Many of today's common medical conditions, from osteoporosis to hyperactivity, were not recognized as medical conditions a century ago. Medicalization is the term for the process by which these phenomena and many others have come to be viewed as medical conditions. Peter Conrad, a sociologist at Brandeis University, has spent his career studying various aspects of medicalization, and his new book includes updates of some of his earlier writings as well as some new ideas about the topic. After an introductory chapter, four chapters present case studies in medicalization, and three final chapters discuss additional theoretical topics.

The four case studies are the meat of this slim volume, and they draw on articles that Conrad has previously published elsewhere. In the first case study, Conrad argues that the male aging process has been medicalized, as seen in recent discussions of erectile dysfunction, male-pattern baldness, and most controversially, "andropause," the purported male counterpart to menopause. Each of these three phenomena could be thought of as part of the natural aging process for men; even the low testosterone levels characteristic of andropause may be typical for men of a certain age. However, as Conrad notes, all of these conditions are now in the province of medicine, technical terms are used to describe them (e.g., "androgenic alopecia" for baldness), physicians serve as gatekeepers by diagnosing them, and pharmaceutical companies are eager to develop medications to treat them. Conrad points out how each of these conditions involves an extension of a medical category: extremely low testosterone levels, for instance, have been treated medically for some time, but by lowering the diagnostic threshold, the category of "low-testosterone men" is extended to include most aging men.

The second case study tracks the expansion of a medical category (attention deficit hyperactivity disorder, or ADHD), from children to adults. Conrad shows how national support groups and self-diagnosed advocates expanded the concept of ADHD to include adults–even successful, high-achieving adults who would not seem to have a psychological disorder. In ADHD, according to Conrad, more than one thing is medicalized; in children, it is bad behavior, whereas in adults, it is underperformance (often defined by the potential patient's lack of satisfaction with his or her accomplishments). Certainly, many testimonials of adults with ADHD diagnoses include complaints about forgetfulness, distractibility, and other problems that could be due to a mismatch between the individuals and their chosen occupations and lifestyles rather than any neurological dysfunction. Conrad notes that adults with ADHD diagnoses are, just like children, encouraged to begin treatment with medication; indeed, one drug, Strattera, was designed specifically for adults with ADHD, and is advertised in commercials showing a man "forgetting his car keys, arriving late for appointments, and unable to complete work assignments on time"–not the gross and disabling impairment that one expects from a medical disorder, but problems that most adults have from time to time.

The third case study concerns a topic with well-known ethical issues: prescribing human growth hormone (HGH) to individuals of short stature. Until 1985, HGH could only be obtained from cadavers, and as such, it was only available for children whose own bodies could not produce sufficient HGH. But after synthetic HGH was developed, it began to be prescribed for children who were, for whatever reason, simply at the bottom tail of the height distribution. Moreover, drug companies and physicians found other uses for HGH that had little to do with height per se: keeping AIDS patients from the "wasting" phenomenon common in late stages of the disease, and helping cancer patients to maintain weight during chemotherapy. However, as Conrad notes, the most controversial applications of HGH involve its prescription as an enhancement rather than as therapy for a deficiency. For instance, HGH's ability to increase muscle-to-fat ratios has made it interesting to professional athletes and their trainers, as well as middle-aged individuals searching for an "anti-aging" drug. Conrad does not explicitly condemn these uses, but he notes the issues that they raise, including unequal access to HGH, the fairness of allowing drugs to enhance "natural" talent (as in athletic competition), and the ways in which prescribing drugs can reinforce societal values about aging and other topics.

Conrad's final case study, homosexuality, is actually a study in demedicalization — the process by which a condition stops being viewed as a medical condition. Conrad details the recent history of attitudes towards homosexuality, including an initial medicalization period (during which homosexuality changed from a sinful behavior to an unfortunate condition deserving of pity) followed by a longer demedicalization period. In the latter period, the American Psychiatric Association dropped homosexuality from its official guide to mental disorders, all but a few mental health professionals declined to "treat" it, and society as a whole became more tolerant of variations in sexual behavior. However, as Conrad notes, these changes have actually coincided with an increase in the degree to which sexual orientation is seen as determined by genes and biology. Therefore, although medicalization typically requires that a condition be thought of in biological terms, biological framing is not always sufficient for medicalization.

Conrad's book is helpful in a variety of ways, but most importantly for its attention to the diversity of medicalization. Specifically, the book points to the range of stakeholders whose interests influence the process; unlike exposés of the pharmaceutical industry "inventing" medical problems and portrayals of physicians imposing their own views of health on the public, Conrad emphasizes the multiple, interrelated causes of medicalization. He is especially sensitive to the way in which consumerism in the health care arena leads to an expansion of diagnostic categories–after all, for consumers to have something "treated," and especially to have it paid for by insurance, it must first be labeled as a disorder. In general, then, Conrad offers a more nuanced perspective on medicalization than those offered elsewhere.

The book also has certain failings. Conrad refuses to explicitly judge whether the medicalization of a given condition is appropriate; this is understandable, given his perspective as a social scientist, but it makes some of his evaluations seem awkward as he tries to avoid coming out for or (more often) against medicalization. Also, the book is uneven in its accessibility; the case studies are extremely accessible, whereas some of the theoretical chapters are written at a higher level. Finally, when Conrad gives technical details about a given disorder, the reader must trust his concise descriptions of epidemiology and physiology. I can only evaluate the case study of ADHD with regard to these technical issues, but in that chapter, Conrad appears to misstate some of the details. He claims that the gender ratio (male prevalence to female prevalence) has changed from 9:1 to 3:1, but in fact current estimates span that entire range. He also claims that "the genetic nature of ADHD is still contested," but this isn't true in any meaningful sense; researchers agree that individual differences in impulsiveness, hyperactivity, and inattention are due in part to genetic differences between people, even if the mechanisms by which genes affect these behaviors are not entirely understood. Certainly, much of Conrad's scholarship on ADHD is meticulous and his careful reading of a great deal of technical literature is evident, but these mischaracterizations are still worrisome. Admittedly, the book is short, and at times I felt as though there was not sufficient space for the detailed exposition that some of these technical issues deserved.

Overall, then, The Medicalization of Society is an accessible yet nuanced introduction to a fascinating and important topic. Readers do not need any background in medicine or academic sociology to appreciate Conrad's inquiry, and the experience of living in the 21^st century United States is enough to understand what he's talking about. Of course, in a way, that's the whole point of the book.

© 2007 Benjamin J. Lovett

Benjamin J. Lovett, Ph.D., is an assistant professor of psychology at Elmira College, where he teaches classes on a variety of topics in psychology and his research focuses on the conceptual and psychometric foundations of psychoeducational assessment and psychiatric diagnosis.

Categories: General, Ethics, Philosophical