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Keywords:

  • women's sleep management;
  • medicalization;
  • healthicization;
  • personalization;
  • social context

Abstract

  1. Top of page
  2. Abstract
  3. Introduction
  4. The medicalization of women's sleep
  5. Managing women's sleep within a healthist culture
  6. Personalization: the hidden dimension of women's sleep management
  7. Method
  8. Personalization: the core of sleep management
  9. Medicalization: the other end of the spectrum
  10. Challenging the medicalization of sleep
  11. Healthicization: the link between personalization and medicalization
  12. Conclusion
  13. Acknowledgements
  14. References

Abstract  This paper addresses sleep, which to date has been a neglected area within the sociology of health and illness. We explore the extent to which the concepts of medicalization and healthicization provide appropriate models for understanding the management of women's sleep disruption. The prescription of sleeping pills remains as an indicator of the medicalization of sleep, while the trend towards the healthicization of sleep as part of healthy lifestyle practice is reflected in the increased focus of the media, pharmaceutical and complementary health care industries on sleep. The paper analyses qualitative data on women aged 40 and over to argue that the medicalization-healthicization framework fails to encapsulate a complete understanding of how women manage sleep disruption within the social context of their lives. It suggests that by looking inside the world of women's sleep we uncover a hidden dimension of self-directed personalized activity which plays a key role in women's response to sleep disruption. We propose an alternative model for the management of women's sleep which incorporates a core of personalised activity, linked to strategies associated with healthicization and medicalization.


Introduction

  1. Top of page
  2. Abstract
  3. Introduction
  4. The medicalization of women's sleep
  5. Managing women's sleep within a healthist culture
  6. Personalization: the hidden dimension of women's sleep management
  7. Method
  8. Personalization: the core of sleep management
  9. Medicalization: the other end of the spectrum
  10. Challenging the medicalization of sleep
  11. Healthicization: the link between personalization and medicalization
  12. Conclusion
  13. Acknowledgements
  14. References

In developing a theoretical framework for the study of sleep, Williams (2002: 185) proposes that sleep may represent yet ‘another chapter in the medicalization or healthicization story’. He argues that sleep is ‘caught up in the tangled web of health and illness, morality and risk, safety and danger, across the lay/professional divide’ and as such is a target for ‘colonisation by various forms of expertise, whether cased in terms of medicalization or healthicization’ (2002: 189). This paper aims to explore Williams's proposition in relation to empirical data on women's sleep, and to suggest an alternative framework for the conceptualization of women's sleep management. As a basis for our discussion, we first position women's sleep within the medicalization-healthicization paradigm.

The medicalization of women's sleep

  1. Top of page
  2. Abstract
  3. Introduction
  4. The medicalization of women's sleep
  5. Managing women's sleep within a healthist culture
  6. Personalization: the hidden dimension of women's sleep management
  7. Method
  8. Personalization: the core of sleep management
  9. Medicalization: the other end of the spectrum
  10. Challenging the medicalization of sleep
  11. Healthicization: the link between personalization and medicalization
  12. Conclusion
  13. Acknowledgements
  14. References

Since the pioneering work of Zola (1972), the concept of medicalization has become a central theme in sociological studies of the relationship between health and illness. Conrad (1992) describes medicalization as a process of social control whereby both deviant behaviour and natural life events are reconstructed as illnesses or disorders and placed under the jurisdiction of the medical profession. The term has been used widely in association with conditions as diverse as infertility (Becker and Nactigall 1992), chronic fatigue syndrome (Broom and Woodward 1996), and ‘natural’ death (Seymour 1999).

As a physiological process, sleep has always had the potential to become absorbed into the medicalization paradigm. Indeed, it is the focus of extensive scientific study and the subject of a weighty volume entitled The Principles and Practice of Sleep Medicine (Kryger et al. 2000). In the UK alone there are numerous sleep clinics and laboratories which conduct research into the mechanisms of sleep and/or treat specifically-named sleep disorders including sleep apnoea, restless legs syndrome and narcolepsy, each characterized by specific medical aetiologies, diagnostic measures and treatment regimes.

Women's sleep is particularly vulnerable to medicalization. According to Riessman (1983: 5), women are perceived as more likely than men to have ‘problematic experiences defined and treated medically’, as evidenced by the medicalization of such ‘natural’ female processes as menstruation (Oinas 1998), childbirth (Wertz and Wertz 1989), pre-menstrual syndrome (Bell 1987, Riessman 1983) and the menopause (Bond and Bywaters 1998, Griffiths 1999, Ballard 2002). In relation to sleep disruption both women and older age groups report increased rates of sleep difficulty, with women 1.3 times more likely than men to report insomnia-like sleep problems (Walsh and Ustun 1999). Research conducted by the National Sleep Foundation in the US (NSF 1998: 2) found that the ‘average woman aged 30–60 sleeps only six hours and forty-one minutes during the workweek’, considerably less than the recommended eight hours per night. Moreover the incidence of poor sleep in US women is increasing, with 47 per cent of women aged 40–49, and 50 per cent of those aged 50–60 experiencing difficulty sleeping ‘often or always during the past month’. According to the study, almost one-third of women aged between 30 and 60 reported that their sleep problems frequently interfered with their daily activities, including job performance and caring for family, as well as interpersonal relationships. As Walsleben and Baron-Faust (2000: xiii) observe, women are ‘probably the most sleep-deprived creatures on earth’, with hormonal factors and the competing demands of careers and children contributing to poor sleep outcomes.

In this environment, it is not surprising that women's sleep has become associated with the process of medicalization. The high incidence of tranquilliser use among women (Gabe and Bury 1996) since the development of effective hypnotics in the 1960s is evidence of this trend. The medicalization of sleep disruption has been achieved by a consensus between the medical profession, assuming the status of ‘experts’ on sleep problems, patients (mainly women) seeking a solution to their sleep problems through medication, and the pharmaceutical industry with vested interests in the promotion of products to meet the needs of the lay population and the medical profession.

