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    The Shifting Engines of Medicalization* PETER CONRAD Brandels Unverty Journal of Health and Socal Bebvior 2008, Vo 46 (March): 3-1 Social scientists and other analysts have writen about medicalization since at Teast 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. Ths article contends that changes {in medicine in the past two decades are altering the medicalizaron 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 ‘reaiment, but their role has become more subordinate Inthe expansion or contrac- tion of medicalization. Medicalization is now more driven by commercial and ‘marke interests than by professional claims-makers. The definitional center of ‘medicalization remains constant but the availabilty ofnew 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 ‘writen about medicalization since atleast the 1970s, While early critics of medicalization focused on psychiatry Szasz 1970) or a more general notion of medical imperialism (Dich 1975), sociologists began to examine the processes of medicalization and the expanding realm of medicine (Freidson 1970; Zola 1972), As sociological studies on medicaliza- tion accumulated (see Conrad 1992, 2000) it became clear that medicalization went far beyond psychiatry and was not always the product of medical imperialism, but of more ‘complex social forces. The essence of medical- {zation became the definitional issue: defining «problem in medical terms, usually as an illness ‘This is a revised version ofthe 2004 Leo G. Reeder Award lecture presented atthe meetings ofthe Amer ican Sociological Association, Augst 16,2004, in San Francisco, California. My thanks io Renee Anepoch, Charles Bos, ity Bradshaw, Pil Brown, Stefan Timmermans, snd the anoaymous reviewers for comments on an earlier version ofthis article [Address corespondene to Petr Conrad, Deparenest ‘f Sociology, MS, Brandes University, Wala, MA 02484-9110 (ema conrad@brandeis du), or disorder, or using 2 medical intervention to treat it. While the medicalization process could be bidirectional and partial rather than complete thee is strong evidence for expan- sion rather than contraction of medical jurisdiction. RISE OF MEDICALIZATION Most ofthe erly sociological studies took a social constructionist ack in investigating the rise of medicaization. The focus as on the creation (or eanstruction) of new medical categories with the subsequent expansion of teal jurisdiction Concepts such as moral entrepreneuts, professional dominance, end ciaimsemaking were cental to the analytical discourse, Studies of the medicalization of Iyperactvin child abuse, menopause, pst-ai- tnate sess disorder (PTSD), and slcobolism, mong others, broadened our understanding of the ange of medicalizaon and the attendant social processes (See Conrad 1992). ‘fone conducted a meta-analysis the stales from the 1970 and 1980s several social factors ‘would predominate At the risk of oversimpli- 3 4 JOURNAL OF HEALTH AND SOCIAL BEHAVIOR CHANGES IN MEDICINE fication, 1 suggest that three factors underic most of those analyses Fist, there was the power nd authority ofthe medical profession, whether in terms of professional dominance, pysician centropreneurs, of in its extremes, medical colo- nization Here, the cultural er professional inf tence of medical authority is eritcal. One way ‘oranothe, the medical profession andthe expan- sion of medical jurisdiction was a prime over for medicalization. This Was true for hyperactivity, menopause child abuse and child birth, among others. Second, medicalization sometimes occurred through the activities of social movements and interest groups. In these ‘eases, organized efforts were made to champion ‘amedicl dentison fora problem ur wo pruete the veracity of a medical diagnosis. The classic example here i aleaholism, sth Both Aloaholies Anonymous and the “alcoholism movement” central to medicalization (with physicians reluctant, resistant, or iresolute)- But social movements were also critical in the medicalization of PTSD (Scott 1990) and ‘Alzheimer’s disease (Fox 1989). Some efforts ‘were less successful, as in tho ease of mule chemical sensitivity disorder (Kroll-Smith and Floyd 1997). In general, these were organized _gassroots efforts that promoted medicalzation. ‘Third, dere were diosted organizational or infer ‘or inira professional activities that promulysted ‘medicalization, as was the case wih obsteti- cians and the demise of midwives (Wertz and Wertz 1989) or the rise of behavioral pedi- atrie in the wake of medical contol of child hood diseases (Pawluch 1983; Halper 1990), TTo be