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BOOK TITLE: The new blackwell companion to medical sociology

USER BOOK TITLE: The new blackwell companion to medical sociology

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.
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212 joseph e. davis

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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214 joseph e. davis

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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216 joseph e. davis

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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medicalization, social control, and the relief of suffering 217

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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218 joseph e. davis

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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medicalization, social control, and the relief of suffering 219

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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220 joseph e. davis

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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medicalization, social control, and the relief of suffering 221

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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medicalization, social control, and the relief of suffering 223

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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224 joseph e. davis

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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medicalization, social control, and the relief of suffering 225

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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226 joseph e. davis

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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medicalization, social control, and the relief of suffering 227

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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228 joseph e. davis

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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medicalization, social control, and the relief of suffering 229

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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230 joseph e. davis

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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medicalization, social control, and the relief of suffering 231

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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232 joseph e. davis

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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