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The Shifting Engines of Medicalization*

PETER CONRAD
Brandeis University

Journal of Health and Social Behavior 2005, Vol 46 (March): 3–14

Social scientists and other analysts have written about medicalization since at
least the 1970s. Most of these studies depict the medical profession, interpro-
fessional or organizational contests, or social movements and interest groups
as the prime movers toward medicalization. This article contends that changes
in medicine in the past two decades are altering the medicalization process. Using
several case examples, I argue that three major changes in medical knowledge
and organization have engendered an important shift in the engines that drive
medicalization: biotechnology (especially the pharmaceutical industry and
genetics), consumers, and managed care. Doctors are still gatekeepers for medical
treatment, but their role has become more subordinate in the expansion or contrac-
tion of medicalization. Medicalization is now more driven by commercial and
market interests than by professional claims-makers. The definitional center of
medicalization remains constant, but the availability of new pharmaceutical and
potential genetic treatments are increasingly drivers for new medical categories.
This requires a shift in the sociological focus examining medicalization for the
twenty-first century.

Social scientists and other analysts have or disorder, or using a medical intervention to
written about medicalization since at least the treat it. While the medicalization process
1970s. While early critics of medicalization could be bidirectional and partial rather than
focused on psychiatry (Szasz 1970) or a more complete, there is strong evidence for expan-
general notion of medical imperialism (Illich sion rather than contraction of medical
1975), sociologists began to examine the jurisdiction.
processes of medicalization and the expanding
realm of medicine (Freidson 1970; Zola
1972). As sociological studies on medicaliza- RISE OF MEDICALIZATION
tion accumulated (see Conrad 1992, 2000) it
became clear that medicalization went far Most of the early sociological studies took a
beyond psychiatry and was not always the social constructionist tack in investigating the
product of medical imperialism, but of more rise of medicalization. The focus was on the
complex social forces. The essence of medical- creation (or construction) of new medical
ization became the definitional issue: defining categories with the subsequent expansion of
a problem in medical terms, usually as an illness medical jurisdiction. Concepts such as moral
entrepreneurs, professional dominance, and
claims-making were central to the analytical
* This is a revised version of the 2004 Leo G. Reeder discourse. Studies of the medicalization of
Award lecture presented at the meetings of the Amer- hyperactivity, child abuse, menopause, post-trau-
ican Sociological Association, August 16, 2004, in matic stress disorder (PTSD), and alcoholism,
San Francisco, California. My thanks to Renee
among others, broadened our understanding of
Anspach, Charles Bosk, Libby Bradshaw, Phil Brown,
Stefan Timmermans, and the anonymous reviewers the range of medicalization and the attendant
for comments on an earlier version of this article. social processes (see Conrad 1992).
Address correspondence to Peter Conrad, Department If one conducted a meta-analysis of the studies
of Sociology, MS-71, Brandeis University, Waltham, from the 1970s and 1980s several social factors
MA 02454-9110 (email: conrad@brandeis.edu). would predominate. At the risk of oversimpli-
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4 JOURNAL OF HEALTH AND SOCIAL BEHAVIOR

