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CHAPTER TITLE: Chapter 10: medicalization, social control, and the relief of suffering

BOOK AUTHOR: Joseph Davis

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Medicalization, Social Control, and the Relief of Suffering

Joseph E. Davis

Through much of the short history of medical sociology, medicalization has been one of its most important and successful concepts. Medicalization is the name for the process by which medical defi nitions and practices are applied to behaviors, psychological phenomena, and somatic experiences not previously within the con- ceptual or therapeutic scope of medicine. Under various terminological rubrics, medicalization has been studied by many scholars, including sociologists, anthro- pologists, physicians, and historians, and is also regularly encountered in psychiatry, law, social work, and bioethics. Since the 1960s, scholars have produced a rich conceptual literature on medicalization and an extensive array of case studies and historiography. Not confi ned to academic journals, a concern with medicalization also fi gures prominently in the mass media and popular press, and has long provided analytical purchase for consumer movements in health.

If anything, the signifi cance of medicalization is growing as its forms and expres- sions multiply and ever wider realms of behavior and feeling are brought within the ambit of medical explanation and management. The expansion of medical jurisdic- tion is a long – standing process. What is new is the pace and scope of the expansion. In a few short decades, a great many new diseases and disorders have been defi ned. Between 1968 and 1994, the Diagnostic and Statistical Manual of Mental Disorders , the US diagnostic system, grew from 180 categories of mental illness to over 350 (Healy 1997 ). The boundaries of disorders are also expanding, and new medical technologies and psychoactive medications, from Ritalin to Prozac, have prolifer- ated and are utilized by millions worldwide. The synthesis of new pharmaceuticals, research in genetics and aging, and other developments promise to extend medical- ization even further.

This chapter explores major conceptual issues and lines of research. This task is complicated by theoretical differences. There has never been a consensus on the meaning of medicalization. One difference arises over where to draw the line between medicine and other cultural discourses and institutional practices which employ the language of pathology but do so in non – medical conceptual models and/ or apart from medical interventions. Another difference concerns the question of

The New Blackwell Companion to Medical Sociology, edited by William C. Cockerham, John Wiley & Sons, Incorporated, 2009. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/uwm/detail.action?docID=485665. Created from uwm on 2023-09-22 15:24:47.

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medicalization as a transfer of conceptual and jurisdictional domains. This is how the concept was originally used but some no longer do so (sometimes signaled by the use of “ biomedicalization, ” see, e.g., Clarke et al. 2003 ; Estes and Binney 1989 ). I will need, therefore, to offer an interpretation.

A further complicating factor is the sheer scope and diversity of the research lit- erature. Previous assessments have distinguished two subtypes of medicalized phe- nomena: deviant behaviors, such as school misbehavior and child abuse, and “ natural life processes, ” like childbirth and menopause. Over the past decade, as medical defi nitions and treatments spread to a wider range of experiences, the research grew more complex. I divide the new literature into two further subtypes. The fi rst com- prises studies investigating how problems of living and troubling experiences, from overeating to shyness, have been given medical defi nition. The second comprises studies examining biomedical enhancements – for example, new cosmetic proce- dures, human growth hormone for short stature – whose use is not to treat illness but to improve healthy people in one or another capacity. The conceptual shift constituted by medicalization is somewhat different in each of these four subtypes. There is also variation in terms of which features of the social environment are most salient, which groups are driving the process and which are affected, and what social consequences are theorized to follow. This variation requires sorting out. Generaliza- tions one fi nds in the literature do not necessarily hold for every subtype.

The chapter, then, begins with defi nitional issues, tracing the evolution of the concept of medicalization over time, identifying key shifts in perspective, and pro- viding some explanation for them. I next discuss the meaning of medicalization in the four subtypes and explore the variations. I conclude with a few thoughts on future directions.

THE EMERGENCE OF THE CONCEPT OF MEDICALIZATION

The concept of medicalization emerged from the intellectual and social ferment of the 1950s and 1960s as a critique of medicine and the expansion of its conceptual model to the analysis of social ills and attendant policy (Sutherland 1950 ; Szasz 1956, 1960 ; Wootton 1956, 1959 ). Most discussions characterize the concept ’ s evolution as a single story (e.g., Ballard and Elston 2005 ; Lupton 1997 ; Nye 2003 ), creating something of a caricature in the process. I will argue that there were two distinct, if somewhat overlapping, lines of infl uence. The fi rst tradition was a cri- tique of medicine as authoritarian and imperialistic. The second was a critique of the expanding role of medicine in the social control of deviant behavior.

Medical i mperialism

The fi rst critique, refl ecting the liberationist concerns of the 1960s and the deep sense of social crisis, directed a powerful challenge to the medical profession and its role in the capitalist/patriarchal social order. The pioneers of this perspective were the loosely assorted group in the United States and United Kingdom that came to be known as the anti – psychiatrists, including Thomas Szasz (1960) , Erving Goffman (1961) , David Cooper (1971) , and R.D. Laing ( 1967 ; on anti – psychiatry

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medicalization, social control, and the relief of suffering 213

see Crossley 2006 : Ch. 5; Sedgwick 1982 ). Their views were diverse and refl ected different theoretical orientations. In general, however, they shared a highly critical view of available therapies and psychiatric institutions, largely rejected the medical model of mental disorder, and regarded much mental illness as expectable responses to diffi cult circumstances. By the early 1970s, anti – psychiatric views were also being expressed by “ radical therapists ” with a Marxist critique of capitalism (Radical Therapist Collective 1971 ) and second – wave feminists with a stinging rebuke of patriarchy (e.g., Chesler 1972 ).

In the early 1970s, social scientists, feminists, and others widened the critique to mainstream medicine. A highly infl uential version of this left – libertarian argument was Ivan Illich ’ s Medical Nemesis , which claimed that the “ medical establishment ” had become a “ major threat to health ” (1976: 3), both through the direct side effects of medical practices and through “ social iatrogenesis. ” By the latter term, Illich ( 1976 : 41) referred to the impact of medicine on the social environment – for example, increasing “ disabling dependence, ” lowering “ tolerance for discomfort, ” abolishing the “ right to self – care ” – and on the experience of suffering. Organized medicine, he argued, “ has undermined the ability of individuals to face their reality, to express their own values, and to accept inevitable and often irremediable pain and impairment, decline, and death ” (Illich 1976 : 127 – 8). Other critiques of the political economy of health care at the time, Marxist and feminist, portrayed medi- cine as authoritarian, as continuously seeking to expand its professional empire (in service to the capitalist ruling class and/or the patriarchal order), as detracting from rather than improving people ’ s health, and as depoliticizing social arrangements (e.g., Ehrenreich and English 1973 ; Frankfort 1972 ; Navarro 1976 ; Waitzkin and Waterman 1974 ).

Another infl uential contributor to this critical literature was the social philoso- pher Michel Foucault, whose early work on insanity and hospitals situated him among the anti – psychiatrists (Foucault 1965, 1973 ). In these writings, Foucault emphasized medical control and surveillance, the fabrication of scientifi c knowl- edge, the power of the profession to label and discipline, and the “ docile body ” of the patient caught in the “ clinical gaze ” exerted by medical practitioners. Over the course of the 1970s, however, Foucault published a series of essays dealing with medicalization that modifi ed his earlier position (Nye 2003 ). He shifted away from an emphasis on medicalization as domination by doctors and the state and replaced it with a view of medical discourse and practice as moral/disciplinary guidelines by which patients are to understand and regulate their own lives. The power of medi- cine, he now argued, is exercised not primarily by direct coercion but rather, in the words of Deborah Lupton ( 1997 : 99), “ through persuading its subjects that certain ways of behaving and thinking are appropriate for them. ” In contrast with his earlier writings, Foucault characterized medical power as dispersed, emergent at sites outside of direct medical encounters, and involving the complicity and partici- pation of ordinary people.

