Markers of Midlife

Markers of Midlife:

Interrogating Health, Illness and Ageing in Rural Australia

Narelle Louise Warren

Submitted in total fulfilment of the requirements of the degree of Doctor of Philosophy

June 2007

Key Centre for Women’s Health in Society The University of Melbourne

Abstract

The aim of this thesis is to explore rural women’s midlife experiences and interrogate the roles of health, social and community factors in these. In the cultural imagination, midlife signifies the onset of ageing and is thus framed in a discourse of decline. For women, it is often considered in terms of menopause and the end of fecundity and fertility. I propose that women’s experience of midlife is much broader than this; instead, it is characterised by transformation in multiple life domains and health status is important. I suggest that the continuity theory of ageing is useful when conceptualising the life course. The concept of habitus enables exploration of how identity is re/constructed during the ageing process in response to changing bodily circumstances, such as health problems. Fieldwork was conducted in Waterside (pseudonym), an isolated Australian community, between 2001 and 2003. In-depth interviews were conducted with twenty-four women who self-defined as midlife; three participated in follow-up interviews. I also conducted a focus group discussion with midlife women, in-depth interviews with the local doctors and participated in community life. These provided important contextual data. Midlife encompassed several decades: participants ranged in age from 41 to 62 years. My sample was ethnically homogenous, consisting of women from Anglo-Australian or Western European backgrounds. Reproductive histories, family structures, social networks and the health status of participants were varied. Women described how health status shaped their midlife experiences and mediated their identity construction. Personal narrative analysis demonstrated the polysemous nature of the term ‘menopause,’ which women often used to refer to midlife. Participants used four narrative strategies to describe their midlife experiences. These were not exclusive: some women drew upon two strategies in telling their stories; others described temporal shifts in the strategies used as their health status changed. Women who experienced few health problems tended to use Maintaining narratives, in which they described their efforts to preserve their current health status. Contemplating narratives were told by women who personally had good health yet whose experience was shaped by the illness of close others (e.g. partners or parents). Personal growth was central to their stories. Women who experienced long-term health problems employed Negotiating narratives to describe their on-going project of bodily management. The final narrative strategy, Navigating, was used by

women who experienced adverse health events during midlife; these were often related to their menopausal transition. Midlife for them was about reconstructing their identity to incorporate their changed health status. The role of place was important in women’s self- health management practices and health-seeking behaviours. Interrogating health and illness in the ageing process has important implications for midlife health promotion. Although participants often referred to midlife as menopause, health was conceptualised more broadly than dominant models of ageing suggest. My findings suggest that health services, and the cultural scripts informing them, need to incorporate the diverse needs, goals and aspirations of midlife women in order to support women when they ‘…enter that other age.’

Declaration

This is to certify that:

(i) the thesis comprises only my original work towards the PhD except where indicated in the Preface,

(ii) due acknowledgement has been made in the text to all other material used,

(iii) the thesis is less than 100,000 words in length, exclusive of tables, maps, bibliographies and appendices.

______

Narelle Louise Warren

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Acknowledgements

When I returned to my home-town to begin my study in 2001, I had no idea of the journey that lay ahead of me; my research has shown me a world that I was never really cognizant of – that of midlife women. I am incredibly grateful and indebted to the women who participated in my research. Their willingness to let me into their lives has touched me in many ways and I feel blessed with the gifts of their midlife stories.

There are many people without whom my research, and this thesis, would not have been possible. The academic support I received throughout my candidature has been fantastic and unparalleled. My primary supervisor, Dr Milica Markovic, provided insightful guidance, inspiration, empowerment, friendship and on-going support throughout my doctoral candidature. My research would have also never eventuated without Professor Lenore Manderson who enhanced my life on many levels, providing motivation, mentoring, guidance, support and friendship. I’ve been lucky to have worked closely with them as both colleague and student for the past five years, and have benefited tremendously from this opportunity. Thank you. My co-supervisor, Dr Andrea Whittaker, provided wonderful support and ideas throughout my candidature, introducing me to many new ways of conducting research and giving me valued work experience. I am extremely thankful to her. Dr Shelley Mallett, my administrative supervisor, and Associate Professor Marilys Guillemin both also provided invaluable feedback that helped direct my thesis, which I greatly appreciate.

My family have been wonderful, with their on-going support. Dad’s (Gary) quiet belief that I could achieve my goals and dreams has encouraged me to keep going, even though seven years is a ridiculously long time to do any study. Glen, Jade, Kerri, Kristy and Trevor have provided welcome support, chats, cups of tea, and reasons to have a study break. I’ve also been blessed with happy smiles and magnificent cheering from Luci, Isobel and Taj. Jenny, my mum, has been my dearest friend: her unwavering faith, open heart and (particularly lately) acceptance and tolerance have been supreme. The ‘puppies’ provided hours of cuddles and reassurance – the wonder of dogs. Riding Vanity – and, not so long ago, Shadow-the-wonder-horse and Secret – gave me many hours of joy, peace and, most importantly, space to think. I miss them terribly. My partner, Brad, has been very patient and supportive – even when the ‘why’ of doing a PhD became incomprehensible to him. He inspires me every day.

I’m incredibly fortunate to have many friends who gave me their ears, shoulders, and hugs time after time. I value Sarah and Helen’s friendship and support tremendously. My PhD student pals, especially Nat, Suzanne, KT, Bella and Poy, have been special friends and colleagues. I’m so glad we all were together for (at least part of) these tricky times. Pat Galvin’s friendship and swim

coaching has kept me going – the Saturday morning sessions kept me sane. Kathleen Nolan has given me lots of personal support and formatting help over the recent years – I am thankful on multiple levels. Without my friends and family, I would never have finished my research and, certainly, never gotten through the period of illness that disrupted my life. Social participation is the corner stone of life and for coping with challenges that crop up along the way. I’m very lucky!

In memory of my Nana,

Mary Ellen Jessie Bobbin

and for

Jenny & Gary Warren

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Table of Contents

Abstract ...... i Declaration ...... iii Acknowledgements...... v Table of Contents ...... ix List of Tables...... xi List of Figures ...... xii

Prologue: Thinking About ‘That Other Age’...... 1

Chapter 1: Marking Midlife...... 3 Aims and objectives ...... 24 Overview of the thesis ...... 25

Chapter 2: Returning Home: Methodological Reflections...... 29 Going home ...... 33 Waterside...... 43 Entering the field ...... 50

Chapter 3: Being Healthy in Waterside ...... 69 The Australian health care system ...... 69 Preventive health care and Australian women’s health policies ...... 77 Waterside: historical landscapes of health care ...... 80 Women in Waterside: socially-mediated understandings of health ...... 86 Midlife health: beyond menopause...... 99 Narrative strategies used by women in midlife ...... 101

Chapter 4: Positioning Menopause...... 115 Socio/cultural construction of menopause in Australia...... 116 Menopause, discursively ...... 117 Menopausal models ...... 119 Local biologies of menopause in Waterside...... 130 Menopause: the end of reproduction? ...... 134 ‘No more periods. This is good!’...... 143 ‘It’s warm in here, isn’t it?’ Menopause and bodily symptoms ...... 152

Chapter 5: The Body-Self Working Together: Maintaining and Contemplating Narrative Strategies ...... 181 Maintaining narratives: responding to images of ageing...... 182 Contemplating narratives: a changing identity ...... 197

Chapter 6: Working with Disruptive Bodily Signs: Negotiating and Navigating Narrative Strategies...... 217 Negotiating narratives: incorporating bodily limitations ...... 219 Troublesome bodily signs: biographical disruption or flow?...... 237 Navigating narratives: adapting to new bodily circumstances...... 246 Midlife narrative strategies and the body-self ...... 260

Chapter 7: Managing Health, Managing Age ...... 265 Preventive health ...... 267 Rural and remote health care in Australia ...... 283 Primary health care in Waterside ...... 296 Habitus and women’s health-seeking...... 308 Embodying rurality...... 311

Chapter 8: ‘You Enter that Other Age’: Time, Age and the Life Course...... 323 Menopause: a culturally significant marker of midlife...... 323 Adjusting to ageing ...... 330 Health and the life course...... 338

References ...... 343

Appendices...... 378

List of Tables

Table 2.1: Working model of home ...... 31

Table 2.2: Industry in Waterside, 2001 ...... 45

Table 2.3: Population changes in the two decades preceding the study ...... 48

Table 2.4: Socio-demographic characteristics of Waterside residents...... 49

Table 2.5: Summary of interview participants...... 56

Table 3.1: Health service provision and availability in Waterside from 2001-2003 ...... 85

Table 3.2: Recurring themes common to each of the four narrative strategies...... 103

Table 4.1: Menopause age and self-defined menopausal status compared with age at last child.. 135

Table 4.2: Commonly reported ‘menopausal’ symptoms...... 153

Table 4.3: Number of symptoms reported by participants ...... 155

Table 4.4: Prevalence and severity of ‘menopausal’ symptoms reported by participants...... 158

Table 7.1: Reported participation in preventive health screening programs...... 271

Table 7.2: Hysterectomy and tubal ligation rates for women in five areas of Australia ...... 286

Table 7.3: Health service utilisation by type of narratives told by midlife women...... 304

List of Figures

Figure 1.1: A greeting from a 40th birthday card ...... 9

Figure 1.2: ‘The seven dwarves of menopause’...... 11

Figure 2.1: Overlooking Waterside from nearby peak ...... 44

Figure 2.2: Map of Waterside township area ...... 46

Figure 2.3: Recruitment strategies ...... 53

Figure 3.1: Overview of the Australian health care system ...... 71

Figure 3.2: Main providers of primary health care, and referral patterns, in Australia...... 76

Figure 3.3: Inter-relationships between the four narrative strategies...... 109

Figure 4.1: Biomedical staging of menopausal status ...... 121

Figure 4.2: Biomedical model of menopausal status...... 122

Figure 4.3: Boundaries of menopausal status categories...... 125

Figure 5.1: Body-self relationship expressed in the Maintaining narrative strategy ...... 195

Figure 5.2: Body-self relationships in Contemplating narratives ...... 198

Figure 5.3: Graphic representation of the ‘Sandwich Generation’...... 206

Figure 6.1: Cycle of biographical disruption and health problems...... 244

Figure 8.1: Women’s narrative constructs of body, self and being...... 338

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Prologue

Thinking About ‘That Other Age’

In my mind, I am six and sitting beside my Nana (grandmother). We’re in the car. I can’t recall much about it, just the big bench seat, lots of talking, and her hands peeling mandarins.

We’re on our way to Timbertown, two hours drive away, with my Pop (grandfather), who is having some kidney-related tests. We arrive at the hospital – the closest to Waterside – and he is quickly taken away for his procedure. Nana and I are getting ready to visit a family friend who has recently had a baby, the reason for accompanying Pop today, when I need to go to the toilet. It’s in a small dark room, along a seemingly endless hallway. After I finish using the toilet, Nana rubs her stomach and says she isn’t feeling very well, she’s got heartburn. She looks woozy as she sends me to get someone to help. I run down the hallway, yelling, and some people, doctors and nurses (I think), come pushing a wheelchair. She sits – collapses, more like it – in the wheelchair, and tells them to take me to her friends. She tells me she’ll see me in a little while. The last time I remember seeing her is in the distance, at the end of the hallway as I am led away. Endless hours later, I’m allowed to see my Pop, who sits on the end of the hospital bed crying. He tells me that my Nana had a heart attack and died.

I don’t remember the drive home, just that there were no mandarins or silly chatter, and the empty expanse of the shiny brown seat beside me. When we got home, my mum, seven months pregnant with my youngest sister and wearing a brightly coloured knit jumper, cries.

Flashing forward to now, 27 years later, almost to the day. Writing my thesis has brought this memory into clear focus, making me wonder what it was like for my Nana. She wasn’t old. She was only 60 when she died – by most definitions, she was still in midlife and

thus, too young to die. Indeed, several of the women in my study were her age. Yet, due to

her health status, compromised by diabetes and associated cardio-vascular complaints, she

did not live beyond midlife. She neither became an old woman nor entered ‘that other age’.1

Menopause wasn’t a big concern for her. My mum said that Nana’s long-term poor health – diabetes and hypertension – meant that she did not pay menopause much attention.

Too much other stuff was happening in her life: being a wife, mother and sister, caring for her grandchildren (mostly me, the eldest), and being involved in the community, having slowed down her work duties some years before. In addition, while continuing to do her household tasks, she dealt with the daily challenge of managing her health – controlling diabetes, trying to take care of swollen ankles (due to fluid retention) – not easy tasks when the nearest medico was several hours drive away. My understanding and memories of Nana’s story have profoundly shaped my doctoral research. Thinking about her experience, in light of the cultural consolidation2 of meanings given to the reproductive body, where midlife is

largely understood in terms of menopause, I question the role of other influences on how

women experience the life course. Drawing upon my Nana’s story, I interrogate the role of

health – including experiences of good and poor health, information seeking, and access to services – on women’s experience of midlife. In doing so, I question the centrality and

meanings of menopause, the culturally significant marker of women’s ageing within

Australian society, to women’s own understandings of midlife and, through this, I seek to

gain an understanding of midlife: the gateway to ‘that other age.’

1 From one of my participants, Aspidistra. 2 This term is borrowed from Gullette (1997)

Chapter 1

Marking Midlife

Midlife is a term that has been used to describe the point in a person’s life span – as if it were a discrete period of time – where their ageing begins and their youth ends: it is, as Gullette

(2003:71) argued, the process of turning “into-being-no-longer-young.” In this way, concepts of midlife are tautological. Midlife is constructed as a pivotal position in social and cultural understandings of the ageing process, during which transitions occur – particularly the shift from ‘maturation’ to ‘ageing.’ However, by applying a statistical concept of median, when midlife occurs can only be determined retrospectively – by knowing a person’s age at death, the middle years of their life can be determined. In Australia, life expectancy is about 82 years for women (ABS 2004), making the age when midlife begins at around 41. On the other hand, for women at least, midlife has been determined predominantly by the onset of menopause, which usually occurs around the age of 51 in Australia and other developed countries (see Kaufert et al. 1987; Hill 1996; McKinlay 1996; Dudley et al. 1998; Dennerstein et al. 2000; Gold et al. 2001; Mishra et al. 2002; Anderson et al. 2004; Mansfield et al. 2004;

Dillaway 2006). In an attempt to get away from the reductionist approach of midlife as menopause, research has focussed on the role of transitions in defining this life stage

(including Fishbein 1992; Napholz 2000; Dentinger and Clarkberg 2002; Glazer et al. 2002;

Kagawa-Singer et al. 2002; Koch and Mansfield 2004, 2005; Pasqualina and Sonja 2005;

Perrig-Chiello and Perren 2005). However, much remains unexplored about how people make sense of and define their own understandings of midlife.

The experience of ageing is an indisputable reality of human existence; it occurs,

continually and consistently, throughout the life cycle, beginning at birth and concluding at

death. Ageing is constructed in various ways and associated with a range of meanings, which

are themselves often contextually specific, shaped by temporal, social, cultural, and individual

forces. Social and cultural understandings of ageing privilege old age rather than explore chronological progression through the life course (Cohen 1994)3 and, as a result, the focus in

ageing research has remained on the experience of the elderly. The focus on old age and its

construction as synonymous with ageing has given rise to a dichotomy between maturation

and ageing. As this suggests, ageing is not considered a life-long phenomenon and instead, is

commonly constructed as the binary opposite of ‘youth,’ with the former beginning and the

latter ending at midlife. Despite the importance of midlife in the process of biographical and

chronological ageing, little research has explored the lived experience of midlife itself, thus

highlighting the need for contextually relevant and temporally significant understandings of

midlife.

Midlife and culturally constructed (middle) ageing

Age and ageing are determined across multiple domains connected to, yet distinct from,

chronological and physical ageing. Keith (1980) argues that biological ageing is itself

culturally constructed: the age-related meanings given to a physical, bodily event differ

between cultures, as the literature on menopause indicates. I discuss this further in Chapter 3.

Keith suggests that differentiation between ages involves complex social boundaries based

upon cognitive, corporate, ideological or normative and interactional (discussed above)

3 Although the emphasis placed upon the life course in ageing theory may be a western-centric cultural artefact, as Wray (2007) argued, I have maintained the construction of midlife as a life stage given this study was situated within a western context (as outlined in Chapter 2).

dimensions (ibid.). Using Keith’s schema, age is employed cognitively. Culturally shared understandings give meaning to different stages and ages throughout the life course. For example, turning 40 has a culturally salient meaning for many Anglo-Australians (see work by

Burns and Leonard 2005). The corporate dimension of age is primarily used in relation to work and is employed as a tool to determine one’s appropriateness for being recruited into, and released from, a given institution (Keith 1980); for example, age is used to evaluate whether someone should retire or not or to assess a person’s fit into a particular corporation.

Ideological or normative understandings of age rely upon social norms about the timing and occurrence of life events and transitions. The social clock concept (Neugarten

1979, 1996) illustrates such normative constructions of age, by dictating the expectations an individual needs to meet at different periods in their life. Where the social clock is not met, socially adverse outcomes (such as reduced social support) occur. For example, the social clock would indicate that women should undergo menopause at around 50 years of age, and hence women who experience early menopause describe feeling unsupported and marginalised (Boughton 2002). Age at first birth is another example of the social clock: in

1975, an elderly primigravida was aged 35 or over; by 1999, this age had risen to 40 (Gilbert et al. 1999). These shifts reflect population-wide (normative) changes in the average age at first birth. Rook and colleagues (1989), however, did not find the anticipated adverse outcomes in people whose life events were timed differently to the social clock, leading them to suggest that whilst the social clock concept is useful to understand the impact of social norms on constructs of age, the life cycle is more fluid than this would indicate. The specific time lines and events are cultural constructs, assumed and implicit. The social clock is both normative and interactive; people evaluate their own life in terms of others,’ relative to the life course time line (Rook et al. 1989; Helson and McCabe 1994).

At midlife, through social and cultural changes premised on assumptions about the

nature of the biological body, ‘maturation’ is transformed into ‘ageing,’ a pejorative term

commonly viewed in terms of decline (Gullette 2003). Midlife forms the space between

maturity and ageing and, therefore, is situated as a type of silence or absence within the life

course, whilst simultaneously signifying one’s entry into an invisible social category (Unruh

1983). As already noted, it is also widely understood as a period of transition and

transformation in most life domains: in family and marital relations, in social and biological

reproduction, in employment and economic participation, in community and social integration, and in personal domains, such as appearance, health, identity and temporal

understandings of the life course (Ballinger and Walker 1987; Buck and Gottlieb 1991;

Hunter and Sundel 1994; Banister 1999a; Wethington 2000; Ballard et al. 2001; Dillaway

2005a, 2005b). As such, midlife is characterised by uncertainty, ambiguity and identity change

– trying to make sense of a time of life for which women feel unprepared for and for which

few cultural scripts exist.

Images and metaphors

Midlife is typically associated with gendered and stereotyped images perpetuated through folk

beliefs, popular media and medical ideologies, which construct midlife as a difficult, stressful

and challenging life stage. Three metaphors dominate cultural understandings of midlife and

reinforce gendered stereotypes of the ageing process: beliefs about midlife as a stagnant (also

boring and conservative) time ‘stuck in the middle’ are depicted by the ‘sandwich generation’

metaphor (Nichols and Junk 1997; Remennick 1999); midlife as a time of grief and loss is

suggested by the concept of the ‘empty nest’ (Radloff 1980); and midlife as a time of

heightened stress is emphasised by the notion of the ‘midlife crisis’ (Wethington 2000).

The metaphor of a sandwich is used to construct midlife adults as negotiating the competing demands of caring for their dependent children4 and ageing parents (Miller 1981;

Hamill and Goldberg 1997). Elderly parents are constructed as needy and dependent, and whose care places a sometimes unreasonable demand on their midlife children.

Simultaneously, it is assumed that the care given to the often-adolescent children is equally taxing. This stereotype emphasises the stressful nature of the ‘extra’ demands caused by elderly parents, constructing the midlife adult as caught in the middle. In contrast to the stereotype, however, Nichols and Junk (1997) found that less than one in five American adults provided care5 for their elderly parents. They also identified the gendered nature of

‘sandwich’ care – men tended to provide financial support where women tended to provide instrumental (hands-on) support. Their findings indicated that midlife children did not regard their ageing parents as dependent and they did not feel pressured or expected to provide assistance (ibid.: 322) and thus, directly contradict the assumptions on which this metaphor is based.

An alternative metaphor for midlife is that of the ‘empty nest syndrome,’ which focuses on the maternal role and argues that women experience depressive reactions, identity crises, marital conflict and diminishing quality of life after their children are grown and leave home (Radloff 1980; Adelmann et al. 1989; Dennerstein et al. 2002). It is based upon three assumptions: that the maternal role is essential to women’s sense of self and wellbeing (ibid.), that parenting is rewarding and neither stressful nor challenging for most people, and that the maternal role ceases when children leave home. Such a stereotype may not be relevant to the current generation of midlife women (Adelmann et al. 1989): overwhelming research

4 This stereotype does not construct dependent children as necessarily being particularly young but instead, defines them as being financially reliant on the midlife parent. 5 Assistance with daily tasks, such as shopping, transportation or, to a much lesser extent, financial assistance (Nichols and Junk 1997).

indicates that few women experience negative feelings following their children’s departure

from the parental home (see Hunter and Sundel 1994). Women have fulfilling lives outside

of their parenting role (ibid.) and parenthood is often described as stressful. Dennerstein and

colleagues (2002) also suggest that, in the present, the ‘empty nest’ is actually a ‘revolving

door,’ where children may leave and re-enter the household; they also found that women

frequently report increased happiness and fewer daily hassles when they were not co-habiting

with their children. Women reported that life satisfaction was related to parental role

continuity, regardless of whether or not they resided with their children (White and Edwards

1990).

Both metaphors – the sandwich generation and the empty nest – suggest that midlife

for women is characterised by difficult transitions in roles related to their

maternal/reproductive functions. These contribute to the notion of the ‘midlife crisis,’ a

pervasive and powerful metaphor of middle ageing in many western countries, where

reaching midlife triggers personal turmoil (Wethington 2000). The construct of the ‘midlife

crisis’ describes this life stage as a time of disruptive life events, which are prompted by

changes in personal goals, feelings as though one is entrapped by life roles and choices,

decline in the physical body, and realisation of one’s ageing and approaching mortality

(outlined by Wethington 2000). Midlife crisis has a chronological component and is

stereotypically understood in the cultural imagination as prompted by one’s 40th birthday

(ibid.; for an example, see Figure 1.1 below).

Message on card front Message inside card

Figure 1.1: A greeting from a 40th birthday card

In western culture, as Wethington (2000) identifies, midlife is commonly described in terms of crisis, and is thus emphasised as stressful, rather than simply as another life transition, characterised by growth.

Cultural scripts of middle-ageing

The absence of midlife cultural scripts, or accounts about how midlife can be lived, has prompted widespread perceptions of midlife as problematic and difficult (Rubenstein 2001).

The construction of midlife in this way is misleading: although it is a time of transformation across life domains, it is often described as a positive life stage where women experience a range of opportunities that had not previously been available to them (Hunter and Sundel

1994; see also Andrews 1999).

Cultural scripts (or frames of reference) – cultural and social rules, practices, customs, norms, beliefs and taken-for-granted assumptions (Goffman 1974; Wierzbicka 1994; Mehta

1997) – play an important role in providing guidance and informing accounts of how ageing

can be experienced; at the same time, they shape how ageing is positioned within a society.

Ginn and Arber (1995) argued that cultural and social age scripts are based on gendered

norms about age-appropriate attitudes, behaviour, perceptions, chronological age and the

timing of life course events. They suggest that women’s midlife is based upon different

determinants (most often reproductive roles and family/marital norms) to those for men

(ibid.), although both are subject to stereotypes. For example, stereotypes about ageing

women highlight wrinkles or sagging breasts and skin; those about men emphasise greying

hair, balding or the development of a paunch). These cultural scripts therefore dictate that

the process of becoming old starts earlier in the lifespan for women than it does for men,

beginning with the onset of physical changes (Sontag 1978). Gendered ageing is socially and

culturally mediated: Ballard and colleagues (2005) found that although women became aware

of their own ageing due to physical changes when they were about 40 (i.e. 8-15 years before

most women reach menopause: Dennerstein et al. 2000), their ageing was more salient

through the media, self-monitoring (comparison with images of themselves when younger)

and through comparison with peers (see Hepworth 2000).

Dominant cultural scripts of ageing, borne out of processes of medicalisation6 and

constructing ageing as decline, may account for widespread understandings of women’s

midlife as synonymous with menopause, as I discuss in Chapter 3 (also refer to Martin 2001).

Gendered scripts of midlife have primarily focussed upon the role of changing sex hormones

and, for women, reproductive abilities (Gullette 2003), placing particular emphasis upon the

menopausal transition – itself constructed as negative, troubling and problematic (for

example, see Figure 1.2).

6 Keith (1980) argued that the medicalisation of the life course is a cultural fact which is, to a large degree, unrelated to age-related health needs.

Figure 1.2: ‘The seven dwarves of menopause’ (source unknown)7 – an example of how menopause and midlife are represented in dominant cultural scripts.

Few alternatives exist beyond the ‘midlife as menopause’ script, evidenced through the proliferation of lay biomedical and feminist works which reinforce these scripts (see, for example, Melamed 1983; Cabot 1991; Greer 1991; McCain 1991; Sand 1993; Campioni 1997;

Boston Women's Health Book Collective 2005). The focus on menopause has diverted attention from other factors or life domains that may be salient during this life stage. For example, as already noted, research suggests that many women describe midlife in terms of personal growth and development, expanding consciousness and adaptation to changing life circumstances (see Mitchell and Helson 1990; Apter 1996; Wilmoth 1996; Napholz 2000;

Picard 2000; Grossbaum and Bates 2002; Howell and Beth 2002; Sampselle et al. 2002;

Arnold 2005; Barrett 2005; Pasqualina and Sonja 2005; Perrig-Chiello and Perren 2005). Such understandings of midlife may be explained, at least in part, by the ‘third age’ theory.

The construction of midlife as signifying the end of a previous and the beginning of a new stage of life originates in Laslett’s (1991) theory of the third age, which corresponds with the years of midlife. An individual’s life course is conceptualised as comprising of four ‘ages,’ which correspond roughly with childhood and adolescence (the first age, characterised by dependence, immaturity, education and socialisation), young to middle adulthood (the

7 This cartoon was emailed to me from a midlife participant from another study (Warren, et al. 2006).

second age, characterised by independence, maturity and responsibility), midlife and old age

(the third age, characterised by the quest for personal fulfilment), and advanced old age (the fourth age, characterised by dependence, bodily decay and, eventually, death) (ibid.). The third age theory provides a rough framework for exploring identity and self-development in midlife and, in contrast to dominant cultural scripts, does not characterise ageing in terms of lost opportunities and difficult times (Andrews 1999).

The third age theory, however, has several shortcomings, addressed in part by popular sociological theories (discussed below). Firstly, the life course is conceptualised on the basis of generalised understandings of life trajectories (Bury 1995). It implicitly constructs the opportunities and generativity of the third age as finite. The fourth age is depicted in terms of decline and decay (ibid., Blaikie 1999), which may relate to its proximity to death and dying and arise from cultural scripts constructing death as something to be feared; thus this age is socially reviled. In addition, the third age concept fails to consider fully how contextual, cultural, social and structural forces may influence the ageing experience and, as a result, does not fully address the impact of health status on the phenomenology of ageing.

Sociological theories of (middle) ageing attempt to redress this and seek to provide accounts about how the body and self are experienced from midlife onwards.

Theorising middle-ageing: sociological perspectives

Sociological theories about the ageing process have been concerned largely with the embodied experience of age, and how people construct their sense of self and identity in relation to the bodily changes associated with growing older. The body, constructed as “the site of biographical experience, culturally mediated and socially located” (Cunningham-Burley and Backett-Milburn 1998:142), is therefore understood to provide insight into the positioning and importance placed upon midlife.

Particular concepts have dominated theorising about the embodied experience of

(middle) ageing, and offer different ways of exploring identity in the ageing process (Ogle and Damhorst 2005). In particular, the notion of the ageing body as distinct from the continuity of the self has dominated much theorising about old age (Kaufman 1981; Cohen

1994). Two of these theories (the mask and the masque of ageing, described below) hold particular sociological sway and draw upon the metaphor of the mask/masque in their exploration of identity management and maintenance. This metaphor has implications for the study of identity, which is constructed as continuous and maintained in the face of bodily discontinuity. Midlife is central to both theories as it is during midlife that the mask/masque is first developed, refined and employed.

The mask of ageing

The ‘mask of ageing’ (Featherstone and Hepworth 1991a, 1995) theory is concerned with how people reconcile the changes to their external, physical body with their sense of self.

The self is constructed as unchanging, constant and ageless, infinitely renewable (Turner

1995), whilst the physical body is in a process of decline. The body therefore ‘masks’ and struggles against the true (youthful) inner identity (Ballard et al. 2005), dragging the forever young spirit into old age (Andrews 1999). Central to this theory is the acceptance of a cultural assumption that ageing can and should be transcended (ibid.). The socially imperative ‘task’ of the ageing individual (that is, in midlife or older) is therefore to resist the physical signs of ageing through regulatory practices (Turner 1995). Age-resistance is seen as the central project of midlife. Individuals are encouraged to employ technologies of the self

(such as hair dying, cosmetic surgery, or increased exercise) and consumer goods (products

through which attributes of the self are inferred)8 to defer or delay ageing (Ballard et al.

2005). In this way, development of a youth-preserving ‘midlifestyle’ is a social and moral imperative during midlife (Featherstone and Hepworth 1991a, 1991b; Turner 1995; Gilleard

and Higgs 1996).

Although it is widely accepted, the mask of ageing theory is not without its problems.

Firstly, it constructs ageing in terms of decline and loss; however, phenomenological studies of ageing (including Cremin 1992; Hurd 1999; Dillaway 2005b) do not reflect such a construction and demonstrate that older adults do not necessarily and always view ageing as

troublesome or problematic. More important to chronological ageing is the impact of health-

related factors, such as the experience of disease and declines in health status (Dennerstein et

al. 1994; Sherman 1994; Cunningham-Burley and Backett-Milburn 1998; Ogle and Damhorst

2005). The role of health in the experience of ageing is given little consideration by the ‘mask

of ageing’ theory, which is concerned with the implications of changes on physical appearance.

The premising of the mask of ageing theory on the notion of a Cartesian split between mind (self) and body, which are constructed as distinct and opposing forces, is also

troubling. The inherent tensions of such dualism are not problematised or articulated

through empirical investigations and, as such, remain abstract (Andrews 1999; Wray 2007).

The construction of the ageing body as problematic or absent, as Oberg (1996) highlighted,

is also intriguing, given the focus on holistic body/self notions (that is, the embodied self)

promoted in the sociological literature addressing earlier life stages (Leder 1990; Bendelow

and Williams 1995a, 1995b; Shilling and Mellor 1996; Williams 1998; Budgeon 2003). Finally,

8 For example, certain technological goods – such as iPods, sports cars, or particular styles of clothing – are associated with youth culture; possessing one such product represents an element of ‘belonging’ to that culture. ‘Midlifestyle’ refers to the practices and ownership of such possessions which enable the appearance and engagement with images and ideologies of ‘youth’ (Featherstone and Hepworth 1991b, Biggs 1997).

by emphasising the ageless self, the mask of ageing constructs the process of getting older as ahistorical and discontinuous, thus disrupting of identity. Andrews (1999) argues that, by minimising the process of ageing itself, life experiences and events – all of which prompt changes to notions of self and identity – become constructed as meaningless.

The masque of ageing

In contrast to the age-deferring ‘mask of ageing’, the psychodynamic theory of the ‘masque’ or ‘masquerade’ (Woodward 1995; Biggs 1997, 1999) uses the concept of masking to refer to the simultaneous revealing and hiding of the ageing self. The masque refers to the embodied performance of the self, which is enacted both through (such as spoken and body language) and on (such as adornment) the body. The masque is a protective mechanism that provides a shield through which the ageing person’s self (persona) can interact with the wider social world. In this way, the masque protects the self from the negative effects of societal ageism and, at the same time, is the medium through which individuals can express themselves and engage in society (Biggs 2004). The self, while not in essence ageless, maintains the performance of agelessness, which, as Biggs (ibid.) argues, adds meaning to the ageing experience. The concept of masquerade attempts to provide explanation of the tension between the inner and outer worlds of ageing people and, in doing so, begins to address some of the criticisms of the ‘mask of ageing’ theory. Although it offers a pathway to resolve the tension between the self and the body in ageing, the concept of masquerade accepts the construction of ageing as loss and centres around the problematic notion of the ageless self

(Andrews 1999) and remains in need of empirical grounding (Marshall 1996; Wray 2007).

Some attempts have been made to reconcile the two approaches to the metaphor of mask/masque. Ballard and colleagues (2005) posit that ageing occurs in two simultaneous ways, which are determined using different criteria, occur along different timelines and at

different speeds. Public ageing begins earlier in the life course; its visibility means that it is both determined and monitored through social interactions. Appearance plays a central role in public ageing. On the other hand, private ageing is related to health status. It occurs later in the life course and is determined on the basis of key indicators relating to functional ability

(for example, aches and pains in joints limiting mobility). It is hidden and evaluated by the individual in terms of their own bodily history. Although private ageing is not related to social factors per se, it confirms (to the woman) that she is ageing and assumes that her experiences occur universally (ibid.). The increased salience of both public and private ageing, Ballard and colleagues (ibid.) argue, indicates entry into a new stage of life.

Issues of continuity and discontinuity (Hazan 1984; Cohen 1994; Neugarten 1996;

Andrews 1999) are central to the ageing experience, impacting upon the social body (that is, society as a whole, Cohen 1994). Ageing results (ultimately) in the discontinuity of the body and the self (at death); simultaneously, it challenges the continuity of hegemonic social and cultural meanings (that is, when the elderly die, so too does some of their cultural and social knowledge, Cohen 1994). Until death, however, the life course can be framed within a discussion of continuity theory.

Continuity

Contrasting the mask/masque theories, the continuity theory of ageing developed by Atchley

(1989) positions each life stage within the context of an individual’s biography – thus provides a historical approach to each person’s account of getting older (Andrews 1999;

2000). It understands ageing as an evolutionary process in which self and identity are simultaneously continuous and changing. Ageing is a dynamic process in which one progresses through the life course (by getting older), yet is changed and shaped by events that occur. The continuity theory of ageing, theorised by Atchley (1989:183), “offers a

parsimonious explanation for and description of the way adults employ concepts of their past to conceive of their future and structure their choices in response to the changes brought about by normal ageing.”

Continuity is maintained in two ways: derived from external forces, such as by participating in social domains or activities that remain consistent (Atchley 1989), and based upon internal forces, such as strategies and constructs about the self and identity (a reflexive process, akin to ‘private ageing;’ ibid.). Particular patterns of practices, ideas, skills and constructs are developed during the life course; other patterns persist over time (Andrews

1999) and are continually revisited and revised in terms of the personal (individual), social and cultural context (Unruh 1983). In this way, identity is both durable and dynamic (Atchley

1989; Andrews 1999). In considering ageing as a process which evolves through the life course, Andrews (1999:316) argues that a greater understanding of “the selves we will become” during the ageing process can be reached. Central to her argument is the notion that self-identity in old age is, at least in part, comprised of earlier constructs of self

(“ongoing personhood,” ibid.:311). Self-identity throughout the life span is developed in the context of, and reflects, social, cultural and historical changes and forces.

More directly relevant to the central task of this thesis are the implications of ageing on individual and personal notions of continuity and, in particular, on identity and how it is shaped, developed and/or changed as one’s biography progresses. As the mask/masque theories highlight, physical bodily attributes are central to subjective and (socially) objective understandings of identity (Faircloth 2003). However, dominant sociological explanations and theories about the ageing experience have omitted the everyday realities of getting older

(Blaikie 1999; Wray 2007; also see Marshall 1996).

Midlife markers

In her analysis of the ageing body, Schwaiger (2006:13) suggests that midlife is an “important transitional period, when the attitudes, comportment, and practices that mark social identity in our youth and early adulthood are challenged, and where we become marked by our destiny of ‘old age’.” A critical exploration of midlife therefore is required in order to understand fully how identity is re/constructed during the ageing process. If ageing is associated with invisibility (Kamler et al. 1995), decreased social worth and cultural value, and the avoidance of age-related stigma (Ogle and Damhorst 2005), as sociological and gerontological theories suggest, midlife marks a critical point in the life course whereby previous modes of existence undergo profound shifts in self and identity. Relating midlife to the life course, however, is likely also to be socially and culturally constructed: Wray (2007) demonstrated that women from non-western backgrounds understood midlife as an indistinct phenomenon that was not tied to the life course.

Central to the call for a critical, empirically-grounded understanding of midlife

(Schwaiger 2006; Wray 2007) is recognition of the ambiguous age status encompassed within notions of ‘midlife.’ When it begins and ends continues to be contested: Benson (1997) argues that the chronological limits of midlife vary according to the social, demographic and economic conditions in which one lives. Although theorists have suggested that it variously occurs between 30 and 60 (Featherstone and Hepworth 1991a) or 45 and 55 (Greer 1991), setting such chronological boundaries may be an unnecessary and misguided task due to considerable historical/temporal (described by Benson 1997; Wethington 2000) and cultural variations. Wray (2007) argued that midlife is demarcated not only by chronological notions of time, but is also influenced by social, cultural and embodied experiences of time; thus the lived experience of midlife is determined by contextual factors that vary within and between geography, cultures, social groups and individuals.

This thesis is concerned with exploring such markers of midlife within a group of

Australian women. My use of ‘markers’ here diverges from the epidemiological use of the term, where markers indicate the presence of pathology or risk of disease (Biderman and

Herman 2000). Instead I am concerned with the social meaning of the term (following Keith

1980), exploring what factors and forces influence women’s understandings of themselves as midlife.

Factors shaping ‘midlife’ self-definitions

Research into the dynamic nature of age identity9 has highlighted the considerable discrepancies which exist between subjective (individual) and objective (social) constructs of ageing (Hurd 1999). For example, Cremin (1992) noted that older people, despite being positioned as elderly (“being old”) by members of their social networks, only described feeling old in particular contexts and circumstances. Feeling old occurred in response to specific, sometimes transitory, events which threatened central aspects of their self identity

(for example, independence); constructs of being old derived from their ability to engage in social roles, such as being a parent (ibid.). Sherman (1994) argued that subjective understandings of middle10 and old age are based upon a hierarchical ordering of multiple life dimensions and, thus, age identification is a highly complex process of negotiation which is constantly revised based upon changes within these dimensions.

The multiple dimensions used in subjective evaluations of age (feeling old), in the hierarchical order established by Sherman (ibid.), are as follows: 1. chronological age, 2.

9 Logan and colleagues (1992) define age identity as the “labels that reflect how people perceive themselves in terms of age.” 10 As Sherman (1994) notes, very few studies exploring age identity have been concerned with midlife adults and, instead, have investigated ‘old’ age identities. Exceptions include: Logan et al. (1992), Barrett (2003, 2005) and Sherman (1994). Other studies on midlife and identity have not been primarily concerned with understandings of age identity (as I discuss earlier in this chapter).

health, 3. role transitions (in parenting, grand-parenting or relating to work), and 4. in relation to a peer-reference group. The reliance on chronological age in subjective understandings of age identity is contested as many people describe feeling younger than their chronological age might suggest (Cremin 1992; Logan et al. 1992; Laz 1998; Hurd

1999). Chronological age, however, does provide rough age boundaries: for example, Logan and colleagues (1992) found that ‘young’ had an upper boundary of about 52 years.

Studies on midlife participants argue that the role of health status within age identity is significant (Barrett 2003) – and that this has both a functional and comparative dimension

(Sherman 1994). For women, health in midlife is conceptualised as much broader than menopause (despite assumptions to the contrary – see, for example: Fishbein 1992; Jones

1993; Kuh et al. 1997; Rousseau 1998; Avis 1999; Glazer et al. 2002; Kagawa-Singer et al.

2002). Functional health status – presence or absence of disease or illness – is particularly

significant in the adoption of a midlife age identity: Logan and colleagues (1992) found that changes in health status prompted a transition in age identity, from considering oneself

‘young,’ to ‘middle-aged’ self-identification. Furthermore, they found that having a subjectively poor or low health status was associated with identifying oneself as ‘old,’ which may relate to cultural understandings about ageing and being old (ibid.). The most common reason for starting to feel older among midlife participants in Sherman’s (1994) study was related to a change in their functional health.

Comparative health status is comprised of two distinct components. Sherman (1994:

399) suggested that comparing oneself with peers is an important task in determining one’s age identity, and she argued that individuals feeling “‘better off’ than others their age were more likely to consider themselves middle-aged rather than old.” At the same time, however, the role of health in age identity is made salient through comparing one’s current self and health status with themselves at an earlier point in the life course (Sherman 1994; Barrett

2003) – with “the retrospective self” (ibid.:405). Use of the retrospective self implies continuity: changes in health, relative to health status when they were younger, were interpreted by participants as signifying their ageing (ibid.). These retrospectively-identified changes in health do not refer only to disease and illness but also included individual responses to exertion, changes in fitness and strength, or stamina.

Midlife age identity has also been associated with changes in roles, particularly marital roles (husband/wife) or parenting (i.e. relating to children). These relate to the symbolic association of particular roles with age status and, at the same time, are influenced by the demands associated with particular roles. Becoming a grandparent, for example, is salient in the construction of a midlife identity (Logan et al. 1992; Sherman 1994): as are the reduced demands associated with children growing and leaving home (Barrett 2005; also see Dillaway

2006).

Work on midlife also highlights the domain- and context-specific nature of midlife age identities (Sherman 1994; Barrett 2003). Nikander (2000) suggests that midlife age identity is a mutable construct that is applied in different ways in different situational contexts. She argues, for example, that midlife women may feel their chronological age when at work but feel much younger when looking at their life history (ibid.). This may be class- related; Barrett (2003) found that midlife women from lower socioeconomic backgrounds tended to report feeling older earlier in the life course compared with middle or upper class women. Although these studies both explored situational contexts of midlife identity, no research has been done on women’s age identity within the context of place and geographic location. This question is explored in this thesis.

As the process of age identity construction, reconstruction and consolidation occurs throughout the life course, I suggest the concept of the habitus offers a way of exploring the lived experience of age within a specific geographic context. It complements the evolutionary

nature of ageing described by Atchley’s (1989) continuity theory of ageing. Habitus has

bodily, social and cultural dimensions, as I describe in the following section, and is

comprised of practices and behaviours for identity management and maintenance. As the

embodied self evolves, so too does habitus. Furthermore, changes to the body or self-identity may require adoption of new forms of habitus. In this way, behaviours and practices (which shape habitus) performed at different stages during the life cycle provide important insights into how various social domains and cultural scripts shape the lived experience of ageing.

Habitus

The concept of ‘habitus,’ developed by French theorist Pierre Bourdieu (1977), offers a useful way of exploring the ageing process. Through analysing the interplay of individual and social factors (Vilhjálmsdóttir and Arnkelsson 2003), it enables exploration of the impact of health on the lived experience of getting older, a central concern of this thesis. Bourdieu

(1977) argued that social interaction11 takes place within a socio-cultural field or context.

People acting within that context do so on the basis of habitus, “a socially constituted system

of cognitive and motivating structures” (ibid.:76), a mechanism that produces practices

(including social representations and attitudes) or dispositions12 that enable individuals to

cope with a range of situations. These practices emerge from individual experiences

(articulated more fully by Lau 2004), are determined by past conditions and practices, and

contribute to a sense of capital (resources which have social value).

11 Where the individual acts upon the social world, the social world impacts on the individual, or where individuals interact with one another. 12 Lau (2004) argues that the concept of habitus is ambiguous and has been incompletely theorised. In particular, he suggests that the personal psychological motivations of social actors remain unaccounted. In my analysis, I suggest that these motivations both shape and are influenced by external social forces and, as a result, contribute to the development of habitus and require consideration.

Although Bourdieu did not discuss ageing in his work, Dumas and Turner (2006) argue that the process of ageing impacts upon the social world and generates an age habitus, that is, a way of thinking, feeling and acting about the ageing process (ibid.). They (2006:152) state that:

The habitus that is confronted by aging and by its biological constraints acquires new dispositions and engenders particular practices that provide an understandings of the world quite different to that of young people. By being closer to the end of life, to a state of corporeal necessity, the body incorporates a sense of urgency in the later phase of the life course, which can prompt the creation of a new relation to the body. For aging populations, time (especially the time left to live) is a significant change in their conditions of existence, providing a sense of what place they hold in the world. Drawing upon their argument that the concept of habitus evolves relative to changing social conditions (on both macro and micro levels), such as cultural scripts of ageing or in terms of social participation, and bodily conditions (changing health status, functioning or physical appearance), I argue that the adaptation of habitus which occurs during midlife is of particular importance. In particular, I suggest that the acquisition of a midlife habitus occurs in response to a series of unique changes, including bodily changes (such as health-related events), community/social changes (relating to community participation, for example), and psychosocial changes (including women’s responses to transitions in their social roles and interpersonal relationships) occurring in women’s lives.

Previous research exploring ageing through the notion of habitus has been limited, and has primarily focused on the experiences of specific and exceptional population groups: elite athletes (Tulle 2003), professional boxers (Wacquant 1995), and professional dancers

(Turner and Wainwright 2003; Wainwright et al. 2005, 2006a, 2006b), for example. Although these works provide important insights into how bodily practices shape the lived experience

of ageing, their focus is on individuals who have used their bodies to explore the limits of

bodily capacity and capabilities (Tulle 2003:235), rather than providing insight into the

experiences of everyday social actors. Dumas and Turner (2006) argue that the ageing

process is one of declining physical capital (“loss of health, strength and bodily appearance,”

ibid.:152). Given this, it is of interest, therefore, to explore how individuals adapt habitus and

maintain their social position during ageing, particularly during the midlife years, when they

are, variously and potentially, between young and old (Gullette 1997) or in the prime of life

(Fodor and Franks 1990; Mitchell and Helson 1990).

AIMS AND OBJECTIVES

The aim of my research was to explore how Australian women experience midlife,

particularly in terms of their health and health self-management, through an exploration of

continuity and habitus. As very little research has been concerned with the experiences of

women in rural areas, I was interested to explore how geographic location and isolation

might impact upon the understandings and meanings given to women’s experiences. The

objectives of my research were:

1. To identify how women perceive and define midlife; 2. To examine the extent to which societal and biomedical images and models compare with the realities and experiences of midlife; 3. To examine how health status impacts upon women’s midlife age identity; 4. To explore how women feel about their bodies as they approach and pass through midlife; 5. To understand the ways in which women feel their bodies change as they (middle) age, and how they negotiate these changes; and 6. To identify ways in which the place of residence influences how women negotiate and manage their bodies during midlife.

In following research arguing that chronological age does often not correspond with subjective age (such as Cremin 1992; Logan et al. 1992; Tulle 2003), I sought to understand the social and cultural markers used by women to construct their self-categorisation as

‘midlife.’ In particular, I was interested in how they constructed their age-identity and what factors were salient in their understandings of both the process of getting older and of this particular life stage. These markers of midlife are explored throughout this thesis.

OVERVIEW OF THE THESIS

The discussion of midlife that forms the basis of my thesis brings together discussions of the life course, ageing and development. In doing so, I challenge the exclusivity of traditional theoretical domains (described above) which position ageing theories under the umbrella of gerontology – predominantly concerned with old age, the elderly and the process of

‘becoming’ old – which are constructed as discursively different from notions and theorising around maturation and development. In my thesis, I also seek to provide empirically grounded insight to the experience of midlife for women in a western context.

This thesis tells the story of midlife women in Waterside, a rural Australian community, and explores my proposition that women’s health-related experiences and, where applicable illness events, shaped their understandings of midlife, ageing and the life course. It is organised thematically yet in keeping with the story’s plot. In Chapter 2, I discuss the research methods and ethical considerations of this research. To do my research, I returned to my home town; the associated insider-outsider dynamics, issues of representation, and my positioning within the research are discussed.

In Chapter 3, I contextualise my research by describing the Australian health system, specific policies relating to women’s health and provide an historical overview of health in

Waterside. Against this background, I outline the four inter-related narrative strategies used

by women to discuss and give meaning to their health-related experiences. I refer to these as

‘Maintaining,’ ‘Contemplating,’ ‘Negotiating’ and ‘Navigating.’ In doing this, I draw upon

their notions of normality and continuity, and situate health experiences within women’s

biographies. This chapter is concerned with exploring what health means for women and its

implications for their lived experiences of midlife.

Chapter 4 challenges dominant understandings of midlife as based on the biological

body, with particular (excessive) focus on menopause as fully encompassing women’s

midlife. As noted by Brown (1982), midlife encompasses a longer period of life than the

physiological moment of menopause. I describe the slippages in women’s understandings of

midlife and menopause, and explore how these concepts are shaped by meanings given to

biological, social and cultural factors. I also describe how women’s experience of

menopausal-related bodily events shape how they manage their health.

The role of health status on understandings of the body, the self and age identity are explored in Chapters 5 and 6. Women who did not experience bodily problems are described in Chapter 5. I explore how changes in health status shaped the understandings of midlife tasks for these women. In particular, I highlight how the women who told Maintaining narratives about controlling the body were concerned with warding off future bodily ailments; in contrast, Contemplating narratives were used by women who experienced role changes due to others’ health. Chapter 6 describes the experiences of women who experienced problematic health during midlife. In this chapter, I contrast the experiences of women who had a biography characterised by health troubles (who told Negotiating narratives) with those who experienced health difficulties for the first time during midlife

(those who used Navigating narratives).

In Chapter 7, through exploring the impacts of place on women’s health management behaviours and practices, I seek to develop an understanding of how

geographical location and community context may influence women’s age identity and their understandings of midlife. In particular, I note that women embody particular characteristics of place and rurality in their health management, which has implications for their age and self identity. The concluding chapter explores how women conceptualise midlife as relative to

‘that other age’ (older age) based upon multiple social, cultural and embodied markers. I demonstrate how my findings contribute to contemporary theories of ageing by highlighting the role of health status in shaping women’s lived experience of midlife. In addition, I explore how dual concepts of continuity and change are employed by women in their understandings of middle ageing, which are influential in shaping their understandings of ageing, health and the life course.

Chapter 2

Returning Home: Methodological Reflections

Within western contexts, social research conducted at ‘home’ is a rare occurrence. At home the mystery of the exotic and/or the unfamiliar, which characterises most ethnographic research, is absent. The legitimacy of the ethnographic endeavour is established as one works in an environment of personal distance (geographically/physically, culturally and socially); and so the researcher thus must travel out of her comfort zone in order to conduct her study

(Manderson 1985; Amit 2000). Although there may be hidden layers to individuals’ experiences, research at home is constructed as transparent, readily known and eminently accessible and thus, of little research interest or value. This seems to be a peculiarity of anthropology and ethnographic research in western contexts. Although many of my international student colleagues returned to their home countries and communities to conduct their research, an assumed and unquestioned practice, my return home for research was regarded by some as problematic, inappropriate and unethical (not dissimilar to those described by Caputo 2000).

Part of the problem inherent in home town research lies in the difficulty of separating home and the field (Amit 2000) – Caputo (2000) described fieldwork ‘at home’ as a process of blurring the traditional boundaries between home and field. Home in this context is assumed to be profoundly subjective and characterised by static and stable social relations (Amit 2000). It is perceived as not amenable to gaining an in-depth (dare I suggest, objective) understanding of the cultural and social processes that shape human experience. In contrast, the field is assumed to be dynamic, shifting and beguilingly unknown; it also exists

independently and autonomously of the researcher. The outside-ness inherent in this

construct of the field suggests one reason why home town research is viewed so

problematically: in my home town, the process of ‘becoming’ (Hastrup 1990), a central task

in the practice of ethnography, preceded my research and, indeed, my memory. In contrast

to other ethnographers, I am unable to reflect upon my introduction to the field and explore

the newness of the locale in this thesis. Instead, I reflect upon how processes of ‘belonging’

rather that ‘becoming’ shaped my inquiry.

As a result of this problematic construction of ‘home’ as a field site (highlighted in

the edited volumes by Manderson 1985; Amit 2000), limited literature provided insight or

guidance on negotiating the relationships involved (of particular assistance was Manderson

1985). In this chapter, I begin to redress this silence. Firstly, I conceptualise ‘home.’ The

experience of going home is then discussed. Issues such as belonging and positioning,

representation and anonymity are explored before I describe ‘Waterside’ (a pseudonym), my home town and the community in which I conducted my doctoral research. In doing this, I highlight changing demographics and health services. I then outline the methodology used in researching midlife in Waterside, including the iterative process of data collection and sampling. I finally describe the women who participated in my study.

Conceptualising ‘home’

Central to this research is my conceptualisation of home. My concern with ‘home’ is derived in part from the disciplinary location of my study (Manderson 1985), which is positioned as straddling the divide between sociology and anthropology. Home has been defined in a range of ways in anthropological and sociological research, often quite broadly (such as in terms of within one’s country of birth or residence, see volume edited by Amit 2000). In contrast, my concept of home is much more localised and specific. Similar to Madden (1999), I returned

to my home town to conduct my doctoral research and thus, my concept of home bears some resemblance to his description of home. Yet due to the specific nature of each community, they vary on some key components. Tönnies’ (1957) concept of gemeinschaft is important here: in my home town, interactions are close and personal, occurring on a one-to- one basis. One cannot readily escape the notice of others, as occurs in larger societies.

Community members are bound to one another on the basis of social obligations arising out of their position within the community, which is in turn mediated by factors such as kinship.

Madden (1999) describes his working model of home, which is outlined in Table 2.1.

Table 2.1: Working model of home Home is… Familiar “I know it very well, it is a geographical region within which streets, highways, back roads, houses, sheds and other buildings, and landscape are known.” Parochial “It is a place that elicits a defensive stance from me, despite my ambivalence towards it.” Discrete “I know where it starts and ends, in both a geographical and social sense. I have it mapped out in my mind.” Habitual “Old habits of speech, manners, attitudes and moods come back to me when I go home. One could say that my personality changes when I go home, or conversely, that I just become my self again.” Permanent “After well over a decade of living in Melbourne, I still go down ‘home to the country.’” Birth “It is where I spent my childhood, and also my youth. As such, it has played a large part in the construction of my adult personality.” Death “It is where family members and relations are buried.” Ambivalence “Home is a place I felt the need to leave, and yet I also feel the need to return. It is a problematic, yet attractive domain.” Source: Madden (1999: 261)

In situating my research in geographic and personal space, I address each of these. The appeal of this model for my research relates in part to cultural understandings of place and home: both research projects were conducted in rural Victoria, albeit in very different communities. Waterside is small (as I describe later in this chapter); my understanding of home is situated in terms of its precise geographic and social space. It is a place that I know

extremely well, where the geography has an emotional and existential meaning for me.13 It has helped direct my life biography; my ‘home’ is deeply embedded within my concept of self; thus, to some extent, by situating my research in my home town, I am conducting an odyssey into my self and my biography. St Pierre (1999) argues that going home is about slowing down, taking time and falling back into the habits of growing-up years. Home, for me, is about old patterns and practices – tracing and retracing steps I’ve taken before – and one of the challenges of doing research at home is the need to be conscious of these subconscious patterns, which are central to the experience of living in the community.

The permanency of home is maintained despite my physical geographic and temporal distance. Although I left Waterside in 1992, and have lived in three cities since, returning is always “going home.” This partly relates to my family continuing to live there although, as

Madden (1999) identifies, it also relates to my beginnings and others’ endings: it is a place where several generations of my family were born and raised. My mother’s family played an important role in the establishment of Waterside, arriving in the region not long after it was settled, and remaining there for the ensuing six generations. Genealogy is central to my understanding of home – it is what tied me to the community in the beginning and it is what draws me back again. Many loved ones are buried in the ground at home and revisiting them in my mind always brings me home to Waterside. Central to my experience of home – and of particular importance in my research – was the issue of belonging, which I explore using the lyrics from the song ‘since I’ve been around’ (below) as a device for engaging with the

13 This can be seen through my continued involvement in community activism. Recently, the local government has proposed to change dramatically part of the beach landscape near Waterside and I have become actively involved in a conservation group seeking to preserve this area. The landscape has played a central role in my personal history and life trajectory; it also has particular cultural and social meanings. Thus the proposal to quarry the area and create a man-made marina presents an affront, almost a desecration, of my younger self. This is particularly poignant given that this is also an area which has a spiritual significance for my peers and me – a close friend’s (cremated) ashes are scattered there.

ambivalence involved in the physical action of returning home to conduct fieldwork, and how changes in my social role influenced the process of the return.

GOING HOME

Walking down the main street, of the town where I was born Looking at the things I’ve seen so many times before I take a deep breath, smile and kick a stone along the ground Been so long since I’ve been around

There’s comfort in the way that everything still looks the same, People that I bump into, they call me by my name It almost feels as though I never even left this town Been so long since I’ve been around

And my girlfriend lived on Hawdon St, man was she a sight Sometimes I would sneak into her bedroom late at night Now she’s not there, I’m told her family long since left the town Been so long since I’ve been around

Many of my friends, they found some other place they’d rather be But I’ve still know one good mate, she’s gonna keep me company I think I’m gonna call her up, we’ll go and paint the town Been so long since I’ve been around

I stopped on by her place, years ago I knew her well “Let’s go drink to old times sake at the Adelaide Hotel’ She said it’s twenty years now since they shut that old place down Been so long since I’ve been around

You know, the hospital’s still standing, down over by the river shore That’s the place I took my first breath, so many years before I take a deep breath now and feel my chest begin to pound Been so long since I’ve been around

Now I’m lying by the river, feeling lazy in the shade Children shout and splash about in the water where I played I’m thinking I could stay a while, maybe settle down Been so long since I’ve been around

– Lyrics from ‘Since I’ve been around,’ Josh Cunningham (The Waifs)

Returning home to conduct my research provoked ambivalence, simultaneously generating feelings of familiarity and belonging, contrasting with feelings of alienation in response to often-significant changes within the community (both socially and geographically). Situating my research in my home town was a continuation – and the making concrete – of a life-long ethnographic journey, beginning when I was born (also described by St Pierre 1999): as long

as I can remember, I have been gathering information about the community – that is,

absorbing, building and recreating community mythologies about what it means to be a

community member. The song lyrics (above), by Australian folk group The Waifs, reflected

the key challenges of my fieldwork experience: negotiating the tension between still

belonging and no longer being part of the community, and interrogating the taken-for- granted community knowledge and assumptions (see Van Ginkel 1998). In exploring these tensions, Rapport (2000) describes the case of Greg, who manages to maintain a sense of being grounded (groundedness) and at home, despite living in a different community.

Through genealogy and the belonging of his family to the community, coupled with local knowledge, Greg described how he maintained a sense of attachment and belonging to the community. In the following section, I explore some of the mechanisms by how I actually and symbolically maintained a feeling of belonging to the Waterside community.

Belonging

Going home to a small town is a qualitatively different experience from going home to a larger regional centre or city (also discussed by Manderson 1985). In a small town, social ties are typically close and networks are relatively small (discussed above and as noted by Tönnies

1957), and these shape the research process. My mother’s family have been resident in

Waterside for over 100 years, since the early 1890s, and are one of four families who have remained in the district since that time. Our family therefore occupies a historical place in the community. Many of the older buildings in the town centre were constructed by my grandfather, and this influences my ongoing sense of belonging. Through marriage and the production of subsequent generations, a considerable proportion of the community are my relatives, including many of the very long-term residents of Waterside (and their descendents). As a result, most people remembered my name and, as my parents and siblings

lived in Waterside,14 many were aware that I was doing post-graduate studies in women’s health. With the exception of one, I knew all of my participants – some for many years – prior to commencing data collection; their awareness of my studies allowed me to segue from being primarily identified as my mother’s (their peer’s) daughter to being positioned as a researcher who was interested in them and with whom they wanted to talk. I gained autonomy. As Rapport (2000) argued, my claim to ‘belonging’ in Waterside was an artefact of my family’s continued presence and participation in community life. However, my knowledge of community expectations regarding social participation also enhanced my sense of ‘belonging.’ In many ways, I was behaving in normative and expected ways, which ensured that I remained a part of the community; I attempt to describe these habitual ways of non- resident belonging below and suggest ways in which they impacted upon my research.

Positioning

Things changed in the years between my leaving home for study and returning to conduct my research. Many of my friends and peers had left town, as I had. It is a fact of life in many

Australian rural communities that, due to very few career and educational opportunities, many young people out-migrate to cities and larger regional centres (Alston 2004). This was no different in Waterside, where the only occupational opportunities available for young people were in the construction industry (inaccessible to most women in the community), in the seafood processing factory or in the service industry (such as waiting tables or being a supermarket cashier).

14 At the start of my data collection, my two sisters both lived in Waterside; my brother was also there on a part-time basis. During my research, however, one of my sisters and my brother also moved away from Waterside.

By leaving home to seek educational opportunities, despite my gender, I behaved in

normative and accepted ways; this normativity was reinforced by both the regularity of my

visits home and as I actively maintained key social engagements during these visits. In

behaving in such a way, I ensured my ongoing ‘belonging’ in the community. I visit my

parents and sister (and thus, visit Waterside) several times each year, ensuring that I visit

around shared cultural holiday events, which include long weekends and public holidays. On

each visit, I encounter other Waterside ‘children’ – now-adults who grew up in the

community and whose parents continue to reside there – reinforcing the social norm of the

return visit. To maintain my sense of belonging and having a place (position) in Waterside,

each visit is characterised by at least one community-based activity. A prolonged excursion

into the community itself – enacted by going to the store in the centre of town – is important

as it signifies ‘the return’ and invites engagement with community members. Store visits, for example, typically take over half an hour during which grocery shopping is the secondary

purpose – the primary purpose of going to the supermarket is to encounter community

members and answer their (often quite personal) questions about one’s life: what you are

doing (questions about life purpose and direction); who you are doing it with (questions

about partnerships and family); and what are you going to do next (questions about

aspirations and future directions). The visibility of this activity and willingness to engage with

other community members are thus central features of the return. By participating in such

rituals, the claim of belonging is validated and legitimated.

My position within the community impacted on how I conducted my research. Many

of my participants were personal acquaintances of my family members or friends, and this

brought its own obligations (also described by Pedersen 1998). Others were my own

acquaintances. Issues of trustworthiness and assurances of confidentiality therefore needed to be addressed and emphasised throughout the research process.

Representation

Researching personal acquaintances raised questions that are not encountered in other field sites. It introduces the concept of ‘relational ethics,’ which Ellis (2007:4) describes “seek to deal with the reality and practice of changing relationships with our research participants over time.” My relationships with almost all of the participants in this study were durable and persisting; our knowledge of each other pre-dated my research and, in many cases, began whilst I was still a child. Because these relationships pre-exist in home town research, the power dynamics and positioning of both researcher and researched are profoundly changed.

Although issues of power are inherent in the researcher-participant relationship (see the edited volume by Wilkinson and Kitzinger 1996), which primarily relate to the distinction between ‘us’ (the researcher) and ‘them’ (the researched), these are altered in research at home. My new role as researcher (compared with ‘daughter’ or ‘one of the kids’) redressed the age-based power dynamics that had existed throughout my childhood and adolescence, thus bringing power into balance (also see Titley and Chasey 1996). Kitzinger and Wilkinson

(1996) argue that the process of conducting research positions the researched as less empowered than the researcher, and I was mindful of this throughout my research. In shared historical understandings of power and status divisions in Waterside, participants, by virtue of being my parents’ age and thus ‘grown-up,’ were of a higher status than I (‘child’). In addition, perhaps by virtue of our prior relationship, participants felt a sense of ownership of the project and frequently telephoned me with ideas about what I should be exploring and with suggestions for theorising about their lives.

