Download - Women and the illness role: rethinking feminist theory

Women and the illness role: rethinking feminist theory

MARlON PIRIE York university*

Une femme adopte le r6le de malade. Comment analyser ce phenomhne? Je propose dans les pages qui suivent une thbrie fbministe de l’adoption du r61e de malade qui met l’accent sur des formes culturelles et phenomenologiques d’investigation. Diverses auteures feministes ont rkemment trait4 ce probleme en soulignant comment le contr6le social patriarcal sur les femmes peut s’exercer par la definition mgme des maladies. Mais les etudes produites dans ce cadre ont tendance A negliger la fapn dont les femmes vivent les maladies ainsi d6finies. Ces etudes sont alors incapables de comprendre pourquoi certains types de maladies - le syndrome pr6-menstruel, par exemple - acqui&rent une credibilite certaine, alors que d’autres dont l’etiologie et la symptomatologie sont similaires demeurent dam l’ombre. Un paradigme plus etoffc? du comportement de malade, comme celui propod ici, examinerait de plus prhs la relation entre structure sociale et exp6rience sociale de la maladie, ainsi qu’entre idblogie et biographie. En derniere analyse, je propose un paradigme qui explore la designation des maladies a trois niveaux d’analyse: U les activies productrices des groupes dominants qui ont un inter& politique ou commercial dans la d6signation medicale; 2/ les activit4s produdrices de celles et ceux qui adoptent la dbsignation; et 3/ les trajets ou dbterminants culturels qui predisposent l’adoption collective de certains types de maladies A l’exclusion de certaines autres.

This paper advances a feminist theory of women and illness behaviour which places a stronger emphasis on cultural and phenomenological forms of investigation. Current theoretical treatments of this topic by feminist scholars focus on how definitions of illness may be viewed as patriarchal forms of social control of women. Rarely do such studies investigate the personal experience of

* I wish to thank Professor Tom Wilson for his continuing support of my work, Professor Thelma McCormack for her critical comments on an earlier version of this paper delivered at the Learned Societies Conference, June, 1987, and Professor Norman Bell for his col- laboration on the empirical project out of which the ideas for this paper developed. The author is, of course, solely responsible for the ideas presented here. This manuscript was received in May, 1987 and accepted in February. 1988.

Rev. canad. Soc. & Anth./Canad. Rev. Soc. 8c Anth. 25(4) 1988

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women adopting the illness role. As a result, such approaches fail to articulate how it is that some categories of illness, such as the premenstrual syndrome, come to be credited with plausibility, while others similar in aetiology and symptomatology, are ignored. A more comprehensive paradigm of illness behaviour as suggested by this paper would explore, more fully, the relationship between social structure and the social experience of illness; between ideology and personal biography. Ultimately, the paradigm suggested here explores illness labelling at three levels of investigation: l/ the productional activities of dominant groups with commercial and/or political self-interests in medical labelling; 2/ the productional activities of those adopting the label; and 31 the cultural pathways or determinants which predispose the collective adoption of some illness categories, and not others.

In discussing the relevance of feminist theory to the sociological study of women and health, it is instructive to recall something of the aims, content, and spirit of discovery involved in the feminist research enterprise. In the social sciences, feminist research incorporates two distinct but complemen- tary goals. The first is a humanistic, value oriented one, where political change and a commitment to social justice are primary (McCormack, 1981b: 2). As Margrit Eichler in a recent review of the topic asserts: ‘At the most fundamental level, feminist scholarship is committed to understanding and improving the situation of women’ (Eichler, 1985: 624). At the same time, feminist research has increasingly embraced what are often called the ‘soft paradigms’; models which emphasize reflexivity (of both the researcher and her subjects), subjective experience, cognitive structures, intuition, personal biographies, and perhaps most controversially for the social sciences, feelings. Feminist theory has long rejected the value of processing lifeless variables in favour of attempting to understand the subjective experience of human beings. The preferred epistemology among feminist scholars is and has long been ‘characteristically phenomenological’ (McCormack, 1987: 2) and its preferred modes of investigation have remained characteristically qualitative. (See Baumrind, 1980; Oakley, 1981; Stanley and Wise, 1985; Eichler, 1985; McCormack, 1987; for a discussion of feminist applications of qualitative research).

The complementarity of these aims is suggested by the argument that it is not largely, but only through the phenomenological investigation of women’s subjective experience that 1/ identity and credibility will be res- tored (McCormack: 1987) and that 21 women’s understanding of their own political efficacy in an oppressive society would be revealed (often via the research enterprise itself). Incorporating these aims, then, the spirit of feminist research involves not only a consciousness-seeking, but a consciousness-rais ing process, as well. Lillian Rubin’s combined phenomenological humanistic approach (1976; 1979; 1981) stands out as an exemplary model of the feminist research enterprise.

The phenomenological orientation of feminist research in the area of women and illness behaviour, however, has not been as fully utilized as it

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might be. In terms of empirical research, quantitative studies far outweigh qualitative studies; structural variables are preferred over process variables as modes of measurement. Indeed almost no studies on gender and health exist which address the way in which symptoms are labelled and the severity of illnesses assessed by individuals (Verbrugge, 1985: 156).

Similarly, theoretical discussions tend to reject phenomenological approaches to the study of women and illness behaviour. The preferred orientation here is to develop macro analyses which are largely directed towards identifjling agents of social control and the strategies of medical labelling in which they engage. While such discussions are useful in their ability to identify the non-medical motives influencing the medical labelling process, there is no attempt to explain how medical labels themselves become internalized by the subjects involved.

