Medicalization of Health Issues PDF

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Eastern Mediterranean University

Sinem YILDIZ İNANICI

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medicalization social health sociology of illness

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This document provides an overview of medicalization, defining it as the process by which non-medical issues become defined and treated as medical problems. It explores various facets of medicalization, including its characteristics, types, and consequences, from historical to contemporary contexts. The document uses case studies and research examples to illustrate the points made.

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medicalization Sinem YILDIZ İNANICI 2 3 4 concept ‘to make medical’ Medicalization is the process by which nonmedical problems become defined and treated as medical problems often requiring medical treatment. The focus of medicalization is on the process by which human problems or conditions become...

medicalization Sinem YILDIZ İNANICI 2 3 4 concept ‘to make medical’ Medicalization is the process by which nonmedical problems become defined and treated as medical problems often requiring medical treatment. The focus of medicalization is on the process by which human problems or conditions become defined and treated as medical problems. 5 Characteristics of Medicalization (1) The definitional issue is central to medicalization; that is, how a problem is defined is key to what is to be done about it. (2) Thus medicalization is more of a continuum than a binary either/or distinction. For example, some problems are almost completely medicalized (e.g., schizophrenia, epilepsy), while others are only somewhat medicalized (e.g., Internet addiction, sexual addiction), with still others contested or somewhere in between (e.g., obesity, opiate addiction) 6 Characteristics of Medicalization (3) Medicalized categories can expand or contract. attention deficit hyperactivity disorder (ADHD) was for many years seen as a disorder of children but it is now seen as a lifespan disorder, including adult ADHD. Posttraumatic stress disorder emerged in the 1970s as a diagnostic category depicting Vietnam veterans and has expanded to include survivors of violence, sexual abuse, or natural disasters. Now it can even be applied to individuals who have witnessed violence or disaster. 7 (4) Physician involvement in medicalization is variable. With the medicalization of alcoholism, physicians were minimally involved; rather, the emergence of Alcoholics Anonymous was central to this process. With many other examples of medicalization, direct medical involvement is a key. (5) Medicalization is bidirectional; that is, there can be medicalization as well as demedicalization. The most common example of demedicalization has been homosexuality, which due to the 1974 vote of the American Psychiatric Association and subsequent changes became ‘officially’ demedicalized (Conrad, 2007). 8 One recent study (Conrad et al., 2010) estimates that medicalized disorders cost about $77 billion or about 3.9% of our health care expenditures, more than is spent on all of US public health. Medicalization is by its nature a ‘bad’ thing? Medicalization is not a normative process, in itself neither bad nor good. Historically, for instance, there are many examples of beneficial medicalization, such as epilepsy and, in important ways, childbirth. 9 Together with sociologists, anthropologists in the 1970s and 1980s often described medicine as an institution of social control, with health professionals acting as the agents of such control (Lock and Nguyen, 2010: p. 70). 10 Definition Jesse Pitts (1968), ‘social control’: the social processes involved in regulating the behaviour of individuals and groups. «redefining certain aspects of deviance as illness rather than crime’ is one means whereby deviant behaviour is controlled, adding ‘medicalization is one of the most effective means of social control’ 11 What counts as illness is socially constructed and a product of social factors (Conrad and Barker, 2010). Irving K. Zola (1972) ‘Medicine as an institution of social control’ He defined medicalisation as the process of ‘making medicine and the labels “healthy” and “ill” relevant to an ever increasing part of human existence’ (Zola 1972: 487), 12 Medicalization and Mental Health Reflecting upon the American Psychiatric Association’s designation of grief as a diagnostic category in the diagnostic and statistical manual– fifth edition, Kleinman (2012) cautions against: Turning ordinary bereavement into an appropriate target of medical intervention. He describes the medical profession’s ability to reframe experience in ways that can influence culture change, for example, around death. 15 How medical models of causation ignore sociopolitical context and individualize aspects of mental health for example, showing how hunger and related distress, or nervos, in Northeast Brazil, were medicalized and treated through medical interventions such as pharmaceuticals rather than through social and political reform. a need to explore both micro- and macro level contexts, individual experiences and social relations, local contexts as well as broader political and economic forces (e.g., Scheper-Hughes and Lock, 1986; Singer, 1989; Taussig, 1980). 