I am maturing fast now, but no sign of a period. Is it not needed yet, or? ...... Bransen, E. (1992) Has menstruation ever been medicalized? Or will it never happen.
Sociology of Health & Illness Vol. 20 No.1 1998 ISSN 0141–9889, pp. 52–70
Medicalisation by whom? Accounts of menstruation conveyed by young women and medical experts in medical advisory columns Elina Oinas Department of Sociology, Abo Akademi University, Finland
Abstract The term medicalisation is considered in the light of an empirical study on menstruation as discussed in medical advisory columns. The focus is on how the medical profession responds to young women’s questions about their maturing bodies. The questions are seldom of a medical nature; rather, they are concerned with normality and coping with menstruation in everyday life. The doctors’ response is clear: the patient need not worry, the medical profession is both willing and able to take over the responsibility for, and control over, the body. The medicalisation of menstruation that can be found in advisory columns strengthens the position of the medical establishment as the legitimate authority on the body. Nevertheless, the letters sent to the magazines do not lend support to the idea of medicalisation as an endeavor pursued by the medical profession alone. The letters are also a means whereby young women try to establish standards for proper female gender behaviour in an area where lay society remains silent.
Keywords: medicalisation, menstruation, adolescence, female body, gendered health
Introduction The term medicalisation has been a key concept in the field of the sociology of health and illness. With this concept, sociologists have tried to capture the transfer of knowledge and decision-making concerning health from lay people to the medical profession (Zola 1972, Conrad and Schneider 1980, Conrad 1992). Over the past 30 years, sociologists have generally used this concept to characterise a negative development in western societies, i.e. the increasing social control of everyday life by medical experts. The dichoto© Blackwell Publishers Ltd/Editorial Board 1998. Published by Blackwell Publishers, 108 Cowley Road, Oxford OX4 1JF, UK and 350 Main Street, Malden MA02148, USA.
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mous notion of the medical profession as powerful and the lay society or patients as passive victims, which has traditionally been inherent in the medicalisation concept, has, however, more recently been questioned (e.g. McLean 1990, Dull and West 1991, Becker and Nachtigall 1992, Bransen 1992, Wiles and Higgins 1996, Broom and Woodward 1996). The relationship between modern medicine and lay populace appears to be more complex than the earlier sociological theories suggest (Williams and Calnan 1996). Williams and Calnan call for further qualitative and ethnographic research on this so far rather neglected but theoretically central area within the sociology of health and illness. In the debate about the medicalisation of various aspects of everyday life, women have been presented as a group particularly vulnerable to the expansionist endeavours of the medical profession (Ehrenreich and English 1979). This genre of research has focused on women’s reproductive health (Lupton 1994). Radical feminists have identified the patriarchal society and its extension – patriarchal medicine – as the key forces behind the medicalisation of an ever-increasing part of women’s health concerns (Ehrenreich and English 1979, Oakley 1980, Corea 1985a, 1985b, Daly 1990). This interpretation has been challenged by others who see a more complex process of alliances between various groups of the medical profession and various groups of women differentiated, for example, by social class (Riessman 1983). This latter interpretation suggests that the medicalisation of women’s bodies has tended to be a matter of gains and losses for various groups of women. Hence, different groups of women with conflicting interests have either actively participated in or been affected by the medicalisation of women’s life events and health. This suggests that women can neither be viewed as a homogeneous group (Lorber 1994, Doyal 1995) nor as passive victims of the medicalisation process (Gabe and Calnan 1989, Bransen 1992, Denny 1996). This paper addresses the issue of knowledge claims about the body: whose knowledge matters when bodily processes are discussed? It examines how the medical establishment responds to young women’s questions about their maturing bodies. The empirical material of this study consists of medical advisory columns in general health magazines, women’s magazines, and youth magazines. The importance of magazines and other life-style guides for identity formation in current consumerist cultures has been convincingly presented by Aldridge (1994) and Warde (1994). Yet, the influence of the magazines on their readers’ behaviours and values is not a simple one-way indoctrination (Barker 1989, Kehily 1996). Barker suggests that the possible influence depends on a tacit ‘contract’ between the magazine and the reader. The text must ‘relate to some aspects of our lives in our society’ (1989: 261). The data of this study consist of the published letters sent to the magazines and the answers given by the medical experts. The columns have an important role in the public discourse on menstruation since they are among the few public arenas where the phenomenon is © Blackwell Publishers Ltd/Editorial Board 1998
