‘ If you grow them,know them ’: Discursive constructions of the pink ribbon culture of breast cancer in the Australian context

Abstract

The ‘pink ribbon culture’ dominates understandings of breast cancer in Western societies. We describe this as an ‘illness culture’, consisting of neoliberal discourses and practices, which construct the breast cancer experience. We take a feminist post-structuralist approach to review current breast cancer lay materials available to women in Australia, to examine how breast cancer is discursively constructed within this context. Further, we consider how women with breast cancer are positioned and what the implications are for women’s lives. We discuss neoliberal discourses of ‘individual responsibility and empowerment’ and ‘optimism’, and the central practices that focus on individual health behaviours and survivorship. This illness culture has productive and restrictive effects for women’s subjectivity. Whilst women are positioned as ‘empowered’ regarding their health, this comes at the price of self-regulation and responsibility. Support and information additionally reposition women in feminine, heteronormative ways, whilst excluding women who do not fit narrow cultural stereotypes.

Keywords

breast cancer neoliberal discourse pink ribbon culture Australia women’s health

Exploring the pink ribbon culture as a neoliberal ‘illness culture’

The social and discursive experience of breast cancer has shifted significantly in the last 20–30 years in industrialised, English-speaking, Western societies (King, 2006; Sulik, 2011). Historically, cancer was constructed through religious discourses as attributable to personal sin, and later through medical discourses as caused by cancer-prone personalities (Sontag, 1977/2001). Such constructions of breast cancer mirrored the positioning of women, especially during the Victorian era, as victims of their own bodies (Thorne & Murray, 2000; Ussher, 1989). In turn, this afforded doctors with power and control in decision making, thus often requiring women to undergo treatments without their consent (Thorne & Murray, 2000).

The way in which breast cancer is socially understood and personally experienced has since been fundamentally re-shaped through breast cancer activism, which emerged in the late 1980s (Klawiter, 1999). Whilst there are several strands to this health movement, mainstream contemporary understandings of breast cancer are constructed through what is termed the ‘pink ribbon culture’. This is, in effect, an illness culture, within which breast cancer has been re-constructed from being a ‘stigmatised disease’ to ‘a cause’ around which people have formed a collective purpose of raising awareness and support (King, 2006). At the centre of this culture stands the ‘breast cancer survivor’ – quite different from the ‘cancer victim’ of earlier discourses (Kaiser, 2008).

The pink ribbon has become synonymous with breast cancer, since its first use by Evelyn Lauder, breast cancer survivor and owner of Estée Lauder, as part of the first American National Breast Cancer Awareness Month in 1992 (Kaiser, 2008). The idea of using a ribbon to depict an illness stemmed from the pre-existing HIV/AIDS red ribbon (Sulik, 2011). As Sulik (2011) explained, the pink ribbon culture is based on ‘deeply held beliefs about gender and femininity, mass-mediated consumption and the [biomedical] cancer industry’ (p. 9). This observation is evidenced in other analyses of the pink ribbon culture (see Ehrenreich, 2009; King, 2006; Klawiter, 1999), which all draw attention to the celebration of neoliberal individualism, feminine ideals, and the imperative for optimism that are central aspects of this illness culture.

Applying feminist post-structuralism

Following earlier critiques of the pink ribbon culture, we examine this illness culture by taking a feminist post-structuralist approach to analyse the discourses and practices that construct it. We understand feminist post-structuralism as ‘a mode of knowledge production which uses post-structuralist theories of language, subjectivity, social processes and institutions to understand existing power relations and to identify areas and strategies for change’ (Weedon, 1987, p. 40). Within this framework, we conceptualise a discourse as a collection of interrelated statements that form around socially recognisable values and meanings, which are circulated through the operation of power relations and within specific social contexts, rather than located within individuals’ thoughts or behaviours (Hollway, 1983). Thus, we are interested in how the experience of breast cancer has come to be constructed through particular discourses and practices that circulate in Western society and have cohered to form a specific illness culture. The ways that women can experience their breast cancer are shaped and constrained by culturally relevant beliefs about health and illness, themselves transmitted through institutions such as medicine and the media. Discourses of breast cancer offer women a number of subject positions, which allow them to receive support, but at the same time constrain their subjectivity with regard to their illness. In taking a feminist approach, we focus on the discursive and material effects this has in shaping women’s lives. As our title suggests, we examine how discursive constructions of breast cancer – such as the imperative of breast surveillance – can shape women’s subjectivity in both productive and restrictive ways (e.g. as both empowering and an imperative to be followed).

In this paper, we review existing breast cancer lay materials and critiques of the pink ribbon culture, and illustrate our argument – that the pink ribbon culture is a neoliberal illness culture – with examples from the Australian context and elsewhere. We show that, in many ways, the pink ribbon culture operates within Australia in similar ways to other English-speaking Western countries, yet it also diverges in other ways. We draw on various resources, information packs, campaigns and the websites of several prominent Australian breast cancer organisations (e.g. Breast Cancer Network Australia (BCNA), Cancer Australia (CA), the McGrath Foundation, National Breast Cancer Foundation (NBCF)), as well as women’s autobiographies and current newspaper articles relating to breast cancer in Australia. These are by no means exhaustive or systematically selected, but are used to exemplify the discursive and social construction of breast cancer, embedded within a particular context and circulated through current lay materials available to women with the illness.

As we argue, although elements of the pink ribbon culture are beneficial and empowering, there are some limiting effects of this culture, in terms of how breast cancer is constructed and how women with breast cancer are positioned, namely, in gender normative ways and as personally responsible for their health and illness. Further, the construction of breast cancer needs to be considered contextually, which we illustrate by situating our analysis specifically within the current socio-historical context of Australia.