fication, I suggest that three factors underlie CHANGES IN MEDICINE
most of those analyses. First, there was the power
and authority of the medical profession, whether By the 1980s we began to see some profound
in terms of professional dominance, physician changes in the organization of medicine that
entrepreneurs, or, in its extremes, medical colo- have had important consequences for health
nization. Here, the cultural or professional influ- matters. There was an erosion of medical
ence of medical authority is critical. One way authority (Starr 1982), health policy shifted from
or another, the medical profession and the expan- concerns of access to cost control, and managed
care became central. As Donald Light (1993)
sion of medical jurisdiction was a prime
has pointed out, countervailing powers among
mover for medicalization. This was true for
buyers, providers, and payers changed the
hyperactivity, menopause, child abuse, and child- balance of influence among professions and
birth, among others. Second, medicalization other social institutions. Managed care, attempts
sometimes occurred through the activities of at cost controls, and corporatized medicine
social movements and interest groups. In these changed the organization of medical care. The
cases, organized efforts were made to champion “golden age of doctoring” (McKinlay and
a medical definition for a problem or to promote Marceau 2002) ended and an increasingly buyer
the veracity of a medical diagnosis. The driven system was emerging. Physicians
classic example here is alcoholism, with both certainly maintained some aspects of their domi-
Alcoholics Anonymous and the “alcoholism nance and sovereignty, but other players were
movement” central to medicalization (with becoming important as well. Large numbers of
physicians reluctant, resistant, or irresolute). But patients began to act more like consumers, both
social movements were also critical in the in choosing health insurance policies and in
medicalization of PTSD (Scott 1990) and seeking out medical services (Inlander 1998).
Alzheimer’s disease (Fox 1989). Some efforts Managed care organizations, the pharmaceu-
were less successful, as in the case of multiple tical industry, and some kinds of physicians (e.g.,
cosmetic surgeons) increasingly saw patients as
chemical sensitivity disorder (Kroll-Smith and
consumers or potential markets.
Floyd 1997). In general, these were organized
In addition to these organizational changes,
grassroots efforts that promoted medicalization. new or developed arenas of medical knowledge
Third, there were directed organizational or inter were becoming dominant. The long-influential
or intra professional activities that promulgated pharmaceutical companies comprise America’s
medicalization, as was the case with obstetri- most profitable industry and became more so
cians and the demise of midwives (Wertz and with revolutionary new drugs that would expand
Wertz 1989) or the rise of behavioral pedi- their influence (Public Citizen 2003). By the
atrics in the wake of medical control of child- 1990s the Human Genome project, the $3 billion
hood diseases (Pawluch 1983; Halpern 1990). venture to map the entire human genome, was
To be sure, there were other contributing launched, with a draft completed in 2000.
factors that were implicated in the analyses. Genetics has become a cutting edge of medical
Pharmaceutical innovations and marketing knowledge and has moved to the center of
played a role with Ritalin and hormone replace- medical and public discourse about illness and
ment therapy (HRT) in the medicalization of health (Conrad 1999). The biotechnology
hyperactivity and menopause. Third-party payers industry has had starts and stops, but it promises
were factors in the medicalization in terms of a genomic, pharmaceutical, and technological
future that may revolutionize health care (see
whether insurance would pay for surgery for
Fukuyama 2002).
“gender dysphoria,” obesity, or detoxification
Some of these changes have already been
and medical treatment for alcoholism. However, manifested in medicine, perhaps most clearly in
it is significant that in virtually all studies where psychiatry where the cutting edge of knowledge
they were considered, the corporate aspects of has moved in three decades from psychotherapy
medicalization were deemed secondary to and family interaction to psychopharma-
professionals, movements, or other claims- cology, neuroscience, and genomics. This is rein-
makers. By and large, the pharmaceutical and forced when third-party payers will pay for drug
insurance industries were not central to the treatments but severely limit individual and
analyses. group therapies. The choice available to many

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THE SHIFTING ENGINES OF MEDICALIZATION 5

doctors and patient-consumers is not whether to Biotechnology
have talking or pharmaceutical therapy but rather
which brand of drug should be prescribed. Various forms of biotechnology have long
Thus, by the 1990s these enormous changes been associated with medicalization. Whether
in the organization of health care, medical it be technology such as forceps for childbirth
knowledge, and marketing had created a (Wertz and Wertz 1989) or drugs for distractible
different world of medicine. How have these children (Conrad 1975), technology has often
changes affected medicalization? facilitated medicalization. These drugs or
In a recent paper, Adele Clarke and her technologies were not the driving force in the
colleagues (2003) argue that medicalization is medicalization process; facilitating, yes, but not
intensifying and being transformed. They primary. But this is changing. The pharmaceu-
suggest that around 1985 “dramatic changes in tical and biotechnology industries are becoming
both the organization and practices of contem- major players in medicalization.
porary biomedicine, implemented largely Pharmaceutical industry. The pharmaceutical
through the integration of technoscientific inno- industry has long been involved in promoting
vations” (p. 161) coalesced as an expanded its products for various ills. In our 1980 book
phenomena they call biomedicalization. By Deviance and Medicalization (Conrad and
biomedicalization they mean “the increasingly Schneider [1980] 1992) the examples of Ritalin,
complex, multisited, multidirectional processes Methadone, and psychoactive medications were
of medicalization that today are being recon- all a piece of the medicalization process.
stituted through the emergent social forms and However, in each of these cases it was physi-
practices of a highly and increasingly techno- cians and other professionals that were in the
forefront. With Ritalin there were drug adever-
scientific biomedicine” (Clarke et al. 2003:162).
tisements promoting the treatment of “hyper-
Clarke et al. paint with a very broad brush and
activity” in children and no doubt “detailing” to
create a concept that attempts to be so compre-
doctors (e.g., drug company representative’s
hensive and inclusive—incorporating virtually
sales visits to doctor’s offices). But it was the
all of biotechnology, medical informatics and
physicians who were at the center of the issue.
information technology, changes in health This has changed. While physicians are still
services, the production of technoscientific iden- the gatekeepers for many drugs, the pharma-
tities, to name just a few—that the focus on ceutical companies have become a major player
medicalization is lost. This new conception, in in medicalization. In the post-Prozac world, the
my judgment, loses focus on the definitional pharmaceutical industry has been more aggres-
issues, which have always been a key to medical- sively promoting their wares to physicians and
ization studies.1 especially to the public. Some of this is not new.
Along with Clarke et al. (2003), I see some For most of the twentieth century the industry
major changes in medicalization in the past two has been limited to promoting its wares to physi-
decades (cf. Gallagher and Sionean 2004). I see cians through detailing, sponsoring medical
shifts, where they see transformations. I see events, and advertising in professional journals.
medicalization as expanding and, to a degree, However, since the passage of the Food and Drug
changing, but not morphing into a qualita- Administration (FDA) Modernization Act of
tively different phenomena. My task remains 1997 and subsequent directives, the situation
narrower and more focused on the medicaliza- has changed.
tion process. Revisions in FDA regulations allowed for a
wider usage and promotion of off-label uses of
drugs and facilitated direct-to-consumer adver-
EMERGENT ENGINES OF tising, especially on television. This has changed
MEDICALIZATION the game for the pharmaceutical industry; they
can now advertise directly to the public and
In the remainder of this article, I want to create markets for their products. Overall, phar-
examine how three major changes in medical maceutical industry spending on television
knowledge and organization have engendered a advertising increased six-fold between 1996 and
shift in the engines that drive medicalization 2000, to $2.5 billion (Rosenthal et al. 2002), and
in Western societies: biotechnology, consumers, it has been rising steadily since. Drug compa-
and managed care. nies now spend nearly as much on direct-to-