Most such analTses tend to focus on the particular problems of the female reproductive role, an aspect of women’s experience which would seem to lend itself most fruitfully to phenomenological investigations. These argu- ments generally comment on how ‘patriarchal discourses’ of illness foster negative labels of menstruation, menopause, and childbirth, as ways of restricting women’s participation in society. The tone such discussions often take is exemplified in the following passage by Paula Weideger in her widely cited book Female Cycles (1982). As explanation for the relationship between cultural views of menstruation and the position of women in society, Weideger argues that

A committed misogynist will use any example of women’s ‘weakness’ to bolster his prejudice. He already uses the very existence of menstruation and menopause to prove that woman is unpredictable and unfit for positions of trust and responsibility. (Weideger, 1982: 13)

She then goes on to explain that it is through these patriarchally fostered cultural views that women so readily embrace natural events such as menstruation and menopause as illness constructs.

What is problematic about the typical feminist analyses of women and illness behaviour is that the relationship between the construction of illness labels and their subsequent adoption as illness role behaviour is assumed but never explained. There is no exploration of how women themselves in- terpret bodily events associated with the reproductive function. There is no exploration of the generative properties of the social interaction within which illness labels are adopted by individuals. There is no exploration of the social and cultural context within which certain illness labels, such as the premenstrual syndrome are credited with plausibility by large numbers of people, while others, such as the Epstein Barr Virus Syndrome; receive comparatively less notoriety. Ultimately,there is no attempt in analyses such as Weideger’s to explain the relationship between abstract categories of knowledge and their internalization as part of one’s personal biography.


What may be said of such studies as Weideger’s, then, is that however humanistically oriented, the rhetoric of feminism is continually cited, but the voice of women seldom heard. The result is a somewhat simplistic causal model which argues that ideological forms of knowledge flow in a more or less undiluted form from patriarchal structures of control and deposit themselves unproblematically on unwitting, passive subjects. Such models are appealing in their ability to identify the politics of medical labelling, but in assuming that the construction of a label ensures its collective adoption, these analyses ignore the central fact that illness is a world made meaningful only through culturally situated social interaction. In point of fact, if the ‘essence’ of feminist research is its insistence on beginning from the point of view of women’s reality; its insistence on asserting the validity of women’s experience (often ouer the validity of theory); its insistence on exploring the contradictions between women’s involvement in everyday experience and the ‘language of theory’, (Stanley and Wise, 1985: 135,163)’ then feminist analyses of women and the illness role fall far short of the stated goals of the feminist research enterprise.

It is in the context of such questions and issues that the present discussion is formulated. It is the purpose of this paper to suggest a preliminary conceptual schema of illness behaviour which reaffirms the commitment to exploring the subjective experience of the actor as she attempts to make sense of a culture-bound world of illness. Both the emphasis on subjective experience and the emphasis on illness as a culture-bound category of knowledge are essential to a research enterprise committed to exploring the way in which women make sense of a world largely designed by and for men.

Agreeing with the position that illness labelling can constitute an ideological form of social control, the rationale for incorporating a phenomenological orientation is based on the premises that V there exists a determinate relationship between ideology and individual experience; and 2/ this relationship is discoverable ultimately through phenomenological forms of investigation (Wuthnow, 1985). The rationale for emphasizing the importance of regarding illness as a culture bound syndrome is based on the premise that the meaning illness holds for any individual is grounded in, though not reducible to, the network of meanings any illness has in a particular culture; the metaphors associated with disease; the basic values, practices, and cultural preoccupations which determine how some bodily states and events and not others become coded and subsequently adopted as ‘illness’ states (Good and Good, 1980: 176).

The central position of this paper, then, is that a full exploration of the illness labelling process involves examining three (but by no means sequen- tial) phases of reality construction processes. First of all, the social construction of medical knowledge must be traced to the productional activities of dominant groups with commercial and/or political self-interests. This is essentially the mode of analysis adopted by the current feminist models. Secondly, the social construction of medical knowledge needs to be inves- tigated at the level of the productional activities of the subjects themselves; the face-to-face encounters where the world of illness is made meaningful

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to the actor. And thirdly, this reality construction process needs to be inves- tigated in terms of the cultural determinants which predispose the collective adoption of some illness categories, and not others.

This paper will begin by reviewing the labelling theory and social control literature out of which the more recent feminist critiques of women and illness behaviour have emerged. From there, a new conceptual framework incorporating a phenomenological and cultural orientation will be presented. The paper will conclude with a discussion of how such a framework may be applied to the study of women and illness behaviour by referring to the author’s own research on the premenstrual syndrome.

THE SICK ROLE: FROM FUNCTIONALISM TO LABELLING THEORY

The labellingbocial control models of illness behaviour emerged in response to the essentially conservative position at least implied in the original Par- sonian conceptualization of the sick role. While Parsons’ model of the sick role is well-known to most sociologists, it is worthwhile to review certain of those premises contained in his theory, since that model provided the major impetus for exploring the question of social control and illness labelling strategies as political processes.

Essentially, Parsons argued that while malingering was to be considered deviant, the illness role in general should be regarded as a predictable, indeed adaptive response to social life. Illness allows the individual temporary but legitimate exemption from normal obligations and duties, or, as the following citation illustrates, legitimate, non-disruptive (albeit displaced) ex- pressions of social discontent.