Discursive constructions and positionings of breast cancer

We identify two discourses that appear to shape the pink ribbon culture and that construct understandings of breast cancer: the discourse of ‘individual responsibility and empowerment’ and the discourse of ‘optimism’. We discuss these discourses separately, around some of the practices that make up these discourses; however, they need to be viewed as intersectional in the way that they construct breast cancer and position women with breast cancer. In taking a feminist post-structuralist approach, we discuss both the productive and restrictive effects these discourses have for understanding breast cancer and how women are positioned in relation to their illness.

Discourse of individual responsibility and empowerment

As we illustrate in this section, within the discourse of ‘individual responsibility and empowerment’, women are positioned as ‘empowered’ when they are seen to engage in personal testimony about their cancer, practices that maintain their femininity and breast self-surveillance strategies. Women’s empowerment is constructed through the information and support offered to women with breast cancer, and on a structural level through medical and informational resources, such as those offered in Australia. Attention to empowerment does serve to position women as in control of their illness trajectories in ways that were previously disallowed; however, we argue that it also locates the management of health and illness in the domain of personal responsibility, reflective of the neoliberal individualism of Western society (Rose, 1999).

The neoliberal focus of this individualism is exemplified through practices that encourage others to support women with breast cancer by engaging in consumerist and sporting activities to raise both money and ‘awareness’ for the illness. This has played out in the Australian context through men supporting women (as their partners). Whilst this inclusion of men dismantles breast cancer as an illness that only affects women, it can reproduce gendered and heteronormative constructions of women with breast cancer. Further, the focus that is placed on white, heterosexual, middle-class women within the pink ribbon culture becomes evident through the construction of awareness campaigns aimed at women and through a critical examination of the support given to women, points we will explore below. Such a gendered, classed and heteronormative focus raises questions about who benefits from the existing breast cancer support services.

Personal testimony

After a long history of breast cancer being constructed as a shameful and private disease, great efforts were made to break the silence, to empower women with breast cancer (King, 2006). This began with women writing public accounts of having breast cancer and, frequently, discussing the medical (mis)treatment they endured, serving to raise awareness about breast cancer and to politicise the experience (Anglin, 1997). These testimonies were written by educated and politicised women (particularly in the US) such as journalist and activist Rose Kushner (1975), lesbian African-American poet and author Audre Lorde (1980) and journalist Betty Rollin (1976). For example, Lorde’s (1980) work described the difficulties she faced within the context of biomedicine, as well as her decision not ‘to pass’ by choosing not to wear a prosthesis after surgery. In more recent decades, feminists’ personal accounts are infused with critical commentaries about the prescriptive effects of the pink ribbon culture, the individual responsibility placed on women to ‘survive’ and the marginalisation of women who do not fit the white, heterosexual, middle class norm (see Batt, 1996; Ehrenreich, 2009; Jain, 2007; Stacey, 1997). For instance, Batt (1996) detailed the activism she engaged in, after her diagnosis, which involved her critiquing the breast cancer industry for perpetuating the interests of powerful stakeholders, such as pharmaceutical companies, over the interests of women.

Women in significant political, economic and social positions, including US politicians’ wives such as Betty Ford (1974) and Happy Rockefeller (1974), actress Shirley Temple Black (1973) and Nancy Brinker (1982), founder of the Susan G. Komen breast cancer organisation, also spoke out about their breast cancer (King, 2006; Klawiter, 1999). Their voices moved the conversation from literary and radical circles to mainstream media and to wider society. This enabled widespread attention to breast cancer and its subsequent destigmatisation; however, these women represented ‘all-American, hypernormal femininity’ (King, 2006, p. 112), thereby shaping future constructions of women with breast cancer – as white, heterosexual, and middle- to upper-class. For instance, Jain (2007) described the challenging nature of her recent experience negotiating her lesbian sexuality within the heterosexualisation and hyper-femininity that is promoted by the pink ribbon culture.

In the Australian context, TV presenter Sally Obermeder (2013) is one example of the prolific number of current celebrities who has published her breast cancer story. Her book, ‘Heartache, hope and some very high heels: Never stop believing’ recounted moving from a glamorous life where she had what we are encouraged to believe is ‘everything’ (a ‘wonderful’ husband and a baby just conceived through IVF), to her ‘fight’ against cancer, to her eventual survival. As the title exemplified, the message was one of hope and positivity, as well as the promise that women can maintain their femininity. The cover featured a photograph of Obermeder as a youthful woman, with no signs of having undergone cancer treatment. This book, like many current breast cancer accounts, celebrated personal endurance and a return to ‘normal’ life. As Herndl (2006) argued, breast cancer autobiography has become a narration of ‘self-healing’ which enables a woman to reconstruct her life in light of her illness, as well as offer hope and relief to others. Although this can be helpful for some, this narrative can be constructed as a ‘how to’ for others, with a focus on reclaiming the one identity position as ‘woman’, whilst ignoring women’s multiple identity positions (Herndl, 2006).

Hyper-femininity

Constructions of women with breast cancer have been shaped in the image of the women who spearheaded the ‘mainstreaming’ of personal testimony about breast cancer – white, heterosexual women, who identified chiefly as wives or mothers (Anglin, 1997; Montini, 1996). Montini (1996) discussed how many breast cancer activists lobbying for informed-consent legislation and other policy changes in the 1980s in the US felt constrained to express ‘gender-appropriate’ emotions such as grief and downplay ‘inappropriate’ emotions, such as anger, to present an acceptable face to male legislators.

