“It’s just part of being a woman”: cervical screening, the body and femininity

Social Science & Medicine 50 (2000) 429±444

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``It's just part of being a woman'': cervical screening, the body and femininity Judith Bush* Department of Epidemiology and Public Health, School of Health Sciences, The Medical School, University of Newcastle, Newcastle Upon Tyne NE2 4HH, UK

Abstract This paper explores the importance of cervical screening discourses in framing women's perceptions of femininity. In-depth interviews with 35 women Ð which focused on experiences of, and feelings about, cervical screening Ð highlighted how medical discourses embedded within the cervical screening programme shape the feelings of normalcy and sense of obligation associated with having smear tests. With the introduction of the invitation based call and re-call programme in the UK, cervical screening has moved from an ad hoc system to a programme of mass surveillance and regulation of women's bodies. The paper highlights the ways in which cervical screening discourses were negotiated, accepted and resisted by the women interviewed. Possible theoretical explanations as to why cervical screening discourses have become important in framing femininity are discussed. The paper concludes by suggesting that the meaning and objective of mass screening programmes must be brought into question and reconsidered by feminists and those involved with the planning, implementation, research and use of screening services. # 1999 Elsevier Science Ltd. All rights reserved. Keywords: Cervical screening; Body; Femininity

Introduction The cervical screening programme is the largest screening programme in the UK and the western world. Today in the UK 85% of women are having smear tests (Oce of Population Censuses and Surveys, 1997). Every 3±5 years women aged 20±64 are sent an invitation asking them to attend for a smear test followed by a series of reminder letters if they do not respond. For most women having a smear test has become an obligation (Howson, 1993 cited in McKie, 1995). However, the implications of mass

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screening discourses for framing constructions of femininity, and the attributes and characteristics that are associated with `being a woman' have been largely ignored in the literature. Debates concerning the importance of medical discourse have begun to emerge in recent years (e.g. Ussher, 1989; 1992; Dyck, 1995). However, most feminist work on femininity continues to focus on the importance of cultural discourses, whilst the literature on cervical screening Ð dominated by contributions from the traditions of health services research, primary care and public health/epidemiology Ð has largely been focused on the importance of achieving high uptake rates and the reasons why women don't come forward for smear tests when invited (e.g. Eardley et al., 1985; Elkind et al., 1988; Orbell, 1996; Jones and Neilson, 1998).

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This paper is based on the ®ndings from an empirical study exploring women's views on, and experiences of, cervical screening. Emergent themes arising from qualitative analysis of semi-structured, in-depth interviews with 35 women, highlighted how Ð although contested Ð having a smear test is generally viewed as a `normal' part of being a woman. In this paper I explore the ways in which the women interviewed negotiated, internalised and resisted cervical screening discourses. The ®rst section outlines the literature on femininity and highlights emerging debates on the importance of medical discourse. The second section outlines theoretical perspectives on gender and the body which may be useful to conceptualising how discourse frames the construction of femininity within the context of cervical screening. This is followed by a discussion of the key features of the current cervical screening programme and the forms of discourse embedded within it. Next, the paper goes on to discuss Ð based on empirical evidence Ð the implications of such discourses for perceptions of femininity. The paper concludes by considering the implications of this research for the cervical screening programme and feminist debates on women's health care.

Femininity, discourse and the body Discursive practices concerning women and the body regulate the way in which women see themselves and they are therefore fundamental to women's identity and sense of self (Lupton, 1994). A large body of feminist literature has explored the importance of bodily discourses in the production of femininity. Discourse has been de®ned by Ransom (1993) as:. . . the structured ways of knowing which are both produced in, and the shapers of, culture. Discourses are not merely linguistic phenomena, but are always shot through with power and are institutionalised as practices. (p. 123) Most feminist work on discourse and identity has focused on the way in which cultural discourses have worked to homogenise and normalise the female body by presenting women with an ideological picture of femininity and by insisting that all women aspire to this ideal (e.g. Orbach, 1988; Bartky, 1990; Smith, 1990; Young, 1990). However, medical discourse also plays a fundamentally important role in de®ning femininity. Indeed, it has been argued that medical discourse is now the dominant discourse in controlling women's bodies and that medical discourses provide the basis for much of the cultural construction of femininity (Ussher, 1992). For centuries women's bodies have been de®ned as

`Other' in medical discourse; as a source of danger, destruction and contamination, and as especially threatening to the moral order of society (Ussher 1989, 1992). Feminist literature which has explored how medical discourses regulate the way in which women see themselves has tended to focus on the way in which women have been socialised into looking to the crucial biological events of their lives Ð menarche, pregnancy, childbirth and menopause Ð for their sense of self (Ussher, 1989). However, as Foster (1995) argues, . . . feminist health care activists have . . . paid little attention to the ulterior motives behind mass screening programmes (p. 126).

Cervical screening discourse In the British National Health Service, the introduction of the call and re-call programme and GP contracts in the late 1980s facilitated the movement from a variable, ad hoc cervical screening system to one of population surveillance (Milburn and MacAskill, 1994). Dramatic changes to the cervical screening system were introduced in response to criticisms that the existing re-call only programme (see DHSS, 1985) had failed to substantially reduce deaths from cervical cancer (Anon, 1985; Richards, 1985; Murphy et al., 1987). It was widely believed that the main reason for this was `reverse targeting' (Roetzheim et al., 1992). As women had to be entered into the system before they could be re-called, the vast proportion of smears were being taken from those thought to be least at risk of developing cervical cancer; those who had had a smear test before (predominantly white, well educated, middle class women). This meant that a large number of women (predominantly older, working class women and those of ethnic minority) were not reached at all by the system. Subsequently, in the new invitation based call and re-call programme introduced in 1988 (see DHSS, 1988) the government focused attention on the importance of attaining high uptake rates. The focus on uptake rates was also re¯ected in the introduction of the GP contract in 1989 which introduced a two tier payment system for performing cervical smears (Health Departments of Great Britain, 1989). The lower payment is given to GPs who have, in the last 5 years, screened 50% of eligible women on their lists between the ages of 25 and 64 whilst the higher payment is given to GPs who have screened 80%. By 1990, 91% of GPs were receiving target payments and 67% were achieving the higher payment (National Audit Oce, 1992).