According to the historian Robert Nye, the shift in Foucault ’ s thinking was “ ultimately infl uential ” in defeating what Philip Strong (1979) , using the phrase common at the time, referred to as the “ medical imperialism thesis. ” Beyond the infl uence of Foucault – an impact felt less in North American medical sociology than in other places and disciplines – the thesis was undone by empirical studies.

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The evidence for it was always thin, as Strong (1979) argued, and subsequent research only complicated the picture further. Historical studies of medicalization in Western Europe and the United States, for instance, as Nye ( 2003 : 121) docu- ments, have not shown a direct relationship between “ the process of medical profes- sionalization and the growth of either a medical model of health or a medical regime allied to state power. ” Neither has the stream of sociological studies appearing over the past four decades.

Deviance and m edical s ocial c ontrol

The second tradition of medicalization critique, while infl uenced by the crises of the 1960s, the writings of Goffman and Szasz, and even the early work of Foucault, had different origins. Building on Talcott Parsons ’ (1951) functionalist analysis of medical practice, this critique grew out of new approaches to the study of deviant behavior and social control. For Parsons, illness is an inherently social and role – structured phenomenon. When people become sick, he argued, there is available a social role, the “ sick role, ” which channels them to the doctor. If the doctor legiti- mates the sickness, the sick person is both relieved of responsibility for the illness and freed from some or all normal duties. Illness in this sense, like crime, is a form of deviance from normative role performances and is disruptive to society. Like crime, it is a problem of social control, and the doctor is a control agent who regulates entry to the sick role and “ exposes the deviant to reintegrative forces ” (Parsons 1951 : 313). Reintegration, however, does not involve punishment but treatment. The sick role also imposes obligations: it requires the sick person to seek to “ get well ” and to comply with medical advice. In Parsons ’ view, individuals are often unconsciously motivated to seek illness (deviance) as a refuge from the strains and pressures of their normal roles and, in providing relief from such pressures, medical social control generally has positive effects for individuals and the social system.

While retaining the sick role analysis, sociologists in the 1960s rejected both Parsons ’ notion of deviance as motivated by personal needs and his optimistic view of medical social control. A key development was the emergence of the “ labeling ” or “ societal reaction ” perspective on deviance. In this counterintuitive approach, deviance is conceptualized as a property of social groups, a label which they apply to behavior rather than a quality intrinsic to the behavior itself (Becker 1963 ; Erikson 1966 ; Kitsuse 1962 ). Theoretical attention expands from the rule – breaker to the larger system of social control, both the socially defi ned norms or rules and the rewards and sanctions that enforce them. That system cannot be evaluated, as Parsons wanted, on the basis of universalistic, functional criteria because all of its elements are variable – relative to time, cultural context, and social group – and are shaped, in signifi cant part, politically (Becker 1963 : 7).

The labeling perspective, including applications in medical sociology such as Thomas Scheff ’ s (1966) infl uential book on mental illness, fundamentally reoriented the study of deviance. Related theoretical developments, from phenomenological (Berger and Luckmann 1966 ) and confl ict perspectives (e.g., Lofl and 1969 ), further confi rmed the importance of attending to the sociohistorical process by which devi- ance designations arise or change, and to the central role of social and political

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medicalization, social control, and the relief of suffering 215

confl ict in the process. By the late 1960s, sociologists were studying emerging cat- egories of deviance, the competing interest groups driving the creation and applica- tion of deviance labels, and the evolution of social policy (Conrad and Schneider 1980 ). It was in this research context that new interest arose in the powerful social control aspects of medicine (Kittrie 1971 ; Pitts 1968 ) and in the application of “ the belief system underlying medical science … to more and more social problems ” (Taber et al. 1969 ).

Medical sociologists called the extension of medical social control “ medicaliza- tion ” and widened the focus beyond psychiatry to the whole fi eld of medicine (Freidson 1970 ; Pitts 1968 ; Zola 1972 ). They argued that medical jurisdiction over disapproved forms of behavior was expanding relative to the traditional institutions of religion, law, and the family, and was extending beyond medicine ’ s original and, by implication, legitimate mandate into areas of life “ far beyond concern with ordinary organic disease ” (Zola 1972 : 494) and any proven methods of treatment. They challenged the notion that medicine was a morally neutral enterprise, docu- mented how physicians can act as moral entrepreneurs, and argued that shifting problems that were “ not ipso facto medical problems ” (Conrad 1975 : 18) to the medical domain would concentrate inappropriate power in medical hands. They did not, however, identify medical imperialism as the primary stimulus for medicaliza- tion. It would be a mistake, Irving Zola ( 1972 : 487) argued, to see medicalization as the “ result of any professional ‘ imperialism ’ ” on the part of physicians. Far larger cultural and institutional forces were at work, and studies showed that other interest groups were also drivers of the process.

Through the 1970s, medicalization research in this tradition focused on deviant behavior and medical social control. This work culminated in the infl uential text, Deviance and Medicalization , by Conrad and Schneider (1980, 1992) . They described the medicalization of deviance as involving a shift from “ badness to sick- ness. ” Behaviors, they argued, “ that were once defi ned as immoral, sinful, or crimi- nal have been given medical meanings ” (Conrad and Schneider 1980 : 1) and the medical profession mandated to provide treatments for them. The authors observed, however, that not all medicalization concerned deviant behavior or social problems. Other non – medical problems had been drawn into medical jurisdiction, including pregnancy, childbirth, and contraception (Conrad and Schneider 1980 : 29; see Zola 1972 ). In subsequent years, as empirical studies accumulated, the early concern with deviant behavior was augmented by analyses of medicalization in many other areas. And as more phenomena were brought under the rubric of medicalization, the concept evolved.

THE EVOLVING MEANING OF MEDICALIZATION

As the concept of medicalization evolved, it shed some features of its original for- mulation and retained others. In order to better understand the specifi c types of medicalized phenomena and the differences between them, it will be helpful to fi rst discuss these changes. Reappraisals of the lay role, the effects of medicalization for individuals, and the role of the medical profession all contributed to a far more nuanced and complex view of medicalization.

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Active l ay r ole

The imperialism thesis characterized patients as passive or victims and generally uncritical in the face of medicine ’ s expansionist tendencies. By the 1990s, this picture had given way to a much more active conceptualization of the lay role in and contribution to the medicalization process. For those infl uenced by the later Foucault, the emphasis on medical surveillance came to include thinking about normalization and control in terms of “ technologies of the self, ” Foucault ’ s term for refl exive techniques people learn in order to manage their own emotions, inter- personal relationships, body, and so on (Foucault 1988 ). Writing in this vein, the historian Nye ( 2003 : 117) argues that what replaced the imperialism thesis was a view of medicalization as “ a process whereby medical and health precepts have been embodied in individuals who assume this responsibility for themselves. ” Though too narrow, this defi nition is consistent with Foucault ’ s observation on the nature of discourse – it can be normative and coercive, yet also voluntary – and recognizes that contemporary medical practice requires active subjects not passive ones (Rose 2007 : 110). Empirical cases of medicalization using the Foucauldian framework, therefore, often concentrate on the experiences and practices of everyday life, such as patient interactions with health care providers (e.g., Cowley, Mitcheson, and Houston 2004 ; Lupton 2003 ; Malacrida 2003 ; Williams and Calnan 1996 ), women ’ s reactions to medical technologies (see, e.g., papers in Lock and Kaufert 1998 ), and so on. These studies demonstrate, inter alia , the complex and pragmatic ways in which people respond to medical authority and connect medical knowledge and practices to experiences of chaotic life events, healthcare needs, and self – defi nition.