Advice on restoring women’s looks and (interchangeably) their self-worth stems from programmes such as Reach to Recovery and Look Good, Feel Better, which have been dominant sources of advice for women since the 1950s (Batt, 1996; Klawiter, 1999), originally in the US and now internationally (King, 2006). Such programmes aimed to encourage compliance with (often painful and disfiguring) medical treatment by focusing on the restoration of women’s pre-surgery appearance with prostheses and make-up (Batt, 1996). Whilst these may appear to some as empowering, they centralise the importance of appearance to women’s identities, both assuming and creating an expectation that all women’s primary concern should be the restoration of a feminine appearance.

Femininity continues to be emphasised, for example, in the My Journey Kit, which is an Australian resource offered by BCNA (2012). Amongst other information, advice is offered on how to ‘feel attractive’ during and after breast cancer treatment. For example, readers are told, ‘Some women say they feel more sexually alive if they pamper themselves with treats such as visits to the beautician or buying lovely scarves or sexy lingerie’ (p. 162). Although some women may find this advice useful, it reinforces heteronormative and gendered assumptions about women’s bodies, the link between external beauty and self-worth, and the value of women’s beauty practices. It additionally focuses on consumerist practices – shopping and pampering – which echo neoliberal individualism and are only available to women with enough capital to spend on them (should they want to).

The issue of breast reconstruction illustrates one of the complex decisions that women face, namely, managing that decision in relation to other identity positions that they hold. This decision goes deeper than simply restoring one’s feminine identity or sense of wholeness. In a US study of sexual minority women’s decisions regarding reconstruction, Rubin and Tanenbaum (2011) argued that the nuances of breast reconstruction are consistently glossed over in attempts to ‘restore’ women’s bodies and their femininity. They found that some bisexual women and lesbians felt ambivalent about reconstruction, not wanting to be ‘the kind’ to get plastic surgery, whilst not wanting to be criticised as ‘oppositional’ by being one-breasted. Breast cancer has become a ‘cosmetic crisis’ as opposed to a health crisis (Rubin & Tanenbaum, 2011). Similarly, Jain (2007) provided a personal, feminist-oriented account of her experience of simultaneously negotiating not having a reconstruction and not wanting to make the decision into a ‘statement’.

These examples raise a question of how far the pink ribbon culture supports women who do not conform to narrow ideals of femininity. Whilst self-care practices, like using make-up, can be helpful for some, the focus on appearance restoration also limits the consideration of other social issues, such as socio-economic positions or political values, serving both to homogenise and commodify all women.

Pink awareness and self-surveillance

Women’s femininity and their personal responsibility for breast cancer are also constructed and performed through ‘breast awareness’ campaigning. The message of ‘early detection and screening’ is central to the pink ribbon culture, and has become ubiquitous, being broadcast through various channels, ranging from women’s personal testimonies to public fundraising events (King, 2006; Klawiter, 1999; Sulik, 2011).

An analysis of pamphlets distributed by the National Cancer Institute in the US (Davis, 2008) demonstrated a dominant discourse of risk, and of individual responsibility for minimising that risk. In these pamphlets, breast cancer is constructed as an illness that can be ‘personally prevented or detected [by individual women] at the earliest possible moment through appropriate behaviours and practices’ (Davis, 2008, p. 66). Similarly, CA (2013) offers an online resource to Australian women, explaining, ‘There are some simple things you can do to reduce your risk of breast cancer’ (emphasis in original). Suggestions listed were engaging in exercise, lowering alcohol consumption and maintaining a healthy body weight. Although these modifiable risks are important, they do not themselves determine cancer. But such campaigns implicitly position women as somewhat personally responsible for staving off the illness.

There is also a host of other breast cancer awareness campaigns. For example, ‘mamming’ is an international ‘meme’ or trend, which involves predominantly young women (and some men) taking photographs of their breasts resting on public surfaces and uploading the photographs to social media sites, as a strategy designed to remove the ‘awkwardness’ of mammography and to persuade women to engage in breast screening (This is Mamming, 2013). Awareness-raising is often paired with fundraising (King, 2006). For instance, one Australian man set out to raise awareness about breast cancer and funds for the McGrath Foundation by going ‘boob-sledding’ (using a bob sled shaped like a pair of breasts) in the Antarctic (Galliott, 2013). The McGrath Foundation is one of the largest Australian breast cancer fundraising organisations and funds the provision of breast care nurses across Australia (McGrath Foundation, 2013). It also runs awareness campaigns, such as Curve Lurve, with a campaign slogan, ‘If you grow them, know them!’, and a logo of a 1950s pin-up model (http://www.curvelurve.com.au/). The model is depicted as young and curvy, which is in line with the slogan. This mobile programme was aimed specifically at younger women, offering ‘awareness’ resources, and information to teachers, parents and teenagers via the website and various events across Australia.

By using popular channels of communication, such as Twitter, Facebook, and Instagram, such campaigns can be effective in raising awareness about the illness on a broad scale. Some of these campaigns, such as Curve Lurve, also provide women with important information about their breasts and how to identify any changes in them. Mobile information campaigns additionally overcome the barrier of geographical distance that can often hinder women’s access to health information, which is especially relevant in countries, like Australia, where there are dispersed populations. Further, combined fundraising/awareness campaigns draw attention to breast cancer and raise funds for invaluable services, such as the McGrath breast care nurses.

These campaigns, nevertheless, often involve the objectification of women’s breasts (e.g. photographs featuring breasts propped up by objects), as well as the promotion of idealised forms of femininity, through the use of images of young, healthy women (e.g. Curve Lurve) which can alienate women of varying ages or body shapes. Saywell, Beattie, and Henderson (2000) also identified the ways in which breast cancer has been sexualised in the media and in lay contexts, whilst mastectomies and signs of disfigurement are glaringly absent.