Yet despite media attempts to portray women as victims of medicalization through widespread addiction to hypnotics (e.g.Panorama 13 May 2001), Williams and Calnan (1996: 1613) suggest that, rather than being passive consumers in a culture of medicalization, individuals have become ‘critical reflexive agents’ in managing their health. While the potential for medicalization may exist, the extent to which it actually occurs is related to women's experiences and perceptions of health and illness (Ballard 2002), with many women resisting taking prescription medication except as a last resort (Griffiths 1999). The emergence of a widespread ambivalence towards the use of benzodiazepines accompanied by ‘a measure of acceptance of tranquillisers and their role in everyday life’ (Gabe and Bury 1996: 90) is evidence of a more recent restructuring of the medicalization model of the 1960s and 1970s. The fall in the number of prescriptions for benzopdiazepines from 16.5 million in 1991 to 13.2 million in 2000 (Phelan et al. 2002: 290) suggests that women are either seeking alternative ways of dealing with sleep problems, or taking a more active role in the medicalisation of their sleep. In this context, the medicalization of sleep through tranquilliser use is only one of a number of choices which women have in coping with sleep disruption.

Managing women's sleep within a healthist culture

  1. Top of page
  2. Abstract
  3. Introduction
  4. The medicalization of women's sleep
  5. Managing women's sleep within a healthist culture
  6. Personalization: the hidden dimension of women's sleep management
  7. Method
  8. Personalization: the core of sleep management
  9. Medicalization: the other end of the spectrum
  10. Challenging the medicalization of sleep
  11. Healthicization: the link between personalization and medicalization
  12. Conclusion
  13. Acknowledgements
  14. References

Alongside this restructured medicalization model, there is ample evidence to suggest that the social nature of sleep and the multiplicity of factors which contribute to sleep disruption create the potential for sleep management to become a target for healthicization. Rather than focusing on specific disease aetiologies, healthicization claims to recognize the role of multiple causal agents, embedded within the social context of people's lives, as responsible for creating the potential for imbalances in health and wellbeing. Armstrong (1995) proposes that the trend towards healthicization (or surveillance medicine) in society finds its foundation in the problematization of normal lifestyle factors such as diet, stress and exercise. In the healthicization context, these become risk factors around which the construction of future health or illness is predicated. It is the individual's responsibility, rather than the medical profession’s, to ‘transform the future by changing the health attitudes and health behaviours of the present’ (Armstrong 1995: 402). While medicalization exonerates individuals from moral responsibility for their health, healthicization extends into all aspects of life offering ‘no absolution from individual responsibility, accountability and moral judgement’ (Zola 1972: 492).

From a sociological perspective, sleep is deeply embedded within the social context of our lives. As Williams and Bendelow (1998) note, sleep is a socially-prescribed and culturally-patterned role which enables society to function. Sleep not only has a biological and psychological purpose but also impacts on our performance during the day. It influences the way in which we accomplish the tasks and responsibilities which constitute our waking roles, and, in turn, is influenced by the nature and constraints inherent in these roles. Women's attempts to meet the expectations of modern society in their working and domestic roles impose both restrictions on the time available for sleep as well as physical and psychological intrusions into their sleep (Hislop and Arber 2003). Moreover, as social roles and responsibilities may structure women's sleep, so too does disrupted sleep have an impact upon these roles. Poor sleep may trigger increased stress, lethargy, headaches, poor concentration, irritability and poor appearance. In these circumstances, women may feel that to gain control over their sleep may in some ways provide a means through which to regain control over their lives. A healthist approach to sleep management, with its focus on individual agency, may appear to offer salvation while avoiding the stigma and dangers associated with medicalization.

In seeking to improve their sleep, women have the moral support of a prevailing healthist culture in which the interrelationship between sleep and good health is well established. According to the Omnibus Sleep in America Poll (NSF 2000), American adults rank sleep as the third ‘most important component of good health’, alongside good nutrition and regular exercise. These findings support studies from the 1980s and 1990s which highlight the relationship between good sleep and wellbeing. Calnan (1987: 25) found that, regardless of socio-economic background, women regarded adequate sleep, rest and relaxation as valuable for the maintenance of health. Its value lay ‘mainly in terms of enabling them [women] to fulfil their family responsibilities or helping the family economy’. Blaxter (1990), in her analysis of data from the 1984/5 Health and Lifestyle Survey, refers to the strong association between health and sleeping habits, placing it alongside smoking, consumption of alcohol, exercise and diet as central to a healthy lifestyle. In citing the individual's health status as ‘the overwhelmingly dominant predictor of sleeping habits’, Blaxter (1990: 127) suggests a reciprocal relationship between health and sleep. Not only is good sleep important to health, but health determines the quality of our sleep. Thus behaviours which promote health, such as diet and exercise, may also promote better sleep.

Indeed, like diet and exercise before it, sleep has recently been ‘discovered’ as a potential risk factor for a healthy life and is now being promoted as a key health issue by the media. As the following two examples show, the need to take the risks of poor sleep to our health seriously is being driven home with great force. In somewhat alarmist tones, the subheading to an article in Reader's Digest (Brink 2001: 100) warns that ‘skimping on sleep could be the death of you’. The article claims that ‘our productivity, our safety, our health are at risk’ if we don’t get enough sleep. Citing research carried out by pre-eminent sleep scientists in the US, it suggests that lack of sleep can drive down growth hormone levels, accelerating weight gain; alter our white blood-cell counts and immune-response modifiers leaving us open to infection; and even increase our risk of breast cancer through disruption of hormone levels. The article proposes that to help improve sleep, people should give up caffeine and alcohol late in the day and, if necessary, take sleeping pills for a short time.

