Medicalization

Medicalization is central to the idea that medicine is an institution of social control, implying that all knowledge, including scientific and medical knowledge, is a social product, developed through processes of interpretation and negotiation that play a critical role in evaluating and legitimizing deviance. In this social constructionist perspective, illness and disease are forms of social deviance that need to be controlled or regulated through specially sanctioned agencies such as medicine. Medicalization is a concept that captures the processes through which medicine and medical culture categorize physical, emotional and social phenomena as normal or not-normal, and thus encroach on various aspects of social life. Political economists have argued that medicalization occurs primarily in capitalist societies that are characterized by processes of specialization and differentiation through which medicine expands its boundaries and colonizes new areas of the body and mind. Similarly, medicalization has proved a valuable analytic tool for feminists interested in exploring and explaining the relationship between medicine and the female body. Finally, while medicalization processes are not without conflict, medicalization is increasingly driven forward by the pharmaceutical industry.

Keywords: Deviance; Diagnosis; Functionalism; Medicalization; Political Economy of Health; Sick Role; Social Constructionism; Social Control

Overview

Medicalization is central to the idea that medicine is an institution of social control. Irving Zola (1972), whose work explores medical authority and power in capitalist societies, originally developed the concept. In Zola's framework, illness and disease are viewed as forms of social deviance that need to be controlled or regulated through specially sanctioned agencies such as medicine. Medicalization is a concept that captures the processes through which medicine and medical culture categorize physical, emotional, and social phenomena as normal or not-normal. In doing so, medicine encroaches on various aspects of social life and, to a degree, wins social consent from members of society for doing so (de Swaan, 1990). Diagnosis is important in the process of medicalization because it is through diagnosis that claims are made about what is considered normal and what is not.

Political economists have argued that medicalization occurs primarily in capitalist societies that are characterized by processes of specialization and differentiation, through which medicine expands its boundaries and colonizes new areas of the body and mind (Illich, 1976). Similarly, medicalization has proved an invaluable analytic tool for feminists interested in exploring and explaining the relationship between medicine and the female body. Central to the concept of medicalization is the idea that all knowledge, including scientific and medical knowledge, is a social product, developed through processes of interpretation and negotiation that play a critical role in evaluating and legitimizing deviance.

The Medicalization Thesis

The medicalization thesis emerged primarily in the 1970s as a way of explaining the expansion of modern medicine and its apparent ever-increasing reach into corners of social life. The concept of medicalization is derived from two main approaches to the study of health, illness and disease. First, medicalization is related to the political economy of health, in which good health (in capitalist societies) is viewed as a resource, as well as a state of being. As such, struggles between different social groups ensue over access to and control over whatever is required to produce and maintain good health (such as housing, food, medical care). Those who experience poor health, disabilities and/or advanced age, have less capacity to engage in this struggle for health (or to contribute to the production of commodities) and therefore come to be marginalized by society, or are viewed as deviant.

Political Economy

In the political economy perspective, certain social groups (e.g. minorities, women, people with disabilities, low income groups) have less access to resources that support good health and consequently experience poorer health. In this view medicine contributes to and reproduces social inequalities because its primary focus is on returning those who are sick (deviant) to the labor force, rather than addressing the conditions that create disease in the first place. Thus, medicalization plays a key role in labeling already marginalized social groups as socially deviant, and in securing social power, authority and status for doctors as members of a prestigious profession. Indeed, as more resources are devoted to disease and illness (deviance), medicine's status and power as a profession has grown, such that members of society tend to view medicine as a panacea for life's problems, rather than turning their attention to what is making them sick in the first place; that is, in the political economy perspective, social inequalities. While the political economy perspective was predominant in the 1970s, social constructionist perspectives largely displaced it in the 1980s and 1990s.

Social Constructionism

Social constructionism underpins the second element of the medicalization thesis. This perspective assumes that definitions of illness are the products of social processes and interactions between social groups. These interactions are characterized by inequality, in the sense that not all social groups have equal access to the capacity to produce knowledge or define what counts as knowledge about the human body and its vicissitudes (Nettleton, 1992). Medical practitioners have the power to define what counts as disease and illness as a consequence of negotiations with the state, which have resulted in their designation as professional groups, or experts (Witz, 1992). Such expertise can be considered a social resource, since all societies have social groups that are viewed as experts in relation to illness and disease (with the expertise to heal), from shamans to surgeons. However, the expertise that is conferred on medical practitioners by society also enables them to pass considerable judgment on which phenomena (be they behaviors or symptoms) come to be categorized as disease or illness, and how phenomena that are defined as medical should be handled. This power can have detrimental consequences, as we see especially in the case of childbirth.