sure, there wee other contributing factors that were implicated in the analyses. Pharmaceutical innovations and marketing played ole with Ritalin and hormone replace ‘meat therapy (HRT) inthe medicalization of Inyperactviy and menopause. Thid-pary payers ‘were factors in the medicalizaion in terms of ‘whether insurance would pay for surgery for “gender dysphoria.” obesity, or detoxification and medical treatment for alcoholism. However, itis significant that in virally all studi where they were considered, the corporate aspects of ‘medicalization were deemed secondary (0 professionals, movements, or other elaims- ‘makers. By and large, the pharmaceutical and ‘insurance industries were not central to the analyses. By the 1980s we began to see some profound, changes in the organization of medicine that Ihave had important consequences for health matters, There was an erosion of medical authority (Star 1982), heath policy shifted from concerns of acces o cost eontol, and managed fate became central, As Donald Light (1993) has pointed out, countervailing powers among buyers, providers, and payers changed the balance of influence among professions and ‘other social instttions. Managed eur, attempts at cost controls, and corporatized medicine changed the organization of medieal care. The “golden age of doctoring” (McKinlay and Maree: 2002) cane a iseasingly buyer driven system was emerging. Physicians ‘certainly maintained some aspects oftheir domi ‘ance and sovereignty, but other players were becoming important a5 well. Large numbers of patients Regan to act mote lke cousumers, bot fn choosing heelth insurance policies and in secking out medical services (Inlander 1998) ‘Managed care organizations, the pharmacet- tical industry, and some kinds of physicians ‘cosmetic surgeons) increasingly saw patients 33 ‘consumes or potential marke. Tn addition to these organizational changes, nev or developed arenas of medica knowledge ‘were becoming dominant. The long-inftential ‘pharmaceutical companies comprise America’s {ost profitable industry and became more 50 with evolutionary new drugs tht would expand their influence (Public Citizen 2003). By the 1990s the Human Genome project, the $3 billion ‘venture to map the enti human genome, ws launched, with a draft completed in 2000. Genetics has become a cutung edge of medical knowledge and has moved to the center of ‘nedieal and public discourse abou illness and health (Contad 1999). The biotechnology industry has had stars and stops, bu it promises f genomic, pharmaceutical, and technological ature that may revolutionize healthcare (see Fukuyama 2002) ‘Some ofthese changes have already been ‘manifested in medicine, perhaps most clearly in psychiatry where the eusing edge of knowledge has moved in three decades fom psychotherapy and family interaction to psychopharms- ‘cology, neuroscience, and gonomies. Ths isrein- forced when third-party payer wil pay for drug tneatments but severely limit individual and {group therapies. The choice avalable to many ‘Tue Suurrine ENGINES oF Mepicatizarion dctors and patint-consumers isnot whether to ‘ave talking or pharmaceutical therapy but rae ‘which brand of drug should be prescribed “Thus, by the 1990s these enormous changes in the organization of health care, medical Knowledge, and marketing had created a different world of medicine. How have these ‘changes affected medicaliztion? Tina recent paper, Adele Clarke and her colleagues (2003) ague that medicalization is intensifying and being transformed. They suggest that around 1985 “dramatic changes in both the organization and practices of contem- porary biomedicine, implemented largely ‘through the integration of technoscientificinno- vations” (p. 161) coalesced as an expanded phenomena they call biomedicalization. By biomedicalization they mean “the increasingly complex, multisite, multidirectional processes of medicalization that today are being recon- stituted through the emergent socal forms and practices of a highly and increasingly telino- Scientific biomedicine” (Clarke etal. 2003:162). Clarke et al. paint witha very broad brush and create a concept tht attempis to he so compre- hensive and inclusive—incorporating virtually all of biotechnology, medical informatics and information technology, changes in health service, the production of technostintfic iden tities, to name just a few—that the focus on ‘medicalization i lost. This new conception, in my judgment, loses focus on the definitional issu, which have always been akey to medical- ization studies" ‘Along with Clarke et al (2003), I see some ‘major changes in medicalizaton