agreement, with disagreement being expressed on six of the essays. In those six essays, the students reported not knowing what menarche meant but had drawn pictures related to menarche or menstruation, or vice versa. After discussion, we ultimately did not select those essays for further analysis; thus, only essays and drawings of 53 participants were included in the qualitative analytic processes—picture analysis and essay analysis.
Second, two authors interpreted the pictures that the students had drawn about menarche. The first author of this study had worked as a school nurse in a public elementary school for 23 years and had received certification in art therapy for children. In addition, the corresponding author has long studied children with psychological trauma. Thus, both of the authors had expertise in children’s psychology. In this analysis process, we converted the pictures into coding units by observing and interpreting them through discussion. In terms of the coding scheme, we decided to focus on four elements of the picture: objects (i.e., the meaning of the objects), implied feelings and emotions (e.g., sadness, happiness, anger), words or signs that appeared in the pictures, and students’ descriptions of the picture. We coded each element, and all these codes were integrated into the text data for the summative content analysis, which was the next step.
The summative content analysis was conducted on the essays as well as the text derived from the drawings. According to Hsieh and Shannon (2005), summative content analysis, which is considered more appropriate and useful for written text, comprises two levels of analysis: (a) manifest content analysis and (b) latent content analysis. Manifest content analysis focuses on identifying and quantifying the usage of certain words or content, whereas latent content analysis focuses on interpreting the content in order to understand the underlying meanings of the text.
Thus, we initially conducted the latent content analysis to determine the meaning of menarche among female elementary school students in South Korea. Data analysis began by reading all the essays repeatedly to obtain a sense of their overall meaning. Then, we highlighted and captured key thoughts and concepts throughout the essays, which were labeled as codes. The codes from the pictures were integrated into the codes that emerged from the essays. Then, all related codes were grouped into concepts. As all the raw data were in Korean, all the concepts were translated into English at this point. The corresponding author—who obtained her PhD in the United States—translated the concepts, and one bilingual Korean–American student confirmed the results of the translation by cross-checking the English and Korean concepts. Then, related concepts were in turn grouped into clusters (called categories in this study). The categories were finally grouped into major themes. During this process, we constantly reviewed and compared all the codes, concepts, categories, and themes to confirm their consistency.
Next, we conducted the manifest content analysis. We went through all the essays and pictures and counted the number of concepts for each theme that appeared in the essays and pictures. We then compared the mean number of concepts for each theme using a t test between fifth- and sixth-grade students and between students who had experienced menarche and those who had not.
Results
Only 67.1% (n = 53) of the 79 students could provide a definition of menarche. In their explanations, most children used the words menstruation or first menstruation, although some students used metaphorical or symbolical expressions, such as “first bleeding,” “beginning of a painful life,” or “being an adult.” In addition, there were several biological definitions, such as “capacity for having a baby” and “a consequence of failing pregnancy.” In total, 46.9% (n = 15) of students in fifth grade and 23.4% (n = 11) of students in sixth grade reported not knowing the meaning of menarche. Interestingly, six of these students, all of whom were in sixth grade, had experienced menarche.
The latent content analysis of the essays and pictures revealed a total of 28 concepts and 12 categories. From these, a total of five themes representing the meaning of menarche in female adolescents in South Korea emerged: (I) something unfamiliar, (II) lack of welcome, (III) reaching maturity, (IV) pain and discomfort in my body, and (V) changes in my daily life (Table 1).
Themes, Categories, and Concepts.
General Themes of the Content
Theme I: Something unfamiliar
The first theme, “something unfamiliar,” represented students’ feelings of unfamiliarity and novelty in relation to menarche (Figure 1). Many students stressed that menarche is their first experience of menstruation, and that they had never experienced it before; thus, they did not know what it was like, how to deal with it, or whether they would get used to it. They further expressed feelings of embarrassment, surprise, curiosity, and amazement. One student wrote that she did not know much about menarche, and only had learned about it through books or friends’ experiences.
It (menarche) is not very familiar to me because I experienced it for the first time in my life. (sixth grade and experienced menarche) I did not know what was going on. I was very surprised. (sixth grade and experienced menarche)
Picture and description by a student representing Theme I: “Something unfamiliar.”
