International Journal of Medical Sociology and Anthropology ISSN: 2546-9763 Vol. 2 (2), pp. 066-075, February, 2013. Available online at www.internationalscholarsjournals.org © International Scholars Journals

Review

Review on Medicalisation: A critical appraisal with special reference to India

Zulufkar Ahmad Khanday

Department of Sociology, Aligarh Muslim University, Aligarh, Uttar Pradesh, 202002, India. E-mail: k.zulufkar.amu@gmail.com, Tel.: 8171286053

Accepted 10 December, 2013

The concept of medicalization emerged from the intellectual and social turmoil of the 1950s and 1960s as a critique of medicine as authoritarian and the expansion of its conceptual model to the analysis of social ills and attendant policy. “Medicalization” refers the process by which non-medical problems become defined and treated as medical problems, usually in terms of illness and disorders”. This review is based mainly on three objectives; (a) first is to explain the nature of medicalization- i.e. what medicalization actually is and why there is need of de-medicalization, (b) second is to explain the how the medicalization has negative effects on the health of people- i.e. ‘the medical establishment has become a major threat to health’ and providing a dossier of medicine’s adverse effects – the wrongs and harms it has done – through processes of clinical, social and cultural ‘iatrogenesis’ or doctor-induced conditions, and finally (c) third is to explain the impact of the dominance of professional medical power on the people’s lives especially including women. This paper is mostly based on the secondary sources such as books, articles, journals, papers, reports etc. Besides this some data has been collected from online sources. Key words: Medicalization, De-medicalization, Re-medicalization, Power, Caesarean section delivery.

INTRODUCTION

The concept of medicalization emerged from the intellectual and social turmoil of the 1950s and 1960s as a critique of medicine as authoritarian and imperialistic and the expansion of its conceptual model to the analysis of social ills and attendant policy or a critique of the expanding role of medicine in the social control of deviant behaviour (Cockerham WC, 2010). “Medicalization” describes a process by which non-medical problems become defined and treated as medical problems, usually in terms of illness and disorders” (Conrad P, 2007). It is defined as the way in which the scientific knowledge of medical science is applied to behaviours or conditions which are not necessarily biological and this concept was developed (originally in the United States) in the early 1970s, associated with the view of medicine as an instrument of social control (Turner B, 2006). An illustration of the medicalization as a phenomenon is provided by the condition of “alcoholism. Until the middle of

the twentieth century, most people viewed alcoholics as morally weak people easily tempted by the pleasure of

drink. Gradually, however, medical specialists redefined alcoholism so that most people now consider it a disease, rendering individuals “sick” rather than “bad”. Similarly, obesity, drug addiction, child abuse, promiscuity and other behaviours that used to be moral matters are widely defined today as illnesses for which people need help rather than punishment (Thomas RK, 2002).

On the other hand it can be said; that medicalization is the process through which areas of everyday life have come under the purview of medical authority. It can also be seen as an attempt to provide an alternative interpretation to problems of existence [Wainwright D (2008)]. It refers to the increasing influence of medical institutions and the medical profession on aspects of life that previously had not been considered medical issues. For example, disruptive behaviour by children is now more

likely to be defined as attention deficit disorder, with drugs being prescribed for its treatment (Thomas RK 2002).

Medicalization is now established as a key sociological concept; however it is difficult to be specific about when

Khanday 066 it entered the social scientific glossary. It seems that the process was first referred to by critics of the growing influence of psychiatry in the 1960s (although these critics did not use the term explicitly), and grew in popularity in the 1970s when linked with the concept of social control. Since then, medicalization has been applied to a whole variety of problems that have come to be defined as medical, ranging from childbirth and the menopause through to alcoholism and homosexuality (Gabe J, Bury M, Elson M, 2004). Some analysts have suggested that the growth of medical jurisdiction is “one of the most effective transformations of the last half of the twentieth century in the West”. For nearly four decades, sociologists, anthropologists, historians, bioethicists, physicians and others have discussed and written about medicalization. These analysts have focused on the specific instances of medicalization, examining the origins, range and impact of medicalization on society, medicine, patients, and culture. While some have simply examined the development of medicalization, most have taken a somewhat critical or sceptical view of this social transformation (Conrad P, 2007).

Objectives

This review is based on three main objectives: (a) To explain the nature of medicalization, (b) To explain how the medicalization has negative effects on the health of people. (c) To explain the impact of the dominance of professional medical power on the people’s lives.

RESULT AND DISCUSSION

Medicalization is a key concept in the sociology of health and illness because it sees medicine as not merely a scientific endeavour, but a social one as well. It is the process through which areas of everyday life have come under the purview of medical authority. Medicalization can also be seen as an attempt to provide an alternative interpretation to problems of existence (Wainwright D 2008).