Campaigns frequently focus on raising awareness amongst young women, which is problematic, given that breast screening is most widely available to women 50 years and older, both in Australia (Department of Health, 2013) and in other countries (Gøtzsche & Jørgensen, 2013). Further, a recent Cochrane review of breast screening (Gøtzsche & Jørgensen, 2013) – the largest to date – determined that reductions in breast cancer mortality rates were not significantly related to breast screening, but were more to do with improved treatments and better integrated interdisciplinary medical teams. In a pamphlet written for lay audiences, Gøtzsche, Hartling, Nielsen, and Brodersen (2012) additionally outlined the risks of unnecessary pain, false alarms, over-diagnosis, and unnecessary treatment. Continued promotion of ‘breast awareness’, in light of this recent evidence, is not only misleading and potentially harmful, but serves to position women with breast cancer as negligent in not having acted to detect or prevent the disease. Breast awareness messages are constructed through a discourse of ‘individual responsibility and empowerment’, but this can also operate as a discourse of duty and of blame, and one which reproduces the neoliberal focus on self-care (Lemke, 2001; Rose, 1999).

Pink consumerism

The pink ribbon culture engages the wider community in the support of women with breast cancer through pink marketing and consumerism. It encourages the purchase of ‘pink’ products with the promise of contributing financially to ‘raising awareness’ and supporting biomedical research (King, 2006; Sulik, 2011). In her analysis of corporate philanthropy and consumerism, King (2006) noted how the ‘insidiously gendered nature of cause-related marketing […] helps reproduce associations between women and shopping’ (p. xxv). ‘Pink’ items tend to be those associated with the performance of traditional hyper-femininity – beauty products, hair driers and jewellery.

Breast cancer has been constructed into a money-making ‘brand’ (Sulik, 2011), which is not only evident in countries like the US, but also in Australia. This is at times very explicit: the Australian NBCF (2013a) website includes a page entitled ‘Cause-related product marketing’. This encourages businesses to pair their products with the NBCF, with the ‘opportunity to acquire new customers through customers’ affiliation with our cause’ (NBCF, 2013a, emphasis added). Elsewhere, website users are encouraged to ‘show your support for breast cancer research by going shopping!’ (NBCF, 2013a). This ‘pink marketing’ equates direct action with consumer spending, thus diverting the focus away from political action (e.g. campaigns for overcoming inequalities in health care) and towards neoliberal consumer choice and individual responsibility.

Fundraising through fitness

Another characteristic of the pink ribbon culture, linked to consumerism through its classist assumptions and its emphasis on individual effort, is its focus on exercise-based fundraising activities (King, 2006). These have taken the form of walks, runs, cycling events and even dragon boat racing, which all involve the participation of women with breast cancer, side-by-side with individuals and corporations who publicly support ‘the cause’ (King, 2006; Klawiter, 1999; Sulik, 2011). This focus on exercise marks another important class distinction, as King (2006) pointed out, in that it is the middle and upper classes who have leisure time and energy to invest in physical fitness. Again, activism has been diverted from (radical) political action, this time to physical action, with exercise being constructed in a neoliberal, individual-focused worldview as a sign of healthy and responsible citizenship (King, 2006).

Like other Western countries, Australia has numerous breast cancer fundraising events through fitness activities. BCNA, for instance, is partly funded by 14 fun runs held across Australia each year, as well as by other fitness events (BCNA, 2013). One of the most iconic fundraising events in Australia has been the Pink Test, founded in collaboration between the McGrath Foundation, Cricket Australia and other corporate sponsors (McGrath Foundation, 2014). This event is held as part of the Boxing Day Test cricket match, when cricketers (and spectators) wear pink, and money is raised through attendance and affiliated events, such as the Jane McGrath High Tea (Sydney Cricket and Sports Ground Trust, 2010).

These events stem from the history of the organisation, which was founded by Jane McGrath, who died of breast cancer in 2008, and her husband Glenn McGrath, a prominent Australian cricketer. Similar to the Susan G. Komen Foundation, the McGrath Foundation developed from one woman’s experience of having breast cancer and her desire to help others and to spread the message of breast awareness (McGrath Foundation, 2013). Referencing the family’s cricketing background and an Australian cultural valorisation of (men’s) competitive sport, the foundation’s logo uses wickets to represent people. It seemingly presents an image of a man (black wickets) supporting and comforting a woman (pink wicket turned inwards) – ‘together we can make a difference’ (https://www.mcgrathfoundation.com.au/).

This foundation is responsible for two unique aspects of the construction and experience of breast cancer in Australia. First, the foundation’s primary aim is to fund breast care nurses who provide free support to women with breast cancer across Australia, with an emphasis on rural areas (McGrath Foundation, 2013). Australia has a geographically dispersed population, making this source of support invaluable. This service additionally remedies some of the economic inequalities women can face regarding access to support and treatment. Second, events and campaigns hosted by the McGrath Foundation are built on the premise that both men and women need to be involved in raising awareness (and funds) for breast cancer. As Glenn McGrath commented on the Foundation’s website:

We never saw this as something that just affected Jane. It was something that affected our entire family and our friends. In this way, it’s just as much a bloke’s issue and our [McGrath Foundation] nurses are there for the entire family unit.

Glenn McGrath, Founder and Chairman (McGrath Foundation, 2013).

