Pathology or source of power? The construction and experience of premenstrual syndrome within two contrasting cases

Abstract

This research examines the construction and experience of premenstrual syndrome (PMS) in the context of intimate couple relationships, through examination of two contrasting cases analysed using thematic decomposition of narrative interviews. Judith and her male partner pathologised premenstrual change, constructing the premenstrual self as out of control, and the epitome of the ‘monstrous feminine’. Judith reported feeling over-burdened and uncontrollably angry premenstrually, associated with relationship issues and absence of partner recognition or support. In contrast, Sophia normalised premenstrual change, challenging the association between PMS and the construction of woman as deviant or dysfunctional. Sophia reported heightened energy and creativity premenstrually, and engaged in self-care supported by her woman partner. These cases demonstrate that premenstrual distress is an intersubjective experience, with constructions and material practices within relationships providing the context for premenstrual women being positioned as pathological and needing to be contained, or conversely, as sensitive and needing support.

Keywords

Premenstrual syndrome critical realism case studies narrative thematic decomposition relationships lesbian health women’s health

Introduction

For centuries, expert explanations for women’s reproductive distress have centred on the corporeal body, with the wandering womb, and more recently raging hormones or neurotransmitter imbalances, positioned as to blame. In Western medicine, premenstrual change is positioned as premenstrual syndrome (PMS) or premenstrual dysphoric disorder (PMDD), a fixed and unitary pathology within the woman, deemed to be caused by biomedical or psychological factors (Bancroft, 1993; Steiner and Pearlstein, 2000). However, the absence of reports of premenstrual psychological distress in many non-western contexts, such as China, Hong Kong, and India (Chang et al., 1995; Hoerster et al., 2003; Yu et al., 1996) and reports of an association between diagnosis of PMDD and acculturation in migrant women living in North America (Pilver et al., 2011) raise questions about the validity of individualising biomedical and psychological theorising of premenstrual change (Cosgrove and Caplan, 2004). This has led to the suggestion that PMS and PMDD are socially constructed labels or culture-bound syndromes (Chrisler, 2004). From a feminist social constructionist perspective, premenstrual change is deemed to be a normal part of women’s experience, which is positioned as PMS or PMDD because of western cultural constructions of the menstruating woman as labile or dysfunctional, and the premenstrual phase of the cycle as a time of pathology (Chrisler and Johnston-Robledo, 2002; Ussher, 2006). In this view, women monitor premenstrual moods and behaviour in relation to often unrealistic feminine ideals of calmness, consistency and capability (Brooks et al., 1977; Ussher, 2004), and blame themselves, or their bodies, for perceived transgressions, taking up the subject position ‘PMS sufferer’ (Chrisler and Johnston-Robledo, 2002).

Understanding premenstrual change as a social construction does not mean that the reality of premenstrual change is denied, however. Feminist theories of embodiment facilitate acknowledgement of the materiality of corporeal experience (Kuhlmann and Babitsch, 2002) and of the ‘intertwining’ of mind and body within a woman’s social and cultural context (Einstein and Shildrick, 2009: 295). In this vein, there is convincing evidence that during the premenstrual phase of the cycle, some women experience embodied and psychological change, accompanied by an increased sensitivity to external stress (Sabin et al., 1999; Ussher and Wilding, 1992). Emotions such as anger, sadness or irritability – as well as creativity or sexual desire – can also feel more powerful than usual premenstrually (Chrisler et al., 1994; King and Ussher, 2013), and the multiple tasking that is a normal part of many women’s lives can be more difficult (Slade and Jenner, 1980). However, women are not passive ‘sufferers’ of premenstrual change, despite their characterisation as such within biomedical discourse (e.g. O'Brien et al., 2011). Positive premenstrual changes, either alongside negative changes or as the only premenstrual changes experienced, have been reported (Chaturvedi, 1990; Chrisler, et al., 1994), and some self-identified PMS sufferers accept premenstrual change as a normal part of experience, embracing the access to the creative energy and emotions they experience at this time (Ussher and Perz, 2013a).

Women’s interpretation and negotiation of premenstrual change may be influenced by relational context. There is a growing body of research reporting an association between relationship strain and reports of PMS, with evidence that relationship satisfaction can deteriorate premenstrually (Clayton et al., 1999), and that married women reported greater disruption of daily living as a result of premenstrual symptoms than single women (Dennerstein et al., 2010). This suggests that the most commonly reported psychological ‘symptoms’ of PMS and PMDD – anger and irritation – could be conceptualised as a legitimate response to the material circumstances of women’s lives, including over-responsibility, lack of support, or relationship tension (Figert, 2005; Ussher, 2003a). There is also evidence that Western women can experience negative pre-menstrual changes in emotion, behaviour or embodiment, but not discursively construct these as PMS, and not experience distress associated with such change (Cosgrove and Riddle, 2003). To position these women as ‘false negatives’ who really have PMS (Hamilton and Gallant, 1990) is to misinterpret the intrapsychic negotiation and resistance of dominant discourse in which they are engaged. Indeed, women who resist the moniker PMS could be seen to be ‘rewriting ideologies of gender’ through creating ‘alternative’ or ‘counter discourses’ (Day et al., 2010: 238) which subvert the construction of premenstrual change as pathology (Ussher and Perz, 2014).