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6 JOURNAL OF HEALTH AND SOCIAL BEHAVIOR

consumer (DTC) advertising as in advertising was the first wave of new antidepressants called
to physicians in medical journals, especially for selective serotonin reuptake inhibitors (SSRIs).
“blockbuster drugs that are prescribed for SSRIs had the same or better efficacy than older
common complaints such as allergy, heart burn, antidepressants, with fewer disturbing adverse
arthritis, ‘erectile dysfuction,’ depression and effects. These drugs caused a bit of a revolution
anxiety” (Relman and Angell 2002:36). The in the pharmaceutical market (Healy 1998), and
brief examples of Paxil and Viagra can illustrate with $10.9 billion in sales in 2003 have become
this, but there are many others (see Conrad the third best selling class of drugs in the United
and Leiter 2004). States (IMS Health 2004). When Paxil (parox-
Male impotence has been a medical problem etine HCl) was approved by the FDA in 1996
for many years. In March 1998, the FDA it joined a very crowded market for antide-
approved Viagra (sildenafil citrate) as a treat- pressants. The manufacturer of Paxil, now called
ment for erectile dysfunction (ED). When intro- GlaxoSmithKline, sought FDA approval to
duced, Viagra was intended primarily for the use promote their product for the “anxiety market,”
of older men with erectile problems or ED asso- especially Social Anxiety Disorder (SAD) and
ciated with diabetes, prostate cancer, or other Generalized Anxiety Disorder (GAD). SAD and
medical problems (Loe 2001). A demand for a GAD were rather obscure diagnoses in the Diag-
drug for erectile problems surely existed before nostic and Statistical Manual of Mental Disor-
Pfizer began advertising Viagra. However, it was ders (DSM): SAD (or “Social Phobia”) is a
Pfizer who tapped into this potentially large persistent and extreme “fear of social and perfor-
market and shaped it by promoting sexual diffi- mance situations where embarrassment may
culties as a medical problem and Viagra as the occur,” and GAD involves chronic, excessive
solution. The initial Viagra promotion was anxiety and worry (lasting at least six months),
modest (Carpiano 2001), but Pf izer soon involving multiple symptoms (American Psychi-
marketed very aggressively to both physicians atric Association 1994:411, 435–36).
and the general public. At first it was with Bob Marketing diseases, and then selling drugs to
Dole as a spokesman for elders, but soon it treat those diseases, is now common in the “post-
was with baseball star Rafeal Palmeiro and the Prozac” era. Since the FDA approved the use of
sponsorship of a Viagra car on the NASCAR Paxil for SAD in 1999 and GAD in 2001,
circuit, expanding the audience and the market GlaxoSmithKline has spent millions to raise the
for the drug. Virtually any man might consider public visibility of SAD and GAD through
himself to have some type of erectile or sexual sophisticated marketing campaigns. The adver-
dysfunction. “Ask your doctor if Viagra is tisements mixed expert and patient voices,
right for you,” the advertisements suggest. providing professional viability to the diagnoses
Viagra sales were sensational. In the first year and creating a perception that it could happen
alone, over three million men were treated to anyone (Koerner 2002). The tag line was,
with Viagra, translating into $1.5 billion in sales “Imagine Being Allergic to People.” A later
(Carpiano 2001). In 2000, Viagra was ranked series of advertisements featured the ability of
sixth in terms of DTC spending and sales. By Paxil to help SAD sufferers brave dinner parties
2003 Viagra reached $1.7 billion in sales and and public speaking occasions (Koerner
was taken by six million men, which may not 2002). Paxil Internet sites offer consumers self-
include all those who purchased it from Internet tests to assess the likelihood they have SAD and
sites. By 2003, Levitra and Cialis were intro- GAD (www.paxil.com). The campaign success-
duced as improvements and competitors for a fully defined these diagnostic categories as both
share of this large market. The drug industry has common and abnormal, thus needing treatment.
expanded the notion of ED and has even Prevalence estimates vary widely, from 3 to 13
subtly encouraged the use of Viagra-like drugs percent of the population, large enough to be a
as an enhancement to sexual pleasure and rela- very profitable pharmaceutical market. The
tionships. Recent estimates suggest a potential marketing campaign for Paxil has been
market of more than 30 million men in the extremely successful. Paxil is one of the three
United States alone (Tuller 2004). The medical- most widely recognized drugs, after Viagra and
ization of ED and sexual performance has signif- Claritin (Marino 2002), and is cur rently
icantly increased in the past six years and shows ranked the number six prescription drug, with
no signs of abating. 2001 U.S. sales approximately $2.1 billion and
When Prozac was introduced in 1987, it global sales of $2.7 billion. How much Paxil