In the above quote, attention is drawn to ‘the bloke’ – a typically Australian way of depicting men (casual, down to earth, traditionally masculine) – who is constructed as part of the ‘family unit’. This construction unproblematically generalises this experience to ‘all’ families, constructing them within the mould of the heteronormative, nuclear family, which disallows space for alternative family formations or sexual orientations. This reference to breast cancer being a ‘bloke’s issue’ does not draw men in as people who could get breast cancer, but rather as being affected based on the illness of their female partners.

This theme of men supporting the women they love is echoed in other Australian campaigns, such as men and women wearing purple bras to raise money on Purple Bra Day (Breast Cancer Care WA, 2013), and resources such as, ‘When the woman you love has early breast cancer’ (CA, 2011) and ‘So I bit down on the leather’ (NBCF, 2013b). Such campaigns and resources are undoubtedly helpful for women with breast cancer and their male partners; however, they do reinforce heteronormative values. Further, attempts to appeal to ‘blokes’ draw on and reinforce Australian constructions of traditional masculinity that are entwined with values such as ‘mateship’, sport and men’s patriarchal role in the family unit (Moore, 1998).

This promotion of exercise within the pink ribbon culture is also evident in the information and advice given to women with breast cancer, as demonstrated in a 2012 issue of the BCNA newsletter, The Beacon. The theme of this issue was ‘the benefits of keeping active’, which included advice from ‘experts’ such as dieticians, as well as women’s personal stories of using exercise to cope with treatment side effects (BCNA, 2012). In the editorial, CEO Maxine Morand commented, ‘It’s something we all know we should do but that many of us don’t prioritise. I can relate to the many reasons […] too busy, too tired, can’t be bothered, have to get dinner on, have to get kids to school […]’ (BCNA, 2012, p. 1, emphasis added). This extract highlights the value that is placed on exercise and constructs it as a moral imperative (‘should’), whilst simultaneously positioning women in traditionally gendered roles as wives and mothers (within the domain of household chores and child care).

The focus on health can also be reproduced through women’s personal stories, such as those published in this newsletter (e.g. ‘My quest to improve my health’, and ‘Transformation of an arthritic couch potato’), which repeatedly featured words such as ‘achievement’, ‘motivation’, ‘energised’, ‘positive’ and ‘new me’ (BCNA, 2012, pp. 7–12). These stories, again, promote the neoliberal discourse of ‘individual responsibility and empowerment’ by constructing women as responsible for improving their health and wellbeing through a project of self-improvement. The construction of advice, such as in The Beacon (the name symbolises hope), additionally reproduces the intersecting discourse of ‘optimism’, through positive language. Encouraging women to be proactive in restoring their health appears to be genuinely empowering. However, it is important to consider other factors that shape women’s health and ‘recovery’, such as their sociocultural and economic positions and their subsequent access to support and resources, such as their ability to engage in physical activities or follow specialised diets (Rao, Warburton, & Bartlett, 2006).

Support and information

A significant aspect of the pink ribbon culture is its focus on providing support to remedy the sense of loneliness and isolation attendant on breast cancer (King, 2006; Sulik, 2011). Contemporary programmes include hospital visiting, breast care nurses (in Australia) and support groups, which may be lay- or professional-run and may be online or in-person (Hordern, 2000; Ussher, Kirsten, Butow, & Sandoval, 2008). Breast care nurses provide women with information and psychosocial support, and also help women to gain some control over their illness by assisting them in decision making (Hordern, 2000), which is a significant move away from earlier decades when women had little to no control over their cancer treatment. Support groups act in a similar capacity and can be extremely beneficial (e.g. Coreil, Wilke, & Pintado, 2004; Ussher, Kirsten, Butow, & Sandoval, 2006). They provide spaces in which women can learn about the illness and treatment choices, construct a survivor identity and gain a sense of empowerment and of community (Sandaunet, 2008; Ussher et al., 2006).

Support groups are not, however, helpful to all. For instance, lesbians have reported choosing not to join support groups for fear of experiencing homophobia (Sinding, Grassau, & Barnoff, 2006), or have found that no support groups exist for their partners (Barnoff, Sinding, & Grassau, 2005). At the time of writing this paper, we could find only three groups across Australia that were targeted directly to lesbians or women in same-sex partnerships, and advertised on prominent breast cancer (e.g. BCNA) and LGBT health websites (e.g. ACON, n.d.). Lesbians who have participated in mainstream support groups in the US have reported dissatisfaction and a sense that ‘heterosexual’ support groups provide no space within which their experiences and concerns can be acknowledged (Barnoff et al., 2005; Matthews, Peterman, Delaney, Menard, & Brandenburg, 2002).

Women from minority ethnic backgrounds have also experienced difficulties with regard to existing support structures. For example, Indigenous Australian women (McMichael, Kirk, Manderson, Hoban, & Potts, 2000) and Aboriginal women in Canada (Poudrier & Thomas-MacLean, 2009) have found that differences in language and values have made them feel excluded from support groups and have identified a lack of culturally sensitive health professionals. Betancourt, Green, Carrillo, and Park (2005) emphasise the importance of practising ‘cultural competence’ to overcome disparities in health care by recognising the diverse health beliefs, values, communication strategies that people utilise and by reconstructing the health system in order to take these into account.

Women’s health and recovery from breast cancer has been promoted on a structural level in several ways in Australia. For example, approved breast cancer treatments and medication are heavily subsidised for all citizens and permanent residents, through the Australian Government Medicare and Pharmaceutical Benefit Schemes, making most breast cancer treatment freely available regardless of financial circumstances. However, support organisations like BCNA also encourage women to inform themselves about the limits of such schemes and how such limitations might affect their illness trajectories. Such approaches could be empowering for women in making informed choices about their treatment and enable them to contribute to discussions with health providers.