Participants therefore described my position as an ‘insider’ on the basis of our shared community connections, as a positive and useful thing. They felt they could ‘trust’ me to use their stories wisely and not to misrepresent them. For many participants, the trust based upon our shared insider-hood meant that they felt that I would keep my word. Keeping my

word was fundamental to the development of trust and the relationships of reciprocity that I

developed with participants. The ongoing relationships between participants and my family

members also ensured that I would represent them appropriately and not misuse their

stories: in this way, being an insider ensured accountability. Home town research therefore

offers a unique approach to employing a ‘friendship as method’ approach to data collection

(Tillmann-Healy 2003; Ellis 2007); the possibility of leaving the field is precluded as it is unrelated to geography and instead pertains to social, cultural and historical notions of

connection. In addition, as Tillmann-Healy (2003) suggests, there is no clear separation between researcher and participant. All parties are actively involved in shaping and conducting the research. That said, however, issues relating to anonymity still require consideration and negotiation.

Anonymity

Originally, I was very concerned with assuring participants that their stories would be kept

confidential and anonymous, and sought to ensure this as much as possible. While collecting

data, I was surprised to learn that whilst confidentially was important, anonymity was less of

a concern for participants and many chose pseudonyms by which they potentially could be

identified. Several even stated that I should use their given names and, when pressed, stated

their nicknames should be used as their pseudonym for this study. This raised questions for

me about whether anonymity is important and, indeed, whether it is possible when

researching small communities. Furthermore, participants were only interested in

confidentiality insofar as their stories did not become fodder for gossip, rather than relating

to disguising their identities (Giordano et al. 2007).

Reflecting on this, it seems that the way pseudonyms are used in research primarily

serves the interests of ethics committees and, to a lesser extent, researchers (Grinyer 2002),

rather than acting in the interests of participants. Ellis (2007), for example, describes how participants in two small communities were still able to identify themselves based upon the stories they told, despite her efforts to disguise their identities; in addition, they were able to recognise other participants and make judgements of those people on the basis of those stories. Theoretically, pseudonyms are used to prevent such occurrences – if this is not possible, the appropriateness of providing assurances of anonymity should surely be challenged. Further complicating the issue of anonymity are issues around ownership, empowerment and distress. Grinyer (2002) found that most participants preferred to be referred to by their real names in any dissemination of the research: use of a pseudonym meant that they felt distanced and alienated from their own stories, their accounts of intimate and personal experiences. I would suggest further that, by asking participants to nominate a pseudonym for their accounts, feelings of shame, guilt and/or secrecy can unintentionally be invoked. That is, by requesting that participants nominate a pseudonym, we implicitly suggest that there is something about their story from which they might wish to be distanced.

The anonymity of the community is perhaps even more problematic. Nespor (2000) has argued that, regardless of effort used, community anonymisation is unreliable as the community’s identity can be revealed through a range of ways. She argues that, in order to meaningfully give a community a pseudonym, one needs to “indexically locate the places in everyday worlds that participants, readers and writers share” (ibid.:555). I attempt to do so below.

How best to deal with issues of anonymity when conducting research in an institutional context is fraught with challenges and the question of how best to represent our communities – in all of their social, cultural and geographical vibrancy – while fulfilling institutional requirements. In my research, ethical and departmental clearance was conditional on the anonymisation of both participants and the community. The atypical

nature of my home town, which I have termed Waterside, means that its disguise is

somewhat tenuous.

Negotiating the use of pseudonyms for participants was not straight-forward. Several

selected a pseudonym that was meaningful for them, which was most often a ‘nickname’

from their youth or a whimsical name which provided insight into their imagined futures or

into hidden aspects of their self (Manderson, personal comm., 2005). For example, Maude

selected her pseudonym based on her enjoyment of the film ‘Harold and Maude;’ she stated

that, like Maude in the film, “my plan is to be eccentric in my old age.” Treasure’s choice of

pseudonym was related to her deceased husband: he used to always call her his treasure. But

several participants were unable to choose a pseudonym and one simply wanted to use her

own name. These women were all randomly allocated pseudonyms based on common names

given to babies in their year of birth; in this way, these pseudonyms were qualitatively ‘equal’

(Grinyer 2002) to their real names. Whilst this is an imperfect approach, I have attempted to

maintain connections for participants with their stories while concurrently disguising their identities.

Pragmatics and fieldwork: responding to life circumstances

Many of the decisions I made about my research occurred in direct response to my life circumstances during my candidature. As my research was unfunded, the negotiation of

competing demands and conflicting needs influenced many of the choices that I made and

undoubtedly shaped my study and its findings. At the same time, however, I was committed

to doing a qualitative, preferably ethnographic, study; the compromises reached are reflected

in my decisions in terms of field site, recruitment and data collection. The decision to return

to my home town – suggested by my supervisor and head of department – occurred in direct

response to these circumstances. Because of the constraints placed on my study by my full-

time employment, I needed a research site that did not require a long process of entry and acceptance. My choice of field site was strongly influenced by the time constraints placed on data collection (which I describe at the end of this chapter). Locating the research in my home town provided two advantages. Firstly, my position within the community meant that the need to spend time being accepted (as occurs in ethnographic studies in exotic locales) was minimised; my frequent visits home meant that my presence, rather than absence, was noted by community members. Due to working hours, data collection occurred over two and a half years, from mid-2001 until the end of 2003, during which time I returned to Waterside on weekends, long weekends, holidays and short breaks. In order to maintain community participation, I was not away for longer than two weeks at any one time during this data collection phase. In addition, my family members acted as my unofficial ‘research assistants,’ assisting with recruitment (I describe their role in detail below). In the following section, I describe the community of Waterside, before describing the specific details about how I conducted my research.

In reflecting upon my fieldwork experience, there are only two things that I wish I had done differently, although perhaps neither of these would have dramatically altered what

I present in this thesis. I wish that I had had more time and confidence when recruiting participants. Several women asked me regularly about my project – how it was going, what I was finding – yet never specifically inquired about participating. At the time, I believed that it was ethically inappropriate to ask if they would like to learn more about the project. As I have gained more experience as a researcher – obtained through my employment activities –

I realise that introducing the possibility of participating to interested individuals is part of my role as a researcher. The things I would have done differently relate to the actual content of the interview themselves. I wish that I had asked more questions about women’s experience of menopause and, perhaps, used a menopause symptom scale as this would have enabled

greater comparison between my study and others. My reasoning for not doing so is sound:

when designing my study (and throughout this thesis), I argued that a life stage must be

about more than a biological/physiological event, no matter how culturally constructed

(following arguments by Brown 1982; Richards et al. 1997; Lock and Kaufert 2001). In

addition, such a focus would have been meaningless for participants who hadn’t reached

menopause, yet considered themselves midlife (Liza, Louise and Nola). Due to time and

geographical constraints, I was unable to interview most women more than once; this was

also difficult because many participants were highly mobile and led busy lives (for example,

Musical migrated overseas; Mac and Liza migrated elsewhere in Australia). Those who I did

not manage to interview more than once supplemented the interview data with telephone

calls, letters and cups of tea when I was in town; in this way, I gained insight into their lives

on an ongoing basis.

Despite these constraints and limitations, I believe that the data achieved the aims

and objectives of my research project. In addition, doing doctoral research ‘the hard way,’15 as part-time ethnographic research ends up being (although it never seemed that way in the beginning), had its benefits. Most importantly, as I gained knowledge and skills in doing and reporting research through my employment as a research fellow, I gained insight into my own data. I recently attended a workshop conducted by Catherine Riessman (Victoria

University, January 2007) who emphasised that in the process of gaining life experience and insight as an individual, one’s data analysis is enhanced and enriched. Revisiting the data, she argued, is useful and insightful. I have analysed my data three times. Part-time research facilitated this and gave me time to read, absorb, understand and analyse participants’ stories.

15 As described by one of my friends and colleagues, also a PhD student at the time.

WATERSIDE

The community of Waterside lies within the land of the Maap (Bidawal) people, where the

Tinoormitter (Jin Noor Mitter) tribe resided in an area along the coast of Victoria, Australia near where two inland river systems meet the ocean (Clark and Anderson 2005). Waterside is a culturally significant area for the Maap people, who lived from fishing, as the area where the township is now located was used as a place of refuge from revenge and tribal justice (ibid.).

Little is known about the history of Aboriginal settlement in the area beyond this (Howe

1990), although the history of European settlement is troubled, characterised by challenges between the local Aboriginal tribes and pastoralists (who wanted to run cattle in the region) over territory from the mid-1840s until 1871 (ibid., Clark and Anderson 2005). Conflicts between the local tribes and settlers resulted in the deaths of many Maap people, and none of their descendents remain in present day Waterside.

European settlement in Waterside was characterised by changes in the accessibility of the township area, an issue which continues to shape everyday life in Waterside. The settlement of Waterside began with the construction of a lighthouse on nearby Red Granite

Island,16 which lies less than 2 kilometres from the coast and 13 kilometres from the

(present) Waterside town centre. The lighthouse, built following a number of shipwrecks along the coast, enabled greater ocean access to the area by making it much safer for large boats to navigate (MDHS 1980). Land access was problematic, however, until the development of an access road in 1918 (ibid., Howe 1990).

Waterside is located at the entrance to an extensive lake system, surrounded by ocean front beaches. It is the most geographically isolated community in Victoria, the south- easternmost state of mainland Australia. The community occupies about 6.5 square

16 All place names are pseudonyms.

kilometres (ABS 2001) and lies within a large national park and UNESCO biosphere reserve.

The surrounding environment is beautiful and largely untouched. Present day access to

Waterside is obtained via a 23 km long and very winding ‘blind’ road17 through the ‘bush’

(Australianism, eucalypt forest). Geographic isolation continues to characterise life in the

community. As I describe below, the nearest services are located about one hour (c.92 km)

drive away in Paradise (pseudonym). Paradise, however, is also small (population 3299) and services are limited. Figure 2.1 is a photograph taken from a peak overlooking Waterside, and illustrates the geographic isolation of the community.

Waterside To main highway

Figure 2.1: Overlooking Waterside from nearby peak (elevation 490 m)

The geographical space of the community

Waterside is 3 hours drive from the nearest regional centre, and about 7 hours drive

(although only about 550 km) from the state capital, Melbourne. Services in the community

are limited, although comprehensive. There is one local school for children from the

beginning until the end of their schooling (Prep through to year 12); a kindergarten offers

pre-school education four mornings a week. A mobile library service drives into Waterside

17 Davis (1983) introduced the concept of the ‘blind road,’ which occurs when the community can only be accessed by one road – i.e. one road in, the same road out.

for one evening and one morning per fortnight. The town centre is comprised of several stores: two supermarkets, two service (petrol) stations, a pharmacist (chemist), butcher, bakery, post office, video store, newsagent, fishing equipment store, hotel, restaurant and a government office, which accommodates fisheries compliance officers and park rangers. On the outskirts of the town, there are golf and bowling clubs, the police station, the medical centre, the community health and support service, an airport and an industrial area which consists of a seafood processing factory, storage sheds, concrete yard, welding business and two mechanics (electrical and marine). Table 2.2 shows the main areas of employment by industry in Waterside.

Table 2.2: Industry in Waterside, 2001 Industry Number of employees (% of workforce) Agriculture, forestry, fishing18 38 (9.5) Manufacturing 22 (5.4) Electricity, gas and water supply 3 (0.8) Construction 22 (5.4) Wholesale trade 25 (6.2) Retail trade 49 (12.1) Accommodation, cafes and restaurants 55 (13.7) Transport and storage 9 (2.3) Communication 9 (2.3) Property and business services 40 (10.1) Government administration and defence 12 (3.1) Education 44 (11.1) Health and community services 34 (8.5) Cultural and recreational services 21 (5.2) Personal and other services 18 (4.4) Source: DPI (c. 2001)

Since recent Victorian state legislation (April 2003, see Victorian Government Minister for

Agriculture 2002) banning commercial lake fishing, the main industries in Waterside are abalone fishing, tourism, construction and human services. The geographical location and physical environment has shaped the position of industries in Waterside and also has

18 Not shown in this table due to the unavailability of data are the seasonal workers who are employed on a casual basis at the local abalone fishermen’s cooperative, a food processing factory.

influenced the distribution of the local population. A map of Waterside is shown in Figure

2.2 (below).

‘Crathong’

To Red Granite Lake Road Island

‘Raheen’

To highway

Industrial Town precinct centre

To beaches Southern Ocean

Figure 2.2: Map of Waterside township area

The community of Waterside is loosely comprised of three parts, ‘Crathong,’19 ‘Raheen’ and the township proper, which are connected to one another by a single road running along the edge of the lake (shown in Figure 2.2, above). A much longer alternative access road was constructed during the 1970s. This spatial distribution of the community relates to the

19 Pseudonyms

pastoral history of the area and also to the reliance on the lake system for transport within the township area – the two outlying sections were originally used for farming cattle and access between them and the town centre was via boat, until the construction of the lake road in the mid twentieth century.

Each of these areas has some socio-demographic variation, with an historical basis.

The Crathong area is approximately 5 kilometres from the town centre; its residents tend to be elderly and many have retired to the area. However, a significant proportion of dwellings are holiday houses or apartments, or bed and breakfast accommodation. Crathong continues to be widely perceived as being populated by residents of a higher socio-economic status, due to the spectacular views which command much higher land prices. Raheen lies between the town centre, from which it is approximately 1.5 kilometres, and Crathong, a little over 3 kilometres away. Although this was historically a relatively small pocket of houses on the way to Crathong, it is now much larger due to the subdivision and development of several large farms. The residents of Raheen are similar to those who live in the town centre itself: both areas have fewer elderly residents (as a proportion of the population) and many more young families, probably because of access to the educational, sporting and community facilities – all of which are predominantly aimed at younger residents – and greater affordability of housing. It must be noted, however, that the affordability of land and housing has changed dramatically during the past few years,20 which has influenced the demographic structure of these areas. In addition, dramatic changes to land use occurred over the decade prior to my study; these have accelerated since I began fieldwork. Previously vacant or forested land has been cleared and subdivided for residential purposes. For example, large tracts of bushland,

20 My sister is a local real estate agent and has thus been aware of changing prices in both rental and sales properties. Since 2003 (approximately), land prices have dramatically increased which, it is speculated, is due to drops in interest rates. For example, where a suburban-sized vacant block of land would have previously sold for around $35,000 to $50,000, blocks are now (2007) selling for over $110,000.

previously used only by bushwalkers and horse-riders (such as me), have since been cleared and are now land-marked not by trees but by houses, sheds and people.

Profile of Waterside residents

Waterside is a small community, with 1041 permanent residents (ABS 2001). Not all are long-term residents, however, as is illustrated by the steady population growth and indicators of population stability, shown in Table 2.3 (below). The community now includes a large stable pool of residents, accounting for about half of the population. Although the exact size

of the transient population (both short or long-term residents) is not indicated by these

figures, which include people who have remained within the community yet moved house,

local anecdote suggests that over one-third of the community is highly mobile, migrating in

and out of Waterside.

Table 2.3: Population changes in the two decades preceding the study Year 198121 1986 1991 1996 2001 Total population 726 826 961 982 1041 Male/female 51/49 54/46 52/48 52/48 51/49 population ratio22 Living at the same 306 292 396 489 564 address 5 years ago (42.1%) (35.4%) (41.2%) (49.8%) (54.2%)

Roughly equal numbers of men and women comprise the community, which reflects

the commonness of heterosexual marital or de facto partnerships (see Table 2.4, below). Of

those who are not, most parents raising their children alone are women (many full-time

mothers) and, unsurprisingly, most unmarried people who live alone are men. Such factors

shape gender relations in the community and impact on the experience and positioning of

21 Data was obtained from the Australian Bureau of Statistics Census of the Australian Population Community Profiles, by year: (ABS 1981, 1986, 1991, 1996, 2001). Additional data is from the Department of Primary Industries (DPI c. 2001). 22 Data on male/female ratio and residential mobility was obtained from the Victorian Government Department of Primary Industries (c. 2001).

women in Waterside. Gender differentials in community roles shaped access to employment, resources and, thus, power, which led several women to describe Waterside as ‘a man’s town’

(discussed below).

Table 2.4: Socio-demographic characteristics of Waterside residents Marital status23 Total Highest level of education24 Total Married 460 No formal education 3 Separated 36 Primary and early secondary 98 Divorced 78 Some secondary schooling 378 Widowed 48 Completed secondary 289 Never married 221 Still studying 30 Not stated 52 Age structure25 Household size26 Under 18 years 229 1 person 143 18-34 years 137 2 people 163 35-49 years 218 3 people 52 50-64 years 238 4 people 48 65-79 years 165 5 or more people 20 80 years and older 49 Not stated 5 Labour Force Household income % Employed 401 Lowest quartile 43.8 Unemployed 46 2nd quartile 32.1 Unemployment rate 10.4% 3rd quartile 16.8 Labour force participation rate 52.8% Highest quartile 7.3 Country of birth Ancestry28 Australia 816 Australian 391 East Asia 3 Indigenous Australian 0 New Zealand 13 Oceanian 16 North America 3 North-West European 733 South-East Asia 10 Southern/Eastern European 47 United Kingdom27 87 North African/Middle Eastern 3 Western Europe 28 South- or North- East Asian 30 Not stated/elsewhere 75 People of the Americas 3 Sub-Saharan African 3 Not stated 52 Language spoken at home Religious affiliation English only 958 Buddhism 12 Western European languages 24 Christianity 552 South-East Asian languages 6 Hinduism 3 Other Asian languages 3 Other religion 6 Other/Not stated 31 No religion 310 Not stated 150 Source: (ABS 2001)

23 All data is from people aged 15 years and older (ABS 2001). 24 Data refers to primary and secondary schooling only and is from people aged 15 years and older (ibid.). 25 The male/female ratio in Table 2.2 indicates more men than women in the community; this is seen through all but five age groups: 25-29 years (15 men cf. 18 women); 30-34 (29 cf. 34); 35-39 (26 cf. 28) and 45-49 (37 cf. 49) – which directly involves women in my study. 26 Data on household size, income and labour force participation from DPI (c. 2001) based on 2001 census data (ABS 2001). 27 Includes Ireland 28 Totals add to greater than 1031 due to multiple responses (i.e. ancestry stated for both parents; ibid.)

Waterside is a relatively homogenous community. Residents are mostly of Anglo-Australian

or European descent and, at the time of my research, there were no indigenous Australians

resident in the community (ABS 2001). Indeed, since I was a small child, there were no

community members with Aboriginal ancestry although substantial numbers live in the

nearest town on the highway and, until about the late 1980s, many people of Polynesian

descent were in the community – an artefact of the abalone industry. At the time of data

collection, there were 207 women aged between 35 and 65 (roughly ‘midlife,’ Benson 1997;

Shweder 1998) residing in Waterside. Adults aged in this third (approximately) of the life

course comprised the largest proportion of the population, indicating the suitability of the

community for the present study. Data indicating that the next largest population group were

those aged under 18 supports my earlier comment that many younger residents leave the

community in search of career or further educational opportunities. It is worth noting that

the industrial composition of the community impacts on other age groups in quite a different

way. For example, some of the midlife women in my study worked in relatively low skilled

service positions – without such employment, many would be forced to leave the town for

economic reasons. These women performed vital roles in Waterside, providing essential

labour and ensuring that businesses and services were able to continue: maintaining

community (re)generation.

ENTERING THE FIELD

I returned to Waterside to commence fieldwork in May 2001, just as the weather was turning cold and people were turning to their homes for the coming months. Although Waterside is warmer than most other parts of the state, it is extremely exposed to the ocean and winds blowing from the Southern Ocean. Winter is known for being blustery and cold. Many

houses are quite old, having been built in the 1950s and 1960s as holiday shacks, and are therefore poorly insulated; heating and staying warm is therefore an ongoing challenge through the winter months and, as a result, unless they have good reason, many people stay close to their homes. None of this was surprising to me; having grown up in the area, I knew of and understood the reasons behind the populace’s tendency to hibernate (of sorts) throughout the winter. However, I also knew that winter presents unique opportunities for engaging with the environment and with other community members. Many locals work in the tourism industry and its highly seasonal nature means that when the weather is warm, community social life is often very quiet as people are otherwise occupied. Cooler weather therefore presents opportunities for community fundraising nights and social activities.

When I entered the field, I realised that although I had an idea about that midlife was about more than menopause, I had no idea what that more was. At the time, I had just turned

27 and therefore had no personal experience of midlife to draw on; however, I did have my mother, aunts and their friends. Informal discussions with these women guided my early research and emphasised the need to provide a conceptual space in which midlife women could talk about their experiences (Gattuso 1996). As a result of these informal interactions, I realised that focus group discussions would be invaluable in my research process as they would direct my research by highlighting themes that were important to women during this life stage. Kitzinger (1996) suggests that focus group discussion are a useful way of examining the understandings, attitudes and needs of particular groups, and argues that they also enable identification of shared and common knowledge. Because I wanted to gain an understanding about what were the salient features of women’s midlife experience, focus group discussions were an appropriate method to use.

Recruitment

To recruit participants for the focus group discussion, and with the intention of providing information to women about my study, I placed an advertisement in the local newspaper

(‘the Waterside mouth’, see Appendix 1). Almost all residents read the paper each week and it is an effective medium for communicating with members of the community. Community notices from the paper are announced on the community radio station several times each week. I was also interviewed on two radio shows, at which time I described the focus group discussions and interviews and invited women to contact me about participating.

Midlife women were invited to either contact me directly if they were interested in learning more about my research or to come to the community health centre on the appointed day. Although I placed the recruitment advertisement and was interviewed on local radio, I had to return to Melbourne due to work responsibilities. Rather than calling my mobile telephone, women who were interested in the study instead approached my sister

(and, to a lesser extent, my mother and youngest sister), who gave them information about the study. The majority of women who expressed interest in the study itself did not want to participate in a focus group discussion. These participants told my sister that they were interested in participating in an interview, and she gave them an information statement about the project. A few days after this, I contacted them with more information about the study and, at that time, organised a time to conduct their interview. I deliberately did not specify what I meant by midlife in my recruitment advertisement; instead, given that one of my research objectives was to understand how women defined midlife, I sought for women who self-defined as midlife to participate.

Focus group Participate in advertisement focus group N=10

Contact family members (n=11) 3 participants Contact Narelle directly (n=9)

Participate in interview Via network N=24 sampling (n=1)

Figure 2.3: Recruitment strategies

Recruitment was a multi-faceted activity which occurred over an extended period of time (about 30 months) and is illustrated in Figure 2.3 (above). Community visibility aided recruitment as some women approached me in the street following the publication of my advertisement. Ash, for example, approached me in the fruit and vegetable section of the supermarket. At this time, she described how, before midlife, she did not know what to expect; participation in this research offered a way for her to guide other younger women through this time of life (similar to women in Warren et al. 2006). In addition, participants were either recruited or encouraged to participate through network (‘snowball’) sampling.

Ash, following our interview, talked about her experiences with her friends, Serena, who then became interested in my study. Other women had discussed the need to share information with their friends, both of whom then participated in the study (for example, Iris and Hattie;

Nola and Ferdie, Abbie and Daphne).

Focus group discussions

Ten women aged between 34 and 72 participated in the focus group discussion. Marital

status varied: two women were divorced, one was widowed, and seven were either married or

in de facto relationships. All but one had children; interestingly, she was the only participant

who was employed full-time. Other participants engaged in the labour force on either an

informal or casual basis (five women). The remaining women were either retired (two

women) or involved in full-time care of their children (one woman) or grandchildren (one

woman).

At first everyone seemed a little awkward; although several of the women were

acquaintances, only two pairs of women knew each other well. The discussion began with

afternoon tea, over which I asked women to talk about what midlife meant to them.

Participants talked about geographical isolation, being far from their family members, loneliness, their relationships with their partner and parents, menopause, their concerns about potential health problems (particularly breast cancer) and social support. Many spoke about the difficulties of their children growing and leaving home – which always entailed

them moving some distance away. Overwhelming, they emphasised that midlife was a very

busy time of life, during which they had to negotiate competing demands from their families,

their peers and the community with their own desires and priorities. All of the women

expressed how good it felt to talk with other women about issues important to them.

Particularly important was the opportunity to share health experiences – all participants

raised the difficulties with gaining information about their future health concerns, particularly

in terms of menopause and ageing. Information from the focus group was used to identify

themes that I could discuss with participants during in-depth interviews.

The focus group had an additional benefit, which fulfilled women’s need for support.

As participants left the focus group discussion, they agreed amongst themselves to continue

meeting once a month and to centre their meetings on issues of concern to them. For example, in the following meeting, women invited the local social worker and a community advocate to talk about their rights and access to community services. After six years, a core group of six members remain closely connected. These women meet once a month for lunch, discussion and to provide each other with social support.29

In-depth interviews

The main component of my study was in-depth interviews. I conducted interviews with 24 women who self-defined as midlife over two and a half years; three women participated in both parts (focus group and interviews) of my study. All of the twenty-two Australian-born participants were Anglo-Australian; the other two women were born in Western Europe

(Scotland and Germany). Participants ranged in age from 41 to 62 (born between 1941 and

1959), reflecting the diversity of ages included in ‘midlife.’ This data was supplemented by interviews with two local GPs – who I interviewed either formally (Dr Alex) or informally

(Dr Kerry) – which provided additional information about health concerns and insight into how health was formally managed (that is, within the context of the medical centre). Table

2.5 (below) shows the ages and other socio-demographic details of participants in my study.

29 The most recent meeting was held in May 2007, six years after the original focus group.

Table 2.5: Summary of interview participants Age at interview Total Number of pregnancies Total 40-44 2 0 0 45-49 2 1 7 50-54 11 2 7 55-59 7 3 5 60-64 2 4 5 Marital status Number of children Married / de facto 13 0 3 Divorced 6 1 5 Separated 2 2 8 Widowed 1 3 5 Never married 2 4 3 Age at first marriage Age at birth of first child Never married 2 No children / live births 3 15-19 years 3 15-19 years 1 20-24 9 20-24 7 25-29 6 25-29 6 30-34 1 30-34 4 35-39 3 35-39 2 40-44 1 Employment status Age at birth of last child30 Not in labour force 11 20-24 years 2 Casual 6 25-29 4 Part-time 4 30-34 4 Self-employed / full-time 3 35-39 5 40-44 1

Prior to conducting each interview, I explained the study in detail, provided

participants with an opportunity to ask questions and sought their informed consent.

Interviews were conducted at a time and place convenient to participants, and thus, most

often occurred in their homes during the day, when their partners were at work. Like those

described by Wray (2004), my interviews were often constructed as social encounters and

took place over numerous cups of tea or coffee. Each interview lasted a minimum of one

hour, with most lasting from ninety minutes to two hours.

Three women, Hattie, Cynthia and Serena, were interviewed twice – their second interview was conducted approximately two years after the first. Although I had originally intended to interview each woman twice, time constraints placed on both participants and on me meant that this was often difficult and thus follow-up interviews did not eventuate.

30 Age at last child only provided for women with 2 or more children.

However, longitudinal data from participants who only had one formal interview was obtained through discussions on the telephone or in the town centre; data from these participants is supplemented by that collected during these informal encounters. For example, Daphne telephoned to update me on how the other women in the support group

(described above) had helped her cope with her depression. Similarly, Ferdie recently gave me a lift (in her car) and, on our trip, updated me about her decision to cease taking hormone replacement therapy and how this had impacted on her bodily symptoms.

Interviews often had a strong performative component, particularly when I was interviewing women I knew well (such as Ferdie, Abbie, Daphne, Liza and Maude). This notion calls on Goffman’s (1969) work arguing, that the presentation of self during everyday social interactions occurs through a series of performances. Denzin (2001:24) suggests that performance in interviews is a self conscious act – as opposed to the unselfconsciousness described by Goffman – and states that “interviews arise out of performed events. They transform information into shared experience.” Interviews became performance because they needed to be distinguished from our usual, mundane social encounters; they do this by rehearsing our social positions relative to one another. The recording device played an important role signifying the unusual (i.e. interview) encounter, and distinguishing it from the mundane encounter. I use an excerpt from my interview with Abbie to illustrate this concept of performance. In it, Abbie and I both engaged in positioning ourselves in relation to each other and then, agreeing on a shared understanding about the community. Firstly, she positioned herself in relation to age by comparing herself with my mother and, in doing so, claimed her moral (Denzin 2001) position as friend and peer:

I was talking to your mum the other day and she said she’s going to work one less day a week and I thought ‘that’s great,’ because she’s always worked. So

she might get a bit of time to think for herself without having to worry about everybody else. For just a few hours even. I then reinforced and encouraged this positioning:

I hope so. She said she’s enjoying catching up with you. Abbie acknowledged my reinforcement and then positioned both of us relative to each other

(italics) within the community:

It’s been good. Been great, yeah. That’s another good thing about Waterside because it’s a bit like being part of a big family and you know, you go various ways and then you come back together and you know, it’s a bit like family like that, isn’t it? At the end of this small story, she sought reinforcement of her claims about the nature of the

community, which I provided:

It’s good that you can actually depend on people because if people say they’ll do something or be there for you, they will be. (Interview with Abbie, age 54) Similar performances occurred throughout most of the interviews.

Interviews were open-ended, with the aim of encouraging women to tell stories

about their midlife experiences. A list of interview themes (provided in Appendix 2) was

used to guide my questioning; however, I rarely consulted it during the course of my interviews. During interviews, I encouraged women to tell their story in their own words and time. At the start of each interview, participants were asked if they could ‘please tell me your story about midlife.’ Some found this an easy task, while others required more direction. In these instances, I asked women either to tell me what midlife meant to them or to tell me five words that described midlife. Throughout interviews, I asked probing questions to clarify or provide further detail about their accounts. In ensuring that participants directed the interviews, themes were only probed if they were raised by the participant herself and I did not introduce new or unrelated themes (Gubrium and Holstein 2002; Charmaz 2004). In

particular, I did not ask women about menopause, as I wanted to learn how they understood midlife and did not want to reproduce the biomedical approach.

Although women talked at length about many issues, few discussed their sexual relationships, intimacy and desire. I suggest that this most likely relates to our prior relationship as participants whom I did not know particularly well discussed these topics without hesitation. At the end of each interview, I asked participants if they had a pseudonym (chosen by 11 participants) they would like me to use in writing up my research and if they would like to receive a copy of the interview transcript (which I sent to 21 participants).

Data management

Managing my data and keeping track of ideas was a difficult process. I was in a state of constant geographical and intellectual flux, characterised by my fortnightly travel between

Melbourne and Waterside, and the ensuing shifts in mind-sets, from the world of research work to that of PhD research, and back again. I spent much of my time talking fieldnotes into my tape recorder on the long road trip or frantically and sporadically writing field notes.

The quality of my fieldnotes reflects this constant flux; some are highly detailed accounts of events, coloured by my interpretation and responses, yet others are incomplete descriptions of community activities. In order to gain some sense of control and order within these chaotic circumstances, after transcribing the first four interviews, I decided that my time would be best used on reading and analysing them. This meant that my interviews were transcribed by a third-party, but which I checked to ensure they were done so reliably.

Once the first few interviews were transcribed, I read through them and began identifying common themes (as described by Ryan and Bernard 2003; Markovic 2006). In contrast to the information on social belonging and family relationships that had

characterised the focus group discussion, I became aware of the emphasis placed on the role of mental and physical health in women’s accounts. During the following interviews, I began to ask more questions relating to women’s understandings and experiences of health, being healthy and illness. As my research progressed, I noticed that women imposed a narrative structure on their experiences, which prompted me to become intrigued with the idea of using a narrative approach to analyse the data, which I describe in the following section.

Data and compromise

While women emphasised their menopausal experiences, they also described how health during midlife was about much more than menopause (which I discuss in Chapter 3). This realisation prompted a key compromise in my data analysis, which was also influenced by the small sample size. Other studies on menopause consider women who have had hysterectomy separately from those who have not, and categorise the former as having had a ‘surgically- induced’ menopause. However, given that the four women in this study retained their ovaries and so continued to experience menstruation-related bodily signs (such as fluid retention, bloating, cramping and pains) until peri-menopause, I have analysed my sample group as a whole, rather than distinguishing between women on the basis of whether they have a uterus or not. This follows research (in which I was a co-investigator) conducted with a similar sample of Australian women, of whom all perceived their hysterectomy as enabling them to lead socially fulfilling and productive lives (Markovic et al. in press[a]). In my study, all four participants who had undergone hysterectomy had voluntarily ceased reproduction prior to their surgery, which was performed for benign reasons (fibroids, heavy bleeding or uterine prolapse) in all cases.

Rigour, validity and analytical quality

When conducting qualitative research, multiple techniques and strategies are used to ensure the rigour – the validity, reliability, trustworthiness and integrity – of data collection, analysis and dissemination (see discussions by Morse 1999; Sparkes 2001; Whittemore et al. 2001;

Pyett 2003; Tobin and Begley 2004; Cho and Trent 2006; Rolfe 2006). During my PhD study, I employed several strategies in order to ensure the rigour, and thus quality, of my research and its findings; the strategies used varied depending on the stage of the research process, as I describe below. To ensure validity in data collection – that what I was finding reflected the midlife experiences of women in Waterside – I employed methodological triangulation (Maggs-Rapport 2000; Tobin and Begley 2004): focus group discussions identified themes or issues of importance in midlife women’s lives; during participant observation, I sought to observe these themes as they appeared in the daily experiences of women in Waterside; and the themes either informed my interview schedule or were introduced by women during the course of each interview. Later, as I analysed my data, I was mindful of those themes which were identified by women at various stages of the data collection process and sought to compare their occurrence between interview transcripts

(and thus, between participants; see Markovic 2006). The broad themes identified by women

– menopause, health, family, social support, and factors associated with the local community

– frame my analysis and form the ‘bare bones’ of this thesis.

To ensure that my research was rigorous, I also employed other strategies during analysis and dissemination of the data. Koch ([1991] 2006) identified three dimensions of analytic rigour: credibility (or internal validity), when the description and interpretation of the research process and its findings are faithful and can be recognised by others; transferability

(external validity or generalisability) is concerned with how well the research process can be

applied in another context and how meaningful and applicable the findings are to other

contexts; and dependability (also referred to as reliability), in which the research process itself,

decisions made, and the reasoning behind these decisions are made explicit. Tobin and

Begley (2004) add two additional dimensions: confirmability, which ensures that the findings

are clearly derived from the data, and authenticity, which emphasises the need for a

“sophisticated understanding” (ibid.: 392), beyond individuals’ constructions, of the

phenomenon being researched. Each of these five dimensions was important in my research

process and is addressed below.

The concept of credibility, or internal validity, is constructed via the reflexivity and

self-scrutiny of the researcher (Whittemore et al. 2001; Pyett 2003; Koch [1991] 2006) and is

concerned with whether the researcher’s interpretation of the findings fits participants’ views

(Tobin and Begley 2004). Thus, in my study, validity was ensured through drawing on Pyett’s

(2003:1171) argument that reflexivity may include “checking our method, our analysis and

our interpretation not only with the academic literature but also with the population we are

researching.” Thus, in doing my analysis, I regularly discussed my findings with the research

participants. Where my interpretation of the data differed from participants’, I revisited the

data and considered it in light of their feedback. As I discussed earlier in this chapter, my

relationship with participants – whereby they became ‘co-researchers’ of sorts (Koch [1991]

2006) – meant that this process of consultation was central to the research itself. In addition,

I regularly consulted with my supervisors and academic colleagues – many of whom were

midlife women themselves and formed a type of ‘reference group’ – to ensure that my

interpretation was comprehensive and did not misrepresent my participants. Finally, my

supervisors provided guidance in analysing the data from interviews which I conducted

towards the beginning of data collection; this type of ‘investigator triangulation’ ensured the validity of my interpretation and analytic rigour of the study.

In reflecting on the external validity (transferability or generalisability) of research,

Sparkes (2001) described the ‘diversification of meanings perspective,’ which is widely used in qualitative research. Based on this approach, validity is understood by the researcher “to be socially constructed within specific discourses and communities, at specific historical moments, for specific sets of purposes and interests,” (ibid.: 542) rather than a single, objective truth (see Riessman 1993; Tobin and Begley 2004). As I did not seek to gain a generalised understanding of midlife female experience but rather sought to develop insight into what experiences were shared by midlife women in rural Australia, the transferability of findings may be limited in terms of context, and thus may not apply to women in well- serviced regional or urban centres or who reside in other countries.

Koch ([1991] 2006) and Tobin and Begley (2004) highlight the importance of record- keeping in assuring the dependability of a qualitative research study. Such records need to be reflexive and clearly explain the process of research, the decisions made by the researcher and the reasoning behind such decisions (which Koch [1991] 2006 terms ‘analytic choices’).

A field journal was kept throughout my research for this purpose and this chapter details my record-keeping during the process of conducting, analysing and interpreting the data: the research context and relationships which shaped my research and the reasoning behind my decision-making have been clearly outlined and described. In addition, the confirmability of findings is ensured through the use of detailed excerpts from interviews throughout this thesis to illustrate my interpretation.

The authenticity of research is concerned with the believability, or truthfulness, of the accounts presented and their interpretations. Sparkes (2001) argues that authenticity offers an

alternative to validity for assessing rigour, and is derived from a sense of connection between stories told by multiple storytellers. Through this thesis, in telling women’s stories and drawing them together, I have attempted to provide an in-depth analysis of the experiences of women in midlife. The process of telling these stories is described in the following section.

Narrative analysis

People tell stories in order to make sense of the events and actions in their lives (Riessman

1989, 1993). Telling a story is “a natural human process that [helps] individuals understand their experiences and themselves” (Pennebaker 2000:3). Stories are not merely a means for recounting one’s life experiences, however. Stories that people tell about their lives – their

“autobiographies” (Bruner 1987) – are complex. By telling a story, a woman constructs her identity in a particular way (Frank 1995). The narrator situates her story in relation to past, present and future actions, events and choices, positioned in time, place and space (Mattingly and Lawlor 2000), and intimately shaped by social, cultural and bodily events. Bruner (1987) argues that in telling a story about her own life, she is engaging in a continual process of interpreting and reinterpreting her own biography: what Giddens (1991) termed the reflexive project of the self (see also Gauntlett 2002). In telling one’s story, the narrator seeks to order experience and gain control over events that are otherwise uncontrollable (see Broyard 1992).

Thus, stories offer a way to reconcile separations between the idealised and the lived version of life (Riessman 1993). Illness narratives (illness stories) are particularly useful in this way: they provide a way of reconsolidating and affirming one’s identity and place in the world despite the uncertainty and disruption posed by illness or disease (as discussed, for example, by: Bury 1982; Kleinman 1988; Good 1994; Mattingly and Garro 1994; Frank 1997;

Riessman 2002; Carolan 2005).

Narrative analysis, therefore, offers a way of understanding how people give meaning to their own experiences (Riessman 1990a, 1990b) at a particular point in time. As Bruner

(1987) argues, one’s narrative construction of self is unstable and may change depending on social, cultural, interpersonal influences and expectations. He argues that individuals structure their experiences through narrative by using internal and external criteria about the ‘rightness’ of the account and the weighting (that is, the emphasis or relevance) of individual components which comprise the story, for example, about what they emphasise and what they omit (ibid.).

During my research, I was concerned with how women made sense of and gave meanings to their midlife. My interest was less in the spectacular or stand-out moments in their lives and more with their everyday experiences of life. Narrative analysis allowed understanding of the women’s interpretations of, and the weight (relevance or importance) placed upon, particular aspects of their lives and, thus, provided insight into the lived experience of midlife. In addition, the narratives women told about their experiences provided local accounts of the life course (see also Gubrium and Holstein 1998; Holstein and

Gubrium 2000), which meant that I was able to explore how women understood that living in Waterside (place) shaped their lives.

Approaching the task of analysis was daunting; perhaps due to my connection with the participants, I was reluctant to treat their stories as objects of analysis. Following a workshop with Arthur Frank in 2005, I became intrigued with his idea of thinking with, rather than about, stories (discussed in Frank 1995, 1997, 2003, 2004) and sought to do this in my analysis. Thinking with stories exerts moral influence on the teller and listener (Morris

2002). Frank (2002) described how the story calls to be heard; thus, my data analysis was a process of ‘spending time’ with the women’s stories, reading them as I would a novel and then putting them away. I would then go about my daily business, leaving the stories alone

and letting them percolate. When I was least expecting it,31 the stories began to make sense:

in this way, I was responding to their calls. The notion of ‘thinking with stories’ emphasised

the need to maintain the integrity of the stories by keeping them whole. It explains, at least in part, why my data is presented as passages of text.

My analysis was also influenced by Mishler’s (1995) and Riessman’s (1990a, 1993,

1997, 2002, 2003, 2004) work on personal narratives. Both emphasise the need to conduct multiple levels of analysis. Following Mishler’s (1995:90) typology of narrative analysis models, I sought to take into account who was telling and what (‘reference and temporal order’), coherence and structure of the text (‘narrative strategies’) and the contexts and consequences of women’s stories (‘narrative functions’).

At the start of each interview (as described above), I invited women to tell me a story about their midlife experience. For many, the invitation of the story was confusing and confronting, and most were uncertain about where to begin. Following my story-telling invitation, Hattie, for example, responded: “you probably need to ask me some things because I don’t know where to start.” The question about where a midlife story begins was one I wanted to explore during my research. I had anticipated that the women who had voluntarily participated in the study (and thus who self-defined as midlife) might readily locate the beginning, yet this was often not the case. The following excerpt from my interview with Sam highlights some of women’s difficulties in beginning their stories:

I was wondering if you would like to share your story of your midlife? Do you mean forty to fifty odd?

31 For example, halfway through swimming training, during a soccer game, or when out cycling or horse-riding; interestingly, these ideas always came to me when I was body-focused and, therefore, not engaged in thinking. During the workshop with Frank, he recommended taking the stories for a walk – which I was doing.

Well, that depends how you define midlife. That has been a challenge for my research, what actually constitutes midlife. I think forty to sixty might actually be the parameters, but I am not sure. This is the other issue that I am grappling with, what is midlife? Well say my experiences of midlife, so you could say forty to sixty or you could say from when your period started to decline… (Sam, age 56).

Interviews were characterised by stories which occurred on multiple levels. Women told stories about their day-by-day activities, which they often described as “a bit boring, very ordinary” (Biggs, aged 53) – which Bamberg (2004:367) calls ‘small stories’ – and drew links from these stories in answering the broader question about ‘what does midlife mean?’

(presumably, a ‘big story’). The analysis I present in this thesis uses Bamberg’s idea of ‘big’ and ‘small’ stories, yet applies them differently. The stories women told were frequently messy and all were shaped by multiple motives, events and actions. Some women told several stories at once, moving between different plots and weaving them together. Hattie, for example, told three stories concurrently and, in doing so, moved between the following story lines: health as important feature of her midlife experience, her isolation and lack of social support, and turning 50. Others, such as Sam, used one story line throughout the entire interview (midlife as a difficult time of life), yet drew upon many smaller stories in telling that big story. The messiness of women’s stories illustrated a key story (or meta-narrative): midlife is an extremely busy period of life, characterised by changes across social, cultural, personal and bodily domains. I turn now to these stories.

Chapter 3

Being Healthy in Waterside

Lay understandings of health and being healthy evident in women’s narratives provide insight into the role of health status in their constructs of age identity. Health was about more than menopause. It did not always relate specifically to health status, that is, the absence or presence of diseases or ill-health conditions. Yet, as argued by Litva and Eyles (1994), notions of health always require an index against which current health status is evaluated.

Social participation was important in women’s understandings of being healthy.

In this chapter, I explore how and what factors are important when midlife women in Waterside conceptualise health and being healthy. I contextualise this, and then discuss in subsequent chapters, by first describing the Australian health system before turning to an illustration of health care provision in Waterside. Women in this study related their midlife experiences in terms of personal understandings of health – that is, “normal for me” – as opposed to shared social and medical understandings of ‘normal’ health status. For women with problematic bodily signs, on-going health concerns and concern with quality of life were described as normal in the context of their wider lives (cf. Clavarino 1999).

THE AUSTRALIAN HEALTH CARE SYSTEM

The Australian health system is complex, with multiple layers encompassing public and privately funded providers (Australian Government Department of Health and Ageing

2006). The public system is funded and regulated through three tiers of government:

federal,32 state/territory33 and local (Healy 2002). Funding ‘trickle-down’ occurs throughout the system: the federal government funds the states for some health-care responsibilities; the states then fund local governments (such as shire councils) which deliver health care to smaller areas within the state, as I describe below.

Health services are funded through the health insurance scheme, ‘Medicare’, which is administered by the federal Department of Health and Ageing (DHA). The federal government also funds general and some specialist medical services, Aboriginal health services, pathology, and diagnostic imaging services, and subsidises most pharmaceuticals through the Pharmaceuticals Benefit Scheme (PBS: Healy 2002; Swerissen 2002). Via ‘trickle down’ funding, the federal government also funds home and community nursing and care services, which largely service older people, people with disabilities, and provide post- hospital-discharge care. These services are regulated at the state level.

State governments receive federal funding to administer public hospitals (including accident and emergency departments), and are wholly responsible for mental and community health care (Healy 2002), youth health, drug and alcohol counselling, and some allied health services(Swerissen 2002).34 In addition, health workers are regulated by the state government,

through their professional associations. Although their role in developing health policies is

minimal, local governments play a key role in delivering wider public health programs: they

administer and deliver individual services, such as post-discharge, home, and aged care. An

overview of the Australian health system is shown in Figure 3.1 (below).

32 Also known as the national or Commonwealth government. 33 As Victoria is a state, I will refer hereafter to the state government. For much of Australia, the state (or territory, in the case of the Northern Territory and the Australian Capital Territory) government is responsible for administering services as I describe in this section. 34 The supported allied health services include: podiatry, physiotherapy, occupational therapy, nutrition, social work and counselling, and some dental care. Most state-funded allied health services are delivered through public hospitals and community health centres (Swerissen 2002); these services are also privately funded, either by the individual directly or through private health insurance.

Federal government State government

General Medical Community Community mental health Pathology nursing Youth health Diagnostic Imaging Home & Drug & alcohol counselling Pharmaceutical community care Allied health

Primary & Aboriginal health services

community care Emergency departments in hospitals

Acute & Specialist health services Public hospitals continuing care Delivery via local government

Figure 3.1: Overview of the Australian health care system35

Not all health services receive public funding. Dental health services are (mostly) privately funded; publicly funded dental health services are available to low income36 earners but are often located in urban areas and have long waiting lists (AIHW DSRU 1998), thus limiting economic and geographical access (Marshall and Spencer 2006).

Privately funded health care accounts for approximately 29% (data from 1999/2000,

Healy 2002) of overall Australian health expenditure. Enrolment in private health insurance is voluntary; however it is strongly encouraged by federal government subsidies for individuals (Australian Government Department of Health and Ageing 2006). An additional taxation levy, the ‘Medicare levy,’ is imposed upon individuals with annual incomes over

AUD$50,000 who do not enrol in private health insurance and acts as a penalty for non- compliance. Private health insurance is promoted to enable patients to have wider choices of

35 Based on information from Swerissen (ibid.). 36 Low income is determined by either receipt of social security/welfare income payments or earning a taxable income under that determined by the Australian Government’s Family Assistance Office. The low-income threshold was not available and the exact figure varies by family composition and circumstances. People who fulfil low-income criteria are issued a ‘health care card,’ and possession of this entitles the bearer and, in some instances, their dependents to reduction in the costs of primary and hospital health care, and pharmaceuticals (Australian Government Family Assistance Office 2004).

specialists for tertiary health care, reduce elective-surgery waiting times, and access private hospitals, yet this is not always the case (Healy 2002). Negotiating the layers of the health system may be confusing and frustrating because access to care changes depending on the health problem: in some cases, care can be accessed within both systems simultaneously while in others, such as cancer, despite having full private health cover, patients are still treated within the public system.

Fragmented care

Adding further complexity to health care seeking in Australia is the ‘double-up’ of services, whereby multiple providers may deliver similar services within the health system. This results from the different funding tiers of the health system (Savage et al. 2005). There is little cohesion across health services (cf. Humphreys et al. 2002), which operate within vertical frameworks (‘silos’), These silos significantly impact on the delivery of care, particularly in terms of primary health, due to the resulting fragmentation of health services (Swerissen

2002; Mann 2005). The coordination of health care among primary (mostly provided by general practitioners), acute and continuing (provided to a large extent by hospitals), and community (exercised through community health centres) providers is insufficient, and contributes to problems with consistency and quality of health care (Swerissen 2002:88). The establishment of a collaborative approach between primary and subsequent health care providers has recently emerged as an issue of importance in Australian health practice.

Such fragmentation within the health system is of particular interest: the main health problems in Australia are typically chronic in nature and current trends indicate that their prevalence will continue to increase in the future (Mathers et al. 1999, 2000). As a result, primary health care has become mostly concerned with providing basic care for chronic conditions; while more specialised care is provided by tertiary medical professionals

(specialists). The transformation of primary health care from being concerned predominantly with acute (and emergency) health conditions to responding to and managing chronic health concerns has resulted in increased emphasis on preventive health care and health promotion, alongside the more traditional treatment and management approaches to health care. In the following section, I outline the provision of primary health care in Australia.

Primary health care

In Australia, primary health care is the first point of contact between individuals and the health system (Swerissen 2002; Smith et al. 2004) and forms the foundation of the wider health system, directing and informing the provision of post-primary health care by identifying emerging health issues and managing newly emerging population groups (such as following the arrival of new migrant populations). Providers encounter and respond to a range of health conditions, and their roles are frequently complex with multiple, often highly demanding, duties.

General practitioners (GPs) are the most common providers of primary health care, comprising 43% of the medical workforce (Healy 2002). They occupy a central position within the health system, as one woman in Markovic’s (1998:95) study emphasised: “general practitioners are the law here.” GPs are private providers, yet are mostly paid through public health insurance: 85-100% of the consultation fee is met, either directly or indirectly,37 through Medicare. Individuals are able to consult the GP of their choice and no formal

restrictions are placed on health-seeking behaviours; as such, individuals can freely change

GPs (Haas 2005) or attend consultations with multiple GPs (as I have discussed in detail

elsewhere, Warren et al. 2006). The dominance of GPs as the main primary health care

providers, instead of other health professionals (such as nurses), is at least in part due to the

successful enterprise of medical dominance and the claim of the medical profession to

definitive and authoritative health information (as argued by Friedson 1970; Illich 1976;

Conrad 1979).

Primary health care is also provided by other health professionals. These are

particularly important in rural or isolated communities, where access to a GP is problematic

(as I describe below; also see Rogers et al. 1998). Formal primary care may be provided by

nursing and allied health professionals. Pharmacists provide health information and advice in

addition to their dispensary roles; their role is particularly important in the delivery of rural

primary care (ibid.). Hospital accident and emergency departments also have a role in primary

health care delivery (Laurence et al. 2004; Zeitz et al. 2006). During recent years, there has

also been wider recognition of the importance of complementary and alternative medicine in

primary care (Parker and Tupling 1977; Siahpush 1999; O'Brien 2004; Wye et al. 2006),

involving GPs as well as many allied health professionals.

37 Payments to GPs occur through two modes. Fee-for-service consultations are paid for by the individual patient, who later can claim for reimbursement of 85% of the overall consultation fee through Medicare (Elliot 2002, Healy 2002). Alternatively, some general practices offer ‘bulk-billing’ services, where the general practice directly bills the Medicare scheme – in this scenario, the GP accepts the schedule fee (approximately 85% of the fee-for-service charge) only (Buetow 1995), whilst the patient has no out of pocket costs (Elliot 2002, Healy 2002). Bulk-billing is in decline, however, particularly in rural and remote areas (Smith, et al. 2004, Commonwealth Department of Health and Ageing 2005), largely due to providers’ perceptions that it does not provide adequate remuneration for their services and also due to an undersupply of medical practitioners in specific geographical areas. Thus, where GP services are in demand, they can charge more for services, which leads to lower bulk-billing rates (Buetow 1995, Elliot 2002).

Referral networks and access to other health providers

Primary care providers mediate access to tertiary and specialist care through their referral networks, and referral to other providers – both primary providers and those in other levels of the health system (such as hospitals, secondary providers or traditional medicine practitioners) – forms an important part of the primary and public health responses to

Australian health care needs. These networks encourage mutually supportive health care environments for all health providers and facilitate improvements in health status, whilst prioritising the needs of individuals who require medical and health care (WHO 2003).

A ‘referral’ occurs when a provider directs the patient to a specialist, who has expertise in diagnosing and treating that type of health problem (such as a gynaecologist for reproductive health problems, see Manderson et al. in press). Referrals can be doctor- or patient-initiated; the latter is common where the GP and patient have different interpretations of the symptomatology (cf., for example, Glenton 2003; Whelan 2003;

Markovic et al. 2006; Nettleton 2006). However, within the public health system, specialist consultations can only be accessed via a GP, who functions as a gatekeeper38 (Buetow 1995;

Healy 2002) unless patients are admitted to hospital. Without a GP’s referral, individuals cannot seek reimbursement for their costs through Medicare (Australian Government Health

Insurance Commission 2003); thus very few patients consult specialist providers in this way.

Several types of referrals occur within the Australian health care system. Figure 3.2 illustrates these: ‘First call’ indicates the different providers who an individual might consult about their health in the first instance. ‘Primary pathways’ refer to referrals from a primary provider to a specialist or hospital, or to referrals between primary health care providers

38 My other research (Warren, et al. 2006, Manderson, et al. In press, Markovic, et al. In press [a], In press [b]) has demonstrated the role of general practitioner as a gatekeeper in women’s experiences of gynaecological and reproductive health concerns.

(such as from a GP to an alternative medicine practitioner). Other referrals also occur, although these tend to occur less frequently (such as referrals from accident and emergency departments to a GP); these are labelled ‘other referrals’.

Accident & Emergency Hospital / acute care facility department Nurse

Community health centre GP

Allied health provider Specialist provider

Complimentary / Treatment-seeking paths alternative health Pharmacist practitioner First call Primary pathways Other referrals

Figure 3.2: Main providers of primary health care, and referral patterns, in Australia

All primary health care in Australia involves preventive health and health promotion, i.e. programs and policies aimed at improving health status throughout the health system. These preventive programs are important given the rising rates of cancers observed across

Australia, a trend which, with the exception of cervical cancer, is projected to increase in the future (AIHW et al. 2005). The decreasing incidence of cervical cancer has been attributed to the widespread implementation and success of national screening programs (ibid.), particularly the National Women’s Health Policy.

PREVENTIVE HEALTH CARE AND AUSTRALIAN WOMEN’S HEALTH POLICIES

In 1989, given concerns about the rising rate of female-specific cancers and illnesses, the federal government developed the National Women’s Health Policy. This policy sought to improve the health of Australian women by 2000 through responding to social forces impacting upon women’s health status and their access to services (Commonwealth

Department of Community Services and Health 1989). Seven priority areas in women’s health were identified across five sections of the health system structure, which shaped subsequent health services. These seven priority areas were:

• Reproductive health and sexuality (across the reproductive life-span);

• Health of ageing women;

• Women’s emotional and mental health;

• Violence against women;

• Occupational health and safety;

• The health needs of women as carers; and

• The health effects of sex role stereotyping on women (Commonwealth Department

of Community Services and Health 1989).

At the same time, the five structural areas emphasised within the National Women’s Health

Policy were:

• Improving health services for women;

• Improving the provision of health information for women;

• Commitment to research on women’s health;

• Enhancing women’s participation in health decision-making; and

• Appropriate, gender-sensitive training of health providers (ibid.).

The latter five areas were of particular significance as they were areas to which the federal government committed funding and resources and led to the development of women’s health centres (including research centres).

As a result, two main preventive health strategies – the National Cervical Screening

Program and the BreastScreen Australia program – were implemented across Australia, with the primary aim of enhancing women’s health outcomes. These programs are founded on understandings that early detection leads to improved health outcomes and decreased mortality (Speedy and Hase 2000; Wray 2004) and, accordingly, seek to detect pre-cancerous cervical and breast changes.

National Cervical Screening Program

The National Cervical Screening Program (developed in its current form in 1995) was originally derived, in 1988, from the Australian Health Ministers’ Advisory Council recommendation that an Australia-wide cervical screening policy would improve women’s health outcomes by reducing the incidence of cervical cancer (Australian Government

Department of Health and Ageing 2006). This recommendation, and its subsequent enactment, moved cervical screening programs from the state and territories to the federal level (for greater detail, see Wray 2004), and resulted in a nationally-coordinated program.

The program seeks to conduct routine biennial Papanicolaou screenings (‘Pap smears’) on all women aged 18 to 70 years of age who have ever been sexually active. In addition, vulval and pelvic examinations are recommended, and often occur at the same time as the Pap smear

(Wray 2004). Despite this program, not all women participate in cervical screening programs.

Wray (ibid.:37) argued that social factors underlie the differential access of women to screening programs by socio-economic status, sexuality, ethnicity, country of birth, and length of time resident in Australia. Such trends are reflected in the lower cervical screening

rates reported in lesbian, Indigenous and some migrant women (Jirojwong et al. 2001a,

2001b; Taylor et al. 2001; Wain et al. 2001; Fernbach 2002; McNair 2003; Binns and Condon

2006; Manderson and Hoban 2006).

BreastScreen Australia Program

Breast cancer is currently the third cause of mortality among Australia women (Mathers et al.

2000). Rising breast cancer rates during the 1980s and 1990s prompted the introduction of breast screening programs (AIHW et al. 2005), but rates of breast cancer continue to be high: approximately one in eleven women will be diagnosed with breast cancer during their lifetime (AIHW 2004). BreastScreen Australia originated in 1990 from a joint state and federal government initiative, and aims to provide mammographic screening, free of charge, to all women aged between 50 and 69 years, with a target of screening 70% of well women

(with no signs or symptoms of breast cancer) within this age group (Australian Government

Department of Health and Ageing 2006). Younger (aged 40-49 years) and older (aged 70 and over) women are able to access free BreastScreen services at their request (ibid.), although they are not screened in the same routine, systematic way of women in the target age group.

Under the BreastScreen Australia program, women undergo screening every two years, which enables on-going surveillance of breast tissue and allows early detection of any changes, as Speedy and Hase discuss (2000). Widespread geographical coverage is sought and, thus, mobile mammography units visit rural and remote areas. Like cervical screening, some population groups are reluctant to attend for breast cancer screening, such as

Indigenous women (McMichael et al. 2000).

It is within the Australian health system context, with these specific women’s health policies, that women’s experienced were positioned. Their stories of being healthy were also placed within the context of their place of residence. This was significant in my study as

changes in the socio-demography and geographical layout of Waterside prompted other

changes within the community, particularly in terms of health service provision. I outline

these changes in the following section.

WATERSIDE: HISTORICAL LANDSCAPES OF HEALTH CARE

Over the past 15-20 years, there have been significant changes in the delivery of health care

within Waterside. This has, to some extent, been in response to changes in population size

and socio-demographic structure, but has also occurred with wider political changes in models of health care—and specifically reflected the state-wide demise of bush nursing centres and the rise of the community centre model of health care. Historically, health care in

Waterside was delivered through the local bush-nursing centre, which was staffed by two nurses, who lived on the premises and were ‘on-call’39 twenty-four hours each day. The

centre was established in mid-1950s (circa 1956, Edwards and Edwards 2006), in response to

fund-raising and campaigning by local women. Each fortnight, one of two (male) general

practitioners would visit from the nearest rural centre large enough to support both a general

practice and community hospital, 154 km away in Timbertown (pseudonym). The GPs

consulted on a rotating basis; each GP would consult in Waterside once every four weeks.

During their consultations, held every second Saturday morning at the bush-nursing centre,

the GPs would deliver care relating to chronic health management, antenatal/obstetric care,

and primary health care; acute cases were referred (by ambulance) to the Timbertown

hospital.

During the early years following the establishment of the bush-nursing centre, no

trained paramedics were stationed in Waterside. Instead the ambulance was staffed by local

39 ‘On call’ means available to attend health-related emergencies as requested.

men rostered to drive, none of whom received any formal medical or health training. Very few of these men possessed any first aid qualifications at all (Edwards and Edwards 2006).

From the 1980s, ambulance drivers were voluntarily recruited from the community; these volunteers (usually between 6 and 10 volunteers at any time, O'Meara et al. 2004) received some paramedic and first-aid training. The nearest general practice was approximately 86 km away in Paradise, which involved one hour driving and crossing the interstate border.

Similarly, pharmaceutical needs were unable to be met within the community, other than basic first-aid supplies, which could be obtained at the local store (e.g. adhesive dressings, ointments and antiseptic washes). Filling prescriptions therefore required a minimum drive to

Paradise, Timbertown, or beyond.

Bush nurses provided all health care throughout the year and were a central part of the community. Pregnant women received most of their ante-natal care from the bush nurses, and this was supplemented by two or three consultations with the visiting GPs during the course of their pregnancy. The birth itself was a medicalised event. Most women were hospitalised or sent to stay near the hospital a few days prior to their due date, although several were rushed to the hospital either by car or ambulance on commencement of labour.

Home births were not widely practiced; one study participant, Musical, had the first (and only) home birth in Waterside since the inception of the bush nursing centre. Because of the distance from Waterside to any of the nearby hospitals,40 all of which were over an hour’s drive away, Edwards and Edwards (2006) reported that many women had children in the ambulance on their way to hospital. My mother was one of the last women to give birth en route; in 1975, she delivered twins in the ambulance, two weeks prematurely.

40 The nearest hospital was in Beachview, a small community about 110 km away, which was a drive of approximately 75 mins.

Seeking health care in Waterside was problematic on levels unrelated to geographical

isolation and physical access. Gossip often impacted upon residents’ ability to seek help and

advice in managing their health. Health problems were discussed among community

members who did not always understand or interpret people’s experiences accurately, which affected the ability to access empathetic and effective care for certain health conditions, particularly for mental illness. In these instances, recovery was often problematic and the inadequacy of care compounded an already incredibly difficult time in people’s lives, both health-related and in terms of social support, adding to feelings of isolation and disconnectedness from the community.

In addition to social and community factors, systems of health care governance had impacts upon women’s ability to seek health care in Waterside. Health care in urban centres was based on a centralised system of provision. Major hospitals and essential primary health care facilities (such as women’s health centres, or preventive medicine clinics) were located in metropolitan or large regional centres, such as St Mary, about three hours’ drive away. This had the effect of decentralising important health services away from rural and remote areas and thus, patients were required to travel considerable distances to obtain basic care, particularly mental health care. Until the mid 1980s, most specialised health care could be obtained in Hillsville or Timbertown (each about two hours drive away). Following widespread re-structuring of local government and associated health services, the delivery of more specialised care was channelled to larger centres with a stronger health infrastructure— which were considerably further away from Waterside.

This model of health care persisted until 1989, when a pharmacy and a general practice were established in Waterside, each staffed by a single provider (a pharmacist and a general practitioner, respectively). Prior to the introduction of these services, considerable time would often elapse between the first bodily sign and accessing medical care and

receiving medical treatment. The establishment of the general practice (Waterside Medical

Centre) changed the focus of medical care from acute care to broadening medical services, and developing preventive health care capacity within the community—something that had been neglected in the previous medical and health care models (Le Sueur 2004). Once the medical centre was established, other primary health care providers (such as a dentist, optometrist and an obstetrician/gynaecologist) began to make regular visits to the community, enhancing the health-seeking options of residents.

Increasing patient load and heightened demands placed upon the (part-time) general practitioner led to a second GP (also on a part-time basis) joining the practice, which began operating full-time. Outside of their clinic hours, the general practitioners located at

Waterside also rotated on-call for 24-hours, which reduced community reliance on the volunteer community paramedics. At around the same time as the medical centre was established, restructuring of the bush-nursing centre occurred, thereby beginning the transformation into the community health centre. Many primary health care duties were delivered by the general practitioner (and later, practitioners) rather than the bush-nurses, who became responsible for delivering home and aged care, chronic health management, and responding to community issues (particularly domestic violence and drug/alcohol abuse,

Laughlin 2004).

