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'My Wife Ordered Me to Come!': A Discursive Analysis of Doctors' and Nurses' Accounts of Men's Use of General Practitioners
Sarah Seymour-Smith, Margaret Wetherell and Ann Phoenix J Health Psychol 2002 7: 253 DOI: 10.1177/1359105302007003220 The online version of this article can be found at: http://hpq.sagepub.com/content/7/3/253

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My Wife Ordered Me to Come!: A Discursive Analysis of Doctors and Nurses Accounts of Mens Use of General Practitioners

Journal of Health Psychology Copyright 2002 SAGE Publications London, Thousand Oaks and New Delhi, [13591053(200205)7:3] Vol 7(3) 253267; 023220

Abstract
This study used a discursive approach to analysing doctors and nurses accounts of mens health in the context of general practice. The analysis worked intensively with interview material from a small sample of general practitioners and their nursing colleagues. We examine the contradictory discursive framework through which this sample made sense of their male patients. The interpretative repertoires through which doctors and nurses constructed their representations of male patients and the subject positions these afforded men are outlined in detail. We describe how hegemonic masculinity is both critiqued for its detrimental consequences for health and paradoxically also indulged and protected. These constructions reect a series of ideological dilemmas for men and health professionals between the maintenance of hegemonic masculine identities and negotiating adequate health care. Men who step outside typical gender constructions tended to be marked as deviant or rendered invisible as a consequence.

SARAH SEYMOUR-SMITH, MARGARET WETHERELL, & ANN PHOENIX

The Open University, UK

S A R A H S E Y M O U R - S M I T H has a degree in psychology from Derby University. She is currently carrying out doctoral research at the Open University. Her project is on gender and health and is predominantly concerned with the ways in which the social construction of masculinity acts as an important inuence on health and illness. M A R G A R E T W E T H E R E L L is Professor of Social Psychology at the Open University. She is one of the founders of discursive psychology and has published extensively on developing appropriate theories and methods of discourse analysis for social psychology. Her empirical research includes work on masculinity and race. She is the author of Discourse and social psychology (with Jonathan Potter, Sage), Mapping the language of racism (Harvester Wheatsheaf) and Men in perspective (with Nigel Edley, Harvester Wheatsheaf). She is currently co-Editor of the British Journal of Social Psychology. A N N P H O E N I X is a Senior Lecturer in psychology at the Open University. Her research interests include social identities (including those of race, ethnicity, gender and motherhood). Publications include Black, white or mixed race (with Barbara Tizard, 2nd edn, 1993 and 2002), and Young masculinities (with Stephen Frosh and Rob Pattman, 2001).
COMPETING INTERESTS: ADDRESS.

None declared.

Keywords
discourse analysis, general practice, health, identity, masculinity
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Correspondence should be directed to: S A R A H S E Y M O U R - S M I T H , The Open University, Walton Hall, Milton Keynes, MK7 6AA, UK. [email: S.E.SeymourSmith@open.ac.uk]

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T H I S A RT I C L E F O C U S E S on the ways in which health care professionals (doctors and nurses working in general practice settings) represent and make sense of their male patients. Using discourse analysis we examine how this group constructs masculinity and investigate their accounts and versions of what men are like. We argue that the discursive environments created through these formulations of the male patient are likely to have some clear practical consequences for the ways in which men negotiate health and illness. In an important sense, health and illness are mediated through discourse. People learn how to tell stories of their illnesses, the conventional metaphors and imagery to use and what is appropriate to include (Frank, 1995: 3) and similarly they learn what it is to be a male patient. The discourse of our sample of health care professionals can be seen as a simple reection and description of doctors and nurses everyday experiences of the men in their care but such descriptions are also deeply implicated in the formation and continuation of the reality of the male patient. The prevailing discursive environment sets the normative parameters though which men perform their identity in the surgery, sets up the taken for granted and in so doing creates forms of deviance and can render the experience of some groups of men invisible. In recent years a number of researchers have explored the connections between masculinity, health and illness (Brewer, 1998; Charmaz, 1994; Courtenay, 2000). Particular attention has been paid to the ways in which hegemonic forms of masculinity (dominant masculine cultures and values, Carrigan, Connell, & Lee, 1987) might impact negatively on patterns of illness and mens experiences and behaviours (Cameron & Bernades, 1998; Campbell, 1997; Eisler, 1998; Holroyd, 1997; Jadack, Hyde, & Keller, 1995; Sabo & Gordon, 1995). Holroyd (1997), for instance, found that men tend to use health services less often than women: specically, men attend doctors surgeries less frequently and delay seeking help when they are ill. Cameron and Bernades (1998) have demonstrated the consequences of traditional expectations of masculinity for mens experiences of prostrate cancer. There is general agreement that further qualitative research is required to further investigate the broad patterns evident from quantitative studies (Macintyre, Hunt, &