16 Medicalization and Women’s Health Medicalization of women’s bodies and health (e.g., fertility, pregnancy, childbirth, menopause) Anthropologists have explored how (e.g., via cesarean section or natural birth), where (e.g., in a hospital or at home), and when (e.g., prolonged pregnancy and induced labor) women give birth, as well as the ideological and sociocultural frames which may influence such decisions (e.g., Behague, 2002; Davis-Floyd, 2003; Donner, 2003; Westfall and Benoit, 2004). 17 They have also described how resistance to medicalization contributed to the emergence of the home birth movement and the use of alternative therapies (Davis-Floyd, 1993, 2003; Lock and Nguyen, 2010). An important line of anthropological research connects how, by extending the sick role over a broader range of human conditions, medicalization can excuse an individual from social roles and expectations (e.g., related to school, work, caregiving) (Lock, 2001; Scheper-Hughes and Lock, 1986). 18 Social Consequences of Medicalization Sociologists, focusing on the emergence and treatment of diagnoses such as ADHD, mild depression, obesity, and menopause (see Conrad, 2007; Horwitz and Wakefield, 2007) , have expressed concerns about the pathologization of everything, that is, turning all human differences into diagnoses and treatable disorders. 19 Wentzell’s (2013) ethnographic research revealed how older Mexican men resisted a medical model of Aging and its associated antiaging interventions by Rejecting the use of erectile dysfunction drugs. Men framed decreased sexual activity as a means of fulfilling socially valued gender norms. 20 Has the medicalisation of childbirth gone too far? Over the past few centuries childbirth has become increasingly influenced by medical technology, and now medical intervention is the norm in most Western countries. Hospital birth was uncommon before the 20th century, except in a few major cities.1 2 Before the invention of forceps, men had been involved only in difficult deliveries, using destructive instruments with the result that babies were invariably not born alive and the mother too would often die. 21 In the 19th and 20th centuries, medical influence was extended further by the development of new forms of analgesia, anaesthesia, caesarean section, and safe blood transfusion. The World Health Organization and Unicef estimated the average maternal mortality ratios for 1990 as 27 per 100 000 live births in the more developed countries compared with 480 per 100 000 live births in less developed countries, with ratios as high as 1000 per 100 000 live births for eastern and western Africa.4 22 The WHO has estimated that almost 15% of all women develop complications serious enough to require rapid and skilled intervention if they are to survive without lifelong disabilities. 5 Despite this, the decreases in maternal, perinatal, and infant mortality in the West owe much to the impact on health of developments in disease control, smaller family sizes, and higher standards of living, including improved diet. In England and Wales in the early 1930s, for example, maternal mortality was lower among women with husbands in manual occupations, who were mainly cared for by midwives, than among those who were married to men in non-manual occupations, who were more likely to have care from doctors.8 23 Increasing rates of unnecessary intervention In many countries women who have straightforward pregnancies are subjected to routine intravenous infusions and oxytocin in labour. Women without obstetric complications are encouraged to have electronic fetal monitoring and epidural analgesia. Frequently labour will be in the dorsal position and delivery in lithotomy. Perineal injury is standard. 24 Caesarean section rates in the United States, Canada, Italy, and the United Kingdom are all about 20%9; obstetricians must be held account able for these rising rates. 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. However, Hopkins found that doctors were active participants in decision making and used their expertise and authority to convince women to ``choose” a caesarean.10 25 In Spain, obstetric care includes routine enemas, pubic shaving, and episiotomy, procedures that are not much 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.11 26 Long term morbidity after childbirth can be substantial,12 and this is particularly related to instrumental and caesarean delivery. Specific concerns relate to painful intercourse and urinary and anal incontinence. 