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In order to understand the nature and power of the discourses implicit within the current cervical screening programme, it is necessary to consider the key changes made to the cervical screening system with the introduction of the call and re-call programme. There are four points which are of particular signi®cance. Firstly, the emphasis on uptake rates within current cervical screening policies Ð and the measures implemented within the new call and re-call programme to maximise attendance Ð has had a profound e€ect on the nature of women's participation in the programme. Before the introduction of the call and re-call programme women had to opt into the system; now, many GPs are rapidly moving towards a recall system designed to allow only a few women in very speci®c categories to opt out (Foster, 1995). The call and re-call programme is based on a whole series of invitation and reminder letters. Women are only excluded from the call and recall programme for non-medical reasons if they inform the health authority in writing that they no longer wish to be included in the programme and thus facilitate the permanent opt out clause. The invitation and reminder system is therefore used as a means of pressurising women into behaving in the `correct', desired way by having a smear test and by making it very dicult for them to opt out of the system. Health care workers have been responsible for creating a professional discourse on non-attendance (Gregory and McKie, 1991). `Non-attenders' are labelled as deviant as their behaviour deviates from the medically constructed norm of having a smear test and they are blamed for threatening the success of the cervical screening programme (see Mihill, 1994). The `attender'=normal, `non-attender'=abnormal dichotomy is heavily re¯ected in the literature on cervical screening which has been dominated by studies seeking to identify characteristics (such as age, socio±economic status, ethnicity, health beliefs etc.) which are typical of `non-attenders' and which may explain their deviant behaviour (see for example Eardley et al., 1985; Elkind et al., 1988; Orbell, 1996; Jones and Neilson, 1998). The emphasis on non-attendance within policy and the literature has remained despite the fact that uptake rates have markedly increased following the implementation of the call and re-call programme, from 43% in 1989 to 85% in 1997 (National Co-ordinating Network, 1994; Oce of Population Censuses and Surveys, 1997). The second key change made to cervical screening policy as part of the introduction of the call and recall programme was the expansion of the target group of women. When screening was ®rst introduced in the UK during the 1960s, `at risk' women were de®ned as those women who were sexually active. This re¯ected early epidemiological studies which reported to have found that the incidence of cervical cancer was greater

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in women who had had more sexual partners (e.g. Keigley, 1968; Fraumeni et al., 1969; Rotkin, 1973). The group of women targeted by the cervical screening service thus comprised `married women', those who were pregnant and those who were taking the oral contraceptive pill (Parliamentary Correspondent, 1964). However, within the new call and re-call programme the target group has been broadened to include all women aged 20±64 (National Audit Oce, 1992). The call and re-call programme has therefore vastly increased the number of women being subjected to smear tests and routinised, regular, internal examinations. The call and re-call programme also marks a fundamentally important extension and exacerbation of the traditional focus of medical discourse as it is based on the perceived need for surveillance of women's bodies outside of the direct context of reproduction. Thirdly, by expanding the target age group, the call and re-call programme has also increased the proportion of a woman's life span which is subjected to the medical gaze. Surveillance of women's bodies has traditionally been associated with speci®c parts of a woman's life span Ð such as pregnancy and the menopause. However, cervical screening now covers most of a woman's adult life. Fourthly, the call and re-call programme has increased the frequency with which cervical screening is carried out in many regions. Whilst health authorities are now required to instigate re-call `at least' every 5 years (DHSS, 1988) many now re-call women every 3 years. The discourses embedded within the cervical screening programme widen, deepen and lengthen women's dependence on the medical profession. They also reproduce and exacerbate gender inequalities in health. Although men may also be observed and controlled by the health care system (McKie, 1995) there are no national screening programmes for male genitalia or big killers of both men and women, such as lung and bowel cancer. Also, despite the fact that the HPV virus Ð which is thought to play a key role in the development of cervical cancer Ð is transmitted sexually, men are excluded from surveillance of their sexuality (McKie, 1995). It may thus be argued that cervical screening discourses exacerbate and reproduce gender inequalities and further minimise the responsibility of men in sexual and reproductive health issues. Recently, it has been argued in an important paper by McKie (1995), that medical in¯uence and control are operationalised over women's bodies within the cervical screening programme. Conceptualising power in terms of medical surveillance, McKie (1995) argues that cervical screening is based on the perceived need to police women's sexuality: that within the cervical screening programme, women's sexual activity and cer-

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vical health are utilised as mechanisms for the operation of power over women:. . . the female body, in this case the cervix, is a site for state, professional and male surveillance and control, through a preventive service which many feel obligated to participate in (McKie, 1995) Within the call and re-call programme, cervical screening has become a service based on ``surveillance of numbers for the attainment of targets'' (McKie, 1995). McKie's (1995) paper makes a fundamentally important contribution towards re-conceptualising cervical screening in a way which has so far been ignored within feminist debates on health care (Foster, 1995). The ®ndings from the empirical research upon which this paper is based extends such debates by highlighting how the forms of medical power embedded within the call and re-call programme frame the way in which women see their bodies and themselves.

Identity, gender and discourse A large body of work has explored the way in which power is operationalised through the body via discourse, and detailed reviews of this literature are found elsewhere (e.g. Turner, 1991; Shilling, 1993; Lupton, 1994). This paper will focus on aspects of this work which may be useful for exploring how discourses embedded within the cervical screening programme frame perceptions of femininity. The poststructuralist writings of Foucault have proved particularly in¯uential in understanding the way in which medical power is exercised through the body (for detailed reviews see Shilling, 1993; Dyck, 1995; Lupton, 1994). However, responses from feminists to Foucault's work have been varied (see Bordo, 1993; Ramazanoglu, 1993). Those who have used his work as a means of exploring the e€ect of discourse on femininity have focused on the power of discourse to normalise, homogenise and produce `docile bodies' (Bordo, 1989). Applying a Foucauldian perspective to cervical screening it may be argued that the national focus on the need for high uptake rates, the 9 measures brought in order to ensure attendance Ð and their enforcement by health professionals, the media and health promotion material Ð have together presented a ``co-ercive, standardized ideal'' (Bordo, 1989) of women as attenders for cervical screening. This construction of woman is also homogenising and normalising, erasing class and other di€erences; insisting that all women aspire to this ideal (Bordo, 1989). However, whilst it has been argued that Foucault has provided ``considerable ammunition to feminists