The introduction of these services preceded changes in community demographics during the 1980s and early 1990s, as discussed above. Following increased medical service provision,41 larger numbers of older people chose to retire in Waterside, many of whom had holidayed there over a long period of time (not dissimilar to the community described by

41 Increased medical service provision may have had a direct relationship with the increase in population size; given distances from hospitals, having accessible primary health services was important (Larson, et al. 2004, Larson 2006).

Andrews and Kearns 2005). The outcome of these demographic changes was that Waterside

had a higher proportion of elderly residents (22%) compared with the total local government

area (20%, East Gippsland Shire Council c1994), which demanded revision of the other

(non-GP) local health services. Consequently, the bush nursing centre became the location

for multiple community and health services: it currently contains an independent living

facility for the elderly, an all-purpose community centre, and a neighbourhood house

(directed at providing welfare and educational support, and childcare to community

members). In addition, the community health centre coordinated emergency (targeted at women following family breakdown or who have experienced domestic violence) and youth crisis housing.

At the time of data collection, primary health care in Waterside was delivered through two parallel services: the local medical centre (privately run by two GPs) and the state-funded community health service. In addition, there was a single-vehicle ambulance service, which was staffed by three on-call volunteer paramedics, who provided emergency care in collaboration with the GPs throughout the year (O'Meara et al. 2004). During the summer school vacation period (December to February), two full-time paramedics were employed by the Victorian Rural Ambulance Service (RAV). A summary of health care services in

Waterside is shown in Table 3.1.

Table 3.1: Health service provision and availability in Waterside from 2001-200342 Health care service Number – frequency Medical practice 1 General practitioner 2 Community health centre 1 Community nurse 1 full-time, 2 part-time & 2 casual Continence nurse Visiting – 1 day/month Diabetes education nurse Visiting – 1 day/month Maternal & child health nurse Visiting – 1 day/fortnight Stoma nurse Visiting – 1 day/month Other health professionals Audiologist Visiting – 1 day/month Dental health service Visiting – every 2 years Dietician Visiting – 1 day/month Home /aged care 10 full-time & part-time home carers Occupational therapist Visiting – 1 day/month Optometrist Visiting – 1 day every 3 months Physiotherapy Visiting – 2 days/week Podiatrist Visiting – 1 day/fortnight Psychiatrist Visiting – 1 day/month Social worker / family counselling One week/fortnight Speech therapist Visiting – 1 day/month Youth worker 2 Preventative health check-ups Blood pressure / blood glucose checks 2 clinics in 2003-2004 BreastScreen Visiting – every 2 years Pap (cervical) screen Visiting – 5 sessions/annually (also by GPs) Other health services Aged care activities 1 co-ordinator – volunteers & staff Exercise classes 1 instructor Community (neighbourhood) house 1 co-ordinator – volunteers & staff Rural ambulance service43 1 Paramedic 2 full-time – summer vacation period only Volunteer ambulance drivers 3 Pharmacy 1 Pharmacist 1 Bone density testing – nurse Visiting – ad hoc (approximately annually) Alternative therapists 3 Massage/remedial therapists 3 (part-time)

Since data collection, there have been some additional changes in primary health care delivery in Waterside. The appointment of a permanent, full-time community paramedic by

Rural Ambulance Victoria shifted the management of emergency and traumatic health cases from a GP-centred model to a paramedic-model. This move was particularly significant for health service delivery in Waterside and, through alleviation of demands and pressure placed

42 Source: Smith (2004), Laurence (2004) and Waterside District Health & Support Service (2003, 2004) 43 Source: O'Meara and colleagues (2004)

upon the GPs, suggested a reflexive turn towards the historical model of community-based emergency health care coordinated by the bush nurses and volunteer ambulance personnel.

Changes in the delivery of health care in Waterside were particularly pertinent to my participants given that they were aged from their late 30s to their early 50s when the first permanent medical practitioner began practice in Waterside. Such changes had their own implications on the access to information and services for women, as women described to me during our research encounters. As I will demonstrate during this thesis, health information continues to be limited. For example, little exists beyond the pamphlets and books on menopause provided by the Community Health Centre.

WOMEN IN WATERSIDE: SOCIALLY-MEDIATED UNDERSTANDINGS OF HEALTH

Women’s understandings of health were not always clear, given the abstract nature of the concept of ‘health.’ Instead, they described the ways in which they practiced health – that is, what they did to be healthy (cf. Litva and Eyles 1994). Even when women experienced objectively poor health (either continuously or as discrete events), they often emphasised that their participation in social, family and community life was either not impacted on by their ill-health or was impacted, but in ways that they could cope with (cf. Walters and Charles

1997) – something that Litva and Eyles (1994:1085) also observed: “Being healthy is apparently so important to an individual’s sense of personal worth that often illness or physical disability will be dismissed, denied or renegotiated.” Where women told stories about how their health might impact upon their social roles, they emphasised their health management practices and behaviours, and highlighted how these led to improvements in their health status, as Daphne described:

I have recently had a big, long period of really bad depression. I don’t usually get depressed, [it has lasted] about six months, I think… I am getting better

now. [How have you been coping? What strategies have you been using?] I have been seeing the family counsellor who comes here every two weeks and that’s really helping me, to talk it through… The doctor did prescribe some antidepressants for me because [they] said that, because I have been feeling so rotten for the last few weeks, [they] said I was in a stress cycle, and that the antidepressants would help break the cycle but I felt that I’d already started to break the cycle, because I was already getting better… so that’s good. (Daphne, age 59)

Several women mentioned mental health problems (depression) in the context of a discussion of health management practices. This was often related to me through narratives about structural, environmental, or situational stressors; in particular, the loss of someone close was an important stressor. This loss did not always relate specifically to a death, although this was a factor for some women such as Treasure, who experienced a period of depression following her husband’s death. Other women described feelings of loss following changing relationships, such as Aspidistra, who felt down after her youngest child moved away from home, or Mac, who experienced difficult times after her marriage break-up.

A possible reason why women contextualised their narratives of depression or sadness in terms of stressful life events may have been a way to avoid being constructed as

‘emotional or unstable’ (Walters and Charles 1997:1734), given the stigma that continues to be associated with mental illness. Women in my study were aware of such stereotypes and actively sought to avoid or deny them. Abbie described how her mental ill health arose out of a series of challenging life events. Due to shared community (mis)understandings that her nervous breakdown arose from some sort of personal weakness or frailty, however, she experienced significant social exclusion and stigmatisation:

You always knew what was happening to the person next door and, if they were ill, you’d do something about it. Except for certain things. I mean, when

I was 30, I had a nervous breakdown and I did that totally alone… people are so scared of things like that, so I was virtually, no one wanted to know me, and that was really hard… It was shocking… I was really alone. I had agoraphobia. My mum was in Melbourne, dying of cancer… And then we found that the house had [structural problems], this house we built with our bare hands… then I heard things being said about how my mother was mad and [that] I took after her. She was dying of cancer and people were saying she was mad. They thought she was taken to an asylum or something, I don’t know. But that was really hurtful and I dropped my bundle then, for quite some time. (Abbie, age 54)

By explaining her mental health in terms of external stressors, rather than due to internal factors, Abbie contested others’ perceptions of her as ‘unstable’. Almost two-thirds of Canadian women (Walters 1993) reported ‘stress,’ which they described as having a causal relationship with the onset of disease and/or illness. The socio-demographic profile of women who experienced depression in Walters’ (1993) research was similar to those in my study; her participants’ low socioeconomic status suggested considerable financial stressors: low family incomes, low levels of formal education, and lack of full-time employment. In her study, she found links between social structural factors and mental health problems: women with more (financial and social) resources reported ‘stress’, those with medium access to such resources reported ‘anxiety’, and those who had the fewest resources reported higher levels of ‘depression’ (Walters 1993:395). Similarly, in my study, financial security played a significant role in women’s disclosure of mental health problems: those who had either high personal or family incomes (e.g. Chappers, Biggs or Nola) did not mention depression in their narratives, yet those who had low or unstable sources of income (e.g. Mac, Hattie,

Abbie, Cynthia, Daphne, Lesley or Treasure) all told narratives about depression. Women who had middle family or personal income levels reported some depression, low self-esteem

or general worry (e.g. Aspidistra, Samantha, Ferdie, Musical or Iris), although this occurred more often in response to their experience of disruptive bodily signs. Despite the relatively widespread occurrence of mental health issues, women in this study overwhelmingly understood their midlife health experiences as ‘healthy,’ albeit mediated by context.

Self-constructions as ‘healthy’

Women’s constructions of themselves as healthy, despite significant and on-going health problems, served an important social role. It indicated their availability to participate in everyday community life and their ability to continue carrying out their usual roles and responsibilities (from Litva and Eyles 1994). At the same time, the construction of themselves as ‘healthy,’ regardless of objective assessments about health status, also signified these women were not enacting the ‘sick role’ (Parsons 1952), the adoption of which would indicate or justify exclusion from certain activities. From this, a paradox emerged in the women’s narratives – they rejected midlife complaints, and specifically menopause, as an ill health condition or disease, and instead constructed their bodily signs as variously “normal for me” or “normal for women my age” (cf. Walters and Charles 1997).

Biomedical understandings were central to, but not exclusive in, women’s own definitions of midlife. For many participants in my study, engaging in health promoting behaviours was important, regardless of the narrative strategies they used. While the narratives of women who experienced non-problematic bodies focussed on health maintenance, all participants described their engagement in such behaviours, such as physical activity, eating healthily, participating socially, and avoiding unsafe (e.g. smoky or polluted) environments. Participants’ definitions of health were simultaneously associated with biomedical definitions (similar to the older rural women described by de la Rue and Coulson

2003) and performance of their social roles: parenting, paid employment, and community

work. Aspidistra, for example, drew links between the disruptive experiences of menopausal

symptoms (including hot flushes and “crawling skin”) and her participation in mothering,

work and voluntary community roles. As she ceased being actively involved in mothering

(when her youngest left home) and work (when she retired), she stated that she felt “like I

am a real non-entity again” and her menopausal symptoms became more intense.

Participation in social roles was therefore part of her understandings of being healthy.

Keeping up appearances – the social obligations of being healthy

Litva and Eyles (1994) argued that individuals experience a social mandate to manage their health problems and to not allow them to disrupt their regular roles; to allow disruption is to invite social marginalisation. Even where women found that poor health was impacting upon

their everyday life, they described feeling pressure to maintain an appearance that everything was alright. Cynthia found her hot flushes significantly impacted upon her ability to work, yet she was unable to stop work completely; both she and her husband were in low paid, casual jobs that did not provide sickness benefits and thus, neither were able to stop working for financial reasons:

[The hot flushes] slowly built up… It was coming every 6 weeks, I would have warming… just constantly. I used to get a break between 12 [mid]night and about 3 or 4 in the morning. I wasn’t waking up then, but they were just constant… what I call ‘extreme hot,’ and that is when I decided to go on the oestrogen… I tried all sorts of… different things but it just got to the point [when] I virtually had to give up work and everything [all social and community activities] because I was getting so tired. (Cynthia, age 50)

During our follow-up interview, Cynthia again highlighted how she had to continue working even though her energy levels were low, due, she later learned, to a vitamin B12 deficiency (pernicious anaemia):

I went down a bit in energy and everything like that, but that turned out to be the B12. I was probably was suffering a bit from it while I was [at my old job]… All my time has been taken up [moving house several times] and working. (Cynthia, age 50)

Cynthia, like other participants, emphasised her inability to control her bodily events, so instead she sought to regulate the impacts these had on her wider life. In particular, her social position (determined by income, occupation and employment status) influenced the strategies available to her for health self-management. For women who had precarious incomes, such as Cynthia, disruptive bodily events impacted on their sense of control and they described feelings of anxiety and depression, which are often hidden from public view; this silence around women’s distress is culturally normative (Walters and Charles 1997). To do otherwise, is to invite social exclusion. In this way, my findings resemble those of Walters and Charles (ibid.), who found that the bodily, social and economic unpredictability in women’s lives had profound impacts upon women’s self-identity, involvement in the community, and ability to access support resources, which shaped the coping strategies used by women. In their study, as in mine, ‘management’ of health concerns was an imperative that many women were required to fulfil (ibid.). The emphasis on ‘managing’ one’s health and its impact on women’s lives shaped where and from whom they could draw support during difficult times, often leaving women to feel socially isolated.

Ageing and ‘being healthy’

Whilst women’s health status determined their social participation to some extent, their understandings of being healthy or not healthy correlated with their involvement in social activities, roles and responsibilities. The impact of social participation on understandings of health, and constructions of themselves as healthy, were also influenced and shaped by the ageing process. Ageing is constructed as becoming ‘unhealthy’ or as not possessing health.

The intersection of ageing and health has been characterised by two related features: social marginalisation and reduced re/productive capacity, which I discuss below.

Processes of social marginalisation are experienced with ageing (discussed by, amongst others, Featherstone and Wernick 1995; Gilleard and Higgs 1996; Harrington and

Kunkel 1996; Minichiello et al. 1996; Fleming 1999; Hurd 1999; Gubrium and Holstein 2000;

Faircloth 2003; Oberg 2003). This is not dramatic: there are no segregations on the basis of age (although the presence of retirement villages and aged care facilities may suggest otherwise); rather it occurs on the basis of shifts in re/production (as argued by Martin

2001). Changes in re/production are biologically and socially determined: people retire from the workforce, and their capacity to be socially and economically productive is then minimised and limited. This can be seen through arguments (cf. Shapiro and the Boston

Women's Health Collective 1989) that ageing post-reproductive women (even more so than ageing men) are regarded as socially obsolete: the cessation of re/production accompanying ageing is perceived to undermine the fundamental values of modern society (that is, social and economic growth, as argued by Turner 2003); when, as in the case of ageing female bodies, the capacity for reproduction is no longer accessible, the social utility of the non- reproducer is devalued further (for more detailed discussion, refer to Sontag 1978).

Komesaroff and colleagues (1997a:4) argued that menopause is culturally constructed to signify the onset of a “slide into [socially constructed] uselessness and disrepair.” Therefore,

the process of ageing is one of becoming ‘unhealthy’ and is characterised by social non- participation (see Litva and Eyles 1994; Walters and Charles 1997).

Evidence from my fieldwork, however, contested such arguments and demonstrated the ways in which women continued to lead productive lives and perform socially necessary roles. As discussed in Chapter 3, participants’ re/productive roles were changing. Although women were not longer biologically reproductive, they remained socially and culturally reproductive: in terms of raising their children, providing food for productive (i.e. workers) others, and via formal and informal education. In addition, relationships with grandchildren enable continued fulfilment of re/productive roles, particularly where the woman was engaged in their on-going care. At the time of my study, six participants were grandmothers; yet due to geographical distance, only one (Cynthia) was involved in the day-by-day care of her grandchildren. Furthermore, after their children left home and they retired (where applicable) from the paid workforce, many participants described having more time for community activities, such as running for local council (as one participant did) or becoming involved in volunteer work. Almost every participant volunteered at some level with community groups and organisations, often in multiple capacities, as Treasure and Lois described:

I help at the [aged care centre] once a month. I give out lunches and things… I’m involved in the radio and meeting lots of people… I’ve done two years… I have been helping at the [annual Community Arts] festival. I catered at the Arts Council two Easters ago, I catered for the volunteers. That was pretty full on, it was pretty busy for three weeks. I got a team together and we just made sandwiches and heated pies up and delivered stuff. I think I was in the radio then as well. I’ve been keeping busy, I quite enjoyed that… We had fun, it was good. (Treasure, age 62)

Well I’ve been on the radio… Did the pony club and I’ve done volunteer work with the community house. I’ve been with the Arts council and did one of the festivals here… bits and pieces everywhere… I think my longest stint was when I was involved with the radio when it first started and I did that for about 10 years and 2 shows a week. (Lois, age 57)

In Waterside, the community radio station and newspaper, community information

centre, local Arts Council, school library, church-run opportunity shops, environmental

groups (such as the Coast Care and Coast Action groups) and community health centre

(consisting of an aged care centre and community house) all relied on volunteer workers for their everyday running; without these workers, they would be unviable. Older women, who often had time available, were the main providers of such labour, performing roles that were essential for the continued functioning of the community. For some participants, voluntary work was akin to full-time employment, as Sam described: “I always did a lot of voluntary work. I went to the school council and all those things and tried to keep myself involved anyway.” Chappers, for example, was involved in both the Arts Council and the community radio station, which consisted of attending multiple meetings and hosting radio shows weekly; to do this with a full-time job would have been impossible.

As presented above (and throughout this thesis), the lives and experiences of the midlife women in my study clearly challenged negative images of women’s ageing. This was partly due to the construction of women’s roles and labour force participation in Waterside

(described in Chapter 2), as many women interviewed at the time when they were raising children either did not participate in the paid workforce, or in part-time or casual (and often precarious) employment. After their children had either left home or joined the workforce, women described much higher levels of social and economic participation compared with

when they were younger. For some participants, such as Maude, voluntary work was supplemented by part-time or casual employment:

I’m a carer for the elderly… [I’m] only working part time with the [community health centre]… I’m organising some rock n’ roll nights and music trivia [for the radio station]. I like organising things. (Maude, age 50)

Similarly, Lesley’s narrative illustrated the multiple layers of women’s social and economic participation:

I did radio for years and years and years, but then I just wanted a little rest from that. I still do some fundraising for them. I don’t actually do the shows at the minute but I might again. Sometimes you just need a break. Then I am still in the Walking Group. I used to run that until about four years ago but then Mrs M took it over, because I had run it for quite a few years and I still wanted to be in it but I didn’t really want to run it anymore. I still belong to that, which is good. I really enjoy that. [Also] I’m still on the Arts Council and I help them just with whatever’s going on. In the office sometimes and like, on Thursday night, we’ve got a concert night so I’ll go and do the door [collect the entry fee from people attending]. That sort of thing. Apart from that I’ve just been working. I’ve been at the post office for a little while; I went there for three days and ended up being there about five weeks. But that was good because I really needed the money. I’m still doing some home care jobs up at the [community health centre] and then I do modelling for life drawing up the coast [in Short Point]. (Lesley, age 50)

Despite such evidence demonstrating the importance of midlife (and older) women to the fabric of the Waterside community, women acknowledged their internal struggles to reconcile pervasive negative images of ageing with the realities of their experiences. Maude, for instance, worked part-time yet expressed her preference for full-time employment. She was unable to find such work, which she related to age-related stereotypes about ageing

women’s productivity. The following excerpt from our interview demonstrated her

frustration borne of images equating ageing with uselessness and their implications on women’s labour force participation:

I really don’t like the attitude [towards employing older people] in the work force. [Employers] are losing a lot of really good people, people who’ve got quite a long amount of good quality work time left in them. I figure [believe] I’ve got at least 15 years of good quality work time and I’ve had experience, I’ve got common sense. I’ve got a lot of things that say a younger person wouldn’t have just because of my life experience… But for me to go out into [local employment agency] and put myself down for a job now at 50, I’ve got Buckley’s [an Australianism for ‘no chance’]. Yet I’ve still got so many skills, especially people-related skills, to offer. And so that annoys me. That’s really silly. [Employers] are cutting their own throats really by not accessing a resource. Also, I’m not going to go off and have babies either. (Maude, age 50)

From her frustration at associations of ageing and incompetence, Maude challenged

negative stereotypes and images of midlife women; in doing so, she advocated the notion of

midlife women as productive, capable, and valuable social resources. Advocating alternative

images of midlife women’s lives was a common theme for many participants in my study

who sought to emphasise the positive aspects of women’s ageing and the ways in which,

through the ageing process, they became empowered. In doing so, their narratives presented

images of midlife women being healthy, in the sense described earlier in this chapter and by

Litva and Eyles (1994) and Walters and Charles (1997).

Social understandings of ageing as ‘not health,’ and the narrative imperative

These expectations and assumptions about ageing women as socio-culturally unhealthy (as opposed to due to biophysiological reasons) render people, and particularly women, from midlife and beyond invisible and socially less valuable/valid. As Frank (1997, 2000:361) argued, groups of silenced people have the greatest need to tell their stories and reclaim their social position:

…storytellers tell stories to remind those who share their form of life what it is they share; people’s sense of being together is enriched within the storytelling relation. Storytellers also offer those who do not share their form of life a glimpse of what it means to live informed by such values, meanings, relationships, and commitments. Others can witness what lives within the storyteller’s community actually look, feel, and sound like. Storytellers tell stories because the texture of any form of life is so dense that no one can describe this form of life; the storyteller can only invite someone to come inside for the duration of the story.

Such stories have value in and of themselves, in empowering and validating the teller (ibid); in addition, they play an important role in reducing the levels and feelings of marginalisation experienced by the storyteller(s). More importantly, as Riessman (2002:697) argued, these stories tell us about “the social spaces they inhabit, and the societies they live in” and provide insights into the particular society and social conditions that constrain and liberate their narrators. Following from this, just as ill people “need to become storytellers in order to recover the voices that illness and its treatment often take away” (Frank 1995: xii), midlife women have a strong desire to recover their voices. In part, they have been silenced by an oppressive double standard of ageing, which Sontag (1978) argued derived from a focus on physical attractiveness; thus becoming (visibly, physically) aged is socially unacceptable for women and renders them as unworthy citizens, yet enhances attractiveness and power for

men (ibid.). For participants in this study, such as Daphne, story-telling was always a process

of re-empowerment, of regaining their voices, in a society where they often described feeling

marginalised or invisible – as if they were somehow worthless, due less respect or somehow

possessed less humanity – occurring due to their physical and reproductive (discussed in

Chapter 4) ageing:

I don’t think [my sense of personal power] is responded to from outside… I think the down side of getting older is that you start to become invisible to some people. (Daphne, age 59)

The nature of the community itself may have compounded this. Many women in this study described reaching a point where they felt their lives and life experiences were

unimportant in many of their social relationships. As they aged, participants perceived that

their social contributions to the community were no longer seen as valuable or important as

they had been when they were younger—when they were more actively involved in raising

their children, taking care of their household and/or in paid employment. This perception

presented a paradox within women’s stories as it occurred despite having become

increasingly more involved in community organisations, as discussed earlier in this chapter.

At the same time, women described feeling as though their social support options had

become more limited. In this way, these changes that they described indicated their feelings

that their socio-cultural capital had reduced or become devalued. For example, through not

having close family nearby to support her, Hattie’s sense of marginalisation and decreased

visibility that she experienced as she aged was exacerbated:

I’m seeing everyone around me with families knowing that there is no one in the world for who I am any more than the fourth priority in their life if something is wrong and I really need help, and there’s nobody else in the world for whom sharing my good times is any more than their fourth priority

either. And that’s really, that is a real feeling of loneliness and isolation. You see, before, I used to think ‘that’s alright, because eventually this will change.’ Now, for the last couple of weeks, I’m thinking ‘well, I’m 50 and it hasn’t changed.’ (Hattie, age 50)44

Hattie highlighted the ways in which the invisibility experienced by some midlife women is contextual. It was not necessarily due to her age that she felt isolated. However, the combination of geographical (due to living in Waterside) and social (due to no family) isolation, which have also contributed to her underlying depression (as reflected in this quote), rendered her even more socially invisible than perhaps gender and age on their own may have; her ill-health also profoundly impacted upon her social participation. Through their understandings of ‘health’, participants in this study responded to Pearsall’s (1997) call for women to develop alternative frameworks for representing their ageing experiences. They discussed and enacted multiple models of ageing: some adapted cultural mandates equating ageing with deterioration and decline, albeit in subtle ways, whilst others challenged these images. For many, changes in health status were central to their responses to ageing: in particular, many women experienced problematic health problems from earlier in their life course; thus decline in health was not directly related to ageing.

MIDLIFE HEALTH: BEYOND MENOPAUSE

For many participants in my study, possibly due to the sampling strategy used, midlife was, in some way, mediated by their health status. The emphasis on health may have been an artefact of my position as a student within a research centre for women’s health. The focus of the interviews on health-related aspects of midlife was only possibly and partly an artefact of the

44 Sections of this quote appear elsewhere in the thesis.

study design. Australian data indicate that around 80% of all women experience some

symptoms in midlife (described in greater detail in Chapter 4 Richards et al. 1997). This

suggests that health and bodily signs may have a significant role to play in women’s midlife

experiences. As has been argued elsewhere (Banister 1999a, 1999b; Burns and Leonard

2005), women’s midlife narratives were not exclusively about physical and/or physiological bodily changes; instead, they incorporated aspects of life relating to intimate relations, relationships with their children and family members, changing social participation, and personal aspects of gains and losses. In this study, participants discussed both mental and physical health status. The midlife narratives of some participants are illness narratives; these narratives focus on these participants’ experiences of ill-health and disease, and demonstrate the importance of their poor health in shaping their midlife experiences, as Hattie illustrated:

I was wondering if you’d like to tell me your experience of midlife, so far? I’ve found my ill-health very relevant… One of my big experiences of midlife that has been pivotal actually has been the fact that I’ve had bleeding. And I mean that has ripples through all sorts of bits of your life, in terms of inconvenience and relationship things, fatigue and whatever. (Hattie, age 50)

All of the women in this study used personal narrative styles in telling their stories.

They expressed their relief at having an opportunity to tell their stories, particularly if they

had problematic health histories (and thus told more easily discernible illness narratives) or if their health concerns had been dismissed by others, for example, if they were viewed by others as hypochondriacs or attention seekers, such as Hattie, whose first doctor believed she presented for psychological reasons:

I now have a local doctor who has taken [the bleeding and associated anaemia] really seriously and in hand, but the doctor who was previously

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treating me didn’t take it very seriously as a quality of life issue. And seemed to think that it was [hand signal suggesting ‘all in my head’]. (Hattie, age 50)

Emphases on health-related issues appear to reflect what was actually happening for these women during this life stage. During data analysis, in which I developed a theory of narrative types in order to maintain the integrity of the stories (see Chapter 2). I noted that narratives tended to follow basic structures and consisted of similar features (cf. Riessman

1993). Following this line of analysis further, I identified that women used four broad types of narrative strategies. I discuss these below.

NARRATIVE STRATEGIES USED BY WOMEN IN MIDLIFE

The first narrative strategy, a ‘Maintaining’ narrative, was used by women whose narratives were not preoccupied with past or present health concerns, yet who told stories about their concerns with maintaining good health, both in the short and long-term. Similarly, the

‘Contemplating’ strategy did not dwell on their past or present health concerns. These women told narratives that focused on the future in terms of their mental and emotional changes; changes to the physical body were of secondary importance. Caring for significant people in their lives in addition to their children – such as parents or partners – had an important role in these women’s stories. The antagonist in their stories was often the illness of another (i.e. partner) and how his illness had profound effects on the narrator’s life. In contrast to these first two narrative strategies, women who used ‘Negotiating’ narratives told stories about their life histories consisting of managing their on-going health concerns, many of which had started when they were younger. In telling their stories, these women placed particular emphasis on those health conditions which continued to characterise their midlife, as Ash described:

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My health started deteriorating in my late forties, early fifties. That’s when I discovered I had lupus. I used to think that a lot of this was due to menopause through ignorance. (Ash, age 60)

The chronic nature of many health conditions experienced by women who used the

Negotiating narrative strategy meant that they often called upon the quest story-telling

structure (Frank 1995). The final narrative strategy was what I termed the ‘Navigating’ strategy; this type of narrative tended to be used by women who had not experienced any personal health concerns earlier in their lives yet, at midlife, had begun to have (usually adverse) health events that made them aware of their changing bodies. For many of the women who employed this fourth, Navigating, narrative strategy, menopausal symptoms played a key role in their midlife health experiences and, as such, often impacted on other areas of their lives. I discuss this narrative strategy in detail in Chapter 6; where appropriate, I refer to women’s menopausal experiences (explored in Chapter 4). Appendix 3 shows the narrative strategies used by each participant.

In describing the four narrative strategies in this thesis, I discuss how participants’ understandings of their body, their self, and the relationship between the two impacted upon their embodied experiences of midlife. Women’s understandings, as I will demonstrate, varied by factors relating to identity, health status, acceptance (or not) of biomedical-based and social representations of women’s ageing, and their own (socially informed) expectations of this life stage, as is illustrated in Table 3.2 (below).

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Table 3.2: Recurring themes common to each of the four narrative strategies employed by midlife women in Waterside45 Maintaining Contemplating Negotiating Navigating Identity Stable Changing Stable Changing Focus Maintaining physical body Inner self/personal Attaining feelings of health and Coming to terms with and learning development well-being, within a bodily context how to manage a disruptive body of illness Health status No major health concerns No major health concerns On-going health problems Recent health problems Long-term health None None One or more chronic health One or more conditions that may conditions conditions: ‘My health started require on-going management: ‘I… deteriorating in my late forties early ripped all the ligaments in my feet. I fifties. That’s when I discovered I had to go to bed for nearly two had lupus and I used to think that months. I couldn’t walk at all. It was a lot of this was due to menopause terrible… I thought this is going to through ignorance.’ be very bad…’ Self-management of Few symptoms requiring Few symptoms requiring Largely self-managed with some Self-management with considerable symptoms management, managed entirely management, managed entirely assistance from medical assistance from medical/health by self by self professionals professionals Access to health care Annual check-ups and Annual check-ups and Multiple consultations: a range of Multiple consultations: GP, visiting preventive health screening preventive health screening specialists, GP specialists, community health centre Personal life cycle46 Early menopausal transition, Menopausal transition Menopausal transition, post- Menopausal transition peri-menopause menopause Body image Minor changes Medium changes Some disruption Major disruption ‘I probably notice [bodily ‘[My body] has got very much ‘When you start getting aches and ‘Physical exercise was absolutely changes], albeit though with wider and heavier, not that I pains, you look for ways to ease impossible… I was feeling so sick I exercise, it’s not so bad. You do was ever sylph like, but it has them. [They aren’t] going to go was just staying in bed all the notice… loose skin a bit, more certainly gotten bigger…’ away… my immune system was time… After that, I was getting up, wrinkles but then, I’m outside a run down… I’ve been working doing a few things, sleeping in the lot.’ really hard to get it back up. I feel a morning and in the afternoon…’ whole lot better.’ Role of others Social support from partner, Social support from partner, Comparison/information-sharing Information-sharing with peers; family, and/or friends family, and/or friends with peers; social support from social support from partner, family, partner, family, and/or friends and/or friends

45Informed by Markovic’s (2006) model 46Determined using the menopausal stages defined by Guthrie et al. (1996); Dudley et al. (1998)

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Social participation Stable, little change; lessened Somewhat lessened compared Stable, continues earlier trends Somewhat reduced, due to health due to children leaving home to earlier in their lives whereby it is mediated by health status status Disruptive I’ve been really lucky with I’ve been through menopause. I’ve had bleeding. And I mean that My skin used to crawl. I used to get menopausal menopause, incredibly lucky It’s all happened and it’s been has ripples through all sorts of bits itchy and get creepy crawly skin… symptoms because apart from the very easy… I’ve sailed through of your life, in terms of the hot flushes were bad, the mood occasional hot flush, I haven’t the physical stuff of it very inconvenience and relationship swings were bad, and also loss of really had any symptoms. easily… I’ve had some of those things, fatigue and whatever. self esteem. physical things like hot flushes, but very few of them. Usage of hormone Did not use Did not use Long-term usage Short- and long-term usage therapy

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Constructing the narrative typology

When analysing the data, I paid particular attention to the women’s health status and health problems, and how these influenced their actions and interactions. The main dimensions across which I analysed women’s midlife experiences are shown in Table 3.2, with the exception of their partnering status and social/community participation. These two dimensions were difficult to encapsulate in a table format as women expressed high levels of ambiguity when describing their experiences. For example, within each narrative strategy, there was variation of partnership status. I have chosen to refer to women’s intimate relationship status in terms of ‘partnership’ rather than ‘marital’ status, as women experienced various kinds of partnerships, with partnering itself a dynamic process within their lives, beyond the tradition categories indicated by ‘marital status’ (that is, married, divorced/separated, widowed or single). Some participants were married, whilst others were divorced, separated or widowed, but within the category of ‘single,’ some women had never married; others had long-term de-facto partners, non-live-in partners (such as long-term boyfriends who lived in a different household) or short-term partners. There was no clear association between partnership status and the narrative strategies employed by women.

Most women did not describe the presence or absence of a partner as determining their health status, although they often highlighted the ways in which their health impacted upon their partnerships. Women described their health and social/community participation in terms of a symbiotic relationship, whereby their health status influenced their social participation; social and community perceptions and attitudes shaped their understandings of themselves as healthy (or not) and thus, determined how they conceptualised health.

There were some similarities across all women’s narratives, which did not seem to be mediated by health status. In particular, participants all described feelings of loss when their

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children left home (which was often to move to a city several hours away, see Chapter 2).

Without exception, as discussed in Chapter 4, women expressed their contentment at having reached the end of their reproductive years, which they had voluntarily ceased many years before midlife. Identity was a salient issue across women’s narratives, although this varied in different ways to their health. Women who used Maintaining or Negotiating narrative strategies related their stories in terms of having a stable identity: during midlife, they were enacting an identity that had been theirs for a considerable period of time. Changes in their self identities were minimal and did not require the active adaptation that was described by women who used the Contemplating or Navigating narrative strategies.

Given the emphasis in both popular and academic literature on menopause, I was interested to learn whether women experienced problematic health events during their midlife, and to what extent these health events were related to menopause. Menopausal status and experience of menopause-related symptoms became a significant factor in the development of my typology of the four narrative strategies. All participants indicated that they had experienced some types of menopausal symptoms, although these varied somewhat.

Several women indicated that they had experienced hot flushes and were able to readily manage these: after reading through and analysing their interview transcripts, I became aware that this group of women told their midlife story in one of two ways: either they focussed on their body and their bodily maintenance behaviours, or they spoke about menopause in terms of a ‘feminist empowerment model’ (see Chapter 4) and focused on personal development. In this thesis, these ways of story-telling are called the Maintaining and the

Contemplating narrative strategies.

Of the remaining narratives, one of two things were happening for women. All described their disruptive menopausal symptoms; some, however, also highlighted other, long-term (or chronic) health conditions as being at least as important to their midlife

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experiences as their menopausal experiences. Specifically, their narratives centred around their bodily management skills, which they had developed over a long period of dealing with various health challenges. From their stories, I began to see that their narratives highlighted how accomplished they were at managing various bodily events, both as they occurred and on a day-to-day basis; for this reason, I suggest that their narratives are concerned with

Negotiating their health within a context of illness (Lindsey 1996).

In contrast, the remaining narratives appeared to be centred largely upon problematic or disruptive bodily events related, directly or indirectly, to menopause. These bodily events tended to be acute or short-term and the women who experienced them were therefore able to see an ‘end-point’, something that was missing from the Negotiating narrative strategy.

The women who used this type of narrative strategy emphasised their learning processes and how they were coming to terms with managing their health. Such health events were disruptions in their biographies which were previously untroubled by illness. Women who used these narratives emphasised that this was their first experience of troublesome bodily experiences, and as novices, they described their skill development in self-health management. For this reason, I argue that the women who used such narrative strategies were concerned with Navigating novel bodily events.

Typologies of midlife

These four narrative strategies share some resemblance to those defined and described by

Banister (1999a, 1999b) and Burns and Leonard (2005). Each of these studies identifies four narrative themes, into which women’s midlife stories were divided. Banister (1999a), concerned with understanding how women understood and made sense of their bodily changes associated with the midlife stage, developed a typology centred around the phenomenology of the ageing body. It contained themes on: ‘sensing incongruence’ (women

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attempting to reconcile ambiguities of bodily experiences), ‘having more questions’ (women

trying to make sense of their bodily changes), ‘sensing loss and longing’ (perceiving midlife in

terms of a series of losses, and longing for those elements of their younger lives), and ‘caring

for self’ (positive personal development). In contrast, Burns and Leonard (2005) explored

how women positioned midlife in terms of their life cycle; their typology identified similar

themes as Banister (1999a, 1999b), yet analysed these in relation to women’s narratives of their earlier lives. In doing so, they emphasised the role of personal agency within these

stories. ‘Breaking out’ stories described women taking active steps to distance themselves

from their old ways of life, whilst ‘stress relief’ stories illustrated the impact of time and

circumstances on liberating women from their old roles and responsibilities. ‘Continuing

contentment’ stories were concerned with stability through the life course, whilst in contrast,

‘stories of loss’ centred around women’s adaptation to a series of losses and often dramatic

disruptions.

Both of these typologies contain elements that run through the narratives described

in this thesis, and each narrative strategy contains one or more of these themes

simultaneously. For example, regardless of the narrative strategy, all participants described

some sense of coming to terms with the ambiguities and paradoxes that occurred in their day

to day lives; in doing so, women often understood these ambiguities, at least partially, in

terms of some sort of loss. Aspidistra, for example, was saddened (“devastated”) when her

last child left home; yet she also appreciated the resulting levels of freedom which allowed

her to do what she wanted. In her case, she was able travel around the world with her

partner. At the same time, few women told stories of continuing contentment; women who

used Negotiating narrative strategies discussed having stability in their health but did not

describe this in terms of ‘contentment.’

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Throughout this thesis, I have described my participants’ experiences in terms of these narrative strategies. The narrative strategies highlight the different techniques employed by women to describe their own understandings and embodied experiences of midlife, while maintaining a level of fluidity and permeability. The type of narrative strategy a participant used was largely determined by her health status; thus, whilst women typically employed only one narrative strategy, due to their personal health-related experiences, some women told narratives that incorporated two strategies, such as Maude (who used both Maintaining and

Contemplating narrative strategies) and Daphne (who used both Contemplating and

Navigating narrative strategies). The ways in which the narrative strategies relate to each other is shown in Figure 3.3 (below).

Maintaining Negotiating

Contemplating

Navigating

Figure 3.3: Inter-relationships between the four narrative strategies

Whilst the other narrative strategies were largely incompatible, the Contemplating narrative was often used in conjunction with other strategies. Both Maude and Daphne primarily used one narrative strategy, and their case studies are presented in terms of these strategies, yet both drew upon Contemplating narrative strategies in their understandings of the life-cycle.

In doing this, Daphne relied upon positive ageing imagery promoted by feminist

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empowerment models, yet she also described the negative aspects of ageing, thus highlighting the ambivalence of the midlife phase:

[There’s] this business of becoming a crone. When you go through menopause, you suddenly realise, ‘I am getting wise.’ [You start] thinking on a different level, and you’re thinking, ‘I have got all this accumulated knowledge and wisdom.’ You know, it is quite exciting… but then there are other times that you feel totally useless. (Daphne, age 59)

Part of Daphne’s ambivalence arose from her ongoing, problematic health, which significantly restricted her ability to perform her usual social roles and responsibilities. In contrast, Maude did not feel restrained by her bodily experiences; instead, she reflected on the accumulated knowledge she had acquired through ageing, and constructed midlife as a time of personal growth and development. Consequently, she described her acceptance and appreciation of her midlife stage:

I wouldn’t want to be anywhere else than where I am right now because my [mental/emotional] head-space means that much to me. It’d be really nice to have the capacity of physical fitness that I had, say, when I was 25 but I wouldn’t want that head-space again. My mind and head, and my spiritual development, have all grown so much. [I’ve gained] compassion and understanding for human beings. That’s just something that life gives you… That’s going back to how older people are dismissed and yet they have all [of] that [knowledge]. (Maude, age 50)

For other participants, the process of story-telling itself was dynamic. Women such as Serena made a transition from using one narrative strategy (in her case, maintaining narratives) to another (navigating narratives); this shift was not deliberate but rather occurred in response to changes in her health status between her initial and follow-up interview (two years later). Should the problematic bodily symptoms of women who used the Navigating

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strategy continue over a long period of time, I would expect their narratives to begin to resemble those of women who used the Negotiating narrative strategy.

Midlife and narratives of illness

In many ways, the narratives of women who experienced problematic bodily symptoms were illness narratives. Their stories told of selves profoundly shaped by their past or present experiences of ill-health. Skultans (2000) argued that the value of narratives lies in their creation and shaping by the narrator; thus women’s narratives provided important insights into the motives and reasons behind their health management. The motives behind these practices were particularly important when exploring the ways in which women managed their own health concerns, as they demonstrated how women sought formal and informal advice and support in controlling their bodily signs (cf. Martin 2001). The struggle for the self’s control over the body, and its signs and signals (as described by Martin, ibid.), was central to the Negotiating and Navigating narratives. In describing this struggle, these illness narratives, as Skultans (2000:8) argued, “emphasise the inevitable conflict between intention, aspiration—character if you like—and the contingencies of the flesh imposed by the material world.” Furthermore, these two narrative strategies highlighted the different ways women understood the various health conditions they encountered; that is, the practices women used to cope with bodily events (cf. Martin 2001). Women’s illness narratives also provided important information about the social and cultural context, as Mattingly and Garro (1994;

Garro 1994) highlight in emphasising women’s attempts to reconcile their inner and outer worlds, the “double landscape” of illness (described by Mattingly and Garro 1994).

In telling their illness stories, these participants employed the broad narratives described by Frank (1995). The Negotiating narrative strategies evoked narratives of quest and the search for ways to better manage their bodily signs and symptoms. Women who

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used Navigating narrative strategies drew upon narratives of restitution, based upon their assumption that their current bodily experiences would be resolved post-menopausally; women expected that their problematic bodily events would cease after they had passed through their menopausal transition. During her memoir detailing her midlife illness experience, Clendinnen (2001) described, like women who used the Navigating narrative strategies, the novelty of her illness. In using the term ‘novelty’, I do not refer to images of entertainment or ornamentation but, instead, call upon understandings of the newness of the illness experience, highlighting the contrast between these women’s previous (good) health and their recent health challenges. No woman who used a Navigator narrative strategy had been seriously ill before midlife and thus, the experience of problematic bodily signs was unusual.

At the same time, women who employed the Negotiator and Navigator narrative strategies constructed the relationship between the body-self in different ways to those who predominantly employed the Maintaining or Contemplating narrative strategies. Rather than positioning either the body or the self as the foreground of their stories, with the other as the background, these women constructed their body and their self as having equal importance in their narratives. Women who used these narrative strategies described their self as being under constant revision. As their self construct was dependent upon the needs and demands of their bodily events, which were constantly changing, their understandings of their self shifted in response. In this way, the self was dynamic, yet mediated by their bodily events.

Social determinants and health narratives

Walters (1993) found that social class impacted upon the types of mental health problems women recounted and shaped their responses to these. Within my participants’ narratives, class played an important mediating role in how women responded to their illness,

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particularly in terms of whether they sought second opinions or specialist advice (Chapter 7).

Beyond influencing women’s access to formal care, social class did not shape the patterning of women’s ill-health experiences (as it did in Walters’ study). For example, Biggs, Nola and

Chappers lived in high income households, yet they employed different narrative strategies.

Similarly, Maude, Treasure, Mac, Cynthia, Lois and Daphne had low household incomes, yet this did not seem to predict which narrative strategy they used. However, given the small number of women in high income households or with a post-secondary school education, it was difficult to gain a full understanding of the patterning of problematic health by social class.

Age, in contrast, appeared to play a significant role in women’s health experiences.

Illness narratives which were expressed through the Negotiating and Navigating strategies were generally told by participants aged in their fifties or sixties, with the exception of Nola, who had experienced poor health for a long time and felt that this had indelibly shaped her midlife experience, as she stated during our interview: “a lot of midlife is there!” Younger participants, aged in their forties and very early fifties, who were either pre- or peri- menopausal, and had not experienced any serious health problems in their lives, tended to use Maintaining narrative strategies. Contemplating narrative strategies were used by women regardless of age, from their mid-forties until their late-fifties, in relation to the feminist empowerment ideology which influences it. This narrative strategy draws upon images of feminine strength and power that came of age during the 1970s, around the same time as when participants were similarly ‘coming of age.’ The chronology of this movement may explain why women who predominantly used other narrative strategies also employed this strategy. Women who used the Negotiating and Navigating narrative strategies tended to be in their fifties or early sixties and were either peri- or post-menopausal. They tended to experience a problematic or disruptive menopausal transition, which was salient given the

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association of ill-health or decline in health with the ageing process. These women were

aware of the wider social images equating old age with decline; given their bodily events, their

narratives were concerned with reconciling their life trajectory in terms of their illness

experience(s).

In the following chapter, I explore women’s experiences of menopause. Women’s

menopausal experiences varied between narrative strategies in relation to the number and

type of symptoms reported (see Appendix 3). Narrative strategies, however, did not determine the degree of importance that women placed on their menopausal experience and, as a result, my exploration of women’s menopause experiences forms a backdrop for the following two chapters (Chapters 5 and 6), in which I outline each of the four narrative strategies employed by women in my study, and relate these to the broader theoretical literature around health, the body and women’s lives.

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Chapter 4

Positioning Menopause

Midlife cannot be explored without considering the role and impact of menopause which, as reflected through women’s understandings, biomedical knowledge, and popular media, is the culturally significant marker of (middle) age for women (Skultans 1970; Gullette 1997).

Given the importance placed on women’s reproductive abilities in all societies, including in the western world (Martin 2001), the bio/physiological event of menopause – which ends fertility, fecundity, and reproducibility – is also emphasised as the defining socio/cultural47 event and the major crisis in midlife (Lock 1998; see also Martin 1997). In addition, increased social dependence on medical understandings of the life course (McCrea 1983) in Western societies has led to the use of ‘menopause’ as a synecdoche for women’s midlife (also noted by Dan and Bernhard 1989; Lock 1998). Menopause symbolically indicates the end of

‘youth,’ and therefore signifies the onset of multiple losses (Fu et al. 2003), including loss of fertility, attractiveness (Sontag 1978), and social worth and value (Martin 2001), at least in

Western societies. It is constructed as signifying the onset of poor (general) health (Hardy and Kuh 2002), the start of a downward trend continuing and intensifying throughout the remainder of the life course.

The concept of menopause, based on biomedical knowledge and reflected through popular cultural media (Shoebridge and Steed 1999), is constructed upon a series of assumptions about women’s bodies (Kaufert 1988) which prevent the full separation of the

47 My use of socio/cultural, as opposed to socio-cultural, derives from Melby, Lock and Kaufert’s (2005) work. This conceptualisation of the term enables ‘social’ and ‘cultural’ factors to stand alone, whilst also interacting, and more accurately reflects Lock’s (2001) concept of ‘local biology’.

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biological and physiological from the social, cultural and chronological aspects of the life

course. Understandings of and meanings attributed to menopause are based on ‘local

biologies’ (Lock 2001); that is, complex interactions of biological and socio/cultural factors

and influences (Melby et al. 2005) shape the lived experience of midlife and, thus,

menopause. In writing this chapter, I was interested to learn how “local categories of

knowledge and experience” (inherently social concepts, yet which sometimes have a biological basis: Lock 2001:483) shaped and constituted women’s lived, embodied experience

of midlife and menopause.

In this chapter, I explore the local biology of menopause in Waterside. I begin by

describing the socio/cultural construction of menopause in Australia, and to do this, I

outline the discursive frameworks and dominant models of menopause which influence

women’s expectations, understandings and experiences. Participants’ constructions of

menopause are then explored in detail, enabling discussion about the local biology of

menopause in Waterside. Finally, I discuss the positioning of menopause within women’s

constructions of the life course and, in particular, midlife.

SOCIO/CULTURAL CONSTRUCTION OF MENOPAUSE IN AUSTRALIA

Menopause is a slippery concept: it means different things among cultures and, within

cultures, is attributed alternative meanings and given particular connotations on the basis of

gender, age, class and social position. In particular, the language of menopause shapes the

meanings given to it; Zita (1997:97) argued that “the meanings of that event [menopause], its

cultural, historical, and personal interpretations, are dependent on the rhetorical strategies

used to re/present and interpret all of what it is.” Socio/cultural understandings directly

inform and shape the personal meanings women give to their own experiences. In describing

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their own experiences and understandings of menopause, participants also brought to bear social and cultural understandings of their own physiology and life course.

‘Menopause’ is a polysemous term reflecting the complex realities of women’s midlife

(primarily bodily) experiences (Kaufert 1982). Discursively, the term menopause refers to two co-occurrent realities or domains: socio/cultural and biological/physiological (ibid.:144).

The particularities of each are derived from the relationship between medicine, science, and women’s bodies (through temporal and historical change; McCrea 1983; Bell 1987; Martin

1997). Each domain continues to be contested. For example, little consensus has been reached on the range of physical and psychological symptoms associated with ‘menopause’

(as discussed further below; Kaufert and Syrotuik 1981; Avis et al. 2001; Melby et al. 2005).

Both domains contribute to the lived personal experience of menopause, as long documented: Skultans (1970) argued, 35 years ago, that women use the concept of

‘menopause’ to reflect social and cultural truths. In doing so, they acknowledge the biological reality of menstrual cessation; simultaneously, situating their discussions within a quasi- medical framework (for example, by referring to ‘symptoms’) enables them to legitimate the distress and confusion they experience with changes in social roles.

MENOPAUSE, DISCURSIVELY

The co-occurrence of menopause-related symptoms with multiple social and non- menopausal bodily changes has meant that ‘menopause’ is now widely understood as signifying the onset of women’s physiological ageing (Bell 1987; Ballard et al. 2001). Gullette

(1997) argued that current understandings of ‘menopause’ arose out of a process of cultural reconstruction, which transformed an often-minor biological event into what is now the dominant image of women’s midlife and ageing, an image created and perpetuated by

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biomedicine. Discursively, menopause is now the magic marker of women’s ageing (ibid.),

signifying the onset of decline and decay (Sontag 1978; Banner 1993; Gullette 2003).

The polysemous nature of the term menopause, as widely used by participants in this

study (see below), indicates that their lived experiences of midlife – social role changes and

reproductive ageing – are no longer regarded as distinct components of women’s life

experience. Instead, as women in this and other studies describe (for example: Kittell et al.

1998; Banister 1999a; Walter 2000; Hvas 2001; Dillaway 2005a, 2005b), the boundaries

between socio/cultural and physiological realities have blurred, shaping current

understandings of midlife and menopause.

‘Midlife’ or ‘menopause’? Instances from the field

It is virtually impossible to attempt to speak about Australian women’s midlife experiences

without engaging, at some level, in a discussion about menopause. This was evident whilst I

was recruiting study participants in Waterside. Although my advertisement in the local

newspaper never mentioned ‘menopause’ (Appendix 1), women – regardless of whether or

not they were interested in participating in my study – approached me and described their

menopausal symptoms. For example, whilst shopping one day, Emily started talking with me about her hot flushes and how she felt as though she was constantly ‘wet’ (drenched in sweat). On other occasions, other community members (usually midlife men) would question my research topic as they perceived it: ‘Why do you want to study menopause?’ These examples, common occurrences and not single events, show how midlife was identified with menopause and its biological consequences.

The socio-political climate frames women’s knowledge of reproductive ageing. Two models dominate discussion about menopause in Australia, reflected and promoted directly and indirectly through popular cultural media. The biomedical model has power, as reflected

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in almost all Australian studies exploring women’s menopausal experiences (for example,

Morse et al. 1994; Dudley et al. 1998; Dennerstein et al. 2000; Mishra et al. 2002; Anderson et al. 2004; Guthrie et al. 2004; McVeigh 2005; Travers et al. 2005, 2006). Although women in Waterside ultimately developed their own personalised understandings of when, what and how menopause is experienced, they drew upon aspects of these models, as discussed below, in their own understandings.

MENOPAUSAL MODELS

In Western societies, current understandings about menopause48 are based upon two main frameworks,49 biomedical and feminist, which although opposed, are based on similar central tenets (Kaufert 1984) and draw upon biomedical explanatory models. As Davis (1989:49) argued: “whether medicalisation is reified or rejected, it remains the focal point of analysis.”

The medicalisation of menopause (that is, the application of biological and/or medical constructions to understanding women’s menopausal experience, see Riessman 1983;

Kaufert and Gilbert 1986; Bell 1990; Meyer 2001) is the main concern of both rubrics – the biomedical model encourages medicalisation whilst the feminist model challenges the appropriateness of the approach. Both make additional, shared assumptions: firstly that midlife and thus ageing for women is characterised by negative images, and that post- menopausal life poses health risks for women, which require negotiation or minimisation

(Kaufert and Gilbert 1986). In addition, both models construct women as passive agents or

48 Reflected in lay health information and popular media (Carlson, et al. 1997, Gannon and Stevens 1998, Lupton and McLean 1998, Shoebridge and Steed 1999, Coupland and Williams 2002). 49 Multiple other rubrics for understanding menopause exist. However, I believe these are different labels applied to particular aspects of these two broad frameworks. Specifically, I suggest that biological reductionism (Zita 1997) can be positioned within the broad biomedical framework; similarly, the less widespread alternative therapy discourse (Coupland and Williams 2002) views menopause as a pathological condition which requires treatment and, thus, replicates the biomedical approach, with alternative therapies applied in place of pharmaceuticals.

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‘victims’, either of their own bodies (biomedical) or social structural factors (such as the social institution of medicine, as central to feminist arguments, Davis 1989). The difference between the two models lies in the interpretation of the meanings of the menopausal transition and its implications for women’s lives. These differences are discussed in the sections below.

Biomedical understandings of menopause

In the biomedical model, menopause is determined by the final cessation of menstruation. It is understood as a pathological condition caused by oestrogen (hormone) deficiency (McCrea

1983; Kaufert and Gilbert 1986) due to ovarian depletion (when no more follicles remain in the ovaries, as a result of reproductive ageing) – the result of a process that begins at birth and ends at the final menstrual period (Mason 1976; Barbo 1987; Sherman 2005).

Menopause is determined, retrospectively, after one year of continuous amenorrhoea (that is, lack of menstrual bleeding; Greendale et al. 1999; Sherman 2005). At the same time, menopause is constructed as a process during which a series of physiological changes and

‘symptoms’ occur, preceding and following the cessation of ovarian function; the period of time during which this process occurs is called ‘the peri-menopause’ or ‘climacteric’ (Kaufert

1982; Barbo 1987; Dudley et al. 1998). The menopausal transition – changes from ‘regular’

(within women’s own bodily experience) menstrual cycles to no menses – involves women progressing through three different stages of menopause (Dudley et al. 1998), which are exclusively determined by the presence or absence, and patterning, of menstrual periods

(Garamszegi et al. 1998; Guthrie et al. 2004; Mansfield et al. 2004). Precise staging of the biomedical model of menopause status, developed at the ‘Stages of Reproductive Aging

Workshop’ (‘STRAW,’ aimed at developing universally applicable understandings of reproductive ageing, Soules et al. 2001), is shown in Figure 4.1.

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Menarche Final menstrual period

Life course Stages -5 -4 -3 -2 -1 +1 +2 Terminology Pre-menopause Menopausal Post-menopause transition (Reproductive) Peri-menopause

1yr

Figure 4.1: Biomedical staging of menopausal status (adapted from Sherman 2005:5S)50

During pre-menopause, women are assumed to menstruate and ovulate regularly; this stage includes women’s reproductive life (ibid., Soules et al. 2001). Peri-menopause occurs when irregularities occur in the length, flow or patterning of menstruation and persist until the onset of menopause (Dudley et al. 1998; Soules et al. 2001; Sherman 2005); ovulation is assumed to be sporadic and unpredictable due to ovarian depletion. Peri-menopause begins 2 to 8 years before the final cessation of menstruation (median 3.8 years: McKinlay et al. 1992) and persists for one year after the final menses (Sherman 2005). The final stage of the transition, post-menopause, occurs after menstruation has ceased completely. Within this model, assumptions are made about hormonal stability across the life course: in pre- menopause and post-menopause, hormones are constructed as ‘stable’ (Figure 4.2, Kaufert et al. 1987) and less problematic than the peri-menopausal hormonal patterns.

50 In this figure, the 7 stages of reproductive ageing identified in the STRAW workshop are shown in relation to the final menstrual period (the menopause) and number. For example, 5 reproductive stages before menopause is identified as stage -5.

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Observed menstrual pattern Assumed hormonal profile Menopausal status

Regular menstruation Stable Pre-menopausal

Irregular or semi-recent Hormonal Peri-menopausal menstruation disturbance

No menstruation Stable Post-menopausal

Figure 4.2: Biomedical model of menopausal status (adapted from Kaufert et al. 1987).

Post-menopausally, hormonal stability is understood in terms of complete oestrogen deficiency. Oestrogen absence is understood to prompt subsequent declines in health status

(such as bone or cardiovascular health: Gorodeski 1994; Sherman 2005; Alexander and

Clearfield 2006; Kamel 2006), femininity and womanliness (including in sexual functioning, see Dennerstein et al. 1997, 2001; Wilson [1966] 1968), youthfulness and physical attractiveness (often described in terms of skin changes; Sampselle et al. 2002; Hall and

Phillips 2005), and social position (derived from social norms based upon biomedical assumptions equating ageing with decline, Sontag 1978; Martin 1997, 2001; Zita 1997).

Within this model, menopause is constructed as a harbinger of both present and future decline and loss on multiple levels (Coupland and Williams 2002), which requires treatment through medical technologies, such as hormone replacement therapy (HRT; Davis 1996), to return women’s bodies to a ‘normal’ state (Kaufert and Gilbert 1986:11).

Lock (2001:500) argued that biomedicine’s efficiency in “linking menopause with disease and oestrogen with prevention” has resulted in menopause being constructed as a health risk (Murtagh and Hepworth 2003a, 2003b). This risk is treatable pharmacologically:

HRT is therefore constructed as imperative for protecting and maintaining health and normality

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by treating menopausal hormonal deficiency, and is promoted as the only appropriate51 way of redressing other menopausal losses: of libido, vaginal fitness, youthfulness (for further discussion, see: Gonyea 1996; Lupton 1996; Harding 1997; Cutler and Genovese-Stone 1998;

Griffiths 1999; Shore 1999; Dennerstein et al. 2002; Hoffmann et al. 2003; Murtagh and

Hepworth 2003a; Sievert 2003; Kahn 2005). In this way, it offers women a way to regain what they have lost. Despite findings suggesting that HRT itself poses a risk to women’s health by increasing the risk of some cancers and some cardiovascular outcomes, including coronary heart disease and stroke, as indicated by the early cessation of the Women’s Health

Initiative (WHI) trial (Wassertheil-Smoller et al. 2003. Also see Hulley et al. 2002;

Birkhaeuser 2005; Schonberg et al. 2005; Canonico et al. 2006; Hsia et al. 2007), women are still being reminded of their ‘moral responsibility’ to take HRT to protect against the range of losses associated with decreased oestrogen (see Guillemin 1999; Green et al. 2002; Hoffmann et al. 2003; Murtagh and Hepworth 2003a, 2003b). Reports contradicting the WHI study

(such as Hulley and Grady 2004; Grodstein et al. 2006) and the focus in the WHI study on older women (aged 50-79) have been adopted by menopausal societies (reflected in position statements such as Skouby et al. 2005)52 and colleges of gynaecology (for example, Collins et al. 2007) as supporting the widespread prescription of HRT for symptom relief.

51 That is, developed through biomedical knowledge structures (Coupland and Williams 2002). 52 This was particularly evident when I attended the session on ‘the implications of the Women’s Health Initiative and the treatment of menopause’ at the 3rd Asia/Pacific Conference on Sexual and Reproductive Health in which the presenters, all gynaecologists and members of various International Menopausal Societies, spent the session discussing the (apparently major) flaws in the methodology of the WHI and thus, the irrelevance of such findings to the treatment of menopausal women.

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Critiquing the biomedical model

Biomedical staging of the menopausal transition is problematic, as its understandings of

hormonal changes contradict other (biomedical) understandings of women’s bodies, which

are much more ‘unruly’ and unpredictable than this model suggests (Figure 4.2). The assumptions of hormonal stability pre- and post-menopause have been shown to be

incorrect: hormonal fluctuations occur throughout the menstrual cycle (which enable ovulation and menstruation) and due to socio-environmental factors (including nutrition, body weight, stress, cigarette smoking, and chemical exposure: Baker 1985; Harlow and

Ephross 1995; Windham et al. 2005; Bretveld et al. 2006; Buck Louis et al. 2006). Post- menopausal hormone stability is also questionable: surveillance data indicates that many post-menopausal women experience increases in menopause-related symptoms (Li et al.

1996; Anderson et al. 2004), thus contesting hormone-derived arguments or the alignment of major oestrogen depletion and cessation of menstruation. In addition, the reliance on the final menstrual period in defining menopause is problematic – a woman’s last period may occur within multiple contexts unrelated to menopause (Kaufert et al. 1986), such as before the final pregnancy (Beyene 1986, 1992) or following hysterectomy (regardless of whether an oophorectomy was also performed, Elson 2002).

Menopausal status categories and boundaries require further clarification (also noted by Sherman 2005). Within the model, there are no exclusive categories (Figure 4.3): perimenopause is constructed as beginning at the onset of menopausal bodily changes – which occur during pre-menopause (Mitchell et al. 2000) – and ending during the early post- menopause stage (also see Kaufert 1988). This process may be graphically presented as follows:

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Peri-menopause Pre-menopause Post-menopause

Last menstrual period

Figure 4.3: Boundaries of menopausal status categories

Some attempt has been made to clarify this. Peri-menopause is now understood to continue until one year after the final menstrual period, until menopause is ‘diagnosed,’ at which point

‘post-menopause’ begins (see Buxton-Blake 2003). This definition is counter-intuitive and not reflected in women’s subjective understandings (as I demonstrate below).

At the same time, although peri-menopause is bounded (albeit ambiguously) in this model, no indication is given for when pre-menopause begins or when post-menopause ends: presumably, all women of reproductive age (or younger) are ‘pre-menopausal.’ Indeed,

Soules and colleagues (2001) define pre-menopause as the period between menarche and the onset of the menopausal transition, indicating that women’s entire lives can be

(physiologically) located in relation to menopause. Similarly, within this model, women are considered post-menopausal until death. Such definitions, however, are of limited use to women and their health providers, particularly given the inherent and assumed universality of experience: data has shown that women’s experiences vary considerably within each category

(refer to Kaufert et al. 1987; Mansfield et al. 2004; Dillaway 2006) and among cultural groups

(such as Beyene 1986; Lock 1994; Berger 1999). In addition, the ambiguity of perimenopause suggests that the biomedical staging of menopause has been arbitrarily determined – for example, by using signs (cessation of menstruation) that are not reflected in women’s subjective understandings (Garamszegi et al. 1998); as such, the legitimacy of biomedicine’s claim over menopausal knowledge is contested.

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Biomedical assumptions about the nature of the menopausal transition have not been

replicated in research mapping women’s reproductive (st)ageing. The biomedical model

treats each menopausal stage as homogenous and stable, regardless of whether a woman is at

the beginning or end, with sudden movement from one stage to another (Kaufert et al.

1987). However, this period of transition is neither straight-forward nor predictable:

women’s midlife menstrual changes occur along a continuum from regular menstruation to

permanent amenorrhoea (ibid.) and considerable variation is observed within each

menopausal status category. Among 324 women, Kaufert and colleagues (1987) identified

131 different patterns of menstrual change in contrast with the alleged ‘normal’ menopausal

pathway. Some women oscillated or ‘flip-flopped’ between stages – for example, having

menses monthly, then six-monthly, then monthly again (ibid., Mansfield et al. 2004; Dillaway

2006); some were ‘stuck’ in the peri-menopausal stage, experiencing long periods of irregular

menstruation; other women thought they were post-menopausal, only for their periods to

resume (Kaufert et al. 1987). This data indicate that there is no universal menopausal

transition, in terms of menstrual change,53 even within relatively homogenous populations.