nthe past two decades (cf. Gallagher and Sionean 2004). Isee ‘hin, where they cee taneformations. I see ‘medicalization as expanding and, to a degree, changing, but not morphing into a qualita: tively different phenomena. My task remains narrower and more focused on the medicaiza- tion process. EMERGENT ENGINES OF ‘MEDICALIZATION In the remainder ofthis article, I want to examine how three major changes in medical ‘knowledge and organization have engendered a shift in the engines that drive mediealization in Wester societies: biotechnology, consumers, and managed care Biotechnology Various forms of biotechnology have long been associated with medicalization. Whether ithe technology such as forceps for childbirth (Were and Wertz 1989) or drugs for disractble children (Conrad 1975), technology has often facilitated medicalization. These drugs or technologies were not the driving force in the medicalzaton proces; facilitating, yes, ut not ‘primary. Bur ths is changing. The pharmaceu- tical and biotechnology industries are becoming major players in medicalization. Pharmaceutical indusr. The pharmaceutical {industry as long been involved in promoting its products for various ills. In our 1980 book Deviance and Medicalization (Conrad and ‘Schneider [1980] 1992) the examples of Ritalin, ‘Methadone, and psychoactive medications were alla piece of the medicalization process. However, in each of these cases it was physi- cians and other professionals that were in the forefront, With Ritalin there were drug adever- ‘isements promoting the treatment of “hyper- activity" in children and no doubt “detailing” to doctors (eg., drug company representative’ sales visits to doctor’ offices). But it was the physicians who were a the center ofthe issue. ‘This has changed, While physicians are stil the gatekeepers for many drugs, the pharma- ceutical companies have become a major player in modicalization. Inthe post-Prozac world the ‘Pharmaceutical industry has been more agwres- Sivoly promoting their wares to physicians and ‘especially othe pubic. Some ofthis isnot ew. For most of the twentieth century the industry ‘has been limited to promoting its wares to physi- cians through detailing, sponsoring medical ‘events, and advertising in profesional journals, However, since the passage ofthe Food and Drug ‘Administration (FDA) Modernization Act of 1997 and subsequent directives, the situation has changed. ‘Revisions in FDA regulations alowed for a ‘wider usage and promotion of off-label uses of drugs and facilitated drect-to-consumer adver. tising, especially on television, This has changed ‘the game forthe pharmaceutical industry: they can now advertise directly to the public and ‘create markets for their products. Overall, phar- ‘maceutical industry spending on television advertising increased six-fold between 1996 and 2000, to $2.5 billion (Rosenthal etal, 2002), and ithas been rising steadily since. Drug comps- ties now spend nearly as much on directo 6 JOURNAL OF HEALTH AND SOCIAL BEHAVIOR consumer (DTC) advertising as in advertising to physicians in medical journals, especially for “blockbuster drugs that are prescribed for common complaints suchas allergy, heart bur, artis, “eretiledysfuction,’ depression and anxiety” (Relman and Angell 2002:36), The ‘brief examples of Pail and Viagra can illustrate this, but there are many others (see Conrad and Leiter 2003), ‘Male impotence has been a medical problem for many years. In March 1998, the FDA approved Viagra (sildenafil citrate) as a treat- ‘ment for erectile dysfunction (ED), When intto- duced, Viagra was intended primarily for the use of older men with erectile problems or ED sso ciated with diabetes, prostate cancer, or other ‘medical problems (Loe 2001) A demand for a drug for erectile problems surely existed before Pfizer began advertising Viagra. However, twas Pfizer who tapped into this potentially large market and shaped it by promoting sexual difi- culties as a medical problem and Viagra asthe solution. The initial Viagra promotion was modest (Carpiano 2001), but Pfizer soon marketed very aggressively to both physicians tnd the general public. At Trst it was with Bob Dole as a spokesman for elders, but soon it ‘vas with baseball star Rafeal Palmeiro and the sponsorship of a Viagra car on the NASCAR circuit, expanding the audience and the market for the drug, Virually any man might consider himself to have some type of erectile or sexual dysfunction, “Ask your doctor if Viagra is right for you," the advertisements suggest, ‘Viagra sales were sensational, Inthe first year alone, over three million men were treated