Medicalization

Summary

Medicalization describes the process by which non-medical problems become defined and treated as medical problems, extending biomedical authority into domains of social and moral life previously outside its purview. The concept has three principal theorists. Foucault showed that the birth of the modern clinic in late eighteenth-century France reorganized the relationship between the doctor’s gaze, the patient’s body, and the language of disease, making pathological anatomy the foundation of a new medical epistemology. Illich, in his 1975 Medical Nemesis, argued that the medical establishment had become a major threat to health through three forms of iatrogenesis: clinical (direct harm from treatment), social (the destruction of autonomous coping through professional monopoly), and cultural (the expropriation of the individual’s power to suffer, heal, and die). Lock and Nguyen extended the critique to global biomedicine, showing how the universalist assumptions of biomedical technology obscure significant biosocial variation across populations and how medicalization both extends social control and generates resistance.

Definition and Scope

Medicalization of life — the institutional colonization of liberty through affluence — has become a built-in feature of all social relations in rich countries, with poor countries quickly following.(Illich, 1975) A physician-based health-care system that exceeds critical bounds is sickening for three reasons: it causes clinical damage, obscures pathogenic political conditions, and expropriates the individual’s power to heal.(Illich, 1975)

Illich distinguishes three levels: clinical iatrogenesis (direct medical harm), social iatrogenesis (impairments caused by the institutional shape health care has taken), and cultural iatrogenesis (destruction of people’s capacity to deal with weakness, vulnerability, and death in a personal and autonomous way).(Illich, 1975)(Illich, 1975)(Illich, 1975)

Historical Development

Enlightenment Origins: Secularization and Statistical Medicine

The process that twentieth-century critics called medicalization has an Enlightenment prehistory. Porter’s Enlightenment (2000) documents how the long eighteenth century progressively moved explanations of illness, madness, suicide, and even death from supernatural and moral frameworks toward psychological and legal categories. Occurrences hitherto explained supernaturally — madness, suicide, infanticide — were “secularized as part of the ‘disenchantment of the world’”: infanticide ceased to be viewed as the product of bewitchment and was reinterpreted as child murder in a civil context; suicide shifted from sin to pathology.(Porter, 2000) This was medicalization not as a modern imposition but as Enlightenment emancipation — the replacement of theological guilt by scientific management.

The same period saw the first systematic quantification of illness. Bills of mortality, actuarial tables, and comparative life expectations helped transform illness from a providential event into a natural regularity amenable to prediction and control.(Porter, 2000) Physicians began plotting biomedical regularities statistically: physiological operations were weighed, measured, and numbered. Porter notes that late Enlightenment luminaries Richard Price and William Frend were both prominent actuaries — the man who advocated for democratic rights and the physiological physician shared a common commitment to numerical management of life and death. This statisticalization of illness was the intellectual foundation on which nineteenth-century hospital medicine and twentieth-century epidemiology would both be built.

The medicalization of pain provides a sharp illustration of the same secularizing process. Before the nineteenth century, pain was understood holistically; the distinction between physical and mental suffering was not clinically operational. The modern separation of physical from mental pain was driven not by scientific evidence of two distinct kinds but by the professionalization of medicine and by the progressive shift from understanding pain as a God-given trial to understanding it as a problem to be solved. (German E. Berrios & Roy Porter (eds.), 1995) This reframing was the cultural precondition for anaesthesia: it was only when pain ceased to be seen as spiritually valuable that its elimination became straightforwardly desirable, and the deliberate relief of suffering became a medical imperative rather than an interference with divine providence. (German E. Berrios & Roy Porter (eds.), 1995)

The same medicalized gaze extended into social and political life. Nineteenth-century psychiatrists applied the concept of delirium to religious enthusiasm, revolutionary political activity, and the social aspirations of the lower classes — describing these as forms of delirium or analogous states — thereby extending psychiatric authority from the asylum into the wider social domain and pathologizing dissent as symptom. (German E. Berrios & Roy Porter (eds.), 1995) This is Conrad and Schneider’s “depoliticization” function of medicalization operating in its earliest and most explicit form.

Foucault: The Birth of the Clinic and Bio-Power

The exact superposition of the body of the disease and the body of the sick person is a historically contingent formation specific to nineteenth-century medicine and pathological anatomy, not a timeless medical truth.(Foucault, 1963) Classificatory medicine from Sauvages to Pinel organized disease in a space of families, genera, and species independent of anatomical localization, treating the body as a secondary support rather than primary site.(Foucault, 1963) In classificatory medicine, the individual patient was paradoxically treated as a disturbance or negative element that had to be subtracted from the disease to reveal its pure essence.(Foucault, 1963)

A medicine of epidemics necessarily required a political police apparatus: supervision of cemeteries, food markets, housing, and abattoirs, with health regulations read at church services.(Foucault, 1963) The pre-Revolutionary period generated two contradictory medical myths: a nationalized medical clergy with power over bodily health, and a utopia of disease’s total disappearance in a well-organized society — both expressing the same project of complete medicalization of society.(Foucault, 1963)

The hospital replaced the family as the proper domain for clinical observation because it provided a neutral, homogeneous domain where all forms of pathological events could occur in comparable conditions.(Foucault, 1963) Foucault also documented the rise of “bio-power” — power over life — involving the abandonment of coercive instruments such as capital punishment in favor of more insidious ruling techniques to manage and render individuals more productive; medicine was arguably the primary network through which bio-power was exercised.(Jackson (ed.), 2011) For Foucault, medicine became implicated in the exercise of government toward the end of the eighteenth century, extending disciplinary control and surveillance into the fabric of the body itself.(Jackson (ed.), 2011) The nineteenth-century invention of disease as an administrative entity shifted medicine’s focus from healing persons to managing pathological categories, transforming sickness from personal experience into clinical case.(Illich, 1975)

Illich: Medical Nemesis

The medical establishment has become a major threat to health through disabling professional control that has reached epidemic proportions.(Illich, 1975) The layman, not the physician, has the potential perspective and effective power to stop the iatrogenic epidemic, making medical reform a political rather than a professional task.(Illich, 1975)

Changes in Western disease patterns over the past century are not significantly related to the activities of the medical profession; they are dependent variables of political and technological transformations.(Illich, 1975) Tuberculosis mortality in New York declined from over 700 per 10,000 in 1812 to 48 per 10,000 after World War II — before antibiotics became routine — demonstrating that medical intervention was not the primary cause of decline.(Illich, 1975) Conrad and Schneider corroborate this judgment: the dramatic “conquests of disease” in the 19th century were by and large not the result of new medical knowledge or improved clinical practice, but of changes in social conditions — rising living standards, better nutrition and housing, and public health innovations like sanitation. “With the lone exception of vaccination for smallpox, the decline of these diseases had nearly nothing to do with clinical medicine,” yet medicine was the beneficiary of popular credit for the improvement.(Peter Conrad and Joseph W. Schneider, 1980)