Medicalization has been a central concept in medical sociology since the early 1970s (Wainwright D, 2008). Sociologists have studied medicalization since the late 1960s. The first studies focused on the medicalization of deviance but soon the concept was seen to be applicable to a wide range of human problems that had entered medical (Conrad P, 1975).The key to medicalization is definition; that is a problem is defined in medical terms, described using medical language,

understood through the adoption of a medical framework or “treated” with a medical intervention (Conrad P, 2007). According to Conrad and Schneider (1980), medicalization can occur on three distinct levels: (1) conceptually when a medical vocabulary is used to define a problem, (2) institutionally, when organizations adopt a medical approach to treating a problem in which they specialize, and (3) at the level of doctor–patient interaction when a problem is defined as medical and medical treatment occurs. As these distinctions illustrate, the process often involves physicians and their treatments directly. However, this is not necessarily so, as in the case of alcoholism where the medical profession may be only marginally involved or not involved at all (Pescosolido BA, Martin JK, McLeod JD, Rogers A 2004), (Gabe J, Bury M, Elson M 2004). Peter Conrad and Joseph Schneider (1980) in their well-known text Deviance and Medicalization: from Badness to Sickness attempted, following Zola, to identify the conditions under which behaviours are medicalized, pointing to a range of social forces such as the decline of religion, and the entrepreneurial endeavours of pharmaceutical companies. But they also argued that ‘medicalization is not possible without the complicity or willingness of at least some part of the medical profession’ adding that there are often medical professionals who act as entrepreneurs for medicalization (Scott J, 2006).

Medicalization is often associated with the control of deviance, normal life events, and the ways in which deviant behaviours that were once defined as immoral, sinful or criminal have been given medical meanings (Gabe J, Bury M, Elson M, 2004).

Talcott Parsons, in his extensive writings on medicine (1950s and 1960s), had contended that illness constitutes a form of social deviance that needs to be controlled by society and had pointed to medicine’s power to determine whether a person who was behaving as sick, was actually sick or not, and to legitimate their illness (Scott J, 2006). Medicalization of deviance encompasses or includes alcoholism, mental disorders, opiate addictions, eating disorders, sexual and gender difference, sexual dysfunction, learning disabilities, child and sexual abuse and other areas of human life. Certain common life processes have been medicalized as well, including anxiety and mood, menstruation, birth control, infertility, childbirth, menopause, aging and death.

One example of the medicalization of the human body laid by Sancheeta Ghosh (2010) is caesarean-section delivery. The rising trend in caesarean-section (C-section) rates, in both developed as well as developing countries, the higher preference accorded to this mode of delivery points to the growing medicalization of women’s health (Ghosh S, 2010).

Studies have shown how, over the past few decades,

067 Int. J. Med. Sociol. Anthropol.

Table 1. Trends in caesarean section delivery: Percentage of women who had undergone caesarean section delivery by states*, from NFHS- 1, NFHS- 2 and NFHS-3.

Percentage of women who have caesarean delivery

States NFHS-1

(1992-93)

NFHS-2

(1998-99)

NFHS-3 (2005-06) Difference from NFHS-1

U.P 0.6 2.7 5.9 5.3

Haryana 2.3 4.2 5.0 2.7

H.P 1.6 6.8 13.1 11.5

J&K 5.7 10.6 14.1 8.4

Punjab 4.2 8.3 14.4 10.2

Delhi 4.6 13.4 12.0 7.4

Gujarat 2.7 8.6 8.8 6.1

Rajasthan 0.7 3.0 4.2 3.5

M.P 0.7 3.0 6.8 6.1

Maharashtra 3.4 9.9 15.6 12.2

Goa 13.7 20.0 25.5 11.8

Orissa 1.5 5.2 6.1 4.6

West Bengal 3.3 13.5 15.0 11.7

Assam 2.3 5.0 6.5 4.2

Bihar 1.1 3.0 4.1 3.0

A.P 4.4 14.7 27.5 23.1

Tamil Nadu 7.1 17.5 23.0 15.9

Karnataka 3.7 11.0 15.3 11.6

Kerala 13.2 29.8 30.1 16.9

India 2.9 7.1 10.6 7.7

childbirth has come under the influence of medical technology. According to Johanson et al. (2004), birth has become too ‘medicalized’ and the higher rates of unnecessary obstetrical intervention raise concern for the mother’s health. Bruekens (2001) in this context, argues that over-medicalization of maternal care has become a worldwide epidemic. In fact, medicalization, in general, has taken control over human life and maternal health comes also under its ambit (Ghosh S, 2010; Bruekens P, 2001).

It is often argued that with thriving private practice in many countries, obstetricians increasingly prefer c-section birth over normal child birth. In addition, there is evidence from Western countries that women too often prefer to deliver the child through the c-section. The rates of caesarean section in many countries have increased beyond the WHO-recommended level of 5

-15 %, almost doubling in the last decade. In high-income countries like Australia, US, Germany, Italy and France, the rates have gone up phenomenally in the last few decades. Similar trends have also been documented in low -income countries, particularly in Latin America and some countries in Asia (Ghosh S, 2010).

There are medical explanations for the performance of c-section delivery. Surgical intervention during pregnancy is usually performed to ensure safety of the mother and child under conditions of obstetric risks (Mishra US, Ramanathan M, 2002). Keeler and Brodie (1993), argued that, ignoring the financial costs, a c-section is best if the price in terms of morbidity and risk to mother of the operation is less than the discomfort and risk to mother and child of prolonged normal delivery. A number of medical factors such as mother’s age, breech

Khanday 068 presentation of the baby and the size of the child at birth are considered possible risk factors leading to c-section delivery (Keeler BE and Brodie M, 1993).