Sweeting, 1996). As yet, there is little information on the kinds of conicts that might occur between masculine identities and the identity of the patient and the ways in which these identities are mediated. There has also been little investigation of the discursive context set by the views of health care professionals in clinics, hospitals and surgeries, and the patterns these help sustain. Existing discursive research has been primarily interested in deconstructing media representations of mens health and is revealing about the broad narratives around masculinity, health and illness found in the public sphere. For example, Coyle and Morgan-Sykes (1998) analysed a six week guide to mens health from a British newspaper, the Independent, examining the enactments of masculinity evident. They found that mens health was constructed as in crisis and men were presented as the new victims. These patterns resemble those found in other similar moral panics in the media such as over boys underachievement in schools. Coyle and Morgan-Sykes noted that the presence of competing cultural expectations of masculinity (traditional masculinity versus the new man) tended to be constructed in the newspaper as a principal cause of confusion and anxiety in men rather than a positive sign of choice. Alternative enactments of masculinity were not presented in ways that might appeal to men but as potential indicators of effeminacy or vanity. Admiration for the traditional man seemed to lead to ambivalence about abandoning traditional modes of masculinity. Overall the discursive organization of the newspaper series compromised any effort to convince men to perform masculinity differently for the sake of their health. Instead the message seemed to be that it was better to risk the potential health dangers of being macho than ending up a feminized male. Coyle and Morgan-Sykes argue that although hegemonic masculinity was seen as problematic, it was also protected. Similarly, Lyons and Willott (1999) analysed the dominant discourses found in a set of feature articles in the womans section of another British newspaper (the Mail on Sunday, titled A womans guide to mens health). They also found that mens health was constructed as in crisis and men were positioned as victims of social change. Lyons and Willott argued that in

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this example of newspaper discourse health was constructed as a womans concern with men as the risk taking superhero women need to protect. Women were positioned as having to coerce their male partners to look after themselves as if they were children. Lyons and Willott concluded that the dominant discourses reinforced unequal social relations and womens nurturing role. The aim of the research reported in this article is to explore how the emerging patterns evident in public discourse around mens health might be played out in more everyday settings. Is the representation of mens health as womens business, for example, identied by Lyons and Willott shared by health professionals? How do hegemonic conceptions of masculinity structure the ways in which health providers evaluate and make sense of their male patients? Our goal is to contribute an intensive investigation of the discourse of a small sample of general practitioners and their nursing colleagues to the growing body of qualitative research on gender and health. Our study employs the theory and methods of discursive psychology (Edwards & Potter, 1992; Potter, 1996; Potter & Wetherell, 1987; Wetherell, 1998; Wetherell, Taylor, & Yates, 2001a, 2001b). For further applications of this approach to health psychology see HortonSalway (2001) and Radley and Billig (1996). Discursive psychology provides a systematic framework for the analysis of interview and interactional data. The specic analytic approach adopted in this article synthesizes ne grain conversation analysis/ethnomethodology (Edwards & Potter, 1992; Hutchby & Wooftt, 1998; Potter, 1996) with an interest in wider cultural, historical and power relations. Our focus is on the ways in which the interpretative resources of a culture, community or institution organize peoples everyday situated activities (see Wetherell, 1998 for a detailed defence of this synthetic view). In this study we aim to identify the principal interpretative repertoires (Potter & Wetherell, 1987) the doctors and nurses drew upon when discussing their male patients and examine the subject positions (Davies & Harre, 1990) these afforded male (and female) patients. An interpretative repertoire (see Edley, 2001, for an extended description and discussion of this analytic concept) is a recognizable routine of

arguments, descriptions and evaluations found in peoples talk often distinguished by familiar cliches, anecdotes and tropes. Interpretative repertoires are the commonplaces (Billig, 1991) of everyday conversation and the building blocks through which people develop accounts and versions of signicant events and through which they perform social life. Interpretative repertoires are what everyone knows. Indeed the collectively shared social consensus behind an interpretative repertoire is often so established and familiar that only a fragment of the argumentative chain needs to be formulated in talk to form an adequate basis for the participants jointly to recognize the version of the world that is developing. A typical nding in research on interpretative repertoires (Edley & Wetherell, 1997; Gough, 1998; Willott & Grifn, 1997) is that peoples discourse tends to be highly variable and inconsistent since different repertoires construct different versions and evaluations of participants and events according to the rhetorical demands of the immediate context. Billig, Condor, Edwards, Gane, Middleton and Radley (1988) note that much everyday discourse is organized around dilemmas and involves arguing and puzzling over these. In our analysis we will pay particular attention to the ideological dilemmas constructed for health professionals when, for example, discourses of care meet discourses around masculinity. Typically, interpretative repertoires also set up subject positions (Davies & Harre, 1990). Common to discursive and social constructionist research (Gergen, 1994; Reissman, 1993) is the claim that identity (personhood) is constituted and reconstituted through discourse and is thus exible, contextual, relational, situated and inected by power relations. Davies and Harre argue that who one is is always an open question with a shifting answer depending on the positions made available through talk, in interaction and conversations. The story-lines of everyday conversations provide us with a position to speak from and they allow the positioning of others as characters with roles and rights. Of particular relevance to this analysis is their insight that one speaker can position others by adopting a story line which incorporates a particular interpretation of cultural stereotypes to which they are invited to conform (Davies & Harre, 1990: 54). Doctors
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and their nursing colleagues are, of course, in a powerful position in terms of dening expectations about the typical characters male patients might act out.

