Doing health, doing gender: teenagers, diabetes and asthma

Clare Williams*

Social Science Research Unit, Institute of Education, 18 Woburn Square, London WC1H ONS, UK

Abstract

Although most research linking health disadvantage with gender has focused on women, recent work indicates

that hegemonic masculinities can also place the health of men at risk. The importance of comparing the experiencesof women and men has been emphasised and this paper focuses on the ways in which the social constructions offemininities and masculinities a�ect how teenagers live with asthma or diabetes. The majority of girls incorporated

these conditions and the associated treatment regimens into their social and personal identities, showing a greateradaptability to living with asthma or diabetes. However, this could have detrimental e�ects in terms of control, asgirls sometimes lowered expectations for themselves. In addition, two aspects of the treatment regimens, diet and

exercise, were found to disadvantage girls and advantage boys, because of contemporary meanings of femininitiesand masculinities. The social construction of femininities meant that these conditions were not seen as the threatthat they were by the majority of boys interviewed, who made every e�ort to keep both conditions outside their

personal and social identities by passing. The majority of boys maintained a `valued' identity by feeling in control oftheir body and their condition. However, for the small minority of boys who were no longer able to pass the impactof chronic illness led to a `disparaged' identity. The interaction of gender and health is seen as a complex two-wayprocess, with aspects of contemporary femininities and masculinities impacting on the management of these

conditions, and aspects of these conditions impacting in gendered ways upon the constructions of gender. # 1999Elsevier Science Ltd. All rights reserved.

Keywords: Gender; Identity; Stigma; Adolescence; Teenagers; Asthma; Diabetes

Introduction

This paper explores the interaction of gender withthe management of chronic illness during adolescence,focusing on the ways in which the social constructionsof femininities and masculinities a�ects how young

people live with asthma or diabetes. The majority ofresearch linking health disadvantage with gender hasfocused on women (Nathanson, 1975), but more recent

research such as that by Cameron and Bernardes

(1998) indicates that hegemonic masculinities can alsoplace the health of men at risk, both in terms of being

a risk factor in the aetiology of disease, and in theways in which men manage illness. The importance ofcomparing the experiences of women and men hasrecently been highlighted (Verbrugge, 1997) and

Charmaz (1995, p. 287) states:

As the research in chronic illness grows, studying

men and women comparatively in conjunction withmarital, age and social class statuses, in addition totype of illness, can substantially re®ne sociologicalinterpretations of the narratives of chronically ill

people.

Social Science & Medicine 50 (2000) 387±396

0277-9536/99/$ - see front matter # 1999 Elsevier Science Ltd. All rights reserved.

PII: S0277-9536(99 )00340-8

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* Tel.: +44-171-612-6397.

The paper aims to make a contribution to the litera-

ture by exploring how teenage girls and boys live with

and manage two di�erent conditions. Young people

with asthma or diabetes were interviewed as they are

both conditions requiring high levels of self-care,

which can also have similar high levels of personal

responsibility for `juggling' treatment (Bytheway and

Furth, 1996). In terms of the control of both asthma

and diabetes, it appears that the mid-teens is a critical

time when control worsens, particularly for young

women (Gregg, 1983; Pond et al., 1996), which ®ts in

with the overall pattern of a gradual emergence of

excess morbidity in females during adolescence

(Sweeting, 1995).

A central theme to be explored is the way in which

the teenagers in this study incorporated asthma and

diabetes into their personal and social identities. These

terms were developed by Adams et al. (1997) based

upon Mead's (1961) analysis of the self, particularly

his dialectic between the `I' which they termed ``per-

sonal identity'' and the `me' or ``social identity'', con-

ceptualised as ``the sum of an individual's group

memberships, interpersonal relationships, social pos-

itions and statuses'' (Adams et al., 1997, p. 199). This

is a key issue because the gendered ways in which

speci®c illnesses impact on the personal and social

identities of individuals can a�ect how they choose to

live with the illness, including the management of

medication regimens. As Saltonstall (1993, p. 12)

states:

. . . the doing of health is a form of doing gender.

This is not because there is an essential di�erence

between male and female body healthiness, but

because of social and cultural interpretations of

masculine and feminine selves Ð selves which are

attached to biological male and female bodies.

Health activities can be seen as a form of practice

which constructs the subject (the `person') in the

same way that other social and cultural activities

do.

