Medicalization is one way of dealing with the more troublesome aspects of human diversity, and adversity: by treating them as medical problems. There is a subtle distinction to be made between medicalization and pathologization, which is specifically treating something as a disease; there is considerable overlap between the two, but I will focus here on the slightly broader concept.

In many ways medicalization is preferable to criminalization, another way of dealing with behaviours which are seen as being problematically outside the norms of society, but it is worth noting how much the two approaches have in common. Both are based on the idea that someone's behaviour is a problem, and either one can lead to profound stigmatization and a loss of liberty for its object. Medicalization can also work to undo stigma, though: it explicitly calls for understanding the causes of someone's behaviour and thinking, in terms that make it clear that they are not entirely their fault. The thing to do with a medical problem is to treat it, not to punish the person it affects.

This is one reason that the whole question of moral responsibility is such a complex one. It is fundamental to the whole concept of crime and wrongdoing, and our justice system usually assumes that the responsibility for any act lies with the person acting. Morally, this only works if the person is in control of their actions, and there are many times when we have to accept that this is not the case. This is why insanity is a complete legal defence for most crimes (in British law) although it only applies when the defendant does not understand that they are doing wrong. Sometimes criminal sanctions can be avoided or reduced by accepting treatment, and while you might lose just as much liberty by being forced into treatment as you would from going to jail, the intent is quite different.

Putting a name to something as a medical or biological condition can be a route into understanding what is going on, both for the person affected and those around them. It can make it possible to tap into a pool of knowledge and support, and bring the relief of realizing that other people are going through similar things. Of course, much of this really comes from putting a name to it, medical or not.

There are a number of general questions to consider when trying to figure out whether it's useful to view any given thing as a medical problem. First of all, is it even meaningfully a thing at all, or just a collection of loosely correlated observations? Is there an underlying cause, and do we know how to treat it? Is the thing we are talking about necessarily a problem as such, and is it one best dealt with by medical professionals? A related question is whether medication is a good idea, but it is worth noting that the desirability of drug use is not necessarily implied by a medical approach, or ruled out by its rejection. (1)

In 2012 alone, around one in five US citizens was diagnosed with a psychiatric disorder. (2) This is an enormously higher rate than at any previous point in history, a fact which cries out for some kind of explanation. Perhaps people are more likely to be mentally ill than ever before, in which case there must be something about modern life that is leading them to be so. Perhaps genuine mental illness is simply being recognized far more of the time than it ever was before. Then again, it is also possible that some patterns of behaviour and psychology are being treated as pathological when it would be more constructive to view them as part of the normal range of human experience, or problems best dealt with in other ways. Whatever the case, the new DSM-5 - the USA's 'psychiatric bible' - will lower the bar for what counts as a mental illness in many cases, creating millions of new potential patients at a stroke. Without wishing to imply that commercial considerations are necessarily central to this phenomenon, I do think it is worth noting that these patients also become customers, as long as they do not get too much better.

Other people have investigated and discussed the rise of medicalization in a psychiatric context far more thoroughly than I could hope to. Instead, I want to look at a few of the specific variations between people which can be seen through a medical lens. In each case I think there are plausible arguments for the usefulness of a non-medical perspective. Whether this ought to exist alongside the medical angle is something I invite you to consider.


Homosexuality

Although well on its way to normalization in much of the West at this point, for most of the twentieth century having sexual feelings about someone you share a gender with was treated as a symptom of a mental illness in many countries. Alan Turing was one of many who accepted an experimental kind of chemical castration, using oestrogen to reduce libido, as a 'treatment' for homosexuality. This allowed him to avoid serving jail time after he was arrested for homosexual activity, which at that time was being treated as a criminal offence and a sign of mental illness. Two years later he was found dead, apparently by his own hands. Nobody has ever devised a treatment for homosexuality that works in more than a tiny minority of cases, which has been one factor in the growing unpopularity of a medical approach to sexuality.