with Viagra, translating into S15 billion in sales (Cazpiano 2001), In 2000, Viagra was ranked Sixth in ters of DTC spending und sales. By 2003 Viagra reached $1.7 billion in sales and ‘yas taken by six million mea, which may not include all those who purchased it from Internet sites. By 2003, Levitra and Cialis were intro- ‘duced as improvements and compedtrs for share ofthis large market. The deug industry has ‘expanded the notion of ED and has even subtly encouraged the use of Viagra-ike drugs asan enhancement 19 sexual pleasure and rela- tionships, Recent estimates suggest a potential ‘market of more than 30 million mea in the ‘United States alone (Tuller 2004). The medical- ization of ED and sexual performance has signif> ‘cantly increased in the past six years and shows no signs of abating. ‘When Prozac was introduced in 1987, it was the first wave of new antidepressants called selective serotonin reuptake inhibitors (SSRIS). ‘SSRIs had the same or better efficacy than older antidepressants, with fewer disturbing adverse effects. These drugs caused abit of revoation inthe pharmaceutical market (Healy 1998), and ‘with $10.9 Billion in sales in 2003 have become the third best selling class of drugs inthe United States (IMS Health 2004). When Paxil (parox= cetine HCI) was approved by the FDA in 1996 itjoined a very crowded market for antide- ressans. The manufacturer of Paxil now called GlaxoSmithKline, sought FDA approval to eee eli Reis ase ly Social Anxiety Disorder (SAD) and Generalized AnxityDisoder (GAD). SAD and GAD were rather obscure diagnoses inthe Diag- nastic and Statistical Manual of Mental Disor- ders (DSM): SAD (or “Social Phobia”) is a petsstent and extreme “fer of social and perfor ‘mance situations where embarrassment may ‘eeun" and GAD involves chronic, excessive anxiety and worry (lasting at least six months), involving multiple symptams (American Psychi- atric Association 1994411, 435-36). “Marketing diseases, and then selling drugs to treat thse diseases, is ow common in the “post Prozac’ era Since the FDA approved the wse of Paxil for SAD in 1999 and GAD in 2001, ‘GlaxoSmithKline has spent millions to raise the public visibility of SAD and GAD through sophisticated marketing campaigns. The adver- tisements mixed expert and patient voices, providing professional viability tothe diagnoses dnd creating a perception that it could happen to anyone (Koerner 2002). The tag line Was, “Imagine Being Allergic to People.” A later sees of advertisements featured the ability of Puniloltelp SAD suffers Wave dite pastes and public speaking occasions (Koerner 2002). Paxil Internet sits offer consumers self tests to asses the lkoihood they have SAD and GAD (www:paxil.com), The campaign sucess- filly defined these diagnostic categories as both ‘common and abnormal, thus needing weatment. Prevalence estimates vary widely, fom 3to 13 pereent of te population, large enough tobe @ ‘ety profitable pharmaceutical market. The marketing campaign for Paxil has been extremely suecessil. Paxil is one ofthe three ‘most widely recognized drugs, afer Viagra and Claritin (Marino 2002), and is eurrently ranked the number sx prescription drug, with 2001 USS. sales approximately $2.1 billion and tlobal sales of $2.7 billion. How much Paxil ‘Tae Sturivc Ecoves oF MeDicaLizarion ‘was prescribed for GAD or SAD is impossible to discern, but by now both Paxil and SAD are everyday terms. While there have been some concerns raised about Paxil recently (Marshall 2004), it is clear that GlaxoSmithKline’s ‘ampaign for Pil increased the medicalization ‘of anxiety, inferring that shyness and worrying ray be medical problems, with Paxil as the proper treatment Children’s problems constitute a growing smatket for psychotropic drugs. Ritalin fortten- tion defiest hyperactivity disorder (ADHD) has a long history (Conrad 1975) but pethaps nov ean be seen asa pioneer drug for childrens behavior problems. While the public may be ambivalent about using drugs for troubled children (McLeod et al. 2004), a wide aray of psychotropic drugs are now prescribed for chil- Gren, especially simulans and antidepressants (Olfion etal. 2002). Whatever the benefits or risks, this has become big business for the drug industry. According to a recent survey, spending on behavior drugs for children and ‘adolescents rose 77 percent from 2000 through 2003. These drugs are now the fastest growing {ype of medication taken by children eclipsing antibiotics and asthma treatments (Preodenbeim 2008) ‘At the other end of the life spectrum, itis likely that the $400 billion Medicare drug benefit, despite its