Applications

The Example of Childbirth

Many researchers, especially those from feminist perspectives, have argued that childbirth and pregnancy have been socially constructed as a medical problem. In pre-modern societies it is generally noted that pregnancy was not viewed as a separate or special kind of experience. Researchers have argued that women expected pregnancy and childbirth to be accompanied by pain and discomfort (Donnisson, 1977) and there was very little formal advice given to women before or during pregnancy and childbirth. Instead, women tended to rely on each other for support through pregnancy and childbirth and they learned informally about what to expect through oral sharing of information.

Historically, childbirth attendance was mainly the preserve of women known as midwives who specialized in assisting friends and kin in giving birth. However, medical men who also practiced birthing wished to formalize the knowledge and practices of midwives as a way of developing a specialized, professional group (Witz, 1992). This process of formalization challenged the primacy of midwives in the early eighteenth century and subsequently, in the nineteenth century, as medicine became increasingly scientific, pregnancy and childbirth came to be seen as a pathological-and therefore clinical-event, in part because the men who attended births were largely associated with hospitals and hospital based medicine (Turner, 1987).

This specialized location enabled them to create a systematic knowledge base that supported the view that pregnancy needed to be managed via medical interventions and not allowed to simply happen as a natural event. The development of forceps (Wajcman, 1991) was critical in this process as it allowed doctors to deliver babies that would not otherwise have survived. However, it also allowed doctors to discredit midwives and marginalize them from the process of pregnancy and childbirth and in doing so, redefine pregnancy and childbirth from a natural event to a pathological event requiring medical surveillance and management. As Oakley (1980) argued in her classic study of the history of childbirth, the development of birthing technologies, from forceps to Cesarean sections, provided a way of restricting the informal practice of midwifery and cementing technical intervention as the hallmark of modern obstetrics.

In the twenty first century, pregnancy and childbirth continues to epitomize the significance of medicalization, as new technologies ensure that the pregnant woman and the baby she carries is supervised and monitored from early in conception through to delivery and even beyond (Apple, 1995). Nonetheless, there has been backlash against the medicalization of pregnancy and childbirth and growth in midwife deliveries as an alternative to medical supervision. For instance, in New Zealand, a majority of women register with a midwife rather than an obstetrician to manage their pregnancy (Jutel, 2006). Such a change allows the medicalization process as one of negotiation rather than as undisputed dominance and social control.

Further Insights

Medicalization, Deviance & Social Control

Central to the concept of medicalization is the idea that medicine is an institution of social control whose primary function is to deal with illness as a form of social deviance. This claim is based on the observation that areas of life that might be defined as natural or social have increasingly come under the scrutiny of medical culture and practice. For instance, natural human processes such as childbirth, aging and menstruation have all been defined as medical problems that require medical solutions. Zola (1972) argued that medicine has been central to handling social deviance in contemporary capitalist societies as the social power of religious institutions has diminished. In doing so, medicine develops experts upon whom people come increasingly to depend, in ways that diminish their own capacities to make judgments and deal with problems (Illich, 1976).

In medieval and pre-modern Europe and early America, religious institutions were generally charged with identifying and defining behaviors as deviant and dealing with them through punishment and/or marginalization. For instance, in Puritan New England, witches were viewed as deviant, or, in fact, as sick (Gevitz, 2000). In seventeenth century Salem, Massachusetts, they were viewed as dangerous and therefore deviant by religious governors. Consequently, these women and girls were treated in ways that punished them and warned other members of society that such differences would not be tolerated. In modern Western societies, medicine has taken over the role of "processing" deviance, by identifying and labeling certain behaviors as socially inappropriate and/or dangerous (such as homosexuality). In this understanding of deviance, people who are different in ways that society cannot accommodate are not categorized as "evil," as they may have been viewed in the past, but instead they are categorized as "sick."

The Sick Role

Talcott Parsons (1951), the functionalist sociologist, developed a theory for explaining how medicine handles sickness as deviance, and how people participate in the process of managing deviance. In the functionalist perspective, illness is considered deviance and the patient-physician relationship is a primary mechanism of social control that functions to restore social stability. In his view, illness is considered deviant behavior because when people are ill, they threaten the stability of the social order, as they are (often, though not always), unable to perform their usual social roles. Illness, as understood in the functionalist perspective, violates social norms and is potentially disruptive. Therefore, it requires a social response. Medicine provides a social response that treats people who are ill, or sick, with the aim of restoring them to health, or to social functioning. Part of this social response requires people who are sick to take on a special role that permits their absence from production until they are considered well enough to return (by physicians). Therefore, the sick role exists to pull the sick person into a relationship with a physician, who helps to heal the sick person and integrate them back into their normal social roles (e.g. parent, wife, worker).

