Doing health, doing gender: teenagers, diabetes and asthma

Abstract

Although most research linking health disadvantage with gender has focused on women, recent work indicates that hegemonic masculinities can also place the health of men at risk. The importance of comparing the experiences of women and men has been emphasised and this paper focuses on the ways in which the social constructions of femininities and masculinities affect how teenagers live with asthma or diabetes. The majority of girls incorporated these conditions and the associated treatment regimens into their social and personal identities, showing a greater adaptability to living with asthma or diabetes. However, this could have detrimental effects in terms of control, as girls sometimes lowered expectations for themselves. In addition, two aspects of the treatment regimens, diet and exercise, were found to disadvantage girls and advantage boys, because of contemporary meanings of femininities and masculinities. The social construction of femininities meant that these conditions were not seen as the threat that they were by the majority of boys interviewed, who made every effort to keep both conditions outside their personal and social identities by passing. The majority of boys maintained a ‘valued’ identity by feeling in control of their body and their condition. However, for the small minority of boys who were no longer able to pass the impact of chronic illness led to a ‘disparaged’ identity. The interaction of gender and health is seen as a complex two-way process, with aspects of contemporary femininities and masculinities impacting on the management of these conditions, and aspects of these conditions impacting in gendered ways upon the constructions of gender.

Introduction

This paper explores the interaction of gender with the management of chronic illness during adolescence, focusing on the ways in which the social constructions of femininities and masculinities affects how young people live with asthma or diabetes. The majority of research linking health disadvantage with gender has focused on women (Nathanson, 1975), but more recent research such as that by Cameron and Bernardes (1998) indicates that hegemonic masculinities can also place the health of men at risk, both in terms of being a risk factor in the aetiology of disease, and in the ways in which men manage illness. The importance of comparing the experiences of women and men has recently been highlighted (Verbrugge, 1997) and Charmaz (1995, p. 287) states:

As the research in chronic illness grows, studying men and women comparatively in conjunction with marital, age and social class statuses, in addition to type of illness, can substantially refine sociological interpretations of the narratives of chronically ill people.

The paper aims to make a contribution to the literature by exploring how teenage girls and boys live with and manage two different conditions. Young people with asthma or diabetes were interviewed as they are both conditions requiring high levels of self-care, which can also have similar high levels of personal responsibility for ‘juggling’ treatment (Bytheway and Furth, 1996). In terms of the control of both asthma and diabetes, it appears that the mid-teens is a critical time when control worsens, particularly for young women (Gregg et al., 1983, Pond et al., 1996), which fits in with the overall pattern of a gradual emergence of excess morbidity in females during adolescence (Sweeting, 1995).

A central theme to be explored is the way in which the teenagers in this study incorporated asthma and diabetes into their personal and social identities. These terms were developed by Adams et al. (1997) based upon Mead's (1961) analysis of the self, particularly his dialectic between the ‘I’ which they termed “personal identity” and the ‘me’ or “social identity”, conceptualised as “the sum of an individual's group memberships, interpersonal relationships, social positions and statuses” (Adams et al., 1997, p. 199). This is a key issue because the gendered ways in which specific illnesses impact on the personal and social identities of individuals can affect how they choose to live with the illness, including the management of medication regimens. As Saltonstall (1993, p. 12) states:

…the doing of health is a form of doing gender. This is not because there is an essential difference between male and female body healthiness, but because of social and cultural interpretations of masculine and feminine selves — selves which are attached to biological male and female bodies. Health activities can be seen as a form of practice which constructs the subject (the ‘person’) in the same way that other social and cultural activities do.