limits, may increase phar- ‘maceutical treatments for a range of elder prob- Jems as well. This pliy shift in benefits i ikely to encourage pharmaceutical companies to ‘expand their markets by promoting more drug solutions for elders ‘Genetics and enhancement, We are atthe dawn of the age of genomic medicine. While there has been a great investment in the Human Genome Project and celebration when the draft of the human genome was completed ‘in 2000, most of genetic medicine remains on the level of potential rather than current prac- tice, For example, we have known about the specific genes for cystic fibrosis and Hunt- ington: disease fora decade, but these have yet ‘o tansate int improvements in treatment, Thus far, genetics has made its impact mostly in terms ofthe ability to tes for gene mutations, earirs, for genetic anomalies, Despite the publicity given to genetic studies (Conrad 1997), we have learned that only a few disorders and traits are linked to a single gene, and that genetic complexity (several genes operating together, gene-environment interactions) is the rule z (Conrad 1999), But Ihave little doubt that fenomics will become increasingly important in the future and impact medicalization. Although the genetic impact on medicaliza- tion sil ies in the realm of potential, one can imagine when some of the genetic contribu- tors to problems such as obesity and baldness are identified, genetic tests and eventually teat- ‘ments will soon follow. Obesity isan increasing problem in our society and has become more ‘medicalized recently ina number of ways, from, 4 spate of epidemiological studies showing the ‘Increase in obesity and body fat among Amer- ican to the huge rise in intestinal bypass oper= ations, Today physicians prescribe the Atkins or South Beach dict and exercise; tis possible in the future that there could be medivalinter- ‘ventions in the genes (assuming they can be identified) that recognizes satiation, Gene therapy has not yet succeeded for many prob- lems, but one could imagine the rush to ‘genetic doctors i there were away to manipu- Tate genes to control one's weight. We know that baldness often has a genetic basis, and with ‘Rogaine and hair ansplans it has already begun to be medicalized, However, with some kind ‘of edie genetic intervention that ether stops baldness or regenerates hair one could see bald- ness move directly inta the medical sphere, perhaps as a genetic “air growth disorder” ‘A large area for growth in genetics and ‘medicalization will be what we call biomed- ical enhancement (Conrad and Potter 2004; Rothman and Rothman 2003; Elliott 2003). “Agaia, thsi til inthe realm of potential, but ‘the potentials ral. There is agret demand for ‘enhancements be they for children, our bodies, ‘or our mental and social abilities. Medical ‘enhancements area growing form ofthese. One ‘could imagine the potential of genetic enhance- ‘ments in body characteristics such as height, ‘musculature, shape, or color; in abilities such ‘as memory, eyesight, hearing, and strength; ot in talents (e.g. perfect pitch for musie) and performance. Enhancements could become a huge market ina society where individuals often seek an edge or a leg up. While many penetic improvements may remain in the realm of science fiction, there are sufficient monetary incentives for biotechnology companies to invest in pursuing genetic enhancements. ‘The potential market for genetic enbance- rmentsis enormous. To geta sense of the possible impact, I recently examined human growth hormone as an existing biomedical enhance 8 JOURNAL OF HEALTH AND SOCIAL BEHAVIOR ‘ment (Conrad and Pocer 2004). Synthetic human ‘growth hormone (hGH) became available in 98S, and it ws approved fr some very limited purposes including growth homonedefiency (arare hormonal disorder). Shortness c Erected engeder er protons a viduals. There is evidence that shorter people carn oss money, get fewer promotion, ean be stigmatized, and ean have problems with sve ‘mundane tasks as finding proper Fitting adult clothes (Conrad and Potter 2004; Rothman and Rothman 2003). Parents often ave concerns that thei children willbe too short and no have the option of going to physicians for growth hormone treatments. Genentech, manufacturer of Protropin, a brand of hGH, encouraged ofPlabel” uses of AGT for children who sere extremely short but had ao growth hormone Geficiene. In areal sense these children with idiopathic short stature (ISS) canbe called ‘rmal” shor's; they ate just short, from short parents or genetic makeup. Although hGH therapy’ cam be very expensive ($20,000 a year for perhaps five