More than that, it has has been successfully argued that homosexuality itself is not, inherently, a problem. It is only problematic when other people are unable to deal with someone's sexuality, or when they are unable to cope with the knowledge of their own feelings. These considerations are very relevant when considering the validity of fetishism still being listed as a psychiatric disorder, and they are also worth bearing in mind in several of the following contexts.


Addiction

Treating addiction as a medical condition is especially fraught from an ethical and legal point of view. It is quite clear that once a person succumbs to addiction, their so-called free will is profoundly compromised, but usually the addict will have indulged in the behaviour that first led to the addiction much more freely than that. How much moral responsibility does a person bear for behaviour that results from a self-inflicted medical condition? Does it make a difference if the addiction comes out of medicating to ease the intolerable pain of another medical condition? What about the unbearable pain of being alive in the first place? To what extent is addiction - or any medical condition - ever really self-inflicted, and to what extent do these things just happen to us?

On a more practical note, do our medical professionals have prescriptions that are any help? Here the answer is yes, to a point, but addiction is notoriously hard to treat effectively, and many people have had better luck with social and spiritual programmes, rather than medical ones - not that there is necessarily a clear line to be drawn there.


ADHD

This is one of the most contentious diagnoses of our time. There are at least three big reasons that people get worked up about attention-deficit hyperactivity disorder. One is the medication of children and young adults with psychoactive drugs, which they may be prescribed for years on end and whose effects on the growing brain are not yet very well understood. Another is that some of the symptoms of the condition overlap with what would have formerly been seen as someone just being a naughty kid who won't pay attention.

What does it do to notions of personal responsibility when a child's disruptive behaviour is blamed on a medical condition? By attacking the problem on a neurological level, might we be shoving aside underlying sociological problems? By turning to drugs, might there be a danger of cementing problems that could have been adequately addressed by some combination of teaching and therapy or growing up? Another reason people are concerned about this diagnosis is that more and more people are being diagnosed with it every year - the rate of diagnosis in the USA has tripled over the course of the last ten years. (2)


Depression

That depression is a serious problem is completely uncontroversial, but some psychologists question the usefulness of seeing it as a disease or a disorder, as such. Relatedly, many doubt the efficacy of anti-depressant medication, and worry that it is often the treatment of first resort, when therapy achieves better results on average and is far less likely to have unpleasant side effects.

One argument against treating depression as a disease is that unhappiness, listlessness and the other symptoms of depression can all be very natural responses to life being awful, and life is sometimes pretty awful. To say that someone is suffering from a disease called depression is to say that it is wrong - disordered - for them to be feeling the way they do; their suffering is the result of a disease, to be treated as such. Much of the time, of course, such experiences are sparked by events in the person's life, and these factors must be considered carefully when making a diagnosis of depression. At what point does grieving become a disorder? At what point does a preoccupation with the meaninglessness of one's life count as a symptom, rather than a normal human response to unemployment and a lack of social stimulation? It is, at best, profoundly difficult to draw clean lines in such cases. Controversially, the DSM-IV specifically defines 'major depressive disorder' to exclude cases of recent bereavement, an exclusion which is removed in the DSM-V. (2, 3, 4, 5)

While there is probably merit in treating depression as a neurological condition at least some of the time, the interplay between different levels of explanation in any given case can be quite complex. The feedback loops that sustain it can involve not just the brain's chemistry and biology, but also the mind's narratives and strategies, and the person's social interactions, habits and situation. The high rates of depression in many industrialized countries, especially in times of recession, suggest that depression can be a symptom of wider social malaise, while the upsurge in depression at times of economic recession point to the importance of material conditions. Any strategy for increasing the mental well-being of a population probably needs to look beyond a strictly medical perspective.