Apart from offering support services, breast cancer organisations also provide breast cancer information, which is intended to be both helpful and empowering. However, as we have argued elsewhere (see Gibson, Lee, & Crabb, under review), such information is often presented with the assumption that the reader is white, heterosexual, middle-classed and leads a gender normative life. For instance, Australian resources have been developed to support women’s male partners, such as ‘When the woman you love has early breast cancer’ (CA, 2011) and ‘So I bit down on the leather’ (NBCF, 2013b). Whilst it was acknowledged in the NBCF (2013b) booklet that ‘of course not all partners are male’, there appeared to be no corresponding resources for female partners. As we discussed earlier in this paper, such resources have the effect of positioning men as women’s primary carers, excluding same-sex partners and other family members and marginalising women who are not in relationships. Further, with titles such as that of the NBCF booklet, resources aimed at men reinforce traditional constructions of men as tough or as in protective roles in relation to women.

Information offered by Australian cancer organisations has similarly tended to create only marginal spaces for women who come from a range of ethnic or linguistic backgrounds (see discussion in the Australian version of Batt, 1996). For example, photographs used in booklets such as in the My Journey Kit only featured visibly white women, except on a single page that advertised free interpreters for medical appointments (BCNA, 2012, p. 40). Any acknowledgement of Indigenous women or women from so-called ‘culturally diverse’ backgrounds was made on specific pages, such as those entitled ‘Culture and language’ (BCNA, 2012, p. 39), or in entirely separate resources, such as ‘Let’s talk about living with cancer’ for Indigenous people (Cancer Council Queensland, 2008). This has an obvious ‘othering’ effect for women of Indigenous and ethnic minority backgrounds.

The provision of support services and information is undoubtedly important for women with breast cancer, and enables control and understanding in ways denied by traditional biomedicine (Thorne & Murray, 2000; Ussher, 1989), in keeping with the broader women’s health movement (King, 2006). However, this wealth of information and support implicitly places responsibility on the individual woman to inform herself, take action and thus prevent or recover from breast cancer, overlooking the fact that women with breast cancer are from a range of backgrounds and hold a range of beliefs, values, linguistic abilities and economic resources.

Discourse of optimism: Empowerment or self-regulation?

The second discourse, of ‘optimism’, intersects with the discourse of ‘individual responsibility and empowerment’, by positioning women as able to take control of their illness. As we discuss in this section, this can be extremely productive in remedying some of the power imbalances within the treatment of women’s health. However, this discourse can be restrictive by circulating an imperative of optimism that can sometimes disallow the voicing of other responses to, or meanings around, breast cancer. In addition, the positioning of ‘survivor’ is central to the discourse of ‘optimism’. This positioning can provide women with a sense of optimism about their futures, but can have limiting effects when survivorship is constructed firmly within an individual’s responsibility, placing the burden of survivorship on the individual.

Positive thinking

A discourse of ‘optimism’ flows through the pink ribbon culture through emphasis on practices such as ‘positive thinking’ (Ehrenreich, 2009; Sulik, 2011). These practices can be promoted by medical professionals (Sulik, 2011; Wilkinson & Kitzinger, 2000), support groups (Coreil et al., 2004; Sandaunet, 2008) and friends and family (McKenzie & Crouch, 2004). Ehrenreich’s (2009) analysis of optimism has been influential in explaining how it plays out in the pink ribbon culture, and describing the resulting imperative to think positively that can have restrictive effects for women’s experiences of breast cancer.

Such a focus on optimism can certainly be useful for some, as Milden (2005) argued in response to Ehrenreich’s critique of women who express optimism. Indeed, by ‘thinking positive,’ carers of people with cancer have spoken of being able to function in extraordinary situations, and being able to help themselves and their relatives with cancer, to deal with pain and the fear of death (Youll & Meekosha, 2013). Nevertheless, a critical analysis suggests that compulsory optimism is not always useful for all people with cancer (Broom, 2009; Youll & Meekosha, 2013).

Despite evidence that optimism and other personal traits do not predict survival (Ehrenreich, 2009; Sulik, 2011), the link between positive thinking and health is embedded in medical thinking and lay materials such as self-help books. Empirical psycho-oncological research has a strong focus on ‘fighting spirit’ (Antoni & Lutgendorf, 2007) and the ‘post-traumatic growth’ experienced by women who have survived breast cancer (Manne et al., 2004). In addition, following the self-help movement, people with cancer have started to use complementary and alternative medicine (CAM) to gain control over their illness and to empower themselves in response to the dominance of biomedicine (Broom, 2009). The practice of CAM, Broom (2009) demonstrated, very often utilises discourses of positive thinking and self-control. As Youll and Meekosha (2013) identified in carers’ responses to cancer, positive thinking can work as a strategy of resistance, allowing people to position themselves as ‘medical consumers’ (p. 31), who resist medical dominance by informing themselves, thereby becoming productive individuals who act in response to the illness. This strategy additionally supports the principles of the women’s health movement, which undergirds the pink ribbon culture, through the promotion of women’s empowerment over their health (King, 2006).

The imperative of positive thinking can, however, turn all too quickly into governing practices of self-control and responsibility (Broom, 2009). Drawing on Foucault’s theory of governmentality, Youll and Meekosha (2013) understood positive thinking as a ‘technology of the self’ that supports neoliberal values of ‘responsibility, independence and self-reliance’ (p. 32). Hence, positive thinking goes hand-in-hand with exercising self-control, reining in any negative emotions, and being proactive in monitoring one’s illness trajectory (Broom, 2009; Youll & Meekosha, 2013). According to Rose (1999), ‘every citizen [in Western neoliberal society] must now become an active partner in the drive for health, accepting their responsibility for securing their own well-being’ (p. 6). As Broom (2009) noted, whilst this can be an effective strategy for some, it places a ‘degree of self-responsibility for disease or disease progression […] squarely on the individual patient’ (p. 75).