It has been argued that chronic illnesses, with their

unpredictable trajectories and uncertainties (Bury,

1991) may particularly threaten dominant masculinity,

which is characterised by self-control, independence

and self-su�ciency (Seidler, 1998). Arguably the threat

may be greatest during adolescence, which Prendergast

(1995) describes as the time when heterosexual values

are most powerfully pursued and enforced. However

Miller et al. (1993) found the social practice of mascu-

linities to be bene®cial in key aspects of cystic ®brosis

management. For example, because of the importance

of sport and exercise to the social construction of mas-

culinities, many of the boys interviewed were engaged

in considerable amounts of exercise, which bene®ted

their condition. Although all of the young people were

aware of their reduced life expectancy, the young mendealt with this by `putting it to one side' and by gener-ally being less willing than the girls to incorporate cys-

tic ®brosis into their social identities. The young menwere also found to maintain a more positive attitudein their everyday experiences of living with cystic ®bro-

sis, expressing a greater sense of control over theirhealth and lives than did the girls.

When exploring the e�ect of chronic illness on thegendered identity of adults, Charmaz (1995) foundthat the social construction of masculinities could have

both bene®cial and adverse e�ects. Many of the menshe interviewed attempted to conceal their illness, par-

ticularly in public settings, and drawing on the workof Connell (1987) to help explain their behaviour, shestates that chronic illness can ``relegate a man to a pos-

ition of `marginalized' masculinity in the gender order''(Charmaz, 1995, p. 268). Charmaz (1995, p. 286) alsoargues that although traditional assumptions of male

identities can encourage men to recover from illness,such assumptions can lead to a narrow range of `cred-

ible' behaviours for men, in that ``an uneasy tensionexists between valued identities and disparaged, that is,denigrated or shameful ones''.

In contrast, women are often perceived as more ableto cope with ill health than men because of the stereo-typical expectations of femininity as being adaptive

and passive (Coppock et al., 1995). Charmaz (1995)found that women with a chronic illness generally

showed a greater adaptability than men, and thatwomen ``rarely persisted in tying their futures to recap-turing their past selves when they de®ned physical

changes as permanent'' (Charmaz, 1995, p. 280).However, Miller et al. (1993) found that the teenagegirls in their study were less likely than the boys to ex-

perience a sense of positiveness in relation to theireveryday experience of living with cystic ®brosis, which

they felt was due to the social practice of femininity.This led to passivity, feelings of powerlessness and anemphasis on attractiveness which in turn led to a

decline in health status, with the lack of physical ac-tivity and the need to be attractive rather than activehaving a powerful adverse e�ect on morbidity.

Stigma is closely linked with gender and illness man-agement. In his research on children, Prout (1989)

found the stigmatising e�ects of illness to be gendered.For boys, illness could be an isolating and threateningexperience and Prout (1989, p. 350) noted the accusa-

tion of `skiving' which greeted almost every boy on hisreturn to school, stating that, ``it underlined a basic

feature of the boys' culture, that being physically ®tand tough was highly valued and that sickness . . . wasa stigmatising form of weakness and incompetence''.

In contrast, Prout (1989) found that sickness was seenas something quite di�erent for girls, with the `best

C. Williams / Social Science & Medicine 50 (2000) 387±396388

friend' group being mobilised and visits being made tothe girl's home. Go�man (1963) described a variety of

coping strategies which related mainly to whether ornot the stigma was obvious to others (discrediting), orcould be hidden from others (discreditable). Someone

with a potentially stigmatising condition such as dia-betes or asthma has the option of trying to hide it, andone of the main coping strategies which Go�man

(1963) described as being used in this situation is `pas-sing', which entails trying to pass as `normal' with theconstant risk of exposure.

The extent to which individuals choose to pass mayalso impact on adherence to treatment regimens. Muchof the professional literature on `non-compliance' isbased on the premise that it is deviant behaviour, lead-

ing to the blaming of patients (Donovan and Blake,1992), with the `compliance' of young people identi®edas particularly problematic by health care professionals

(Klingelhofer, 1987; Pond et al., 1996). In contrast,Conrad (1985) argues that from the patient's view-point, altering medication can be seen as an attempt

by the individual to assert some control over their ill-ness, and he sees the modi®cation of medicine as`active self-regulation' rather than non-compliance.

It appears that the social constructions of feminin-ities and masculinities may interact in complex wayswith overarching concepts impacting on chronic illness,such as stigma and compliance, as well as with more

speci®c aspects relating to the management of particu-lar chronic illnesses. By exploring the extent to whichteenage girls and boys incorporate asthma and diabetes

into their identities, and how this impacts on the waysin which they live with and manage these di�erent con-ditions, the paper aims to help begin unravelling these

issues.