Parsons, for example, once claimed that women ‘often seize upon illness as a compulsively feministic way of reacting to (their) exclusion from the life open to a man’, or as an ‘institutionalized way out of the burdens of her heavy “human relations management”’ (Parsons and Fox, 1968: 380-1). And while Parsons in no way endorsed illness as an adaptive response to the burdens of responsibility, he did ultimately view the sick role as both a predictable, but at the same time potentially abusive strategy of coping with the pressures of social life. In order to counteract the potential disruptions malingering might engender, Parsons recommended that all sick individuals should attempt to regulate the illness role by seeking out com- petent and objective, (i.e., professional-medical) help. The illness role, then, was seen by Parsons as a socially predictable but potentially deviant form of institutionalized interaction, the function of which was to allow a legitimate respite from social obligations.

At a very general level, Parsons’ theory of the sick role has been criticized for being politically conservative; normative in content, if not ideological in intent. By the very nature of what Parsons’ theories investigate (namely the forces securing social harmony and stability), the status quo is ultimately, if not intentionally, legitimated. Following this line of critique, McCormack argues, for example, that Parsons’ emphasis on micro role behaviour and not the larger macro processes of social relationships automatically removes


the larger socio-political spheres from scrutiny. She points out, as well, that ‘if work were fulfilling and secure, if interpersonal relationships provided for self-development and personality growth, if community life gave citizens a sense of political efficacy, few would prefer illness to health ...’ (McCor- mack, 1981a: 41,42).

Parsons’ theory of the sick role provided the stimulus for the development of a body of research interested in how medical knowledge operates as a vehicle of social control. For many of the reasons cited above, this school was particularly concerned with the way in which Parsons’ theory rein- forced the status quo, particularly the elitism and authority of the medical profession. Social control theorists argue that both the select social positions and training programs of physicians cannot help but engender a certain propensity to preserve the status quo. This school is quick to point out that medical labelling and action may be rationalized in terms of the dominant political and cultural biases of a given system. As the most profound example of such abuse of the power to define health and illness, social control theorists point to the Soviet countries (see, for example, Szasz, 1974).

The Social ControVLabelling theories of illness are represented by such researchers as Thomas Szasz (19741, Irving Zola (1971), Eliot Freidson(l970) and Peter Conrad (1975) although European thinkers such as Michel Foucault (1965,1975) have also explored the relationship between the iden- tification and treatment of mental illness and social context. Both Zola and Szasz are more interested in how social control operates through the medical profession, (largely regarded as a handmaiden of larger socio-political forces). Eliot Freidson focuses more specifically on the professional dominance of doctors, per se. Peter Conrad examines the political and social conditions under which the ‘discovery’ of disease entities have occurred, and what self-interests are being served by that discovery. All are concerned, however, with the way in which the creation and regulation of medical knowledge serves self-interests other than those of the patients. The models proposed by Eliot Freidson and Peter Conrad have been the ones most often adopted in feminist analyses, and for that reason are being reviewed here.

Freidson, like all social control theorists views the absolute power doctors have in defining health and illness as inherently problematic. He argues, for example, that the nature of the doctor-patient relationship is fundamentally hierarchical and essentially demeaning to the majority of patients. The key characteristic facilitating the power doctors have over patients, according to Freidson, is information control, a self-imposed state which eventuates in doctors being loath to give even perfunctory information to patients whom they regard at best as ‘management problems’; and at worst as ‘little more than a nuisance’ (Freidson, 1970: 142). Freidson’s proposed remedy to this situation is to have patients take a more active role in the delivery of healthcare services, both at the personal and at the political level.

It is not surprising that feminist theories of women and illness behaviour have found Freidson’s model appropriate to the phenomena they address. In the first place, Freidson’s attack on the hierarchical nature of the doctor

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patient relationship cannot but strike an all too familiar chord of recogni- tion in most women. Tired of a male-dominated medical profession’s ap- propriation of definitions of health and illness for women, the edict that women need to ‘reclaim their bodies’ has become not only the basis of the women’s health movement, but the main stimulus underlying most feminist theoretical discussions of women and health, as well. Feminists often explain the question of women’s ‘excess’ morbidity and ‘abuse’ of healthcare services, for example, often by referring to the professional dominance thesis. The feminist position here argues not that illness is a predictable response to an oppressive social order, but rather that many of the typical ‘female’ illnesses are the result of a coercive and highly effective labelling process exercised by the medical profession operating not only in its own self-interest (in insuring its monopoly over healthcare) but in those of the state and other agents of control eager to restrict women’s equal participation in society. According to this tradition, if a male-dominated healthcare system did not impose categories of illness on ordinary bodily events such as menstruation, menopause, pregnancy and childbirth, the differential morbidity rates between men and women, it is argued, would diminish sub- stantially. (See Trypuc, 1984; Weideger, 1982; Delaney, et al., 1976; McRae, 1983; Weitz and Sullivan, 1985, for discussions of professional dominance.) Freidson’s exhortation to exercise more control over the labelling and treatment of illness has since become the cornerstone of the women’s health movement, best expressed by the title of the Boston Women’s Health Collective’s medical manual for women, Our Bodies, Ourselves (1976, see also 1984).

