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DEVIANCE AND MEDICALIZATION
FROM BADNESS TO SICKNESS

DEVIANCE AND
MEDICALIZATION
EXPANDED EDITION,
WITH a NEW AFTERWORD by the AUTHORS
PETER CONRAD
JOSEPH W. SCHNEIDER
Foreword by Joseph R. Gusfleld
Illustrated
Recipient of 1981 SSSI

Charles Horton Cooley Award
TEMPLE UNIVERSITY PRESS

Philadelphia
Temple University Press, Philadelphia 19122
Copyright © 1992 by Temple University
All rights reserved
Copyright © 1980 by The C. V. Mosby Company

Copyright © 1985 by Merrill Publishing Company
Printed in the United States of America
The paper used in this publication meets the minimum

requirements of American National Standard for Information
Sciences-Permanence of Paper for Printed Library
Materials, ANSI Z39.48-1984 §
Library of Congress Cataloging-in-Publicafion Data
Conrad, Peter, 1945-

Deviance and medicalization : from badness to sickness:
with a new afterword by the authors IPeter Conrad, Joseph
W. Schneider; foreword by Joseph R. Gusfield.
p. cm.
Originally published: St. Louis: Mosby, 1980.
"Recipient of 1981 SSSI Charles Horton Cooley
Award. "
Includes bibliographical references (p. ) and indexes.
ISBN 0-87722-998-8 (cloth). -. ISBN 0-87722-999-6
(paper)
1. Deviant behavior. 2. Social control.
3. Mental illness. 4. Mental health policy.
5. Social ethics. I. Schneider, Joseph W.,
1943- . II. Title.
[HM291.C64 1992]
302.5'42-dc20 92-13441
FOREWORD
The idea of progress is by no means spent. granted." Before they can be explored, their
Western societies, and the United States in par- status as problems must be understood. This
ticular, retain the optimism of the Enlighten- challenge to the attribution of "deviance" as
ment in the belief that in science and technology something clear and unambiguous to the sociol-
will be found the means for achieving good and ogist has been the central note i!1 the loud chal-
avoiding evil. There is hardly a chapter in the lenge to past theories and studies of crime,
history of the achievements of science as glori- mental health, 'and the other social problems
ous as that of bacteriology's defeat of infectious that make up the content of undergraduate texts.
diseases. Where today is the fear of diphtheria, In the writings of influential sociologists such
typhoid, smallpox, or poliomyelitis? The tech- as Howard Becker, Eliot Freidson, Erving
nical apparatus of medicine and its practitioners Goffman, Thomas Scheff, and others, loosely
have been the recipients of that beneficial called "labeling theorists," the approach
movement in the eradication of human woes. stressed the ways in which one group used
That such diseases have become the metaphor "deviance" to define another. More recently,
for many other, perhaps less tractable, woes is in the hands of sociologists with a greater inter-
the major thought of this volume. Peter Conrad est in the construction of cognitive categories,
and Joseph Schneider have given a clear and there is a deeper interest in the ways in which
definitive description and analysis of how the categories are articulated and utilized. Here
"medical model" has become so much of the such sociologists as Aaron Cicourel, Jack
reality of contemporary public problems. The Douglas, Harold Garfinkel, and David Sudnow
contribution is both to the general sociological are predominant. Most recently the entire tradi-
analysis of social problems and to the specific tion has moved toward an even more historical
debate and discussion of medicine as a para- concern for the development of social prob-
digm with which to understand and respond to lems, as indicated in Malcolm Spector and John
public problems usually termed "deviance." Kitsuse's work, Constructing Social Problems.
During the past two decades, sociology has As Conrad and Schneider indicate, they agree
begun to return to its historic emphasis on the with these two authors that "the process by
socially shared character of human problems. In which members of groups or societies define a
a stress on human events as interpreted phe- putative condition as a problem . . . is the dis-
nomena rather than objectively and abstractly tinctive subject matter of the sociology of social
viewed, this past generation of sociologists has problems. ,,*
called attention to the necessity for an analysis A belief in the multiplicity of ways to con-
of public problems to explain the reality of the ceive the world of nature and of humans and a
problem itself. How is it that a particular phe- skepticism about the claims of the medical
nomenon comes to be considered "problemat- model to greater validity underlie this signifi-
ic" and invested with a certain nature? Alcohol-
ism, homosexuality, racial conflict, rebellions, * Spector, M., and Kitsuse, J. Constructing social
child abuse, and the many situations seen as problems, Menlo Park, Calif.: The Benjamin/Cum-
public problems are not to be "taken for mings Publishing Co., 1977, p. 415.
v
vi FOREWORD
cant book. The recent public attention to the atlVlzmg light of social anthropology in the
mass suicide of the People's Temple at Jones- hands of sociologists.
town, Guyana, is an example of the opposing In at least two significant ways this book
character of popular thought. After the news of greatly advances our use of social construction-
Reverend James Jones and his followers, the ist perspectives. First, it emphasizes the history
media of communication searched out many ex- of particular problems. Alcoholism, homosex-
perts for public guidance and an explanation of uality, child abuse and child hyperactivity, opi-
how the mass suicide of 900 people could oc- ate addiction, and mental disturbance-the spe-
cur. Most often television, radio, newspapers, cific cases studied here-have not been constant
and magazines turned to psychiatrists, psychol- phenomena. They have changed through history
ogists, and sociologists with the assumption and even now are in the process of being as
that this bizarre behavior was a sign of sickness, well as having become. This attentiveness to
of abnormality. It could only be explained as the history of problems is crucial to any under-
something that "normal" people could never standing of the cultural and social framework
do. within which public problems and public issues
Such interpretations lost sight of the multi- are discussed. History is, at least here, also a
fold histories of the normalization of many sim- relativizing device. It gives distance and
ilar phenomena. The Charge of the Light Bri- strangeness to what is otherwise seen as near
gade or the stubborn refusal of military heroes and familiar. The medicalization of social prob-
to surrender, as at the Alamo, seems "normal" lems, in each of the cases, is not the culmina-
to those who have rehearsed such actions as the tion of a movement to find a solution to the
response to the rules of their societies. The problems but only another period in which one
hara-kiri of the traditional Japanese ritual sui- imputed reality is substituted for another.
cide seems understandable to Western minds There is in this stance a certain ironic
who have come to know something of Japanese mood-a distancing of the observer from the
history and culture. In view of the fact that the observed. Those being analyzed-the members
members of the People's Temple were isolated of the society, official agents, major spokes-
from continuous outside contacts, imbued with men-are caught up in the Enlightenment view
a sense of beleaguerment, and had an authori- of history as evolution toward progress. Science
tarian social organization, the Jonestown mass is, in this formulation, outside of history-not
suicide may be unusual or bizarre, but it can be itself a target of study. Those doing the analyz-
seen as normalized within that social existence ing-the sociologists themselves-are not so
and not a sign of sickness. The Indian suttee is caught up. They will not give medicine and its
only "sick" to the stranger who fails to recog- claim to authority through science any special
nize the preparation for it in Indian socialization consideration or status. They take it as topic
and the difficult life the widow faced if she did rather than resource.
not immolate herself on her husband's funeral The second aspect of Conrad and Schneider's
pyre. work that is significant is that they take serious-
Implicit in all of us who are identified with ly the perspective that public definitions of
studying social problems as social constructions public problems are the outcomes and continual
is a deep-seated belief in the relativism of fact. objects of claims that interested groups put forth
There is no "true" problem or "true" solution. in public arenas. Homosexuality is the clearest
Reality, like morality, is subject to explanation instance of how the nature of the problem has
and analysis. It is, but it need not be. At least been fought about in public places. The appella-
in many of the realms customarily studied by tions of sin, illness, and alternative sexual pref-
sociologists, not only is "one man's moral tur- erence all indicate different ways of "seeing"
pitude another man's innocent pleasure" but the phenomena of homosexual relationships.
what is fact today and may never have been Organizations, groups, and individual persons
fact until today may be fiction tomorrow. Sci- seek to influence the definition of the problem
ence and medicine are not exempt from the rel- and the belief in the "facts" about it. Some of
FOREWORD vii
their claims receive greater support by the pub- both obligated and entitled to be helped. De-
lic than others. In 1979, laws concerning homo- fined as having medical problems, they are fit
sexuality were objects of elections in several objects of treatment by medical institutions.
states, and opposing groups debated, discussed, They can be cured and helped by a technical
and even fought about these issues. * The same knowledge.
has certainly been the case in other areas of so- It is this shift in moral and institutional set-
cial concern, especially alcoholism, drug addic- tings that has been the occasion for so much of
tion, and child abuse. What is essential to Con- the recent debate about the acceptance or rejec-
rad and Schneider's perspective is that these tion of the medical model in what have been de-
conflicts involve claims to have factual belief fined, in public arenas and in social studies, as
as well as moral judgment accepted or rejected. problems of deviance. Conrad and Schneider
In the eyes of many self-designated "homosex- are adept in describing and analyzing this issue
uals," to be seen as "ill" is to be derogated. and its development. Solutions to human prob-
Hence they struggle to achieve a "normaliza- lems often create new problems in solving ini-
tion" rather than a "sick role." They liken tial ones. This has been the case with the use of
themselves to participants in the black and medicine in the public problems described in
the civil rights movements and not to the this volume. The transformation of problems
mentally ill and the struggle for institutional from ones of badness to ones of sickness has a
facili ties. ring of humanitarian concern. The love of man
This focus on a "politics of reality" is part of for man or woman for woman, the wildness of
the importance of Deviance and Medicaliza- children, or the desire to continually use opiates
tion. It is essential to the third significant fea- comes to be seen in neutral, amoral terms. The
ture of the book and to its special importance: onus of being "bad people" is cast off when the
the specific analysis of how the medical model same phenomena are now viewed as "disease."
has been used in the social construction of the It makes it less possible for morally upright
reality of social problems. Looking at medi- people to ignore these people's "problems"
cine as only another form of constructing social and makes feasible development of institutional
solutions has the consequence of raising ques- and public facilities for their care.
tions concerning the adequacy of that model But in the wake of this change came at least
and the possibility of alternatives to it. three new issues that raise significant questions
Conrad and Schneider have given us a three- concerning the application of the medical meta-
fold conception of the metaphor of medicine in phor. The concept of compulsive behavior sug-
contemporary public problems. "Sickness" has gests helplessness and loss of control that is it-
a cognitive, a moral, and an institutional di- self an unflattering self-portrait to which many
mension. To define people who behave object. Better to be thought a sinner, but re-
"strangely" -homosexuals, opiate addicts, hy- sponsible for myself, than to be a victim of the
peractive children, and child abusers-as "sick fates! There is a moral connotation to sickness
people" changes their role in society and their that underlies the humanitarian perception of
status as deviants. "Illness" puts the object of the deviant as victim.
concern under a different moral light than does There is also another meaning implicit in
"sin" or "preference." It introduces an ele- compUlsion, although also contained in the idea
ment of compulsion into the cognitive reality of of sin. Accepting this concept is an admission
the phenomenon. As Talcott Parsons suggested, of deviance; a way of agreeing with the label-
my slipped disc is a legitimate excuse for not ers. One says, "I am thus and so, and I should
giving that lecture today. The "sick" are nei- wish to be otherwise [what I have elsewhere
ther criminal nor morally responsible for their called the' 'reluctant deviant"]; if I am not bad
"disease." However, as sick people, they are because I am sick, my supposed affliction is
bad." Homosexuality, addiction to opiates, and
* Gusfield, 1. California ceremony. The Nation, Dec. drinking too much are "deviant" with all the
9, 1978, 227, 633-635. moral connotations that term implies. It is this
viii FOREWORD
consideration that leads many arrested and solution to social problems on individual treat-
drinking drivers to object to the label "alcohol- ment. The face-to-face model of the physician-
ic." In recent years the struggle of homosex- patient is considered the model of how to deal
uals to shed the label of "sickness" for the with the cases described in Deviance and Med-
status of an accepted alternative form of sex icalization. This psychologizing of social prob-
similarly indicates that the medical metaphor is lems leads away from the analyses of the social
not as neutral and as amoral as it seemed in its structure of culture-the socially shared in-
inception. stitutions and meanings in the society as ele-
These two considerations of the moral status ments in the problems. The problems of alco-
of compulsion are foundations for the second hol use are located in the alcoholic. The al-
problem of medical metaphors as public issue. cohol industry, the governmental policies of
With the attribution of disease, the individual is legal and tax programs, and the structure of
delivered up to a body of institutional experts- work are all ignored. In my current interest in
psychiatrists, child guidance counselors, physi- drinking and driving, I have been impressed by
cians, alcohol treatment practitioners, social the enormous emphasis on drinking and the
workers-who seek the person's rehabilitation. drinker as causal elements while such institu-
In becoming technical objects, the deviants give tional aspects as lack of alternate means of
rise to a new group of control agents and agen- transportation are ignored both as causal agents
cies whose power is suspect. The basis of this and as possible considerations in providing ave-
suspicion is partly the general fear of being nues of solution. Sociological definitions of
powerless and partly the suspicion, much sup- public problems, unlike psychological ones,
ported by historical outcomes and the social raise issues of group interests and moral com-
constructionist analysis presented here, that the mitments and move into public and political
supposed technical expertise is both shaky as arenas.
fact and not very successful in its outcomes. In this analysis of medicalization, where is
The application of social and medical science to the sociologist? What does the sociologist bring
the range of issues described has not been salu- to the ongoing understanding and even the solu-
tary. tion of public problems? I believe that the so-
Last, as Conrad and Schneider emphasize, ciologist brings the stance of the ironist to pub-
the effect of medicalizing public problems is lic phenomena. "The aim of the Ironic state-
their depoliticization. By removing the prob- ment," writes Hayden White, "is to affirm
lems as ones on which honest and reasonable tacitly the negative of what is on the literal level
people might differ and in presenting one defi- affirmed positively." * This is exactly what
nition as inherently and "really" preferential, Conrad and Schneider do. They treat the medi-
the medicalization of social problems depoliti- cal model as something strange, not as some-
cizes them and diminishes the recognition of thing that is "taken for granted" as "normal."
differences in moral choices that they represent. When a body of thought or a phenomenon is
Again, the recent movement for homosexual taken as problematic, as something to be ex-
rights or the redefinition of mental illness im- plained, its naturalness, its claim to "reality,"
plied in the works of R. D. Laing and Thomas is called into account. Thus to choose to exam-
Szasz have given clear recognition of this. Sim- ine the way in which homosexuality was trans-
ilarly, the tendency to "blame the victim," in formed from sin to sickness or heavy drinking
William Ryan's words, carries this conception from evil to addiction is to make the medical
even further. * model itself less than accepted on the strength
There is another aspect to the depoliticizing of its correctness-its greater grasp of the real-
effect of medicalization. It puts the responsibility of its object. This examination is in the
ity for the problem on individual causes and the
* White, H. Metahistory: the historical imagination
*Ryan, W. Blaming the victim. New York: Vintage in nineteenth century Europe. Baltimore: Johns Hop-
Books, 1971. kins University Press, 1973, p. 37.
FOREWORD Ix
classic tradition of the sociologist as exposer of cial character of what purports to be universal,
ideology who, in an ironic stance toward human sociology can contribute to public life what the
behavior, uncovers what purports to be truth arts contribute to human life-the visions of
and finds beneath the sheet of universalistic other realities, other ways of conceptualizing
science the particular bed of specific cultures, human actions, other possible ways of inventing
groups, and human interests. * human institutions.
The implications of sociological irony for However, is all a ceaseless and fluid process
public problems are vastly significant. The in- of multiple realities in which any situation may
tervention of science into human affairs has car- be defined in any fashion? Is there amidst the
ried the hope that human problems might be skepticism of the sociologist any "realer reali-
susceptible to solution by technical knowledge ties," or are all systems equally possible? The
and skill as some problems of nature have been. sociologist may dodge the metaphysical diffi-
(The tremendous effect of bacterial knowledge culties of the ironic stance by claiming finite,
is the commanding case in point.) In being although mUltiple, possibilities in nature. We
skeptical about the source of technical knowl- cannot completely dodge the charge of a cruel
edge and the definition of social problems as Olympianness. Conrad and Schneider, like
technical, medical ones, the authors of Devi- many of us who affect the sociological disposi-
ance and Medicalization cannot escape the tion, offer no way by which the sufferers can
charge of undermining the authority of the cope with their suffering. Mental illness has in-
technical treatment and therapy professions. deed undergone a variety of definitions through-
Fortunately, the Socratic hemlock is not avail- out history. How does that realization enable a
able. society or an individual to face the phenomena
On another level, the ironist has also been a that the definitions encompass? Are Conrad
moralist of sorts, and the sociologist here fol- and Schneider telling us that there is no "men-
lows. In displaying the ways in which the medi- tal illness" problem? That any conception of
cal metaphor of sickness depoliticizes moral excessive drinking is only the particular con-
and social conflicts, the sociological analyst struction of a time and a place? What happens
brings moral choice into the foreground. The to the urgency and exigency of the situation?
sociologist makes it necessary for the partici- To be sure, it seems easier to accept this view
pants in public problems to confront them as when the problem is homosexuality, or even
issues, as matters of choice, unconstrained by opiate addiction, but are we not again in danger
the natural order of things. As long as men and of making another metaphor under which to in-
women could believe that some persons were clude phenomena whose differences are also
by nature slaves and others free, slavery need significant?
not have been faced by slaveholders as a moral An earlier, more positivistic social science
choice. The way in which homosexuality is be- knew where it stood. Less ironic, it sought an
ing redefined is indicative of the process by engineering solution to known social problems.
which the transformation from a technical to a Convinced that one could find a science for
nontechnical formulation repoliticizes the issue. understanding social life and a technology for
As a society, we shall have to decide the moral acting toward it, it possessed a mission, a stand
status of homosexuality if it is not construed as from which to address the society. Can the
illness. We shall have to decide whose side we sociological perspective embodied in this book,
are on. as in a good deal of the work of others I have
The irony of the sociologist has much in mentioned, including myself, find any such
common with the imagination of the artist. Like platform, or is our relation to social policy
the artist, the sociologist indicates that there are that of the "disinterested observer of the pass-
alternatives to the present. In showing the spe- ing scene" whose skepticism and irony lead to
understanding, powerlessness, and escape from
*Brown, R. H. A poetic for sociology. Cambridge: commitment? Can we only echo Freud's state-
Cambridge University Press, 1977. ment? "I have not the courage to rise up before
x FOREWORD
my fellowmen as a prophet, and I bow to their