Research in the deviance/social constructionist tradition also came to emphasize the active, collaborative role of the lay public in contributing to medicalization. Studies of specifi c cases demonstrated that medicine was not monolithic but fac- tionalized. Vested interests and subspecialties within the medical system differ in what they regard as legitimate diagnoses and exert differential pressure to medicalize problems (Strong 1979 ; Williams 2001 ). Studies showed that social movement, grassroots, and patient advocacy groups often worked aggressively to secure medical recognition for a favored condition or diagnosis, or, in the case of homosexuality, demedicalization, and were sometimes successful even in the face of medical resis- tance (e.g., Bayer 1981 ; Conrad and Schneider 1980 ; Scott 1990 ). Studies also began to explore the “ lay perspective ” and the ambivalent, calculated, and uncritical ways in which people respond to and struggle with medicalized defi nitions (e.g., Becker and Nachtigall 1992 ; Bransen 1992 ; Broom and Woodward 1996 ; Gabe and Calnan 1989 ; Treichler 1990 ).

Gains and l osses

The recognition of an active lay role contributed to a less negative reading of the effects of medicalization. Early on, the contributors to the deviance literature rec- ognized that medicalization could have mixed effects (Conrad 1975 ; Pitts 1968 ). Though “ skeptical of the social benefi ts of medical social control ” and clearly emphasizing its “ darker ” consequences, Conrad and Schneider (1980) attributed a number of progressive aspects to the medicalization of deviance. Among others,

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these included the possibility of less punitive means of control; the extension of the sick role benefi ts, including institutional legitimation and removal of blame; and an optimistic prognosis (Conrad and Schneider 1980 ). In the following years, the lit- erature increasingly noted particular clinical benefi ts and improvements in quality of life for individuals, as well as the symbolic, sick role advantages. Accordingly, defi nitions of medicalization took on a more neutral cast (e.g., Conrad 1992 ), permitting room for recognition of genuine medical advances and independent assessment of why people might seek medicalization and what might be socially or individually gained or lost when medicalization occurs.

Feminist critiques, which had often characterized women as victims of medicine and scientifi c medical knowledge as biased and sexist, were particularly affected. While claims of repressive medicalization remain, at least since Catherine Kohler Riessman ’ s seminal article on “ Women and Medicalization ” (1983) , and Emily Martin ’ s The Woman in the Body (1987) , feminists have also pointed to empower- ing possibilities in medicalization, the expansion of a discourse of rights and less stratifi ed relations in the medical sphere, and possibilities for resistance and women ’ s self – help activism. A less uniformly critical view and a lowered apprehension of the medical profession has come to prevail (e.g., Annandale and Clark 1996 ; Broom and Woodward 1996 ; Lock 2004 ; Oinas 1998 ; Riska 2003 ).

The m edical c omplex

Along with a greater emphasis on the lay role, wider appraisals of the social trans- formations sweeping medicine, in the United States and elsewhere, brought attention to the growing institutional matrix in which medicine was embedded. Already in the 1970s, medical sociologists were observing how the changing organizational and economic infrastructure of medicine was undermining its professional strength. A rising consumer movement in health care – signaled by increasing litigation and other demands for accountability, “ doctor – shopping ” behavior, elaboration of lay referral systems, and patient advocacy – also indicated “ a radical process of change ” was underway in the doctor – patient relationship (Reeder 1972 : 407; see Fox 1977 ; Haug 1976 ). Medicine was undergoing a “ deprofessionalization ” or “ corporatiza- tion ” in the view of some (e.g., McKinlay and Stoeckle 1988 ), while others argued medicine was being constrained by a growing number of “ countervailing powers ” including new government regulation, the rise of managed care, and consumer demand (Light 1991, 1993 ). These changes were widely read as an indication that medical authority was on the decline (e.g., Cockerham 1988 ; McKinlay and Stoeckle 1988 ; Starr 1982 ), that the so – called “ golden age of doctoring ” was over (McKinlay and Marceau 2002 ). New actors had entered and changed the social structure and practice of medical care and reduced the power and moral authority of physicians (Imber 2008 ; Rothman 1991 ).

In light of these realities, research on medicalization underwent a quiet but important change. Where the medicalization critique, writes Robert Dingwall ( 2006 : 34), “ had originally been focused on the disciplinary role of doctors as agents of social control … it now became much more of a challenge to the extending infl uence of the medical – industrial complex as a whole. ” This complex included not only medical professionals and advocacy groups, but also consumers, managed care

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organizations, and commercial interests, particularly the pharmaceutical industry (Clarke et al. 2003 ; Conrad 2007 ; Gallagher and Sionean 2004 ). Together these forces had created a different, more dynamic world of medicine, enlarging the scope and generating new processes of medicalization. Research shifted in an effort to capture important changes in medical surveillance and self – monitoring, new dis- courses of risk and consumer choice, and the growing commercial promotion of medical technologies and medications.

Although in some instances the defi nition of medicalization got radically extended, losing sight of medicine (Davis 2006a ), most research continued in practice to rec- ognize the medical profession as the vital link in the medicalization process. It retains the power to defi ne illness and control the technical procedures of interven- tion (Pescosolido 2006 ). At the same time, it has become clear that many additional actors infl uence, even co – constitute, the defi nition of disorder categories. These actors include social movements and advocacy groups (Conrad 2007 : Ch. 3; Davis 2005 ; Moynihan and Cassels 2005 ), everyday clinical practices (Young 1995 ), new technologies – CT scans, ultrasounds, etc. – diagnostic techniques, and medications (Healy 2007 ; Rosenberg 2007 ), pharmaceutical marketing activities (Lane 2007 ; Singh 2007 ), and forms of popular medical communication from scientists, physi- cians, and journalists (Golden 2005 ; Watkins 2007a, 2007b ). No doubt there are others. It has also become clear that other institutions play an important role in medical social control. These include, as always, the state (as I write the US govern- ment is considering linking food assistance for the poor to anti – obesity efforts [Black 2008 ]) and its agencies, as well as managed care organizations, insurance compa- nies, pharmaceutical manufacturers, international NGOs, and more. And it has become clear that as Illich (1976) and research in the Foucauldian tradition have emphasized, discourses of health and illness have widely penetrated Western societ- ies and become deeply embedded in individuals ’ subjectivity and interpretation of everyday experience (Turner 2004 ). As anthropologist Jean Comaroff ( 1982 : 55) writes: “ We look to medicine to provide us with key symbols for constructing a framework of meaning – a mythology of our state of being. ” People readily seek to be diagnosed, affecting not only the utilization of medical interventions but also the expansion of medical categories themselves (Conrad 2007 ; Tone 2008 ).

Medical s ocial c ontrol

The more complex picture of how medicalization comes about greatly enriched but did not fundamentally change the defi nition of medicalization. Medicalization is the extension of the conceptual and normative domain of medicine to problems, states, or processes not previously within the medical sphere, leading to medical manage- ment and treatment of them . Medical jurisdiction remains crucial to the defi nition. As Thomas Szasz ( 2007 : xiii) notes, “ we … do not speak of the medicalization of malaria or melanoma ” as these are already and properly within the medical sphere (cross – cultural research is, of course, another matter). Medicalization also continues to signify an encroachment. The medicalization of a problem or process, however it comes about, involves medicine ’ s norms and metaphors contravening and poten- tially driving out conceptual models or practices already used for that problem or process (Garry 2001 ). As noted above, the encroachment is not necessarily adjudged

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in negative or clear – cut terms. But the fact of an encroachment remains central to how the medicalization process is defi ned.

The encroachment, inconsistent and a matter of degree, is conceptual and norma- tive. Some subtitles of recent books dealing with medicalization provide examples of the shift: How Normal Behavior Became a Sickness (Lane 2007 ); How Psychiatry Transformed Normal Sorrow into Depressive Disorder (Horwitz and Wakefi eld 2007 ); On the Transformation of Human Conditions into Treatable Disorders (Conrad 2007 ). With medicalization, a problem, state, or process nested within a pre – existing conceptual model, something “ bad, ” or “ normal, ” or “ natural, ” is descriptively transformed into a disorder, illness, defi ciency, or target of medical intervention. The transformation gives the problem a changed signifi cance, individu- alizes it, and brings it within a new set of tacit assumptions. Once recast, the problem is now defi ned as a deviation from physiological or psychological ideals of proper functioning and is presumed to have a basis in some underlying process that necessitates or justifi es technical intervention. The affl icted individual, separated from broader social context, is the “ host ” for these impersonal (asocial and amoral) processes and the symbols of healing marginalize or exclude his or her social rela- tions (Comaroff 1982 ).