A second direction taken by social control theorists interested in the social construction of medical knowledge comes out of the labelling school in deviance. This orientation, exemplified in the work of Peter Conrad (Con- rad, 1975; Conrad and Schneider, 1980), for example, is less concerned with the professional dominance of doctors acting in their own self-interest and more concerned with how medical knowledge operates indirectly as an ideological strategy of social control. Conrad and others writing in this tradition investigate how certain overt behaviours acquire the status of disease and what self-interests are evident in the labelling processes involved. The main premise here is that when individual (or collective) behaviour becomes socially disruptive, labelling that behaviour as illness (as opposed to deviance) has the effect of mitigating the stigmatizing properties of that behaviour. When ‘badness’ is seen as ‘illness,’ the individuals concerned are no longer responsible for their action; a condition which ultimately results in the depoliticization of that same behaviour. Aptly termed the ‘medicalization of deviance’ this labelling approach would look at alcoholism or hyperkinesis, for example,as cases in point. Alcoholism is often seen as a problem of the individual’s biochemical makeup (thereby removing from the individual any responsibility for the disease). At the same time, this medical definition of a social behaviour removes from scrutiny the kinds of social pressures (including media programming) which motivate people to engage in substance abuse in the first place. Labelling theorists argue that by locat-


ing the pathology within the individual rather than society, social problems are effectively translated into individual problems, through means which are normally regarded as humanitarian, altruistic and, subsequently, apolitical.

The dominant labellers, then, although often facilitated by the medical profession, may not, in fact, be physicians themselves. Rather, those with the power to define illness could be anyone with particular commercial or other non-medical motives and self-interests. Labelling theory proceeds by examining the social circumstances under which certain diseases are ‘discovered’ and Subsequently exploited by groups with a vested interest in commercial gain or power consolidation of some type. One way of exploit- ing the power to define health and illness is to engage in profit-seeking commercial enterprises by promoting and marketing ‘cures’ or treatments. Other forms of exploitation involve authority figures in society, such as teachers and parents, attempting to ‘regulate’ behaviour through medical labelling processes. Such was the case,according to Conrad (1975) with the ‘discovery’ of hyperkinesis and the widespread usage of ritalin in an attempt to control disruptive behaviour in school-age children. According to this school of thought, the dominant labellers of disease are not necessarily, (indeed, not often), doctors, but any group or individual who has acquired the morally legitimated authority to impose definitions of health and illness on groups of lesser power. Such labellers are aptly referred to as ‘moral entrepreneurs,’ a term well-known to sociologists acquainted with the work of Howard Becker.

A recent feminist adaptation of this model is found in Frances McRae’s study of the ‘discovery’ of menopause as a disease entity (McRae, 1983). McRae traces the ‘discovery’ (or medicalization) of menopause to the commercial interests responsible for promoting the dissemination of synthetic estrogen in the early 1960s. The author discovered that a program original- ly (and one may say ironically) aimed at curing male impotence created a market for, and an interest in, hormone replacement therapy. Among the promoters of estrogen replacement therapy was Robert A. Wilson, who founded an institution to promote research on estrogen with the assistance of a 1.3 million dollar grant from the pharmaceutical industry. The ultimate ‘discovery’ of menopause as a ‘deficiency disease’, according to McRae, came with the publication of Wilson’s Feminine Foreuer (1966, cited in McRae, 1983) where he describes menopausal women as ‘living decay’. McRae’s central thesis is that by ‘individualizing’ the problems of menopause, physicians and other ‘moral entrepreneurs’ turn attention away from social structural interpretations of women’s conditions, and more importantly from the power structures in society which facilitate medical labelling. By accepting a medical model of menopause, McRae argues that the locus of the solution, then, becomes the medical/industrial complex itself, ever ready to exploit women’s passivity, dependency, and culturally conditioned fear of loss of femininity, where the ‘vulnerable status of women makes fertile ground for medical imperialism’ (McRae, 1983: 120).

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In adopting this model, McRae and other feminists writing in this tradition have indeed identified power relations in society which influence the medical latklling process. Moreover, these analyses do place the sick role in a larger social, political and historical framework, a theoretical strategy which, as pointed out earlier, is distinctly lacking in the original Parsonian model.

There are major problems, however, in limiting analyses to the identifica- tion and exploration of those who create medical knowledge. This problem may be conceptualized as an inability to distinguish between ‘naming’ and *explaining’; which, in feminist theories of illness labelling involves ‘naming’ the ideological strategies of a patriarchal elite, without proceeding to explain how those strategies actually work. We need only pause to reflect on the tautologies present in an argument which infers abstract concepts such as patriarchy, misogyny or even commercial self-interest from observations of social life, and then imposes them back as explanations for the ordered phenomena out of which they were inferred in the first place. In other words, in the pr ess of abstraction, abstract concepts and categories are given causal force. What is not taken into consideration in the analyses cited above, is the fact that women are, as Margrit Eichler points out (1985: 622) historical actors as well as ‘the acted upon’; subjects as well as objects. While the dominant medical labellers are named, what is not explained is the process by which women themselves adopt certain illness categories at certain periods in social history, while rejecting others. As mentioned earlier, it has never been adequately explained why at this time in the history of our culture, the premenstrual syndrome has gained such immediate and pervasive notoriety when equally obscure and undifferentiated (and therefore potentially exploitable) syndromes, such as the Epstein Barr Virus Syndrome,or even the Toxic Shock Syndrome have received little attention, by comparison. It has never been adequately explained why young adoles- cent women, and not older or prepubescent women, or men of any age, tend more readily to succumb to anorexia nervosa. This is not to say that attempts have not been made to explain the differential adoption of illness roles and categories of disease by age, class and gender. But many such attempts merely speculate on the role of the media and other social forces as ‘illness socializing agents,’ often operating on behalf of agents of social control. For example, a typical ‘explanation’ of the social distribution of anorexia nervosa argues that young women are forced to compare themselves to unrealis- tic aesthetic standards in our culture, and hence, fetishize thinness to the point of distorting their own sense of bodily realities. While there may be a certain degree of truth in these speculative discussions, the process by which ideology becomes translated into personal biographies is left unexplained.