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brought up. The by now rich sociological literature on menstruation in western cultures shows that the experience of menstruation is marked by three features: silence, shame and medicalisation (Patterson and Hale 1985, Martin 1987, Laws 1990, George and Murcott 1992, Block et al. 1993, Lovering 1995, Prendergast 1995, Lee and Sasser-Coen 1996). The concepts of silence and medicalisation form the key issues of this study. Silences as components of a discourse are as important as any text or talk (Foucault 1981). The way the silence around menstruation is met by the medical experts in the columns is the key question of the empirical study. The basic assumption of this study is that there are alternative ways in which doctors could answer the questions in the letters. Medicine is not an objective science in the sense that it exists outside, or above, culture and society. On the contrary, medicine is part of culture, a social institution that is both formed by society and an active agent forming that society. The theoretical frame of reference used for the study is Foucault’s views on knowledge and power (Foucault 1977, 1984). There are, however, differing readings of Foucault within the sociology of health and illness. They probably derive from the differences, even contradictions, in Foucault’s earlier and later work. In The Birth of the Clinic (Foucault 1973 [1963]), which is widely used by health researchers, the medical gaze and regimen create a ‘panoptic system of surveillance’ of the population. Social control is the theme, as it is in the earlier understandings of the notion of medicalisation. Foucault’s later work, in contrast, emphasises more subtle, individualised ‘technologies of the self’ (Foucault 1988), that is, constructive elements in all discursive practices. Here, I try to show that a combination of both readings is possible. The analysis of the medical experts’ answers is based on the notion of discursively produced ‘docile’ bodies. Nevertheless, the argument put forward here is that medicalisation is not only an endeavour pursued by the medical profession. It is also a way whereby the young women construct themselves as they explore the boundaries of proper female gender behaviour and the ‘normality’ of the female body.
Method and material The material used for this study was taken from medical advisory columns in Finnish health, youth, and women’s magazines in 1991. Among all journals in these categories in Finland, ten magazines had a medical advisory column. All letters and answers in these were examined. The final material consists of all the letters and answers that relate to menstruation. The number of letters-answers is 142.1 The columns give information about the interaction between lay persons and the medical establishment. The unusual situation, treating a ‘patient’ on a page of a magazine, can be regarded positively in a study of medical discourse and medicalisation. A doctor has to be careful when she or he © Blackwell Publishers Ltd/Editorial Board 1998
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writes statements that could be read by her or his colleagues. Doctors hardly want to risk their reputation within the profession, let alone the advertisement value that the column has for the doctor. Group discipline within a profession must be strong in order to legitimate its monopoly within a certain area (Freidson 1970). Hence, I consider the answers given by the 15 doctors in the material to represent wider, commonly accepted views within the profession. The doctors’ responses included in the material are written by eight men and seven women. Some, but not all, of the doctors are specialists in gynecology.
Letters: normality and control Those who write letters to magazines can hardly be deemed representative of all young women in Finland. On the contrary, they represent a special group who do not have other access to information. Generally, these letter writers are young – mostly teenagers. Only a few letters in my study had been written by women older than 25, and some by 12-year-old girls. In the medical advisory columns menstruation is a frequently appearing topic. Indeed, in magazines directed to youth, it is the most common individual issue.2 The questions posed concern three major issues: normal menstrual cycle and flow, menstrual problems, and everyday life routines while menstruating. Normality The largest group of questions, almost half the total number, asks for information about what the normal menstruation or menstrual cycle is.3 Mostly the writers ask whether their bodies are functioning normally. For example: Is my cycle normal, when there are 25–30 days between my periods? I am maturing fast now, but no sign of a period. Is it not needed yet, or? The vast number of questions about normality indicates that the writers are interested in their own bodies and how the body should function. Their questions reflect a normative ideal that they connect with being a woman. The body is changing, but it is hard to know whether the changes are ‘normal’ or not. Many questions are of a phenomenological nature: questions about the colour or smell of the discharge, its amount or consistency. To answer these questions seldom requires any special medical knowledge. Problems The second group of questions, more than one-fourth of the total number, are about perceived problems related to menstruation. Writers ask whether it is possible to get help for problems like pain during or before a period, heavy flow, or irregularity. Most of the problems are conceived as normal © Blackwell Publishers Ltd/Editorial Board 1998