There is, however, a parallel argument among social scientists, that the decision to perform a caesarean section is often strongly influenced by non-medical factors, which act alongside the medical determinants. Researchers have found a strong correlation between increasing c-section delivery and socio -economic and cultural factors. Studies show that in case of developed countries, doctors’ preferences for this surgical procedure, coupled with women’s demands are responsible for the increasing trend. Different rates of c -section in public and private hospitals suggest that non -medical factors, such as economic gain and pressures of private practice, may motivate doctors to perform surgical deliveries (Potter JE, Berquó E, Perpétuo I, Ondina LF, Hopkins K, Marta RS, Maria C, 2001). It is also believed that the increasing trend of the caesarean delivery in the developed countries could be attributed to the increasing demand from patients and informed decision making. Women's requests for caesarean section is considered to be an important determinant of birth outcome, particularly in countries with growing privatization and options for patient choice (Ash A, Okah D, 1997). It is often argued that the power of decision-making in the home and seeking medicalized health care were associated with higher maternal education and family incomes.

With the increase in institutional deliveries and growing access to gynaecological and obstetric care, c-section deliveries too have shown an increasing trend. A study by the Indian Council of Medical Research (ICMR) in 33 tertiary care institutions noted that the average caesarean section rate increased from 21.8 percent in 1993-94 to 25.4 percent in 1998-99 (Kambo I, Bedi N, Dhillon BS, Saxena NC, 2002). According to the National Family Health Survey (1992-93) two states, Kerala and Goa have shown the highest percentage of c-section deliveries (Mishra US and Ramanathan M, 2002).

A rising trend in c-section rates, from 11.9 percent in 1987 to 21.4 percent in 1996 has been reported from Kerala. Another study in Jaipur showed that c -section rates in a leading private hospital rose from 5 percent in 1972 to 10 percent in late 1970s and to 19.7 percent between 1980-85 (Kabra SG, Narayan R, Chaturvedi N, Anand P, Mathur G, 1994). Studies show that in India, the rate of c-section delivery is relatively much higher in private hospitals rather than in public health facilities. For instance, Padmadas et al. (2000), observed in the case of India the caesarean deliveries are mostly occurring in private rather than public institutions. (Ghosh S, 2010) * Percentages given for major states only:

The trend in caesarean section delivery shown in above given table 1 makes this apparent that there is a significant increase in the percentage of birth by c-section in many states in India. At the all -India level, only 2.9 per cent of birth was by c -section in NFHS-1 and it has increased to 7.1 in NFHS-2 and 10.2 in NFHS-3. The difference in c -section delivery from NFHS-1 to NFHS-3 is relatively high in states like Andhra Pradesh, Goa, Kerala, Tamil Nadu, West Bengal and Punjab. A rapid increase in c-section rates has occurred in these states from 1992 to 2006. The rate is highest (27 per cent) in the state of Andhra Pradesh in 2005 -06 (although the rate was as low as 4.4 per cent during 1992-93 in the state). It is important to consider that states with rapid demographic transition show high incidence of caesarean childbirth in comparison to other states. (Conrad P, 2007).* Institutional delivery (Delivery in health facilities, such as, public which includes govt. hospital, dispensary, primary health centres etc and private health facilities and NGOs or trust hospitals).

The table 2 shows that there is a positive relation between increasingly institutionalized birth and percentage of c-section delivery. Only institutional deliveries would result in use of a medical intervention in order to facilitate better outcomes. It is a well known fact that institutional delivery provides an opportunity to deal with delivery complications. More importantly, it also helps the doctor to decide on the type of delivery to be performed, normal or caesarean, based on the intensity of the complication. In safe motherhood strategies it is universally accepted that provision of essential obstetric care and ensuring institutional delivery are the best options to reduce maternal mortality in all contexts. Unfortunately, in the current scenario, this useful medical intervention which improved the outcomes of various complications of pregnancy, has now led to overuse or inappropriate use of caesarean delivery in many countries.

Thus the increasing trend in caesarean section delivery and institutional births in India makes it clear that how the aspects of life (especially the child birth and maternal care) that earlier had not been considered medical issues are coming under the control of medical institutions and the medical profession. The impact of caesarean section delivery on maternal and child health, and the high cost of this technique compared with normal delivery, is a serious public health issue. Developing countries, as other regions of the world, are faced with the challenge of making the best use of limited resources to improve the health of women and children. Morbidity and mortality caused by unnecessary interventions is a serious problem, and a worldwide epidemic of obstetrical interventions could have a negative health impact on both women and children.

069 Int. J. Med. Sociol. Anthropol.

Table 2. Trends in Institutional births in India and major states.

Percentage distribution of live birth in health institution and birth by states, from NFHS-2 and NFHS-3.