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THE SHIFTING ENGINES OF MEDICALIZATION 7

was prescribed for GAD or SAD is impossible (Conrad 1999). But I have little doubt that
to discern, but by now both Paxil and SAD are genomics will become increasingly important
everyday terms. While there have been some in the future and impact medicalization.
concerns raised about Paxil recently (Marshall Although the genetic impact on medicaliza-
2004), it is clear that GlaxoSmithKline’s tion still lies in the realm of potential, one can
campaign for Paxil increased the medicalization imagine when some of the genetic contribu-
of anxiety, inferring that shyness and worrying tors to problems such as obesity and baldness
may be medical problems, with Paxil as the are identified, genetic tests and eventually treat-
proper treatment. ments will soon follow. Obesity is an increasing
Children’s problems constitute a growing problem in our society and has become more
market for psychotropic drugs. Ritalin for atten- medicalized recently in a number of ways, from
tion deficit hyperactivity disorder (ADHD) a spate of epidemiological studies showing the
has a long history (Conrad 1975) but perhaps increase in obesity and body fat among Amer-
now can be seen as a pioneer drug for children’s icans to the huge rise in intestinal bypass oper-
behavior problems. While the public may be ations. Today physicians prescribe the Atkins or
ambivalent about using drugs for troubled South Beach diet and exercise; it is possible in
children (McLeod et al. 2004), a wide array of the future that there could be medical inter-
psychotropic drugs are now prescribed for chil- ventions in the genes (assuming they can be
dren, especially stimulants and antidepressants identif ied) that recognizes satiation. Gene
(Olfson et al. 2002). Whatever the benefits or therapy has not yet succeeded for many prob-
risks, this has become big business for the lems, but one could imagine the rush to
drug industry. According to a recent survey, genetic doctors if there were a way to manipu-
spending on behavior drugs for children and late genes to control one’s weight. We know that
adolescents rose 77 percent from 2000 through baldness often has a genetic basis, and with
2003. These drugs are now the fastest growing Rogaine and hair transplants it has already begun
type of medication taken by children, eclipsing to be medicalized. However, with some kind
antibiotics and asthma treatments (Freudenheim of medical genetic intervention that either stops
2004). baldness or regenerates hair, one could see bald-
At the other end of the life spectrum, it is ness move directly into the medical sphere,
likely that the $400 billion Medicare drug perhaps as a genetic “hair growth disorder.”
benefit, despite its limits, may increase phar- A large area for growth in genetics and
maceutical treatments for a range of elder prob- medicalization will be what we call biomed-
lems as well. This policy shift in benefits is likely ical enhancement (Conrad and Potter 2004;
to encourage pharmaceutical companies to Rothman and Rothman 2003; Elliott 2003).
expand their markets by promoting more drug Again, this is still in the realm of potential, but
solutions for elders. the potential is real. There is a great demand for
Genetics and enhancement. We are at the enhancements, be they for children, our bodies,
dawn of the age of genomic medicine. While or our mental and social abilities. Medical
there has been a great investment in the enhancements are a growing form of these. One
Human Genome Project and a celebration when could imagine the potential of genetic enhance-
the draft of the human genome was completed ments in body characteristics such as height,
in 2000, most of genetic medicine remains on musculature, shape, or color; in abilities such
the level of potential rather than current prac- as memory, eyesight, hearing, and strength; or
tice. For example, we have known about the in talents (e.g., perfect pitch for music) and
specific genes for cystic fibrosis and Hunt- performance. Enhancements could become a
ington’s disease for a decade, but these have yet huge market in a society where individuals often
to translate into improvements in treatment. Thus seek an edge or a leg up. While many genetic
far, genetics has made its impact mostly in terms improvements may remain in the realm of
of the ability to test for gene mutations, carriers, science fiction, there are sufficient monetary
or genetic anomalies. Despite the publicity given incentives for biotechnology companies to invest
to genetic studies (Conrad 1997), we have in pursuing genetic enhancements.
learned that only a few disorders and traits are The potential market for genetic enhance-
linked to a single gene, and that genetic ments is enormous. To get a sense of the possible
complexity (several genes operating together, impact, I recently examined human growth
gene-environment interactions) is the rule hormone as an existing biomedical enhance-

