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Doctor-Patient Communication
Sociology of Health & Medicine > Doctor-Patient Communication
Table of Contents
Abstract Keywords decades and within medicine, communication is increasingly seen as a critical skill-set in the delivery of care. The doctorpatient relationship is a special kind of relationship since, while patients may not know their doctors in a personal sense (and often, vice versa) they are nonetheless asked to disclose intimate details of their personal lives and reveal their bodies for examination. This vulnerability is not reciprocated from doctors to patients. There is, therefore, a degree of social imbalance in this relationship (albeit one that is socially sanctioned) which may have a bearing on communication. Barriers to effective communication between doctors and their patients, such as class, gender, race and health literacy are discussed.

Overview
Communication & the Ceremonial Order of the Clinic Barriers to Doctor-Patient Communication Social Class Gender Time Factors Race

Overview
Doctor-patient (or client-professional, practitioner-patient, lay-professional) communication is the primary expression of doctors relationships with their patients. Communication has been the focus of scholarly study and public concern for several decades and within medicine, communication is increasingly seen as a critical skill-set in the delivery of care. The doctorpatient relationship is a special kind of relationship since, while patients may not know their doctors in a personal sense (and often, vice versa) they are nonetheless asked to disclose often intimate details of their personal lives and reveal parts of their bodies for examination. This vulnerability is not reciprocated from doctors to patients. There is, therefore, a degree of social imbalance in this relationship (albeit one that is socially sanctioned). This may have a bearing on communication; that is, the full range of oral, facial, bodily and symbolic expressions that people use when they interact and exchange information with each other. Classic studies in sociology have highlighted the potential for conflict in doctor-patient communication and identified how assumptions about patients based on class, gender, age and race influence the content and tone of communication. Moreover, research has shown that patients who understand their doctors are more likely to acknowledge their health problems, understand their treatment options, modify their health-related behaviors and adhere to treatment recommendations. Given this compelling evidence, two thirds of medical schools now provide their students with instruction on how to communicate with patients

Further Insights
Patient-Centered Care Teaching Communication Skills Communication & Cultural Competence

Viewpoints
Improving Patient Communication Conclusion

Terms & Concepts Bibliography Suggested Reading

Abstract
Doctor-patient (or client-professional, practitioner-patient, lay-professional) communication is the key expression of doctors relationships with their patients. Communication has been the focus of scholarly study and public concern for several

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Doctor-Patient Communication

Essay by Alexandra Howson, Ph.D.

Keywords
Cultural Competence Communication Functionalism Health Care Disparities Medical Encounter Patient Centered Care Role Format Sick Role
and how to develop interpersonal skills to support effective communication (Travaline et al., 2005). Such skillswhich include listening, explaining, questioning, counseling and motivating patientsare becoming core competencies for medical practice, and in the U.S., demonstration of such skills are required for licensure and board certification. Nonetheless, there continue to be many barriers to effective communication between doctors and their patients, such as gender, race and health literacy. Communication & the Ceremonial Order of the Clinic Physician-patient communication has been central to scholarly research for at least fifty years and the ideal medical encounter (for which communication is critical) is increasingly viewed as one that is patient-centered (Mead & Bower, 2000) from obtaining the patients medical history to conveying a treatment plan. The medical or clinical encounter entails much information sharing about symptoms, diagnosis and treatment options in what has been historically and is increasingly recognized as a therapeutic relationship that provides the first step toward healing (Travaline, Ruchinskas & DAlonzo, 2005). However, studies of patient-doctor communication demonstrate that communication is rarely patient-centered, and is in fact influenced by many characteristics and ideas. There is a surprising degree of regularity and ritual associated with communication between doctors and patients, or, more correctly, with the medical encounter. In a classic study of outpatient clinic visits in Scotland, Phil Strong (1979) found that there is an unspoken set of rules and rituals that guide the medical encounter or consultation. These rituals, encoded as role formats (or as Erving Goffman might put it, social scripts), provide tacit resources that both patients and doctors call upon, depending on their assessment of the encounter (that is, what kind of consultation they consider it to be). Strong identifies four such formats: Bureaucratic (doctor and patient are both polite and avoid conflict, though doctors assume patients to be less than competent); Charity (doctors draw attention to patients incompetence);

