Grappling with methodological issues

5.12.1 Naming weight without defining or stigmatising overweight. Many of the terms used to refer to overweight appear to have very fixed meanings e.g., to be obese is to have a BMI of over 30. Some terms are, or have taken on, derogatory connotations, or have been used in the past to shame or humiliate a person with issues around weight, or have had that effect. In the use of the descriptor, weightfull, I found a term that did not have fixed meanings. While it has continued to satisfy my criteria, it met with some derision in the medical school environment: “Why don’t you just call fat, fat?” I was asked.

5.12.2 Relating with participants. Overall I encouraged participation and acknowledged a diversity of views about weight and WLS. Increasingly through the research, my understanding of weightfullness, my analysis of medical interventions and my concerns about the practices of weight consultation were growing. At times during interviews with doctors or WLS participants, I was called on to express agreement with certain hegemonic views. Years of experience in working with mediation clients in my counselling practice allowed me to steer a path which neither agreed with nor denied these ideas. Overall, my response was to respond with interest in the expression of a diversity of experiences throughout the process.

The unsettled nature of participant/researcher relationships in the field (Bateson, 1989; Fielding, 1993; Wainwright, 1997) has been written about a great deal. Particularly with the women in this research, I puzzled as Bateson (p.101) did, about how to understand these relationships:

[…] these women are not "interviewees", not "subjects" in an experiment, not "respondents" to a questionnaire. There is a symmetry in our mutual recognition but there is asymmetry in that I am the one who goes off and weaves separate skeins of memory into a single fabric. But they weave me into their projects as well.

Although each interview was a discrete event, the connections with participants began well before I met them and continue to this day with some intermittent contact. This has taken a number of forms. One example was when a participant asked me at

issue. One of the boundaries that I set myself in counselling was to engage with clients only on work-related matters while they were free to continue to contact me. I used this same standard in relation to the research: Consequently I turned down the opportunity to work with and have a friendship with one of the doctors on an ongoing basis; I did not make another appointment to consult a specialist who gave me advice about Lipedema when I met him in a research capacity. I was encouraged by one surgeon to discuss a personal issue with another surgeon in the research but I chose not to.

My familiarity with the surgeons and the area of WLS was a factor that I needed to bear in mind constantly. In the first interview with Michelle, we discussed the referral by her surgeon back to the local surgeon. We both interpreted his motivation as caring and distinctly lacking in self-interest:

participantR: Yeah, so he wasn’t out there saying you know, “Come

on, come on!”

Michelle: But yeah, seemed genuine. That is the thing I

appreciate about him (her surgeon).

What is interesting was this acceptance by both Michelle and participantR of the altruistic motives of her surgeon. While as participant-R, I asked: “What did you think about him saying that?” as being also his patient, I was clearly disposed to accept this surgeon’s motives as straightforward. Later in the research, it became evident that a business pact existed between the surgeons. Such a relationship made it difficult for the more experienced surgeon to accept patients from outside his own immediate area without placing pressure on that relationship. The interviews with Michelle pointed to one of the difficulties that is also a benefit in research, when a researcher who is engaged in and familiar with the research area and participants.

5.12.3 Representation and the use of key participants.

Altheide and Johnson(1994, p.489) wrote of the need for researchers “to substantiate their interpretations and findings with a reflexive account of themselves and the processes of their research.” In this methods section I have discussed how I worked in the interviews. I have done so in the interests of thickening the research foundations as well as to bring these interviews alive. The aim of transparency can be somewhat frustrated in qualitative research by the sheer weight of words required to do that. I have chosen representative excerpts to add texture both in this chapter and in the substantive data chapters but I acknowledge that choosing has been a challenge. In the methods section, I have quoted from SusieB, Michelle, Rosie, Shona and Marjorie:

These participants were interviewed twice because, through the time of the research, they underwent a further WLS project. As well, the first four participants occupied key positionings within the WLS community. These participants appear frequently within the data chapters because the decisions they took and their multiple experiences were seminal to the development of the thesis argument.

5.12.4 Resisting a takeover by the dominant voice. I began this project in a Medical School Department focusing on Public Health and completed it in a Health Sciences faculty at a different university. Within a public health department, as within the media and in the mainstream medical journals, the current anti-fat focus of research relates disease as correlated with fatness. This brought with it a sense of closure and determination that being overweight as defined by the BMI was connected unproblematically to definitive and negative disease outcomes.