Yet, under the guise of healthicization, the locus of control for health may merely have shifted from the medical profession to commercial interests, with the individual caught somewhere in between. Commercial enterprises have been quick to take advantage of the focus on poor sleep as a potential health risk. Again, women are being targeted, with recent research showing a strong association between female gender and the purchase of over-the-counter medications (Phelan et al. 2002). Supported by extensive marketing and generous advertising budgets, sleep medications, herbal teas, and CDs and books which promise the elusive dream of a good night's sleep, have found their way onto the shelves of supermarkets and pharmacies as well as internet shopping sites. Despite the questionable benefits, safety and side effects of some of these products there is apparently a ready market in today's 24-hour society with its emphasis on ‘quick-fix’ solutions to problems. An advertisement in Good Housekeeping (September 2001: 155), for example, encourages women under the heading ‘Pillow Talk’ to take Nytol before going to bed as ‘a bridge back to a normal sleeping pattern’, while an article in the same magazine (June 2001: 36) invites insomniacs to rest their ‘weary head on the Norso Magnetic Pillow Insert and wallow in its relaxing magnetic field for a sound night's sleep’ for £28. Meanwhile, the website of Boots, a leading UK pharmaceutical company (www.wellbeing.com) currently displays around 100 items under the category sleep, ranging from Sleepeaze Herbal; a ‘traditional herbal remedy for the relief of tenseness and irritability, so promoting natural sleep’, to Sleep Cones; ‘small rubber cones on an adhesive strip [which] stimulate the H7 acupuncture points located on the wrists’, believed to help relieve sleep disturbances.

As the above evidence shows, sleep is undoubtedly associated with medicalization and healthicization. Yet understanding how women manage their sleep is not just about fitting it into the medicalization-healthicization paradigm. There is another important chapter to the story which may be overlooked in a determination to accommodate sleep management within existing paradigms; a core of self-directed personalized activity which is central to an understanding of women's sleep management.

Personalization: the hidden dimension of women's sleep management

  1. Top of page
  2. Abstract
  3. Introduction
  4. The medicalization of women's sleep
  5. Managing women's sleep within a healthist culture
  6. Personalization: the hidden dimension of women's sleep management
  7. Method
  8. Personalization: the core of sleep management
  9. Medicalization: the other end of the spectrum
  10. Challenging the medicalization of sleep
  11. Healthicization: the link between personalization and medicalization
  12. Conclusion
  13. Acknowledgements
  14. References

Phelan et al. (2002: 287) assert that ‘people experiencing problems with sleeping might consult their doctor, try self-treatment with non-prescription medicines or other remedies, or take no action’ (authors’ emphasis). For the most part, women do not regard sleep disruption as an illness, but as an inconvenience which threatens their ability to function effectively in public and private roles. Yet, rather than ‘doing nothing’ and ‘putting up’ with sleep disruption as Phelan et al. suggest, women are highly motivated to take personal responsibility for finding solutions within the home to try to overcome their sleep problems. It is this personalization of sleep management which is a key chapter in the story of women's sleep. Aimed at relieving symptoms of tiredness, poor concentration and irritability so that women can carry out their roles effectively, sleep management at the personalization level involves women taking responsibility for their sleep, as they have always done, through recourse to personal strategies within the home, ranging from taking hot baths and drinking cocoa, to relocating to other rooms or beds. In this context, women manage their sleep alongside the wider spectrum of tasks and routines which comprise everyday life.

In accordance with Fayol's (1949, cited in Grey 1999: 563) conceptualization of management as a series of activities, sleep management for women involves choosing between a range of strategies designed to help improve the quality of their sleep, and, by association, the quality of their daily lives. While personalized strategies may form the core of these activities, women's sleep management also permeates the cultures of healthicization and medicalization through the use of over-the-counter products, alternative therapies and prescription medications. We suggest that the management of women's sleep is best understood, therefore, in terms of an interplay between personalized, healthist and medicalized strategies, with choice of strategy mediated by individual perceptions of the severity of sleep disruption, family and work constraints, attitudes to alternative products and practices and perceptions of the role of the medical profession and prescription drugs in the treatment of poor sleep. We draw on data from empirical research carried out as part of an EU-funded project, Sleep in Ageing Women, to illustrate the interrelationship between these strategy types.

Method

  1. Top of page
  2. Abstract
  3. Introduction
  4. The medicalization of women's sleep
  5. Managing women's sleep within a healthist culture
  6. Personalization: the hidden dimension of women's sleep management
  7. Method
  8. Personalization: the core of sleep management
  9. Medicalization: the other end of the spectrum
  10. Challenging the medicalization of sleep
  11. Healthicization: the link between personalization and medicalization
  12. Conclusion
  13. Acknowledgements
  14. References

This paper is based on qualitative data from 10 focus groups of women aged 40 and over (N = 82) which were held in a medium-sized city in southern England in Spring 2001. Citing Vaughn et al. (1996), Smithson (2000: 106) states that focus groups are ‘particularly useful at an early stage of research as a means for eliciting issues which participants think are relevant, which can then be used to inform the design of larger studies’. In the absence of existing empirical studies on women's sleep, the use of focus groups in the early stages of this project enabled a broad exploration of the subject of women's sleep providing insights into women's experiences of sleep in the context of their social roles as working women, partners and/or mothers, thus informing subsequent research design.

Participants were recruited through poster advertisements and through direct contact of the researcher with key informants. Posters were placed in community centres adult education organizations, libraries, GP surgeries, cafes, sports centres and on notice boards in social and community centres and in retail outlets. Snowballing from initial recruits also proved a successful recruitment strategy, with respondents asked to advertise the project through their own professional and social networks.

Two focus groups were held for each of the age groups 40–47 (coded 1.1 and 1.2), 48–52 (coded 2.1 and 2.2), 53–59 (coded 3.1 and 3.2), 60–69 (coded 4.1 and 4.2), and 70 and over (coded 5.1 and 5.2). Focus group sessions, each approximately one-and-a-half hours in length, were held in the researcher's home and, in the case of older participants, in community settings. Participants were paid an incentive of £20.

At the beginning of each session participants were asked to complete a short questionnaire. In terms of socio-demographic characteristics, approximately half (54%) of the women were married or living as married, while 36 per cent lived alone. The majority (72%) of the women had children; however, fewer than one quarter (22%) still had children living at home. Single-parent households comprised six per cent of the sample. While 42 per cent of the women held graduate qualifications, 37 per cent had qualifications at or below O-level standard. Almost half (48%) worked on a full- or part-time basis, while 46 per cent were retired.

A focus group guide, comprising broad discussion topics, was used to promote discussion and interaction between participants. These topics included attitudes to sleep, patterns of sleep sleeping as a shared experience, ageing and sleep, effects of poor sleep and strategies for overcoming sleep problems. Probes were used as appropriate to gain further insights into women's sleep experiences.