seeking to `reclaim' the body from `medicalization''' (Soper, 1993), feminists are also acutely aware of the limitations of Foucault's ideas on power and the body. McNay (1992) argues that one of the most serious limitations of Foucauldian theory when used within a feminist context is that it reduces social agents to passive bodies which may not act in an autonomous fashion. Alternative conceptualisations of the role of cervical screening discourses in framing femininity must therefore be sought which conceive of women as active agents, not passive bodies. Butler's (1990, 1993) notion of `gender as performance' o€ers such an alternative reading. Based on a genealogical critique of the foundational categories of sex, gender and desire as a speci®c formation of power, Butler (1990) argues that far from being a `natural fact' being female is actually a cultural performance, whose naturalness is constituted through discursively constrained performative acts that produce the body through and within the categories of sex: Gender is the repeated stylisation of the body, a set of repeated acts within a highly rigid regulatory frame that congeal over time to produce . . . a natural sort of being (p. 33) There are several levels at which Butler's thesis appears appropriate for an analysis of the importance of cervical screening discourses to framing femininity. The ``set of repeated acts'' may be interpreted as constituting the various acts involved with having a smear test; disrobing, the exposure of personal parts of the body, the internal examination and the smear test itself Ð all are repeated at regular intervals. The ``highly rigid regulatory frame'' is produced via the very nature of call and re-call system; the invitation and reminder system has been designed to ensure that as many women as possible conform to the desired behaviour of having a smear test, and that that they undertake this prescribed behaviour whenever prompted. A ®nal possible framework for exploring the way in which medical discourses contained within the cervical screening programme may frame femininity is provided by Smith (1990) who argues that femininity is discursively mediated through women's activities. The main thrust of Smith's thesis is that whilst femininity is textually mediated, women are not simply entangled in its discourse; they have to actively `do femininity': ``Women are not just the passive products of socialisation; they are active; they create themselves'' (p. 161). For Smith, femininity is conceptualised in terms of ongoing actual practices of individuals: femininity requires knowing what needs to be done to remedy one's body, assessing the possibilities, and acting upon them (Davis, 1995). Viewing femininity as a discourse, Smith (1990) argues that women interpret discourse via

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ideologies and doctrines of femininity which are explicit and publicly spoken and written. Young women learn these ideologies and doctrines from `texts' of femininity: i.e. images, icons, descriptions of behaviour etc. Although Smith's work is concerned with the way in which discourses on femininity are mediated in relation to the beauti®cation of the body, there are clearly ways in which such an approach could be used to explore how femininity is framed by cervical screening discourse. The institution of medicine has, as discussed earlier, played an extremely important role in producing ideologies and doctrines of femininity (Dyck, 1995). Adopting Smith's perspective it may be argued, for example, that the mechanisms implemented within the call and re-call programme to ensure attendance Ð the dissemination of personal invitations, reminders and the use of health promotion material Ð constitute texts which present smear tests as something necessary and `normal': something that women should attend for regularly. Further consideration of the relative appropriateness of the above approaches for conceptualising the way in which cervical screening discourses frame femininity will be made after the empirical study, methods and key ®ndings have been described. Empirical study The empirical research upon which the arguments presented in this paper are based on a PhD study which explored women's experiences of, and views on, cervical screening (see Bush, 1996). The aim of the study was to explore personal interpretations of smear tests and the ideas, concepts and language that women use when talking about them. Thirty-®ve semi-structured, in-depth interviews were carried out with women aged 20±64 living in two contrasting communities in a connurbation in South Yorkshire, UK during 1995/6. One community Ð located in the north-east of the conurbation Ð was a traditional, working class, ex-manufacturing area with a higher proportion of the population in socio±economic classes III manual, IV and V (approximately 65% based on 1991 Census). The other, located in the south-west, is a predominantly middle class area with a higher proportion of its economically active population in occupational classes I, II and III non-manual (approximately 47% based on 1991 Census). It is important to stress that there were no place speci®c di€erences between the women from the two study communities in terms of the analytical themes discussed in this paper: the same concerns were common to women from both communities. The interviewees were recruited from a preliminary

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questionnaire survey of 800 women. A sample of names and addresses of women aged 20±64 was downloaded by the local health authority from their patient register. The ®nal page of the questionnaire asked women if they would be willing to take part in an interview at a later date (33% indicated that they would). Interviewees were purposively selected in order to re¯ect a broad ranging group in terms of cervical screening experiences, age and socio±economic criteria. Interviewees were asked if they would prefer to be interviewed alone or with a friend/relative. Only one interviewee asked to be interviewed with a friend. Due to the sensitivity of the additional cultural, religious and language factors that are integral to debates surrounding ethnic minority women and cervical screening, this research focused speci®cally on `white' women. The women interviewed had varied cervical screening histories and attendance patterns which did not ®t the rigid `attender'/`non-attender' labels attached to women's screening status (as also noted by Gregory and McKie, 1991). Many of the women interviewed had not responded initially (within 6 months) to an invitation they had received at some time in the past. For those women who were old enough to have been screened both before and after the introduction of the call and re-call programme, most had begun to have smear tests more regularly in response to receiving invitations. Three of the interviewees had not had smear tests for over 10 years. However, all of the women interviewed had had at least one smear test and none of the women interviewed had never had a smear test. Only a handful of women responding to the questionnaire fell into this category and none of these women were willing to be interviewed. Five of the interviewees had had an abnormal result and four of these had had lazer treatment to remove abnormal cells. One of the interviewees had had a radical hysterectomy due to cervical cancer. The interviews were based on a semi-structured indepth interview schedule covering a wide range of topics including personal experiences of cervical screening, reasons for having smear tests, if/how cervical screening is discussed with friends and relatives, and feelings about, and access to, information about cervical screening. The interviews lasted between 30 min and 2 h 30 min. All interviews were tape recorded (with the interviewees permission) and then transcribed in full. The transcript data were then analysed Ð together with qualitative comments from open ended questions included in the questionnaire survey Ð based on a method described by McCracken (1991). This analytical process inscribes a movement from the particular to the general. Constant comparison of emergent conceptual categories ensures that lower order and higher