Materials, participants and procedures

The data for this study consisted of taperecorded interviews conducted by the rst author (female and aged 34 at the time of the interviews). Ninety-eight general practice surgeries in the Midlands area of the UK were contacted and asked if any of their doctors or nurses would consider being interviewed about mens health. Nine participants from eight surgeries volunteered (six doctors, a consultant and two nurses). The doctors and consultant were all male except for one female GP; both of the nurses were female. Their ages ranged from 34 to 58. The doctors professional experiences were mainly routine training in general practice, although some had other more specic training (such as casualty and paediatrics) and the consultant was a hand specialist. Both of the nurses worked in primary care and one of the nurses ran a nurse-led practice but they both had experience in other areas such as sexual health or hospital-based work. One of the GPs was Asian but the rest of the participants were white. Each interview lasted approximately one hour. Anonymity of the participants is preserved in the extracts which follow through the use of pseudonyms. The tapes were transcribed using a simplied version of the scheme developed by Gail Jefferson (Potter & Wetherell, 1987, see Appendix for transcription notation). The interview topics fell into three broad sections. The rst section was designed to set the scene and asked questions about the practice the participant worked in and their area of expertise. The second section asked questions about men attending their surgery and this is the section that we have generally focused on in this article. Questions from this section included: (a) How many men use the practice? (b) Do men place importance on their health? (c) Do many of the men bring their partners with them to the consultation? The last question had emerged as a key issue in previous pilot research (SeymourSmith, 1998). The nal section concentrated on asking questions about developing social
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policies and practices around mens health and health education. Analysis followed the procedures used in discursive psychology and conversation analysis (Edley, 2001; Edwards & Potter, 1992; Hutchby & Wooftt, 1998; Potter & Wetherell, 1987). The whole data corpus was rst worked through to build up a le of instances of descriptions of male patients and their characteristics. Most of these examples, as noted, came from the second section of the interview. Analysis of the le proceeded through identifying the main repetitive patterns evident in these accounts. The interpretative repertoires presented below summarize these patterns. Further analysis then focused on elaborating the positioning of self and others evident in the material in the data le and this stage of the analysis was particularly crucial for considering the implications of the constructions presented by the sample. Absences were also noted since what is not said is as important for describing patterns as what is said (Billig, 1991). We thus askedwhat potential ways of representing men are missing from these accounts? Finally, we focused on dilemmas. We examined the dilemmas raised for health care professionals as they negotiated inconsistencies in their dominant interpretative repertoires and also the dilemmas potentially raised for male patients by the patterning of the taken for granted combined with what was absent or not part of everyday understandings.

Analysis and discussion

We begin by identifying three linked interpretative repertoires repeated pervasively across the sample. Each of these repertoires depends on a relational contrast between men and women and each treats masculinity and femininity as obviously dichotomous binary categories. The combination of these repertoires sums up the common sense evident in the sample about male and female patients and indicates the pattern of taken-for-granted cultural resources which were readily available to our sample of health care professionals.

Women are health conscious and responsible while men are not
The rst interpretative repertoires is evident in

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SEYMOUR-SMITH ET AL.: MY WIFE ORDERED ME TO COME!

Extracts One and Two. In Extract One, Dr Andrews is responding to a question concerning

whether men bring their partners to the consultation with them.