The study

This paper reports on part of a larger project which

explored how teenagers with asthma or diabetes nego-tiated responsibility for self-care with their main carer,usually their mother (Williams, 1998). In depth inter-

views were conducted with 20 young people agedbetween 15 and 18 years with asthma, and 20 with dia-betes (10 females and 10 males in each group).Interviews were also carried out with the parent most

involved in helping the young person manage thechronic illness, who in all cases except one was themother. The young person and parent were inter-

viewed separately, usually consecutively, and all(except one) of the interviews were conducted in theirhomes.

Nearly all cases of diabetes occurring in childrenand young people are of the insulin-dependent, or`Type 1' category. All of the young people interviewed

had insulin-dependent diabetes, where there is a severe

lack of insulin, and daily insulin injections are necess-

ary for survival. Asthma is a more variable condition

than diabetes, so young people were recruited who had

been diagnosed as having moderate or severe asthma,

and who were prescribed regular anti-in¯ammatory

inhalers (preventers) in addition to inhaled bronchodi-

lators (relievers). Although asthma and diabetes both

have speci®c treatment regimens, there is arguably

more leeway in the management of asthma, in that it

may be possible to be more ¯exible with treatment, in

the short term at least. In contrast, ketoacidosis due to

lack of insulin in diabetes can rapidly lead to coma

and death if untreated.

Just over half of the sample of young people was

located through ®ve hospitals in South West London.

In addition, 13 were identi®ed through seven GPs in

the same area and four through young people who had

been interviewed. The respondents were mainly white

(one quarter came from various ethnic minority

groups) and all social classes were represented,

although the majority were middle-class. In order to

increase the diversity of the sample, a letter was placed

in `Balance', a magazine for people with diabetes pub-

lished by the British Diabetic Association which

resulted in contact being made with two mother/son

pairs. In addition, interviews were carried out with the

mothers of three young men who were concerned

about their sons' poor control of diabetes, but the

young men themselves declined to be interviewed.

The interviews were conducted as ¯exible, semi-

structured `guided conversations' (Lo¯and and

Lo¯and, 1984) in an attempt to increase the likelihood

that respondents' own accounts and meanings would

take priority. The interview guide consisted of a series

of prompts relating to topics such as treatment, stigma,

and illness management, and this was updated as new

areas for discussion emerged from the interviews. With

permission, the interviews were taped and fully tran-

scribed.

Transcripts were read several times and were coded

using a system of open coding, described by Strauss

and Corbin (1990, p. 61) as: ``the process of breaking

down, examining, comparing, conceptualizing and

categorizing data''. A grounded theory approach was

taken, which allowed themes and concepts to emerge

from the data and inform the theoretical framework

(Charmaz, 1990). The coded data was compared for

similarities and di�erences in the experiences of the

people interviewed, and over time the codes were

grouped into broader, conceptual themes, which even-

tually became part of the larger theoretical framework.

In the following sections I have quoted from the tran-

scripts of the recorded interviews, the quotes being il-

lustrative of the particular perspective being discussed.

C. Williams / Social Science & Medicine 50 (2000) 387±396 389

Chronic illnesses and identities

In this study, the vast majority of girls interviewed

were found to incorporate asthma or diabetes into

their social identities. This manifested itself in various

ways, including girls telling people about their con-

dition and being prepared to treat themselves in public

settings:

Jemma: ``I was quite happy to tell people because I

think if you can educate people then there won't be

these problems, and people saying, ``Oh, why is she

wanting to inject herself?'' They'll understand it,

and I think if you shy away from it then other

people will as well and they'll tend to be embar-

rassed about it.''

Viri: ``No, I always tell everyone, just in case

(asthma).''

In contrast, most of the boys with diabetes or

asthma made it as invisible or as small a part of their

lives as possible, particularly in public settings. They

managed this in many ways, including not talking

about their condition in public, even with close friends,

and not allowing the treatment regimens to `spill over'

into their public lives. As a consequence, the condition

was not seen as an integral part of their social identi-

ties, but as something separate:

Scott: ``I just carry on as normal, one injection in

the morning, one in the evening. It hasn't a�ected

my life at all, hasn't changed anything, nobody

really knows except my family.''

Jack: ``It's not what boys talk about really Ð not

being sexist, but that's the sort of thing that girls

talk about, problems and things. At school a boy

might ask quickly about it [asthma] and I'd say,

``oh, it's OK'', but they'd never ask questions like

what happens when I get it, anything like that . . . at

school it was, ``right, I've got asthma, I'll keep it to

myself and the people that know, they know, and

the people that don't know it won't a�ect them sort

of thing''.''