The US Department of Health, Education, and Welfare calculated that seven percent of all hospitalized patients suffer compensable injuries; one in five patients at a typical research hospital acquires an iatrogenic disease, with one in thirty leading to death.(Illich, 1975) Survival rates for the most common cancers remained virtually unchanged over twenty-five years prior to 1975, despite American Cancer Society proclamations reminiscent of military optimism.(Illich, 1975)

A radical monopoly is distinct from a commercial monopoly: it disables people from doing or making things on their own by reshaping the milieu itself, not merely by cornering a market.(Illich, 1975) Diagnostic imperialism extends the medical gaze to label healthy people as patients-at-risk, with regional screening studies finding only 67 out of 1,000 people completely fit while fifty percent were referred to a doctor.(Illich, 1975)

Cultural Iatrogenesis

Cultural iatrogenesis sets in when the medical enterprise saps the will of people to suffer their reality, undermining the ability to face pain, impairment, and death with meaning.(Illich, 1975) Traditional cultures derive their hygienic function from equipping individuals to make pain tolerable, sickness understandable, and death meaningful; most healing is a way of consoling and comforting people while they heal themselves.(Illich, 1975)

Medical civilization constitutes a new goal — eliminating suffering, sickness, and death as technical problems — that is in direct opposition to every cultural health program it encounters in the process of colonization.(Illich, 1975)

Lock: Biomedicine as Sociotechnical System

Biomedicine is a sociotechnical system cobbled together since the end of the nineteenth century and based on an assumption of the universality of human bodies that are everywhere biologically equivalent.(Margaret Lock and Vinh-Kim Nguyen, 2018) Biomedicine’s universalist assumptions obscure significant biosocial variation across populations, making an anthropology of biomedicine essential to reveal how historical, political, and environmental contexts shape biomedical technologies.(Margaret Lock and Vinh-Kim Nguyen, 2018)

Medicalization describes the process by which non-medical problems become defined and treated as medical problems, extending biomedical authority into domains of social and moral life previously outside its purview.(Margaret Lock and Vinh-Kim Nguyen, 2018) Medical pluralism remains widespread worldwide, demonstrating that biomedicine alone is insufficient to meet health needs, while processes of medicalization both extend social control and generate resistance.(Margaret Lock and Vinh-Kim Nguyen, 2018)

Phenomenological Critique: The Objectified Body

Aho’s Heidegger’s Neglect of the Body (2009) offers a complementary angle on medicalization drawn from phenomenological philosophy. Biomedicine decontextualizes and de-animates the body into a Körper — a depersonalized system of chemical, electrical, and mechanical functions — stripping the lived body of its subjective dimension.(James Aho, Kevin Aho, 2009) This reduction is not merely a theoretical stance; it is actively reproduced through clinical training. MRI studies show that brains of medical professionals looking at acupuncture procedures activate regions of emotional control and rational thought, while laypersons activate empathic pain regions, suggesting that medical training reshapes perception of the body at a neurological level.(James Aho, Kevin Aho, 2009)

The broader history of modern medicine is, on this account, a centuries-long narrative in which patients’ verbal accounts have been progressively superseded by technologically mediated discoveries — from stethoscope to MRI.(James Aho, Kevin Aho, 2009) What Foucault described as the reorganization of the clinical gaze becomes, in phenomenological terms, the institutional displacement of the Leib (the body as lived from within) by the Körper (the body as inspected from without). This is one mechanism by which medicalization operates at the level of perception itself, not only at the level of institutional policy or diagnostic category.

Elias: Civilizing Process as Medicalization Precursor

Norbert Elias’s The Civilizing Process (1939) offers a long-run historical account of how bodily behavioral standards become progressively internalized and then medicalized. Crucially, Elias showed that hygienic justifications for behavioral prohibitions arrive after the behavioral change is already established through social pressure, not before: “Hygiene was not the reason for the prohibition on eating from a common dish with the same spoon others used. The prohibition was established by the social pressure of courtesy long before hygienic knowledge could have explained or demanded it. Only later did hygienic arguments enter as rationalizations of what was already socially required” (Elias, Norbert, 2000). On this account, medicine is often a late-arriving legitimation system for social norms already operative in the culture, not the origin of those norms.

Elias also documented that thresholds of shame and repugnance — the zone of bodily experience that feels natural, normal, or embarrassing — are historically variable rather than fixed human traits (Elias, Norbert, 2000). As these thresholds advance over time, more conditions fall below the acceptable, making them candidates for the medical management of shameful bodies. The advancing threshold of repugnance driven by social distinction (upper groups continuously imposing finer standards of conduct (Elias, Norbert, 2000)) means that the expanding scope of medicalization is not primarily driven by scientific discovery but by the socially produced elevation of what counts as an acceptable body.

Conrad and Schneider: From Badness to Sickness

Peter Conrad and Joseph Schneider’s Deviance and Medicalization: From Badness to Sickness (1980) provides the most systematic sociological account of how deviance designations shift between institutional frameworks. Their core argument is that the historical transformation from “badness” (sin/crime) to “sickness” is not a natural evolution but a profoundly political process: “Deviant behaviors that were once defined as immoral, sinful, or criminal have been given medical meanings… In many cases medical treatments have become a new form of punishment and social control.”(Peter Conrad and Joseph W. Schneider, 1980) The analytical orientation is interactionist: morality is socially constructed and relative to actors, context, and historical time; “those who have comparatively more power in a society are typically more able to create and impose their rules and sanctions on the less powerful,” making deviance “actions or conditions that are defined as inappropriate to or in violation of certain powerful groups’ conventions.”(Peter Conrad and Joseph W. Schneider, 1980) Three major paradigms have successively dominated deviance designations — sin, crime, and sickness — with the medical paradigm now ascending as the dominant framework in post-industrial Western societies.(Peter Conrad and Joseph W. Schneider, 1980)

Conrad and Schneider adopt a “historical-social constructionist” framework that directs analytical attention not to the etiology of deviant behavior itself but to the etiology of deviance designations: “Who defines what as deviant? How does one group manage to have their definition of deviance legitimated? How do deviance designations change as political and economic conditions change?”(Peter Conrad and Joseph W. Schneider, 1980) The phenomenological underpinning of this framework derives from Peter Berger and Thomas Luckmann’s three-stage model of reality construction: externalization (people construct a cultural product, e.g., the idea that strange behaviors are caused by mental illness), objectivation (that product takes on objective reality independent of its creators), and internalization (people learn these “objective facts” through socialization and take them for granted).(Peter Conrad and Joseph W. Schneider, 1980) This model explains how medical categories that began as contested political designations become self-evident facts of social life.