Feminist criticism of the biomedical model of women’s bodies centres around its

inherent notions of ‘normality,’ the index point against which all women’s bodies are

compared. ‘Normality’ within this model relies upon notions of fecundity and fertility; thus, a

‘normal’ female body is constructed as one which can reproduce (Martin 2001). Such reproductive essentialism has profound implications for menopausal women and, as a result, women’s bodily events are constructed as pathological and in need of biomedical intervention, whether or not problematic symptoms are experienced. This is pertinent given stereotypes of the menopausal woman: although data indicate that 75-80% of women

53 The model assumes this is a biological ‘constant’ and not influenced by cultural or social factors.

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experienced menopause-related symptoms of varying levels of intensity or severity (Porter et al. 1996; Abernethy 1998; Gracia and Freeman 2004; Jean Hailes Foundation for Women's

Health 2005a; Chiou et al. 2006, 2007),54 most women will not seek medical assistance for these as they do not evaluate them as problematic (Morse et al. 1994; Calvaresi and Bryan

2003; Melby et al. 2005). Less than one in four women (22% or fewer, with some variance by study) report severe symptoms during the menopause (see also: Morse et al. 1994; Porter et al. 1996; Richards et al. 1997; Jokinen et al. 2003). Such findings suggest that the biomedical model does not adequately capture and reflect the experiences of women who do not experience difficulties at menopause. Further, in their meta-analysis of cross-cultural studies of menopausal experiences, Melby and colleagues (2005) found that the biomedical model of menopause contrasted considerably when compared with women’s local accounts of the transition. As most information on menopause derives from clinical studies of a small proportion of menopausal women seeking treatment for highly problematic symptoms

(Morse et al. 1994; McCrea 1983; Kaufert 1988; Lock and Kaufert 2001), the claims of universal knowledge about the transition must be questioned. Data from these women should not be constructed as representative of women in the general population.

In addition, despite extensive research demonstrating the cultural, social, and individual contribution to menopausal symptom aetiology (including Fox-Young et al. 1999;

Hardy and Kuh 2002; Calvaresi and Bryan 2003; Lee et al. 2004; McVeigh 2005; Xu et al.

2005), the biomedical model fails to consider the impact of such factors on women’s menopausal experiences (such as its timing in the life course, Riessman 1983). As the precise

54 One Finnish study (Jokinen, et al. 2003), however, argues that the figure is much higher than this and suggests that 95% of women aged 52-56 have experienced any of twelve categories menopausal symptoms at some stage; not all of these women viewed their symptoms as problematic – indeed 89% classified them as being of mild (36%) or moderate (53%) intensity. Presumably, not all women viewed their symptoms as pathological or sought medical attention in the treatment. As I will discuss in this chapter, the classification of certain bodily events as menopausal may lead to over-reporting of symptoms, particularly those that are less problematic.

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mechanisms linking symptoms (discussed later in this chapter) with menopausal endocrine changes remain unknown (Kronenberg 1994; Freedman 2001; 2005),55 the claim of biomedicine to authority over menopause requires reconsolidation. The feminist/empowerment model is the most authoritative challenge to this authority and offers an alternative, albeit imperfect, understanding of women’s menopausal experiences.

Empowering feminist knowledge of menopause

The feminist/empowerment model was developed in response to and presented itself as the

‘anti-thesis’ of the biomedical model (Kaufert 1982). Proponents of the model argue that women’s midlife should not be characterised solely by physiological events, that is, the cessation of menses and associated bodily changes, but rather, argue that midlife has a highly psychological or cognitive component. This model does not challenge the process of menopausal change described by biomedicine; rather it is concerned with the interpretation and implications of that model. Two premises (identified by Davis 1989) underlie the feminist model. Firstly, menopause is constructed as a normal, natural and unremarkable process in women’s lives (Posner 1979) that should not be subject to unnecessary and potentially iatrogenic processes of medicalisation (including HRT, Kaufert 1986:75). Weed (1999) argues that menopause needs to be approached through the ‘Wise Woman’ way, whereby bodily processes and hormonal changes are viewed as ‘normal, healthy and sacred;’ she calls for the reconceptualisation of menopause as “a time for intense introspection and personal growth”

(ibid.:267). This approach acknowledges symptoms and recommends a complementary medical approach – herbal treatments to ease symptoms and empowering women through

“storytelling, simple ceremony, and dietary herbs” (ibid.).

55 Although endocrinal changes are widely posited as the cause of vasomotor symptoms, Freedman (2001, 2005) has suggested that neural pathways may also play a role in the occurrence of hot flushes.

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Secondly, the model emphasises women’s experiential bodily knowledge to evaluate or assess menopausal status (Kaufert 1986) and argues that this knowledge should be privileged over medical professionals’ knowledge (Davis 1989). By challenging biomedical constructions of menopause, the feminist/empowerment model returns control and choice over one’s life course to women, and provides an alternative construct for women to describe their menopausal experiences (for example, see Melamed 1983).

Despite its position as the ‘anti-thesis,’ the feminist/empowerment model is not without its own concerns. Menopause has generally been considered by proponents of this approach as an afterthought, secondary to issues such as menstruation, pregnancy and childbirth (Davis 1989). Menopause, however, requires consideration on its own (see Velde and Pearson 2002). Unlike other reproductive events within a woman’s life course, less certainty surrounds the menopausal transition: its boundaries are more fluid (for example, compared with pregnancy or childbirth: Davis 1989; Kaufert and Lock 1997), progress from one stage to the next is unclear and poorly defined (compared with menarche), as its progress within each stage (Kaufert et al. 1987), and women often describe feeling unprepared and anxious about what they will experience due to this uncertainty (Hvas 2001).

The social contexts and position of menopause within wider processes of ageing are not acknowledged within this model (Dillaway 2005b:400). By emphasising menstruation, it minimises women’s responses to their own reproductive ageing. For many women, social roles associated with reproduction, such as ‘mother’, remain important (Dillaway 2006), even after their menstruating lives have ended. In addition, the emphasis placed upon the natural, normal, and unproblematic nature of the menopausal passage in the feminist approach discounts, devalues and invalidates the experiences of women who have problematic menopausal transitions and who often do require biomedical assistance with symptoms

(McCrea 1983; Davis 1989). As indicated earlier, international research indicates that the

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majority of women experience some bodily events during menopause; however, these experiences are not adequately represented by the feminist account of menopause. Despite arguments that the ‘naturalness’ of the menopausal transition legitimates the spectrum of women’s menopausal experiences (Zita 1997:102), the construction of menopause as

“positive or at least a neutral experience” suggests that women who experience menopause as neither positive nor neutral, but instead as highly disruptive or troublesome, impacting upon their wider lives, cannot be adequately accommodated by this model.

Both of these models are widely used in discussions of menopause in Australia, yet neither adequately captures all, or even most, women’s experiences. Understandings of menopause provide important insights into the meanings women place upon their own bodies and into how they anticipate experiencing the remainder of their lives (their imagined biographies or life trajectories). By exploring the lived experience of menopause for women

in Waterside, the meanings given to that transition and the systems of health management

employed by women, the importance of health and health behaviours on the ageing process

is illuminated. I turn to these issues now.

LOCAL BIOLOGIES OF MENOPAUSE IN WATERSIDE

Participants constructed menopause based upon social, cultural, biological, and physiological

domains, which they perceived as interconnected yet also distinct. Women most often

referred to their experience of ‘menopause’ as a process of change, rather than a single event

(Kaufert 1988), as illustrated by referring to ‘the menopause’:

I just thought, ‘oh yeah, it must be the menopause or something.’ (Cynthia, age 50)

I started blaming the HRT or the menopause… (Ash, age 60)

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I think I have actually finished with the menopause now. (Lesley, age 50)

Women did not understand menopause as an event; instead they discussed the liminal nature of menopause, emphasising the process as a journey or transition.

Menopause was clearly important in women’s understandings of midlife. However, in contrast to popular cultural messages, it was not the defining event of midlife for most participants; social aspects of women’s life courses, particularly those related to parenting roles and their children, were most salient, even though women described their understandings of ‘midlife’ at least partly in relation to their reproductive history and reproductive ageing. Carolyn’s narrative highlighted the complexity of women’s understandings of midlife, menopause and the difficulty for women to separate these two concepts. When questioned about her midlife experience, she responded in relation to her menopausal symptoms, yet she contextualised her response in terms of her reproductive history, as the following quote illustrates:

Could you tell me about your midlife experience? Mine was fairly easy, I think, except for some hot flushes. I don’t think I had too many mood swings and things. Um, I believe mine was fairly ideal. I had a funny background in that I didn’t have normal periods for many, many years. Didn’t think I could have any children. Then they finally thought I had cancer and said I needed a hysterectomy but then, lucky, they sent me to a specialist who dealt with these things and I actually had a little tumour on my pituitary gland that [meant that] my body had always produced too much prolactin. I used to always have milk in my breast[s]. I thought it was normal. I thought it was [to do with] the [menstrual] cycle, which it wasn’t… They managed to give me a drug, so I was able to have my child. By then I was 41. After that, I did go back to normal periods [until] about 6 years ago, and then they gradually petered out. (Carolyn, age 58)

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Carolyn drew upon multiple realities of menopause; in this way, her experiences were not unique. Like the other participants in this study, she used menopause as a synecdoche for midlife; more importantly, however, her narratives of midlife were concerned with social factors, including changes in relationships with her child and partner, her working life, and her involvement in the local community.

In this chapter, I explore the relative contributions of biological, physiological, social and cultural factors to women’s experiences of menopause and midlife. In doing so, I suggest that women construct their understandings of ‘menopause’ and ‘midlife’ by interweaving all of these factors. My findings demonstrate, as Skultans (1970) argued, that women’s understandings of menopause do not so much reflect biological or physiological knowledge and discourse about women’s bodies; instead they highlight social and cultural expectations of women’s bodies, roles, and life course. Participants simultaneously used two strategies to articulate their understandings of menopause: defining and describing. Definitions and descriptions relied upon highly complex and often inter-related factors. Some participants described themselves as menopausal or as having passed through menopause, despite continuing to experience regular (cyclical) bleeding. For example, Maude, at the start of my interview with her, described how menopause had not impacted upon her libido or sexual responsiveness:

I used to think to myself, when menopause hits, my libido will just go. Bullshit, it doesn’t work that way at all… Everything’s functioning just fine, last I heard [experienced]. (Maude, age 50)

As the interview progressed, she told me a story about deciding against having a tubal ligation, and related her feelings about not ending her fertility through sterilisation (that is, unnaturally) to her experience of (natural) menopause:

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I just felt really strange about all of this [the idea of having the tubal ligation]... and so I didn’t get it done [undergo sterilisation]. At that stage, I thought, ‘I wonder how I’ll go at menopause, whether I’ll really be sad that I can’t do that [have another child, regardless of] whether I want to or not.’ When it all [menopause] happened, it felt great, I didn’t have any [feelings of sadness]. But that was a natural time and that’s a big difference. If I’d had my tubes done [lay term for tubal ligation or female sterilisation] then, for me, it would have been like giving away a precious gift, even though I wasn’t going to use it. But as it stands now, it’s my natural time.

However, later, when I questioned her about menstrual change, Maude revealed that she was still menstruating, albeit irregularly: although she described her experiences as post-menopausal or late peri-menopausal, she was unable to know whether her most recent period was her last

(and thus, whether she was truly past menopause); therefore she would be defined as peri- menopausal (according to biomedical definitions, Dudley et al. 1998). Maude’s description of menopausal status as unrelated to menstrual change was a common theme among women in my study.

Women’s construction of menopause was clearly associated with factors outside of the physiological/biological event of menopause. Four main conceptual domains were important to their definitions of menopause, each of which will be discussed in this chapter: the end of reproduction and changes in associated social roles, menstrual change, symptom experience, and chronological age and biography. For some women, menopause also provided an impetus for personal growth and self-development; this is discussed as part of the latter domain as women related changes in self-identity to their social role changes. As I illustrate, although many participants defined menopause in terms of a single domain (often, end of reproduction), their descriptions about menopause almost always included detailed consideration of the other three domains.

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MENOPAUSE: THE END OF REPRODUCTION?

Women’s stories highlighted that reproductive ability and particularly reproductive history was central to how midlife was positioned. Midlife was defined in relation to the biological act of reproduction, “the end of child-bearing” (Ash, age 60) or as signifying the “lack of reproduction” (Biggs, age 53), yet women emphasised social markers of reproductive status, rather than the end of fecundity, when describing both midlife and menopause. Iris, for example, defined midlife in relation to her reproductive history, linking midlife to the biological body; at the same time, however, she related midlife to social aspects of her reproductive role (indicated by the use of italics):

Probably, for a woman, it [midlife] is marked by menopause and pre- menopause. I think it is probably also marked by the fact that your children are growing and leaving home… (Iris, age 50)

Almost without exception, other participants similarly defined midlife in terms of changes in their social roles associated with reproduction.56 The physiological aspects of reproduction were less salient for most participants as most women had voluntarily ended their reproductive lives (either by sterilisation or long-term contraceptive use) a long time before reaching menopause (Table 4.1).

56 These social role changes are discussed in detail in a later section of this chapter.

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Table 4.1: Menopause age (by self-reported last menstrual period) and self-defined menopausal status compared with age at last child Age (years) at birth of last child 20-24 25-29 30-34 35-39 40-44 No children Age at menopause Not yet at menopause 0 2 3 2 1 1 40-44 years 2 0 0 1 0 1 45-49 0 1 1 3 0 0 50-54 1 2 1 0 1 1 Menopausal status Pre-menopausal 0 1 1 1 0 0 Peri-menopausal 0 2 2 1 1 2 Post-menopausal 3 2 2 4 1 1

Table 4.1 compares the ages at which women had their final child (assumed to be the point when they completed their families) with age at self-reported menopause. Although I employ biomedical definitions of menopausal stages here, I describe the difficulties in classifying women’s menopausal transitions below. In this table, women who reported that they had finished their periods some time before or who had been told they had gone through menopause by their doctor (based on blood test results) described themselves as post-menopausal. Women who described themselves as ‘still going through menopause’ were considered peri-menopausal. Those who experienced symptoms yet continued to menstruate and described themselves as ‘menopausal’ were included in the peri-menopausal group.

Women who were still menstruating and had not experienced symptoms that they understood to be related to menopause were considered pre-menopausal.

With the exception of three participants (Hattie, Lesley and Louise, discussed later), women emphasised menopause as being unrelated to the completion of their families and thus, they did not describe menopause in terms of their reproductive ability. Biggs explained that following the birth of her fourth child, she felt her family was complete, and rather than continue to take oral contraceptives indefinitely, her husband had a vasectomy:

Well, really, honestly, after I had Jess [pseudonym], I really didn’t want any more children. For a while I thought I could have had six. I loved having

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children and I loved being pregnant. We knew that we’d have a few children and I said to Dave [husband, pseudonym], ‘I think six would be nice,’ but he felt six was far over the top... We could handle six of us but not eight of us. So really once I had Jess, we decided four children—two boys, two girls— that was sufficient. I would say that, after that, I really never ever thought about having [more] children… Dave had a vasectomy. Nearly straight after [birth] because we really knew that we didn’t want more children so rather than me going back on the pill, he was more than happy. He said, ‘no, you’ve had the children and done all that,’ and he was more than happy to have a vasectomy (Biggs, age 53).

This example illustrates how, often many years before becoming physiologically unable to have further children, some women (or their husbands, as in Biggs’ example) took permanent measures, such as tubal ligation (n=5), vasectomy (n=1) or medically-indicated hysterectomy

(n=4) to end their reproductive careers. For some, such as Biggs, the decision not to have more children was related primarily to the idea of completing their families. Women did not describe the decision-making about ending their reproductive lives in a vacuum. Sterilisation occurred within the context of other wider life events that may not have related to their reproductive capacity. Lois, for example, described a range of considerations in her decision to undergo tubal ligation:

[My tubal ligation] was well after having my son, because my marriage wasn’t going so well and I wasn’t even going to take the chance of getting pregnant. In fact, I’d even left my husband. And I was having a lot of laparoscopies done because… I started developing adhesions, so every 12 months, they had to operate and clean the adhesions out. I was in my 30s and I said to the gyno [gynaecologist], ‘while you’re in there cleaning the adhesions, tie my tubes’. I had made the decision [not to have more children]. I also didn’t like to take the birth control pill and the only way out was that [sterilisation]. (Lois, age 57)

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In contrast to Lois, who decided to have a tubal ligation following a relationship breakdown,

Treasure sought sterilisation after her traumatic recovery from a miscarriage:

There’s eighteen months between them [children]. Then we went to England and I had a miscarriage… I ended up bleeding very badly so I ended up in hospital and then I got an infection… it took me a while [to recover] though. That knocked me a bit. I had tubal ligation when we got back here [to Australia]… Did you want to have more children? Well, no. I think after that miscarriage in England, we decided, Jack [husband, pseudonym] said, ‘I’d rather have you than risk it again,’ because I really wasn’t too good. We decided then that we had two. It was a few years later. I think we were happy with two… I would have been about 35 or 36. Yeah. About 36. (Treasure, age 62)

The imposition of the biological body on women’s social choices, as in Treasure’s life, did not result in women feeling regret at the inability to have their desired family size. For the two women whose reproductive history led to them completing their families earlier and with fewer children than they had hoped, decision-making about family size was not difficult; both Treasure and Abbie emphasised being pragmatic in deciding to end their reproductive careers based upon past bodily events. Both described making decisions based upon their future health, wellbeing and quality of life. Abbie, who underwent a procedure to suspend her uterus (which had prolapsed following the birth of her large babies, see Jackson and

Smith 1997) before having a hysterectomy, described being happy with her family’s composition, even though she did not have a family of the size that she had previously imagined:

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I had a… prolapsed womb… The bowels and bladder were playing up as well, so they [the doctors] had to do a big repair job on the bladder as well. Sew it back, and all that sort of stuff. I had big babies. For me, I had big babies. You’re little… [My husband’s family] are all big, big boned people and they [children] took after [them], both of them. I would have liked four children, but had to stop at two. Was that a hard decision to make? No, not with that. Not at all. If they were easy, I would have loved four. (Abbie, age 54)

Regardless of the context within which decision-making about ending their reproduction occurred, none of these women expressed discontent with their decision not to have further children. Voluntarily ending one’s own reproductive career was not particular to women with children, nor was contentment at midlife following that decision. One of the three participants who had not had children described having come to terms with her

(non)reproductive career many years before menopause. Serena had wanted children in her first marriage, but after that dissolved in her late thirties, she became reconciled to childlessness and thus did not mourn lost reproductive potential during her menopausal transition:

I did try to have children. I had a miscarriage and after that the marriage got a bit rocky but it wasn’t anything to do with not having kids so much as other reasons. A lot of it was to do with my first husband. His brother had a mentally retarded boy and he was really frightened that the same thing would happen to him so he didn’t really want children. In a way it did have a bit to do with it... So yes I did want children but now I’m quite glad that I didn’t. Not being selfish but the way the world is…

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When you reached menopause and that was the end of reproductive possibilities, was that difficult at all? No. Not really, because I had come to terms with it before then. (Serena, age 52)

Although this was not stated during her interview, Serena implicitly challenged widespread beliefs that women, particularly those who do not have children, would feel grief for their lost reproductive potentiality at menopause. She was not alone in this: other women in my study described living lives that challenged such beliefs or popular images (described by

Sontag 1978). For example, Ash described how she completed her family (of four children) in her twenties and, as a result, believed that popular images associating menopause with loss of fertility and fecundity did not reflect most women’s life experiences (see Gullette 1997):

[At menopause] I wasn’t feeling like I wanted to have more children because I’d made up my mind that I wasn’t going to have any more kids anyway, when I was 29… I didn’t go through any fears that I missed out on that [having any more children] or I’m barren or anything. None of that rubbish. Because you decided consciously? Yes. When you’re 50 years of age, you’re not thinking of having another child. (Ash, age 60)

As Ash suggested, in contrast to biomedical expectations, women did not mourn the loss of reproductive ability and instead, perceived menopause as liberating them from menstruation.

However, even though these definitions were incongruent with their own reproductive biographies (see Table 2.2), the persistence of the association between the end of reproduction and menopause was reflected in women’s own definitions of menopause.

Although most women voluntarily ended their own reproductive careers some time before menopause, many defined menopause in relation to their reproductive ability. Despite

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challenging the expectation of grief over lost fertility at menopause, when I asked Ash what

midlife meant to her, she associated it with the end of child-bearing. As illustrated in the

following quote, Ferdie described menopause in terms of ‘no more babies,’ yet had ensured that she would have no more babies in her late twenties:

I haven’t had one [menstrual period] for about two months now to speak of… I’d say that’s no more babies for Ferdie. How do you feel about that? That’s okay, I had my tubes tied a long time ago. So, not being able to have babies physically has been a choice? Yes. I had them tied a month before I met Alex [husband, pseudonym]. One month almost to the day… Simon [first husband, pseudonym] [and I] had long since separated and it just occurred to me one day. It was about September in 1984. Annie [daughter, pseudonym] was 10. I was just hanging clothes on the line and it popped into my head that I should go and have my tubes tied so I did. I went and saw the doctor and he said, ‘you can have it done.’ I had to go off the pill for six weeks before then… I said, ‘let’s do it.’ Had it done in December and met Alex in January. So it happened for a reason, which is a pity because he would have made a great dad… It was like someone had zapped this thought into my head. (Ferdie, age 54)

These examples suggest that women define menopause based upon biomedical and physiological models, even though this definition is not represented in their own life trajectories. This was also true, on some level, for two of the three childless women who participated in the study. Lesley had decided when she was younger that she didn’t want to have children, yet described a moment of reflection around menopause when she realised that she could no longer change her mind:

I never really wanted any children and that was my choice, but I think when I realised that that [menopause] was happening, I realised then [that] I didn’t

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really have any other choice about whether I was going to have children or not. Whereas before, I had always sort of still had the choice. Because I have always been so healthy, I could have quite easily still had a baby when I was forty; quite sure, which people do now, [but] maybe not a first one. So I think that was one of the main things where that was really the end of ever having thought about that again if I wanted to change my mind, which I didn’t really. And was the decision not to have children, was that something you had for a long time? Yeah. I never ever wanted children even when I was young. I don’t know why. All the girls that I went to school with… that was all they used to talk about when we were young and I never really felt like that, ever. It wasn’t as if I didn’t meet the right people or whatever, because Jason [ex-partner, pseudonym] was very keen to have some children. So was Felix [ex-partner, pseudonym], and I was pregnant to both of them. But then I decided, no, I couldn’t do that. Which upset both of them a lot but I think that really it was my choice. (Lesley, age 50)

For Lesley, menopause did not so much prompt feelings of loss or grief about the ending of her reproductive potential; rather, it enabled her to reflect upon her decision, made when she was much younger, not to have children. As is clear from her quote, this decision was not made lightly: by terminating multiple pregnancies, she actively sought to ensure that her decision was maintained.

Only one participant, Hattie, described feeling a level of sadness at menopause, which she associated with the end of fecundity and the possibility of having children:

I had early menopause. That was another thing. I had finally come to terms with the fact I hadn’t had children… I think I was 41. [My doctor said], ‘you’re post-menopausal.’ So I had a twenty-four-hour total out there, cry, you know, beside myself. This is finally the death of the dream that I will ever have a child. (Hattie, age 50)

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Menopause, for Hattie, signified the end of a potential life choice, which she had not realised

earlier due to her poor health and circumstances; she had been pregnant when she was 23,

but terminated the pregnancy because of relationship difficulties with her then-partner. At

the time, she thought that she would eventually have a child; however, circumstances did not

eventuate as she had imagined. Going through menopause early, Hattie described ambivalent

feelings: on the one hand, sadness about the death of her potential future whilst, on the

other, feelings of liberation from social responsibilities and from the limitations and

inconveniences of menstruation:

[After the doctor told me I was post-menopausal,] then I thought, ‘this is the most liberating thing that can ever happen to me because… the only person I have to make decisions about is me and my dogs’… When I first discovered I was post-menopausal, because I hadn’t had my period for a while, I was so thrilled. I mean about that side of it. (Hattie, age 50)

For many participants, menstruation played a more important role in women’s descriptions

of menopause than the end of reproduction. Whilst menstrual change is central to the biomedical model, and thus to health providers’ understandings of menopause, this was not

necessarily the case for women themselves. As this section demonstrated, women’s definitions

were incongruent with their descriptions of menopause: they typically defined menopause in

terms of the end of reproduction, yet did not describe it in terms of reproductive change.

Instead, like Hattie, they described feeling liberated from the constraints imposed by

menstruation, suggesting that menstrual change played a key role in their understandings of

menopause. However, women constructed the end of menstruation very differently from

health professionals and, thus, biomedicine.

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‘NO MORE PERIODS. THIS IS GOOD!’

As already noted, menstruation is central to biomedical definitions of menopause, insofar as menopause is exclusively determined by the presence or absence of menstrual periods

(Kaufert 1986; Barbo 1987; Derry 2002; Guthrie et al. 2004).57 Menstrual change played an important role in many participants’ descriptions of menopause. Although only one woman,

Sam, defined menopause (which she used as a synonym for midlife) in terms of menstrual change: “…from when your period started to decline,” others emphasised being freed from the rituals of menstruation. Six participants who reported having difficult or problematic periods described feelings of celebration or relief at the end of menstruation. For example, Musical described intense pain during menstruation, which lasted from menarche at 14 until menopause in her 40s. Her periods came regularly; every 35 days she had 6 days of flooding:

[From interview notes] During her period, the bleeding was so heavy that she needed to have a towel underneath her, in addition to the pad, as she felt as though something was being dragged down from her uterus. Often, she would walk around with her hands against her vulva in her panties, because it felt like she was being supported. Otherwise, she felt like she was losing something, or that something was going to fall out. They were also very painful. She used to walk around for days with hot water bottles on her stomach because of the pain. (Musical, age 55)

Musical also experienced intense mood swings; given an idea of her menstrual life, it is unsurprising that, although she experienced considerable disruption from psychological and physiological symptoms (as discussed below), she considered the end of menstruation empowering and liberating.

57 The biomedical understanding of menopause is more complex than this simple description. The model is outlined and critiqued above.

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Menopause freed other women with problematic periods from worrying about bodily

cycles; in particular, they were able to be less watchful over all of their bodily events. This

was illustrated by Carolyn (refer to quote above), who had experienced very irregular periods

from menarche (at 11) due to a tumour on her pituitary gland; as a result, menstruation was

not something she ever felt like she could predict or expect. Menopause offered Carolyn

greater regularity and predictability. She described the slowing down and cessation of her

menstruation as very easy: “I believe mine was fairly ideal… about 6 years ago… they

gradually petered out… I think I’ve been pretty lucky.” For Carolyn, end of menstruation

was positive not only because it was largely unproblematic and she experienced few

symptoms, but also because it meant that she no longer needed to monitor her bodily flows

continually.

Almost all participants felt positively about menopause. None expressed feeling

sadness at the end of menstruation. For some, menopause was more about dealing with

highly disruptive symptoms than appreciating the end of their periods. In general, women

shared feelings about menstrual change similar to those expressed by Hattie: ‘No more periods. This is good!’ Participants used celebratory language when describing the end of

periods that menopause brought:

The big bonus is when you don’t have your periods anymore. I mean, that’s the great bonus [of menopause]. (Ash, age 60)

How did you feel about going through menopause? Good in one sense: no more periods. That was a good thing. Not too worried really. (Serena, age 52)

My period’s stopping, which is just pure joy! I haven’t had anything else [symptoms], it’s been really good. That’s been fantastic. (Maude, age 50)

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Freedom from restrictions (including those imposed by cramping, pain or flow) placed by menstruation on women was an important factor contributing to participants’ elation. Anglo-Australian women do not experience ritual exclusion from certain domains or restriction from particular activities during menstruation,58 as occurs in other social and cultural groups (for example, the edited volume by Buckley and Gottlieb 1988; also see

Douglas 1966; Montgomery 1974; Rasmussen 1991) but they do experience menstrual- derived limitations upon their social participation. Turner (2003) argued that, in Western societies, despite its promotion as ‘healthy’ and ‘natural,’ attitudes towards menstruation reflect wider social anxieties about women’s leaky bodies; this would suggest that menopause alleviates some of these anxieties (although new anxieties may result from other leakages, such as urinary incontinence: Peake et al. 1999, 2003).

Although few participants actually articulated feeling restricted by menstruation, certainly many felt that their period was no longer necessary and eagerly anticipated the absence of their periods. Because she had finished having her family, Biggs could no longer see the point of menstruating:

I had four healthy children… so I was just terribly fulfilled and happy with what I had, and didn’t want more children. We had a nice family. It [having more children] wasn’t an issue. It has never been an issue for me. It’s never been a problem. The only thing I felt was I didn’t think I needed to keep getting my periods, that was a bit of a hassle. (Biggs, age 53)

As noted above, women associated menstruation with fertility, yet participants didn’t see it as something that a woman needed to have if she didn’t want to have (more) children.

Thus menstruation was only seen as useful when trying to conceive – the rest of the time, it

58 Very little research has considered the symbolism invested in menstruation or menopause by Anglo- Australian women.

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was perceived as a nuisance. Changes in the regularity of menstrual cycles emphasised the

bodily surveillance that women engage in continually, and from which menopause offered a relief:

I still am [getting my periods] but I think they’re about to stop… The last two or three months it has just been really weird. I’m supposed to have my period and it’s a nuisance… I have to wear a panty liner because you just get little smudges. I haven’t had one for about two months now to speak of. (Ferdie, age 54)

In Australia, the menstruating body and the non-menstruating body are

socio/culturally constructed in different ways (Koutroulis 2001). Menstruation is

simultaneously constructed in two, seemingly opposite, ways: on the one hand, as a central

part of women’s ongoing health, in particular associated with women’s mental health (ibid.,

see also: Ussher 1989, 1992); on the other, as a nuisance, associated with shame, secrecy and

dirt. Menstruation is stigmatised and thus, used to control women’s behaviours and requires

renegotiation of social relationships (Koutroulis 2001:197). In this way, it places restrictions

upon women’s lives. In addition, unless they are using hormonal contraceptives or other

technologies, women are unable to control menstrual timing, flow or duration, and their

competence is undermined. Extrapolating Koutroulis’ (2001) argument, women’s bodies are

socio/culturally constructed and reconstructed continually throughout the menstrual cycle –

as the body moves from menstruating to non-menstruating, and back again – and thus, from

being shameful, stigmatised and dirty to being more normal (although not totally normal,

which is the stable, controlled male body) yet still unpredictable. This may explain, at least in

part, why participants described menopause in such celebratory terms and why many eagerly

anticipated it: menopause provides women with the ongoing embodied experience of being a

non-menstruating woman, ending the stigma, shame and notions of dirt or uncleanliness,

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which are symbolised by the menstruating body, and the practical difficulties of its management and its discomforts.

Menopause meant that women no longer needed to negotiate the socio/cultural connotations of menstruation. In addition, it offered escape from the necessity of sanitary products to contain bodily flows and protect clothes during menstruation. The politics of feminine hygiene products was an issue for women in my study. Since 2000, menstrual sanitary products have attracted a 10% goods and services tax in Australia (GST, also known as a ‘luxury’ tax: Kronemann 2000),59 inflating the already high price of sanitary hygiene products (making them 10% more expensive). Menopause freed women from these products and the associated costs:

You think ‘farewell to tampons and pads…’ (Chappers, age 59)

I am so rapt that I'm no longer having to buy tampons, and having to pay luxury tax on tampons. I always felt so resentful about the prices that they had and always thought that there should be a woman politician in there campaigning to get the luxury tax taken off. Because it’s such a luxury! Yeah, cause it’s such a luxury. But I’m highly delighted not to be spending my money on tampons any more! (Grace, age 50) What I resent most is the fact that tampons are so expensive and I think there is quite a sizable tax on them… (Iris, age 50)

‘That’s it,’ or is it? Uncertainty and menstrual change

As the previous section illustrated, women eagerly greeted the end of menstruation.

However, many described the time leading up to their final period as being confusing and

59 The New Tax System (Goods and Services Tax) Act 1999 (Commonwealth of Australia 1999) added a 10% additional tax onto all non-essential consumerables. Certain goods are exempt from this tax, such as condoms, due to their role in maintaining health and preventing disease. Despite being used by all women at some stage in their lives, sanitary products are not considered ‘essential’ under this Act and thus, attract an additional tax.

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uncertain, due to considerable variations in their menstrual cycles; this was largely due to women’s expectations that menstrual change would follow a clear trajectory, as described by health professionals, popular media, and other women (Lock 1986; Abernethy 1998; Gannon and Stevens 1998; Berg and Lipson 1999; Woods and Mitchell 1999). Before menopause, women assumed that the menopausal transition – from pre-menopause to post-menopause – would be straight-forward and clearly staged (see Figure 4.2). They expected that menstruation would be followed by a marked and recognisable period of menstrual change, followed by the end of menstruation. When this was not the case, women sought to develop alternative understandings of a menopausal trajectory, to match their own experiences. Their narratives indicate their difficulties in reconciling the predominant biomedical trajectory of menopause with their own experiences, particularly when characterized by high levels of menstrual irregularity and unpredictability:

I was still menstruating when I went on HRT.60 Fairly regularly but it might be once every six weeks or once a month… I just thought ‘what the hell’s going on? Here I am every month still getting my periods, although they might only last one or two days, they’re there,’ so I was confused. (Chappers, age 59)

At the time of our interview, about nine years had elapsed since her final period, yet

Chappers was clearly able to recall the confusion she experienced as her menstrual patterns changed and she approached menopause. Confusion often stemmed from women’s expectations: information they had obtained from doctors, lay health information sources

(such as in brochures or self-health books, for example: Cabot 1996), and popular women’s

60 Some women commence taking HRT before they cease menstruating. Women often reported an overlap between symptoms and menstruation, where the onset of disruptive symptoms occurred some time prior to their final period.

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magazines directly or indirectly led women to believe that menopause was a gradual process of menstrual change. For example, information from the Jean Hailes Foundation, a

Melbourne-based institute which provides menopause-related information and services to women, which many participants consulted about their menopausal health, states:

Menopause symptoms can begin gradually over two to six years before your last menstrual period. Perimenopause is the time when periods fluctuate until they stop. (Jean Hailes Foundation for Women's Health 2005b)

The lack of clarification over fluctuating contributed to women’s confusion about what to expect. Some women described being ‘caught out’ by unexpected menstruation, which affected them symbolically – making them concerned about soiling (as argued by Koutroulis

2001) – and in their social interactions:

[My doctor reduced my HRT dose]… I was flooding. Oh right, so very heavy? Once again, sleeping on a towel.61 With the flooding, would you know that you were going to start bleeding? You would know when you had. It would happen and you would know? It would happen, and you’d go, ‘oh, that doesn’t feel like normal,’ and I was constantly getting clothes in a mess. No white pants? No light coloured pants at that time, no. And it was just horrible. You tend to take a change of underwear with you in your bag. So that is really not anything to look forward to and I thought, ‘okay, I may as well rip the whole lot out [have a hysterectomy] because I’m not putting up with this’…

61 As she had done periodically throughout her menstrual life.

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[Reducing the HRT dose] seems to have worked, but whether that’s [the dose is] why I’m running out of puff now or because of [age]? I have heard women say that their last few periods, before it dwindles away, will be very heavy? Yeah, I know. The first [heavy] one was last August because it was when… I was staying at [my daughter’s] place. That [menstrual flooding] started then and I would have the most horrendous pains in the belly. I would be sitting there with a hot water bottle. You know, like when you first start your period and you get terrible cramps. (Ferdie, age 54)

In contrast to the notion of fluctuation, Ferdie had expected that her periods would gradually decline in regularity, duration and flow. She expected some irregularity in terms of when her period would come (thus, in terms of regularity), yet felt completely unprepared for the volume of blood that she lost. Some participants spoke about ‘flooding’ (heavy periods), some described ‘spotting’ (light or sporadic bleeding), and others, such as Ferdie, talked about both. Women’s expectations of a linear transition from regularly menstruating to no longer menstruating, as described by biomedical practitioners and literature, therefore were not reflected in their lived experiences.

Ferdie was not alone in feeling unprepared for these embodied changes. Many women described ‘stop-start’ experiences of menstrual change, whereby their periods would appear to stop – sometimes for several months – then starting again. These participants, who were still menstruating but had noticed cyclical changes at the time of our interview, described the unpredictability of their menstrual timing as a source of confusion:

I would just go to [my doctor] and say, ‘look, I think I have completely finished now because I haven’t had a period now for six months.’ Then the next day sometimes I would have another one. So that was a bit disconcerting because you never really quite knew [when to expect a period], although I could always feel myself that I was going to [menstruate]. Sometimes they

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would come for two days. Other times only one day and then other times they’d be like a whole period again… Last month, I thought that’s finally it and I went and had a smear test and whatever, and then the next day I had one. So maybe it’s still going on. So [my doctor] said it’s just going to be like that for a while and I can’t do anything about it… as I still keep having periods, I’m not really quite sure what is going to be coming up, because every time I think, ‘well that’s it,’ something else will happen. (Lesley, age 50)

During changes in menstrual cyclicity, women expressed hope that each menses was their last. Lesley was frustrated by the persistence of menstruation: each time she had a period, she thought it was the final one. Yet, as they continued to come (albeit lighter and less frequently), she described feeling disconcerted and hoped that she would get no more.

This was echoed by others: although she had been menstruating regularly only until her most recent period five months earlier, Biggs hoped that it was the final one:

Do you still get them [periods]? Not since Christmas. They have only just stopped then. I actually was regular till then. So that could have been the last one? Very hopefully!

Biggs’ expectation that the period five months previously was her final menses suggested that she understood menopause as following a biomedical trajectory, according to three distinct stages (peri-menopausal, menopausal, post-menopausal; Dudley et al. 1998). However, as discussed earlier in this chapter, this understanding of patterns or stages – often constructed as definitive and universal – is challenged by North American data which indicated that women’s self-reported menopausal transition often persists for considerably longer and has a much less uniform trajectory than biomedicine would suggest (Kaufert et al. 1987; Mansfield

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et al. 2004; Dillaway 2006). Similarly, Australian research (Garamszegi et al. 1998) has highlighted considerable disparities between women’s subjective assessments of their

menopausal status and biomedically-determined categorisations (see also: Matthews 1992;

McKinlay et al. 1992, 1996).

‘IT’S WARM IN HERE, ISN’T IT?’ MENOPAUSE AND BODILY SYMPTOMS

The importance of menopause in women’s understandings of midlife was mediated by their

symptom experiences. Their embodied experiences shaped their constructions of the

menopause: either as ‘a thing in itself’ (see Kaufert 1982), which extended over considerable

periods of time, or as a single bio-physiological event that had little impact on their wider

lives (refer to ibid., Ballard et al. 2001). Participants’ understandings were derived from other

women’s reporting of symptom experience, intensity, duration, and context. Women

perceived that their symptoms were due to subtle hormonal changes (see Figure 4.2) and

many relied upon biomedical knowledge to make sense of their bodily experiences and

manage their symptoms.

Population studies indicate that most women in Western societies experience some

physical and emotional symptoms during their menopausal transition (Woods and Mitchell

2005). Australian women report high levels of symptoms during menopause (Guthrie et al.

2004; Lee et al. 2004; McVeigh 2005), particularly when compared with women in other

countries (Fu et al. 2003; Anderson et al. 2004). Confusion persists around what bodily signs

are menopausal symptoms, and which derive from other factors. Some studies have

associated a broad range of symptoms with the menopausal transition (for example:

Nedstrand et al. 1996; Dennerstein et al. 2000; Guthrie et al. 2004; Im 2006). Table 4.2 is an

inventory of bodily signs and symptoms associated with the menopausal transition in

Australian (Dennerstein et al. 2000) and Canadian (Kaufert et al. 1988) women.

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Table 4.2: Commonly reported ‘menopausal’ symptoms (adapted from Kaufert et al. 1988; Dennerstein et al. 2000) Aches or stiff joints Dry nose or mouth Shortness of breath on exertion Backaches Forgetfulness Skin irritation (crawling/dryness) Bladder infections Headaches / migraines Sore throat Breast soreness / tenderness Hot flushes Swelling of body parts Chest pain on exertion Irritability Tingling in hands and feet Cold sweats Lack of energy Trouble sleeping Depression Loss of appetite Upset stomach Diarrhoea / constipation Nervous tension Urine control problems Difficulty concentrating Night sweats Vaginal discharge Discomfort on passing urine Persistent cough Vaginal dryness Dizzy spells Rapid heart beat Weight gain or loss (>3kg) Dry eyes Shortness of breath at rest

Epidemiological data suggests that very few of these symptoms are due to the menopausal transition and instead derive from concurrent biological, cultural, social, spiritual, cognitive, and psychological changes (McVeigh 2005; Woods and Mitchell 2005).

Although considerable research has indicated that only vasomotor symptoms (hot flushes or night sweats: Kaufert et al. 1988), their social sequelae (such as embarrassment or sleep disturbances: Woods and Mitchell 2005), and vaginal atrophy (pain during intercourse, vaginal dryness, or blood in vaginal discharge: Dennerstein et al. 2000) are related to menopause, no other symptoms have been conclusively associated with menopausal endocrine changes (Kronenberg 1994; Calvaresi and Bryan 2003). The aetiology and phenomenology of hot flushes is unknown and no association has been found between vasomotor symptoms and physiological pathways (Kronenberg 1994). For example, Xu and colleagues (2005) noted that women report increasing incidence and frequency of hot flushes as they proceed through the menopausal transition – peaking during early post-menopause

(Dennerstein et al. 2000; Woods and Mitchell 2005). However, they argued that explanatory models linking oestrogen deficiency with hot flushes do not explain why these symptoms are

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neither universal nor limited to menopausal women (Xu et al. 2005): hot flushes are reported

by men (who report much lower levels of related distress: Calvaresi and Bryan 2003) and pre-

menopausal women (6-13%: Woods and Mitchell 2005).

Anthropological studies have demonstrated that there are no universal menopausal

symptoms, and instead symptom experience is related to biological, environmental, and

cultural variables (Beyene 1986; Lock 1986; Martin et al. 1993; Chirawatkul and Manderson

1994; George 1996, 1998, 2001). For example, Beyene (1986, 1992) found that in cultural

groups where women’s ageing is not associated with a loss of status, women did not report

any menopausal symptoms. Lock’s (1986, 1988, 1991, 1994, 1998, 2001) comparative study

of menopause in Japanese, American, and Canadian women highlighted differences in the

prevalence and nature of actual symptoms: whilst hot flushes were commonly reported in the

North American sample, they were much less common in Japanese women, who tended to

report symptoms such as shoulder stiffness. Other research has highlighted differences in the

prevalence of menopausal symptoms depending upon country of birth or residence,

suggesting the importance of culture in symptom experience (Mishra et al. 2002; Anderson et

al. 2004). This was shown even in culturally-similar populations, such as Anglo-Australian62 and British women, who demonstrated markedly different symptoms. For example, Lee and colleagues (2004) found that women born and resident in Australia reported higher rates of heavy menstruation and hot flushes, and fewer headaches, aches and pains, or urinary incontinence than British-born women resident in either Australia or Britain.

These studies indicate that that most ‘menopausal’ symptoms result from life events related to social and cultural phenomena, such as the death of parents or spouse, or to changing social roles or positions. For example, although vaginal dryness and sexual

62 Many of whom were of British descent.

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dysfunction have been identified as menopausal symptoms (Woods and Mitchell 2005), they are also commonly associated with reduced sexual activity, which may follow from stress

(Pearce and Hawton 1996; Manderson 2005).

Menopausal symptom-reporting in Waterside

Women in Waterside were highly symptomatic, with one-third (33%) of participants reporting five or more core symptoms (refer to the list of symptoms in Table 4.2). Symptoms and number of symptoms varied by menopausal status (Table 4.3, below).63 These rates were not dissimilar to other Australian women: Dennerstein and colleagues (2000) found that between 22% (pre-menopausal and peri-menopausal) and 36% (post-menopausal) of urban

Victorian women reported five or more symptoms.

Table 4.3: Number of symptoms reported by participants (%)64

Number of symptoms Pre-menopausal Peri-menopausal Post-menopausal n=3 n=9 n=12 None 33% 0 0 1-2 33% 33% 25% 3-4 33% 22% 42% 5 or more 0 44% 33%

The symptoms were often mediated by factors relating to age and other health events. For example, the three pre-menopausal women experienced few symptoms, which were not specifically associated with the menopausal transition and may have been due to other factors. One, Nola, reported severe weight gain, fatigue and depression; however, as she was undergoing treatment for leukaemia (as discussed in Chapter 7), these symptoms may have related to her disease or treatment rather than menopause; in addition, she described a range of demands placed upon her by family and work:

63 Menopausal status in Table 4.2 is defined using biomedical definitions. 64 All % shown are rounded to the nearest decimal place.

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[From fieldnotes] Nola spoke of always being busy. She recently spent two weeks in Split Point [approximately nine hours drive away] with her daughter after the birth of her second grandchild in March, and then headed home. As soon as she arrived back in Waterside, Jamie [third child, early 20s] telephoned her, saying ‘you never come and visit me,’ so she went to visit him overnight in Pelican Point [two and a half hours drive away] and took him out to dinner and stocked his freezer with food, before heading home… Nola is always busy, running the office [for two businesses that she runs with her husband], working on the farm [beef cattle, 40 minutes drive away], and with her family… The farm is hard work and requires a lot of time, as the cows are calving at the moment. (Nola, age 41)

Given her health status and the demands of her roles as wife, mother and grandmother, it was unsurprising that Nola reported often feeling tired. She associated her weight gain with the leukaemia treatment, which had drained her energy for participating in exercise. Like

Nola, other women reported symptoms that might loosely be associated with their menopausal transition, but they often explained these in terms of social factors.

For the participants who underwent hysterectomy prior to menopause (Abbie,

Treasure, Cynthia and Lois), menopause was not associated with menstrual change; instead they determined when menopause occurred based upon bodily changes:

I felt that I was menopausal because I used to always get… cramps in the… ovaries. So I knew, because I’d lost the uterus but I was still getting the cramps in the ovaries, and [then] they’d stopped… (Abbie, age 54)

Thankfully I only had hot flushes, I didn’t have mood swings or anything like that… I had a hysterectomy when I was 40 and I never had menstruation, but I have the ovaries still… (Cynthia, age 50)

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Participants reported a range of symptoms, which varied in intensity and by the stage of the menopausal transition (Table 4.4);65 these reports indicated ‘ever had’ symptoms as opposed to currently experienced symptoms and thus both currently- and previously experienced symptoms are shown. The categorisation of symptom severity was an artefact of data analysis. Women did not describe their symptoms as severe, mild or moderate; instead they used descriptions about how disruptive or troublesome their symptoms were: ‘My skin used to crawl and I used to get itchy and get creepy crawly skin… That was a horrible symptom.’ (Aspidistra, age 57; symptom categorised as severe).

65 The three most commonly reported ‘symptoms’ – hot flushes, depression and weight gain – are shaded in the table.

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Table 4.4: Prevalence and severity of ‘menopausal’ symptoms reported by participants Symptom Mild Moderate Severe Symptom Mild Moderate Severe Menopausal status Menopausal status Dizzy spells 0 2 0 Hot flushes 6 4 5 Peri-menopausal 1 Peri-menopausal 3 1 2 Post-menopausal 1 Post-menopausal 3 3 3 Low energy 0 2 2 Night sweats 1 1 3 Peri-menopausal - 1 Peri-menopausal 1 - 3 Post-menopausal 2 1 Post-menopausal - 1 - Fatigue 0 1 4 Vaginal dryness 0 1 1 Pre-menopausal - 1 Peri-menopausal 1 - Peri-menopausal - 2 Post-menopausal - 1 Post-menopausal 1 1 Mood swings 2 0 3 Lowered libido 1 2 1 Peri-menopausal 1 1 Peri-menopausal - 2 - Post-menopausal 1 2 Post-menopausal 1 - 1 Depression 0 3 8 Weight gain 6 6 1 Pre-menopausal - 1 Pre-menopausal 1 - 1 Peri-menopausal 2 1 Peri-menopausal 3 4 - Post-menopausal 1 6 Post-menopausal 2 2 - Crying spells, ‘teary’ 1 0 1 Skin changes (elasticity) 0 3 3 Peri-menopausal 1 1 Peri-menopausal 2 2 Post-menopausal 1 1 Aches and pains 0 0 4 Allergies 0 0 5 Peri-menopausal 1 Peri-menopausal 3 Post-menopausal 3 Post-menopausal 2 Vagueness/memory loss 0 3 2 Crawling skin 0 0 2 Peri-menopausal - 1 Peri-menopausal 1 Post-menopausal 3 1 Post-menopausal 1 Heavy bleeding 0 2 3 Peri-menopausal 1 1 Post-menopausal 1 2

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Participants did not report many symptoms associated with the menopause in other studies

(shown in Table 2.1. See Kaufert and Syrotuik 1981, 1988; Dennerstein et al. 1993, 2000;

Avis et al. 2001; Hardy and Kuh 2002; Mishra et al. 2002; Anderson et al. 2004; Lee et al.

2004; Travers et al. 2005; Woods and Mitchell 2005), such as headaches, shortness of breath, tingling extremities, coughs or sore throats, diarrhoea or constipation, or appetite changes.

This is likely a methodological artefact, as I did not use a symptom checklist (such as those described Punyahotra et al. 1997; Dennerstein et al. 2000; Calvaresi and Bryan 2003; Im

2006) and instead relied upon participants’ descriptions of factors that they considered impacted upon their midlife experience.

Patterns of symptom reporting may reflect participants’ difficulty in knowing the causes of their bodily signs. Some women may have attributed symptoms (e.g. mood swings, weight gain) that were caused by their other health problems (e.g. thyroid dysfunction) to menopause (discussed in Chapter 6). These findings highlighted the influence of cultural understandings about menopause on the women’s interpretation of symptoms (Berger 1999).

For example, in Anglo-Australian culture, headaches, coughs, sore throats or shortness of breath are (generally) not constructed as menopause-related, and instead they are often attributed to a head cold or other infection. Women’s understanding that allergies were related to their menopausal transition was surprising, however, as allergies are not commonly culturally constructed as related to menopause.

Participants often situated their symptom experience within a particular social context – thereby providing their own explanatory model for their bodily signs. This was the case for the three most commonly reported symptoms: hot flushes (reported by 15 of 24 participants) and night sweats (6 participants), weight gain (13 participants), and depression

(11 participants).

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‘It’s warm in here, isn’t it?’ Vasomotor symptoms

In his investigation into the phenomenology of hot flushes, Kronenberg (1994; supported by work by Freedman 2001; 2005) suggested that flushes did not result from physiological events alone, but rather comprised of somatic and psychological domains, which vary between individual women. Although it is most often considered as a single bodily sign, a hot flush may involve a range of bodily sensations, including sweating, flushing, and changes in heart beat (ibid.). Given these multiple bodily events and their social, cultural and individual variations, I was interested to explore how women in Waterside described their experiences of hot flushes. Hot flushes and their nocturnal equivalent, night sweats, were the most common symptoms reported by women in the study – nearly two-thirds (15 of 24) of participants experienced hot flushes at some point during midlife; six of these women also experienced night sweats. Hot flushes were disruptive or upsetting for most (nine) of the fifteen women who reported them.

Women understood hot flushes as being the most recognisable sign of whether they were menopausal or not; in addition, the difficulty of their transition was judged in terms of the disruption or discomfort caused by their flushes. Ferdie described how her first experience of hot flushes (in her mid forties) led to her doctor’s realisation that she was menopausal:

I have a friend who is a doctor. I remember one time we were out [boating] on the lake here. I have always been a ‘cold frog’ but everyone on the boat was pulling on jumpers and I was in a t-shirt, so I thought they’re playing tricks on me. I said, ‘it’s warm in here, isn’t it?’ [My friend] leaned forward and said, ‘no, it’s not, but we can fix that up.’ Then we were around at their place one time… there was a whole crowd of people there and I was just sitting there and I started to have a hot flush. So I melted into the background and just sat there, dripping wet. And [my friend] very quietly got up and went away and came back in with a fan and sat it down in front of

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me, and he said, ‘I think you [had] better come and see me.’ So I went to see him and he took blood tests and I was [peri]menopausal at the time. (Ferdie, age 54)

She found that the hot flushes became more intense and problematic as she progressed through her menopausal transition; she used HRT to regain some control over her bodily symptoms and as a way of minimising the disruptions they caused:

Can you describe a hot flush? A hot flush? Well everything is going along quite normally and then suddenly. It’s not that it comes from your feet because it doesn’t. It sort of starts about your chest and then you just feel it seep up and it’s just hot – hot, hot, and you drip. I don’t have very thick hair, as you know, and I get all this wet hair around the back. It’s just horrible and it lasts for generally just a couple of minutes then it goes again. Does that happen regularly? Not so much now that I’m on my little [hormone] patches, but it used to. I still get them in the night. You wake up and you’re just wet. Last Christmas, not this summer but the one before, I was sleeping on a towel most nights; otherwise I would have to change the sheets every other day. It is just horrible. (Ferdie, age 54)

Hot flushes were the major cause of distress for participants and the predominant reason why women sought medical assistance with symptom management, which often involved using hormone replacement therapy (HRT), as Ferdie described. Several women explained that they had been concerned by the findings of the Women’s Health Initiative trial

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(Wassertheil et al. 2003)66 and had addressed these concerns with their doctor; as they were taking the HRT for treatment of symptoms and not for long-term bodily management, they were reassured that their risk of a cardiovascular event or stroke was minimal and thus continued to use it. For these women, the disruptions posed by symptoms were more troublesome than their extremely low risk of an adverse health event. The benefits of HRT

were echoed by other women who reported highly disruptive (‘severe’) hot flushes:

[Going on HRT] was truly miraculous because literally within a week of starting the things, I stopped having hot flushes and just felt a lot more energetic and revived. So that was absolutely terrific. The best thing since sliced bread. I’ve had a couple of adjustments along the way but it was just like it was a miracle! … [Before HRT], nights, sleeping was hell. I’d have very broken sleeps because you know, you’d go to bed and you’d feel okay and then you’d wake up in the middle of the night just absolutely boiling, so you’d fling all of the covers off and you’d just be hot and sweaty all over, so [you would] flap the sheets up and down, or the doona, then put them all on again and then drift off to sleep. Then it would be like that all night. I’d wake up in the morning absolutely buggered [exhausted] because I hadn’t had a proper rest. During the day wasn’t quite so bad, but I can remember my kids being down here with some of their friends, we’d all be sitting around the dinner table and suddenly I’d feel this heat, the temperatures rising, you know? My sons’ pals would go [say], ‘here she goes again,’ and pick up a piece of paper and sort of flap it at me. And you really feel that you look peculiar, that you must be going brick red, but you’re not. It just makes you feel hot and sort of sweaty, I suppose. (Chappers, age 59)

I don’t have periods anymore but I am still getting the hot flushes… the reason I decided to go on it [HRT] was because I was working at the time. I

66 Most participants who took HRT were interviewed before the results of the WHI trial were released, with the exception of Lois. During informal discussions, all participants who took HRT explained that they had discussed it with their doctor and been reassured of its safety for them.

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was working and I was still having these horrible symptoms and it was very embarrassing, being at work and breaking out in sweats, especially when you are at the counter [reception]… This one day it just got the better of me and I said [to my doctor], ‘could he have a look at me? I can’t stand it any longer.’ And he said, ‘you will just have to go on HRT,’ and I have been on it virtually ever since. I stopped about 4 months ago thinking I could cope with one of these herbal remedies that are available over the counter, but anyway I have decided now that I am still too uncomfortable… so I am going to see the doctor again and get another lot of HRT. (Aspidistra, age 57)

Hot flushes left women feeling embarrassed or uncomfortable, significantly impacting on their social interactions. This social disruption was the primary reason for women’s decision to use HRT, as indicated by Aspidistra: once she retired, she ceased taking HRT in favour of over-the-counter herbal remedies to manage her hot flushes – suggesting the social embarrassment related to hot flushes while she was still working. However, due to the extreme discomfort she experienced since, Aspidistra decided to recommence taking HRT.

Data suggested that women sought HRT for hot flushes based upon a hierarchy of reasons, whereby social considerations were privileged over bodily discomforts.

Although women emphasised social more than individual impacts in their experiences of hot flush-derived distress, bodily discomfort was also important. In particular, the post-menopausal participants often described experiencing vasomotor symptoms for considerable time after their last menstruation and many reported that the symptoms became worse over time. Thus, the end of hot flushes signified the end of the menopausal transition.

Chappers described how she recently realised that her menopausal transition was over because when she stopped taking HRT, she no longer had hot flushes:

I went off the HRT a few months ago… I was away and I forgot to take my script [prescription] with me, so therefore I couldn’t do anything about it,

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apart from go off to a doctor. And I thought, ‘well I’ll just see how I get on.’ I had stopped [HRT] once before, because I forgot to fill in my script, and after about six weeks, I immediately started having hot flushes again, so that would have been about seven years ago; but this time nothing. (Chappers, age 59)

Not all participants perceived their vasomotor symptoms as troublesome or problematic.

Some women felt that symptoms could be explained by factors other than menopause. For

example, Biggs described experiencing night sweats during warm weather – which she

attributed to menopause – yet which only occurred under specific conditions, instead

suggesting that her symptoms may have been due to environmental factors and, thus, were

not menopausal:

Occasionally I will get a hot sweat in bed at night, but normally it’s a hot night and I still have a doona [on the bed]. We have the electric blanket on, even in summer, before going to bed, and I have the fire going… it normally wakes me up. Normally, I’m in bed asleep and I’ll sort of wake up, and I’ll feel a bit thirsty… I have a glass [of water] by my bed. Then I just have a glass of water and turn over... so I don’t know how it starts. I just feel a bit hot... It wakes me up. I’d say that’s what wakes me up. I just feel a bit hot and then I kick my legs out and have a glass of water. And then I’m cooled down and I’ve snuggled back up. (Biggs, age 53)

Other women similarly described their hot flushes occurring within a context where they were feeling physically hot. They described how their bodies, which had previously been very affected by the cold, reacted to external heat by producing internal heat, tying their bodily

changes to the characteristics of their physical environments:

[From fieldnotes] Musical’s hot flushes were quite horrific: every time her body would get hot, she would have a flush. It would start from around her

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waist, or just below her breasts, and move up towards her head. This happened every time she got warm – if she was cooking tea, having the combustion stove going or having her hands in hot water – so every time she got warm, she would have a flush. (Musical, age 55)

Other women related their experience of hot flushes to social factors. Sam attributed her nightly hot flushes to a combination of her husband’s bodily heat and the outside air temperature, rather than to her physiological changes:

When I turned fifty, I was in Queensland. I couldn’t actually tell if I was having hot flushes or whether it was the temperature in Queensland. And, as some people who are married know, men seem to generate a lot of heat, so what with the temperature in Queensland and the hot body man laying in bed with me, I wasn’t sure if it was me or him! So I don’t think I really suffered hot flushes. Well, it never got to the stage where I needed to go and get medicine. (Sam, age 56)

Sam also believed that she felt the heat more in Queensland – and thus had hot flushes at night (as opposed to night sweats) because she had moved from Victoria, where the weather was much cooler:

After coming from Victoria and going to Queensland… it was great because in Queensland, we [had] always worn pyjamas [in Victoria] and [in Queensland] you took your pyjamas off. So I do remember getting out of bed and throwing the mattress on the floor trying to get cool and everything, and I think the hot flushes weren’t a problem. (Sam, age 56)

Women’s explanatory models of hot flushes therefore drew on a range of factors: some women understood their experience of vasomotor symptoms in relation to hormonal explanations (thus, the biomedical model) and their management of these symptoms relied

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upon HRT. Hot flushes caused varying levels of distress and impact upon women’s lives:

social interactions with family, work colleagues and clients, and wider social networks. Yet no

universal explanation or impact was seen in women’s stories: some drew upon the physical or

geographical environment whilst others viewed flushes as relating to internal factors.

Gaining weight

Weight gain is not an uncommon phenomenon in midlife women: Brown and colleagues

(2005) found that Australian mid-aged women gained approximately 0.5 kg yearly – which

equated to around 2.42kg over five years. Research has suggested that body weight increases

occur relative to chronological age and not to menopausal physiological changes – the most

rapid rates of weight gain occur during women’s late reproductive years (Sammel et al. 2003).

In my study, most participants reported some weight gain, which they explained as an expected – although undesired – part of their ageing process. Although co-occurrent with

menopause, women associated their increasing weight not to hormonal changes, but to age and to changing social roles. For example, Iris believed that her weight gain was related to

physical activity: as she got older and her children became more independent, she became

less physically active and thus put on weight:

I think [my body] getting wider has, it has made me much more wanting to cover myself up, and wear clothes that don’t accentuate it... I really should do more exercise, the exercise bit [of weight loss] is what I am not doing… When you are young, you don’t tend to put on weight as easily, I don’t think. When I ran around after the kids when the kids were little, I [was much slimmer] and I guess when you get to middle age, you don’t burn up energy as much, then you start stacking it on [gaining weight]. (Iris, age 50)

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Like Iris, other participants emphasised their physical fitness, or lack, in discussing their body shape changes, and explained their lack of participation in exercise to do with their lower energy levels – which they associated with ageing:

I have nothing to complain about, except getting older and finding it harder to do things, because I don’t have the steam [stamina] that I used to have. But I’m not alone in that area. I think when you’re younger, you’ve got a lot more drive and a lot more energy. So I can still do most things, but I find that if I do a massive stint in the garden, after ploughing along for a couple of hours, I need to sit down for a little while, whereas 20 years ago, I would have just kept on going. (Chappers, age 59)

Bodily symptoms also contributed to lower energy levels. Specifically, women who described vasomotor symptoms perceived them as contributing to their weight gain because they resulted in high levels of fatigue:

I virtually had to give up work and everything because I was getting so tired… [All night I was] up and down, and you are not sleeping properly, and I think the sweating. Because you are constantly drinking and sweating, I was getting really tired. (Cynthia, age 50)

Although women anticipated weight gain as part of ageing, many found it difficult to come to terms with their changed body shape and described how it persisted despite their often futile efforts. For example, although Aspidistra walked daily, she continued to gain weight, and so sought to focus more on her body’s capabilities (‘everything works’):

Oh I am not happy about the body changes, I hate the extra weight. I hate it, but you know I’m alive, ain’t I? And everything works, so you have to be happy and grateful for what you have got. You seem to take lots of exercise?

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It doesn’t help. It doesn’t help with the weight much at all. So yes, I think as long as we can keep doing things, you keep doing them. I can’t be worried about the weight. (Aspidistra, age 57)

[From fieldnotes] Jasmine has gained some weight as she’s gotten older (she’s still quite slim) but ultimately likes and respects her body as it is strong and reliable, and she can still do all that she wants to. (Jasmine, age 52)

Women’s stories reflected their acceptance of midlife weight gain as part and parcel of their ageing. Few participants were obese; those who were also reported serious health problems (see Chapter 7) which had contributed to their weight gain. In addition, 6 of the 13 women who reported weight gain also described psychological symptoms (feeling teary or depressed): although they did not themselves make the link, associations have been found between depression and weight gain during midlife (Sammel et al. 2003). In the following section, I discuss women’s mental health experiences.

‘Highs and lows’

Current or previous episodes of depression were reported by eleven women (almost half of the sample). Many women (n=8) described incredibly difficult periods of time; as a result, they were categorised as experiencing ‘severe’ depression. A further three participants experienced less intense periods of depression, which I called ‘moderate’. Social factors, particularly relationships with partners, played a central role in women’s experience of depression and data indicated that, where women had low accessibility to social capital, they were more likely to report feeling depressed. For example, Sam described feeling alone within the community and having little family support as major factors contributing to her depression:

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I think the thing that affected me more [than any other symptom]… is depression, highs and lows, you know, and learning to cope with that. I never took any medication to take with that, I just thought that it was something that you just you know had to get over yourself… I can remember when I came back to Waterside [having left about 15 years previously] and I was 53, you know, and some of these [business owners in the community] had said things to me and I just burst out into tears. And one day I was in the supermarket, and these ladies were in their little group and they weren’t talking to me. And I was feeling as if, you know, why can’t I break in on the scene? And by the time I had got to the check out, the tears were just rolling down my face, and I thought, ‘I’ve just got to get out of here.’ I’m a pretty bubbly person, so you have got no control over these emotions. So I think the emotions were to me a bigger concern than [hot flushes], and the problem with the emotions was that the family [of hers] didn’t want to know about it, the husband didn’t want to know about it, you know. So there was no family support. (Sam, age 56)

Sam’s example indicated that having family is not important in itself; as she was married with three children, it was the quality of the support that was more important. Musical related her experience of extreme mood swings and depression to social factors and described how her relationship with her partner played a key role in her experience of psychological symptoms.

