Nick Fox

Katie Ward

Health identities: from expert patient to resisting consumer

Keywords: body, Deleuze, health, identity, subjectivity

This article explores the formation of 'health identities': embodied subjectivities that emerge out of complex psychosocial contexts of reflexive modernity, in relation to data on health and illness practices among groups of people and patients using medical technologies including weightloss drugs and the erectile dysfunction drug sildenafil (Viagra). We examine a range of health identities, from the 'expert patient' -a person who broadly adopts a biomedical model of health and illness, to a 'resisting consumer', who fabricates a health identity around lay experiential models of health and the body. The understanding of health identities is developed within a theoretical framework drawing on previous work on body/self and the work of Deleuze and Guattari. It is concluded that the constellation of health identities reflects the diversity of relations in an industrialized, technology-driven, consumer-oriented and media-saturated society.

Introduction: health as identity practice

For social scientists, it has been a fundamental principle that the categories 'health' and 'illness' are not to be defined simply in terms of the anatomy, physiology and genetic make-up of an individual. Studies of the experience of sickness, disability, infirmity and pain, predominantly from within a phenomenological perspective, have established the social, cultural and psychological components that underpin how both individuals and societies understand health and illness [START_REF] Charmaz | Loss of self: A fundamental form of suffering in the chronically ill[END_REF][START_REF] Herzlich | Illness: From causes to meaning[END_REF][START_REF] Baszanger | Deciphering chronic illness[END_REF]. However, social theorists have also recognized the complex interactions between the social, embodiment and subjectivity, and the 'problem' of how to avoid privileging one of these three ontological entities has predictably generated a wealth of theory and dispute (Nettleton and Watson, 1998;[START_REF] Williams | The lived body[END_REF][START_REF] Fox | Beyond health: Postmodernism and embodiment[END_REF]. In this article, we will draw on some empirical data to examine the ways in which health (a socially constructed phenomenon), the body (an entity that is both physical and social in character) and identity (the emergent, always 'becoming-other' reflexive sense of self) flow together in the practices of individuals and groups.

In a previous article [START_REF] Fox | Refracting health: Deleuze, Guattari and body/self[END_REF], the relationship between embodiment and identity was theorized by an application of the work of Deleuze and Guattari. Emergent identity was 'a consequence of the confluence between embodiment on one hand, and on the other, the physical and cultural worlds which impinge and limit, yet also make possible ' (2002: 349). Fox argued that we should talk of body/self, to emphasize how closely these two entities are tied together. The article examined a range of identities that are forged from the reflexive confluence of the body with its physical, psychological and emotional (affective) relations or attachments. Among these emergent identities were a number associated with relations that are constitutive of 'health' and 'illness' ('fitness', 'ageing', 'slimming' and so forth). What we come to call the 'health' of a body is the outcome of: refracted and resisted relations, biological capabilities or cultural mind-sets, alliances with friends or health workers, struggles for control over treatment or conditions of living. Health is neither an absolute (defined by whatever discipline) to be aspired towards, nor an idealized outcome of 'mind-over-matter'. It is a process of becoming by body-self, of rallying affects and relations, resisting physical or social territorialization, and experimenting with what is, and what might become. (Fox, 2002: 360) That article concluded that health and illness are 'political' categories, as much to do with the physical and cultural possibilities and constraints surrounding a person's body as with any characteristic of the body itself. Furthermore, identities emerge within the contexts of these possibilities and constraints. For the social scientist, this links the study of health (and illness) with identity, and means we must study 'health', 'body' and 'identity' together, as emerging from activity and practice, and located within the totality of a body's physical and social relations. Health identities are features of the clustering of relations around specific aspects of embodiment, such as sport and exercise, body modification, disability or growing old. This approach was applied in a study of ageing among people in Thailand and Australia, which explored the reflexive forging of ageing identities from 'their myriad affective, physical, philosophical, social and cultural relations (with their beliefs, their families, their life experiences, their gender and ethnicity, their care and their bodies)' (Fox, 2005: 514). The identities of older adults were the outcome of these confluences between body and milieu: hugely complex and idiosyncratic, yet accessible to empirical study through the documentation of relations and their reflexive construction. The study found that identity, embodiment and notions of health and illness were mutually constitutive within contexts of relations with the material world, culture and psychosocial engagements.

health: 10(4)

In a society that is increasingly interested in all aspects of health and embodiment, from the 'cyborg technologies' [START_REF] Haraway | Simians, cyborgs and women[END_REF][START_REF] Balsamo | Technologies of the gendered body[END_REF] of body modification by pharmaceuticals [START_REF] Monaghan | Drug taking, 'risk boundaries' and social identity: Bodybuilders talk about ephedrine and nubain[END_REF][START_REF] Potts | Deleuze on Viagra (Or, what can a Viagra-body do?)[END_REF] or cosmetic surgery [START_REF] Negrin | Cosmetic surgery and the eclipse of identity[END_REF] to genetic therapies (Le [START_REF] Breton | Genetic fundamentalism or the cult of the gene[END_REF] and cloning [START_REF] Petersen | Replicating our bodies, losing our selves: New media portrayals of human cloning in the wake of Dolly[END_REF], identity will be forged within the context of these kinds of health-related practices. Health technologies are also identity technologies, and the consumption of these technologies may forge associated health identities. An opportunity arose to explore health identities during a study of consumption of pharmaceuticals for lifestyle reasons. In this article, we report this research, focusing on the forging of different health identities and how these relate to systems of thought and expertise.

Patients, health experts and health consumers

Conceptions of patient and health professional relationships have evolved since [START_REF] Szasz | A contribution to the philosophy of medicine[END_REF] identified three models: 'active-passive', 'guidance-co-operation' and 'mutual negotiation' for interactions. Recent UK policy recapitulates Tuckett et al.'s (1983) description of doctor-patient encounters as meetings between experts, suggesting a future in which 'expert' patients will manage their own illnesses and conditions in partnership with their health and social care providers (Department of Health, 2001: 5). People with chronic conditions can now receive training as expert patients [START_REF] Shaw | Expert patient: Dream or nightmare[END_REF], including:

• recognizing, monitoring and responding to symptoms; • managing acute episodes and emergencies; • using medications;

• adopting appropriate aspects of lifestyle including healthy diet, exercise and relaxation, and not smoking; • interacting appropriately with health care providers; • seeking information and using community resources; and • managing negative emotions and responses to illness. (Wilson, 2001: 134) Critics of the expert patient notion argue that it ignores entrenched professional power and structural constraints to do with access to resources [START_REF] Tang | Human agency and the process of healing: Lessons learned from women living with chronic illness -re-writing the expert[END_REF] and conflates experience and education (Wilson, 2001: 135). Paradoxically, patient expertise both assumes compliance and accepting responsibility for the management of health [START_REF] Thorne | Attitudes toward patient expertise in chronic illness[END_REF]. Professionals have been slow to embrace the concept, dismissing efforts by patients to theorize or explain their condition [START_REF] Henwood | Ignorance is bliss sometimes': Constraints on the emergence of the 'informed patient' in the changing landscapes of health information[END_REF]. Uneasiness with associating patients with expertise has led to other proposed epithets, including 'involved' [START_REF] Hjortdahl | The informed patient': Rapid responses[END_REF], 'autonomous' [START_REF] Coulter | The autonomous patient: Ending paternalism in medical care[END_REF]'resourceful' (Muir Gray and[START_REF] Muir Gray | The resourceful patient[END_REF].

Meanwhile, a consumer movement has also affected the landscape of patient/professional interactions. Many medical conditions now have an advocacy or support network offering advice and information to sufferers.

Fox & Ward: Health Identities

Numerous websites, interactive forums and e-mail lists allow people to share information and discuss their condition and its treatment [START_REF] Bessell | Quality of global e-pharmacies: Can we safeguard consumers[END_REF][START_REF] Mendelson | Gentle hugs: Internet listservs as sources of support for women with lupus[END_REF][START_REF] Mitchell | Autism emailing lists[END_REF]. The validity of information on these sites varies, and organizations such as the Association of the British Pharmaceutical Industry (ABPI) argue that there is a need for 'gold standard' websites including the National Electronic Library for Health (NELH) and NHS Direct Online, which can provide trusted information to consumers. Some pharmaceutical companies are collaborating with patient groups to support dissemination of information about conditions, including potential pharmaceutical treatments [START_REF] Fox | A sociology of technology governance for the information age: The case of pharmaceutical consumption[END_REF].

This consumerist approach to health and illness has been fuelled by the development of treatments for so-called 'lifestyle' conditions, including male pattern baldness, erectile dysfunction and weight loss. Online pharmacies cater to a global market for health care products (Fox et al., 2005a), and some of the best-selling pharmaceutical products have been developed with such markets in mind. In the UK, 'e-clinics' use online consultations to assess people's suitability for medications such as sildenafil (Viagra) or the weight-loss drug orlistat (Xenical), before selling these products directly to consumers.

Thus, government policy on expert patients and the rise of independent consumers of health care both emphasize the centrality of self-management of health and illness. However, our research into health identities suggests that there is a continuum of identity practices, from a relatively medicalized 'expert patient' to an independent consumer of health information and products, often constructing notions of health and illness in contrast to a biomedical or professional perspective. In this article we draw together research data, some of which has been published more fully elsewhere (Fox et al., 2005b(Fox et al., , 2005c)), to explore this continuum and to develop an understanding of how health identities emerge in the confluence of cultural contexts and experiences of embodiment. We look at three different case studies to explore these emergent identities.