27 Contribution of midwives to medicalisation Olsson and coworkers made video recordings of midwives' consecutive encounters with women and couples at antenatal and postnatal consultations.16 The authors found that “a mechanistic and medicalised understanding of childbirth” seemed to dominate the discussions. Kirkham found “learned helplessness and guilt” among UK midwives— respondents spoke of a world in which they were constantly threatened by blame.17 28 “Demedicalisation” of birth So what can be done to “demedicalise” birth? A study commissioned by the Canadian health minister suggests that maternal or newborn programmes in Ontario can maintain low caesarean section rates over time, regardless of their size, location, level of care they provide, and population they serve. Twelve critical success factors, including “the right attitude, focus, leadership, teamwork, support, and a personal and financial commitment to best practice and continuous quality improvement”were identified based on practices at four Ontario hospitals with comparatively low caesarean rates.19 The “right attitude” included taking pride in a low caesarean rate, developing a culture of birth as a normal physiological process, and having a commitment to one to one supportive care during active labour. 29 Exploring the medicalisation of childbirth through women’s preferences for and use of pain relief In spite of increasing interventions, maternal and neonatal mortality rates have shown small variations and have not decreased over the past ten years, raising questions about whether medical intervention is justified to the current extent. Important to consider is that women’s expectations and perceptions of birth are influenced by interplaying private, professional, and public discourses on pregnancy and birth. 30 Women’s attitudes towards birth may therefore be shaped by their background, experiences, values, beliefs, and needs, which in turn reflect the social and political (in terms of resources) birthing environment and the dominant birthing discourse in a particular culture or country [5,14]. Previous research has shown that primiparas are more likely to prefer non-pharmacological methods compared to multiparous women, and that women with a fear of birth are more likely to desire epidural analgesia. 31 Although pharmacological methods (epidurals, opioids) are associated with reduced pain and increased control for some, making birth manageable and even enjoyable… Some women who use them are more likely to experience negative side effects, negative encounters with healthcare providers, and a sense of guilt and/or failure [16–18]. 32 On the other hand, women who use non-pharmacological methods (e.g. massage, relaxation) may not have as efficient pain relief, but find it gratifying to actively work with their physiological responses in collaboration with their birth supporters. Although the evidence on the impact of epidural analgesia is limited and ambiguous , rates are increasing mainly in middle and highincome countries. 33 Acknowledging its efficacy and benefits and stressing that the risk of complications is relatively small, epidural analgesia is nevertheless associated with a number of side effects, partly depending on the dosage of added local anaesthetic: maternal hypotension motor blockade maternal fever and itching urinary retention longer first and second stages of labour, headache, short-term backache, and lower breastfeeding rates [4,16,19–21]. 34 research The primary aim of this study was to explore the medicalisation of birth through women’s preferences for and use of pain relief. The secondary aim was to investigate whether the presence of a birth plan had any impact on use of pain relief, rate of intervention, and satisfaction with the birth experience. As in Swedish labour wards in general, the ward was obstetrician-led but with midwives as the primary caregivers for women with normal births, calling upon an obstetrician in the event of a complication and upon an anaesthesiologist for the administration of an epidural. 35 The labour ward under study offered all different forms of pain relief around the clock, with the midwives administering all but epidural and spinal analgesia. The prevalence of the various methods of pain relief for primiparas/multiparas respectively in this setting was at the time of the study: bath 12.8%/5.2%, Transcutaneous Electrical Nerve Stimulation (TENS) 5.8%/2.6%, nitrous oxide 86.5%/73.3%, epidural analgesia 53.2%/21.0%, and pudendal nerve block 11.8%/3.0%. 36 400 women, who gave birth in the above-mentioned hospital between March and June 2016, were handed written information about the study a few hours after birth, regardless of age, parity, ethnicity, mode of delivery, or preferences for pain relief. 259 women (64.8%) consented to participate and gave their written consent prior to being discharged from hospital, usually within 48 h after birth. 37 Women who had elective caesarean sections (n = 16), twins (n = 3), or extremely premature births (less than 28 weeks of gestation) (n = 1) were excluded. Thus, 239 women were included in the study, of which the majority were healthy with normal pregnancies and were expected to have uncomplicated vaginal births, according to the medical records. Of these, 129 women (54.0%) had written a birth plan. 38 Data was also gathered on women’s satisfaction with their birth experience, using an evaluation form estimating satisfaction on a Visual Analogue Scale (VAS) ranging from 0 to 10. The evaluation form was part of routine care and was filled in by most women before being discharged from the hospital, generally within 48 h. after birth. As part of the labour ward’s quality management, women rating their birth experience 3 or below were offered counselling by a specially trained midwife, usually within three months postpartum. 