The Association Between Somatization and Perceived Ability: Roles

in Dysmenorrhea Among Israeli Arab Adolescents

SARI GOLDSTEIN-FERBER, PHD,

AND

MICHAL GRANOT, DSC

Objective: The aim of this study was to investigate whether somatization and attitudes toward menstruation predict the incidence
of pain intensity and dysmenorrhea among Israeli Arab adolescent females. Methods: Participants were 160 Israeli Arab
adolescents, including 50 Muslims, 50 Christians, and 60 Druze. A 20-item questionnaire was used to assess attitudes regarding
menstruation. The short version of the Brief Symptom Inventory was used to measure the level of somatization. Results: Factor
analysis of the Attitudes Toward Menstruation Instrument revealed two significant composites: perceived ability and impurity
during menstruation. High levels of somatization predicted pain intensity and low levels of perceived ability predicted the
prevalence of dysmenorrhea. Although the Israeli Muslim adolescents revealed higher levels of somatization as compared with their
Christian and Druze counterparts and the Druze revealed the lowest levels of perceived ability compared with the other subgroups,
no significant role for ethnicity and impurity was found. No differences were found between groups in scores of menstrual pain and
prevalence of dysmenorrhea. Higher levels of somatization and lower levels of perceived ability, as well as a greater portion of
Muslim and Druze and higher levels of religiosity, were found among rural residents. Conclusions: The role of cultural variables
and personality traits in the complexity of dysmenorrhea as a socio-bio-psychological phenomenon is proposed in light of
contemporary interactive models. It is suggested that within the Israeli Arab minorities the impact of cultural background on health
affects more the perceptual and cognitive levels and are not generalized to overt behavior and morbidity such as dysmenorrhea. Key
words: dysmenorrhea, somatization, adolescence.
VAS visual analog scale; ATMI Attitudes Toward Menstruation Instrument.

INTRODUCTION
s part of many adolescence changes, experiences and
challenges, menstruation onset, menarche, is a very significant event. Dysmenorrhea, or menstrual pain, is defined as
chronic pelvic pain that occurs in about 15% to 70% of young
women (12). Wood et al. (3) found that dysmenorrhea is
most common between the ages of 15 and 19 and that 82% of
the women in this age group experience such pain. This pain
gradually increases from the age of 15 and then begins to
decline by the age of 20 and following parity (4,5). There are
two types of dysmenorrhea: primary versus secondary dysmenorrhea. This article focused on primary dysmenorrhea
which in contrast to secondary dysmenorrhea, affects most
women throughout the menstrual years and declines gradually with every live birth and is the leading cause of school
and work absence in this age group (6).
Several etiological theories have been proposed as possible explanations of dysmenorrhea. The first group of theories represents the underlying physiological mechanism of
menstrual pain, according to which the role of prostaglandins has been suggested (6,7). Primary dysmenorrhea is related to myometrial contractions induced by prostaglandins
originating in secretory endometrium, which results in uterine
ischemia and pain (8,9). In addition to the physiological
perspective, various psychological theories have also been
proposed, emphasizing the role of personality factors and
attitudes toward menstruation (10). In line with this approach,
Koff and Rierdan (11) found that negative attitudes toward

From the Faculty of Social Welfare and Health Studies, University of

Haifa, Haifa, Israel.
Address correspondence and reprint requests to Sari Goldstein-Ferber,
PhD, Department of Nursing, Faculty of Social Welfare and Health Studies,
University of Haifa, Haifa, Israel. E-mail: sarig@research.haifa.ac.il
Received for publication October 31, 2004; revision received September
18, 2005.
DOI: 10.1097/01.psy.0000197644.95292.00
136
0033-3174/06/6801-0136
Copyright 2006 by the American Psychosomatic Society

