SOCIAL CONSTRUCTIONISM

1. SOCIAL CONSTRUCTIONISM How Illness and Disease are Constructed

2. Illness and Disease :What’s the difference? • Disease: refers to pathological changes within the body which are expressed in various physical signs and symptoms. • Illness: an individual’s subjective interpretation and response to these signs and symptoms.

3. Sociological Perspectives • Previously disease remained the concern of doctors and the experience of illness was examined by social scientists. • The boundary between the two has been challenged , what were formerly seen as “natural” categories – disease and the body - are now also studied by sociologists. • Sociologists argue that these ‘natural’ categories are the products of social activities and do not simply reflect unchangeable biological facts. • Sociology argues that all knowledge, including medical and scientific knowledge, is socially dependent i.e. that all knowledge is socially constructed.

4. The 18th Century Woman, The Prince and the Pins

5. The 18th Century Body in a Doctor‘s Diary • “[She] was standing in front of the mirror with a bunch of pins in her mouth when she was startled by a prince who approached her from behind and slapped her on the back, whereupon all the pins fell into her throat. However, she felt no pain from the pins, and on the third day she passed all of them through her urine.” Duden, B. (1991) The Woman Beneath the Skin: A Doctor’s Patients in Eighteenth Century Germany. London: Harvard University Press pg. 70

6. Understanding the 18th Century Body • Duden (1991) argues that the body we know today is fundamentally different from the body we would find in the 18th century. • The difference is not only how the working of the body is understood but also how the body was actually experienced. • Duden argues, therefore, that the body is a cultural construction and how it is understood, and more importantly, how it is experienced must be related to the historical context in which it lives.

7. The Body, Illness and Disease in 18th Century Germany • Most illnesses and treatments were related to the general idea of internal and external bodily fluidsor ‘flux’. • Fluids such as blood, milk or pus both moved around the inner body and were excretedfrom it. • Bodily fluids were all essentially the same but they could be transformed in terms of their form, colour and consistencyso milk could resemble diarrhea.

8. The Body, Illness and Disease in 18th Century Germany • Integral to physical health and well-being was the flow ofthese fluids, their obstruction would result in illness and disease. • If a woman’s menstrual blood was blocked it could cause illness but this would not be problematic if the menstrual blood was secreted in another form such as diarrhea (Duden 1991:109). • “Inner flux” was the most common complaint people presented to the doctor and it was connected to a range ofailments such as headaches, ringing in the ears, rheumatism and the loss of sight.

9. The Body, Illness and Disease in 18th Century Germany • When “inner flux” did not circulate, it became hard and began to stagnate. There were various treatmentsto ensure that “flux” could escape from the body : • “blister raising plasters” : would divert the fluid so it could be drawn out of the body and • “fontanels” : were small artificial wounds through which the fluids could drain.

10. The Body, Illness and Death in 18th Century Germany

11. The Body, Illness and Death in 18th Century Germany • “The wife of a shoemaker, forty years of age, ‘has an oozing and sometimes foul-smelling sore under the breast for many years. Having dried up in 1721, it moved to an untoward place, namely to the genitals, ad muliebra.’ The pains, especially when passing urine, were so intense that the woman tried to soothe them with cold washes. This bottled up the flux, upsetting the stomach and the guts, causing great anxiety in the stomach and the lower body. During the next years, whenever the flux, having returned to its old place, dried up, she immediately requested help, for ‘fear of dangerous ill effects’.

12. Illness and Death in 18th Century Germany • Treatment was a mustard plaster: “She placed the plaster under her breast, it dissolved the skin, and already within an hour ‘the flux could be lured out again, and the woman soon felt…relief’. • The woman died thirteen years later and the cause of death was this: “After she had fallen down the cellar stairs, the flux under the breast subsided and failed to return, whereupon all the matter got stuck in her head” (Duden 1991: 107-108).

13. THE SOCIOLOGICAL INTERPRETATION • Duden argues that: • the way in which we experience our own body now is influenced by the ideas of human anatomy and physiology which became established at the end of the 18th century. • the history of medical knowledge does not involve the gradual unfolding of the ‘truth’ about the body and disease, but that these categories are dependent on their social, cultural, and historical context. • In other words, they are socially constructed.

14. FEATURES OF THE SOCIAL CONSTRUCTIONIST DEBATE • The social constructionist debate is one of the most important in social science analyses of health and illness. • It is part of a critical approach to biomedicine and biomedical knowledge that emerged in the 1970s. • Many of the assumptions and values of the medical profession and biomedicine were challenged and criticised for being consistent with the patriarchal and capitalist structures of the society in which they were located.

15. FEATURES OF THE SOCIAL CONSTRUCTIONIST DEBATE • From this emerged an anti-psychiatry movement which argued that much of what was labelled a mental illness was simply a social construction created by psychiatrists who acted as powerful agents of social control. • Diagnosing someone as schizophrenic for example, enabled psychiatrists to declare that person unfit to participate fully in social life. • Diagnostic categories were called into question and the application of medical knowledge was seen as being political and not just a technically neutral act.

16. Themes in the Social Constructionist Debate • These ideas in the social constructionist debate have been applied to question the assumptions on which biomedicine’s autonomous and extremely powerful position in society is based. • There are several different aspects to the social constructionist debate, two of the most important are “problematisation” and “medicalisation”

17. This approach states that diseases are not simply real but are products of social reasoning and social practices. Calling a set of symptoms “bronchitis” does not mean that a discrete disease exits as an entity independent of social context. The Problematization of Reality

18. The Problematization of Reality: Bronchitis • That is how medical science at a given place and time with the aid of laboratory tests and theories has come to define it. • Someone with bronchitis will experience pain and suffering but the interpretation of it will vary between time and place.