40 The women’s answers were identified and classified into five variables: 1. Non-pharmacological methods(breathing techniques, relaxation, massage, bath or shower, hot packs, TENS, acupuncture, and sterile water injections) 2. Nitrous oxide 3. Epidural analgesia as a second choice 4. Epidural analgesia 5. Conferring with the midwife. 41 42 43 44 46 Multiparas were more satisfied than primiparas, 8.4 vs 7.4, (p <.001), and women without epidural analgesia were more satisfied than women with epidural, 8.3 vs 7.2, (p <.001). Primiparas without epidural analgesia were more satisfied than those with, 8.1 vs 6.9 (p =.002), and multiparas without epidural analgesia were slightly more satisfied than those with, but not on a significant level, 8.4 vs 8.1, (p =.348). Even the women who had explicitly stated in their birth plans that they wanted an epidural (n = 23) were more satisfied if they did not have one, 8.8 vs 7.6, (p =.047). 47 The higher the number of interventions, the lower the level of satisfaction (r=.31, p <.001). 48 This study shows that parity rather than birth plan was a greater determinant for use of pain relief, frequency of interventions, and level of satisfaction Primiparas using more pain relief, having more interventions, and being less satisfied with their birth experiences than multiparas. In regards to satisfaction with the birth experience, two days after birth most women were very satisfied - women without epidural analgesia and interventions slightly more so. 49 Medicalization of grief There are a number of consequences of medicalization including increased medical treatments, insurance coverage, and changes in stigma. The recent removal of the bereavement exclusion (BE) from the Diagnostic and Statistical Manual of Mental Disorders (DSM-5; American Psychiatric Association [APA], 2013) has prompted much debate about what is considered a socially appropriate length of time for bereaved individuals to grieve. 50 There are three major macrolevel and microlevel consequences of this medicalization of grief: 1. As with other changes that have been medicalized, removing the BE may lead to the overdiagnosis and overtreatment of major depression, as more individuals fall under the criteria for major depression. 2. There is the potential for the pharmaceutical industry to market a treatment for this increased population of those considered to have major depression. 3. The changes to the BE call into question the loss of traditional and cultural methods of grieving with the introduction of psychiatry in the human emotion of grief. 51 Bereavement first appeared in the third edition of the DSM (DSM-3) in 1980 The DSM-3 distinguished between uncomplicated, or a normal reaction to loss, and complicated grief: Unless an individual experienced severe expressions of grief including those of the latter half of the statement, then he or she was considered to exhibit normal grief. 52 The DSM-3 committee noted that depressive symptoms, within the context of bereavement, were a normal reaction to the death of a loved one, whereas if these symptoms occurred outside of bereavement, they would be abnormal (Mojtabai, 2011). A number of studies on widows and widowers revealing an improvement in their symptoms of depression over time (e.g., Clayton, Desmarais, & Winkour, 1968) served as the impetus for the guidelines in the fourth edition of the DSM (DSM-4; APA, 1994). The DSM-4 operationalized the duration of these symptoms as persisting for longer than two months after the loss, stating: 53 These symptoms had to exist for at least 2 weeks, although the diagnosis could not be given until at least 2 months following the death of a loved one. 54 It is important to note that complicated grief (CG) is a contested category of intense and prolonged grief that differs from major depression in that it is characterized by an intense sense of yearning, recurrent thoughts of the deceased person, and feelings of intense loneliness and hopelessness, which can result in a variety of poor behaviors (Prigerson et al., 1995; Shear et al., 2011). There was much debate as to whether prolonged grief disorder should be included in the DSM-5, with the ultimate decision being not to include it (Bryant, 2014). 55 The DSM-5 that was released in May 2013 changed the BE, removing the 2-month waiting period (Fawcett, 2010). The new criteria allow a bereaved individual to be diagnosed with major depression after 2 weeks of experiencing symptoms. There are four major arguments that prompted the removal of the BE in the DSM-5. 