The Western conceptualisation of emotion as stable, consistent and under control is central to the conceptualisation of premenstrual change as pathology. In this vein, Chrisler (2008) describes PMS as an archetypal example of a gendered ‘disorder’ where loss of control, particularly in relation to women’s expression of anger, is constructed as illness. The fear of being overwhelmed by the ‘menstrual monster’ is described as a ‘recipe for psychological disaster’, as women are socialised to believe that they ‘need to work at self-control in every waking hour’ (Chrisler, 2008: 2). Chrisler argues that gender role socialisation and beliefs about femininity affect women’s sense of whether they can (or should) control emotional or physical changes experienced premenstrually. This socialisation includes the internalisation of unrealistic standards against which women measure ‘successful’ self-regulation; the influence of self-objectification, self-sacrifice and over-responsibility on self-monitoring of internal sensations and needs; and gendered constructions of power and self-efficacy. Chrisler suggests that the fear of losing control, and concerns that others will think we are out of control, ‘can be a form of internalized oppression that serves to enforce gender roles and keep women from developing authentic selves’ (Chrisler, 2008: 9). In this paper, we draw on this theoretical proposition to contrast the premenstrual experiences of two women: one who accepted the common descriptor of the PMS self as ‘out of control’ and one who resisted the pathologisation of the premenstrual self, using a qualitative case study approach.

Whilst case studies are ubiquitous in medicine, they are relatively unusual in feminist and health psychology. However, it has been argued that the case study should be ‘central to health-related research’, standing as the ‘prerequisite for understanding how suffering is communicated and alleviated’ (Radley and Chamberlain, 2001: 321, 323). Case studies are particularly suited to the investigation of the meaning involved in negotiating health and illness, capturing the unique and holistic characteristics of a participant’s relationship with his or her condition (Watts et al., 2009). In understanding the person as a case, researchers are acknowledging the ‘presentational features through which the person’s experience is reflected’, allowing analysis of how and why the person identifies as having a specific illness (Radley and Chamberlain, 2012: 394). More specifically, case studies that adopt a narrative methodology – examining the stories people tell about their experience – reveal how illness gets integrated into people’s lives and how social and relational factors impinge on this process (Gray et al., 2005). The situation of narratives in a broader socio-historical context also serves to reveal social structures and processes, not just personal realities (Murray, 1999). In contrast to aggregate-based research that seeks to make generalisations or investigate predictor variables across populations, case study research seeks to elaborate upon ‘pattern and meaning within the particular’ (Radley and Chamberlain, 2001: 324), allowing generalisation to theoretical propositions, rather than to populations (Bryman, 1988), with case comparison acting as a way of testing or evaluating theory (Silverman, 1993). Case study methodology thus allows the theoretical proposition that PMS is a socially constructed category negotiated in the context of relationships, with fear of loss of control acting as a form of internalised oppression, to be explored in the context of individual women’s lives.

In this analysis, we adopt a critical realist epistemology, which recognises the materiality of the body, and other aspects of experience, but conceptualises this materiality as always mediated by culture, language and politics (Bhaskar, 1989). This approach moves beyond the realism-constructionism, or mind-body, divide, and avoids the distinction between the subjective and objective, or mental and physical aspects of experience. This is because materiality (including embodiment) is not deemed reducible to discourse, or without meaning unless discursively interpreted; rather, ‘material practices are given an ontological status that is independent of, but in relation with, discursive practices’ (Sims-Schouten et al., 2007: 102). Material, discursive and intrapsychic factors are thus deemed of equal importance, and inseparable, leading to the description of research as ‘material-discursive-intrapsychic (MDI)’ (Ussher, 1999, 2000). This MDI approach facilitates acknowledgement of the interconnection of emotional and physical changes across the menstrual cycle; the material and relational context of women’s lives that may precipitate distress; PMS and PMDD as socially constructed categories and the psychological negotiation in which women engage to make sense of their experience.

Method

Participants and procedure

This analysis is part of a broader study on the experience of PMS in the context of relationships, involving interviews with 60 women who presented as experiencing PMS, and 23 of their partners (Ussher and Perz, 2013a, 2013b). Women were recruited from a range of contexts: advertisement in the media and Women’s Health Centres; online chat-rooms and email lists; a relationship counselling organisation and a lesbian mother–baby network. One-to-one 60-minute semi-structured interviews were conducted, adopting a narrative approach (Murray, 1999), to examine women’s stories about their subjective experience of PMS, and the negotiation of PMS in the context of relationships. The interviewer began by asking women to describe how she, or her partner, was when she had PMS, then describe a typical experience of PMS and explore how this varied across relational contexts. The interviews were transcribed verbatim, and pseudonyms allocated to participants. Ethics approval was obtained from the University Human Ethics Committee.