years) and yield only moderate results (2-3 inches), in 1994 13,000 children with ISS wore treated inthe United States. These ‘numbers are undoubtedly greater now, since the FDA recently approved an Eli Lilly growth hormone, Humatrope, for ue for short statuted clulden inthe lowest 1.2 percent ofthe popu lation. There are several lessons for biomed- ical enhancement here. Fist, a private market for enhancements for children, even involving significant expense exists and canbe tapped by biotechnology companies. Second, bistech- nology companies, ike pharmaceutical compa ries, will work to inerease the size of their markets. Third, the promotion and use of biomedical enhancements wil iereese mecia- ization of human problems, in this case short stature, Imagine if genetic interventions to increase a childs height were available. ‘Wedo not yet have biotechnology companies promoting genetic enancemens, but we will Biotech companies are already poised lo use DIC advertising to promote gentic tests. They will employ many ofthe same marketing state- ss asthe pharmaccuticalcorspanis, whichis no surprise, since many of them are the same or linked, The promotion of genetic tess may also contribute to medialiation. A positive Finding fon a genetic test—that one has a gene for 8 particular problem (cancer, aleoholism)—may create a new medicalized status, that of “potentially il” This ean have an impact oa one's identity, social status, and insurability and it may ereate new categories of pre-caneet, pre-aleobolism, or similar labels. This could expand medical sureillanee (Armstrong 1995) and the medical gaze Consumers In our changing medical system, consumers of health care have become major playets. AS health care becomes mare commodified and subject to market forces, medical care has ‘become mote like other products and services. ‘We now are consumers i choosing health insu ance plans, purchasing health care in the market- place, and celecting inotitutions of eare. Hospitals and health care institutions now ‘compete for patients as consumers. wll biel cite several examples about how ‘consumers have become a major factor in ‘medicalization: cosmetic surgery, adult ADHD, [hGH therapy, end the rise in pharmaceutical advertisements ‘Cosmetic surgery isthe exemplar of consu- ‘mers in medicine (Sullivan 2001), Procedures from tummy tucks to liposution 19 nase jobs to breat augmentation have become big medical business. The body has become project, from “extreme makeover” 19 minor toueht ups, aud sedicine has become the vehicle for improve- ment. In a sense, the whole body has become tmedicalized,picce by picce. To use just one ‘example, from the 1960s through 1990 two nillion Women received silicone breast implants, 80 pereent for cosmetic purposes (Jacobson 12000; Zimmerman 1998). In the 1990s a ‘Swirling controversy concerning the safety of Scone nplants besa pubic wlen consaes ‘groups maintained that manufacturers hed ‘mislead women about silicone implant safety, Teading the FDA in 1992 to call fora volun~ tary moratorium onthe distribution and implan- tation of the devices (Contad and Jacobson 2003). The market for implants plummeted. In 1990 there were 120,000 implants performed by 1992 there were 30,000. But with the introx duction of apparently safer saline implants, breast augmentation inereased by 92 peceent from 1990 to 2000. According to the Amer- ican Society for Aesthetic Plastic Surgery (2004), in 3003 there were 280,401 breast ‘sugmestatons inthe United States, making this procedure the second most popuiar cosmetic Surgery following liposuction, While plastic ‘Tue Suen Evcrses oF Mecatszavion surgeons do promote rest augmentation aa Drslict (curent cost around $3,000), the Iedisalizsion of beasts and bole sven largely bythe consumer market Overall, 83 milion Americans had cosmetic msl procs ‘lures in 2003, 220 percent aise from the previous year and a whopping 277 percent rise Eince 1997 (Ametian Society for Aesthetic Plastic Surgery 2004), While the media and profesional promotion is emund ily $M ofthese rocedres are pid ir ety ot of he consimers pocket Since the ely 1970s, Ritalin has been & common teatment for ADD (emery Known ' typeractivgy) in children, However, nthe 1990s a new phenomenon emerged: adult [ADMD Resatchers had shown fo yeas tha ‘hslever ADHD was, it often peste beyond Childhood, bt nthe 1990s we began fo see ‘Mul coming wo physicians aig to be eal tated for ADHD snd tated wih medication, ‘This was in pare result of several books, including one wit the evosave tile Driven to Distraction (allel and ate 1934) long ‘eth spite f pone ales tat