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but inconvenient. Help is not asked for maintaining or gaining physical health, but for making everyday life easier: Dear Doc! Please tell me what I can do when menstrual flow is really heavy. I am 14 years old and I have had my period for two years. My cycle is rather regular and the flow takes 6–8 days. What shall I do when blood is pouring like from a shower and I always have to wear both one night and one regular pad at the same time. At school I am always afraid of the flow leaking through my pants. I wouldn’t want to visit a doctor (pseudonym Big Love4). What other medication is there for menstrual pain besides headache pills? I have rather heavy pain. Is there a reason to go to the doctor because of it? Hi Doctor! My problem is my period, it is really irregular. It comes any time. Sometimes the flow is one day, then nothing for weeks and then again flow for a solid week. I can’t stand this thing. Is there no way of getting rid of it altogether? You see, I am not going to have children (pseudonym Bonne Annee -77). In many of these letters the actual question is how to live as if not menstruating – that is, how to avoid breaking the ‘taboo’ of menstruation (see Buckley and Gottlieb 1988). Laws (1990) has suggested that the notion of ‘etiquette’ should be used instead of ‘taboo’. ‘Taboo’ is traditionally based on a belief in supernatural powers, which is seldom the case in western societies. Rather, the silence has to do with social sanctioning, like ridicule and criticism, of those who do not follow the etiquette. Often, central to the notion of etiquette is the emphasis on hierarchical relations between different groups of people. In the case of menstruation, etiquette marks out the hierarchy of power between men and women: women should not make men aware of the existence of menstruation either implicitly or explicitly. This social rule is clearly internalised by the writers of the letters. In fact, it is even extended to cover situations and places understood as masculine – for example, public places. One effect of the etiquette is that women have to put great effort into trying to live as if they do not menstruate (Block et al. 1993, Berg and Block Coutts 1993, Prendergast 1995). Thus, the experience of menstruation is dominated by the efforts of concealment, and the body is viewed from the spectator’s perspective (see Patterson and Hale 1985, Martin 1987, Ussher 1989, George and Murcott 1992, Lee 1994, Prendergast 1995). The negative feelings towards menstruation in the letters are mostly caused by the practical difficulties of menstruating involved in getting through the day without violating the etiquette. Nevertheless, positive feelings are also frequent – for example, many girls express pride in having started to menstruate. © Blackwell Publishers Ltd/Editorial Board 1998
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Weight problems, which seem to occupy the mind of most of the writers, often cause menstrual problems. Most of the letters that involve cases of irregularity or a total absence of menstruation have to do with underweight and heavy dieting. The writers do realise that their weight and their menstrual disorders are connected, and they wonder whether they have a health problem or not. Most would not want to stop dieting, but menstruation is considered important. In the following letter the writer is worried about her fertility, but there are also letters where no explicit reason for the importance of menstruation is expressed. I am an 18-year-old girl. My periods started when I was thirteen. In the beginning it was relatively regular. At the age of fifteen I lost five kilos, with the result that I had my period less often and very irregularly. It did not concern me because I thought it would regularise with time. A year ago I went to a doctor. The gynecological examination showed nothing abnormal. The doctor said the regularity will return, because I am not underweight. The situation is still bothering me, since I have periods only five times a year. Do I have a well-founded reason to worry? Can infrequent periods cause infertility? Is a hormonal treatment the only way to solve the situation? I exercise some and eat a variety of vegetable-based food (Summergrass -71).
Routines The third group of questions, slightly under one-fourth of the questions, deals with routines of everyday life with menstruation: Can you swim, exercise, have sex, go to the sauna, etc? Some ask about the proper way or frequency of washing oneself. The use of tampons gives rise to many questions. This is a typical letter: Help! I am a 12-year-old girl and I have a few problems. I am overweight, I am 152 cm tall and weigh 47 kg. I have a lot of kilos around my stomach – how can I lose weight? Secondly, my menstruation started recently. Can I swim during my period? I use pads, I don’t know how to use tampons. A visit to a gynecologist is often asked about or commented on. Many say straight out that they are not going to go, others ask about details: how much does a visit cost, can you choose between a male or female doctor, and what happens during a visit. A recent survey has shown that timidity and shame are in fact major factors hindering young women’s usage of gynecological health care in Finland (Sihvo et al. 1995). The common theme running through all the letters is insecurity and anxiety. The last group of questions about routines in particular indicates that © Blackwell Publishers Ltd/Editorial Board 1998
