menopausal transition of korean immigrant women: a literature review

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Menopausal transition ofKorean immigrant women: Aliterature reviewEun‐Ok Im RN, PhD a & Juliene G. Lipson RN,

PhD, FAAN ba Post‐doctoral fellow, Department ofCommunity Health Systems , University ofCalifornia , Box 0608, San Francsico, CA, 94143,USAb Department of Community Health Systems ,University of California , San Francisco,California, USAPublished online: 14 Aug 2009.

To cite this article: Eun‐Ok Im RN, PhD & Juliene G. Lipson RN, PhD, FAAN (1997)Menopausal transition of Korean immigrant women: A literature review, HealthCare for Women International, 18:6, 507-520, DOI: 10.1080/07399339709516307

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MENOPAUSAL TRANSITION OF KOREANIMMIGRANT WOMEN: A LITERATURE REVIEW

Eun-Ok Im, RN, PhD, and Juliene G. Lipson, RN, PhD, FAANDepartment of Community Health Systems, University of California,

San Francisco, California, USA

The menopausal transition needs to be understood in terms of themultiple mediating factors within the context in which womenexperience it. For immigrant women especially, the menopausalexperience is complicated by multiple transitions and social margin-ality, so it cannot be adequately explained without considering thiscomplexity. In this paper we review the literature on the meno-pausal transition of a group of vulnerable immigrant women in twoways: describing the transitions themselves (menopause, immigra-tion, and housewife to employee), and describing factors that medi-ate the menopausal transition experience (family norms, meaning ofmenopause and women's work, and health practices). We empha-size the context and suggest areas of needed research.

Culture imposes its own influence on the meaning and symptoms ofthe menopausal transition (Beyene, 1986; Boulet, Oddens, Lehnert,Vemer, & Visser, 1994, Chang & Chang, 1996; Lock, 1986). Social andeconomic factors also affect women's menopausal experience (Abe &Moritsuka, 1986; Ballinger, 1985; Greene, 1983; Uphold & Susman,1981). Immigration adds yet another dimension to such vulnerability andthe menopausal experience is more complex because of the process ofcultural and social transitions. Women immigrants experience stressorsrelated to transplanting old roots and searching for new roots, economicstruggle, hardship and marginality in the host society (Anderson, 1990;Meleis, 1991), and needing to meet basic needs without the knowledgeof resources and shortcuts that natives take for granted (Lipson &Meleis, 1985). However, until recently, researchers have rarely exploredthe menopausal experience of vulnerable immigrant women while con-sidering the totality of the complex factors and the context in which the

Received 28 October 1996; accepted 14 May 1997.Address correspondence to Eun-Ok Im, RN, PhD, Post-doctoral fellow, Department of

Community Health Systems, Box 0608, University of California, San Francsico, CA 94143.

Health Care for Women International, 18:507-520,1997 507Copyright © 1997 Taylor & Francis

0739-9332/97 $12.00 + .00

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508 E. O. Im and J. G. Lipson

women are experiencing their menopausal transition. Hence a lack ofknowledge limits the ability of clinicians to guide such women with cul-turally competent health care.

This review explores the menopausal transition of one group of vulner-able immigrant women while considering the mediating factors within thecontext, and suggests areas of needed research. Using transition theoryto ground this review, we critically review the literature on Koreanimmigrant women's menopausal transition in the context of two othertransitions—the immigrant transition and the transition from housewifeto employee. Thus the review emphasizes the context for understandingthe menopausal transition rather than limiting discussion to menopauseitself, as very little is known on this population. By menopausal transi-tion, we are talking generally about a period beginning with perimeno-pause (Li, Lanuza, Gulanick, Penckofer, & Holm, 1996) and ending a fewyears after menstruation has ceased.

TRANSITION THEORY

Many Korean immigrant women in midlife simultaneously experiencethree major transitions: the bio-psycho-socio-cultural transition of meno-pause, the cultural transition of immigration, and the social/economictransition from working in the home to working outside the home. Theirexperiences can be examined using transition theory because it applies toall types of transitions: developmental, situational, health/illness, andorganizational (Chick & Meleis, 1986; Meleis & Trangenstein, 1994;Murphy, 1990; Shumacher & Meleis, 1994).