Obesity

It has become commonplace for pundits and even public health professionals to talk about an 'obesity epidemic'. This is odd, because usually only diseases, particularly contagious diseases, can have epidemics, and hardly anyone seems to think that obesity is a disease as such. It is, however, widely regarded as a medical problem (6) - on the one hand, as a symptom of over-eating disorders, and on the other hand as a cause of many other maladies. Damage caused to the musculo-skeletal system by high levels of body fat is uncontroversial; obesity is also blamed for heart disease and diabetes, although there is a case for thinking the common causes of a bad diet and inadequate exercise might be important there. There is some reason for thinking that diabetes (or pre-diabetic insulin resistance) causes weight gain, rather than - or as well as - being caused by it. (7) Obesity surely can be both a symptom of and a contributor to medical problems, but there is a whole complex of reasons why someone becomes fat, and considering obesity in isolation as a cause of medical complaints is not necessarily helpful, given the possibility of being both fit and fat at the same time. There is also evidence that overweight and even mildly obese people are statistically less likely than thin people to die early, which is curiously at odds with most of what we read on the topic. (8)

Once again, the treatability of obesity is one thing to consider when we are looking at the question of whether it is constructive to see it as a medical issue. The proportion of people who are able to maintain what is seen as a healthy weight, after having once been obese, is something like one in twenty - not an insignificant number, but few enough to suggest that maximising health while overweight may be a more effective strategy than pushing weight loss in most cases. (9, 10) The reasons why weight loss is usually the strategy of choice are probably more social than medical.


Autism

This is another case of something which is not usually considered a disease, as such, which quite often gets talked about in terms of an epidemic. The number of diagnosed cases of autism spectrum disorder has been rising and rising over the last two or three decades, and nobody is completely sure whether this can be explained entirely by increased diagnosis, or if the trend also reflects increasing numbers of people affected by it. This is worth considering on a local as well as a global level - it is quite possible, even if the proportion in the overall population has remained constant, that demographic factors may be leading to a rise in certain areas, such as Silicon Valley. (11)

Treating autism as a medical condition is controversial for a number of reasons. For one, it is not always a problem. Although some autistic people are totally unable to function as economically productive members of modern society, others manage to get by quite well. It is certainly true that the differences in expectations and interpretations between the autistic and neurotypical populations cause a good deal of misunderstanding and friction, and there are some things that one or the other group typically finds very much harder, but how problematic these things are largely depends on the relations between autistic people and others.

Another contentious aspect of the medicalization of autism is yet again the question of treatability. A great many different 'treatments' for autism have been proposed and attempted, but so far, all signs point to autism being an ineradicable aspect of a person's neurological makeup and personality, and many supposed treatments have proven actively harmful. (12, 13, 14, 15) This doesn't mean that there is no use trying to teach autistic people how to integrate with the rest of society as well as possible, but 'treatment' is not necessarily the right lens through which to look at such interventions.

We must add to this the question of the desirability of treating autism. If it is a fundamental part of who someone is, and it doesn't inherently make them unhappy, they may not want to be transformed to be more like other people. How do we decide when something is a problem, medical or otherwise, and when we just need to accept it as one aspect of human diversity?

Another thing to consider here is the availability of support. Whether or not we see autism as just part of the rich tapestry that is humankind, nobody would deny that some autistic people need support that other people wouldn't. Our society has many mechanisms in place to help people with medical conditions, but we are not always so good at providing support to people on the basis that they're just a bit different from most of the population. Medicalization often comes with more resources being allocated to a problem - usually medical resources, of course, which may or may not be the most appropriate kind.


Transsexuality, Transgender, Intersex

Variations in sex and gender can also cause problems that people need support to get through, and that can include medical support. At the same time, gender identity and sexual anatomy are naturally variable, and that is not necessarily a problem. (15, 16) When it is a problem, that is often because other people can't deal with it, but not always. Some people are so affected by gender dysphoria that they feel very much better and saner if they are able to alter their physical sex using hormones and sometimes surgery, something which is only possible if their gender difference is treated as a medical problem. Children who are born intersexed are sometimes operated on very early in life, allowing them to be more neatly categorized until such time as they are able to make up their own mind about how they want to be seen, and taking away the option of retaining their intersex nature.