menstruation are associated with dysmenorrhea. Regarding

the role of personality traits in dysmenorrhea, there are
conflicting results. Several researchers reported that dysmenorrheic women tend to be more preoccupied with bodily
sensations, tend to express greater negative attitudes toward
illness, and have more negative affect toward menstruation
than do nondysmenorrheic women (1217). In contrast, others
did not find any personality differences in dysmenorrheic
women as compared with nondysmenorrheic subjects (18 19).
Contemporary interactive models combine physiological
and affective factors together with cognitive variables. According to these models, stress and negative emotional
arousal may exacerbate menstrual pain, either by affecting
physiological processes or by decreasing the womans perceived ability to cope with the pain once it is experienced, thus
suggesting reciprocal effects between physiological factors
and emotional-cognitive factors (10,20 22). One can assume
that the affective facet in the above-mentioned models corresponds with previously designated categories of personality
factors and that the cognitive aspects are considered as attitudes or health beliefs. This is in accordance with current
views in the psychology of illness and health (e.g., 23).
One of the personality factors outlined in contemporary
interactive models is that of somatization. This psychological
trait, which is also termed as bodily concerns (17), relates to
patients who complain about symptoms that have no medical
basis and who may use physical complaints to elicit care
(24 25). The broad category of somatization includes the
somatoform disorders that encompass pain disorders (24) and
is found to be strongly associated with chronic pain syndromes and dysmenorrhea (26 27). Thus, beyond the role
played by negative attitudes, somatization may further contribute to the perceived intensity of menstrual pain and development of dysmenorrhea among adolescents.
This study was based on contemporary interactive models
to evaluate the role of both affective components and attitudes
toward menstruation among Arab adolescents living in Israel.
Although culturally based attitudes toward menstruation were
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DYSMENORRHEA AND SOMATIZATION IN ARAB ADOLESCENTS

considered in the interactive models, there is debate regarding
the effect of socialization processes on attitude development
regarding menstruation. One large multi-country study identified different patterns of beliefs and preferences regarding
menstruation that were distributed as a function of cultural
background. Data in this multi-country study were obtained
from a WHO non-nationally representative sample of 5322
parous women from 14 cultural groups between 1973 to 1980
and a subsample of 500 women with detailed daily diaries
from 10 countries (Egypt, India, Indonesia, Jamaica, Korea,
Mexico, Pakistan, Philippines, UK, and Yugoslavia). According to the results, beliefs such as bathing behavior during
menstruation, fertility and femininity issues, interpretations
and implications of menstruation, and beliefs about not washing hair or body during menstruation explained more than
53% of the estimated variance. The authors concluded that
beliefs, which reflect socialization according to demographic
variables, appear to affect choice of contraceptive methods
and family size which exemplify the complexity of socialization effects on female identity and her perceived attitudes
toward menstruation and fertility issues in general (28). In
contrast, Sigmon et al. (17) and others did not find an effect of
sex role socialization or other cultural attitudes on menstrual
symptoms.
Arabs constitute the largest minority group in Israel, comprising 20% of the total population. About 80% of the Arabs
are Muslims, and the rest are Christians and Druze. In a
patriarchal society, menstruation, pregnancy and birth are
considered as major events in the female developmental process (29 31). According to this cultural perspective, menstruation represents the girls entrance to her expected social role
as a mature woman. From the time of menarche, her family
may impose stricter rules on her regarding social behavior.
While menstruation may involve positive changes in the
social role of the Israeli Arab girl, it may also lead to a conflict
in attitudes regarding menstruation that may be expressed by
negativity and the development of dysmenorrhea. Evidence
showing that there is an alteration in the regular daily activity
of Arab women during menstruation (3235) may reflect such
an attitude conflict (11). Given the unique patterns of each
subgroup of the Israeli Arab population, the present study
aims to explore the roles of attitude and personality variables
associated with menstruation among these three subgroups of
Israeli Arab adolescents.
This study aimed to explore primary dysmenorrhea only in
young Israeli Arab adolescents. The uniqueness of this study
lies mainly in the psychosocial focus on dysmenorrhea and the
investigation of this phenomenon from a cultural and psychological perspective. Also, the contribution of this study to the
body of knowledge lies in the expansion of the research on
dysmenorrhea, usually examined mainly from the angles of
pain and gynecology, to the examination of somatization in
order to consider the psychosomatic aspects of the phenomenon as they correspond with cultural alignment and personality attitudes.
Psychosomatic Medicine 68:136 142 (2006)