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order themes are generated by, and grounded in, the empirical data. The qualitative analysis then went on to situate women's views on, and experiences of, cervical screening within the discourses which shape and de®ne them. Positioning experiences in this way is important because experience does not give privileged access to knowledge. As Scott (1993) argues, an essentialist approach to experience Ð which views ``experience as incontestable evidence and as an originary point of explanation'' (p. 24) Ð decontextualises experience and fails to address questions about the constructed nature of experience. One of the main objectives of this study was therefore to explore how `the personal' engages with the institutional picture vis aÁ vis cervical screening; to explore the relationship between what goes on in the variety of women's lives at an individual level and the way society is structured at a more general level (Edwards, 1993). This paper constitutes my own, personal interpretation of the views and experiences expressed by the women who took part in the study. The ®ndings are speci®c to this study and the women interviewed. I do not contend that this work is wholly generaliseable. However the research does provide an alternative way of conceptualising cervical screening which could be explored with other groups of women. The higher order themes which emerged from the qualitative analysis highlighted the ways in which discourses mediated by the cervical screening programme frame and regulate both how women conceptualise femininity, and also their behaviour. How women negotiate, accept and resist these discourses appeared to be important in terms of couching women's general views on cervical screening and also in in¯uencing the nature of their participation in the cervical screening system. The data section will begin by outlining the various ways in which the feelings of normalcy associated with having smear tests were re¯ected in the transcripts. I will then go on to explore the discourses responsible for regulating these feelings. Cervical screening discourses and femininity One of the most salient themes to emerge from the qualitative analysis concerned the feelings of normalcy and correctness associated with having a smear test. This was re¯ected in two main ways, each of which will now be described. Firstly, in the way in which having a smear test was commonly viewed as a normal part of being a woman, and secondly, in the feelings of deviance associated with non-attendance for a smear test. In order to protect anonymity, names of all interviewees have been changed.

Smear tests are a normal part of being a woman The feelings of normalcy associated with having a smear test were re¯ected in the way in which the interviewees often referred to having a smear test as a `normal' Ð even `natural' Ð thing for women to do; as a `a fact of life' or `just part of being a woman'. In particular, this was re¯ected in responses to the question `Why have you decided to have smear tests?'. Although concerns surrounding the fear of developing cervical cancer and thinking that smear tests were compulsory were also voiced in response to this question (as will be discussed later) the most common responses evolved around notions of normalcy: Claire: To be honest I always thought that it were a fact of life . . .you just accept that you're a woman and you have to put up with these things [26, waitress, south-west community]. Maureen: I think you accept it's part and parcel of being a woman [48, civil servant, north-east community]. Tina: . . . it's a natural thing that a woman should do [32, clerk, north-east community]. Some interviewees mentioned that women have to accept cervical screening as a normal part of being a woman, whilst there is no comparable screening ethos for men:Sandra: I think women have to come to accept that that's part of their life. Em . . . a bloke, alright he might go and have his blood pressure checked and his heart checked and things like that but you try and get a bloke to . . . you know, have a personal part of his body examined. . .and 9035141060f them would run a mile [29, bar worker, south-west community]. Women in the under 30 age group tended to talk about smear tests as something that they'd grown up expecting to have to have when they were older. This is illustrated by the following rationale for having smear tests expressed by two friends who were interviewed together:Louise: It doesn't seem like . . . a thing that you think about. I don't think about it really. I don't think `Oh should I have it or shouldn't I?' I just go and have it done. You've got to . . . [22, student, south-west community] Vicky: Yeah . . . you think `I'm 20 and I'm a woman. Oh I'll start me cervical smears soon'. It's all like, well that's what I think anyway, it's sort of like a

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natural progression into womanhood. Like, as soon as you've started your periods or whatever you start having smears and things [25, student, southwest community]. Often the reasons for having smear tests drew on women's obligation to attend, to look after and respect their own bodies:Int: Why have you decided to have smear tests? Heather: I feel that it's something that you're duty bound to do really, to . . . you know, there's no excuse not to [24, housewife, south-west community]. Int: Why do you put up with having them . . . if you really don't like having them done, why do you think it is that you do actually have them done? Esther: (long pause). . . because I think it's up to women to em . . .look after their bodies as best they can. You have the opportunity to have this test and you ought to have it done. The fact that you don't like having it done is really not an excuse or a reasonable excuse for not having it done [61, nursery teacher, south-west community]. It may be argued that such ®ndings suggest an internalisation of the medically constructed notion of smear tests as a social norm Ð a `progression into womanhood' Ð particularly amongst younger women. However, although there was a general sense of obligation associated with attending for smear tests, important resistances were encountered. Firstly, many interviewees resented the way in which women were the only ones to be under medical surveillance for cervical cancer. For example, one interviewee, who had had to have a hysterectomy due to cervical cancer, felt that the role that men play in cervical cancer was not recognised and that men should also be under medical surveillance for this disease:Gillian: . . . maybe it would be a good idea to say that all men have got to be circumcised, you know, at birth. Because I honestly do think that if there was a disease that could be proved was carried by women, you know, one of the prime causes of it, which they seem to think that a lot of it is caused, uncircumcised men's partners tend not to get it so there must be a connection there. Perhaps they should say, you know, all men should be circumcised at birth. [48, sales assistant, south-west community]. Secondly, it was clear that not all women view hav-

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ing a smear test as a `normal' part of being a woman. Women over 65 (mothers, aunts etc.) were often cited by the interviewees as not attending for smear tests because they were not socialised into the concept of preventive health care when they were younger, and because these women still regarded intimate, sexual parts of the female body with a stigma and sense of taboo:Int: Do you know anyone who's never had a smear test or who hasn't had one for a long period of time? Sandra: About 2 years ago me and me sister had to just about drag me mother kicking and screaming . . . The last examination she had was when I was a new baby . . . me mother just couldn't bring herself to the idea, you know, that it were just, `for nothing' as she put it. I says `It's not for nothing. It's to check your health to ®nd out that there's absolutely nothing, you know, to worry about. You'll be OK then for another couple of years, nothing to worry about'. `Yeah but it all seems like a bit of a waste of time'. I mean she didn't mind people feeling up her ¯ue when she were having a baby because of the simple reason that she were gonna get a baby at the end of it. [29, bar worker, south-west community]. The feelings of normalcy that younger women associated with having smear tests, contrasted sharply with the feelings of strangeness associated with having internal examinations in a preventive context, which were felt to be characteristic of some older women.

Deviance associated with not attending for a smear test In addition to the feelings of normalcy associated with cervical screening, many interviewees referred to have a smear test as a `correct' form of behaviour: as the right/correct/proper thing for women to do. Notions of deviance were associated with non-attendance. There were two main illustrations of this. Firstly, feelings of deviance were re¯ected in the way in which women talked about smear test invitations that they had not responded to initially:Int: Can you remember roughly how many invitations you've had in the past? Esther: Em. . . they did send me an invitation to go which I didn't, an appointment which I didn't keep, but they did send me another one. They sent a follow up letter. So I thought well, you know, I'd better behave myself and go [61, nursery teacher, south-west community].