Characteristics of transition include process, disconnectedness, per-ception, and patterns of response (Chick & Meleis, 1986). MidlifeKorean immigrant women are in a process of a cultural transition due toimmigration, a climacteric transition associated with aging, and a roletransition from housewife to employee. With regard to the pervasivecharacteristic of disconnectedness, associated with disruption of the link-ages on which the person's feelings of security depend, menopausalKorean immigrant women experience feelings of loss, marginalization,and culture and role conflicts. Perception and meanings of transitionevents vary among persons and societies, influencing their outcome.Thus it is important to understand what immigration, menopause, aging,and women's work mean in the perspective of Korean women, becausethese meanings influence their transition experiences. Because transitionis a personal phenomenon, not a structured one, it is assumed that, to bein transition, a person must have some awareness of the changes that areoccurring. Menopausal Korean women feel the changes in their environ-ments, menstrual patterns, internal perceptions and cognitive processes,

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Menopausal Transition 509

and roles. Finally, patterns of response are observable and nonobservablebehaviors that reflect both intrapsychic structure and processes as well asthose of the wider sociocultural context. In Korean culture, for example,it is not considered negative for a woman to be passive and shy. Womenwho blush easily are typically considered to be decent women, particu-larly those who were raised under the influence of Confucianism. In thiscontext, "hot flash" is rarely regarded as bad.

Transition theory provides a good framework for the following litera-ture review (Chick & Meleis, 1986) in that it illuminates relationshipsbetween transitions and other domain concepts: transition is character-ized by disconnectedness; some factors mediate the process of transitionand may bring about connectedness; and nursing therapeutics mediatethe process of transition, ultimately affecting health/illness outcomes.

THE LITERATURE

An extensive literature search on Korean immigrant women in theUnited States was conducted using the MEDLINE and MELVYL dataretrieval systems including medical, public health, biology, psychology,and social science databases from 1966 to 1996. Title and keywordsearches included "Korean immigrants," "women," "immigration," "tran-sition," "health," "illness," "health care practices," and "menopause" overthis thirty-year period. Relevant publications were reviewed in order tolocate additional citations.

The multiple transitions of many Korean immigrant women are com-plicated by low social class and marginalization in the new country, roleconflict with spouses, low self-esteem, anxiety about future life, a rela-tively negative attitude toward menopause, and lack of social support. Itis quite likely that the complexity of multiple transitions and social mar-ginality negatively influence the menopausal transition. We organize thiscomplexity by describing the transitions themselves (menopause, immi-gration, and housewife to worker) and factors that mediate the meno-pausal transition experience (family norms, meaning of menopause andwomen's work, and health practices).

The Transitions

MenopauseThe research on the menopausal transition of Korean immigrant

women has been mainly conducted by biomedically oriented Koreanphysicians or nurses in South Korea. Researchers have rarely dealt withmenopause as a normal bio-psycho-socio-cultural change, instead focus-ing on the physiological aspects of the menopausal experience in a frag-

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mented manner. The studies have medicalized menopause and ignoredwomen's own experiences. The most frequently explored aspect of themenopausal transition of Korean women has been hormonal imbalance(Cheung, Yu, & Woo, 1989; Hwang, Lee, Yu, & Woo, 1989; Min & Ku,1985; Shin & Chang, 1985) or specific menopausal symptoms or out-comes such as hot flashes, sweating, and osteoporosis.

Recently researchers have broadened their approach to menopauseamong Korean women (Im, 1994; Lee & Chang, 1992; Lee, 1994; Yoon,1989). The most frequently explored psychosocial aspects are midlifechanges such as retirement, children leaving home (the empty nest syn-drome) or changes in marital relationships. The findings show that manymenopausal Korean women have regarded their children as the purpose,fruition, and absolute meaning of their lives (Yu & Chi, 1986). Under thestrong influence of Confucian norms, Korean women tend to sacrificethemselves for child rearing. In this context, most Korean women reportseparation problems as their children become adults, with attendant feel-ings of loss, depression, anxiety, and sadness (Park, 1982). Despite thisnew research direction, these studies of the menopausal transition ofKorean women are limited by inappropriate study designs, conveniencesampling methods, culturally incompetent instruments, and androcentricviews on menopause. However, they do suggest that Korean immigrantmiddle-aged women, especially those who endured tremendous hardshipto enhance their family's quality of life and children's opportunities inthe new country, may experience loss, depression, anxiety, and sadnesswhen their children leave.