The question of how to deal with gender variation is especially difficult when it comes to how to deal with children and adolescents. Feminists have been fighting for decades against children being socialized to feel confined to rigid gender roles. Part of that is arguing that it is not abnormal for young people to express themselves in ways that go against prevailing gender stereotypes, whether that means girls being assertive or playing rough, boys wanting to look pretty or play with dolls, or any number of other variations. Some kids go further than that, and have a strong and persistent feeling that their body is mismatched with who they are, but the question of how best to deal with such feelings - and when and how to involve medical professionals - is not easy to answer. One strategy is to delay puberty to give the child more time to think about their gender expression before it is transformed by sex hormones, which makes it easier to deal with than it would be after they have been bathed in a set of hormones that feel wrong for them. Another strategy is to hold off on medical treatment until after puberty, in case the adolescent feels more comfortable with their gender once their biological sex is fully developed.

Many cultures have long-established roles for people with gender identities outside of the two-sex paradigm, and whatever feelings you might have about the role of medical interventions in this context, it is clear that life would be made easier for people with divergent gender identity and biology if society was less rigid in its gendered expectations. Life would probably also be a lot easier for women, and many men, since those expectations tend to hold people back in all sorts of ways. As in all of these cases, we need to work out how best to deal with any problems that arise in the context of our present society, but the bigger question is what kinds of societal change might help us to deal better with these things in the future.


Conclusions

As we have seen, there is a good deal of contested ground where medicalization is questioned by those affected by it, and where it is not clear that treatment is the most appropriate response to any problems associated with somebody's differences. A medical model often leaves out much of the story behind those problems, locating them squarely in the medicalized individual when the trouble can often be seen to come largely from the attitudes of others.

A lot of this has to do with questions around the idea of normality - what is perceived as normal and abnormal, how to deal with it when someone doesn't conform with conventional ideas of normality, and why such deviations lead to problems. There is no doubt that medical professionals have a role to play in dealing with some of these problems, but in many cases the medical model is built on normative assumptions which are worth examining closely. Above all, doctors and other medical professionals are human beings: extensively trained and placed in positions of considerable authority, but still just as fallible as everyone else, and just as prone to getting stuck on pre-conceived ideas. Individuals and societies often have a tough time dealing with diversity, for many reasons - some of them quite rational, some of them downright foolish. People vary widely in their ability and readiness to accommodate people whose appearances, needs or patterns of behaviour differ from what they are used to. The medicalization of any dimension of human difference should be looked at carefully in the context of the society in which it occurs; it is generally an ethical and sociological issue, as well as a scientific one.

References

  1. A More Humane Approach to Mental Health, Peter Kinderman. See also Careful that you don’t throw the baby out with the bath water - a response to Kinderman's argument against psychiatric diagnosis in general, that he made in this London Philosophy Club talk
  2. Allen J. Frances on The Overdiagnosis of Mental Illness (video)
  3. Bereavement Exclusion Debate, Dr. William Coryell
  4. DSM-5: proposed changes to depressive disorders, J.C. Wakefield.
  5. Depression, Bereavement, and “Understandable” Intense Sadness: Should the DSM-IV Approach Be Revised?, Mario Maj
  6. Medicalizing Obesity: Individual, Economic, and Medical Consequences, George L. Blackburn
  7. Pre-diabetes and weight gain
  8. Recipe for a long life: overweight people have LOWER death risk, Jeremy Laurance
  9. People can be fat yet fit, research suggests, Michelle Roberts - health editor, BBC News online
  10. Health at Every Size: Toward a New Paradigm of Weight and Health, Jon Robison
  11. Autism link to 'geek genes', BBC
  12. Presenting the self: Negotiating a label of autism, Charlotte Brownlow
  13. On the ontological status of autism: the 'double empathy problem', Damian Milton
  14. The normalisation agenda and the psycho-emotional disablement of autistic people, Damian Milton
  15. The Misbehaviour of Behaviourists, Michelle Dawson
  16. The Medicalization of Transgenderism, Whitney Barnes

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