This article offers a critique and reconstruction of the concept of medicalization. Most researchers describe medicalization as the redefinition of social problems as medical concerns, and track its spread by the proliferation of disease language and diagnostic categories. Forensic psychiatry and disorders like psychopathy are often cited in these debates. I argue that focusing on discourse overlooks how medical language can justify or mask non-medical practices and outcomes, and lead researchers to identify medicalization where it has not occurred. Building on other critiques of medicalization and recent studies of medical and legal expertise, I propose an alternative conception based on conditions for the performance of medical practice and other forms of expert labor. I distinguish the participation or intervention of medical practitioners from the medicalization of expert practice and identify several institutional factors that facilitate the latter. I illustrate this approach using a critical historical case: the first adult penal psychiatric clinic in the United States, founded by the eminent psychopathologist Bernard Glueck at New York’s Sing Sing Prison in 1916. Glueck’s extensive writings reveal little evidence of medicalization: psychopaths were largely defined and diagnosed according to penal rather than medical criteria, and they received additional punishment rather than treatment. A review of recent research confirms that psychopathy remains primarily a penal rather than medical condition. I conclude that focusing studies of medicalization on practice rather than discourse clarifies the concept and avoids reifying the notion of a medicalized society.
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Wacquant (2009, p. xxii) sharpens the insight by pointing out that “medicalization often [serves] as a conduit to criminalization at the bottom of the class structure as it introduces a logic of individual treatment” that resembles the assignation of criminal guilt.
Psychiatry was not a primary focus of the Rockefeller Foundation in the 1910s. But the Foundation did regularly support the efforts of the National Committee on Mental Hygiene, including providing ten thousand dollars to fund Glueck’s work at Sing Sing. John D. Rockefeller Jr., the Foundation’s president, was interested in the theories of eugenics that undergirded many medical and charitable interventions of the time, and used foundation funds to support eugenic efforts (Fosdick 1952; Gunn 1999; Rockefeller Foundation 1916).
For these reasons, Glueck’s clinic can be considered in analytic terms a “most likely” case: if medicalization did not occur under these favorable circumstances, it is less likely to have elsewhere (Flyvbjerg 2006, p. 231).
Debates over the links between psychopathy and criminality repeat themselves “as regularly as clock-work,” though unfortunately with an “extreme paucity of enlightenment” (Karpman 1948, p. 523). See, among many examples from across the decades, Blackburn 1988; Bowman and Rose 1952; Huddleston 1926; Karpman 1948.
The jurisdictional distinctions between these fields were constantly at issue, with psychologists typically claiming the feebleminded and psychometric techniques and psychiatrists claiming the mentally diseased and medical techniques. For a view of the disciplinary terrain at the time, see Healy 1922.
Some defense experts, however, have used fMRI brain scans of defendants in capital cases to argue for leniency (Phillips 2013), while one experimental study suggests that the label of psychopathy is less relevant to hypothetical juror decisions than predictions of high propensity for future violence (Cox et al. 2010).
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I am very grateful to Bernard Harcourt and Kristen Schilt for advising the undergraduate thesis that formed the original basis for this article. I also thank Alex Barnard, Lindsay Berkowitz, Leah Jacobs, Christopher Muller, Josh Seim, Loïc Wacquant, discussants at UC Berkeley, UC Irvine, and the 111th Annual Meeting of the American Sociological Association, and the Editors and reviewers at Theory and Society for their extensive and incisive comments. This research was partially supported by a Graduate Research Fellowship from the National Science Foundation.
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Showalter, D. Misdiagnosing medicalization: penal psychopathy and psychiatric practice. Theor Soc 48, 67–94 (2019). https://doi.org/10.1007/s11186-018-09336-y
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