Extract Onetaken from Interview 1 with a male GP 1. Dr Andrews: yeah it is very common and the ones who are brought (1) kicking and 2. screaming by partners 3. Interviewer: (laughs) 4. Dr Andrews: will often sit (.) quietly probably in that seat [points to seat] and the partner 5. will sit there and say hes got this and that tell him tell him shell be saying 6. you know come on 7. Interviewer: mm (laughs) 8. Dr Andrews: and hell say oh yes o.k. I suppose I do (.) and theyre not very forthcoming 9. Interviewer: right (.) what er why do you think that is (1) wha why do the men not not= 10. Dr Andrews: I suppose either because= 11. Interviwer: =I suppose {there are a few reasons 12. Dr Andrews: {they dont yes I mean they either view 13. whatever theyre experiencing as not serious 14. Interviewer: mm 15. Dr Andrews: er and and irrelevant (.) or if it is a serious problem then theyve either had a 16. problem admitting 17. Interviewer: {mm 18. Dr Andrews: {that its there(.) erm (1) or (.) or just had a problem with presenting with it 19. Interviewer: mm Extract Twotaken from Interview 3 with a male GP 1. Interviewer: so:o there are more women using the practice {than men 2. Dr Crawford: {oh yeah yeah I would say so 3. Interviewer: (1) mm (.) do you why do you think that is 4. Dr Crawford: erm two reasons I think rstly (.) women's health is very much in (.) the 5. news 6. Interviewer: yeah 7. Dr Crawford: and women are much more health conscious I would think than men are (.) 8. so they also tend to come to the surgery with children {so they know their way 9. Interviewer: {mm 10. Dr Crawford: here and they get to know the doctors and they are comfortable with it 11. Interviewer: right 12. Dr Crawford: erm (.) so I think its a combination of things 13. Interviewer: mm 14. Dr Crawford: ermm (1) thats probably a lot to do with it they they come for smears they 15. come for ante-natal care so it isnt a big deal to them to come (.) whereas men 16. tend I think to hide their health problems and pretend everything is all right 17. Interviewer: right 18. Dr Crawford: so and they dont come till their wife makes them an appointment 19. Interviewer: (.) Ive heard that so many times (laughs) 20. Dr Crawford: oh yeah absolutely mm (.) its its amazing you know they just do not come 21. you nd records remarkably little in {(.) for a lot of men who have got 22. Interviewer: {mm 23. Dr Crawford: problems but wont admit it

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In these extracts women and men are positioned very differently. Women are constructed as more health conscious and thus more responsible. They are seen as more comfortable with coming to the surgery (Extract Two, line 10). Women admit problems and take steps to attend the doctor when ill. It is women who take their children to the doctors and push their male partners into making an appointment. In contrast men are positioned as childlike (Extract One, lines 12), as passive (Extract One, lines 56), as ignorant about health issues but also as stoical (lines 1218 in Extract One and lines 1523 in Extract Two). Dr Andrews in Extract One constructs quite a detailed comic scenario to illustrate these claims. In lines 1 and 2, the humour works through the implicit conation of two

social categories men and children (men are brought, kicking and screaming) and through disrupting what everyone knows about the characteristics of these categories. The normative characteristics of one category are assigned to the other. The impression of the male patient as a recalcitrant child is then reinforced through the words assigned to the female partner tell him tell him.

Men dont talk about emotional issues

A second strand in this developing common sense was the notion that men are bad at talking about emotions. This was presented in a similar fashion as a taken-for-granted fact which everyone knows about men.

Extract Threetaken from Interview 8 with a male GP 1. Interviewer: why do you think their partners do come 2. Dr Hall: I think because they say Im coming because he wont tell you anything 3. Interviewer: right (laughs) 4. Dr Hall: (1) so thats very often the thing that (Ive found) 5. Interviewer: so why dont men (1) 6. Dr Hall: ermm dont know (.) I mean certainly (.) if its an emotional thing 7. Interviewer: yeah 8. Dr Hall: very often the guy the partner will come Im not sure whether its because er 9. shes insisted on coming or (.) you know you can tell by the way they come in 10. if its an emotional thing { and he turns to her to explain his emotional problem 11. Interviewer: { laughs) 12. Dr Hall: (2) now once shes provided the sort of the initial (.) sort of idea of the problem 13. I can now turn to him Ive got to sort of its almost like (1) pulling (1) toenails 14. you know 15. Interviewer: yea:h Extract Fourtaken from Interview 1 with a male GP 1. Interviewer: mm (.) mm (4) do you think men (.) perhaps dont place as much importance 2. on their health as women but kind of leading from that or ( ) 3. Dr Andrews: no ( ) 4. Interviewer: no 5. Dr Andrews: no I dont think thats true erm (3) dont know whether men worry less about 6. their health or (3) or perhaps er analogous to may be even talking with friends 7. about feelings and things you probably dont share those issues where 8. women{ I 9. Interviewer: {mm 10. Dr Andrews: guess (.) probably do quite freely and certainly for you know personal 11. problems I doubt very much that a man would discuss with his mates 12. Interviewer: yeah mm (.) 13. Dr Andrews: about symptoms that he has to see what their experience would be that just 14. doesnt happen usually
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SEYMOUR-SMITH ET AL.: MY WIFE ORDERED ME TO COME!

Dr Hall stresses in lines 9 to 10 in Extract Three that if it is an emotional thing the man turns to the woman to explain his problem. Even after this initial help Dr Hall describes eliciting further information as like pulling toenails (lines 1314). Again this narrative has comic overtones and a scripted anecdotal quality as evidenced by the laughter from the interviewer (in Extract Three, line 3 and line 11). The comic moments in Extract Three once more concern the positioning of men as passive and incompetent. We will consider in more detail later why the participants collude in treating this as funny rather than, for example, tragic or pathetic or a cause for concern. In Extract Four, the premise that men do not talk about their emotions is presented in a more documentary style, almost sociologically, and as a general observation about men in general rather than in the form of an anecdote about a particular manifestation.