In particular, she highlighted that her responses to his behaviours, where she felt resentful at being responsible for the day-to-day household and family management, informed her negative feelings:

Wally [husband, pseudonym] was an alcoholic and so we had that to work through… That wasn’t easy. Wally was drinking heaps and the girls, life was just crazy. And again, even within the situation, I was isolated and lonely and feeling abandoned, all that sort of stuff. Um, but so I took a job, I started work, so that I would have a legitimate out sometimes and also generate a little bit of income that I could call my own, so I felt like I had a bit of

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choice… And ah, when life descended into chaos due to drinking or hangovers or whatever… and I was trying to raise children and keep the game high and things kept descending into chaos, and I hated that. It wasn’t the people [husband and his friends] I hated at all, it was just the way the situation was. I was always left behind, like they could always do what they wanted to because they were free. I had children to look after, to get to bed, to clean, all that sort of stuff. So it was a very, very difficult time. But it was lonely because even though there were people around, I would never be part of it because I had these young children to raise and I couldn’t smoke anything I wanted, and drink anything I pleased, and stay up until 6 in the morning like everybody else used to, you know. That was very, very difficult. I got ugly and resentful and ah, verbally very abusive and scathing and I could feel myself descending into this horrible place. (Musical, age 55)

For some women, family did not alleviate their depression or enhance their mental health;

instead, it was a source of stress, contributing to the challenges posed by depression. Women who did not report depression also did not describe family troubles or feeling unsupported by their families, suggesting that family-based stress may play a role in women’s experience of depression (at least during the menopausal transition). For example, Jasmine described her relationships with her partner and children as very strong and explained that she felt strongly connected to specific community groups despite not feeling comfortable in large group settings; she reported very few of the common ‘menopausal’ symptoms. Although her symptom experience may or may not be related to her available social supports, recent research by Blumel and colleagues (2004) found that family problems exacerbate women’s experience of menopausal symptoms, supporting my argument that, whilst not the cause, lack of familial support contributes to the experience of symptoms.

Social supports did not only come from the family: feelings of belonging in the community were important to many women in my study. Like Sam, those who felt as though

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they did not ‘fit in’ to the community or did not ‘belong’ to any groups – and thus who did not have access to community-based social support (that is, outside of the family) – described feelings of depression. For example, Hattie, who did not have any family nearby, explained that her experience of depression derived from feeling as though she did not have any important, close social ties:

I [have] become even more aware than usual of my social isolation. I was just thinking, in these last actual couple of weeks, I was thinking, ‘uhuh,’ and I thought, ‘yeah, I’m feeling depressed.’ I wasn’t just feeling sad, I was feeling depressed and I thought, ‘ah, ok, what is this about?’ And I thought, I know what this is about, it’s the start of winter and I’m seeing everyone around me with families knowing that there is no one in the world for who I am any more than the fourth priority in their life if something is wrong and I really need help. And there’s nobody else in the world for whom sharing my good times is any more than their fourth priority either. And that’s really, that is a real feeling of loneliness and isolation. You see, before, I used to think, ‘that’s alright, because eventually this will change.’ But now, for the last couple of weeks, I’m thinking, ‘well, I’m 50, I’m 50 and it hasn’t changed…’ (Hattie, age 50)

Involvement in work was also a factor. Daphne described how, after her work contract ended, she became depressed:

I have recently had a big long period of really bad depression and I don’t usually get depressed. [It’s lasted for] sort of about six months I think. When my job finished, I loved doing that. I loved the [computer] job, it was great fun. That project finished and sort of it was like [nothing]. I love teaching people one-to-one. I just get such a buzz out of it. We used to run… a monthly free internet [service] in Drummer [a small settlement about 45 minutes drive away]. It was lovely meeting all those people and they are so different… It was great fun and they were just getting so much out of it, and they were lovely. You know, they did a lovely tribute when we finished and

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they were really grateful for it. So that was nice but when I finished that and I really pushed myself into [a community arts] job… [but] I didn’t really want to do it, I didn’t really want to be involved in the [arts events] this year, and I got so depressed. (Daphne, age 59)

Daphne’s depression was partly related to her financial situation – which prompted her to seek another, less desirable job (in community arts) – and partly due to changes in her work situation, from a position she enjoyed and in which she felt valued in, to one that she found stressful and much less personally rewarding.

Skultans (1970) argued that women’s experience of menopause was predominantly one where they were trying to make sense of changes in social roles. This argument is supported by my data. As the excerpts above illustrate, changes in family, work and social participation impacted upon women’s mental health. Midlife was a time of life when changes in these three domains occurred concurrently, which, for some women, resulted in feelings of depression, uncertainty and low self-esteem. For example, Mac described great feelings of anxiety and depression after living through a dramatic life change. At the time of our interview, her husband had recently left her with serious debts after their business failed, including many that she was unaware of, and she had neither employment nor ongoing accommodation:

I actually had a situation where Don [husband, pseudonym] had gone, the shop was gone, people needed to be paid and I didn’t know what was happening in town [with husband’s debts] but I was beginning to understand. I had the kids and I was in the units [that she owned]. I thought I’d stay and work on them, because we were going to change [renovate] them. They weren’t ours in the end. [When I found that out,] I just sat there and you could almost feel the downhill slide and its okay to go mad. That was definitely one of those times. And the kids were hungry, so I had to keep

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moving. I had to provide something. I had to feed them… I was in such a state of shock. I didn’t know what to do. Then I felt I shouldn’t be here, I knew I was panicking, and I found out about it when they had gone and it was a shock. It still amazes me. I still get the shivers now. Such a horrible time, [now] every time I think I can’t cope with anything, I think, ‘yeah I did…’ I was under a huge pile, I was in the middle. Yeah it was, bloody incredible. I was in a huge tangle of wool that was all knotted and I am in the middle with the kids and whatever remained financially from years of work… It wasn’t just the outside public things of paying bills… It was also the internal things that I had to ask for help, because I had to get out of the units… I was in such a dead hole. (Mac, age 47)

Being deserted and left with huge financial burdens led Mac to become depressed and experience feelings of low self-esteem and worth. Like other midlife women, Mac’s emotional state was less to do with her changing hormonal profile and much more to do with wider changes in the social domains of her life.

Marking the boundaries of menopause

Symptom experience was an important factor when women were assessing whether they were ‘not yet’ at menopause, ‘menopausal’ (by which they meant peri-menopausal), or ‘post- menopausal’. This had implications when they were locating themselves in relation to the menopausal transition. Menopause began much earlier in the life course than these models suggest: women did not determine menopausal onset on the basis of reproductive or menstrual changes. Instead they described subtle hormonal changes occurring during their late thirties and early forties which triggered the onset of menopausal symptoms. For example, Aspidistra noticed psychological symptoms that appeared several years before the onset of physical symptoms, and preceded the cessation of her menses; for her and other

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women, changes began not long after the births of their youngest children, in their late thirties:

When I was 36, I think my hormones really started changing at that point in time. I would say that to the doctors and they would say, ‘don’t be silly you are too young.’ I really feel that there was a change from there on, whether the pregnancy did it or not. (Aspidistra, age 57)

She linked these early hormonal changes to the emotional symptoms that she experienced throughout her menopausal transition:

It has been quite difficult. I have had quite a lot of emotional problems with menopause [since then]. (Aspidistra, age 57)

Musical also believed that her menopausal symptoms started when she was still menstruating regularly, soon after the birth of her last child, and continued until long after she ceased menstruating. She noticed that her mood swings were related to her menstrual cycle and, as a result, she believed that signified the onset of her menopausal transition:

There was a cycle. We used to argue a lot… I was always the provoker, always. It was a fortnightly thing. So it was menstrual and ovulating time… I was not aware at all of anything to do with ovulation until that time… I would have been late 30s then, and [then] it wasn’t til I got onto HRT [that I realised what was happening]… Wally [husband] didn’t know how to handle me and the moods. You didn’t know that it was menstrual or menopausal related? No… But it most definitely was. And it was a real thunderclap when I realised that... Even when it was happening, I can remember thinking, this happens about every 2 weeks, but it didn’t correlate. I wasn’t putting it down to [menstruation or menopause] then, but it was definitely that. So that’s why I think that the menopausal stuff was actually happening, or changes were

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happening, long before when I was having hot flushes at 42. That’s when I started to take notice of the physical. (Musical, age 55)

Similar trends appeared when discussing the end of menopause with participants.

The final menses was not constructed as the onset of post-menopause; instead, women considered themselves as continuing to be ‘menopausal,’ to some degree, until most of their physical symptoms ceased. Women associated symptoms such as vaginal dryness or low libido with ageing and, as a result, they did not describe them as related to menopause. When defined by women, menopause therefore ended much later than either the biomedical or feminist/empowerment models indicate, as several participants experienced bodily symptoms for some years after their final menstrual period. Some of these women found that menopausal symptoms that were mild or moderate before the actual event of menopause

(the final menstrual period) started to get worse when they were clinically considered post- menopausal. Hattie, who went through menopause (determined by hormone tests) at 41, had few symptoms around the time of her actual menopause:

I didn’t realise I was going through menopause because… the symptoms of menopause are also symptoms [generally feeling unwell, headaches, fatigue and associated low energy levels] that I get when I’m being allergic to something. (Hattie, age 50) 67

However, after four years of total amenorrhoea, Hattie began to experience heavy bleeding, which doctors explained in terms of her hormonal profile (thus, as related to menopause):

After about four years… I started doing this weird bleeding, you know, just, a bit of bleeding… for about two or three weeks or four weeks, on and off…

67 Hattie’s allergies are discussed in greater detail in Chapter 6.

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By the time of our interview, nine years after being diagnosed as post-menopausal, Hattie

was experiencing very heavy bleeding,68 which she related to menopause and which placed

severe limitations upon all aspects of her life:

I’ve had bleeding… and I mean that has ripples through all sorts of bits of your life, in terms of inconvenience and relationship things, fatigue and whatever… I’ve had an experience of anaemia... the fatigue that you have from anaemia and low iron is intense, it is disabling. That has had ripples right through my relationships, through my life, including in relationships because it so governs what I can or can’t do, what commitments I keep, even just daily… I had to lie down for 80% of the time… my house, and basic self-looking-after, turned into chaos because I was so exhausted. And I found that very frustrating… I was doing very heavy bleeding. I was very tired but I mean it was like, I could just feel it, like a waterfall. I mean, it was incredible stuff.

Many doctors give women approaching menopause blood tests to evaluate their hormone

levels69 and menopausal status. On the basis of such tests, Hattie’s doctor diagnosed her as

post-menopausal. However, she continued to define herself as being menopausal based upon

her on-going experience of bleeding. Clinical markers, such as the hormones measured in

blood tests, are therefore imprecise in defining the end of menopause.

These boundaries become even more blurred by the use of hormone replacement

therapies (HRT) which, by stopping many symptoms, seemingly ended peri-menopausal

problems. However, women in my study found that this was only the case whilst HRT was

68 Post-menopausal bleeding is relatively common among women (Wagman 1988), particularly those who take HRT (Karakoc and Erenus 1998). It is not always associated with pathology; however, in just under 50% of cases, post-menopausal bleeding is associated with endometrial cancer (Schindler and Schmidt 1980). In Hattie’s case, it was associated with hormone levels (discussed elsewhere in thesis). 69 Guthrie and colleagues (2004) found that hormone profile changes during the menopausal transition: post- menopause is diagnosed on the basis of FSH (follicle stimulating hormone, which increases during perimenopause), decreased oestradiol and increased testosterone levels.

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being used regularly. Ash, who was 60 at the time of our interview, described continuing to experience hot flushes when she stopped taking HRT, even though she last had a period when she was about 50:

[I was] developing hot flushes, so I was put on the hormone replacement when I was probably about 49 as a trial to see how that would go. How long ago was that…? Ten years now. So it’s been a long period? It’s been a long period on the hormone replacement. I went off it a few weeks ago and I had to go back on it because I was having terrible hot flushes again and life was just miserable. (Ash, age 60)

Despite the suggestions in books, magazines, and brochures therefore that perimenopause is a relatively brief life phase, women in Waterside expected and experienced otherwise. Based on observations of older women – mothers, aunts, sisters, friends – they assumed that symptoms would continue over an extended period. For example, Cynthia had had hot flushes since she was 40, yet did not perceive this as particularly long or excessive:

On my dad’s side of the family, his sisters and his mother started [to have hot flushes] around 40 as well. [Now] my aunty is in her 80s, and my grandmother was 90 odd when she died, and they still had hot flushes… [and] my mum suffered a lot with mood swings with menopause… she was 30 by the time she had me, … so I was only 12 when she thought she was going through menopause. It was extremely difficult and I was ever so grateful [that I didn’t have an experience like hers], I did not want to have that. I don’t know whether that was menopause with mum, because [she] was

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68 when she passed away and she was still getting the odd period,70 so I don’t know. So those kinds of menopausal symptoms went for a long time [for your mother]? Yes, a very long time. (Cynthia, age 50)

However, not all women viewed menopause as a long-term process of change. A minority of participants viewed it as the menopause – a brief, distinct event from which they had moved, or would move on. Typically, these women experienced few mild to moderately intense symptoms, which persisted for only a short period of time. For example, Grace’s last menses occurred more than a year before our interview, since which time she had experienced only a few, mild hot flushes. She already regarded menopause as an event that was in the past:

I’ve been through menopause, it’s all happened and it’s been very easy. It’s [period] all just disappeared and I’ve sailed through the physical stuff of it very easily. I haven’t had any, I’ve probably had some of those physical things like hot flushes but very few of them. And then, just nothing. It’s all just gone 'ta ta' [‘goodbye’]! (Grace, age 50)

She experienced menopause as the end of menstruation; any symptoms she had were largely forgettable (‘I’ve probably had…’) and these did not cause her a great deal of distress or concern. This was particularly true for women who were peri-menopausal: Biggs, who had not menstruated for about six months, described how she experienced very few symptoms:

Occasionally I will get a hot sweat… [Vaginal] dryness, I have had none at all. No changes sexually or anything like that at all. I know some of the symptoms… I have been really lucky. (Biggs, age 53)

70 This may have been pathological, e.g. endometrial cancer (Schindler and Schmidt 1980, Wagman 1988).

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Despite continuing to menstruate (within the last three months), Maude believed that menopause had already occurred: ‘when it all [menopause] happened.’ Based on her own experiences, she constructed the menopausal transition as consisting of a few, easily resolved, difficulties:

I’ve been really lucky with menopause, incredibly lucky because apart from the occasional hot flush, I haven’t really had any [symptoms]… I haven’t had anything else, you know, it’s been really good. That’s been fantastic. (Maude, age 50)

Reproduction has a pivotal role in women’s understandings of the life cycle (see

Brown 1982; Hubbard 1990; Gifford 1994; Albury 1999; Martin 2001), within which menopause indicates the absolute end of fecundity and fertility (Kaufert 1982:145). The women in my study had all ended reproduction voluntarily some years prior to their actual menopause, or, in the case of three participants, have not commenced at all. They therefore perceived being fertile as a nuisance or a restriction, and spoke of being restrained by their monthly periods, contraception, and family rearing duties.

Menstrual history, itself a component of reproductive history, was integral to definitions of menopause, and participants used multiple benchmarks in constructing these definitions, combining chronological age, physiological changes, bodily events, and menstrual factors. As illustrated, women both employed and challenged the popular cultural understandings of menopause as a synecdoche for midlife. Participants defined midlife as relative to their menopausal status. However, narratives around women’s menopausal transition did not dominate their midlife stories. Instead, menopause occupied a distinct place within their narratives, yet was distinguished from the entirety of midlife, which they related to social and familial relationships, employment, and community involvement. In

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accordance with Ballard and colleagues’ (2001) findings, for participants in my study, menopause was one of many concurrent life transitions: women did not necessarily associate ageing with their menopausal transition, as the social context, non-menopausal health events and bodily changes were significant in women’s understandings of midlife and growing older.

Sherman (1994) argued that the most common reason for people’s sense of their own ageing related to changes in health status. As I will discuss in the following chapters, health was an important marker underlying women’s understandings of midlife and the life course.

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Chapter 5

The Body-Self Working Together: Maintaining and

Contemplating Narrative Strategies

“I’m a middle-aged high school dropout with stretch marks and a droopy ass.” Paulette Bonafonté, Legally Blonde (2001)

Distinguishing between the body and self, whilst also speaking about their embodied midlife experiences, was characteristic of the narrative strategies used by women who had few or no problematic bodily events. Women who employed a Maintaining or Contemplating narrative strategy emphasised either their body or their self as the primary object of their stories, although they drew links between the two. In many ways, both narrative strategies responded to wide-spread images of ageing women which, as reflected in the above quote from a recent popular film, are often negative. However, what distinguished each of these narrative types was the ideological response of the narrator to such images, which was inherent throughout the stories. Women who used the Maintaining narratives accommodated these negative images in their stories as the undesired outcome that they actively sought to avoid. Those who used Contemplating narrative strategies tended to be more subtle in their responses to negative images of women’s ageing. In their narratives, they demonstrated their active resistance of notions of decline and decay. They emphasised the positive aspects of ageing, framing these within a discourse of personal growth and liberation, while simultaneously downplaying the role of the body in their stories.

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These narrative strategies were not primarily concerned with the problematic body,

yet themes of bodily disruption or bodily betrayal underlay many of the stories women told.

Specifically, women who used Maintaining narrative strategies emphasised their concerns

about ending up having a f/ailing body in the course of ageing – throughout their stories, they explained their body (and therefore, health) maintenance in terms of warding off bodily

failure. Their narratives indicated that they believed that ageing was marked by ailments or

infirmity, which the narrators actively sought to avoid. I use the term ‘f/ailing’ in order to

encapsulate both the medical and social constructions of illness: in examples where they

became ill, they were ‘ailing’; this was understood by women who told Maintaining narratives

in terms of bodily failure – hence f/ailing. In contrast, women who used Contemplating

narrative strategies highlighted their encounters with other f/ailing bodies and how these

interactions had impacted upon the narrator’s life, personal growth, and levels of social

participation (their inclusion or, in one case, exclusion).

MAINTAINING NARRATIVES: RESPONDING TO IMAGES OF AGEING

Few participants enjoyed health status completely free of disease or health problems—yet

concerns about future infirmity shaped their midlife health behaviours and influenced the

ways in which women who used Maintaining narratives cared for their bodies. Their health

problems and concerns were often minor and, whilst they impacted upon the Maintaining

lifestyle, they did not lead to widespread life disruptions or changes in their health

management activities and behaviours. These women viewed menopause as a natural part of

life and therefore it was not described as problematic. This did not mean that the participants

who told narratives about their bodily maintenance had no peri-menopausal symptoms; in

fact, many of these women experienced hot flushes. However, compared with their peers,

they tended to feel that their symptoms were of little significance.

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Participants who used Maintaining narrative strategies tended to have concerns derived from bodily changes, which they associated with ageing, but not necessarily connected with menopause. Many women who used these narratives embodied images equating ageing with decline. Their stories echoed Feldman and Poole’s (1999) argument that society is less understanding of the physical implications of women’s ageing, particularly in relation to their physical appearance. Through their bodily maintenance practices, women who used Maintaining narratives were embodying social expectations about ageing; Öberg and Tornstam (1999) argued that negative (‘gerontophobic’) images of ageing are largely targeted at women, who are then socially pressured and compelled to maintain a ‘youthful’ body. Underlying such images, they argued (ibid.:629), are certain expectations and dictates about bodily maintenance, as social identity, and therefore social worth is highly determined by the physical body, which in turn impacts upon women’s self-concepts (Gibson 1996).

Women maintained their appearance, and denied the inscription of signs of age on their bodies, in order to retain their status and power (Sontag 1978). The loss of these – physical attractiveness and thus, status and power – along with re/productive capacity results in the erosion of women’s social values, and was something that participants who employed

Maintaining narrative strategies sought to avoid through their bodily practices. Engaging in bodily maintenance, ‘looking after oneself,’ is therefore a moral imperative in our society

(Litva and Eyles 1994; Turner 1996; Oberg and Tornstam 1999), which the women who told

Maintaining narratives both embodied and enacted. In telling their stories, they highlighted how they continued to be productive social members, through being active in the community, despite no longer being able to reproduce. They participated in activities and engaged in behaviours, most often exercise- or diet-related, that functioned to deny their anticipated decline. In illustrating the common themes identified in Maintaining narratives, I present the case study of Biggs.

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Keeping up appearances: Biggs

Throughout our interview, Biggs told stories about body maintenance. Her narratives revolved around her feelings of freedom from the constraints imposed by parenting and changes in the parental relationships with her children. She described these constraints as follows: needing to keep set meal- and bed-times, having a structured daily routine, or needing to be in Waterside during school terms. Midlife was a time where she was able to focus on maintaining her health and body through physical activity:

My whole life now is unstructured and I’m doing things I really enjoy doing. What sorts of things do you do? Sport. A lot of exercise. Every day I ride my bike. I try to play tennis and I often do an hour of aerobics as well. Then I garden and mow, walk on the beach, take a dog for a walk each day… I actually do a lot of ankles, wrists, joints but gentle-not-full-on like aerobics, and I do 100 sit ups every morning and weights before I go bike riding. I think all that has helped. If you keep your muscle tone it sort of can help keep your joints. (Biggs, age 53)

She emphasised throughout our interview that her concern with bodily maintenance was not about vanity, but rather about preventing loss of mobility and, thus, loss of lifestyle.

Her mother and grandmother had both continued to be active in their old age and had experienced few age-related problems. Despite her family history being characterised by positive ageing experiences, Biggs’ stories belied her fear of ageing. Throughout her narratives, she reiterated her belief that if she, like her mother and grandmother, continued to exercise, she would reduce the possible difficulties that could be encountered as she aged.

In her mind, as evident below, ageing was synonymous with negative images: disablement, bodily betrayal, and decline; her maintaining behaviours were therefore in direct response to these images. Her beliefs about the benefits of self-maintenance resonated throughout her

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life history – participation in sport and exercise was central in her life and she described a multiplicity of benefits in midlife from this involvement:

I feel better. I have so much energy when I keep fit and I feel so good. I think that’s part of why I do it, plus I’ve always done it. I’ve always been an active person my whole life. All my family played a lot of sport so I was bought up playing sport. So I have never not played sport. It was just harder to fit a lot more in with the kids because I was tired running around after four kids…

Through maintaining fitness, her community participation continued – she was very active in sporting groups throughout her life and exercising meant she had high levels of energy and felt good, which, in turn, allowed her to participate in various social interactions.

More importantly, body maintenance was important for her participation in her family – playing sports and exercising together were central to her family life and activities.

Secondly, she believed her physical activity minimised signs of physical ageing: her body had not changed in a way that caused her worry – her repetition that her physical bodily changes did not cause her distress or worry reaffirmed her stance that bodily maintenance was not about vanity; instead, it echoed the importance to her of warding off infirmity that might accompany her ageing and reflected her understanding of ageing as meaning decline.

Such sentiments were emphasised in the following narrative:

My [breasts] have sagged but I am very small anyway. I probably notice [my bodily changes], albeit though with exercise, it’s not so bad. You do notice, like loose skin a little bit, more wrinkles but then I’m outside a lot. I spend a lot of time in the sun. But it doesn’t worry me as such. But also it’s another wonderful thing because my eyes have deteriorated somewhat and you don’t notice it so clearly unless you put your glasses on and you’ve got a mirror there. In some ways, I must be vain. I am very conscious of teeth and I whiten my teeth, because naturally as you get older, your teeth yellow and it’s

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something I’ve never liked. So that’s a sign of vanity I guess. Physically, you do notice but it is so gradual. From when I’m twenty to when I look in the mirror now it would be an enormous difference. I’m sure it would be, but it is so gradual. I feel really lucky I’m not grey yet, although it has never really phased [worried] me going grey. My sister is quite grey and it always bothered my mother. Age really bothered my mother. Turning forty really bothered her and going grey really bothered her. It hasn’t for me, it has never been something that’s [been a concern]. I think some ladies with grey hair cut nicely look so smart so I must honestly, honestly say it has not bothered me. One thing I can tell you and I know it will bother me is if I can’t get around. I’m really hoping that if I exercise correctly, so that I don’t have great problems so that I can still keep exercising. I think I’d find it very difficult if I suddenly got struck with rheumatoid arthritis and I couldn’t do things. That for me would be a whole different outlook. See we still ski every year and those sorts of things I really love. Dave [partner, pseudonym] and I love it together. We play tennis together. I mean what would [age-related disablement or infirmity] be for me then? I don’t know how I’d deal with it actually.

Biggs’ concern about the ageing of her physical body, which would reduce her mobility, was re-emphasised through comparison of her own attitudes towards ageing with her mother’s, who, whilst she experienced few age-related problems, was concerned about the visible signs of ageing. At the same time, comparisons with her sister, who experienced considerable problematic bodily events associated with menopause, served to highlight her own feelings of good fortune. In addition, Biggs was very worried about the possibility of losing mobility and stated that, should she become immobilised in the future, she was uncertain whether she would be able to cope. She believed that maintaining her participation in exercise was likely to increase the likelihood of retaining present levels of mobility in the future and, thus, had a protective function.

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On the surface, Biggs’ bodily maintenance behaviours (in her case, physical activity) were not a denial of bodily ageing. The underlying message throughout her narrative was that ageing was perceived by some women to be negative, with implications either for a woman’s body image or social participation. Biggs’ fears about losing mobility, however, highlighted her beliefs about the possible negative consequences of ageing. These beliefs did not exist independently of her life; she illustrated the association between exercising and maintenance of a mobile, functional body throughout our interview. She believed that physical fitness does not necessarily vanish with ageing and found examples in her own family, as well as others, to support her belief:

[My grandmother] was probably my inspiration. She worked until she was 85… She was always very fit. She wasn’t ever sick and could run around. Now when I look and see older women who exercise, they always seem quite happy and a little bit more energetic. Not always, you can’t say it for everyone and there are a lot of other influences but I think it certainly can help mentally and physically… and then you’re more likely to be out there meeting people because you’re out there doing something. It’s a snowballing thing. I saw an old guy in the paper last week. He was 80 or 81 and he is up at 5.30 am. He used to be a [football] player or something and his photo was in the paper. He just looked so fit, active. Things like that I aspire to. If you enjoy doing it, for starters. See, I enjoy the exercise I do.

To a lesser extent than exercising, Biggs emphasised the role of eating a healthy diet for her bodily maintenance, largely for oral health and to ensure that her weight did not increase. Her diet was built upon her mother’s and grandmother’s healthy eating practices, so she felt that her healthy eating was only partly self-driven:

…both [of] my parents have all their own teeth and my mother never let us have (ready-made) cakes or biscuits when we were growing up. We had fruit and, on Sunday nights, she used to make either a homemade cake or scones

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and that was our sweets. She was exceptionally strict. I wasn’t nearly as strict [with] my children. My father always had a huge vegetable garden and my mother always had big pots of vegetable soup. Really good, lots of vegetables. So I was brought up [that way].

This quote highlighted her understandings of the social, as opposed to genetic, inheritance of healthy behaviours which shaped her dietary practices. Social inheritance played an important role in her Maintaining practices (also exemplified by the aforementioned quote about her grandmother’s physical fitness). Biggs believed that her family’s philosophies about what constituted health and a healthy lifestyle were positive and had contributed to her good

health.

Her beliefs about ageing were facilitated by a lack of difficult or complex other health

conditions:

The one thing I must say about it all is that I still feel like I’m twenty. It’s not until I look at my kids and think Andrew [son, pseudonym] can’t be twenty- eight because I really feel no different. Body feels the same. I feel just the same.

Like other women who used Maintaining strategies, Biggs experienced few peri- menopausal symptoms, and those bodily changes that she experienced were easily managed:

I know that there’s some [arguments] for [HRT], but if I can keep healthy and I don’t need to, I don’t feel I need to, then I won’t. Occasionally I will get a hot sweat in bed at night but normally it’s a hot night and I still have a doona. Normally I’m in bed asleep and I’ll sort of wake up and I’ll feel a bit thirsty… And I have a glass by my bed and then I just have a glass of water and turn over normally. I just feel a bit hot, sometimes I kick my feet out, my legs out, have a sip of water, occasionally because I’m half awake I’ll go to the

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toilet and then I’ll just go back to bed and go back to sleep… I have had [no dryness] at all. No changes sexually or anything like that at all.

As her last menstrual period was only 6 months before our interview, Biggs was aware that the meanings and understandings she had of midlife may change. Several of her friends had difficult menopausal experiences with many symptoms and, when comparing her experiences with theirs, she felt that she was fortunate. Her body maintenance beliefs, however, were also echoed in her understandings of menopause: she explained that, if she kept healthy (which she associated with exercise and diet), troublesome and problematic symptoms may be avoided.

In her stories, Biggs did not highlight the importance of maintaining a youthful appearance; rather, she described her acceptance of unavoidable physical changes, such as loose skin and greying hair. By focusing her narratives on bodily maintenance and emphasising the protective aspects of her behaviours, Biggs was able to pursue and see her behaviours – which were ultimately about prevention of ageing (and thus, maintenance of youth) – as socially acceptable (indeed, a socially mandated) response to age-related bodily changes.

Warding off decline: Maude

Maude was also concerned to maintain her body through physical activity. However, whilst

Biggs was concerned with bodily maintenance for the long-term prevention of age-related decline, Maude’s bodily maintenance was in response to slightly different understandings of embodied ageing. Although avoidance of disability or infirmity formed part of the incentive behind her body maintenance, she developed a newly heightened awareness of her own mortality following her 40th birthday. Understandings of ‘midlife’ and the salience of age

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categories varied between women; the importance Maude placed upon her fortieth birthday, which others may regard as too young for midlife, justifies inviting women who self-define as midlife to participate in this study.

For Maude, body maintenance occurred partly in response to a desire to use her body whilst she was still able. In this way, associations she made between ageing and infirmity mediated her midlife experiences:

I’m probably fitter now than I’ve ever have been in my life because I do a lot more physical stuff. I mean I’ve really taken on the adage ‘move it or lose it’ because I really do believe that. Sometimes I get lazy about my pushbike riding or something, and I think to myself ‘why am I doing this? I don’t really want to do it.’ Then I think, ‘rubbish. Can you see yourself riding this pushbike when you’re 60? Well, you mightn’t be able to, so get out and do it now. Enjoy it now.’ So I guess your approaching mortality makes you value the time you have now a lot more. Well, for me anyway. When you’re younger, you don’t really think that you can get old or that you could be infirm in any way. You can’t see yourself on one of those walking frames. Now, working with the elderly like I do, I see it and I know these people have taken care of themselves. I’ve seen dementia come in people who have been really very astute and good strong minds, and yet, dementia’s still got them and you see their mental faculties fail them. And so that awareness of what happens and almost the inevitability of it. At the same time, I think you have to give your best shot, you know, really look after yourself to the best that you can… you’re old for a long time, so you’ve got to live now and do what you’ve got to do now while you’ve got the time you’ve got and while you’ve got the health you’ve got. (Maude, age 50)

In contrast to Biggs, Maude’s desire for bodily maintenance was based on her experiences of working with ill, elderly community members. As illustrated above, Maude believes that taking care of one’s body does not guarantee a healthy and/or vital old age –

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degenerative conditions, such as dementia, are not directly related to bodily care or lack of care. Accordingly, she talks about appreciating one’s body and activities while she is able:

I play. I go kayaking and pushbike riding. I like organising things, I’ve just organised a weekend over at [a homestead] and we’re having a winter solstice get together, because I always celebrate the solstice. We’re having a dinner party over there… I like organising. I don’t know why I do that. I get all these ideas about what would be fun to do and I can’t help myself. It’s good. I enjoy it.

As illustrated in this excerpt, bodily maintenance was therefore important to her so she could enjoy her lifestyle – Maude based her bodily experiences in terms of the present.

Ensuring that her body continued to function well into the future was not the primary reason behind her maintaining, although it did play some role in motivating her bodily maintenance; rather, Maude sought to enjoy her body to its full capacity whilst she was still able. She did this through participating in exercise and, in doing so, she anticipated that her body would function without major health problems for longer than if she had not been as active.

Throughout her life history, not ‘letting herself go’ was extremely important to

Maude. She described herself as possessing a great deal of self-pride, which prompted her desire for maintaining a healthy body:

I’ve always been really hard on [my body] because I’ve always… I thought I was fat. Now I think ‘oh God, I wish I’d known I looked like that!’ So I’ve always given myself a bit of a hard time. It’s a really hard balance because I think you have to keep an eye on yourself, you can’t ever let yourself go. You’ve got to… I mean, if you feel yourself putting on a few kilos and you feel it’s over your healthy limit, you’ve got to work at taking them off. I’ve got a lot of self-pride. I mean, my mother had a lot of self-pride, has a lot of self-pride too, and it’s just something, that I’ll never ever let myself go. People say ‘but you’re looking really good for 50,’ and I’ll think ‘what am I

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supposed to look like at 50?’… Most of the time, I don’t think about it. I’ll get myself dressed, put my make-up on at home, do whatever I’ve got to do there and then go out and just don’t think about what I look like once I’m out. You’re too busy enjoying yourself and it’s too late then anyway. So if you’ve made a muck-up of things, it’s too late, you’re out there, may as well just enjoy. I mean I’ve always looked after myself. I used to do yoga a lot and I’ve always been physically active. One thing I really do resent is I had a motorcycle accident when I was 30, and I really banged up my knee badly. It was a truck driver who came out and it was nothing we could help at all. Now that knee still plays up and my other knee is stuffing up too, because it’s had double the work from the gammy [sore, lame] knee. And I really resent that because I think I’ve looked after myself well and I don’t like having to wear the consequences of someone else’s mistake.

During this narrative, Maude reaffirmed that she had looked after her body

throughout her life – and hasn’t “let herself go” – something that others notice and

comment on. She believed that she had always been her body’s most harsh critic, probably

due to socialised notions of self-pride and the effects of that on her embodiment. She had taken care of her body – she expanded her discussions of her body to include dialogue about

her self, thus connecting the body-self. She paid particular attention to bodily events outside

of her control that occurred in the past and impacted upon her present day embodiment,

using the motorcycle accident as an example. During her discussion of that accident, she

transferred responsibility for her problematic knees from herself to another, external actor.

Thus, her knee troubles did not derive from a breakdown in her care of her own body and,

by implication, herself; rather, her injury was (largely) the consequences of another’s actions.

Like others who used Maintaining narrative strategies, menopause was not

particularly troublesome for Maude, although she experienced some hot flushes. She did not

describe these as disruptive or particularly troublesome; instead she described them as being

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a little confusing in terms of clothing. Overall, she believed that menopause was a positive life event:

I’ve been really lucky with menopause, incredibly lucky because apart from the occasional hot flush, I haven’t really had any symptoms… it’s been really good. That’s been fantastic.

As with the other women who employed Maintaining narratives (and also those who used Contemplating narratives), the main consequence of the menopausal transition for

Maude was the slowing down and (recent) cessation of menses,71 itself a positive aspect of ageing which brought little and easily manageable bodily changes.

Popular cultural images of midlife women also impacted upon Maude’s midlife experience. She found those stereotypes consisted of a blueprint which did not accurately reflect her experiences, or those of her peers, and lead to ageing women prematurely:

The outside image of how a 50 year old is supposed to be? I reckon they try and make you old before your time, they really do. I guess the image of the older person, maybe not so much for us group coming through, because we’re going to make damn sure we change that image, you bettcha. So ten years prior, it really, I think, they just try to age you before your time…

Maude emphasised the importance of challenging images and stereotypes about ageing women. She believed that, to advocate this image, maintenance of a fit, able, healthy and productive (although not reproductive) body was imperative. Emphasising that the baby boomer generation is capable of changing these images, she gave a personal example of their

71 See Chapter 4 for discussion about Maude’s menopausal status. Given that Maude’s most recent period occurred several months (but less than one year) prior to our interview, she is not considered ‘post- menopausal.’

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effectiveness. In this way, Maude also employed some Contemplating narrative strategies, as she contemplated the impact of these images upon her life:

My journey… I’ve been on a journey for a long time. I had a visitation when I was 8 years old and it set me on a spiritual journey and I’ve been on that ever since… I’m stubborn about ‘its [age] not going to get me yet.’ I’m going to keep active, I want to keep active and Maude’s [character from film ‘Harold and Maude’] been a wonderful influence… My mind and head, and my spiritual development, have all grown so much. Compassion, understanding for human beings. And that’s just something that life gives you. That’s once again going back to how older people are dismissed and yet they have all that, you know.

Maintaining narrative strategies, such as those used by Maude and Biggs, focused on actions taken by the narrators to ward off major bodily changes. These women were typically in their early to mid 50s and sought, as their ultimate goal, the continued use of their bodies, for their foreseeable future, in ways similar to their present levels of function and ability.

Inherent in these narratives, therefore, is a commitment and desire for identity maintenance, achieved through bodily maintenance. Women who used Maintaining narrative strategies challenged dominant fatalist attitudes regarding the inevitability of decline with ageing (Fox

2005). In this way, these narrative strategies differ from the Contemplating and Navigating techniques, which were concerned with the narrators’ paths towards coming to terms with identity change, which I discuss in greater detail later in this and the following chapter.

Participants who used Maintaining strategies sought to avoid disease or infirmity, and believed that they could do this through continuing participation in physical activity.

However, physical activity was not the only medium through which they sought bodily maintenance. Social and community activities were also important in their narratives, as they believed that these activities were important for their mental health maintenance, as

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described in detail throughout Maude’s case study. Implicit and explicit in their behaviours were their challenges to the equation of ageing with decline—to some degree, all of the women who told Maintaining narratives referred to such associations, even though they sought to challenge them.

Of particular significance in these narratives were women’s associations of the body and the self—for them, care of the self occurred through care of the body (cf. Foucault

1988), thus highlighting the importance of the body itself (see Figure 5.1).

Self

Body

Figure 5.1: Body-self relationship expressed in the Maintaining narrative strategy

The body was the primary medium upon which their midlife experiences were enacted and, through this, they were able to preserve their sense of the self. The stories contained within the Maintaining narrative strategy demonstrated how women actively sought to shape their bodies into a true representation of their self. In this way, women epitomised the ageing post-modern body by actively shaping their own subjectivities through their practices of bodily maintenance (described by Fox 2005) and challenging assumptions of the inevitability of ill-health and decline.

Women who used Maintaining narratives did not speak about mental fitness as an indicator of healthy ageing. This may stem from the public view of older people that is mainly concerned with their physical attributes, in contrast to (the often-invisible) mental attributes, with the exception of considerable health promotion of negative aspects of mental

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ageing, such as Alzheimer’s disease or dementia.72 In Maude’s case, her personal work

experiences led her to believe that in midlife and beyond, she could only control her physical

fitness rather than her mental health, which she believed was determined by biological

factors.

Maintaining narratives highlighted the dynamic nature of midlife, and of the stories

women told about their experience of this life stage. As I will describe in Chapter 6, many of

the women who used Navigating narrative strategies would have told narratives about bodily

maintenance prior to, or had they not experienced, a significant health event or bodily

disruption. Serena, one of the few participants with whom I was able to conduct a formal

follow-up interview, had originally told detailed stories about her strong commitment to

bodily maintenance. By the time of our follow-up interview eighteen months later, however,

she had experienced a disruptive health event (shingles), which had long-term impact upon

her health and significantly changed her self-concept. Thus, the narratives she told then

related to her experiences navigating her challenging bodily signs and symptoms.

In the following section, I describe the Contemplating narrative strategy, which varies

from the Maintaining narrative strategy in terms of perceptions of physical and mental

health. As I illustrated above, Maintaining narratives emphasised the physical body and

described women’s attempts to control their long term physical health, through ‘taking care

of’, or maintaining, their bodies. In contrast, women who told Contemplating narratives

viewed physical and mental health in an opposite way—through personal experience, they

believed that mental health was controllable whereas the physical body was not. Regardless

of their desires and health-promoting personal behaviours, they therefore believed that their

72 Dementia is an ageing related disease, accompanied by images of incompetence in decision-making and communication, lack of autonomy and mobility, and increased reliance on others (Australian Government Department of Health and Ageing 2005).

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lifestyles and biographies could potentially be disrupted, challenged, and irrevocably changed through the actions of the ‘unruly’ physical body (cf. Manderson 2002; Peake and Manderson

2003; Markovic et al. 2004, 2005).

CONTEMPLATING NARRATIVES: A CHANGING IDENTITY

Like those who used Maintaining narratives, participants who used Contemplating narrative strategies had typically not experienced any personally disruptive ill health during their lives.

Further, they did not report any significant or chronic health problems during midlife and had not experienced disruptive or troublesome symptoms associated with menopause. Whilst the end of reproduction was central to their definitions of ‘midlife’, menopause and associated complaints, concerns or problems were not significant features in their stories.

Instead, these women told stories about midlife focusing on the mental and emotional changes or challenges they encountered during this life stage; personal development was a significant feature (Banister 1999a; Burns and Leonard 2005). Women who employed a

Contemplating narrative strategy also emphasised changes in their identity, although in different ways. For Grace, identity transition focused primarily on self-concept (thus, centred on internal factors). Other women, such as Iris and Treasure, experienced profound changes in their social identities (external factors) which influenced self-concept. Others, such as Mac, experienced a combination of internal (self-concept) and external (marriage breakdown, financial crisis) factors with profound impact on their identity.

Although all participants, regardless of the type of narratives they told, engaged in a similar form of life-evaluation to some extent, women who told Contemplating narratives were unique as their narratives largely centred on the non-physical, more esoteric aspects of their life. This could be seen in instances where their story was specifically about bodily issues, yet their focus continued to be on emotional and spiritual issues. For example, whilst

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Mac told a story about injuring her hand whilst moving house—“I couldn’t pick up stuff

physically and carry it [because] I had my hand in a bandage”—this was not the focus of her story.

Instead, her narrative described her no longer feeling as though she needed to prove her independence, as she had when she was younger; in telling her story, she used the injury and the personal (i.e. her own) and social (i.e. others’) responses to the accompanying (short-

term) functional limitations to illustrate how she had changed as she got older: “[I’ve learned

that by] taking what has been offered around you, you get used to being your own person.” In using this

technique, Mac described the processes of personal growth and development. The body was

as an instrument to actualise the self in these narratives, as shown in Figure 5.2 and contrasts

with the foci of the Maintaining narratives (see Figure 5.1).

Body Self

Figure 5.2: Body-self relationships in Contemplating narratives

The body as secondary to the self (mind) in these narratives is no doubt related to the

shifts in self-concept and self-identity as described by women (cf. Gilleard and Higgs 1996,

2000). Contemplating narrative strategies were typically employed by women who considered

midlife, to some extent, as a time for pause—for making sense of their life thus far, whilst

simultaneously thinking about and planning for what would or could happen in the future.

At the same time, women who used Contemplating narrative strategies tended to have a

positive or optimistic view of ageing, which they emphasised through stories about liberation

from old roles and responsibilities. Rather than focussing on losses, their narratives were

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focussed on future opportunities for growth or for putting themselves first, as Mac described:

I’m happy to think about where I am and how I got to where I am. What I’m discovering is really nice stuff, really good stuff. [I have] far more strength than anything I had when I was younger. If I could become that and go back, I don’t think I would. This is exactly where I want to be. (Mac, age 47)

In this way, women’s narratives echoed those in Guillemin’s (1999) study, in which participants characterised menopause as the start of a new season of their lives, something they positively anticipated. Women viewed midlife as a time of reflection or for consolidating their resources; they typically spoke of their personal strength and resilience, which they described as being something they had acquired as they aged.

This is not to suggest that bodies were totally omitted in Contemplating narratives; instead, as I illustrate in the following section, the narrators’ bodies were largely mentioned in relation to wider discussions of age-related changes. In contrast to the Maintaining narrative strategy discussed earlier, however, the body-self relationship was reconfigured by women who used Contemplating narratives instead to be in the form of a self-body schema.

Contemplating the future: Grace

Grace perceived ‘midlife’ as being directly related to her menopausal experiences and reproductive capacity. Her stories were shaped by her limited symptom experience and had this not been the case, her subsequent experience and understandings of midlife could have been quite different. Given her non-problematic bodily experiences, she ‘sailed through’ the physical menopausal symptoms, experiencing only (very few) hot flushes:

I’m 50 this year, and I’ve been through menopause. It’s all happened and it’s been very easy. (Grace, age 50)

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Menopause for Grace, therefore, was a discretely contained physiological life-event

that did not cause her a great deal of disruption. Although our interview went for well over

an hour, the above excerpt was one of only two references that she made to her physical

body. Grace was less concerned with her physical body and its changes – the stories she told

centred on her feelings of liberation following the end of her menstruating life and on

preparing herself mentally for changes she felt were awaiting her in the future. During our interview, she spoke about the impact of wider, non-corporeal, changes she had encountered:

Mentally, I think [non-menopausal changes have] been more interesting for me. I think I am going through changes and I suppose I’ve started to reorient my mind towards projecting what’s going to happen in the future and thinking more about that. Now that I’m hitting 50, I’m looking… well, I suppose work-wise, you’re thinking more about retirement and what you’re going to do, in that that’s going to happen in the next five years or so… So I’m going to hit the stage where I retire, [my children] are going to leave and probably by then… And then, [I’m thinking] about me and just my whole wellbeing, and what I’m going to do with myself both mentally and physically… Yeah, it’s changed my focus a little bit from what it was.

Grace was largely concerned with her mental well-being in relation to the future; her considerations about the future in terms of her body were about her physical location

(“What I’m going to do with myself…”) in the world, rather than physical changes. She also

perceived changes in her mental outlook as in some way part of her menopausal transition;

for her, these were much more central aspects of that transition than were the physical

aspects. In this way, she viewed her physical body as distinct from her self. The body was a

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vessel within which the self was contained, needing to be maintained so that the self could achieve its goals and aims:

Certainly physically, there are like I’ve realised that you just, my body has sent me messages that no, you can’t do things the way you used to do them. Like I’ve got a shoulder injury at the moment, which I got over summer and that’s because [my son] and I decided that we’d heave all this furniture around, that sort of thing. And I basically pulled my arm really badly, and I thought 'oh yeah, okay, you’ve got to stop thinking that you’re twenty. You can’t do that. You’ve got to actually get some other people to help you do that now.' But that’s alright, as long as… you remembered that that was going to happen, then it was fine. But if you forgot, then you could often go into a real downer and go you know 'it’s all miserable and everyone’s miserable and I’m miserable and the world’s not worth knowing.' But if you think about it, and you’re aware of it, it helps.

Even her narratives of the physical experience of living in an ageing body focused on the mental and emotional aspects of her bodily changes. For Grace, ageing was about re- identification of self. In the future, her bodily changes will require her to modify her physical activities, but more importantly, mental functioning, unaffected by ageing, will allow her to make decisions to ensure that she is still achieving her goals despite impaired mobility. What was meaningful for Grace was the process involved in learning to cope with and respond to her bodily limitations. Within Contemplating narratives, women described controlling the body through mental means. For Grace, the body had a supporting role whilst her self was centre stage, with self-identity at the core.

Identity reassignment was a much more salient issue for Grace. Specifically, the psychological shift that led her to no longer view midlife women as older or as different from herself (that is, as ‘other’) was a central task. Through this shift, she realised that she had

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become one of them (an ‘other’) and described this process as requiring considerable mental

shifts:

I suppose it’s just that readjustment. Kind of like when you were in your twenties and thirties or whatever, you still tended to think women who went through menopause were older. And now I’m sort of there myself and thinking, well that’s me now. So, yeah, mentally, you have to readjust to how people might look at you, which is different to how you might feel about yourself. Because you’ve still got the same brain, it doesn’t matter how old you are. You’re still you and you accumulate experiences and things. But sometimes you go [think] 'Oh yeah, young people actually consider me now an older person. That's okay, that’s fine, it’s nice.’ But you do have to remind yourself now and again that it’s okay for there to be a bit of distance because they go and do stuff with younger people and that’s fine. And then they come to you when they want to talk to you and you’re almost going into that kind of elder status. Almost. It’s a different adjustment. It is all an adjustment. It’s weird. And I guess I expect to feel more of that as I get older.

In contrast to the women who told Maintaining narratives, Grace expected some physical

changes and expected and accepted that society would ‘classify’ her as an old person, but

focussed on the continued functioning of her mental abilities—‘the same brain’.

In contrast with other women in this study (such as Daphne, who used both

Negotiating and Contemplating narrative strategies, discussed later), Grace did not readily or

easily embrace her new ‘elder’ status. Rather, she felt uneasy about identifying herself in this way, despite being in the midst of the process of change to accommodate this new identity.

Influencing these feelings was her acceptance of the end of reproduction and its meanings

for her. Her friends had described feelings of apprehension and uncertainty about the

approaching end of their reproductive life. In this regard, prior to menopause, Grace had

been troubled by what her response might be; again her concerns were less about physical

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changes and more about her emotional responses to the changes accompanying her ageing identity:

In terms of image about yourself, you sort of wonder ‘is it going to be that different for me?’ ‘Am I going to grieve that I’m no longer able to have children?’ ‘Am I going to go through that?’ But I haven’t found it like that at all. I’ve found it quite a relief to go, ‘yeah, yeah, that’s put a neat bow in that package of life, that’s tied that lot up.’ I’ve had children and it’s great and I really enjoyed it, you know. But its fine, that’s over with. I’ve found it quite interesting that I haven’t regretted it.

This identity transition and its associated uncertainties serve to contribute to the liminality of the midlife stage. For Grace, as with many other women, midlife was a time betwixt and between different identities (specifically, between the identities of reproducer; van Gennep 1960). The identities of reproducer (or at least reproduce-able) and elder (or non-reproduce-able) are mutually exclusive (given their age- and/or life-stage-specific nature) and do not easily sit together – in fact, each of these identities (reproductive woman and elder) signifies membership of a distinct social group. Several women (such as Maude and

Daphne, both of whom used multiple narrative strategies) transformed the identity of ‘elder’ and expressed this in terms of ‘the crone,’ due to their association of the latter with female empowerment, strength, and autonomy (for further discussion, refer to: Walker 1988;

Rountree 1997; Leonard et al. 1999). What makes the Contemplating narrative strategy distinct from other strategies is the consciousness of thought given to considering this shift.

Without the bodily distractions expressed through other narratives (Maintaining, Negotiating and Navigating), higher-level contemplation of this identity shift is possible. Embedded within and running through Grace’s narrative, therefore, is her understanding of midlife as a time of identity transition and for re-conceptualising her ideas about her self.

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At the same time, narratives about the self were not told about the self in isolation

from other selves. Grace’s narratives about the self involved her parents as the index against

which she was evaluating her life direction:

… I mean, my dad’s already died but mum’s still with me, but maybe that’ll change in the next five, six years as well. So, I’m thinking that life’s going to offer a lot of things that I’m going to need to think about.

The self is social and exists in relation to other selves. Narration was generally concerned

with the intersection of autonomous and (in)dependent others interacting with the

protagonists (in this study, the participants), however this was not always the case. In

contrast to Grace, the Contemplating narratives narrated by Treasure and Iris centred on

their roles when caring for others, outside of their parental caring.

Parental caring, in contrast to other care work (see further below), also had a place in

women’s narratives. However, these were common across all narrative types, and were not

privileged by many women in the study. Four possible explanations for this could be posited.

Firstly, the anticipation or expectation of parental role duties due to the women’s status as mother (where applicable) may make these duties mundane and assumed, thus, not out-of- the-ordinary enough to discuss in detail. Alternatively, parental caring was often a role that had began many years before, when the women were in their 20s or 30s; the continuation of this care work into midlife was therefore not novel or necessarily associated with a particular life stage. Thirdly, caring relationships with children were not highlighted as demanding or particularly problematic by participants; by the time of participation, their children had left home or reached independence. Most participants who had children were not living with or seeing their children on a daily basis, largely an artefact of geography. Thus, the salience of parental caregiving in their daily lives was reduced. A final possible explanation for

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participants’ not privileging their parental caregiving may relate to the on-going, hands-on nature of parental caring whereby the intensity of these caring roles was reduced as their children became independent. Regardless, none of the women who used the Contemplating narrative strategy placed particular emphasis on their mother-carer roles, although their relationships with their children were present in their narratives: “You’re always their mother” (Treasure).

Consequently, women who used Contemplating narrative strategies did not highlight these responsibilities in the same ways as other caring roles. It was their non-parental caring relationships, for example those with parents or partners, that were of central importance in

Contemplating midlife narratives. Grace’s ageing parents prompted higher levels of contemplation about her own future, mortality, and life direction and aspirations:

[Midlife] seems to be the age when you are dealing with death of lots of things, not only parents, but you are faced with that saying goodbye to a certain section of your life and going on to the next section, so it’s both.

The death of their own parents highlighted the liminal nature of midlife for the women in this study, which contrasted, to some extent, with the omnipresence of the

‘sandwich generation’ construct. As described in Chapter 1, the notion of the ‘sandwich generation’ has been well described in popular and research literature, and conceptualises midlife adults as being caught between the generations either side of them, caring for both ageing parents and their own offspring (see my graphic representation of this concept in

Figure 5.3, also refer to Remennick 1999). This metaphor often does not sufficiently consider the other demands placed upon midlife women which, therefore, impact upon their self-construct, identity, and health outcomes (particularly mental health). The relevance of

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the sandwich metaphor is thus largely dismissed (although not entirely) through

Contemplating narratives.

Ageing parents Partner’s needs

Midlife woman Competing work & other needs Children

Figure 5.3: Graphic representation of the ‘Sandwich Generation’

The use of Contemplating narratives offered women a way to subtly challenge this construction of midlife through several mechanisms: firstly, as I will describe in the remainder of this chapter, the bread on the edge of the sandwich is also constituted by women’s own concerns (where relevant), or those of their partners, particularly their health related concerns. At the same time, other demands on women’s time (by work or through their voluntarism) also compete for her time and energy. Thus, to continue the metaphor, the meat in the sandwich also becomes the sandwich itself.

Non-parental caring, however, had profound effects on some of the women who used Contemplating narrative strategies. For Treasure and Iris, caring for their terminally ill partners meant that their partners’ needs were privileged over their own and their own bodily experiences were subsumed by this caregiving. When confronted with other bodies that demanded more (caring) attention than their own, and whose immediate requirements often took precedence, these women’s bodily needs became less central to their day-by-day experience. Their stories reflected this. Women’s lives changed dramatically across a range of life spheres, from both geographical location to social participation, in response to their partners’ illnesses. As the following case study demonstrates, for Iris, the privileging of her

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partner’s bodily needs over her own meant that she experienced periods of social isolation, away from friends and family while they sought treatment for his illness. Social isolation and decreased social participation, and the accompanying changes in her social capital, therefore, characterised her narratives.

Caring work and regaining a sense of self: Iris

Iris’ narrative privileged the self over the body for quite different reasons than Grace’s.

Around the time of our interview, Iris had taken leave from her job to care for her husband,

Des, who was terminally ill with an aggressive form of cancer (he passed away not long after our interview). Simultaneously, her children were in the process of completing their secondary schooling, leaving home and moving to a city several hours away. All of these events (job, children, husband) limited her social participation and, consequently, themes of isolation ran throughout her narratives of midlife.

Her sense of social isolation and associated loneliness had started with her husband’s diagnosis nine months preceding our interview, when he began an intensive treatment regime, requiring his relocation to the treating hospital in a city over 500 km from Waterside.

As Iris did not want to be apart from him, she decided to move into temporary accommodation nearby:

We were away from home for six months, which was really strange… [Our youngest child] Gus was here by himself… I haven’t worked all this year, that has been really strange, not being at [work] because I don’t see [clients] as often, I don’t see [colleagues] as often. Well, I don’t see some of them at all… I miss not being at [work], I never worked full time but I really, really love [my clients] so I really miss being [there]. (Iris, age 50)

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The rapid progression of Des’ illness meant that large, somewhat drastic changes

were made to their lifestyle to accommodate his health status and her new role as carer-

partner. Many of these changes were physically and emotionally unsettling and led to

substantial disruptions in her lifestyle, which prompted shifts in her longer-term life

priorities:

…it has made me think into the future: what will happen, that sort of thing. It has also made me value the moment because knowing that it could be stopping makes you think [about the importance of that].

The immediacy of the present, and the need to value her day-to-day life, was heightened by her partner’s anticipated foreshortened life. For both of them, his illness and its prognosis was a very unexpected outcome: both aged under 50 at the time of diagnosis,

neither had considered that the other would become seriously ill at that point in their lives.

Iris’ story reflected the notion of control over health inherent in Contemplating narratives:

women who told such stories did not believe that they could control their physical health:

It certainly plays havoc with our [social] relations… It has impacted on me quite a bit more. I am just thinking of the things that I do now that I didn’t do before, but at home I have become a meditator. I never did any meditation before – a little, because I had done yoga – but I am getting into that a bit, and it just makes you think of things differently.

Since her husband had become ill, opportunities to do things that Iris enjoyed had reduced considerably, and so, social participation was fitted around her caring duties. As she described, meditation had become a technique to obtain some time to focus on herself; it provided a space within which she could also contemplate her life. The shifts in the ways she enacted her day to day life were also accompanied by a change in focus inwards. Home

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became the central stage upon which she lived her life, as highlighted in her narrative. Most changes were directly related to her caring duties, which determined the remainder of her daily life activities:

On a week day, [I] get up at 6 and go for a walk with the dogs, come home and feed the dogs and do meditation. At 7.30, I give Des his first lot of medication for the day and then there is a half an hour break between that and the next feed and the next lot of medication, so I listen to [talkback radio]. The morning [feed, via drip] takes quite a long time, 1 ½ hours so it is from 8 to 9.30 that that is going through. Then I tend to do things like the dishes and the washing and the sort of stuff that you just do to get it out of the way. After that, I do shopping or I clean the house. Then he has another lot of medication at 11.30. The last few weeks in that morning time, I have been doing some drawing and painting too. Then he gets up at about 12. He has another feed then, and then, from then until 4, lately I have had my own time because he has been too tired to go out. We have been using that time to go out and have a walk on the beach or have a sit or that sort of thing, so he gets a bit of outside. And then another feed at 4. I go to yoga one day a week and I have given up badminton… it just makes me frustrated, so I think I don’t need to be frustrated. Sometimes I go for a walk with Hattie [her friend] in the afternoons after the 4 [pm] feed… and then I come home and make dinner for [our son] and me. Then we just [relax] in front of the TV… [My husband] sleeps all morning and I can have… some time for myself then… I haven’t slept in for 9 months… I can use a bit of time but my day is very structured because of the medication and feeds.

Whilst such shifts in daily routine are common in the narratives of those experiencing serious illness (Frank 2002; Wray 2004), what is interesting about Iris’ (and Treasure’s, see below) narratives are how the antagonising event in her stories is, unlike for women who employed Negotiating or Navigating strategies, not her own illness. Iris’ observation of her partner’s physical changes prompted her to engage in higher levels of meditation on her life:

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I have had a bit of experience [with my parents’ illnesses] but it is very different from [that], because [my husband’s illness] ties you to the house, like you can’t, and I don’t want to, go out for too long because I worry then. I worry about what if something happens while I am out? [When I went out], I was concerned about him being here by himself, because he is not, like the last few days he has not been really good. He has had a chest infection and another infection that they don’t know what it was, so he is on two lots of antibiotics and he still gets very breathless as a result of the pneumonia he had and he gets very tired. So just putting the feeds in [via a tube], he could sleep through that, which I guess doesn’t matter much, but I guess I get a bit worried about him being here by himself. If [our son] is here, it is fine. As long as someone is here.

Illness was not new to Iris’ life yet, although she had experienced the illness of significant others (her parents), these had not changed her life to the same extent that her partner’s illness had. During our interview, she did not express feeling burdened or resentful towards her partner about these changes, but rather, she expressed her concern about his care when she was not there, and emphasised how she wanted to be with him.

Whilst the emotional burden of caring was highlighted through Iris’ stories, another central theme running through her narratives concerned the loss or reduction in her levels of freedom, independence, and autonomy: “There is certainly not as much freedom as I had before.” In addition to the need to be more physically proximal to Des than she had prior to his illness, which was certainly a major factor limiting her autonomy, her social participation also impacted by others’ responses to his illness. Following his diagnosis, and while they were living out-of-town for his treatment, her/their friends became more distant and less inclusive:

It has been very interesting to watch people’s reactions to it too, because unless you have had a sickness in the family or deaths in your family it kind

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of brings you up short, very abruptly, and some people, like I said before, these people have never visited us. I am really surprised [they] haven’t.

As illustrated by Iris, the experience of caring for an ill partner clearly impacts on the lives of women who adopt this role, whether out of choice, necessity, or other reasons. Through the changes in their lifestyle and social participation, in addition to the constant fear about their partner’s mortality, the two women in this study who actively cared for terminally-ill partners used Contemplating narrative strategies to understand midlife. A recent Australian study

(Team 2006) found that social isolation was significant for many female caregivers’, despite their desires for social interaction. Caring for a family member, particularly where high-level care was involved, often entailed demands on women’s time, resulting in fewer opportunities for socialising or obtaining social support for the carer or the person who they cared for

(ibid.). The burden of care-giving therefore impacted on many dimensions of women’s lives, and those who cared for their family member may have used Contemplating narratives for two related reasons: to come to terms with their situation and social isolation, and as a way of drawing upon their inner resources, thus enhancing their coping abilities (cf. Walters and

Charles 1997). In the following section, I turn to Treasure, who used Contemplating narratives to reflect on the impact of such caregiving.

Improved wellbeing: Treasure

In many ways, Treasure’s narratives echoed Iris’. Her partner, Jack, had passed away from a neurodegenerative condition three years prior to our interview, and she had been his full- time carer for a decade preceding his death. By the time we spoke, she had resided in

Waterside for approximately ten years; and for the six and half years of caring for Jack, she

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had received some respite care. Treasure explained that the years of caring for Jack, during which he experienced depression, left her with few inner resources following his death:

We had a good marriage. He knew he was depressed, he was going to see about it and I just had to keep going. I think after he died, I packed up a bit because I was mentally and physically exhausted… I got the respite [care assistance]. Not a lot… He was also incontinent, so having nursed had helped me a lot, but I got so tired. I think that [is why] I unfortunately had to put him in a nursing home… He was in a nursing home for the last seven months; so I stayed [nearby] then and went down to see him every day, fed him. (Treasure, age 62)

For Treasure, caring work was something that she had always done, firstly professionally through her work as a nurse, then informally, caring for her elderly parents until their deaths and subsequently, her husband:

I nursed my Mum and my Dad. Dad died a long time ago, he had a heart attack but I gave up nursing at [a hospital] and I nursed him. Then Mum died when she was about 76. I nursed her at home. I have done a lot of nursing… I really enjoyed nursing but I think having nursed Jack for those seven years, I had had enough.

Caring work is often assumed to be women’s work or part of the feminine role

(Team et al. 2007). Years of doing such caring work had left Treasure with high levels of stress and exhaustion; she described feeling overwhelmed and mentally drained. Her life situation had been made more difficult by financial problems that arose during the early stages of her husband’s illness. Managing his depression, stress, and ill-health was a priority for Treasure and her narratives reflected this:

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Having Jack sick, I think I said [to myself], ‘okay we’ve [had financial problems], blah blah.’ I was more concerned about him... He was so appreciative but he couldn’t talk much.