reproach that I can offer them no consolation:
for at bottom that is what they are all demand-
ing-the wildest revolutionaries no less pas-
sionately than the most virtuous believers." *
Joseph R. Gusfleld
*Freud, S. Civilization and its discontents. New

York: W. W. Norton & Co., 1961, p. 92. (Original-
ly published 1930.)
PREFACE
The subject of this book is the gradual social This book is intended for students of devi-
transformation of deviance designations in ance in the broadest sense. Although we have
American society from "badness" to "sick- endeavored to write to make our investigation
ness. " This has been the most profound change and analysis available to undergraduate sociol-
in the definition of deviance in the past two cen- ogy-of-deviance students, we cover territory
turies. By examining the medicalization (and unfamiliar to many of our colleagues. Sociolo-
demedicalization) of deviance in American so- gists of deviance have only recently come to
ciety, we may also investigate the general socio- appreciate the changing definitions of deviance
historical processes of defining deviance. Thus as an important area for study. As will be
this book has a dual focus: it is a historical and apparent, we build on the work of both sociol-
sociological inquiry into the changing defini- ogists and historians who have pioneered this
tions of deviance and an analysis of the trans- territory. Frequently we draw together materials
formation from religious and criminal to medi- that have not been collected previously, and oc-
cal designations and control of deviance. casionally we make original scholarly contribu-
Our investigation is both analytical and con- tions of our own. One objective in writing this
crete. We develop a conceptual framework book is to provide students with a historical
grounded in the labeling-interactionist and con- dimension to the study of deviance that has
flict approaches to deviance. This directs our commonly been ignored or glossed over in
attention to an analysis of the changing concep- much previous sociological work.
tions of deviance and social control rather than Finally, this book represents the first major
to the behavior of deviance or individual etiol- sociological examination and compilation of the
ogy. Moreover, we see the transformation of medicalization of deviance. It is in part an at-
deviance designations, from moral to medical, tempt to set the historical "record" straight and
as collective and political achievements rather make some order out of unordered "facts," or
than as inevitable products of the natural evolu- more precisely, out of facts that have been pre-
tion of society or the progress of medicine. viously ordered in different ways. Thus our
We therefore pay special attention to the role of work is neither the first nor the last-word on the
the medical profession and its champions in the medicalization of deviance. A great deal more
creation of deviance designations. Since the investigation and analysis are necessary, but we
medicalization of deviance is multifarious and believe we have collected much material that
not uniform, we endeavor to paint pictures de- will facilitate future research and writing on this
picting how and to what extent medicalization topic. Rather than a definitive statement on the
is achieved in each instance examined. Within a medicalization of deviance, we see our book as
broad framework (outlined in Chapter 2) each a good beginning toward greater understanding.
case is permitted to retain its own analytical and When a 2-year project such as this book is
historical integrity. In the final two chapters we finally completed, there are many people to
attempt to draw out commonalities and the thank for their support and various contribu-
general theoretical significance of the cases. tions. We are grateful to all the people who
Thus the book may be read from beginning to gave us their intellectual, emotional, and ma-
end, or each chapter may be read separately. terial sustenance, but a few deserve special
xl
xII PREFACE
mention. For their comments on drafts of vari- worked beyond the call of duty to help bring
ous chapters, we thank Selden Bacon, Vern this book to completion, checking references,
Bullough, Karen Conner, Ronald Gold, Mere- locating sources, writing for permissions, typ-
dith Gould, Laud Humphreys, Harry Levine, ing the final draft, and in general being suppor-
Kenneth Miller, Michael Radelet, Charles Sil- tive. We thank Carol Kromminga and Claudia
verstein, William Sonnenstuhl, and Malcolm Thornton for the tedious but valuable work of
Spector. We are grateful to Joseph Gusfield for indexing.
his appreciation and support of our ideas and For allowing us to reprint materials we had
for writing the foreword. Our students at Drake published previously, we acknowledge Social
and New York Universities deserve thanks for Problems, The Sociology of Health and Illness,
listening to our developing analyses and pro- D. C. Heath and Company, Greenwood Press,
viding feedback to our arguments and ideas. All and Penguin Books.
are, of course, absolved of responsibility for Finally, we thank Libby and Nancy, the
any omissions and for errors that may appear women who share our lives, for their support,
here. love, understanding, and tolerance.
We thank Laurel Ingram and Sandy Huck-
stadt for deciphering and typing various chapter Peter Conrad
drafts. A special debt is owed Dee Malloy, who Joseph W. Schneider
CONTENTS
1 Deviance, definitions, and the medical profession, 1

Sociological orientations to deviance, 1
Witchcraft in Salem Village, 3
Universality and relativity of deviance, 5
Social control, 7
The medical profession and deviance in America, 9
Emergence of the medical profession: up to 1850, 9
Crusading, deviance, and medical monopoly: the case of abortion, 10
Growth of medical expertise and professional dominance, 13
Structure of medical practice, 14
Overview of the book, 16
Suggested readings, 16
2 From badness to sickness: changing designations of deviance

and social control, 17
A historical-social constructionist approach to deviance, 17
Deviance as collective action: the labeling-interactionist tradition, 18
Social construction of reality: a sociology of knowledge, 20
Politics of definition, 22
Politics of deviance designation, 25
Deviance, illness, and medicalization, 28
The social construction of illness, 29
Illness and deviance, 32
Medicalization of deviance, 32
Expansion of medical jurisdiction over deviance, 34
The medical model and "moral neutrality," 35
Summary, 35
3 Medical model of madness: the emergence of mental Illness, 38

Smitten by madness: ancient Palestine, 38
Roots of the medical model: classical Greece and Rome, 39
Dominance of the theological model: the Middle Ages, 41
Witchcraft, witch-hunts, and madness, 42
The European experience: madness becomes mental illness, 43
The great confinement, 44
Separation of the able-bodied from the lunatics, 44
Entrance of the physician, 45
Emergence of a unitary concept of mental illness, 47
The 19th-century American experience: the institutionalization of mental illness, 48
Asylum-building movement: a new "cure" for insanity, 49
xiii
xlv CONTENTS
The science of mental disease, 52

Freud, psychoanalysis, and medicalization, 53
Reappearance of the somaticists, 54
Mental illness and the public, 56
Reform and institutionalization, 56
Public acceptance, 57
Mental illness and criminal law, 58
The third revolution in mental health, 60
Psychotropic medication, 61
Decline in mental hospital populations, 62
Sociological research, 62
Psychiatric critique, 65
Community mental health: a bold, new approach, 66
Federal action and professional growth, 66
Community psychiatry, 67
Community psychiatry and the medical model, 69
Medical model of madness in the 1970s, 70
Summary, 71
4 Alcoholism: drunkenness. Inebriety. and the disease concept. 73

Physiology of alcohol: uncontested application~ of the medical model, 73
Alcohol and behavior: the question of control and the beginning of contest, 75
Disinhibitor hypothesis, 75
Deviant drinking as disease: historical foundations, 78
Colonial period, 78
The disease of inebriety and the concept of alcohol addiction, 79
Disease concept and the American temperance movement, 82
An enemy and a weapon: disease and abstinence, 82
Rise of the inebriate asylum and the rush to Prohibition, 83
Post-Prohibition rediscovery: the Yale Center, Alcoholics Anonymous, and the lellinek
formulation, 85
Yale Research Center of Alcohol Studies, 86
Alcoholics Anonymous, 88
lellinek formulation, 90
Is alcoholism a disease? 97
Medical response to the disease concept, 98
Supreme Court and the disease concept, 100
Future of the disease concept of alcoholism, 102
A coming crisis? 102
Scientific claims, 103
Summary, 106
5 Opiate addiction: the fall and rise of medical Involvement. 110

Nature of opiates, 110
A miracle drug: pre-19th-century use of opiates, III
Politics of opium in the 19th century, I I3
Recreational use in England and China, 113
Medical uses: from a panacea to a problem, 114
Discovery of addiction as a disease, 115
Addicts and addiction in a "dope fiend's paradise," 116
Entrepreneurs and the morality of opium: the creation of an evil, 117
CONTENTS XV
American attitudes toward opiate addiction: from empathy to anxiety, 119

First prohibition of smoking opium, 120
Discovery of heroin, 120
Criminalization and demedicalization, 121
A quest for international control and the United States' response, 121
Harrison Act: the criminalization of addiction, 123
Reign of the criminal designation, 127
Addiction becomes a "criminal menace," 128
Why narcotics laws have failed, 129
Reemergence of medical designations of addiction, 130
Support for a medical designation, 131
Excursus: the British experience, 132
Methadone and the remedicalization of opiate addiction, 134
"Heroin epidemic" and available treatment, 135
Adoption of methadone maintenance as public policy, 136
Methadone revisionists, 139
A final note on methadone and medicalization, 141
Summary, 142
6 Children and medlcallzatlon: delinquency. hyperactivity. and

child abuse. 145
Discovery of childhood, 145
Origins of juvenile delinquency, 146
Childhood deviance into the 19th century, 147
Child-savers and the house of refuge, 147
Child-savers and the ideology of child welfare, 149
Juvenile court, 150
William Healy, court clinics, and the child guidance movement, 152
Medical-clinical model of delinquency today, 154
Discovery of hyperkinesis, 155
Medical diagnosis of hyperkinesis, 155
Discovery of hyperkinesis, 156
A sociological analysis, 159
Child abuse as a medical problem, 161
Historical notes on the maltreatment of children, 161
Child protection, 162
Medical involvement and the discovery of child abuse, 163
Child abuse as a medical and social problem, 165
Social scientists' views of child abuse, 166
Changes in the definitions of what constitutes child abuse, 168
Children as a population "at risk" for medicalization, 169
7 Homosexual"y: from sin to sickness to life-style. 172

Moral foundations: the sin against nature, 172
Ancient origins: the Persians and Hebrews, 173
Contributions of the Greeks, 174
From sin to crime: early Christianity and the Middle Ages, 176
New moral consensus: sin becomes sickness, 179
Medicine and moral continuity in the 18th century, 179
Masturbation and threatened manhood: a crusade in defense of moral health, 180
xvi CONTENTS
Consolidating the medical model: the invention of homosexuality, 181

Hereditary predisposition, 181
Criminalization and medicalization, 182
Homosexuality as a medical pathology, 183
Rise of the psychiatric perspective, 185
Contribution of Freud, 185
Sacrificing Freud: the reestablishment of pathology and the promise of cure, 187
Demedicalization: the continuing history of a challenge, 193
The armor of pioneering defense: "nature," knowledge, and medicine, 194
Spreading skepticism: social change and social science research, 196
Rise of gay liberation: homosexuality as identity and life-style, 199
Official death of pathology: the American Psychiatric Association decision on
homosexuality, 204
Beyond sickness, what? 209
Summary, 211
8 Medicine and crime: the search for the born criminal and the
medical control of criminality. 215
Richard Moran
The therapeutic ideal and the search for the born criminal, 216
Lombroso and the emergence of a biological criminology, 217
Danger of therapeutic tyranny, 222
A century of biomedical research, 223
Psychosurgery and the control of violence, 224
The XYY chromosome carrier, 226
The Lombrosian recapitulation, 226
Behavior modification, 228
Positive reinforcement, 230
Negative reinforcement, 232
Biotechnology, 235
CIA and mind control, 237
Summary and implications, 239
9 MediCine as an institution of social control: consequences for

society. 241
Types of medical social control, 241
Medical technology, 242
Medical collaboration, 244
Medical ideology, 245
Social consequences of medicalizing deviance, 245
Brighter side, 246
Darker side, 248
Exclusion of evil, 251
Medicalization of deviance and social policy, 252
Criminal justice: decriminalization, decarceration, and the therapeutic state, 252
Trends in medicine and medicalization, 254
Punitive backlash, 256
Some social policy recommendations, 256
Medicalizing deviance: a final note, 258
Summary, 259
CONTENTS xvii
10 A theoretical statement on the medlcallzatlon of deviance, 261