It was di�cult for boys to express why they behaved

in this way, and the impression given was that it was just

`natural' behaviour. For example, Richard had a friend

and classmate who also had diabetes, but when I asked

him if they discussed diabetes, he laughed, saying:

Richard: ``No, we don't discuss diabetes at all . . .

that's your business if you're diabetic sort of

thing.''

Sometimes the interviews with mothers could help

throw some light on the issue. For example, when

interviewed, Martin said he did not have any problems

in terms of his diabetes treatment, but according to hismother:

``He won't do them [blood sugars] at school now,he absolutely refuses, he won't even do an injectionat school. He's on three injections a day and the

hospital would like him to go on to four but hewon't do it in front of his friends, and he doesn'tlike the fact that he is diabetic in that respect, he

wants to be normal.''

There were also di�erences in how the impact ofasthma and diabetes was perceived by teenage girls

and boys. Girls appeared more likely to think aboutand worry about their condition, as Reena and Sharonillustrate:

Reena: ``It just means you've got to control yoursugar level, your diet and everything . . . You've gotto put a lot of e�ort into it and Ð it's horrible, it's

dreadful, I hate it.''

Sharon: ``You've just got to have it [asthma] thereat the back of your mind, all the time.''

In contrast, the boys generally tried to ignore theircondition, and to think about it as little as possible:

Martin: ``I don't really think about it [diabetes]

because I'm used to it, it's kind of natural.''

Donald: ``I just try and forget about it [asthma],

you know, put it aside, try and put it aside and geton with things. I don't think it a�ects my life thatmuch . . . I'm not too worried about things.''

In many ways these ®ndings support those of Milleret al. (1993), and it seems that the extent to which theteenage girls and boys interviewed incorporated their

conditions into their identities re¯ects the di�erentialgendered meanings of chronic illness. If, as Adams et al.(1997) suggest, social and personal identities are ``irre-vocably interconnected'', the fact that the majority of

girls accepted being `asthmatic' or `diabetic' as part oftheir social identities would also mean that these con-ditions were assimilated into their personal identities. In

contrast, most of the boys did not accept the social (orpersonal) identities of having asthma or diabetes.Although boys found it hard to articulate why they

managed in this way, it seemed that signs of illness wereseen by them as potentially stigmatising. This led toboys working hard to pass in public settings wherever

possible (Go�man, 1963), and one of the main ways thiswas achieved was in the use of speci®c strategies relatingto diabetes and asthma regimens.

Treatment regimens and diabetes

The majority of clinics that the teenagers attended

C. Williams / Social Science & Medicine 50 (2000) 387±396390

recommended four daily injections of insulin, in the

hope that this would lead to increased ¯exibility of life-

style, and better control of blood glucose levels.

However, there was a marked di�erence in the number

of daily insulin injections which the girls and boys

interviewed gave themselves. Only one of the girls

interviewed followed a regimen of twice daily injec-

tions, three injected themselves three times a day,

whilst six of the girls injected themselves four times a

day, which usually meant injecting themselves in public

settings, such as at school. This re¯ected the fact that

for them diabetes was seen as part of their social iden-

tities. For example, Alice is on four injections per day

and said:

Alice: ``I have to do one injection at school.''

Int: ``Do you mind that?''

Alice: ``Well, I mean, I don't mind it any more. I

used to, because other people sometimes ®nd it a

bit uncomfortable . . . I mean, it's not too bad now,

people accept it, but they used to ®nd it quite

uncomfortable, especially the boys, because I just

used to sit there and do it.''

In contrast, of the 10 boys with diabetes, none had

ever attempted to follow a regimen of four injections

per day, four injected themselves three times a day and

six chose a regimen of two daily injections. Phillip and

Richard both explained why they chose to remain on

two daily injections:

Phillip: ``It's just that when I'm with my friends and

I'm doing stu� with my friends it's [diabetes] not

there, and I can keep it like that, and then when I

get home I can do my insulin, and it's just there, at

home.''

Richard: ``I'd have to keep vanishing every lunch-

time, and I'm going to have to take an injection, a

syringe into school which will probably get noticed,

and there's not really many places to do it Ð I

mean, the toilets have hardly got locks on the

doors, half of them.''

It seemed that in order to pass and to keep diabetes

from their social identities, boys chose not to inject

themselves in public settings, but tried as far as poss-

ible to keep diabetes contained within the private

sphere, at home. This enabled boys to manage their

condition at home, and to pass in public. Boys also

passed by keeping to what was often quite a strict rou-

tine, and by being adherent to their chosen regimen,

which generally resulted in good control of their dia-

betes. For example, Julian explained:

``I just do my injection in the morning and night,

eat the same amount at about the same time every

day, and forget about it.''

