The Sociology of the Body PDF

6 The Sociology of the Body Sarah Nettleton In Tom Stoppard’s (1967) play Rosencrantz and Guildenstern are Dead, the two central characters lament the precariousness of their lives. Rosencrantz seeks solace in life’s only certainty when he comments th...

6 The Sociology of the Body Sarah Nettleton In Tom Stoppard’s (1967) play Rosencrantz and Guildenstern are Dead, the two central characters lament the precariousness of their lives. Rosencrantz seeks solace in life’s only certainty when he comments that “the only beginning is birth and the only end is death – if we can’t count on that what can we count on?” To this he might have added that he could reliably count on the fact that he had a body. The “fact” that we are born, have a body, and then die is of course something that does seem to be beyond question. It is something that we can hold on to, as we live in a world that appears to be ever more uncertain and ever more risky (Shilling and Mellor 2017). But is this fact so obvious? Ironically, the more sophisticated our medical, tech- nological, and scientific knowledge of bodies becomes, the more uncertain we are as to what the body actually is. For example, technological innovations can disrupt boundaries between the physical (or seemingly natural) and social body. With the development of assisted conception, when does birth begin? With the development of life-extending technologies, when does the life of a physical body end? With the development of prosthetic technologies, what constitutes a “pure” human? It seems the old certainties around birth, life, and death are becoming increasingly unstable. It is perhaps not surprising, therefore, that attempts to understand the social and eth- ical significance of the body have become central to sociological debates. Attempts to develop a sociological appreciation of the body important in the subdiscipline of the sociology of health and illness. Health, disease and illness are fundamentally embodied experiences that are embedded in social contexts (Nettleton 2020). How bodies are conceptualized, maintained, monitored and managed is therefore pro- foundly political and so contentious. The aim of this chapter is to delineate some of the key developments in the sociological theorizing of the body and to assess their significance for a number of substantive issues in medical sociology. To meet this aim, the chapter will first review the main perspectives on the sociology of the body and social theorists who have informed each of these approaches. Second, the The Wiley Blackwell Companion to Medical Sociology, First Edition. Edited by William C. Cockerham. © 2021 John Wiley & Sons Ltd. Published 2021 by John Wiley & Sons Ltd. 106 Sarah Nettleton chapter will outline the parameters of the sociology of embodiment or perhaps more ­appropriately an embodied sociology. Concepts which have emerged from these debates such as flexible immunity bodies, body projects, biovalue and virtual bodies will also be discussed. Finally, a number of substantive issues which are central to medical sociology will be considered to highlight the merits of incorporating the body into the analysis of matters associated with health and illness. These issues are: illness and injury, body work, and embodied health inequalities. Sociological Perspectives on the Sociology of the Body There is a substantial literature on the sociology of the body which spans a range of perspectives. There are, however, alternative ways in which the body is understood and analyzed, with the most obvious approaches being rooted within the physical sciences and classified as being part of a naturalistic perspective (Shilling 2012). In this chapter, however, we will focus on three main sociological approaches. First, those which draw attention to the social regulation of the body, especially the way in which social institutions regulate, control, monitor, and use bodies. Our bodies are highly politicized. Whilst we might like to think that we own and have control of our own bodies and what we do with and to them, we do not. What we can do with our bodies is constrained by legal diktats and social norms, as is evident in contemporary debates on topics such as euthanasia, organ transplantation, and abortion. Feminist scholars have illustrated ways in which medicine has for centuries controlled the bodies of women (Martin 1989; Mason 2013; Ussher 2006). Regulatory practices further constrain bodies through processes of categorization which can be difficult to resist, a readily obvious example is the imposition of static gender categories often rooted in biological essentialism (Connell 2012). A view that prompts important questions about the ontology of the body. A second perspective within the sociology of the body focuses on the ontology of the body. A number of theorists have asked the question: What exactly is the body? Their answer is that in late modern societies we seem to have become increasingly uncertain as to what the body actually is. For most sociologists the body is to a greater or lesser extent socially constructed. However, there are a number of variants of this view, with some arguing that the body is simply a fabrication (Armstrong 1983) – an effect of its discursive context – while others maintain that bodies display certain characteristics (e.g. mannerisms, gait, shape) which are influenced by social and cultural factors. Productive conceptual frameworks however recognize the inter- play between the biological body and social relations. Reflecting gender for example, and the “gender-biology nexus” Annandale and her colleagues (2018), outline a the- oretical framework that takes into account the “gender-shaping of biology” and the “biologic-shaping of gender” seeing these as co-“constitutive shaping processes.” This approach is helpful not least because it moves beyond an ontological impasse but also helps us appreciated how gender inequalities in health operate (Williams and Bendelow 1998). The third approach pays more attention to the way the body is experienced or lived. Whilst this phenomenological orientation accepts that the body is to some  The Sociology of the Body 107 extent socially fashioned, it argues that sociology must take account of what the body, or rather embodied actor, actually does. In this sense it is perhaps more accurately described as a sociology of embodiment or embodied sociology rather than a sociol- ogy of the body. This approach to the study of the body has gained much currency, particularly in relation to illness (Carel 2016; Leder 1990). It has to some extent emerged as a result of creative debates within this field of study which have attempted to counter the dominant structural approach that concentrates on the social regula- tion of bodies. This research, which has outlined the ways in which bodies are socially regulated however, remains