Analysis

After transcription, the interviews were read and reread in order to identify themes relating to the construction and experience of PMS. Themes were then grouped, checked for emerging patterns, variability and consistency, commonality across women, and for uniqueness within cases. This process follows what Stenner (1993: 114) has termed a ‘thematic decomposition’, a close reading that attempts to separate a given text into coherent themes that reflect subject positions allocated to, or taken up by, a person (Davies and Harre, 1990), with the term ‘decomposition’ indicating that the interview is recognised as a ‘living whole’ (Watts et al., 2009: 495).

Two contrasting accounts, Judith and Sophia, were chosen as explanatory and descriptive case studies (Yin, 2003). Case analysis has been described as consistent with the methodological technique of ‘purposeful sampling’ (Lincoln and Guba, 1985), in which an information-rich case or cases are chosen for in-depth study (Crossley, 2007). Information-rich cases are defined as those from ‘which one can learn a great deal about issues of central importance to the purpose of the research’ (Lincoln and Guba, 1985: 40), acting as ‘exemplars’ that show ‘something about the class to which it and other members belong’ (Radley and Chamberlain, 2001: 326). We chose Judith as she constructed the premenstrual self as out of control and a sign of monstrosity in the context of absence of relational support. In contrast, Sophia normalised premenstrual change, challenging the association between PMS and the positioning of women as deviant or dysfunctional and reported a supportive relational context. However, in other ways, the women were similar: presentation of premenstrual changes, number of children and living in a long-term relationship.

In analysis of the two cases, we examined the narratives of PMS as actively configured accounts which reflected the way that the premenstrual self was constructed by the women within the context of the interview (Riessman, 2002). Analysis of each case began with a close reading of the transcript to identify the core narrative and explore ‘the point of the story’ (Mishler, 1986: 236). We started with the premise that subjectivity is a fluid and ongoing construction, leading us to examine how premenstrual change was narratively constructed and performed in Judith and Sophia’s accounts, the strategic purpose of this performance (Riessman, 2002), and their ‘preferred identity claims’ (Riessman, 2003: 8). We asked questions such as: What kind of story do Judith and Sophia place themselves in? How do they position themselves to the audience? How do they position other characters in their narratives in relation to themselves, and what were the consequences of this construction for their experience of premenstrual change?

Results

Both Judith and Sophia gave similar accounts of feeling angry, irritable and depressed, as well as more paranoid about other people, when they ‘had PMS’. In terms of physical changes, both women reported sore breasts and Sophia also reported a sore lower back premenstrually. Both rated their premenstrual distress as high on a scale of 1–10 (8 and 9, respectively), and rated their coping as moderately low (4 and 3, respectively). However, they differed in their accounts of relationship dynamics and partner support, in their construction of PMS, and in their mode of coping with premenstrual change.

Pathologising premenstrual change: The case of Judith

Judith was a 39-year-old woman living with her husband and her 4-year-old twin boys, for whom she acted as a full-time mother. Both children were diagnosed with Asperger Syndrome. Judith described her marriage as ‘unhappy’, and reported ongoing issues with her husband that were neither discussed nor resolved. A construction of premenstrual change as pathological was pervasive in Judith’s account; she described the changes she experienced premenstrually as abnormal, deviant and uncontrollable, invoking imagery of mental illness when she described herself as being a ‘nutter’ when premenstrual. The experience of oscillating between feeling ‘volatile’ and feeling ‘stable’ was central in Judith’s account of her menstrual cycle. This can be seen in the way she repeatedly contrasted the abnormality of PMS and the normality of the ‘rest of the month’, ‘I know that I am … a bit more volatile than I would normally be’; ‘I know once I actually get to the period, that I’ll feel back to normal and happy again’; ‘you know you are behaving a bit out of your normal character (during PMS)’.

In Judith’s account, her construal of premenstrual change as pathological was associated with the interpersonal dynamics of her relationship, which were described as negative, ‘I’m probably not living in the perfect marriage’. She said that her husband did not understand or acknowledge the problems she experienced premenstrually, ‘I’m married to a Neanderthal man that doesn’t talk about things’, positioning her husband as reinforcing her perception of her premenstrual behaviour as a departure from rational, acceptable behaviour. In the following excerpt, Judith describes her husband’s typical reaction to her during the premenstrual phase of her cycle and the consequences for how she experienced premenstrual distress:

Oh, he’ll always say to me the next day, or whatever, you need to apologise to me for that. And yeah, nine times out of ten, like, you know, I’ve tried to explain it to him that I don’t, you know, mean it, and I know it’s bad, I’m … it’s bad in myself, I hate it in myself that I lose the plot, because I try very hard to be a calm person, so um, yeah, so I usually end up apologising (laugh), grovelling for a day or two (laugh).