Clinical (in which the doctor and patient tacitly agree on the doctors expertise and authority); and Private (in which the doctor focuses on selling his competence). Core to these formats is the way the doctor typically asserts control over the communication process and directs the conversation by the following tactics: interrupting patients or breaking off conversation; excluding the patient by writing while they tell their story; eliciting information from patients but not explaining why such information was required. Strong (1979) notes that such tactics cement the asymmetry between doctor and patient, and subsequent studies in social psychology have confirmed their use. Conflict & Power Indeed, studies of doctor-patient communication often begin with the observation that the relationship between doctors and their patients is unequal in terms of power, status and knowledge. For instance, in Talcott Parsons (1951) discussion of the sick role (a socially deviant state) the patient is entitled to be sick, provided she or he assumes certain obligations, such as making an effort to get well. Accordingly, doctors are obliged to help patients get well. How they interact and communicate with each other is central to how the sick role is negotiated, since doctors occupy a position of authority in relation to the patient (Nettleton, 1992). While such asymmetry is unproblematic in a functionalist view of the social world, it ignores the potential for conflict between doctor and patient, or of the potential for value judgments to influence the process of making clinical decisions. For instance, doctors may discount information that patients provide and be dismissive toward them. In studies of how patients use emergency rooms, researchers have found that doctors are often dismissive of patients because in their view, based on the symptoms that patients describe, some patients should not be in the ER in the first place. That is, patients are judged as being over-anxious (especially mothers of young children, see Roberts, 1992) or, in certain situations (such as patients who are injured but who have also been drinking alcohol) may be judged for behaving in ways that are seen as irresponsible. In such cases, patients may be judged as normal rubbish (Jeffery, 1979); that is, they are seen as presenting with symptoms that are considered inappropriate or trivial. While doctors usually do not explicitly inform patients of what they are thinking or what their value judgments are, they may communicate disapproval non-verbally by not listening to patients or not demonstrating empathy. More recent research confirms that in situations characterized by prejudice and fear, such as in the case of consultations about HIV risk, doctors may handle communication ineffectively in ways that make patients feel uncomfortable or even stigmatized (Epstein et al., 1998). Barriers to Doctor-Patient Communication Social characteristics such as gender and race influence the content and tone of doctor-patient communication and many studies have demonstrated how the social backgrounds of both patients and doctors create barriers to effective communication. Many
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Doctor-Patient Communication

Essay by Alexandra Howson, Ph.D.

studies have found social class, gender and racial differences in physician communication style; how physicians talk with patients and communicate non-verbally. Social Class First, social class differences are significant in determining how doctors communicate with their patients. Although there have been some changes in medical school recruitment, medicine is largely practiced by members of the middle or upper middle class and as such, reflects values associated with hard work, delayed gratification, economic independence and autonomy (Mechanic, 1974). These values influence communication style, especially in terms of the language and the forms of expression used by doctors. For instance, members of the middle class tend to be more verbally explicit, while working class members tend to rely more on non-verbal communication. This means, in doctor-patient encounters between middle class physicians and working class patients, physicians may be more likely to talk than their patients (Cooper & Roter, 2003). In addition, patients whose health literacy levels are low (that is, they have difficulties reading and understanding written medical information and education materials), which is often associated with social class, are more likely to report poor communication with doctors in face-to-face encounters (Schillinger et al., 2004). Gender Second, there are differences between male and female physicians in the way they interact with their patients in general (Brody & Hall, 2000). Male physicians have been found to engage less in non-verbal gestures that communicate warmth and empathy, such as smiling, eye contact, nodding, hand gesturing, direct body orientation (facing the patient) and back-channel responses (such as saying mm-hmm to acknowledge what the patient is saying) (Cooper & Roter, 2003). Similarly, observation studies have found that male physicians talk more than female physicians and when they do so, they are more likely to provide the patient with biomedical information, than to engage in psychosocial conversation that explicitly invites comment from patients about their expectations, feelings and life circumstances (Krupat et al., 2000). On the other hand, female patients are more likely to ask questions than male patients, which may explain why they are given more information than male patients (Waitzkin, 1985), or given information rather than socio-emotional support. These differences in communication style may translate into differences in how physicians treat their female patients, which researchers have historically explained in terms of patriarchal or sexist ideologies (Nettleton, 1992). Time Factors Third, doctors may lack the time and skills to communicate effectively with patients. Patient consultations are generally short and doctors learn to describe and understand disease and illness in a specialized language, which patients may view as jargon. Such jargon gets in the way of establishing common ground between doctors and patients (Stacey, 1988) and may contribute to patient dissatisfaction (Williams, Weinman & Dale, 1998).