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8 JOURNAL OF HEALTH AND SOCIAL BEHAVIOR

ment (Conrad and Potter 2004). Synthetic human one’s identity, social status, and insurability, and
growth hormone (hGH) became available in it may create new categories of pre-cancer,
1985, and it was approved for some very limited pre-alcoholism, or similar labels. This could
purposes, including growth hormone deficiency expand medical surveillance (Armstrong 1995)
(a rare hormonal disorder). Shortness can be and the medical gaze.
devalued and engender social problems for indi-
viduals. There is evidence that shorter people
earn less money, get fewer promotions, can be Consumers
stigmatized, and can have problems with such
mundane tasks as finding proper fitting adult In our changing medical system, consumers
clothes (Conrad and Potter 2004; Rothman of health care have become major players. As
and Rothman 2003). Parents often have concerns health care becomes more commodified and
that their children will be too short and now have subject to market forces, medical care has
the option of going to physicians for growth become more like other products and services.
hormone treatments. Genentech, manufacturer We now are consumers in choosing health insur-
of Protropin, a brand of hGH, encouraged ance plans, purchasing health care in the market-
“off-label” uses of hGH for children who were place, and selecting institutions of care.
extremely short but had no growth hormone Hospitals and health care institutions now
deficiency. In a real sense these children with compete for patients as consumers.
idiopathic short stature (ISS) can be called I will briefly cite several examples about how
“normal” shorts; they are just short, from consumers have become a major factor in
short parents or genetic makeup. Although hGH medicalization: cosmetic surgery, adult ADHD,
therapy can be very expensive ($20,000 a year hGH therapy, and the rise in pharmaceutical
for perhaps five years) and yield only moderate advertisements.
results (2–3 inches), in 1994 13,000 children Cosmetic surgery is the exemplar of consu-
with ISS were treated in the United States. These mers in medicine (Sullivan 2001). Procedures
numbers are undoubtedly greater now, since the from tummy tucks to liposuction to nose jobs
FDA recently approved an Eli Lilly growth to breast augmentation have become big medical
hormone, Humatrope, for use for short statured business. The body has become a project, from
children in the lowest 1.2 percent of the popu- “extreme makeover” to minor touch ups, and
lation. There are several lessons for biomed- medicine has become the vehicle for improve-
ical enhancement here. First, a private market ment. In a sense, the whole body has become
for enhancements for children, even involving medicalized, piece by piece. To use just one
significant expense, exists and can be tapped by example, from the 1960s through 1990 two
biotechnology companies. Second, biotech- million women received silicone breast implants,
nology companies, like pharmaceutical compa- 80 percent for cosmetic purposes (Jacobson
nies, will work to increase the size of their 2000; Zimmerman 1998). In the 1990s a
markets. Third, the promotion and use of swirling controversy concerning the safety of
biomedical enhancements will increase medical- silicone implants became public when consumer
ization of human problems, in this case short groups maintained that manufacturers had
stature. Imagine if genetic interventions to mislead women about silicone implant safety,
increase a child’s height were available. leading the FDA in 1992 to call for a volun-
We do not yet have biotechnology companies tary moratorium on the distribution and implan-
promoting genetic enhancements, but we will. tation of the devices (Conrad and Jacobson
Biotech companies are already poised to use 2003). The market for implants plummeted. In
DTC advertising to promote genetic tests. They 1990 there were 120,000 implants performed;
will employ many of the same marketing strate- by 1992 there were 30,000. But with the intro-
gies as the pharmaceutical companies, which is duction of apparently safer saline implants,
no surprise, since many of them are the same or breast augmentation increased by 92 percent
linked. The promotion of genetic tests may also from 1990 to 2000. According to the Amer-
contribute to medicalization. A positive finding ican Society for Aesthetic Plastic Surgery
on a genetic test—that one has a gene for a (2004), in 2003 there were 280,401 breast
particular problem (cancer, alcoholism)—may augmentations in the United States, making this
create a new medicalized status, that of procedure the second most popular cosmetic
“potentially ill.” This can have an impact on surgery following liposuction. While plastic

