Moving Sideways and Forging Ahead
Reimagining “-Izations” in the Twenty-First Century
In the Introduction to this volume, we write that medicalization is a useful concept that has been highly debated within the social sciences, history and biomedicine itself. Although we do not entirely agree with Rose who suggests “medicalization has become a cliché of critical social analysis” (Rose 2007:700), his call to move “beyond medicalization” resonates with us and others. Medicalization still has utility for social analysts if we take it, following Rose (2007:702) as “the starting point of an analysis, a sign of the need for an analysis, but … not … the conclusion of an analysis”. We also do not entirely agree with Kleinman (2012) who argues that medicalization is no longer an interesting or useful concept because it applies to a process in which conditions move from one category (e.g., badness) to another (e.g., sickness). At the same time we agree with Kleinman that either/or thinking cannot grasp complex processes leading to and emanating from social suffering and global health inequality. In addition to adding related concepts (biomedicalization, pharmaceuticalization and geneticization) alongside that of medicalization, scholars are more recently using the concept of medicalization in new and different ways such as “ambivalent medicalization” (Crowley-Matoka and True 2012) and what might be called “simultaneous medicalization and demedicalization,” in which professional groups such as lactation consultants are actively working toward demedicalization and medicalization at the same time (Torres 2014).
The role of the analyst of this phenomenon is to not only critique but to engage with its messy and theoretical/practical areas. As the title of the Introduction to this book suggests (Bell and Figert 2015), we still need to engage older critiques about medicalization processes but with newer studies and new tools. To do so, we embrace the conceptual tools of biomedicalization, pharmaceuticalization, the pharmaceuticalization of public health, and geneticization in order to show that medicalization is a capacious concept but it may not fully capture the global dynamics of biomedicine, the pharmaceutical industry and technologies of genetics in medicine. There is certainly a fair amount of overlap but medicalization alone is not adequate for understanding what is going on in the globalizing world of the twenty-first century precisely because it is rooted in modernity and categorical thinking (Bell and Figert 2012a). These “-izations” are related and coevolving concepts and processes; this becomes especially visible when analyzed within a global context. In this chapter we look back over the past forty years of scholarship on medicalization, turn sideways to other disciplines that contribute to this growing field and look ahead to the next decades. We argue that alone each of the concepts captures distinct processes, that each is related to the others, and that each sometimes but not always overlaps with another. In this chapter, we suggest that instead of throwing out one or all of the “-izations” we can move sideways and forge ahead by examining new ways of thinking: globally, scientifically, socially.
Our discussion begins here with the widely accepted definition and description of medicalization from US sociologist Peter Conrad as “defining a problem in medical terms, usually as an illness or disorder, or using a medical intervention to treat it” (2005:3; emphasis in original) and as “a process by which nonmedical problems become defined and treated as medical problems, usually in terms of illness and disorders” (2007:4). Historians and anthropologists document how medicalization as a phenomenon (as opposed to an analytic term) has its beginnings in late seventeenth- and early eighteenth-century Western modernization along with the application of scientific knowledge to social life (Lock 2004). This location of medicalization within large-scale social processes such as modernization and positivism and public health programs of the modern state echoes throughout the historical and anthropological literature (Nye 2003; Rosenberg 2006). To simplify, “medicalization” is a process associated with modernity, and reflects societal and medical practices designed to control and regulate diseases, illnesses and injuries. Foucault’s (1965, 1977[1975]) work on the modern state, the clinical gaze and the embodiment of surveillance and control is often cited in the medicalization literature as a major influence on the scholarship about this process (e.g., Lupton 1997; Nye 2003). According to Foucault, medicalization as a process was co-constructed along with modern capitalism and the state. The process of medicalization exemplifies a modern mechanism of power – a manifestation “of the right of the social body to ensure, maintain, or develop its life” (Foucault 1978:136). The modern state replaced the ancient right to take life with the power to foster life. The power over life evolved in two forms that were “linked together by a whole intermediary cluster of relations” (Foucault 1978:137): disciplining the individual body and optimizing its capabilities and regulating the species body (population). The beginning of what Foucault called “biopower” (Foucault 1978:140) is marked by the “explosion of numerous and diverse techniques for sub-jugation of bodies and the control of populations.” Whether medicalization was “co-constitutive of modernity” (Clarke et al. 2003:164) or “the product as well as the cause of societal faith in medical knowledge and practice” (Ballard and Elston 2005:237), the turn to medicine as an institution of social control was part of a more general process of modernization.1
The concept of medicalization was introduced into the medical sociology literature in the 1970s to understand and look critically at “the involvement of medicine in the management of society” (Zola 1972:488; see also Pitts 1968 for one of the earliest references as it related to definition and social control of deviance). Medical sociologists began to use the concept of “medicalization” to examine the dynamics of an expanding medical institution and the related processes of professional authority, control and the construction (and active defense) of medical diagnoses (Freidson 1970; Zola 1972). At this time, the connection between the dynamics of medicalization and those of deviance and social control was highlighted with examples such as hyperactivity, sexuality and alcoholism (Conrad and Schneider 1980). Scholars showed how deviance was gradually transformed from a religious and criminal problem into a medical problem that is defined, treated and controlled by the medical establishment.