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there is an urgent need for information, and almost no sources available. Most of the questions are not medical. They could be asked of almost any woman or teenage girl. Still, these young women write to a magazine and ask a doctor. It is obvious that there is a strict silence related to menstruation as well as to sexual maturing on the whole in society. ‘Etiquette’ prevents young women from seeking information in some other way. In many letters the column is praised as very important, for example: ‘Thank you for the column, it has given me peace of mind . . .’ (Pseudonym Worried). Whether these young women regard a medical expert as the only authority on their bodies is not obvious. It is possible that at least some write to a magazine because there is no other way of asking anonymously without violating the etiquette. However, the letters imply an unquestioned confidence in medicine. The writers appear to expect the doctor to have the ultimately true and right answers. In the case of questions about normality the writers seem to be convinced that there is an ideal or natural body, with which her own can be compared and measured. Even if the letters express an evident interest in the writer’s own body (Lee 1994), they also express an inability to know and understand the body without a doctor’s assistance. The separation between the ‘self’ and the ‘body’ is obvious (Bransen 1992). The body is something almost frightening and foreign, and a doctor’s reassurance that everything is as it is supposed to be is needed. The internalised requirement of concealing and controling bodily functions in public underlies the need for getting medical assistance. The findings do not lend support to the notion of a decline in public confidence in biomedicine (see Weitz 1996: 235), rather they indicate that the writers are unknowingly promoting a medicalisation of menstruation. Their letters constitute a setting where the writer is asking medical experts to provide a manual of procedure for female gender display during menstruation. To understand the writers’ point of view a (late) Foucauldian understanding of power is useful. Along with viewing medicalisation as a strategy used by the medical profession in a search for status and domination, medicalisation can also be seen as a constitutive process in which patients voluntarily participate in order to define proper gender behaviour. In the following section I focus on the different types of medical authority that appear in the answers to the lay letters.
Medical authority and knowledge Faced with the questions presented in the letters, the doctors have alternative ways of responding, depending on which medical authority on the body the writer wishes to advocate. When the letters express an insecurity about the normality of the body, one alternative is to stress the importance of a visit to a doctor, who knows best, and simultaneously to imply that the body is always at least potentially sick. Another alternative is to encourage © Blackwell Publishers Ltd/Editorial Board 1998
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the young women to trust their own knowledge or actively to seek information, to feel and learn about the body themselves. The doctor’s response to the etiquette of menstruation has to do with medicalisation. If menstruation is to be totally hidden and not to affect daily life at all, some help from a doctor may be needed. This is shown in most of the letters about the routines and problems. Here the experts can either question the etiquette or accept (and reinforce) it. The answers provided by the doctors show that doctors indeed use the columns as a means of socialising young women to become regular and obedient users of medical services (see Riessman 1983, Klein 1991). The medicalised body image is strongly put forward in the texts. Still, the discourse is not homogeneous but shows that alternatives are possible and do exist. In most of the answers the message is ‘go and see a doctor.’ The problems that should be taken to a doctor are of different kinds. In most of the letters, they are seldom connected to any physical disorder. Whether it is greasy hair, weight problems, a violent father or loneliness at issue, the suggestion is – go to a doctor. In some answers the doctor is portrayed as a possible listener in case there is no one else: You can always go and talk to a doctor, too, even several times, just for a discussion. Listening is a part of a doctor’s job, often much more important than talking. In most of the cases the visit to a doctor is, however, suggested as an important way of maintaining good health. You can never be quite sure if everything is all right; therefore it is good to let an expert have a look. The patients’ own ability to judge is not given much credit: Dieting without asking advice of an expert is always to some degree risky for your health. Medical authority on the body is extended to such a point that it is not even necessary that the patient touches her own body. In one answer it is suggested that the writer should go to a doctor to have a tampon that has been left in the vagina removed. In other answers about the same matter it is suggested that the patient tries to remove it herself. Even if the first answer is an exception, it reveals something crucial about the discourse, one aspect of which is that the patient does not need to get involved with the interior of her body. To know and feel the body is the job of the medical profession, not the lay ‘owner’ of the body. The image of the female body created in the answers is of a body that is always at least potentially sick. In the following answer a completely healthy 19-year-old is told to face the facts of life – that is, visit a gynecologist: © Blackwell Publishers Ltd/Editorial Board 1998