The discourse of ‘optimism’ involves rhetorical devices which can deny the possibility of coming to terms with the illness and with the inevitability of death (Broom, 2009; Willig, 2011). Despite the enticing quality of positive thinking, some people with cancer have found that ‘hyper-positivity’ can be restrictive and unhelpful, by eliminating opportunities for grieving or facing fears regarding mortality (Broom, 2009). When people regulate their emotions, this can deny the expression of legitimate feelings such as sadness or anger (McKenzie & Crouch, 2004), or deny communication with others (Youll & Meekosha, 2013).

This focus on positive thinking also serves to construct recovery from the illness as an individual triumph and any other outcome as a personal failure (Herndl, 2006; Willig, 2011). Any woman who demonstrates acceptance of the illness or the possibility of death is positioned as ‘giving up’, and as letting down not only herself, but all women. For instance, one Australian woman wrote a newspaper article about the difficulties of her treatment, including the anger and fear she experienced – ‘Overnight you are converted to a number, defined by a disease, prodded and poked like a slab of meat’ (Cassrells, 2012). A reader with breast cancer responded with, ‘Where is your fighting spirit?’, whilst another commented, ‘It’s sad that Deborah Cassrells felt so scarred [sic] […] I just follow my belief that we don’t have the right to be happy but the duty to be happy’ (emphasis added). Both women described all that they ‘overcame’, as well as their gains from breast cancer, which follows the canonical breast cancer narrative of Western society (Herndl, 2006). Such responses to ‘negative’ thinking emphasise the imperative of self-regulation that shapes responses to breast cancer within the pink ribbon culture, as well as broader understandings of health and illness within current Western, English-speaking countries.

Survivorship and the neoliberal subject

Within the pink ribbon culture, and through the discourse of ‘optimism’, women with breast cancer are positioned as survivors who enact the positive traits of hope, courage and moral fortitude (Ehrenreich, 2009; Kaiser, 2008; King, 2009; Sulik, 2011). Despite the history of the term ‘survivor’ within the HIV/AIDS movement, survivorship no longer holds such political meanings, and instead focuses on the individual and the role she plays in overcoming breast cancer (Sulik, 2011).

The story of survivorship is often cast as a ‘quest narrative’, one of the canonical narratives of Western society (Frank, 1995). Within this narrative, ‘illness is the occasion of a journey that becomes a quest’ during which there is ‘something to be gained through the experience’ (Frank, 1995, p. 115, emphasis added). Thus, survivor stories involve the narrator confronting and overcoming her illness, in the process gaining something, or being positively transformed. In this way, the illness experience is imbued with a sense of purpose and worth (Frank, 1995), and the individual becomes an empowered heroine, who has taken control and ultimately succeeded.

Quest narratives not only organise the individual’s story, they are also signposts for others (Frank, 1995). As Frank (1995) explained, ‘the quest narrative recognises ill people as responsible moral agents whose primary action is to witness’ (p. 134) and thus impart knowledge and meaning about the illness experience to others. A central aspect of the pink ribbon culture is the creation of a space in which women can construct and share their narratives, through personal accounts (Herndl, 2006), support groups (Sandaunet, 2008), public events and the media (McKay & Bonner, 2004).

Ultimately, at the centre of the pink ribbon culture stands the heroic breast cancer survivor (Kaiser, 2008; Sulik, 2011). In accounts of survivorship, women reconstruct breast cancer as an opportunity for self-growth (Herndl, 2006); many report becoming ‘better people’, speaking of becoming ‘less selfish, stronger, more tolerant, compassionate, giving, affectionate and social’ (Oxlad, Wade, Hallsworth, & Koczwara, 2008, p. 162). Survivors also talk about learning to live in the present and to appreciate life more (Obermeder, 2013; Oxlad et al., 2008), and some change their priorities in life (Parry, 2008; Wilkinson & Kitzinger, 2000). Survivors are thus commonly portrayed as strong and courageous women, who serve as ‘living proof the disease isn’t so bad after all’ (Ehrenreich, 2009, p. 27), and as inspirational to others (McKay & Bonner, 2004). Such constructions can be restrictive, however, and provide no space for women with advanced or incurable cancer.

The position of being a breast cancer survivor exemplifies what Davies et al. (2006) termed the ‘neoliberal subject’ – ‘an individualised, competitive, free and responsibilised subject’ that is ‘free and in control of itself and responsible for its own fate’ (p. 88). ‘Free choice’ is a central aspect of this neoliberal understanding of subjectivity (Stuart & Donaghue, 2011, p. 101). Feminists have examined this notion of ‘choice’ for its effects on women’s subjectivity, particularly regarding women’s beauty practices (e.g. Braun, 2009). In relation to health, the range of treatment options or support services may give the appearance of ‘choice’, yet it can obscure the limitations of some choices (e.g. not all medication is subsidised by the Australian PBS), or which choices are available to whom (e.g. support services for male, not female, partners).