When people adopt the sick role, they are not viewed as responsible for being sick (that is, their deviance) and therefore, they are not necessarily stigmatized for being sick (or deviant-although there are exceptions in diseases that are viewed as the consequence of social behaviors that are perceived to be deviant, such as sexually transmitted diseases). Consequently, as long as members of society inhabit the sick role appropriately and fulfill the obligations that come with it, including submitting to medical care and intervention, they are not, in Parsons' view, categorized as deviant (just sick). Central to the process of categorizing people as sick or not sick, is the related process of diagnosis.

Medicalization & Diagnosis

Interpretative perspectives on medicine, disease and deviance claim that diagnosis is not a value neutral process. Indeed, diagnostic categories are often imbued with assumptions about social categories such as race, gender and age. Because these assumptions change over time and place, so do the diagnostic categories. For instance, in the nineteenth century, the phenomenon of runaway slaves was understood as a disease-drapetomania-and in the twentieth century, there is a shifting smorgasbord of physical, emotional and social phenomena that are increasingly viewed as medical disorders, such as female sexual dysfunction (Tiefer, 2006) and compulsive shopping (Lee & Mysyk, 2004).

Diagnosis is central to the process of medicalization because it is an interpretative and social process that is built on and helps to build a formal system of classification or nomenclature that serves to legitimate medicine as a profession of authority (Jutel, 2009). This process involves describing a phenomenon in medical terms, which then is incorporated as a disease concept which relies on an understanding of disease categories as socially constructed (Hacking, 2001). It is this process of categorization that lies at the heart of medical authority, because of its role in legitimizing sickness (de Swaan, 1990), and in establishing and modifying the boundaries of what is considered normal or abnormal. Indeed, scholars have argued that social assumptions influence how and which symptom clusters come to be identified as diseases (Aronowitz, 2001).

The case of homosexuality is a classic example of how behaviors that are considered socially deviant have been categorized as disease, and therefore become subject to medical surveillance. The Diagnostic and Statistical Manual of Mental Disorders (DSM) is the key classificatory text of modern psychiatry and until 1973, homosexuality was listed as a psychiatric condition. However, during the preparation of the DSM-III, gay activists protested at American Psychiatric Association conventions against the categorization of homosexuality as mental illness. Ultimately, homosexuality was removed from the DSM-III as a diagnostic category (Kirk & Kutchins, 1992). Diagnosis, then, can be understood as a process that involves fixing diagnostic labels to socially deviant behaviors.

This understanding of diagnosis and its role in medicalization processes is also seen in the case of obesity in the US. Obesity has shifted from being seen primarily as a sign of weakness or moral lassitude arising from gluttony and sexual excess that primarily targeted women in the early twentieth century (Stearns, 1999) to a disease that requires medical treatment at both the level of the individual and public policy (Boero, 2007). Boero argues that the "obesity" label was initially used to designate undesirable or stigmatizable "differences" that could be treated through interventions such as drugs, jaw wiring, or bariatric surgery. However, while obesity was initially treated as a problem for individuals, and interventions designed accordingly, obesity is now seen as a wider social problem-or epidemic-that has the consequence of extending "medical jurisdiction over health itself in addition to illness, disease, and injury" (Clarke et al., 2003, p. 162). In contrast, there are patients and advocacy groups who refute that obesity is a disease and suggest instead that obesity has been medicalized because society discriminates against size (Jutel, 2006).

Medicalization & Pharmaceuticals

In the twentieth century, research on medicalization has turned to the prevalence of pharmaceuticals as panaceas for the ailments and aches of everyday life as well as the controversies and conflicts that accompany their use. In the 1970s, pharmaceuticals were viewed as key objects in the process of medicalization. Ivan Illich (1976) noted, for instance, that if contemporary American society was dependent on medicine and medical experts in general, then the consumption of drugs in particular fuelled that dependence. Yet, as Williams et al. (2008) note, while pharmaceuticals were viewed as part of the problem of the engine of medicalization, they were not viewed as its driver. Increasingly, researchers argue that the pharmaceutical industry plays a key role in medicalization. Consequently there are a number of case studies that follow the development of not only drugs to treat particular diseases but also the creation of new disease categories (such as ADHA, erectile dysfunction and bipolar disorder) to which they can market their products.

While doctors were seen as the drivers of medicalization in the twentieth century, the pharmaceutical industry is seen in the twenty-first century as a key driver because of the direct relationship that "big pharma" has with health consumers as well as with doctors and health care practitioners through direct-to-consumer advertising (DTCA) and Internet purchase via e-pharmacies (Fox et al., 2005). This process of medicalization via pharmaceuticals occurs in two main ways. First, drug consumption in the domestic context has increased, especially drugs that enhance or suppress dietary and increase sexual appetites. Second, consumers increasingly see drugs as a normal-and normalized-means of dealing with everyday life (Fox et al., 2007). Thus, the extension of pharmaceuticals into domestic, everyday life contributes greatly to contemporary medicalization.