Conrad and Schneider identify five defining properties of deviance: it is universal but lacks universal forms; it is a social definition, not a property inherent in behavior; it is created through collective rule-making; it is contextual; and defining it always involves power.(Peter Conrad and Joseph W. Schneider, 1980) The Salem witch trials of 1692 serve as their paradigm case of deviance production — a physician who examined afflicted girls found no medical problems, but a colleague announced “the evil hand is on them,” illustrating how behavioral definition can be externalized to supernatural authority, enforced through unfalsifiable evidence, and backed by community power structures.(Peter Conrad and Joseph W. Schneider, 1980)

The ancient history of madness illustrates the same social-constructionist principle in a different institutional setting. In Hebrew scripture, madness was attributed to divine retribution for sin, yet prophets who behaved in equally strange and bizarre ways were not classified as mad but as divinely inspired — demonstrating that identical behaviors receive radically different social labels depending on context and perceived social function.(Peter Conrad and Joseph W. Schneider, 1980) Greek medicine, by contrast, produced the first naturalistic theory of madness, attributing it to imbalances of the four humors — blood, phlegm, black bile, yellow bile. Conrad and Schneider note that the terms Hippocrates coined to depict madness (epilepsy, mania, melancholia, paranoia) remain common today, marking the persistence of categories invented as part of a particular theoretical framework.(Peter Conrad and Joseph W. Schneider, 1980)

Institutional authority over deviance is not fixed but contested. The particular deviance designation — sin, crime, or sickness — determines which institution holds legitimate social control authority: if drug addiction and alcoholism are diseases, the medical profession is the legitimate agent of control; if they are crimes, jurisdiction falls to criminal justice.(Peter Conrad and Joseph W. Schneider, 1980) Medicalization of deviance is formally defined as “the defining and labeling of deviant behavior as a medical problem, usually an illness, and mandating the medical profession to provide some type of treatment for it,” with concomitant use of medicine as an agent of social control seeking to limit, modify, regulate, isolate, or eliminate deviant behavior “with medical means and in the name of health.”(Peter Conrad and Joseph W. Schneider, 1980) Parsons’ analysis of the sick role provides the structural mechanism: its four components (exemption from normal responsibilities, non-responsibility for one’s condition, obligation to want to recover, and obligation to seek medical care) constitute the institutional form through which medicine exercises social control over those it designates as ill.(Peter Conrad and Joseph W. Schneider, 1980) Social control itself is understood as the power to have a particular set of definitions of the world realized in both spirit and practice, a power that during the Middle Ages was vested in the Church, shifted to the state with secularization, and has increasingly passed to medicine.(Peter Conrad and Joseph W. Schneider, 1980)

The ascent of medicine to this authority was not inevitable. The American medical profession consolidated dominance through a combination of professionalization, elimination of sectarian competition, and the achievement of a legally supported monopoly: the Flexner Report of 1910, funded by the Carnegie Foundation, effectively made all non-scientific types of medicine illegal and created near-total AMA monopoly of medical education.(Peter Conrad and Joseph W. Schneider, 1980) The AMA-led criminalization of abortion between 1866 and 1877 exemplifies “medical crusading” in service of professional self-interest rather than patient welfare — regular physicians used antiabortion legislation to eliminate competition from irregular practitioners who performed abortions and had lucrative practices.(Peter Conrad and Joseph W. Schneider, 1980) A further structural driver of medicalization has been third-party payment systems: since insurance programs cover only “sickness,” more human problems become defined as medical conditions so that their costs qualify for coverage, creating institutional incentives for expanding diagnostic scope.(Peter Conrad and Joseph W. Schneider, 1980)

The medical model itself rests on a specific epistemological assumption: the “doctrine of specific etiology,” according to which each disease is caused by a specific agent, and medicine accordingly focuses entirely on the internal environment of the body while largely ignoring the external social environment.(Peter Conrad and Joseph W. Schneider, 1980) The model is claimed to be morally neutral — medical designations are presented as rational, scientifically verifiable conditions rather than moral judgments — but this neutrality is illusory: “the adoption of a medical model of behavior” is itself “a political decision.”(Peter Conrad and Joseph W. Schneider, 1980) Thomas Szasz argued that the 19th-century shift from religious to scientific-psychiatric frameworks represented a radical shift away from viewing humans as responsible agents acting in the world and toward viewing them as responsive organisms being acted upon by biological and social forces.(Peter Conrad and Joseph W. Schneider, 1980)

Kleinman: Medicalization as Social Control and the Psychiatric Case

In Rethinking Psychiatry (1988), Arthur Kleinman developed a distinct angle on medicalization: psychiatry, he argued, is the medical specialty most deeply implicated in the conversion of social and moral problems into medical ones, precisely because its subject matter — aberrant behavior, distressing experience, disrupted social functioning — sits at the boundary where medicine, law, and religion have always competed for authority. Medicalization is an alternative form of social control, inasmuch as medical institutions come to replace legal, religious, and other community institutions as the arbiters of behavior (Arthur Kleinman, 1988). This is not always harmful — in certain societies, medicalization can authorize useful social change that is otherwise politically unacceptable — but it can also trivialize social problems, convert realistic assessments of oppressive social conditions into psychiatric diagnoses, and be weaponized by states.

Kleinman’s most pointed illustration of weaponized medicalization was the Soviet use of psychiatric diagnosis to label political dissidents as mentally ill and detain them in prison hospitals (Arthur Kleinman, 1988). The antebellum American case is equally stark: in 1854, Louisiana physician Samuel Cartwright identified “drapetomania” in enslaved Africans, the “disease” of running away from bondage, and prescribed whipping as treatment.(James Aho, Kevin Aho, 2009) A case closer to the routine was dysthymic disorder applied globally: in much of the world, what DSM would classify as a psychiatric disorder may represent a realistic response to chronic deprivation, where feelings of hopelessness and helplessness accurately map a person’s actual position in an oppressive social system (Arthur Kleinman, 1988). Labeling such responses as psychiatric illness is itself a form of social control, deflecting attention from structural causes and locating the problem in individuals rather than in conditions.

Medicalization as social control is not, however, a one-way process. Sickness can also function as a form of passive-aggressive resistance against the standards of bodily normality, a “protolanguage” by which the body somatizes social dissent.(James Aho, Kevin Aho, 2009) The sick role is both an instrument of control (removing persons from social life, placing them under medical authority) and a space in which social suffering can be expressed when other channels are foreclosed.

The extreme historical case was the Nazi program. Kleinman, drawing on Robert Lifton’s documentation, argued that the entire Nazi apparatus of murder in the death camps was organized under the legitimation of biomedicine and with the active participation of physicians: psychiatric hospitals became the first killing stations, and the medical killing of disabled psychiatric patients became the prototype for the Holocaust (Arthur Kleinman, 1988). What distinguished Nazi psychiatrists was not irrationality but the opposite — they acted conscientiously within what they understood as the paradigm of appropriate professional and scientific work (Arthur Kleinman, 1988). Medicalization, on this account, does not only produce social control through the quotidian expansion of diagnostic categories; it provides the legitimating apparatus for the most extreme forms of institutionalized violence.