States NFHS-2(1998-99) NFHS-3 (2005-06)

Inst_Del* Public Private Inst_Del Public Private

U.P 15.5 7.2 8.0 24.7 6.4 18.3

Haryana 22.4 6.0 16.4 34.6 13.2 21.2

H.P 28.9 23.2 5.7 49.1 42.3 6.7

J&K 35.6 35.6 5.9 51.1 41.7 9.5

Punjab 37.5 7.6 29.8 51.2 12.3 38.8

Delhi 59.1 29.1 29.7 52.7 27.5 25.1

Gujarat 46.3 11.2 35 52.5 13.9 38.7

Rajasthan 21.5 15.7 5.6 31.6 20.0 11.6

M.P 20.1 13.1 7.0 38.3 20.8 17.5

Maharashtra 52.6 24.3 28.3 71.2 34.3 37.1

Goa 90.8 38.5 51.4 92. 2 44.0 48.4

Orissa 22.6 19.1 3.4 39.1 30.6 8.7

West Bengal 40.1 31.6 8.5 51.9 37.8 14.2

Assam 17.6 11.7 5.9 26.2 14.7 11.4

Bihar 14.6 3.8 10.8 25.1 4.8 20.4

Andhra Pradesh 49.8 12.3 37.3 75.6 27.7 48.1

Tamil Nadu 79.3 37.4 41.1 90.1 53.8 36.5

Karnataka 51.1 27.6 23.3 64.1 34.8 29.5

Kerala 93.0 36.3 56.7 99.3 35.6 63.8

India 33.6 16.2 16.7 44.8 23.4 21.4

Medicalization is dynamic and frequently can expand in new directions. During the medicalization era, 1940–1985, the jurisdiction of medicine expanded dramatically (Pescosolido BA, Martin JK, McLeod JD, Rogers A, 2004; Gabe J, Bury M, Elson M, 2004). One visible area of expansion is how aging men’s lives and bodies are increasingly coming under medical jurisdiction. Television programs about successful aging, magazine articles about the best therapy for hair loss, and images used to promote the latest erectile dysfunction medication consistently tell men to “see your doctor”. This movement of aging from a natural life event to a medical problem in need of treatment is an example of medicalization (Conrad P, 2007). Most early sociological studies took a social constructionist tack in investigating the rise of medicalization. The focus was on the creation (or construction) of new medical categories with the subsequent expansion of medical

jurisdiction. Studies of the medicalization of hyperactivity, child abuse, menopause, post-traumatic stress disorder, and alcoholism among others, broadened our understanding of the range of medicalization and its attendant social processes (Conrad P, 2007).

Regarding the nature of medicalization it has been noted earlier that there is no such agreement about its cause. Some have argued that the expansion of medical jurisdiction is primarily a consequence of the medical profession exercising its power to define and control what constitutes health and illness in order to extend its professional dominance. Others have considered medicalization to be the result of broader social processes to which doctors are simply responding. It was only through the polemical writings of the Austrian refugee and former Catholic priest, Ivan Illich; the concept of medicalization came to the attention of a wider audience. In his Medical Nemesis of 1975, modified

Khanday 070 and republished as Limits to Medicine in 1977. Ivan Illich presented a forceful critique of modern medicine, by asserting that ‘the medical establishment has become a major threat to health’ and providing a dossier of medicine’s adverse effects – the wrongs and harms it has done – through processes of clinical, social and cultural ‘iatrogenesis’ or doctor-induced conditions. Ivan Illich (1926–2002) in his medical nemesis (1976) promulgated the idea that societies were becoming increasingly medicalized. Doctors were becoming the new priesthood and modern medicine were creating overdependence on technical fixes. Thus, Illich (1976) for example, attributes medicalization to the increasing professionalization and bureaucratization of medical institutions linked with industrialization. For him, the expansion of modern medicine has created a dependence on doctors and taken away people’s ability to engage in self-care (Turner B, 2006). Illich, who has so far produced the most radical critique of modern or industrialised medicine, argues that death, pain and sickness are part of being human. All cultures have developed means to help people cope with all three. Indeed health can even be defined as being successful in coping with these realities. Modern medicine has unfortunately destroyed these cultural and individual capacities, launching instead an inhuman attempt to defeat death, pain and sickness. It has sapped the will of the people to suffer reality. People are conditioned to get things rather than to do those [www.bmj.com/content/324/7342/859.full (01/11/13)]. Illich used the concept of iatrogenesis, which means ‘doctor-caused illness’, that is to say, harm would not have been caused without the medical intervention. Illich argues that the ‘damage done by medicine to the health of the individuals and populations is very significant’ (Illich, 1993). This aspect of iatrogenesis is referred to as ‘clinical’ iatrogenesis and Illich cites drug therapies, doctors or hospitals as the cause of harm (Barry AM, Yuill C, 2002). A second aspect is that of ‘social iatrogenesis’ which means the expansion of medicalization into social life means there is a blind belief in medical progress and expertise, and an institutionalization of medicine as an industry that commodifies and sells health. Those working in the medical establishment and the medical industry promote the consumption of medical products as the only means of realizing people’s health expectations. Hence, Illich (1976) revealed that ‘medical practice sponsors sickness . . . reinforcing a morbid society that encourages people to become consumers of curative, preventative, industrial and environmental medicine. Consequently, through social iatrogenesis, ‘the responsibility for health has been appropriated from individuals by medicine and the medical industry’ and people no longer take responsibility for their health