crucial for our understanding of the body in society. Social Regulation of Bodies In his book Regulating Bodies, Turner (1992) suggests that late modern societies are moving toward what he refers to as a “somatic society;” that is, a social system in which the body constitutes the central field of political and cultural activity. The major concerns of society are becoming less to do with increasing production, as was the case in industrial capitalism, and more to do with the regulation of bodies. Turner (1992: 12–13) writes: our major political preoccupations are how to regulate the spaces between bodies, to monitor the interfaces between bodies, societies and cultures … We want to close up bodies by promoting safe sex, sex education, free condoms and clean needles. We are concerned about whether the human population of the world can survive global pollution. The somatic society is thus crucially, perhaps critically structured around regulating bodies. The concerns of the somatic society are also evidenced by the way in which con- temporary political movements such as, pro- and anti-abortion campaigns, debates about fertility and infertility, and disabilities coalesce around body matters (Ettorre 2010), as do politics of environmentalism all of which highlight our embodied vul- nerabilities (Bulter 2015). Bodies are regulated within society through the institu- tions of governance notably law, religion, and medicine. The role of religion, law, and medicine is especially evident at the birth and death of bodies. As society became more secularized it also become more medicalized, with medicine now serving a moral as well as a clinical function (Busfield 2017). Developing an analytical framework which works at two levels – the bodies of individuals and the bodies of populations – Turner (2008) identifies four basic social tasks which are central to social order. We might refer to these as the four “r” s. First, reproduction, which refers to the creation of institutions that govern popula- tions over time to ensure the satisfaction of physical needs, for example the con- trol of sexuality. Second, the need for the regulation of bodies, particularly medical surveillance and the control of crime. Third, restraint, which refers to the inner self and inducements to control desire and passion in the interests of social organization. Fourth, the representation of the body, which refers to its physical presentation on the world’s stage. Turner’s conceptualization of these four “r”s owes a great deal to the ideas of Foucault, especially his writings on normalization and surveillance. These draw 108 Sarah Nettleton attention to the ways in which bodies are monitored, assessed, and corrected within modern institutions. A central theme which runs through Foucault’s (1976, 1979) work is that the shift from pre-modern to modern forms of society involved the dis- placement of what he terms sovereign power, wherein power resided in the body of the monarch, by disciplinary power, wherein power is invested in the bodies of the wider population. Disciplinary power refers to the way in which bodies are regu- lated, trained, maintained, and understood; it is most evident in social institutions such as schools, prisons, and hospitals. Disciplinary power works at two levels. First, individual bodies are trained and observed. Foucault refers to this as the anatomo- politics of the human body. Second, and concurrently, populations are monitored. He refers to this process as “regulatory controls: a bio-politics of the population” (Foucault 1981: 139). It is these two levels – the individual and the population – which form the basis of Turner’s arguments about regulating bodies that we have discussed above. Foucault argues that it is within social institutions that knowledge of bodies is produced. For example, the observation of bodies in prisons yielded a body of knowledge we now know as criminology, the observation of bodies in hospi- tals contributed to biomedical science, epidemiological surveys of communities gen- erate knowledge of health risk factors. In fact, it was the discourse of pathological medicine in the eighteenth century which formed the basis of the bodies in Western society that we have come to be familiar with today. The surveillance and more especially self-surveillance of bodies has dispersed exponentially since Foucault was writing, but not in ways that his thesis would anticipate. Not least because technologies have become networked through a mul- tiplicity of digital self-monitoring and self-tracking devices that generate data on individuals everyday bodily practices such as, sleeping, walking, running, eating and breathing. These data may be of value not only to individuals keen to reflect on their own bodily practices, but also to commercial enterprises who harvest vast quantities of data from populations for analysis and marketing. The digital health sector emerges as a major aspect of the contemporary political economy of health, where profits are made from tracking data such that sociologists now speak of “digital bodies,” “quantified bodies” and “the quantified self” (Lupton 2016; Prainsack 2017). Bodies become entangled in digitized networks opening up the potential for generation of novel categorizations of somatic groupings around levels of fitness, weight, diets, sexual practices, alcohol use, and so on. These cat- egorizations may in turn may be classed, racialized, and gendered. Digitized bio- political data is therefore generating somatic social categories suspectable to new modes of regulation. Through these discussions, we can see that the regulation of bodies is crucial to the maintenance of social order. This observation forms the basis of Mary Douglas’s (1966, 1970) classic scholarship on the representation of the symbolic body. The ideas of Douglas – an anthropologist – have been drawn upon extensively by med- ical sociologists. She argues that the perception of the physical body is mediated by the social body. The body provides a basis for classification, and in turn the organi- zation of the social system reflects how the body is perceived. The social body constrains the way the physical body is perceived. The physical expe- rience of the body, always modified by the social categories through which it is known,  The Sociology of the Body 109 sustains a particular view of society. There is a continual exchange of meanings between the two kinds of bodily experience so that each reinforces the categories of the other. As a result of this interaction the body itself is a highly restricted medium of expression. (Douglas 1970: xiii) Thus, according to Douglas (1966), the body forms a central component of any classificatory system. Working within a Durkheimian tradition she maintains that all societies have elements of both the sacred and the profane, and that demarca- tion between the