While I continue to work with medical students in a Medical School, my choice was to move my thesis between institutions: This reflected a choice for feminist input into a feminist project. I have wished to open up the project to diverse understandings of the potential relationships between weight and health.

5.12.5 Focus and title for the research. This research and thesis process began life as a discourse analysis of weight in consultation. Once in the field, the significance of WLS became apparent. The reader might well ask what did she expect if she interviewed people from a WLS support group website. As I have written elsewhere, I could not have foretold the explosion of materials that entered the media, including real life stories on television and in magazines in the form of sensational or pseudo documentary style programmes and articles. It was clear to me from the first interview in which WLS was discussed, that all other experiences of weight faded in comparison with the intensity of contemplation and results of WLS. Thus, following the first four interviews with women, I became particularly interested in WLS options particularly as these related to practices of consultation. From a working title of A Matter of Fat: Power Relations, Doctors and Weight-Full Woman Patients, this thesis is entitled: (D)- graded female bodies and the emergence of weight-loss surgery: A discourse analysis of narratives relating a precarious moment in the medicalisation of women’s weight. 5.13 Consulting the texts and writing-up the thesis

narrative therapy approaches have received little attention in health research though they have been suggested more recently in relation to research in psychotherapy (Riessman & Speedy, 2007). In the initial stages, I called my research orientation Foucauldian-feminist discourse analysis emphasising a transdisciplinary approach. While I have since related the specifics of a bricolage based on narrative therapy philosophy and modes of enquiry, this thesis has always been about tracing the operation of power through the range of narratives in which these occur. This methodological focus meant that the research moved from being limited to obesity, weight interventions and the influence of medical consultations on decision-making over weight and health. These were the original foci for extensive literature reviews, and I needed to return to the literature to carry out an extensive review of the history of medical/surgical interventions, trading in health, and the ethics of medical practice. This has allowed a context of understanding and reflection on the very problematic aspects of WLS practices.

5.14 In reflection and moving on

My research text became a gathering place for narratives of women’s lives as they lived with and managed weightfullness. However, within the context of the over-arching shaping of lives by hegemonic cultural and moral norms within Western society, I became focused in on two specific areas: Expert processes of consultation and the reach of medical technology, specifically WLS, into women’s lives. These areas remain both significantly unquestioned and convincingly inevitable within the rhetoric of medical technology as progress and the hegemonic weight/health connection.

Following an introduction to the history of medicine as a science, its encultured biases and the increasing reliance on expertise in modern medicine, I moved in chapter four to introduce the specifics of my methodology as a transdisciplinary bricolage based within narrative therapy. In chapter five, I have shown how methodology was translated into the ways and means of working through this thesis. I have worked also through the various aspects of researching as an ethical form of critical narrative enquiry that suggested the need to consider ethical consultation practices in WLS later in the thesis. Having proceeded through participant selection, the use of data and technologies and the nature of interviewing, I have indicated a process of qualitative analysis without the use of data-technology programmes. The use of diverse narratives aids complexity, adding to the reliability and validity of my account. In the final

paragraphs I have spoken of some of the conundrums in this research and showed how I moved to resolve them.

Through each of the following data chapters six to ten, I build my thesis that WLS decision-making is a precarious moment in the medicalisation of women’s weight. From being exposed to a lifetime engendering of slimmed weight for women (Chapter 6) to the commodification of health interventions targeting women (Chapter 7), WLS participants were primed and recruited into reducing weight through radical surgery options when these were promoted as medically indicated. But these surgeries were experimental and they came with a range of side effects that threatened ongoing life, health and well-being (Chapter 8). Professional practices of consultation were poor particularly in relation to what could be discussed and how ongoing problems could be understood or resolved (Chapter 9). In Chapter 10, I show how the relentless drive to trade in WLS promoted formulaic informed consent processes that lacked moral and relational commitments to the protection of WLS patients. These patients could not consent to these procedures because they were denied access to disconfirming information that would have precluded their involvement.

I begin in chapter six to understand through the narratives of women participants how the engendering of weight in Western society increases the likelihood of an uptake in risky WLS options.

“Being a problem is a strange experience […] this double consciousness, this sense of always looking at one's self through the eyes of others, of measuring one's soul by the

tape of a world that looks on in amused contempt and pity” (W. E. B. Dubois, 1903/2007, p.1).

CHAPTER SIX