In addition, the majority of these boys did not

appear to have had any thoughts about not takingtheir insulin, and this again related to keeping diabetes

invisible:

Richard: ``I don't see any point, no, I mean, itwould cause more trouble. I mean, if you do an

injection how long does it take, two minutes? Don'tgo and do an injection, how much feeling awful isthat going to promote?''

Although the majority of boys with diabetes adheredto their chosen regimens, which generally resulted ingood control, these `strict' routines could impact on

their day-to-day lives, giving them less ¯exibility.However, for these boys the most important factorappeared to be that the diabetes remained outside their

social identities, and therefore invisible to others,which enabled them to pass. In contrast, although sixof the girls with diabetes had chosen a regimen of four

injections per day which should have resulted inimproved blood sugar control, this did not necessarilyfollow. One of the reasons for this was the genderedimpact of the focus upon diet in diabetes. Diet is one

of two examples highlighted in this paper of howspeci®c aspects relating to the treatment regimen of achronic condition can interact with the social construc-

tions of femininities and masculinities. The secondexample, exercise, was found to impact on the manage-ment of asthma and diabetes, and both will be dis-

cussed later in the paper.

Treatment regimens and asthma

The 10 girls interviewed all associated control ofasthma with the correct taking of preventive medi-cation. Nine of them claimed to take their preventer

inhalers regularly, usually morning and evening, whilstone took it occasionally. These girls with asthma hadlearned from experience that they needed their preven-

ter inhalers. For example, Carol, a 15-year-old whohad had asthma for three years had only been takingher preventer inhaler as prescribed for the previous sixmonths:

``When I ®rst started it was OK but then I forgot acouple of times, and then I couldn't be bothered todo it, to try and remember. I thought, ``oh no, it's

not worth it, I'm alright, you know, I don't needit''. But I've found out since I've been taking it thatit's helped me . . . I know if my asthma really

a�ected me I wouldn't be able to go out with him[boyfriend], I won't be able to do the things I wantto do, so I know I've got to take my inhaler to con-

trol it so I can carry on and do everyday things Iwant to do.''

The regular taking of preventer inhalers indicates an

C. Williams / Social Science & Medicine 50 (2000) 387±396 391

incorporation of asthma as a part of both the personal

and social identities of these girls. However, as with

the girls with diabetes, this acceptance of asthma could

also have negative e�ects, in that girls could lower

their expectations for themselves. Here, Carol describes

how she has learned to adapt her life to asthma:

``I realise now I've got to get on with it, because I

can't get rid of it, it's not as easy as that, so I have

to learn to live with it . . . if I take it easy then I can

do things Ð it can't Ð won't stop me from doing

anything as long as I'm careful . . . I won't give up,

I still do some sport and hopefully, one day I will

be able to run again. When I ®rst got it, I said to

my Mum, ``I'm not going to stop doing what I

want, I don't care about asthma, it's not going to

change my life'', and it has, you don't realise how

much e�ect it does have. When I look back I realise

how stupid I was to just think I could carry on in

life.''

In contrast, the approach of seven of the 10 boys

with asthma was typi®ed by boys saying that they

were growing out of their asthma, and so no longer

needed regular preventive medication. It is worth not-

ing that all of these boys had been identi®ed by their

GP or hospital consultant as having moderate or

severe asthma, and at the time of interview a number

had recently had severe attacks requiring hospitalis-

ation. However, unlike the girls with asthma such as

Carol, these boys were most unlikely to `be careful', or

to think that asthma might change their lives. All of

the boys took their reliever inhaler if they felt they

really needed it, although they would do this as `invis-

ibly' as possible, but only three took their preventer

inhaler regularly. It was not that these boys denied

that they had asthma, but more that they saw it Ð

and made it Ð a separate, minor part of their lives, by

thinking about it as little as possible, and by treating

asthma as an episodic, acute illness rather than a

chronic illness. Consequently boys felt that they did

not have to rely on regular preventer inhalers, and in

this way, boys were able to keep asthma outside their

personal and social identities:

Paul: ``It's not a case of, ``no, we don't have asthma

so we don't have to take it'' or anything, but it

doesn't occur to us most of the time because I

mean, I can't say that most of my life is ruled by

my asthma attacks and that, so until recently I for-

got I had asthma at all and then you get your

attack and you think, ``oh'', and then when you're

over it you just forget about it.''

Int: ``You don't think of having asthma day-to-

day?''

Paul: ``No, it's not like diabetes where you have to

take your injection every day. My uncle and

grandma, they're taking their injections every day,and if they don't they get a�ected, but if I don't

take my inhaler chances are I'll be alright.''