Historical and conceptual background, 261
American society as fertile ground for medicalization, 263
An inductive theory of the medicalization of deviance, 265
A sequential model, 266
Grounded generalizations, 271
Sociologists as challengers, 274
Hunches and hypotheses: notes for further research, 275
A concluding remark, 276
Summary, 276
Afterword
Deviance and medlcallzatlon: a decade later, 277
Some conceptual issues, 277
Deviance and Medicalization and social constructionism, 279
Reflections on medicalized deviance a decade later, 280
Mental illness, 280
Alcoholism, 281
Opiate addiction, 282
Homosexuality, 283
Hyperactivity, child,abuse, and family violence, 284
New areas of study and future issues, 286
References, 288
Bibliography, 293
Author Index, 311
Subject Index, 317

DEVIANCE AND MEDICALIZATION
1 DEVIANCE, DEFINITIONS,
and the MEDICAL
PROFESSION
A slow but steady transformation of de-

viance has taken place in American
society. It has not been a change in
behavior as such, but in how behavior
tions to deviance and illustrate the interactionist
view of deviance with the example of the infa-
mous episode of deviance in 17th-century
Salem Village. We discuss the universality and
is defined. Deviant behaviors that were once de- relativity of deviance and define the concept of
fined as immoral, sinful, or criminal have been social control. Because this book focuses on the
given medical meanings. Some say that rehabil- importance of medicine in the changing defini-
itation has replaced punishment, but in many tions of deviance, we offer a capsule analysis of
cases medical treatments have become a new the development and structure of medicine in
form of punishment and social control. This American society. The criminalization of abor-
transformation is certainly not complete and has tion serves as an example of medical involve-
not been entirely unidirectional. These changes ment in deviance definitions. Finally, at the end
have not occurred by themselves nor have they of the chapter we present an overview of the
been the result of a "natural" evolution of so- rest of the book.
ciety or the inevitable progress of medicine.
The roots of these changes lie deep in our social SOCIOLOGICAL ORIENTATIONS
and cultural heritage, and the process itself can TO DEVIANCE
be traced through the workings of specific peo- There are many ways to study what sociolo-
ple, events, ideas, and techniques. We believe gists call deviance. Even if we limit ourselves
that, aside from its technical and intellectual as- to sociological perspectives, there is a great
pects, this change is surely profoundly politi- variety of assumptions, definitions, and re-
cal in nature with real political consequences. search methods from which to choose. We be-
This book presents an analysis of the historical lieve, however, that there are two general ori-
transformation of definitions of deviance from entations to deviance in sociology that lead in
"badness"* to "sickness" and discusses the distinct directions and produce different and
consequences of these changes. It focuses on sometimes conflicting conclusions about what
the medicalization of deviance in American deviance is and how sociologists and others
society. should address it. We call these two orienta-
In this first chapter we introduce our study of tions the positivist and the interactionist ap-
deviance. We delineate the two major orienta- proaches. Others have made similar distinctions
using different labels: correctional and appre-
* Although perhaps a bastardized term, we believe
ciative (Matza, 1969), absolutist and relativist
"badness" expresses best the general unequivocal (Hills, 1977), scientific and humanistic (Thio,
morality typical of virtually all traditional major de- 1978), and objectivist and subjectivist (Goode,
viance designations, for example, "sin," "crime." 1978). Such labels are merely signposts that
Our subtitle, From Badness to Sickness, allows us to summarize content. It is to the substance of
emphasize precisely the kinds of changes we believe
inherent in the medicalization of deviance, that is, a these two orientations that we now tum.
shift from explicit moral judgments of deviants to the The positivist approach assumes that devi-
implicit and subtle morality of "sickness. " ance is real, that it exists in the objective experi-
1
2 DEVIANCE AND MEDICALIZATION: FROM BADNESS TO SICKNESS
ence of the people who commit deviant acts are both for those labeled and the authors of
and those who respond to them. This view of such attributions. The major questions about
deviance rests on a second important assump- deviants an interactionist might ask are, Who
tion-that deviance is definable in a straightfor- made these deviants? How did they do it? and
ward manner as behavior not within permissible With what consequences?
conformity to social norms. These norms are This classification, of course, simplifies
believed part of a moral or value consensus in some complex and contentious theoretical is-
society that is both widely known and shared. sues. Some of these will be evident in later
Positivists devote much of their study of devi- discussions. General categories such as these
ance to a search for causes of deviant behavior. necessarily do a certain degree of violence to
In sociology such causes are usually described reality, but we believe this distinction is es-
in terms of some aspect of social and/or cul- sentially faithful to broad patterns of sociologi-
tural environment and one's socialization. Posi- cal theory and research. Finally, we do not
tivists outside sociology typically search for mean to suggest that these two orientations are
causes in physiology and/or psyche. In medi- never combined in research on deviance; in
cine, for example, this search is called etiol- fact, some of the best studies have adopted ele-
ogy. * The major questions about deviants the ments of both.
positivist might ask are, Why do they do it? and The approach taken in this book is decidedly
How can we make them stop? interactionist. Our main concern is with chang-
The interactionist orientation to deviance ing definitions of deviance and the conse-
views the morality of society as socially con- quences of these changes. The interactionist
structed and relative to actors, context, and his- study of deviance usually focuses on the social
torical time. Fundamental to this view is the processes of defining and labeling deviants in
proposition that morality does not just happen; contemporary society. Only rarely have inter-
since it is socially constructed, there must be actionists ventured into history and attempted to
constructors. Morality becomes the product of use similar assumptions to understand the de-
certain people making claims based on their velopment of historical definitions of deviance.
own particular interests, values, and views of What makes this book different from most in-
the world. Those who have comparatively more teractionist studies is that we focus explicitly
power in a society are typically more able to on the sociohistorical development of the defi-
create and impose their rules and sanctions on nitions of deviance. To the extent we succeed
the less powerful. In consequence, deviance be- in adding this historical dimension to the inter-
comes actions or conditions that are defined as actionist study of deviance, we have made a
inappropriate to or in violation of certain contribution to the development and clarifica-
powerful groups' conventions. Such deviance is tion of the interactionist approach.
believed to be caused not by mysterious forces This book is a study of deviance, but it is also
beyond the individual's control but rather the a study of morality. In the interactionist view
consequence of particular definitions and rules the morality of a society - the application of
being applied by members of certain groups to notions of "right" and "wrong" -are relative
other people and/or situations. The interaction- and socially constructed. There is no absolute
ist view assumes that the behaviors called devi- morality, although in a world of competing
ant are by and large voluntary and that people moralities we may prefer some over others be-
exercise some degree of "free will" in their cause they seem to us more human and life-sup-
lives. Deviance is then a social definition, and porting. Morality and deviance are both prod-
research focuses on how such definitions are ucts of complex social interaction. In our study
constructed, how deviant labels are attached to of changing definitions of deviance we are also
particular people, and what the consequences studying changing morality. The individuals
and collectivities engaged in defining deviance
* It may be helpful to remember throughout this book are at the same time defining morality. Al-
that the medical model of deviance is essentially a though we mention this several times through-
positivist or correctional one. out this text, it might be useful to keep in mind
DEVIANCE. DEFINITIONS. AND THE MEDICAL PROFESSION 3
that this is as much a study of morality as it is a suffered a temporary loss of hearing and loss of
study of deviance. memory and often felt as if they were being
A word should be said about the term "devi- choked and suffocated. Vivid and frightening
ance." We use it in its technical, sociological hallucinations tormented and terrified them.
sense to refer to behavior that is negatively de- Whatever this fearful malady was, it was also
fined or condemned in our society. When we contagious. Other girls soon were stricken.
use the term, we do not imply any specific judg- The girls were taken by their parents to phy-
ment or that we think the behavior is bad or sicians who examined them but found no medi-
sick. On the contrary, in some cases a consid- cal problems and were puzzled by this strange
erable disjunction exists between our views and behavior. A local physician, however, believed
the dominant societal view. We use the term that he understood the problem but that it was
"deviance" to depict how the behavior or ac- out of his realm of expertise. "The evil hand is
tivity is generally defined in society. on them," he announced. The girls were vic-
To introduce our study of deviance and mo- tims of witchcraft.
rality, we turn now to an event of 17th-century The Devil was at work in Salem Village.
Massachusetts: the witchcraft phenomenon of Within a short time half a dozen young girls
Salem Village. Our intention is to illustrate were stricken. Fears and suspicions mounted.
what deviance is and how it is created in a par- Who, the community leaders asked, were the
ticular social setting. Devil's accomplices? Who had afflicted these
poor children? Ministers from nearby commu-
WITCHCRAFT IN SALEM VILLAGE nities were summoned to help Salem Village
In 1692 in the New England community of deal with its emergency. These observers con-
Salem Village occurred one of the most remark- firmed the community's worst fears: the girls'
able and notorious episodes of deviance produc- maladies were real and resulted from super-
tion in American history. * In the cold January natural forces.
winter of that year a number of young girls were "The motions of their fits," wrote the Reverend
stricken with a strange malady and began to be- Deodat Lawson, "are preternatural, both as to the
have in alarming ways. The first two affected manner, which is so strange as a well person could
were Betty Parris (age 9) and Abigail Williams not screw their body into; and as to the violence also
(age 11). Betty became forgetful, distracted, it is preternatural, being much beyond the ordinary
and preoccupied. She sometimes would sit star- force of the same person when they are in their right
ing fixedly at an invisible object and, if inter- mind." The Reverend John Hale of Beverly con-
rupted, would scream and begin an incom- firmed Lawson's description.' "Their arms, necks
prehensible babble. and backs," he wrote, "were turned this way and
that way, and returned back again, so it was impossi-
[Abigail] too was absent-minded ... and began ble for them to do of themselves, and beyond the
to make babbling and rasping sounds .... She got power of any epileptic fits, or natural disease to ef-
down on all fours and ran about under the furniture, feet." (Hansen, 1969, p. II).
barking and braying, and sometimes fell into convul- The community leaders and the ministers
sions when she writhed and screamed as if suffering
reached a decision. "The girls must be induced
the torments of the damned. (Starkey, 1949, p. 40)t
to name their tormenters; the witches must be
In addition to the "fits," the victims frequently ferreted out and brought to justice" (Starkey,
1949, p. 45).*
With little urging, the girls named the three
*Our discussion provides only a brief summary of
the events at Salem. For more detailed description witches who were terrorizing them: Tituba, a
and analysis, see Marion L. Starkey (1949), Kai T. slave from the West Indies who was acquainted
Erikson (1966, pp. 137-59), Chadwick Hansen with voodoo and magic; Sarah Good, a pipe-
(1969), and Paul Boyer and Stephen Nissenbaum
(1974).
t Reprinted by permission of Curtis Brown, Ltd. *Reprinted by permission of Curtis Brown, Ltd.
Copyright © 1949 by Marion Lena Starkey, re- Copyright © 1949 by Marion Lena Starkey, re-
newed 1977. newed 1977.
4 DEVIANCE AND MEDICALIZATlON: FROM BADNESS TO SICKNESS
smoking woman known for her slovenliness many people packed the meeting house to see
and begging and considered neglectful of her the alleged witches examined. The afflicted
children; and Sarah Osborne, a woman of girls were given a place of honor in front of the
higher standing, but who was negligent in her hall. When the accused were brought in, the
church attendance and had scandalized the com- girls began to yell, writhe, and convulse in ap-
munity a year or so earlier by living with a man parent agony. When questioned, the girls
for a short time before he became her husband pointed to specters of the accused flying around
(Erikson, 1966). The accused women were all the room, pinching and tormenting their vic-
marginal members of the community; in effect, tims. (Of course, none of the observers could
they were outsiders even before the accusa- see these specters.) Sarah Good and Sarah Os-
tions. borne categorically denied their guilt. But when
The preliminary hearings took place in the Tituba spoke, a hush settled over the meeting
meeting house. They were presided over by col- house, for Tituba was confessing to consorting
ony magistrates, who were to ascertain whether with the Devil. For 3 days she told the aston-
enough evidence existed for an actual trial. This ished court about the' 'invisible world" of spir-
was serious business in Salem because the Puri- its and apparitions with which she had contact.
tans took literally the biblical injunction "Thou She suggested there were still others in the com-
shalt not permit a witch to live." Conviction of munity with whom she (and the Devil) had con-
witchcraft meant sure death. Certain rules of sorted. These three women were dispatched to
evidence were agreed on. jail to await trial, but the witch-hunt had only
They would accept as proof of guilt the finding of
begun.
any "teat" or "devil's mark," that is to say any un- Salem Village was in crisis. Somber excite-
natural excrescence on the bodies of the accused. ment was giving way to fearful panic. The Dev-
They would accept as ground for suspicion of guilt il was out to take people's souls, and the good
any mischief following anger between neighbours. God-fearing people of Salem must fight him to
And most important of all, they would accept the the hilt. The afflicted girls were the instruments
doctrine that "the devil could not assume the shape through which the dastardly witches could be
of an innocent person in doing mischief to man- discovered. They performed their witch-finding
kind." (Starkey, 1949, p. 53)* chores with zeal and gusto. The girls seemed to
It was this final criterion of evidence that was relish all the attention they received and the
critical. It simply meant that the Devil could not power they were given. Within the next 6
appear in the form of anyone who was not months this troop of young girls accused nearly
guilty of witchcraft. This was called "spectral 200 people of consorting with the Devil. Some
evidence." It enabled hallucinations, dreams, righteous and upstanding citizens were accused,
and visions to be accepted in court "as factual as well as individuals from distant communi-
proof not of the psychological condition of the ties. Farmers, grandmothers, children, even a
accuser but of the behavior of the accused" reverend; if the girls claimed the individual's
(Starkey, 1949, p. 54). It was evidence that was specter was haunting them, the accused was
impossible to disprove, for if one of the girls ac- taken to prison to await a hearing. The commu-
cused a person's "specter" or "shade" of nity was stunned, but the fear of witchcraft pre-
haunting them, the accused was left without a vailed.
defense. It was prima facie evidence for associ- Dozens of the accused were brought to trial,
ation with the Devil and thus guilt of witch- and before the year was out, 19 witches had
craft. been executed by hanging, two had died in jail,
The hearings must have been quite a scene. and one was crushed to death during an interro-
There was a somber excitement in town, and gation. When the girls began to accuse some of
the town's most respected individuals, how-
* Reprinted by permission of Curtis Brown, Ltd. ever, doubts about their infallible judgment be-
Copyright © 1949 by Marion Lena Starkey, re- gan to grow. Toward the year's end people
newed 1977. were openly expressing concern about the trials
DEVIANCE, DEFINITIONS, AND THE MEDICAL PROFESSION 5
and executions and especially about the validity will develop this concept of deviance consid-