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THE SHIFTING ENGINES OF MEDICALIZATION 9

surgeons do promote breast augmentation as a of this has been the increasing medicalization
product (current cost around $3,000), the of unhappiness (Shaw and Woodward 2004) and
medicalization of breasts and bodies is driven expansive treatment with antidepressants.
largely by the consumer market. Overall, 8.3 Nonprofit consumer groups like CHAAD,
million Americans had cosmetic medical proce- National Alliance for the Mentally Ill (NAMI),
dures in 2003, a 20 percent rise from the and the Human Growth Foundation have become
previous year and a whopping 277 percent rise strong supporters for medical treatments for the
since 1997 (American Society for Aesthetic human problems for which they advocate. These
Plastic Surgery 2004). While the media and consumer advocacy groups are comprised of
professional promotion fuel demand, virtually families, patients, and others concerned with the
all of these procedures are paid for directly out particular disorder. However, these consumer
of the consumer’s pocket. groups are often supported f inancially by
Since the early 1970s, Ritalin has been a pharmaceutical companies. CHAAD received
common treatment for ADHD (formerly known support from Novartis, manufacturer of Ritalin;
as hyperactivity) in children. However, in the the Human Growth Foundation is at least in part
1990s a new phenomenon emerged: adult funded by Genentech and Eli Lilly, makers of
ADHD. Researchers had shown for years that the hGH drugs; and NAMI receives over $6
whatever ADHD was, it often persisted beyond million a year from pharmaceutical companies
childhood, but in the 1990s we began to see (Mindfreedom Online 2004). Spokespeople
adults coming to physicians asking to be eval- from such groups often take strong stances
uated for ADHD and treated with medication. supporting pharmaceutical research and treat-
This was in part a result of several books, ment, raising the question of where consumer
including one with the evocative title Driven advocates begin and pharmaceutical promotion
to Distraction (Hallowell and Ratey 1994), along ends. This reflects the power of corporations
with a spate of popular articles that publicized in shaping and sometimes co-opting advocacy
the disorder. Adults would come to physicians groups.
and say, “My son is ADHD and I was just like The Internet has become an important
him,” “I can’t get my life organized, I must have consumer vehicle. On the one hand, all phar-
ADHD,” or “I know I’m ADHD, I read it in a maceutical companies and most advocacy
book.” Since Ritalin for adult attention prob- groups have web sites replete with consumer-
lems is an off-label use of the medication, the oriented information. These often include self-
pharmaceutical companies cannot directly adver- administered screening tests to help individuals
tise either the disorder or its treatment, but there decide whether they may have a particular
are other ways to publicize the disorder: There disorder or benefit from some medical treat-
are any number of Internet web sites describing ment. In addition, there are thousands of bulletin
adult ADHD and its treatment, and the advo- boards, chat rooms, and web pages where indi-
cacy group Children and Adults with Attention viduals can share information about illness, treat-
Deficit and Hyperactivity Disorder (CHAAD) ments, complaints, and services (Hardey 2001).
has become a strong advocate for identifying This has for many individuals transformed
and treating adult ADHD. It is well known that illness from a privatized to a more public
CHAAD gets most of its funding from the drug experience. On these web sites people suffering
industry. Even so, CHAAD is a consumer- from similar ailments can connect and share
oriented group and, along with adults seeking information in new ways, which, despite the
ADHD treatment, has become a major force in pitfalls of misinformation, empower them as
what I have called elsewhere “the medicaliza- consumers of medical care. Both corporate
tion of underperformance” (Conrad and Potter and grassroots web sites can generate an
2000). increased demand for services and dissemi-
Adult ADHD is only one example of what nate medical perspectives far beyond profes-
Barsky and Boros (1995) have identified as sional or even national boundaries.
the public’s decreased tolerance for mild In our current medical age, consumers have
symptoms and benign problems. Individuals’ become increasingly vocal and active in their
self-medicalization is becoming increasingly desire and demand for services. Individuals as
common, with patients taking their troubles to consumers rather than patients help shape the
physicians and often asking directly for a scope, and sometimes the demand for, medical
specific medical solution. A prominent example treatments for human problems.2