1. the changes are based on data from recent studies finding no major difference between bereavementrelated depression and depression caused from other life stressors (Fawcett, 2010; Flaskerud, 2011; Kendler, Myers, J., & Zisook, 2008; Zisook & Kendler, 2007). For example, bereavement-related depression was considered similar to depression related to other stressful life events in terms of risk factors, intensity, characteristics, biology, symptoms, and response to treatment (Pies & Zisook, 2010; Zisook & Kendler, 2007). 56 2. Three international studies including those of Karam et al. (2009), Kessing et al. (2010), and Corruble et al. (2009) (Lamb, Pies, & Zisook, 2010). These three studies from Lebanon, Denmark, and France revealed that individuals who were excluded from the diagnosis of depression due to bereavement actually had more severe symptoms than those with non-bereavement related depression (Lamb et al., 2010). These studies implied that bereaved individuals who are excluded from receiving the diagnosis of major depression may develop more severe depression mbecause they are unable to access different treatments mfor their depression. In addition, others have argued that the inability to recognize and treat these symptoms may result in a ‘‘public health disaster’’ for those who did not receive treatment (Pies & Zisook, 2010). 57 3. A third argument for removing the BE in the DSM-5 is that this change would be parallel to existing international criteria in the International Classification of Disease (ICD-10; Pies & Zisook, 2010). The unification of the criteria for depression related to bereavement in the DSM and the ICD would make the diagnosis more consistent. 58 4. Finally, the fourth rationale for removing the BE in the DSM-5 is that clinicians should be able to properly distinguish ‘‘productive’’ grief from more serious reactions of grief including feelings of isolation and the inability to be consoled. Moreover, clinicians should evaluate patients’ experiences and examine phenomenological differences rather than solely using diagnostic check-lists (Pies & Zisook, 2010). This idea of the phenomenology of grief comes from the notion that there is a distinction between normal sorrow and severe depression that clinicians are best able to evaluate. Sorrow involves a feeling of being closely connected with others, whereas depression includes feelings of loneliness and separation from others. It is important for clinicians to distinguish between normal and more severe reactions to grief (Pies & Zisook, 2010). These medical and psychiatric professionals are some of the important claims-makers in the changes the DSM-5, yet there are many others who oppose their views. 59 Criticisms of the removal of the BE in the DSM-5. First, longitudinal data indicate that those who experienced a single, brief depressive episode due to bereavement had unique symptoms and no greater risk for future depression compared to those who experience other types of depression (Mojtabai, 2011). Similarly, a comparison of bereavement-related depression and depression from other sources revealed that there are distinct differences between uncomplicated and complicated depression for both bereavement and other losses (Wakefield et al.,2007). These two studies support the previous criteria in the DSM-4 of the BE as a way to distinguish between different types of depression and thus do not support the elimination of the BE in the DSM-5. 60 Second, there have also been important criticisms of the studies cited as evidence for the BE changes in the DSM-5. Some research compared all bereavement-related depression to depressions caused from other life stressors (Zisook & Kendler, 2007). Critics of the changes considered this type of comparison problematic because they believed there needed to be a distinction between uncomplicated and complicated reactions to grief in the bereavementrelated depression group because the BE did in fact distinguish between the two categories (Wakefield & First, 2012). In addition, the international studies by Kessing et al. (2010), Corruble et al. (2009), and Karam et al. (2009) that were previously mentioned were also criticized because they were believed to have either not correctly tested the BE or used samples that were too small to draw any worthy conclusions (Wakefield & First, 2012). 61 The third major criticism to the removal of the BE is that the BE already considered severe expressions of grief. About 10–15% of bereaved individuals reportedly experience severe expressions of grief (Bonanno, 2004). It is these individuals to which the new DSM targets (Flaskerud, 2011). Many proponents of the changes argue that the DSM-5 will allow health professionals to identify bereaved individuals who need help. Yet, the criteria to help these individuals who experience severe grief already existed in the DSM-4 (Frances, 2010). 