two is fundamental to the functioning of social systems. Thus, societies respond to disorder by developing classificatory systems which can des- ignate certain phenomena as matter out of place. “Where there is dirt there is system … This idea of dirt takes us straight into the field of symbolism and prom- ises a link-up with more obviously symbolic systems of purity” (Douglas 1966: 35). Anything which transcends social, or bodily, boundaries will be regarded as pollution. Ideas, therefore, about bodily hygiene tell us as much about our cultural assumptions as they do about the “real” body and our medical knowledge of it. Furthermore, any boundaries that are perceived to be vulnerable or permeable will need to be carefully regulated or monitored to prevent transgressions (Nettleton 1988; Longhurst 2001). Bodies that transcend boundaries can be politically vul- nerable, most especially where politicians invoke symbolic and cultural represen- tations of bodies deemed as “out of place” as we see in the politics of migration, borders and popular nationalism. Boundaries and classificatory systems play into discrimination that is both en- acted (Shields 2017) and lived. For instance, a qualitative study of Arab Canadian immigrant women found that living in a new country, experiencing isolation and alienation of the body and bodily practices such as infant feeding, eating exercising and so on became sites of frustration (Oleschuk and Vallianatos 2019). The authors found that women talked in terms of embodied boundaries in two ways. One, they framed their bodies in relation to their own bodies when living in their home country and/or in relation to Arab women still living there which portrayed ways of living or a former sense of themselves now lost. Two they also framed their bodies in rela- tion to the dominant images of Canadian women from whom they felt alienated and wanted to resist. The authors suggest that this embodied boundary talk reveals both the structural pressures of immigration, while it also enables them “to reframe the impact of those pressures (i.e. their weight gain and poor eating and exercise habits) into a narrative of immigration based on dignity.” Social changes have bodily correlates in that what bodies are permitted to do, and how people use their bodies, is contingent upon social context. The work of Elias (1978, 1982) demonstrates this on a grand scale. Elias is concerned with the link between the state and state formations and the behaviors and manners of the sociology of the body the individual. He offers a figurational sociology; this means that he works at the level of social configurations, rather than societies. In fact, for Elias, societies are the outcome of the interactions of individuals. In his studies of “The Civilizing Process” (first published in 1939 in German), Elias (1978) examines in detail changes in manners, etiquette, codes of conduct, ways of dressing, ways of sleeping, ways of eating, and changing ideas about shame and decency associated with bodies. According to Elias, the civilizing process began in the Middle Ages 110 Sarah Nettleton within court societies where social mobility became more fluid and people’s futures could be determined not only by their birthrights, as had been the case under the feudal system, but also by the extent to which they were in favor with the sovereign or their advisors. In short, people were more inclined to be on their best behavior. Medieval personalities were characteristically unpredictable and emotional, they were inclined to be indulgent, and there were virtually no codes surrounding bodily functions. However, within court societies, codes of body management were developed and copious manuals were written on how to and where to sleep and with whom, how to behave at meals, appropriate locations for defecation, and so on. Changes in behavior impacted on social relations and, as social relations transformed, so the compulsions exerted over others became internalized. This process, according to Elias, was accelerated in the sixteenth century. His analysis reveals how greater self-control over behaviors was associated with the body and a heightened sense of shame and delicacy: The individual is compelled to regulate his [sic] conduct in an increasingly differenti- ated, more even and more stable manner … The more complex and stable control of conduct is increasingly instilled in the individual from his earliest years as an automa- tism, a self-compulsion that he cannot resist. (Elias 1982: 232–233) This civilizing process involves three key progressive processes (Shilling 2012): socialization, rationalization, and individualization. Socialization refers to the way in which people are encouraged to hide away their natural functions. Thus, the body comes to be regarded more in social rather than natural terms. In fact, we find many natural functions offensive or distasteful; for example, if someone sitting next to us on a bus vomits over our clothes or if someone willingly urinates in an “inappropri- ate” part of our house. Rationalization implies that we have become more rational as opposed to emotional and are able to control our feelings. Finally, individualiza- tion highlights the extent to which we have come to see our bodies as encasing our- selves as separate from others. It is important, therefore, that we maintain a socially acceptable distance between ourselves and others. Furthermore, how we “manage” and “present” our bodies (Butler 1990; Goffman 1959) has become especially salient in a late modern context. Some argue that this is because the body has become a prime site for the formation and maintenance of the modern self and identity. Bodies in Late Modern Societies Sociological theorists have argued that a key feature of such late modern societies is risk (Beck 1992; Douglas 1986; Giddens 1991). Doubt, Giddens argues, is a per- vasive feature which permeates into everyday life. Our self and identity are a con- tinuous embodied reflexive process (Crossley 2006) where we continually revise our biographical narratives. The reflexive self is one that relies on a vast array of advice and information provided by a myriad of sources. What has all this got to do with the body? Well, a number of theorists have suggested that the body has come to form one of the main sites through which  The Sociology of the Body 111 people develop their social identities. Whilst the environment and the social world seem to be “out of control,” the body becomes something of an anchor. Giddens points out that the self is embodied and so the regularized control of the body is a fundamental means whereby a biography of self – identity is maintained. Giddens (1991: 218) states: The body used to be one aspect of nature, governed in a fundamental way by processes only marginally subject to human intervention. The body was a “given,” the often inconvenient