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10 JOURNAL OF HEALTH AND SOCIAL BEHAVIOR

Managed Care the threshold for treatment decreasing and
becoming more inclusive. The recent Medicare
Over the past two decades, managed care policy shift declaring obesity as a disease could
organizations have come to dominate health care further expand the number of medical claims
delivery in the United States largely in response for the procedure. As the New York Times
to rising health care costs. Managed care requires recently reported, “the surgery has become big
preapprovals for medical treatment and sets business and medical centers are scrambling
limits on some types of care. This has given to start programs” (Grady 2003:D1).
third-party payers more leverage and often But managed care organizations affect
constrained both the care given by doctors and medicalization by what they don’t cover as well.
the care received by patients. To a degree, When there is a demand for certain procedures
managed care has commercialized medicine and and insurance coverage is not forthcoming,
encouraged medical care organizations and private markets for treatment emerge (Conrad
doctors to emphasize profits over patient care. and Leiter 2004). As noted earlier, prior to this
But this is complex, for in some instances year, hGH was only approved for the very few
managed care constrains medical care and in children with a growth hormone deficiency. The
other cases provides incentives for more prof- FDA approval of Humatrope expanded the
itable care. number of children eligible for growth hormone
In terms of medicalization, managed care is treatment by 400,000. It will be interesting to
both an incentive and a constraint. This is clearly see whether managed care organizations will
seen in the psychiatric realm. Managed care has cover the expensive hGH treatments for these
severely reduced the amount of insurance children.
coverage for psychotherapy available to indi- In effect, managed care is a selective double-
viduals with mental and emotional problems edged sword for medicalization. Viagra and erec-
(Shore and Beigal 1996), but it has been much tile dysfunction provides an interesting example;
more liberal with paying for psychiatric medica- some managed care organizations’ drug bene-
tions. Thus managed care has become a factor fits cover (with co-pays) either four or six pills
in the increasing uses of psychotropic medica- a month. While it is unclear how these insur-
tions among adults and children (Goode ance companies came up with these figures, it
2002). It seems likely that physicians prescribe seems evident that managed care strictures both
pharmaceutical treatment for psychiatric bolster and constrain the medicalization of male
disorders knowing that these are the types of sexual dysfunction. Increasingly, though,
medical interventions covered under managed managed care organizations are an arbiter of
care plans, accelerating psychotropic treatments what is deemed medically appropriate or inap-
for human problems. propriate treatment.
In the 1980s I would frequently say to my
students that one of the limits on the medical-
ization of obesity is that Blue Cross/Blue Shield MEDICALIZATION IN THE
(then a dominant insurance/managed care NEW MILLENNIUM
company) would not pay for gastric bypass oper-
ations. This is no longer the case. Many managed The engines behind increasing medicaliza-
care organizations have concluded that it is a tion are shifting from the medical profession,
better financial investment to cover gastric interprofessional or organizational contests, and
bypass surgery for a “morbidly obese” person social movements and interest groups to biotech-
than to pay for the treatment of all the poten- nology, consumers, and managed care organi-
tial medical sequelae including diabetes, stroke, zations. Doctors are still gatekeepers for medical
heart conditions, and muscular skeletal prob- treatment, but their role has become more subor-
lems. The number of gastric bypass and dinate in the expansion or contraction of
similar surgeries in the United States has risen medicalization. In short, the engines of medical-
from 20,000 in 1965 to 103,000 in 2003, with ization have proliferated and are now driven
144,000 projected for 2004 (Grady 2003). In the more by commercial and market interests than
context of the so-called obesity epidemic by professional claims-makers.
(Abelson and Kennedy 2004), bypass operations The definitional center of medicalization
are becoming an increasingly common way to remains constant, but the availability and promo-
treat the problem of extreme overweight, with tion of new pharmaceutical and potential genetic