Men are the serious users of the health service

The nal interpretative repertoire evident in the data constructed men as serious users of the health service compared to women who are seen as presenting with routine or standard problems. Consider rst Extract Five, which follows from a discussion about the relative numbers of female and male patients attending the surgery. Nurse Brent constructs womens health here as routinely medicalized. In lines 6 to 13 she lists womens health as including family planning,

smear tests, pregnancy, ante-natal and postnatal care, childcare responsibilities and HRT. The notion of standard presentations without considering illness (which turn out to cover a signicant portion of a womans life) implies that health issues are part of everyday experience for women. This normalizes womens presence at health services but as a consequence women are also seen as the less signicant patients and this works rhetorically to construct men as the more serious users of the health service. The association of gender with proper patient is reconstructed here and a different denition of the proper patient emerges compared to, for example, Extract One considered earlier. As Nurse Brent simply states in line 15 of Extract Five, men you tend to only see if they are ill. Extracts Six and Seven come from the same doctor. The rst again follows a discussion about the greater number of female patients attending his practice (this was in response to a question about the number of men making appointments to see him). In Extract Six Dr Andrews, although careful not to dene all mens problems as signicant, constructs mens attendance as usually a signal of something more major (lines 8 to 9). In contrast women are described in lines 11 to 15 as attending for less worrying or more minor problems. In Extract Seven (a response to the question do many men bring their partners to the consultation with them?) Dr Andrews constructs two different scenarios for women

Extract Fivetaken from Interview 2 with a female nurse 1. Interviewer: (1) mm why do you think that might be that more women 2. Nurse Brent: oh theres a range of reasons (.) mm (1) and the usual reasons would be that 3. you know we follow up women far more closely with things like womens 4. health issues 5. Interviewer: right 6. Nurse Brent: family planning smears (.) ER pregnancy and ante natal and post natal care 7. er those are all women it tends to be women that bring children into the 8. surgery although we do have dads that bring their their children along (.) 9. women have problems with ongoing family planning (.) erm once theyve had 10. their children (.) mm and then theres issues to do with medical and hrt 11. Interviewer: right= 12. Nurse Brent: =and all of that so those are the sort of standard presentations without 13. considering illness 14. Interviewer: mm 15. Nurse Brent: erm:m whereas men you tend to only see if they are ill 16. Interviewer: right
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Extract Sixtaken from Interview 1 with a male doctor 1. Dr Andrews: not{very many at all {and if they do come its usually for something 2. Interviewer: { not {no 3. Dr Andrews: (1) to them certainly fairly major you know like a stress problem at work or (.) 4. or erm theyve found out that theres a family history of heart disease and they 5. want to get their blood pressure checked or something 6. Interviewer: RIGHT yeah 7. Dr Andrews: its not always a (2) not always a signicant medical problem as such but to 8. them its usually (.) I would guess more (2) more of a worry than something 9. that a woman might present with 10. Interviewer: right (.) {so you 11. Dr Andrews: {you know a woman might come along with say a chest infection or 12. (.) hay fever or something like that but if a man comes of that sort of age (.) 13. then you you sort of almost on your guard waiting for (1) some{ (.) various 14. Interviewer: {mm 15. Dr Andrews: problem yeah

Extract Seventaken from Interview 1 with a male doctor 1. Dr Andrews: and then and theres two ways that can go theres thats either going to be 2. completely trivial and its the woman worrying about it 3. Interviewer: right 4. Dr Andrews: and there isnt anything wrong and the mans right (.) 5. Interviewer: mm 6. Dr Andrews: or (.) the mans been hiding something and (.) it is serious 7. Interviewer: (.) right 8. Dr Andrews: thats usually the way those{sort of scenarios develop yeah 9. Interviewer: {thats interesting yeah yeah has 10. that happened (.) quite 11. Dr Andrews: (.) pretty often yeah

bringing their male partners to the surgery. In the rst scenario, the women are hypochondriacs who have ordered the men to attend for something trivial. Here it is not men who are wasting the doctors time but women. The use of the extreme case formulation completely trivial (line 2) builds up this construction of women as worrying too much. In the second scenario the man has been stoical and hidden his illness and the loud it is serious (line 6) emphasizes the conclusion. It is worth noting that in both scenarios women are not constructed positively but in each scenario men are constructed respectfully. Men are either misled by women or seriously ill. In this repertoire, therefore, the evaluation of men and women has reversed compared, for example, to the rst repertoire considered.
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The formula: She told me to come and see you

In this analytic section we want to focus in more detail on one formulaic construction found in the great majority of the interviews. This formula is already evident in the extracts above. It was a central trope in all three of the interpretative repertoires already discussed. In the rst two repertoires it was often presented as an anecdote or in narrative form and very frequently worked up as a joke and played for laughs. Formulaic responses have a canonical avour, a sense of what men are like. Indeed very often jokes, anecdotes and stories serve this function of revealing and playing with what is already strongly established. As will become evident, these anecdotes are given greater descriptive verisimilitude through reported