Race Finally, there are differences in race and ethnicity. For instance, doctors and patients are more likely to communicate effectively with each other if they share a similar racial or ethnic background, or are race concordant (Cooper-Patrick et al., 2000). In particular, African-American patients experience less participatory visits with their doctors (that is, they are less likely to be included in making decisions about their care) than are other racial or ethnic groups. Indeed, one study found that when African American and Hispanic patients are able to choose their physician, they are more likely to choose a physician who is racially concordant (Saha et al., 1999), because they feel such physicians are more likely to be culturally sensitive to their needs and more likely to share their values, beliefs and experiences. When patients and physicians do not share a similar racial and ethnic background, visits are likely to be shorter, patients are less likely to participate in decisions about their care, and to be less satisfied with their physician (Cooper-Patrick et al., 2000). However, racial concordance between doctor and patient does not necessarily, on its own, contribute to quality of communication between doctor and patient (Misra-Hebert, 2003) and it is not necessarily the case that if the patient and physician are of the same race, there are no barriers to communication. In part, racial or ethnic similarity is a marker for cultural similarity, whereby members of a group share beliefs, values and behaviors that are learned and shared by the members of a group (Misra-Hebert, 2003) and extends beyond racial, ethnic or gender boundaries. Accordingly, cultural competence has become increasingly important in doctor-patient communication.

Further Insights
Patient-Centered Care Communication matters because it has consequences for patient health and health outcomes. Broadly, studies have found that when communication is effective (i.e., when patients are able to ask questions, doctors talk less than patients and provide socioemotional support along with providing biomedical information), care is more patient-centered. When care is patient-centered, there is some evidence that patient outcomes are better, such as pain control, blood pressure and health status (Stewart, 1995) and patient satisfaction (Kaplan et al., 1995). Concomitantly, communication lies at the heart of patient-centered care. Patient-centered care has emerged over the last three decades as an approach to medicine that is sensitive to patients cultural and personal preferences and values, family relationships and lifestyles (Institute of Medicine, 2001). Patient-centered care includes the patient and her family as part of the health care team and emphasizes participation and collaboration, and encourages patients to take responsibility for being involved in decisions about their care. Consequently, communication skills are increasingly taught as a set of technical skills, not only in medical schools but also as part of continuing medical education. Behaviors that are thought to be associated with effective communication include:
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Doctor-Patient Communication

Essay by Alexandra Howson, Ph.D.

Gathering data from the patient, for instance through openended questions; Building relationship with patients, by using empathy, reassuring patients and responding when patients express emotions; Building partnerships with patients by asking for their input and opinion and inviting patients to solve problems jointly; and Counseling (Roter, 2000). Teaching Communication Skills While many medical schools teach communication skills to their students, there is considerable debate over which skills to teach and how to teach them. For instance, some training tools focus on improving communication in the context of poor health literacy and emphasize using plain, nonmedical language, slowing down speech, limiting information and offering it in different formats, such as images as well as text (Weiss, 2009). Other tools emphasize how racial and ethnic issues affect communication and focus on cultural competency and the need to understand, respect and empathize with patient perspective, or focus more generically on patient-centeredness and the need to incorporate the patient as a key player in the health care team. Overall, there is a growing body of behavioral research to support training approaches and content, and at least some agreement on core skills, such as listening, using open-ended questions to elicit patient information, providing and explaining information, counseling and educating patients and taking patient preferences into account. Moreover, teaching these skills has become more of a priority in relation to health care disparities. The Institute of Medicine (Unequal Treatment, 2002) published a report that identified doctor-patient communication as a possible source of disparities for minority patients. A consequence of this report, and the research that supports it, is that in addition to teaching communication skills to medical students and practitioners, skills in cultural competence are also required. Communication & Cultural Competence Cultural competence emerged in medicine as a way to bridge cultural distance between physicians and patients in the interest of reducing racial disparities in health care. Racial disparities are racial or ethnic differences in the quality of healthcare that are not due to access-related factors or clinical needs, preference, and appropriateness of intervention (Unequal Treatment, 2002). Cultural competence includes ways of addressing interpersonal and institutional sources of racial disparities in health care (Saha et al., 2008) and is becoming especially pertinent as the proportion of ethnic minorities in the U.S. continues to increasecurrently 25% of the overall population (US Census, 2000)and is viewed as a national priority in health care. Cultural bias has been identified as a potential source of disparities or at least a barrier to communication between patients and physicians and cultural competence may be a way to overcome this barrier. Cultural competence has many definitions, but generally refers