ImmigrationKorean immigrants' experiences following immigration have been

relatively well documented, but the research has several limitations.Most studies only describe or enumerate their difficulties, rarely dealingwith the dynamic process of transition. Moreover, the studies rarelycompare the experiences of Korean women and men even though therehave been reported gender differences in the immigration experience(Cho, 1987; Hurh & Kim, 1984, 1988, 1990). Rarely do these studiesexamine the influence of social class on Korean immigrants (Cho,1987; Light & Bonacich, 1988), instead lumping the whole populationtogether. Furthermore, they show inconsistent findings that are also dif-ficult to generalize because the studies are conducted in specific geo-graphical areas.

The most frequently reported difficulties among Korean women in theUnited States are language; marginality; difficulties in relationships withspouses, other Koreans and children; alienation and loneliness; and lackof social support (Hurh & Kim, 1984; Nah, 1993; Miller, 1990). The Ian-

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Mcnopausal Transition 511

guage barrier is reported to be the most serious problem experienced byKorean immigrant women (Hurh & Kim, 1984; Miller, 1990; Nah,1993), followed by differences in the culture and social systems betweenKorea and the United States, and transportation problems (Hurh & Kim,1984; Nah, 1993). Even when they have successfully adapted to this newworld, their daily economic struggles and marginality in the new societycontinue. Their job opportunities are restricted by their not knowing thelanguage, and their education and training may not be recognized. Tieswith the extended family are sometimes broken or altered.

Strong ethnic attachment has been reported by many researchers.Indeed, Korean immigrant women's adaptation to the new culture hasbeen reported to be very slow (Hurh & Kim, 1984). Miller (1990) reportedthat approximately half of the respondents experienced language prob-lems and were not exposed to the American printed media at all. Almostnone used English at home. Most of Hurh and Kim's (1984) respondentsreported that family duty should be given priority over individual inter-ests; nearly all thought it was necessary for their children to speak Koreanwell; the majority preferred the Korean ethnic church over Americanchurches; about half of them desired to return to Korea; and most Koreanimmigrants opposed interethnic marriage (Miller, 1990). Moreover, theirsocial participation and interpersonal relations are largely confined totheir own ethnic group, e.g., most of Hurh and Kim's (1984) participantsactively participated in Korean voluntary associations, whereas only avery small proportion of them were members of American voluntaryorganizations. Such strong ethnic attachment may help Koreans to man-age their lives without adequate social supports and resources, but it canalso inhibit their acculturation and ultimately maintain their marginality.

Housewife to EmployeeIn traditional Korea, women household managers and childbearers

were more highly valued and better rewarded than those who pursuedother options (Cho, 1987). Traditional Korean women rarely dreamedabout deviating from their wifely status. Most middle-aged Koreanimmigrant women were raised, socialized, and educated in an environ-ment emphasizing traditional gender roles and were housewives beforeimmigration (Light & Bonacich, 1988). However, immigration imposeda transition from traditional housewives to immigrant women employees.Koreans' primary reasons for migration are to improve their family'squality of life and further their middle-class aspirations in the new landof opportunity rather than being driven out by immediate hunger orpolitical persecution in Korea (Hurh & Kim, 1990; Light & Bonacich,1988). They are committed to the middle-class work ethic, and bothwomen and men work hard to fulfill their aspirations.

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In addition to the lack of pre-employment experiences, most middle-aged Korean immigrant women work under unfavorable labor marketconditions (Kim & Rew, 1994). The lower the income of husbands, thehigher the proportion of wives who are employed (Hurh & Kim, 1984).A typical first-generation Korean immigrant woman routinely works tento fifteen hours a day, seven days a week, going without vacations formany years (Yu, 1987). She started out as a cleaning woman or seam-stress, then worked at a hamburger stand or small sandwich shop jointlywith her husband.