and inadequate seat of the self. With the increasing invasion of the body by abstract systems all this becomes altered. The body, like the self, becomes a site of interaction, appropriation and re-appropriation, linking reflexively organised processes and systematically ordered expert knowledge. […] Once thought to be the locus of the soul … the body has become fully available to be “worked upon by the influences of high modernity” […]. In the conceptual space between these, we find more and more guidebooks and practical manuals to do with health, diet, appearance, exercise, love- making and many other things. According to this thesis, therefore, we are more uncertain about our bodies; we perceive them to be more pliable and are actively seeking to alter, improve, and refine them. Flexible Immunity Bodies The idea that contemporary societies are characterized by change and adaptability has also been articulated by Emily Martin (1994) in her empirical study of contem- porary ideas about immunity in North America. By way of data collected via inter- views, analyses of documents, participant observation, and informal exchanges, she (Martin 1994: xvii) found that “flexibility is an object of desire for nearly everyone’s personality, body and organization.” Flexibility is associated with the notion of the immune system which now underpins our thinking about the body, organizations, machines, politics, and so on. In her interviews with ordinary men and women, the idea of developing a strong immune system appeared to be in common currency. To be effective, that is to protect the body against the threats of disease and illness, the immune system must be able to change and constantly adapt. These notions of immunity found on the street reflect those found in labora- tory science where immunological understandings of immunity transformed from understanding of an immune “self” working to defend and discriminate against the foreign “non-self” (Tauber 1995). Tauber documents the fragmentation of the self- versus-non-self (S/NS) system, as immunological understandings of, for example autoimmunity, chimerism, transplantation and parasitism come to see the immune system reconfigured as an “immune-nervous system” with the creative capacity to be “over-written.” Cohen (2009) in his book A Body Worth Defending finds congruence between judicial, political and biological cultures. Network conceptions of immunity displace bounded systems in all these spheres in ways that have led scholars to reflect on im- mune-political life (Davis et al. 2016) and the begin to forge a “biopolitics of immu- nity” (Brown and Nettleton 2018). Brown points to the merits of Italian ­philosopher 112 Sarah Nettleton Esposito’s (2008) notion of an “immunity paradigm” in which the political and biological become inextricably intertwined. While modernist notions of immunity implied enclosure, protection and defense, we now recognize that immunity also requires a degree of openness, “hospitable forms of immunity” that can “preserve life” (Esposito 2008: 53–54). Perhaps, the most readily obvious examples are organ transplantation and vaccination. The latter involving the introduction of a patho- gen for individual and collective benefit, something Durkheim (1982) recognized when writing about how by inoculating ourselves with smallpox, where a vaccine increases our chances of survival through collective, herd immunity. The biopoli- tics of immunity are foregrounded in these and other immunological matters, for example debates on antibiotics and antimicrobial resistance are found to manifest as debates on public politics and personal responsibility (Brown and Nettleton 2017, 2018). What this scholarship offers is not only provides a valuable analysis of late modernity but also reveals how our accounts and interpretations of our bodies are historically and socially contingent, and that they are not “immune” from broad- er social transformations (see also the discussion about the work of Elias above). How we experience our bodies is invariably social, and one of the central thrusts of modern times is the sociology of the body that we feel compelled to work at creating a flexible and therefore adaptable and socially acceptable body. The Body as a Project Shilling (2012) also argues that the body might best be conceptualized as a “body project”; an unfinished biological and social phenomenon, which is transformed, within limits, as a result of its participation in society. The body is in a continual state of “unfinishedness;” the body is “seen” as an entity which is in the process of becom- ing; a project which should be worked at and accomplished as part of an individual “self-identity” (Shilling 2012: 4). Body projects become more sophisticated and more complex in a context where there is both the knowledge and technology to transform them in ways that in the past might have been regarded as the province of fiction. There is a vast array of medical technologies and procedures to choose from if we want to shape, alter, and recreate our bodies – from various forms of techniques to “assist” conception, to gene therapies, to forms of cosmetic surgery and so on. These projects are also gendered as illustrated by Brumberg’s (1998) feminist his- torical analysis of adolescent girls where she finds the contemporary imperative to perfect the appearance of the body displaces the constraints imposed by the social conventions and restrictions placed on young women in the nineteenth century. There is, of course, an irony here. As we expand our freedoms, knowledge, tech- nologies and expertise, to alter bodies we become more uncertain and insecure we become about what the body actually is and what its boundaries are. And yet it also seems that as the opportunities to work on our bodies proliferate they coalesce around a limited range of repertoires that are rooted in ideologies of individual- ism. This is evidenced by Gill et al.’s (2005) study of body projects and the regu- lation of masculinity. Based on 140 qualitative interviews with men aged between 15 and 35 from differing regions in the UK sampled to ensure representation of class, race, and sexual orientation found the authors found “an extraordinary homo- geneity” ran through the men’s talk (p. 56). There was a shared set of discourses  The Sociology of the Body 113 that were ­consistently embraced the merits of: individualism and being different; ­libertarianism and having an autonomous body, rejection of vanity and narcissism, the value of being well balanced and not obsessional and the importance of being a morally responsible body. Men’s body and identity talk the authors argue is struc- tured by a “grammar of individualism” (p. 57). Bio-value and Virtual Bodies Whilst the above discussion has highlighted the body as an unfinished and malleable entity which has become central to the formation of the