The normative meanings in the medicalized defi nition lie latent, as medicalization researchers have long stressed, in medicine ’ s claims about nature and about value neutrality. In resetting and regulating the boundaries of acceptable behavior, bodily states, and subjectivity, medicalized approaches inescapably draw on cultural symbols and values. Ideals of proper functioning cannot but embody specifi c values and normative evaluations – of expectable self – control, the well – adjusted personal- ity, the boundaries of individual responsibility, beauty, the tolerable level of dis- comfort, safe practices, proper social comportment, appropriate levels and expression of emotion, and so on – as well as images of selfhood. The unique power of medical knowledge and technique is that it “ naturalizes ” its underlying symbolic and norma- tive frameworks (Lock 2004 ). That is, it gives them the status of empirically derived facts about the human organism. As such, naturalization disengages social and moral values and the answers these values propose to existential questions from the public languages of morality or social philosophy (Comaroff 1982 ; Zola 1975 ). Moral responsibility and feelings of guilt and abnormality, seemingly removed with the medical label, are often then reasserted by focusing, in Zola ’ s words, on the “ individual ’ s role in his own demise, disability and even recovery ” (Zola 1972 : 491; see Becker and Nachtigall 1992 ). Because naturalized, medical morality denies value legitimacy to alternative possibilities and a patient ’ s own good appears to mandate its careful observance. It is, as a result, very diffi cult to challenge.

As the conceptual and normative encroachment of the medical model remains primary, then, so too does the long – standing concern with the relationship of medi- calization to the production, maintenance, and regulation of social order. Medicine is an institution of social control – in tandem, as noted above, with many other institutions – and it is concerned with the relief of suffering. Both aspects are now more clearly recognized. This recognition leads to a deeper understanding of the appeal of the individualizing and internalizing dynamic of the medical model, its implicit materialism, and its image of self – determining selfhood. And it permits a more subtle analysis of the role of medicine in promoting conformity to dominant

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cultural values and defi nitions of the good life, depoliticizing social issues, reinforc- ing patterns of stratifi cation, expanding the scope of pathology, and shrinking the range of ordinary human variability. When wedded to the state, medical social control can be directly coercive. More often than not, however, medicine functions to create new expectations and secure adherence to social norms when responding to individual needs and desires, when called upon by society to monitor and address “ at risk ” and vulnerable populations, when employing the agency of people to regu- late themselves, and when helping people return to their conventional social roles or adjust to new ones. Social control is not so much the motivation of medicine as it is its effect.

Finally, medicalization and medical social control involve medical supervision and treatment. This dimension of medicalization has been analytically downplayed in the literature, the defi nitional issue made primary. However, in reviewing the literature, and once certain non – medical discourses are bracketed (see below), it is clear that both a defi nition in terms of illness, or disorder, or defi ciency, or relief of suffering and a treatment modality are necessary for medicalization. Both dimen- sions are mutually constitutive and act back on one another in a complex feedback loop. In many cases, clinical innovations – a new technology, diagnostic technique, or medication – come fi rst and create the possibility if not the impetus to consider extending medical jurisdiction. In other cases, a medical conception is proffered even in the absence of an effective treatment. However, medicine is an applied fi eld, and only that which it can in some way treat will it long defi ne as medical, and that which it treats it will legitimate as medically appropriate.

TYPES OF MEDICALIZED PHENOMENA

Without any attempt to be exhaustive, I want to consider the four subtypes or arenas of medicalized phenomena (an overview is provided in Table 10.1 ). I distinguish each subtype by the nature of the conceptual transfer involved, but the lines are not rigid. Some cases can certainly be categorized in more than one way. There are also several types of cases that I do not treat as instances of medicalization, and thus exclude from this conceptualization. There is overlap in the medicalization literature with cultural discourses and institutional practices at some remove from medicine but which enlarge the sphere of human feeling and behavior deemed pathological. These include discourses within feminism, such as “ battered women ’ s syndrome ” (Kurz 1987 ), and the broader “ politics of victimhood ” (Brown 1995 ), where “ Iden- tity can be legitimately claimed … only to the extent that it can be represented as denied, repressed, injured or excluded by others ” (Rose 1999 : 268). In articulating a history of victimhood and survivorship, this politics draws on psychological languages and models of suffering, but it does not involve a clinical medical model or depoliticize problems, just the reverse.

Another discourse and set of institutionalized practices at some remove from medicine is the “ therapeutic ” as a cultural ethic. In his pioneering study, The Triumph of the Therapeutic , Philip Rieff (1966) observed that therapy, in the narrow sense of treating psychic disorder, was becoming a wider cultural system of meanings and symbols. Central to the therapeutic is a language for the management

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Table 10.1 Subtypes of medicalized phenomena

Deviant behavior Natural life processes

Everyday problems of living

Enhancements in healthy people

Conceptual shift

From “ badness to sickness ”

From natural process or life event to medical – technical problem

From normal/ expectable behavior or feelings to medical pathology

From well to “ better than well ”

Social contex t Liberal, humanitarian ideology; rationalistic approach to life

Advances in medicine and risk assessment; feminist efforts to gain control over biology

Expansion of mental illness categories; availability of SSRI drugs; consumer culture

Advances in neuroscience and genetics; competitive society; culture of self – fulfi llment

Agents driving the process

Social movements; lay interest groups; the state

Medical specialties; consumers

Psychiatrists; pharmaceutical companies; patient advocacy groups; consumers

Medical specialties; pharmaceutical companies; consumers

Groups affected

Children; women; middle class

Women; the aged (including men)

Middle class and affl uent

Critique Shift attention from environment to individual; eliminate alternative interventions

Medical surveillance and control; loss of autonomy and lay knowledge; narrow defi nitions of normal

Homogenization of life; blindness to environmental causes; less tolerance of minor problems; false promises

Reproduction of suspect norms; promotion of individual over social goods; undermine social solidarity

of subjectivity in which the self is characterized by its power to actualize itself and by its vulnerability to victimization from without and pathology from within (Furedi 2004 ; Nolan 1998 ; Rose 1999 ). Society is inherently repressive and unhappy child- hoods, “ toxic socialization, ” and personal dependencies lead to a wide variety of adult problems. These problems are often framed as “ addictions ” or “ diseases ” – for example, “ co – dependency, ” “ sex addiction ” – and play a central role in identity narratives, which are utilized in self – help subcultures to explain why experience has fallen short of therapeutic ideals (Illouz 2008 ; Rice 1996, 2002 ). The conceptual model is not medical, but rather “ therapeutic, ” though it is sometimes mistakenly characterized as medical in the medicalization literature.

Medicalization is the extension of the conceptual and normative domain of medicine to problems, states, or processes not previously within the medical sphere, leading to medical management and treatment of them.

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222 joseph e. davis

Second, there is overlap in the medicalization literature with certain health discourses and attendant practices that enlarge the range of day – to – day experi- ences considered relevant to health and illness. Holistic health is an ideological movement and diverse collection of alternative therapies, which has traditionally operated from a non – medical conceptual framework (Gevitz 1988 ; Lowenberg and Davis 1994 ). Holistic health has been characterized both as representing further medicalization (e.g., Arney and Bergen 1984 ; Crawford 1980 ) and as a form of demedicalization (Berliner and Salmon 1980 ), but its techniques are principally directed to staving off problems already medically defi ned. The same is true of health promotion, a general designation for educational initiatives aimed to fi x attention on behavioral risk factors and individual behavioral imperatives, such as physical fi tness and general wellness activities. It is sometimes depicted as the medicalization of lifestyle, but it does not generally represent a conceptual transfer in the sense used here.