Theme II: Lack of welcome
The second theme dealt with negative emotions and attitudes toward menarche (Figure 2). Many students felt that the onset of menarche was unwelcome and expressed various negative feelings and emotions toward it, including hate, disgust, sadness, and weirdness. In addition, they feared it; more specifically, they feared both menarche itself and that it was an indication that they would no longer grow. For instance, several students wrote that they would not grow taller after experiencing menarche, as their growth plates would stop growing. Finally, several students reported feeling ashamed of this taboo topic; they wrote that they felt shame about writing or talking about menarche, especially in front of male students, and felt that others would tease them if they experienced menarche.
I feel shame, and feel that I am not supposed to know about it. Actually, I don’t want to know. (fifth grade and did not experience menarche) [When I am talking about it (menarche),] my face turns red. I will not get taller, once it comes. (fifth grade and did not experience menarche)
Picture and description by students representing Theme II: “Lack of welcome”
Theme III: Reaching maturity
The third theme addressed students’ view of menarche as a transition from childhood to womanhood (Figure 3). Indeed, many students used the words “adult,” “woman,” or “growth” and drew pictures representing this transition from being a child to being a woman. Most students expressed positive feelings in relation to this aspect of menarche. They used emotion-related words such as “healthy,” “beautiful,” “joyful,” and “gifted” when writing about menarche as part of their growth process. Furthermore, students wrote about the importance of taking responsibility for their body by stressing that they could get pregnant once they began the menstruation cycle.
After I experience menarche, I should be careful with my body (be careful to keep my virginity). Since it turns me into a real, mature woman. (fifth grade and did not experience menarche)
Picture and description by students representing Theme III: “Reaching maturity.”
Theme IV: Pain and discomfort in my body
The fourth theme revolved around the physical pain and discomfort following menarche (Figure 4). Students reported their own experiences or their friends’ experiences of uterine cramps and bodily discomfort, and there were numerous pictures that represented menstrual pain. Several students expressed feeling completely out of control when their menstrual pain came, with one student referring to it as “being conquered.” In addition, some students used expressions related to explosions (or bombs in the pictures) to describe menstruation and menarche, as they began suddenly, could not be controlled, and were accompanied by pain and blood. Finally, students wrote about several methods of alleviating the menstrual pain, such as taking a rest, eating right, and warming the belly.
When experiencing menarche, I feel like lightning strikes in my belly. (sixth grade and experienced menarche) When menarche begins, I will feel pain in my back and belly. (fifth grade and did not experience menarche)
Picture and description by students representing Theme IV: “Pain and discomfort in my body.”
Theme V: Changes in my daily life
The fifth and final theme referred to participants’ experiences of the changes in their daily lives as a result of beginning menstruation (Figure 5). After menarche, they began experiencing menstrual flow periodically, which greatly influenced their daily lives. Obviously, they began needing to care for the vaginal bleeding on their own, and had to be cautious to avoid wetting their pants with blood. They had to behave carefully and always prepare a menstruation pad when their period suddenly came. In addition, they had to endure unpleasant feelings of wetness when they were having their period. The students also wrote about what that they had been forced to give up since menarche, such as going to the swimming pool or wearing what they wanted (e.g., white clothes).
It (menarche) must be really uncomfortable. (fifth grade and did not experience menarche) I could not go to the swimming pool, and it smells miserable. (sixth grade and experienced menarche)
Picture and description by a student representing Theme V: “Changes in my daily life.”
Differences in Themes Between Fifth and Sixth Grades and Between Experience and No Experience of Menarche
The t tests were performed to compare the participants by grade and experience of menarche in terms of the themes of their essays and pictures. We quantified the themes by counting the frequency with which the concepts of each theme appeared in their essays and pictures. We assumed here that the more frequent use of certain words or content (concepts) of certain themes meant that participants attached greater importance to that theme.