Kleinman also developed a more anthropological account of medicalization as a historical transformation in the idioms through which distress is communicated. In traditional societies, religious and moral idioms of distress — somatic complaints, spiritual language, moral frameworks — communicated what was wrong and shaped the social form of distress. What is now labeled depression was earlier labeled as medical disorder (humoral imbalance), religious problem (guilt or sinfulness), moral weakness (acedia), or fate — illustrating the historical contingency of contemporary psychiatric categories. (Arthur Kleinman, 1988) Modernization has progressively weakened these idioms and replaced them with psychological ones: an intrapsychic language of stress, existential angst, and self-defeating introspection (Arthur Kleinman, 1988). There is no scientific evidence that this shift represents cognitive progress or a healthier way of dealing with misery. What it represents, Kleinman suggests, is the medicalization of the way people narrate their own suffering: the substitution of one idiom, anchored in body, spirit, and community, with another, anchored in the individual psyche and professional diagnosis.

From this perspective, the neuroses themselves — depression, panic disorder, anorexia nervosa — represent medicalized versions of socially caused psychophysiological syndromes of human misery (Arthur Kleinman, 1988). Cross-cultural research supports this interpretation: Southeast Asian refugees in Canada respond to acculturation stress with packages of diffuse symptoms that clinical researchers and patient vulnerabilities then elaborate into discrete disorder categories. The categories are not discovered but partly manufactured by the diagnostic framework itself. Of all medical specialties, psychiatry has the most pervasive relationship to culture: its diagnostic criteria are infiltrated with cultural norms and biases, and which behaviors are called disease, sin, or crime depends on which societal values prevail at the time (Arthur Kleinman, 1988).

Key Debates

Counterproductivity

Counterproductivity is distinct from declining marginal utility and negative externalities; it is a built-in social frustration where institutions paradoxically undermine the very purpose for which they were created.(Illich, 1975) Effective health care depends on the synergy between autonomous self-care and heteronomous medical services; beyond a threshold, industrial medical expansion first restricts, then cripples, then paralyzes autonomous response.(Illich, 1975)

The five common political remedies for overmedicalization — consumer protection, equal access, professional reform, pluralism of medical sects, and environmental engineering — all tend to deepen medicalization rather than reduce iatrogenesis.(Illich, 1975)

Illich’s Self-Revision

Illich’s original definition of health as the intensity of autonomous coping ability inadvertently prepared the ground for a system-analytic worldview that reduces persons to self-regulatory systems.(Illich, 1975) The term immune system did not appear in biological textbook indexes before 1972; within a decade it became ubiquitous and was adopted as a metaphor for markets, cultural units, and families.(Illich, 1975) Bioethics reduces each person to a life and is thereby helpless to prevent the total management of the person now transformed into a system.(Illich, 1975)

The Medicalization of Melancholia: From Diagnosis to Pharmacology

The history of melancholia’s transformation into “depression” offers one of the most detailed case studies in medicalization: a condition with continuous history stretching back to the Hippocratic Corpus was redefined, reclassified, and ultimately reconstituted as a pharmacological target over the course of the twentieth century.

The psychopharmacological revolution of the 1950s and 1960s produced the first generation of drugs demonstrably effective for depressive states — iproniazid, imipramine, and their successors — and with them came a theoretical account of why they worked: the catecholamine hypothesis, which proposed that depression resulted from deficiency of catecholamine neurotransmitters (norepinephrine, and eventually serotonin) at synaptic junctions (Radden, Jennifer (ed.), 2000). As Radden’s contributors analyze, this hypothesis created a pharmacological bridge between the drug’s mechanism and the disorder’s definition: depression became, in the research literature, the condition that catecholamine-active drugs treat (Radden, Jennifer (ed.), 2000).

The definitional drift this produced was substantial. Once the catecholamine hypothesis was established, symptoms responsive to antidepressant treatment acquired diagnostic priority — creating what Radden’s anthology calls a pharmacologically driven redefinition of the disorder’s boundaries (Radden, Jennifer (ed.), 2000). The publication of DSM-III in 1980 codified a version of this drift: it introduced the category of “major depressive episode” defined primarily by vegetative signs (sleep disturbance, appetite change, psychomotor agitation or retardation, loss of energy) and minimized the older affect-based criteria (fear, sadness without cause) that had defined melancholia from the Hippocratic tradition through the nineteenth century (Radden, Jennifer (ed.), 2000). As Radden documents, this was not a discovery of a new natural kind but a reclassification driven partly by the theoretical implications of pharmacological treatment and partly by the institutional pressures of psychiatric nosology (Radden, Jennifer (ed.), 2000).

The result is a textbook case of the pattern Illich described: an institution built around a new technology (antidepressant drugs) reshaped its diagnostic categories to match the technology’s scope, expanding the definition of treatable depression to encompass presentations that the previous tradition had classified differently, and in the process constituting new populations of patients.

Case Studies in Medicalization

Alcoholism: The Politics of the Disease Concept

The transformation of chronic drunkenness into “alcoholism” (a disease) is Conrad and Schneider’s fullest case study in the political construction of a medical category. The scientific evidence for the disease concept of alcoholism was consistently thin: acceptance of the concept “turns not on its validity but rather its viability.”(Peter Conrad and Joseph W. Schneider, 1980) The Yale Center of Alcohol Studies, founded in the 1930s, deliberately introduced the slogan “alcoholism is a disease” at summer school sessions not as a scientific claim but as a deliberate political strategy to “de-moralize” local and state government policy and popular thinking about people with drinking problems.(Peter Conrad and Joseph W. Schneider, 1980) The appeal of this reframing was not primarily scientific: courts and jails would be relieved of a growing burden of cases, and officials would be freed from the “morally objectionable position of righteous indignation and condemnation” typical of pre-Prohibition reactions to drunkenness — the moral crusader becomes a humanitarian guardian.(Peter Conrad and Joseph W. Schneider, 1980)

Alcoholics Anonymous, founded in 1935, was built on a medical foundation supplied by psychiatrist Dr. W. D. Silkworth, who advised Bill W.: “Give them the medical business, and give it to them hard. Pour it right into them about the obsession that condemns them to drink and the physical sensitivity or allergy of the body that condemns them to go mad or die if they keep on drinking.” Although medical opinion on this claim was skeptical at the time and subsequent research has failed to support it, the idea that chronic drunkenness marked physiological sensitivity rather than moral degeneration was appealing to both drinkers and those who cared for them.(Peter Conrad and Joseph W. Schneider, 1980) AA’s labeling function was therapeutic in a different sense: transforming the stigmatized identity of “drunk” into the more socially acceptable identities of “sick,” “repentant,” “recovered,” and “controlled.”(Peter Conrad and Joseph W. Schneider, 1980) Jellinek’s 1952 phase-progression model of addiction, built on AA questionnaire data, illustrates the epistemological trap: his discovery of progressive phases of alcohol addiction was in part a product of adopting a disease-addiction perspective at the outset, making the finding “an almost inevitable consequence of the disease-addiction perspective he adopted at the outset.”(Peter Conrad and Joseph W. Schneider, 1980) His central concept of “loss of control” rests on a circular argument — the drinker is assumed to have lost control because they did not reduce drinking they would be expected to reduce.(Peter Conrad and Joseph W. Schneider, 1980)