Issue

The Medicalization of PMS

While medicalization is generally viewed critically as a source of power and undisputed authority, it is also marked by negotiation and conflict. For instance, pre-menstrual syndrome (PMS) emerged as a broad term to encompass a variety of female experiences that have subsequently come under the purview of gynecology (Rodin, 1992). PMS is a diagnostic category that focuses on hormonal imbalance but it reflects ideas about femininity and the female body and about a woman's place in society in terms of career. Rodin argues that just as hysteria was defined in the nineteenth century in terms of its unpredictability (and marriage was offered as a solution), the category of PMS in the twentieth century was sometimes used to legitimate claims that women ought not to be given positions of responsibility in the workplace or in public life. Yet, PMS has also been used to support the legal category of 'diminished responsibility' in the United Kingdom as a defense for women charged with crimes of violence (usually against domestic partners).

Anthropologists have suggested that the cluster of symptoms that women experience that are categorized as PMS may be culturally specific. Johnson (1987) suggested that PMS is a kind of cultural safety valve through which women give expression to the social contradictions of living in capitalist societies which expect citizens to engage in productivity, and also be reproductive. Emily Martin, in her book, Woman in the Body, takes this observation further to argue that in Western capitalist societies the bodily and material disruptions women experience are not readily accommodated. It is difficult for them to carry the burdens of both production and reproduction. Hence, PMS provides women a measure of reprieve. This analysis suggests that women themselves have contributed to the social construction of medical categories (or medicalization) as a way to find solutions to their embodied experiences, especially those that disrupt their lives. The medicalization of symptoms associated with PMS invites further investigation, but it also provides a mechanism through which women have been able to find legitimization and authoritative support for symptoms associated with pain and discomfort. In such circumstances women are not necessarily the victims of medicalization but participants in the construction of discourses that define female embodiment.

Conclusion

Although medicalization is central to the idea that medicine is an institution of social control, its power may be modified by social protest (as in the case of homosexuality and the DSM). Further, when people who have symptoms and discomfort do not have the benefit of diagnostic category, this can cause distress and make it difficult for them to claim benefits and legitimacy for their illness (Nettleton, 2006). Thus, medicalization, through the process of diagnosis, may have social benefits. Nonetheless, it seems clear that medicalization continues as a process that defines and categorizes areas of life that have not hitherto been understood in terms of disease. Pharmaceutical companies may play a critical role in this process, as they support the categorization of certain symptoms as disease, in order to promote their products. While professional expansion and the pursuit of prestige may explain medicalization processes in the twentieth century, this "disease-mongering" (Williams et al., 2008) may be the new engine of medicalization.

Terms & Concepts

Deviance: Differences in behavior from what is generally considered the social norm.

Diagnosis: An interpretative and social process that is built on and helps to build a formal system of classification or nomenclature that serves to legitimate medicine as a profession of authority.

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.

Medicalization: The processes through which medicine categorizes physical, emotional and social phenomena as normal or not-normal.

Political Economy of Health: An analytic approach in which health is viewed as a resource, as well as a state of being. As such, struggles between different social groups ensue over access to and control over whatever is required to produce and maintain good health (such as housing, food, medical care).

Sick Role: A special role that sanctions the absence of people from production until they are considered well enough to return (by physicians).

Social Constructionism: A philosophical perspective that views social phenomena as created through social action and interaction.

Social Control: The formal or informal mechanisms that regulate individual and group behavior.

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Suggested Reading

Brown, P. (2008). Naming and framing: The social construction of diagnosis and illness. In Brown, P. (ed.) Perspectives in Medical Sociology. Long Grove, Ill: Waveland Press.

Busfield, J. (2006). Pills, power, people: Sociological understandings of the pharmaceutical industry. Sociology, 40:297-314.

Campos, P., Saguy, A., Ernsberger, P., Oliver, E. & Gaesser, G. (2006a). The epidemiology of overweight and obesity: Public health crisis or moral panic? International Journal of Epidemiology. 35:55-60.

Engelhardt, H.T. (1992). The body as a field of meaning: Implications for the ethics of diagnosis. In Peset, J.L. and Gracia, D. (eds). The Ethics of Diagnosis. Netherlands: Springer.

Healy, D. (2006). The latest mania: Selling Bipolar Disorder. PLoS Medicine, 3, e185.

Moynihan, R. & Cassels, A. (2005). Selling sickness: How drug companies are turning us all into patients. Sydney: Allen and Unwin.