Until we attempt to understand the intervening reality construction and selection processes linking the production of categories of knowledge to their eventual adoption as personal biography, much of the phenomenon of illness labelling will remain steeped in tautological reasoning. The following discussion is directed towards suggesting a preliminary conceptual schema capable of delineating those processes.

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PHENOMENOLOGY, CORRESPONDENCE THEORY AND CULTURE-BOUND ILLNESS CATEGORIES

At present, the most effective paradigm capable of investigating the link between categories of knowledge and personal biographies is the phenomenological approach articulated in the work of Berger and Luck- mann (1967) and Berger and Kellner (1970). Berger and Luckmann’s The Social Construction of Reality (1967) develops a general epistemology of the nature of reality construction. Berger and Kellner’s widely cited study entitled ‘Marriage and the Construction of Reality’ (1970) emphasizes a more situated context for reality construction processes, and in that respect provides a useful starting point for building a more comprehensive paradigm of illness behaviour.

Berger and Kellner’s central premise is that marriage is the key milieu or social context in which prevailing cultural categories and social arrangements become translated into personal biographies. Since we cannot per- ceive the world as a whole, Berger and Kellner argue, we need to ‘mediate’ this larger reality through face to face encounters with our intimates. This mediation process involves daily conversations where the social world becomes ‘our world’, duly translated and personalized to the extent that we no longer recognize a clear-cut distinction between the public and private spheres of meaning. While we construct personal meanings as social reality during the course of interaction, we simultaneously experience this reality as somehow ‘out there’ awaiting our arrival on the scene. When this private- ly constructed, but externally perceived, reality is presented to us for valida- tion, the final legitimation process is secured almost exclusively through daily conversations with our spouses (Berger and Kellner, 1970). The authors emphasize, moreover, that the reality bestowing force of social relationships depends not on proximity per se, (as Goffman, for example, would argue) but on those face to face encounters which are ‘credited with primary significance’ (Berger and Kellner, 1970: 53)’ where an investment in the relationship influences the reality construction processes (even to the extent to where spouses of’ten ‘rediscover’ and reconstruct their past).

Berger and Kellner’s paradigm of marriage as the central reality bestowing context of social life remained virtually unchallenged until very recently. In an attempt to make the Berger and Kellner thesis relevant to current social relationships, Norbert Wiley (1983) argues that their model of the marital conversation was grounded too much in a post-war version of an ‘unusually talkative’ family. Wiley suggests, rather, that family structures have changed to include single as well as dual parent families; other social contexts often take the place of (or compete with) the marital dyad as primary groups charged with emotional investments and narcissistic involvements with self esteem and identity formation. Moreover, Wiley (1983: 27) argues that because of these narcissistic involvements, marital conversations are more highly invested with emotional, irrational, unconscious needs; characteristics of reality construction processes which are receiving long overdue attention in non-clinical modes of investigation.

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The social-phenomenological models, then, argue that marriage or some other socig context capable of continued face to face encounters and credited with primary affective investments provides the key reality-bestowing context for making sense of social life. Given that the inner world of illness requires as much ‘mediation’ or ‘making sense’ as the outer world of social action, then the family or some parallel primary group, according to this model, would be essential to that reality bestowing process. Since the adoption of an illness role is central to one’s identity, self-esteem, and strategies of relating to intimates, it seems worthwhile to explore the influence that groups credited with primary significance have on the way in which the meaning of illness is negotiated and ultimately adopted by individuals faced with the necessity to code or recode certain bodily events as health or illness. The phenomenological orientation inherent in the Berger and Kellner thesis provides a logical corrective to the social control/labelling theories of illness behaviour.

The implications of incorporating a more phenomenologically oriented approach, while providing a corrective to current models on the one hand, challenge certain central assumptions contained in those models, on the other. Essentially, in graffing the Berger and Kellner thesis to the social control model, the doctodpatient relationship may no longer be regarded as the central reality bestowing context in determining illness categories. Rather, the ‘labelling role’ of the physician might best be regarded as one of providing an external reference point which merely poses the category, so to speak. In other words, the labelling processes characterizing the doctor/patient interaction might be conceptualized as relevant only to one phase of the reality construction process; that phase which presents the possibility of either adopting or rejecting a medical label. Indeed, in support of incorporating a phenomenological orientation as a corrective to the current emphasis on doctors as the dominant labellers in society, one need only refer to the extensive literature on patient non-compliance with medical advice (Mumford, 1983: 515). As further evidence of the role primary groups play in central reality be-

stowing contexts determining illness roles, one may refer to the more clini- cally oriented literature on family scapegoating (Vogel and Bell, 1968); family symptom carriers (Minuchin et al., 1978) and family identified patients (Satir, 1964). These models examine how family members come to be labelled ill, particularly when the illness state appears to have no organic cause. There is considerable empirical evidence, for example, documenting how irrational processes characterizing family interaction operate to create ‘identified patients’. In such families, less powerful members often acquire an illness state which, upon clinical examination, is seen to symbolize conflicts felt by more powerful members. For example, if status achievement was an issue which caused spousal conflict and disillusionment, it was often observed that a child in the family would acquire a condition or disability which affected his or her academic achievement. This designation of the ‘identified patient’ is a process which Good and Good (1981: 179) suggest is much the same as dream symbolization where the illness labels, like dreams,


come to condense ‘a network of significant experiences and symbols’ signify- ing highly affect-laden events arising in the patient’s life. Family theorists, such as Vogel and Bell, (1968) argue that these labels derive, not out of individual experiences, but out of group conceptualizations, values, and meanings associated with the symptoms.