A substantial portion of the early sociological work on medicalization focused specifically upon the technically competent power and authority of physicians in modern society and in the medical encounter itself. As numerous reviews of the literature point out, in medical sociology, “medicalization” has its roots in Parsons’ concept of the sick role (1951). At one level, the sick role refers to individuals and interactions in the medical social control of deviance. However, the sick role is also about the larger social structures in which the interactions are situated – the institution of medicine and physicians’ state sanctioned authority to diagnose and treat diseases in people seeking “technically competent” help (Freidson 1970). By virtue of having the authority and professional power in modern society to define and control what is formally recognized as a disorder, sickness or deviance, physicians play an important role in the medicalization process (Freidson 1970; Zola 1972; Illich 1975; Conrad and Schneider 1980).
Throughout the period from the 1970s to the early 1990s medicalization scholars continued to refine the concept by documenting how the jurisdiction of medicine expanded and redefined elements of the life cycle and moral, social and legal problems and turned them into medical matters. In the 1980s, most of the sociologically generated scholarship moved away from an explicit focus on deviance and scholarship in the USA took a social constructionist approach to medicalization in its examination of the construction of diagnostic categories and professional process and social control of behaviors (Conrad 1992).
During the early part of this period, an important turn in the development of medicalization scholarship came about when researchers began to point out that medicalization was not just a process done to people but that people and groups were also active agents in advocating for or against diagnoses or the medicalization or demedicalization of life processes.2 Using perspectives from both the sociology of professions and the sociology of scientific knowledge, medical sociologists were heavily engaged in documenting cases of medicalization such as in the care of children and of veterans of the Vietnam War (Halpern 1990; Scott 1990). Feminist scholars focused on women’s bodies (e.g., Riessman 1983; Bell 1987b) and documented cases of the gendered nature of medicalization. Women’s health movements (Boston Women’s Health Book Collective 1973) also emphasized the unique ways in which women’s bodies were more susceptible to medicalization through processes such as childbirth, PMS and menopause (McCrea 1983; Riessman, 1983; Bell 1987a; Figert 1995). By the 1990s the medicalization analysis of gender moved its focus beyond the reproductive realm for women (Plechner 2000; Riska 2003; Barker 2005) and medicalization scholars began to ask how, why and under what circumstances men’s bodies are also medicalized (Loe 2004; Rosenfeld and Faircloth 2006; Conrad 2007).3
The 2000s: Putting the Bio- into Medicalization, Pharmaceuticals and Genomics
The rise of gender scholarship, the growth of the institution of medicine and the pharmaceutical industry, and other factors contributed to continued scholarly interest in developing the concept and studying the dynamics of medicalization and its related processes in the 2000s. Scholarship revitalized and refocused our analytic gaze from the power and authority of the medical profession and the documentation of cases of medicalization to consider the active participation of individual patient/consumer/users individually and collectively (Brown and Zavestoski 2004; Crossley 2006), resistance to pharmaceuticals (Figert 2011; Williams, Martin and Gabe 2011), and the use of medical prescription drugs for nonmedical purposes (Williams, Gabe and Davis 2008). It has also explored new “engines” of medicalization including the pharmaceutical industry (Conrad 2005), and the role of technoscience (Clarke et al. 2003).