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Secondly, some of the interviewees told me about women who they knew who had not attended for smear tests and how they had adopted the role of trying to persuade them to have one:Int: How do you feel about smear tests and cervical screening as a particular form of preventive health care? Christine: I know some of the girls I work with'll say `I'm not going,. I've had a letter. I'm not going' and they won't go. And I'll say `Well you should go' and I always make sure that, you know, I go myself. . .whenever I've got to, you know . . . I know it's coming up and they'll send me a letter and I'll make sure I make an appointment and go. I've never missed going [38, admin ocer, south-west community]. Women who did not attend for smear tests were sometimes referred to as `silly', `stupid', `ignorant', `foolish' or `complacent':Int: Have you ever known anyone who's been really nervous about going for a smear test or who's never had one or put it o€ for a long period of time?Irene: Personally I think they're foolish. I mean for the bit of time it takes . . . its nowt worth arguing over. I think it's foolish . . . just silly, stupid. I mean it's for your own good isn't it? [51, reprographics technician, north-east community]. Interestingly, however, although there was a general feeling that all women should want to have smear tests, only one interviewee Ð one of the ®ve interviewees who had had laser treatment for cervical abnormalities Ð felt that cervical screening should be made compulsory:Int: When you look back on your past cervical screening experiences how do you feel about them in general? Laura: I think they're a good thing. I think everybody should be made to have them. Cause I know some women who'll say `I don't want to know what I've got' you know, which to me is stupid cause if you have got something they can do something about it. [29, sales assistant, south-west community]. The empirical material presented in this section has highlighted the power of cervical screening discourses in instilling in women the medically constructed notions of `attender=normal, non-attender=abnormal'. However, two points must be made in order to

contextualise such views. Firstly, it must be remembered that women's attitudes may well have been exaggerated by their reaction to me and to the interview situation. The research participants are likely to have interpreted my role as a researcher on women and cervical screening within the discourses which dictate that having a smear test is the correct, proper, normal thing to do. Therefore, they may have felt obliged to emphasise how `good' they've been by having regular smear tests. Secondly, resistances were made to the deviance associated with non-attendence. There was some evidence that women who had not had smear tests when invited were doing so, not because they were `irresponsible' or `feckless' as is the common perception amongst health professionals (as noted by McKie, 1995), but because they were actively resisting the system. There were two main illustrations of this. Firstly, one woman responding to the questionnaire put a line through all the questions included in it and wrote the following:I do not wish to take part as it encroaches on a person's privacy. It is OK for those who want it done. I wish to be excluded. If a woman has trouble with her private parts she should urgently seek medical advice. However, I do not fall into this category. I have never had any woman's complaints. No one in my immediate family has ever su€ered from female related illnesses. Your aim is for the many sick women to come forward which is a good thing. But not to be pressurised if they are not su€ering from any female related illness. I know you do your best to get women all in one mind. But surely a woman knows if she is ill or not. We are not living in the 19th century. She should know by any discharge or heavy periods she may have or lumps in her breast. I have given sucient comments now on the subject and do not wish to be given another lea¯et. All I want is privacy to do what I think best. [30±39, housewife, south-west community] Although such a response could be construed by the medical profession as indicating non-attendance through ignorance or mis-information, it may also be argued that the response illustrates resistance at several levels. The respondent's words re¯ect that she is resisting the way in which cervical screening entails an invasion of women's pride and dignity; the violation of a woman's right to decide who looks at her body or `private parts'; the threat to a woman's right to decide when she is ill and when she requires medical attention, and the abuse of women's control over their own bodies. It also illustrates scepticism towards the normalising characteristics of screening Ð of ``trying to get women all in one mind''. Resistance leading to non-attendance is a dicult

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issue and begs obvious ethically challenging questions. However, not-attending for a smear test was only one form of resistance expressed by the interviewees. Other resistances to the attender=normal/non-attender=abnormal dichotomy were also expressed. For example, although most of the interviewees believed that it was in a woman's best interests to have smear tests and that all women should want to have them, some expressed resentment towards the medicalized control of women, by stressing the fact that whether or not a woman has a smear test must be her own, individual decision:Int: How do you feel about women who don't attend for smear tests? Helen: I think it's a personal decision. I don't think it should be compulsory. I think it's the person's decision. But I think any woman who doesn't take advantage of it is silly. [51, care assistant, northeast community]. Also, one woman responding to the questionnaire described the anger she had felt when she had gone to see her GP about a matter un-related to cervical screening and had noticed that her medical notes has been `emblazoned with a sticker' because she hadn't responded to her last smear test invitation:I was annoyed to ®nd that because I hadn't had a smear test my medical record card had been emblazoned with a sticker. I feel as though I should be the one taking responsibility for my own health Ð so a reminder would be sucient. To a certain extent whether I have a smear or not is my business and nobody else's. [40-49 teacher, south-west community] Such words clearly illustrate a resistance to the singling out and pathologisation of `non-attenders' and to the way in which such treatment takes away a woman's responsibility Ð and right Ð to decide if and when they should have a smear test. The paper so far has focused on the way in which women negotiate, accept and resist cervical screening discourses which dictate that having a smear test is the correct, normal thing for women to do. However, the study also found that the feelings of normalcy and correctness associated with having a smear test are not only framed within, but are also regulated by discourse. Regulatory discourses and cervical screening The qualitative analysis identi®ed three regulatory discourses which appeared to play an important role in

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regulating the way in which women view their bodies, and their feelings about Ð and participation in Ð the cervical screening programme. Firstly, pressure exerted within the call and re-call programme; secondly, opportunistic screening, and, thirdly, fear of developing cervical cancer. Regulatory discourses embedded within the call and recall programme It was clear that discourses embedded within the call and re-call programme have an important part to play in regulating both attendance for cervical screening and the feelings of normalcy and correctness that are associated with having smear tests. This was re¯ected in the way in which the interviewees talked about the invitations and reminders that they had received. There were mixed views about the call and re-call system. Some of the interviewees felt that the invitations made cervical screening appear compulsory:Lesley: . . . when this letter arrived and said I had to go. . .I was petri®ed! . . . And I just thought, you know, if I could get out of it I would've done Int: When you got your ®rst invitation through the post, what went through your mind? What was the ®rst thing that you thought of? Lesley: How do I get out of this! That was me ®rst thought. And then `God, they've caught me'. Em . . . (pause) . . . and then I thought, once I'd thought about it and I'd sort of been pressured a little bit. I thought well yes it is a good idea. And I'm pleased that they caught me because I wouldn't have gone otherwise . . . And I do think it's important that they make it em . . . an order in a way, because I think people wouldn't go otherwise. [27, business manager, north-east community]. Many of the interviewees who had had smear tests before the introduction of the call and re-call programme described how beginning to receive invitations had made having smear tests seem more ``normal and the thing to do''. Receiving invitations had often led to the interviewees having smear tests more frequently:Int: So you think the invitation scheme's a good one? Helen: Oh, yes I do. De®nitely. For people like me anyway that . . . perhaps not so much now, as I say I'm more aware of it and I do look at the year and I think `Yes I've got to go this year for my smear test', but that's only because the invitation thing has put me in that frame of mind I think, you know.