In this passage, Judith positions premenstrual change as a pathological internal state, for which she assumes blame, appearing to internalise her husband’s inference that she was responsible for her ‘bad’ behaviour premenstrually.

This description of the ways in which Judith and her husband communicated about premenstrual distress reflects a broader, cultural construction of negative premenstrual change as pathological and of the premenstrual woman as the epitome of the monstrous feminine (Ussher, 2006). For example, Judith described how she conveyed premenstrual change to her husband in the form of a warning, reinforcing the construction of the premenstrual woman as dangerous.

I’ll often warn him now, you know, if he starts to aggravate me, or something, I’ll just say, you know, “I’m just letting you know it’s that time of the month, so back off,” or … (laugh), “you know what’s going to come at you!”

PMS was not explicitly named in their relationship, but rather referred to as ‘that time’. Substituting the term PMS with the pseudonym ‘that time’ served to position premenstrual change as an unmentionable experience. Judith described how others, including her husband, would use this term to label her premenstrual distress in such a way as to demean her and attribute blame to her.

I just hate being labelled … “oh, it’s that time! Here she goes again!” kind of thing, because you know, yourself, that you are behaving a bit out of your normal character and that, but you just don’t feel like you have much control over it, neither.

The phrase ‘here she goes again’ could be seen to infer that PMS is an inherent part of Judith’s identity, reinforcing the notion that her premenstrual emotions are unreasonable and unacceptable. However, Judith herself emphasises a lack of control over her premenstrual emotions, constructing PMS as something that happens to her, with little potential for agency.

At the same time, Judith reported that the only time she or her husband would discuss underlying issues in their relationship was in the heat of the moment when she was premenstrual. This pattern of communication may have served to reinforce Judith’s perception of PMS as a departure from normal, acceptable behaviour and of herself as volatile or difficult premenstrually. She described self-policing in the context of her ‘unhappy marriage’ when she was not premenstrual, a practice that was ruptured when she ‘had PMS’. At this time of the month, Judith said she was unable to tolerate the problems she experienced in her relationship, ‘come that time, everything’s intensified and magnified, and you’re like, “no, I’m not going to push that aside anymore. I’ve had it!”’. She expressed a desire to censor herself when she experienced this kind of ‘emotional upsurge’: ‘if I … had some way of maybe suppressing or controlling my emotions at that time of the month, I guess, it would be not so much of a rollercoaster at that time; it would be a lot more steadier’. However, Judith described how a ‘loss of control’ premenstrually created a barrier to suppressing her normally well-contained negative emotions.

Judith expressed a desire to avoid her husband premenstrually in order to better manage her premenstrual distress, ‘basically, I would like him to move out of the house for that week, really, would be very nice’. A perceived sense of entrapment in her relationship, amplified during the premenstrual phase of her cycle, prevented Judith from implementing this strategy, ‘I feel trapped then … I feel pretty much like a caged tiger or something, pacing … ’. From this ‘trapped’ position, Judith felt unable to take time out from others, especially her husband. She described time out as a ‘luxury’ she could not procure due to her responsibilities as a wife and mother.

The responsibility of caring for her twin 4-year-old sons was described by Judith as demanding, particularly during her premenstrual phase when she told us that she experienced diminished physical and emotional resources. Judith reported receiving little to no support from her husband in caring for their children throughout the month, ‘both my children have got Asperger’s … It’s a form of autism … I carry that burden and stress with me all the time, too, because he doesn’t really understand that or accept that, neither’. Judith told us that she experienced premenstrual anger and irritation towards her children, which she attempted to contain by ‘trying hard’ not to yell, ‘get cranky’ or become impatient. She described how the intensity of her premenstrual symptoms, coupled with a perceived loss of control, meant this strategy was not always successful. Although Judith expressed a deep love for her children, she described feeling overwhelmed by her maternal responsibilities premenstrually.

I love my children to death, but that’s probably the only time that I ever feel that I would just want to get up and walk away and go away by myself for a couple of days, and just be away from the whole thing.

In contrast to Judith’s account of PMS as internal pathology, this account implicitly positions premenstrual distress as situational, a reasonable response to life stresses, compounded by absence of support. Avoiding her children premenstrually was presented as the one strategy Judith felt would assist her in coping with this sense of over-responsibility; however, due to her husband’s “emotionally immature” and unsupportive behaviour, she construed this strategy as an ideal, rather than a possibility.