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I am a 19-year-old girl and I am worried about blood clots in my menstrual flow. Last time there was a clot the size of at least my little toe. Usually these clots appear during the first days of bleeding, last time they were there daily. What are they? What happens when you go to a gynecologist? Is an examination always necessary? Would it not be enough for me to describe the symptoms? Why do the feet have to be put in those stirrups? – it is such an embarrassing posture. Does the examination hurt very much? What should I do with my problem when I am not up to visiting a gynecologist? I am also just terrified of going to a doctor (Sufferer from doctorphobia). Dear friend suffering from doctorphobia, you are by no means the only one to whom a visit to a doctor is a horror, and going to a gynecologist impossible even to think about. But there is no other way but to take the bull by the horns and adjust to the rocky side of being a woman. In treatment, a physical examination is essential, even if many things can be sorted out by a discussion. It is understandable and quite natural for a young girl to have a fearful attitude towards the first gynecological examination – after all it concerns a very intimate area. The relationship of a 19-year-old to her own body and its functions can be very confused, anxious, even shaming. In these situations good contact with a doctor can as a matter of fact help clear things up, remove fears, and ease the feeling of growing up to be a woman. You are worried about clots in your menstrual flow. When blood runs out of the body, it coagulates, and if this did not happen, we would bleed dry. This means coagulation is a normal phenomenon. The size you mentioned is not especially big, so you do not need to worry. Probably the amount of your menstrual flow is within the limits of normal. To make sure, you can have your hemoglobin measured, for example, in a health care centre. If it is normal, everything is all right. The gynecological examination you will have to face some time anyway; if not now, then later. I wish you a good doctor relationship. In a friendly, but patronising way the young woman is shown that even if the problem she has with doctors is usual, it is a matter of her own insecurity, immaturity and other qualities. She has not learned to accept all the sides of being a woman, of which seeing gynecologists is one. In contrast to most others, in this answer it is not suggested that the patient should visit a doctor because of the actual problem, blood clots. So it is even more striking that the doctor puts such an effort into urging that it is a necessity for women to visit gynecologists. It is taken for granted that this woman, like all women, will have to learn regularly to submit her genitalia and internal reproductive organs to the scrutiny of a doctor. © Blackwell Publishers Ltd/Editorial Board 1998
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The way gynecological consultancies are conducted is not problematised. The text does not answer the question about what happens in the consulting room. Instead the gynecologist tries to convince the patient to hand over control to the doctor and to trust him or her completely. The questioned patient’s posture, with the feet up, is functional for the doctor, giving not only a better working position but also total control over the situation. The position has been challenged and changed in feminist-oriented health centres in the USA (see, e.g. Federation of Feminist Women’s Health Centers 1991). The importance of a positive patient experience of the pelvic examination has recently been documented by several researchers (Williams et al. 1992, Olsson and Gullberg 1991, Frye and Weisberg 1994). Another strategy for strengthening the position of the medical profession is never to question other physicians’ treatments (Weiz 1996: 231). The letters often refer to an earlier visit to a doctor, which has left unanswered questions about a detail, or sometimes everything: In all the hurry some things remained unclear. (Grateful for information.) The doctor did not tell me anything. The fact that a patient did not get sufficient information about the diagnosis, treatment or medication does not invoke any reaction by the column doctors. It is only suggested that the patient should visit a doctor again. A false or incomplete diagnosis is not openly suspected, but it is suggested that further investigations are probably necessary. Only in one case did the doctor clearly state that he would treat the patient differently from the patient’s own doctor. The strategy of keeping up the image of never-failing medicine serves the profession at the expense of the patient. The omnipotence of medical knowledge is the underlying message in most of the material. Premenstrual syndrome (sometimes called premenstrual tension) is an exception. In two answers it is stated that the reason behind it is unknown. Still, this does not affect the necessity for treatment: Is there a disturbance in my hormone production? Just before my period I sometimes feel totally intolerable: my breasts are tender, I feel heavy and anxious. I gain weight – 1–2 kg – and I feel puffy. I cannot concentrate. The worst part is that I am more nervous than normally. Some social situations can feel quite impossible, as I cannot stay calm. My troubles start about a week before my period and then lessen at the start of it. I have had the trouble ever since I began to menstruate, which was as late as the age of 15. Now I am 24 years old. My menstrual cycle is irregular (Tomboy). The symptoms you have before menstruation belong to a well-known syndrome called premenstrual tension. Doctors do not know the exact reason for it. They have suggested several kinds of causes for it. When © Blackwell Publishers Ltd/Editorial Board 1998