to the ability of physicians to provide patient-centered care by adjusting their attitudes and behaviors to the needs and desires of different patients and account for the impact of emotional, cultural, social, and psychological issues on the main biomedical ailment (Misra-Hebert, 2003, p. 293). In practice, cultural competence means different things, but includes, first, language sensitivityfor instance, using interpreters when language barriers existand learning about how different cultures treat non-verbal communication (Misra-Hebert, 2003). For instance, bodily and social gestures differ across cultural groups, as do concepts about appropriate personal space. While personal space for many Anglo-Saxon Americans is generally considered to be about 18 inches, personal space in many cultures is often considered to be much closer. Second, cultural competence in communication includes finding out more about the patient experience of disease. In a classic study, medical anthropologist Arthur Kleinman and colleagues (1978) argued for a distinction between disease (a biological concept) and illness (an experiential state), in which the latter is influenced by cultural norms (whether, for instance, it is acceptable to express pain in front of other people) and personal health belief systems. This argument is increasingly taken seriously by medical educators who suggest that in culturally competent care, doctors need to be able to understand patient experience and their own interpretation of what ails them (what Kleinman et al., refer to as the cultural construction of clinical reality). Finally, culturally competent communication is designed to help doctors negotiate with patients in terms they understand and to which they subscribe. In practice, this means respecting patient preferences (for instance, for complementary or alternative therapies such as herbal remedies, or for including family members in decision-making).

Viewpoints
Improving Patient Communication While teaching communication skills to doctors is an important corrective to the power imbalance that may be an inherent part of the Doctor-patient relationship, some researchers argue that patients also need to be taught communication skills, especially among populations for whom health literacy levels are low. In part, this drive to communication may be because poor communication between doctors and patients can lead to malpractice suits, where communication errors include inadequate understandings of diagnosis or treatment or where patients feel their concerns have been ignored (Weiss, 2009). Consequently, some studies have used waiting-rooms as places to talk to and coach patients about communication and in particular, which questions to ask and how to ask them during the clinical consultation (e.g. Cegala et al., 2000). One study found that following such an intervention, patients overall perceptions of their health improved and their blood sugar decreased (Greenfield et al., 1988), which suggests that empowering patients to participate in their care can lead to better communication and perhaps even better health.
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Doctor-Patient Communication

Essay by Alexandra Howson, Ph.D.

Conclusion Doctor-patient communication has long been of concern for medical practitioners, educators and researchers. Ineffective communication has been found to impact patient experience and outcomes and is associated with social factors such as gender, class and race. These differences have been explained in different ways. For instance, feminists have argued that power imbalances between primarily male doctors and female patients help to explain why doctors often ignore patient preferences and choices. Scholars in the political economy of health have argued that poor communication is a result of the social distance between middle class doctors and working class patients. The recognition that race and ethnicity also impacts communication has brought new urgency to the debate because of evidence that links ineffective communication to racial disparities in health care. Consequently, there is a shift toward training doctors in both cultural competency and patient-centeredness, which have both been found to improve communication in ways that might reduce disparities. However, communication is a two-way street, and some patient groups advocate that patients too, need to be coached in how to best communicate with their doctors, so that they feel comfortable asking questions and participating in decisions about their treatment options and care.