In light of the above, the aims of this study were twofold:

(a) to characterize dysmenorrhea in three subgroups of Israeli
Arab adolescents (Muslims, Christians, and Druze), and (b) to
evaluate the role of both somatization and attitudes toward
menstruation in these ethnic groups. We hypothesized that
somatization will predict menstrual pain and that attitudes
toward menstruation will predict dysmenorrhea. We also hypothesized that differences will be found between the three
ethnic groups in the prevalence of dysmenorrhea and we had
a two-sided hypothesis for each ethnic group.
METHODS
Sample
The sample consisted of 160 nonmarried Israeli Arab adolescents from
three subgroups: Muslims (n 50), Christians (n 50), and Druze (n 60).
All participants were high school students in grades 10 to 11 who were
attending public schools comprised of both boys and girls. Mean age of the
girls in the total sample was 15.7 0.8, with no significant differences found
between subgroups. As for residence, 107 reported living in Arab villages and
53 in towns. In general, most of the subjects were from medium-low socioeconomic status. There were no differences in characteristics of menstruation.
The number of children in the family ranged from 1 to 8 (mean 4.6 2.1),
with no significant differences found between subgroups. The refusal rate was
very low and only two subjects refused to fill-in the questionnaires.

Instruments
Characteristics of Menstruation and Dysmenorrhea
The characteristics of menstruation were assessed by collecting data
regarding the age at first menstruation, the duration of menstrual bleeding,
whether pain is experienced during the first 1 to 2 days of menstruation, and
the level of menstrual pain intensity as measured by visual analog scale (VAS)
with the regular medical ruler tool (36). Participants were also asked to rate
on a 5-point scale: 1) whether there was a change in their regular functioning
due to menstrual pain (ranging from 1 no change to 5 a drastic reduction
in regular behavior), and 2) whether they used analgesia to reduce the
intensity of their menstrual pain. The presence of dysmenorrhea was defined
by a response to the first question that was greater than two and/or a positive
response to the second question.

Attitudes Toward Menstruation Instrument (ATMI)

A 20-item questionnaire was used to assess attitudes regarding menstruation. The questionnaire was created in Hebrew and translated to Arabic. The
subjects filled in the Arabic version. The Arabic version was achieved using
back-and-forth translation and dual-language speakers check ups on a different subjects pool with acceptable to high internal consistency ( ranging from
0.65 to 0.7). Subjects were asked to rate their level of agreement with each
item on a 5-point scale ranging from 1 do not agree at all to 5 very much
agree. Factor analysis with orthogonal Varimax rotation was conducted to
define the different domains of the questionnaire (see Table 1). The two
different factors were revealed including items that significantly contributed
to the variance above the cutoff point of 33.9.

Impurity
This domain included six items that assessed the degree to which women
perceived menstruation as an impure event. Five of them turned out to
contribute a significant portion of variance. For example: I believe that the
menstrual blood is different compared with other sources of bleeding;
I think that it is forbidden by God to have sex during menstruation;
I believe that women during menstruation are impure. (Cronbach 0.69).

Perceived Ability
This factor included eight items that evaluated the perceived extent to
which the women subjectively perceive her ability to cope and maintain
137

S. GODSTEIN-FERBER AND M. GRANOT

TABLE 1.