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the symptoms are as disturbing as they are for you, it is certainly good to seek help. Among the different alternatives a certain kind of contraceptive pill is probably the best choice for you, especially considering what you write in the end of the letter . . . so finally I give you the usual advice: go either to a GP or to a gynecologist. Tell about your problems as frankly as you have in your letter. I am convinced that you will find help. [From both the letter and the answer, only parts that concern PMS are cited.] The rhetoric of sovereign knowledge can be seen in a new light when answers to questions about routines are examined. Questions about hygiene and risk of infections, for example, connected with swimming or sex during menstruation receive varying, even contradictory, answers. This is not surprising since there is actually no information about these issues in medical text books (Oinas 1996). Still, the arbitrary answers given are all expressed as facts. One of the fifteen doctors has a different attitude towards the dominance of medical knowledge.5 As often as she suggests a visit to a doctor, she encourages the teenagers to learn to know their own bodies and their rhythms. She suggests that the readers should actively search for information in medical [sic] books, or talk to their mothers or health care nurse at school. To give credit to mothers is unusual in medical texts, which usually have a tendency to blame mothers (Laws 1990, Oinas 1996). You can also feel with your finger which way your vagina lies in, so that you will know how to push in a tampon. In the library you can find really good books on human anatomy and physiology. There are clear pictures. Ask a librarian, if you cannot find the books yourself – normally these books are found in the medical department. Ask your mother to estimate whether the difference in the size of your breasts is really significant. Your mother has life experience, so she will certainly be happy to help you. Giving a more active role to the patient does not take away any of the authority of medical knowledge. This doctor shows that it is possible to extend the usual discourse that uses most of the column space in emphasising medical authority. Thus, giving room to the patient’s experience and knowledge does not lead to a significant loss in the status of medical knowledge. As Wiles and Higgins (1996) show in their study on private-sector consultancies, a shift from the paternalistic patient-doctor relationship towards mutuality (or even consumerism) does not present a challenge to medical authority, because the inherent imbalance of power between the © Blackwell Publishers Ltd/Editorial Board 1998
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two parties remains untouched. The model of mutuality in fact offers least threat to medical authority. Broom and Woodward (1996) have argued that it is useful to distinguish conceptually between medicalisation and medical dominance. The decrease in medical dominance presented by the doctor quoted above does not equal a demedicalisation of menstruation. The key issue for medicalisation is in the maintenance of the status of medical knowledge (Conrad 1992). As long as the superiority of medical knowledge over lay beliefs is maintained, there is no real risk of loss in medical authority. To establish or reinforce medical authority does not require subordination of the patient, even if many doctors act in such a way, as is apparent in this study. Common to all answers is a supportive attitude in nonmedical matters that do not concern the physical body. Even if the discourse presented in the answers does emphasise the superiority of medical knowledge about the body, the doctors in other ways do encourage the readers to develop an active, self-conscious attitude and responsibility in their lives. This is understandable, considering the nature of the columns: so many letters deal with nonmedical issues. In the youth magazines especially there is a lot of nonmedical advice to the teenagers, where the reader is represented as a conscious, active agent in her own development towards adulthood. The doctors offer the readers attentive support alongside more conventional medical intervention (see Gabe and Calnan 1989). This support may be characterised as collaborative medicalisation, as it is a step away from the traditional medical domination (see Broom and Woodward 1996: 367). As Wiles and Higgins argue (1996), a move from a paternalistic manner strengthens medicalisation.
Representing the body: normality and control General claims of superior knowledge and, hence, authority concerning the body, are not the only ingredients in the medicalisation processes. According to the findings of this study, the representation of the female body is a reason for a shift in the ‘ownership’ of the body from the young women themselves to medical experts. During the years of maturing from a child to an adult, both socially and physically, a new relationship with the body has to be established by the girl-becoming-woman, and a new understanding of the meanings of having a female body is developed (Ussher 1989, Lee 1994, Lovering 1995, Prendergast 1995, Rudberg 1995). The letters to the medical advisory columns show that the young women have an interest in and respect for the medical account of bodily functions. It is of interest to examine more closely how the female body as a normative ideal is constructed in this discourse, and how the representation affects the process of medicalisation of menstruation. As shown earlier by Martin (1987), the medical vocabulary used for © Blackwell Publishers Ltd/Editorial Board 1998