of "spectral evidence." After the magistrates erably as we proceed.
reversed their earlier decision and decided to Deviance is a universal phenomenon. All
disallow spectral evidence, there remained no societies have definitions of some behaviors or
way other than confession to ascertain gUilt in activities as deviant or morally reprehensible.
witchcraft. Nearly all those still accused were The very notion that a society has social norms
acquitted. The hundred or so yet residing in or rules ensures the existence of deviance.
jails were released, and the few who had con- There can be no deviance without social rules
fessed or had been found guilty were granted re- (and, as far as we know, there can be no society
prieves. The witchcraft hysteria of Salem Vil- without rules and norms, either). As Emile
lage was over. Durkheim (1895/1938) pointed out, deviance is
Witchcraft as deviance is a fascinating sub- "normal" to society. "Imagine a society of
ject to study. Numerous scholars have at- saints," wrote Durkheim,
tempted to understand what happened in Salem
a perfect cloister of exemplary individuals. Crimes
Village in 1692. Most agree that the girls' be-
[or deviance], properly so called, will there be un-
haviors today would be diagnosed as "hyste-
known; but faults which appear venial to the layman
ria," a psychological disorder rather than a re- will create there the same scandal that the ordinary
suit of witchcraft, and that nearly all the ac- offense does in ordinary consciousnesses. If, then,
cused were innocent. Several theories have this society has the power to judge and punish, it
been postulated as to the causes of the witch- will define these acts as criminal [or deviant] and
craft outbreak. Starkey (1949) suggests that it will treat them as such. (pp. 68-69)*
was a case of mass hysteria caused by Puritan
repression and gUilt. Erikson (1966) theorizes Durkheim touches on many important aspects
that the witch trials were an attempt to resolve a of deviance in this short passage: deviance is
"crisis" over the social boundaries of the universal, deviance is a social definition, social
changing Puritan colony. Hansen (1969) asserts groups make rules and enforce their definitions
that there were undoubtedly a few practitioners on members through judgment and social sanc-
of witchcraft in Salem, and the girls' fear of be- tion, deviance is contextual, and defining and
witchment made them hysterical. We need not sanctioning deviance involves power. Let us
choose between these theories here because we consider these one at a time.
present the Salem witchcraft example only to il- 1. Deviance is universal, but there are no uni-
lustrate the social construction of deviance versal forms of deviance. There are few acts, if
rather than to explain the behaviors involved. any, that are defined as deviance in all societies
The example will serve us through the next few under all conditions. Incest probably conforms
pages as we begin to develop our study of devi- most closely to a universal definition of devi-
ance. ance. Yet different societies consider different
activities to be incest: some societies prohibit
UNIVERSALITY AND RELATIVITY only brother-sister relations, whereas others
OF DEVIANCE consider relations between third cousins to be
What is deviance? For the moment, let us say incestuous. A few societies encourage sexual
simply that deviance consists of those catego- relationships between parents and children, and
ries of condemnation and negative judgment in several, siblings may engage freely in all sex-
which are constructed and applied successfully ual activity until puberty. Premeditated murder
to some members of a social community by oth- is also considered deviant in most societies, but
ers. We intentionally avoid the notion that the there are societies in which a man who kills an-
essence of deviance is in actors' behaviors;
rather, we argue that it is a quality attributed to
such persons and behaviors by others. For ex- * From Durkheim, E. Rules of the sociological meth-
od. New York: The Free Press, 1938. Copyright
ample, "witchcraft" and all it entailed in 1938 by the University of Chicago. (Originally pub-
17th-century Salem Village was deviance. We lished, 1895.)
other man for committing adultery with his wife herited a long tradition of defining certain be-
is deemed justified. Even incest and murder are haviors as witchcraft (Currie, 1968). Witch-
not universally deviant. craft, regardless of whether we believe in it,
Deviance is also relative. Different societies was a generally accepted category for "devi-
define different activities as deviant. In contem- ant" behavior to the Puritans. In Puritan soci-
porary American society the young girls of ety there were certain more or less agreed-on
Salem might find their behavior defined as de- criteria for assignment to this deviant category
viant (i.e., hysterical) rather than the behaviors (p. 4, just as we have criteria for apply-
of those they accused of witchcraft. Certain ing our contemporary definitions of deviance.
forms of homosexuality were acceptable among As sociologists we may study the origins of
the cultural elite in classical Greece, but in witchcraft as a category of deviance, as well as
America such conduct is condemned and stig- study the "causes" of witchcraft behavior. In
matized. Suicide is considered deviant and un- other words, we may examine the etiology of
godly in most of the Christian world, whereas social definitions of deviance separately from
in Imperial Japan it could be an honorable act. the etiology of the behaviors labeled as deviant.
The extremely suspicious and treacherous be- We can ask, for example, how it was that abor-
havior of the Dobu of M~lanesia would be lation was defined as deviant until recently rather
beled "paranoid" by modern psychiatric stan- than ask what caused people to have or perform
dards, but it would be the accepting and unsus- the abortions (we present this example later in
picious individual who would be a deviant this chapter). Again, the definition is separated
among the Dobu. Ruth Benedict's (1934) no- from the behavior or act. Deviance definitions
tion of "cultural relativity" is useful here: each may change over time. Witchcraft is no longer
society should be viewed by its own concep- a relevant type of deviance in American soci-
tions and standards. What is deviant for a society, but juvenile delinquency, opiate addiction,
ety is relative to that society: witchcraft among and child abuse, unknown to the Puritans, are
the Puritans, hysteria and paranoia in American well-accepted contemporary categories of devi-
society. ance. The approach we take in this book is to
2. Deviance is a social definition. That is, analyze the changing definitions of deviance,
deviance is not "given" in any behavior, act, which mayor may not be related to actual
or status. It must be so defined intentionally by changes in "deviant" behavior. We develop
"significant" actors in the society or social this further in Chapter 2.
group. In Erikson's (1966) words, "Deviance 3. Social groups make rules and enforce their
is not a property inherent in any particular kind definitions on members through judgment and
of behavior; it is a property conferred upon that social sanction. Although we view deviance
behavior by the people who come into direct or definitions as social categories, in reality they
indirect contact with it" (p. 6). Deviance may are not separate from their use and application.
be seen as a label attached to an act or behavior Definitions do not create themselves: "social
or as a category by which certain behaviors are groups create deviance by making the rules
defined. Thus deviance is a socially attributed whose infraction constitutes deviance, and ap-
condition, and "deviant" is an ascribed status. plying those rules to particular peopJe and la-
Deviance does not inhere in the individual or beling them as [deviants]" (Becker, H. S. ,
the behavior; it is a social judgment of that be- 1963, p. 9). The leaders of Salem Village "cre-
havior. In short, it is not the act but the defini- ated" deviance by making and enforcing rules
tion that makes something deviant. whose infraction constituted deviance. (Had
This view of deviance allows us to separate they ignored the girls' behavior, the witch trials
the definition of the behavior and the behavior probably never would have occurred.) Admit-
itself. Each may be studied separately. In this tedly, most instances of deviance are not nearly
light we see deviance as a system of social cate- as clear examples of the creation and applica-
gories constructed for classifying behavior, per- tion of rules to produce deviance as the Salem
sons, situations, and things. Puritan society in- episode, but collective rule making, social
judgment, and the application of sanctions enforcement, usually by powerful groups over
(penalties) are central to all types of deviance. people in less powerful positions.
What is important to remember is that "soci-
eties" do not make rules and define deviance; SOCIAL CONTROL
people acting collectively do. Social control is a central and important con-
4. Deviance is contextual. By this we mean cept in sociology. Developed by Edward A.
that what is labeled as deviant varies by social Ross (190 1) around the turn of the century, the
context-especially according to such condi- term was used to describe the processes soci-
tions as society, subculture, time, place, who is eties developed for regulating themselves. So-
involved, and who is offended. Willfully taking cial control meant social regulation. In the past
another's life usually is considered deviant, but two decades, however, its common sociological
not on a battlefield when the victim is defined as usage has changed. Perhaps dating from the
the enemy. Marijuana smoking is by law devi- work of Talcott Parsons (1951), social control
ant in most states, but in many youth subcul- began to be used in a narrower sense to mean
tures it would be the nonsmoker who would be the control of deviance and the promotion of
defined deviant. Masturbation was defined as a conformity. This is the common usage today,
sin and disease in Victorian times but today is although there are some who call for a return to
considered healthy. Suicide by an 80-year-old its original meaning as societal regulation
man with terminal cancer may be considered by (Janowitz, 1975).
many as justifiable, whereas a suicide attempt Social control is usually conceptualized as
by a college student ordinarily is seen as devi- the means by which society secures adherence
ant and usually leads to psychiatric treatment. to social norms; specifically, how it minimizes,
Thus "what" and "who" are "deviant" de- eliminates, or normalizes deviant behavior.
pends significantly on social context. Even when we limit our discussion of social
5. Defining and sanctioning deviance in- control to the control of deviance, it is still a
volves power. In general, powerful people and broad and complex topic. We introduce here a
groups are able to establish and legitimate their few dimensions of social control most directly
morality and definitions of deviance. Those be- relevant to our argument in this book (for more
longing to the more powerful groups in soci- complete discussions see Pitts, 1968, and Rou-
ety, in terms of social class, age, race, ethnic- cek, 1978). Social control operates on both in-
ity, profession, sex, etc., can enforce their cate- formal and formal levels and through "posi-
gories of deviance on less powerful groups. It is tive" and "negative" forms. Informal controls
seldom vice versa. In the witchcraft example include self-controls and relational controls.
the community and religious leaders of Salem Self-controls reside within individuals (although
Village (all men) were able to implement their their source is external and therefore social)
categories of deviance on the accused witches and include internalized norms, beliefs, morals,
(mostly women). Similarly adults make rules self-concept, and what is commonly called
children must live by, the middle and upper "conscience." Relational controls are a regular
classes define deviance in the lower classes feature of the face-to-face interactions of every-
(perhaps that is one reason why so much devi- day life. They include such common interac-
ance is found among the lower classes), tions as ridicule, praise, gossip, smiles, disap-
and a prestigious profession such as medi- proving glances and "dirty looks," mythmak-
cine makes rules whose violation is near- ing, group ostracism and support, and essential-
ly universally termed sickness. We shall dis- ly any negative or positive sanction for behav-
cuss the power dimension further in Chap- ior. Informal controls both inhibit individuals
ter 2. from behavior that might be considered devi-
In summary, deviance is universal yet widely ant and encourage conformity by positive sanc-
variable. It is in essence a social judgment and tion. In most cases these informal controls do
definition and therefore culturally relative. De- not lead to an individual being defined and la-
viance is socially created by rule making and beled as deviant, for we are all subject to these
controls daily. Fonnal social control is less to have a particular set of definitions of the
ubiquitous in everyday life, but its conse- world realized in both spirit and practice. To the
quences are usually much more profound and extent that such definitions receive widespread
enduring to the individual and society. (Sociol- and/or "significant" social support, this power
ogists have studied negative and fonnal social becomes authority and thereby considerably
control far more thoroughly than infonnal and more secure from attack and challenge. This
positive social control, perhaps because the authority, not uncommonly, may become
latter are much more difficult to study.) Fonnal vested in a dominant institution. For example,
social controls are institutionalized fonns of so- during the Middle Ages and through the Inqui-
cial control. Although they include "the 'offi- sition the Church had the authority and power to
cial' laws, regulations, and understandings that define activities as deviant. With the decline of
are supposed to encompass all the members of a the Church and the subsequent secularization,
group or society" (Buckner, 1971, p. 14), so- the state increasingly gained authority to define
ciologists usually think of fonnal social control deviance. When an institution (e.g., the church,
in tenns of institutions and agents of social con- state, medical profession) gains the power and
trol. They may be depicted as social control authority to define deviance, that is, to say what
apparatuses that operate, explicitly and implic- kind of a problem something is, the responsibil-
itly, to secure adherence to a particular set of ity for dealing with the problem often comes to
values and nonns, and in this work, to sanction that institution. In this sense we can say institu-
deviance. In our society we usually think of the tions can define their own social control "turf."
criminal justice system, with the police, courts, Representatives of an institution may linguisti-
correctional facilities, and auxiliary personnel, cally stake claims to deviance territory and thus
as the major institution of social control. attempt to justify their authority and legitimacy.
Other institutions such as education, wel- In areas where an institution's definitions be-
fare, the mass media, and medicine are also come dominant and accepted, it is capable of
frequently depicted as having social control defining the territory of its work. The institution
functions. and the practitioners within it become desig-
The greatest social control power comes from nated "experts" in dealing with the problem, or
having the authority to define certain behaviors, at least stewards of its social control.
persons, and things. This right to define may It is important to remember that any given
reside in an abstract authority such as "the "problem" can be viewed by different eyes
law" or God but is implemented commonly and thus may be defined and analyzed in differ-
through some institutional force such as the ent ways. For example, the problems of deviant
state or church. Such institutions, then (or, per- drinking can be seen as "caused" by sinful-
haps better, the people who represent them), ness, moral weakness, psychological distur-
have the mandate to define the problem (e.g., bance, genetic predisposition, adaptation to
as deviance), designate what type of problem it stress, or other influences (the problem could
is, and indicate what should be done about it. also be defined as caused by the promotion and
In our witchcraft example, representatives of distribution of the liquor industry). What the
the church (ministers) and the state (magis- problem "really" is may be debated and ar-
trates) agreed on the definition of the problem, gued; deviant drinking is not obviously one cer-
wi tchcraft (so, incidentally, did the physician), tain type of problem. The right to define a
but it was essentially a theological definition "problem," and thereby locate it within a par-
that prevailed (i.e., it was a question of witch- ticular social control turf, is achieved typically
craft, or consorting with the Devil). As we through enterprise, strategy, and struggle. We
mentioned earlier, a modem psychiatrist might will encounter numerous examples of this
have defined the problem as the young girls' be- throughout the book.
ing "hysterical," but there were no psychia- This book examines how increasing fonns of
trists with any authority in Salem to challenge deviant behavior have been defined as medical
the witchcraft definition. problems and thereby properly under medi-
Social control, then, can be seen as the power cal social control. We examine how medicine
achieved the authority to define problems as drift toward natural explanations of disease and