Keith: ``Because asthma just tends to be so episodic

and you get lulled into a false sense of securitywhen you don't display any symptoms.''

Paul and Keith had both attended hospital within

the past year for the treatment of severe asthmaattacks. However, in contrast to the girls interviewed,this experience had not resulted in them taking preven-

ter inhalers. The medication strategies the majority ofboys with asthma employed appeared to have little incommon with the boys with diabetes, the majority ofwhom kept to a strict routine with their regimen, and

had no thoughts of not taking their insulin. However,this di�erence may relate more to the nature of the in-dividual conditions and the treatment regimens. In

terms of diabetes, not following treatment can havealmost immediate e�ects, meaning that boys would nolonger be able to pass. In contrast, most of the boys

with asthma felt that there was a good chance nothingwould happen if they omitted their preventive asthmatherapy. In addition, whilst the taking of preventer

inhalers may be seen positively for girls, in terms ofthe positive meanings that taking responsibility canhave for femininities (Green and Hart, 1996), White etal. (1995) draw attention to the negative meanings sen-

sitisation to bodily well-being and preventive medi-cation may have for boys and men, threatening theirplace in masculine hierarchies. It seems that for these

boys, control over their personal and social identitiesas `normal, healthy males' was more important thancontrolling potential episodic occurrences of asthma.

Despite this active self-regulation which might be seenas having a negative impact on the health of boys,there were other aspects of the treatment of asthma,such as the importance of exercise, which generally

had a bene®cial e�ect for boys. The gendered impactof both exercise and diet on the management ofasthma and diabetes will now be discussed.

The gendered impact of exercise

The value of exercise in helping to control bothasthma and diabetes may be seen to particularly ad-

vantage teenage boys, for whom the institution ofsport is important, serving to construct and reconstructmasculinities (White et al., 1995). In this study, as

Miller et al. (1993) found, there was a pronouncedemphasis on the importance of sport and exercise forboys with asthma and diabetes, with boys' self-assess-

ments of their health very much linked to the amountof sport they played. For example, Jasvir told me:

``Every Tuesday I go to the swimming pool, and

C. Williams / Social Science & Medicine 50 (2000) 387±396392

Wednesdays and Fridays I do weight training, andif I can't keep to those actual days, I'll make it

another day . . . to look good and feel good I haveto go and do it, I feel better (diabetes).''

In contrast, many of the girls participated in little

sport or exercise. Along with diet, this was anotherissue about which girls frequently expressed guilt, andwas often seen by them as a major cause of their per-

ceived unhealthiness:

Becky: ``No, I don't think I'm healthy but I thinkthat's to do with the fact that I don't do enough

sport and I don't eat a healthy enough diet, andthat makes me feel guilty (diabetes).''

Joanna: ``Asthma makes you unhealthy Ð youcan't run as fast, can't do much exercise, aerobicsmakes you red-faced, it's better not to bother Ðbut then I feel guilty.''

Exercise was also used by boys with diabetes to con-trol their blood sugar levels in contrast to many of thegirls, who tended to give themselves more insulin. For

example, Scott said:

``If I go too high [blood glucose level] what I woulddo is, like, I would jog on the spot or something. I

do a lot of jogging or running. I run round thehouse because it's usually at night that it happens.It never happens during the day, and so I run

round the house and just use up the energy andthen I'm OK.''Int: ``So you wouldn't give yourself more insulin?''

Scott: ``No, I control it myself. I wouldn't want togive more insulin in case it [blood glucose level]goes down too low. Now I know a safe remedy I'drather just like wear it o�, rather than give myself

more insulin.''

The gendered impact of diet

Diet is seen as critical in the control of blood glu-

cose, and in this study was found to have a genderedimpact in terms of the control of diabetes. In contrastto boys, who rarely mentioned diet, girls often adapted

their diets in ways which resulted in sub-optimal con-trol of their diabetes, as assessed by themselves. Forexample, Clare said:

Clare: ``No, it [diabetes control] could be a lot bet-ter, but I don't keep to my diet properly, like, if Iwant to eat something I shouldn't, say, if I'm going

out, I'll just put a bit more [insulin] in.''

Girls overwhelmingly mentioned poor diet as thekey reason for their sub-optimal control of diabetes,

and this was usually combined with feelings of guiltand negative health evaluations:

Jemma: ``I'm on a diet now because I'm eating toomuch and I want to lose weight. I'm conscious ofhow much I weigh, and even though I eat, I know I

shouldn't be eating so I feel terrible guilty and goand eat some more because I feel guilty, and it's avicious circle, so I'm not healthy at all.''