problems (Larkin M, 2011). The third aspect is that of ‘cultural’ iatrogenesis, which denotes a dependence on medicine to cure and to care for. Illich argues that cultural iatrogenesis means that people no longer take responsibility for their own health problems and the diagnosis of their symptoms. Illich asserts that ‘medical practice sponsors sickness . . . reinforcing a morbid society that encourages people to become consumers of curative, preventative, industrial and environmental medicine’ (1993: 158). The result of this dependency is a situation of medical nemesis, where the harm caused by medicine is difficult to eliminate except by recourse to further medical intervention, which in itself results in further harm. Illich paints a picture of an inevitable decline into an increasingly unhealthy world, where the provision of health care ultimately has a negative effect on our well-being (Barry AM, Yuill C, 2002). Furthermore, Illich is the view that a proportion of new burden of disease is itself the result of medical interventions in favour of people who are or might be sick of this plethora of therapeutic side-effects. In a case of Asha and Sushil there was nothing aberrant about the diseases that they acquired as side effects of the treatment. Asha even cited her doctor who had told her that she had to bear with the side effects of surgery and medication as there was nothing abnormal about them nor can anything be done to stop them. The only way to deal them is to prescribe further medication (Bhardwaj R, 2010). Irving Zola adopted Freidson’s explicitly social

constructionist stance, quoting his comment that ‘The medical profession has first claim to the jurisdiction over the label of illness and anything to which it may be attached, irrespective of its capacity to deal with it effectively.’ He then proceeded to gloss Freidson’s claims about medicine’s tendencies ‘to label as illness what was not previously labelled at all’, by using the term medicalization, which he defined as the process that makes ‘medicine and the labels “healthy” and “ill” relevant to an ever increasing part of human existence’ (Zola’s italics). Medicine, Zola recommended, is becoming a ‘major institution of social control’ and ‘the new repository of truth’ (Scott J, 2006).

On the one hand it can be said that Irving Zola in his article “medicine as an institution of social control” published in sociological review (1972) analysed the increasing pervasiveness of medicine in terms of: (1) expansion into more and more areas of life, (2) absolute control over techniques, (3) access to intimate areas of life, and (4) medical involvement in ethical issues (Wainwright D, 2008; Gabe J, Bury M, Elson M, 2004). Brief explanations regarding the Irving Zola’s four components of medicalization in society are as: Expansion into more and more areas of life: the expansion

071 Int. J. Med. Sociol. Anthropol. of what is deemed relevant to the good practice of medicine, arguing that the shift to multi-causal models of illness was leading to more and more aspects of a person’s life becoming relevant to their illness– with medicine exploring these wider aspects in order to diagnose and treat illness, and also to prevent it. Absolute control over techniques: medicine’s absolute control over certain procedures, particularly treatments such as surgery and drugs, permitted the extension of medicine well beyond the diagnosis and treatment of organic disease, as with cosmetic surgery or the prescription of many psychotropic medicines. Access to intimate areas of life: medicine’s absolute access to certain ‘taboo’ areas– the inner workings of our bodies and minds– meant that anything that could be shown to affect either body or mind could be declared an illness. Hence, for instance, the increased use of doctors to deal with personal problems, alcoholism and drug addiction. Medical involvement in ethical issues: medicine was increasingly deemed to be relevant to the ‘good practice of life’ and so had greater authority to tell people how to live their lives (Scott J, 2006).

Irving Zola (1972) too, has argued that medicalization is rooted in the development of an increasingly complex technological and bureaucratic system and a reliance on the expert. Therefore many writers tend to conceive medicalization in a negative way, focusing on how the phenomenon has resulted in a form of medical social control that serves particular interests in society. In other words it can be said that health has become a ‘paramount value’ in society the sphere of medicine inevitably assumes significance as an institution of social control.

Thus the negative effects of medicalization and Irving Zola’s opinions on medicalization– that is the medical establishment has become a major threat to health and providing a dossier of medicine’s adverse effects– the wrongs and harms it has done – through processes of clinical, social and cultural ‘iatrogenesis’ or doctor-induced conditions; expansion of modern medicine has created a dependence on doctors and taken away people’s ability to engage in self-care; the modern medicine has unfortunately destroyed the cultural and individual capacities, launching instead an inhuman attempt to defeat death, pain and sickness; has sapped the will of the people to suffer reality; people are conditioned to get things rather than to do those; doctors were becoming the new priesthood and modern medicine and medical techniques were creating overdependence on technical fixes (Thomas RK, 2002).

Irving Zola ideas regarding medicalization and its side effects on human body can be supported through many studies from India. For example Mundle et al studied the medical abortions of 149 women in a government-run

primary health centre in a village in the Nagpur district, Maharashtra in India. All women reported bleeding - 8.6 days on average-but this is expected and was reported by many women as similar to or less than that experienced during a normal menstrual cycle. Three-quarters of the women involved in the study mentioned nausea and 65% reported abdominal cramping for three days on average. However, women reported low levels of pain (Boler T, Marston C, Corby N, Gardiner E, 2009).

The side effects reported in another study largely reflect the prevalence and severity of side effects reported in other studies from India. For example, a review of 239 medical abortions between April 2002 and February 2003 by Parivar Seva Sanstha, a registered Non Government Organisation (NGO) in India, found that whilst women complained of nausea, abdominal cramps, bleeding and vomiting after taking misoprostol, very few women required medication. The same study found that, after taking misoprostol, 89% of women had vaginal bleeding and 84% had abdominal pain, the majority of which was moderate or mild (Boler T, Marston C, Corby N, Gardiner E 2009). Therefore it can be said that people are conditioned to get things rather than to do those and all this provides the way that there is the need of de-medicalization.