Recordings were made of each focus group, then transcribed and entered into the qualitative data analysis package QSR NVivo. Following careful reading for emergent themes, data from each focus group were coded within its context into index categories. Data for each category were then merged across focus groups, before being retrieved for further in-depth analysis of underlying meanings and interactional insights produced by the group dynamic.

As an adjunct to focus group data, the paper also draws on data from one-to-one interviews conducted with five GPs (coded GP1-5) to gain insights into medical perspectives on the treatment of sleep disruption. Each interview was recorded and transcribed to facilitate analysis.

Personalization: the core of sleep management

  1. Top of page
  2. Abstract
  3. Introduction
  4. The medicalization of women's sleep
  5. Managing women's sleep within a healthist culture
  6. Personalization: the hidden dimension of women's sleep management
  7. Method
  8. Personalization: the core of sleep management
  9. Medicalization: the other end of the spectrum
  10. Challenging the medicalization of sleep
  11. Healthicization: the link between personalization and medicalization
  12. Conclusion
  13. Acknowledgements
  14. References

The term ‘insomnia’ is now widely used throughout the sciences and the media to describe the lay experience of sleep disruption. Defined in the International Classification of Sleep Disorders (American Sleep Disorders Association 1990) as ‘difficulty in initiating and/or maintaining sleep’, the incidence of insomnia in the population is estimated at varying between 10 and 50 per cent (Zorick and Walsh 2000). Yet while focus group data suggest that, according to this definition, the majority of women in our study have experienced either acute or chronic insomnia at some stage of their lives, only one women actually used the term ‘insomnia’ to describe her condition:

A:If you are an insomniac you can’t help getting hung up on not sleeping. It is normal.

B:Well is it an illness, is it a diagnostic affliction?

A:I am an insomniac. Yes, someone who doesn’t sleep very well.

Int:Did the doctor tell you that?

A:No. It is the term, isn’t it? (2.1: 38).

The failure of the medical term ‘insomnia’ to infiltrate the lay population suggests that women perceive sleep disruption as a normal ‘fact of life’ outside the scope of medicalization. Yet they do not consider this disruption desirable (Hislop and Arber 2003). In response, women have developed a range of personalized strategies over time to manage their sleep without recourse either to externally invoked healthy lifestyle practices or medical intervention. We suggest that personalized activities lie at the heart of women's sleep management. These activities include rituals and routines which aim to create an environment conducive to sleep and to offset potential sleep disruption, and responsive measures which seek to ameliorate disturbance once it occurs.

For women in our study, pre-bed routines and rituals developed over the lifecourse were seen as a necessary precursor to sleep; a ‘must do’ behaviour perceived as helping sleep onset. Deeply embedded within the individual's psyche, these activities range from cleaning teeth and having a warm bath, to having a snack and/or hot drink before bed:

I couldn’t go to bed if I had not sort of hung my clothes up or put them in the laundry basket. If it was untidy I wouldn’t sleep properly (2.1: 18).

Int:What do you do before you go to bed at night?

A:I have wine. Always red.

Int:So you think it helps you get off to sleep?

A:Oh, definitely. My mother-in-law who was then in her nineties said ‘those sleeping pills aren’t going to work’, so she went onto the red wine.

B:A nice big sleeping pill in a glass then (4.2: 14).

In addition to these pre-bed routines and rituals, women take an active role in addressing disruptions during sleep by choosing from a range of personalized responsive strategies designed to improve their sleep and their feelings of wellbeing the following day. The normative response to waking during the night involves staying in bed, either lying and waiting until sleep is resumed or adopting simple strategies, such as counting sheep, positive self-talk or relaxation techniques, to help re-establish sleep:

[I don’t get up] because I keep telling myself that of course I am going to go back to sleep in a minute . . . I don’t worry about it anymore because there is no point (2.2: 19).

I will lay there and sort out if I have got any clean underwear for the next day and then I think I have 15 minutes more [sleep] if I know I have got a pair of knickers for the morning (3.1: 11).

Relocation, moving either to another bed or another room, is a strategy used by a substantial minority of women when the above practices fail to restore sleep. Women who wake during the night and are unable to get back to sleep after what they consider a reasonable time may get out of bed and relocate in the house, either temporarily or for the remainder of the night. As well as distancing women from the source of disturbance, this strategy also fills the time void created by broken sleep with useful activities:

I get up if I know I am not going to get back to sleep, I make a drink and read, then I come back to bed, listen to the World Service and the talking will send you back to sleep (1.1: 18).

Probably about half past one I am awake again and can’t get off again, so I go to the toilet, go back to bed, go downstairs, have a cup of tea, and go back to sleep if I’m lucky (5.1: 13).

Relocation from the double bed also becomes a pragmatic solution to snoring and general restlessness when they interfere with sleep:

It's me that is the fidgety one and we’ve now got single beds and I tell you I wouldn’t want to go back to a double one (5.1: 15).

Strategies such as these give women a sense of active agency in managing their sleep. Yet choice of strategy may involve an interplay between the constraints imposed by social structures and women's desire to take control of their sleep. As a socially-embedded phenomenon, women's sleep and the strategies used to improve its quality, are responsive to the circumstances associated with their roles and responsibilities in the public and private spheres. While women may recognize and understand the relationship between these strategies and good sleep, the constraints imposed by their social circumstances may often intrude on their ability to choose strategies which optimize their sleep performance. These may include time pressures and fatigue arising from responsibilities at work or in the home, or constraints imposed by the gendered division of labour within the household:

I used to nearly always have a bath and I used to read. But I am stuck for time now [because of work and family pressures] (1.2: 13).

I would like to do more exercise but when I get home from work I am too tired. But I know that is what I should be doing (3.1: 41).

Women with partners and/or children may be further constrained in their uptake of responsive strategies during the night. While lone women are free to turn on the light to read, listen to the radio, or clatter around the house at night making cups of tea, other women experience a sense of guilt in adopting strategies which may disturb their partner's sleep:

My partner has real sleep problems so I feel bad if I wake him up because I know how hard he finds it to sleep (1.2: 24).

