Social construction, medicalisation and social control

This essay looks at social construction, medicalisation and social control. Each is defined. Then my interpretation is given. I have looked at the connection between each concept and illness. A variety of interesting examples are given. Each concept is a useful analytical tool and essential for an informed analysis of illness. Social construction means that “the way people view themselves and others is not natural but shaped by the society in which they live. 1” People ‘see’ the world not directly but through a set of conceptual ‘lenses’.

In my interpretation of this definition I focussed on the phrase ‘not natural’ and the word ‘shaped’. ‘Not natural’ is important because it draws attention to the possibility of other ways of viewing the world. The use of the word ‘shaped’ begs a very important question: “What forces are shaping social construction? ” Following this train of thought one must acknowledge the place of values in social construction. These conceptual lenses shape the construction of such aspects of life as gender, work, time and illness. What constitutes illness has changed over time.

Some groups who were not historically viewed as ill have been initiated and some that were seen as ill have been freed of the label. For example, those formally seen as drunks have become alcoholics and slow children now have learning disorders2. In the opposite direction, homosexuality has gone from being a mental illness to a lifestyle choice. These examples highlight that illnesses, syndromes and disorders are not inherently so. The classification of certain characteristics or behaviours as ‘illness’ depends on someone interpreting and labelling them as such and having the influence to make the label stick.

Groups that are organised and have access to propaganda are more likely to be successful in labelling reality. In pre-Enlightenment times, disease was viewed as the outward sign of a corrupt soul. As the Christian discourse lost credibility and truth and objectivity sought to replace superstition, medicine and modern conceptions of illness emerged3. Physicians were able to replace religious notions of madness with medical notions of mental illness because they were more organised and influential than their competitors4.

Illness is created, or socially constructed according to an elite group’s assumptions of what is ‘normal’5. The social construction of illness has not ended though. In fact, it continues to expand, redefining non-medical problems in medical terms and proposing medical solutions. This process is known as medicalisation. I have included two definitions of medicalisation as both highlight important aspects of this fascinating process. The first states that medicalisation is “the process through which medical perspectives and treatment become increasingly influential and common in society6”.

The key word in this definition is ‘influential’ as it alludes to the power relations driving the process. The second definition describes medicalisation as “the process of defining an increasing number of life’s problems as medical problems7” this draws attention to the fact that political, structural and cultural problems are not being given political, structural and cultural remedies. The consequences of this are cultural and clinical iatrogenesis. Cultural iatrogenesis is the dependence of the population on drugs and other treatments due to the focus on cure over prevention.

Clinical iatrogenesis follows from cultural iatrogenesis. It is the side effects of drugs and other treatments, medical accidents and other ‘doctor-caused illnesses’, which often require treatment of their own8. Many areas of life have been medicalised. Birth is one such area. This used to be an event managed by the mother, her family and a female midwife. Today, every stage of the pregnancy (including, in the case of invitro fertilisation, conception) is monitored by a physician. The birth itself is increasingly becoming a medical procedure, with increasing numbers of caesareans9.

Death is another area subject to medicalisation. The process has been applied to both the dying and to those they leave behind. Most people want to die at home. The reality is that most will die in hospital. In addition, the bereaved are assisted in following a ‘healthy’ path of mourning10. A particularly useful example of the socially constructed nature of illness and of medicalisation can be gleaned by examining the subject of sexual activity. In pre-medicine times it was monitored in terms of what was a righteous or sinful level of sexual activity.

In the nineteenth century, engaging in too much sex was sign of a disease. Today, too little intercourse is problematic. (Note that the pharmaceutical company selling Viagra has much to gain from the construction of high levels of sexual activity as healthy)11 The medicalisation and demedicalisation of sexual identity is a useful illustration of the interplay of power between competing groups. As mentioned earlier, homosexuality was previously defined as a disease. However, the definition was reversed after the organization and uprising of homosexuals and their sympathisers.

The gay community were not only successful in redefining homosexuality as a lifestyle choice – and, therefore, within the realm of normal – but in defining those who opposed homosexuality as homophobic and, therefore, diseased! So, the process of medicalisation was used to validate the views of first the heterosexual community and then the homosexual community. This highlights the authority of the medical discourse Sexual activity aside, the examples so far have dealt with behaviour that is qualitatively distinct from that of the general population.

That the behaviour is abnormal seems commonsense, not determined according to an elite group’s values. A better example of how the medical elite labels behaviour as deviant and needing treatment can be gained by looking at behaviour that is quantitatively different to the general population. This group of ‘illnesses’ are known as addictions. Addicts perform activities that most people also do. However, addicts do them ‘to excess’. Alcoholics are addicted to alcohol. Gambling addicts gamble too much. One of the newest deviants is the net addict – someone who uses the internet to excess12.

Birth, death, sexual activity, sexual identity, gambling and alcohol and other drug use, as well as criminal behaviour, eating and child development have all been medicalised13. However, the original and most entrenched area of medicalisation is that of mental health. Conrad and Schneider14 explored the medicalisation of madness. In biblical times, they note, prophets and mad people exhibited similar behaviour. The label they received depended on how people around them defined them. In medieval times, madness was believed to be incurred by God.

It was viewed as punishment, a warning, or a test from God. The Church prescribed what action should be taken to appease Him. In this way the church was the main institution of social control. Roughly 200 years ago, capitalist social relations became prominent while religious social relations diminished. A new institution was needed to manage deviants previously defined as mad. Medicine claimed this role. It became the institution of social control. Social control is a “mechanism that aims to induce conformity, or at least to manage or minimise deviant behaviour15”.

When interpreting this definition, the second clause is particularly important. It emphasises that social control is about protecting the ‘healthy us’ from the ‘deviant, unhealthy them’. Physicians exert control over patients by use of the clinical gaze. The physician has the power to declare ‘truths’ about the patient that are supported by society16. The patient is required to take on the sick role. Parsons identified social control as a main function of medicine and pioneered the sick role.

The sick role is appealing to patients because it allows them to take time off work and relinquish responsibility of caring for themselves and any dependants without moral repercussions17. In return, the patient must want to get better, must seek advice from a technically competent professional and must follow medical orders, such as taking medication18. The conversion of social or structural problems into medical ones transforms them into issues of the individual. This makes social control easier because it eliminates other ways of looking at the problem that would involve structural or social solutions.

Focussing on the individual prevents deviant subcultures from developing19. Mental illness was historically treated with surgery or shock treatment. In the 1950s psychotropic (mood altering) drugs were used to treat the mentally ill. They worked not by helping the deviant individuals but by sedating them. Today, medicine’s main tool of control is therapy. It works to reinforce dominant values of work ethic and discipline20. Another aspect of social control is surveillance. This was mentioned already in regard to physicians monitoring pregnancy.

It can also be observed in procedures such as general check-ups, mammograms, pap smears and school-based vision/scoliosis/orthopaedic examinations. Medical records, such as immunisation records, are also evidence of the surveillance role of medicine. Social construction is the process whereby reality is interpreted and categorised according to a set of values. Medicalisation is a form of social construction. One of the consequences of medicalisation is social control. The concepts of social construction, medicalisation and social control are not only useful in analysing illness – they are essential.