"sickness" rather than "badness" and analyze the emergence of medicine as an occupation
the consequences of this transformation. We separate from the Church (Cartwright, F. F.,
begin this discussion in the next chapter. Be- 1977).
fore we start this examination, however, it is But European medicine developed slowly.
important to review briefly medicine's rather The "humoral theory" of disease developed by
recent rise to dominance in American soci- Hippocrates dominated medical theory and
ety. practice until well into the 19th century. Medi-
cal diagnosis was impressionistic and often in-
THE MEDICAL PROFESSION AND accurate, depicting conditions in such general
DEVIANCE IN AMERICA terms as "fevers" and "fluxes." In the 17th
Since the dominant theme of this book con- century, physicians relied mainly on three tech-
cerns the change in definitions of deviance from niques to determine the nature of illness: what
badness to sickness and the expansion of medi- the patient said about symptoms; the physi-
cine as an agent of social control, it is important cian's own observations of signs of illness and
to have some understanding of the historical the patient's appearance and behavior; and,
development of medical practice and the medi- more rarely, a manual examination of the body
cal profession. Medicine has not always been (Reiser, 1978, p. I). Medicine was by no means
the powerful, prestigious, successful, lucrative, scientific, and "medical thought involved un-
and dominant profession we know today. The verified doctrines and resulting controversies"
status of the medical profession is a product (Shryock, 1960, p. 52). Medical practice was
of medical politicking as well as therapeutic a "bedside medicine" that was patient oriented
expertise. This discussion presents a brief over- and did not distinguish the illness from the
view of the development of the medical profes- "sick man" (Jewson, 1976). It was not until
sion and its rise to dominance. Thomas Sydenham's astute observations in the
late 17th century that physicians could begin to
Emergence of the medical distinguish between the patient and the dis-
profession: up to 1850 ease. Physicians possessed few treatments that
In ancient societies, disease was given super- worked regularly, and many of their treatments
natural explanations, and "medicine" was the actually worsened the sufferer's condition.
province of priests or shamans. It was in classi- Medicine in colonial America inherited this
cal Greece that medicine began to emerge as a European stock of medical knowledge.
separate occupation and develop its own theo- Colonial American medicine was less devel-
ries, distinct from philosophy or theology. oped than its European counterpart. There were
Hippocrates, the great Greek physician who re- no medical schools and few physicians, and be-
fused to accept supernatural explanations or cause of the vast frontier and sparse population,
treatments for disease, developed a theory of much medical care was in effect self-help. Most
the "natural" causes of disease and system- American physicians were educated and trained
atized all available medical knowledge. He laid by apprenticeship; few were university trained.
a basis for the development of medicine as a With the exception of surgeons, most were un-
separate body of knowledge. Early Christianity differentiated practitioners. Medical practices
depicted sickness as punishment for sin, engen- were limited. Prior to the revolution, physicians
dering new theological explanations and treat- did not commonly attend births; midwives, who
ments. Christ and his disciples believed in the were not seen as part of the medical establish-
supernatural causes and cures of disease. This ment, routinely attended birthings (Wertz and
view became institutionalized in the Middle Wertz, 1977). William Rothstein (1972) notes
Ages, when the Church dogma dominated theo- that" American colonial medical practice, like
ries and practice of medicine and priests were European practice of the period, was character-
physicians. The Renaissance in Europe brought ized by the lack of any substantial body of us-
a renewed interest in ancient Greek medical able scientific knowledge" (p. 27). Physicians,
knowledge. This marked the beginning of a both educated and otherwise, tended to treat
their patients pragmatically, for medical theory tributed to the low status and lack of prestige of
had little to offer. Most colonial physicians early 19th-century medicine. At this time, med-
practiced medicine only part-time, earning their icine was neither a prestigious occupation nor
livelihoods as clergymen, teachers, farmers, or an important economic activity in American so-
in other occupations. Only in the early 19th ciety (Starr, 1977).
century did medicine become a full-time voca- The regular physicians were concerned about
tion (Rothstein, 1972). this situation. Large numbers of regularly
The first half of the 19th century saw impor- trained physicians sought to earn a livelihood
tant changes in the organization of the medical by practicing medicine (Rothstein, 1972, p. 3).
profession. About 1800, "regular," or edu- They were troubled by the poor image of medi-
cated, physicians convinced state legislatures to cine and lack of standards in medical training
pass laws limiting the practice of medicine to and practice. No doubt they were also con-
practitioners of a certain training and class cerned about the competition of the irregular
(prior to this nearly anyone could claim the title sectarian physicians. A group of regular physi-
"doctor" and practice medicine). These state cians founded the American Medical Associa-
licensing laws were not particularly effective, tion (AMA) in 1847 "to promote the science
largely because of the colonial tradition of med- and art of medicine and the betterment of public
ical self-help. They were repealed in most states health" (quoted in Coe, 1978, p. 204). The
during the Jacksonian period (1828-1836) be- AMA also was to set and enforce standards and
cause they were thought to be elitist, and the ethics of "regular" medical practice and strive
temper of the times called for a more "demo- for exclusive professional and economic rights
cratic" medicine. to the medical turf.
The repeal of the licensing laws and the fact The AMA was the crux of the regulars' at-
that most "regular" (Le., regularly educated) tempt to "professionalize" medicine. As
physicians shared and used "a distinctive set Magali Sarfatti Larson (1977) points out, pro-
of medically invalid therapies, known as 'hero- fessions organize to create and control markets.
ic' therapy," created fertile conditions for the Organized professions attempt to regulate and
emergence of medical sects in the first half of limit the competition, usually by controlling
the 19th century (Rothstein, 1972, p. 21). Phy- professional education and by limiting licens-
sicians of the time practiced a "heroic" and ining. Professionalization is, in this view, "the
vasive form of medicine consisting primarily of process by which producers of special services
such treatments as bloodletting, vomiting, blis- sought to constitute and control the market for
tering, and purging. This highly interventionist, their expertise" (Larson, 1977, p. xvi). The
and sometimes dangerous, form of medicine regular physicians and the AMA set out to con-
engendered considerable public opposition and solidate and control the market for medical ser-
resistance. In this context a number of medical vices. As we shall see in the next two sections,
sects emerged, the most important of which the regulars were successful in professionaliza-
were the homeopathic and botanical physicians. tion, eliminating competition and creating a
These "irregular" medical practitioners prac- medical monopoly.
ticed less invasive, less dangerous forms of
medicine. They each developed a considerable Crusading, deviance, and medical
following, since their therapies were probably monopoly: the case of abortion
no less effective than those of regulars practic- The medical profession after the middle of
ing heroic medicine. The regulars attempted to the 19th century was frequently involved i~
exclude them from practice; so the various sects various activities that could be termed social
set up their own medical schools and profes- reform. Some of these reforms were directly re-
sional societies. This sectarian medicine cre- lated to health and illness and medical work;
ated a highly competitive situation for the regu- others were peripheral to the manifest medical
lars (Rothstein, 1972). Medical sectarianism, calling of preventing illness and healing the
heroic therapies, and ineffective treatment con- sick. In these reform movements, physicians
DEVIANCE. DEFINITIONS. AND THE MEDICAL PROFESSION 11
became medical crusaders, attempting to influ- azines. The advertisements offered euphemis-
ence public morality and behavior. This medi- tically couched services for "women's com-
cal crusading often led physicians squarely into plaints," "menstrual blockage," and "ob-
the moral sphere, making them advocates for structed menses. ' , Most contemporary ob-
moral positions that had only peripheral rela- servers suggested that more and more women
tions to medical practice. Not infrequently were using these services. Prior to 1840 most
these reformers sought to change people's val- abortions were performed on the ummarried
ues or to impose a set of particular values on and desperate of the "poor and unfortunate
others or, as we shall soon see, to create new classes." However, beginning about this time,
categories of social deviance. Throughout this significantly increasing numbers of middle- and
book we will often encounter medical crusad- upper-class white, Protestant, native-born
ers. We now examine one of the more reveal- women began to use these services. It is likely
ing examples of medical crusading: the crimi- they either wished to delay childbearing or
nalization of abortion in American society. * thought they already had all the children they
Most people are under the impression that wanted (Mohr, 1978, pp. 46-47). By 1870 ap-
abortion was always defined as deviant and ille- proximately one abortion was performed for
gal in America prior to the Supreme Court's every five live births (Mohr, 1978, pp. 79-80).
landmark decision in 1973. This, however, is Beginning in the 1850s, a number of physi-
not the case. American abortion policy, and the cians, especially moral crusader Dr. Horatio
attendant defining of abortion as deviant, were Robinson Storer, began writing in medical and
specific products of medical crusading. Prior to popular journals and lobbying in state legisla-
the Civil War, abortion was a common and tures about the danger and immorality of abor-
largely legal medical procedure performed by tion. They opposed abortion before and after
various types of physicians and midwives. A quickening and under Dr. Storer's leadership
pregnancy was not considered confirmed until organized an aggressive national campaign. In
the occurrence of a phenomenon called "quick- 1859 these crusaders convinced the AMA to
ening," the first perception of fetal movement. pass a resolution condemning abortion. Some
Common law did not recognize the fetus before newspapers, particularly the New York Times,
quickening in criminal cases, and an unquick- joined the antiabortion crusade. Feminists sup-
ened fetus was deemed to have no living soul. ported the crusade, since they saw abortion as a
Thus most people did not consider termination threat to women's health and part of the oppres-
of pregnancy before quickening to be an espe- sion of women. Religious leaders, however, by
cially serious matter, much less murder. Abor- and large avoided the issue of abortion; either
tion before quickening created no moral or they didn't consider it in their province or found
medical problems. Public opinion was indiffer- it too sticky an issue to discuss. It was the phy-
ent, and for the time it was probably a relatively sicians who were the guiding force in the anti-
safe medical procedure. Thus, for all intents abortion crusade. They were instrumental in
and purposes, American women were free to convincing legislatures to pass state laws, espe-
terminate their pregnancies before quickening cially between 1866 and 1877, that made abor-
in the early 19th century. Moreover, it was a tion a criminal offense.
procedure relatively free of the moral stigma Why did physicians take the lead in the anti-
that was attached to abortion in this century. abortion crusade and work so directly to have
After 1840 abortion came increasingly into abortion defined as deviant and illegal? Un-
public view. Abortion clinics were vigorously doubtedly they believed in the moral "right-
and openly advertised in newspapers and mag- ness" of their cause. But social historian James
Mohr (1978) presents two more subtle and
important reasons for the physicians' antiabor-
* We rely on James C. Mohr's (1978) fine historical
account of the origins and evolution of American tion crusading. First, concern was growing
abortion policy for data and much of the interpreta- among medical people and even among some
tion in this section. legislators about the significant drop in birth-
rates. Many claimed that abortion among mar- made abortion criminal in every state. A
ried women of the "better classes" was a major by-product of this was a shift in American
contributor to the declining birthrate. These public opinion from an indifference to and
middle- and upper-class men (the physicians tolerance of abortion to a hardening of attitudes
and legislators) were aware of the waves of im- against what had until then been a fairly com-
migrants arriving with large families and were mon practice. The irony was that abortion as a
anxious about the decline in production of na- medical procedure probably was safer at the
tive American babies. They were deeply afraid tum of the 20th century than a century before,
they were being betrayed by their own women but it was defined and seen as more dangerous.
(Mohr, 1978, p. 169). Implicitly the antiabor- By 1900 abortion was not only illegal but
tion stance was classist and racist; the anxiety deviant and immoral. The physicians' moral
was simply that there would not be enough crusade had successfully defined abortion
strong, native-born, Protestant stock to save as a deviant activity. This definition re-
America. This was a persuasive argument in mained largely unchanged until the 1973 Su-
convincing legislators of the need of antiabor- preme Court decision, which essentially re-
tion laws. turned the abortion situation to its pre-1850
The second and more direct reason spurring condition.
the physicians in the antiabortion crusade was This was not the first nor the last medical
to aid their own nascent professionalization and venture into the moral world of norm creation
create a monopoly for regular physicians. As and deviance. German physicians in the 18th
mentioned earlier, the regulars had formed the century proposed development of a "medical
AMA in 1847 to promote scientific and ethical police" who would supervise the health and
medicine and combat what they saw as medical hygiene of the population as well as control
quackery. There were, however, no licensing activities such as prostitution (Rosen, 1974).
laws to speak of, and many claimed the title Physicians were actively involved in the Tem-
"doctor" (e.g., homeopaths, botanical doctors, perance and "eugenics" movements of the 19th
eclectic physicians). The regular physicians century. The first legal and involuntary medi-
adopted the Hippocratic oath and code of ethics cal sterilizations performed in the United States
as their standard. Among other things, this oath were on "criminals" by crusading physicians
forbids abortion. Regulars usually did not per- seeking both to curb crime and protect the racial
form abortions; however, many practitioners of stock (Fink, 1938). The following impassioned
medical sects performed abortions regularly, defense of such selective and "reformist" ster-
and some had lucrative practices. Thus for the ilization appeared in the New York Medical
regular AMA physicians the limitation of abor- Journal in 1902, written by a surgeon at the In-
tion became one way of asserting their own pro- diana Reformatory:
fessional domination over other medical practi- It is my judgment, founded on research and observa-
tioners. In their crusading these physicians had tion, that this is the rational means of eradicating
translated the social goals of cultural and pro- from our midst a most dangerous and hurtful class.
fessional dominance into moral and medical Too much stress cannot be placed upon the present
language. They lobbied long and hard to con- danger to the race. The public must be made to see
vince legislators of the danger and immorality that radical methods are necessary. Even radical
of abortion. By passage of laws making abor- methods may be made to seem just if they are shown
tion criminal any time during gestation, regular to be rational. In this we have a means which is both
physicians were able to legislate their code of rational and sufficient. It remains with you-men of
ethics and get the state to employ sanctions science and skill-to perpetuate a known relief to a
weakening race by prevailing upon your legislatures
against their competitors. This limited these
to enact such laws as will restrict marriage and give
competitors' markets and was a major step to- those in charge of State institutions the authority to
ward the regulars' achieving a monopolization render every male sterile who passes its portals,
of medical practice. whether it be almshouse, insane asylum, institute
In a relatively short period the antiabortion for the feebleminded, reformatory, or prison. The
crusade succeeded in passing legislation that medical profession has never failed in an attempt,