A normal emotion, or source of power: The case of Sophia

Sophia was a 28-year-old woman, who worked full time as a manager in a health centre, living in a ‘full house’ with her woman partner of six years, and her partner’s two children, aged 8 and 12. Sophia described a ‘healthy’ relationship with her partner, where both parties supported each other, yet also maintained their independence. In her account, Sophia actively challenged and resisted the notion of premenstrual change as pathological. She rejected the construction of PMS as ‘this stuff that happens to me … (and) is part of me, hell or high water’. Rather, she construed it as a ‘normal’ emotional, psychological and physical response to hormonal fluctuations. Sophia explained how she was able to ‘un-pack’ and ‘challenge’ the pathologisation of premenstrual change from a ‘feminist’ perspective.

I understand that these things (such as PMS) are human things that are happening … that there are structures of oppression … which would like me to believe that I’m just being a hysterical woman. But that’s historical … by saying to myself, “no, what’s happening to me now is real,” is … a way of challenging that, and saying, “yeah, I know, but you can’t put that stuff on me anymore.

Sophia described how her partner supported and encouraged her in adopting this construction of PMS. In the following passage, she described how redefining premenstrual change from a feminist perspective was a shared ‘journey’ between herself and her partner.

I’m really fortunate in that my partner is such a strong feminist as well. And I think we feel the same about these things. So that, you know, we really affirm each other in that. And we fight some of those battles together.

The ways in which PMS was named and communicated in the context of Sophia’s relationship appeared to facilitate an understanding of premenstrual change as both ‘real’ and ‘valid’. When premenstrual, Sophia said she would apply the label PMS as a ‘preface’ to any conversation, providing a ‘framework’ her partner could use to interpret her behaviour. However, Sophia’s partner would raise PMS as a point of discussion only after menstruation occurred. This was to avoid the perception that premenstrual emotions were being dismissed, or positioned as pathology, which was recognised to be inflammatory. Sophia described a ‘loss of perspective’ premenstrually, which she identified as a barrier to successfully resolving interpersonal conflict at this time. She told us, ‘I tend to get really cranky with my partner, and think about our relationship too much. And wonder about all the ins and outs of things like that’. In hindsight, however, she said she felt that she and her partner could address any issues that arose premenstrually from a more rational perspective.

I don’t think it’s anybody’s place to say, “Are you premenstrual right now?” I don’t think that’s ever a good call. But you can say, in hindsight, “do you think maybe you were premenstrual then?” after the person’s started bleeding … That’s fine.

Sophia’s construal of negative premenstrual change as a natural ‘human’ phenomenon that she could both accept and control appeared to facilitate her ability to cope premenstrually and to reframe the premenstrual phase of the cycle as a potentially positive time of the month. For example, she described how a perception of agency enabled her to legitimise time-out on her own, and to channel the ‘energy’ she experienced premenstrually in a positive and creative way.

Sometimes I go, “good, I might lock myself away now, and just get a lot of work done.” And sometimes you can really connect with some deeper energies that are going on, I think, in the kind of bracket. Um … Something … something … I … I feel like something in me, creatively, is willing to go further in that time.

A position of resistance to the pathologisation of premenstrual change may have served to facilitate Sophia in ‘maximising’ premenstrual ‘energy’, rather than attempting to suppress or hide it. She also described increased sexual energy premenstrually, ‘it’s a great time to shag’, and in the following passage describes how writing provided a useful forum for challenging and resisting attempts by ‘the structures of oppression’ to ‘minimise’ women’s experiences of premenstrual change.

I wrote about PMS … I talked about how I feel like, if all these women who were premenstrual at the same time could channel that feeling, then we could take on the whole world! (laugh). We could probably stop war. We could do a range of things. If we were allowed to channel it and not kind of package it into little feminine boxes of tampons and snakeskin and floral patterns. If we didn’t … have to minimise it, but we could maximise it. Wow, that would be cool. And so potent.

Rather than being a sign of the monstrous feminine, premenstrual emotions are thus positioned as a source of positive female power.

At the same time, Sophia described her passage to coping with negative premenstrual change as a ‘solo’ journey, involving strategies of self-care. She emphasised her role as an active agent in coping with negative emotions that she experienced premenstrually: ‘ … if I feel like I’m getting really, really low, I know I have to do something with that, or I’m going to feel really sorry (laugh) and sad’. Anticipating premenstrual emotions, and modifying her life accordingly, was described as an important strategy.

Once you are, you know, educated in yourself about saying, “okay, this is a cyclical thing,” and you can kind of plot it and also channel it. And yeah, then you become in control of it a little bit more. You know, as well as saying, “okay, this is a bad time to get really drunk or stoned,” you know, but you can look after yourself in it.

Whilst this ‘solo’ coping was effective, Sophie also identified the important role of her partner in facilitating this process, through supporting and encouraging her to be active in developing self-care strategies to cope with her PMS.