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describing bodily processes belongs to the domain of industrial production, with its requirements of productivity, efficiency, regularity, predictability and controlability. The body is represented as a machine, separate from the self, the mind, and the owner. Sociologists of health and illness have identified the machine model as one of the features behind the crisis of modern medicine (Turner 1992: 155). The young woman is depicted in these columns as if not menstruating herself; she is not actively involved in the process, but the menstruation happens to her. The terms used when describing menstruation picture it as something autonomous, even with a will of its own: Your cycle is still searching for its own rhythm. Your menstrual cycle is not working normally. The body-machine is expected to function according to certain standards. These standards are the medical definitions of normality: the normal length of the cycle and menstruation, normal amount of the flow defined by medical research. Within the given limits, a woman’s body is normal; if not, then medical intervention is needed. The normality requirement is, however, not quite definite since certain individual variations have to be accounted for, at least to some degree. The ‘normal abnormality’ of the teenage menstrual cycle is an especially confusing contradiction. It seems that there are no established standards for how far the abnormalities of a teenage cycle are to be tolerated. The evaluation has to be made by the doctor on his or her own. Thus, the answers vary among the doctors. One doctor can also use different criteria in two apparently identical cases. The most common way of solving the problem of lack of standards is a strong emphasis on the machine metaphor. One generic body type is portrayed, and the patient is compared with it. The patient’s body produces either too much or too little of some hormone, and this abnormality should be ‘straightened out,’ as one doctor puts it. This applies to the young women also, with the exception of the first year after the menarche. Your periods should already be settling down to regularity, and if they do not agree to that, they can easily be disciplined with the pill, which usually regularises the cycle immediately. The machine metaphor has one crucial consequence: the machine has to be under control. A machine out of control is a disaster in the cultural imaginery of industrialised societies, as Martin (1987) points out in her study on medical metaphors on menstruation. In the material of this study the control ideal is obvious, but it is not expected that the teenager herself would manage this. The control can be achieved with the doctor’s assistance. The theme ‘control through medical assistance’ summarises the organising logic of the medical discourse presented in the magazine columns as it draws together three central aspects in the discourse. The first aspect is the notion of the autonomous body, strange to the owner, following the © Blackwell Publishers Ltd/Editorial Board 1998
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body/mind dichotomy. The second aspect is the constant potential of the female body-machine to fail and to cross the borders of normality. The third aspect is the medical sovereignty in knowing and understanding the body. The first two construct a setting of constant need to control, an ideal the woman can hardly live up to. The third provides the solution, the helping medical profession that rescues the woman from her problem. The instrument whereby control can be gained is hormonal treatment: the contraceptive pill is generally suggested. The pill is not only presented as the best contraceptive method, but as the most effective treatment for menstrual disorders: irregularity, heavy flow, menstrual pain and premenstrual syndrome. In one answer the pill is put forward as ‘the best, most reliable and safest alternative’ for a single young woman who, writing about her menstrual discomfort and sexual problems, explicitly writes that she dislikes hormonal treatment. Information on how the pill works or what possible side effects it can have is not given in any of the answers. The idea of the 28-day cycle is going to be a reality if more and more women ‘normalise’ their cycle to 28 days with the help of the pill. Statistics show that the campaign for the pill has been successful: as many as 72 per cent of Finnish women under the age of 25 use the pill as their major contraceptive method (Sihvo et al. 1995). The cycle controlled by hormones, taken orally, is even called ‘normal’ in some of the texts. However, there are also those who make a distinction between a woman’s own hormone production and cycle, on the one hand, and the pill cycle, on the other; but none of these, either, present the pillproduced cycle as negative. The requirement of the normality of, and control over, the body and its processes can be seen as one part of the etiquette around menstruation. Menstruation is neither to be noticed by others nor felt by oneself. It should not alter a woman’s normal daily life. For example, a period can ‘effortlessly’ be moved by any doctor to another, more convenient time. An issue that can be avoided with the machine metaphor is sexuality. Research on women’s own accounts on menstruation (Lee and Sasser-Coen 1996, Rudberg 1995) has suggested that menarche and menstruation are significant symbols of female sexuality and womanhood. In the answers about menstruation in the medical advisory columns, sexuality is a theme that does not emerge at all. Menstruation is not, however, left completely without meaning, as it is in the medical text books (cf. Martin 1987, Kalbfleisch and Bonnell 1996: 268, Oinas 1996). A regular (but harmless) menstruation is needed to show that the machine works properly.