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It's sort of made it more normal and the thing to do [51, care assistant, north-east community]. Some of the interviewees felt that the invitation and reminder system was a good thing because it reminded them when it was time to have a smear test:Int: How do you feel about being sent invitations? Yvonne: It's good because sometimes you do, you forget. . .You're busy being a mother and a housewife . . . there's other things on your mind. You can't think of everything. It's a good idea. [31, housewife, north-east community]. However, resistances were made to the regulatory nature of the call and re-call system. Some women felt that the invitations were too forceful: like demands and orders rather than invitations. For example, the questionnaire repondent who had expressed resistance towards the singling out and pathologisation of `nonattenders' (see above section), circled all references to `invitation' on her questionnaire and wrote `more like a demand', referring to the call and re-call system as a `series of nagging letters':The series of nagging letters annoys me. I get a nagging letter every 3 years Ð which I ignore Ð then another nagging letter arrives so I go and have a smear or I get a sticker put on my medical record card! I would appreciate a reminder and that's all [40±49 teacher, south-west community]

Regulatory pressure exerted by opportunistic screening Feelings of compulsion associated with having a smear test were also often mentioned by women who had started to have smear tests opportunistically, as part of the routine tests and examinations performed on women who take the Pill and as part of ante- and post-natal checks. Several interviewees described how, when they ®rst started having smear tests as part of taking the Pill, their doctors had made them feel that having a smear test was compulsory:-

Some of the interviewees in this situation had not known what smear tests were for or what exactly they involved:Enid: I don't think I knew much about them [when I ®rst started having smears]. I certainly didn't know what they were doing. . .You were there and it happened . . .and I was frightened to death I think. I didn't know anything about it. . .and I think I was too scared to ask questions. It was something that was just done. I didn't really know why. And I think it's only the last few years that I've been really aware of . . .why and the importance of it . . . with all the publicity and that. [49, retired, south-west community]. The ®ndings from this study suggest, as Grant (1994) argues, that the introduction of the Pill has facilitated the advancement of medical control over women. However, feelings of resentment were expressed towards the way in which smear tests had been made to appear compulsory within the context of taking the Pill:Sandra: The ®rst time I had it done was when I went on the Pill like . . . and it was like `Well if you want the pleasure you've got to take the pain'. I thought they're doing this on purpose, it's like a ¯amin' test to see if you'll go through with it, you know. If it puts you o€ having the Pill then you don't really want it [29, bar worker, south-west community]. Feelings of compulsion associated with having smear were also expressed in the context of being pregnant:Carol: . . .it were just automatic, you went back after you'd had your baby, you went back and had a smear test. And then, I went on the Pill and automatically when you're on the Pill they give you a smear. It's just one of them things . . . [39, sales assistant, north-east community].

Christine: They're o€ered you, but they're o€ered you in a way that em . . .you don't think it's an option: you think you've got to have them . . .not for a long time did I realise that it was optional, I can decide not to have one if I don't want to [38, admin ocer, south-west community].

Although the proportion of women ®rst recruited into the cervical screening system through opportunistic screening has now vastly reduced due to the introduction of the call and re-call programme (and the extensions of the target group to all women aged 20± 64), such regulatory discourses are still likely to have particular implications for young women, aged under 20, who either start taking the Pill, or who have a child, before they are old enough to receive invitations.

Nicola: I've had to have them 'cause I'm on the Pill. You don't have the smear, you don't get the Pill [34, part time waitress, south-west community].

Fear The ®nal discourse responsible for regulating attendance for cervical screening was fear. Cervical cancer is

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a disease regarded with a sense of terror, dread and fatalism by most women (King, 1987; Posner and Vessey, 1988). Fear was re¯ected in the interview transcripts in ®ve di€erent ways. Firstly, there was evidence to suggest that fear has resulted from the internalisation of medical discourses surrounding the female body as a site of risk, liable to going out of control if not kept in check (Lupton, 1994):-

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families to go through the physical or emotional pain experienced by their friend or relative:Int: When did you start having smear tests?

Helen: I believe there's quite a big percentage of women that er. . .do have er . . . cervical cancer. So if you can sort of er . . . er, ®ght it before it's there and then if you are unfortunate enough to have it then it's caught within the early stages. Because it's not like a cold it doesn't go away [51, care assistant, north-east community].

Ann: When I was 35 my father in law got lung cancer and he died within 6 weeks of lung cancer. He died in December and by the January I was knocking on the doctor's door saying `Can I have a smear?'. I'd never thought about it until then. I don't know whether they are inviting you now but they weren't inviting you then. . . not until you'd actually got into the system; you had to put yourself into the system ®rst. And it was only when my father in law died of cancer that I thought, `Oh god' Ð you know Ð `I don't want to go through that' [53, college tutor, south-west community].

Secondly, fear of developing cervical cancer was re¯ected in the way in which many of the interviewees felt that a 3 year interval between smear tests was too long and that they should be available more often:-

Fourthly, fear of developing cervical cancer was also often cited as one of the reasons why women continue to have smear tests despite disliking having them so much:-

Ruth: I don't think they're done frequent enough, to be honest. I think 3 years is too long. . .to me an awful lot can happen in 3 years. Em. . . I don't know if cancer of the cervix works more slowly than cancer in another part of you . . . but you hear people who suddenly ®nd they have cancer and only have weeks to live, you know. And I think well if that can happen then 3 years is an awful lot. . .it can have spread surely [31, admin. assistant, north-east community].