The results are shown in Table 2. We observed a significant difference in the occurrence of concepts per essay related to the theme of reaching maturity between fifth- and sixth-grade students. Specifically, the concepts related to reaching maturity appeared an average of 2.18 times per essay in fifth graders, but less than 1 time (.61) per essay in sixth graders. This finding shows that fifth-grade students seemed to focus more on the transition from childhood to womanhood when being asked to write or draw menarche compared with the sixth-grade students.
Differences in Theme Occurrence Between Fifth- and Sixth-Grade Students and Between Those Who Experienced and Those Who Did Not Experience of Menarche (N = 53).
p < .05.
In addition, when dividing the participants by experience of menarche, we found that two themes showed significant differences between the groups: reaching maturity and pain and discomfort in my body. In terms of the concepts related to reaching maturity, the students who had experienced menarche mentioned these less than once (.55) per essay, whereas those who had not experienced menarche mentioned it about 1.45 times per essay. In addition, the concepts related to pain and discomfort in my body were mentioned about 2.45 times per essay among students who had experienced menarche, whereas these concepts were mentioned only about 1.48 times per essay among students who had not experienced menarche. In sum, those who had not experienced menarche tended to focus on menarche’s relationship to maturity, whereas those who had already experienced menarche focused more on the pain and discomfort in the body.
Discussion
The conceptual framework representing the process of adaptation to menarche was built around Schlossberg’s (1981) Transition Theory, and is illustrated in Figure 6. Regarding the event of menarche in women, adaptation to the transition process can be influenced by three primary factors: preparation for menarche through internal/institutional support system, perception of menarche, and ethnicity (i.e., the cultural norms of the individual). The perceptions of menarche tend to differ by culture because they are shaped by sociocultural factors such as cultural values and religion. From the perspective of medical anthropology, which focuses on concepts of health and illness within the cultural context, menstruation and menarche are influenced by ritual practices and cultural attitudes in females (Britton, 1996). In addition, several previous studies have demonstrated that preparation for menarche also affects females’ perception of menarche (Erbil et al., 2012; Uskul, 2004).
Conceptual framework based on Schlossberg’s (1981) Transition Theory.
In terms of the perceptions of menarche in female adolescents in South Korea, we extracted five themes as a result of our analysis: (I) something unfamiliar, (II) being unwelcome, (III) reaching maturity, (IV) pain and discomfort in my body, and (V) changes in my daily life. As in other countries, female adolescents in South Korea were prone to view menarche in a negative light, as evidenced by Themes 2, 4, and 5. The majority of students reported not feeling delighted to have menarche for various reasons, including the pain, discomfort, shame, and inconvenience associated with it. This finding was similar with the findings in other countries: For instance, Uskul (2004) interviewed 53 women from 34 countries to examine their experiences of menarche. She reported that most women showed only negative emotions in relation to menarche, with only a few women reporting only positive emotions or ambivalent emotions.
Nonetheless, in the current study, female students used positive expressions when writing about Theme III (reaching maturity), such as “beautiful” or “gifted.” However, Theme III appeared significantly more often in essays written by fifth-grade (younger) students or students who had not experienced menarche compared with their corresponding groups. Conversely, the students who experienced menarche tended to focus more on Theme IV (pain and discomfort in my body) than on Theme III. Assuming that those who were younger and who had not experienced menarche were more likely to be influenced by formal or informal education or social and cultural values, rather than their own experiences; we can infer that education (both formal and informal) and Korean sociocultural circumstances symbolize women’s menarche as maturity and the beginning of the ability to reproduce.
Regarding the cultural aspects, our results are consistent with those reported in Uskul’s (2004) study. She found that although females in general showed a fear of becoming women and losing their childhood, one woman from East Asia reported that menarche is considered positive and important in her country, as it reflects the ability to bear children. We could explain this phenomenon from the perspective of Confucianism, a philosophy that has had considerable influence in most East Asian countries, including China, Korea, Taiwan, Japan, and so on (Park & Chesla, 2007). Confucianism stresses the importance of the family; in fact, families are often valued more than are individuals. Confucian families, especially women, are asked to have offspring as part of the Confucian obligation to continue the family line (Y. C. Lee, 2007). When considering the fact that South Korea is still considered the most Confucian country—namely, wherein people are still asked to adhere to various Confucian duties (Kalton, 2000)—we might conclude that these sociocultural values and thoughts continue to influence the meaning of menarche among young female adolescents.