For a long time, I think, it was, you know, I looked for external answers, and I said, “there’s got to be somebody who can fix this for me, or something I can do that makes this easier, you know, quickly,” um, but I think that she recognises, like I do, that it’s one of those things that you just do solo. You just have to. Um, and so, she appreciates that.

Sophia highlighted the importance of taking time out from both her partner and her partner’s children premenstrually. She described how her role in the lives of her partner’s children as a ‘friend’ rather than a parent enabled her to defer parental responsibilities: ‘I can say, “Look, I’m not dealing with that right now. You can go and talk to mum about it”’. Sophia construed this as a beneficial strategy for herself and for the children, as she felt she lost ‘perspective with them’ and was more reactive premenstrually, preventing her from seeing things from their point of view, ‘ … they (the children) need for somebody else to go, “Actually, no. The kid’s right in this instance”’.

A shared experience of premenstrual change between Sophia and her partner engendered empathy, ‘I guess being in a lesbian relationship, you recognise premenstrual-ness in the other person. And you go, “Okay, I know what that is. I know what that feels like. And I understand”. You’ve got empathy. And that is great’. However, two menstruating women in an intimate relationship could also be problematic. In her survey, Sophia wrote: ‘sometimes she and I have the same cycle and sometimes not! This is EXTREMELY difficult of course, as sometimes she starts to bleed and I start to get PMS’. In the interview, Sophia emphasised the importance of being understood by her partner. From this ‘place of understanding’, Sophia said she was able to ‘re-package’ premenstrual change as a ‘human’ experience, rather than a pathological one. This balance between support and independence was construed as the cornerstone of Sophia and her partner’s ‘healthy’ relationship; a dynamic that prevented the two from becoming ‘co-dependent’. Thus the ‘solo work’ involved in PMS was construed as a benefit, rather than an impediment to a successful relationship.

Discussion

The analysis of these two cases allows us to explore the theoretical proposition that PMS is a socially constructed category negotiated in the context of relationships, with fear of loss of control acting as a form of gendered oppression (Chrisler, 2008). The case of Judith illustrates how construing premenstrual change as ‘out of control’ and as a threat to idealised representations of femininity is associated with a pathologisation of premenstrual experience, and lack of agency. Judith made a clear distinction between her ‘normal’ acceptable self when not premenstrual and her abnormal unacceptable self when premenstrual, a sentiment echoed by many other women in the broader study (Ussher and Perz, 2010, 2013a), and by women in previous research on PMS (Cosgrove and Riddle, 2003; Swann and Ussher, 1995). Judith emphasised disapproval of her ‘PMS self’, as she felt unable to regulate her emotions and behaviour in accordance with societal expectations of the ‘good woman’, who is in control, positive and loving towards her partner at all times (Chrisler, 2008; O'Grady, 2005). More specifically, a diminished capacity premenstrually to meet the expectations of a ‘good mother’ – remaining calm, relaxed, and patient, willingly spending time with her children, and putting their needs first (Brown et al., 1997) – was described by Judith as particularly destabilising. Judith’s account reveals how discursively constructing premenstrual changes in emotional expression as a form of pathology, beyond her control, is one way of reconciling these two conflicting selves. By attributing transgressive emotions or behaviour to ‘PMS’, Judith is able to express anger and frustration towards her husband and keep a core sense of self as ‘good’ intact. However, in doing so, she is not addressing the needs or issues that lead to the emotions that emerge in the premenstrual phase of the cycle, and is reinforcing the pattern of self-silencing that characterises her experience of the ‘non-PMS self’, a common pattern in women who present with PMS (Ussher and Perz, 2010).

In contrast to Judith, Sophia constructed premenstrual change as a natural part of her biological make-up, rather than a form of pathology. Although she experienced negative emotional and physical changes during the premenstrual phase of her cycle, which she attributed to her body, Sophia did not interpret these changes as a complete shift of self, or herself as out of control. Resisting the notion of premenstrual change as pathological meant Sophia was not faced with the challenge of reconciling two conflicting ‘selves’ and did not engage in self-castigation for any changes in her behaviour and emotions premenstrually. The case of Sophia illustrates how constructing premenstrual changes as ‘normal’ can alleviate some of the suffering often associated with these changes, and lay the foundations for developing effective self-care and other coping strategies, central to women-centred psychological interventions for PMS (Ussher, 2008; Ussher et al., 2002).