Conclusions This article addresses the medical representation of the female body by examining the medical discourse on menstruation. The focus is on the way © Blackwell Publishers Ltd/Editorial Board 1998
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in which the medical establishment responds to young women’s questions about their maturing bodies. Knowledge claims about the body are the major concern: whose knowledge matters when bodily processes are discussed? The questions posed by the readers of the medical advisory columns concern three major issues: normal menstrual cycle and flow, menstrual problems, and everyday life routines while menstruating. Most of the questions in the letters are not of a medical nature. They reflect the silence, the ‘etiquette’ around menstruation in a society that prevents young women from finding information about menstruation elsewhere. The letters express an unquestioned confidence in the medical profession: medicine possesses the right answers about the body. The discourse in the letters produces an ideal, ‘natural’ or generic body, known only to the medical experts. The teenagers’ own bodies are to be compared and measured against the ideal. The body is depicted as separate from the self, as a stranger. The doctor is needed to mediate between the self and the body, to reassure the teenager that her own body works like the ideal one. The central theme of the letters is a contradiction colored by anxiety: on the one hand, there is an interest in one’s own body but, on the other hand, an alienation from the body, expressed through a need for a doctor to interpret the body to the young woman. In the letters a double stance towards medicalisation can be identified: on the interactional level medicalisation is resisted, the writers often firmly state that they do not want to see a doctor. On the other hand, the superiority of medical knowledge, which after all is the core of medicalisation (Conrad 1992), is beyond question in these letters. The doctors’ response is clear: the young woman does not have to worry, the medical profession is both willing and able to take over the responsibility for and control over the body. The Cartesian split is institutionalised in the answers. The body is something the young woman does not have to know or even to touch. She only has regularly to bring the body in for a medical examination. Imagery from industrial production is used to stress this advice. The body is pictured as a machine that has to follow the medically defined rules of normality and control. The constant potential of a malfunctioning machine is always to be taken into consideration. Medical assistance in gaining normality and control is essential. It is in this sense that the medical advisory columns are used as a professional strategy to strengthen the position of the medical establishment as the only legitimate authority of the body. The young women’s uncertainty serves this purpose. The findings at first sight suggest that needs are being met. The letters insist on medicalisation, and the doctors are willing to help. Yet, the case is complicated by three factors: the writers of the letters are young, female, and (potential) patients. All these attributes are known to create a hierarchy of power on their own, so from the position of triple ‘handicap’ in the patient-doctor relationship the letter-writing young women can hardly be considered powerful agents. Menstruation as a gendered, female phenome© Blackwell Publishers Ltd/Editorial Board 1998
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non, is of special interest here. The call for medicalisation in the letters is the consequence of shame, anxiety, and taboos about menstruation – that is, the negative label put on menstruation in western culture. I argue that the young women cannot be viewed as informed agents as in other cases of women’s efforts to expand medicalisation. In cases such as childbirth (Rajan 1996), postpartum depression (Taylor 1995), PMS (Rittenhouse 1991, Stoppard 1992) and infertility (Becker and Nachtigall 1992, Denny 1994) researchers have pointed at women’s own efforts to increase medical interest in the phenomenon. The letters cannot be regarded as a document of the young women’s own interest in a medicalisation of their health, but rather as a document of a lack of alternatives in a culture of shame and silence. The response from the doctors, by contrast, adds nothing new to the medicalisation debate. In this sense, the theme of professional domination and monopolisation has not become outdated even if the latest research has shown that doctors are not the only agents in the medicalisation process. Address for correspondence: Elina Oinas, Department of Sociology, Åbo Akademi University, FIN-20500 Åbo, Finland
Acknowledgements I wish to thank Elianne Riska, Judith Lorber, Elizabeth Ettorre and the anonymous referees for their helpful comments, and the editors for their patience.
Notes 1
2 3
4 5
The majority of the letters about menstruation were found in the magazines directed to adolescents. These are Regina, SinäMinä, and Suosikki. Health magazines Kauneus ja Terveys, Kotilääkäri and Terve Elämä published letters about menstruation regularly. The medical advisory column in the family magazine Seura is large, but few questions dealt with menstruation at the time of the study. The women’s magazines Eeva and Kotiliesi and the baby-care magazine KaksPlus had modest columns, and only one question dealt with menstruation. Whether the letters are ‘real’ is, of course, impossible to know for sure, but the way those about menstruation are written indicates that the writer is sincere. It is possible that the number and proportion of letters written about menstruation is even larger than the number of the published ones: from the editorial point of view repetitious ‘am I normal?’ questions are not very interesting. For example, in one magazine, Suosikki, that strives to answer all questions, most of the letters about menstruation are published in a smaller-print section. In some magazines, especially in the youth ones, writers use pseudonyms. Many pseudonyms, like this one, are originally in English. This ‘deviant’ doctor is a woman, but to argue for a causality between her gender and her behaviour would be too simple. The tendency of professional © Blackwell Publishers Ltd/Editorial Board 1998
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discourse to overcome the gender of the doctor has been noted by several researchers (Lorber 1985, Elstad 1994). Others have argued that it is inappropriate to assume any essential gendered qualities, like superior social and emotional competence of women (Riska 1993). Elsewhere in the material no difference between male and female doctors was found.
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