and it will not fail in this. (Sharp, 1902, pp. 413- some deviance became defined as disease.
414). The medical profession would have an increas-
ing role in defining and controlling deviance.
In the 20th century, physicians were central
This ' 'power" rested at least in part on the
figures in crusades for social hygiene (Burn-
ham, 1972) and birth control (Gordon, 1975). growth of medical expertise and professional
dominance.
Physicians often saw their scientific and profes-
sional values as the values that ought to guide Growth of medical expertise and
the behavior of others. Frequently they argued professional dominance
for certain positions in the name of science
Although the general public's dissatisfaction
when the issues were actually moral. As John
with heroic medicine remained, the image of
C. Burnham (1972) observes, "Repeatedly the
medicine and what it could accomplish was im-
leaders of American medicine sought to impose
proving by the middle of the 19th century.
such values upon others, that is, to exercise so-
There had been a considerable reduction in the
cial control" (p. 19).
incidence and mortality of certain dread dis-
American medicine and physicians have had
eases. The plague and leprosy had nearly dis-
a long-lived, historic involvement with devi-
appeared. Smallpox, malaria, and cholera were
ance and social control. Some diseases were
less devastating than ever before. These im-
considered indistinguishable from deviant
provements in health engendered optimism and
behavior; sufferers were treated as both deviant
increased people's faith in medical practice.
and sick. Physicians perhaps always have had a
Yet these dramatic "conquests of disease"
significant role in the control and treatment of
were by and large not the result of new medical
conditions such as leprosy and epilepsy. Lepro-
knowledge or imprOVed clinical medical prac-
sy, a long-term degenerative disease that
tice. Rather, they resulted from changes in
severely and horribly mutilates its victims, was
social conditions: a rising standard of living,
widespread in the 12th and 13th centuries. It
better nutrition and housing, and public health
was a highly feared disease (although it is not
innovations like sanitation. With the lone ex-
very contagious), and its sufferers were stigma-
ception of vaccination for smallpox, the decline
tized and treated as deviants because of their
of these diseases had nearly nothing to do with
frightful appearance. Since no physical cure
clinical medicine (Dubos, 1959; McKeown,
was known, the only means of dealing with the
1971). But despite lack of effective treatments,
disease was social. Physicians were the diag-
medicine was the beneficiary of much popular
nosticians. If the diagnosis was firmly estab-
credit for improved health.
lished, the leper was segregated for life.
The regular physicians' image was improved·
He was expelled from human society and deprived of well before they demonstrated any unique ef-
his civil rights; in some places a Requiem was held fectiveness of practice. The AMA's attacks on
for him, and thus he was declared dead as far as so- irregular medical practice continued. In the
ciety was concerned. He lived in a leprosarium out- 1870s the regulars convinced legislatures to out-
side the city walls in the company of other lepers,
law abortion and in some states to restore li-
all of whom were dependent on charity for their sus-
censing laws to restrict medical practice. The
tenance. (Sigerist, 1943, p. 73)
AMA was becoming an increasingly powerful
Epilepsy was considered both a disease and a and authoritative voice representing regular
sign of supernatural demonic possession (i.e., medical practice.
deviance) until the 20th century. Surely uncon- But the last three decades of the century saw
trolled seizures were a frightening form of devi- significant "breakthroughs" in medical knowl-
ant behavior, and epileptics were severely stig- edge and treatment. The scientific medicine
matized and frequently segregated (Temkin, of the regular physicians was making new med-
1971). Thus the lines between sickness and ical advances. Anesthesia and antisepsis made
deviance sometimes were not clearly drawn: possible great strides in surgical medicine and
some diseases were considered deviance, and, improvements in hospital care. The bacteriolog-
as we shall demonstrate in upcoming chapters, ical research of Koch and Pasteur developed the
"genn theory of disease," which had impor- tion, and more rigorous examinations for cer-
tant applications in medical practice. It was the tification to practice. The enactment of Flex-
accomplishments of surgery and bacteriology ner's recommendations effectively made all
that put medicine on a scientific basis (Freid- nonscientific types of medicine illegal. It
son, 1970a, p. 16). The rise of scientific medi- created a near total AMA monopoly of medical
cine marked a death knell for medical sectarian- education in America.
ism (e.g., the homeopathic physicians eventual- In securing a monopoly, the AMA regulars
ly joined the regulars). The new laboratory sci- achieved a unique professional state. Medicine
ences provided a way of testing the theories and not only monopolized the market for medical
practices of various sects, which ultimately led services and the training of physicians, it de-
to a single model of medical practice. The well- veloped an unparalleled "professional domi-
organized regulars were able to legitimate their nance." The medical profession was function-
fonn of medical practice and support it with ally autonomous (Freidson, I 970b). Physicians
"scientific" evidence. were insulated from external evaluation and
With the emergence of scientific medicine, a were by and large free to regulate their own per-
unified paradigm, or model, of medical practice fonnance. Medicine could define its own terri-
developed. It was based, most fundamentally, tory and set its own standards. Thus, Eliot
on viewing the body as a machine (e.g., organ Freidson (1970b) notes, "while the profession
malfunctioning) and on the genn theory of dis- may not everywhere be free to control the terms
ease (Kelman, 1977). The "doctrine of specific of its work, it is free to control the content of its
etiology" became predominant: each disease work" (p. 84).
was caused by a specific genn or agent. Medi- The domain of medicine has expanded in the
cine focused solely on the internal environment past century. This is due partially to the prestige
(the body), largely ignoring Ute external envi- medicine has accrued and its place as the
ronment (society) (Dubos, 1959). This para- steward of the "sacred" value of life. Medicine
digm proved fruitful in ensuing years. It is the has sometimes been called on to repeat its
essence of the "medical model" we discuss in "miracles" and successful treatments on prob-
Chapter 2. lems that are not biomedical in nature. Yet in
The development of scientific medicine ac- other instances the expansion is due to explicit
corded regular medicine a convincing advan- medical crusading or entrepreneurship. This
tage in medical practice. It set the stage for the expansion of medicine, especially into the
achievement of a medical monopoly by the realm of social problems and human behavior,
AMA regulars. As Larson (1977) notes, "Once frequently has taken medicine beyond its prov-
scientific medicine offered sufficient guarantees en technical competence (Freidson, 1970b). In
of its superior effectiveness in dealing with this book we examine a variety of cases in
disease, the state willingly contributed to the which personal problems or deviant behaviors
creation of a monopoly by means of registra- become defined as illness and therefore within
tion and licensing" (p. 23). The new licensing medical jurisdiction.
laws created regular medicine as a legally en- The organization of medicine has also ex-
forced monopoly of practice (Freidson, 1970b, panded and become more complex in this cen-
p. 83). They virtually eliminated medical com- tury. In the next section we briefly describe the
petition. structure of medical practice in the United
The medical monopoly was enhanced further States.
by the Flexner Report on medical education in
1910. Under the auspices of the Carnegie Foun- Structure of medical practice
dation, medical educator Abraham Flexner Before we leave our discussion of the medi-
visited nearly all 160 existing medical schools cal profession, it is worthwhile to outline some
in the United States. He found the level of general features of the structure of medical
medical education poor and recommended the practice that have contributed to the expansion
closing of most schools. Flexner urged stricter of medical jurisdiction.
state laws, rigid standards for medical educa- The medical sector of society has grown
enormously in the 20th century. It has become can medicine has always operated on a "fee-
the second largest industry in America. There for-service" basis, that is, each service ren-
are about 350,000 physicians and over 5 mil- dered is charged and paid for separately. Sim-
lion people employed in the medical field. The ply put, in a capitalist medical system, the more
"medical industries," including the pharma- services provided, the more fees collected. This
ceutical, medical technology, and health insur- not only creates an incentive to provide more
ance industries, are among the most profitable services but also to expand these medical ser-
in our economy. Yearly drug sales alone are vices to new markets. The fee-for-service sys-
over $4.5 billion. There are more than 7000 tem may encourage unnecessary medical care.
hospitals in the United States with 1.5 million There is some evidence, for example, that
beds and 33 million inpatient and 200 million American medicine performs a considerable
outpatient visits a year (McKinlay, 1976). amount of "excess" surgery (McCleery et al.,
The organization of medical practice has 1971); this may also be true for other services.
changed. Whereas the single physician in "solo Medicine is one of the few occupations that can
practice" was typical in 1900, today physi- create its own demand. Patients may come to
cians are engaged increasingly in large corpo- physicians, but physicians tell them what proce-
rate practices or employed by hospitals or other dures they need. The availability of medical
bureaucratic organizations. Medicine in modem technique may also create a demand for itself.
society is becoming bureaucratized (Mechanic, The method by which medical care is paid for
1976). The power in medicine has become dif- has changed greatly in the past half-century. In
fused, especially since World War II, from the 1920 nearly all health care was paid for directly
AMA, which represented the individual physi- by the patient-consumer. Since the 1930s an in-
cian, to include the organizations that represent creasing amount of medical care has been paid
bureaucratic medicine: the health insurance for through "third-party" payments, mainly
industry, thc? medical schools, and the Ameri- through health insurance and the government.
can Hospital Association (Ehrenreich & Ehren- About 75% of the American population is cov-
reich, 1970). Using Robert Alford's (1972) ered by some form of medical insurance (often
conceptualizations, corporate rationalizers have only for hospital care). Since 1966 the govern-
taken much of the power in medicine from the ment has been involved directly in financing
professional monopolists. medical care through Medicare and Medicaid.
Medicine has become both more specialized The availability of a large amount of federal
and more dependent on technology. In 1929 money, with nearly no cost controls or regula-
only 25% of American physicians were full- tion of medical practice, has been a major factor
time specialists; by 1969 the proportion had fueling our current medical "cost crisis." But
grown to 75% (Reiser, 1978). Great advances the ascendancy of third-party payments has ef-
were made in medicine, and many were directly fected the expansion of medicine in another
related to technology: miracle medicines like way: more and more human problems become
penicillin, a myriad of psychoactive drugs, defined as "medical problems" (sickness) be-
heart and brain surgery, the electrocardiograph, cause that is the only way insurance programs
CAT scanners, fetal monitors, kidney· dialysis will "cover" the costs of services. We will say
machines, artificial organs, and transplant sur- more about this in Chapter 9.
gery, to name but a few. The hospital has be- In sum, the regular physicians developed
come the primary medical workshop, a center control of medical practice and a professional
for technological medicine. dominance with nearly total functional auton-
Medicine has made a significant economic omy. Through professionalization and persua-
expansion. In 1940, medicine claimed about sion concerning the superiority of their form of
4% of the American gross national product medicine, the medical profession (represented
(GNP); today it claims about 9%, which by the AMA) achieved a legally supported
amounts to more than $150 billion. The causes monopoly of practice. In short, it cornered the
for this growth are too complex to describe medical market. The medical profession has
here, but a few factors should be noted. Ameri- succeeded in both therapeutic and economic ex-
16 DEVIANCE AND MEDICAlIZATION: FROM BADNESS TO SICKNESS
pansion. It has won the almost exclusive right criminal" and the medical treatments used to
to reign over the kingdom of health and sick- "cure" and control criminals.
ness, no matter where it may extend. The final two chapters present a general anal-
ysis and conceptual understanding of the medi-
OVERVIEW OF THE BOOK calization of deviance. Chapter 10 describes
In this chapter we introduced the sociological and analyzes three types of medical social con-
study of deviance and social control and offered trol, elaborates on the important social conse-
a brief analysis of the development of the medi- quences of medicalizing deviance, and ex-
cal profession and practice. We locate our study amines implications of recent and future social
in the labeling-interactionist sociology of devi- policy on medicalization. Chapter 11 endeavors
ance that has emerged in the past two decades. to present a theoretical statement on the medi-
Our- emphasis differs from most interactionist calization of deviance, serving both as a sum-
work in that we focus on historical construc- mary of what we understand about the process
tion and change of deviance definitions. of medicalizing deviance and suggestions about
Chapter 2 presents the analytic perspective issues those who study the problem need to pur-
used for the remainder of the book: the politics sue.
of deviance definitions and designations. We
also present some introductory thoughts about
the medicalization of deviance. Chapters 3
SUGGESTED READINGS
through 8 consist of substantive sociohistorical Erikson, K. T. Wayward puritans. New York: John
Wiley & Sons, Inc., 1966.
analyses of the changing definitions of various An excellent and highly readable account of devi-
categories of deviance. Throughout we attempt ance among the 17th-century Puritans. Erikson
to focus on people, groups, and organizations explores the Antinomian controversy, the Quaker
as they contend about particular definitions invasion, and Salem witchcraft as "crime waves"
of deviance. Chapter 3 examines the oldest and and develops a theory of deviance as boundary
marking.
most widely accepted example of medicaliza- Freidson, E. Professional dominance. Chicago:
tion, the medical model of madness. It traces Atherton Press, 1970.
the events, discoveries, and people involved A critical analysis of the social structure of medi-
with the promotion and diffusion of the concept cal practice. Freidson outlines the perquisites and
of mental illness. Chapter 4 focuses on the de- consequences of professional dominance from a
sociology-of-work perspective.
velopment of the disease concept of alcoholism,
Goode, E. Deviant behavior: an interactionist ap-
highlighting how nonmedical groups can use proach. Englewood Cliffs, N.J.: Prentice-Hall,
medical means to their own ends. Chapter 5 Inc., 1978.
examines the fall and rise of opiate addiction A thoughtful and intelligent introduction to the rel-
as a medical problem, illuminating with par- ativist-interactionist approach to the study of devi-
ance. The first eight chapters are especially useful.
ticular clarity the political struggles between Rubington, E., & Weinberg, M. S. Deviance: the
supporters of criminal and medical definitions interactionist perspective (3rd ed.). New York:
of addiction. Chapter 6 reviews the develop- Macmillan Publishing Co., Inc., 1978.
ment and legitimation of the designations of A well-integrated collection of articles that in-
juvenile delinquency, hyperkinesis, and child cludes some of the best examples of the interac-
tionist approach to deviance. Either this book or
abuse and suggests that children, because of
Goode's could profitably be read as a companion
their position in society, are a population at risk to Deviance and Medicalization.
for medicalization. Chapter 7 traces the defini- Wertz, R. W. & Wertz, D. C. Lying in: a history of
tions of homosexuality from sin to sickness to childbirth in America. New York: The Free Press,
life-style, noting the profound moral continuity 1977.
in definition and social response. The recent Traces the definition and treatment of childbirth
from a family event to a medical event. This is a
demedicalization by the American Psychiatric well-presented case of the medicalization of a non-
Association is examined and found more sym- deviant activity.
bolic than real. Chapter 9 (written by Richard
Moran) outlines the long search for the "born
2 FROM BADNESS
to SICKNESS
CHANGING DESIGNATIONS of DEVIANCE and
SOCIAL CONTROL
T his chapter departs from the historical