Deviant b ehavior

As already noted, the conceptual shift that distinguishes this arena is, in Conrad and Schneider ’ s (1980) apt phrase, “ from badness to sickness, ” where “ badness ” signifi es socially problematic behaviors explicitly classifi ed in moral terms, whether as immoral, sinful, criminal, or the like. Studies have explored a wide variety of cases, historical and contemporary: insanity (Scull 1975 ; Szasz 1970 ) and its rela- tionship to social groups such as the poor and homeless (Snow et al. 1986 ; Weinberg 2005 ); many disapproved sexual practices, from homosexuality (Greenberg 1988 ) to pedophilia (Jenkins 1998 ; Sutherland 1950 ); some abusive behaviors, such as physical child abusing (Antler 1981 ; Pfohl 1977 ), and some forms of stigmatized victimhood, as in the cases of rape and sexual abuse (Davis 2005 ); many compulsive behaviors, including alcoholism (Appleton 1995 ; Conrad and Schneider 1980 ; Tournier 1985 ), opiate addiction (Conrad and Schneider 1980 ), excessive gambling (Rosecrance 1985 ; Rossol 2001 ), overeating (Salant and Santry 2006 ; Sobal 1995 ), and “ uncontrolled ” buying (Lee and Mysyk 2004 ); and many socially problematic behaviors of children, including disruptive and impulsive conduct at school (Conrad 1975 ; Malacrida 2003 ; Singh 2004 ), aggressive behavior, delinquency, and more (Harris 2005 ; Healy 2007 ).

Studies suggest that the medicalization of deviant behavior is much more likely for some groups than others. The group that stands out most sharply is children, perhaps especially middle – class boys. A great deal of attention has centered on the emergence and public controversy over the category of attention defi cit/hyperactiv- ity disorder (ADHD) for school misbehavior and inattention and, especially in the United States, Canada, and Australia but rising worldwide (Scheffl er et al. 2007 ), its treatment with medication. A broader set of children ’ s problems, from irritability and mood swings to verbal outbursts and “ maladaptive aggression, ” is now also commonly diagnosed under new and emerging categories like conduct disorder , pediatric bipolar disorder , and oppositional defi ant disorder , and treated with anti- depressants, antipsychotics, anticonvulsants, and other medications (Findling, Steiner, and Weller 2005 ; Groopman 2007 ; Harris 2005 ; Martin 2007 ). Medical treatments, including medication, are being used alongside psychosocial interven-

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tions with children who have been maltreated – sexual, physical, and emotional abuse and neglect – or exposed to violence, and seen to be at risk for various mental illnesses and risky behaviors (Cohen et al. 2006 ).

Women ’ s deviance, compared to men ’ s, is more likely to be medicalized than to be criminalized. Women, for instance, represent a majority of those who physically abuse children. This category has been medicalized and is dealt with, at least in the United States, in the mental health system or through family support or reunifi cation programs (Chaffi n 2006 ; Newberger and Bourne 1978 ). Even in severe cases, it is rarely prosecuted (Chaffi n 2006 ). Men, by contrast, represent a majority of those who sexually abuse children. This medicopsychiatric category is heavily criminalized (Jenkins 1998 ). Further, there is a clear social class dimension in this arena. The principle appears to be, in the words of Conrad and Schneider ( 1980 : 275), that when “ a particular kind of deviance becomes a middle – class rather than solely a lower – class ‘ problem, ’ the probability of medicalization increases ” (see also Pitts 1968 ). They cite the medicalization of alcoholism, opiate addiction, hyperactivity, and abortion as examples. Rosecrance (1985) fi nds the same pattern with compul- sive gambling.

Studies show the medicalization of deviant behavior is often very unevenly and insecurely institutionalized, with non – medical groups and the state often taking the lead in pressing for medicalization. Some cases are partly within medical jurisdiction and partly in other domains – the arenas of law, social services, therapeutic self – help, and so on. Some cases begin in the medical domain but then shift elsewhere. Physi- cal child abuse, for example, was temporarily under medical jurisdiction as the “ battered child syndrome ” but eventually moved back to the jurisdiction of child protective services (Davis 2005 ). The overlap and instability is often related to pragmatic questions of effectiveness and disciplinary interest, as well as shifting social conditions, institutional demands, and political struggles (Weinberg 2005 ). Over the past few decades, for instance, a lack of psychiatric treatment success, combined with new and intense public concern, has shifted the management of sexual offenders in a far more stigmatized and criminalized direction (Jenkins 1998 ). It is also in this arena that the clearest case of demedicalization – homosexuality – can be found, which, predictably, followed a political fi ght (Bayer 1981 ; Spector 1977 ).

There is a strong tendency in this arena to label problems as “ diseases ” or “ ill- nesses ” for the sake of symbolic benefi ts, such as increasing tolerance, enhancing willingness to provide social services, and, perhaps most importantly, removing blame and stigma so as to motivate affected persons to adopt the sick role and seek help. Treating obesity itself as a disease is a clear example. Studies fi nd that parents often welcome an ADHD diagnosis because it attributes their child ’ s problems to an organic disorder rather than their own failings (Malacrida 2003 ). Alcoholism, to give another example, has been described as a disease by some within medicine and is included as a substance disorder in the offi cial manuals. Except for treating the short – term effects of intoxication, however, medical professionals have little to offer by way of treatment. That role is typically played by lay therapeutic groups, like Alcoholics Anonymous, now a worldwide movement, which employ a disease concept but reject a medical model (Trice and Roman 1970 ). In the case of alcoholism, the meaning of “ disease ” may be primarily metaphoric (McHugh and

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Slavney 1998 :182), aimed to secure normative benefi ts and treatment services but not traditional medical attention (Tournier 1985 ).

Research in the medicalization of deviant behavior has raised a number of con- cerns about its individual and social consequences. Medical answers to deviance and social problems defl ect attention from the environment to the individual. The exclusion of social context obscures both the role of social structures and injustices in creating the conditions for problems to arise and the role structural change might play in ameliorating them. Individual, depoliticized answers are attractive in policy matters because adapting individuals to their social environment is far easier than the other way around. This is the path of least resistance, as Barbara Wootton ( 1959 : 329) noted many years ago: “ Always it is easier to put up a clinic than to pull down a slum. ” Medical answers can close off public deliberation of complex societal problems, deny value legitimacy to alternative social or political interpreta- tions (see Lock 1991 on adolescent dissent in Japan), and eliminate other strategies of intervention. The medicalization of deviant behavior can, through the effects of labeling, create deviance and weaken a sense of agency. It can concentrate power in the hands of the medical profession and other elites for enforcing standards of normality, and, in some cases, lead to the violation of civil liberties. While there is recognition that medical means of social control may be humane, there is also concern – especially so in the case of children – that it is relentless and pervasive.

Natural l ife p rocesses

Research on the medicalization of “ natural life processes ” followed closely on the heels of deviant behavior research and quickly outstripped it in sheer volume of work. The conceptual shift is a transformation in the meaning of everyday bodily processes and life – course events from natural human experiences to medical – technical problems. An immense body of research – historical, contemporary, cross – cultural – has been conducted in this arena. Studies have explored the medicalization of reproductive processes and events, including childbirth (Martin 1987 ; Treichler 1990 ; Wertz and Wertz 1989 ), birth control (Gordon 2002 ; Tone 2001 ), abortion (Riessman 1983 ), involuntary childlessness/infertility (Becker 2000 ; Becker and Nachtigall 1992 ), and menstruation (Bransen 1992 ; Chrisler and Caplan 2002 ; Oinas 1998 ), as well as medical interventions in life – cycle events and the aging process, as with menopause (Bell 1987 ; Lock 1993 ; Watkins 2007b ), andropause (Conrad 2007 ; Watkins 2007a ), impotence (Fishman 2007 ; Tiefer 1986, 1994 ), hair loss, and many other features of aging (Conrad 2007 ; Estes and Binney 1989 ; Rothman and Rothman 2003 ).