In terms of the preparation for menarche through internal/institutional support system, which is also a factor influencing people’s adaptation to transition based on Schlossberg’s (1981) Transition Theory, this study supports the view that current education on menstruation given to female adolescents, both by schools and mothers, tends to focus more on the biology of the condition than on their actual experience. Britton (1996) examined how women learned about menstruation by conducting a qualitative study of 20 women and found that the typical sources of this information were their mothers, female siblings, peers, and school education; however, there were differences in information about menarche according to the source. The education from mothers and schools related more to biological aspects, such as reproductive functions, whereas education from peers focused on practical information, such as what to do and what they would deal with.
In the current study, 32.9% (26 out of 79) of the students reported not knowing what menarche was. Actually, we were amazed that 23.4% (n = 11) of the students in sixth grade reported not knowing what menarche was, despite likely having observed their friends’ experiences of menstruation or menarche. Furthermore, six of the participants in sixth grade who had already experienced menarche reported not knowing what menarche was. This might be because the word “menstruation” is more frequently used than is “menarche.” Nevertheless, this still represents a lack of education about menarche and menstruation given by either families or schools. Indeed, Theme I in our study was termed something unfamiliar. Although the students might have known the definition of menarche, they still felt that it was unfamiliar. As numerous previous studies have shown that insufficient preparation and a lack of knowledge about menarche can lead to negative perceptions of menarche and further negative health consequences in females (Uskul, 2004), systematic education programs appear to be urgently needed. Moreover, as written above, education programs should include not only the biological and cultural perspectives on menarche but also more practical information and psychological support.
In summary, our results suggest that Korean female adolescents had inadequate preparedness for experiencing menarche overall and that they tended to shift their perceptions from positive to negative when experiencing menarche. In addition, Korean cultural norms seem to view menarche positively and valuably, which might influence the perceptions of those who have not yet experienced menarche. In order to help them undergo this transition process in a healthy and stable way, health professionals must develop education programs to strengthen two major factors influencing the transition process: preparation for menarche and perceptions of menarche. Positive perceptions of menarche should be achieved through providing emotional support as well as education with specific practical information—for instance, how to use a menstruation pad, when to get them, whom to visit to ask for them, how to alleviate menstrual pain, and so on.
This study has some limitations. First, as we collected the data from only one school, the results of this study cannot be clearly generalized. Second, some students might have received prior education on either menarche or menstruation, and so it is possible that the data were influenced by formal or informal education.
Nonetheless, the current study is meaningful in that it can inform many health professionals around the world on the thoughts and values concerning menarche among East Asian female adolescents. In particular, this was perhaps the first study to compare the themes related to menarche by age and experience of menarche using a summative content analysis. We hope that the findings of this study can be used to facilitate education about menarche and menstruation for female adolescents, and consequently ensure that they have the proper knowledge and sufficient preparation for menarche. This would hopefully lead to more positive attitudes toward and perceptions of menarche and their subsequent experience of menstruation.
Conclusion
In conclusion, all human beings experience multiple transitions throughout their life trajectories, and in women, one of these is menstruation. In this study, we examined the perceptions of menarche in female South Korean adolescents, which is a major factor influencing the process of adapting to transitions based on Schlossberg’s (1981) Transition Theory. We qualitatively analyzed the essays and drawings of 53 female adolescents in South Korea. This yielded five themes: (I) something unfamiliar, (II) lack of welcome, (III) reaching maturity, (IV) pain and discomfort in my body, and (V) changes in my daily life. We further compared the focus of these themes by grade (fifth and sixth grade) and experience of menarche (experience or no experience), and found that the fifth-grade participants and those who had not experienced menarche tended to focus more on Theme III (reaching maturity), whereas participants who had experienced menarche focused more on Theme IV (pain and discomfort in my body). We also confirmed an overall lack of knowledge about menarche among Korean female adolescents. This study shows an urgent need to develop education programs in order to prepare female adolescents for menarche.
Footnotes
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was supported by an Inha University Research Grant (2018).