Social scientists Alfred Lindesmith, Howard Becker, and Jock Young demonstrated that the physical dependence model of addiction is both oversimplified and misleading: addiction is not the automatic consequence of a drug’s pharmacological properties but a complex process in which the individual learns to use the drug under particular circumstances and to interpret withdrawal symptoms as drug-related through culturally supplied frameworks.(Peter Conrad and Joseph W. Schneider, 1980) The medical profession’s formal endorsement of alcoholism as a disease has often been symbolic and reluctant, driven more by external legal and political pressures than by genuine clinical conviction. The National Council on Alcoholism’s 1972 publication of “Criteria for the Diagnosis of Alcoholism” in the American Journal of Psychiatry — created by a blue-ribbon committee — promulgated medical guidelines premised on the disease definition and encouraged physicians to adopt it, but this institutional initiative was as much a political strategy as a scientific contribution.(Peter Conrad and Joseph W. Schneider, 1980)

Medicalization created an entire industry of professional “alcohologists” — treatment centers, researchers, and counselors — with institutional interests in perpetuating and expanding the disease definition regardless of scientific evidence.(Peter Conrad and Joseph W. Schneider, 1980)

Opiate Addiction: Between Medical and Criminal Frames

The history of opiate addiction in America offers the clearest example of a deviance designation oscillating between medical and criminal frameworks for purely political reasons. In the 19th century, opiate addiction was predominantly viewed medically: addicts were “poor victims” of a disease to be treated, not scorned, partly because the addicted population was largely middle-class and white and addiction was associated with physician-prescribed medication.(Peter Conrad and Joseph W. Schneider, 1980) Anti-Chinese racism drove the first prohibitions: the 1875 San Francisco ordinance banning opium dens was not a health measure but a racial measure targeting Chinese immigrant laborers.(Peter Conrad and Joseph W. Schneider, 1980)

In 1898, the German Bayer Laboratory introduced a new morphine derivative marketed as a “non-addicting substitute” for morphine or codeine and named “heroin” for its “heroic” properties. Within five years of market introduction it was abundantly clear that heroin was at least as addictive as morphine. Unlike morphine and codeine, it then had no medical definitions — it was a drug that had only “recreational” uses — and thus became “quickly imbued with far greater negative connotations than either of its sister drugs,” illustrating how the presence or absence of medical legitimacy directly shapes moral status.(Peter Conrad and Joseph W. Schneider, 1980)

The Harrison Act of 1914, originally a tax-and-registration law that preserved physician control over opiates, was transformed through Treasury Department interpretations and a series of Supreme Court decisions (1915–1922) into a de facto prohibition law that criminalized addiction — demonstrating how administrative and judicial action can override legislative intent to produce a new deviance designation.(Peter Conrad and Joseph W. Schneider, 1980) Between 1919 and 1923, approximately 44 narcotics clinics providing medical maintenance to addicts were opened, then systematically closed after the Treasury Department distorted evidence of their operation to discredit the medical approach; the AMA subsequently endorsed only institutionalization, effectively surrendering medical jurisdiction over addiction to law enforcement.(Peter Conrad and Joseph W. Schneider, 1980) Criminalization became a self-fulfilling prophecy: it created an addict subculture, inflated drug prices through illegal-market scarcity, forced addicts into property crime to finance habits, and changed the addict population from predominantly middle-class white women to young lower-class black men — which intensified moral condemnation.(Peter Conrad and Joseph W. Schneider, 1980)

Alfred Lindesmith’s 1947 sociological theory of addiction provided the central counter-model to the pharmacological account: “Addiction occurs only when opiates are used to alleviate withdrawal distress, after such distress has been properly understood or interpreted… If the individual fails to conceive of his distress as withdrawal distress brought about by the absence of opiates, he does not become addicted.” This centering of cognitive interpretation rather than drug pharmacology as the mechanism of addiction offered a direct challenge to the disease model and its assumption that the drug’s chemistry was determinative.(Peter Conrad and Joseph W. Schneider, 1980)

Re-medicalization required coordinated institutional action across three domains: the 1955 New York Academy of Medicine report, the 1958 ABA-AMA Joint Committee interim report, and the 1962 Supreme Court decision in Robinson v. California collectively re-legitimated the medical definition of addiction after three decades of criminal dominance.(Peter Conrad and Joseph W. Schneider, 1980) Methadone maintenance was adopted as national drug policy under Nixon not primarily for therapeutic reasons but political ones: it was cheap ($2,000 per addict per year versus $8,000 for prison) and promised to reduce crime statistics before the 1972 election.(Peter Conrad and Joseph W. Schneider, 1980) Its rapid decline after 1974 was equally political — driven by failure to reduce crime statistics, post-election disengagement, and law-enforcement agency reports of diversion — revealing that the same political logic that creates medicalization can also reverse it.(Peter Conrad and Joseph W. Schneider, 1980)

Homosexuality: From Krafft-Ebing to the APA Vote

The medicalization of homosexuality was accomplished through a paradox: scientific rationalism, which appeared to promise tolerance, became the vehicle for a new form of moral regulation by translating religious prohibitions into medical pathologies, with the underlying moral principles remaining essentially unchanged.(Peter Conrad and Joseph W. Schneider, 1980) The early medical grounding for pathologizing deviant sexuality came from 18th-century theories of health as nervous system equilibrium: the body was conceived as a closed system of vital nervous energy, and activities that made “repeated, unusual, and ‘unhealthy’ (immoral) demands on one’s body would lead inevitably to its depletion, debility, wasting, and disease. Thus immorality, as evidenced by social behavior, was believed causal of sickness and disease.”(Peter Conrad and Joseph W. Schneider, 1980)

The rallying point for this medicalization of variant sexual activity in the 18th and particularly 19th centuries was masturbation. The terms “onanism” and “the secret sin” were used to include a variety of deviant sexual practices, including same-sex conduct. The chronic masturbator depicted in the writings of moral crusaders represented the antithesis of traditional male sex-role characteristics, directly prefiguring the subsequent psychiatric stereotype of the homosexual — making the anti-masturbation crusade a covert medicalization of homosexuality more broadly.(Peter Conrad and Joseph W. Schneider, 1980)

Criminalization and medicalization were concurrent rather than competing processes in the late 19th century: as same-sex conduct was attributed to biological-genetic roots, blame was lifted from actors’ wills and relocated in their biology, making medical intervention a “particularly viable intellectual and philosophical alternative” to punitive prosecution.(Peter Conrad and Joseph W. Schneider, 1980)