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SEYMOUR-SMITH ET AL.: MY WIFE ORDERED ME TO COME!

speech, either the supposed speech of the male patient or his female partner. As Bakhtin has argued (cited in Maybin, 2001) when speakers act out, report or construct the words of others an evaluative accent is frequently added. In this case the evaluative accent was usually critical and reinforces even more strongly the positioning of the male patient as hapless and helpless. Extracts Eight, Nine and Ten present a series of responses to the question do many men bring their partners with them to the consultation? In Extract Ten, lines 16, for example, the response to the question constructs the kind of comic routine typically found in the data. First, the timing and sequencing of the initial reply (line 3) signal some conversational expectation is being broken for effect and cues the listener that some kind of revelation is about to be unfolded. In an interview situation one does not expect

questions to be followed or answered quite as directly as here. The researcher asks the question in line 1 and this is quickly followed by a stressed and extended no followed by laughter. The lack of a pause, the short negative response accompanied by laughter but without the kind of extended elaboration which would be usual in the interview all signal that something different, possibly a joke, is coming. This breaking of the usual conversational expectations helps manufacture the humour. In line 4 the researcher repeats the no and laughs. Dr Andrews then delivers the punch line (while laughing) in line 5 that many of the partners bring their men to the consultation. This is greeted with loud laughter from the researcher. Again there appears to be some collusion in this construction of men, signaled by the laughter, between the doctor and the researcher. There is once more the sense of

Extract Eighttaken from Interview 8 with a male GP 1. Interviewer: do many of the men (.) er bring their partners with them to the consultation 2. Dr Hall: difcult to know whether they bring them or whether their partner says Im 3. coming (laughs) 4. Interviewer: (laughs) Extract Ninetaken from Interview 6 with a female doctor 1. Interviewer: (1) eem (coughs) do many of the men bring their partners with them to the 2. consultation 3. Dr Frome: (1) some 4. Interviewer: some 5. Dr Frome: (yes) some do 6. Interviewer: right 7. Dr Frome: some are dragged by their partners 8. Interviewer: right (laughs) 9. Dr Frome: (laughs) 10. Interviewer: does that ha happen (1) quite often or 11. Dr Frome: (.) or youll get the er opening line (.) she sent me 12. Interviewer: yeah= 13. Dr Frome: =you know 14. Interviewer: (laughs) yeah Extract Tentaken from Interview 1 with a male GP 1. Interviewer: mm (3) mm (.) do many of the men bring their (.) partners with them to the 2. consultation= 3. Dr Andrews: =no:oo (laughs) 4. Interviewer: no (laughs) 5. Dr Andrews: many of the partners bring their men {to the consultation (laughing) 6. Interviewer: { (LAUGHS) really 7. Dr Andrews: oh yes (.) or:r the men come in and say my wife has ordered me to come 8. Interviewer: right
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we know what men are likethis is recognizable stuff. The prevalence of formulaic responses of this kind demonstrates how gender operates as a powerful organizing practice for making sense of everyday reality. But these formulaic stories also reveal something very interesting about doctors and nurses construction of masculinity in combination with the variations in the main interpretative repertoires noted above. At one level men are roundly criticized in this discourse yet the critique does not bite or quite engage. It is done humorously and tolerantly and as already noted under the rubricwe know what they are like. Men are assigned characteristics that might have important consequences for their health care but the doctors and nurses interviewed tend to construct these as entertaining foibles. In addition men are respected for their stoicism and for only attending the surgery when they are really ill. The positioning of men and women is thus ambivalent and paradoxical. Women are health conscious and that is usually seen as a good thing but women worry too much. Men do not take responsibility for their own health but they are usually the properly ill

patients. In the following sections, further insight is gained into this pattern as we continue to explore the consequences and implications of these constructions of the male patient.

The male doctor as patient

Extract Eleven demonstrates a shift in focus from the doctors talking about men as patients to becoming patients themselves. In Extract Eleven, Dr Andrews uses himself as an example to reinforce the factuality and credibility of his description of the differences between female and male patients. His discourse also constructs a positive version of selfhe presents himself as stoical about minor aches and pains like other men. It is worth noting how the binaries constructed in this discoursemale versus female and positive (stoical) versus negative (overly worried)work in tandem. The discursive logic in this extract, and more generally with dichotomously constructed categories, is such that if one category is good the other must be bad. Yet the negative attributions across the gender categories are not equivalent. We saw earlier that when men are constructed as bad