late modern reflexive self, other postmodern analyses have suggested that the body is not so much uncertain as un/hyperreal. In other words, the body has disappeared – there is no distinc- tion between bodies and the images of bodies. Drawing on the work of Baudrillard, Frank (1992) challenges the conventional idea that the body of the patient forms the basis of medical practice. It is the image of the body which now forms the basis of medical care. Real diagnostic work takes place away from the patient; bedside is secondary to screen side. For diagnostic and even treatment purposes, the image on the screen becomes the “true” patient, of which the bedridden body is an imperfect replicant, less worthy of attention. In the screens’ simulations our initial certainty of the real (the body) becomes lost in hyperreal images that are better than the real body. (Frank 1992: 83) The “Visible Human Project” (VHP), described on the US National Library of Med- icine, National Institutes of Health website as: the creation of complete, anatomically detailed, three-dimensional representations of the normal male and female human bodies. Acquisition of transverse CT, MR and cryo- section images of representative male and female cadavers has been completed. The male was sectioned at one millimeter intervals, the female at one-third of a millimeter intervals. (National Library of Medicine 2008) Fascinated by this undertaking, Catherine Waldby (2000) subjects the VHP to socio- logical scrutiny and highlights some intriguing features. Not only do images of the inner reaches of the body become accessible to a wide audience, but also the trans- formation of bodies into a “digital substance” contributes to the blurring of bound- aries between the real and the unreal, the private and the public, and the dead and the living (Waldby 2000: 6). She argues that the whole exercise represents a further extension of Foucault’s notion of bio-power. The VHP is at once a means of both examining and experimenting on the body and, therefore, it is also a means by which knowledge of bodies is generated and circulated. In addition, the establishment of knowledge contributes to the production of “surplus value” in that there are significant commercial interests that benefit through the related production of medical technologies be they equipment, drugs, and so on. This is what Waldby calls “biovalue,” which refers to the yield of vitality produced by the biotechnological reformulation of living processes” (Waldby 2002: 310). Two factors precipitate the generation of biovalue. First, the hope that biotechnologies 114 Sarah Nettleton will result in a better understanding and thereby treatment of disease. Second, the pursuit of exchange value of biomedical commodities – be they patents or pills – that are the yield of the interventions. Indeed, biovalue is “increasingly assimilated into capital value, and configured according to the demands of commercial economies” (Waldby 2000: 34). The counterpart to the VHP, observes Waldby, is the Human Genome Project (HGP) in that both projects are means by which the body comes to form a database, an archive and so a source of bioinformation. The digitization of bodies however further complicates the dualism between virtual and real bodies presumed in the work of Frank and Waldby. The infiltration of the bodies of the relatively mobile and relatively wealthy by smart, wearable biosensor technologies creates further scope for biovalue and commodification of bodies as evidenced through on-line plat- forms that harvest biodata, such as 23andMe and other genetic testing organizations (Saukko 2018). Historically, perhaps one of the most profound impacts of the production of images is in relation to pregnancy. Barbera Duden (1993) argues that the use of technologies which enable the fetus to be visually represented has contributed to the transformation of an unborn fetus into a life. The imagining of the unborn has meant that the fetus has become an emblem, a “billboard image.” Her study addresses the following puzzles: How did the female peritoneum acquire transparency? What set of circumstances made the skinning of women acceptable and inspired public concern for what happens in her innards? And pertinently: how was it possible to mobilize so many women as uncomplaining agents of this skinning and as willing? (Duden 1993: 7). In an amazingly short space of time, “the scan” became a routine and ubiquitous experience for most pregnant women in many Western societies. This prompts tensions between the way the body is experienced or lived and the way the body is observed and described by “medical experts” (Dumit 2010). This tension is explored empirically by Lie and her colleagues (2019) in their study of parents’ experiences of an in-utero MRI (iuMRI) device that has been developed to increase accuracy of diagnosis of foetal brain abnormalities, it is not therefore used routinely but accessed in addition to ultrasound anomaly scanning. From their analysis of the parents experiences they conclude that while, the “‘medical’ gaze may work to separate the foetal body from its social identity” by contrast “the ‘parental’ gaze often does the opposite, reconstructing or reinforcing foetal and parental identities” (p. 376). Thus the lived experiential, embodied view of the body is retained even in instances where it becomes reduced to representation in a digitized form. Sociology of Embodiment A sociology of embodiment has developed out of a critique that the literature on the body has failed to incorporate the voices of bodies as they are experienced or lived (James and Hockey 2007). Drawing on phenomenological analyses, this approach proposes that much of the existing literature has failed to challenge a whole series of dualisms such as: the split between mind and body; culture and nature; and reason and emotion. Such socially created dualisms are pernicious, not only because they are false, but also because they serve to reinforce ideologies and social hierarchies.  