It has been argued that chronic illnesses, with their unpredictable trajectories and uncertainties (Bury, 1991) may particularly threaten dominant masculinity, which is characterised by self-control, independence and self-sufficiency (Seidler, 1998). Arguably the threat may be greatest during adolescence, which Prendergast (1995) describes as the time when heterosexual values are most powerfully pursued and enforced. However Miller et al. (1993) found the social practice of masculinities to be beneficial in key aspects of cystic fibrosis management. For example, because of the importance of sport and exercise to the social construction of masculinities, many of the boys interviewed were engaged in considerable amounts of exercise, which benefited their condition. Although all of the young people were aware of their reduced life expectancy, the young men dealt with this by ‘putting it to one side’ and by generally being less willing than the girls to incorporate cystic fibrosis into their social identities. The young men were also found to maintain a more positive attitude in their everyday experiences of living with cystic fibrosis, expressing a greater sense of control over their health and lives than did the girls.

When exploring the effect of chronic illness on the gendered identity of adults, Charmaz (1995) found that the social construction of masculinities could have both beneficial and adverse effects. Many of the men she interviewed attempted to conceal their illness, particularly in public settings, and drawing on the work of Connell (1987) to help explain their behaviour, she states that chronic illness can “relegate a man to a position of ‘marginalized’ masculinity in the gender order” (Charmaz, 1995, p. 268). Charmaz (1995, p. 286) also argues that although traditional assumptions of male identities can encourage men to recover from illness, such assumptions can lead to a narrow range of ‘credible’ behaviours for men, in that “an uneasy tension exists between valued identities and disparaged, that is, denigrated or shameful ones”.

In contrast, women are often perceived as more able to cope with ill health than men because of the stereotypical expectations of femininity as being adaptive and passive (Coppock et al., 1995). Charmaz (1995) found that women with a chronic illness generally showed a greater adaptability than men, and that women “rarely persisted in tying their futures to recapturing their past selves when they defined physical changes as permanent” (Charmaz, 1995, p. 280). However, Miller et al. (1993) found that the teenage girls in their study were less likely than the boys to experience a sense of positiveness in relation to their everyday experience of living with cystic fibrosis, which they felt was due to the social practice of femininity. This led to passivity, feelings of powerlessness and an emphasis on attractiveness which in turn led to a decline in health status, with the lack of physical activity and the need to be attractive rather than active having a powerful adverse effect on morbidity.

Stigma is closely linked with gender and illness management. In his research on children, Prout (1989) found the stigmatising effects of illness to be gendered. For boys, illness could be an isolating and threatening experience and Prout (1989, p. 350) noted the accusation of ‘skiving’ which greeted almost every boy on his return to school, stating that, “it underlined a basic feature of the boys' culture, that being physically fit and tough was highly valued and that sickness… was a stigmatising form of weakness and incompetence”. In contrast, Prout (1989) found that sickness was seen as something quite different for girls, with the ‘best friend’ group being mobilised and visits being made to the girl's home. Goffman (1963) described a variety of coping strategies which related mainly to whether or not the stigma was obvious to others (discrediting), or could be hidden from others (discreditable). Someone with a potentially stigmatising condition such as diabetes or asthma has the option of trying to hide it, and one of the main coping strategies which Goffman (1963) described as being used in this situation is ‘passing’, which entails trying to pass as ‘normal’ with the constant risk of exposure.

The extent to which individuals choose to pass may also impact on adherence to treatment regimens. Much of the professional literature on ‘non-compliance’ is based on the premise that it is deviant behaviour, leading to the blaming of patients (Donovan and Blake, 1992), with the ‘compliance’ of young people identified as particularly problematic by health care professionals (Klingelhofer, 1987, Pond et al., 1996). In contrast, Conrad (1985) argues that from the patient's viewpoint, altering medication can be seen as an attempt by the individual to assert some control over their illness, and he sees the modification of medicine as ‘active self-regulation’ rather than non-compliance.

It appears that the social constructions of femininities and masculinities may interact in complex ways with overarching concepts impacting on chronic illness, such as stigma and compliance, as well as with more specific aspects relating to the management of particular chronic illnesses. By exploring the extent to which teenage girls and boys incorporate asthma and diabetes into their identities, and how this impacts on the ways in which they live with and manage these different conditions, the paper aims to help begin unravelling these issues.