Methods

The research reported here was part of a larger study on consumption of pharmaceuticals and the role of the Internet, conducted as part of the ESRC Innovative Health Technologies programme between 2002 and 2004. 1 As part of the study, we looked at people's use of various lifestyle pharmaceuticals, both prescription-only medicines (POMs) and pharmacy medicines (PMs). The main methods used for this element of the research were documentary approaches and 'online ethnography'.

The first of these predominantly required searches of websites devoted to information about pharmaceuticals and those enabling purchase of PMs and POMs. We focused on specific conditions such as weight loss, erectile dysfunction and depression, and located websites that would provide drugs health: 10(4) related to these conditions. The names of specific pharmaceuticals were entered into search engines to identify commercial websites, informationproviders and other links. From these searches we were able to identify both Internet pharmacies and online clinics, and sites devoted to consumer information and interaction using online technologies such as discussion forums.

The online ethnographic work entailed observation and participation in discussion forums and subsequent interviews with participants, typically by e-mail. This is an emerging approach that has adapted 'face-to-face' ethnographic methods [START_REF] Mann | Internet communication and qualitative research: A handbook for researching online[END_REF], and can be used to explore how communication technology is experienced in use [START_REF] Hine | Virtual ethnography[END_REF]. Despite the lack of direct engagement with participants as in traditional ethnography, [START_REF] Thomsen | Ethnomethodology and the study of online communities: Exploring the cyber streets[END_REF] suggest that multi-method triangulation, involving textual analysis, prolonged participant observation and qualitative interviews can provide valid and reliable data.

During this phase, KJW subscribed to various online message forums that we considered would enable us to understand the range of patterns of health identity practice, from that of an 'expert patient' to a 'health technology consumer' (more detail of the forums is provided in the following sections). In each, a period of acculturation to the norms of the values of the groups was followed by participation in the forums, which involved asking questions of forum participants. Some participants responded to the questions via the forum, while others chose to e-mail their responses direct to the e-mail address, which provided the opportunity for 10 in-depth interviews. Participation in the forums took place over a period of months during 2003. A total of 36 interviews were conducted with participants in the forums. The forums and names of participants have been changed throughout to protect anonymity, and postings have been reproduced verbatim. For a full discussion of online ethnography, see Fox et al. (2005c).

Expert patients

The first case study we consider here illustrates an 'expert patient' health identity. The growing attention paid by the media to obesity and weight loss has been reflected in a plethora of websites and discussion groups on the Internet (Thompson and Heinberg, 1999: 347). We undertook research on 'X-Online': a public discussion forum established in 2001 devoted to weight loss and the use of prescription drugs such as orlistat (Xenical) that disrupt the digestion of fat. It had about 500 registered users, predominantly females between 30 and 40 years from the UK, USA and Australia, with a daily traffic of 20-30 messages. Participants addressed a variety of topics concerning the effectiveness of the drug, its side-effects, their progress and their encounters with the medical profession. The forum was typified by high levels of support, encouragement and advice for others concerning diet and for those new to using Xenical (Fox et al., 2005b).

Fox & Ward: Health Identities

Within X-Online, being overweight had complex meanings for participants. Members applied biomedical constructions of the body as 'treatable', aiming to restore 'good health', but also revealed their feelings and social meanings surrounding weight gain. Users of the forum were thoughtful and reflexive about the causes of overweight and the difficulties inherent in living in western society where there is a strong cultural bias towards slimness. One participant had vivid memories of realizing she had a 'weight problem'. Being overweight was a family issue, and weight gain had become part of her family's culture and history.

My mother died in my early teens, but I remember her going to Weight Watchers. . . . My father used to be a long-distance runner, but broke his leg in a nasty fall, and had to stop running. He has been overweight ever since. My younger brother lost a lot of weight in his early 20s and has kept it off for about eight years so far.

In the X-Online forum the users exchanged a high volume of information, including exercise tips, diets and progress reports. Questions about the appropriate way in which to take Xenical were frequent in the forum, while discussion in one thread was dedicated to side-effects of taking Xenical, and how to manage their diet to avoid the unpleasant side-effect of diarrhoea. Participants used an explanatory model based on a medicalized understanding of the treatment, and often made reference back to medical and pharmaceutical professionals. Jessica asked about foods that might trigger unpleasant side-effects.

I'm getting my Xenical tomorrow (hopefully) but am scared to death of the side effects . . . Does it really make you lose control of your functions if you should overindulge on fats? . . . How is this really different from a serious laxative? Does Xenical have any impact on sugar/carbs that are fat-free? If you do not eat fat, is it still working? I was wondering about this, am I understanding right that if you haven't eaten much fat that the X works on the fat stored in your body??? Or am I just wishing???

This post received the response: I don't think it works on the fat stored. only on the fat you digest. so if you aren't eating a lot of fat i believe it is still taking 30% of the fat you did digest. i guess it is best to ask the xenical people, but, i believe that is how it works. Some participants were taking anti-depressants while also using Xenical, and one articulated concerns about the interaction between drugs:

The Xenical seems to have stopped working since my doctor increased my dosage of Effexor. I have deliberately eaten a high fat content meal for 3 days running and suffered no ill effects . . . Has anyone else experienced this? I phoned the Xenical hotline and they said that if you're using Xenical properly you shouldn't be getting any oily 'waste' at all !!! . . . Be glad of any help.

One response to this posting reiterated the medical model underpinning how participants saw their use of Xenical: 'I really think u should go to the health: 10( 4) doc tho, it doesn't sound normal what u are going thru! take care and let us know what happens ok?'

These kinds of information exchange were a first step in becoming 'expert patients', and our findings suggest that participants in this forum regarded the most highly valued expertise as biomedical, as opposed to social or experiential. During interview, users such as Gemma described how they had used the Internet to research their condition prior to seeking medication.

My reaction to the suggestion to go on Xenical was to do all the research I could first. I was totally prepared for all the side-effects that I might experience . . . The research I did was on the Internet mainly . . . I actually found the X-Online group during that research as I was looking for feedback from people who had taken it. I probably looked into it for three weeks or so before actually going to my own doctor for a prescription.

Most participants had obtained Xenical from their family doctors, and regarded this relationship as important. Lesley managed her condition within a medical model, checking advice from her doctor against other users' experiences.

I phoned the GP today and asked him if I could have X . . . One thing concerns me though, he gave me a warning that 90% of the people taking it, are incontinent. From what I have seen in this group, you are all managing okay, surely if you go over the fat grams you are supposed to have each day, then you'll suffer with the "Os" [diarrhoea], but if you stay within the limits, wont you be fine??

Kelly revealed that her doctor provided little information about Xenical, which led her to carry out personal research and use the forum as a space to ask questions:

My doctor just prescribed me the Xenical . . . She didn't go into detail about much of anything. I looked on the computer and found out a little about the medicine. I was wondering if someone could explain to me what I'm supposed to eat . . . what not to eat . . . how am I going to feel and things of this nature . . . Engagement with the forum supported participants' self-management of their weight, working alongside the medical professional in a shared enterprise. Their use of Xenical accepted a biomedical perspective on overweight as abnormal and to be treated. Most participants equated a healthy lifestyle with slimness, with numerous contributions that discussed exercise, healthy eating, recipes and tips to achieve a healthy body and lifestyle. Julie accepted the notion that weight gain was associated with illness and saw losing weight as a route to a healthy lifestyle. Gemma revealed that she wanted to have children and believed that being overweight would lead to a difficult and unhealthy pregnancy.

In summary, our analysis suggests that the participants in X-Online construct a health identity that is grounded in medical knowledge and perspectives on body mass and shape and their own culturally mediated Fox & Ward: Health Identities experiences of their embodiment. Participants were engaged in an enterprise to alter their body shape to one that is culturally acceptable in the West, but the content of discussions within X-Online were located in relation to medical model discourses concerning pathology, treatment and restoration of health and fitness. Good health was associated with slimness and weight loss; and the forum promoted mainstream medical advice about a healthy lifestyle. This medicalized health identity is broadly in line with the previously described notion of the expert patient developed by Wilson (2001: 134).

Blurring identity: from expert patient to technology consumer

The second case study we researched was concerned with male impotence and treatments for erectile dysfunction. We subscribed to a number of online discussion forums including an impotence support group and lists more specifically concerned with the use of sildenafil (Viagra) and similar pharmaceutical treatments for erectile dysfunction. These lists had male and female respondents from the UK, USA, Canada, South Africa and elsewhere and supported an active discussion on a range of topics. We posted questions to the participants and also conducted online interviews. The impotence support list served as a broad forum for discussion of sexual function while groups such as the V-Board (our pseudonym) included an extensive 'buying guide' for purchase of Viagra and similar pharmaceuticals from Internet pharmacies and discussion boards for both men and women to describe the effects of Viagra and consider the impact of the technology for their sexual identity.

Like the other forums we have reported here, a significant feature of V-Board was information seeking and exchange. One participant wanted to find out whether Viagra would be a suitable treatment for his perceived reduced sexual function: I'm curious about the possibility that the use of Viagra might also be helpful in speeding up the 'process' to ejaculation. It seems to take much longer to orgasm now than it used to, and I've heard that using Viagra can be helpful in that regard. Anybody have any experience with this?