A case in point is anorexia nervosa. Refusing to eat always involves issues of control (either self-control, or parental control and manipulation) at some level. The anorectic symptom as expressed in the child may embody (and therefore absorb) the meanings and feelings attached to issues of control which plague the entire family. In such cases, the husband may not feel he exerts appropriate control over his wife’s behaviour; she over his; they over their children. The resultant feelings are lack of self-esteem, fear of loss of control, and general disillusionment with the ability to participate effectively in intimate relationships. Because these issues are often too conflict laden and emotionally charged to be confronted openly by the adult members, the symbolic content of the illness category, anorexia, invites expression of these feelings in less threatening and more easily contained interactional circumstances. (See Minuchin et al., 1978, for a discussion of how these illness labelling processes operate within families.)

The clinical phenomenological models of reality construction, then, provide an important corrective to the emphasis placed on the centrality of the medical profession as the dominant labellers of illness. Although these models are outside what one may regard as ‘mainstream’ sociology, they do provide empirical evidence of the key role families and other primary groups play in organizing the way in which the meaning of illness becomes negotiated. Moreover, and perhaps of even greater value to medical sociology, the clinical approaches provide a highly refined qualitative methodology designed to observe and code the structure of meaning embedded in interaction.

The influence of culture and its impact on the illness labelling process, however, requires further refinement within these models. While the clini- caUphenomenologica1 models acknowledge and often discuss the importance of cultural background in the illness construction processes, they have not developed a systematic model for examining the selection processes involved in the way certain social groups afford certain disease categories credibility, while ignoring others. In other words, the clinical/phenomenological frameworks emphasize the important aspect of reality construction processes, but pay less attention to reality selection processes. These models do not attempt to account for the intervening structural and cultural conditions which afford some categories of illness plausibility, while others remain relatively unacknowledged, despite their ‘discovery’ by moral entrepreneurs or other agents of social control. It is the selection process discussed earlier as an important third step in the social construction of medical knowledge which requires much stronger theoretical development in both medical and clinical sociology, and most particularly feminist analyses developed within these sub-disciplines.

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The process by which categories of knowledge are selectively credited with plausibility is best addressed by what Robert Wuthnow (1985) calls ‘correspondence theory’. The major proponents of this model are most interested in how ideology becomes legitimated and subsequently experienced as normal, day-to-day, social life. The central premise of the correspondence model is this: the extent to which new forms of knowledge will be collectively internalized or credited with plausibility will depend upon the extent to which they are dramatized by both existing social beliefs and existing social practices - what Wuthnow terms, ‘vital aspects of collective life’ (Wuthnow, 1985: 800). Accordingly, Weber (1958) has argued that the modern concept of capitalism derives, at least in part, from earlier practices of Calvinism. More recently, Wilson (1977) argued that the contours of American ideology with its inherently unreflexive view of social life derives not merely from a commitment to, but the actual practice of, scientific rationalism (thus demonstrating Wuthnow’s point (1985: 801) that a rational ideology will be more likely to emerge within a ‘rationally organized society’).

The correspondence model argues further that the genesis of new ideological forms can be traced by examining the social and cultural filter- ing processes (what Wuthnow terms ‘plausibility structures’) through which they have been disseminated - often randomly, and often without apparent conspiratorial intent.5 Medical anthropologists, for example, have long recognized the importance of examining the influence of plausibility structures or cultural pathways on the selection of illness categories among non western world cultures. This school argues that illness categories often condense meanings and symbolize a number of culturdly-specific experien- tial currents in a patient’s life. Medical anthropologists, Good and Good (1980) have discussed obesity as a culture-bound pathology in western world societies. In our society, Good and Good argue, we place a high premium on mastery, instrumentality, and rationality. To be overweight denotes a lack of control, self-indulgence, and an irrational tendency to engage in non-in- strumental (indeed, self-destructive) behaviour. Obesity, then, may be regarded as a physiological pathology which mirrors a social pathology. Con- sequently, the labelling of obesity as an illness category is more likely to occur in a society such as ours where self-control and self-mastery have become strong cultural preoccupations.

To summarize the argument thus far: social control models provide a framework for identifying the conditions under which categories of medical knowledge become introduced and promoted in our society. Social control theory, therefore, has provided an important contribution to the sociological and anthropological study of illness labelling. However, a more comprehensive framework as suggested by correspondence theory is required to accommodate the phenomenological component of illness labelling, and to investigate the plausibility structures through which illness categories become duly disseminated. Such a model would 11 acknowledge and discuss the primary role the medical/industrial process plays in introducing and promoting illness categories; 21 provide some conceptual schema and method for determining how those illness categories become selectively


chosen by some and not others, and 3/ incorporate a conceptual and methodological framework capable of examining the information processing dynamic wherein illness categories become translated into personal biography at the level of small, primary group interaction. In other words, the social production of any form of knowledge involves three fundamental steps; I./ the introduction or provision of abstract categories of knowledge; 2/ the selection process by which some categories (and not others) are enter- tained as relevant to one’s own social situation; and 3/ the meaning negotia- tion processes which endow abstract categories of knowledge with personal meaning, such that the social world of illness becomes ‘our world’.