Treasure’s midlife had been highly stressful and full of complex and challenging events. Her narratives were chaotic, as many sub-narratives intruded into the broad narrative that she maintained. Her stories resemble those outlined by Riessman (1990a), who identified how, in the face of disruptive life events, people will often tell complicated stories that may not, on the surface, appear to be coherent yet which, when viewed as a whole, maintain a plot line throughout.

Social participation also played an important role in Treasure’s midlife narratives. In

Waterside, she was able to draw on formal support available in the community, such as the medical centre and the community health centre. Following her voluntary work at the latter, which also has some aged care facilities, she became involved with several community-based arts groups and, through these networks, was able to access support:

When Jack was sick, I had the support then. Meeting people, I still don’t know everybody but I have met a lot through the radio and I help at the [aged care facility] once a month. I give out lunches and things. It’s a caring community. It really is, I find. Whereas [it wasn’t] in the city.

Jack’s illness did not impact upon her social participation in the same way as it did for

Iris, who experienced isolation from her social networks. The caring roles of both, however, impacted significantly on their lives. The differences in social support experienced by

Treasure compared with Iris are apparent for several reasons. Firstly, and perhaps most significantly, I interviewed Iris about her midlife and thus, her caring role, whilst she was still actively engaged in it, whereas my interview with Treasure occurred three years after her

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partner’s death. Retrospectively, her experiences of isolation may have been minimised due

to a recall bias.

The second explanation I would like to posit relates to their social status within the

community. To explain this further, the positions within the community held by Treasure

and her partner Jack were not impacted upon by his illness; when they arrived in the

community, he was ill and continued to be so until his death. At no time during his

community life was he, or Treasure, less visible than they had been previously. In contrast,

Iris’ partner Des had held a position of authority and considerable visibility within the

community prior to his illness. As he rapidly became very ill and frail, his visibility was

simultaneously reduced. Such a rapid change in status may have prompted both Des’ and

Iris’ sense of social isolation.

A third explanation, which may have been co-occurrent with the second, relates to

the type of illness: certain forms of disease are ascribed a ‘spoiled identity’ (described by

Goffman 1990) which is based upon ‘bodily’ or ‘character’ anomalies/defects. Moral

judgements are made about these anomalies, and typically relate to contagion or personal responsibility, which then lead to stigmatisation and social isolation of the ‘spoiled’ person.

For example, Des’ cancer (a ‘bodily’ defect) may have resulted from cigarette smoking when he was younger, which therefore evoked social notions of personal responsibility and, possibly, ‘character’ defects—both of which highlighted a moral weakness, and may have justified social exclusion and stigmatisation. Stigma, as described by Frank (2002:91), is

“literally, a sign on the surface of the body marking it as dangerous, guilty, and unclean,”

which socially demands that the person so marked must remove herself (or himself) from

society, both actually (by hiding from view) and socially. Where the ill person does not

remove herself from view, she is removed by other social members through social exclusion.

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Social exclusion resulting from stigma has been widely discussed in relation to cancer

(Wilson and Luker 2006), particularly those cancers that have behavioural or lifestyle risk factors, such as cervical (Braun and Gavey 1998, 1999; McMullin et al. 2005), breast (Hubbell et al. 1996), lung (Chapple et al. 2004; Leveälahti et al. 2006) or, as in Des’ case, oesophageal cancer. In late modern society, stigma is attached to those diseases that have a moral component or element in understandings of their causation. Hunt (1998) found that moral reasoning is applied to social understandings of cancer in order to make sense of events, which are otherwise difficult to understand. This was demonstrated in Iris’ account: at the same time as her husband was becoming socially isolated, she too experienced stigma due to her caregiving role. Iris’ account therefore reflected Team’s (2006) findings that stigma associated with illness does not only affect the ill person, but also profoundly impacts upon the lives of those who care for them, and thereby impacted upon her opportunities to be engaged in social and community life. This was not entirely generated by other members of the community, but also came from Des and, due to her role, Iris. In his own illness narratives, Frank (2002:99) stated, ‘I needed other people desperately but, feeling stigmatised,

I was cautious of them.’ Iris described this ambivalence in her stories: needing others yet simultaneously feeling the need to be removed from them.

Iris’ and Treasure’s experiences may have differed by life experiences and training.

Treasure, a nurse, was used to caring for others; for Iris, this was a new and unexpected role.

In addition, the presence of respite care in Treasure’s case (her husband was in a nursing home for seven months) was a source of formal social support, which may have affected her ability to participate in social activities. Social support in the context of ill-health was central to the experiences of midlife for women who used Contemplating narrative strategies. Such health events highlighted to these women the ways in which the physical body could not be controlled whilst the mind (self) was able to be controlled, thus becoming the focus of their

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stories. In contrast, as I discuss in the following chapter, many women in this study experienced personal ill-health, which had considerable impact on their wider lives, their social support networks, and their mental health. The Negotiating and Navigating narrative strategies were used by women who did not believe they could control either their physical or mental health on their own. The women who used both of these narrative strategies highlighted their reliance on external supports, most often the medical profession, in their attempts to regain control over their (associated) bodily signs and symptoms. As discussed further in the following chapter, what set these two narrative strategies apart was the duration for which the ill-health condition(s) persisted, and the extent to which this impacted upon their self perceptions.

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Chapter 6

Working with Disruptive Bodily Signs: Negotiating and

Navigating Narrative Strategies

A decade ago, when I was in my early fifties, I fell ill. ‘Fall’ is the appropriate word; it is almost as alarming and quite as precipitous as falling in love. It is even more like falling down Alice’s rabbit hole into a world which might resemble this solid one, but which operates on quite different principles. Pain, death and loneliness are domestic presences there, in grey-green masks and gloves. So are humour and kindness, which come in all sorts of uniform. You are granted the dubious privilege of being a child again in a place which sometimes resembles a child’s nightmare, and at others a well-run nursery. It is also a world in which, like Alice, you are subject to unscheduled and surprising transformations (Clendinnen 2001:1).

The experience of illness has profound impact on the self, whether it is characterised by relatively short-term symptoms that will eventually be resolved or whether the illness and its associated signs become on-going features of the daily lives of the sufferer, as in chronic illness. Many women in my study experienced the disruption imposed upon their selves by their bodily events, and told narratives about the struggle between their body and their self

(cf. Martin 2001). The central fact of illness is that it occurs within the context of one’s wider, everyday life, as Garro (1994) argued, and as such requires the adaptation of normal, everyday practices and routines to respond to its disruptions.

Bourdieu’s (1977) notion of habitus comes into play when exploring health management behaviours and in their responses to illness. As suggested in Chapter 1, habitus enables individuals to cope with a range of situations; these practices are determined by past

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conditions and practices. One woman may therefore tell different stories about her illness if she were in a different social and/or cultural location, or were she operating in a body possessing a different health status – all of these features may comprise the cultural field

(context). Where the context was familiar, as in the case of long-term illness, the skills or personal resources that she drew upon to manage her health formed part of the habitus; this can be seen through the narratives of women employing the Negotiating strategy. In contrast, where the context was unfamiliar, dissonance occurred between the habitus and the context, which women described using the Navigating strategy as leading to a high level of disruption; this posed considerable health-management challenges.

In telling their illness stories, participants employed the broad narratives described by

Frank (1995); the Negotiating narrative strategies evoked narratives of quest and the search for ways to better manage their bodily signs and symptoms. In contrast, women who used

Navigating narrative strategies drew upon narratives of restitution, based upon their assumption that their current bodily experiences would be resolved post-menopausally— following the passing of time. That is, women expected that their problematic bodily events would cease after they had passed through their menopausal transition.

At the same time, women who employed the Negotiator and Navigator narrative strategies constructed the relationship between the body-self in different ways to those who predominantly employed the Maintaining or Contemplating narrative strategies. Rather than positioning either the body or the self as the foreground of their stories, with the other as the background, these women constructed their body and their self as having equal importance in their narratives. Women who used these narrative strategies described their self as being under constant revision, and working around the needs and demands of their bodily events.

In this way, the self was dynamic, yet mediated by their bodily events.

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Negotiating narrative strategies, discussed in the following section, were employed by women who had experienced prolonged bouts of (often chronic) illness. Central to their narratives was the struggle between their body and their self in their attainment, and the search for resolution, with the aim of enabling them to live an uncomplicated, unproblematic life.

NEGOTIATING NARRATIVES: INCORPORATING BODILY LIMITATIONS

For several women, midlife health problems were another health challenge in a life which had consisted of many similar health concerns. Unlike the first two narrative types, the biographies and life trajectories of women who used Negotiating narrative strategies were neither shaped nor determined by the presence or absence of health problems specifically related to their life stage. Instead, the illness experiences of these two groups of women were

“inseparable from [their] life history” (Kleinman 1988:8). Their narratives followed a similar pattern and consisted of many smaller stories about managing their symptoms with the ultimate aim of maximising their wellbeing and quality of life. These narratives are illustrated by examples of decision-making, weighing up different bodily signs and making an evaluation about how to respond to these bodily events. I have termed these narrative strategies

‘Negotiating,’ given the on-going nature of their health management behaviours and activities, as opposed to the relative newness of complicated health status experienced by women who employed ‘Navigating’ narratives, which I discuss later in this chapter.

Throughout these narratives, the body was the antagonist against which the self was diametrically opposed; the body inhibited and prevented the self from partaking in ways which were desired or ideal.

Women telling Negotiating narratives tended to have an extended personal history of ill-health, whereby they had to negotiate their own health problems and concerns in the

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context of their other life demands. All of these women reported troublesome or disruptive menopausal symptoms, most commonly in the form of hot flushes, mood changes and/or aches and pains. Such bodily symptoms added high levels of complexity to their midlife experiences, particularly when their existing health conditions presented symptoms similar to menopause, as they were often difficult to manage. Although all who told Negotiating narratives were taking some form of hormone replacement therapy, many expressed uncertainty about what symptoms were related to menopause and an associated changing hormone profile, and what symptoms were due to their other health conditions (which I described in Chapter 4).

In the following section, I provide a case study of Ferdie, who described regaining

control over her body through strategies for managing problematic and confusing bodily

signs and symptoms.

Regaining control: Ferdie

Confusion about causality and the ensuing treatment-seeking for their symptoms presented numerous challenges for participants who used Negotiating narrative techniques, as these women were often unable to determine which symptoms could be attributed to what condition. For several, the co-occurrence of multiple conditions, many of which presented similar or vague symptoms, offered considerable challenges to their attempts to gain control over their body. For many women, attempting to gain control over their bodies through health management relied upon the presence of others: for example, health professionals aided women in responding to her bodily signs and symptoms (discussed in greater detail in

Chapter 7). Women’s vague, non-specific symptoms impacted upon her own (self-) health management. Ferdie, for example, relied on biomedical explanations and remedies to assist her to keep symptoms under control so that she could maintain an adequate quality of life.

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For her, maintaining this quality of life meant being able to carry out her daily activities

(work, family, and household duties) without high levels of pain or discomfort.

Ferdie had experienced poor health due to hypothyroidism for most of her adult life.

Hypothyroidism occurs when the thyroid gland does not produce sufficient levels of thyroid stimulating hormone (TSH, Topliss and Eastman 2004). It affects women at a much higher rate than men (5:1) and diagnosis is sometimes difficult, due to the presence of multiple and vague symptomatology, including fatigue and lowered energy levels, weight gain, feelings of muscle weakness (Heitman and Irizarry 1995), changes in mood and deteriorating mental health (Larisch et al. 2004). These signs are confusing for women, who are often unsure what is underlying them.

In addition, Ferdie was diagnosed with Ross River Fever during her late 40s, three years prior to our interview. Ross River Fever is a vector-borne virus, spread by culex annulirostris (inland only), ochlerotatus vigilax or ochlerotatus camptorhynchus mosquitoes, that predominately affect people in rural areas (NSW Department of Health 2000). Symptoms include fever and chills, bodily aches and pains, joint stiffness, fatigue, and a skin rash (ibid).

In some cases, it remains in the body for many years after infection, with periodic recurrence of symptoms. Both Ross River Fever and hypothyroidism present symptoms that can also be attributed to menopause, which caused confusion and frustration for Ferdie, as she described in the following excerpt:

First thing in the morning you climb out of bed and [you’ve] got to get the ankles working again and, I don’t know, I can’t do the things I used to do. When I got Ross River, I stopped doing everything because I couldn’t and now it hurts when I try and get back into it. I don’t know if I should blame that on midlife but if I was younger, I think I would have bounced back quicker. (Ferdie, age 54)

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In addition to the aches and pains that she experienced in part due to the Ross River

Fever, she experienced mood changes, which may also be caused by a decrease in TSH

levels, as she explained:

The thing about the thyroid is that it produces hormones as well as your reproductive bits and so menopause and the thyroid problem tend to present the same symptoms. Mood swings, hot flushes. Not so much hot flushes with the thyroid, but mood swings and vague[ness].

Ferdie encountered ongoing difficulties in answering her own questions about what

condition was responsible for what symptoms. Such questions were central to her own responses to her bodily events. The lack of clarity, and accompanying absence of a direct

answer, meant that managing her symptoms, and thus her wider health status, was constantly

challenging. Ferdie’s narratives sketched images similar to those of Martin (2001) which

described fragmentation of the self away from the body. Her self-health management,

described as ‘taking responsibility’ for one’s own health, was a key mechanism for her to

regain some level of control over a body which was dictating the performance of the self.

Self-health management often involves working in collaboration with medical professionals

to improve or maintain one’s health, but the emphasis when describing self-health management is on the role of the ill person (the experiencing person, indicated by ‘self’)

within those relationships, as demonstrated below.

Self-health management

One aspect of self-health management involves regular surveillance, or evaluation, of one’s

own body for any changes in order to determine what is “normal for me” (as discussed in

Chapter 4), and what is pathological, and therefore in need of a medical (or medical

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knowledge based) response. In conducting such evaluations of their bodies, participants used distant, medicalised gazes when studying their bodies. The constant surveillance objectified their bodies, which women expressed through their speech, as Ferdie did: ‘the ankles,’ ‘the thyroid’ (cf. Manderson and Stirling 2007). Where bodily events were perceived to be part of a ‘normal’ woman’s life course or not disruptive and therefore easily incorporated into women’s biographical flow, women sometimes used non-possessive patterns of speech (e.g.

‘menopause’).73 This suggested that even though women understood their bodies as unpredictable and uncontrollable, these events did not impact on the self (cf. Martin 2001).

The internalisation of the medical gaze and the applicability of it to the observer’s body is what Foucault (1984, 1985, 1988, 1989) argued has been one of the triumphs of medicine, and is the ultimate aim of medicalisation. The practice of medicine and the clinical gaze are taken into the home (i.e. out of the clinical setting) and the individual adopts, to some degree, the role of the medico. In doing this, medical-style bodily checks are conducted on a daily, weekly, or monthly basis and occur in a way that is demonstrated, and often prescribed, to them by their medical practitioner. The checking of one’s body for

‘abnormalities’ (as determined by biomedical parameters) is a way in which individuals informally adopted the role of the medical profession (ibid.; Turner 1987, 1992, 1996).

Women who told Negotiating narratives frequently engaged in self-surveillance of the body – a practice not confined to this group of women. Such policing of the body has been described elsewhere in ambiguous terms: either as empowering (as described throughout the edited volume by Lock and Kaufert 1998) or as removing bodily autonomy and authority

(e.g. literature on medicalisation, specifically in the context of women’s health, Bell 1990;

Komesaroff et al. 1997b; Martin 1997, 2001); my participants who used Negotiating narrative

73 Women rarely stated ‘my menopause;’ this is not always the case, as they often describe ‘my periods’.

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strategies typically described their encounters with medicine in terms of their empowerment

and knowledge, and as offering them a way to regain control over a body that was often out

of control (cf. Peake et al. 1999, 2003).

Self-surveillance practices have been widely and regularly employed by women across

a range of contexts, from reasons concerned with body image (for example, ‘watching their

weight’) to those related to preventive health (for example, breast self-examinations). Within

this sample, this group of women did it in ways suggesting that they engaged in practices of

medicalisation and had, to some extent, adopted the role of the medical professional

themselves in an attempt to regain/maintain control over their bodies, which they expressed

as ‘being in control’ or ‘getting [body/illness] under control’. Their active medicalising of their own bodies was empowering and provided a way of seeking certainty given the uncertain context of their bodily events.

As Ferdie’s narratives demonstrated, uncertainty due to disruptive bodily events was a common feature in the life stories of all participants who used Negotiating narratives.

Women who told these narratives actively engaged in medicalisation as a technique for managing their bodily disruptions and regaining control over their lives, which had been disrupted for extended periods due to their ill-health. Hattie’s midlife narrative, outlined below, highlights the ways in which the health experiences of this group of women dictated their social participation and, in this way, contributed to the ongoing control of the body over the self.

Living in a complicated body: Hattie

When I first interviewed Hattie, she had recently turned 50 and was in the process of evaluating her life – not dissimilar to women who told Contemplating narratives. Her health, however, had complicated her lifestyle since her late 20s, when she first began exhibiting

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symptoms of auto immune system dysfunction. During the time that had elapsed since then, her life had largely consisted of managing her high levels of environmental allergies and sensitivities (mostly undiagnosed). As already noted (Chapter 3), after she became post- menopausal (early) at 42, she began to experience considerable amounts of breakthrough bleeding, despite trying multiple hormone therapy regimens in order to halt it, which resulted in low blood iron levels (anaemia). The combination of the allergies with the disruptive bleeding and its accompanying anaemia left her physically drained. Fatigue became a defining feature of her midlife experience:

I’ve found my ill-health very relevant… One of my big experiences of midlife that has been pivotal actually has been part the fact that I’ve had bleeding… That has ripples through all sorts of bits of your life, in terms of inconvenience and relationship things, fatigue and whatever. But I’ve also had a big experience of anaemia and I’ve had the experience that I now have a local doctor who has taken that really seriously and in hand, but the doctor who was previously treating me didn’t take it very seriously as a quality of life issue. And I already have another problem that creates intense fatigue in my life but I would think even for a woman who didn’t have that… the fatigue that you have from anaemia and low iron is intense, it is disabling, and that has had ripples right through my relationships, through my life, including in relationships because it governs what I can or can’t do, what commitments I keep, even just daily looking after myself properly. So that’s had a really, really major influence on my life. (Hattie, age 50)

As Hattie recognised, her health was a major factor in her lived experience, as it had profound impact on her social and community participation. An extensive literature has found that an individual’s response to illness and her ensuing psychological health, particularly their coping, are mediated by factors relating to social support (see, for example,

Lambert et al. 1990; Bloom et al. 2001; Kawachi and Berkman 2001). Family is a crucial

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source of social support and, where the family support is limited, support from friends becomes central (Walters and Charles 1997; Seeman 2000). Hattie had a very limited extended family—her mother, her only family member, was suffering dementia and required high level care, thus resided in a facility in a city some six hours drive from Waterside:

Being alone without family, I find, has huge ramifications on my midlife, because it [has significant impacts] on my life, but also [impacts upon] the changes in midlife. What I see around me, the people in their midlife are doing a lot of family and extended family stuff, and I don’t have that opportunity.

Consequently, Hattie’s friends were important in helping her long-term coping with her illnesses. Her health status, however, prevented her from participating in many social activities, which in turn restricted the levels of support she was able to receive from her friends. Her allergies began prior to her arrival in Waterside yet what had changed during her midlife, was the addition of a further health condition, which further disrupted her life.

Where the presence of a partner may help to alleviate some of the burden of caring for oneself during serious illness, Hattie was not partnered at the time of her first interview and, due to her poor health, believed that this was unlikely to change in the future. From

Hattie’s perspective, her health prevented her from obtaining this form of social support:

I think, well the reality is, I wouldn’t want to share my life with someone who’s got the problems I’ve got and the limits I’ve got. If I was healthy and fit, I would find that really difficult. That’s a really big ask, and what I’ve found so far is that it just doesn’t work, because when I have gone into relationships with men, it’s usually they either end up being fairly damaged people, or people who have expectations in a relationship that I think are not appropriate… But sometimes I’ve tried to adjust because I think it’s a big ask asking them to put up with what I’ve got to put up with, so perhaps I have to try and do this. But I’ve finally come to this stage in life where I think, ‘no it’s

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lonelier being lonely in relationship than being on my own.’ And if I can’t have an appropriate, decent relationship, I’d rather be alone.

As she alluded to in this quote, during her previous relationships, Hattie attempted to compensate her partners for her health-related limitations by accepting their expectations or behaviours that, had she not been ill, she would not have permitted. Her body posed limitations on her physical and mental health. Thus, her bodily experiences operated in ways that were contrary to positive self-concept and wellbeing.

Hattie’s physical health – experienced through her body – impacted directly upon her self. Her self was inseparable from her body, yet the latter (body) operated as a direct barrier to the enactment of the self. As she described, because of her body’s maladies, she was unable to experience features that she believed were essential to being-in-the-world. In particular, Hattie felt that her bodily experiences were the primary barrier to her formation of new, intimate relationships yet also profoundly impacted upon her capacity to engage in friendships. Hattie’s environmental and chemical sensitivities isolated her from others, as her potential bodily responses to new or different environments prevented her from going to many places. For example, when we were scheduling our interview, she wanted it to occur somewhere outside of her home yet, due to her allergies, this alternative venue could not be smoky (from wood-fired stoves or heaters) or have dog hairs, and needed very good ventilation. Given that our interview was in winter, and many homes in Waterside were heated using wood heaters (due to high electricity costs and limited gas supplies), our options were limited; Hattie indicated that this was a common occurrence when she was trying to maintain and manage her friendships.

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Health status and bodily limitations: Daphne

Bodily limitations, sometimes literally placed upon the performance of the self, were common themes running through the narratives of women who used a Negotiating strategy.

Daphne had been actively involved in the arts community in Waterside for over twenty years and, following her retirement, had decided to commence a performing arts course, a decision which involved a move to a much larger city several hours away. She developed pain, stiffness and limited movement due to polymyalgia and arthritis and found that not only was she unable to use her body for performance, but she was unable to move around the stage:

I went for two years, first of all really struggling with it and then I just couldn’t function. I was doing a university course at the time and I couldn’t drive. I had to drive [to the campus] and I couldn’t drive the car some mornings. I was only able to continue going to classes for a while because my friend had [a] car. But when [her friend no longer had the car], I just thought I can’t do this any more. It was a performing arts course so there is a lot of physical stuff in it and I just couldn’t do it, so I had to drop that course and come back to Waterside. It was very disappointing, but it wasn’t hard to make the decisions because I just physically wasn’t able to do it because in performing arts there is so much physicality… There were a lot of things I couldn’t do, that were really difficult. I had to climb up these old airplane stairs at the back of the set and trying to get up the balcony thing and it was difficult. (Daphne, age 59)

Although her experiences of returning to study illustrated her point, this was not the only context in which she was unable to move around. Polymyalgia rheumatica is an auto immune disorder characterised by stiffness and aches in the shoulder, neck and pelvic regions

(Salvarani, et al. 1997). Diagnosis is difficult as no consensus exists in terms of either symptoms or aetiology, although it has been associated with giant cell and rheumatoid arthritis (ibid.). Due to her bodily aches and generalised stiffness, Daphne found that general

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movement around the community was also difficult. She believed her health had compromised her lifestyle and quality of life prematurely, as she is limited in ways that much older women who live in the community are not:

It [polymyalgia] makes you into an old person. I am an old lady too early. I felt really bad this morning because I had to get someone else to come and pump up my [car] tyre for me. I said to Alison [worker at the service station] when I went and told her, ‘this just makes me feel like an old lady now’ and I am only sixty. I see Virginia [woman in her mid 70s] skipping around the main street and walking to and from home with a backpack on. She is much older than me. I watched Betty [another woman in her 70s] jump the gate of the house next door the other day, and I thought, ‘Oh no, why can’t I be like that?’

A common theme employed throughout Negotiating narratives was bodily betrayal of the self, as described by Daphne; its implications reverberated throughout the narrators’ wider lives. It required women to renegotiate their commitments and, although often reluctantly, seek help from others to manage their affairs—for example, when Daphne had to get someone else to inflate her car tyre or hired someone to maintain her house and garden, since pain prevented her from doing this:

[In terms of my] body getting older, I don’t really think about it as much until I want to do something. Like Kevin’s [son] doing jobs for me today, I am paying Ronald to cut back [my garden] because the vine there has got beyond me. I can’t do it anymore. Particularly [since] the [onset of] polymyalgia… That’s the frustration, not being able to do those jobs yourself. This is a large block of land and it is just becoming overwhelming. But the jobs have to be done. I love to garden but I haven’t done any gardening for years.

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At the same time as bodily events placed limitations upon the daily lives of women using a

Negotiating narrative strategy, confusion about symptom experience added further

complexity to their self-health management.

On-going management, or no choice but medicine: Ash

For Ash, the diagnosis of Systemic Lupus Erythematosus (SLE or Lupus) in her late 40s

resolved her uncertainty about what was happening to her body, and ten years later, her on-

going management consisted of long-term medication for SLE and HRT. SLE is a disease of the immune system caused by the body’s inability to detect the boundaries between self and non-self (Mendelson 2006). In much the same way that the body is confused about what is foreign and what is not (thereby triggering an immune system response), Ash, like Ferdie, was confused as the symptoms of the SLE became apparent:

I started getting very arthritic and stuff like that. Being a pretty active person and playing a lot of sport and everything, I couldn’t work out what was really going on. Then I developed hot flushes, so I was put on the hormone replacement when I was probably about 49, as a trial to see how that would go. Then over a period of time it seemed to just get worse and I started blaming the HRT or the menopause and so forth and it had nothing to do with it. It was just a fact that I was a lupus sufferer and for some reason it started at that stage of life, which was most unusual… There are lots of symptoms but the main factor with me was stiffness in joints, knee, ankles, elbows, fingers. I didn’t think I was suffering from the fatigue but I was, because I really had to be in bed by eight o’clock at night… The other thing was that I did suffer having a bit of a temperature in bed at night. Because those three factors were going on, then they started looking a bit more and I had a lot of blood tests [at which time, lupus was diagnosed]. Which in time down the track, a few years later, turned out to affect my liver. (Ash, age 60)

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SLE is a chronic autoimmune connective tissue condition affecting mainly women, which causes inflammation of body tissues (Better Health Channel 2000; NLM and NIH

2005).74 Aetiology is uncertain, and diagnosis is often problematic due to non-specific symptoms, including fatigue, photosensitive skin rash, chest pain, joint pain, swollen lymph nodes, numbness and tingling in extremities (D'Cruz 2006). It is a chronic condition and ranges in severity from mild to life-threatening, which largely occurs when inflammation of major organs occurs, resulting in potential dysfunction (ibid., Klippel 1997; Better Health

Channel 2000). Treatment largely occurs through lifestyle interventions (healthy diet, participating in physical activity and through stress management) or, where necessary, medication. Medication may consist of non-steroidal anti-inflammatories, corticosteroids, immunosuppressant or anti-malarial drugs (Murtagh 2006); adherence to medical treatment regimes has been shown to significantly improve health outcomes for people whose organs

(such as liver or kidney) are affected (Gladman 1995).

SLE-related inflammation affected Ash’s liver; thus, the potential for liver dysfunction meant she was unable to cease her (corticosteroid) medication. Her understandings of the importance of adhering to a medication regime were based on information detailing the historically poor prognosis for women with SLE prior to the development of such treatments:

[I don’t ever forget my medication] because it’s so important that I have to [take it]. Back in the 1950s, they didn’t know. Lupus will always attack some organ in the body. Liver was very unusual. Kidney was one of the main [commonly affected organs], or the heart, or the brain, so now what they do is they treat the organ that’s been damaged. Back in the 1950s, you had five

74 The ‘Better Health Channel’ (www.betterhealth.vic.gov.au) is a health information website developed and maintained by the Victorian State Government. All articles are posted subject to rigorous peer review and are approved by relevant community-based disease-specific organisations. In this instance, the ‘Lupus explained’

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years life expectancy. So because you know it’s very serious, you just don’t forget.

Ash’s understandings of the centrality and, indeed, the imperative of adhering to a

medication regime as part of her ongoing health management were constructed and derived

from biomedical understandings of SLE. Uncertainty and unpredictability are core features

of the lived experience of SLE and thus, the search for bodily control is an important theme

in these stories (Mendelson 2006). Bodily control was also important to Ash. Through

medication, Ash believed she was able to gain some level of control over her bodily signs and

symptoms and avoid unwanted effects on cognitive functioning. Her reliance on medication

to the end of her life meant that Ash’s identity shifted to accommodate her chronically ill

identity.75 This also amended her imagined biography which had, until that point, consisted

of continuing activity and family life. In addition, her notion of “normal for me” also changed, so that ‘normal’ now consisted of a strict medication regime and accommodation of its side effects. Like Martin’s self and body image schema (2001:77-78), Ash’s narratives were concerned with the opposition of the body and the self: her body needed controlling by her self yet, in responding to her bodily signals, her self needed to adapt to her body’s needs.

Self-health management was therefore a central aspect of Ash’s daily life. Several years prior to our interview, Ash ceased taking HRT after a close family member was diagnosed with breast cancer; an increased risk of which is implicated in long-term HRT usage (although this is contested, see La Vecchia et al. 2001; Banks et al. 2003). At that time, her menopausal symptoms returned and became very disruptive:

website was designed in conjunction with Lupus Australia, which is the peak body supporting and advocating for people living with lupus (www.lupusaustralia.com, www.lupusvic.org.au). 75 This reflected the identities of women in Mendelson’s (2006) study.

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It’s been a long period [since her SLE diagnosis]. The hormone replacement, I went off it a few weeks ago and I had to go back on it because I was having terrible hot flushes again and life was just miserable. It’s like living in the tropics and your body feels constantly wet… That would last probably five or ten minutes and then it would just gradually go and go back to normal again. But then in another hour or half an hour it would happen all over again.

These disruptions were minimal whilst she was under medical treatment.

Medicalisation impacted upon her life in two, seemingly contradictory ways: firstly, it was presented to her within a discourse of fear around undesirable outcomes should she discontinue pharmacological treatments. At the same time, however, Ash used it to rebalance the self-body relationship and enable herself to perform in desired ways. Whilst her symptoms and bodily signs were relatively easily managed once she recognised the underlying pathology complicating her health, this was not true for all of the women who told

Negotiator narratives. For example, in contrast to Ash, Abbie found that her biography was peppered with distinct, seemingly unrelated health events, all of which had impacted upon her well-being. When these events were combined with her menopausal experiences, they were highly distressing—and exacerbated by some of the negative aspects of living in a small community such as Waterside, i.e. gossip and lack of health support.

A central component of the Negotiating narrative strategy was therefore related to the interaction of the body-self. In similar ways to the women who employed Maintaining narrative strategies, these women sought to gain control over their unruly bodies, which were interfering with their desired embodiment (i.e. how they presented themselves to the world).

Medicalisation, whilst imposing controls over the women through the processes of diagnosis and subsequent application of treatment regimes, allowed them to regain control over their bodies, and therefore opportunities to have a meaningful existence, as defined by them.

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While I explore the implications of their ‘taking control’ in Chapter 7, Abbie’s case study illustrates how some women were empowered through their encounters with medicine.

Knowledge and self-health management: Abbie

Abbie’s midlife story, like Hattie’s, was situated within a life of considerable problems associated with menstruation, which may possibly explain the importance each of these women placed upon the menopausal transition itself. In addition, such a health history may also explain her interest in being an empowered patient, through self-education, and her experience of negotiating medical encounters.

Abbie had a hysterectomy at 40, when her ovaries were retained. She believed she went through menopause much earlier than other women, at around 43, although she was uncertain about when exactly she passed through her menopausal transition: due to the hysterectomy, she no longer experienced menstrual bleeding and thus, had no visible signs to indicate exactly when she became post-menopausal. She therefore defined menopause not as the end of her periods or cessation of menstruation, but as a reduction in hormone levels

(described in Chapter 4). Due to her early age at menopause, she experienced co-occurrent bodily signs, which challenged both her and her doctor’s notions about menopausal symptoms:

By the time I was 43, my oestrogen levels had gone very, very low, so I had a lot of big problems associated with that really early. I went to the doctor, and I was getting a bit of depression, but you know I tend to get depressed in the winter time. Anyway, it was winter time. And I went to the local doctor and I said, you know, I felt that I was menopausal because I used to always get cramps in the ovaries. So I knew, because I’d lost the uterus but I was still getting the cramps in the ovaries and they’d stopped, so I went to the doctor… He said ‘no, you’re too young, you’re far too young.’ I had read that when you have a hysterectomy and you only lose your uterus, that your

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ovaries can give up because there’s no need for them to work anymore. I’d read that and I told him. [He said], ‘No no no no no, we’ll put you on anti- depressants’. So I was given an anti-depressant and I brought it home. I had it for a couple of days and I thought ‘I’m going to throw these bloody things away, it’s not what I need.’ So I went back to him and I said ‘I demand you take my oestrogen level’, so he did and they were very low. So I went on HRT. (Abbie, age 54)

Through her knowledge of menopause, which she described as greater than that of her doctor, she became an active participant in the medicalisation of bodily signs. Her privileging of her own menopause-related knowledge over his was related to both his [young] age and self-admitted lack of familiarity with menopause. Abbie sought as much information as possible with the aim of becoming as informed as possible; in this way, she acted as a lay health expert. Although she dismissed his diagnosis of depression, she did not seek alternative explanations for her embodied experiences; that is, she did not consult other medical or health professionals, such as community nurses or alternative health providers, possibly because of geographical location and the very few available options. Instead, she persisted in seeking a medical diagnosis and subsequent treatment. Treatment for Abbie was not as straight-forward as it was for Ash; she and her doctor attempted multiple combinations of hormones to manage her health over a period of about eight years, as she described:

I was on HRT and on and off different kind of doses for years and it didn’t seem to work. There were all kinds of problems with that. I put on a lot of weight, felt uncomfortable basically and then I had a very low libido, so they put me on some testosterone. That was dreadful, so I threw that away and then I went on. I was having progesterone, oestrogen and testosterone at one stage. Then I threw them all away and I heard about some people in Melbourne that were doing a thing where they tailor-made… the natural

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phyto-oestrogens for you personally. I went on those for a while but I found those not too good either after a few years.

Abbie eventually ceased taking HRT for her symptoms, although in the time between

her cessation of the medication and our interview, she had resumed and ceased HRT several

times; in addition, she had taken anti-depressants at various stages since her late forties.

Throughout her narratives, Abbie emphasised the ways in which she was an active, equal

participant in her own health care. She described her doctor as equally uneducated about

menopause and midlife health issues as she was at the beginning of her menopausal

transition (hence, the difference in opinion about whether she had actually began her

transition), which she emphasised through her first story. Paralleling her story about getting

the HRT dosage correct was a narrative about how Abbie and another woman (Chappers,

also a participant in this study) actively sought out information and educated themselves

about menopause, and then passed this information along to the local GP:

That was back in the 80s and in those days, there was even less research done. It was incredible how little research was done. So I started reading books and finding out all that I could, along with another woman in town. We started reading together and we were bombarding the doctor with all of this stuff, the poor man, like ‘read this, read this, read this’… There was only this one other woman who was available to talk about it… One day I got this phone call and she said ‘help’, so I went around there with what research I had and we talked about it and then she rang around doing her research, and then we helped each other.

In this way, Abbie was not merely a passive medicalised body. Like others who used

Negotiating narratives, she had experienced long-term health problems and therefore had

devoted considerable attention to recognising bodily signs for many years. Even in midlife,

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when dealing with her menopause-related problems, Abbie actively pursued treatments which suited her rather than adopting general advice from health professionals, as evidenced by her pursuit of individualised hormone treatment regimes.

TROUBLESOME BODILY SIGNS: BIOGRAPHICAL DISRUPTION OR FLOW?

Women who used Negotiating narrative strategies typically narrated complex stories within which they were constantly balancing out the impacts of the narrative antagonist (their body) upon the protagonist in their stories (their selves). The complexities inherent in their stories, however, were related to much wider influences than suggested by a struggle between body and self; within their narratives, the body-self relationship was dynamic and constantly reframed as they learned new techniques for responding to health concerns. Their surveillance of their own bodily signs and active engagement in processes of medicalisation indicated that these women employ such mechanisms to redress potential imbalances of power. These mechanisms related specifically to doctor-patient power relations, but equally as pertinent, they were important in the struggle between the two elements of their being: the body and the self. In this way, women who told Negotiator narratives behaved in ways similar to those described by Fox (2005) who argued that, in postmodernity, the treatment of illness is no longer the domain of the medical profession but instead derives from shared understandings of and negotiations between the doctor and their patient.

The concept of biographical disruption was introduced by Bury (1982:169), who described illness as ‘precisely that kind of experience where the structures of everyday life and the forms of knowledge which underpin them are disrupted’. In this way, the experience of illness has profound impact on the individual, by enforcing changes in social relationships, roles, and systems of knowledge. For example, as I describe in the previous section, Ash’s illness led to high levels of fatigue, aches and pains; consequently, her social participation

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altered – she was unable to participate in sports in the same way as she had previously, which meant that her interactions with her friends changed. In addition, her family-based roles were affected, as she was unable to continue household duties. Her interactions with her partner, children and in-laws also changed due to her decreased energy levels. Whilst these social changes led her to reconstruct her self-identity, her identity was more pertinently affected by the ways in which she imagined her future. Her re-imagined future, post-diagnosis, was characterised by on-going considerations of her chronic illness.

One of the features that distinguished the women who used Negotiating and

Navigating narrative strategies was the way in which they employed the concepts of biographical disruption and biographical flow. Whilst the participants who employed the

Negotiating strategy described the initial biographical disruption of the onset of their ill- health (years earlier) and had resulted in transformations of their biography, this was not the case for women who used the Navigating narrative strategy. Given their past health histories, they understood their current illness experiences in terms of ‘biographical flow’ (Faircloth et al. 2004): as an ill-health event in a life course characterised by ill-health events. That is, they related stories where their illness had been absorbed into their self-construct and incorporated into their biographies.

In contrast, those who used Navigating narratives described their current or recent ill-health as a type of biographical disruption, albeit a minor one. The disruptions experienced by women who used Navigating narratives were typically less profound than those described by those who employed the Negotiating narrative strategy, related to the presence and persistence of long-term and chronic health conditions. Women who employed the Navigating narrative strategy described experiencing health events that made them re- evaluate and re-assess their self-concept and self-identity in addition to their social positioning. In this way, I suggest their narratives call upon the concept of biographical

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disruption, yet they understood these disruptions in terms of a type of biographical flow.

Their use of these two seemingly opposing concepts added further complexity to women’s narratives, which was expressed by their expectation of some disruptive menopause-related symptoms. Most participants in this study expected (and experienced) some hot flushes and night sweats during their menopausal transition. Where these were participants’ only (or main) symptoms, they employed narratives of biographical flow, as is evident through the

Maintaining and Meditating narrative strategies. In much the same way, Faircloth and colleagues (2004:248) found that older people viewed stroke as an ‘ordinary experience of old age’ and employed conceptual strategies to normalise their health status in relation to their age. Other symptoms which were not wholly expected, such as itchy or ‘creepy crawly’ skin

(as Aspidistra described) or vagueness, incorporated aspects of both biographical disruption and flow – women normalised and expected that they would have some health problems in midlife, yet those with multiple or troublesome symptoms described the challenges in managing these – a biographical ‘hiccup’ of sorts, which prompted some changes in their concepts of self and identity. Before I describe the experiences of women who employed the

Navigating narrative strategies, I will illustrate biographical disruption and flow using

Serena’s illness stories.

Embodying disruption: Serena

Between our first and second interview, Serena was affected by shingles, a condition caused by movement of the chicken pox virus (varicella-zoster virus) into the nervous system

(National Institute of Neurological Disorders and Stroke 2006a, 2006b). This results in mild to intense tingling or burning pain, and is characterised by the appearance of blistering or a rash; after the initial outbreak of shingles, individuals may experience postherpetic neuralgia, persistent pain caused by nervous system damage, or postherpetic itch, which is intensely

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painful and difficult to treat. Serena contracted a form of shingles known as ‘opthalmic shingles,’ which occurred around her eyes and upper face. This increased her risk of eye infection and also, more significantly for Serena, posed a threat to her eyesight. Serena’s narratives demonstrate the dynamic nature of women’s midlife, particularly in relation to their health. Her ill-health forced her to make radical changes in her self-concept and prompted her to change the narrative strategy she employed during our interviews, from a

Maintaining strategy in our first interview to a Navigating narrative strategy in our follow-up interview eighteen months later.

Serena’s illness prompted radical revision of her identity and imagined future. During our first interview, she described her commitment to bodily maintenance and understood midlife as a time to participate in fulfilling and meaningful activities for her:

[Midlife is] a stage in my life when I am coming to the end of my working life and starting new projects in my life… Because I’m an outdoor person, I’ve got a chance now to do bike riding, bush walking, those sorts of things, and photography, which I like to do. I have been doing a little bit beforehand but I haven’t been able to do it as much. So it’s a big positive as far as that goes for me. (Serena, age 52)

She had encountered some sports injuries and hot flushes but, prior to her illness, her biggest health-related concern was maintaining her physical appearance:

You retain your muscle strength if you work on it, you don’t actually lose that but it’s the outside appearance that is the problem. Your skin doesn’t stay as taut as what it used to and your eyesight [gets worse].

She denied that she was concerned about her own physical ageing, yet her stories highlighted the ways in which she had adopted negative images of ageing and, accordingly, shaped her health-related behaviours and practices:

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I just say yeah I’m getting old. I don’t wish that I was younger because I know that’s pointless I just say, ‘oh yes, I’m getting older,’ but then again I look a lot better than say a lot of other people. It doesn’t really worry me to the extent. A lot of people hate ageing and really have a thing about it. It doesn’t worry me. I know it’s going to happen and that’s all there is to it and my ambition is to keep as fit as I can and as healthy as I can.

At this time, several months before she became ill with shingles, Serena imagined a biography characterised by continuing good health, which she anticipated maintaining through her own behaviours and practices. She assumed that her health status would not change.

Also relevant was the way in which Serena referred to her body. She referred throughout the interview to her body parts in various voices which, as Manderson and

Stirling (2007) argued, described her relationship [of her self] to them. At the same time, her talk about her body parts highlighted the fragmentation of her self from her body (cf. Martin

2001). During our first interview, Serena referred to the body parts that allowed her self to perform in desired ways as belonging to her: “my Achilles” [tendon], “my toes”, “my eyesight”, “my (body) weight.” For body parts that did not restrict her self-representation, yet which did not conform to her ideal or desired body image, Serena generally used a second person referent to refer to and describe her body parts as: “your legs”, “your skin”, “your muscles”. For those body parts she felt did not accurately represent her self, she spoke of her body in distant, abjectified language: “the (excess) weight”, “the flab” [body fat], reflecting her alienation from these body parts (cf. Manderson and Stirling 2007). Her language illustrated the ways in which she fragmented her body-self relationship, which was mediated by the degrees of control the self was able to exert over the body. This fragmentation is important when analysing Serena’s story using Bury’s concept of biographical disruption.

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Bury (1982) described several aspects of biographical disruption that arise from

illness. Firstly, the initial disruption upsets the woman’s assumptions about her bodily signs

and events, which he called the ‘what is going on here’ stage (ibid.:169), where individuals evaluated their bodily signs and tried to make sense of them in terms of their previous bodily

knowledge. Using Leder’s (1990) theory, it is this aspect of illness that calls the body into view by making it the object of attention and signifying it as pathological in some way. As such, the bodily events call for a response from the self, firstly making sense of the bodily signs and then responding to these. Participants who used Navigating narratives often described initial feelings of confusion at the first onset of their troublesome symptoms.

Serena first began experiencing bodily signals which were completely incongruent with her previous bodily experiences; these were unexpected and prompted her to seek medical attention:

I got an earache. Then it went to the temple and then it went to the eye and half of the head over an eight-day period. I went to the doctors twice in that eight days and they said to me that they thought it was shingles but because no rash had come out [appeared], they really couldn’t physically diagnose it. I was going up to ‘Harbour Lights’ [six hours drive away] to see a friend and half way [there] in the car, it came out in a rash right there.

In describing the onset of her illness, Serena immediately distanced her self from her

body. Her language in this interview – as can be seen above: “the temple”, “the eye”, “half of

the head”, “it came out in a rash” – indicated how she had re-evaluated her body-self

relationship(s) following her illness, which itself impacted upon her identity (cf. Hartman

2004; Manderson and Stirling 2007). In addition, the physical restrictions imposed by her

illness changed her self-identity from being an active person, to someone attempting to

return to her previous lifestyle following illness:

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I’ve gone back to doing exercise. I just start off with doing my stretching and stuff. I’ve done some work in the garden, which got neglected because I didn’t have time… I’m much better now. I feel stronger and yesterday I went for a 3-hour bike ride with one of the neighbours. I felt really good… didn’t feel tired… Not that we went fast, we just pottered around but still, you know, it’s exercise.

This excerpt illustrates Bury’s second point, that illness causes profound disruptions in people’s explanatory systems, which entails reconceptualisation of their imagined (future) biography. Whilst this was a more significant feature of the Negotiating narrative strategy, some women who used the Navigating strategy described their changed understandings of their self due to their encounters with illness. In addition, Serena’s understandings of ageing and her own biographical stage were challenged by her illness:

I wasn’t sick. I’d never had a cold, a flu, anything, since I’ve been here. I [thought that] because I kept fit, I was fine, but obviously old age has caught up with me.

Her illness prompted her to re-evaluate her current position within her own life course. Prior to her illness, she had not spoken of her age-based identity in terms of ‘old-age’ as she had discussed midlife as one stage of the ageing process. Through becoming ill, Serena re- evaluated her age-identity, which shifted from ‘midlife’ to ‘old-age’.

Bury’s third point, that one’s response to illness-related disruptions involves mobilisation of resources, could be observed through Serena changing her community commitments and drawing upon her social support networks in different ways than she had prior to her illness. Before she became ill, Serena had been a mobilising force behind the development of a community information centre and had volunteered at the local church-

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run opportunity shop (op shop). She attributed her susceptibility to illness to the stress

associated with the demands of her (unpaid) roles:

I was working hard and doing a lot in the [information centre] almost every day. I was trying to find volunteers everyday and when I couldn’t find them, I’d be working down [there] myself… I felt obliged to oversee to make sure that the right information was given out and not the wrong information. So there was that sort of pressure there… it was a constant thing getting bigger and bigger.

Serena’s understanding of her community work pressures – and the associated stress – as

having a causal role in her experience of illness reflects recent work by Williams (2000), who

argues that life crises and stressors play a significant role in the onset of health problems.

Indeed, this was not only the case for Serena; other women also described biographical

changes as prompting the onset of their health problems. As I detail below, Aspidistra believed that changes in her family structure (her children all leaving home) prompted

depressive feelings – and stress – which, in turn contributed to her disruptive experience of

menopausal symptoms. From women’s narratives, I suggest that a cycle can be observed in many women’s lives, whereby illness and biographical disruptions are intrinsically linked into

a perpetuating loop, as shown in Figure 6.1.

Navigating

Biographical disruption Health problem

Figure 6.1: Cycle of biographical disruption and health problems

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Using Figure 6.1 as a model, Serena’s work stress was a form of biographical disruption, which impacted upon her health in ways that caused further biographical disruptions. From her narratives, it appeared that Serena’s task was to arrest this cycle in order to halt or slow the development of further health problems or greater levels of biographical disruption. Her ill-health already caused considerable disruptions in her life; accordingly, Serena was unable to continue acting in her work roles and therefore changed her position in her workplace.

Richardson and colleagues (2006) found that individuals experience greatest levels of biographical disruption in terms of their working lives. Whilst this was not wholly the case for Serena, changes in her workforce participation were significant in her life experiences.

She described having no choice in these role changes:

I backed right off from the [information centre] totally. Some people stepped in and took over what I was doing. I still did the money but [someone else] counted it and brought it to me, so all I had to do is bank it. I only did my first shift back in [there] on Tuesday and that’s from about [four months ago]… I [also] backed out of the op [opportunity] shop, [another volunteer] did all [of] my shifts in the op shop, so I got out of everything until I got better. I had to.

Her illness also impacted upon her social participation and ability to care for herself.

She described needing other residents to help her carry out her day-by-day life, where she had previously been self-sufficient:

[I had] friends and people like that supporting me [when I was sick]. That was really fantastic. They were bringing meals and stuff because when I got back from Harbourtown, I couldn’t see. I had just the eyelashes showing through and the other eye was all swollen up. [Gavin, my husband] was really crook [sick] with a bad case of the flu [common cold] and our neighbours bought food and stuff, so it was really good. So there was plenty of support from people in town.

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By seeking support from others during her period of ill health, Serena’s participation in the

Waterside community also changed; she relied on others for some of her care, something she

had not done before, and this challenged her own notions of independence and self-efficacy.

Her body became an object that constrained the true representation of her self, a tool that

disrupted her biographical flow. Thus, her stories of managing and responding to her bodily

signs and health events were, like other women who used the Navigating narratives, stories

of attempts by the self to regain control over the body and restore biographical flow.

NAVIGATING NARRATIVES: ADAPTING TO NEW BODILY CIRCUMSTANCES

Women who encountered disruptive and troublesome health problems for the first time

during midlife told the fourth broad group of narratives, which I have termed the ‘Navigator’

type. Until a distinct point in their biography, these women had enjoyed good health. In

general, they had not given their body a great deal of, nor had it demanded any, attention.

Serena was the exception, having originally used Maintaining narrative strategies, an adverse health event led to a transformation of her stories, which became Navigating narratives. In a similar way, many of the other women who told their stories through Navigating narrative strategies would have most likely incorporated aspects of a Maintaining narrative strategy

(particularly in relation to weight maintenance) had they not experienced a disruptive health event. Indeed, several referred to their past health and health behaviours through

Maintaining narratives, as Cynthia described:

I always tended to eat good food, and lots of water and I drink apple cider vinegar in the morning to cleanse and everything like that. Plus I do yoga I have done yoga since my mid 20s and I think that really keeps you [healthy]. (Cynthia, age 50)

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Like Cynthia, the participants who employed the Navigating narrative technique often described their health maintenance behaviours, but these were not the focus of their stories.

Rather, they told stories about how they had experienced, seemingly out of the blue, given their previously unproblematic health, one or more body- and/or health-related events, leading to changes from enjoying their good health and engaging in some behaviours aimed at sustaining and maintaining this good health, to responding to their bodily signs and symptoms.

Winterich (2003) suggests the need to understand why some women experience their menopausal symptoms as problematic yet others do not and, to this end, argued that social issues play an important role in women’s understandings of their bodily signs as problematic or challenging. In this study, social factors played a significant role in women’s interpretations of their menopausal symptoms, as their bodily signs either influenced or were affected by events in their wider lives. The Navigating narratives had a strong menopausal health focus. I understood women’s stories to employ a Navigating, as opposed to

Negotiating, narrative strategy because they described their health challenges as discrete events that did not require the on-going bodily surveillance and management described by women who told Negotiating narratives. These participants understood their menopausal symptoms to be problematic in some way, and therefore contrasted the interpretations given by women who used Maintaining or Meditating narrative strategies. Finally, like Negotiating narratives focussed on the chronic nature of health complaints, the health concerns of women who employed Navigating narratives were relatively short-term and widely perceived as having a distinct end-point. For example, women assumed that their menopause-related complaints would resolve themselves when they had passed through the menopausal transition.

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The midlife health problems of some women who employed these Navigating narrative strategies derived to some extent from earlier life events which did not manifest themselves until they reached their mid to late forties. Lesley believed that she was living with the consequences of alcohol abuse when she was younger, assuming it was going to cause arthritic pain:

I have a lot of pain in the winter, because I have had so many broken bones. I broke my leg skiing and I broke my arm once when I hit Larry [ex- partner]… I know later on I’ll probably get a fair bit of arthritis… All through my life, apart from my drinking, which has at times escalated to a fair bit, my father was an alcoholic and I think that runs in the family. Apart from that, which I bring on myself, [before now] I haven’t really had a lot of ill health. (Lesley, age 50)

For many participants who used the Navigating narrative strategy, menopause was a central event, often the main health challenge they faced during their midlife, yet they did not tell stories exclusively about menopausal bodily events. What distinguishes this narrative strategy from the other three was the way women’s narratives described their processes of learning to respond and manage adverse bodily events; it was the first time in their biography when their body was a barrier for them to attain their goals or perform their desired activities. Women used navigating narratives they first began to experience problematic body signs, which they described as unfamiliar and confusing. These narratives are distinguished from Negotiating narratives by the narrator’s experience of managing and responding to bodily events.

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A stressful time: Lesley

Lesley described a recent period of her life when a plethora of challenging health events occurred at the same time, after a life of having good health and high levels of wellbeing:

… my Mum had died and then I started drinking a fair bit again, because I was really enjoying it. Then I lost my driver’s licence because I got picked up for drink-driving [driving under the influence of alcohol]. That was the first time ever and that was a big shock to me after thirty years of driving, not being able to drive. Then I fell down the back stairs of my other house in the dark one night when I was carrying a lot of stuff out… It was just on dusk and… I was walking down the back stairs. It had been raining the day before and there must have been some moss on the bottom step, so I missed one step and landed on the bottom step and ripped all the ligaments in both my feet. I had to go to bed for nearly two months. I couldn’t walk at all. It was terrible. And [the doctor] said I’d have been better off if I’d broken it because when you do ligaments it’s really bad. I could hear them going and I thought this is going to be very bad. And then they [my feet] just blew up like balloons… So that took me a while to get over that really because I had to go to physio[therapy] for about a month and then I really couldn’t walk at all and I couldn’t ride my bike and I couldn’t really exercise at all. So I got really depressed then but I think all of that was maybe all to do with my Mum and the whole thing. I don’t know. It was like a compilation of events. My Mum dying and all that business and then getting drunk and then losing my licence and falling down the stairs and doing that. But as [the GP] said, maybe it’s just telling me I just need to sit down for a few months and just try and get over all of this… That was probably one of my blackest years I would say.

Within a short period of time, Lesley had experienced both physical and emotional challenges, which were due to related causes that she had never experienced before. This first experience of feeling let down by her body led to the onset of depression, which led her to resort to excessive (alcohol) drinking. Both the events themselves and their impact upon her

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wider life were disruptive to her self-construct, and notions of independence and wellbeing.

She resolved her depressive feelings, and many of the other health issues, once she regained mobility:

Once my feet came better, I started to walk around a lot, then I started not drinking so much because it was not helping my cause really at all. It just sort of came good in the end. Everything sort of seemed to work itself out. I finished up my Mum’s estate… so that was alright. Then I went to court and got my licence back, and that worked out all right. Then my feet gradually started to get better, so I think I just lost weight as I felt a bit better.

Lesley’s story demonstrated the interaction of external events on health and the experience of multiple life stressors on midlife women’s wellbeing. Lesley’s mother’s death and the stress related to dealing with the estate led to her increased drinking. This impacted negatively on her social (e.g. ability to drive a car) and physical (e.g. her feet) health which, in turn, impacted on her mental (as indicated by her depression) health. Whilst she managed to resolve many of these stressors (for example, sorting out her mother’s estate and regaining some mobility), some persisted and she was not able to completely return to her previous health status:

I still need fluid tablets for my feet, because one is really good and one is not too bad. But in the heat, [they’re] always pretty bad. I used to have a lot of fluid in the heat before anyway. So I go [to the doctor] and he checks them out, but as he says, there’s really nothing we can do now, I just have to keep taking the fluid tablets. It’s just a thing; the more I’m on them [my feet], the more fluid I get. But I just have to be able to walk, go out, work and what else, so I just try and ignore it. Hopefully it will go away eventually.

Thus, even though many of the issues that had initially contributed to Lesley’s poor health were resolved, as were their effects, she continued to feel some impact upon her life.

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She described walking as an activity that was central to her social participation in Waterside, both for moving around the community (including carrying out her day-to-day business, such as visiting friends or doing her shopping) and as a distinct activity, such as participation in the local walking group:

I am still in the Foot Mobiles Walking Group. I used to run that until about four years ago. Then Joan [a local woman] took it over, because I had run it for quite a few years and I still wanted to be in it but I didn’t really want to run it anymore. So I still belong to that, which is good [because] I really enjoy that… This Tuesday we’re going to the river, just to check out all the little [plants] and things like that.

Her inability to walk therefore impacted on some of her social participation and, in this way, Lesley’s period of poor mental and physical health resonated throughout her

(personal and community) life. Unlike the women who used the Negotiating narrative strategy, however, these wider life impacts were not ongoing: Lesley realised that her health would improve over time. In this way, the short-term nature of her health complaints shaped the stories which she told about her health experiences and also how she understood her biography.

Intimate relationship changes: Chappers

Like Lesley, other women who employed Navigator narratives understood their health concerns in terms of biographical disruption. For some, like Chappers, the bodily disruption was not profound, more of a ‘hiccup’ involving night sweats, vagueness and hot flushes, yet the implications of these bodily events had profound impacts upon other areas of her life:

I became a single person in my midlife because my partner left, so that was fairly significant, having got married originally at the age of just 19 and then

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at the age of 51 or something, to find yourself being a single person… you think of all the stories they talk about, the middle-aged man going through a midlife crisis and running away with the younger woman and… it really happens… I think Gregory [her former partner] found [my menopausal symptom experience] absolutely, like most men, couldn’t cope with it at all… I think that for a lot of men when their partner’s go through menopause, it’s a real crisis for them as well, because they can see, they’re looking in the face of something that’s [saying], ‘oh god, I’m fifty’. The old [realisation that] ‘life is creeping on’ and you’re now into the second half. And presumably the second half isn’t going to be quite as long as the first half! So I think they find it quite threatening. (Chappers, age 59)

Chappers believed that her menopausal experiences in some way contributed to the break-up of her relationship. Throughout our interview, she related many of her troublesome symptoms in terms of her former partner’s responses. By doing this, she expressed her feelings that her ageing, signified by her menopausal symptoms, prompted his realisation of his own mortality and subsequent midlife crisis, which led to his affair and their separation.

At the same time, she described his frustration with her psychological symptoms (vagueness and memory loss); through doing this, her stories emphasised the ways in which specific symptoms are gendered, and how the meanings of these symptoms are based on gendered constructions:

There were other women in [Waterside] who were going through exactly the same thing, so we used to get on the phone with each other and compare notes, and laugh like mad… Abbie [and I] used to chat [talk] with each other on the telephone quite frequently about where we were at, what we were up to and how vague we both were… She was doing equally silly things, and Brenda [a local woman] was as well. Brenda was constantly putting the washing in the fridge and the butter in the cupboard, and then wondering why she’d go to the cupboard and [think], ‘why have I put half a kilo of

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butter in the cupboard?’… [We] women used to laugh about it like mad, but the men found it entirely unamusing. I think they used to get on the phone too and compare notes about how their various women had obviously lost the plot, how menopause was the most frightful thing, and perhaps we all should be herded together with straightjackets and taken away.

By highlighting her (and her friends’) amusement at the impact of their psychological symptoms, Chappers emphasised the intensely negative responses from their male partners.

Little research has addressed gendered responses to women’s menopausal symptoms, yet narratives such as Chappers’ indicate that men’s responses to their (female) partner’s menopausal transition may play a significant role within their midlife experiences.

Such a silence seems in need of further exploration (cf. Manderson 2005), given the considerable attention paid to sexual functioning and sexual relationships related to menopausal status and ageing (including, but not limited to these: Hawton et al. 1994; Pearce and Hawton 1996; Dennerstein et al. 1997, 2001, 2002; Mansfield et al. 2000), which tend to be constructed as physical problems to be resolved (for example, vaginal dryness,

Dennerstein et al. 2001). Analyses of gender and the climacteric have typically centred on the biophysiological aspects of menopause and andropause (or ‘male menopause’), without consideration of either transition as a gendered social construct. Where gender has been considered, it has been through exploration of these transitions as only affecting one sex or another, rather than having impacts upon both men and women, and research to date has explored the differing constructs of the sex undergoing that transition accordingly. For example, menopause has been considered a ‘female’ condition and research has explored meanings of femininity or womanhood across the menopausal transition (such as Robinson

1996; Hallowell 1998; Goldstein 2000). There has been no research exploring the different ways in which the partners (male or female) understand or respond to a woman’s

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menopausal symptoms. Yet it is apparent from Chappers’ narrative that her and her partner’s

responses to her menopausal symptoms were patterned by gender, and these responses

played a significant role in how their midlife relationships were enacted, which in turn

impacted upon her midlife experience itself.

Drawing on work by Hislop and Arber (2003), I suggest that Chappers’ former

partner’s discontent with her midlife symptoms may have related to her (in)abilities to carry out her work roles; through experiencing vagueness, her work performance was impaired, evidenced by her account of ‘filing’ a large cheque in the freezer:

[I was] being so vague, and doing completely stupid things like putting a cheque for $60,000 in the freezer instead of [banking it] at the post office! Which I did think was very funny afterwards! I just said ‘well obviously I was freezing the assets!’… [Gregory] didn’t think it was funny that I’d put $60,000 in the freezer, and the more I laughed about it, the crosser it made him. [He] just couldn’t comprehend at all.

Whilst Chappers’ psychological symptoms caused her some concern, as demonstrated through her need to discuss them with her friends, they were not her primary concern.

Instead, the vasomotor symptoms caused her discomfort. As discussed in Chapter 4, she

described the hot flushes during the day, particularly during social interactions, and the

sleeping difficulties due to her night sweats, which impacted upon her day-time energy levels,

as challenging:

Nights [and] sleeping were hell. I’d have very broken sleeps because [I]’d go to bed and feel okay, and then [I]’d wake up in the middle of the night just absolutely boiling. So [I]’d fling all of the covers off and just be hot and sweaty all over, so flap the sheets or doona up and down, then put them all on again and drift off to sleep. It would be like that all night. I’d wake up in the morning absolutely buggered [exhausted] because I hadn’t had a proper

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rest. During the day wasn’t quite so bad, but I can remember my kids being down here with some of their friends, we’d all be sitting around the dinner table and suddenly I’d feel this heat, the temperature’s rising. My sons’ pals would [say], ‘here she goes again’ and pick up a piece of paper and flap [fan] it at me. And you really feel that you look peculiar, that you must be going brick red, but you’re not. It’s just that you feel hot and sort of sweaty, I suppose.

She described her discomfort in having unexpected hot flushes at inappropriate times, yet felt that her ex-husband had an insensitive reaction to her symptoms. He found her vasomotor symptoms problematic and frustrating, whilst Chappers felt she was unable to continue with their disruptive implications and sought medical advice. Hislop and Arber

(2003) suggested that many women consider disrupted sleep as a part of their normal lives; this was not the case for Chappers, who considered her difficulty sleeping as something that required medical attention. It is possible, however, that her partner may have viewed this differently and interpreted her highly disrupted sleep as normal (see Hislop and Arber

2003).76 At the same time, such gendered differences in responding to menopausal symptoms may also reflect wider community constructions of men’s and women’s roles, whereby women were expected to keep the household running smoothly, so as to enable their male partners to participate in paid employment without home-based distractions.

Coming to terms with changing roles: Aspidistra

The influence of bodily symptoms on women’s relationships was also significant for other women who used a Navigating narrative strategy, yet these were mediated by their social circumstances. Women highlighted changes in their home lives as being important to their

76 Chappers did not discuss whether her night sweats impacted upon her ex-partner’s sleep, which may have shaped his responses.