Bibliography
Brody, L.R. & Hall, J.A. (2000). Gender, emotion, and expression. In, M. Lewis & J. Haviland-Jones (Eds.), Handbook of emotions, 2nd ed. (pp. 338-349). New York: Guilford. Cegala, D.J., McClure L., Marinelli, T.M., & Post, D.M. (2000). The effects of communication skills training on patients participation during medical interviews. Patient Education and Counseling, (41), 209-222. Cooper, L. & Roter, D. (2003). Patient-provider communication: The effect of race and ethnicity on process and outcomes of healthcare. In Smedley, B.D., Smith, A.Y. and Nelson, A.R. (eds). Unequal Treatment: Confronting racial and ethnic disparities in health care. Washington, D.C.: The National Academies Press. Cooper-Patrick, L., Ford, D.E., Vu, H.T., Powe, N.R. Steinwachs, D.M. & Roter, D.L. (2000). Patient-physician race concordance and communication in primary care. Journal of General Internal Medicine. (15), 106. Epstein, R.M., Morse, D.S., Frankel, R.M., Frarey, L., Anderson, K., Beckman, H.B. (1998). Awkward moments in patient-physician communication about HIV risk. Annals of Internal Medicine, 128(6), 435-42. Retrieved February 9, 2010 from EBSCO online database, Academic Search Complete. http://search.ebscohost.com/login.aspx? direct=true&db=a9h&AN=387988&site=ehost-live Greenfield, S., Kaplan, S.H., Ware, J.E., Jr., Yano, E.M., Frank, H.J.L. (1988). Patients participation in medical care: Effects on blood sugar control and quality of life in diabetes. Journal of General Internal Medicine. (3), 448457. Institute of Medicine. (2001). Crossing the chasm: A new health system for the 21st century. Institute of Medicine. (2002). Unequal treatment: Confronting racial and ethnic disparities in healthcare. Jeffery, R. (1979). Normal rubbish: Deviant patients in casualty departments. Sociology of Health and Illness, 1 (1), 90-107. Retrieved February 9, 2010 from EBSCO online database, SocINDEX with Full Text. http://search.ebscohost.com/login.aspx?direct=true&db=sih&AN=11006793 &site=ehost-live Kaplan, S.H., Gandek, B., Greenfield, S., Rogers, W., Ware, J.E. (1995). Patient and visit characteristics related to physicians participatory decision-making style: Results from the Medical Outcomes Study. Medical Care, (33), 1176-1183.

Terms & Concepts


Communication: The full range of oral, facial, bodily and symbolic expressions that people use when they interact and exchange information with each other. Concordance: Shared identity between patient and physician based on demographic attributes such as age, gender or race. Cultural Competence: The ability of physicians to provide patient-centered care by taking the needs and desires of different patients into account as well as how emotional, cultural, social, and psychological issues affect the main biomedical ailment. Functionalism: A sociological perspective based on application of scientific method to the social world, that sees the social world as a social system with needs that need to be met in order to maintain order and stability. Health Care Disparities: Racial or ethnic differences in the quality of healthcare not due to access-related factors or clinical needs, preference, and appropriateness of intervention. Patient-centered Care: An approach to medicine that is sensitive to patients cultural and personal preferences and values, family relationships and lifestyles. Role Format: Rituals that guide doctor-patient communication and that both patients and doctors call upon, depending on their assessment of the encounter. Sick Role: A special role that sanctions the absence of people from production until they are considered (by physicians) well enough to return.

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Doctor-Patient Communication

Essay by Alexandra Howson, Ph.D.