The transition from a housewife to an employee engenders physicaloverload, role conflict, and stress among Korean immigrant women. Thetransition is a gendered transition. Macroscopically, women are employedin the informal-sector female occupations such as paid domestic work,child care, and garment and electronic assembly (Hurh & Kim, 1990;Light & Bonacich, 1988). Microscopically, women are responsible formost household tasks, similar to married women living in Korea (Kim &Rew, 1994), uncomplainingly adding job demands to their usual responsi-bilities, doing the second shift (Hochschild, 1989)—or a double day—after working long hours in a dead-end, low-status job. Employed wivesshoulder this double burden because of financial needs and persistence ofthe traditional gender role ideology of woman as homemaker (Hurh &Kim, 1990). Employment outside the home means additional work thatbrings no intrinsic reward in most cases (Kim & Hurh, 1988).

Most studies of employed Korean immigrant women provide no infor-mation about the hardships they endure in the mainstream labor market,and no vivid descriptions of their work experiences or cultural conflictsin attitudes and values about women's work. Rather, the studies providequantitative descriptions of socioeconomic status and other related fac-tors and may not be applicable to Korean immigrants who do not live inthe neighborhood where the surveys were conducted.

Mediating Factors

Family NormsConfucianism places special importance on the family as both the

basic unit of society and the fundamental social structure and empha-sizes tradition and authority as guides to social behavior (Moon & Pearl,1991). Despite recent change in family structure, loyalty to the familyremains in Korean Confucian culture. Thus Koreans usually have astrong sense of family loyalty. For example, Koreans speak of "ourhome" and "our father" where Westerners would say "my home" and"my father" (Sawyers & Eaton, 1992).

On the basis of Confucian philosophy, Korea has traditionally main-

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tained a patrilineal family system that encompasses multiple generationsof family members through the male line (Kim & Hurh, 1987). In tradi-tional families relationships between men and women, one generationand the next, and the elderly and the young were always vertical, and theposition of women was very low. In spousal relationships the husbandwas metaphorically considered the sky while the wife was considered theearth. Women were supposed to obey the orders of men. This traditionalfamily system provided an undemocratic, well-defined set of maritalroles (Kim & Hurh, 1987). A husband was expected to command hiswife, and she was expected to obey and to serve her husband, her par-ents-in-law, and other members of the family lineage. Married womenwere thus confined to a domestic role in their husband's family.

Even though Korean families have changed, patriarchal and Con-fucian norms are deeply rooted; the traditional family system and atti-tudes persist in Korean immigrant families (Kim & Hurh, 1987). MostKoreans still prefer sons over daughters and believe in the right andresponsibility of sons to support aged parents and to perpetuate the lin-eage (Kim & Hurh, 1987). Thus Korean immigrant women continue tobe in a relatively lower position than men in their ethnic community andfamilies. Moreover, the power imbalance and gender discrimination,which have been rationalized by patriarchal and Confucian norms, aretaken for granted. The norms are reinforced by their preservation's beingconsidered "good tradition." Korean culture still labels "good wife" thewoman who silently observes patriarchal and Confucian tradition. Thesenorms make Korean immigrant women's transitional experiences moredifficult and force them to sacrifice for their families and take the sacri-fice for granted. Yet the influence of these family norms on women'sdaily experiences has not been studied.

Meanings of MenopauseResearch on the meaning of menopause in Korean women in the United

States is scarce, and that in South Korea is limited. However, cultureundoubtedly mediates the meaning of menopause. Western researchersoften assume that high social status and good self-esteem serve asbuffers against potential menopausal symptoms, and women in manynon-Western or developing societies do not suffer from menopausalproblems because they experience a rise in status at the end of theirreproductive life (Lock, 1986). Negative attitudes toward menopause andaging in general in a particular culture are regarded as responsible for thesuffering from climacteric symptoms (Oddens, 1994).