The term “homosexuality” was invented in 1869 by Hungarian physician K. M. Benkert (pseudonym Kertbeny) as a political argument against legal repression, claiming the condition was congenital rather than chosen — the first medical category for same-sex conduct was thus created as a defensive political intervention, not a clinical discovery.(Peter Conrad and Joseph W. Schneider, 1980) Richard von Krafft-Ebing’s Psychopathia Sexualis (1886) was the pivotal work establishing homosexuality as a physiologically based psychiatric pathology: by accumulating more than 200 case histories under diagnostic labels, Krafft-Ebing gave same-sex conduct the status of a medical “entity” — “a ‘thing’ people can ‘have’” — rather than a moral transgression.(Peter Conrad and Joseph W. Schneider, 1980) Freud’s contribution was paradoxical: he rejected congenital theories, normalized homoerotic desire as part of universal psychosexual development, and explicitly stated homosexuality “is assuredly no advantage but it is nothing to be ashamed of, no vice, no degradation, it cannot be classified as an illness”(Peter Conrad and Joseph W. Schneider, 1980) — and further expressed pessimism about psychiatric cure, proposing that psychoanalysis should instead aim for “harmony, peace of mind, full efficiency, whether he remains a homosexual or gets changed.”(Peter Conrad and Joseph W. Schneider, 1980) Yet his psychoanalytic framework considerably strengthened medical dominance over the definition and treatment of homosexuality.(Peter Conrad and Joseph W. Schneider, 1980) Post-Freudian psychiatrists (Bergler, Bieber, Socarides) sacrificed this non-pathologizing view and established a consensus that homosexuality was a serious psychopathology amenable to cure via heterosexuality.(Peter Conrad and Joseph W. Schneider, 1980) Edmund Bergler’s characterization of homosexuals as “injustice collectors” and “psychic masochists” who are “essentially disagreeable people… a mixture of superciliousness, fake aggression, and whimpering” represents the extreme case of medical rhetoric thinly veiling traditional moral hostility.(Peter Conrad and Joseph W. Schneider, 1980) Irving Bieber’s 1962 psychoanalytic study concluded homosexuality was a “pathological deviation from the biologic norm” rooted in pathological mother-son bonding and detached fathers, claiming that “a constructive, supportive, warmly related father precludes the possibility of a homosexual son”; he reported 37% of analytic patients converted to exclusive heterosexuality.(Peter Conrad and Joseph W. Schneider, 1980) Charles Socarides pushed the jurisdictional claim to its furthest point: “Only in the consultation room does the homosexual reveal himself and his world. No other data, statistics, or statements can be accepted as setting forth the true nature of homosexuality” — asserting exclusive medical authority and opposing decriminalization without simultaneous medicalization.(Peter Conrad and Joseph W. Schneider, 1980)

Magnus Hirschfeld, by contrast, founded what may have been the first homosexual civil rights organization in 1897 — the Scientific Humanitarian Committee, whose motto was “Justice through Science” — and conducted the first nonclinical study of sexual attitudes and practices, sending questionnaires to over 10,000 men and women to build a picture of homosexuality not filtered through police files or psychiatrists’ offices.(Peter Conrad and Joseph W. Schneider, 1980) Havelock Ellis similarly chose subjects who were “generally healthy, happy, successful, intelligent, and sensitive human beings rather than the tortured and neurotic figures that emerged from Krafft-Ebing’s work,” explicitly pointing out that the positive picture in his cases was “probably due to the fact that none of them had come from police files or psychiatrists’ offices” — a methodological critique of clinical sampling that anticipated later epidemiological objections to psychiatry’s evidence base.(Peter Conrad and Joseph W. Schneider, 1980)

DSM-I (1952) classified homosexuality under “Sociopathic Personality Disturbance”; DSM-II (1968) gave it its own designation (302.0) under “Sexual Deviation,” making it official medical pathology backed by the APA.(Peter Conrad and Joseph W. Schneider, 1980) Kinsey’s 1948 research found 37% of adult white males had some homosexual experience and argued that the medical categories “normal,” “abnormal,” and “pathological” were inappropriate for describing sexual behavior.(Peter Conrad and Joseph W. Schneider, 1980) He concluded that homosexuality as an identity or disease entity did not exist — only homosexual acts — making it a medical artifact rather than a congenital or psychic condition.(Peter Conrad and Joseph W. Schneider, 1980) Evelyn Hooker’s 1956 study used psychological tests and found that a panel of psychiatrists could not distinguish homosexuals from heterosexual controls on emotional health, directly challenging the pathology definition.(Peter Conrad and Joseph W. Schneider, 1980)

The Stonewall rebellion of June 1969 catalyzed a militant phase of gay liberation politics that directly targeted the APA’s disease designation.(Peter Conrad and Joseph W. Schneider, 1980) Judd Marmor had argued in 1965 that the “pathology” of homosexuality came down to its contradiction of a culturally preferred pattern, and that diagnosing it as a treatable illness “puts psychiatry clearly in the role of an agent of cultural control rather than of a branch of the healing arts.”(Peter Conrad and Joseph W. Schneider, 1980) Gay activists disrupted the 1970 APA meeting in San Francisco, targeting aversion therapy and confronting Bieber directly: “You are the pigs who make it possible for the cops to beat homosexuals: they call us queer; you — so politely — call us sick. But it’s the same thing. You make possible the beatings and rapes in prisons, you are implicated in the torturous cures perpetrated on desperate homosexuals.” This shift from polite petition to direct confrontation in psychiatry’s own conference rooms changed the political terrain.(Peter Conrad and Joseph W. Schneider, 1980)

The challenge was mounted in the scientific language of psychiatry itself: the evidence for psychiatric disease theories was consistently sketchy, and treatment cure rates never approached 50%.(Peter Conrad and Joseph W. Schneider, 1980) At the 1973 APA panel on homosexuality in the nomenclature, psychologist Charles Silverstein catalogued the methodological flaws in past medical research and concluded in language designed to appeal to the scientific profession on its own terms: “It is no sin to have made an error in the past, but surely you will mock the principles of scientific research upon which the diagnostic system is based if you turn your backs on the only objective evidence we have.”(Peter Conrad and Joseph W. Schneider, 1980) Robert Spitzer proposed a middle course: defining homosexuality as “an irregular form of sexual behavior” that should not constitute a psychiatric diagnosis, while coining “sexual orientation disturbance” for those who were troubled by their homosexual feelings — a formulation intended to avoid endorsing both full pathology and full normalization, and to neutralize the charge that psychiatrists were “acting as agents of social control.”(Peter Conrad and Joseph W. Schneider, 1980)

In December 1973 the APA Board of Trustees voted to remove homosexuality per se from DSM-II, replacing it with “Sexual Orientation Disturbance”; 58% of the voting membership subsequently endorsed the change in referendum.(Peter Conrad and Joseph W. Schneider, 1980) Thomas Szasz argued the decision represented co-optation rather than a genuine civil liberties victory: psychiatrists had merely redrawn the boundaries of medical jurisdiction rather than surrendering it.(Peter Conrad and Joseph W. Schneider, 1980) The limits of diagnostic change were visible in subsequent survey data: a 1977 survey of 2,500 psychiatrists found 69% still considered homosexuality a “pathological adaptation” despite the APA decision.(Peter Conrad and Joseph W. Schneider, 1980) Public attitudes changed even less: in none of four national surveys conducted between 1973 and 1977 did the percentage saying homosexual relations are “always wrong” drop below 75%.(Peter Conrad and Joseph W. Schneider, 1980)

Conrad and Schneider note an unexpected consequence: demedicalization without moral vindication left gay people more vulnerable to political attack, because the sick role had provided official protection against moral crusaders and state persecution.(Peter Conrad and Joseph W. Schneider, 1980) The full arc of homosexuality’s career across institutional frameworks — “First, such behavior was sinful, then criminal, and then for about the last 100 years, a sickness. Only recently has this latter designation been challenged by a movement striving for yet another definition, that of ‘life-style’ or personal choice”(Peter Conrad and Joseph W. Schneider, 1980) — exemplifies the book’s central argument that deviance designations are political products rather than natural kinds.