“ Natural ” in this context does not mean culturally unmanaged, nor does it imply that these processes and events are physically experienced in the same way. A study comparing Canadian and Japanese women, for instance, found that while the Cana- dians often used hot fl ashes to defi ne themselves as menopausal, the Japanese used quite different types of physical markers (Lock 1993 ). Rather, “ natural ” is simply a way of identifying physiological experiences and events that are everywhere part of the human condition. In many cases of medicalization, medical defi nition is framed in terms of illness or disease. With natural life processes, however, that is far less clearly, or perhaps not at all, the case. There is some talk of disease in this

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arena. Studies of the medicalization of menopause, for instance, typically note the efforts of a small segment of medical experts in earlier eras to characterize meno- pause as a “ defi ciency disease ” (Bell 1987 ; McCrea 1983 ). But the evidence in these studies suggests that in only a small minority of women did doctors see menopause as anything other than “ a normal phase of the female life cycle ” (Bell 1987 : 538). There was concern for pathogenic processes related to menopause in this minority. There were also recommendations for widespread use of hormone replacement therapy (HRT) to give individual women relief from physical discomfort and restore their customary functioning. Additionally, HRT was recommended to address increased risk for some forms of cancer, and until recently, for risk of chronic con- ditions, such as osteoporosis and cardiovascular disease. But none of this indicates that doctors considered menopause itself a kind of sickness, or that women consid- ering HRT do either (e.g., Griffi ths 1999 ). When the word “ disease ” is used in this arena, it is used analogically or for a subset of people who experience severe distress (as, offi cially, with the clinical categories of premenstrual syndrome and premen- strual dysphoric disorder).

Rather than disease or illness, with natural life processes the common terms are words like “ imbalance, ” “ condition, ” or “ dysfunction, ” which signify a departure from some biological standard which uses the youthful body or the absence of pain, suffering, or risk as the baseline. Setting the standard typically goes hand in hand with the development of new medical devices, diagnostic technologies, or medica- tions that promise to more effectively, for example, relieve pain and resolve com- plications of the birthing process, smooth physiological and psychological changes related to menstruation, menopause, or andropause (male menopause), “ solve the problem of childlessness ” for couples (Becker and Nachtigall 1992 : 460), control when pregnancy occurs, or address the “ anguish ” of declining sexual potency and the loss of hair and muscle mass. Studies show these standards not only shift with and replicate cultural norms, but are also in part constituted by the diagnostic technologies and treatments which, through the actions of doctors, marketers, medical popularizers, and others, redraw the boundaries of normal/abnormal, tolerable/intolerable, safe/unsafe, and lower the threshold for seeking medical atten- tion (cf. Barsky and Boros 1995 ).

Further, because these interventions address bodily experiences that can be painful, distressing, dangerous, and disruptive, consumer demand has long played a very important role. As is obvious from the list above, women ’ s natural life pro- cesses are much more likely to be medicalized than men ’ s. Research, originating in the feminist version of the medical imperialism critique, has traditionally empha- sized the role of the male – dominated medical profession, its ideology and economic interests, and the rise of new specialties, such as obstetrics and endocrinology, as agents of medicalization. However, studies over the past two decades have increas- ingly documented the demands of lay women, and now men, and social class dif- ferences in this arena. In many of these cases, from obstetric technologies to oral contraceptives, assisted reproduction to going on HRT (Lazarus 1997 ; Rothman and Rothman 2003 ; Tone 2001 ; Wertz and Wertz 1989 ), educated and “ well – to – do women ” have been at the forefront of efforts to “ reduce the control that biology had over their lives ” (Riessman 1983 : 98). In general, this has led – very unevenly, to be sure – toward greater technological intervention, medication use, and medical

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supervision. Voluntary utilization rates of medical interventions in many natural life processes are high, and despite resistance, show little sign of slackening (though there are important cross – national differences, see DeVries 2005 ). Much the same class dynamic is at work among men in matters such as treating impotence and undergoing vasectomy (Conrad 2007 : Ch. 2; Gordon 2002 ).

Research on the medicalization of natural life processes generally recognizes, at least implicitly, that sometimes medical interventions are necessary and life – saving. There has also been the trend among some feminists, noted above, to argue that women can and do fi nd the use of medical technologies and medications an empow- ering experience (e.g., Annandale and Clark 1996 ; Beckett 2005 ). At the same time, the range of concerns and criticisms remains considerable. As with the medicaliza- tion of deviant behavior, there are concerns about the individualizing and depoliti- cizing dynamic of the medical model, the power of the medical profession, and its monopoly over the technologies of intervention. Studies have sought to highlight ideological components that shape medicalization in this arena, with criticisms centering on the reinforcement of gender roles and stereotypes, the devaluing of women ’ s bodies, and the narrowing of the defi nition of “ normal ” with respect to the body and to specifi c processes, such as the length of labor or the intensity of menstruation. Studies have also emphasized the alienating nature of some medical procedures and hospital settings, the loss of patient autonomy, the extension of surveillance, the stripping away of lay knowledge of the body and practices, like midwifery, and the closing off of non – medical solutions, such as with infertility. Diagnostic technologies (such as fetal monitors) and physicians are criticized for overstating the risks of natural processes and understating the risks of medical technologies, increasing the danger of iatrogenesis, and generally fostering overuti- lization of high – tech and surgical procedures.

Everyday p roblems of l iving

The early work in this arena was centered on the medicalization of anxiety and tension and their treatment with minor tranquilizers, such as Valium and Librium (e.g., Cooperstock and Lennard 1979 ; Koumjian 1981 ; Lennard and Bernstein 1974 ). However, the medicalization of everyday life problems began to get sustained attention only in the 1990s. The conceptual shift is a transformation in the meaning of personal diffi culties and responses to life events from normal and expectable behavior and feelings to medical disorders. The body of research is already extensive and has explored the medicalization of such emotional experiences as sadness, unhappiness, grief, loneliness, and alienation (Elliott 1998 ; Healy 1997 ; Horwitz and Wakefi eld 2007 ; Karp 2006 : Ch. 7), anxiousness (Tone 2008 ), heightened mood (Martin 2007 ), shyness and fear of criticism (Lane 2007 ; Scott 2006 ), and outbursts of anger (Lane 2007 ) within new or expanded mental illness categories of major depressive disorder, generalized anxiety disorder, mania, social phobia/avoidant personality disorder, and intermittent explosive disorder. To these and other emo- tions and personality issues (premenstrual dysphoric disorder easily fi ts here; also see Chodoff 2002 ), studies have also explored the medicalization of problems of living such as perfectionism (Davis 2008 ), lack of libido (Hartley 2003 ; Hartley and Tiefer 2003 ), and work underperformance (Conrad 2007 ) under the categories of

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obsessive – compulsive personality disorder, female sexual dysfunction, and adult attention defi cit/hyperactivity disorder. In virtually every case at least one of the treatments, and often the primary one, is pharmacologic.

Studies in this arena generally recognize or presuppose a boundary between normal and expectable experience and a chronic and debilitating condition. While this boundary is often diffi cult to draw with any precision, medicalization refers to its profound blurring, the shift in a very short period of time, for example, from regarding social phobia as “ a rare and usually mild mental disorder ” to one of “ the most common ” (Katzelnick and Greist 2001 : 11). The literature identifi es a number of key forces contributing to this confl ation of normality and pathology. One major factor, widely documented, is the revolution in psychiatry occasioned by the 1980 and subsequent revisions of the Diagnostic and Statistical Manual of Mental Dis- orders (e.g., Horwitz 2002 ; Horwitz and Wakefi eld 2007 ; Kutchins and Kirk 1997 ; Lane 2007 ). Importantly, the DSM holds that mental disorders “ must not be merely an expectable and culturally sanctioned response to a particular event, for example, the death of a loved one. ” Rather than circumstantially appropriate responses, they must be a “ dysfunction in the individual ” (quoted in Horwitz 2007 : 214). The problem is, however, according to Allan Horwitz ( 2007 : 214), “ that many of the DSM ’ s criteria sets for particular disorders contradict its own defi nition. ” The for- mulaic and acontextual diagnostic criteria, he argues, fail to differentiate between expectable responses to life events and internal dysfunctions, a failure that has led to greatly infl ated epidemiological estimates and a radical expansion of the scope of pathology.