62 For example, the BE in the DSM-4 already accounted for thoughts of suicide, and thus the individual would, by definition, classify as having a mental illness (Wakefield & First, 2012). These issues illuminate the importance of paying careful attention to the way the DSM defines the BE. 63 With the introduction of bereavement-related issues in the DSM beginning with the DSM-3, there has been a transformation in the culture around issues of death and dying that has led to changes in who and what social institutions can intervene in these once-deemed private emotions. Western society can be characterized as death-denying in which death is a taboo subject (Harris, 2009). 64 There has been a historical transformation in the nature of grief as an object of psychological study, such that changes ‘‘around death, dying, and grieving in the 20th and 21st centuries represent shifts in ideology and culture that have left an open space for psychologists to step in and provide guidance amid this uncertainty and ambiguity surrounding mourning’’ (Granek, 2014, p. 32). Although religious institutions historically provided ways for dealing with issues around death and grief (Granek, 2014; Seale, 1998), there are now societal expectations of how bereaved individuals should behave (Harris, 2009). 65 The medicalization of grief results in three major consequences including overtreatment and overdiagnosis, an expanded market for pharmaceutical companies, and the loss of traditional and cultural methods of grieving that are all expressed on both the macro- and microlevels. 66 Overtreatment and Overdiagnosis One important macrolevel consequence of the elimination of the BE is that it could lead to overdiagnosis and overtreatment of grief (Frances, 2010). By eliminating the 2-month ‘‘normal’’ grieving period, it is possible that the symptoms of those who seek treatment immediately (following the 2-week minimum for the presence of symptoms) may eventually resolve on their own without medical or psychiatric intervention. On a macro-level, overdiagnosis would result in an expanded number of individuals considered to have major depression. 67 Clinicians should be both mindful and skilled in their ability to differentiate between clinical depression and normal depressive emotions in recently-bereaved persons (Friedman, 2012). Further, clinicians and researchers should recognize the importance of the context of the death, especially for those who have experienced traumatic deaths (Thieleman & Cacciatore, 2013). 68 Overtreatment is also a microlevel concern. If intervention for some individuals’ grief is unnecessary, their feelings or symptoms may worsen with treatment (Horwitz & Wakefield, 2007). On a microlevel, as with any condition that requires treatment with prescription drugs, there may be side effects which oftentimes are worse than the condition itself and may lead to other conditions (Flaskerud, 2011). 69 Expanded Market for Pharmaceutical Companies Opportunity for pharmaceutical companies to create new markets for drugs (Frances, 2010; Friedman, 2012). Death is a naturally occurring life event; 2.5 million Americans die each year (Murphy, Xu, & Kochanek, 2010). Medicalizing grief would potentially open up a huge market for pharmaceutical companies. 70 This medicalization of grief could also have repercussions on insurance companies by legitimatizing coverage for prescription medications. According to a 2012 study, 69% of DSM-5 committee members reported financial ties to pharmaceutical companies, which was a 21% increase from the proportion of DSM-4 task force committee members (Cosgrove & Krimsky, 2012). 71 Loss of Traditional and Cultural Methods of Grieving On a macrolevel, prescribing a pill for intense feelings of grief may ultimately eliminate traditional coping mechanisms (Flaskerud, 2010). For example, research may illuminate how religious communities have responded to these changes in the BE, and perspectives from different religious traditions may help to inform how the DSM affects traditional grieving (Peteet, Lu, & Narrow, 2011). 72 On a microlevel, grief is a very personal matter, and many opponents to the changes question whether there should be a restriction placed on the length of time an individual has to grieve. In other words, is it appropriate for clinicians to intervene, and if yes, when should they do so? Here the authority of the medical profession is visible in its ability to define what is normal and abnormal. The removal of the BE illustrates the relation between social control and medicalization, demonstrating how defining grief in medical and psychiatric terms may erase human difference and individuality in the grieving process. 73 Last Word… There are three major macrolevel and microlevel consequences of this medicalization of grief: 1. As with other changes that have been medicalized, removing the BE may lead to the overdiagnosis and overtreatment of major depression, as more individuals fall under the criteria for major depression. 2. There is the potential for the pharmaceutical industry to market a treatment for this increased population of those considered to have major depression. 3. The changes to the BE call into question the loss of traditional and cultural methods of grieving with the introduction of psychiatry in the human emotion of grief. 74

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