The concept of the ‘neoliberal subject’ can also be extended to analyse women’s subjectivity in relation to their health. Breast cancer is constructed as an illness that threatens the individual woman, who is expected to remain vigilant (in response to this threat) by engaging in self-surveillance, in order to ward off a diagnosis. If a diagnosis does arise, she is then positioned as needing to take control by staying well informed about the illness, and being proactive and optimistic in order to emerge as a breast cancer ‘survivor’. Women with breast cancer are thereby constructed as self-reliant, empowered and agentic in dealing with their illness. However, in turn, this subject position places a great deal of the responsibility of health (and survival) on the individual woman. Further, within the pink ribbon culture, women are positioned as having a plethora of treatment ‘options’ and support services, which serves to highlight their ‘choice’ and ‘agency’, but not all women necessarily can, or want to, ‘choose’, whilst dealing with their illness.

Conclusion

Within Western society, an entire illness culture has been constructed around breast cancer, which shapes understandings of its development, the illness experience and ‘recovery’. We have chosen to illustrate two intersecting discourses that currently construct breast cancer: the discourse of ‘individual responsibility and empowerment’ and the discourse of ‘optimism’. These discourses are indicative of the neoliberal values and practices dominant in contemporary Western society, which emphasise individual control, self-actualisation, consumerism and responsibility (Broom, 2009; Lemke, 2001; Rose, 1999).

The pink ribbon culture has undoubtedly benefited many women, their families and friends. Through the operation of the pink ribbon culture, breast cancer has effectively been constructed as something that is ‘sayable’. Women can now speak about the illness, they can narrate their experiences, and can thereby (re)construct their sense of selves (Herndl, 2006). By orienting towards socially recognisable constructions of breast cancer, women can access a great deal of support, and share support and information with each other. Strategies such as personal testimony have also been used to promote ‘breast awareness’ amongst well women and society, to raise people’s awareness about the illness, and to garner funding for breast cancer research and resources. As illustrated in the Australian context, even men have been encouraged to participate in fundraising events, which have positioned men as supporting the women they love. Such campaigns are also promoted by breast cancer organisations as vital for supporting women with breast cancer and for funding services, such a specialised breast care nurses.

Women are further constructed as having control over the illness when they are seen to engage in self-surveillance or modify their behaviours in attempts to prevent breast cancer. They are thereby positioned as responsible for taking control of their health. They are similarly ‘empowered’ when they are seen to engage in practices such as exercise or positive thinking, or to reinstate their femininity through beauty practices. Such practices may help many women to deal with a difficult illness experience and repair or sustain their identities in light of a life-threatening illness.

These discourses and practices, however, can be restrictive. Whilst women are positioned as empowered, they are simultaneously positioned as individually responsible for maintaining or restoring their health. This is similar to the ways in which women are constructed as responsible for their ‘recovery’ from other difficult experiences, such as depression (Lafrance, 2009). This is perpetuated through practices that promote self-care (e.g. exercise, beauty practices) and self-surveillance (e.g. breast checking). Breast cancer is thus constructed as an individualised problem that requires an inward focus on self-regulation, rather than an outward consideration of contextual factors that shape and constrain the development and experience of the illness and meanings that construct current understandings of breast cancer.

Women are positioned in very particular ways within the pink ribbon culture. White, heterosexual, middle-class women are positioned as central within the construction of information and support services, as exemplified by some Australian resources offered to women. This becomes apparent when considering what, if any, space is provided for lesbians, women from ‘culturally diverse’ backgrounds and Indigenous women both in Australia and in other Western countries. Women are also constructed in traditionally gendered ways. This places pressure on women to conform to beauty ideals that are promoted through the pink ribbon culture. Breast reconstruction, prostheses and the use of make-up thus become less about ‘choice’ and more about expectations, as some feminists have noted in their breast cancer accounts (Batt, 1996; Ehrenreich, 2009; Jain, 2007). This has additionally constructed breast cancer as a personal, cosmetically-oriented crisis, with less attention paid to sociopolitical concerns, such as potentially unequal access to resources.

Whilst the pink ribbon culture has shaped women’s experiences and provided many material benefits to (some) women, it is questionable whether all women will identify with the dominant discourses of this illness culture. It would be useful, therefore, to explore the nuances and multiplicity in women’s storytelling and meaning-making. This could include considerations of how women negotiate their breast cancer experiences within pink ribbon spaces and in light of the various identity positions they simultaneously hold. In doing so, attention could be paid to the active role that they play in drawing on and resisting dominant constructions of breast cancer. Such an analysis would additionally counterbalance current critiques of the pink ribbon culture, including this one, which predominantly focus on the discursive construction of this illness culture on a social and structural level.

Whilst acknowledging the multitude of resources now available, particularly demonstrated here in the Australian context, we suggest that greater attention could be paid to presenting information in culturally competent ways that address women from a range of backgrounds (Betancourt et al., 2005), rather than offering segregated information to women who are not white, heterosexual or middle-classed. Health campaigns should also avoid presenting women as uniformly young and feminine, which could enable a wider range of women to identify with the messages.

In taking a feminist post-structuralist approach to critiquing the pink ribbon culture, we have endeavoured to illustrate how this neoliberal illness culture has productive effects, in empowering women, whilst simultaneously placing responsibility on women for their health and illness, and limiting how it can be experienced.

Footnotes

Author Biographies

Alexandra Farren Gibson is a PhD candidate in the School of Psychology at the University of Queensland. Her PhD involves a critical examination of the pink ribbon culture and the space provided for women from minority backgrounds. Broadly, she is interested in social constructions of health and illness, cancer, women’s health, and gender and sexuality.

Christina Lee is a professor of Health Psychology at the University of Queensland. Her research covers both qualitative and quantitative work on women’s health, and is informed by a feminist approach to scholarship.

Shona Crabb in a Senior Lecturer in Public Health at the University of Adelaide. She is interested in qualitative and critical approaches to women’s health, health promotion and risk communication.

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