Another participant wrote to get advice as a novice user of Viagra:

It sounds like there is a lot of experienced Viagra fans out there. Well, I'm about to try it out for the first time. I purchased the 100mg pills over the 'net. Does any one out there have any advice for me? I am a little worried about if I should split the pill and try a smaller dosage to start . . . Questions to the forum sought information about both the science behind erectile dysfunction and how Viagra might counter this condition, but also how to obtain the drugs. Many posts shared information about how to obtain Viagra without consulting a physician, about the various generics health: 10(4) such as 'Indian Viagra' and how much these various versions cost per tablet. This participant asked about both the science and the means to access Viagra:

I don't have a clue what to believe and what not to believe. I looked up ED and this is what it said: Erectile dysfunction, or ED, can be a total inability to achieve erection, an inconsistent ability to do so, or a tendency to sustain only brief erections. I would say my boyfriend has the last of these 3 . . . the tendency to sustain only brief erections. He's already had Viagra and we both enjoyed the results, immensely, but he's not willing to go to a doctor to get it. Can anybody help me sort this all out, please?

For many participants, information seeking concerned the impact of drug interactions, perhaps because they were using other medications such as anti-depressants or blood-thinning drugs. Some participants had become expert on using cocktails of drugs to increase sexual arousal: I'm thinking about taking 50 mgs of Viagra one hour before sex and 150 mgs of trazodone/Desyrel 2 hours before sex. The dosage and timing of the Viagra are obvious, regarding the dosage of Desyrel, I read that it would be the best and safest dose to increase potency. I would take it 2 hours before sex because then peak plasma levels are obtained. I don't know however if it would be adequate to take the Desyrel only on days you plan to have sex. . . . By the way, I live very close to an emergency room and or not very priapism-prone. These participants were using pharmaceuticals within a medical context, to address a lifestyle problem perceived by them as a deviation from normal sexual function, or to address a loss of performance as a consequence of illness or ageing. For example, the following participant on V-Board used tadalafil (Cialis) to enhance a perceived reduction in arousal: I for one am very excited and impressed, and we are trying as a husband and wife to discount or not let the 'placebo effect' influence our experience with Cialis. I don't feel that I have extreme ED, but sometimes I am amazed at how 'dead' my part can be . . . so to have anything work well -and as well as Cialis, I am ready and willing to use it.

Pharmaceuticals such as Viagra have also created potential for recreational uses, often by males and females who from a medical point of view would not be considered to be sexually dysfunctional. The discussion forums included postings that reflected this alternative, non-medical use of the drug as a 'cyborg technology' to enhance sexual performance beyond physiological or psychological constraints. The following participant sought information from the forum on how Viagra might artificially enhance arousal: I hope I am not offending anyone here with my question. I am a 23yo female and I want to know if my male gay friend can get an erection while with me after he takes the pill. He is very curious about straight sex and I have assured him I would be understanding and careful with him. By the way, I think he is so

Fox & Ward: Health Identities gorgeous so I am thrilled about this opportunity! But because he is gay, I am kind of wondering if he will be able to get hard with me -I am hoping Viagra will be a great catalyst . . . any suggestions or similar experiences will be extremely helpful.

Another forum focused on these non-medical uses of Viagra and similar drugs. One participant described how he had used Viagra to sustain erection:

Now i realise this great medicine should not be abused and I don't want to start any competitions but can i just say that after sneaking off with a long time friend of mine for a enjoyable weekend, i racked up 12 hours of non stop action on day one, 16 hours on day two and only 4 hours on day three due to the fact my supply had run out (I ate 8 of those blue M&M's that weekend). The only side affects i suffered was the fact I tore all my stomach muscles and could not walk or laugh for 3 days.

While drugs such as Viagra are not licensed for prescription to women, a theme on some forums was its impact when taken by females. A female contributor posted the following:

Just wanted to let all you unbelievers out there know that I tried Viagra and it certainly DOES work for women; at least it worked for me. I was wet and more abnormally swollen than usual. Not only did I want my partner constantly, and with a kind of insane intensity, but when we went out to a bar afterwards, I was also almost irresistibly sexually drawn to other men in the bar. It was an effort to pull myself away. So Viagra definitely FEELS like a drug. We both didn't take more than half, and I wouldn't recommend more than that. He was hard for over 24 hours, and I also experienced effects for about that long.

In summary, the impact of pharmaceutical technologies for erectile dysfunction has enabled both the effective treatment of a medical condition and the exploitation of the technology for non-clinical uses. These discussion forums perform a number of functions, from enabling the sharing of experiences of sexual function and the use of various technologies to treat problems, offering personal testimonials to different treatments, through to about how to obtain pharmaceuticals without medical consultation. Like other medications for 'embarrassing' conditions, Viagra has benefited from the rise of online pharmacies such as 'ShytoBuy'. There is a consumerist orientation to the postings on these message boards, and while erectile dysfunction is a psychologically devastating disease for sufferers, the opportunities to purchase an effective treatment can blur a health identity as patient, and open up potential to engage actively as a consumer of what Potts (2004: 27) describes as a 'tool' to achieve a particular desired outcome, which may or may not be clinically indicated.

health: 10( 4)

Resisting (anti-)consumers

The final case study we report upon explores health identities forged and sustained through their explicit opposition to a medical model of disease and treatment. Anagrrl (our pseudonym) is one of a number of semiunderground 'pro-anorexia' or 'pro-ana' websites and discussion forums. This movement supports those in an anorexic condition, but unlike mainstream support groups for people with eating disorders, regards the condition as sustainable and survivable. Like similar groups, Anagrrl had been persecuted by the media as supporting a dangerous and potentially fatal condition, but at the time of the research was a thriving community that provided a comprehensive website and message forum, where participants exchanged ideas, provided support and shared experiences, achievements and perceived failings. The site included recipes to promote healthy anorectic eating, advice on nutritional supplements and 'thinspiration': photographs of slim celebrities to inspire and sustain anorectic behaviour. 2 Participants were predominantly from the USA, UK, New Zealand and Australia, overwhelmingly females between 14 and 42 years, with the majority around the ages of 17 to 20 and in full-time education.

An anti-medical and 'anti-recovery' ethos underpinned the site, with anorexia regarded as aspirational, contributing to a positive pro-ana identity among its members. Lily, the founder of the website, described the movement as the means for people with anorexia to take an active role in living with what society considered a debilitating, dangerous and shameful disease. Anorexia, she suggested, was defined by insecurity and vanity on one hand, and the relentless striving for perfection on the other. Becoming pro-ana was complex, risky and obsessive, entailing a stringent regime of eating, fasting, purging and exercising to restrict calorie intake to a 'survival level' of about 700 calories per day, but with the aim of safely sustaining this regime. Unlike pro-recovery groups, anorexia was not seen as abnormal or inherently pathological.

Using a combination of text and photographs, participants in the group framed their bodies to reflect and re-create the values of the pro-ana movement. These photographs seemed to have been selected to present a deliberately staged version of the self, with close attention to hair, makeup and clothes. Other members would compliment the pictures, noting that the subject was exceptionally thin and beautiful, and a source of thinspiration. Other identity strategies included creation of a 'signature', which often contained the user's current and goal statistics and measurements. Participants appeared to apply a standard format, incorporating their height, current weight (cw), high weight (hw), low weight (lw) and goal weights (gw). For example, this was Jenny's signature, 'H:5'2; cw:100 down five lbs; hw:120; lw:75lbs; 1st gw:90lbs; 2nd gw:80; 3rd gw:70lbs ~ I always was told to test the limits~'. Marcy used as her signature a lyric from the Manic Street Preachers' song 4 stone, 7 pounds: '. . . i wanna be so skinny that i

Fox & Ward: Health Identities rot from view . . .' Participants' analysis of anorexia was overwhelmingly social. They located the causes within the beauty industry, media obsessions with celebrity lifestyle, and the equation of slimness with being considered beautiful, successful, happy and healthy. For one participant we interviewed, comments by a peer had led to her becoming anorexic: I've always been 'thin' or so they've told me. But what triggered me was my best friend's boyfriend. He always used to criticise me and make fun of me and call me ugly. It hurt so much I contemplated suicide. Then it was probably May when my ED [eating disorder] started, I think it was because I thought, Well, I'm skinny, I have that much going for me, Maybe if he notices how skinny I am he won't bother looking at the rest of my imperfect body. I was 89 pounds then and now I'm 94, I think in July I noticed I had an ED, I started researching things on the internet about Anorexia, and everything applied to me . . . It was scary But I thought I would take control and show that fat ass a thing or two! For participants in Anagrrl, low body weight was less important than the underlying pain and alienation that had driven them to adopt a pro-ana identity. Many saw the process of becoming and sustaining this identity as a place in which control and purity could be found. Jenny described how anorexia represented a form of security and comfort in an often-disordered environment:

I think of my ed [eating disorder] as a sanctuary from the pain that I've lived through. I have control over myself when I restrict, and I have control over my body when I purge and that is what has got me through the hard times in my life, the times when there was no control or stability in sight.

