Medicalization of Deviance

This article examines the medicalization of deviance through a sociological lens. A definition of deviance is offered in terms of behavioral conduct, and indicates potential reasons individuals behave in a deviant manner. Next, a description of the medicalization of deviance is offered that describes ways deviant behaviors have been re-categorized as medical conditions that can be treated through the use of pharmacological interventions. Accompanying applications are offered through the lens of alcohol and substance abuse. Issues are discussed that relate to treatment and conflicting philosophies. Subsequent areas of research for sociologists examining this phenomenon are suggested.

Keywords Deviance; Medicalization of Deviance; Social Constructionism Theory; Social Learning Theory; Socialization

The Medicalization of Deviance

Overview

From a historical perspective, the study of deviant behavior and social control began in the late 1960s. Interest emerged in ways categories of deviance are created, how the conflict among interest groups shapes the definition of what is considered deviant, and detailed ways that social policy about deviance develop and change over time (Horwitz, 1981, p. 750). From a reflective perspective, Higgins (1998) observes that "many of us take for granted" that those who engage in deviant behavior "are different kinds of people than we are" (p. 141). This belief is reinforced by stereotypical images of crime and deviance promulgated by the mass media, which often portray offenders as immoral, impulsive, insane, or otherwise unique (Donziger, 1996). From a definitional perspective, Brezina (2000) indicates that deviance and conformity can best be described as

"labels or definitions that are differentially applied to various individuals and their behaviors—not in terms of the personal attributes of the individuals, nor in terms of the intrinsic qualities of the behaviors individuals display… Second, sociological theories of deviant involvement are based on the implicit or explicit rejection of explanations focusing on unique personal characteristics, especially abnormal traits of a biological or psychological nature" (p. 72).

Akers (1994) indicates that sociological theorists tend to assume that biological and psychological variations are "more or less within the normal range" and that little or no deviance is directly caused by abnormal physiology or psychology (p. 69). Merton (1938) had previously indicated that strain theorists provide the most forceful argument in this regard by stating that participation in deviant behavior most often represents "the normal reaction, by normal persons, to abnormal conditions" (p. 672). Moreover, Orcutt (1978) indicates that deviance is socially constructed and exists in relation to "interactional processes through which acts and actors are socially defined as deviant" (p. 346). According to researchers, deviant behavior emerged in society after “component elements of the social and cultural structures existed in contradiction, thereby exerting pressure on individuals to engage in forms of illegitimate behaviors (Merton, 1957; Sumner, 1994).” Merton (1995) also indicates that deviant behavior is “more likely to emerge in societies where the emphasis on cultural goals was inconsistent with the available means to achieve them” (Parnaby & Sacco, 2004, p. 3).

Social Learning Theory

From a theoretical perspective, social learning theory (Akers, 1985; Burgess & Akers, 1966) posits that people hold definitions of deviance and prosocial behavior that vary according to how they are reinforced:

… the definitions themselves are learned through reinforcement contingencies operating in the socialization process, and they may function less as direct motivators than as facilitative or inhibitory "discriminative stimuli" or cues that signal that certain behavior is appropriate and likely to be rewarded or inappropriate and likely to be punished in a given situation. It is the anticipated reinforcement or punishment that provides motivation for the behavior independently of whatever motivation to engage in or refrain from an act comes from the fact that it conforms to or violates one's beliefs or definitions (Akers, 1996, p. 239).

Akers (1996) further states, "Deviant models are available outside the family and other conventional socializing institutions, in the media, and among peers" (p. 239).

Brezina (2000) indicates that the tendency of individuals to rationalize their deviant involvement can be observed across a wide spectrum of deviant behavior, from academic cheating to interpersonal violence. Moreover, while rationalizations employed by academic cheaters and violent offenders may differ in substance and form, they serve essentially the same function or goal: to justify deviant acts and to neutralize moral prohibitions (p. 77). Stanley Milgram's (1974) classic "obedience" experiments, as described by Higgins (1998), also suggest that ordinary people—not just deranged or disturbed people—have the capacity to deliver harm when circumstances make it doable or justifiable (p. 138–141).

Punishment & Reward

Sykes and Matza (1957) point out that the prohibition of an act and definitions that justify the deviant act may be a product of an embedded general normative system. Patterson (1975) notes that, unaware of the system criteria, "parents and other socializers may make inefficient or inconsistent use of rewarding and punishing sanctions with the unintended outcome of reinforcing behavior that is contrary to their own normative standards" (cited in Akers, 1996, p. 239). Moreover, perceived behaviors and rewards play a role in whether individuals violate the general normative system. For example, an individual's "learned normative definitions may be violated because the rewards for the behavior outweigh the normative inhibitions. Individuals may refrain from law violation, despite having learned definitions favorable to violation, because individuals may anticipate more cost than reward attached to a given violation" (Akers, 1996, p. 239).