19. The Problematization of Reality • In this sense then the idea of medical discoveries is misleading. • There are no fixed realities of the human body waiting to be discovered. • There are fabrications or inventions by biomedicine which implies that the disease was established through certain investigations which confirmed its reality.

20. Constructing Mental Illnesses: The Jerusalem Syndrome

21. Constructing Mental Illnesses: The Jerusalem Syndrome • Since the 1980s there has been an increasing number of tourists who, on arriving in Jerusalemhave some kind of psychotic episode or breakdown. • Tourists now treated in one central facility and between 1980-1993, 1,200 tourists with have been referred there. • On average about 100 tourists are seen annually and about 40 of them require hospitalisation. • Three main types of patients have been identified.

22. Jerusalem Syndrome: Type 3 Patient • Main diagnostic criteria: • First criterion: no previous history of psychiatric illness. • Second criterion: “Subjects” usually arrive with friends or family or part of an organised tour of Mediterranean countries. • Third criterion: On arrival subjects develop an acute psychotic reaction that develops in seven identifiable stages.

23. 7 Stages of Type 3 Patients • 1. anxiety, agitation, other unspecified reactions; • 2. declaration of the desire to split away from the group or family; • 3. a need to be clean and pure, obsession with taking baths and showers, compulsive fingernail and toenail cutting;

24. 7 Stages of Type 3 Patients • 4. using hotel bed-linen to make an ankle length, toga like gown which is always white; • 5. the need to scream, shout or sing out loud psalms, verses from the Bible, religious hymns or spirituals;

25. 7 Stages of Type 3 Patients • 6. a procession or march to one of Jerusalem’s holy places; • 7. delivery of a ‘sermon’ in a holy place - this is usually very confused and based on a unrealistic plea to human kind to adopt a more wholesome, moral, simple way of life. Bar-El, Y. et al (2000) Jerusalem Syndrome. British Journal of Psychiatry 176: 86-90.

26. MEDICALIZATION THESIS • It is indirectly related to social constructionism - it does not question the basis of medical knowledge as such but challenges its application. • It draws attention to the fact that medicine operates as a powerful institution of social control. • It does this by claiming expertise about matters of life which had previously not been regarded as medical matters e.g. ageing, childbirth, alcohol consumption and childhood behaviour.

27. MEDICALIZATION‘S CRITIQUE OF BIOMEDICINE • Medicine constructs or redefines aspects of ‘normal’ or accepted everyday life as medical problems. • Professionals tend to offer technological or biomedical solutions to what are inherently ‘normal’ aspects of everyday life or social problems. • Medicine has become a major institution of social control and this has been related to an increasing complex and bureaucratic system which encourages a greater reliance on experts.

28. MEDICALIZATION‘S CRITIQUE OF BIOMEDICINE • High-tech modern medicine has become increasingly dangerous to the population’s health by: • reducing their autonomy and their ability to cope with their problems; • making them dependent on the medical profession; • damaging their health by the side effects of drugs and surgical interventions; • The medical system operates in close relationship with the manufacturers of pharmaceuticals and medical equipment, and this relationship is not necessarily in the patient’s interest. • Illich, I. (1977). Limits to medicine: Medical nemesis: the Exploration of health. NY: Penguin

29. Theoretical Basis of Medicalization • Inherent in the medicalization thesis are Marxist and Phenomological approaches to health and illness. • This thesis considers definitions of illness to be products of social interactions or negotiations which are unequal because people do not have equal influence on the social construction of reality. • Medical professionals are more able to define what counts as sickness than ordinary people. • Medical professionals, therefore, have great scope for social regulation because if matters have to be defined as medical concerns, then health professionals have the authorityto monitor, intervene and pass judgements upon them.

30. The idea of medicalization has been most developed in relation to childbirth. The control of pregnancy and childbirth has been taken over by a mainly male medical profession. Hans Sachs, Eygentliche Beschreibung Aller Stande auf Erden (1568). MEDICALIZATION OF CHILDBIRTH

31. MEDICALIZATION OF CHILDBIRTH • Childbirth is surrounded by a whole range of technologies and women are closely monitored from the acknowledgement of conception until after the baby is born.

32. MEDICALIZATION OF CHILDBIRTH • In many countries women who have straightforward pregnancies are subjected to: • routine intravenous infusions; • they are encouraged to have electronic fetal monitoring; • and epidural analgesia; • labour will be in the dorsal position.

33. Medicalization of Childbirth: Increase in assisted delivery rates and major surgery • Caesarean section rates in the United States, Canada, Italy, and the United Kingdom are about 20%. Paranjothy S, Thomas J, (2001) Royal College of Obstetricians and Gynaecologists Clinical Effectiveness Support Unit. National sentinel caesarean section audit report. London: RCOG Press • Brazil, with a 36% caesarean section rate, is often portrayed as a country where there is an unusually high demand for caesarean sections, especially among more affluent women. • Research has found that doctors were active participants in decision making and used their expertise and authority to convince women to `choose” a caesarean. Hopkins K. (2000)Are Brazilian women really choosing to deliver by cesarean? Social Science & Medicine 51:725­40.

34. Medicalization of Childbirth • In Spain, obstetric care includes routine enemas, pubic shaving, and episiotomy, procedures that are not evidence based and which ignore the WHO's guidelines on the care of women in labour. • The extent of medicalisation in Spain is reflected in: • some of the highest caesarean section rates in Europe (26.4% in Catalonia with a 40% increase over five years); • obstetricians have been criticised for not allowing women to participate in decisions about their maternity care. Bosch X. (1998) Spanish doctors criticised for high tech births. BMJ317:1406.