'Recovery' from anorexia was not a desired option for most participants in Anagrrl. In contrast to medicalized explanatory models of anorexia, the website and discussion forum devoted most of its space to exploring the safe management of a dangerous condition, to sustain both low body weight through tips and advice on use of weight-loss drugs, and also a pro-ana identity. The site offered support 'in a non-judgmental way', rather than a 'politically correct' approach in which support was given to achieve recovery, said one respondent. Anagrrl enabled its members to play out a health identity that was valued and provided, as Charlotte remarked in an interview: I joined a pro-recovery anti pro-ana site and they were all politically correct and trying the proper support in a recovery type position -but they had an article on pro-ana and I looked into it -at first just to get some triggering pics and stuff, but came across this site and have found on the whole that the support I receive on there is much better than the support I received on the other . . . maybe one day I will be 'ready' for recovery but i certainly am not yet -and I am sick and I like to know there are people out there who feel the same way as me.

Both Amy and Emily commented in interviews that they proactively sustained their ana health identity, and that their ability to choose an identity was crucial: health: 10(4) I would recover if I were pregnant, which will never happen due to my anorexia. I would also recover if I reached the point in my life where I wanted to marry someone close to me. It's not fair to put my life in danger when I am so valuable to someone else. I will only recover when I truly want too. last time I was forced. I could've fought back harder but I felt badly doing that to my parents. my dad wouldn't sleep cause he worried about me, and relatives kept calling my parents asking if I was okay. but now I seem to have a problem with binging and no one seems to give a damn. anyway that's a whole other long story. moral of story . . . don't change for anyone else, only for yourself.

In summary, these data demonstrate the emergence of a health identity that is not only grounded in an assertion of self around particular values, behaviours and cognitions, but is highly resistant to conventional models of health, be they inspired by biomedical, social or psychological explanations of anorexia [START_REF] Bruch | Eating disorders: Obesity, anorexia and the person within[END_REF][START_REF] Grogan | Body image[END_REF][START_REF] Berg | Eating disorders: A patient-centered approach[END_REF][START_REF] Luck | The Scoff questionnaire and clinical interview for eating disorders in general practice: A comparative study[END_REF][START_REF] Gremillion | Feeding anorexia: Gender and power at the treatment centre[END_REF]. Elsewhere, we have argued that the pro-ana movement constitutes a coherent anti-medical explanatory model of anorexia capable of offering explanations of the aetiology, epidemiology, prognosis and management of the condition. It is perhaps because of this coherence that a self-actualizing health identity manifests. In place of the expert patient whose identity we noted earlier emerges in the confluence of a medicalized embodiment, we see a resisting consumer (consumption of weight-loss drugs, low-calorie recipes and thinspiration; non-consumption of food), who rejects the medicalized body and conventional cultural values concerning body shape.

Health identities: what can a body do?

We chose to describe here three different types of engagement that individuals had with medical knowledge and expertise, with health technologies and with their embodiment practices. In the X-Online case study, we see people engaged in body modification (weight loss) using a pharmaceutical technology within the framework of medical expertise on fat metabolism. For these people, their own expertise in applying a technology towards a body objective paralleled a medical model, in which slimness was desirable and 'healthy'. They adopted a health identity located within relations with medical knowledge in which they were foremost 'patients' and secondarily 'expert'.

Individuals in the second case study manifested a range of relations with biomedicine in their exploration and use of a 'cyborg' technology [START_REF] Haraway | Simians, cyborgs and women[END_REF][START_REF] Balsamo | Technologies of the gendered body[END_REF]. Both weight-loss drugs and pharmaceuticals to treat erectile dysfunction are grounded in biomedical models of physiological function and both serve to treat a condition that is culturally defined as abnormal. However, in part because of the economic relations surrounding

Fox & Ward: Health Identities the use of Viagra, in part because of the wish by some individuals not to label themselves as impotent by consulting a family doctor, and in part because of the potential for the drugs to achieve 'hyper-normal' sexual performance and to enhance or extend normal sexual function, the relation with medical knowledge diverges from that in the first group. Health identities within this category are located along a continuum from the expert patient to an independent consumer, operating outside medical guidance.

The third group that we reported in this article are in some ways the most remarkable. The pro-ana movement has also drawn upon medical technologies in their application of weight-loss medications, although this is by no means central to their health identity. The relations that forge proana health identities run counter to medical perspectives that consider anorexia as quintessentially unhealthy. In contrast, anorexia is regarded by those in the movement as a 'healthy' response to an underlying malaise that inheres in the social relations with family, friends or wider society. The objective of pro-ana is to sustain an anorectic health identity emotionally and physically while the anorexic addresses these underlying problems in her relations and affects. 'Recovery' in a medicalized sense has no part in the ethos, although they accept the possibility of life after pro-ana, once other problems are resolved. They stand at the extreme end of the continuum of health identities we have outlined, rejecting medical and other conventional models of extreme weight loss, appropriating and subverting technologies intended for the obese to sustain their condition.

These three cases suggest a dimension upon which we might map health identities, from expert patient to resisting consumer. This offers explanatory power to the exercise, enabling an analysis in terms of how identifications emerge in relation to or in opposition to biomedicine. It extends the kinds of modelling of patient identities first conceived by Parsons, Szasz and Hollender and others, suggesting both that health identities can be forged independently of medical conceptions of health, yet also acknowledging the continuing power and significance of biomedicine. This locates health identities in relation to a dimension of autonomy/dependence and such a dimension can serve to map a variety of possible health identities. However, it is quite possible to develop further identity dimensions, for example in relation to ideas of natural or holistic 'health' versus intervention and technology, or in relation to physical well-being versus spiritual integrity. Indeed, there are endless dimensions that could be posited, and any mapping of health identities would need to be within a multidimensional space rather than a single dimension. While identities do in part emerge in relation to dominant cultural systems such as biomedicine, their forging cannot be reduced to such a deterministic analysis.

In the introduction to this article we suggested that in order to grasp the character of health identities, we must study 'health', 'body' and 'identity' together, as emerging from activity and practice, and located within the totality of a body's physical and social relations. Health identities are health: 10(4) features of the clustering of relations around specific aspects of embodiment, such as sport and exercise, body modification, disability or growing old. In this anti-essentialist, Deleuzian interaction, none of these elements of health, identity and body is prior; each is constituted in relation to the others. Potts contrasts biomedicine's model of health as grounded in the stable homeostasis of the body, with this way of thinking, so that . . . in opposition to medicine's contention that the organic body functions through the monitoring and regulation of its various systems and processes, Deleuzian bodies come into being in a kind of chaotic network of habitual and non-habitual connections, always in flux, always reassembling in different ways. (Potts, 2004: 19) Deleuzian scholars suggest that the question 'what can a body do?' is a useful way to explore embodiment and identity [START_REF] Buchanan | The problem of the body in Deleuze and Guattari, or, what can a body do?[END_REF][START_REF] Fox | Refracting health: Deleuze, Guattari and body/self[END_REF][START_REF] Potts | Deleuze on Viagra (Or, what can a Viagra-body do?)[END_REF]. The confluence of body/self is processual, constituted from the relations and affects that the material body has with its natural and cultural context. Body/self comes into being only in its relations to physical forces of nature, to cultural and social expectations and constraints, emotional attachments and reflexive understandings. What this body can do depends upon the confluences with these myriad relations. They provide the capabilities and potential but also the limits to what it can do. 'Health' paradoxically is both a characteristic of this emergent body/self, and the conditions or relations that in part define body/self (alongside the many other relations that contribute to identity).

We can apply this understanding to the people we described in this article and their health identities. For the weight-losing body/self, there are confluent relations with medical definitions of normal body shape and the dangers of overweight, and the emergent health identity is the recovering (expert) patient. For the sexually potent, physiology-defying Viagra body/self, relations with medical, pharmaceutical and cultural dispositions upon normal sexual function and behaviour foster a health identity as cyborg lover. For the pro-anorexic slimming body/self, whose relations are pained and oppressive, the health identity is anti-social, anti-medical, resisting (anti-)consumer.

In this analysis, health identities are neither prior, nor are they determined. Rather they emerge from concrete embodiment practices in relation to material, cultural, technological and emotional contexts. We can draw three conclusions.

First, that if there are myriad health identities, then there are as many possible individualized conceptions of 'health' itself. Just as we have noted the 'slimming-body' of a weight loser or anorexic, the 'moving-body' of the athlete or dancer, the 'enhancing-body' of the body-builder or cosmetic surgery enthusiast, the 'diseasing-body' of the chronic sufferer and so forth, we can see all these as 'healthing-bodies'. A health identity is an emergent identification for an individual, but because it is the outcome of the confluence of body/self with its relational contexts, it also structures what Fox & Ward: Health Identities 'health' is for that body/self. For example, for the 'weight-watching' body of the slimmer, the health identity emerges from the confluent relations (physical, emotional and symbolic) with food and its ingestion, and with the cultural contexts that associate overweight and obesity as antagonistic to health. Health for our respondent Julie (see earlier) is structured by her relations to her slimming-body, to her desire to live a 'healthy' lifestyle. Health for pro-ana Jenny (see earlier) was about psychological and physiological control and stability. [START_REF] Kleinman | Patients and healers in the context of culture[END_REF][START_REF] Kleinman | The illness narratives[END_REF] used the concept of 'explanatory models' to describe the narrative frameworks used by lay and professional people, western and non-western, modern and pre-modern, to make sense of disease or other abnormal experiences or behaviours. Our analysis suggests we can extend this notion of an explanatory model by recognizing that these narratives contribute to health identities (and thereby to people's conceptions of health itself). However, we see culture as only one component of the relational contexts within which health identities and ideas of health emerge. Alongside these cultural contexts we must also recognize the confluences of physiological capacities and limits of a body, the sum of psychic and emotional lived experiences, the valuations, beliefs and attachments that a person holds, and the reflexive and social expectations of what a specific body can do. [START_REF] Fox | Cultures of ageing in Thailand and Australia (What can an ageing body do?)[END_REF] found all these elements affected the health identities of older people: that health was as relational and individualized as the body/selves were.