Factor Analysis of ATMI With Varimax Rotation

Factors

Items

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20

A course from God

More fatigue during menstruation
Regularity of menstrual blood
Need for special considerations
Feeling in shape
Regular activity
Pain is an excuse
Sexual relations are forbidden by God
No effect on mood
Sexual relations are affected by religious principles
Impurity during menstruation
Menstruation is similar to sickness
Awareness of difficulty to function as usual
Pain is more a psychological than physiological issue
It is not decent to discuss menstruation
Arab women report less on menstrual pain
Religious women report less
Religion may affect attitudes
Society has a profound impact on women
Physiological factors impact my attitudes
Eigenvalues

Impurity

Perceived Ability

15
6
32
15
1
7
10
60a
21
75a
71a
18
15
46a
9
5
19
67a
1
3
2.27

7
59a
0
59a
63a
53a
35a
5
57a
9
6
10
65a
25
16
10
7
10
23
43a
2.97

Values greater than 33.9 are marked by an asterisk. Values are multiplied by 100 and rounded to the nearest integer.

regular functioning during menstruation. For example: I think that women

cannot function regularly during menstruation; Women who complain
about menstrual pain use this argument as an excuse to avoid functioning;
and I expect the family to reduce my obligations during menstruation.
(Cronbach 0.70). Note that accepted measures of disability/reduced
functioning during menstruation were used to identify dysmenorrheic women,
while assessments of subjective perceptions of ability were used to assess
perceived ability and predict the prevalence of dysmenorrhea.

Somatization
The level of somatization was assessed by the short version of the Brief
Symptom Inventory (BSI), representing one factor in the Symptom Check
List (SCL-90) (3738). This multidimensional screening instrument is a
self-report of psychological distress and multiple aspects of psychopathology
and is often included in the evaluation of pain patients (32). The 13-item
questionnaire rates the frequency of complaints or symptoms in different
areas of the body, including chest pain, headache, low back pain, vomiting,
dizziness, flushes, or numbness. The internal consistency reliability coefficient (Cronbach ) of the short version was 0.78 (39).

Procedure
Data were collected using self-report questionnaires that were completed
during a class at school. The study was approved by each high school
principal, who introduced the study to the pupils and requested that they sign
letters of informed consent. Two female Israeli Arab students from the School
of Nursing at the University of Haifa provided instructions about the questionnaires, with a special emphasis on their confidentiality and anonymity.
The students collected the completed questionnaires, and none of the teachers
or school staff had access to the content of the data.

Data Analysis
Factor analysis was used to define the two composites of the ATMI.
Cronbach was applied to assess the internal consistency. All variables
(attitudes toward menstruation (ATMI), somatization level, and demographic
data) were compared between the three ethnicity groups (Muslims, Christians,
and Druze). Nonparametric Kruskal-Wallis test for ranks was used to compare
138

dysmenorrheic to nondysmenorrheic women on the measure of somatization.

Linear regression was conducted to predict menstrual pain intensity. In
addition, a logistic regression model was applied to predict dysmenorrhea.

RESULTS
Characteristics of menstruation
Mean age at first menstruation was 12.8 0.7, with a
range from 11 to 15 years old (F(2,157) 2.17, p .05). The
mean number of bleeding days was 3.2 2.1, with no
significant differences between groups (F(2,157) 2.42, p
.05). In the entire sample, most subjects (n 129) reported
having painful menstruation to some degree, with 99 describing the pain as moderately intense (n 42) and the remaining
57 as severely intense. The mean VAS scores of menstrual
pain intensity was 4.8 2.7. No significant difference was
found in the level of pain intensity between groups (Christians 5.4 2.3, Muslims 4.9 2.6, and Druze 4.3
0.4 (F(2,131) 1.75, p .05). While 68 subjects were assessed as having dysmenorrhea (45%), no difference in the
prevalence of dysmenorrhea was revealed between groups
(2 (2) 1.102, p .05). The Muslim group revealed higher
levels of somatization (16.2 9.5) as compared with the
Christians (11.1 5.1) and the Druze groups (11.6 7.3)
(F(2,154) 7.11, p .001). The Druze group reveled the
lowest levels of perceived ability compared with the Muslim
and Christian groups (Druze 22.31 5.108; Muslim
25.59 5.78; Christian 29.97 4.22; F(2,1) 28.629,
p .0001). No differences were found in prevalence of
dysmenorrhea and pain intensity between rural and urban
areas of residency (2 (1) 0.58, p .05, t (132) 1.43,
p .05). However, compared with urban areas, in rural areas
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DYSMENORRHEA AND SOMATIZATION IN ARAB ADOLESCENTS