In attempts to better understand and reframe deviant behavior, theorists began to re-categorize deviance from a medicalized perspective, with one caveat: other trends were present in the study of deviance and societal reactions to deviance, and medicalization is only one way of looking at increased levels of deviance (Horwitz, 1981, p. 751). Many political and economic aspects affected the growth of medicalization within the context of the expanding US welfare state and are perhaps the most important unexplained aspects of the developments considered in the understanding of the medicalization of deviance (Horwitz, 1981).

The Medicalization of Deviance

According to Horwitz (1981), the medicalization of deviance "refers to the tendency to define deviance as a manifestation of an underlying sickness, to find the causes of deviance within the individual rather than in the social structure, and to treat deviance through the intervention of medical personnel" (p. 750). Types of deviance that have been viewed through the lens of medicalization include:

• Mental illness;

• Alcoholism;

• Opiate addiction;

• Delinquency;

• Hyperactivity;

• Child abuse;

• Homosexuality; and

• The biological study of crime.

Societal reactions to deviance include deinstitutionalization, normalization, mainstreaming, and the expansion of due process rights, which seem opposed, or at least somewhat related, to medicalization (p. 750). Horwitz (1981) further indicates that "medicalization should not be regarded as the sole, or possibly, even the major trend in deviance definition but rather as one of a number of sometimes conflicting developments in the societal reaction to deviance" (p. 751). He continues,

Social policy toward deviants is undergoing dramatic changes. Medicalization requires a substantial resource base and funding for social services is undergoing a drastic decline. For students of social control this situation raises the question of whether medicalization as an explanation of deviant behavior will decline as resources for treatment are withdrawn (p. 752).

Social Constructionism

The medicalization of deviance can be viewed through the lens of social constructionism, which defines social problems as created by various political and ideological forces rather than being only a "part of the nature of things" (Berger & Luckman 1967, p. 52). Ajzenstadt and Cavaglion (2005) explain that social constructionism

assumes that the meaning of events and human behavior depends on dimensions of cultural and social practices. The construction of a social problem and its cultural categorization (Best, 1995) are a function of the interplay between various interest groups. This interplay subsequently impacts social actions in defining and attempting to resolve problems, while determining the extent of their social and political power, public image, access to the media, and influence on the state apparatus (Pfohl, 1977)—within a specific socio-historical context (Costin, Karger, & Stoesz, 1996; Nelson, 1984). Such individuals can be defined as "claimmakers" (Spector & Kitsuse, 1977), as they utilize a variety of techniques to organize public and official perceptions of the "problem." Claimmakers bring their issue to the public agenda through the influence of power relationships, cultural resources, and professional ideology (Bogard, 2001; Rafter 1992), as well as via a continuous dialogue with their audience, seeking public legitimization in an attempt to make their claims "believable" (Loseke, 1999) (Ajzenstadt & Cavaglion, 2005, p. 256).

More research into this arena is highly suggested, especially the impact of lobbyists on the political arena as a potential manifestation of the definitional process of the medicalization of deviance.

Social Deviance as Disease

Research has suggested that from a political perspective, one means of gaining support in modern Western societies is to frame certain behaviors as a social problem, thereby creating new definitions of social deviance under the heading of a "disease," which could then be scientifically and objectively treated by experts. Framing social problems in terms of a medical model evokes “images of an ongoing condition over which a person has little control and that is amenable to some form of treatment" (Steen, 2001, p. 328). According to this view, when professionals construct a social problem, they cloak themselves in an aura of scientism, objectivity, and "prestige and expert authority" (Freidson, 1973). In this way, individuals can successfully sell an understandable structure of knowledge (Gusfield, 1981). The benefit of creating "ownership of the problem" and new territories of intervention by spreading "scientific" knowledge gives professionals more power and social prestige inside the political system (Cohen, 1985) (Ajzenstadt & Cavaglion, 2005, p. 257).

C. Wright Mills (1943) claimed that social problems, when framed in a positivistic approach, seem to ignore larger social and political "structured wholes" (p. 166). In other words, the medical excuse, by focusing on the individual, silences and denies inherent political strains and social injustices (Halleck, 1971). From past studies on the medicalization of social problems, professionals have demonstrated that categorizing specific behaviors as a disease has an interactive relationship with the existing "hegemonic" moral order (Conrad, 1992; Conrad & Schneider, 1980).