Respect for the elderly is a cultural norm among Koreans (Sawyers &Eaton, 1992). Also Koreans, along with Chinese and Japanese, have aculture rooted in filial piety, wherein care for the elderly from family and

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kin is accepted as a customary and normative duty (Moon & Pearl, 1991;Parish & Whyte, 1978). Hence aging was viewed positively, and meno-pause was welcomed as a sign of a woman's increasing power and con-trol in the traditional Korean family. However, as Korea has rapidlyindustrialized and urbanized, cultural attitudes toward the elderly havealso changed. The increasing population of the old, the geographicmobility of the young, the expansion of the female labor market, adecrease in multigeneration households, and the movement towardsmaller families have affected attitudes toward the elderly. Recent studieson menopause in Korean women in South Korea demonstrate thechanged attitude toward menopause and aging, reporting that manyKorean women perceived menopause as a loss of attractiveness as awoman and becoming useless (Im, 1994; Jung, 1988; "Vbon, 1989; Yu &Chi, 1986). However, some studies have reported that the attitude towardmenopause was still positive (Lee & Chang, 1992; Lee, 1994).

In the traditional Korean family, middle-aged women had power inmanaging and controlling their families. However, in modernized Koreansociety, they lose this power. Middle-aged Korean immigrant womenwho grew up in the transitional Korean society faced a very differentculture in the United States. Despite mixed cultural attitudes and values,they have served their families throughout their lives. However, theirdaughters and sons become acculturated and rarely retain Korean tradi-tional attitudes, values, and ways of thinking. Compared to their counter-parts in South Korea, Korean women in the United States are less likelyto have power in managing and controlling their family members. Theymay be the last generation of women who sacrifice themselves for theirfamilies, and the first generation whose later quality of life will not beguaranteed by their children in the new country. Therefore, relativelynegative attitudes toward aging and menopause and the loss of power andcontrol in their families may make Korean immigrant women more vul-nerable to feelings of loss, depression, and lowered self-esteem in theirclimacteric transition.

Meaning of Women's WorkWomen's work in Korea is a relatively new area of study. Feminist

scholars primarily focus on sexism and gender issues in Korean societyrather than on women's daily experiences (Ewha Women's University,1990; Korean Women's Development Institute, 1991; Shin, 1988). Hencelittle is known about the meaning of women's work and about women'slives in Korean culture.

The Korean language does not have a word that means exactly "work"in English. Rather, the word il usually used in referring to work meanslabor, employment, task, job, vocation, business, errand, matter, thing,

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affair, incident, event, plan, project, scheme, and achievement(Minjungseorim, 1990). Thus work has been defined as any type of physi-cal or psychological effort in a general sense. However, when a woman isasked about //, the question generally asks if she is employed or not.Usually, housework is not regarded as il even though the word il meansany type of physical or psychological effort. Housework is regarded as afunction of gender rather than work. However, housework is really time-and energy-consuming work. Most Korean husbands insist on beingserved traditional Korean foods, which take a long time to prepare (Koreanmeals usually consists of steamed rice, one soup or stew, kimchi, one maindish, and three side dishes). Furthermore, Korean housekeeping standardsare very high, and it is the woman's job to attend to housekeeping and chil-dren's needs, even if it is the man who is staying at home.

With the limited definition of work, women's work has been devaluedand invisible in Korean culture. In particular, low-status jobs such asthose of the domestic worker, waitress, or seamstress are more devaluedin Korean culture than in Western cultures. Korean immigrants' attitudesand values about women's work may be similar to those of women inSouth Korea. Since most are employed in low-status jobs, their attitudesmay make them more miserable and marginalized within their own eth-nic communities.

As many studies on Korean immigrants have shown, women's workhas scarcely changed their gender relations in families (Hurh & Kim,1990; Light & Bonacich, 1988; Yu, 1987). In some immigrant groups,such as Mexicans (Hondagneu-Sotelo, 1994), women's economic contri-bution to their family income is reported to erode men's patriarchalauthority in the family and empower women either to directly challengethat authority or at least to negotiate "patriarchal bargains" (Kandiyoti,1988) that are more palatable to themselves and their children. However,for Korean immigrant women, the cultural legacy of patriarchy continuesintact despite their significant economic contribution to family income,similar to Japanese immigrant women (Glenn, 1986).

Health Care PracticesKoreans' typical approach to health and illness can be classified into

three areas: Korean traditional medicine (Hanbang), Western biomedi-cine, and the shamanistic approach (Chin, 1992; Miller, 1990; Pang,1989). Among Korean immigrants, health care practices are character-ized by this pluralistic approach, which is similar to that of other immi-grants (Chin, 1992). However, because studies are limited in numberthey do not fully explain health care practices. The findings cannot begeneralized to all Korean immigrants since most use convenience sam-pling methods and small samples.