De-medicalization is the political and ideological process by which the medical profession loses influence over various aspects of society or alternatively, the political and ideological process by which the medical profession, as an agent of social control, loses influence over which social problems and behaviours are defined as sickness as opposed to badness (Thomas RK, 2002). For de-medicalization to occur, the problem must no longer be defined in medical terms, and medical treatments can no longer be deemed appropriate interventions. A classic example is masturbation, which in the nineteenth century was considered a disease and worthy of medical intervention but by the mid-twentieth century was no longer seen as requiring medical treatment (Conrad P, 2007). Another most frequently mentioned example is homosexuality in America which, until 1973, was defined by the American Psychiatric Association (APA) as an illness. After protests and picketing by the gay liberation movement and support from some sympathetic psychiatrists, the APA voted to declassify it as an illness, a decision that was later endorsed in the UK. As a result, homosexuality became more widely recognized as a lifestyle choice. With the onset of the AIDS epidemic in the 1980s, however, it became partially re-medicalized, although in a different form. Overall, the evidence to date is that medicalization is far more common than de-medicalization but it remains important to see it as a two-way process (Gabe J, Bury M, Elson M, 2004).

Khanday 072

For Marxists such medicalization is best seen as serving the interests of the ruling capitalist class. From this standpoint, the creation and manipulation of consumer dependence on medicine are merely examples of a more general dependence upon consumer goods propagated by that class. For feminists the focus has tended to be on how a male-dominated medical profession (as a result of patriarchal system) has increasingly defined women’s problems in medical terms and advocated medical interventions. This is manifested in studies of reproduction and birth control, child-birth, infertility, premenstrual syndrome, fetal alcohol syndrome, eating disorders, sexuality, menopause, cosmetic surgery, anxiety and depression (Gabe J, Bury M, Elson M, 2004). Feminist criticisms, such as the British sociologist Ann Oakley in her book The Captured Womb (1984), have accused a medicalized system of ignoring women’s own preferences and experiences. In other contexts, women are similarly seen as the object of patriarchal medical control, for instance over drugs (especially the prescription of tranquillizers) and surgery, and in general the treatment of women within the medical system is accused of serving to enforce passivity and dependence (Turner B, 2006).

Peter Conrad (2007) incisively examined the particular gendered aspects of medicalization. Scholarly examinations of gender and medicalization, which have largely focused on the medicalization of women, have generally ignored the medicalization of men’s lives. Some have argued that men are not as vulnerable to medicalization as are women: the substantial literature on the medicalization of childbirth, premenstrual syndrome, menopause, and anorexia in women clearly shows that more of women’s life experiences are medicalized than men’s. One of several reasons analysts typically give for women’s vulnerability to medicalization is the traditional definition of a healthy body. On the one hand, Alan Petersen notes, that “male bodies have been constructed through scientific and cultural practices as ‘naturally’ different from female bodies, and the bodies of white, European, middle-class, heterosexual men have been constructed as the standard for measuring and evaluating other bodies”. On the other hand, Riessman (1983) suggests that young women are more vulnerable to medicalization than men because their physiological processes (menstruation, birth) are visible, their social roles expose them to medical scrutiny and they are often in a subordinate position to men in the clinical domain. Sociological theory on medicalization suggests that girls, women, and other less powerful groups are increasingly subject to medicine's authority over their bodies and their lives. Because at adolescence girls suffer a significant drop in self-esteem [American Association of University

Women (1991)], teenage girls may be especially vulnerable to medicalization. Some researchers suggest this sudden drop in self-esteem may be due not only to teenage girls' changing bodies, but also to the negative discourse in our culture surrounding women's bodies and sexuality. Many girls receive limited information about these bodily changes and often feel ambivalent about puberty (Martin K, 1996). Health advice columns in teen magazines (teen magazines are ubiquitous in adolescent girls' lives, as evidenced by their high rates of readership - approximately 90 percent of U.S. adolescent girls read them at least occasionally) are one place where explicit discussions of girls' bodies, health, and sexuality take place. Specifically, health advice columns represent one site where female youth may (or may not) come to respect medicine's pro­nouncements on how people should think about their bodies and what they should do with them. What kind of information and advice is being given in these columns? Through a content and textual analysis of the health advice columns in Seventeen and YM (the two leading "mainstream" teen magazines) and those in New Moon and Teen Voices (two "alternative" teen magazines) from 1998 to 1999, (Mccabe J, 2005) it has been suggested that mainstream advice columns present norms and standards for teenage girls through their focus on medical authority, medical language, citation of medical experts, and "normality," especially regarding sexuality and body issues. In contrast, the girls' advice in the alternative magazine is less medicalized, advocates multiple explanations and multiple authorities on the body, and occasionally recognizes problems as socially produced. Through a format where girls answer other girls' questions, girls are cultural producers in addition to being consumers of health and medical knowledge.