frame that organizes most of this book
to present the theoretical perspective
we have used in our study of deviance.
defined as deviant. The power to so define and
construct reality is linked intimately to the
structure of power in a society at a given histor-
ical period. This is another way of saying that
The perspective serves as a general conceptual historical constructions of deviance are linked
framework for the ensuing substantive chap- closely to the dominant social control institu-
ters. The first part of this chapter presents what tions in the society. Our perspective emphasizes
we call a historical-social constructionist ap- a dual point of view: the attribution of deviance
proach to deviance. Ours is a broadly conceived as a historical, social construction of reality and
sociology-of-knowledge approach to the con- the activities involved in constructing new devi-
struction and change of deviance designations ance definitions or designations for social con-
and is rooted in the labeling-interactionist tra- trol. We view religion and the state as social
dition of deviance research. This allows us to control agents that have lost, or in the case of
focus on how certain activities or behaviors the state, transferred, some of their control pre-
become defined as deviant and how they come rogatives in the development of modern socie-
to be designated as one particular form of de- ties. Medical science, in particular, typically
viance rather than another. We attempt to an- buoyed by state legitimation, has grown to
alyze the factors involved in the changes in assume these age-old control functions.
dominant deviance designations from moral or In this section we outline our approach to the
legal categories to medical ones, or more sim- study of deviance. Our concern is not so much
ply, from "badness" to sickness. This requires with deviants per se but with the social proces-
a historical view of deviance definitions and ses through which certain forms of behavior are
designations. The second part of this chapter defined collectively as one type of problem or
introduces the general discussion first, of the another. In this sense, ours is a sociology of
concepts illness and deviance, and then of the deviance designations or categories. These cate-
social construction of illness. The final section gories are socially constructed entities, "neither
summarizes the theoretical approach developed immutable nor 'given' by the character of ex-
in this chapter. ternal reality" (Gusfield, 1975; p. 286), that
shift and change over time and place. More
A HISTORICAL-SOCIAL specifically, our approach focuses on how cer-
CONSTRUCTIONIST APPROACH tain categories of deviant behavior become
TO DEVIANCE defined as medical rather than moral problems
Since deviance is an attributed designation and how medicine, rather than, for example,
rather than something inherent in individuals, the family, church, or state, has become the
our approach focuses on the historical, social, dominant agent of social control for those so
and cultural processes whereby individuals, identified. In short, our concern is with how
behavior, attitudes, and activities come to be certain forms of deviant behavior have become
17
problems for medical jurisdiction and been aspects of deviance: especially the levels of
designated as sickness rather than badness. interpersonal reactions (e.g., identification,
We present our analytical approach here definition, and contingencies of deviant label-
somewhat inductively, tracing its roots from the ing) and organizational process (e.g., official
labeling-interactionist tradition and the sociol- labeling and its attendant consequences). Thus
ogy of knowledge. we have developed considerable knowledge
about contingencies in labeling, deviant ca-
Deviance as collective action: reers, deviant subcultures, deviant identities,
the labeling-Interaction 1st tradition and the effects of stigma.
As noted in the previous chapter, the la- The "macrosociological" aspects of the
beling-interactionist perspective views devi- labeling perspective have received less attention
ance as relative to time, place, and audience and consequently are not as developed in the
and as an attribute that is conferred on people sociological literature. Thus we know consider-
by others. This perspective posits that the pro- ably less about the "collective definition of
cesses of identifying, defining, and labeling deviance" (Davis & Stivers, 1975) than we do
behavior as deviant should be central concerns about deviance-processing organizations, devi-
of the sociology of deviance. The labeling- ant careers, and stigmatized identities. Certain-
interactionist approach turns the analysis away ly this imbalance is not inherent in the labeling
from the individual and the "causes" of his or perspective itself. There have been a few
her behavior, which have so long preoccupied studies that focus on this collective process of
the sociologist, to the "societal reaction." deviance definition and designation. Becker, in
Rather than being viewed as an objective con- his seminal discussion of the Marijuana Tax
dition, deviance is regarded as a social prod- Act of 1937, which rendered the sales and use
uct, produced by the joint action of the "devi- of marijuana deviant, developed the concept of
ant" and various social audiences. moral entrepreneurs to describe those who
Although the labeling perspective emerged "lobby" for the creation of social rules. Such
from a symbolic interactionist social psychol- works as Kai Erikson's (1966) study of devi-
ogy, the focus on social process allowed for ance in the Puritan colonies, Anthony Platt's
analysis of a wide range of activities related to (1969) study of the child-saving movement
deviance production. As Howard Becker (1973) and the "invention of delinquency," Joseph
points out, a central tenet of such an interaction- Gusfield's (1963) analysis of the Women's
ist view is that deviance is "collective action." Christian Temperance Union's crusade for pro-
"In its simplest form, the theory insists that we hibition, Elliot Currie's (1968) analysis of the
look at all people involved in any episodes of control of witchcraft in Renaissance Europe,
alleged deviance" (p. 183). Edwin Schur William Chambliss's (1964) study of the origin
(1971) clarifies the essence of this approach: and change of vagrancy laws, and David Mat-
za's (1966) essay on the disreputable poor are
Processes of social definition, or labeling, that con-
perhaps the classic labeling-interactionist
tribute to deviance outcomes are actually found on
studies that have examined the origin of de-
at least three levels of social action, and all three
require analysis. Such processes-as they occur on
viant categories. * Although a few other studies
the levels of collective rule-making, interpersonal
reactions and organizational processing-all con-
*A few studies that focused on the collective defini-
suitute important concerns of the labeling school. (p.
tion of deviance were done before the emergence
11).*
of the labeling tradition, most significantly Suther-
land's (1950) analysis of the diffusion of sexual
Most studies of deviance from a labeling- psychopath laws and Kingsley Davis' (1938) paper
interactionist perspective have focused on the on the ideology of the mental hygiene movement (see
social psychological and microsociological Chapter 3). Nonsociologists have also explored the
collective definition of deviance, such as Thomas
Szasz's (1970) essays on mental illness and David
*Schur, E. Labeling deviant behavior. New York: Musto's (1973) analysis of the history of opiate ad-
Harper & Row, Publishers, Inc., 1971. diction in America.
FROM BADNESS TO SICKNESS 19
have appeared recently, relatively less attention the study of those defined as deviant. A fully
is still given to how "society" defines an act developed labeling-interactionist perspective
as deviant. must also account for the development and
Sociologists whose work falls within the change of deviance designations.
labeling-interactionist tradition have themselves Malcolm Spector and John Kitsuse (1977)
pointed to this underdeveloped aspect of the recently have taken a similar approach to the
perspective. Howard Becker (1973), in his dis- study of social problems. In contrast to tradi-
cussion of deviance as collective action, notes tional functionalist and normative approaches
that all parties involved in deviance production to social problems, Spector and Kitsuse suggest
are fit objects for study. that sociologists study the collective activities
involved in how certain conditions come to be
At a second level, the interactionist approach shows defined as social problems. They are not con-
sociologists that a major element in every aspect of
cerned with how such social conditions
the drama of deviance is the imposition of definitions
-of situations, acts, and people-by those powerful
developed but rather with how these alleged
enough or sufficiently legitimated to be able to do so. conditions came to be seen as social problems.
A full understanding requires the thorough study of Social problems emerge and are legitimated
those definitions and the processes by which they through the action of various "claims-making"
develop and attain legitimacy and taken-for-granted- groups in society. Spector and Kitsuse suggest
ness. (p. 207)* that sociologists need to study the interaction
between these claims-makers and responders
Eliot Freidson suggests that sociologists of concerning the definition of social conditions
deviance have recognized only one of the two and what ought to be done about them. They
major sociological tasks in the study of devi- see a parallel situation in the study of deviance:
ance. He points out, as do we, that sociologists
have investigated rather thoroughly the etiology Central to the subject matter of the sociology of
of various forms of deviant behllYior but largely deviance is the processing of the definitions of devi-
ance which may result in the development of in-
have "failed to recognize the other task" of
fonnally recognized and enforced categories, as well
studying the etiology of deviance designations. as the establishment of official categories and
Freidson's (1970a) notions are similar to the populations of deviants. The theoretical problem is to
perspective we develop here: account for how categories of social problems and
deviance are produced, and how methods of social
[Sociological researchers] have followed the mod-
control and treatment are institutionally established.
el of medicine in setting as their task the detenni-
(Spector & Kitsuse, 1977, p. 72). *
nation of some stable, objective quality or state of
deviance (e.g., criminal behavior) and have sought to One final point concerning the labeling-
detennine its etiology. They have failed to recognize interactionist perspective of deviance is impor-
the other task of studying the way conceptions of tant. Labeling studies have been criticized for
deviance are developed and the consequences of the being "apolitical" and for avoiding structural
application of such conceptions to human affairs ....
considerations in their analysis (e.g., Taylor,
This task does not require explanation of the cause
I., et aI., 1973). By investigating the collec-
of behavior so much as it requires the explanation
of the cause of the meaning attached to the behavior.
tive and historical dimensions of the develop-
(pp. 213, 216, emphasis added) ment of deviance categories in a given society,
we can begin to examine these structural and
Since the labeling-interactionist approach ar- political elements involved in defining this or
gues that deviance is an imputed or attributed that behavior as deviant: Who defines what as
condition, a social construction, it makes the deviant? How does one group manage to have
study of the imputer or definer as important as their definition of deviance legitimated? How
*From Becker, H. S. Labeling theory reconsidered. *Courtesy Malcolm Spector & John Kitsuse,
In H. S. Becker, Outsiders. New York: The Free Constructing social problems. Copyright © Benja-
Press of Glencoe, Inc., 1973. Copyright © 1973 min/Cummings Publishing Co. 1977.
by Howard S. Becker.
do deviance designations change as political knowledge approach is that ideas do not de-
and economic conditions change? Whose inter- velop in a vacuum but rather are generated
ests do deviance designations serve? The defini- and elaborated in a specific social milieu. Using
tion of any behavior or action as deviant is this approach, we view deviance designations
essentially a political matter, as Becker (1963, as products of the society in which they exist.
p. 7) has noted. In large part the success of such The task of such an analysis is to investigate,
definitional process is decided by who has the usually in a historical,frame, the social sources
power to legitimate their definitions. Such a of these ideas and to trace their development or
perspective must eventually lead to the study demise.
of the distribution of power in a society, how A few labeling-interactionist sociologists
those with power are able to effect the pro- have pointed clearly in the direction of the
duction of deviance designations, and whose sociology of knowledge to aid in this "other
interests these designations support. * task" of sociologists studying deviance, exam-
The labeling-interactionist sociologists, al- ining how conceptions of deviance are devel-
though actually producing few studies on the oped (e. g., Goode, 1969). As Freidson (1970a)
process of the collective definition of deviance, states,
have developed a framework that allows for
study of the macrosociological process of devi- The other task is one that is essentially defined by the
sociology of knowledge. It is created by the recogni-
ance definition. In that this perspective views
tion that deviance is not a state as such. so much as
deviance as an attribution, it allows us to study
an evaluation of the meaning of a state. Its problem
the etiology of definitions separately from the for analysis then becomes not the etiology of some
etiology of behavior. Thus the investigation of state so much as the etiology of the meaning of a
the origin, development, and change of devi- state. Thus, it asks questions like: How does a state
ance designations becomes a central task for the come to be considered deviant? How does it come to
sociology of deviance. be considered one kind of deviance rather than an-
other? . . . What does the imputation of a partic-
SOCIAL CONSTRUCTION OF ular kind of deviance do to the organization of the
REALITY: A SOCIOLOGY OF interaction between interested parties? (pp. 215-
KNOWLEDGE 216)
Although the labeling-interactionist perspec- The only way to answer such questions about
tive presents us with the questions to ask con- the emergence of dominant deviance designa-
cerning the development of deviance designations is to attempt to locate their origins in his-
tions, it is a sociology-of-knowledge approach tory and identify the social groups and activities
that is necessary to answer them. The sociology that generate and support them. In this fashion
of knowledge involves relating "knowledge" we can begin to understand the meanings we
or cultural facts to specific social and structural attribute to certain forms of behavior.
forms in a given society. It sees knowledge There are several different paths we could
as linked intimately to social organization or take toward a sociology-of-knowledge analysis
interaction that can be located in a historical of deviance designations. We have chosen to
frame. The basic assumption of a sociology-of- follow the phenomenological and conflict per-
spectives. Both view ideas-and in our case,
deviance designations-as products of histori-
* Sociologists with perspectives other than labeling- cally locatable social interaction or social or-
interactionist may also see the collective definition of
deviance as a central sociological concern. As Steven
ganization. But they vary as to where they
Spitzer (1975) points out in his theoretical discus- would ultimately locate the source of the idea
sion of a Marxian approach to the study of deviance, and what factors they would take into account
"Most fundamentally, deviance production involves in their analysis.
the development of and changes in deviant categories The phenomenological perspective views
and images" (p. 640). Although Spitzer would call
for a class-based analysis of deviance designations, deviance designations as "socially constructed
he agrees that such designations should be central realities," typifications (commonly understood
in the study of deviance. categories or types) that are products of social
interaction and central in our interpreation of dominate others. There are two general schools
the world. "Reality" is defined not as some- of deviance conflict theorists, the pluralists and
thing that exists "out there" for the scientist or the Marxians. The pluralist conception sees
anyone else to discover but as a social construc- society as made of a variety of competing inter-
tion that emerges from and is sustained by est groups in conflict for dominance, status,
social interaction. The social world is thus both wealth, and power (e.g., Lofland, 1969;
interpreted and constructed through the medium McCaghy, 1976). The Marxian perspective
of language. Language and language categories views conflict as a product of the class struc-
provide the ordered meanings by which we ex- ture of society and the relation people have to
perience ourselves and our lives in society. the economic system (e.g., Quinney, 1974;
They make the social world (objects, behavior, Taylor, I. et aI., 1973). For the pluralist, the
etc.) meaningful. conflict is most often played out in the conven-
Peter Berger and Thomas Luclemann (1966) tional arena of institutionalized partisan poli-
are perhaps the major proponents of this per- tics, with different interest groups attempting
spective. They view reality construction as a to legislate their laws or laws that benefit them.
social process of three stages: externalization, The Marxian view sees law as much more a
objectivation, and internalization. Externaliza- reflection of the interests of a ruling class. In
tion is the process by which people construct a this view, laws and deviance designations are
cultural product (e.g., the idea that strange part of the "superstructure," the culture and
behaviors can be caused by a mental illness). knowledge of a society, which is determined
Objectivation occurs when cultural products by the economic "substructure." Dominant or
take on an objective reality of their own, inde- socially "popular" ideas bear the insignia of
pendent of the people who created them, and the ruling economic class and serve to rein-
are viewed as part of objective reality (e.g., force its interests. A conflict approach sees
mental illness causes strange behaviors). Inter- "the subjective conceptions and definitions of
nalization is when people learn the "objective deviance that exist to a given society as ideo-
facts" of a culture through socialization and logical products of interest group competition
make them part of their own "internal" con- or class conflict" (Orcutt et aI., 1977). Devi-
sciousness (e.g., taking for granted that strange ance designations are produced and influenced
behaviors are caused by mental illness). Ob- more by the powerful and applied more to the
jectivation is the institutionalization of the powerless.
socially produced cultural product; it becomes, These two sociologies of knowledge are not
then, part of the available stock of knowledge fully compatible (nor need they be). For
of any society. Language becomes a deposi- example, Marxians would take issue with the
tory of institutionalized collective "sedimenta- phenomenologists' "social construction of