For social scientists, this means that rather than seeking a single 'master' theorization of health (for example, as an evaluation of capacities in comparison with norms or ideals, as an assessment of fitness, body tone, as emotional well-being or whatever), health must be acknowledged to be a highly contextualized outcome of the lived body/self and its relations with its material and psychosocial environment. 3 The second of our conclusions flows directly from this. Health identities (and thus health itself) are legion, constituted from both the biological and the social, the material and the psychic forces that define what a body can do. But these phenomena are amenable to empirical study, as we have shown in this chapter and elsewhere. Simply by asking 'what can a body do?', we can seek the relations and affects that structure health identities and conceptions of health and illness held by a person, whether for reasons of research or in practical or therapeutic settings. There is potential from such maps of identities for understanding much more about 'health' behaviour, 'health' beliefs and patterns of morbidity and health care provision and consumption. Furthermore, this approach firmly establishes embodiment as a key element in the way we understand the social organization of health and illness. It offers a way forward for an empirical sociology of the body: a fertile area for research that has up to now been strong on theory and weak on practical application.

Finally, the research that we were able to conduct with these disparate associations of individuals has contributed further examples of health health: 10(4) identification in the 21st century. Some respondents were pursuing traditional health activities, while others were forging anti-medical identities as consumers of technology and of the body's potential to supply pleasure or control. There is a substantial agenda here for the exploration of health and illness practices, expert patients and body consumers, using the health identity as the starting point for analysis. In an increasingly industrialized, technology-driven, consumer-oriented and media-saturated global health and illness economy, longevity, fitness, body shape and size, youthfulness and so forth will continue to be significant for the emergence of health identities. The body's relations with its physical and psychosocial environment will refract endlessly, producing multiplicity and diversification of bodies, identities and healths.

Notes

1. ESRC project L218252057, funded within the Innovative Health Technologies programme. 2. Examples of 'thinspiration' may be viewed on websites such as http://looking glasssupport.com/StarvingForPerfection/ 3. We have not made too much of this here, but it is worth pointing out that this way of thinking about bodies and health overcomes the criticisms of many theories of embodiment as reductionist, either to the biological or the cultural realm. In this analysis, physical, psychic and cultural relations are all constitutive of what a body can do, and thus of its 'health'.


Natalie Armstrong
email: natalie.armstrong@warwick.ac.uk

Keywords: Cervical Cancer Screening cervical cancer screening, discourse, Foucault

Discourse and the individual in cervical cancer screening

Introduction

A national screening programme for cervical cancer has been established in the UK since 1988. The objectives are to reduce both cervical cancer incidence and mortality through a coordinated programme of regular screening for all women within a wide age range, with the aim of identifying and treating pre-cancerous abnormalities that, if left untreated, may go on health: 11 (1) to develop into invasive cervical cancer. When women are invited to attend for screening, they are sent a locally produced invitation letter together with a nationally produced information leafl et (Department of Health, 2002). Although the invitation letter itself may vary, the information leafl et that is required to accompany all such letters is produced and published centrally. The material contained within this leafl et can therefore be thought of as constituting the 'offi cial discourse' on cervical screening and hence is important for the ways in which it presents screening to women and encourages them to think about it. This discourse is very general in nature as it is produced at the national level and is designed to address a large number of women. This article explores the various ways in which individual women invited to attend for cervical screening interpret, negotiate and make sense of this through considerations of their own individual circumstances, experiences and characteristics, therefore producing conceptualizations of, and discourses upon, cervical screening that are at odds with the offi cial. These then lead to individual women working out and adopting a range of alternative subject positions instead of simply adopting the general subject position suggested to them through the offi cial discourse. Through this process, women demonstrate an active and critical engagement with the offi cial discourse on screening, problematize it, and raise important questions about how screening is presented and communicated to women.

The offi cial discourse on cervical cancer screening

The NHS Cervical Screening Programme (NHSCSP) aims to reduce both the number of women who develop invasive cervical cancer, and the number of women who die from the disease.

Cervical screening in England operates in the context of the National Health Service (NHS), which is funded by general taxation and offers health care free at the point of delivery. Funding is given by the Department of Health to Primary Care Trusts (PCTs) who then commission the provision of services to interpret smear tests, report the results and provide further investigation and treatment where necessary. The programme is therefore organized and delivered locally, through PCTs, but is nationally coordinated by the National Offi ce of the NHS Cancer Screening Programmes.

The leafl et that women receive when they are invited to participate in the screening programme, entitled Cervical screening: THE FACTS, is produced by the Department of Health in association with the NHS Cancer Screening Programmes, and with advice from the Cancer Research UK Primary Education Research Group. This leafl et, and the associated Breast screening: THE FACTS, were introduced relatively recently in order to provide clear information on the benefi ts and limitations of these kinds of screening and to meet the commitment in the NHS Cancer Plan (Department of Health, 2000) that all women should receive a national information leafl et on these kinds of screening by 2001.

The material contained within this leafl et can therefore be thought of as constituting the 'offi cial discourse' on cervical screening and hence is important for the ways in which it presents screening to women and encourages them to think about it. One of the most obvious discursive strategies used is the explicit suggestion that the material contained within represents undisputed facts. The information leafl et is, after all, entitled Cervical screening: THE FACTS, immediately suggesting that the information contained within is objective, scientifi c and, above all, represents some kind of 'truth'. This strong and immediate focus on the leafl et as providing 'the facts' about cervical screening suggests that any other, potentially contradictory, forms of knowledge or information that women may have acquired or developed must necessarily be incorrect. As a consequence it serves to construct the offi cial bodies that produce the material as perhaps the only, or at least the most appropriate, people who can or should speak on such a subject. The material sent out to women in the course of their contact with the NHSCSP therefore seeks to establish itself as authoritative, objective and above all, factual. It presents women with a particular construction of cervical screening and instructs them in how to engage with cervical screening. In common with many other health promotion strategies, individuals are encouraged to behave in ways identifi ed as sensible and responsible and to take appropriate actions to protect their health, in this case to attend for regular cervical screening.

However, it is not simply attendance for smear tests that is required; within the material, women are encouraged to engage with the screening programme in a particular way. The description of the experience of having a smear test is presented in such a way as to minimize its signifi cance and intrusion. The test is repeatedly constructed as a simple test that will take very little time to perform and one that will usually be completely painless. Women are told that 'the test takes just a few minutes' and that the smear taker will 'gently put a small instrument … into your vagina to hold it open'. The test itself is therefore constructed in a particular way and one that, as this article will demonstrate, does not match many individual women's experiences.

It is of course important to stress that this characterization of the offi cial discourse is not to suggest that the medical profession as a whole, other health professionals and those involved in policy making, are unifi ed in their views on screening. Nor do I wish to suggest that this standardized written material is the only means through which women receive information about screening. Instead, the purpose of the exercise is to characterize the offi cial discourse and the way in which the NHS Cervical Screening Programme (NHSCSP), often through and/or with other bodies such as General Practices and Primary Care Trusts, communicates with women and presents screening to them.

health: 11(1)

Discourse and the individual

The intention of this article is to demonstrate how women can and do demonstrate forms of resistance to the offi cial discourse that surrounds cervical screening. This will be achieved through the analysis of qualitative interview data, which explores women's views, experiences and understandings of cervical screening, from the perspective of Foucault's later work on technologies, techniques or practices of the self as providing the means for resistance (Foucault, 1984a(Foucault, , 1984b[START_REF] Foucault | Technologies of the self[END_REF]). Foucault's work on governmentality [START_REF] Foucault | Governmentality[END_REF], and indeed the work of those that have developed this work (see, for example, [START_REF] Burchell | Liberal government and techniques of the self[END_REF][START_REF] Dean | Governmentality[END_REF][START_REF] Dean | Foucault, government and the enfolding of authority[END_REF][START_REF] Rose | Governing 'advanced' liberal democracies[END_REF], can be utilized as a means through which to conceptualize the offi cial discourse on cervical screening. This work overcomes some of the problems of a previous focus on disciplinary power, as it broadens the notion of power to include a more diverse range of the means through which power can operate. There is still the possibility for repressive forms of power, but the category is widened in order to include within it an analysis at the level of individuals and their conduct in everyday life. The concept of governmentality therefore represents an extension towards more diffuse forms of social control. This formulation of power relations does not deny the possibility of a repressive form of power, but it does relegate it to one in a multiplicity of the potential effects of power [START_REF] Mcnay | Foucault: A critical introduction[END_REF]. Foucault is therefore concerned with exploring the ways in which power works as a positive and enabling force through the creation of particular identities. One important way in which this new form of government operates is through discourse, and Foucault sees a 'discursive explosion' as having taken place over the last few centuries. Of particular interest to Foucault were the discourses that began to emerge around sexuality and which served to normalize heterosexuality practised within the marriage relationship. The exercise of power through discourse has the effect that the individual starts to become a self-policing subject. The concept of government is therefore extended right down to the way in which individuals come to govern themselves and become certain kinds of subjects.