Kleinman, A., Eisenberg, L., Good, B. (1978). Culture, illness, and care: Clinical lessons from anthropologic and crosscultural research. Annals of Internal Medicine. 88 (2), 251258. Retrieved February 9, 2010 from EBSCO online database, Academic Search Complete. http://search.ebscohost.com/login.aspx?direct=true&db=a9h&AN=7079458 &site=ehost-live Krupat, E., Rosenkranz, S.L., Yeager, C.M., Barnard, K., Putnam, S.M., Inui, T.S. (2000). The practice orientations of physicians and patients: The effect of doctorpatient congruence on satisfaction. Patient Education and Counseling. 39 (1), 49-59. Mead, N. & Bower, P. (2000). Measuring patient-centredness: A comparison of three observation-based instruments. Patient Education and Counseling. 39(1):7180. Mechanic D. (1974). Politics, medicine, and social science. New York: John Wiley & Sons. Misra-Hebert, A. (2003). Physician cultural competence: Cross-cultural communication improves care. Cleveland Clinic Journal of Medicine. 70 (4): 289-303. Accessed February 9, 2010: http://www.dhss.mo.gov/ SpecialNeedsToolkit/PublicHealth_Health_Hospitals/ Misra-Hebert403.pdf. Nettleton, S. (1992). The sociology of health and illness. London: Routledge. Parsons, T. ([1951] 1991). The social system. London: Routledge. Roberts, H. (1992). Professionals and parents perceptions of A&E use in a childrens hospital. Sociological Review. 40(1): 109-131. Retrieved February 9, 2010 from EBSCO online database, SocINDEX with Full Text. http://search. ebscohost.com/login.aspx?direct=true&db=sih&AN=9203 090852&site=ehost-live Roter, D.L. (2000). The enduring and evolving nature of the patient-physician relationship. Patient Education and Counseling, 39 (1), 5-15. Saha, S., Beach, M. C. & Cooper, L. A. (2008). Patient centeredness, cultural competence, and healthcare quality. Journal of the National Medical Association. 100(11),127585. Schillinger, D., Bindman, A., Wang, F., Stewart, A., & Piette, J. (2004). Functional health literacy and the quality of physician-patient communication among diabetes patients. Patient Education and Counselling. 52(3), 315-23. Strong, P. (1979). The ceremonial order of the clinic. London: Routledge and Kegan Paul.

Stewart, M.A. (1995). Effective physician-patient communication and health outcomes: A review. Canadian Medical Association Journal. (152), 1423-1433. Stacey, M (1988). The sociology of health & healing: A textbook. London: Unwin Hyman. Travaline, J.M., Ruchinskas, R., DAlonzo, G.E (2005). Patient-Physician communication: Why and how. Journal of the American Osteopathic Association. 1105(1):13-18. Accessed February 9, 2010. http://www.jaoa.org/cgi/content/full/105/1/13. US Census Bureau. (2000). Accessed February 9, 2010. http://www.census.gov/main/www/cen2000.html. Waitzkin, H. (1985). Information giving in medical care. Journal of Health and Social Behavior, 26 (2), 81-101. Retrieved February 9, 2010 from EBSCO online database, SocINDEX with Full Text. http://search.ebscohost.com/ login.aspx?direct=true&db=sih&AN=12819555&site=eho st-live Weiss, B.D. (2007). Health literacy and patient safety: Help patients understand. AMA Foundation. Williams, S., Weinman, J., Dale, J. (1998). Doctor-patient communication and patient satisfacion: A review. Family Practice. 15(5), 480-92. Accessed February 9, 2010. http:// fampra.oxfordjournals.org/cgi/reprint/15/5/480.

Suggested Reading
Arora, N. K. (2003). Interacting with cancer patients: The significance of physicians communication behavior. Social Science and Medicine. 57, 791-806. Fisher, S. (1993). Doctor talk/patient talk: How treatment decisions are negotiated in doctor-patient communication. In, The Social Organization of Doctor-Patient Communication. 2nd Edition. Norwood, New Jersey: Ablex Publishing Corporation. Lee, R. G. & Garvin, T. (2003). Moving from informationTransfer to information Exchange in health and health care. Social Science and Medicine. 56: 449-464. Naidoo, J. & Wills, J. (Eds). (2001). Health studies: An introduction. Basingstoke: Palgrave. Shoou-Yih D. L., Arozullah, A.M. & Young, I. C. (2004). Health literacy, social support and health: A research agenda. Social Science and Medicine. 58: 1309-1321. Willis, S. (1995). I want the black one: Being different. In E. Carter, J. Donald and J. Squires (Eds). Cultural remix:
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Doctor-Patient Communication

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Theories of politics and the popular (pp. 141-165). London: Lawrence and Wishar. Wood, R.E. (1998). Touristic ethnicity: A brief itinerary. Ethnic and Racial Studies 21(2), 218 -241. Retrieved

February 25, 2010 from EBSCO online database, SocINDEX with Full Text. http://search.ebscohost.com/ login.aspx?direct=true&db=a9h&AN=443081&site=ehos t-live

Essay by Alexandra Howson, Ph.D.


Alexandra Howson Ph.D. taught Sociology for over a decade at several universities in the UK. She has published books and peer reviewed articles on the sociology of the body, gender and health and is now an independent researcher, writer and editor based in the Seattle area.

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