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THE SHIFTING ENGINES OF MEDICALIZATION 11

treatments are increasing drivers for new medical males and Prozac and cosmetic surgery for
categories (cf. Horwitz 2002). While it is still females (e.g., Blum and Stracuzzi 2004). And
true that medicalization is not technologically there may be more coming, with growing
determined, commercial and corporate stake- markets for andropause and baldness targeting
holders play a major role in how the technology men (Szymczak and Conrad forthcoming) and
will or won’t be framed. For example, if a new the pharmaceutical industry’s ardent search for
pharmaceutical treatment comes to market, the a female equivalent of Viagra (Hartley and Tiefer
drug industry may well pursue the promotion 2003). While corporate medicalizers might wish
of new or underused medical definitions to legit- to include both men and women to increase their
imate their product (e.g, Paxil and SAD/GAD), market potential, gender segmentation is a propi-
attempt to change the definitions of a disorder tious strategy for def ining problems and
(e.g., hGH and idiopathic short stature), or promoting medical solutions, both exploiting
expand the definitions and lower the treatment and reinforcing gender boundaries.
threshold of an existing medicalized problem Medicalization is prevalent in the United
(e.g., Viagra and erectile dysfunction). Thus drug States, but it is increasingly an international
companies are having an increasing impact on phenomenon. This is partly the result of the
the boundaries of the normal and the patholog- expanding hegemony of western biomedicine,
ical, becoming active agents of social control. but it is facilitated by multinational drug compa-
This is worrisome for a number of reasons, but nies and the global reach of mass media and the
perhaps especially “because corporations are Internet. As McKinlay and Marceau (2002) note,
ultimately more responsible to their shareholders “Transnational corporations involved in the
than to patients; shareholder desires are often at globalization of medicine (pharmaceuticals,
odds with patients’ needs for rational drug services, medical insurance, and biotechnology)
prescribing” (Wilkes, Bell, and Kravitz 2000). generate local demand for services .|.|. ” (p. 399).
It may well be to the shareholders’ advantage The pharmaceutical companies’ introduction
for pharmaceutical companies to promote and promotion of “mild depression” as an illness
medications for an ever-increasing array of in Japan has resulted in a dramatic rise in
human problems, but this in no way insures that SSRI treatment since 1999 (Schulz 2004).
these constitute improvements in health and Furthermore, cyberspace knows no national
medical care. And what is the impact of the new boundaries, expediting the dissemination of
engines of medicalization on the rising costs medical knowledge, commercial promotion, and
of health care? consumer desires. Perspectives that germinate
In a culture of increasingly market-driven in Boston today are available in Cairo or
medicine, consumers, biotechnological corpo- Moscow by the evening and in Calcutta and
rations, and medical services interact in complex Yogyakarta, Indonesia the next day. We have no
ways that affect social norms in changing defi- idea yet what the Internet’s impact is on the local
nitions of behaviors and interventions. The rela- and global nature of medical categories and
tionship between normative changes and treatments, but it is a safe assumption that
medicalization runs in both directions. For medicalization will increase with globalization.
example, changing norms about breast augmen- Professional and public concern about
tation are one cause of medicalization, while medicalization may be growing as well. The
at the same time the processes of medicaliza- British Medical Journal (2002) devoted nearly
tion themselves lead to changes in the social an entire issue to medicalization topics, and
norms surrounding breast enhancements. Simi- we increasingly see the term medicalization used
larly, advertisements for Viagra have destig- in the popular press. For years when I talked
matized male erecticle dysfunction, while a with people about medicalization I would always
normalized notion of erecticle dysfunction has need to explain in detail what I meant. Now most
increased the consumer demand for Viagra. people quickly understand what the term means.
I would be remiss if I did not note the But despite the increased awareness and open-
gendered nature of much corporatized medical- ness to the issue, we also need to develop our
ization. This should be no surprise, since own understandings of medicalization in new
women’s bodies have long been objects of and deeper ways.
medical control (Riska 2003). We are now seeing I close with a challenge to sociologists. We
the expansion of largely gendered markets for need to shift our attention in medicalization
medicalization, such as Viagra and Ritalin for research and study the emergent engines of

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medicalization. This means examining the its reliance on a scientific knowledge base
impact of biotechnological discoveries, the influ- and its bureaucratic organization, it is diffi-
ence of pharmaceutical industry marketing cult to see biomedicine as predominantly a
and promotion, the role of consumer demand, postmodern enterprise.
the facilitating and constraining aspects of 2. It is my contention that the consumer orien-
managed care and health insurance, the impact tation toward medical care has expanded,
of the Internet, the changing role of the medical subsuming or reorienting some of the
profession and physicians, and the pockets of social movements promoting medicalization.
medical and popular resistance to medicaliza- Moreover, there is an increasing amount of
tion. This means supplementing our social public and media promotion of health care
constructionist studies with political economic products, procedures, and services that
perspectives. Medicalization still doesn’t further spurs medicalization (including
occur without social actors doing something to medications, surgical procedures, and other
make an entity medical, but the engines that are treatments). These are aimed at individuals,
driving medicalization have changed and we not as patients but as consumers.
need to refocus our sociological eye as the
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Peter Conrad is Harry Coplan Professor of Social Sciences and chair of the “Health: Science, Society, and
Policy” program at Brandeis University.

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