Studies show that the DSM approach has benefi ted certain groups, who have played an active role in promoting the labeling of disagreeable emotions and experi- ences as symptoms of disorders and advocating the use of psychotropic drugs to resolve them. These groups include the psychiatric profession, patient advocacy groups, government agencies, and, perhaps most importantly, the pharmaceutical companies. Studies identify the minor tranquilizers in an earlier era (Smith 1991 ; Tone 2008 ) and especially the new antidepressants, like Prozac, launched in the late 1980s, as decisive developments for the redefi nition of everyday problems in medical terms (e.g., Conrad 2007 ; Healy 1997 ; Horwitz and Wakefi eld 2007 ; Moynihan and Cassels 2005 ; Valenstein 1998 ). These medications (selective serotonin reuptake inhibitors) and others (stimulants, etc.) can treat a range of “ symptoms ” with rela- tively few side effects, have been approved by regulatory agencies for a large number of conditions, and are prescribed off – label for even more. They are often the favored form of treatment by managed care organizations and other payers (e.g., Frank, Conti, and Goldman 2005 ). Studies show they infl uence the defi nition of disorders and prescription rates in at least two ways. First, their clinical effect directly shapes what is regarded as clinically signifi cant symptoms, shaping physician practice and psychiatric defi nitions (Healy 1997 ). Second, their marketing has brought pharma- ceutical companies and the patient advocacy groups and physician experts they fund into the business of marketing not just medications but also the disorders they treat. This includes traditional and new forms of promotions to physicians (Greene 2004 ; Oldani 2002 ), as well as the marketing of medications to the public through “ illness awareness ” campaigns and commercials and, since the late 1990s, through direct – to – consumer advertising (only legal in the United States and New Zealand but seen

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over TV and the Internet elsewhere). These campaigns and ads work to undermine the boundary between normality and pathology and facilitate self – diagnosis by “ showing how mental illness and everyday sufferings look and feel alike ” (Davis 2006b : 77; see also, e.g., Grow, Park, and Han 2006 ).

Consumer demand, stimulated by pharmaceutical marketing, insurance coverage, and other practices, is yet another force contributing to the confl ation. In exploring the popular appeal of medications and self – labeling, studies point to a number of factors beyond the relief of distress, particularly symbolic and sick role benefi ts. A diagnosis, for example, can provide a publicly recognized “ account ” that creates and organizes meaning for painful experience, gives it legitimacy, and may bring some relief from social obligations (Barker 2005 ; Broom and Woodward 1996 ; Davis 2000 ). Inferring the cause of problems from the effectiveness of the medica- tions, doctors, pharmaceutical companies, and other medical popularizers have promoted the idea that for any given emotional or personality problem, “ a chemical imbalance could be to blame. ” Emphasizing a physical cause operates to establish the problem as the sort of somatic diffi culty that regular physicians treat, ruling out other explanations that might involve negative judgments of character or personal- ity. This lifting of responsibility and blame, as Parsons argued long ago and media accounts confi rm, comes as a relief (Valenstein 1998 ). Moreover, the chemical imbalance explanation comes with the sick role benefi t of the promise of a positive prognosis – there is nothing psychologically enigmatic going on that the “ safe and effective ” medications can ’ t correct (Davis 2006b ).

There is no sure way to know if there are group differences in this arena. Studies report evidence suggesting that social class is a factor, noting that the use of psy- chotropic medications is far more prevalent among the middle classes and affl uent. One of the concerns raised in the literature, then, has been with the overuse of scarce medical resources by those with minor problems and subsequent diversion of atten- tion from the underserved population of those with serious mental illnesses. While there is criticism of psychiatry for the DSM and for close ties to the drug companies, there is also criticism, ironically, of physicians for yielding too readily to consumer self – diagnoses and dispensing prescriptions too freely. More generally, critiques emphasize that medicalizing everyday life problems misses the larger social and economic causes of individual distress and the role of change in those arrangements for infl uencing well – being. They argue that medicalization, through defi ning new norms and reproducing social judgments, has reset and narrowed the boundaries for what is acceptable and expected human variation. In echoes of Illich, Arthur Kleinman ( 2006 : 9), for instance, argues that medicalizing “ ordinary unhappiness and normal bereavement … diminishes the person, thins out and homogenizes the deeply rich diversity of human experience, ” and undermines our moral life as a society. Among others, studies also raise concerns about medications – their long – term side effects and power to blunt emotions, decrease tolerance of minor discom- fort, and reshape understandings of personhood – and the culture that produces the demand for them.

Enhancements in h ealthy p eople

Although medicine has long been involved in enhancing human traits, developments in gene therapy and new interventions, actual and potential, have made the medi-

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calization of capacities and characteristics in healthy people a growing arena of research. The conceptual shift, to borrow a term from the psychiatrist Peter Kramer ’ s Listening to Prozac (1993) , is from “ well ” to “ better than well. ” This arena is different from everyday life problems in that medicalization does not begin with a problem. The aim of enhancement “ is not to cure a disease, to make a patient normal or remedy a defi cit, ” but to improve or maximize human capacities or traits (Rothman and Rothman 2003 : ix). However, in practice, it appears that medical treatments for healthy people are in fact legitimated not as simply “ improvements ” or in terms of “ pursuing perfection ” but as treatments for troubles (Davis in prep. ; Elliott 2003, 2007 ; Haiken 1997 ). As the bioethicist Carl Elliott ( 2003 : 120) writes, “ Doctors treat ‘ patients, ’ not ‘ consumers, ’ ” which means that generally enhance- ments must be transformed, however loosely, into treatments. Most human capac- ities and characteristics lie along a continuum, and those who fi nd themselves on the end furthest from conventional expectations or feel they do not match up in some way may perceive disadvantage (President ’ s Council on Bioethics 2003 : 15). Being short has social drawbacks; blushing can be embarrassing; a creased brow can make one look perpetually angry. For many physicians, dispensing growth hormone or beta blockers or Botox is a way to help, even if no diagnosable pathol- ogy is present.

Research in this arena includes studies of specifi c cases, such as cosmetic surgery (Davis 1995 ; Haiken 1997 ; Sullivan 2001 ), hormone treatments for short stature (Conrad 2007 ; Rothman and Rothman 2003 ), new reproductive choices, such as sex selection or choosing a sperm or egg donor based on donor characteristics (Becker 2000 ; Sandel 2007 ), and the extensive off – label use of medications, such as the use of Viagra by young healthy males, the use of Ritalin to improve study habits, or the use of Prozac to “ sculpt ” a desired personality (Conrad 2007 ; Diller 1998 : Ch. 13; Kramer 1993 ; Elliott 2003 ; Parens 1998 ; President ’ s Council on Bioethics 2003 ; Sandel 2007 ). But these examples only scratch the surface, as advances in neuroscience and emerging neurotechnologies are rapidly opening up many new “ quality of life ” interventions with respect to mood and cognitive functioning (e.g., Chatterjee 2004 ; Wolpe 2002 ). Still mostly on the horizon but the subject of exten- sive commentary and popular press coverage are potential interventions based on discoveries in genomic research.