The Sociology of the Body 115 “These dualisms,” Bendelow and Williams (1998: 1) argue, “have been mapped onto the gendered division of labour in which men, historically, have been allied with the mind, culture and the public realm of production, whilst women have been tied to their bodies, nature, and the private sphere of domestic reproduction.” But most important, from a sociological point of view they hinder any effective theoriz- ing which must assume the inextricable interaction and oneness of mind and body. Studies of pain and emotion have, perhaps more than any other, revealed that the body and the mind are not separate entities (Bendelow and Williams 1998). Phenomenology: The “Lived Body” The phenomenological perspective focuses on the “lived body” and the idea that con- sciousness is invariably embedded within the body. The human being is an embodied social agent. The work of Merleau-Ponty, in particular his text The Phenomenol- ogy of Perception has been revisited, and it is regarded by many as critical to our appreciation of embodiment (Crossley 1995, 2006; Csordas 1994). Essentially, he argued that all human perception is embodied; we cannot perceive anything, and our senses cannot function independently of our bodies. This does not imply that they are somehow glued together, as the Cartesian notion of the body might suggest, but rather there is something of an oscillation between the two. This idea forms the basis of the notion of “embodiment.” As Merleau-Ponty (1962) writes: Men [sic] taken as a concrete being is not a psyche joined to an organism, but movement to and fro of existence which at one time allows itself to take corporeal form and at others moves toward personal acts … It is never a question of the incomprehensive meeting of two casualties, nor of a collision between the order of causes and that of ends. But by an imperceptible twist an organic process issues into human behaviour, an instinctive act changes direction and becomes a sentiment, or conversely a human act becomes torpid and is continued absent-mindedly in the form of a reflex. (Merleau- Ponty 1962: 88, cited by Turner 1992: 56) Thus, while the notion that embodied consciousness is central here, it is also high- lighted that we are not always conscious or aware of our bodily actions. We do not routinely tell our body to put one leg in front of the other if we want to walk, or to breathe in through our nose if we want to smell a rose. The body in this sense is “taken for granted,” or as Leder puts it, the body is “absent.” Whilst in one sense the body is the most abiding and inescapable presence in our lives, it is also character- ized by its absence. That is, one’s own body is rarely the thematic object of experi- ence … the body, as a ground of experience … tends to recede from direct experience (Leder 1990: 1). Within this perspective, the lived body is presumed to both construct and be con- structed by, and within, the lifeworld. The lived body is an intentional entity which gives rise to this world. As Leder (1992: 25) writes elsewhere: in a significant sense, the lived body helps to constitute this world as experienced. We cannot understand the meaning and form of objects without reference to bodily powers 116 Sarah Nettleton through which we engage them – our senses, motility, language, desires. The lived body is not just one thing in the world but a way in which the world comes to be. We can see therefore that it is analytically possible to make a distinction between having a body, doing a body, and being a body. Turner (1992) and others have found the German distinction between Leib and Körper to be instructive here. The former refers to the experiential, animated, or living body (the body-for-itself), the latter refers to the objective, instrumental, exterior body (the body-in-itself). This approach highlights that the concept of the “lived body” and the notion of “embodiment” remind us that the self and the body are not separate and that expe- rience is invariably, whether consciously or not, embodied. As Csordas (1994: 10) has argued, the body is the “existential ground of culture and self,” and therefore he prefers the notion of “embodiment” to “the body,” as the former implies something more than a material entity. It is rather a “methodological field defined by perceptual experience and mode of presence and engagement in the world.” This idea that the self is embodied is also taken up by Giddens (1991: 56–57), who also emphasizes the notion of day-to-day praxis. The body is not an external entity but is experienced in practical ways when coping with external events and situations. How we handle our bodies in social situations is crucial to our self and identity and has been extensively studied by Goffman, symbolic interactionists, and ethnomethod- ologists (Heritage 1984). Indeed, the study of the management of bodies in everyday life and how this serves to structure the self and social relations has a long and impor- tant history within sociology. It highlights the preciousness of the body as well as the remarkable ability of humans to sustain bodily control through everyday situations. Marrying the work of theorists such as Foucault and Giddens with the insights of the early interactionists, Nick Crossley (2006) has developed the particularly use- ful concept of “reflexive embodiment.” Premised on Cooley’s (1902) notion of the “looking glass self” and Mead’s (1967) suggestion that we care about, and are influ- enced by, how we think other people see us, Crossley’s thesis is that humans are not merely subjects of regulation but are active agents whose thoughts, actions, and intentions are embedded within social networks. Embodied agents have the capacity to reflect upon themselves and such reflection involves an assessment of what they believe other people (the “generalized other”) think of them. “Reflexive embodiment” refers to the capacity and tendency to perceive, emote about, reflect and act upon one’s own body; to practices of body modification and mainte- nance; and to “body image.” Reflexivity entails that the object and subject of percep- tion, thought, feeling, desire or action are the same. (Crossley 2006: 1) This notion is central to the experience of health and illness, not least because so many bodily practices and techniques are associated with the maintenance and reproduction of bodies to ensure good health and to manage illness. Many of these themes and issues have been explored by sociologists who have studied how people experience illness to explore how bodies are “lived;” how bodies are visualized espe- cially in virtual, digitized spaces then colonized by commercial agencies to generate value and how embodiment shaped by socio-political power relations.  