Extract Eleventaken from Interview 1 with a male GP 1. Dr Andrews: we do get very many woman who present with with (1) very trivial symptoms 2. sometimes and things which probably a a good proportion of the population 3. have experienced 4. Interviewer: mm 5. Dr Andrews: but they they worry that this might represent something (1) serious or unusual 6. or whatever 7. Interviewer: right 8. Dr Andrews: er ( ) and I would ( ) I would bet the same proportion of men probably have 9. the same symptoms= 10. Interviewer: =yeah= 11. Dr Andrews: =and probably dont view it as serious at all= 12. Interviewer: right= 13. Dr Andrews: =and I know personally from my point of view I get twinges and (.) stomach 14. cramps and things 15. Interviewer: mm 16. Dr Andrews: and to me theyre very brief and they dont bother you particularly 17. Interviewer: =mm= 18. Dr Andrews: apart from that moment in time and then they go away again so you think (.) 19. well its gone 20. Interviewer: yeah ( )mm 21. Dr Andrews: its something you live with

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Extract Twelvetaken from Interview 9 with a male GP 1. Interviewer: mm (.) how many men (.) use your practice or have appointments with you 2. Dr Akter: (1) how many (rising intonation) 3. Interviewer: how many men (1) mm do the same amount of men (.) as women (.) {come or 4. Dr Akter: {right I 5. think er:r (.) you nd that (.) men consults less:s (.) than (.) female (1) 6. an:nd children say (2) probably I would say (unclear passage) but if you say 7. from hundred per cent out of (unclear) consultations forty per cent will be men 8. consultations sixty per cent will be women you see 9. Interviewer: right 10. Dr Akter: even the men is not well (.) it is the f er female who brings the men here 11. Interviewer: (laughs) really 12. Dr Akter: yeah and its true I am one of those as well (in a laughing voice) 13. Dr Akter 14. Interviewer: (laughs) 15. Dr Akter: I had actually{er haemorrhoids problem a hernia as well you know (.) in the 16. past I 17. Interviewer: {your wife 18. Dr Akter: knew I wanted to get it done (unclear) and my wife consulted behind my back 19. and gets me there (unclear) 20. Interviewer: (laughing) why do you think that is 21. Dr Akter: I think you know (.) what I actually found (.) that women can make it better (.) 22. and they actually (.) are very responsible for family care 23. Interviewer: right 24. Dr Akter: (1) you know 25. Interviewer: mm 26. Dr Akter: and because (.) she care for family (.) she often meet the doctor she knows the 27. doctor will help her out you see men dont see the doctor as a contact point like 28. that you see 29. Interviewer: right 30. Dr Akter: so er women are better organised at looking after the familys care 31. Interviewer: mm

(not health conscious) and women are constructed as good (health conscious and responsible), male badness is treated as amusing and regarded indulgently as a consequence. There was a striking discrepancy throughout the interviews in the use of humor. At no point were womens constructed weaknesses worked up as amusing or entertaining, condoned or made the subject of the kind of formulaic anecdote discussed in the previous section. We will return to this disparity later but suggest at this point that it reects the hegemonic nature of certain styles of masculinity. It indicates something about the way hegemonic masculinity is now typically performed and the continuing over-valuation of masculinity relative to femininity (Phoenix & Frosh, 2001; Wetherell, 1998). The doctors and nurses

exploration of the typical strengths and weaknesses of male and female patients works from the unquestioned initial premise that masculinity as traditionally dened is already positive and desirable. This conclusion is conrmed in Extract Twelve above. In this extract the doctor positions himself as one of those men whose wife takes responsibility for his health. This positioning could, of course, be done in a number of ways within a number of different evaluative frames. It could be performed as a confession of something very problematic about oneself that needs changing and as an admission of personal failure and difculty. It is striking that Dr Akter does not take this line. He presents his behaviour as obviously problematic on one level, but as also funny and even admirable. It is as if this
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narrative about his wife consulting behind his back and getting him there works in some way as a positive image of himself. Why is this so? We suggest that because masculinity is culturally hegemonic, already positively constructed in relation to femininity, many of the things men do which are constructed as negative also retain an ambivalently positive avour. Negative actions become desirable and even aspirational through the mere fact that they are performed by a prestige category. This suggests that what health care professionals might see as most problematic for male patients is not behaving like a typical man but behaving like a woman. This conclusion is borne out in the next piece of analysis which also indicates the dilemmas for men that this discursive pattern raises and suggests some crucial implications for mens health.

Consider Extract Thirteen. The doctor sets up his narrative through constructing a category of men who you might consider to be less masculine and who have feminine traits. He then moves into an account of one particular bloke who had a lack of testosterone. He constructs men like this as attending more frequently with more trivial problems, a pattern that he associates with female patients. In lines 2728 and in line 18 he heads off potential criticism perhaps because he is talking to a female interviewer by saying that sounds extremely sexist but Im convinced its true. Here the relative valuation of male and female is clearly revealed and why, as a consequence, the failings of male patients who behave in what is dened as a properly masculine fashion are humoured.