In applying these ideas to the case of cervical screening, it can be argued that power is operating through the offi cial discourse in order to construct screening in a particular way, that is as a quick, simple and painless intervention to screen for a disease that all women are potentially at risk from, and, consequently, to construct attendance for screening as something which is simply routine [START_REF] Forss | A qualitative study of women's reasoning about attendance in a cervical cancer screening programme in urban Sweden[END_REF] and, perhaps more importantly, as a responsible and indeed morally correct thing to do [START_REF] Bush | It's just part of being a woman': Cervical screening, the body and femininity[END_REF][START_REF] Howson | Cervical screening, compliance and moral obligation[END_REF]. Empirical work of this kind is very valuable as it moves away from the focus on exploring women's perceptions and experiences of screening solely in the context of how these may infl uence attendance (see, for example, [START_REF] Bentham | Factors affecting non-response to cervical cytology screening in Norfolk, England[END_REF][START_REF] Eaker | Reasons women do not attend screening for cervical cancer: A population-based study in Sweden[END_REF][START_REF] Eardley | Attendance for cervical screening -whose problem?[END_REF][START_REF] Elkind | Reasons for nonattendance for computer-managed cervical screening: Pilot interviews[END_REF][START_REF] Neilson | Women's lay knowledge of cervical cancer/ cervical screening: Accounting for non-attendance at cervical screening clinics[END_REF] and explores how women can be affected by such health promotion messages and feel obliged or constrained in particular ways. However, alongside such an exploration of how women can feel constrained to think and behave in particular ways, it is important to bear in mind that it does not necessarily follow that they do, or that they have no means through which to resist. To do so inevitably portrays women as little more than passive victims who have no option but to think and behave in the ways, and therefore become the kind of subjects, which the discourse encourages.

Foucault's early work is often criticized for focusing too heavily on how individuals are controlled and disciplined within society, and for paying too little attention to how power relations are viewed by the potential subjects (see, for example, [START_REF] Dews | The return of the subject in late Foucault[END_REF][START_REF] Mcnay | Foucault: A critical introduction[END_REF]. It is argued that this can lead to a signifi cant overestimation of the effectiveness of such strategies, as little attention is paid to the other discourses or knowledges that may emerge. Foucault, however, argues that his views on the nature of power have always implied the possibility of resistance, stating that, 'the idea that power is a system of domination that controls everything and leaves no room for freedom cannot be attributed to me' (Foucault, 1984b: 442).

For Foucault, in order for power relations to come into existence there must be a certain degree of freedom on both sides. If there were no possibility for resistance, then there would be no power relations. Foucault's later work (Foucault, 1984a(Foucault, , 1984b[START_REF] Foucault | Technologies of the self[END_REF] develops what he calls 'technologies of the self' as a conceptualization of the ways in which individuals come to understand themselves as subjects, and therefore through which resistance is possible. Within this, a space is opened up between discourse and the individual so that a more fl exible relationship can be possible, with the emphasis placed on how this is worked out [START_REF] Mcnay | Foucault: A critical introduction[END_REF]. A greater element of freedom is allowed to the individual who now has the potential to interpret and negotiate rather than simply conform. Through engaging in 'technologies of the self', individuals have the potential for resistance. McNay discusses this in terms of an 'ethical moment' in the process of mediation between largescale cultural patterns and individual identity. During this moment a level of 'critical self-awareness or refl exivity' (McNay, 1994: 155) is achieved, and forms of identity can be questioned, thereby opening up the space for an exploration of new forms of experience. However, neither is the individual free to act in any way they wish: I would say that if I am now interested in how the subject constitutes itself in an active fashion through practices of the self, these practices are nevertheless not something invented by the individual himself [sic]. They are models that he fi nds in his culture and that are proposed, suggested, imposed upon him by his culture, his society and his social group. (Foucault, 1984b: 441 -2) The relationship is not uni-directional in terms of society merely producing docile bodies, but equally neither can it be seen as a voluntarist process of self-construction. Instead, the process represents a point of contact at which techniques of domination, such as the exercise of power through health: 11(1) discourse, and techniques of the self interact to produce particular subject positions [START_REF] Burchell | Liberal government and techniques of the self[END_REF]. The process is complex as particular discourses inevitably suggest more than one subject position because, while there exists a preferred form of subjectivity, its very existence implies others and the possibility for reversal. [START_REF] Foucault | The history of sexuality volume 1: An introduction[END_REF] explores this through the example of sexuality, arguing that discourses surrounding this served to normalize heterosexuality practised within the marriage relationship and which produced children. Although other forms of sexuality were therefore regarded as deviant, these alternative subject positions were nonetheless inevitably created. In order to be effective, discourses need to be activated through individual agency, and this works most effectively when the subject position advocated is identifi ed by the individual as compatible with their interests. Where this is not the case, then the necessary space for resistance is opened up. As Weedon argues, 'Where there is a space between the position of subject offered by a discourse and individual interest, a resistance to that subject position is produced' (Weedon, 1987: 112 -3).

However, despite having developed such a complex theory of this process, Foucault is still criticized, but now for failing to sustain this and not going far enough in exploring how power and resistance actually work together in this relationship (see, for example, [START_REF] Grimshaw | Practices of freedom[END_REF][START_REF] Ramazanoglu | Introduction[END_REF][START_REF] Ransom | Feminism, difference and discourse[END_REF]. Others, though, have been more open to how Foucault's work contributes an understanding of this relationship, and to the nature of resistance. For example, Davis and Fisher have argued that a relationship between power and resistance is a long-standing assumption within feminist scholarship, and Foucault's conceptualization of power as widely dispersed and pervasive means that resistance can be thought of in the same terms. As such, attention should be focused on how women are 'negotiating at the margins of power' (Davis and Fisher, 1993: 6), how they interact with discourse [START_REF] Kielman | Barren ground: Contesting identities of infertile women in Pemba, Tanzania[END_REF] and their existence as critical subjects [START_REF] Sawicki | Disciplining Foucault[END_REF]. I explore below the ways in which women interact with the offi cial discourse on cervical screening and how they can demonstrate resistance to it, but fi rst I give details on how the qualitative data that will be drawn on was collected.

Methods

The data presented here come from a qualitative interview study carried out in the East Midlands area of England with women who were all being invited to attend for screening, although not all were doing so. The universal approach to screening within a wide age range meant that a large number of women were eligible for inclusion within the study. In order to try to ensure the inclusion of as wide a range of views as possible, a quota sample was employed. This was structured according to both age and ethnic background. Age was identifi ed as particularly important as past research has shown that older women often regard health promotion strategies as no longer relevant to them, but still see them as important for younger women [START_REF] Savage | Older women's illness representations of cancer: A qualitative study[END_REF][START_REF] White | Older women's attitudes to cervical screening and cervical cancer: A New Zealand experience[END_REF]. Therefore the 20-to 64-year-old age group that was invited for screening at that time was broken down into three categories in order to represent a range of ages and stages in the life course. In terms of ethnic background, there exists a wealth of research on how particular ethnic, cultural or religious groups can hold different understandings of health and illness, and have different experiences of health care. For example, work exists on the different beliefs about, and responses to, hypertensive therapy amongst the white population and those born in the West Indies [START_REF] Morgan | Managing hypertension: Beliefs and responses to medication among cultural groups[END_REF], how culturally defi ned concepts of health and illness can infl uence heart health-associated behaviours [START_REF] Higginbottom | Heart health-associated health beliefs and behaviours of adolescents of African and African Caribbean descent in two cities in the United Kingdom[END_REF], the health and illness understandings of African-Caribbeans, and how these may be infl uenced by age and gender [START_REF] Curtis | Gender, ethnicity and self-reported health: The case of African-Caribbean populations in London[END_REF], the role of culture and religion in how diabetes is managed by Kashmiri men [START_REF] Naeem | The role of culture and religion in the management of diabetes: A study of Kashmiri men in Leeds[END_REF], and how the religious beliefs and customs of Muslim women can impact upon participation in breast and cervical cancer screening [START_REF] Sutton | Cancer screening coverage of south Asian women in Wakefi eld[END_REF][START_REF] Underwood | Veiled yet vulnerable: Breast cancer screening and the Muslim way of life[END_REF]. A look at the population statistics for the area where the research was based showed that the three groups making up the vast majority of the population were white British, south Asian and African-Caribbean.

Women were recruited through contact with community groups within the area; in addition, personal contacts and snowball sampling were used to a limited degree. Women were given an information leafl et about the study and asked if they would be prepared to participate. The fi nal sample of women interviewed is shown in Table 1 below.

The intention was to include four women within each cell of the table so as to give a sample of 36 women. This was deemed to be a manageable number within the context of a relatively small-scale project. There is an extra woman in the white British 50-to 64-year-old cell and this represents an individual who, although the cell was full, I interviewed as she was very keen to take part in the research. The cells for south Asian and African-Caribbean women of this age are both one short, and this refl ects a diffi culty in recruiting older women in these groups despite my best efforts to do so.