The Sociology of the Body 117 The Sociology of the Body: Some Illustrative Issues Illness and Lived Bodies The literature on the experience of chronic illness and disability drew attention to many of the themes discussed above prior to the more recent emergence of the body and embodiment literature, most particularly the fundamental link between the self and the body. A number of researchers (Broom et al. 2015; Charmaz 2000) have documented how this occurs in the case of chronic illness. Here the relationship between the body and self can be seriously disrupted. Simon Williams (1996) has illustrated this well by drawing on the findings of research into chronic illness. He demonstrates how the experience of chronic illness involves a move from an “initial” state of embodiment (a state in which the body is taken for granted in the course of everyday life) to an oscillation between states of (dys)embodiment (embodiment in a dysfunctional state) and “re-embodiment.” Attempts to move from a dys-embodied state to a re-embodied state require a considerable amount of biographical work as a result of what Bury (1982) calls “biographical disruption” and can prompt people to engage in what Gareth Wil- liams (1984) terms “narrative reconstruction.” Disruptions and reconstructions are neither isolated nor linear, for while illness may disrupt a biographical trajectory it is more likely to be a series of “ruptures” without clear beginnings, middles or ends. As Riessman (2015: 1057) puts it: “Illness by its very nature disrupts any pretense of temporal continuity, for it lacks the coherence that permits us to identify linkages between cause and effect, before and after.” Crucially these notions of biographical disruption and narrative reconstruction should not be understood as purely cognitive or mental processes. Engman (2019) asserts that the analytic purchase of these concepts has been so enduring precisely because of their implicit embodied basis and suggests that this needs to be made more explicit. From her empirical study of 36 post-operative organ transplant recip- ients she finds the salience of biographical disruption as meaningful feature of the illness experience, depends on the degree to which the participants bodily changes involved a distinctive shift between the “intentions of the body and its capacity to manifest those intensions.” In cases where bodily intentions could not be acted upon, in other words the bodies constrained action this was more likely to trigger the artic- ulation of a biographical disruption, than in cases where bodily changes could be incorporated into day to day lives. When illness pierces a subject’s embodied orientation towards the world, she loses the foundation on which day-to-day life is built. The inability to perform habitual behav- iours that results is, essentially, an inability to utilize all of the accumulated embodied knowledge that previously organized daily life. It is no wonder that this prompts people to re-evaluate the ways that they project themselves into the future – stripped of one’s ability to enact routine behaviours, the future is necessarily uncertain. (Engman 2019: 126) The materiality of embodiment is therefore salient and helps to collapse dual- isms between the body as object and subject both as it is experienced and as it is worked upon. 118 Sarah Nettleton Body Work As Twigg and her colleagues (2011) argued book on the body in health and social care, the material body is essential to any adequate analysis of health care in practice. Body work is work that focuses directly on the bodies of others: assessing, diagnosing, handling, treating, manipulating, and monitoring bodies, that thus become the object of the worker’s labour. It is a component part of a wide range of occupations. It is a central part of healthcare, through the work of doctors, nurses, dentists, hygienists, paramedics and physiotherapists. (Twigg et al. 2011: 171) Medicine, health, care, and the body are inextricably interlinked. Analyses of, or policies on, health and social care which overlook the messy realities of the body will invariably be wanting. The rationalistic approach which has tended to dominate policy debates, “presents a bleached out, abstract, dry account that takes little cogni- zance of the messy, swampy, emotional world of the body and its feelings” and Twigg suggests that a focus on the body “promises to bring the world of policy into much closer and direct engagement with its central subject” (Twigg 2006: 173). In what ways can theorizations on the body and embodiment help us to make sense of health care in practice? There are some excellent qualitative studies of health care work within formal settings that can help us answer this question. Julia Law- ton’s (1998) study of care within a hospice is an excellent example. Her ethnographic study sets out to understand why it is that some patients remain within the hospice to die whilst others are more likely to be discharged and sent home to die. To address this health policy puzzle, Lawton argues we need to focus on the body of the dying person. She found that those patients cared for within the hospice were those whose bodies became unbounded. By this she means that the diseases they were suffering from involved a particular type of bodily deterioration and disintegration requiring very specific forms of symptom control, the most common examples being: incontinence of urine and faeces, uncontrolled vomiting (including faecal vomit), fun- gating tumours (the rotting away of a tumour site on the surface of the skin) and weeping limbs which resulted from the development of gross oedema in the patient’s legs or arms. (Lawton 1998: 128) It is these forms of bodily (dys)functions that people living in Western society cannot tolerate rather than the process of dying itself. Indeed, in those cases where the boundedness of their bodies could be reinstated, patients would be discharged. To address the question of why unbounded bodies are unacceptable in Western soci- ety, Lawton draws upon much of the sociological theorizing outlined above – espe- cially the work of Douglas and Elias. The unbounded body is perceived symbolically, according to Douglas, as a source of dirt – it is matter out of place. The increasingly “civilized” body, according to Elias, has become “individualized” and private, and the “natural” functions of the body are removed from public view. The fact that natural or intimate bodily functions are problematic for health care practitioners is also been explored by Lawler (1991), who again draws upon the ideas developed by Elias and Douglas in her study of nursing care in an Australian  The Sociology of the Body 119 hospital. Quintessentially, the work of nurses is about caring for bodies. This becomes a problem when nurses have to attend to those bodily functions (defecat- ing, grooming, etc.) which in a “civilized” society have become taboo. Consequently, nurses have to learn how to negotiate social boundaries and create new contexts so that both the patient and the nurse can avoid feelings of shame and embarrassment. There is a further fascinating finding highlighted in Lawton’s study, and this relates to the link that we have discussed above between the notion of self and physical body. The two are meshed together. Lawton’s work demonstrates that even where there is a “competent” mind, the lack of bodily controls (Nettleton and Watson 1998: 14–17) affects a person’s capacity to continue with their life projects or their reflexive self. In fact, patients who had the least control over their bodily functions exhibited behavior which suggested a total loss of self and social identity once their bodies became severely and irreversibly unbounded. Take Lawton’s account of Deb- orah, for example: When Deborah’s bodily deterioration escalated, I observed that she had suddenly become a