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understandings of midlife which, for some, resonated throughout their lives and impacted

upon their health status. For example, Aspidistra found that changes in her living situation

coincided with the development of menopausal symptoms, placing additional demands on

her relationship with her husband, Larry:

Six years ago, our youngest one left home, and that was all part of [my menopausal experience]. There is a very real thing called the ‘empty nest’ syndrome, so it was a very emotional time in one way or another. But the symptoms I had at the time, I can remember my skin used to crawl. I used to get itchy and get creepy crawly skin… [The empty nest] was just probably much more relevant for us, for Larry and I as husband and wife, because when we married, he had the four and I had two at home. So… right from the word go there were always kids there and then all of a sudden, it was just he and I. Like we never had time just by ourselves in the beginning, so that was a bit of a shock to me… (Aspidistra, age 57)

She experienced highly disruptive menopausal symptoms and believed they had a somatic basis, as she drew parallels between her embodied experience and events occurring in her wider life. In doing this, Aspidistra emphasised her enjoyment of caring for others and performing nurturing roles. Once she could no longer participate in these duties, she described heightened feelings of discomfort and disruption by her bodily signs, which she related to her self esteem:

Once I went on the HRT [after my child left] that [crawling skin] stopped, but the hot flushes were bad, the mood swings were bad, and also [I had] loss of self esteem. I think just the fact that you realise you are passed your child- bearing years and you enter that other age, it has a bit of an effect on you. I was lucky enough to be offered [work] at the time and that was a tremendous boost to my moral and self esteem. Since I have left work, that [my self- esteem] has suffered again, because I feel like I am a real non-entity again.

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And these symptoms are still on-going, I don’t have periods anymore but I am still getting the hot flushes…

By highlighting the importance of caring for others in relation to her self-identity,

Aspidistra’s stories supported Williams’ (2000) argument that biographical disruptions contribute to the onset of illness. She believed that changes in her family and working lives caused mental health problems, which exacerbated her physical symptoms. Prior to midlife, she had expected some bodily changes and signs yet described feeling unprepared for the psychological aspects of her health. In addition, she had not realised how dramatically changes in her social roles would influence her health experiences.

Women in midlife often report biological changes that affect their sex life (Winterich

2003). Changes in sexual functioning, prompted by her decreased libido, led to her questioning the quality and validity of the relationship with her husband, and highlighted tensions within their relationship:

The other thing I found, which was quite a personal issue, was I completely lacked libido. It just went out the window, so that is not very nice either. You feel pretty, very inadequate in that area. I think the HRT helps a little but not very much, so that could be, I mean I can’t just blame the hormones. It could be a relationship problem, I don’t know. That was another thing. I think that is also one of the symptoms. I don’t know if other people think this.

Participants tended not to discuss the sexual aspects of their relationships, which possibly related to both the generational difference between us and our roles within the community.

However, Aspidistra’s reflections on other women’s experiences of low libido and its impacts on intimate relationships suggested that a cultural taboo around discussing sexuality and sexual relationships prevailed among peers. Her uncertainty about the connection between

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the bodily signal (decreased libido) and the relationship with her husband reflected this social and cultural silence about women’s midlife sexuality. In much the same way as Aspidistra,

Winterich (2003:634) found women whose partners viewed vaginal dryness as problematic perceived their bodily events as symptomatic of their (poor) relationship, rather than related to the menopausal transition. Aspidistra’s husband’s lack of understanding about her decreased sex drive made her question the longevity of their relationship—she described how he would get frustrated with her when she did not want to have intercourse, which further exacerbated her lack of desire:

I just don’t take the initiative [in instigating sex]. I just don’t have any inclination to take the initiative. [The HRT] does help a little, but… it is [his] attitude too, something to do with the relationship… we have been together 22 years. I don’t know whether we will make another 22.

Her comments highlighted the ways in which women’s interest in sex decreased when it was no longer pleasurable, either physically (caused by insufficient lubrication) or emotionally

(caused by her husband’s frustration). In contrast to Aspidistra’s story, and adding further support to Winterich’s (2003)77 argument, Cynthia described how she continued to enjoy sex, even though she was now less likely to initiate intercourse:

I have always enjoyed sex and [I was often] the one to initiate it, to bring it on. The first years of our relationship were pretty intense. Since I have been on the oestrogen [hormone replacement therapy], I have calmed down a lot, but not to the point that I don’t enjoy it or don’t want it. I am just not the instigator any more. When it happens it is really nice… It annoys me that it doesn’t, I like to have that womanly lively feel from feeling sexy or whatever. Was that what it was like for you before?

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Yes, that was one thing that I always used to comment about my relationship with Dan [her partner]. He really made me feel like a woman sexually. Now he still loves me and I still feel like a woman but I haven’t, I feel like I haven’t got that spark and that spontaneous mischief. (Cynthia, age 50)

Cynthia did not highlight problems in the relationship with her partner as being related to changes in her sexual functioning; indeed she emphasised the high quality of their relationship. Whilst she found her hot flushes and night sweats extremely problematic as they impacted upon her daily functioning, unlike Aspidistra, she did not describe lowered self- esteem deriving from her menopausal symptoms or changes in her social role.

Given the socio-cultural value placed upon women’s sexuality and appearance in contemporary western societies (see Sontag 1978; Berkun 1983; Monteath and McCabe 1997;

Toerien and Wilkinson 2003; Ogle and Damhorst 2005), Aspidistra’s stories highlighted the impact of her changing sexual participation on her self-esteem – as her social and sexual participation decreased, so too did her self-esteem and positive self-identity. She embodied dominant cultural images of women’s worth and, due to her menopausal and social role changes, became devalued in terms of such social expectations. The biographical disruptions posed by the changes in her social roles (that is, her children leaving home and ceasing her working life) combined with her health prompted further biographical disruptions in terms of her self and social identities. This echoed Williams’ (2000) assertion that it is difficult to disentangle what prompted what: biographical disruption or ill-health.

77 Similarly, Winterich’s (2003) participants first discussed their sex lives during her study, which also suggested social factors (such as relationship quality) played a key role in women’s experience of problematic sex-related menopausal symptoms, contesting explanations in terms of hormonal deficiencies.

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MIDLIFE NARRATIVE STRATEGIES AND THE BODY-SELF

Women’s narratives highlighted the continual tension between the body and the self. For

those who used Maintaining narrative strategies, the body was the predominant medium

through which their narratives were enacted. It simultaneously overlapped and was

connected to the self, yet remained a distinct entity; in this way, the body enabled

performance of the self. Women controlled their bodies in order to accurately represent their

self. The appearance, or presence, of the body was therefore paramount within these

narratives. In this way, Maintaining narratives contested Leder’s (1990) assertion that the

body only becomes present in situations of disruption, such as those presented by disease or

illness.

Leder’s (ibid.) basic argument, however, was supported through the remaining three

narrative strategies. Women who told Contemplating narratives largely omitted the body

from their stories; the absence of their bodies, therefore, indicated the normality of its

functioning. These narratives were predominantly concerned with the self, which was largely

disembodied (although not completely absent) throughout their stories, indicating its

separateness. In contrast, and keeping in line with Leder’s (1990) argument, the body in

Negotiating narratives was abjectified, an object that betrayed the self, through its long-term

malfunctioning and disruption; bodily events, mostly in the form of ill-health events,

prevented the self from being expressed in ways that were truly representative of its essence.

Drawing on Martin’s (2001) images, the body sent signals to the self, which simultaneously needed to be controlled or managed by the self, yet the implications of which were that the self had to adjust. For example, Hattie’s body reacted to environmental allergens and presented as symptoms of an allergic reaction, which herself then had to control (“get under

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control”). In responding to these sensitivities, however, she also had to change her lifestyle to minimise the likelihood of having an allergic reaction.

Similarly, Navigating narratives were concerned with a body that failed to truly express the self, and became a source of disjuncture between the two parts (body and self) of being. As with women who used Negotiating narrative strategies, the body again sent signals to the self, which needed to be controlled. In managing or controlling these signals, women altered their practices of the self and thus, self-expression. What sets these two narrative strategies apart is the duration for which the body’s problematic signals forced the self to be accommodating. For these latter two narrative strategies, the body dysappeared (Leder 1990;

Bendelow and Williams 1995b), contrasting the appearance of the body in the Maintaining narratives, and the (relative) absence of the body in the Contemplating narratives.

In this way, women who used Negotiating or Navigating narrative strategies described the ways in which their body, and its events, were a barrier to their true self- performance and self expression, through placing limitations upon their ‘being-in-the-world’

(cf. Merleau-Ponty [1958] 2002). Öberg (1996:709) took this further to suggest that, where the body betrays the self, women will draw upon lay theories of ‘the mask of ageing’ ilk, in an attempt to redress the tensions between personal and social identity. The mask of ageing occurred where bodily appearance (upon which social identity was constructed) belied the youthful person inside (personal identity, cf. Featherstone and Wernick 1995), as Daphne described:

I am an old lady too early… [polymyalgia and arthritis] just makes me feel like an old lady now… and I am only sixty. (Daphne, who was actually aged 59)

Daphne’s excerpt highlighted how her problematic body determined the outward expression of herself, which she believed was incongruent with both her self-identity and her

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chronological age. Characteristic of the Negotiating narrative strategy, women who used

these stories described how their body had shaped their ability to truly realise the self over a long period of time, which they often anticipated would continue for the remainder of their life. Interestingly, these women tended to be more optimistic about their health status and future outlook as they had often shaped their concept of ‘being-in-the-world’ to accommodate their bodily limitations. In contrast, Navigating narratives were characterised by dissonance, due to women’s difficulty in adapting to a problematic or disruptive body, and coming to terms with its limitations, after their previous experiences of good health, and thus

being able to truly express the self.

Throughout the previous chapters, I outlined the narrative strategies employed by

women in my study. These strategies differed in terms of participants’ understandings of the

body-self relationship and their definitions of health or being healthy, and were largely

mediated by their health-related experiences, which were sometimes related to their

menopausal transition, although not always. The relationship between the body and the self

was an important theme in the narratives of all participants. In addition, the place of

menopause and associated bodily events were central to their understandings of their

imagined biographies and actual life course trajectories. To some extent, as described earlier,

menopause and the end of reproduction played an important, central role in women’s midlife

narratives and their understandings of their midlife stage. Having said this, menopause was

not the focus of the stories of many participants. The menopausal transition and associated

bodily symptoms tended to only be emphasised by women who used the Navigating, and to

a lesser extent Negotiating, narrative strategies. The importance women placed upon the

menopausal transition varied depending on associated health concerns and problems, and

according to the demands of their social and community roles and responsibilities.

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The privileging of menopause in women’s Negotiating and Navigating narratives raised important questions about why women emphasised the end of reproduction and thus, their biological role, over other stories they could tell about their midlife. Martin (2001) argued that this focus is derived from a socio-cultural focus on production, and thus, derived from social images whereby women’s bodies are largely understood in terms of their ability to reproduce society, both bodily (through having babies) and culturally (through raising and socialising their children). However, in my study, even when women had roles outside of their home, their menopausal experience was important. Irrespective of gender roles, poor experiences of menopause were central in shaping women’s wellbeing. Their definitions of midlife suggested that the only social understandings and constructions available to them were based on this biological reductionist discourse (Inhorn 2006), which they drew upon when making sense of their own life events, even where it did not necessarily fit or explain their stories.

Encounters with the medical profession, and therefore the associated medical discourse and hegemony, played an important role in women’s midlife health experiences.

Women in Waterside both accepted and challenged medical knowledge in various ways, which shaped their health practices and influenced their health. As primary health care was the only mode of health and medical delivery in Waterside at the time of data collection, the following chapter describes how health status – and associated health management practices

– mediated their ageing experiences, shaped their health-seeking behaviours and was central to their understandings of ageing in place.

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Chapter 7

Managing Health, Managing Age

Given the role of health status in mediating women’s experience of age and particularly relating to their experience of midlife, as demonstrated in the previous chapters, health management strategies and practices may allow women to have some control over their age identity. Access to health services was important in their ability to do this. Their capacity to manage their own health problems or maintain their own health was, to some degree, dependent upon the formal health system,78 specifically on the health services available to them in Waterside and neighbouring communities (outlined in Chapter 2). Formal health service utilisation was not the only way in which women responded to their bodily signs and events; however, service provision and access played an important role in the narratives of many participants.

Narratives about managing their health and health-seeking were divided into two components. The first component was concerned with women’s medicalised responses to their bodies, whilst the second aspect of their health-seeking related to self-care. To some degree, this second aspect – what I term ‘self-health management’ – called upon medical explanations, yet women did not experience this medicalisation as disempowering, as has been often argued (see, for example, Klein and Dumble 1994). In contrast, like women described in Lock and Kaufert’s (1998) edited volume, when enacting their self-health management, women blurred the boundaries between lay-person (and therefore passive body) and medical professional. In doing so, they used biomedical understandings to become

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informed patients and actively take part in and shape their medical care and health

management.

These aspects of participants’ health care are the central components of this chapter.

Firstly, in the context of the Australian health system, women’s self-health management and

practices, their interaction(s) with the health system in Waterside and surrounding areas, and

their experiences with the health providers who comprise it, are described. The ways in which women described the medico- and self-derived aspects of their health care were mediated by the predominant narrative strategies that participants employed, which were determined to some extent by their health-related bodily experiences. I conclude this chapter with a discussion of social factors which influenced women’s self-health management behaviours and practices.

Many decisions made by participants regarding their health management were influenced by the fragmentation of the health system. Participants described their frustration at either not knowing which professional to consult about what problem, or having to travel between multiple providers for similar services. Their frustration and confusion was compounded by the geographical isolation of Waterside. Some women, such as Nola, became resigned to the travel involved in managing their health care travelled to both

Hillsville (two hours drive north of Waterside) and Raaft (four hours drive east) to manage her health. Although she accessed basic primary care from the providers in Waterside, she required on-going specialist care which she was unable to access without travel. In Hillsville and Raaft, she consulted an oncologist: one in relation to her recently diagnosed leukaemia and the other to monitor her health following lung cancer twelve years previously. Although they both specialised in oncology, they had different sub-specialities. As a result, Nola was

78 The Australian health system is outlined in Chapter 3.

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uncertain if she could combine her health-seeking by consulting a single oncologist, which would minimise the fragmentation of her health care. In contrast, other women sought to use their personal and local resources in managing their health which, for some, had profound impact on their health outcomes. I describe these strategies and their implications at the end of this chapter.

PREVENTIVE HEALTH

Preventive health has an important role in people’s self-health management practices and in their understandings of age. Levy and Myers (2004) found that attitudes towards ageing determined men’s and women’s presentation for general health check-ups and, in this way, mediated participation in preventive health programs. They noted that people who had positive self-perceptions of ageing tended to more actively seek to maintain a sense of being healthy (which is discussed earlier), which they enacted through health management practices. This may relate to service provision, access and suitability: Hayes (2006) found that as women aged, they became less likely to receive general health check-ups or undergo screening for pre-cancerous changes. In a similar study, Canales and Wilkinson (2002) found that older rural women’s commitment to participating in mammographic screening was related to women’s sense of control over their health and health service factors: their focus was not on maintaining breast health and instead was concerned directly with cancer prevention. In the following sections, I explore how women’s access to screening programs and understandings of health shaped their decisions to participate (or not) in preventive health programs. In doing so, I highlight how these choices were made on the basis of previous and present life experiences; thus, women’s choices were situated within the context of the life course.

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Cervical screening and BreastScreen facilities in Waterside

Women in Waterside have three options for accessing cervical screening. GPs provide pap smears upon request, at any time of the year – women are required to make a normal appointment, during which the pap smear is performed. Unless they possess a health care card, this attracts an out-of-pocket fee, which can later be partly reimbursed by Medicare.

Alternatively, the community health centre runs a women’s health clinic, which runs for two weeks biannually, staffed by two nurse-practitioners from the nearest permanent women’s health service in Riverslea (about three hours drive away). It provides clinical breast examinations, pap smears, health information and other women’s health services. Women also have the option of visiting a health provider for pap smears outside Waterside; this is common in some long-term residents (as I explain below).

The mobile BreastScreen van has been visiting Waterside on a regular two-yearly basis since 2001, in line with the biennial structure of the program. Prior to its introduction, women travelled to either Short Point or Hillsville (up to two hours drive) for breast screening. The inaugural visit, which occurred during data collection, was publicised in the local newspaper and women aged from their late forties through to their early seventies were invited to attend; appointments were made either by telephone or in person. During this visit, seven women were diagnosed with varying stages of breast cancer; at least three subsequently underwent mastectomies. Whilst none of these seven women were my study participants, the very recent introduction of such screening services had profound impact on participants’ preventive health behaviours and practices. The seven women diagnosed with breast cancer were aged from their late fifties through to their early seventies, and most were diagnosed during their first BreastScreen. Their diagnoses reflect data showing that women who delay presenting for screening until they are older have higher cancer detection rates than those who undergo screening from 50 onwards, as recommended (AIHW et al. 2005).

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Delays in attending screening may partly explain the high incidence rate of breast cancer seen in Waterside (32.4 per 1,000 women aged 50 and over)79 compared with national incidence rates (3.04 cases of breast cancer were diagnosed per 1,000 women of all ages in 2002:

AIHW and Australian Government Department of Health and Ageing 2006).

The (seemingly) high incidence of breast cancer in Waterside may have two underlying explanations: access to breast screening (which is impacted by access to and quality of primary health care services; Ross et al. 1994), and performing breast self- examinations (BSE). Most participants, regardless of age, reported that they had not regularly attended breast screening prior to the introduction of the mobile BreastScreen service.

Access to services was therefore an important consideration in women’s presentation for screening for women in Waterside and elsewhere (Schofield et al. 1994; Speedy and Hase

2000) as, although access does not impact incidence rates, it is an important factor in breast- related health outcomes. Wilkinson and Cameron (2004) found that, although the incidence for breast cancer was slightly lower in rural areas, mortality rates were higher, which may reflect stage at detection and treatment.

Access to, and presentation for, breast screening is also mediated by primary care factors: recent research has found that women who do not present to health providers are less likely to undergo regular breast screening (Meissner et al. 2007). However, other data suggests that women who experience access barriers to mammographic services do not ignore their breast health and, instead, women may employ other techniques, most commonly BSE. Siahpush and Singh (2002) found that women who were less likely to attend mammographic screening were more likely to practice regular BSE and thus maintain their breast health. Their findings challenged the notion that access equated awareness, and argued

79 This figure was calculated on the basis of information from the 2001 Population Census (ABS 2001)

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that women with lower access to formal breast screening services were sensitive to breast cancer issues; for these women, BSE offers a way of redressing potential health imbalances created through lack of access.

Maintaining bone density has also been suggested as an important priority in midlife women’s preventive health behaviours. Menopause is understood to be one of the most important risk factors in declining bone density which eventually leads to osteoporosis

(Albers 1990; Guthrie et al. 2000; Williams et al. 2002; Green et al. 2006; Kamel 2006;

Reventlow and Bang 2006). This is compounded by the ageing process: Prince (1999:295) states that the risk of osteoporosis increases from 5% for women aged 65 to 20% for those aged 90. Such information has been used in the widespread promotion of hormone replacement therapy (see Griffiths and Convery 1995; Christiansen 1996; Guillemin 2000).

Women in my study described three forms of bone density screening, which varied in their level of sophistication and cost. Ultrasounds (such as those offered at travelling clinics run by the Australian Bone Density Testing Centre 2007) and dual energy x-ray absorptiometry (DEXA: Prince 1999; Guthrie et al. 2000) both test peripheral parts of the body (such as an elbow or heel). In contrast, quantitative computed tomography (Genant et al. 1987) scans the entire body and is much more invasive and expensive. There are no specific public health bone screening programs in Australia and only women identified as

‘high risk’ of developing osteoporosis (that is, have shown decreased bone density at an earlier screening) receive support through the health system (Prince 1999). The lack of public funding is problematic for many ageing women who, given the construction of bone density as a key issue for them, feel a moral and social obligation to monitor their bone health (see

indicating that 216 women aged 50 to 99 resided in Waterside.

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Reventlow and Bang 2006). In the following section, I explore how women participate (or not) in preventive health programs, and describe the reasons for their choices.

Women’s narratives, health beliefs, and preventive health behaviours

The introduction of women’s health policies has resulted in the emergence of cultural expectations about women’s bodily care. As part of their moral responsibility to be healthy

(Howson 1999), women are socially obligated to engage in self-health care behaviours, which includes participation in preventive health care programs (such as those described above).

During interviews, many participants described their participation in preventive health screening programs; although most had regular pap smears and breast screens, this was not the case for all women (Table 7.1).

Table 7.1: Reported participation in preventive health screening programs Type of screening Attend Rarely/never Not reported attend Cervical 13 5 6 Breast 16 5 5 Bone density 10 2 12

Table 7.1 shows how women participated in preventive health screening programs. Of the seven women who reported rarely or never having pap smears, only one actively avoided cervical screening: I describe Liza’s reasons below. The remaining four women who did not attend cervical screening had all undergone hysterectomy and were thus advised by their doctors that they no longer required pap smears. One of these women, Cynthia, continued to have biennial vaginal vault smears.80 Most women also regularly presented for mammographic screening. It is important to note that none of the 4 participants aged under

80 A vaginal vault smear is performed after hysterectomy, when a pap smear is taken at the top of the vagina (‘the vaginal vault’) (Stokes-Lampard, et al. 2005). Its effectiveness in detecting cellular changes has been debated and it is generally considered an unnecessary intervention with little clinical utility (Fetters, et al. 1996, Stokes-Lampard, et al. 2006).

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50 attended BreastScreen and that four of the women who didn’t report mammographic screening had recently turned 50. This is significant given that, as described above,

BreastScreen is targeted at women aged 50 and over. As interviews were mostly conducted between two visits of the mobile BreastScreen service, it is likely that some women did not

report attending the service even though they had recently reached the target age group.

Bone density screening seemed to occur on an ad-hoc basis, either when women attended a

menopause clinic or during mobile bone clinics, as is reflected in the reported rates of bone

density screening.

Many participants explained their participation in screening and preventive health

care behaviours as both fulfilling their moral obligations of bodily care and behaving

responsibly about their health. Women did not question why they attended screening and, in

the case of pap smears, many were unaware of the aetiology of cervical cancer and the role of

screening in this process. Regardless of the actual or assumed benefits of these practices,

participants adopted some medical roles (through bodily self-surveillance, through practices

such as BSE) and willingly participated in invasive procedures (e.g. pap smears). Howson

(1999:402) argued that women are ‘encouraged and expected to subject themselves to

scrutiny;’ thus, by performing their preventive health practices, incorporated the ‘duty to be

well’ into their everyday practices.

Accordingly, women’s health beliefs played a central role in their preventive health

behaviours. As I demonstrated in earlier chapters, women’s understandings about health

shape their bodily practices and influence the meanings given to their midlife. When

exploring participants’ health beliefs, and how these impacted on their preventive health

behaviours, the narrative strategy that women used to describe midlife also mediated, in

some way, their participation in preventive health programs. Preventive health behaviours

were pro-active rather than reactive; that is, they were widely promoted as ways for doctors

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to take control of women’s health before a problem arises, which contrasted with models of illness management (such as those used by the women who experienced problematic bodily signs). Engaging in preventive health behaviours was an expected part of regular bodily care routines that characterised women’s lives, as Howson (1999:412) argued: “compliance with screening is expressed… as the expected response to what might be seen as part and parcel of the range of interventions which are perceived as a routine and normal aspect of female embodiment.” Accordingly, women described their preventive health practices as normal parts of their lives, regardless of their health status or the narratives they told. What differed between women who told different narratives were the ways in which their preventive health behaviours were positioned in relation to their health beliefs and concerns, which themselves were determined by women’s health status and embodied experiences. As I illustrate below, women who did not experience problematic bodily symptoms (that is, women who told

Maintaining or Contemplating narratives) emphasised their preventive health behaviours within a discourse of ‘looking after my own best interests’ (cf. Howson 1999). In contrast, those women who did experience troubling or challenging bodily signs and symptoms (i.e. those who told Negotiating or Navigating narratives) understood their preventive health practices in terms of warding off further ill-health or disease.

‘Looking after my own best interests’: Maintaining and Contemplating

Exploring women’s narratives of their formal and informal preventive health practices provided insight into how they understood the ageing process. Continuity was a theme common to women who did not experience major health problems, yet the role of the body- self in this changed depending on the narrative strategy used. Women who used Maintaining narratives ensured continuity of their self-identity by engaging in bodily maintenance practices, which involved preventive health behaviours. In contrast, those using

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Contemplating narratives understood their preventive health behaviours as a way of ensuring bodily continuity, which enabled continuity of their personal, self-development tasks. In this way, preventive health practices were important tools for enabling the goals of the self

(expressed via the central project of the narrative strategy) for the women who told narratives about unproblematic bodily events. These are described in greater detail below.

Maintaining narratives and preventive health

Participants who did not experience problematic bodily signs or events described their preventive health as part of on-going bodily maintenance practices, and used direct, factual talk when discussing their preventive health practices. Where they used Maintaining narratives, preventive health practices were described within the context of having few health concerns and non-problematic bodily experiences:

[My health concerns are] very few. I have to say I'm very lucky. In October, there is the breast x-ray [BreastScreen mobile service] coming up [to Waterside] so I will go and have those [tests] and my smear tests and whatever. But no, I've been very lucky. I've had very few things wrong [with my health]. I don't even get the flu. (Carolyn, age 58)

At the same time, understandings of family history and genetic susceptibility shaped women’s preventive health behaviours. For example, Biggs believed that the absence of breast cancer in her family history, combined with her regular biennial attendance at mammography screening, provided her with a sufficient level of control over her body. Her beliefs about her own health status and future health biography minimised the importance of targeted bodily surveillance for potentially troublesome bodily signals (such as signs of breast skin changes) and justified her irregular performance of breast self-examinations (BSEs):

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I have a mammogram every two years. I go to Hillsville. The first one, I went to Short Point and then that closed, [so] I went to Hillsville… They said to me, last time I rang up to make my booking, ‘why don’t you get it done through the free one?’ They will contact me when I’m due for it which I think is this December… They come down to Hillsville. In between those, do you do breast self-examinations? I do, but probably not as conscientiously as I should… luckily I haven’t got any [breast cancer] in the family. (Biggs, age 53)

Whilst Biggs did not routinely check her own breasts, she regularly conducted overall bodily self-assessments. Bodily surveillance through preventive health measures was thus an important part of her body (and therefore, self) care regimen. Thus, engaging in preventive health behaviours was another technique that enabled Biggs and other women who told

Maintaining narratives to maintain their present health status and this was a strategy they employed to ensure the continual flow of their biography (see chapter 3). By maintaining health through preventive health practices and bodily techniques, these women sought to avoid serious or chronic health problems which would challenge their sense of self; this enabled the continuation of their stable self-identity and self-construct. They participated in screening out of a sense of self-responsibility which, as Howson (1999:413) argued, derived from their “rationalisation that the outcome of the smear itself will be normal,” and would therefore allow maintenance of the self. Screening was consequently constructed as a health maintaining behaviour which they engaged in, along with other similar bodily maintenance practices.

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Treasure: a case study of Contemplating narratives and the meaning of screening

Women who told Contemplating narratives also described their preventive health practices and behaviours within a context of personal responsibility to their self. In doing so, they often discussed their practices in similar ways to women who used Maintaining narratives

(described above), as Treasure explained:

I have mammograms [but] not pap smears, because I have had a hysterectomy. Actually sometimes I just wondered [whether I should have a pap smear] because I spoke to Justine [who] said, ‘look, I don’t think it’s necessary.’ I have mammograms every two years. I have no history of breast cancer in my family, but I have been having them regularly… We get the results back and they’ve all been clear. They send a copy to the doctor, which is good. It’s worthwhile having them… [I go to] the visiting [clinic]… They’re good actually, they come here every two years... it’s good having them come here. It makes it a lot easier and then you think, I went up to Hillsville once. But no, it’s very convenient, which is good and it means people go and get one done, otherwise they put it off. (Treasure, age 62)

Treasure described the preventive health checks as providing a way of alleviating her need to worry about her health. Having mammograms meant she didn’t need to worry about her health, and could instead concentrate on reconsolidating herself:

Basically, I am fortunate that I have been reasonably fit… I haven’t noticed great changes apart from getting depressed because of what I have been through [caring for her husband as he was dying] because it takes time. It’s just adjusting. I came back here [from Melbourne, when her husband was in a palliative care unit] for four months and… [my brother] Angus would say, ‘do you want to come for a meal?’ And I would say, ‘no I just want to be left alone.’ I needed that time. You need time to grieve and it’s never going to be the same.

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Thus, for Treasure, participating in preventive health behaviours was a way of removing potential stress that could result from worrying about her health and her body, as the mammographic screening meant she did not have to think about or watch too closely for potential bodily changes. By allowing her relief from bodily concerns, preventive health screenings provided her with an opportunity to concentrate on her self-reconstruction and personal development—which she expressed through her need for time alone—following the death of her husband. She, and the other women who told Contemplating narratives, described their preventive health behaviours in a similar way to those who used Maintaining narratives, and in doing so, highlighted their sense of responsibility to their self (cf. Howson

1999). In contrast, participating in preventive health programs by women who told

Negotiating and Navigating narratives occurred for quite different reasons, which I describe in the following section.

Warding off future illness: Navigating (Lesley) and Negotiating (Ash)

Given the bodily project of health management common to Negotiating and Navigating narratives, women’s participation in preventive health behaviours provided some level of control over their bodies. Women understood preventive health as offering them a way to keep ‘an eye on’ (or monitor) their unruly bodies. This was particularly the case where the participant’s family history included breast cancer. These women’s narratives highlighted their need to have some level of control over their bodies, even though they believed that genetics and inherited risk were ultimately random. For example, Lesley was concerned about her breast health given her family history (her mother died from breast cancer) and used both BreastScreen Australia and private services to ensure that she was screened annually:

I have a mammogram every year… because I’m over fifty and because of my mother’s circumstances. I go to a breast screening [service] once a year.

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Because you can only go to the BreastScreen [program] every two years, that’s all you’re allowed to do81 and I go every year for a mammogram, so the year in between I go up to Hillsville… I have just been to [the] BreastScreen [mobile service] not two months ago, maybe six weeks ago. They were here. I went and had a mammogram there, and then I went and had a smear test the same week. I think they were all here together... I mean, I worry about cancer a lot because it runs in my family and my mother had both her breasts off [mastectomy] with breast cancer. One when she was only about… thirty-five or thirty-six… and then it seemed to go away for years and years because she didn’t have her other breast cut off until she was seventy… She went to have a mammogram and was in there the next week. (Lesley, age 50)

Lesley’s mother’s experience shaped her health beliefs, which in turn influenced her participation in screening. She described feelings of constant fear that she might develop

breast cancer and lose her breasts, which she associated with her identity and feelings of

femininity. She described her annual breast screens as a way of protecting and conserving her

breasts, although she recognized that screening did not prevent cancer developing:

Hopefully I won’t get breast cancer like my mum. I hope not, but at the same time, [if I do] I’m not going to have my boobs [breasts] off either. I already decided that years ago and I’m fifty now. So if I did get it, I would go and get some treatment and carry on, but I would definitely not get my boobs cut off. I know that I wouldn’t be able to because I have always liked them, all my life, and I know that would be one thing I wouldn’t be able to, I just couldn’t imagine having [that] surgery, and I wouldn’t have them off. I would just continue on till I die. That’s not necessarily to say that I am going to get it, [but] it’s awful when that’s over your head all the time. I go and have mammograms every year but in the middle of that too, every two years, I go

81 BreastScreen does not provide for women to be screened more frequently than biennially, regardless of their risk status (Australian Government DHA 2006). High-risk women, such as Lesley, are encouraged to seek advice from their GP or specialist (ibid.). Precisely what this may involve is not explicit; presumably it includes genetic, mammographic or ultrasound screening (Hailey, et al. 2000, Hallowell, et al. 2004).

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and have an ultrasound… I go and have mammograms and stuff but I honestly don’t have a lot of faith in them, I must admit. I know there’s not really a lot else they can do and I know I go and they write back to me to say everything’s alright, there’s nothing there, but I still feel a lot better when I go and have the ultrasound... I do feel a lot better when I go and have those and then there’s a friend of mine in town who was just diagnosed with breast cancer [and she never had a mammography].

Lesley adopted a pro-active approach to her cancer risk and believed that early detection was her best way of addressing this risk. She participated in much higher levels of screening than national women’s health strategies recommended,82 which concurred with recent findings that perceptions of susceptibility to breast cancer predicted higher rates of screening participation (Speedy and Hase 2000). Family history and lay understandings of genetic susceptibility also influenced Ash’s preventive breast health behaviours:

My sister thought she had breast cancer… It turned out [she] didn’t have breast cancer. They were absolutely convinced [that she did] until she went into hospital and had it [the lump] removed… Do you have regular breast mammograms? Yes. I always have them. (Ash, age 60)

Studies have also found that women who visited their GP regularly were more likely to adhere to preventive breast health recommendations, particularly BSE and mammographic screening (Speedy and Hase 2000). Howson (1999) argued that cervical screening was often perceived as an expected and acceptable part of routine presentation for other procedures, such as during family planning consultations or when seeking medical management of menopausal symptoms. When analysing my data, it appeared that women

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who experienced some troublesome or problematic signs – whether these had been a long- term or a recent feature of their lives – regarded preventive health as both an expected and routine feature of their embodied experience; breast and cervical screening were therefore normal features within the medical encounter. At the same time, their acceptance of this was influenced by their familiarity with being the recipient of medical attention and intervention, as the women who told Negotiating and Navigating narratives often described undergoing multiple tests when searching for the cause of their bodily signs. Beyond the frequency of their interactions with medical professionals (more often in women who used Negotiating narratives) and the relational power structures within such encounters (which I describe below: women who told Negotiating narratives described themselves as adopting an ‘active patient’ role), these two narrative types did not differ significantly in regards to women’s participation in preventive health behaviours.

Challenging the social obligations of preventive health practices

Few women challenged the social obligation to keep themselves well through preventive health practices (see Howson 1999:408). Liza and Lois, who told Maintaining narratives, both rejected the moral imperative which propelled most of the other participants to attend screening and challenged the medicalisation of their bodies that occurred through participation in screening. Liza considered that screening was not in her ‘own best interests’

(Howson 1999) and thus did not participate in cervical screening. Her health care behaviours and expectations are discussed in the following section.

82 Biennial mammographic screening is recommended, regardless of risk, for all women aged 50 or older.

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Liza: a case study of resisting pap smears

After two pregnancy terminations in her twenties which left her feeling objectified and disempowered by the medical professionals who treated her, Liza ‘had had enough’ of dealing with health providers and decided that she would no longer present for Pap screening. Her stories were not unique to her; her health beliefs echoed those of women in another study who did not present for mammography due to past negative or humiliating encounters with health professionals (Speedy and Hase 2000). Liza felt the doctors had not treated her with respect and as a result, she actively sought to avoid unnecessary interventions (which she believed the cervical screening to be) and interactions with the health sector. In addition, as she had not been sexually active for several years, she believed that her risk of cervical cancer was low; itself not an unreasonable assumption given low incidence rates in the Australian population. Her understandings of these low rates, however, were premised upon a false belief: the time of last sexual encounter is irrelevant (Neilson and

Jones 1998; Braun and Gavey 1999; Liu et al. 2004) and the rates also reflect the efficacy of cervical screening in cancer prevention (ibid.). Data from 2001 indicated that 9.5 per 100,000 women aged 20-69 were diagnosed with cervical cancer, a drop from 17.1 per 100,000 women in 1991, largely attributed to cervical screening (AIHW and Australian Government

Department of Health and Ageing 2005). Liza was not concerned with cancer prevention: she had a fatalistic view about her health (Shortus et al. 2005; also see Yates et al. 1993;

Beadle et al. 2004), and believed that if she did develop cervical cancer, that was her lot in life and that she would accept it.

Screening and contradiction: Lois

In contrast to Liza, Lois’ non-participation in cervical screening occurred for considerably different reasons; as she had undergone a hysterectomy in her early thirties, her doctors

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advised her that she no longer needed to present for pap smears. However, her breast health

behaviours were contradictory. On one hand, she actively sought to reduce her risk of breast

cancer by stopping hormone replacement therapy (a belief that was supported by data from

the million women study, Banks et al. 2003), even though she realised that this may increase

other health risks:

I did get a little concerned when at one stage they started putting warnings on the packets of the hormone tablets that it could give you breast cancer. Then when I asked Dr Pat [pseudonym], he said ‘Well yes, maybe, and no, but if you take them it helps with [preventing] Osteoporosis.’ I said, ‘I eat enough diary foods and things and who even knows if diary foods have anything to do with preventing it [Osteoporosis] or not.’ But I said, ‘I would rather put up with Osteoporosis than breast cancer.’ So I said, ‘bugger it’ [Australianism, she’d made the decision regardless of the consequences] and I just went off them, because at that stage I wasn’t getting them [symptoms] bad enough anyway. I thought if they really get bad I can go to some herbal tablets like evening primrose but I never got to that stage. So yeah, with those tablets I was just concerned with the breast cancer. (Lois, age 57)

On the other hand, however, Lois appeared to increase her risk of breast cancer by not attending mammographic screening (see McMichael et al. 2000; Hamilton et al. 2003;

Johansson and Bertero 2003):

I do self-breast examinations but I’ve never gone for a mammogram.

This was incongruent with her decision to discontinue HRT, given her concerns about developing breast cancer and being in the target age range. She explained that her non- attendance at the BreastScreen derived from her health beliefs about breast size and her risk of cancer; to this end, she believed that conducting breast self checks would be sufficient to detect a problem:

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Probably because I’ve only got small breasts, I’m less likely to get [breast cancer]… I don’t do [the breast self] examinations as a ritual but I might be watching TV and I’ll have a feel, you know.

What distinguished Lois’ account from Liza’s was her relationship with medicine –

Lois regularly sought professional advice from community health professionals and the local

GPs for physical and mental health reasons: ‘[Following my marriage breakdown], I had a lot of problems and I felt very free to go to Dr Pat and just sit and chat.’ Her non-participation in BreastScreen was not influenced by these consultations as the two services were separate.

In contrast, Liza never attended the GP unless it was an emergency. Her health beliefs had been shaped by social iatrogenic causes; that is, her reasons both related back to medical knowledge and previous encounters with medicine (cf. Illich 1976). The lack of sensitive or appropriate care in the past had shaped her current and future health behaviours. Despite their divergent (non-normative) approach to screening, their stories about taking care of their health and maintaining their bodies continued to resemble those of the other women who told Maintaining narratives: informed by their personal health beliefs, both Lois and Liza engaged in practices that they believed allowed them to continue experiencing their current level of health into the future.

RURAL AND REMOTE HEALTH CARE IN AUSTRALIA

Framing my discussion of women’s health care in Waterside within a context of rural and remote health care in Australia posed considerable challenges due to the heterogeneity which is captured by the terms ‘rural’ and ‘remote’ (as highlighted by Farmer et al. 2003). As a result, there are extreme variations in the health experiences of individuals who live in

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different parts of the country, yet which may have the same geographic classification,83 which

occur within common contexts characterised by limited access to, and the provision and

quality of health care.

Throughout non-metropolitan Australia, poorer overall health status is reported

(AIHW et al. 1998, 2004). For example, data indicate higher rates of disablement,

hospitalisation and death rates from coronary heart disease, stroke, chronic obstructive

pulmonary diseases, diabetes, suicide, injuries, and some cancers (including lung and cervical

cancers) in rural areas, when compared with urban areas, which may relate to lower socio-

economic position (AIHW et al. 1998, 2005; Dixon and Welch 2000; Knox et al. 2005). All-

cause death rates are higher in non-urban areas; more specifically, the number of deaths due

to asthma, injury, burns, interpersonal violence, and male suicide increased in direct relation

to increasing rurality of residence (AIHW et al. 1998; Dixon and Welch 2000).

Adding further complexity to these rural-urban discrepancies in health indicators, the

degree of rurality had additional impacts upon health outcomes. Such rural-urban differences

may be explained by factors such as lifestyle choices or the types of activities in which non-

metropolitan dwellers participate, in addition to issues around access to services. For

example, Dixon and Welch (2000) found that whilst deaths due to injury occurred more

frequently in rural and remote areas, this was partly explained through employment in

higher-risk occupations, including farming, fishing or mining. In Waterside, abalone fishing

(a major industry) involves high-risks to divers’ (abalone fishermen) health as it entails many

hours of deep-sea scuba diving and thus, exposure to highly pressurised gases. The divers are

constantly placed at risk of developing ‘the bends’ (decompression sickness) from scuba

83 Waterside is classified as ‘R7: other remote area’ (AIHW 2004). It varies considerably from other R7 areas (including many Aboriginal communities in central Australia) in terms of health status, life expectancy and the demographic composition of the population (AIHW, et al. 1998, Dixon and Welch 2000).

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diving.84 ‘The bends’ were not uncommon in Waterside and, in the past, several divers died as a result; there are no female divers.

Data also suggest that health services may have a significant role to play in the poorer outcomes reported in rural areas, as there is little variation by geographic location in terms of prevalence rates; the overall prevalence of diabetes is lower in non-metropolitan areas, whilst reported rates of ischaemic heart disease, emphysema, and asthma are similar to urban areas

(AIHW 2005). Similarly, overall incidence and mortality from stroke do not differ by location, yet people in rural areas are more likely to be hospitalised following stroke (AIHW et al. 1998). Such findings suggested that whilst some aspects of health status may not vary by geography, health outcomes (mortality and hospitalisation rates combined with lower average life expectancies: AIHW 2005) are significantly worse in rural and remote areas of

Australia. At the same time, mid-aged men and women in rural areas consistently rate their health as poorer than their urban counterparts (ibid.), which was presumably a reflection of both higher rates of morbidity and mortality from many diseases, and higher levels of reduced activity due to illness (an indicator of short-term or non-disabling illness, ibid.). As I have discussed earlier, understandings of health influence people’s health-related risk behaviours; this was reflected through much higher rates of communicable diseases and injuries in non-urban areas, and may have related to the intersection of lower incomes and education levels, which shaped levels of health literacy (Lee et al. 2004) and impacted on residents’ access to care.

One possible explanation for these health disparities may relate to the models of health used to inform rural health policy. Alston and colleagues (2006) argued that whilst

84 Decompression sickness (or ‘the bends’) occurs when divers do not fully decompress when returning to the surface of the water following their diving. Consequently, the internal bodily air pressure is not returned to equilibrium in relation to external air pressure, causing a series of physiological and neurological complications, which may lead to death in some cases (Gorman 1989, Spira 1999).

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broad Australian health care policies employ rhetoric based on a social model of health, in contrast, rural health services are based on a medical model of care. Women in their study reported a focus on biomedical aspects of health within primary health care encounters, with little emphasis on enhancing their general health status and wellbeing (ibid.). Health services were aimed at treating and responding to their presenting symptomatology, without considering the social context within which women were living, which limited the preventive health capacity of the consultation and restricted women’s ability to effectively manage their own health.

When exploring specific epidemiological data relating to women’s health, considerable disparities exist between rural and urban areas, which may reflect the different health service models applied. The biomedical approach posited to be more widely assumed in rural areas could partly explain the higher hysterectomy and tubal ligation rates for women in these regions (AIHW et al. 1998; Brown et al. 1999; Byles et al. 2000), shown in Table 7.2 below).

Table 7.2: Hysterectomy and tubal ligation rates for women in five areas of Australia Geographical classification Tubal ligation rate (%) Hysterectomy rate (%) Urban 25.8 21.3 Large rural 29.4 23.3 Small rural 30.4 24.5 Other rural 31.5 23.3 Remote 33.3 27.5 Source: Brown (1999)

Parity has also been explored as a factor in these higher rates – women in rural and remote areas have significantly more children than those in urban areas (AIHW et al. 1998; Brown et

al. 1999) – although the hysterectomy rate remained high even after controlling for family

size (Byles et al. 2000). Women’s health-related values may also play a role in this differential,

as rural women may prefer to have their health concerns dealt with relatively quickly, and in a

straight-forward way, rather than to engage in prolonged encounters with the medical

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professions, to which they do not always have easy access. Women’s preference for tubal ligation after completing their families may exemplify this – undergoing this procedure means that they do not have to engage in on-going consultations with medical providers to obtain contraceptives from their last child until menopause, which may be many years.

Data from a longitudinal study of women’s health showed that midlife women in rural and remote areas reported significantly fewer GP, specialist, and allied health consultations than women in urban areas (Brown et al. 1999); at the same time, they were more likely to express dissatisfaction with both the quality and cost of their interactions with medical professionals. No differences were reported by geographical location in terms of women’s participation in cervical and breast screening programs (AIHW 2005), possibly reflecting the effective operation of mobile screening services (Australian Government

Department of Health and Ageing 2006).

Women’s mental health is significantly impacted upon by geographic location.

Bramston and colleagues (2000) found that rural women reported higher levels of mental distress than those living in urban and regional centres, which they related to gendered role performance and expectations of women in these areas. The absence of adequate mental health care for people living in rural areas, as Lockhart (2006) highlighted, resulted in higher rates of under- or nil-treatment of mental illness in many non-metropolitan dwellers experiencing mental health problems. This is a significant concern for rural health care, particularly given that mental illness is often unacknowledged and untreated for extended periods of time prior to diagnosis (Lockhart 2006). Whilst the importance of comprehensive systems for rural mental health care cannot be understated, mental health is not the only area of rural health where considerable differences occur in the encounters between individuals and the health system.

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Rural residents often have few local options when seeking health care, and thus often

do not receive all of the medical assistance they require. Consequently, their health-seeking

behaviours vary based upon their perceived need and own abilities to manage health

problems. They draw upon primary health care providers for management of certain health problems, yet not for all. A recent Australian report (Knox et al. 2005) found considerable

geographic variations in frequency of attendance and patients’ reasons for presenting to a

GP. As rurality increased, residents typically had fewer health system encounters; which

addressed multiple and often-complex health concerns within a single consultation (ibid.). As

a result of limited time and complicated case presentation, patients often did not receive on-

going longer-term management of their symptoms, which was exacerbated by the transience

of the rural health workforce. Continuity of care was therefore a significant problem (ibid.).

At the same time, rural patients presented to their GP for on-going or chronic health

problems, yet managed more short-term, transient health problems themselves, which may

contribute to the later presentation for serious health complications and higher

hospitalisation rates found in non-urban areas (discussed above).

The local health workforce: General Practitioners

Rural dwellers’ access to health care, and people’s health status, were impacted by factors

beyond simple distance-to-service issues; geographical isolation cannot entirely account for health discrepancies between urban and rural areas (Dixon and Welch 2000). For example,

health care in rural and remote areas is delivered in quite different ways than in urban areas.

Health workforce is an important issue. There are significantly fewer general practitioners in

rural and remote areas than urban areas (AIHW et al. 1998) and an inverse relationship

between level of rurality and number of general practitioners (GPs) persists (Knox et al.

2005): the most remote areas have the fewest GPs per capita, which results in considerably

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lower access to medical care. However, the lower numbers of medical personnel associated with geographic isolation did not necessarily translate to fewer referrals to specialists or lower hospitalisation rates (ibid.) and suggests that the issue may relate to the types of care provided

(and sought) rather than the numbers of providers.

Research has suggested that the context of patients’ presentation to providers played a significant role in their health outcomes. During a single consultation, rural and remote patients tended to present to health providers with multiple health problems or concerns

(particularly when compared with patients in urban areas; ibid.:57). Australian data indicated that the health care activities of providers in rural areas differ significantly from those in urban areas. Humphreys and colleagues (2003) found that the likelihood of GPs being involved in providing complex health care increased with the remoteness of the community.

Their data highlighted a relationship between the level of rurality and the number of both highly complex activities and health-related events encountered by GPs in those areas (ibid.).

Knox and colleagues (2005) found that increasing rurality was accompanied by broadening scope of GPs’ involvement in patients’ health care. In delivering care, rural GPs were required to employ a broad range of skills, such as patient stabilisation or forensic medicine, in addition to their usual primary health care provision. The range and complexity of GPs’ work activities was borne from necessity, as opposed to being engaged in through choice, due to the lack of medical care alternatives; they delivered a wide range of services which might otherwise be delivered by specialists or multiple providers (rather than a single provider) in more urbanised areas (ibid.).

In Waterside, for example, the absence of a nearby hospital or critical care facility resulted in higher emergency-care and after-hours demands being placed upon the local GPs

(described in detail by O'Meara et al. 2004), which caused additional strain on health professionals already shouldering a high burden of community primary health care. Recently,

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this situation was resolved through the recruitment of paramedics trained in rural emergency health care (ibid.). Whether this changes the nature of health services in Waterside remains to be seen however, Smith and colleagues (2004) found that rural dwellers expressed a preference for GP-provided health care as opposed to other primary health care providers.

Using Waterside as a case study, this finding has several potential implications.

Firstly, as discussed above, rural residents are forced to rely on their GP for a broader range of services than they might if alternative services or facilities were available.

That is, if other, more specialised services or facilities were readily available or accessible, rural residents might seek care from those, rather than the burden being placed on their GP.

An example of this might be where a patient attended the GP for an optical (eye) examination, rather than presenting directly to an optometrist.85 This commonly occurred in

Waterside, where the optometrist only visited for one day every three months; in between those visits, patients sought this type of specialist care from their GP.

Adding further complexity were issues around continuity of care; data demonstrates that patients prefer to consult the same provider over time, emphasising the importance of the interpersonal relationship that develops over time between doctor and patient (Naithani et al. 2006; Pandhi and Saultz 2006). In Waterside, this continuity of care is not always provided by visiting health providers, evidenced by their description of the GPs as Dr [first name] as opposed to the visiting professionals – “the nurses from Timbertown” (Lesley, age

50) – and may influence women’s decisions to seek specialist types of care from their GP.

Presenting to providers with multiple health conditions had a second implication for women’s experience of health care. Through seeking professional assistance for seemingly minor health conditions, women may have adopted a pro-active approach to their own

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health and thus sought advice before their health problems became aggravated or exacerbated. This was particularly the case for women who told Maintaining narratives, several of whom described presenting to their doctors with non-urgent issues, which may have appeared to be unnecessary, yet which were consistent with their other bodily maintenance behaviours. For example, Biggs consulted her GP after her husband was found to have high cholesterol and high blood pressure, which caused her to question whether their diet was healthy; this was important for her given the significance she attached to healthy eating in relation to her maintaining practices:

I get my blood pressure [monitored] and I had my cholesterol checked recently because Dave’s was high. He had to go back and get it re-checked after stricter dieting… so he has fruit for lunch now like me... He had to go back so he said to [the doctor], ‘I think Biggs should get hers checked too.’ So he dobbed me in.86 I went but mine was very low… My blood pressure was actually up a little bit, not much, but we had a couple of things happen [lately]… (Biggs, age 53)

Another significant factor influencing rural dwellers’ access to health care were issues of confidentiality and anonymity. As described above, women faced limited choice in terms of who provided their health care and one GP fulfilled most of their health seeking needs.

Given the small population of Waterside, like other rural communities, women often knew the GP personally, which influenced their willingness to attend for care, particularly when they required health care for an issue that they perceived as embarrassing (such as a pap smear or breast examination) or potentially stigmatising (for example, in relation to Hepatitis

85 Optometrists conducting eye examinations are one of few specialisations that Australians can visit without a referral from a general practitioner and still attain Medicare coverage. 86 ‘Dobbed me in’ is an Australianism which means ‘volunteered me without confirming with me first,’ and indicates some unwillingness to participate.

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C).87 As a result, the clinical encounter was sometimes awkward or uncomfortable for both

patient and provider, as one of the GPs in Waterside (Dr Alex, female) described:

We miss out on the women’s clinics up here. It’s not that that service isn’t available, because I can provide the same service but there are certainly some women that would prefer to go to a women’s clinic where they feel that people there are specialists in women’s health problems and they’ll get a complete overhaul. And it’s more anonymous than being in a small town. There are definitely some women that would be uncomfortable coming to me about their problems and if they want to go to a women’s clinic or someone else, it’s a long way to go… they can be friends with me or see me as an associate or maybe… on a friendly basis, and then that’s fairly awkward to come about women’s health issues. I used to find it very awkward… when someone I knew came in and asked for a pap smear. I have got used to that over the years and it doesn’t actually bother me now to do breast checks and pap smears and things like that with women I’m friends with, but it does bother a lot of people and I understand that… (Dr Alex, GP)

Not all women in my study, however, found that having an interpersonal relationship

with their health professionals caused problems within their health seeking. Many women

described the importance of feeling comfortable with their doctor (emphasised by Naithani

et al. 2006; Pandhi and Saultz 2006). Several participants described their close friendships

with their GP as enhancing their health care and improving their health outcomes. For

example, as described in Chapter 4, Ferdie believed that her close friendship with Dr Pat led

to her getting help for her disruptive hot flushes before they became too problematic in

terms of her daily life. She believed that her friendship with Dr Pat had meant that she was

able to address her health issues pro-actively, that is, before they became another health-

87 Hepatitis C is a disease of very low prevalence in ‘normal’ (that is, low risk) populations (Crofts 2001, Dore, et al. 2003); however, one of the GPs identified that it is a concern for some midlife women in Waterside who

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related challenge that required managing, and consequently viewed her friendship as empowering her in taking care of her own health. Through their friendship, she was able to gain medical attention and advice both informally (as when they were on the yacht) and within the formal setting of the consultation room (such as when the blood tests were taken).

Similarly, Hattie found that having a friendship connection with her GP (Dr Kerry, who replaced Dr Pat) meant that her health problems were understood and treated in the context of their impacts upon her life, as she reflected upon during our follow-up interview:

had contracted Hepatitis C when younger (Ostapowicz, et al. 2001).

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In terms of your health issues, at our last interview, you were having lots of trouble with bleeding? Yes I was… We had a terrific young doctor in town, who has become a close friend, [who] I also decided to go and see as a doctor, after I heard lots of reports from people who had long-standing illnesses and challenges which had been overcome and solved… Dr Kerry fairly quickly asked me to take… a hormone replacement for post-menopausal women. Within two days, all the bleeding had stopped, [but] I continued [to have] the anaemia, so we did all sorts of investigations for six months and finally decided that I had some internal bleeding. Dr Kerry sent me for investigation and it was discovered that I had an oesophageal erosion, through which I was internally bleeding. Once that was discovered, then [I went on] one tablet a day… Not only has that healed, it seems to deal with the gastritis in my stomach and so I’m able to eat more foods now to which I thought I was sensitive. It has had some good effects on the irritable bowel syndrome, so it just means that I can eat more food, more kinds of food. So I’m not anaemic anymore and that’s great. Dr Kerry keeps a very close check on that, that’s made a huge difference. (Hattie, age 50)

From Hattie’s and Ferdie’s stories, it appeared that women felt that their social

closeness with their provider benefited their access to care (both through their formal and

informal interactions) and improved their health outcomes. This was the case even where the woman and the doctors did not have close personal relationship, as Lois described:

It’s more personalised, I think, because you’re in a smaller community compared to big cities. You live in the same town so you associate with them and it’s more of a friend-to-friend visit so I think you tend to open up a bit more…well that’s me anyway. (Lois, age 57)

Lois emphasised the importance of feeling comfortable with the provider, which led

to her being happier with disclosing psycho-social aspects of her life which may have

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impacted upon the bodily signs and symptoms she was presenting with. I suggest that her high satisfaction with the care provided derived from two complementary social facts: firstly, by constructing her medical encounters as ‘friend-to-friend’ rather than ‘doctor-patient’ or

‘professional-layperson’ redressed the power imbalance that is often inherent in the clinical encounter (see Friedson 1970), which Lois found was empowering:

When I was with Jason [my former partner], I had a lot of problems and I felt very free to go to Pat and just sit and chat [about the problems]. I didn’t feel intimated or that I had to hold back.

Secondly, living in a small community meant that it was very hard for either party (Lois or

Dr Pat, her GP) to be invisible or anonymous; thus, Dr Pat was made more accountable for the care she provided – the small population in Waterside meant that doctor and patient would inevitably encounter each other informally, outside of the clinical setting.

The local health workforce: Other providers

In rural and remote areas, fewer general practitioners means that primary care is also delivered by other health providers – nursing professionals, allied health professionals (such as physiotherapists, chiropractors or podiatrists), pharmacists, or complementary medicine practitioners (AIHW et al. 1998; Healy 2002). Whilst these health professionals provide essential primary care regardless of geographical location, they maintain a pivotal role in rural primary health provision (AIHW et al. 1998; Smith et al. 2004). Within areas where there is no permanent GP, the bulk of primary health care is provided by bush nurses (nurses with experience in rural and remote health issues, including emergency health), remote area nurses, and community paramedics (O'Meara et al. 2004). Community health centres are often positioned as a nexus of health care and acts as the delivery centre for all types of

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health care within that community. They are positioned throughout rural Victoria. Small rural

health services (SRHs, a type of community health centre; Victorian Government

Department of Human Services and Division 2003) are located in communities of less than

5,000 residents and assist in developing sustainable health care systems by coordinating community health resources, with the aim of reducing the load on often-stretched personnel

(as described by O'Meara et al. 2004).

Bush nursing centres are located where permanent community health facilities cannot

be sustained due to low population numbers, within the community itself and in surrounding

areas.88 They provide essential health and community services (Victorian Government

Department of Human Services 2003); without them, community members would need to travel considerable distances from their home to seek basic health care. In addition, bush-

nurses coordinate social support groups and host visiting health and medical practitioners

(ibid., O'Toole et al. 2002). The bush nursing centre in Waterside was redeveloped into a

community health centre during the early 1990s (reflecting other similar state-wide changes

since the 1970s). This occurred despite the small population size (which has never risen

above 1400 residents ABS 1991; 1996; 2001), and may be explained by the remoteness of

Waterside.

PRIMARY HEALTH CARE IN WATERSIDE

At the time of data collection, the primary care services in Waterside fulfilled most women’s

current and future needs, through using the local general practice and the community health

centre; many women also sought health-related support from visiting health providers

(particularly the family counsellor) and the local pharmacy, which provided information and

88 Areas where the population in and around the community is less than 1500 residents.

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services on an ad-hoc basis. Preliminary bone density screening was available at the pharmacy from time to time. This did not provide them with accurate information about their bone density, rather, it provided an indication as to whether further diagnostic screening (not available in Waterside) was required. The closest provider of bone density screening was in Short Point (and was available part-time); thus the provision of the preliminary screening through the pharmacy meant that women did not necessarily have to travel unnecessarily.

Women in my study relied on the GPs for almost all of their health care needs; which meant that the local medical practitioners dealt with a broad range of health issues. Each individual doctor provided complex levels of care across this range, from preventive health care to acting as a proxy for specialist providers. The following narrative, from Dr Alex (one of the two local GPs) highlighted the demands placed upon individual providers in

Waterside:

What are the main health concerns that midlife women in Waterside come to see you about? I think the obvious one, menopause, is an issue and for some women it is an issue because they get side-effects and symptoms of going through menopause… Sometimes it’s a matter of them worrying what they’re going to go through and sometimes it’s because they’re actually experiencing it. The menopause and its symptoms would be one thing, weight gain goes hand-in- hand a bit… people come in, [those] who are concerned about that. Sometimes it’s family history-type issues, because I think once you get to about forty… especially if you have friends or other people your age that are starting to get medical problems, you start to realise that you’ve been healthy so far but you’re getting to an age where you might start getting some health problems. So if there is someone close to them who has had a problem or a family history of a problem at an early age, they start becoming aware about that and perhaps concerned that they should get checked themselves and see if they’re at risk of the same sort of problem…

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Do you do preventive health screenings? Well, all women should have two yearly pap smears and check-ups. I think women are probably more likely, as they get to the age of forty, to take an interest that they may in fact be at risk and starting to become unhealthy, so are more motivated to come in and have those check-ups. If someone has got a [breast] lump, then basically we have to refer them for an ultrasound and mammogram. So it just depends how suspicious you are of it being something to worry about. Sometimes, if I felt very confident it was nothing to worry about, I would just get them to go and have the mammogram and ultrasound and [then] have them come back to myself with the report and then we can discuss it [thus, refers women elsewhere for the radiography; on the basis of these, she diagnoses]. If I feel a bit more concerned that there could be something wrong, I often arrange for them to go and have the mammogram and ultrasound and be seen by someone that does aspirate lumps or does treatment of any further problem [thus, refers to specialist testing and management]. I see if I can arrange for them to have that done on the same day… If they ring up themselves [for a mammography appointment] and they haven’t managed to get an appointment within the week, then I’ll chase it up for them and get them an appointment… If someone presents with an issue or concern that you don’t know much about, where would you gain information? Women’s issues? I basically ring one of the gynaecologist obstetricians that we refer to. It’s the same with any of the specialists… because we are so remote, yet we have a relationship with the ones we use where they’re only too happy to discuss things with us on the phone, give us advice or recommendations and [we] follow it up that way. (Dr Alex, GP)

This excerpt from Dr Alex was concerned with health issues specifically relevant to women in midlife; it also illustrated the ways in which the GPs’ roles were expanded to include services that might otherwise be provided by a specialist. Given the considerable distances involved when seeking health care or advice from specialists and hospitals, the GPs

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in Waterside would attempt to find solutions to health problems through their own networks, as Dr Alex described, before referring patients to providers not in Waterside. Dr

Kerry, another GP in Waterside, described how attempts were made to address a health concern through a few different ways – particularly where there was not a specific treatment protocol – to see if the problem could be managed locally, before referring to an outside specialist. This patient management strategy was not unique to Waterside, and reflects data indicating that GPs in rural areas referred patients to other medical specialists less frequently than those in urban areas (Knox et al. 2005); at the same time, however, they were more likely to refer patients to allied health professionals, hospitals or dentists, which may reflect the distribution of the medical workforce. Taking patients’ individual circumstances into account was clearly an important part of GPs’ duty of care in Waterside, and they actively sought not to make unnecessary referrals. When describing referrals, Dr Alex stated the importance of trying different treatment options (‘trial-and-error’) in treating women for the problematic menopausal symptoms they presented with:

[I] like to see how bad their symptoms are and what stage they’re at and give them a general check-up, but if there’s nothing else wrong, if it is menopause, basically we then would discuss hormone replacement therapy and what it would entail, whether they’re interested in it, what the benefits… or possible risks of it might be. Sometimes they want to go away and think about it and then come back. Other times they know on the spot whether they are interested in trying that. There are a couple of medications that can be used if women don’t want to be on HRT. There are a couple of things that can be helpful and manage hot flushes, so we basically just talk about the options open to do something about it. Sometimes it’s a matter depending on how bad it is [and] how badly affected the woman is, whether they want to go on HRT. Some people hate the idea of it and some people are quite happy about it.

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When a woman comes in and says she wants to go on HRT do you normally get it right the first time or do you have to try a few different times? I think quite often it works well from the beginning, but I always start on a low dose. I always say to people we’ll start on a low dose and see how that goes and may need adjusting. The main thing there is they’re minimising the adverse side effects they might have. [We] might not get the symptoms 100% under control the way they’d like them to be but [it] will hopefully improve their symptoms without giving them any side effects that are unacceptable. Then [I] can review that two months down the track and see if [I] need to increase the dose to get further control of symptoms, and just how they’re going. [I] get some women who disagree with or have a problem or want another and [then I] review it and work out what the problem’s due to and adjust things then… (Dr Alex, GP)

At the same time, the GPs’ ability to manage complex health problems before making a referral was influenced by their participation in professional development and educational activities, which all general practitioners in Victoria are required to undertake as part of their continuing professional accreditation (Peck et al. 2000; General Practice

Division Victoria 2004; Commonwealth Department of Health and Ageing 2005). For example, Dr Alex had done additional training specifically around women’s health and family health, whilst Dr Kerry had undergone professional development in alternative therapies and women’s health.