Medical Social Control of Crime

The medicalization of criminality followed the same logic: during the last century, the biomedical understanding of crime shifted the offender from “someone who has done bad” to “someone who is bad or defective,” eliminating moral guilt and requiring treatment rather than punishment — while paradoxically expanding state control.(Peter Conrad and Joseph W. Schneider, 1980) Nicholas Kittrie identified the rise of the “therapeutic state” in which crime became a problem to be solved by “allegedly neutral technology of medical practice,” making the “major point of confrontation between the parens patriae power of the state and the rights of individuals” less visible.(Peter Conrad and Joseph W. Schneider, 1980) The danger of “therapeutic tyranny,” Conrad and Schneider argue, lies in replacing the diversity of political, social, moral, and religious values with a monolithic health standard, as demonstrated historically by involuntary sterilizations, lobotomies, and Nazi Germany’s use of therapeutic language for political persecution.(Peter Conrad and Joseph W. Schneider, 1980)

Cesare Lombroso’s 1876 work provided the founding document for biological criminology, theorizing that criminals were “atavistic beings” identifiable by physical stigmata: asymmetrical faces, unusual ear size, cranial asymmetry. Because these stigmata resembled the characteristics of “primitive people,” Lombroso held that the criminal was a biological throwback unable to avoid criminality in a modern world.(Peter Conrad and Joseph W. Schneider, 1980) Lindesmith and Levin argued in 1937 that such theories served a conservative political function: “It may be that the theory of the born criminal offers a convenient rationalization of the failure of preventive effort and an escape from the implications of the dangerous doctrine that crime is an essential product of our social organization.”(Peter Conrad and Joseph W. Schneider, 1980)

The biological program found modern expression in multiple directions. The XYY chromosome theory, brought to prominence by Patricia Jacobs’s 1965 study of 197 mentally abnormal prison inmates in Scotland (finding 3.5% XYY against 0.13% in the general population), proposed that an extra Y chromosome created a “double male” doubly aggressive by constitution — though subsequent research failed to support the original claims.(Peter Conrad and Joseph W. Schneider, 1980) Mark and Ervin’s 1967 letter to JAMA concerning urban riots proposed that “subtle” causes of riot behavior included brain dysfunctions in individual rioters, calling for “early warning tests” to screen the “violence-prone” from the normal population — a direct application of the therapeutic model to political unrest.(Peter Conrad and Joseph W. Schneider, 1980)

The behavioral tradition entered criminology through a different route. John B. Watson founded behaviorism in 1913, arguing that human behavior occurs in response to environmental stimuli conditioned over time; his “Little Albert” experiment demonstrated fear conditioning and laid the foundation for aversive behavior modification techniques applied in criminal control settings.(Peter Conrad and Joseph W. Schneider, 1980) The most notorious form of aversive conditioning used drugs: succinylcholine chloride (Anectine), which within 30 to 40 seconds produces “a sensation that has been compared with death, drowning, and suffocation,” was used at Atascadero State Hospital in California on black militants as well as other inmate-patients whose behavior was found to be “uncooperative” or “disruptive,” often without genuine consent.(Peter Conrad and Joseph W. Schneider, 1980) The CIA conducted a 25-year covert mind control program (MKULTRA/MKDELTA) involving 185 scientists at 80 institutions, using LSD, electric shock, radiation, and psychosurgery on unwitting subjects — demonstrating the political weaponization of biomedical research at its most extreme.(Peter Conrad and Joseph W. Schneider, 1980)

A Clockwork Orange’s chaplain poses the ethical paradox running through all of this: “What does God want? Does God want goodness or the choice of goodness? Is a man who chooses the bad perhaps in some way better than a man who has the good imposed upon him?”(Peter Conrad and Joseph W. Schneider, 1980) His further observation — that in choosing to be deprived of the ability to make an ethical choice, Alex “has in a sense really chosen the good” — captures the logical contradiction inherent in coercive therapeutic intervention: the technique that produces conformity destroys the moral agency that gives conformity its value.(Peter Conrad and Joseph W. Schneider, 1980) Conrad and Schneider press the comparison explicitly: Bentham’s Panopticon Prison and Mark and Ervin’s proposed prison hospital “is no more nor less humane” than one another — “the question is which approach is more effective in controlling crime. According to the New Pragmatists, this is the only question.”(Peter Conrad and Joseph W. Schneider, 1980)

Conrad-Schneider: Consequences of Medicalization

In their concluding theoretical chapter, Conrad and Schneider identify three major types of medical social control and seven specific negative consequences of medicalizing deviance.

Medical social control is defined as the ways medicine functions, “wittingly or unwittingly, to secure adherence to social norms — specifically, by using medical means to minimize, eliminate, or normalize deviant behavior.”(Peter Conrad and Joseph W. Schneider, 1980) It operates through three ideal types: medical technology (psychotropic drugs, psychosurgery, behavior modification), medical collaboration (gatekeeping, information provision, institutional roles in prisons and hospitals), and medical ideology (disease designations that support dominant social interests).(Peter Conrad and Joseph W. Schneider, 1980) Medical ideology is the most covert form: defining a behavior or condition as illness “primarily because of the social and ideological benefits accrued by conceptualizing it in medical terms,” as illustrated by 19th-century New Orleans physician S. W. Cartwright’s “drapetomania” — a condition affecting only slaves, whose major symptom was running away from their masters.(Peter Conrad and Joseph W. Schneider, 1980) In contemporary practice, the most widespread form is pharmaceutical: since the emergence of phenothiazine medications in the early 1950s there has been “a virtual explosion in the development and use of psychoactive medications to control behavioral deviance” — tranquilizers, stimulants for hyperactive children, amphetamines for obesity, disulfiram for alcoholism, methadone for heroin — aggressively promoted by a profitable drug industry that often makes pharmaceutical intervention the treatment of choice because it is cheaper than hospitalization or long-term psychotherapy.(Peter Conrad and Joseph W. Schneider, 1980) Medicine, especially psychiatry, has in this way “replaced religion as the most powerful extralegal institution of social control in modern society,” with physicians endowed with some of the charisma of shamans.(Peter Conrad and Joseph W. Schneider, 1980)

Conrad and Schneider do not dismiss the benefits of medicalization: humanitarian and nonpunitive sanctions, reduction of individual blame, an optimistic therapeutic ideology, and access to the prestige of the medical profession are genuine goods.(Peter Conrad and Joseph W. Schneider, 1980) The seven negative consequences they identify are:

1. Dislocation of responsibility: Responsibility is located in “the nether world of biophysiology or psyche” rather than in social action, creating a “dual-class citizenship” — the fully responsible nonsick and the not-completely-responsible sick placed in a position of dependence.(Peter Conrad and Joseph W. Schneider, 1980)

2. Assumption of moral neutrality: Medical language is assumed to be morally neutral but actually carries moral judgments — “to call something a disease is to deem it undesirable” — obscuring the political and moral nature of disease designations behind technological-scientific vocabulary.(Peter Conrad and Joseph W. Schneider, 1980)

3. Domination of expert control: When a problem is defined as medical, it is removed from public discussion and placed on a plane where only medical professionals can legitimately speak, increasing mystification and decreasing democratic accessibility.(Peter Conrad and Joseph W. Schneider, 1980)

4. Medical social control itself: The sick role’s conditional legitimation of deviance is purchased at the price of accepting the inherent undesirability of one’s condition and submitting to a subordinate relationship with an official agent of control (the physician) toward changing it.(Peter Conrad and Joseph W. Schneider, 1980)

5. Individualization of social problems: The medical perspective focuses on the individual’s disorder rather than social conditions, functioning as “blaming the victim” and making medicine a de facto agent of dominant social and political interests.(Peter Conrad and Joseph W. Schneider, 1980)

6. Depoliticization: By defining the overactive schoolchild as hyperkinetic, we ignore the meaning of the behavior in its social context; similarly, Soviet labeling of political dissidents as mentally ill neutralized political protest by reclassifying it as symptom.(Peter Conrad and Joseph W. Schneider, 1980)

7. Exclusion of evil: Sickness provides a vocabulary of motive that obliterates evil intent, rendering evil consequences to “accident status” — pathologizing Hitler’s genocide, for example, prevents recognition of man’s inhumanity to man and the structural conditions that made genocide possible.(Peter Conrad and Joseph W. Schneider, 1980) Conrad and Schneider connect this to Susan Sontag’s observation that in a secular culture where religious connotations of sin and evil have been obscured, cancer (and illness in general) has become “one of the few available images of unmitigated evil and wickedness” — revealing how, in losing a religious vocabulary for evil, modern culture transferred evil’s weight onto the category of disease.(Peter Conrad and Joseph W. Schneider, 1980)

The “medical decision rule” — when in doubt, treat — is nearly the converse of the legal principle “innocent until proven guilty,” and may unnecessarily enlarge the population of deviants while bypassing constitutional safeguards that protect individual rights.(Peter Conrad and Joseph W. Schneider, 1980) Medicalization has emerged not from a formalized social policy but from “various combinations of turf battles, court decisions, scientific innovations, political expediences, medical entrepreneurship, and other influences,” making it “in effect a de facto social policy” — one that operates without the accountability structures attending formal legislation.(Peter Conrad and Joseph W. Schneider, 1980)

The Medicalization of Childhood, Women, and Political Subjects

The Child Study Movement of the late nineteenth and early twentieth centuries promoted quantifiable scales and development charts that established notions of normality and abnormality for children; child-care manuals containing growth charts that parents could fill in made developmental surveillance part of domestic routine long before formal clinical diagnosis.(Jackson (ed.), 2011) Matthew Smith’s work on the historical origins and constructions of attention deficit hyperactivity disorder illustrates how a modern process of medicalization and problematization is being matched in historical studies of children’s conduct — connecting contemporary psychiatric categories to longer patterns of pathologizing children’s behavior.(Jackson (ed.), 2011)

The history of women’s medicine offers several parallel cases of medicalization. Helen King’s study of “green sickness” or “the disease of virgins” traced how a common disorder affecting young unmarried girls was conceived increasingly as a medical problem to be cured by diet, exercise, bloodletting, and marriage, bringing medical control to bear on a disorder previously embedded in female culture and surrounded by mystique.(Jackson (ed.), 2011) From the eighteenth century onward, beginning with the establishment of lying-in hospitals and then women’s hospitals and maternity and child welfare clinics, specialist medical provision for women became increasingly associated with institutions — a move away from the private, domestic sphere and the female attendants (midwives, neighbors) who had managed childbirth within it.(Jackson (ed.), 2011) G. J. Barker-Benfield’s 1976 study denounced the gynaecological profession for what he read as subconscious hostility toward women, emphasizing the use of mutilating surgery — notably clitoridectomy and ovariotomy — as playing out sexual aggression under clinical legitimacy.(Jackson (ed.), 2011)

Political regimes have also used medicalization as an instrument of social control beyond its domestic and pediatric applications. In the Soviet Union during the 1920s, state commissioning of physician research medicalized a series of issues that had previously been treated as questions of law and order, broadening the scope and orientation of public health to encompass social behaviors newly redefined as health problems.(Jackson (ed.), 2011)

Contemporary Relevance

The medicalization critique has gained rather than lost force since Illich wrote. The expansion of diagnostic categories (ADHD, pre-diabetes, sub-clinical depression), the pharmaceutical industry’s creation of disease markets, the quantified-self movement, and the integration of health monitoring into smartphones and wearables all represent extensions of medical authority into previously non-medical domains. Addressing global health inequities requires moving beyond purely technical biomedical solutions to incorporate cultural, economic, and ecological determinants of health.(Margaret Lock and Vinh-Kim Nguyen, 2018)

Questions for review:

• Illich is the strongest single voice; his 1995 self-revision (the preface evidence) is philosophically more radical than the original book.
• Foucault’s Birth of the Clinic provides the epistemological foundation but is not easy to excerpt.
• Lock provides the contemporary anthropological update.
• The connection to domestic medicine and botanical medicine matters here: medicalization is what those traditions resist.

See Also

• public-health — the institutional context medicalization extends
• professionalization — the social mechanism medicalization depends on
• domestic-medicine — the autonomous tradition medicalization displaces
• vital-force — the theoretical basis for trusting the organism over the institution
• paradigm — the epistemological framework for understanding medical authority

Sources

• Illich, Ivan. Limits to Medicine: Medical Nemesis — The Expropriation of Health. Marion Boyars, 1975. (source_id: illich-limitsmedicine-1975)
• Lock, Margaret, and Vinh-Kim Nguyen. An Anthropology of Biomedicine. 2nd ed. Wiley-Blackwell, 2018. (source_id: lock-anthropology-biomedicine-2018)
• Foucault, Michel. The Birth of the Clinic: An Archaeology of Medical Perception. Trans. A.M. Sheridan Smith. Tavistock, 1963. (source_id: foucault-birthclinic-1963)
• Aho, Kevin. Heidegger’s Neglect of the Body. SUNY Press, 2009. (source_id: aho-heidegger-body-2009)
• Conrad, Peter, and Joseph W. Schneider. Deviance and Medicalization: From Badness to Sickness. Mosby, 1980. (source_id: conrad-schneider-deviancemedicalization-1980)
• Jackson, Mark (ed.). The Oxford Handbook of the History of Medicine. Oxford University Press, 2011. (source_id: jackson-oxfordhandbook-2011)