Medicalization can have both constructive and destructive outcomes. Various early writings regarded medicalization as a negative development in Western societies. Labelling something as a medical problem makes it an individual concern, thereby discouraging individuals from discussing their "problem" with others, recognizing non-medical solutions, or attempting to understand the social causes of their "problem" (Conrad P, Schneider JW, 1980). Recently, researchers have questioned this simple characterization and, instead, have argued that medicalization is a complex process.

The major contribution of French social philosopher Foucault to medical sociology is his analysis of the social functions of the medical profession, including the use of medical knowledge as a means of social control and regulation, as he studied madness, clinics and sexuality. Foucault (1973) found two distinct trends emerging in the history of medical practice: “medicine of the species” (the classification, diagnosis, and treatment of disease) and “medicine of social spaces” (the prevention of disease).

073 Int. J. Med. Sociol. Anthropol. The former defined the human body as an object of study subject to medical intervention and control, while the latter made the public’s health subject to medical and civil regulation. The surveillance of human sexuality by the state, church and medicine subjected the most intimate bodily activities to institutional discourse and monitoring. Thus, bodies themselves came under the jurisdiction of experts on behalf of society (Cockerham WC, 2010). Michel Foucault wrote about medicalization in one of his earlier works, Birth of the Clinic: The two dreams (That is, nationalized medical profession and disappearance of disease) are isomorphic. The first dream expressing in a very positive way the strict, militant, dogmatic medicalization of society, by way of a quasi-religious conversion and the establishment of a therapeutic clergy. The second dream expressing the same medicalization, but in a triumphant, negative way, that is to say, the volitization of disease in a corrected, organized, and ceaselessly supervised environment, in which medicine itself would finally disappear, together with its object and raisond’être” (Conrad P, 2007). Michel Foucault saw medicalization not as the simple exercise of personal power by profession intent on extending its boundaries, but as a historical process deriving from the power of clinical knowledge and the redefinition of medicine to include psychological, economic, and social “health” (Turner B, 2006). Michel Foucault argued that the dominance of professional power of doctors led to their convergence around the medical gaze, through which the sick are represented as objects for surveillance and technical intervention (Wainwright D, 2008). In a series of books such as Madness and Civilisation, The Birth of the Clinic and The History of Sexuality, Foucault emphasised the increasing penetration of medical ideas and practices in Western ways of thinking, particularly from the period of the Enlightenment onwards. However his conception of power differed from others such as Zola or Illich. In Foucault’s view, power and knowledge are inextricably linked and power operates through the development and construction of discourses. These constitute ways of seeing and understanding the world and are not just constraining but also productive. Medical discourses are guidelines as to how patients should understand and regulate their bodies, and they create new ways of thinking, new possibilities and new opportunities. For Foucault power does not exist in doctors considered as ‘figures of domination’. Instead it exists in relationships between people [9]. Foucault did not typically use the term “medicalization” but tended “to present a consonant vision that shows the impact of medical discourses on people’s lives” [http://scholar.google.co.in/citations? user=eUTSClMAAAAJ&hl=en]. But most studies of medicalization tend to be social constructionist rather than Foucauldian in orientation (Conrad P, 2007).

British scholar Nikolas Rose (2001; 2007a) has expanded the Foucauldian perspective on bio-politics and offers three phases of bio-politics to understand new forms of medical culture and social control. Risk politics characterizes the first half of the twentieth century, when the focus was on prevention of major public health problems. Two new types of bio-politics followed during the second half of the century. Molecular politics is a reorganization of the medical gaze at the molecular level. This politics is represented by, for example, biological psychiatry, a discipline that looks at the neurotransmitters of the brain to identify chemical imbalances that are seen as the causes of mental pathologies. Current bio-politics has taken the character of etho-politics: it demands an optimization of one’s corporeality to embrace an enlarged will to health and concerns itself with “the self -techniques by which human beings should judge themselves and act upon themselves to make themselves better than they are”. It is argued that this new regimen blurs the boundaries between expert knowledge and the individual’s will to self-regulation. In this kind of society, individuals are still dependent on experts who provide the technologies for rational management of the self (Cockerham WC, 2010).

CONCLUSIONS

Thus we can conclude by asserting that “Medicalization” describes a process by which non-medical problems become defined and treated as medical problems, usually in terms of illness and disorders”. (The concept of medicalization has proved a useful descriptive tool for sociologists and other intellectuals and is still used quite frequently, almost invariably with critical force. Some, following Illich, have also been critical of the professional medical power and of the ideas and practices of medicine. The negative effects of medicalization and Irving Zola’s opinions on medicalization –that is the medical establishment has become a major threat to health and providing a dossier of medicine’s adverse effects – the wrongs and harms it has done –through processes of clinical, social and cultural ‘iatrogenesis’ or doctor-induced conditions; expansion of modern medicine has created a dependence on doctors and taken away people’s ability to engage in self-care; the modern medicine has unfortunately destroyed the cultural and individual capacities, launching instead an inhuman attempt to defeat death, pain and sickness; has sapped the will of the people to suffer reality; people are conditioned to get things rather than to do those; doctors were becoming the new priesthood and modern medicine were creating overdependence on technical fixes, all these

points show that there is the need of de-medicalization. The earliest critiques argued that the medicalization case has

Khanday 074 been overstated and that significant constraints limit rampant medicalization. Some of these critiques conflated de-professionalization with de-medicalization. Others failed to recognize that most studies of medicalization adopt a historical, social-constructionist perspective. Despite of all these criticisms medicalization remains a useful concept for sociologists of health and illness and there is a need to go beyond the accumulation of different cases of medicalization to try and develop a more integrated theory of the process of medicalization, its causes and consequences and to relate these to recent changes in medical organization and knowledge and the growing challenge to medical authority.