My own research on the medicalization of menstruation was instrumen- tal in suggesting the need for a more comprehensive model of illne s be-

of all, it became obvious from the findings that the medical profession was not as influential in ‘promoting’ the disease known today as the premenstrual syndrome as social control models would predict. Indeed, in a sample of 244 licensed female dental hygienists (a profession with a higher than average knowledge of anatomy and biology) only 8.15 per cent (ap- proximately 30) reported that they first heard of the premenstrual syndrome from a doctor. The sources most often cited as the initial purveyor of information on the premenstrual syndrome were women’s magazines, ac- counting for 26.6 per cent of the responses. Other labelling sources cited were randomly dispersed among friends, family members, women’s groups, and television shows.7 Despite the lack of medically legitimated knowledge of this illness state, 43 per cent of the sample labelled themselves sufferers of the premenstrual syndrome - a finding which suggests that doctors are not as influential in the medical labelling processes as many feminist analyses assume. It seemed obvious from these data that other intervening interactional variables beyond the doctor patient relationship were influencing the medical labelling process within this sample of women. It therefore became important to re-examine the efficacy of the current theoretical models attempting to explain the social construction of medical knowledge.

Furthermore, a preliminary analysis of the interview data suggested that the interactional dynamics contained most particularly within the family context had more to do with the adoption of pms as an illness state than either the medical profession or the media. The interview data tended to support the clinical phenomenological premise that under certain conditions illness states may be socially constructed and sustained out of family interactional needs to absorb more conflict laden and disruptive issues that threaten the stability of the spousal and parent dyads. I t became evident from certain of my interviews that the premenstrual phase absorbed a number of conflicts which would otherwise have been disruptive to family functioning. For example, the ‘meaning’ of much of the discontent these women experienced with regard to their marriages, and dual career obligations, became condensed under the general heading of an ‘illness,’ and came to be understood as the result of a temporary biological aberration rather than the manifestation of an enduring social problem. In other words, many

haviour in women than the current feminist analyses have provided. d First

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of the respondents in this study could only legitimate feelings of anger and frustration (largely arising out of dual career obligations) when they were understood to be biblogical rather than social relational responses. The concept of ‘identified patient’ introduced earlier appeared to be operative in some of the primary group contexts of the women interviewed. Hence, despite their almost exclusive clinical usage, the data suggest that this concept is one which deserves more attention in non-clinical, phenomenological studies of similar phenomena.

The very topic of my research - the medicalization of menstruation - suggested the need to investigate models which were more sensitive to the impact of culture (and not merely the political culture) and social structure on the social experience of illness. The role of culture in facilitating the widespread adoption of pms as an illness state becomes apparent, as well, when one explores how the contradictio s and inconsistencies surrounding the research on causes and cures of pms reflect the broader social and cultural ambivalences held with regard to menstruation and fertility. One has only to peruse current advertisements for menstrual products to ascertain that the ‘aesthetics’ (indeed, the reality) of menstruation borders on denial rather than full expression of womanhood. One has only to peruse current cultural stereotypes of the sexually attractive woman to see that theprepub- secent, ‘infantilized’ look continues to represent an idealized form of femininity. Yet, alongside these symbolic representations, stands a paradoxical celebration of fertility with the support of the pro-family movement in Canada, and with the symbolic support of large families through such media representations as ‘Family Ties,’ ‘Eight is Enough’ and ‘The Cosby Show’. Perhaps the strongest example of our own cultural am- bivalence towards fertility is the long-standing debate, despite the current legislative changes, on abortion on demand. These ambivalences we hold with respect to the cultural value of fertility may be seen to be reconstituted in the contradictions and inconsistencies characteristic of premenstrual syndrome symptom-reporting.

Distinct differences in the way in which the premenstrual illness state was expressed and experienced in the workplace and the home, were found, as well. No existing theory in the traditional labellinglsocial control models could account for these differences. For example, where one woman was con- stantly experiencing problems with physical co-ordination at home during her premenstrual phase, she experienced no problems with manual dex- terity while working with patients in the dentist’s office; a situation for which she herself had no explanation. Others who routinely shipped children out to neighbours, family and friends during the premenstrual phase (when mood shifts and feelings of loss of control were at their peak) reported no changes in interactional, affective-expressive, or affective-ex- periential patterns involving even the most difficult clients (generally referred to as the ‘nervous types’ and ‘chronic complainers’). Again, no explanations were offered, and when this anomaly was pointed out, it was as if the contradiction were being noted for the first time.

rg


It therefore became necessary to investigate theories which could account for these inconsistencies in the social experience of illness. A correspondence orientation which investigates the link between social structure, including cultural preoccupations and practices, and the social experience of illness was deemed the most appropriate. For example, an important corollary to the correspondence thesis is the notion that symptoms experienced at different times and in different social contexts within the same culture will be understood and labelled differently (Swartz, 1985: 728). What could then be inferred from my observations is not merely the commonplace observation that social context affects reality construction processes but that different social contexts provide different cultural ‘pathways’ which allow for the legitimation and subsequent integration of the illness role. The metaphors associated with the illness state known as the premenstrual syndrome simp- ly do not prevail in work settings where the interactional dynamics that both shape and sustain the meaning of illness do not allow for its structural integration in these contexts. As Good and Good (1981) point out, ours is a culture which places a high value on self-determination and self-mastery. One may add that ours is a culture which values self-discipline and control, largely in its public domain, while the family, our ‘Haven in a Heartless World,’ is the domain where the irrational, affective needs of which Wiley spoke, can be more appropriately expressed. Menstruation, with its often unpredictable emotional and endocrinological disruptions, represents the physiological obverse of the social values described by Good and Good: self- mastery, control, self-discipline. Hence, in the private sphere of the family, where emotions may run high, where irrational needs are more likely to be acted out, where lack of predictability and control are more often the rule than the exception in characterizing family relational patterns, and where the meanings of day-to-day encounters of family life are likely to become condensed in an illness role, the premenstrual syndrome has a much greater chance of becoming structurally integrated as a credible and appropriate illness state. In the more rationally ordered public domain of the workplace, however, illness states which incorporate an affective component and which appear to express or to mirror uncontrolled, irrational, affectively-charged needs, are much less likely to be afforded credibility and gain legitimacy not only of expression, but of meaning and experience as well.