Individual in-depth interviews lasting approximately one hour were carried out with these women, either in their own homes or on the premises of the community group through which contact was made. The three interviews with south Asian women in the top age group required the use health: 11(1) of an interpreter. All interviews were tape-recorded and transcribed with the participants' permission. Analysis of the material was approached inductively with emergent themes being identifi ed from the interview transcripts and explored for the kinds of discourses and themes that women drew upon when talking about their views, understandings and experiences of screening. The analysis explored the women's development of alternative conceptualizations and discourses on screening that were meaningful to them.

Individualization practices as techniques of resistance

As I argued previously, the offi cial discourse on cervical screening is important for the ways in which it presents screening to women and encourages them to think about it. It is disseminated through the material that women receive when they are invited to attend for routine smear tests and, as such, is necessarily general and uniform in nature. Women therefore encounter a very general discourse on screening, one that is designed to address a large number of women. However, it was clear from the interview data gathered that the vast majority of women do not recognize their views and experiences within this offi cial discourse and, instead, understand and make sense of screening in ways that are meaningful to them. What I seek to do in the remainder of this article is to explore some of the ways in which individual women interpret, negotiate and make sense of screening through a consideration of their own personal circumstances, experiences and/or characteristics. Through doing so, I intend to argue that women engage in the production of alternative conceptualizations of, and discourses on, cervical screening that differ from those contained within the offi cial discourse.

As such, they are not simply accepting unquestioningly the discourse they encounter, and adopting the particular subject position suggested; instead, they are actively and critically engaging with it in particular ways in order to work out their own relationship to and with it. The key concerns of the article are therefore how women work out these relationships and the practices or techniques on which they draw in order to achieve this. Throughout, I argue that these negotiations can be framed as resistance to the offi cial discourse through the employment of Foucauldian theory. Women's use of such practices or techniques represents the means through which a space is opened up between the offi cial discourse and themselves as individuals.

Emotional experiences

When discussing their experiences, women frequently suggested or highlighted things about themselves that could explain their particular feelings or that meant that their experiences were likely to be different from the general presentation of cervical screening. This is most commonly the case when women regard their experiences as more diffi cult or troublesome than those of others and engage in a consideration of what it is about them, in particular, that makes this the case. Given that the presentation of cervical screening within the offi cial material stresses the ease and simplicity of the test, it is perhaps not surprising that it is those who experience diffi culties that engage in these considerations. It is as though they feel a need to negotiate a particular position for themselves in relation to this discourse and to resist the presentation of the test through the employment of their own experience. These discussions are inevitably based upon a certain kind of knowledge, as what women can directly know about cervical screening is largely rooted in their own experiences and, to a much lesser degree, the experiences of those known to them. All of the examples explored here draw upon women's own experiences and an awareness of their bodies and emotions. This form of knowledge is necessarily specifi c and particularistic in nature. A woman knows what having a smear test is like through her own experiences. In this way, a great deal of the knowledge available to women is embodied and experiential [START_REF] Abel | Selective compliance with biomedical authority and the uses of experiential knowledge[END_REF][START_REF] Williams | Lay knowledge and the privilege of experience[END_REF]. Women experience cervical screening through their bodies and, in comparison to health professionals who have access to wider technical and biomedical material, this is the main resource on which most have to draw (Howson, 1998a[START_REF] Howson | Embodied obligation: The female body and health surveillance[END_REF].

Here, I turn fi rst to two women who discussed the particular problems they experienced with the emotional side of cervical screening. While the majority of women discussed feeling slightly nervous and apprehensive before having a smear test, and many spoke of embarrassment during the test itself, these two women stood out as particularly extreme cases. The fi rst of these is Debbie who talks about how much she hates going to have her smear tests and fi nds it very diffi cult to 'pluck up the courage' to go. Debbie says:

It's just something that I just hate, I think it's, you know I don't know what it is, and I know to the nurse it's nothing but I think it's just, perhaps because I'm such a private person. (Debbie,(35)(36)(37)(38)(39)(40)(41)(42)(43)(44)(45)(46)(47)(48)(49)white British) It is immediately clear that having a smear test is a very diffi cult thing for Debbie to do, and indeed Debbie talked at length about how she took months to 'pluck up the courage' to make an appointment for her tests. On the last occasion she had been asked to make an appointment she had 'plucked up courage for about six months to actually ring up the doctor's'. On speaking to the receptionist, she was told that she needed to ensure that the appointment was between the tenth and fourteenth day of her menstrual cycle: something she had not encountered before. Debbie was unable to determine when this would be immediately and so had to say that she would call back. Having then gone away and worked it out, she had to 'pluck up the courage' to make an appointment all over again.

However, what is particularly interesting about Debbie within this extract is the way she negotiates her own position in relation to cervical screening and attempts to explain why it is that she has such problems with it.

health: 11(1)

She appears to suggest that she fi nds it particularly problematic, and goes on to suggest that it may be because she is such a private person that her experiences are so diffi cult. In this way Debbie takes steps towards setting herself apart from other women who perhaps are not so private and do not have the same worries about exposing intimate and personal parts of their body in this way. The fact that it is in the context of a medical encounter that this exposure takes place appears to make little difference to the way Debbie feels about it. In the extract above she says that she knows 'to the nurse it's nothing', implying that she is aware that the nurse has seen this kind of thing numerous times before and that it holds no special signifi cance for her, but this does not help Debbie. For a private person such as herself, this kind of thing will always be troublesome, and in this way Debbie negotiates her own position in relation to the discourse on cervical screening. In doing so she resists one of the central tenets of public health strategies such as screening: namely that individuals should make their bodies available to the gaze of health professionals and that this should be simply routine. This is very much the way that cervical screening is presented within the offi cial discourse as it is discussed in terms of a simple and routine test that will take very little time. Debbie problematizes this and redraws the boundary between the public and the private by drawing on cultural ideas of certain body parts being taboo. Through this she resists the assumption that the medical gaze is permitted unlimited access to the body unproblematically.

Julia also related how she felt very anxious and nervous about going for smear tests, but discusses it in a different way to Debbie. Julia says: I'm not a sick sort of person, in fact I can honestly say the last time I went to the doctor's was three years ago for my last screening, so I think going to the doctor's for me is quite an ordeal you know; I get quite nervous and feel sick about the fact. (Julia,(35)(36)(37)(38)(39)(40)(41)(42)(43)(44)(45)(46)(47)(48)(49)white British) So in a similar way to Debbie, Julia is offering an aspect of herself or her circumstances to explain why her feelings about cervical screening may be different from those of others. Julia very rarely visits the doctor and so the presentation of the cervical smear test as a simple and routine test does little to allay her fear and anxiety. Going to the doctor's is not a routine occurrence for Julia; it is an unusual and unwelcome event and, as such, is something of an ordeal for her. She does not regard herself as the type of person who regularly visits the doctor; indeed, elsewhere in the interview she stressed her very good general health and her reluctance to rely on doctors to resolve minor health complaints. Julia therefore resists attempts within the offi cial discourse to construct screening as routine and stress its role in maintaining good health, by associating it clearly with illness and literally with 'feeling sick' at the prospect of submitting herself to the medical gaze.

Physical experiences

Similar practices of resistance through individualization can be seen within women's discussions of the physical aspects of having a smear test. Again, whilst many made some mention of the test being uncomfortable and even painful, the two women discussed below told how their individual bodies made screening particularly diffi cult for them. I start with Alice, who discussed her experience of smear tests like this: ... every time uncomfortable and painful, they're just horrible … apparently, erm, I've got a funny shape so when the instrument goes in to open your cervix up it doesn't always go properly because of the shape. (Alice,(35)(36)(37)(38)(39)(40)(41)(42)(43)(44)(45)(46)(47)(48)(49)white British) So here Alice, in common with Debbie and Julia before her, explains how and why her experience is in some way different and unique to her. In this way she personalizes cervical screening to her own particular experiences, and indeed to her own particular body. Roberta does a very similar thing in the following extract, in which she discusses the diffi culties she has experienced when having smear tests.

I've had a few; well, I have diffi culties with them I must admit because they can't get at the cervix. I think it's up and back or up and to the side and the nurse has done it the last few times and has apologized profusely for not being able to do it. (Roberta,(50)(51)(52)(53)(54)(55)(56)(57)(58)(59)(60)(61)(62)(63)(64)white British) Again, Roberta has marked her experiences out as exceptional and shows how her personal circumstances and her particular body set her apart from others. As such she goes some way towards challenging the presentation that a cervical smear test is a quick and simple test. Through these discussions, both Alice and Roberta are resisting a further assumption of public health strategies such as screening programmes. I have already suggested that such programmes are premised on the ideas that, fi rstly, individuals should make their bodies available for inspection by the medical gaze and that, secondly, this gaze needs to be made routine if it is to protect the health of citizens. A third premise is that the gaze requires a population of bodies that are homogenous. By surveying a large number of bodies that are 'normal' the gaze can identify the small minority that are pathological and therefore require further intervention in order to prevent illness. Through discussions of their particular bodies as different and problematic, Alice and Roberta are challenging and resisting this notion of homogenous bodies. Further, they are using a form of medical knowledge in order to achieve this as the reasons for their problematic experiences have been provided by health professionals.