However, whilst Sophia normalised premenstrual change, she did position it as PMS and report distress associated with negative changes. Conversely, whilst Judith pathologised premenstrual anger and irritation, she partially attributed this anger to situational factors, exacerbated by her husband’s lack of support. These accounts suggest that both women are drawing on competing discourses when accounting for premenstrual change and distress (see Granek and Fergus, 2012): a biomedical discourse that categorises such change as an internal phenomenon ‘PMS’, alongside a psychosocial discourse that attributes premenstrual emotions to environmental stress; a feminist discourse that normalises premenstrual change and a discourse of PMS as sign of madness. This is analogous to the ‘tight-rope talk’ identified by McKenzie-Mohr and Michelle Lafrance (2011) wherein women construct themselves as both ‘agents and patients: both active and acted upon’ (64), enabling women to take credit for agency in coping and deflect blame for ‘having’ PMS. McKenzie-Mohr and Lafrance (2011: 66) describe this adoption of a ‘both/and’ position as enabling the re-authoring of emancipatory counter-stories, which serve to challenge the oversimplification of ‘either/or’ binaries, where women are ‘agent or patient’, ‘powerful or powerless’. As Brown (2007: 275) has argued, this ‘both/and’ position ‘honors women’s agency and power while not minimizing the impact of oppressive social discourses and social relations’ (cited by McKenzie-Mohr and Lafrance, 2011: 64). This allows us to acknowledge both the materiality and intra-psychic consequences of premenstrual distress, and women’s agency and power in expressing emotion and anticipating or coping with premenstrual change. It also allows us to acknowledge the complexities in women adopting the subject position ‘PMS sufferer’, which both evokes discursive constructions of the monstrous feminine and makes meaning of women’s distress, through legitimising their experiences as ‘real’ (Ussher and Perz, 2014). The reproduction and resistance of discourse are thus overlapping, rather than being discrete and separate processes (Day et al., 2010).

The material context of the relationship with their partners played a central role in establishing and maintaining both Judith’s and Sophia’s positioning of premenstrual change, providing confirmation for the theoretical proposition that PMS is an inter-subjective experience (Jones et al., 2000). In the case of Judith, a perceived lack of partner understanding of the changes she experienced premenstrually reinforced her belief that premenstrual change was deviant and pathological. Her partner’s disapproval and rejection of her behaviour premenstrually, and the construction of PMS as unmentionable in their relationship, provided further impetus for her to reject her ‘PMS self’. This provides a detailed qualitative case illustration of the reports of previous quantitative research that found an association between men’s negative constructions of PMS and women’s premenstrual distress (Sveinsdottir et al., 2002). For example, Cortese and Brown (1989) and Rundle (2005) reported that the coping responses of male partners predicted women’s premenstrual symptom severity, with high levels of premenstrual distress associated with a partner’s avoidance, fear, or anger, and low levels of distress associated with reassurance and support.

Previous research has also reported that women who report PMS also report higher levels of relationship dissatisfaction or difficulties (Coughlin, 1990; Frank et al., 1993) and that over-responsibility within family relationships is a major source of conflict at this time (Ussher, 2003b). Women and their partners have also been reported to evaluate their relationship more negatively in the premenstrual phase, suggesting that some couples are not simply distressed, but rather, are distressed in the luteal phase of the cycle (Ryser and Feinauer, 1992). However, it has also been reported that premenstrual outbursts are associated with legitimate marital conflicts and concerns that women do not address at other times (Perz and Ussher, 2006; Stout and Steege, 1985). When underlying interpersonal problems are suppressed for the majority of the month, then verbalised in a confrontational manner premenstrually, emotions or concerns are likely to be positioned as PMS, and therefore dismissed, as was the case with Judith’s partner. At the same time, Judith’s fear of loss of control and self-blame in relation to premenstrual emotions arguably served as a form of internalised oppression that prevented Judith from feeling legitimate in asking for support, thus reinforcing the gendered division of labour in her relationship, in line with Chrisler’s (2008) proposition.

In contrast, a shared understanding between Sophia and her partner of negative premenstrual change as both ‘real’ and ‘valid’ facilitated a positive ‘framework’ for dealing with premenstrual change, acting to support Sophia when she was premenstrual. Sophia described a shared commitment between herself and her partner in relation to identifying and managing the physical and psychological problems associated with the premenstrual phase of their cycles. Rather than being unmentionable, PMS was acknowledged to be an issue, allowing concerns that were raised premenstrually to be discussed in a calm manner after the event. This provides a detailed qualitative case illustration that confirms previous quantitative research that reported that couple communication is beneficial in facilitating coping with premenstrual distress (Frank et al., 1993), as it is with other health problems (e.g. Gottman and Krokoff, 1989; Manne et al., 2006). Sophia’s partner also facilitated coping and self-care through sharing parental responsibilities and encouraging Sophia to ‘channel’ the ‘energy’ she experienced premenstrually as a way of achieving agency, and resist the construction of the premenstrual self as ‘out of control’. This illustrates how a shared understanding of premenstrual change, coupled with partner support and encouragement, can influence women’s construction of the premenstrual self and facilitate the successful negotiation of distress. These findings were reflected in the larger study, wherein women who normalised premenstrual change were more likely to engage in positive coping strategies, including avoidance of stress, escaping relational demands and care of the self (Ussher and Perz, 2013b). However, all of the women who took part in the research positioned negative premenstrual change as PMS, implying that its occurrence was outside of their control. Further research is needed to examine the complex relationship between fear of loss of control, coping and gendered roles, in relation to premenstrual distress, ideally using a mixed method research design.