These constraints may also affect the use of relocation as a response to sleep disruption. While this strategy is popular with some women, others are reluctant or unable to move because of the perceived stigma associated with partners sleeping apart. The following interaction gives insights into women's attitudes to sleeping apart in our culture which emphasizes togetherness. The focus groups provided a ‘safe’ environment for the discussion of an otherwise sensitive and to some extent taboo topic:

A:Well we go to bed at the same time. Not very successfully though.

Int:Why?

A:We just keep each other awake, it's terrible. It's terrible because we haven’t been together all that long really.

B:Oh, so you’re in love?

A:It's terrible because if he is asleep I’m awake and if I’m awake he's asleep. It just doesn’t work, so I mostly go to the other room and we are getting on better that way.

Int:That's interesting, separate beds.

A:You can start together, you can finish together, but actually sleeping is . . .

Int:Do many people find that works as a solution?

B:Yes . . . He will disturb me when he comes to bed and then apparently I snore or then I have these horrendous dreams and I really do shout, so I wake him. So it's fortunate we’ve got a spare bedroom across the landing. It's the only way I’m going to get some sleep. . . .

C:I think actually more people than you think have separate rooms . . .

B:I feel a separation but he doesn’t. It matters to me that we are together and he says ‘I need my sleep’. I think there is this sort of, for me anyway personally, I don’t like to admit that maybe he spends more time across in the other bed. And there is something about getting older and the separation thing – I don’t know, perhaps I’m not grown up enough about it yet.

D:I don’t know. It does happen quite a lot though.

E:I think people don’t tell you about it.

Int:Why?

E:Perhaps they feel it's a sign that you’re not so close

F:The culture sort of is altogetherness, isn’t it? (4.1: 28–31)

Yet while these personalized activities may form the inner core of women's sleep management practices, they are not always successful in rebalancing women's sleep patterns. Faced with the consequences of sleep disruption having a significant impact upon on their ability to carry out roles and responsibilities effectively, women have traditionally sought help from their GPs, thus medicalizing the management of their sleep. We now look at the role of medicalization in the management of women's sleep in more detail.

Medicalization: the other end of the spectrum

  1. Top of page
  2. Abstract
  3. Introduction
  4. The medicalization of women's sleep
  5. Managing women's sleep within a healthist culture
  6. Personalization: the hidden dimension of women's sleep management
  7. Method
  8. Personalization: the core of sleep management
  9. Medicalization: the other end of the spectrum
  10. Challenging the medicalization of sleep
  11. Healthicization: the link between personalization and medicalization
  12. Conclusion
  13. Acknowledgements
  14. References

According to Conrad (1992), medicalisation involves the adoption of a medical vocabulary and a medical approach involving interaction between the doctor and patient in treating the problem. In the case of specific sleep disorders, such as sleep apnoea, restless legs syndrome and narcolepsy, where the terminology, diagnosis and treatment are well defined, the pathway to medicalization and thus legitimization of the condition is clear. Yet these disorders are relatively rare and thus outside the experience of most women. Of the 82 women who participated in this study, only one had been diagnosed as suffering from a sleep disorder. In the following excerpt, this woman describes her diagnosis of sleep apnoea and treatment with a mask to help her breathing:

I’d been on holiday and shared a room with my daughter. She used to say ‘I’m frightened at night because you stop breathing’. And I was then working at the (name of hospital) and I saw this sleep clinic and I made enquiries. You had to be referred by your doctor. So I think I went to my doctor and just asked to be referred to the sleep clinic. So that was just a straightforward referral. . . . I went to the sleep clinic. . . . I’ve got sleep apnoea and they give you this awful ghastly mask thing (4.1: 51).

Yet while the medicalization of sleep disorders such as this is unchallenged, the medicalization of ‘normal’ sleep disruption is more problematic. As the following excerpts show, medicalization is a carefully considered process which takes place when sleep disruption falls outside the parameters of what is acceptable and normal for the woman concerned and thus is seen as outside her control. While life crises and transitions may provide the trigger for consultation, the medicalization process is prefaced not by personal discomfort alone but by the social implications of severe sleep disruption on performance of daily roles and responsibilities. Rather than representing a transfer of responsibility for sleep to the medical profession, medicalization in this case is the outcome of women evaluating the need for professional help to restore a state of equilibrium and effective functioning. In the first excerpt, one woman, whose father's death co-incided with the birth of her second child, was given a six-week course of Temazepam to help re-establish her sleep patterns to enable her to deal with the crisis of bereavement and the need to look after her children. In the second excerpt, sleeping pills acted as a bridge between the shock of a marriage break-up and the need to carry out duties as the principal of a nursery unit:

It was one of those things whereby you are exhausted, but you can’t sleep . . . at night everything is jangling and that's when you start to get into trouble, and you can obviously go downhill fast at that point. . . . I had this baby to look after and her older sister, so it was pretty crucial really [to go to the GP] (1.1: 46).

I first got to know about it (husband's affair) during the Christmas holidays and I knew I had to go back to work round about 6 January and you don’t face 39 small children and two or three staff when you haven’t slept – at least I don’t – and I went to the doctor and she advised Temazepam (4.1: 36).

The role of crisis reported by women as triggering the push towards medicalization of sleep is acknowledged by GPs in this study. Going to the GP is seen as a last resort when all other measures fail, indicating further a strong sense of individual responsibility for finding non-medical solutions to sleep problems:

It's a build up to a crisis and they just feel they can’t go on. They often use that phrase ‘I just can’t go on any longer’. They think they can deal with it and then the longer it goes on, or some silly mistake they’ve made because they’re tired, makes them come in . . . often they’ve tried over-the-counter things first before they come (GP002).

Sleep may also be drawn into the orbit of medicalization through its association with other medicalised conditions, such as the menopause and depression. In the case of menopausal symptoms, compromised sleep, and its consequences for women's ability to function during the day, is a key factor in their decision to consult a GP. In this case, HRT, designed to ameliorate menopausal symptoms, may act as a de facto sleeping pill by removing the cause of sleep disruption and restoring pre-menopausal sleep patterns:

Int:Do many of your women patients complain of sleep problems?

GP:Yes, the principal lot are peri-menopausal women who want HRT, who say ‘if you don’t give me HRT I will hang myself because I can’t sleep, I can’t concentrate, I’m so tired’ . . . HRT for the peri-menopausal group is startlingly effective – usually their sleep patterns are restored within two weeks (GP002).