Applications

Parsons (1951) indicates that as soon as an individual is labeled as being sick, their label changes their role in society. Categories of "medicalized" deviance include drug abuse, alcoholism, gambling, suicide, sexual addiction, child abuse, hyperactive children, and insanity. In many of these examples, a deviant behavior once viewed as sinful or a criminal behavior has now been characterized as a medical problem. Consequently, a behavior once controlled by a priest or a judge has now become the responsibility of a physician (Rosenberg, 1986). Alcoholism and substance abuse can be examined as applications of the medicalization of deviance (Murphy, 2006).

Alcoholism & Substance Abuse

Drug and alcohol abuse problems are categorized as medicalized deviance. Hospital and other clinical settings offer major treatment and interventions for drug and alcohol problems and medical insurance reimburse costs associated with treatment. Prescription and the distribution of pharmaceutical substances potentially offer a more "medical" way of treating alcoholism and substance abuse problems. Pharmaceutical innovations also offer the potential of moving the treatment for certain drug problems, like opiate addiction, into the medical realm. As Murphy (2006) notes, after a 1987 Gallup poll indicated that

89% of Americans agreed with the statement that "alcoholism is a disease," additional indicators have supported the widespread notion that alcohol problems are indeed medical problems (Peele, 1989). In a 2001 poll conducted by the Pew Research Center, 52% of Americans indicated that drug addiction should be treated as a disease, while 35% said that it should be treated as a crime. One of the latest psychological Diagnostic and Statistical Manuals (DSMIV) outlines several different diagnoses categories that can be given to alcohol or drug problems, from abuse to dependence, also lends support for the argument that alcohol and drug problems have been medicalized (Murphy, 2006, p. 2).

The "War on Drugs" campaign that started during the 1980s perpetuated an advance of federal dollars spent to support alcohol and drug treatment, especially to law enforcement and prisons. In the late 1980s to the early 1990s statistics indicated a decrease in the numbers of drug users, while the amount of money directed to treatment and intervention programs increased (Akers, 1992). Peele (1989) suggests that increasing amounts spent on treatment programs were due to the treatment industry itself widening the definition of abuse to include more individuals with a "problem" (Murphy, 2006, p. 2). Increasing numbers of health insurance companies covering drug and alcohol treatment programs contribute to the increasing numbers of "private hospitals and clinics to treat alcohol and drug problems" (Akers, 2002, as cited in Murphy, 2006, p. 2).

From another perspective, medicalization may not eradicate stigmatization attributed to specific behaviors. Conrad (1992) indicates that certain behaviors may actually be hybrids of medical-moral-legal issues, rather than solely medical problems. The body of research indicated in this realm would specify that responses to a given issue would be different based on a given realm. For example, drug abuse is viewed as a legal category by the courts; religious groups would consider drug abuse to be a moral concern; and substance abuse treatment programs consider abuse to be a medical problem. However, Peyrot (1984) indicates that all of these issues may be integrative. For example, it would be possible for an individual to spend time in jail for purchasing heroin, while still receiving methadone for heroine addiction in a treatment program, which would replace a criminal framework for a medical one and thereby create an integrative definitional category (Murphy, 2006, p. 4).

Moreover, the move toward a more sympathetic and less punitive approach to manage substance abuse issues may have eliminated the negative stigma associated with addictive behaviors. Given the growing number of self-help groups, it seems that the "addict" label is carrying less of a stigma. However, in order for an addiction to be considered as an illness, an individual must first recognize the problem is undesirable and then seek treatment (Parsons, 1951). A caveat for this situation is dependent on whether the treatment is court-mandated, which would also introduce the concept of hybridization (Murphy, 2006, p. 3). Based on these issues, it seems that many issues might complicate the categorization process.

Issues

Legal & Moral Considerations

The use of pharmacological treatments for addiction, such as methadone or naltrexone, is one issue that has been debated among medical providers, as well as treatment providers and those in treatment (Volpicelli & Szalavitz, 2000; Rychtarik et. al., 2000). Central to this issue is that pharmaceuticals might replace one addiction with another by attempting to cure a substance abuse issue with another substance. While some of the treatment drugs may not be habit-forming, and regulations around the prescription and distribution of pharmacological treatments are also very extensive, the issue that addiction might be a moral choice factors into the debate (Volpicelli & Szalavitz, 2000). The idea that addiction continues to be perceived as a matter of self-control, or that individuals with addictions might have a "weak moral character or spiritual problem may be a sign that the use of substitute drugs to alleviate cravings or ease withdrawal may seem too easy" (Murphy, 2006, p. 2).