the Israeli Arab adolescents revealed higher levels of somatization (13.79 8.71 versus 11.07 5.23, t (155) 2.08, p
.05) and lower levels of perceived ability (24.2 5.83 versus
29.09 4.77). More Druze and Muslim Israeli Arab adolescents reported living in rural areas compared with the Christian subpopulation (2 (2) 131.019, 45 of 50 Muslim and 60
of 60 Druze compared with 2 of 50 Christian Arabs Israeli
girls lived in rural areas). Likewise, the Christian group revealed different trends than the other two groups by reporting
lower levels of religiosity compared with the other two groups
(2 (2) 29.91, 49 of 50 Muslim and 56 of 60 Druze
compared with 29 of 50 Christian Israeli Arabs reported on
maintaining religious beliefs and style of life).
Comparison Between Dysmenorrheic and
Nondysmenorrheic Adolescents
No difference in the level of somatization was found between dysmenorrheic (mean 13.16 7.1, range 1 through
39) and nondysmenorrheic subjects (mean 13.24 7.5,
range 3 through 40, F(2,126) 0.951, p .05). However, an
interesting finding was that when the questions assessing pain
symptoms alone were included, the dysmenorrheic women
reported higher scores of pain symptoms (Z 4.4293, p
.035). No differences were noted when questions regarding
the nonpain symptoms alone were analyzed.
Prediction of Menstrual Pain Intensity and
Dysmenorrhea
Linear regression analysis revealed that the level of somatization and perceived ability significantly predicted the intensity of menstrual pain. No significant role was found for
ethnicity or impurity (see Table 2).
The logistic regression analysis that was conducted to
predict dysmenorrhea showed that lower perceived ability
during menstruation is associated with higher prevalence of
dysmenorrhea (see Table 3). No significant role was found for
ethnicity or impurity (see Table 2).
DISCUSSION
This study focused on the characteristics of menstruation
and dysmenorrhea among three ethnic sub-groups of Israeli
Arab adolescents. The results showed an association between
dysmenorrhea and negative attitudes toward functioning, as
expressed by the lower level of perceived ability during menstruation in all three ethnic groups. In addition, high levels of
somatization and lower levels of perceived ability were
TABLE 2.

Linear Regression for the Prediction of Menstrual

Pain Intensity

Predictors

Ethnic group
Somatization
Perceived ability
Impurity

0.007
0.469
0.403
0.098

0.082
5.820
5.201
1.202

.935
.0001
.0001
.232

R2 0.413, F(4,112) 19.6; p .0001.

Psychosomatic Medicine 68:136 142 (2006)

associated with greater intensity of menstrual pain, regardless of ethnic group. Thus, the somatization scores were not
necessarily associated with dysmenorrhea, but with greater
pain intensity. This clearly implies that dysmenorrhea should
be considered as a behavioral manifestation of pain perception
and not a direct result of pain intensity. Moreover, Druze Arab
adolescents showed the lowest level of perceived ability and
the Muslim Arab adolescents showed the highest levels of
somatization suggesting that these two subpopulations in
Israel are more at-risk than the Christian subgroup.
An accepted concept proposed by Bandura (40), which is
known as self-efficacy, relates perceived competence and
behavior such that lack of self-efficacy results in reduced
effective behavior. Efficacy beliefs are context-specific evaluations and are formed through mastery experiences, observations of others, social-verbal persuasion, and interpretations
of physiological and emotional states. Self-efficacy is a cognitive construct implicating ones self-perception about ones
performance ability (41). In other words, self-efficacy develops through the process of socialization similarly to the development of attitudes and characterizes the individuals sense
of his/her performance ability as subjectively perceived. This
possibly was correspondingly expressed by the subjective
phenomenon investigated by the ATMI in the current research.
Another concept which may be valuable to expand the
understanding of the phenomenon revealed by the ATMI is
Rotters concept of locus of control (42). Rotter hypothesized
that individuals differ on their type of expectations for reinforcement and may be classified either as Internals who expect
an internal reinforcement from within themselves or Externals
who expect a reward from the outside on a particular action.
Rotter hypothesized that internals will engage more frequently
in action taking than externals and was able to show that such
individuals present more political involvement (43 44). According to the original concept, locus of control is developed
through socialization and in close relation to cultural impacts
and may be related to performance techniques such as planning, coping, persistence of action and analysis of situation
(43) thus densely associated with self-efficacy. We suggest
that locus of control may be the general construct to describe
activity, ability and functioning in many areas of the individuals life while self-efficacy may represent the available resources of the individual on a particular issue. In the case of
the ATMI, it is possible that it measures the available cognitive and emotional internal resources of the individual as
subjectively perceived and felt by her in the case of menstruation but also may be linked to a more general attitude such as
locus of control.
Although self-efficacy and locus of control per se were not
assessed in this research, it may be that attitudes regarding
regular functioning, as reflected by the level of perceived
ability, express the extent of self-efficacy during menstruation
through decreased prevalence of dysmenorrhea and as a part
of a more general approach toward expected reinforcements.
139