Int: Why do you think you've always gone, even though you don't like it very much?

The need for more regular surveillance and the reassurance that women associated with this was mentioned in particular by those women who had either personally had an abnormal smear result or who knew of another woman who had received such a result: Pam: It's something I've always had for years, and as I say I've had cells changing and . . . I feel. . .safe in the fact that they are keeping an eye on it [55, cashier, north-east community]. Thirdly, fear of developing cancer was often incorporated into women's rationale for having smear tests. For example, some of interviewees who were all aged over 40 and had thus begun to have smear tests before the introduction of the call and re-call programme, described how they had entered themselves into the cervical screening system by personally requesting a smear as a result of a friend or relative being told that they had cancer. Fear appeared to be the main driving force behind the decision to have smear tests: the interviewees themselves didn't want themselves or their

Eileen: Well because I think cancer's far more scary than having a smear, you know. I mean. . .if they can detect it earlier they can do an awful lot these days, can't they? It's one disease that petri®es me . . .and I think I'd rather ®nd it sooner than later [62, retired, north-east community]. Cervical screening was viewed as a way of obtaining knowledge about their bodies that women wouldn't have access to without having smear tests. Having a smear test was perceived to o€er either peace of mind that they didn't have cervical cancer or else the chance to take action if abnormalities were present:Int: Why have you decided to have smear tests? Helen: I think it's a good thing to em . . . em . . .just to sort of tackle it before it comes to the for . . . Peace of mind. . .The reason I go is because, in case I've got it I know and I can deal with it. Er. . .it isn't because `Oh I'm going to have cervical cancer I've got to go and have it done' sort of thing. It's just the fact that if I am going to have it then I'll know and I can deal with it [51, care assistant, north-east community]. Having smear tests for peace of mind has been the main reason highlighted in previous studies as to why women have smear tests (e.g. Elkind et al., 1988). Interestingly, however, the interviewees varied on

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who they felt was `at risk' from cervical cancer. Some drew on the traditional association between cervical cancer and promiscuity. Others felt that all women were at risk, even those who aren't sexually active:Michelle: I think that every woman should have smear tests but I think a lot of women who aren't sexually active think that they don't need one. But I think everyone, every woman should, de®nitely [38, part time shop assistant, north-east community]. Louise: It happens to promiscuous people or . . .I know it's a terrible thing to say but I don't think it will happen to me and I'm not a high risk group, I don't classify myself as a high risk group but. . . then again I've just had a grandmother who's dying of breast cancer so surely I must . . . be at risk. That's worrying. But you do feel removed from it. That's probably the kind of state of mind what allows you to go for a smear. Like you think well . . . `It's not me' sort of thing [22, student, south-west community]. Finally, fears were also expressed in relation to the highly publicised series of errors in the taking and analysing of smears which had begun to appear in the media during the 2 years prior to the study (e.g. Cusick and Hall, 1993; Hunt, 1993, 1994). Usually, although the interviewees were greatly concerned about such errors, they tended to rationalise their fears by arguing that such mistakes hadn't Ð as yet Ð happened in the area where they lived. However, lack of faith in the accuracy and reliability of cervical screening reinforced fears that the 3 year interval between smear tests was too long:Irene: . . . there's a lot of scary stories about and that frightens you doesn't it? [51, reprographics technician, north-east community]. Int: What have you heard recently? Irene: Well, in the newspapers they're getting it wrong . . . I mean if you're going to take the time out to do it they should at least take the time out to do it properly. Int: Can I ask you how it makes you feel when you hear these stories? Irene: Very scared. Scared, yeah. I usually ask them for one is it 2 years or is it 3 years and I'll probably get fobbed o€ by the doctor who'll say I'm not due for another 2 years, so I try to slot in another one by having it done at BUPA you know.

Int: How does the doctor try and fob you o€ what does he actually say to you? Irene: You're not due for one, that's the usual thing. I'll phone up and say ``Am I due for cancer smear?'' and he'll say I'm not due for another 2 years. The above discussion has highlighted how discourses of fear frame both women's behaviour and also the way in which women view their own bodies. It appears women are now being made to feel that they need to be screened on a regular basis Ð sometimes more regularly than the 3±5 years dictated by policy Ð in order to be labelled healthy and free of cervical cancer. Such fears are likely to be exacerbated by the way in which `non-attenders' are portrayed by the medical profession and health promotion material as being at greater risk from cervical cancer. Discussion By exploring the way in which women talk about cervical screening and smear tests, this paper has highlighted the nature of discourses embedded within the call and re-call programme for cervical screening and the implications of these discourses for framing perceptions of femininity. It has been argued that the cervical screening programme has both lengthened substantially the proportion of a woman's life that is now subjected to medical surveillance and regulation and has increased the regularity with which such procedures are now being carried out. The call and re-call programme has been instrumental in establishing having a smear test as a social norm and instilling notions of deviance upon `non-attenders'. As argued by Howson (1993, cited in McKie, 1995) it appears that the obligation to participate in cervical screening has become part of a social discourse incorporating wide social networks. Therefore, just as it has been argued previously that women have looked to their biology for their sense of self (Ussher, 1989, 1992), so it appears from this study that having a smear test is also becoming an important part of `being a woman'. At one level, the ®ndings from this study appear to con®rm the arguments of McKie (1995) who states that cervical screening ``is both creating and re-inforcing a surveillance of women's sexual lives'' and that ``women's sexual activity and cervical health are utilised as mechanisms for the operation of power over women''. However, this study has also found that McKie's arguments surrounding cervical screening as a form of surveillance of the cervix constitute only one form of discourse embedded in the call and re-call pro-