pobliined the sisotder Ads woud come fo pyscans fy, "Myson 18 ADHD ar es ast ike him can get my fe onpanied, Ima hve ‘ADHD! ot know Ins ADHD, Lead iin & book? Since Ritalin for adulation probe lems san of-label we of the medication the haracescalcompaniss emer det ver seth the dsoed oF ts eaten bat thee tre other mays opie the donde There tre any miner of inter web se desing fot ADHD andi stent, andthe soo" acy grup Chen and Adal wth Attention Dette an Hyperctvity Disorder (CHAAD) fas Become rong advocate for dentiing {nd eating alt ADIID. tel known that CHIAAD gets mos ofits finding rom he dog indasry, Even 0, CHAAD isa consumers ‘ened group and along with adults sesking ADHD trenton has become a major fre in ‘vat have called elsewhere “te media. son of tnderperformanee” (Conrad and Poter 2000 ‘Adult ADHD is oly one example of what Barsky and Boros (1998) have identified 98 the public's decreased tolerance for mild symptoms and benign problems. Indias? ifmedicalistion i Becoming increasingly ‘ommon, wth patents aking ter roubles 10 physcions ang often asking directly fora Speciticmatcalsolton. prominent example 9 ‘ofthis has boon the increasing medicliztion of unhappiness (Shaw and Woodward 2004) and expansive treatment with anteressons ‘Nonprofit consumer groups like CHAAD, ‘National Alliance forthe Mentally Il (NAMI), and the Human Growth Foundation have become strong supporters for medical treatments for the ‘human problems for which they advocate. These consumer advocacy groups are comprised of families, patients, and others concerned with he particular disorder. However, these consumer _Broups are often supported financially by ‘pharmaceutical companies. CHAAD received support from Novartis, manufacturer of Rta ‘he Human Grows Foundation sat leas in pat funded by Genentech and Eli Lilly, makers of the AGH drugs; and NAMI receives over 30 millon a year from pharmaceutial eompanies (Mindfreedom Online 2004). Spokespeople from such groups oftea take strong stances supporting pharmaceutical research and teat- ‘ment, rising the question of where consumer ‘advocates begin and pharmaceutical promotion ends. This reflects the power of corporations in shaping and sometimes co-opting advocacy 4 he Internet has become an important conimer eh. On the ons hand hare imaveutical companies and ot advocacy Boys have web snp wid couse Sree inermsticn, These en nea sa scminsteed cei tts tly indv ile decide wheter they may haves parteuar tis or benefit fom some medial heat ton nan he ae hoa ln boar cat om and meh pages nee nd ‘shal can she maton at ey ot ‘en compli and sits (Hedey 201 This fas formany midis tantormed ines from m privatized toa more pubic Cxpsrence On hemo tes pope ing fom similar sent con coed nd share informacion in new ways, whieh, despite the pial of misinfercaton empower esos Consumers of medial eae, Both corporate tnd grassroots web tts can generate an increased demand for services and ise ne medical perpotives far Beyond profes. onal oc vento ound thou area modi age commer ve become incpeanngy vocal ral ace a (fst dean fr svi. Individual consuner rather an pets ep shape ie scape, and sometimes th dem foe media teens for aman problems SSS SS EE 10 JOURNAL OF HEALTH AND SOCIAL BEHAVIOR Managed Care Over the past wo decades, managed care ‘orpaniztions have come to dominate heath care delivery inthe United States largely in response toring health care costs. Managed cae requires [preapprovals for medieal treatment and sets limits on some types of care. Ths has given third-party payers more leverage and often constrained both the care given by doctors and the care received by patients. Ta 2 degree, ‘managed care has commereialized medicine ani encouraged medical care organizations aud doctors to emphasize profits over patient care. But this is complex, for in some instances managed care canstrnins medical care and in other eases provides incentsves for more prot- itable care In terms of medicalizaton, managed care is both an incentive and a constraint This cleaey seen inthe psychiatric realm. Managed care has Severely reduced the amount of insurance ‘coverage for psychotherapy avilable to indi- ‘viduals with mental and emotional problems (Shore and Reigal 1996), bur thas been mich ‘more liberal with paying for psychiatric medica- tions. Thus managed care has become a factor inthe increasing ses of psychotropic medica tions among adults and children (Goode 2002). It seems likely tht physicians prescribe pharmaceutical treatment for psychiatric Aisorders knowing that these are the types of ‘medical interventions covered under managed care plans, cceerating