Scholars from many disciplines are also questioning the adequacy of medicalization as a conceptual tool for understanding these processes. One reason is that physician power and authority is changing – indeed waning – as a result of healthcare reforms, insurance policies and (in the USA and New Zealand) direct-to-consumer advertising (DTCA) of pharmaceuticals (Lock 2004; Rose 2007). Even though the medical profession and physicians remain key players in medicalization they are no longer its major promoters (Conrad 2007:156).
Another significant change is that the pharmaceutical industry has become an important proponent of medicalization by targeting physicians through physician-directed communications and targeting (potential) patients directly and indirectly with advertisements (Abraham 2010a; Padamsee 2011). Medicalization theory assumes that the transformation from deviance as badness to deviance as sickness is associated with less stigma both to the individual and to the group of people affected. Big Pharma has held out advertising as a strategy for not only medicalizing but also destigmatizing conditions such as erectile dysfunction, social anxiety and depression. With greater awareness of certain conditions, comes the promise of normalizing and destigmatizing the effect of the conditions (Phelan 2005). As Payton and Thoits write, medicalization was “thought to reduce the blame and stigma attached to deviant conditions such as mental illness” (2011:56). The dynamics of medicalization involving mental illness both in the USA and in other countries are, however, much more complex than this argument assumes. The results of DTCA in the USA in reducing stigma have been mixed, especially regarding mental illness. Payton and Thoits investigated whether or not the rise of DTCA for depression drugs alters negative public opinion about depression and mental illness more generally and found that DTCA did not change Americans’ negative perceptions about mental illness but did promote the greater acceptance of medical interventions for mental illness (2011). Pescosolido et al. (2010) found similar results in that DTCA increased public acceptance about the biomedical causes of mental illness and increased support for biomedical treatments and services but did not increase overall acceptance of people with mental illness. Thus, DTCA garners support for medicalization and treatment of mental illness pharmaceutically but this does not mean that people with mental illness are any less stigmatized in the USA as the recent debates on gun violence and lack of mental healthcare has made clear.
The global dynamics of the medicalization of mental illness are also complicated, uneven and at times contradictory as studies of prescriptions in Chile, Japan and Argentina demonstrate. Cuthbertson documents the use of antidepressants in Chilean mental health Clinics as a form of “pharmaceutical governance” by the state (2015, Chapter 7, this volume). In Chile, even when depression is viewed as a medical illness, it is also viewed both as a threat to individual worker productivity and to the national economy. In this case then the medicalization of depression and its pharmaceutical treatment is taken to mean an entirely different thing than it might in a different country such as in the USA. In the USA depression is individualized but not seen as a threat to the national economy. As Applbaum (2006) suggests, the later introduction of newer antidepressants (selective serotonin reuptake inhibitors or SSRIs) such as Prozac in Japan in the mid- to late 1990s was the result of successful global marketing strategies by pharmaceutical companies and not by the state. In this case the harmonization of clinical research data from global clinical trials was key. Successful marketing depended on and produced organizational changes in Japanese governmental agencies about accepting foreign clinical research data collected under the International Conference for Harmonization (ICH), and the adoption of US-based diagnostic categories in the Diagnostic and Statistical Manual of Mental Disorders (DSM) and of the WHO’s International Classification of Diseases (ICD). By contrast, SSRIs were used in Argentina in 2001 to treat social suffering as a result of the country’s economic crisis. As Lakoff writes:
doctors’ prescription of SSRIs was dependent neither on a diagnosis of depression nor on a biological understanding of mental disorder. These drugs found a different means of entering the professionally mediated marketplace: doctors understood and used SSRIs as a treatment not for a lack of serotonin in the brain, but for the suffering caused by the social situation – the sense of insecurity and vulnerability that the economic and political crisis had wrought. (2004:247)
In addition to the waning power of the medical profession and the increasing power of the pharmaceutical industry, global health inequality has sharply increased. Whereas some populations in some areas of the world are (over)medicalized or use too many pharmaceuticals, other populations in other parts of the world are (under)medicalized or have limited access to pharmaceuticals (Biehl 2008). The global expansion of clinical trials clearly reflects this. Some populations in some areas of the world serve as research subjects and other populations in other parts of the world benefit from these trial results (Figert and Bell 2014). To put it bluntly, “some people are more medically made up than others – women more than men, the wealthy differently from the poor, children more than adults, and differently in different countries and regions of the world” (Rose 2007:700). Since the 2000s, scholars working in the fields of biomedicalization, pharmaceuticalization and geneticization have been providing evidence of the need to understand how changes in medicalization, the global flow of pharmaceuticals and the increasing turn to genetics shape global health inequality in the twenty-first century. We address each of these in the next section.