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Further, very little is known about how women manage their meno-pausal symptoms. Immigrant women may manage their menopausalsymptoms through integrating multiple treatments. Since menopausalsymptoms have been regarded as normal aging-related phenomena ratherthan pathological phenomena in Korean culture (Jung, 1988; Lee &Chang, 1992; Lee, 1994; Yoon, 1989), Korean immigrant women mayuse Hanbang or natural foods more frequently than Western medicine.They may use honey, ginseng, royal jelly, deer horn, Hanyak (Koreanherbal medicine), and other herbs to manage vague symptoms, Chi'm(acupuncture) to manage musculoskeletal symptoms, and D'um (moxi-bustion) and Buhwang (cupping) to manage symptoms believed to berelated to inner organs. Moreover, when the transition process engendersfeelings of stress and weakness, they may use Hanyak to restore energy,promote health, and prevent illness, as do Koreans in South Korea(Hwang, 1992; Jung, 1988) However, it should be noted that low-incomeKorean immigrant families visit the Western physician's office only inemergency situations (Miller, 1990). They rarely can afford medicalinsurance or expensive traditional medicine (Miller, 1990). Therefore,many low-income Korean immigrant women may live with vaguemenopausal symptoms believed to be just aging rather than pathologicalchanges.

SUGGESTIONS FOR FUTURE RESEARCH

In general, very little is known about the transitions of immigrantwomen, including Korean immigrant women, and few studies haveexplored the menopausal transition within the context of multiple transi-tions. There is a need for more studies in this area, and such studiesshould be directed beyond description to a comprehensive understandingof this experience.

Searching for meaning within context. Using an etic approach, mostprevious studies have focused on the concrete description of women'sexperience out of context or enumerated the factors affecting theirmenopausal experience to generalize for health planning. However, with-out exploring the meaning of menopause within its context, descriptionof sociocultural variables may be useless and their transitional experi-ence cannot be fully understood. Emic perspectives are appropriate inthe exploration of meaning. As posited by feminist scholars, what isneeded here is analysis of lived experience to uncover the meanings ofthe menopausal experience (McBride & McBride, 1982; Woods, 1988).

Searching for the voices of women themselves. With cross-sectionalquantitative research methods using questionnaires and structured inter-views, women's experience has been filtered through the lens of the

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researcher, and women's voices have been inaudible in previous studiesof Korean immigrant women. Consequently, the findings are rarely anaccurate depiction of their transitional experiences related to menopause,immigration, and work, which they themselves could provide. Futurestudies should include the real voices of women in their own words.

Searching for involvement. Meleis (1991) stated that understanding thehealth-care needs of bicultural women, through any research design,should be mediated by a researcher who is of the culture, collaboratingwith others who are of the culture, and immersing oneself in that culture.Most studies of Korean immigrant women have been done by Koreanresearchers, yet they have maintained distance from their research partici-pants in their attempts to remain "objective." When researchers involvethemselves personally, immerse themselves in the immigrants' culture, andexperience their lives with empathic and reflexive attitudes, the study willmore likely provide thick description and comprehensive understanding.

Searching for process and a flexible time frame. Rather than examin-ing the dynamic process of a transition, most studies describe an experi-ence in a static manner. However, it is impossible to determine beginningand end points of transitions because transitions are processes. Ratherthan determining the points, transitions need to be viewed as a flexibletime-framed dynamic process. Researchers need to be flexible in theirtime orientation and to encourage women themselves to describe theirexperiences in terms of their own time orientation—past, present, andfuture. This may promote greater synchrony between the time orientationof researchers and of research participants, ultimately bringing morecomprehensive understanding of their transitions.

Searching for therapeutics. Meleis and Trangenstein (1994) suggestedthat nursing can best facilitate successful transitions toward health andwell-being. Yet very few studies of Korean immigrant women provide adirection for facilitating transitions. Future research should result in usableknowledge and suggestions for helping women move through their transi-tions to maximize their well-being. Knowledge of the transitional experi-ences of immigrant women should be incorporated into interventions tofacilitate successful transitions toward stability and connectedness.

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menopausal transition of korean immigrant women: a literature review

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