Because of societal expectations about body imageand shape, teenage girls are generally more concernedabout diet and weight than boys (Miller et al., 1993),

and it seems that the emphasis on food and weight inthe treatment of diabetes can bring additional pro-blems for girls, because of the ways in which contem-

porary femininities are constructed.Exercise and diet are two examples of how aspects

of the treatment of diabetes and asthma can have a

gendered impact because of the ways in which feminin-ities and masculinities are socially constructed. Theseparticular aspects had a generally positive impact forthe teenage boys interviewed, in terms of how they

controlled and managed these conditions, and a gener-ally negative impact for the teenage girls, supportingthe ®ndings of Miller et al. (1993). However, the inter-

elation between gender and health is complex, and par-ticular aspects of the social constructions of gendercould have both positive and adverse e�ects. The

paper will now explore one example of this, namelycontrol of the body, which served to both advantageand disadvantage boys with asthma and diabetes.

Control of the body and the chronic condition

Earlier it was stated that chronic illnesses may par-

ticularly threaten dominant masculinity, with itsemphasis on control (Seidler, 1998). In this study, boyswere far more likely than girls to say that they could

control their condition with their mind, although theydescribed this in terms such as `willpower' and `beingvery strong mentally'. These feelings of control a�ected

how boys managed their conditions, and their medi-cation regimens. An example of the bene®t of wantingto maintain control was seen in the previous section,when Scott preferred to manage a high blood glucose

by controlling it himself using exercise. However, theimportance for boys of maintaining control can beseen to have potentially positive and negative conse-

quences, as Paul shows:

``Asthma creeps up on you, it just creeps up onyou . . . a lot of the time I know I'm having an

attack, but if I'm playing football I'll say, ``now I'llignore it and I'll play on'', yes, and I'll ®ghtthrough it. I'll say, ``look, I know what's happen-

C. Williams / Social Science & Medicine 50 (2000) 387±396 393

ing, I'll take things slower'', but you've just got tokeep breathing and it goes away, it just goes

because of my mental strength.''

The positive e�ects for Paul could be the ability toperhaps control some of his potential asthma attacks.

However, one of the potentially negative consequenceshad occurred in the month prior to his interview, whenhe had been rushed to hospital with a severe asthma

attack. These feelings of control that boys describedwere also noted by Miller et al. (1993), although theyonly discussed this in terms of the bene®cial e�ects this

had for boys with cystic ®brosis. However, this studyidenti®ed potentially serious adverse e�ects, as Paul il-lustrates. In addition, if these traditional assumptions

of male identities such as feeling in control were notachieved, this could result in `disparaged' or denigratedidentities for boys (Charmaz, 1995).

`Disparaged' identities

There was a small but important minority of boys

who for whatever reason did not appear to feel in con-trol of their condition, and who were consequentlyunable to `pass'. In relation to diabetes, this occurred

when boys ignored their regimens as far as was poss-ible. As previously described, three mothers who felttheir sons' diabetes to be out of control were inter-

viewed, although the boys themselves refused to beinterviewed. One of these, Harry's mother, said:

``He tells people he'll be dead soon anyway so it

doesn't matter what he does, and that seems to behis whole attitude really . . . he just doesn't want todo it [follow treatment regimen], he doesn't want to

know. As far as he's concerned, he hasn't got dia-betes and he carries on as if he hasn't.''

George's mother describes his reaction in the follow-

ing way:

``Within three months [of diagnosis] George hadsettled down into a routine of diet, exercise and

injections, and was coping with bringing down hisblood sugar Ð it didn't last long. At Christmas,George became upset that he couldn't indulge hissweet tooth as he used to, and his blood sugar rose

to levels never before seen. He refused to discuss hisdiabetes management with anyone, so I wrote to hisconsultant in desperation. By now he was saying

things like, ``If I go blind [one of the possible conse-quences of poor blood sugar control] I'll just topmyself'' . . . I would have been devastated but not

surprised if he had attempted to take his own life.''

Although these young men were reported to have in-itially controlled their diabetes very well, they had then

become angry about having the condition and hadconsequently stopped or reduced their treatment regi-

men. However, the symptoms which resulted meantthat these boys were no longer able to pass in publicas they had before. Mark was one of the few boys

actually interviewed who did not feel in control of hiscondition. He told me that his health was `just terri-ble', and he appeared to have given up hope of ever

controlling his asthma:

``I've tried playing football with my friends but Ican't play for long because I'm on the ¯oor grab-

bing my chest and I can't breathe so they send mehome . . . I can't beat it, if it will come it will comeand every precaution I take, it will just come, it just

®nds a way, so I don't bother no more, there's nopoint . . . going up the stairs I'm just like my grand-dad, that's what I'm like with walking . . . I don't gooutside no more `cos of the fumes and all that.''