For some women, the period of medicalization may extend beyond the initial crisis which prompted consultation and treatment. This is particularly the case with women who remain addicted to tranquillisers first prescribed in the 1960s and 1970s and are reliant on the medical profession to continue to meet their need for medication. For some GPs, there is a tension between patient demands for medication, prescription guidelines, and new ways of thinking about drug use and the treatment of sleep problems:

We still have a lot of people in the practice who were put on benzos in the 60s who 30 years later are still on them – they just can’t stop them – they understand that and they want to stay on them (GP002).

GP:We have a lot of people on sleeping tablets who I think are addicted to them. Temazepam. There are some people who I think just need them. We do a review once a year. We try and cut them down but if they can’t then . . .

Int:Does it affect their sleep long term?

GP:I think it doesn’t work, it's not effective. . . . The thought of people being on long-term sleeping tablets is not what I think is good medicine but maybe it's the only answer in some cases (GP004).

The perceived effectiveness of prescription sleeping pills has meant that some women choose to continue to use medicalized strategies to manage their sleep on an on-going basis to help counteract the stresses and worries which affect their ability to sleep and perform optimally the following day. For some women, however, the psychological panacea of having medications available may be at least as important as the actual therapeutic effects, with sleeping pills becoming part of the broader spectrum of personalized strategies which underlie the day-to-day management of women's sleep:

I quite often have sleeping tablets in the house actually. To some extent it depends what is happening the day after. If I am supposed to be working then yes, I will resort to sleeping tablets (3.2: 19).

I take them occasionally – Temazepam – if I have to, but some nights if I can’t sleep I think I am going to pretend to have taken them. . . . I say ‘let's pretend’ and I am lying here because I am expecting that lovely sleep and it does [come] (4.2: 31).

Yet while medicalization continues to play a role in women's sleep management, it takes place today within an environment of growing disillusionment and fear in which the medicalized treatment of sleeping problems is considered almost a form of deviant behaviour.

Challenging the medicalization of sleep

  1. Top of page
  2. Abstract
  3. Introduction
  4. The medicalization of women's sleep
  5. Managing women's sleep within a healthist culture
  6. Personalization: the hidden dimension of women's sleep management
  7. Method
  8. Personalization: the core of sleep management
  9. Medicalization: the other end of the spectrum
  10. Challenging the medicalization of sleep
  11. Healthicization: the link between personalization and medicalization
  12. Conclusion
  13. Acknowledgements
  14. References

The medicalization of a normal event such as sleep involves the concurrent transfer of control for the condition from the patient, and the acceptance of responsibility for treating the condition to the medical profession. While in the past the diagnosis of insomnia and subsequent prescribing of tranquillisers to patients presenting with sleep disruption met these criteria, today the willingness of women and their GPs to support the medicalization of sleep as they did in the 1960s and 1970s is tempered by media alerts about the safety of long-term tranquilliser use:

A recent TV programme about how one shouldn’t have it (tranquillisers) did an awful lot to help us not have to prescribe it. They (patients) don’t believe us but they’ll often believe the telly (GP005).

The resulting stigmatized perception of tranquilliser use in the community, fear of addiction, restrictions on prescription, and the desire by some GPs to promote more holistic approaches to the treatment of sleep disruption have contributed to a shift in faith in the medicalization ideal and a trend towards the demedicalization of sleep. Fear of addiction is very real for women taking sleeping medication. There is a sense of conflict between the need to find an effective remedy to overcome sleep problems and the desire to restrict intake. This can result in patient reluctance to acknowledge poor sleep as problematic, or indecision about whether or not to take prescription medication, each indicative of feelings of discomfort with the medicalization process:

Sometimes they (patients) don’t say anything, they just look terrible and you just sort of say ‘how is your sleep going?’ and then they’re often quite pleased and they’ll elaborate on that cause they might not have felt it appropriate to bring this up in this day and age (GP001).

I feel very worried about taking them and I don’t want to feel dependent. I find I am always saying ‘Do I need one tonight?’ because I have really got to do this, this and this tomorrow and should I have one tonight because I really need a good night's sleep (2.2: 42).

Moreover, the language used by women when describing their use of prescription sleeping medication suggests a stigmatized perception in the community surrounding drug use. This may reflect an underlying belief among women that the management of sleep, as a natural process, should remain within their control. To admit to taking pills implies a sense of guilt and shame associated with acknowledgement of deviation from the norm and loss of control over sleep management. As one woman says ‘I took them very reluctantly because I felt it was giving in by having sleeping tablets’ (4.1: 36). As shown in the following excerpts, the use of qualifying statements may represent an attempt by women to ‘save face’ by distancing themselves from the stigma and guilt which they feel surrounds sleeping pills:

I just have to have some [Temazepam] there psychologically and the doctor is really nice and it is OK. I am not addicted or anything like that (2.2: 965 – authors’ emphasis).

My doctor gave me some (Temazepam) I think at Christmas because I wasn’t sleeping but I don’t like taking them. I just keep them by (4.2: 32 – authors’ emphasis).

Responding to prescription guidelines, GPs may have effectively become active participants in the demedicalizing of sleep, trying to balance the needs of their patients against perceived risks associated with long-term use. This shift is evident when comparing the medicalization of sleep in the 1960s and 1970s, with the approach used by GPs today. In the following excerpt, Mary describes her experience of being prescribed Mogadon after a major crisis in the family affected her sleep:

Mary:I got prescribed in the 70s when doctors were dishing them out. I don’t know if anybody saw that Panorama1 (about tranquilliser addiction)? And I thought, well, that was me.

Int:What did they give you?

Mary:Mogadon. They were saying, ‘oh no you won’t get addicted, it's fine’.

Int:So how long were you on them?

Mary:18 months I should think. I had a private prescription, you could just go back to the pharmacist and they just repeated it . . . when I tried to stop I got cold turkey, it was ridiculous. I thought, I still need these (5.1: 29).

On the advice of her pharmacist, Mary was eventually able to ‘wean’ herself off the medication. The experience, however, has made her reluctant to use sleep medication, preferring instead to rely on her own resources to overcome sleep disturbance:

I’ve never touched anything since. I refuse on principle. I look after myself (5.1: 29).