Managing menopausal symptoms through pharmacological means was not the only time where the GPs deferred referring patients to specialist providers; Dr Kerry described using techniques from cognitive behavioural therapy (CBT) and teaching patients meditation as a first response when patients presented with anxiety or depressive symptoms; in some circumstances, low-dose anti-depressants would be prescribed. At the same time, other explanations for the symptoms, such as thyroid function or oestrogen levels, would be

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explored and, where necessary, a pharmaceutical treatment would be recommended. If the patient used this protocol but did not experience any changes in symptoms, Dr Kerry would prescribe a higher dose or different type of anti-depressant and, in some cases, refer to therapy with a family counsellor at the community health centre. The next response by Dr

Kerry would often consist of varying the anti-depressant medication and referral to a psychiatrist visiting Waterside monthly or, alternatively, practising in another town. The latter was used as a final response due to the high time and financial costs, in addition to the necessity of having access to personal transport, to receive on-going treatment from a provider external to Waterside.

The local GPs explained their reasons for not referring quickly as being strongly related to travel and medical costs. This was not surprising given the employment status and low incomes of many residents in Waterside (described in Chapter 2). Both GPs described being mindful of patients’ socio-economic status and financial situation when planning their treatment and management of their patient’s health, and believed that taking these considerations into account was part of their occupational responsibilities. Patients did not necessarily disclose their income, however, low income was indicated by the possession of a health care card. Therefore, whilst this was a crude indicator, the possession of a health care card gave the provider insight into their patient’s (in)ability to access economic resources for more costly treatment. The impact of their consideration of patients’ financial resources on the GPs’ referral behaviours was further indicated by their readiness to refer their patients to specialists visiting the community health service, as Dr Alex described in terms of responding to women concerned with weight gain:

In terms of the weight gain, how do you respond to those concerns? There are a number of things – we might do a blood test to check they’re not pregnant, especially if it’s a more recent weight gain. If they have any other

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symptoms, like lacking energy and things like that, we might do some blood tests to check the thyroid. I would go over their… diet and activity level and see if there is a problem there that could be tackled. I don’t provide women with actual diets, I’ll discuss healthy eating principles, what they should or shouldn’t be eating. If they want a particular diet, I tend to refer them to the dietician that visits the support service for specifics on diet, but I’ll discuss with them general principles and the types of food and problems with calorie restricting too much, and appropriate exercise levels and how important that is. It might be appropriate in some cases to prescribe medication to help them lose weight but only after we’ve explored the other side of things… I’ll go over that sort of thing and in that age group also discuss other things that impact on health, like diabetes developing, high blood pressure and general benefits of keeping weight down for those sorts of problems as well. (Dr Alex, GP)

Referral to and prescription of non-medical health professionals is a feature of rural health management. Women from rural centres were more likely to consult complementary or alternative health providers than those from remote or urban areas (Brown et al. 1999).

Whether the higher rates of consultation with non-allopathic medical practitioners reflected women’s preferences for care or reflected service provision and access issues remains to be established. Women in Waterside described using multiple complementary and alternative medical practices in their management of their health. For some, this occurred through their

GP whilst others drew upon their own knowledge structures to manage some bodily signs, such as Abbie’s use of Bach flower remedies:

I’ve always been interested in [natural therapies] and folk medicines and stuff like that… [My sister] brought [me] some rescue remedy, one of Dr Bach’s rescue remedies and six weeks after I’d gotten out of hospital [following a head injury], I had to go back to the doctor for a check-up and they said they couldn’t believe how great I was and [they asked] how come I’d been

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recovering so well? And I said, ‘well one thing is Waterside, and the other thing is the rescue remedy.’ They said ‘what’s that?’ you know, and poo- pooed [them]. That… got me on the trail [of] research in [using] those sorts of [remedies]. (Abbie, age 54)

Abbie, along with other participants, sought alternative, non-allopathic modes of treatment from their GPs. Many women in my study described consulting Dr Kerry for acupuncture, which they felt helped them with on-going management of their health, without exposing them to the side-effects of medication. Cynthia, for example, sought acupuncture for her hot flushes to pursue a non-hormonal management strategy:

[The hot flushes] used to happen all the time, just constantly… I had acupuncture and that worked but… I had the acupuncture at the time that I went [on vacation] and then we moved here so I didn’t get to follow it up. That worked and it was really good, but it only worked for about 6 weeks. Dr Kerry likes to practice acupuncture and I am going to go… I think [when] it works, it works, it is better than oestrogen… I would rather not be taking that. I would rather try the acupuncture. For 18 months, I just tolerated [the hot flushes], I tried all sorts of herbs and all sorts of different things but it just got to the point one of those hot spasms, I virtually had to give up work and everything too because I was getting so tired. (Cynthia, age 50)

Cynthia found that acupuncture helped her to manage a range of her health problems, particularly her high levels of fatigue. When hot flushes started interfering with her ability to fulfil her social responsibilities and impacted upon her own sense of personal resilience, she sought Western (through hormone replacement therapy) and alternative (via acupuncture) medical assistance from her GP. The ability to seek primary health care, and the patterns through which women sought out formal care, form the next section of my analysis.

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Seeking primary health care

All of the participants in my research experienced some health problems – whether they were temporary (acute) or long-term (chronic) – and therefore required some primary health care.

For women who told Maintaining or Meditating narratives, their interactions with the medical providers was often around responding to an injury or short-term bodily crisis, such

as when Grace injured her arm, or for preventive health reasons, such as cervical or breast

screening (discussed above). In contrast, women who told Negotiating or Navigating

narratives described establishing close relationships with their providers; the problematic

nature of their health status meant that the GP was a central part of their daily lives (at least

for an extended period of time) and played an important role in enabling them to perform in

desired ways. These two groups of women, however, used the local primary health services

in different ways. Women who told Navigating narratives often consulted general

practitioners and used services delivered through the community health centres; indeed,

several were heavily involved in activities of the latter. In contrast, women who told

Negotiating narratives described high levels of general practice utilisation, with little

attendance at the community health service. Table 7.3 (below) shows women’s patterns of

attendance and consultation at the health services in Waterside by the types of narratives they told.

Table 7.3: Health service utilisation by type of narratives told by midlife women Maintainer Meditator Negotiator Navigator General As required As required On-going health On-going health practitioner management management Community As required As required As required On-going health health service management Visiting health As required and for As required and for On-going health On-going health providers preventive health preventive health management and management and care care for preventive for preventive health care health care Attend health Specialists only or Specialists only Some regular, on- Some regular, on- providers in other where income going health care going health care towns permits (income dependent)

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Women who told Navigating narratives used the greatest number of local health services. In addition, participants who told Negotiating and Navigating narratives concerned with illness used providers outside of Waterside; this was more often related to their need to access specialist consultants rather than a reflection of their preference for a GP who did not live in the community. Throughout the study, only one woman (Biggs, who told a Maintaining narrative) consistently sought primary health care from a provider in another community – when she needed preventive health screening or primary health care (outside of emergencies), she attended her long-term GP in Hillsville (Dr Graham), 143 km away. Whilst her choice of provider was no doubt influenced by her health status (as she had no need to present frequently for medical care), she had not changed her health-seeking preferences following the restructuring of local health services in Waterside and, thus, her choice of GP was an artefact of the historical provision of health care, rather than a specific response to the health providers in Waterside:

Terry Graham in Hillsville has been my doctor right through. He delivered the children and he still is our doctor, and also… stayed with us as a friend… He has been our doctor. He mended [my daughter’s] broken leg, he did [my husband’s] vasectomy, he delivered my children, and we still go to him. Do you ever use the health services in Waterside? Occasionally. Normally for little problems… Like [my son] went down yesterday because he wanted a medical [check-up]… We’re not averse to using them but… touch lots of wood again, we really don’t go to the doctor. So luckily we can normally keep it to our annual check ups. Do you use the community health centre or its services? Not normally. I went [recently] because when I went up to Dr Graham, my blood pressure was actually up a little bit, not much. We had a couple of things happen and I had actually driven up and he said that’s probably what it was and then I had a pap smear. [After that] I just went down [to the community health service] and [the nurse] took it a couple of times and it was

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really low… So I actually had to go and see [her] a couple of times for that but other than that, not at all. (Biggs, age 53)

Being in a high income bracket, Biggs was able to freely choose where she attended her GP and therefore, the cost of travel to Hillsville for a medical consultation was not prohibitive. Income played a significant role in many participants’ health-seeking behaviours, as costs of travel were high. This meant that many women did not want to seek care equivalent to that provided in Waterside from a provider in another community. Similarly, income shaped participants’ presentation to specialists in other communities. For Nola, seeking treatment for cancer (described above), travelling between Hillsville (north of

Waterside) and Raaft (to the West) was challenging. She acknowledged, however, that had she been in a different socio-economic situation, such as if she had a lower income (she was in the highest household income bracket in Waterside) or more demanding work and family responsibilities (Nola was self-employed, with older and largely independent children), obtaining quality health care may have been much more difficult:

[The travel] is tiring and it costs a lot of money… If you’re having tests, someone needs to come with you, which is hard because… well, you can’t always get someone. And plus, it’s a traumatic thing to go through so you don’t just want anyone there as well. And the money part of it, I suppose, if you couldn’t afford it, I don’t know how you’d cope. I wouldn’t have a clue. The cost of petrol? Yeah, and then you have to stay overnight and all that. The government says ‘yes, I’ll help you,’ but they’ll only help people who’ve got no money. If you’ve got some money, they won’t help. (Nola, age 41)

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In contrast, women on lower incomes described seeking all of their care from the local GP, as whilst their medical care was covered by Medicare, other out-of-pocket costs limited their opportunities to seek advice from other providers.

In the following section, I position health care in Waterside in terms of other health services in nearby communities. By doing this, I illustrate the ways in which geographic isolation is compounded by other factors, which also impact upon access to quality health care.

Seeking health care outside Waterside

The nearest community where specialist services could be accessed was approximately 110 km away, ostensibly a distance that would take about one and one quarter hours to travel by road. This meant that just less than three hours elapsed in travel time alone when seeking specialist care, not including time waiting or in the consultation. The reality of travel further extended this time estimate: given road quality, which are often poorly maintained, travel takes considerably longer – the road leading out of Waterside consists of 16 km of very tight bends, requiring careful and slow negotiation. The access road is often pot-holed and contains many patched repairs, all of which impact upon time elapsed in safe travel. In addition, fuel is between 10 to 15 cents more expensive per litre than urban fuel prices and, combined with lower average incomes, provided an additional barrier to access specialist health care. The complete absence of public transport from Waterside, with the exception of a fortnightly, 12-seat, aged care bus run by the local community health centre to Paradise, meant that people who were unable to drive themselves or who did not have access to a car were further restricted in their access to specialist care.

Women in Waterside used several providers to manage their own health, although they relied on the GP for the bulk of their health care. Participants managed the bodily signs

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and symptoms that they perceived were related to short-term health problems by themselves, using ‘commonsense knowledge’ (Cornwell 1984) and lay health management strategies. The ways they employed to manage their own health had a historical basis and reflected wider social phenomena, particularly the historical structure of health care delivery in Waterside

(which I outlined in Chapter 2).

HABITUS AND WOMEN’S HEALTH-SEEKING

Women who told Navigating narratives described a greater reliance on a range of health professionals when compared with Negotiating participants. This trend highlighted an important feature of women’s health management practices and behaviours, particularly given the highly complex and long-term nature of the Negotiating women’s health concerns.

I posit that these different patterns of health-seeking can be explained drawing upon

Bourdieu’s (1977) concept of habitus, which I outlined in Chapter 1. To apply his theories to the narratives of women in my study, I suggest that women’s practices around seeking medical assistance for their health problems (that is, their health-seeking) may be related to habitus. Women who told Negotiating narratives acquired a familiarity when dealing with the medical profession throughout their extended periods of problematic health events. They described fewer encounters with medical professionals, over long periods of time, which reflected their ability and skills to manage their own health problems. That is, they developed a habitus associated with their on-going health-seeking and caring for their own health (i.e.

‘self-health management’) as a direct consequence of their long-term health concerns. Over extended periods of time, the ongoing reality of living in an often-problematic body meant that their sense of the experience being incompatible with their sense of being was reduced.

Thus, the attention-grabbing nature of bodily signs reduced as levels of comfort (or habitus) in responding to bodily signs and events increased.

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Ferdie described how, as she became able to successfully manage her bodily reactions, her new habitus (around bodily management) became acceptable. As she explained, she only risked changing the habitus (by potentially prompting an allergic reaction) for ‘special’ events:

I think [the Ross River Fever] affected my immune system because I became allergic to a whole lot of things that I was never allergic to before. Shampoo, conditioner, I couldn’t use hair spray. I couldn’t use make up for ages, had to be very careful about skin cream – moisturisers and stuff. I had to get Ego89 shampoo and conditioner. They were the only ones I could use for a long time. Sunscreen, some of them still bring me out in blotches but I am getting better… Now I only ever use mousse or hair spray on special occasions. I don’t overload the system with it anymore. Did that change how you feel about how you present yourself to the world? It was really hard when I first couldn’t use it because I used to do my hair to go to work and I used to say, jokingly, I think I’m allergic to work because this rash would go away… when I had my week off but when I’d go back it would start coming again… but I went to the dermatologist and he looked at the rash and he found out it… was all around here… My neck would come out in welts and this rash, like a yoke. Then I was going to work with just washing my hair and not, there was no point blow-drying it because it flopped anyway so I just became as you see me now. El natural… Now when I get dressed up to go out, I think how are they wearing make up these days? How are they doing it? If we just go down the street to the pub for dinner, I don’t wear make up, it’s only when we go somewhere special. So that has made a bit of a difference because I always wore make up out… So that’s why I don’t now. The make up did affect me a little bit but I always thought that that was because it was old, so I threw it all out and bought all new stuff and it still did… I had a lot of make up that I really liked and I threw it all

89 Ego is a brand specially formulated for people with highly sensitive skin, and contains very few allergens. It is available at pharmacies.

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out. But I don’t have a lot of make up now. I only wear it when I’m going somewhere flash… My dermatologist said best not to. (Ferdie, age 53)

When Ferdie first noticed her body becoming more sensitive to cosmetics, this was something novel to her (that is, it was outside of her habitus) and required considerable attention, in the form of firstly determining and then avoiding allergens; however, as time elapsed and she became accustomed to avoiding certain chemicals and not wearing make-up, she gained confidence in self-management of her own health and relied on fewer health professionals. At the same time as she described her increasing confidence and comfort in her self-health management strategies, she highlights their basis – information obtained from a health provider (in this case, a dermatologist to whom she was referred by her GP). As such, whilst she and other participants relied on medicine to manage their health concerns, their narratives also emphasised their autonomy, independence, and power within their interactions with medical professionals—enabling them some level of control within the encounter, as Hattie described:

I have an extremely low testosterone reading and… I instigated taking DHEA,90 which does help lift my testosterone level and which does markedly improve my energy levels when I take it. I know there are three other women in town who are taking it. My doctor didn’t recommend it. I suggested it to my doctor and he investigated it, and said that he could neither encourage or discourage me because there wasn’t enough clinical data on it. However, he agreed when I asked him to do the appropriate blood tests so that we could make sure that I’m taking doses that keep me within the norms of testosterone levels. (Hattie, age 50)

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By taking an active role in their health management, participants simultaneously engaged in and challenged processes of medicalisation. Both Hattie and Abbie in particular emphasised this dual dynamic occurring throughout their encounters with their medical professionals – whereby they used lay information to become educated about their own health status and possible avenues of treatment, whilst seeking care from the GP.

EMBODYING RURALITY

In her exploration of the cultural representation of landscape, Saugeres (2002) explored how men’s connections with the rural landscape become embodied through the practice of farming and subsequent adoption of the farmer identity. This was not dissimilar to what was happening for many of my participants in managing their own health. Drawing on Saugeres’ work, women’s self-management of health problems reflected how rural residents embodied their own (and culturally normative) understandings of rural life. Life in country Australia is constructed, by both urban and rural dwellers, in terms of resilience in the face of adversity, resourcefulness, adaptability and flexibility, independence, autonomy, and self-reliance. These characteristics were reflected through women’s strategies when managing their own health, using health care services, seeking information and sharing knowledge about health conditions.

Being resourceful: Cynthia’s health management

The theme of taking care of their own health was central to women’s stories, in which they emphasised their resourcefulness and self-reliance (also described by Wathen and Harris

90 Dehydroepiandrosterone (DHEA) is an androgen replacement therapy that has been suggested as a treatment for some menopausal symptoms; however, its clinical utility has not been demonstrated (Katz and Morales 1998)

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2007). For example, when responding to their problematic bodily events, the women who told Negotiating and, to a lesser extent, Navigating narratives actively managed their own health concerns, sometimes on their own yet also with the assistance of their health care providers, most often the GP. Cynthia’s behaviours were typical of many women in that she only sought advice from her GP once she had exhausted her personal health management practices and behaviours. Following her consultation with Dr Kerry and subsequent treatment of pernicious anaemia with vitamin B12 injection, she developed skills which enabled her to manage her own health. By being aware of her diet and nutrition (and increasing her red meat consumption), she was able to increase her B12 levels and assist in her treatment:

I went down a bit in energy and everything like that but that turned out to be the B12 (pernicious anaemia)… I was getting melancholy and bluesy91… When I got the B12 fixed up, that melancholy and bluesy bit went away… Since [then], I’ve been on this meat [eating] diet. [I had the] B12 injections to bring the level back up to see whether it was my diet or if I had the [pernicious] anaemia. I [used to] have meat every now and then, [about] once a month, if that. I’d just have a piece of steak. (Cynthia, age 50)

After learning that she had pernicious anaemia, Cynthia increased her meat consumption to several times a week and, through this, had noticed significant changes in her energy levels:

I was tired too, too tired to think sometimes and I was starting to get really, really dizzy even when I lay down. I’d lay down and my head would just go ‘woosh’ [start spinning]. Are you still getting dizzy now?

91 Blue, having depressed mood.

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No. Tired? No, not like that drained feeling. No, not like that. I just get normal tired now [rather than exhausted].

At the time of our follow-up interview, Cynthia was evaluating her bodily responses to her changed diet and drew upon her own bodily knowledge in working out an appropriate response to these:

[I’ve had] like a burning feeling down there [oesophageal area, probably reflux], so I’ve cut out all tea and coffee and everything. [Even] just a sip of red wine will burn all the way down. That’s only since I’ve been eating the meat as well. I get a bit of a bloated belly and things like that, things that I wasn’t getting before… I’m due to go back to Kerry and to see what he says about that.

Cynthia’s resourcefulness was emphasised as she did not entirely rely on the doctor but instead made self-evaluations about her bodily signs, and tried various strategies to manage, before presenting to her GP.

Resilience in the face of depression: Mac

In addition to stories of community and personal self-reliance, women’s narratives also suggested other ways in which they embodied rurality. They believed that a sense of hardiness was something that developed with age. Mac, for example, emphasised how she gained inner strength and developed a greater ability to deal with the depression and anxiety that arose from her adverse life circumstances:

That’s one of the things about being a middle-aged woman, you realise nothing seems to matter… What I feel happens now is that I have more

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confidence. I can’t say to myself, ‘I can’t do that,’ because I’ve done it [before]. [I’d think I couldn’t do] lots of things because [I felt] ‘I’ve got nothing to fall back on’ but I can’t [do that] now. I know I can do things well… I just never thought I was capable enough. (Mac, age 47)

Feeling capable and competent – and thus, self-confident – were important in Mac’s responses. As described earlier, at the time of our interview, she was experiencing transition in all arenas of her life. She emphasised that, due to her age and life experience, she felt much better equipped to deal with these challenges and thus was better able to manage her mental health:

[Regarding her marriage breakdown and unexpected business failure] You must have learned so much about yourself and your personal strength? Strength, yes. When you’re younger you can deal with stuff to a point. That one was very complex though it could have defeated me. I don’t know, [if I was younger] I probably would have handled it differently that’s all. I think the other person [her younger self] might have had more negative after- effects, feeling angry and bitter. Perhaps, I’m not sure what it is. You do think a bit more [as you age]. You know more and you’re more forgiving and more understanding. It doesn’t mean you’re also not capable of blowing your stack and getting upset about things. One of the nicest things I like about getting older is not only do I get less scared, I still get scared, but there’s a bigger stronger bit in the corner of my mind saying looking at the whole situation, looking at what to do.

Mac’s sense of resilience was also generated by factors specific to the community.

She described how having people around her, who were understanding and supportive, encouraged her to remain in the community and seek solutions to her problems:

I was trying to work out what I am going to do – having privacy versus being public, being out and working. I’m really enjoying stuff at the moment… I

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think it’s better to be involved with outside things so there’s volunteer work and stuff like that too. It doesn’t necessarily mean a job but it’s all [participation]. The thing is when you’re this age, you’ve already spent years and years doing unpaid work. The voluntary system is run by men and women but mostly women, and women my age especially, partly because we have got a lot of skills but partly too, it really is good for us. It’s good because when you’re doing it, it means you can get references and you can put [those] things on your c.v. [curriculum vitae]… because you have done the work and have gotten better. It really is true even if you don’t even use it for that purpose you are more confident person.

By participating in volunteer community organisations, Mac received support, built confidence and gained skills that would help her in the future. In this way, she added to her own ability to cope and developed a greater sense of resilience – through these mechanisms, she embodied characteristics of rurality.

Self-reliance, community reliance and local strategies for health management: Lois

Women’s embodiment of rurality was also reflected through their preference to use services and information available to them in Waterside (as discussed above), rather than travelling further afield. Their stories supported Bourke’s (2001) work demonstrating that rural dwellers employ local strategies when seeking health information. Many participants employed local services even when they were discussing stigmatised or very personal health conditions. The personalised response provided by the local services and sense of being cared for was important, as Lois described:

How have you found the health services in town? Look I’ve had no problems. Every time I’ve gone in they’ve been very supportive. At least they make you feel like you’re not just a number, or [that]

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you’ve only got x [an allotted] amount of time with them. They will spend as much time with you as they feel you need. What about in terms of the information you’ve been given? Since they’ve [had] the computers, there’s a lot more information available to the patient. Like, I had chlamydia once and the doctor printed out all this information [from the internet] on it and gave it to me to read. So I feel that with the technology they have now they can give you a lot more information as to explaining it and drawing on a pad… In terms of being comfortable and being able to talk to health professionals, how is the social support in the community? Well I’ve often gone to the district nurses. I was a volunteer with the community [health centre]. At one stage, I had a breakdown, only because when I was little I was sexually abused by one of my father’s friends… I carried that for years and years. I got into my 40’s… Then I went and did a workshop for [working with survivors of] child sexual abuse… I wanted to do that course but Barbara, the head nurse, said “Did I realise that it could really have an impact on me?” I said, “I’m prepared for that but I think I need to do the course” and I did it… With the community [health centre], I was supported in that because it really got to me and I was able to stand up and say something. They gave me free counselling… and I think I was really successful with [that]. I found that I was really comfortable with him [the counsellor] because he just sat there and let me ramble on… the memory is still there but I’ve moved on and I’ve told somebody, and I cried as much as I wanted which I felt I needed. The community house is an important thing to have. And that’s important in terms of your health? Absolutely because you know that you can go to these people and they’re there. They are there to support you and listen to you. (Lois, age 57)

Lois felt supported both by the doctors and by the community health centre workers. She emphasised how self-reliance occurred on two levels: in her own life and within the

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community. By having high quality supports accessible to her within the community, Lois described how she was able to come to terms with past, negative life events – thus contributing to her own sense of resilience and autonomy.

Relying on one another: seeking information and sharing knowledge

Women embodied other characteristics of rurality through their health information seeking practices. Wathen and Harris (2007) found that non-professional sources were important in rural women’s health seeking, and described the importance of lay networks in acquiring health-related knowledge. While the rural women in their study used the internet to do this, participants in my study sought information from other women in the community, particularly to seek information about midlife health and the ageing process. Chappers, for example, described how, when she was approaching midlife, she wished she had been able to talk to older women about what to expect. She had been unable to do so, and described how it was important for her to provide this information for other women:

In retrospect, I wish that I had talked to some women who had already undergone or gone through it [menopause]. They might have been very good as a sort of mentor or something [like that], to say ‘well, it ain’t the end of the world and if this happens or that happens, don’t worry, you’re not alone.’ But I think with women who are older, say women who, say I was 50 or 51, to go and talk to a woman who was maybe 60 or 65, well a lot of them had never had the joys of things like hormone replacement therapy. They just battled along alone and [did] it really tough and sometimes for a very long time. So whilst they might have been able to tell me that ‘yes, you can feel depressed or whatever, but don’t worry about it because if you go onto HRT, your life can change dramatically,’ they’ll [probably have] just go [said] ‘oh well.’ I think they might have said, ‘this is just the way things are.’ But hopefully with younger women now, they will feel happy to ask me if they want to when it [midlife bodily change] starts happening for them. In fact, it

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has started happening for me with a few of my friends, they’ve said ‘I think I might be at the beginning of menopause.’ And I just go ‘quickly whip off to the doctor. Find out what’s going on and get yourself on those magic pills.’ And they have done. But I do have other friends and it’s [HRT has] just been absolutely disastrous for them because they’ve had lots of problems like breakthrough bleeding. (Chappers, age 60)

Chappers described her role as an informal women’s health advocate (see Warren et al.

2006), where she drew upon her own experience to help other women to enhance their midlife health. Through her work as a hairdresser, Musical also acted as an informal women’s health advocate. When women attended appointments with her, they often discussed their health problems:

[From fieldnotes] We talked about the [hairdressing] salon, because Musical ran one. She found that women seemed to be not getting support or answers from the doctors within town. After going through the bodily signs and events that she’d been through, she found that she could often pick it when women coming in to the salon needed some sort of support in terms of their menopausal problems. Therefore, using her experience and the information that she’d personally gathered about her own situation, she often would talk to women about menopause and their particular issues. Musical would either give them something to listen to or read so they could find out about menopause; she would also direct them to places where they might be able to find information. She ended up becoming a sort of informal health advisor, which fulfilled a pretty important role. Last year, she was performing with a group of approximately 7 women and they ended up having an interesting discussion because she asked them about their information seeking about menopause. One woman actually refused to answer; another woman asked Musical whether she ought to be discussing such intimate problems with other women because it’s a very personal issue. Musical said she was amazed

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because, of the 7 women in the group, only two other women participated in the discussion about the menopause. (Musical, age 57)

By sharing information, women became a resource and source of knowledge about ageing and health. In this way, they were both autonomous and resourceful. In responding to their geographic isolation and limited access to formal information and health services, they found ways to make the most of what was available. In many cases, this was through other women.

However, the ways in which women embodied rurality was not always positive.

Although, like other participants in my study, Musical was happy to share her knowledge about menopause and midlife health, not all women felt comfortable to do so. Some women found this informal advocacy confronting and inappropriate. In addition, because of their sense of social isolation, some women felt unable to draw on other women and instead, sought to manage their health themselves. As I describe below, Sam embodied resourcefulness in her health management; for her, however, this was borne out of a sense of isolation and social exclusion.

Managing on my own: Sam

Sam described feeling depressed throughout her midlife, which she felt was exacerbated by a lack of informal support due to her small social network, largely her family, and few appropriate health services. She found it challenging to cope with her mood changes, particularly as she would frequently become teary when in public, which was made into a joke by storekeepers in the community (see Chapter 4). In the following narrative, she described her sense that no one could provide her with the support she needed:

My husband’s sister came for a holiday and she said, ‘you know, you should go to the doctor’s and get some medicine [anti-depressants, HRT or both].’

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But you know, I sort of survived without doing all that… So what I think is that all these other ladies had patches and everything, but the thing is, I had my Ventolin, my asthma medicine… Even though I had this depression sort of thing, it could have been because you are in a new place, and your husband puts you in a big new house, and you don’t know the neighbours, and it can be more that it was, what do they call it? Suburban loneliness [rather than menopause]. Quietness you know, but I always did a lot of voluntary work and tried to keep myself involved anyway… I got off the Ventolin machine because before that, I was taking it four times a day, which was equivalent to eight puffs of Ventolin. So maybe it was the Ventolin that helped me to not have any problems [other than depression and mood swings] with my menopause. It was really great [going off the machine because] I was tied to a machine four times a day, because I was frightened of having an asthma attack… (Sam, age 56)

In the above narrative, Sam described how she suspected that her mood changes were related more to her feelings of being socially excluded than actual physical symptoms.

However, as she was unable to access formal support to manage her feelings of depression and anxiety, she instead used her asthma medication (Ventolin). As the Ventolin was used for reasons other than that for which it had been prescribed, Sam potentially placed her health at risk. Without established networks in Waterside, despite having lived there about thirteen years earlier, Sam reflected on how social factors influenced her self-health management:

I’m an interesting subject because I’ve lived in seven places, in twenty-seven years of marriage. And I have learned that it doesn’t matter where you go, everybody has got their relations, their friends and their network established… I knew when I came back to Waterside – I lived here from 1985 to 1989 – what [the town] was like, and I knew that everybody knows who’s in love with who before they are in love themselves [that is, there’s a lot of gossip]… I have always had no family support because my relations are in Sydney or Melbourne so I’ve had, so we have had to be a pretty self, um…

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Sufficient? Yeah, family, you know. [So] you know I haven’t really taken a lot of advantage of the health services provided by the community health centre. I mean it was good to have [it] there if [you need it]. I have mainly gone to the family doctor and when we lived in Waterside originally there was no chemist… You talk about health socialization and then I talk about community socialization.

Sam believed that women’s understandings of health, and their health-related behaviours and practices, could not be considered without understanding the community itself. Although she was self-sufficient – thus, resourceful – in managing her health, she saw this was in part in relation to her (perceived) marginality. Embodiment of rurality, therefore, may be about more than characterising the peculiarities of geography and landscape (as suggested by

Saugeres 2002) and also may reflect social positioning and community structure.

Participants’ stories reflected Hayes’ (2006) findings that, by caring for their own health through both formal health services and informal self-care strategies, rural women were able to maintain independence and autonomy. Hayes (ibid.) argued that women’s perceptions of themselves as healthy, enacted through engaging in behaviours that they constructed as ‘being healthy’ (see Chapter 3 for further discussion), are related to sense of independence. Independence – variously described as autonomy or self-reliance – has been identified as an important factor contributing to people’s understandings of age (also described by Backett and Davison 1995). By embodying the characteristics of rurality and the

Waterside community, women negotiated their age identity.

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Chapter 8

‘You Enter That Other Age’: Time, Age and the Life Course

In this final chapter, I draw on the preceding discussions to provide insight into how women in Waterside used concepts of health to construct their age identity. I explore how menopause shaped age identity and how women believed that menopause acted as a marker for entering ‘that other age.’ Menopause therefore was a culturally significant indicator of their ageing. I then discuss how women’s health status, and their health-related practices and behaviours, impacted upon their understandings of midlife. I conclude by drawing out the implications of my findings in terms of developing age-appropriate health promotion and service delivery. As demonstrated in previous chapters, health was salient in women’s understandings of midlife. Women sought to maintain their good health through self-health management and preventive health measures.

MENOPAUSE: A CULTURALLY SIGNIFICANT MARKER OF MIDLIFE

Women in Waterside constructed midlife health more broadly than the dominant biomedical model which focuses on the physiological process of menopause as the major health consideration of midlife women. The biomedical model focuses on midlife health in terms of managing symptoms and risk of osteoporosis (in particular), heart disease (including stroke) and Alzheimer’s disease (Clinkingbeard et al. 1999; Guillemin 1999; Meyer 2001; Blumel et al.

2003), all of which are claimed to be managed through the ‘technologies of menopause’

(most often HRT; Guillemin 2000). On the other hand, the feminist/empowerment model does not specifically address the concept of health: it is concerned with spiritual or emotional

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growth and personal development (see, for example, Weed 1999; Meyer 2001; Coupland and

Williams 2002). As I described in Chapter 4, these models are primarily concerned with

defining menopause in terms of the end of reproduction, the cessation of menstruation and

ovarian function, and associated symptoms.

Regardless of the narrative strategy, and despite my expectations at the outset of my

study, the experience of menopause was important to all women’s understandings of midlife.

Participants drew on aspects of both biomedical and feminist/empowerment models in

describing their midlife experiences. However, women constructed menopause differently

from these models. For them, menopause was a social experience, influenced by community

participation, family support and social roles. They used the term ‘menopause’ in multiple,

interchangeable ways, such as when referring to the bodily changes associated with

reproductive ageing. By using ‘menopause’ as a metonym for midlife, participants highlighted

the transitional nature of the life stage and emphasised biographical flow and evolution (see

Atchley 1989). This metonymic use reflected their understandings of ageing in terms of

continuity.

Symptoms were important in this. Not only did women rely upon their experience of

symptoms to determine when menopause began and ended, but also, their symptom

experience shaped how they positioned menopause within the life course. For example, Grace had few, mild symptoms and thus viewed menopause as an event; for her, reproductive

ageing was a relatively unimportant occurrence within her own biography and was not an

important component of her understandings of midlife. In contrast, Cynthia’s experience of

hot flushes, and family experiences of symptoms, meant that she viewed menopause as a

process which continued beyond midlife. Reproductive ageing played a much more

important role in Cynthia’s understanding of midlife than it did for Grace, suggesting that

women associate symptom experience and the meanings of menopause.

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For women such as Musical and Aspidistra (who both used the Navigating narrative strategy), changes associated with the menopausal transition started to occur much earlier than epidemiological data indicates; their stories suggest that commonly used biomedical markers are not the best way to determine whether a woman is beginning to experience menopause-related changes. The findings presented in this thesis suggest that participants understood their menopausal transition as a long process of change which lasts for many years, often much longer than is suggested by popular biomedical or feminist/empowerment literature (Cabot 1991, 1996; Weed 1999; Lyons and Griffin 2003; Jean Hailes Foundation for Women's Health 2005a, 2005b, 2007). This is supported by other studies: Dillaway (2006) argued that reproductive ageing lasts for considerably longer than women expect, with considerable changes occurring over extended periods of time. Davis (1986) described periods of up to thirty years, during which women experienced multiple (primary and secondary)92 symptoms associated with or related to menopause.

Women’s understandings of menopause also changed as they progressed through the life course and as their final menses became a more distant event. Those who viewed menopause as a distinct event tended to employ Maintaining or Contemplating narrative strategies. Women like Maude, Grace and Biggs appeared to reconstruct their notion of menopause as they continued to experience symptoms, regardless of intensity, in the future.

For example, Maude assumed symptoms would only occur around the end of menses. This was not reflected in the experiences of older (post-menopausal) participants, who described symptoms starting around the time of their last period and continuing into post-menopause, that is, after all menstruation had ceased. This supports data indicating that many symptoms

92 Davis (1986) defined primary menopausal symptoms as those bodily signs that occurred due to the cessation of ovarian function and included vasomotor symptoms (hot flushes and night sweats) or changes to vaginal structure (atrophy of vaginal walls). In contrast, secondary symptoms were those relating to somatic and psychological symptoms, such as mood changes or depression (ibid.).

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are experienced during the later stages of the menopausal transition: for example,

Dennerstein and colleagues (2000) found that hot flushes tend to intensify after the final menstrual period. Understandings of menopause were therefore fluid and dynamic; women re/constructed their understandings of menopause and adapted their positioning of the transition within their life course based upon bodily changes occurring as they age.

Entering ‘that other age’

Menopause enabled women to tie their life domains together and, by drawing links between various aspects of life, provided them with a way of locating themselves within the life course and gaining an understanding of their own ageing. In addition, menopause enabled them to be freed from their bodily demands (such as contraception or managing menstruation) and enter into a new status category (of older woman). Iris felt impatient at her prolonged menstrual transition, which she identified as beginning at forty, when she first began having hot flushes; this prevented her from moving on from her child-bearing years, into a new stage of life:

I haven’t [stopped menstruating], and I am so pissed off [annoyed] that I haven’t, because everyone else who turned 50 this year has been through it. And I am still getting my period, and I got hot flushes when I was 40 and I am still getting hot flushes… I keep thinking, ‘if it has happened for 10 years and what if I go though menopause soon? Then will it happen for another 10 years after that?’… It is just annoying, I think, at this stage in your life [to still be having symptoms], but I mean it has been happening for so long that really it is not a big deal. But I think it makes you conscious of the fact that your child bearing days are over and you are joining the [old ladies]. (Iris, age 50)

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Similarly, Aspidistra described her responses to the changing nature of her family and work-related activities as making her aware of time passing. This contributed to her lowered mood and self-esteem. She described her feelings about entering ‘that other age,’ which she viewed with dread as her participation in these roles, themselves associated with relative youth, gave her a sense of purpose:

Five years ago, 6 years ago, our youngest [child] left home… it was a very emotional time in one way or another… the mood swings were bad, and also loss of self-esteem… I was lucky enough to be offered work at the time and that was a tremendous boost to my morale and self-esteem. Since I have left work, that [self-esteem] has suffered again because I feel like I am a real non- entity again. (Aspidistra, age 57)

Menopause was not only understood as an event or process that would happen during a distinct life stage, but was also constructed by women as a rite of passage which gave meaning to their ageing. Drawing upon van Gennep’s (1960) work on transitions between status passages, menopause is a liminal rite of passage – an uncertain process accompanied by physical and social changes – which women must pass through before entering the next stage of their lives. Women in my study viewed menopause as prompting them to take stock of their lives, by coming to terms with what had happened before (such as Iris’ realisation that child-bearing was over) and anticipating the future (such as

Aspidistra’s fears about being a non-entity).

Marking the life journey: menopause, ageing and personal growth

Several women referred to menopause (and thus, midlife), as freeing them from past limitations imposed by their bodies, their social roles and cultural norms, so enabling them to grow in personal power and, to a lesser extent, socio/cultural ‘generativity’ (a term I borrow,

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in both name and meaning, from Erikson 1974). They were concerned with making

contributions that would enhance the lives of future generations – having a legacy of some sort, which was often something small yet meaningful for them. Menopause became a marker on their life journey, indicating when it was time to leave past difficulties behind and

embark on a new, exciting stage. Some, like Daphne, employed the notion of the ‘crone’ to

indicate their social position, post-menopause (after menstruation and symptoms ceased):

I don’t mind ageing, it is not an issue with me. I am me. I am right here in the moment and it is just a passage of life, you know, and there is no point worrying about it or resenting it. I don’t feel like I want to be young again. I have been there. I don’t want to go back there, and I don’t want to stay there. I want to move on and ageing is just part of moving on. Menopause is a liberation. It is fantastic, it gives you power and strength and, if you welcome it and embrace this, if you embrace every period in your life, you can be happy with it. And I do embrace it. I embrace life and I am really conscious of, well, that it is an exciting thing to be. When I was going through menopause, [I was] thinking, ‘this is exciting, I am now a crone,’ and… the crone stage is a very powerful stage in a women’s life if she wants to embrace it. (Daphne, age 59)

Daphne related her growth in personal power and strength to her menopausal

transition. Others, however, described similar changes as relating to socio/cultural aspects of

midlife. They described how their personal development began at a 40, a chronological age

which is culturally understood as signifying the onset of midlife, and occurred independent

of biological or physiological changes. For these women, the social and cultural losses

associated with ageing (including youth, beauty, fecundity, and their previous way of life;

Edelstein 1999; Burns and Leonard 2005) were reconstructed and reconsolidated as positive,

which increased their sense of their own place in the world. In this way, they drew upon the

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feminist/empowerment model to emphasise their changes in self-confidence and the process of seeking meaning in their lives:

Turning 40 was really interesting for me, because at 40 I remember just going through a really conscious change in myself, in my whole manner. I felt very much a girl up until then, who could be pushed about a bit, but at 40, I decided there wasn’t going to be any more bullshit in my life and I didn’t want to know about bullshit. It was a real changing point for me, I guess, and it did change me a lot. I think I’ve probably changed mostly, in all my life, I feel that the most dramatic change in all my life has been from 40 to 50… I think becoming aware of my own mortality, as you get older… there’s no room for crap in your life. You just don’t want to know about that. It’s [the focus is to] just get on with stuff, no dramas… there’s still lots of time for play, and I certainly do play a lot … you know, people put silly things on you sometimes and I don’t want to have anything to do with that anymore. (Maude, age 50)

Women’s understandings of ageing were not always about reconstructing losses as gains. Many experienced some ambivalence towards growing older, which prompted changes in their perspectives on life. In particular, social changes, where women described feeling socially de-valued on the basis of their age, prompted them to sub-consciously shift their life focus. As a result of their changing social positions, many women described how they now led a quieter, more contemplative, existence than they had when younger:

I think the down side of getting older is that you start to become invisible to some people, but it is what you feel in your own personal [life]… Like it is a period where you are not so, it is not such a public life anymore. It is more of a private life. I think that is what I am feeling, why I don’t want to be so active in [community arts] anymore. That is more my public life and that is in the past. I now want to focus on spiritual things and quietly creative things, not publicly creative things. (Daphne, age 59)

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Women often emphasised their growing interest in spirituality, by which women referred to connection to a wider sense of their own place in the world, as opposed to religiosity. They described how an emerging sense of spirituality changed their focus and prompted reflection upon their lives, making sense of the past and anticipating the future

(also discussed by Edelstein 1999). This enabled them to see their own inner strength. This process of reflection was empowering in itself as they had been unaware of, and unable to appreciate, their own attributes and strengths when they were younger:

Reaching this age, women generally, and maybe men do too, I don’t know, expect to be feeling disastrous… I have actually lost a lot of direction in my life but what has happened is that [now] I don’t panic. I’m happy to think about where I am and how I got to where I am, and what I’m discovering is really nice stuff, really good stuff. Far more strength than I had when I was younger. If I could… go back I don’t think I would, this is exactly where I want to be… It’s [this age is] really good but it’s also been difficult. It’s one of the strongest places a woman can be, but society still generally… doesn’t see that. (Mac, age 47)

You have to expect as you get older that things [bodily changes] happen differently, I think. It just does and there is not one little thing you can do about it, so you may as well be accepting of it and do the best you can. There are advantages to getting older, because I think you do get wiser… I think you think about things more, and, by and large, well I know I am more content with my lot than I was when I was younger… Instead of raging against the universe. (Iris, age 50)

ADJUSTING TO AGEING

The menopausal transition did not prompt feelings of fear or dread about ageing (cf. Netz et al. 2005). Most women’s stories, with the exception of Maintaining narratives, did not

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suggest apprehension about becoming old. Physical ageing was considered in two different ways by participants. Those who used Maintaining, Negotiating or Navigating narrative strategies embodied the ‘mask of ageing’ theory (Featherstone and Hepworth 1991a, 1998).

Maintaining women described how they actively sought to defer ageing through keeping active, eating well (‘being healthy’ behaviours) and, for three (Louise, Liza and Maude), by dyeing their hair to ‘cover the grey.’ However, in contrast to the ‘mask of ageing,’ none considered plastic surgery or bodily modification; they were concerned with deferring rather than rejecting ageing. Women who used Negotiating or Navigating strategies were concerned with reconciling their sense of self with their ageing body and its f/ailings.

Participants who used the Contemplating narrative strategy described the process of coming to terms with their new embodied form, drawing upon their past and coming to terms with their position within their life trajectory (see Andrews 1999):

It’s just that readjustment… when you were in your 20s and 30s, you tended to think women who went through menopause were older. And now I’m sort of there myself and thinking, ‘well, that’s me now.’ So mentally, you have to readjust to how people might look at you, which is different to how you might feel about yourself. Because you’ve still got the same brain, it doesn’t matter how old you are, you’re still you and you accumulate experiences and things. But sometimes you go [think], 'oh yeah, young people actually now consider me an older person…’ You’re almost going into that kind of elder status. It’s a different adjustment… I guess I expect to feel more of that as I get older. (Grace, age 50)

For several participants, midlife was a time when they attempted to reconcile their internal feelings – as a still young woman, “feeling like a teenager” (Dillaway 2005b:409) – with external bodily changes:

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[I feel] very comfortable with myself, very happy with my age… Coping with puberty was easier than coping with all the changes of midlife, mainly menopause. I managed to suffer from hot flushes, and [I’m] coping with that, and all the changes that brought. And [coping with] your body changes. When you go about your normal day, I don’t feel any older than 18 or 20. I asked my aunty that, and she is 83, and she said (McCook et al.) she is the same. She said, ‘when you look in the mirror, you think, what happened? What is going on?’… But for some reason, you feel really comfortable with it [your ageing body]. It doesn’t matter and you feel comfortable with life. (Cynthia, age 50)

Such findings suggest that midlife was a time when many women described adjusting their own understandings of ageing and being old, from something that they were not to something that they were becoming. Negotiating age identity was neither straight-forward nor easy. Several participants found it challenging, as it involved challenging stereotypes and dealing with limitations imposed by external social forces, as Ash described:

I don’t like fitting into a stereotype of [ageing]. I just want to be what I have always been and I try to be. I try to keep up with the times, be interested in what’s going on around me. I get very angry when people condone youth. Some people think because they’re older, they’re wiser, and they’re not. It’s the old saying, ‘the older you get, the less you know.’ [But] what really bugs me more than anything else is that when you go shopping these days… it is so hard to find nice clothes for a woman of my age. I am not a teenager and I refuse to dress like an old woman. It’s very hard. (Ash, age 60)

External appearance was a marker of physical ageing, yet was not the most important

component of women’s age-related identity. This related, in part, to women’s feelings about

their bodies, which changed on a daily basis:

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Jasmine talked about changes in her body – how she feels about these fluctuates depending on how good she is feeling about herself in general. She mentioned that whilst sometimes she notices the lines on her face, on other days, they don’t matter so much and thus, she notices them less. The other physical changes she has particularly noticed are that her breasts are more saggy than before, which she really only notices because she doesn’t wear a bra and her eldest daughter often points out to her… During the past four years, she has had two injuries that have impacted upon her body, and these seem to have a much more profound effect on her body and self-image than menopause, which hasn’t yet been a problem for her. The first injury occurred when she broke her collarbone after falling off her mountain bike… It now can’t take the lode off the other arm and tires much more easily, giving her some trouble. Her other injury was sustained to her knee whilst bush-walking. As she leads an active lifestyle, she’s found that this has had an incredible impact upon her midlife experience, as she finds that her ability to go on long bushwalks is impaired. (Field notes, Jasmine, age 52)

Midlife and the Cartesian body

Throughout their narratives, women described varying degrees of separation of their body from their self. The notion of a split between the body and mind (or self, as in participants’ narratives) was articulated by Descartes (1993) and derived from his concern with the functioning of the physiological body. Recent sociological work has challenged this notion of the body and mind (self) as separate entities. Shildrick and Price (1998) argued that embodiment is contrary to Descartes’ theory and challenge his argument that while amputation (of a body limb) removes part of the material (physical) body, the mind is unaffected. Subsequent research on amputation has demonstrated that events occurring to the body profoundly impact psychological functioning, self-esteem and body image (Breakey

1997; Walters and Williamson 1998; Manderson and Peake 2005; Desmond and MacLachlan

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2006). Bendelow and Williams (1995) argued that the popularity of these ‘Cartesian’ theories

on a mind-body split resulted from the broadening scope of medicine; medicalisation both

generated and substantiated ideas about this separation. Within the ever-increasing

medicalisation of existence, the measurable and (somewhat) controllable body, as opposed to

the subjective self, became of primary concern (ibid.). Medicalisation has also influenced

wider social norms and beliefs (see, for example, Zola 1975) and was reflected in my study:

women incorporated medicalised knowledge into their own understandings of their bodies.

For example, by using menopause as a metonym, women defined midlife in terms of biomedical constructions of the life course (particularly in terms of re/production). In addition, participants’ increased engagement in medicalisation blurred the boundaries

between lay people and health professionals (Shaw 2002); this was reflected in women’s

embodiment of rurality (Chapter 7).

Philosophical works have also contested the notion of a mind-body split. In

‘Phenomenology of Perception’, Merleau-Ponty ([1958] 2002) argued that, as the mind can only experience the world through the body (a phenomenon which he termed ‘being-in-the-

world’) it is impossible to separate the two. He conceptualised the body as comprising of two

parts – körper, or the objective, corporeal body (the material body which becomes the subject

of medical discourse), and leib, or the subjective, experienced body (ibid.). We physically

interact with the world through the material body (körper) yet experience it through the

subjective body (leib); thus the objective and subjective are different aspects of the whole.

Recent work by Leder (1990) similarly theorised the body-self and argues that the self

is an integrated being, comprised of both body and mind. The body is the medium which

signifies the self, by separating it from the non-self. Leder posited the notion, widely adopted

in the sociology of the body literature, that the body is experienced by its absence. That is,

the usual mode of experiencing the body is by not attending to the body; we don’t pay

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attention to our body when we are doing our everyday business, for example when reading or watching television. In everyday life, people perceive from and through their bodies; the body is generally not the object of one’s perceptions. Further, he argued, it is only when the body experiences a disruption of some sort, such as illness or injury, that the body becomes present. In this way, he argued that ‘normal’ bodily functioning is characterised by the disappearance of the body, whilst it only appears when the body is in some form of crisis.

Adding further complexity to these debates around the body-self are theories which incorporate a life course perspective. Öberg (1996) argued that the dominant paradigms of ageing within current gerontology (described in Chapter 1) – ‘the ageless self’ and the ‘mask’ or ‘masque’ of ageing – present divergent understandings of the body-self relationship. He argued that the ‘mask of ageing’ promoted a form of dualism through dissociating the body from the self, as seen through the Maintaining narrative strategy. Although the Negotiating and Navigating narratives also draw on this understanding, they are concerned with tension between the body and the self, rather than dissociation. In contrast, the ‘ageless self’ constructs the body in ways similar to the Contemplating narratives told by participants in this study, where it is largely subordinate and invisible throughout narratives (ibid.:708).

Central to this latter point are theories on the in/visible body, which explored the circumstances whereby the body is clearly apparent in or the subject of narratives, and those where it is not. At the same time, Oberg’s (ibid.) and Martin’s (2001) work suggests that the body-self relationship (whether of union or separation) is not concrete; instead, it is dynamic and mediated by gender, age, and (I would add) health status.

Gender similarly challenges notions of a united or inseparable body-self. Despite the theoretical popularity of Leder’s (1990) argument, it fails to adequately account for women’s

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embodied experience,93 as their bodies are always present to some degree given bodily cycles

(such as menstruation or menopause) and events (including pregnancy and birth). Women’s

bodies regularly appear as part of their ‘normal’ functioning; menstruation demands that the

woman pays attention to her body. Bendelow (2002) argued that, for women, bodily

disruption occurs daily (also see Battersby 1998). Indeed, surveillance of the menstrual cycle

and the menses itself are all regular features of a ‘normally’ functioning female experience.

The female body is socially constructed as a ‘leaky’ entity (Shildrick 1997) and, as such, demands constant surveillance to anticipate when a leakage (a social transgression which is

potentially polluting: Douglas 1966; Turner 2003) may occur (as described in relation to

urinary incontinence by Peake and Manderson 1999, 2003). This constant bodily monitoring

was particularly evident in Negotiating and Navigating narratives. Women are therefore

required to manage their bodily signs on a daily basis to pre-empt their body’s actions, which

may impact upon their social positioning. For example, Musical experienced considerable

urinary “dripping” due to stress incontinence (after her third child), which limited her

activities to the point that she could not do sport or other physical activity without urinary

leakage. Due to this, until she underwent a bladder repair procedure, she wore continence

pads and actively avoided activities more vigorous than a brisk walk. At the same time, she

engaged in regular surveillance to ensure that no urinary leakage had occurred (also see Peake

and Manderson 1999, 2003).

Accordingly, women’s bodies were never completely absent in narratives that

participants told, although the degree to which they are absent was mediated by the narrative

strategies used. In her analysis of poetry about breast cancer, Hartman (2004:155) attempted

93 Leder (1990:96) concurs this point in his notes to Chapter 5.

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to resolve this paradox of possessing an embodied subjectivity, yet at the same time viewing the body and the self as discrete, if co-existing, entities:

We may know intellectually that we are split subjects… but in a crisis we tend to find ourselves strongly identified with and attached to the body we are used to and therefore challenged to come to terms with any abrupt changes in it. To this end, Hartman (ibid.:156) argued that these two bodies of thought (dualism or holism) on the self-body relationship may both be partially reflected in women’s experiences:

That is, the body both is and is not the self: if they were entirely separate, the mastectomy would not be traumatic; if they were entirely coextensive, it would not be speakable. Thus, both schools of thought have a place within a individual’s life: the body and self cannot be truly separate if bodily events have profound impacts upon one’s psycho-social wellbeing, as both Hartman (2004) and the much wider body of literature on the impacts of illness and disease on wellbeing and quality of life indicate. Yet the fact that people can and do discuss their embodied life experiences, using objective or distant language (see Martin

2001; Manderson and Stirling 2007), indicates that wholeness or complete body-self union is also not possible. For example, women referred to their menopausal symptoms in the third person which, Martin (2001) argued, indicates distance from the self. Manderson and Stirling

(2007) highlighted the distance between the body and the self indicated by referring to ‘the hot flush’ as opposed to ‘my hot flush’. The objectification of the bodily signs – as Lois described, “when the hot flushes disappeared” – indicated their separation from the self (cf.

Martin 2001).

Participants presented Hartman’s (2004) paradox in their narratives, which reflected both theoretical debates around the body-self. Although they generally took a holistic view of

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their health, through their stories, they continually made distinctions between their self and

body (see Figure 8.1), yet their narratives centred on their embodied experiences.

Body Self

Figure 8.1: Women’s narrative constructs of body, self and being

Figure 8.1 suggests that the boundaries between body and self were fluid and

dynamic. My findings suggest that these boundaries are themselves determined by women’s embodied experiences – that is, the way that the woman experiences her ‘being-in-the-world’ is mediated by bodily events, which in turn dictate whether she perceives her body and self as working together (as a connected whole) or in opposition (with different ‘projects’ of being).

HEALTH AND THE LIFE COURSE

Physical changes on the body’s surface – such as facial lines or sagging breasts – were an

expected part of ageing. Other aspects of ageing were less predictable. Women understood

that ageing could be shaped by uncertain future events, particularly in terms of health, such

as following injury or disease. In attempting to resolve the uncertainty of ageing, social

support and social connections were central: women described how talking with other

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women and learning about others’ experiences provided them with knowledge about what to expect.

Participants contextualised their midlife age identity in terms of their health status throughout their life course, drawing upon their own, their peers’ and their family members’ health-related experiences (not dissimilar to the women described by Kuh et al. 1997). For example, despite her youth (41 years), Nola emphasised that “a lot of midlife is there!” which she related to both her family responsibilities (including being a grandmother) and her need to monitor and manage multiple health problems. As I have demonstrated throughout this thesis, participants’ experiences of health and being healthy were strongly influenced by social forces and community-related factors.

Despite links between social forces and embodied events, participants’ health promoting and maintenance behaviours were largely informed by biomedical notions of causal links between lifestyle factors and health outcomes. All participants emphasised self- care (e.g. through exercise or beauty regimes), keeping busy, social participation and, to a lesser extent, having spiritual beliefs as important in their understandings of health (similar to

Arcury et al. 2001). Social integration, which participants described in terms of being involved in the community,’ and personal responsibility, where they emphasised taking charge of their own health, were important in women’s self-health management.

The four narrative strategies – Maintaining, Contemplating, Negotiating and

Navigating – were used in two ways: they firstly provided a mechanism for exploring how health status shaped women’s construction of midlife. In addition, they demonstrated how bodily changes were incorporated into women’s life narratives and their age identity was re/constructed on the basis of their bodily events. Women who predominately used

Maintaining or Contemplating narrative strategies were concerned with protecting their current physical or mental health status. For those who told Maintaining narratives, bodily changes

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were often subtle and were understood as natural events over which the woman had some

control. Therefore, their midlife project was concerned with maintenance of their bodily habitus and shaping their identity through ensuring the continuity of physical body capacity.

Participants who used the Contemplating strategy described their bodies as changing in noticeable yet gradual ways; however, changes in personal relationships – particularly with their partners – had considerably more influence on their identity than did bodily factors. For these participants, social changes (such as Iris’ partner’s illness or Treasure’s husband’s death) prompted the revision of, or acquisition of a new, personal habitus.

In contrast, participants who drew upon Negotiating or Navigating strategies told stories about managing and responding to their bodily changes. Women who used Negotiating narratives constructed their understandings and definitions of their own health as ‘health- within-illness;’ by doing so, they emphasised the opportunity for personal growth, and thus a sense of health, despite chronic illness (Lindsey 1996; Moch 1989, 1990, 1998). In telling stories about their long-term health management practices, they described the continuity of their bodily habitus which, although sometimes complex, did not require radical revision of their identity. Navigating narratives were concerned with describing how recent health events posed challenges to women’s self-identity. Participants were often unprepared and did not expect these events and, as a result, they actively sought to re/create an identity which incorporated their recent bodily experiences; that is, they told stories about acquiring or developing a new bodily habitus.

These findings have implications for current models of health service planning and delivery. By identifying the domains salient to women’s understandings of midlife and development of a midlife identity, my data suggests that health strategies aimed at women need to acknowledge the heterogeneity of their midlife experience. By identifying the polysemous ways in which women describe ‘menopause,’ my findings suggest that health

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services, and the cultural scripts informing them, must broaden their understanding of what menopause (and thus, midlife) means beyond the dominant biomedical paradigm and incorporate the diverse needs, goals and aspirations of ageing women. By doing so, using

Aspidistra’s words, women will feel appropriately supported and prepared for when they

‘…enter that other age.’

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Appendices

Appendix 1: Recruitment advertisement from the

‘Waterside Mouth’

Inviting any interested midlife women to a focus group discussion

For a PhD research project on women’s experiences of midlife

This research project seeks to identify and describe issues and themes that women in midlife feel are important. In addition, it is concerned with identifying how central the menopause is to women's midlife experiences. Women will be interviewed about their experiences with their health, and their experiences of their bodies as they age. I am also interested to learn about what other issues are important to you during your midlife, and how living in Mallacoota has influenced your experiences.

Until recently, there has been little research into women's midlife experiences. Research done so far has tended to focus on women’s experiences primarily in terms of their menopause. Through identifying issues and sharing experiences, this project is concerned with breaking the silence about women's lives as they age.

I am currently undertaking my PhD at the Key Centre for Women’s Health in Society at the University of Melbourne.

If you would like to hear more about my project or about the focus group discussions, please contact me:

Narelle Warren – (03) 5158 0533 or 0438 440 599

Or come along to: [Focus group location, Community Health Centre] Wednesday 16th May 3 pm

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Appendix 2: Interview themes and question ideas

Please tell me the story of your midlife

Meanings of midlife

K What events do you think have impacted upon your midlife experience? K Can you tell me five words that describe midlife for you? K Ask to tell about photos

Experience of midlife

Changes in body image and self image K What is a beautiful older woman? K How has your hair/beauty routine changed as you get older? K Changes in lifestyle that may lead on from other changes K How has your body changed over the past 5 (or 10) years? K How do you feel about your bodily changes? K How do you feel about your body now? K Are there any factors that you feel have impacted on how you feel about your body? Please describe. K When you look in the mirror, what goes through your mind? K How do you expect your body to be in 10 years?

Centrality of menopause K Change in reproductive status At what point did you realise/decide child-bearing was over? How did that feel? K Could you tell me how you feel menopause has played a role in your midlife experience, if at all? K How has menopause impacted on how you feel about your self and your body? K Have you managed your body any differently? How? K Do you feel as though your body changes should be managed or treated by your doctor? K Do you use HRT? Effects of HRT, including impacts on sexuality and responsiveness How do you feel about women managing their body changes through HRT?

Relationship with partner K Has it changed? How? K Why do you think that is? K Changes in sexuality, desire K Questions about intimacy (ask permission and provide justification)

Health service provision and access K Preventive health Do you have regular pap smears? Breast screening? Bone density checks? General health checks? If so, where and why? If not, why not? K Where do you go if you have a [insert type] problem? How do you find information about it? K What do you think of the health services? Do you feel that they meet your needs appropriately? K As you age, are there any diseases you are concerned about? What are they? K Any health fears?

Social support and social networks

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K Visibility and invisibility K Where do you get social support? From who? K Can you describe if there are any changes in how you feel in social situations? In how you feel others respond to you?

Changes in family structure K Children, parents

Changes in work, status, finances

Popular cultural images K What do you think about the representations of midlife in the media? K What messages do you get from literature, film, ads, magazines, TV, etc? How do you feel about them? Are they applicable to your own experiences?

Ask

How? What? Why? When? Where? Please explain Please describe Can you tell me about…

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Appendix 3: Narrative strategies and characteristics of individual participants

Narrative Pseudonym Age Marital status Age: first Partnership Number of Number of Age: first Age: last Menopause Number of Used Strategy 94 marriage status95 children pregnancies birth birth status96 menopause HRT? symptoms Maintaining Biggs 53 Married 20-24 Partnered 4 4 25-29 30-34 Peri-menopausal 3 No Carolyn 58 De facto 20-24 Partnered 1 1 40-44 N.A. Peri-menopausal 4 Yes Louise 43 Never married - Unpartnered 1 1 35-39 N.A. Pre-menopausal 0 No Liza 46 Divorced 20-24 Unpartnered 2 4 20-24 25-29 Pre-menopausal 1 No Maude 50 Divorced 35-39 Unpartnered 2 2 30-34 35-39 Peri-menopausal 2 No Contemplating Grace 50 Separated 25-29 Partnered 2 2 30-34 30-34 Peri-menopausal 1 No Iris 50 Married 20-24 Partnered 2 2 25-29 30-34 Peri-menopausal 2 No Jasmine 52 Married 35-39 Partnered 2 2 35-39 40-44 Peri-menopausal 2 No Mac 47 Separated 25-29 Partnered 3 3 25-29 35-39 Peri-menopausal 2 No Treasure 62 Widowed 25-29 Unpartnered 2 3 25-29 25-29 Post-menopausal 3 Yes Negotiating Abbie 54 Married 20-24 Partnered 2 2 20-24 20-24 Post-menopausal 4 Yes Ash 60 Married 20-24 Partnered 4 4 20-24 25-29 Post-menopausal 3 Yes Daphne 59 Divorced 25-29 Unpartnered 1 1 30-34 N.A. Post-menopausal 6 No Ferdie 54 Married 20-24 Partnered 1 1 25-29 N.A. Peri-menopausal 8 Yes Hattie 50 Divorced 25-29 Unpartnered 0 1 N.A. N.A. Post-menopausal 5 Yes Navigating Aspidistra 57 Married 20-24 Partnered 3 3 20-24 35-39 Peri-menopausal 6 Yes Chappers 59 Divorced 15-19 Unpartnered 2 2 20-24 20-24 Post-menopausal 9 Yes Cynthia 50 De facto 15-19 Partnered 3 4 20-24 25-29 Peri-menopausal 8 Yes Lesley 50 Never married - Unpartnered 0 2 N.A. N.A. Peri-menopausal 4 No Lois 57 Divorced 20-24 Unpartnered 1 1 20-24 N.A. Post-menopausal 2 Yes Musical 55 Married 35-39 Partnered 3 3 25-29 35-39 Post-menopausal 5 Yes Nola 41 Married 30-34 Partnered 4 4 15-19 30-34 Pre-menopausal 3 No Sam 56 Married 25-29 Partnered 3 3 30-34 35-39 Peri-menopausal 4 No Serena 52 Married 15-19 Partnered 0 1 N.A. N.A. Peri-menopausal 9 Yes

94 Age refers to the participant’s age at the first interview. All other ages reported in this table are grouped into 5 year categories. 95 I distinguish partnership status from marital status as several women were divorced or separated, however had partners who they did not live with. They received support from their partner, yet this support was not indicated by their marital status. 96 Menopause status is based on self-reported symptoms and menstrual characteristics.

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Minerva Access is the Institutional Repository of The University of Melbourne

Author/s: WARREN, NARELLE LOUISE

Title: Markers of midlife: interrogating health, illness and ageing in rural Australia

Date: 2007-06

Citation: Warren, N. L. (2007). Markers of midlife: interrogating health, illness and ageing in rural Australia. PhD thesis, Key Centre for Women's Health in Society, School of Population Health, The University of Melbourne.

Publication Status: Unpublished

Persistent Link: http://hdl.handle.net/11343/39388

File Description: Markers of midlife: interrogating health, illness and ageing in rural Australia

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