Science and medicine changed so substantially in the 1980s that when looking back and trying to analyze it, Adele Clarke and her colleagues (2003) argue that the concept of “medicalization” is no longer fully accurate or adequate to explain the substantive organizational and technological changes in medicine. Clarke et al. (2003) introduced the word “biomedicalization” as a tool for illuminating the complex dynamics and effects of technoscientific innovations ushered in since the mid-1980s. Technoscientific innovations merge “basic” science with “applied” technology. These technoscientific innovations in molecular biology, biotechnologies, genomization and transplant medicine make it possible not only to control but to transform both humans and nonhumans from the “inside out” by producing biomedical solutions for health maintenance, enhancement, and optimization as well as illness (Clarke et al. 2003:162). The concept of “biomedicalization” draws attention to the complexities of this process that also produces new subjectivities as well as new medical subjects. For example, as Sara Shostak demonstrates in her research, screening technologies using molecular biomarkers create new categories of people at risk, new opportunities for biomedical surveillance and intervention, and new forms of self-monitoring and regimens of behavior change (Shostak 2013; Shostak and Moinester 2015, Chapter 11, this volume). Bodies are simultaneously “objects and effects of technoscientific and biomedical discourse” (Mamo and Fosket 2009:927).
The transformation of life beyond the control of bodies and behaviors to the constitution of new forms of life and new subjectivities is associated with a new, postmodern, era in medicine and society more broadly. These dynamics do not easily fit into a conceptual frame of medicalization as either governmental or medical professional control. Adding the prefix “bio” to “medicalization” to make “biomedicalization” draws attention to the complexities of these dynamics (Clarke et al. 2003, 2010). It is a tool for exploring the mutual constitution of political, economic, cultural, organizational and technoscientific trends and processes and connects large, macrostructural changes with new personal identities and subjectivities.
Scholars interested in health inequalities from the perspective of biomedicalization are exploring how the process “carries within itself the ideological, social, and cultural infrastructures that support and maintain racial and class inequalities” (Clarke et al. 2010:29). For example, in his study of BiDil, the first “race-specific drug” approved by the Food and Administration to treat heart failure, Kahn (2010) traces the complex and contradictory pathway through which BiDil was produced by and in turn exploited the processes of biomedicalization. He concludes that BiDil “is part of a much larger dynamic of reification in which the purported reality of race as genetic is used to obscure the social reality of racism” (Kahn 2010:284).
A significant proportion of scholarship in this field takes a feminist approach to biomedicalization, partly because those who developed the concept are committed to feminist health scholarship. As Mamo and Fosket put it, “female corporeality and subjectivity are understood as constituted in and through (cultural) practices of (techno)science” (2009:927). Although the concept of biomedicalization does not necessarily privilege gender, it takes gender – and gendered bodies – seriously. Biomedicalization scholars argue that gender is not a stable, given status but an outcome of performance, following the arguments made by feminist theorist Judith Butler (1993). Gender is “produced in relations – as an effect of power” (Clarke et al. 2010:27). Gender is also not a privileged status or category, but one produced in intersections with race, class, sexuality, disability and so forth. That is, “in life, in bodies, in practice” these categories are “dynamic, changing, and co-constitutive” and thus cannot be understood separately but must be explored simultaneously (Clarke et al. 2010:30). Biomedicalization has been employed, for example, to examine how gendered subjectivities and forms of embodiment are produced in lesbian practices of assisted reproduction (Mamo 2007, 2010), breast cancer prevention technologies (Fosket 2010), contraception/menstruation (Mamo and Fosket 2009) and pharmaceutical interventions for male impotence (Fishman 2010).
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