SUMMARY

The foregoing discussion has presented a conceptual schema to augment the current feminist analyses of illness behaviour in women. It has suggested that the social construction of medical knowledge and its subsequent adoption by social groups involves a three step process. The first stage of this process involves the productional activities of those we generally consider the dominant labellers or social control agents in society; the medical profession, members of the medical-industrial complex, such as pharmaceutical companies, the state, and other groups with commercial, professional and political self-interests. The current analyses of illness behaviour generally

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focus the discussion on this aspect of the labelling process alone. Two other stages in reality construction processes, however, need to be explored to account for l/ the selective adoption of certain illness categories over others and 2/ the translation of those categories into personal biographies of illness. The latter stage of this labelling process requires a strong phenomenological orientation which feminist theory has always upheld as one of its primary mandates. The former stage of this process requires in- tegrating a correspondence model into the existing social control theories in order to detect the structural arrangements and cultural preoccupations which facilitate the legitimation of new illness categories such as the premenstrual syndrome. The author’s current research on the premenstrual syndrome was then discussed in terms of its relevance for the conceptual schema suggested here.

NOTES

Women’s reproductive ‘events’ have often been cited as the main reason for their excess morbidity and subsequently higher usage of healthcare services than men. (See Verbrugge, 1985; and Trypuc, 1984, for a discussion of this position.) It is argued here that the female reproductive function engenders an inordinately high level of past and present abuse by a male dominated medical profession. Feminists view the historical use of such medical practices as ovariotomies and clitoridectomies, as well as the current ‘over medicalization’ of childbirth, as empirical indicators of patriarchal forms of control. (See, for example, Weitz and Sullivan, 1986.) The ‘Epstein Barr Virus Syndrome,’ sometimes referred to as the ‘Yuppie Disease’ is, like pms, a relatively undifferentiated syndrome which incorporates such symptoms as chronic fatigue, depression, and lethargy. The syndrome is believed to be caused by the same virus which is responsible for mononucleosis. While the Epstein Barr Virus Syndrome has received some attention recently, it was ‘discovered’ some years ago, and has not been collectively embraced by the upper-middle, upwardly mobile population from which it derived its colloquial namesake. In a paper entitled ‘Male culture and purdah for women: the social construction of what women think women think,’ Sylvia Hale (1988) explains this process eloquently. Draw- ing heavily on the works of Dorothy Smith, Hale argues that in the social sciences what passes for fact involves the procedures by which data are gathered, analysed and then imposed back as explanations for behaviour. Abstract concepts such as norms, values, and culture are often invoked to impose order upon data, and are then, in turn, given causal force. The social meanings of the original behaviour - the reasons people have for giving certain answers to certain types of questions; the meanings actors attribute to ac- tions - become lost, while the concepts themselves become taken for granted as social facts. Quaiitative researchers in sociology have only just begun to refer to clinical techniques in their methodological strategies. See Good and Good, (1981) for a discussion of clinical interviewing techniques; Brathwaite and Lunn (1985) for the use of projective analyses, and Yolles (1986) for a discussion of transference between interviewer and respondent. It should be noted, however, that ‘cultural pathways’ are themselves prefigured to some extent by the prevailing power structures. As KIeinman (1980: 41) argues, any cultural system is grounded in concepts and sources of legitimated power. Hence, medical categories or vocabularies of illness will reflect certain contours of these power structures. There is a major difference between the way the concept of power is treated by


the correspondence approach and the way it is treated by the social control model, however. The latter assumes a direct, unmediated, relationship between political self-interests and the creation (and subsequent adoption) of illness labels. The correspondence model is more sensitive to the mediating processes of cultural pathways which harbour different degrees and manifestations of the prevailing power structures. This study was conducted in conjunction with two colleagues affiliated with the Univer- sity of Toronto, Dr. Norman Bell and Ms. Dorothea Sweeney. The findings cited here form part of a larger data set collected for my doctoral dissertation, the purpose of which is to examine the relationship between social context and the social experience of illness. Notably, of all the mass media sources cited by women in this sample, not one referred to what is generally regarded by both academics and non-academics as the major authoritative source on pms: Katharine Dalton’s book, Once a Month. This suggests that more research on the role women’s magazines play in medical labelling processes is required. Researchers of the premenstrual syndrome find little agreement as to the universality of symptoms. Tension, anxiety, depression, irritability, hostility and certain physiological symptoms such as abdominal pain and breast tenderness are generally agreed upon as the more common traits of the syndrome. However, other symptoms such as agoraphobia and certain forms of psychoses believed to be related to the syndrome do not meet with the agreement of all (Abplanalp, 1983; Clare, 1983). Modes of treatment range from hormone replacement therapy to psychotherapy, but recent studies here in Canada and in the United States report a high incidence of the placebo effect in ex- perimental studies. (See Abplanalp, 1983; The Toronto Star, March 28, 1987). While Dal- ton (1982) claims that periodicity is the main criterion for delineating the syndrome, recent studies show that from 50 to 80% of women who seek treatment for pms have ab- solutely no symptom free phase (Hopsen and Rosenfeld, 1984).

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