lot more withdrawn. After she had been on the ward for a couple of days she started asking for the curtains to be drawn around her bed to give her more privacy. A day or so later she stopped talking altogether, unless it was really necessary (to ask for a commode, for example), even when her family and other visitors were present. Deborah spent the remaining ten days of her life either sleeping or staring blankly into space. She refused all food and drink … One of the hospice doctors concluded that “for all intents and purposes she [had] shut herself off in a frustrated and irreversible silence.” (Lawton 1998: 129) We see how the bounded body is foundational to the representation and reproduction of a coherent self in the context of societies that extol individualism and where the independent, autonomous body is privileged. Embodiment Inequalities in Health A basic tenet of medical sociology is that social circumstances – in particular material and social deprivation – become inscribed in people’s bodies. In other words, it is argued that health status is socially determined. The reasons why social circum- stances, and more especially social inequalities, impact upon health status have been researched and debated for over centuries. By the turn of the millennium sociologists began to theorize about the links between the sociology of embodiment and health inequalities in ways that provide us with important clues as to why health is socially patterned. Freund (1990) argued that people express “somatically” the conditions of their existence. “Emotional modes of being” he writes are very likely to be linked to structural position. Subjectivity, social activity and the social structural contexts interpenetrate. It is this relationship that comes to be physically embodied in many ways. Irregularity of breathing may accompany muscular tension and experiences of ontological insecurity and the anger or fear that is part of this insecurity. (Freund 1990: 461) 120 Sarah Nettleton This link becomes evident when we mesh together the “lived body” and the s­ tructural perspectives on the body. How people experience their structural context, the mean- ings and interpretations, they ascribe to it, in turn impacts their physical bodies (Peacock et al. 2014). It seems, then, that unequal societies equate to unhealthy societies (Wilkinson and Pickett 2010), or rather unequal societies, are associated with unhealthy bodies. This is not just a result of material deprivation and poverty – the harmful effects of poor housing, poor food, and living conditions per se – though these are undoubtedly impor- tant. But what is also important is one’s socio-economic position. Essentially, those people who are lower down the social hierarchy and who have the least control over their circumstances are more likely to be ill. They are more likely to experience pro- longed stress and negative emotions, which in turn have physiological consequences. This psychosocial perspective on health inequalities points to a growing body of research that demonstrates how certain aspects of social life, such as a sense of control, perceived social status, strength of affiliations, self-esteem, feelings of ontological inse- curity, and so on, lead to variations in health outcomes (Bartley 2016; Elstad 1998). It seems that how people reflect upon, emote about, and internalize their social position and social circumstances is critical. Drawing from work in physiological anthropology, in particular studies of non-human primates, researchers have found that primates who were lower down the social hierarchy, and most importantly had least control and power, exhibited more detrimental physiological changes in times of stress. Authors have argued this may help explain the fact that numerous studies have consistently found that people in social environments with limited autonomy and con- trol over their circumstances suffer proportionately poor health. The key issue here is the degree of social cohesion. Greater social cohesion means people are more likely to feel secure and “supported” and are less likely to respond negatively when they have to face difficulties or uncertainties. In turn, it is social inequality that serves to under- mine social cohesion and the quality of the social fabric (Wilkinson and Pickett 2010) Through a comprehensive analysis of research that documents the various path- ways by which austerity and neo-liberal policies come to be embodied into health out- comes, Sparke (2017) develops the notion “biological sub-citizenship.” This extends Rose and Novas’s (2005) concept of “biological citizenship” articulated to describe how novel forms of citizenship, sociality and collective activism are anchored in and coalesce around shared x (often genetic) characteristics. The prefix “sub” shifts the emphasis from shared biological characteristics and highlights instead “how ill- health embodies changing conditions of political-economic subordination” (Sparke 2017: 287). Sparke writes that, a concept of biological sub-citizenship is useful precisely because it provides a relational way of theorizing how such embodied outcomes of austerity actively prevent people from becoming fully enfranchised biological citizens. It thereby allows us to re-evaluate ideas about enfranchisement into biological citizenship in relation to dynamics produc- ing differentials of disenfranchisement. (p. 288) While shared biologies may bring citizens together (biological citizenship), the privileg- ing of global markets combined with neo-liberal economic, health and social policies  The Sociology of the Body 121 that systematically disadvantage particular groups can lead to exclusion, ­exploitation, extraction and so exacerbate precarious embodiment (biological sub-citizenship). Conclusion This chapter has reviewed some of the key theoretical perspectives within the lit- erature on the sociology of the body and the sociology of embodiment. Drawing on these approaches, it has discussed a number of substantive issues which are of interest to those working within medical sociology. Thus, it has attempted to show that a “sociology of the body” and an “embodied sociology” have made an impor- tant contribution to matters which have traditionally been of interest to this field of study. A key theme running through this chapter is that the more knowledge and information we have about bodies, the more uncertain we become as to what bodies actually are. Certainties about seemingly immutable processes associated with birth and death, for example, become questioned. Furthermore, how we experience and live our bodies has also become central to how we think about ourselves. Bodies are politicized both in terms of identities, and also in terms of how they are monitored and marginalized, regulated and relegated, empowered and excluded. 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