REFERENCES

Cockerham WC (2010). The New Blackwell companion

to Medical Sociology. Wiley Blackwell publication. 350 Main Street. Malden, USA, pp. 16-34.

Conrad P (2007). The Medicalization of Society. Transformation of Human Conditions into Treatable Disorders. Johns Hopkins University Press. 2715 North Charles Street Baltimore, pp. 04-152.

Turner B (2006). The Cambridge Dictionary of Sociology. UK: Cambridge University Press, p.379.

Thomas RK (2002). Society and Health: Sociology for Health Professionals. New York, US: Kluwer academic publishers, p. 292.

Wainwright D (2008). A Sociology of Health. New Delhi, India: Sage publications, pp. 97-111.

Gabe J, Bury M, Elson M (2004). Key Concepts in Medical Sociology. London: Sage publication, pp. 09-61.

Conrad P (1975). The Discovery of Hyperkinesis: Notes on the Medicalization of Deviant Behavior. Social Problems, p. 23.

Pescosolido BA, Martin JK, McLeod JD, Rogers A (2004). (ed.). Handbook of the Sociology of Health, Illness, and Healing: A Blueprint for the 21st Century. New York: Springer, p. 179.

Scott J (2006). (ed.). Sociology: The key concepts. New York, USA: Rout ledge, p.100.

www.bmj.com/content/324/7342/859.full (01/11/2013). Bhardwaj R (2010). Medical Pluralism in India: The

interface of complementary and alternative therapies with allopathy. In Arima Mishra. (ed.). Health, Illness and Medicine: ethnographic readings. New Delhi, India: Orient Black Swan, p. 37.

Barry AM, Yuill C (2002). Understanding health: A Sociological Introduction. New Delhi, India: Sage Publication, p. 29.

Larkin M (2011). Social Aspects of Health, Illness and

Healthcare. New York, USA: Open

University Press, pp. 111-112.

American Association of University Women (1991).

Shortchanging girls, shortchanging America: A

nationwide poll to assess self-esteem, educational

experiences, interest in math and science, and career

aspirations of girls and boys ages 9-15. Washington

DC: The Foundation.

Martin K (1996). Puberty, sexuality, and the self: Boys and girls at adolescence. New York: Rout ledge, pp. 1-15.

Conrad P, Schneider JW, (1980). Deviance and

medicalization: From badness to sickness. St. Louis:

C.V. Mosby Company.

Mccabe J (2005). Sociological Studies of Children and

Youth Sociological Studies of Children and Youth.

Elsevier Ltd.11: pp. 153-191.

Ghosh S (2010). Increasing trend in caesarean section

delivery in India: role of medicalization of maternal

health. Institute for social and economic change.

Bangalore, India: pp. 2-8. Available at

(www.isec.ac.in).

www.ncbi.nlm.nih.gov› Journal List › BMJ › v.324(7342);

pr 13, 2002 (01/11/2013).

Bruekens P (2001). Over-medicalization of maternal

care in developing countries. In Brouwere VD and

Lerberghe WV (ed.). Safe Motherhood Strategies: A

Review of the Evidence. Antwerp: ITG Press.

Mishra US, Ramanathan M (2002). Delivery related

complications and determinants of cesarean section

rates in India. Health Policy and Planning. 17: pp.

90-98.

Keeler BE, Brodie M (1993). Economic incentives in the choice between vaginal delivery and cesarean Section. The Milbank Quarterly. The Milbank Memorial Fund. 71: 365-404.

Potter JE, Berquó E, Perpétuo I, Ondina LF, Hopkins K, Marta RS, Maria C (2001). Unwanted caesarean sections among public and private patients in Brazil: prospective study. Bri. Med. J. Vol. 17: p. 323.

Ash A, Okah D (1997). What is the right number of caesarean sections? The Lancet. Vol. 349: p.1557.

Kambo I, Bedi N, Dhillon BS, Saxena NC (2002). A critical appraisal of cesarean section rates at teaching

075 Int. J. Med. Sociol. Anthropol. hospitals in India. Int. J. Gynecol. Obst. Vol. 79(2): p. 79. Kabra SG, Narayan R, Chaturvedi N, Anand P, Mathur G

(1994). What is happening to cesarean section rates? The Lancet. p. 343.

Padmadas SS, Suresh KS, Nair SB, Kumari KRA (2000). Cesarean Section Delivery in Kerala. India: Evidence from National Family Health Survey. Social Science and Medical Science. p. 51.

Boler T, Marston C, Corby N, Gardiner E (2009). Medical Abortion in India: A model for the rest of the world? Marie Stopes International. London, pp.11-12.

http://scholar.google.co.in/citations?user=eUTSClMAAAAJ&hl=en. (01/11/2013).