S. GODSTEIN-FERBER AND M. GRANOT

TABLE 3.

Logistic Regression for the Prediction of Dysmenorrhea ( Muslim and Druze Adolescents Were Separately Compared to the
Christian Adolescents)

Predictor
Perceived abilitya
Impurity
Muslim
Druze
a

B
0.1009
0.0849
0.1379
1.1713

SE

0.0449
0.0609
0.6940
0.6158

Wald 2
5.0518
1.9448
0.0395
3.6179

95% CI
OR

0.904
0.919
1.148
3.226

Lower

Upper

0.828
0.815
0.295
0.965

0.987
1.035
4.473
10.786

0.05 Significant prediction of dysmenorrhea.

Our findings show that somatization predicts the intensity

of menstrual pain, in accordance with previous suggestions
that somatization enhances the perception of a variety of
noxious stimuli (45). As such, somatization may be regarded
as a personality trait, a view supported by Granot et al., report
of higher pain perception in response to experimental painful
stimuli directed to a nongynecological site in women with
primary dysmenorrhea (46). There are also other reports of
greater pain response to uterine cervical laser therapy (47) and
higher scores of labor pain (48) in dysmenorrheic women.
Furthermore, higher incidences of various other pain syndromes have been reported in dysmenorrheic women (49 50).
This raises the possibility that dysmenorrhea is not just a
syndrome of painful uterine contractions, but rather represents
an enhanced pain perception related to somatization. Our
findings show the interactive roles of both attitudes, such as
perceived ability, and personality traits, such as somatization.
Therefore, the suggested interactive models proposed earlier
gain further support.
Interestingly, the Muslim adolescents exhibited higher degrees of somatization, which may suggest that the cultural
factor had a unique effect on the menstrual experience in this
group. This is in accordance with other reports showing a
higher incidence of somatization within Muslim as compared
with Christian communities (5152) and is in line with the fact
that the female identity in Muslim communities is predominantly affected by their role in the family (53). Further studies
are needed in order to elucidate the nature of how cultural
variables, such as the role of women in the family, are associated with somatization among Muslim adolescents.
Although somatization differed between groups, the frequency of dysmenorrhea and the level of pain intensity did
not. These findings regarding the prevalence of dysmenorrhea
and reported menstrual pain intensity are akin to other reports
from both Western and non-Western societies (54 56). The
greater somatization symptomatology among Israeli Muslim
suggests that the transition from traditional society to modern
life which is apparent among Israeli Arabs nowadays including the changes in womens social role and familial duties, is
demanding and costly for the Muslim Israeli adolescents compared with the adolescents from among the Christian minority
which is more easily affiliated with modern and Western
values. The differences between the Muslim girls who revealed higher levels of somatization and the Druze who re140