psychotropic treatments for human problems. In the 1980s T would frequently say to my students that one ofthe limits on the medieal- ization of obesity is that Blue Cross/Blue Shield (then a dominant insurance/managed care company) would not pay for gastric bypass oper. ‘ions. This is no longer the cas. Many managed ‘care organizations have concluded that its a hneter financial investment to cover gasirie ‘bypass surgery for a "morbidly oboso™ person ‘than to pay for the treatment of all the poten- tial medial sequelae inchuding diabetes, stroke, heart conditions, and muscular skeletal prob- lems. The number of gastric bypass and similar surgeries inthe United Stats has risen rom 20,000 in 1965 to 103,000 in 2003, with 144,000 projected for 2004 (Grady 2003). nthe ‘context of the so-called obesity epidemic (Abelson and Kennedy 200), bypass operations ae becoming an increasingly common way to treat the problem of extreme overweight, with the threshold for treatment decreasing end ‘becoming more inclusive. The recent Medieare ‘policy shift declaring obesity asa diease could further expand the number of medical claims for the procedure. As the Nev York Times recently reported, “the surgery has become big ‘business and medical centers are serambling to stare programs” (Grady 2003:D1), But managed care organizations affect smedicaliztion by what they don't cover aswel ‘When there i demand for certain procedares and insurance coverage is not forthcoming, private markets for weatment emerge (Conrad and Leiter 2004), As noted earlier, prior this year, NGH was only approved forthe very few ‘hikren witha grow hormone deficiency. The EDA approval of Humatrope expanded the number of eden eligible fer grow hormone ‘rentment by 400,000, Tt willbe interesting to see whether managed care organizations will cover the expensive HGH treatments for these children Ineffet, managed care i a selective double- edged sword for medicalization. Viagra and eec- ‘le dysnction provides an interesting example: some managed care organizations’ drug bene- Fits cover (with co-pays) either four or sx pills ‘month. While it fs unclear how thee isut- fnce companies came up with these figures, Seems evident that managed care strictures beth bolster and constrain the medicaliation of male sexual dysfunction, Increasingly, though, managed care organizations are an atbiter of ‘what is deemed medically appropriate or inap- Proprite treatment. ‘MEDICALIZATION IN THE NEW MILLENNIUM ‘The engines behind increasing modicaliza- tion are shifting fom the medical profession, inerprofesional or onganizationsl contest, and social movements and interest groups to biviei- nology, consumers, and managed care organi- zations. Doctors are sill atekeepers for medical ‘ueatment, but thei role has beceme more subor- dinate in the expansion or contraction of ‘modicalization. In sort, the engines of medical- ization have proliferated and are now driven ‘more by commercial and market interests than by professional elims-makers. ‘The definitional center of medicalization emnins constant, ut the availabilty and promo- tion of now pheracutial and potential genetic ‘Tae Sturrine ENciNes oF MepicaLizarion treatments are increasing drivers for nw medical ategores(c.Horwite 2002), While ts sill tur at mediclizatin is not tshnologcally determined, commercial and corporate stake- holders playa major oe in how the technology will or won't be famed. Fr example, ia new Parmaceuticalestment comes o market the rug industry may well pursue the promotion of new or underised medial dfaitons to legi- imate thir product (¢, Paxil and SADYGAD), tempt to change the definitions of disorder (ece., MGH and idiopathic shore stature), oF expand the definitions and lower the treatment Lireshold ofan existing medicalized problem (ca, Viagra and creel djtunetion). Thus drug companies ore having an increasing impact on the boundaries ofthe oma end the patbolog- ical, becoming active agents of socal conto ‘Thisis worrisome fora number of reasons, but perhaps especially “because corporations ae imately more responsible thi sharehlders than optim sharcholdrdesies are often at odds with patients’ needs for rational drug preseribing® (Wilke, Bel and Kravitz 200). Termay well be to the sharcholdes" advantage for pharmaceutical companies to promote medications for an everaneteasing array of human probes, buh no way sures that these constitute improvements ia Reals and ‘medical care, And what she impacto the new cngines of medicalizaion on the rising costs of bath care? Ina cultte of increasingly market-

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