In the larger study, it was reported that partner awareness and recognition of premenstrual change, responsiveness to needs, open communication and responsibility sharing was the most common response to PMS within lesbian relationships, facilitating positive coping and reduction in premenstrual distress (Mooney-Somers et al., 2008; Ussher and Perz, 2008). However, this is not unique to lesbian relationships – many heterosexual women also reported positive support and understanding on the part of male partners (Ussher and Perz, 2013a). This supports the theoretical contention that the involvement of partners in therapeutic interventions for moderate–severe premenstrual distress would be beneficial (Jones et al., 2000), as strategies of relational support and empathy can be facilitated. Conceptualising PMS as an intersubjective experience, and the adoption of couple interventions, also serves to discursively shift the attribution of premenstrual distress from the woman’s ‘raging hormones’ to the context of her life and relationships, which disrupts discourses of self-blame. This in turn may serve to shift the balance of power in relationships when women experience negative premenstrual change, empowering women to take time out, or ask for support, and feel legitimate in doing so.

A couple-based approach to support may also empower women to seriously examine the relational concerns that emerge in the premenstrual phase of the cycle, which may be repressed throughout the remainder of the month, to the detriment of the relationship. Dana Jack has argued that women repress their anger and self-silence, in an attempt to maintain connection with others, under the mistaken belief that anger is inevitably destructive to relationships (Jack, 2001). However, there is consistent evidence that the open expression of anger and disagreement within intimate couple relationships leads to greater relationship satisfaction in the long run, whereas couples who avoid conflict are the least satisfied (Jack, 1991). Indeed Gottman and Krokoff, in a detailed analysis of the role of communication and relationship satisfaction in heterosexual relationships, conclude that ‘wives should confront disagreement and not be overly compliant, fearful and sad but should express anger’, because it is women who generally raise and ‘manage’ marital disagreements (Gottman and Krokoff, 1989: 51).

In conclusion, these two case accounts provide illustration and confirmation of the theoretical proposition that PMS is an ongoing process of negotiation, rather than a stable and fixed syndrome, with levels of distress associated with the discursive constructions and material practices that women and their partners adopt (Ussher, 2011). In this view, PMS is not the underlying pathology that causes distress, but is the label given to the distress, and the context within which a woman experiences and expresses premenstrual change can have a significant impact on its construction and impact. This analysis also demonstrates the utility of a case study methodology for feminist psychology. It allows us to examine the meaning of PMS in individual women’s lives, supporting the contention that the social context must be taken account when examining accounts of premenstrual experience. Case study analysis also facilitates examination of the ways in which distress is communicated and alleviated (Radley and Chamberlain, 2001), and the unique and holistic characteristics of women’s relationship with their premenstrual ‘condition’ (Watts et al., 2009). Through elaborating upon ‘pattern and meaning within the particular’ (Radley and Chamberlain, 2001: 324), case analysis allows generalisation to theoretical propositions about premenstrual change, rather than to populations of women (Bryman, 1988), with comparison of cases acting as a way of evaluating theory (Silverman, 1993). Case analysis can therefore complement and extend the findings of research based on broader samples of women, as well as provide a greater insight into individual women’s lives.

Footnotes

Acknowledgements

This study was funded by a Discovery Grant from the Australian Research Council, ‘An examination of the development, experience and construction of premenstrual symptoms’, DP0588831. Thanks are offered to Julie Mooney-Somers and Lee Shepard for support and assistance in the collection of data. We also thank Cathy Riessman for her advice about the analysis, and comments on early drafts of the paper.

Funding

The author(s) received no financial support for the research and/or authorship of this article.

Author Biographies

Jane M Ussher is Professor of Women’s Health Psychology, in the Centre for Health Research, at the University of Western Sydney, Australia. She is editor of the Routledge Women and Psychology book series, and author of a number of books, including The Madness of Women: Myth and Experience (Routledge 2011). In collaboration with Janette Perz, her current funded research projects include fertility changes after cancer, refugee women’s sexual health, LGBT cancer experiences, and young women's smoking.

Janette Perz is an Associate Professor in the Centre for Health Research at the University of Western Sydney. She researches in the field of reproductive and sexual health with a particular focus on gendered experiences, subjectivity and identity.

Emily May is Principal Psychologist at Fostering Hope Psychology, Sydney, Australia. She has previously worked as a school counsellor, a youth and family worker, and as a research officer at University of Western Sydney, where she was involved in research on PMS.

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