vealed the lowest levels of perceived ability may be related to

the current developments in the transition process toward
more modern views, attitudes, perspectives and style of life.
While the Muslim minority is actively undergoing such psychological and sociological transforming changes, the Druze
are more tied to their religion as yet and are only initiating
such assimilation processes and implementation of foreign
concepts beyond their tradition in their society. As such the
Druze may be protected from generalizing their low perceived
ability during menstruation, which may be related to the
traditional women role during menstruation in this subgroup,
into a more larger frame of symptomatology such as somatization. The Muslim girls may show a more generalizing
response due to the more stressful condition inherent in processes of active social assimilation and change. As the specific
mechanisms in which the socialization processes and culture
affect attitudes toward menstruation and menstrual pain are
still puzzling researchers in this field (17,28), future study
should use cross-cultural designs in order to expand our
understanding of the contribution of cultural attitudes and
personality variables to the development of dysmenorrhea.
However, in light of the conflict in the research reports (e.g.,
17,28) this study supports the view that socialization and
cultural effects may be involved in dysmenorrhea through
their impact on personality traits.
The limitations of the current study lie mainly in the
absence of a Jewish control group from the majority of the
population in Israel. However, all three major minorities in
Israel were represented in this study. Other limitations may be
the lack of individual data on the SES measure and the
inclusion of a general characteristic of SES only, since SES
might be related to myths and health beliefs. However, we
measured the level of religiosity as a self-report variable
which may be more closely associated with myths and health
beliefs than SES and we found that the two sub-populations
who revealed at-risk potential in somatization and perceived
ability, the Muslim and the Druze, also reported significant
more religious beliefs and style of life. Interestingly, the same
subpopulations, the Muslim and Druze Israeli Arab adolescents, reported living more in rural than urban areas. Correspondingly, rural more than urban areas were associated with
lower perceived ability during menstruation and higher levels
of somatization. Differences in prevalence of dysmenorrhea
between rural and urban area were not found probably due to
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DYSMENORRHEA AND SOMATIZATION IN ARAB ADOLESCENTS

a possible greater impact of simply being a part of an ethnic
minority in light of cultural dominancy of the western and
Jewish cultures in Israel. The result that Israeli Muslim and
Druze seem to be more at risk of somatization and perceived
ability compared with the Israeli Arab Christian minority
shows the impact of culture on pain perception. However, the
impact of ethnicity within three Arab minorities in Israel is
shown to be restricted to the perceptual level of pain
experience (somatization) and the cognitive level of available attitudes (perceived ability) rather than appearing in
overt behavior and morbidity such as dysmenorrhea.
It seems that at least in Israel, the transition from traditional
to modern life, which is more apparent in urban areas, is
associated with less symptomatology of the Israeli Arab
women. This transition may be responsible for changing the
locus of control from traditional beliefs only and God (Allah)
to internal responsibilities, action taking and more social involvement. There are contradicting results on the compared
levels of self-efficacy and locus of control between rural and
urban areas in different countries (57 61). As the concepts
self-efficacy and locus of control represent mainly the impact
of socialization on perceived ability and action or coping, it is
not surprising that the differences on those measures between
rural and urban areas are dependent on the cultural background and environment of the subjects, thus revealing differences in results between different regions on the globe.
In sum, the results of the present study reveal the complexity of dysmenorrhea as a socio-bio-psychological phenomenon and demonstrate that the characteristics of dysmenorrhea
in Israeli Arab adolescents are only partially culturally based.
There may be genetic neural sensitivities and individual personality traits, which may be interacting with the cultural
impact. This may imply the importance of education and
clinical support that takes into consideration the role of culture. Among the clinical implications of this study is the
possibility to use the Attitudes Toward Menstruation Instrument to detect at-risk populations especially among minorities
in other cultural backgrounds. Examples for clinical interventions may be verbal psychotherapeutic reflections and ventilation as well as cognitive imaginative methods to reduce pain.
However, when these carried out among minorities they
should include traditional contents as well as respect of and
honor to differences in life conceptualization, basic individual
values, age and sex roles.
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