DEVIANCE & MEDICALIZATION: From Badness to Sickness

1. DEVIANCE & MEDICALIZATION: From Badness to Sickness Peter Conrad & Joseph W. Schneider (Philadelphia: Temple University Press, 1992)

2. Deviance, definitions, and the medical profession

3. 1. Deviance is universal, but there are no universal forms of deviance • Acts like incest and murder come close, but even they are not universally deviant • And what counts as “murder” or “incest” varies • What is deviant for a society is relative to that society: witchcraft among the Puritans, hysteria and paranoia in American society

4. 2. Deviance is a social definition • Deviance is not "given" in any behavior, act, or status • It must be so defined intentionally by "significant" actors in the society or social group • Deviance may be seen as a label attached to an act or behavior or as a category by which certain behaviors are defined • Deviance is a socially attributed condition, and "deviant" is an ascribed status • It is not the act but the definition that makes something deviant • Deviance is a system of social categories constructed for classifying behavior, persons, situations, and things

5. 3. Social groups make rules and enforce definitions through judgment & social sanction • “Social groups create deviance by making the rules whose infraction constitutes deviance, and applying those rules to particular people and labeling them as [deviants]" (Becker, H. S. ,1963, p. 9) • Collective rule making, social judgment, and the application of sanctions (penalties) are central to all types of deviance. • What is important to remember is that "societies" do not make rules and define deviance; people acting collectively do

6. 4. Deviance is contextual • What is labeled as deviant varies by social context - especially according to such conditions as • Society • Subculture • Time • Place • Who is involved • Who is offended

7. 5. Defining and sanctioning deviance involves power • Those belonging to the more powerful groups in society, in terms of social class, age, race, ethnicity, profession, sex, etc., can enforce their categories of deviance on less powerful groups

8. Social control is control of deviance & promotion of conformity • Social control operates on both informal and formal levels and through "positive" and "negative" forms • Informal controls include self-controls and relational controls • Self-controls: internalized norms, beliefs, morals, self-concept, and "conscience" • Relational controls: ridicule, praise, gossip, smiles, disapproving glances and "dirty looks," mythmaking, group ostracism and support • Formal social controls are institutionalized forms of social control, including 'official' laws, regulations, and institutions and agents of social control • criminal justice system (police, courts, correctional facilities, etc.), education, welfare, the mass media, and medicine

9. Emergence of the medical profession – up to 1850 • Humoral theory (Hippocrates) dominated European medicine until well into 19th century -diagnosis was impressionistic, often inaccurate, based on patient reports of symptoms, physicians’ own observations of signs of illness (appearance, behavior) but rarely on manual exam of body • Medicine not scientific • In colonial America, physicians were p/t, also working as clergymen, teachers, farmers, etc • In early 19th c, medicine was low status, not an important economic activity

10. Professionalization • "the process by which producers of special services sought to constitute and control the market for their expertise" (Larson, qtd. on p. 195) -Professions organize to create and control markets • In 1847 American Medical Association (AMA) is formed  The medical profession became functionally autonomous, insulated from external evaluation and largely free to regulate their own performance

11. Crusading, deviance, medical monopoly: the case of abortion • Prior to the Civil War, abortion was a common and largely legal medical procedure in America, free of moral stigma • Pregnancy was not considered confirmed until "quickening" ("first perception of fetal movement,” p. 196) -common law did not recognize the fetus before quickening, an unquickened fetus deemed to have no living soul • After 1840 abortion comes increasingly into public view, services widely advertised in magazines and newspapers • By 1870, about 1 abortion per 5 live births

12. Physicians, not religious leaders, led anti-abortion crusade in late 1860s – But WHY? • concern about dropping birthrates, esp. among native born, "better classes" • to promote professionalization and create a monopoly over medical services -they did this by getting states to sanction their competitors ("irregular doctors," e.g., homeopaths, botanical doctors, eclectic doctors, etc.) • By 1900, abortion was not only illegal in American society, but also deviant and immoral

13. Growth of Medical Expertise and Professional Dominance • last 3 decades of 19th c saw great strides in surgical medicine and improvements in hospital care  rise of germ theory of disease  rise of “scientific” medicine

14. Doctrine of specific etiology • "each disease was caused by a specific germ or agent. Medicine focused solely on the internal environment (the body), largely ignoring the external environment (society)"….this paradigm is the essence of the "medical model"

15. Changes in Medical Practice • Doctors move from “solo practice” to large corporate practices or employment in hospitals or other bureaucratic organizations • Medicine more specialized & more dependent on technology • Medicine expanded as a portion of American economy -projected to be over 1/6th in 2009 (Kaiser, 2009)

16. "fee-for-service" • American medicine has long operated on a "fee-for-service" basis, i.e., each service is charged and paid for separately  more services, more fees, possibly encouraging unnecessary medical care • Medicine is one of the few services that can "create its own demand," since patients go to doctors to find out what procedures they medically need

17. Since the 1930s, a shift to "third party" payments, mainly from health insurance and the government  availability of federal $ without cost controls, leading to “cost crisis” • This has also driven the medicalizationof more and more human problems • “It has won the almost exclusive right to reign over the kingdom of health and sickness, no matter where it may extend.”