The invisibility of gay men Deviant cases

What happens if you are a man who does not t the expected pattern for the male patient emerging here? Often within the interviews stories of men and women who deviated from typical gender constructions were highlighted. Generally these narratives served two purposes: rst they reinforced the hegemonic position; second they problematized the deviant behaviour. A nal striking feature in the interviews was the invisibility of gay men. The male patient was consistently constructed in these interviews as heterosexual. At many points in the interview the interviewer adopted the generic term partner so as not to be gender specic. What tended to happen was that partner was initially repeated by the health professional and then a few turns later changed to wife. If you consider Extract Fourteen it becomes clear that there is

Extract Thirteentaken from Interview 1 with a male GP 1. Dr Andrews: whereas whereas men you might consider to be less masculine 2. Interviewer: yeah 3. Dr Andrews: (1) and certainly ones where they have (.) feminine traits for example I can 4. think of one particular bloke especially but there was one in the last practice I had 5. Interviewer: mm 6. Dr Andrews: erm ones who had a lack of testosterone for a variety of medical reasons 7. Interviewer: mm= 8. Dr Andrews: =who actually do partially feminise and can grow breasts because of this 9. Interviewer: right 10. Dr Andrews: their their health behaviour is probably very (similar) to a womans in the way 11. they present 12. Interviewer: right 13. Dr Andrews: more frequent attending (.) more trivial problems (.) erm more trivial medical 14. speaking 15. Interviewer: yeah 16. Dr Andrews: erm (2) and its du a whole different approach really (.) they (coughs) 17. Interviewer: so you think its to do with hormones and= 18. Dr Andrews: =Im Im sure Im sure there must be (unclear) that sounds extremely sexist 19. but Im convinced its true
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Extract Fourteentaken from Interview 6 with a female doctor 1. Dr Frome: the testicular screening I mean maybe we ought to be sort of (.) er targeting 2. the women and saying you know youve come for your cervical scan has your 3. fella looked at his balls recently 4. Interviewer: right 5. Dr Frome: or something you know and that might well be something that that may be 6. we ought to say to the nurses when you get the women for their cervical give 7. this leaet to her and ask her to give it to her husband 8. Interviewer: mm (.) because the women are actually in already 9. Dr Frome: because weve got them in and and (.) you know we can nd out whether or 10. not theyve got a partner quite easily and that would certainly target a lot of 11. them wouldnt it 12. Interviewer: yeah yeah

no doubt that partner refers to a member of the opposite sex. The prevailing discursive environment thus seems likely to create forms of deviancy and render some groups of men invisible. This may have important implications for health promotion for men seen as inappropriately feminine, men who have no partner or have same sex partners.

Conclusions
The ndings from this study conrm many of the patterns found in previous research. The doctors and nurses interviewed reported that men attended their surgeries much less frequently than women (Holroyd, 1997). In evaluating and making sense of this pattern, the health professionals drew on discourses around masculinity and the male patient familiar from previous studies of patterns in the media and patterns in mens accounts (Cameron & Bernades, 1998; Coyle & Morgan-Sykes, 1998; Lyons & Willott, 1999). Our study has demonstrated the routine deployment of these cultural understandings in the discourse of the doctors and nurses studied. As in Lyons and Willotts investigation, men were positioned as childlike and women as their health supervisors. Like Coyle and Morgan-Sykes, we found that hegemonic masculinity was both criticized and protected. Interestingly, then, there seems to be a high level of consensus in current representations about what men are like displayed across professional and patient, lay, media and policy contexts. How signicant are these ndings? Although

our sample was small and our investigation intensive rather than extensive, the commonality with other research and the uniformity of the pattern across the sample suggests the robustness and pervasiveness of this discourse of the male patient. It could be argued that all we have revealed is doctors and nurses stereotypes but this is to miss the point. Stereotypes or dominant discourse are powerful because they set the horizon for what can be articulated or thought in any relevant context. Interviews are an opportunity to rehearse the taken for granted. There are many aspects of medical practice where these constructions of the male patient will be largely irrelevant. Our interest, however, is in the negotiation of identity and in that context, these dominant discourses must be relevant to understandings of what is possible and what various potential performances of masculinity might mean and how they might be interpreted. As we have demonstrated, the doctors and nurses interviewed constructed a contradictory discursive framework. Hegemonic masculinity was valorized and indulged while simultaneously critiqued. The combination of critique with a positive evaluation of hegemonic masculinity seems likely to reinforce and intensify established patterns and make change difcult. In common with the general ideological climate forming around masculinity in recent years (Phoenix & Frosh, 2002), the status quo was preserved through the construction of men as hapless and helpless but this hopelessness was celebrated and deferred to, positively tolerated and welcomed. We argued that this had some important implications for health promotion in targeting men who transgress or who are
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rendered invisible, and future research might consider how these men manage their identity as male patients and the consequences for them of these dominant discourses.

Appendix
Conventions: (.) (2) {men {yeah (word)/(unclear) (laughs) sent anxious:s RIGHT short pause pause in seconds overlapping utterances utterance difcult to discern laughter in brackets, not transcribed phonetically yet underlining indicates added emphasis semi-colon indicates drawn out letters block capitals indicate louder speech

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