The majority of boys in the study claimed to feel incontrol of their conditions. However, for the few boyswho did not feel in control, this seemed to lead to dis-

paraged or denigrated identities. This supports thework of Charmaz (1995) who argues that traditionalassumptions of male identity can act as a `double-

edged sword', leading to a narrow range of crediblebehaviours for men, with an `uneasy tension' betweenvalued and disparaged identities. However, it should

be noted that these boys were hard to identify throughthe usual channels of GPs, clinic nurses and hospitals,and even when they were located, mainly through theirmothers responding to a letter in Balance magazine,

they declined to be interviewed. This di�culty ofaccess may be one of the reasons why the ®ndings ofthis study di�ered from those of Miller et al. (1993),

who found no boys with disparaged identities.

Discussion and conclusions

Young people in this study were found to manageasthma and diabetes in gendered ways, with the aim of

projecting di�erent, gendered identities. As Charmaz(1991, p. 5) states:

. . .having a chronic illness means more than learn-

ing to live with it. It means struggling to maintaincontrol over the de®ning images of self and overone's life.

The majority of girls showed greater adaptation,incorporating their conditions and the associated treat-ment regimens into their social and personal identities.

The social construction of femininities meant the con-ditions were not seen as the threat that they were forboys. In contrast, the majority of boys made every

C. Williams / Social Science & Medicine 50 (2000) 387±396394

e�ort to keep asthma and diabetes out of their per-

sonal and social identities, attempting to pass(Go�man, 1963). This supports and extends the workof both Charmaz (1995) and Prout (1989), who draw

attention to the stigmatising e�ects that illness canhave for males of varying ages. This research alsobuilds on Go�man's (1963) work by showing how gen-

dered meanings of stigma can impact on strategies fordealing with chronic illness.

One of the bene®ts of exploring the management oftwo conditions is that if examined individually, theself-regulation of the treatment regimens of asthma

and diabetes by boys would appear to have little incommon. However, it seems that these di�erent ways

of managing have the common aim of minimising thepotential threat asthma and diabetes pose to masculineidentities. Whereas strict adherence to treatment regi-

mens enabled boys with diabetes to pass and thusmaintain valued identities (Charmaz, 1995), boys withasthma achieved this by seeing asthma as an acute, epi-

sodic condition which did not necessitate regular pre-ventive medication. In addition, two aspects of the

treatment regimens of diabetes and asthma, diet andexercise, impacted in gendered ways, having a generallypositive e�ect for boys, helping them to pass.

The ways in which the social construction of femi-ninities and masculinities impacted on the managementof illness could be both bene®cial and problematic. As

with the research by Charmaz (1995) on older women,the girls in this study were found to show a greater

adaptability to asthma and diabetes, but this couldhave detrimental e�ects, as girls sometimes lowered ex-pectations for themselves. This, combined with the det-

rimental gendered e�ects of diet and exercise, couldpartly explain why the control of diabetes and asthmaworsens for young women of this age.

For teenage boys, there appeared to be a narrowrange of credible masculine behaviours when managing

chronic illness (Charmaz, 1995). The majority of boysmaintained a valued identity by passing, and by feelingin control of their body and their condition. However,

for the small minority of boys who did not feel in con-trol, and who were no longer able to pass, the impact

of chronic illness led to disparaged identities(Charmaz, 1995). The results of this study indicate thatboys at this stage in their lifecourse are more likely

than girls to move between two extremes in terms ofmanaging diabetes and asthma, with the majoritymanaging well, and a small minority managing very

poorly.By focusing on both teenage girls and boys, it has

been possible to consider some of the ways in whichgender interacts di�erentially with two chronic con-ditions, asthma and diabetes. This is a complex two-

way process, with aspects of the social constructions ofcontemporary femininities and masculinities impacting

on the management of these conditions, and aspects ofthese conditions impacting in gendered ways upon the

social constructions of gender. In other words, theinterplay between health and gender can be conceptu-alised as both plural and reciprocal (Broom, 1999).

Research comparing women and men of di�erent agesand with di�erent illnesses will enable the complexitiesof this interplay to be further explored.

Acknowledgements

I am very grateful to all of the people who partici-pated in this study. Particular thanks go to Sara Arber

who was the supervisor of my Ph.D. on which thispaper is based, and who commented on an earlierdraft of the paper. I also acknowledge the support of

the Department of Health who funded my Ph.D.

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