The 1970s approach described by Mary contrasts with that of those GPs who are adopting a more holistic approach to their treatment of sleep problems. One GP interviewed speaks of the need for open dialogue between doctor and patient to understand sleep problems in relation to the social context of women's lives rather than simply to prescribe a potentially addictive remedy which provides, at best, a temporary solution to a deeper concern:

General practice is very useful because you’re not looking at bits of people, you’re looking at the whole person and that's what's important, and often if you look at the whole person then the sleep problem falls into place . . . Part of it is just listening and either acknowledging that it needs dealing with or that they don’t – it's not a disease and it's only part of normality . . . half the people don’t need pills, they just need to talk about how they’re feeling. I usually try to do that first and ask them to come back and tell me how they’re feeling in a few weeks. If they’re not feeling any better I’d use a small amount of Amitriptyline – two weeks to start off with – I’d tell them they don’t need to take it regularly (GP001).

The reluctance of some GPs to prescribe tranquillisers has, however, at times brought them into conflict with women seeking effective medication for sleeping problems, in so doing denying them access to medication which can alleviate symptoms and restore a sense of balance to their lives:

For about the last six years for a minimum of two nights and usually a maximum of four nights I just don’t sleep at all, and then within 24 hours my period will start and I can sleep again. And the doctor won’t give me sleeping tablets! I’ve even asked for a hysterectomy, I’m so bad with it (1.1: 35).

Yet while wishing to adopt a more holistic approach to treating sleep problems, GPs are constrained by time in educating patients in alternative treatment options. Most consider, in mirroring the views expressed by women, that when patients reach the GP with a sleeping problem, they have exhausted all other options and are seeking prescription medication:

Int:Do you suggest behavioural or lifestyle changes?

GP:Yes, but they’ve usually tried all those before they come to me – a nice walk with the dog, a cup of Ovaltine, a hot bath, relaxation – sometimes I send people for self-hypnosis which works (GP002).

Int:Do women ever talk about taking herbal remedies and things like that?

GP:Yes, they’ve tried things like Nytol and Kalms and camomile tea and those sort of things. If it's worked they don’t come. . . . We talk about caffeine and relaxing and that, but bear in mind we’ve only got 10 minutes. I’ve had leaflets on and off (GP004).

These time constraints are referred to by women themselves who express doubts as to the ability of their GP to solve most sleep problems given their complex aetiology and the limited consultation time available in primary care. Rather than accuse GPs outright of lacking the expertise to deal effectively with sleeping problems, women prefer to preserve the professional status of the medical profession by referring to the constraints of the system. What is emerging, however, is a shared preference between doctor and patient for demedicalizing sleep in favour of self-responsibility, at least until all other avenues have been exhausted:

A:I think I’d go down the alternative route first but if it (sleep problem) intruded into my life that I couldn’t solve it then I would go to my GP. But I’m not sure your GP is the right person to deal with something like that.

Int:Why?

A:Because it's such a complex situation that you can’t solve in such a short period of time.

B:They’re not experts on sleep.

C:They can write you out a prescription, but . . .

A:It's like a lot of these things. You go to the GP with a problem and if it is a standard ‘this is the cure’ then that's the right place to go. But if it's another problem which is much more complex and affects more than just ‘I’ve got eczema’ and he gives you the right cream, it's taken beyond it and I think you need more than that GP. Not that he's not capable or educated enough to do it, it's the fact that they don’t have enough time to deal with such things (2.1: 46).

In the past 20 years, medicalization, once the core of women's sleep management, has been subjected to challenges from the media, the public and the medical profession. The growing scepticism towards the medical profession and the potential dangers of hypnotics have encouraged the adoption of more holistic approaches to sleep management. In an increasingly healthist culture, responsibility for sleep management has shifted from the medical profession to women themselves, mediated by the pharmaceutical and alternative health care industries.

Healthicization: the link between personalization and medicalization

  1. Top of page
  2. Abstract
  3. Introduction
  4. The medicalization of women's sleep
  5. Managing women's sleep within a healthist culture
  6. Personalization: the hidden dimension of women's sleep management
  7. Method
  8. Personalization: the core of sleep management
  9. Medicalization: the other end of the spectrum
  10. Challenging the medicalization of sleep
  11. Healthicization: the link between personalization and medicalization
  12. Conclusion
  13. Acknowledgements
  14. References

It is perhaps the increasing disillusionment with the medical profession as a source of expertise and the growing consensus between doctor and patient towards a more holistic view of sleep disturbance which has opened the door to the forces of commercialism. In so doing, women's sleep is placed within the orbit of healthicization.

The ready market in over-the-counter sleep remedies ensures the maintenance of a sense of self-responsibility for sleep while offering a viable alternative to medical intervention. Alternative remedies mediate between personalized strategies and medicalization, providing a second-tier response mechanism to sleep disruption. Women in the study refer to a wide range of alternative products and practices which they have tried in an effort to improve their sleep, ranging from herbal teas, lavender pillows and relaxation tapes, to herbal sleeping pills, homeopathic remedies and acupuncture. Yet there is a healthy degree of scepticism which characterises women's responses to these products and doubts as to their overall efficacy. The following excerpts give insights into the process of evaluation which underscores women's use of these products. Whereas in the past, medical professionals may have provided input into treatment options, in the era of healthicization and self-reliance, it is women's peer groups who form the key point of contact and information source. In the first excerpt, a woman discusses what, for her, has been an ideal strategy to counteract the disruptions to her sleep caused by menopausal symptoms:

I had this doctor who said try Red Clover [for menopausal symptoms] and that worked . . . before I took it I felt as though I was in a fog sometimes and I think that's because of lack of sleep – you know, feeling very anxious and irritable and snappy (2.1: 16).

In this case, the herbal remedy improved the quality of her sleep, did not interfere with others in the house, was suggested by her doctor (thus indirectly validating its safety), had no side effects, was acceptable socially, and helped her improve her concentration and interpersonal relationships. Yet this viewpoint is contradicted by another woman, for whom Red Clover failed to live up to expectations:

A:I started taking Red Clover with a research project [on menopause] but I gave up.

Int:Did it work?