The four women discussed above all therefore offer aspects about their particular circumstances to mark themselves out as somehow different, and to account for their particular experiences within the cervical screening programme. They explore their own personal and particular positions and go some way towards carving out a niche for themselves within the very general offi cial presentation of cervical screening. These practices serve to highlight their particular positions and work out their own relationships to cervical screening whilst also resisting particular assumptions or tenets of the programme.

health: 11(1)

The changing body

A noticeable resource on which some of the older women within my research drew when discussing cervical screening was the way in which their bodies had and were still changing, and how these changes infl uenced how they thought about screening and the signifi cance that they attached to it. The majority of these discussions revolved around the menopause and the bodily changes associated with this. First, however, I explore the case of Vanessa who, at 57, was one of the oldest women I spoke to. Vanessa had gone for screening in the past but her attendance had lapsed of late due to a particularly bad experience when Vanessa felt she had been treated unsympathetically by the smear taker. What is interesting about Vanessa is the way in which her bodily changes have, in combination with her negative experience, affected her willingness to go for screening and how she feels about it. Although she had always found having a smear test embarrassing, the way in which her body was changing made the experience even more troublesome for her. Vanessa told me:

As you get older you get, like your breasts aren't as fi rm as they used to be, your belly starts hanging down and, you know, little bits of you start going out of shape and you think 'I don't want anybody looking at me like that, you know. I suppose if you're younger and your body's still, like not losing any of its elasticity, you kind of like, maybe you're not that bothered but as you get older I think you become a bit more conscious about how you display yourself; for me anyway that's how I feel. (Vanessa,(50)(51)(52)(53)(54)(55)(56)(57)(58)(59)(60)(61)(62)(63)(64) The way Vanessa's body is changing with age is infl uencing how she feels about going for screening and having to display her body to people. The changes to her body she discusses have altered the way she views herself, and her physical attractiveness, and have made her even more reluctant to display her body in such a way. Like Debbie, Vanessa engages in a redrawing of the boundaries between the public and the private to some degree. She draws upon cultural ideas of the older body being less attractive in a society in which, it could be argued, attractive bodies are associated with youthfulness and with 'everything being where it should be'. Again, the idea that individuals should readily submit themselves to the medical gaze is problematized and resisted.

The bodily changes associated with the menopause also infl uenced women's thinking on cervical screening. Existing research on age and views on cervical screening (see, for example, [START_REF] White | Older women's attitudes to cervical screening and cervical cancer: A New Zealand experience[END_REF] has suggested that menopausal women often regard screening as of little importance to them due to a feeling that that part of their body is 'fi nished with'. This is supported to some degree by the views expressed in my research, as some women suggested that screening was more important for younger women who, they argued, were likely to be more sexually active and to have young children to consider. However, the menopause was also discussed in terms of being a time during which screening may be particularly important due to the perceived uncertainty and 'riskiness' of the body that the menopause brought about. For some women this feeling of vulnerability, combined with an awareness of how their body was changing, made screening more important to them and served to alter its meaning and signifi cance. For Julia in particular, cervical screening had developed from simply a test to check the health of the cervix to providing a more general reassurance that the bodily changes she was experiencing were normal. Julia told me: I feel more wary and in fact I feel more frightened than I have before because my body, since my last smear, has changed completely and I'm told it's normal for my age but I'll be glad when I've had the test and I think 'yeah, that is right', you know, there is nothing untoward happening. And I think maybe it is a very uncertain time for women of our age and maybe it is the most important period of your life to go [attend for screening] through. (Julia,(35)(36)(37)(38)(39)(40)(41)(42)(43)(44)(45)(46)(47)(48)(49)white British) Here Julia responds to the increased uncertainty and vulnerability that she is feeling by re-appropriating the smear test to serve her own purpose. She develops it into serving a wider purpose than that within the offi cial discourse and emphasizes its potential to reassure her that the bodily changes she is experiencing are normal. So while she is even more nervous about attending for her next smear test than she has previously been, she welcomes what she regards as its potential to put her mind at rest. In this way then she has tailored cervical screening to fi t in with her particular feelings and concerns at this stage in her life and to fulfi l the role that she currently requires. However, by doing so, Julia demonstrates unrealistic expectations of screening and what it can tell her about her general health status. While a normal smear test can tell Julia that the menopausal changes she has experienced have not brought about cervical abnormalities, it cannot provide more general information. Through stressing the changes to her body, Julia also goes some way towards questioning the assumption of homogenous bodies discussed previously. By drawing attention to such changes, Julia is drawing a boundary between herself and other women.

It is apparent from both Vanessa and Julia's accounts that the bodily changes they have experienced have altered the way they view cervical screening, and this highlights an important point about the fl uidity of the boundaries between different subject positions in relation to cervical screening. Although women carve out a particular position for themselves in relation to the general offi cial discourse, this is likely to shift and change as their personal situations do. Cervical screening may mean different things to a woman at different stages in her life: factors such as childbirth and menopause for example may alter its signifi cance and meaning. Factors that were once important in defi ning her relationship to screening may cease to be so important and new issues may develop that take their place.

Discussion

In the course of this article I have outlined and discussed the various ways in which women work out their own positions in relation to cervical screening health: 11(1) and the offi cial discourse which surrounds it. I have focused here on three main resources upon which these women drew: emotional experiences, physical experiences, and the changing body. Throughout I argued that these practices can be conceptualized as forms of resistance to the ways in which cervical screening is presented through the offi cial discourse and that, through such practices, women can develop alternative conceptualizations of, and discourses on, screening, which differ from and resist those contained within the offi cial.

It must be made clear that the women within this research who advanced these alternative ways of thinking about cervical screening were not doing so to account for, or seek to justify, non-attendance. Only one woman interviewed had never had a cervical smear test taken and, of the remaining 34, 26 were regular attenders. This talk does not serve that kind of function, as even women who discussed cervical screening in very problematic terms stressed that they overcame these problems in order to attend. They were keen to stress that they had considered these problems in the context of the long-term protection of their health, thereby establishing themselves as responsible citizens [START_REF] Howson | Cervical screening, compliance and moral obligation[END_REF][START_REF] Lupton | The imperative of health[END_REF][START_REF] Petersen | The new public health[END_REF].

The kinds of resistance discussed in this article are important for the means through which they allow women to make sense of cervical screening in ways that are meaningful to them through the consideration and incorporation of their particular experiences, circumstances and characteristics. Women were generally reluctant to think about screening in the very general way presented in the offi cial discourse and were keen to stress the heterogeneity of women and experience and to carve out their own position in relation to the very general. Indeed, some went as far as to use the personal to question the validity and objectivity of the medical presentation. Women were therefore keen to take back some sort of control over how screening is thought about and what meaning and signifi cance the smear test holds for them. I would argue that resistance within this context be framed in terms of women's employment of various resources and practices in order to interpret, re-appropriate and even transform cervical screening and the cervical smear test.

This article has demonstrated that, far from being a straightforward imposition, the relationship between the offi cial discourse on cervical screening and how it is understood and made sense of by individual women is in fact more fl exible. There is clearly a space between the large-scale discourse and individual subject positions within which women draw upon a range of resources and practices that allow them to resist particular aspects of the discourse and make sense of it in the context of their own everyday lives and identities. The fact that this does not commonly lead to women resisting screening behaviourally, through a refusal to attend, should not lead us to think that this resistance is inconsequential. This range of resources and practices is important for the ways in which it infl uences the interpretation of health promotion messages [START_REF] Davison | Lay epidemiology and the prevention paradox: The implications of coronary candidacy for health education[END_REF] and, at times, challenges the

Table 1

 1 Quota sample

	Ethnic group	20-34 years old	35-49 years old	50-64 years old
	White British	4	4	5
	South Asian	4	4	3
	African-Caribbean	4	4	3
	Total = 35

e d g e m e n t s The completed doctoral work on which this article draws was supported by an MRC Health Services Research Studentship. Thanks are due to Elizabeth Murphy and Nicky James for their helpful comments on the thesis as a whole.

Armstrong: Cervical Cancer Screening objectivity of medicine by questioning the purpose of the offi cial discourse. There are clear implications here for how screening is presented and communicated, as the accounts presented in the course of this article suggest that the full range of different women's experiences is not being represented. The resources drawn upon in these kinds of resistance then are important for their ability to suggest and impose points of resistance at the level at which discourse and the individual meet. I would therefore argue that these practices should be viewed as examples of the kinds of 'technologies of the self' Foucault envisaged when considering how resistance may be possible [START_REF] Burchell | Liberal government and techniques of the self[END_REF]Foucault, 1984aFoucault, , 1984b[START_REF] Foucault | Technologies of the self[END_REF][START_REF] Mcnay | Foucault: A critical introduction[END_REF] through the ways in which they impose points of resistance which disrupt the fl ow of discourse and can lead to interpretation, negotiation and transformation.

Note

All patient names are pseudonyms.

Author biography

n at a l i e a r m s t r o n g is a sociologist with research interests in the area of lay perceptions and experiences of health, illness and health care. She is currently a Post-Doctoral Research Fellow in the Health Sciences Research Institute at the University of Warwick.