The possibility of enhancement uses of medical technologies and medications is created by the very development of those interventions. Synthetic growth hormone was developed to treat children with a growth hormone defi ciency, and later given to those who were just short (Conrad 2007 ). Plastic surgery was developed to treat disfi gured and severely burned soldiers beginning with the Crimean War and then later used to enhance the body (Davis 1995 ). A drug like Provigil was developed to treat narcolepsy and then later used to extend wakefulness and increase alertness (Williams et al. 2008 ; Wolpe 2002 ). And so it goes, the fi rst use opening the pos- sibility for the second. The medicalization of capacities and characteristics in healthy people is also facilitated by features of contemporary consumer culture. These fea- tures include a strong emphasis on expressing individuality, reinventing one ’ s self, and revealing an identity that may be hidden by circumstance or accident of birth. In this environment, medical enhancements are appealing as a means by which people can express their true self, change their identity, or fi nd happiness. Studies show that whether getting a facelift or undergoing a sex – change operation, people

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often speak in terms of achieving a more authentic and meaningful life (Elliott 2003 ). The relentless competitiveness and 24/7 demands of contemporary Western society have also been theorized to feed the desire for neurological aids to maintain or better one ’ s position. Indeed, under these conditions, people may feel impelled: “ To not take advantage of cosmetic neurology might mean being left behind ” (Chat- terjee 2004 : 971). In this meritocratic world, mastery and control are among the most highly prized values.

The use of medical technologies for enhancement is generally paid for privately in both the United States and Europe (though see Davis 1995 on the Dutch experi- ment with covering cosmetic procedures). As a result, the middle class and affl uent are the most likely to use them, and intense competition has emerged involving industry, scientists, and clinicians anxious to stake biotech claims and both foster and meet demand. Signifi cant scientifi c innovations and transformations in the organization and practice of medicine are important driving forces. These include the public sponsorship of research and development by scientists and university research departments with subsequent privatization of the “ commodifi able products and processes ” that emerge (Clarke et al. 2003 : 167). The publicly funded Human Genome Project is but a prime example. All the private and university patenting is in turn generating pressure to fi nd any and every therapeutic use and to corner new markets. Pharmaceutical companies are increasingly funding research in academic medical centers, creating signifi cant questions about how commercial sponsorship infl uences study results and subsequent claims about the safety and effi cacy of tested drugs (Angell 2004 ). Pharmaceutical companies have also come to play a very large role in the continuing education of physicians, and, as noted above, aggressively market psychotropic medication and the disorders they treat as “ everyday ” drugs to both doctors and the general public (Mechanic 2006 ). Given the cultural empha- sis on self – fulfi llment and success, the producers of enhancement technologies, from drug companies to cosmetic surgeons, now market them as instruments of self – expression and liberation, promising just the right intervention to improve the quality of one ’ s psychic experience, outer appearance, or social performance (Elliott 2003 ).

The medicalization of capacities and characteristics in healthy people touches on a wide array of issues, including concerns with distributive justice and social strati- fi cation, a trade – off between individual well – being and social goods, and the safety and side effects of clinical interventions. Critical observers argue that infl uential scientists and doctors, as well as the marketers, typically hype the benefi ts and downplay the dangers of enhancements, and that many physicians allow patient demand to drive their care. Studies express social and philosophical concerns that enhancements can create false hopes, weaken individual character, and threaten important features of what it means to be human. They can erode the “ gifted char- acter of human powers and achievements, ” ratcheting up individual responsibility for life outcomes, and diminishing “ our sense of solidarity with those less fortunate than ourselves ” (Sandel 2007 : 86, 89). They can promote cultural norms that are “ morally suspect ” and “ generate pressure to assimilate to an unjust paradigm, ” as with cosmetic procedures that involve unjust images of race and beauty (Little 1998 : 166 – 7) or with the demand for “ designer children. ” In this arena, as in all the others, the individualizing dynamic of medical conceptualization and treatment

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is joined to a concern with the insidious narrowing of norms and standards, the closing off of alternative ways to live, and the subtle but powerful pressures to conform.

TOWARD THE FUTURE

In conclusion, I want to briefl y point to three areas for more focused research and emphasis. First, continuing work in each of the arenas could be usefully enlarged by attending not only to the social construction of medicalized categories but also to the etiology of the behavior or condition that is being medicalized. Studies explor- ing the dynamic interaction between cultural imperatives, cultural anxieties, and disease categories show that the experiences of suffering and feelings of inadequacy being medicalized are not simply being discovered, they are being generated by social change. A new tool for this type of work is the historicized form of concep- tual analysis – “ historical ontology ” – developed by the philosopher Ian Hacking. In exploring transient mental illnesses, he employs the metaphor of an “ ecological niche ” and identifi es four principal “ vectors ” which create it – the illness should fi t into a taxonomy of illness; be socially observable “ as suffering, as something to escape ” ; lie on a line between two elements of contemporary culture, one desired and the other feared; and, fi nally, the illness, “ despite the pain it produces, ” should “ provide some release that is not available elsewhere in the culture ” (Hacking 1998 : 1, 2). Historical ontology is one possible conceptual tool for moving beyond social constructionism (also see Horwitz 2002 ). We need others. The recent call for the development of a “ sociology of disease ” is a welcome development in this regard (Timmermans and Haas 2008 ).

Second, we need more research on resistance and constraints to medicalization. While undeniably a powerful process, medicalization is not monolithic or unidirec- tional but contingent. Research, however, has concentrated on the factors that push medicalization and has devoted far less attention to those that inhibit it. Our under- standing is consequently skewed. After reading in this literature, one could easily come away with a picture of medicalization as an inexorable juggernaut. Over the years, various concepts have been introduced to capture the contingency analyti- cally, including the concept of “ demedicalization. ” There is no consensus on this concept and its use varies widely and confusingly. Conrad ( 1992 : 224) argues that “ Demedicalization does not occur until a problem is no longer defi ned in medical terms and medical treatments are no longer deemed to be appropriate solutions. ” This defi nition is clear enough, yet of doubtful utility since only a very few examples can be found. And given that medicalization is a response to pain, or problems, or some sense of being disadvantaged, it is unlikely that the number of examples will grow.

Yet constraints on medicalization are real. Resistance, passive or active, for instance, is widespread. Despite rising prescription rates in the US and elsewhere, there is considerable resistance to viewing certain behavioral problems of children as properly medical and pharmacologic treatments as appropriate (e.g., McLeod et al. 2004 ). Epidemiological studies always show a gap, often quite large, between diagnosed cases and estimated prevalence in many areas of psychiatry (e.g., Kessler

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et al. 2005 ) and well beyond. Not everyone is running to the doctor, and as noted above, patients often have their own perspective. Physicians can and do contest medicalized defi nitions and the extension of their role. There are new forms of backlash stirring, including the informal movement of medical journalists and academics criticizing the “ disease mongering ” of the pharmaceutical companies (Moynihan and Cassels 2005 ; Moynihan, Heath, and Henry 2002 ). And so on. Uneven, inconsistent, and contested: We need more research to balance our often one – sided picture of medicalization.

Finally, both medicine and society continue to change. Gathering steam for some time, a major, cross – national conversation has now erupted about the promises and perils of real and potential biomedical advances in neuroscience, genomics, assisted reproduction, and more. The issues, touched on only briefl y above, are as funda- mental as they are urgent: Who are we as human beings? What makes for a good life? What obligations do we have to one another? Can we establish normative limits on medical interventions, and if so, where? These and other such basic questions are being debated by politicians, philosophers, scientists of every stripe, bioethicists, theologians, activist groups, and others. The debates very often touch, directly and indirectly, on the question of medicalization. More clearly thematizing key features of medicalization research would bring the fi eld more directly into this important conversation. Many studies of medicalization are windows not just on medicine but on culture and subjectivity. They illuminate how dominant social values and visions of the good life, standards of pathology and normality, and practices of social control are enacted and how they shift and change. And they shed light on the consequences, intended and unintended, for the conduct of life. These fi ndings are relevant, and attending to and drawing them out would make them available to the larger debate about “ life itself ” (Rose 2007 ).

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