The complicated relationship between the legal and medical aspects of abuse is another issue in the medicalization of deviance. While one individual might be arrested for selling or using drugs and is sent for treatment rather than to jail or released early to a treatment setting, another individual might spend time in jail for drug-related crimes and receive no treatment at all. The unclear boundaries associated with substance abuse make it seem unclear as to whether drug and alcohol abuse should be considered as an illness and medical problem, or whether the problem is legal or moral. Based on the competing definitions, it is difficult to negotiate the competing definitions of alcohol and drug abuse and the most appropriate treatment options (Murphy, 2006, p. 7).

Another issue that should be considered in the medicalization of deviance is the ongoing process of defining and reframing specific social conditions into a medical condition. Medicalization is an ongoing process. Competing interests for defining specific behaviors impact behavioral categorization. Researchers need to be informed regarding the multitude of competing definitional frameworks, characteristics, and potential treatments for different kinds of behaviors. While legal, social, moral, and medical categories are common ways of categorizing behaviors, genetic predisposition is also a framework for describing deviant behaviors (Parnaby & Sacco, 2004).

Child Socialization

Socialization is "the process by which individuals acquire the attitudes, beliefs, values, and skills needed to participate effectively in organized social life" (Dunn, Rouse, & Seff, 1994, p. 375). Socialization can also be described as the process through which a "child or other novice acquires the knowledge, orientations, and practices that enable him or her to participate effectively and appropriately in the social life of a particular community" (Garrett & Baquedano-Lopez, 2002, p. 339). Bragg (1976) further indicates that "the socialization process is the learning process through which an individual acquires the knowledge and skills, the values and attitudes, and the habits and modes of thought of the society to which he belongs" (p. 3). Social commentators have observed and taken note of the growing tendency to rely on medications like Ritalin to "suppress the passion of children and to assist in the correction of perceived behavioral problems" (Gosden, 1997, p. 59). Certainly, all of these ongoing outcomes will continue the ongoing debate surrounding the medicalization of deviance. Additional research into the impacts of the medicalization of deviance would be helpful in determining longitudinal impacts on individuals impacted by the label and subsequent treatments.

Clearly, social policy toward deviance and the potential medicalization of deviance is in the process of undergoing dramatic changes. The medicalization of deviance requires a substantial resource base for treatments and interventions, and funding for social services is undergoing a drastic decline. For researchers analyzing the process of social control, the medicalization of deviance raises the question of whether medicalization as an explanation of deviant behavior will decline as resources for treatment are withdrawn (Horwitz, 1981, p. 752). Moreover, other research seems to indicate that "medicalized" treatments indicate ambiguity and confusion over the label, because of the integration of other categories (Parnaby & Sacco, 2004, p. 13) further exacerbating the definitional categories. The last consideration of the medicalization of deviance is the ongoing impact on the socialization of children.

Terms & Concepts

Deviance: Deviance can best be described as a label or definition that can be differentially applied to various individuals and their behaviors, which can be viewed through sociological, moral, legal, and "medicalized" lenses.

Medicalization of Deviance: Medicalization of deviance refers to the tendency to define deviance as a manifestation of an underlying sickness, to find the causes of deviance within the individual rather than in the social structure, and to treat deviance through the intervention of medical personnel (Horwitz, 1981).

Social Constructionism Theory: Social constructionism theory defines social problems as problems that are created by various political and ideological forces rather than being only a "part of the nature of things."

Social Learning Theory: Social learning theory indicates that definitions themselves are learned through reinforcement contingencies operating in the socialization process, and they may function less as direct motivators than as facilitative or inhibitory "discriminative stimuli" or cues that signal that certain behavior is appropriate and likely to be rewarded or inappropriate and likely to be punished in a given situation (Akers, 1996, p. 239).

Socialization: Socialization is "the process by which individuals acquire the attitudes, beliefs, values, and skills needed to participate effectively in organized social life" (Dunn, Rouse, & Seff, 1994, p. 375).

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Suggested Reading

Adler, P. A., & Adler, P. (2012). Constructions of deviance: Social power, context, and interaction. 7th ed. Belmont, CA: Thomson/Wadsworth.

Becker, H. S. (1963). Outsiders: Studies in the sociology of deviance. New York: Free Press.

Curra, J. (2014). The relativity of deviance. 3rd ed. Thousand Oaks, CA: SAGE Publications.

Fox, R. (1989). The sociology of medicine: A participant observer's view. Englewood Cliffs, NJ: Prentice Hall Inc.

Merton, R. K. (1968). Social theory and social structure. New York: Free Press.

Miller, K. S. (1980). The criminal justice and mental health systems: Conflict and collusion. MA: Oelgeschlager, Gunn & Hain.

Shoham, S. G. & Hoffman, J. (1991). A primer in the sociology of crime. New York: Harrow and Heston.