A:No, it didn’t work at all. I felt awful. I didn’t want to go on with it (2.1: 35).

In the following excerpts, women discuss their different experiences of taking the over-the-counter sleep medication, Nytol. The willingness of women to discuss openly their use of these products marks a departure from data regarding tranquilliser use in which women were more circumspect (see above). In these interchanges, women appear to welcome the opportunity to share their experiences, providing information on sourcing the product, product content and effectiveness:

A:I took Nytol for a while.

Int:Was it from the chemist?

A:Yes.

B:Is that herbal?

A:No, chemical.

B:I took the herbal ones for sleep, but they were a complete waste of time.

C:Oh, I took them last year and I thought they were really helpful.

D:I have always got a herbal sort of remedy in my cabinet. Just in case.

Int:And do they work when you take them?

D:Well, yes they do, but I’m not sure whether it's psychological (1.2: 31).

At the same time, however, there remains a degree of scepticism about the use of herbal remedies which may cause women to question their use as a sleep strategy. In referring to the use of herbal remedies where there is as yet no scientific proof of their efficacy, one woman states:

I always assumed if it was any good they wouldn’t flog it to you over the counter. You would have to get it on prescription (1.1: 36).

Yet if pharmaceutical companies are looking to the medical profession for support, they are mistaken. The GPs interviewed in this study expressed doubt as to the value of these products in the armoury of sleep medication:

Int:Do many women try alternative remedies for their sleep?

GP:Some of them do, less here than where I worked before. It's less middle class here. There, people read lots and they’re more worried about things. I don’t know what they take, but to be honest, they don’t seem to be terribly effective (GP003).

So does this approach to sleep management really reflect a trend towards the healthicization of sleep? From the perspective of increased self-reliance, it can be argued that women have incorporated aspects of a healthist approach to the management of their sleep. However, if healthism is defined in terms of a response to perceived risk to long-term future health outcomes, then the relationship with women's sleep management is less clear. There is in fact little evidence in the data to suggest that media focus on the risks of poor sleep to future health is having a significant influence. While women's sleep may improve indirectly as a result of healthy lifestyle practices, it is doubtful whether women recognize a direct relationship between sleep and long-term health outcomes.

Rather than being a true reflection of a shift in approach to sleep management, the trend to healthicization has in effect provided a bridge between self-directed strategies and medicalization. Thus, the cornucopia of resources now available through the commercialization of sleep has provided women with a wider choice of strategies in managing their sleep. If women have always accepted responsibility for managing their sleep, then healthicization has been a welcome addition, increasing the range of options available in the quest to restore balance and normalcy in sleep as a precursor to short-term social function.

Conclusion

  1. Top of page
  2. Abstract
  3. Introduction
  4. The medicalization of women's sleep
  5. Managing women's sleep within a healthist culture
  6. Personalization: the hidden dimension of women's sleep management
  7. Method
  8. Personalization: the core of sleep management
  9. Medicalization: the other end of the spectrum
  10. Challenging the medicalization of sleep
  11. Healthicization: the link between personalization and medicalization
  12. Conclusion
  13. Acknowledgements
  14. References

Women's sleep takes place against a complex backdrop of physical, psychological and social factors which interact to create the potential for sleep disruption. It is not surprising, therefore, that sleep disruption has become an expected, though unwelcome, characteristic of mid-life and older women's experiences of sleep. In this context, the management of sleep disruption is equally complex. As the above data suggest, women's sleep management can be perceived as another chapter of the medicalization story with the medical profession continuing to play an important, though less dominant, role in the diagnosis and treatment of specific sleep disorders, and in the prescription of tranquillisers to those with serious sleep disturbances. At the same time, women's sleep management takes place within a dominant healthist culture which focuses on the preservation of good health through behavioural and lifestyle changes, with the support of over-the-counter medications and alternative health practices.

To uncover the full story of women's sleep, however, we must look within women's experiences of sleep, played out within their individual social context, to reveal the personalized activities which provide the pivotal axis of sleep management. The solutions they choose will reflect the overrriding need to balance the demands of their responsibilities within and outside the household with their need for sleep. For many women, sleep management will take place exclusively within the domain of personalized strategies without the need for healthist remedies or prescription medication. For other women, the availability of non-prescription medications and complementary health interventions provides an optional second-level resource when personalized strategies fail and when self-treatment is favoured as an interim stage before medicalization. In the prevailing healthist culture where responsibility is focused on the individual, the involvement of the medical profession in the treatment of sleep disturbance is seen as a marked response, to be engaged in only when all other measures have been tried unsuccessfully and when the impact of sleep disturbance poses a serious threat to health and wellbeing.

The management of women's sleep thus needs to be seen as comprising a core of personalized activities, with links to healthicization and medicalization. While ultimate responsibility for strategy choice rests with the individual, the degree of actual control which women have over their sleep management must be seen in relation to the social context in which their sleep takes place. While at the level of personalization women may have a range of strategies available through which to mediate sleep disruption, the contextualisation of sleep within the home necessarily imposes constraints on the utilization and outcomes of these measures. Similarly, while healthist remedies are readily available, the pressure of the pharmaceutical and alternative health care industries, attitudes to these products and socio-economic circumstances may affect uptake. Moreover, medicalization is influenced by media alerts and public opinion, which mediate use and, in some circumstances, may even block access to a potentially effective short-term sleep management strategy. Sleep management therefore becomes a considered choice between a number of options which claim to restore the promise of a good night's sleep set within the constraints of social context. Regardless of the options chosen, however, the key goal in all cases remains the restoration of balanced sleep patterns, maintained through the on-going use of personalized strategies, which enable women to participate fully in their roles and responsibilities within the public and private spheres.

Note
  • 1

    Panorama, a British TV documentary programme, broadcast 13 May 2001.

References

  1. Top of page
  2. Abstract
  3. Introduction
  4. The medicalization of women's sleep
  5. Managing women's sleep within a healthist culture
  6. Personalization: the hidden dimension of women's sleep management
  7. Method
  8. Personalization: the core of sleep management
  9. Medicalization: the other end of the spectrum
  10. Challenging the medicalization of sleep
  11. Healthicization: the link between personalization and medicalization
  12. Conclusion
  13. Acknowledgements
  14. References
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