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gramme. This study suggests that cervical screening is not just about surveillance of the cervix and women's sexuality but it also encompasses getting women to behave in a particular, prescribed way. Cervical screening is built upon medical discourses concerning the need for regulation of women's bodies. This study found that three discourses play a fundamental role in regulating the feelings of normalcy associated with having a smear test. Firstly, the call and re-call programme itself. Not only does this programme target the majority of adult women in the UK but it is also built on a philosophy of ensuring conformity to the norm; through invitation, re-call and reminder letters and via instilling of guilt and notions of deviance upon non-attenders. Secondly, it was found that pressure exerted by opportunistic screening plays a role in regulating attendance for cervical screening, and making smear tests appear compulsory. Thirdly, the research highlighted how women's fears about developing cervical cancer if they do not attend for smear tests also regulate their cervical screening behaviour. The interviewees generally felt that they needed to have regular smear tests in order to keep themselves free of cancer. The perceived need for surveillance was exacerbated by medical discourses which dictate that `non-attenders' for cervical screening are at greater risk of developing cervical cancer; a message re-inforced by health promotion material. Regulatory discourses have strong implications for sense of self. As Hewitt (1991) argues, regulating bodies is essential to normalisation Ð ``one of the great instruments of power''. In relation to the ®ndings from this study, at a general level, there are obvious similarities between Foucault's work on surveillance and the way in which medical power is operationalised over women's bodies within the cervical screening programme. Foucault was interested in the construction of both a micro-politics of regulation of the body and a macro-politics of surveillance of populations (Turner, 1991); with ``mapping the relations that exist between `the body' and the e€ects of power on it'' (Shilling, 1993). At the macro level, this study has highlighted how women are being confronted with a standardised ideal of women as attenders for cervical screening Ð that having smear tests is the correct form of behaviour for women Ð an ideal regulated by the medical discourses inherent within the call and recall programme and by health professionals. Foucault's ideas surrounding a `micro-politics of regulation' (Turner, 1991) are also applicable to cervical screening, at least in instances in which women are actually invited for a smear test. Within the call and re-call programme regulation is sustained not only by decree or design `from above', but also power that works `from below', through individual self discipline and self correction to the norm of having a smear test,

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and also through fear of developing cervical cancer. However, in other respects, Foucault's notion of power is not appropriate. Within cervical screening, power is sometimes authoritarian and conspiratorial, and there appears to be no choice involved in having a smear test, especially within the context of opportunistic screening. In addition, this study has highlighted, how cervical screening discourses are actively resisted by some women. Subsequently, Foucault's conceptualisation of `docile bodies' and subjects as passive victims doesn't accurately re¯ect the way in which discourse is negotiated within the case of cervical screening. In Butler's (1990) conceptualisation of gender as a performance, individuals are viewed as active agents regulated by a strict, discursive framework. Butler's belief that the repeated acts performed within this framework ``congeal over time to produce a natural sort of being'' (p. 33) appears to be highly applicable to the case of cervical screening. The call and re-call programme has been instrumental in making smear tests appear normal, because it involves a repeated set of `acts' which are highly regulated by the various mechanisms which are included in the call and re-call programme in order to ensure attendance for a smear test. Therefore there are several ways in which the body within cervical screening may be conceived of in terms of body boundaries, politically signi®ed and maintained. However, a main limitation of adopting Butler's work for cervical screening, is that, within her radical poststructuralist/postmodern perspective, Butler seeks to go beyond the materiality of the body and the notion of the body as a biological reality in her quest to problematise the categories of gender. If Butler's thesis was literally applied to cervical screening it would suggest that men could also wake up one day, decide to adopt a feminine identity and go for a smear test. Butler recognises the problems inherent in the notion of gender as performativity in later work (Butler, 1993). To participate in cervical screening, individuals must have a cervix, they must be, biologically and anatomically female. Therefore, although much of the cervical screening procedure may be likened to a performance, it is still dependent on the materiality of the body and the possession of female biology. Thus, within cervical screening, the body is ``a phenomenon that is simultaneously biological and social'' (Shilling, 1993). Whilst parallels can be drawn between the ®ndings from this study and the work of Foucault and Butler, neither approach fully accounts for the way in which discourses frame femininity within the cervical screening programme. Therefore, of the three theories of gender outlined earlier, the empirical study presented in this paper suggests that the one that most re¯ects the way in which femininity is framed and

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regulated within the cervical screening programme is Smith's (1990) work on the ideologies and doctrines of femininity. The empirical ®ndings presented in this paper suggest that women are `doing femininity' when they attend for a smear test. Discourses on femininity Ð and what women should be doing Ð are mediated via the call and re-call programme. Within the call and re-call programme, when women receive an invitation to attend for screening, they interpret it within the medical ideologies and doctrines which conceive of women's bodies as sites of risk and needy of medical surveillance, and which dictate that having a smear test is a social norm. Women are not passive to cervical screening discourse but active. There is an ongoing process of negotiation and sometimes resistance towards cervical screening discourse at all levels. Smear tests are generally seen as something that they as women can do to actively look after their bodies and their health.

sent may actually be seen as a threat to high uptake rates, as the discourses discussed in this paper are likely to have been largely responsible for the doubling of uptake rates over the last 10 years. Finally, this paper has focused solely on the nature and e€ect of cervical screening discourses. It is important that future work goes on to explore discourses embedded within the other mass screening programme in this country Ð the breast screening programme Ð and whether such discourses have similar implications to those discussed here in relation to how women view their bodies and femininity. The meaning and objective of mass screening programmes should be brought into question and re-considered by campaigners for women's health and those involved with the planning, implementation, research and use of screening services.

Acknowledgements Conclusions The ®ndings of this research have important implications for feminist debates on women's health care. Traditionally, feminists have advocated screening as a means of enabling women to obtain greater knowledge and insight into their own state of health and subsequently to obtain more control over their own body and prevent disease. As Foster (1995) argues, feminists have paid little attention to the ulterior motives behind the cervical screening programme. The arguments presented in this paper con®rm that mass screening is a feminist issue. Cervical screening discourses normalise and discipline women through the body, thus maintaining the disciplinary power of medicine. Based on such evidence feminists must re-think mass screening at all levels. At a conceptual level feminists must address the challenging question of how women as `Other' discourses in medicine Ð which result in the perceived need for regulation and surveillance of women's bodies Ð can be challenged without threatening women's health and well-being. At a practical level, campaigners for women's health must debate how women can make an informed choice about having a smear test. This is important because, ideally, women shouldn't be having smear tests because they see it as part of being a woman, but because they have decided Ð with knowledge of both the advantages and disadvantages of the cervical screening programme Ð that it's something that they personally want to do. The ®ndings from the study also, therefore, have important implications for health promoters. So long as the focus within policy remains on uptake, issues relating to informed consent are likely to be ignored. Indeed, addressing issues surrounding informed con-

The research on which this paper is based was funded by an Economic and Social Research Council PhD Studentship. The PhD was researched in the Geography Department at the University of Sheeld and supervised by Nicky Gregson and Bob Haining. I would like to thank all the women who gave up their time to help me with this study; for sharing their views and experiences with me. Thanks also goes to Nicky Gregson for her comments on earlier drafts of this paper.

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