tions" (e.g., mental illness), which we acquire reality" and argue that "reality" is based on
"as cohesive wholes and without reconstruct- the interests and visions of the ruling class
ing the original process of formation" (Berger rather than emerging out of social interaction.
& Luckmann, 1966, p. 69). In a real sense they Phenomenologists, on the other hand, would
become part of the taken-for-granted everyday have difficulty with the "hidden forces" (e.g.,
vocabulary of a society. It follows that if reality the economic system or means of production)
is socially constructed by human activity, it that Marxians see as determining social life.
can be changed by human activity. Indeed, in Important as these differences may be, how-
Berger and Luckmann' s view, realities are ever, we need not concern ourselves here with
constantly being constructed and reconstructed such disputes. Although our approach is more
in a dialectic process between interacting in- phenomenological and pluralist than Marxian,
dividuals and their social world qua society. both these approaches are insightful in studying
The conflict perspective views deviance des- the development and change of deviance
ignations as the products of social and political designations. The phenomenological perspec-
conflict, and it defines social control as a polit- tive sensitizes us to the socially constructed
ical mechanism by which certain groups can nature of deviance designations-that they
emerge from social interaction and that they there is some evil which profoundly disturbs him.
are humanly constructed and hence can be He feels that nothing can be right in the world until
humanly changed. The conflict perspective the rules are made to correct it. He operates with
sensitizes us to the fact that not all people are an absolute ethic; what he sees is truly and totally
equal in their power to construct reality - that evil with no qualification. Any means is justified
to do away with it. The crusader is fervent and
deviance designations may serve political inter-
righteous, often self-righteous. (Becker, 1963, pp.
ests and that they are created usually through
147-148)*
some type of social conflict. We call this con-
flict the politics of definition. Becker notes that the claims of most moral
crusaders have humanitarian overtones; they
Politics of definition truly think that they know what is good both
What is considered deviant in a society is a for themselves and other people. But the cru-
product of a political process of decision sader or crusading group is also often a self-
making. The behaviors or activities that are interested participant in the deviance-defining
deviant in a given society are not self-evident; process. The crusader (or the group) is not only
they are defined by groups with the ability crusading for a moral change in social rules, but
to legitimate and enforce their definitions. As there also may be a hidden agenda which is
Becker (1963, p. 162) notes, deviance is al- of equal or greater import and not immediately
ways a product of enterprise. It is through obvious.
some type of political process, using "politi- Becker (1963, pp. 135-146) describes the
cal" in its broad meaning of conflict about passage of the Marijuana Tax Act of 1937 as an
power relations, that deviance designations exemplar of moral entrepreneurship. He sug-
emerge and are legitimated. There are several gests that there was little public interest in mari-
ways this can occur. An individual or group juana before a publicity campaign by the
may champion a cause that this or that behavior Bureau of Narcotics. This campaign, led by
should be considered deviant (Blumer, 1971; Commissioner Henry J. Anslinger, aroused
Mauss, 1975). The antebellum abolitionist public interest and was followed by Congress
movement, antipornography crusades in var- passing a law that essentially made marijuana
ious communities (Zurcher et aI., 1971), the illegal. The marijuana smokers, whoever they
Women's Christian Temperance Union's cam- were, were unorganized, powerless, and with-
paign for Prohibition (Gusfield, 1963), the out publicly legitimate grounds for defense.
present-day antiabortion ("right to life") They did not appear at the congressional hear-
groups, and Anita Bryant's recent crusade ings to oppose the law. The bureau had helped
against gay rights legislation are examples of create a new category of deviants, mari-
this. Such campaigns for deviance designa- juana sellers and users (Becker, 1963; p. 145).
tions can be seen as the work of moral entre- Another sociologist, Donald Dickson (1968),
preneurs, those who crusade for the creation of a few years later reanalyzed the origin of the
new rules. * Marijuana Tax Act and concluded that Ans-
linger and the bureau lobbied for its passage
The prototype of the rule creator . . . is the cru-
for organizational rather than moral reasons.
sading refonner. He is interested in the content of
rules. The existing rules do not satisfy him because
He suggests that the bureau, faced with the
threat of a steadily decreasing budget, tried
to present itself as essential to the public wel-
* Becker discusses both rule creators and rule en-
fare as a defender against the peril of marijuana.
forcers as moral entrepreneurs, but only the fonner
concern us here. Becker, and some of the other
authors of labeling studies we present in this section,
did not conceptualize their work in tenns of the *From Becker, H. S. Outsiders; studies in the so-
sociology of knowledge. However, when sociology ciology of deviance. New York: The Free Press of
of knowledge is used as we present it here, these Glencoe, Inc., 1963. Copyright © 1963 by The Free
works are cIearl)l within that perspective. Press of Glencoe.
It attempted to increase its powers and scope In these activities the physician can be seen as
of operations by lobbying for the inclusion of a moral entrepreneur:
marijuana in its jurisdiction. Dickson suggests
[Medicine] is active in seeking out illness. The pro-
it was bureaucratic survival and growth rather
fession does treat the illnesses laymen take to it,
than moral righteousness that prompted the but it also seeks to discover illness of which laymen
bureau's efforts in promoting the anti marijuana may not even be aware. One of the greatest ambitions
legislation (the fact that most states already had of the physician is to discover and describe a "new"
some type of antimarijuana laws supports his disease or syndrome and to be immortalized by
interpretation). In either case, however, it ap- having his name used to identify the disease.
pears that the new deviance designation was a Medicine, then, is oriented to seeking out and finding
product of enterprise, moral or bureaucratic, illness, which is to say that it seeks to create social
and was legitimated through the political pro- meanings of illness where that meaning or inter-
cess. * pretation was lacking before. And insofar as illness
is defined as something bad-to be eradicated or
Although the legal process is the most formal
contained-medicine plays the role of what Becker
and institutionally obvious political avenue by called the "moral entrepreneur." (Friedson, I 970a,
which individuals and groups can influence p. 252)
and promote their definitions of deviance, it
is by no means the only one. Moral entrepre- Medical work can lead to the creation of new
neurs and other champions of deviance defini- medical norms, whose violation is deviance, or,
tions can operate in any social system that has in the cases we present, new categories of ill-
power and authority to impose definitions of ness. This increases the jurisdiction of medicine
deviance on the behaviors and activities of or some segment of it and legitimates the med-
its members. One could expect to find cham- ical treatment of sick deviants. Sociological
pions of deviance definitions in schools, facto- analysis of the 19th-century medical involve-
ries, bureaucracies, and religious and medical ment in the definition of madness (Scull, 1975)
organizations-virtually in any system that has and the more recent cases of the medical defini-
rules and authority. However, in modem in- tion of hyperkinesis (Conrad, 1975) and child
dustrial society, only law and medicine have the abuse (Pfohl, 1977) are prime examples of the
legitimacy to construct and promote deviance medical profession's championing of certain
categories with wide-ranging application. With definitions of deviance. These examples will be
medicine this application even transcends social presented in detail in later chapters. Although
and national boundaries. The labeling of a the •'politics of definition" may be more ob-
disease or illness, the medical designation for scured in the construction of medical designa-
deviance, is usually considered to have univer- tions than in legal ones, the decision to define
sal application. As Freidson (l970a) points out, certain behaviors, activities, or conditions as
the medical profession takes an active role in deviant still emerges from a political process
influencing deviance definitions and designa- that produces and subsequently legitimates the
tions, discovering new "illnesses," and inter- imposition of the deviant categories. And, most
vening with "appropriate" medical treatment. often, the consequences of medical definitions,
especially when they concern human behavior,
are also political. The second section of this
chapter, which discusses deviance, illness, and
*A recent reappraisal of the passage of this legis-
lation posits that since most states already had anti- medicalization, as well as subsequent chap-
marijuana laws, the bureau's publicity campaign was ters, elaborates this point.
actually rather limited, the public interest was mini- Interests, status, and class In the poli-
mal, there was virtually no opposition, and there was tics of deflnHlon. Moral entrepreneurship and
no budget increase for the bureau; the act was a
other championing of deviance definitions are
symbolic piece of legislation, symbolically reassur-
ing congresspeople and others in what they already not the only types of politics of definition. An-
commonsensically believed (Galliher & Walker, other powerful influence on creating deviance
1977). designations is what we call interest politics:
the promotion, directly or indirectly, of defini- Quinney sees law as a political instrument used
ions of deviance that specifically support and by specific groups to further their own interests;
buttress certain class or status interests. This as a tool of those with power to shape the law
approach aligns neatly with the conflict ap- at the expense of others. Definitions of devi-
proach to the sociology of knowledge. In these ance thus created and/or legitimated through
cases we usually find groups or "power blocs" law represent those interests.
rather than individual entrepreneurs attempting But what the interests are, and even whose
to create rules that uphold their needs and in- interests are involved, is not always obvious.
terests. The deviance designation may become Joseph Gusfield (1963) presents us with an in-
an instrumental or symbolic way in which to teresting example in his analysis of the Wom-
achieve ends that are totally unrelated to the en's Christian Temperance Union's crusade
deviance or deviance designations themselves. for Prohibition. Why would the members of
Interest poiitics may focus on interest groups, the WCTU, a largely rural, Protestant, middle-
status interests, or class interests. Each will be class group of women, crusade so fervently for
discussed briefly. the prohibition of alcohol when problem
Richard Quinney is one of the major con- drinking was not. a major concern in their
flict sociologists writing on deviance today. own rural communities? And why did they
His more recent work (Quinney, 1974) assumes support only complete prohibition of alcohol
a Marxian view, but his earlier work is more use rather than restriction and control? They
pluralistic. In one of these early works Quinney were moral crusaders for sure, but why engage
presented a sociological theory of criminal in a moral crusade against a problem that
law, in which he outlined an interest group appeared, at least on the surface, not to affect
model for the origin and development of law them?
and deviance designations. Building on the Gusfield places the Temperance movement
work of legal scholar Roscoe Pound, Quinney and especially the WCTU in a social-historical
developed a theory strikingly similar to the context to attempt to understand this crusade.
early work of Edwin Sutherland. It is based on The movement gained its strength in the late
the pluralist assumptions that society is charac- 19th and early 20th centuries. The United States
terized by diversity, conflict, and change rather was changing rapidly from a land dominated
than consensus; that law, and therefore devi- by native-born, rural, Protestant farmers and
ance definitions, are created by interest groups small-townspeople to one increasingly influ-
in conflict with one another; and that law usual- enced by urban, immigrant, Catholic industrial
ly represents these specific interests rather than workers and other urban folk. The drinking of
all the members of society. Quinney departs alcohol was part of the everyday life of these
from the standard pluralist conception, which urban workers. The rural Protestant culture was
sees law as a compromise of diverse societal in- beginning to decline in influence; they saw their
terests; in his view, law "supports some inter- dominant status as endangered. Gusfield sug-
ests at the expense of others." He proposes gests that the Temperance movement for pro-
four propositions to explain the origin of law hibition of alcohol was an instance of status
through interest group conflict: politics, with the rural Protestant people trying
to legislate their morality and norms. The con-
I. Law is the creation and interpretation of spe- flict, according to Gusfield, was one of diver-
cialized rules in a politically organized so- gent styles of life, and the issue of alcohol was
ciety. the symbol of this conflict. Thus he sees the
2. Politically organized society is based on an in-
Temperance movement as a "symbolic cru-
terest structure.
3. The interest structure of politically organized sade" to try to maintain status in a changing
society is characterized by unequal distri- society. The fact that Temperance advocates
bution of power and conflict. were much less concerned with the enforcement
4. Law is fonnulated and administered within the of Prohibition legislation than with its passage
interest structure of a politically organized so- supports Gusfield's interpretation. The success
ciety. (Quinney, 1969, pp. 20-30) of the Eighteenth Amendment outlawing alco-
hoI was a public affirmation of their morals; it trol persons suspected of being "highwaymen"
was clear to all concerned, regardless of en- who preyed on merchants transporting goods.
forcement, whose law it was (Gusfield, 1967). Thus, as the economic structure changed, the
This analysis depicts how definitions of devi- law shifted and continued to support the domi-
ance (e.g., drinking alcohol) can be symbolic nant economic class in society - first the land-
representations of one group's struggle against owners, then the merchants.
another about issues of morality and style of In summary, the politics of definitions is a
life. process whereby definitions of deviance are
Karl Marx argued law supports the dominant socially constructed. In a world where there are
class's economic interests in society, which in multiple "realities" and definitions of behav-
industrial society is that of the bourgeoisie, or ior, these definitions are constructed through a
the owners of the means of production. It is political process and legitimated in legal stat-
nearly axiomatic among Marxian theorists that utes, medical vocabulary, or religious doctrine.
law reflects the interests of the ruling class. Although negotiations may occur, more pow-
Sociologist William Chambliss (1964) presents erful interests in society are better able to im-
an analysis of the origin and change in the devi- plement their version of reality by creating and
ance called "vagrancy" that points clearly to legitimating deviance definitions that support
the effects of economic changes on law and de- their interests.
viance designations. The first vagrancy statutes
emerged in England in the 14th century after
Politics of deviance
the Black Death decimated the labor force. The designation
lack of an adequate supply of labor forced the The definition of certain behaviors or activi-
feudal landowners to pay higher wages for ties does not necessarily tell us what particular
"free" labor and made it more difficult for designation of deviance will be applied. For
them to keep serfs on the land. Opportunities example, is the offending conduct a sin, a moral
for wages were available, and the landowners problem, a crime, or a sickness? The particular
were hardpressed to keep them from fleeing. deviance designation is often a matter of contro-
Chambliss (1964) concludes that the vagrancy versy: Is deviant drinking a moral weakness or
law was to keep serfs from migrating: "There a disease? Are criminals genetically defective,
is little question but that these statutes were de- psychologically abnormal, morally vacuous, or
signed for one express purpose: to force laborers unsocialized brutes?
(whether personally free or unfree) to accept The professional and popular literatures on
employment at a low wage in order to insure deviance are replete with discussions on what
the landowner an adequate supply of labor at constitutes the nature of nearly any form of de-
a price he could afford to pay" (p. 69). By viant behavior. Such discussion usually takes
the 16th century the focus of vagrancy laws the form of an analysis of the etiology and char-
shifted from a concern with the movement of acteristics of the deviant behavior. It is assumed
laborers to a concern with criminal activities. A generally that if one could only know the cause
vagrant became defined in the law as one who and thus the "true" nature of the deviant be-
"can give no reckoning how he lawfully makes havior, one could prevent or, more likely, con-
his living." Punishment was severe: public trol it closer to its source. But there is an unac-
whipping and, for repeated offenses, cutting off knowledged political dimension to these aca-
an ear. Chambliss points out that this change in demic debates. That is the question of who is
vagrancy laws came about when feudalism was the appropriate official agent of social control
crumbling and there was increased emphasis on for such deviance. Put another way, in whose
commerce and industry. This led to an increase turf does the deviance lie? It is when we view
in trade, on which English commerce was de- discussions of deviance from this angle that
pendent. Transportation, however, was haz- such debates descend from the language of in-
ardous, and the traders were frequently at- tellectual and technical specialization to politi-
tacked and robbed of their goods. The vagrancy cal battles over turf. If drug addiction and alco-
law was revived with the changed focus to con- holism are diseases, then the medical profes-
sion is the legitimate agent of social control; if place to another)? Although it is usually be-
they are crimes, then they are in the jurisdiction lieved that decisions about proper designations
of the criminal justice system. Needless to say, of deviance (i.e., a crime versus a sickness) are
in a society as complex as ours the jurisdictional made on a rational, even scientific, basis, as
lines are not mutually exclusive, and consider- social scientists we cannot assume this. The
able overlap may exist. This, however, does not public identity of the problem is not apparent;
negate the fact that arguments of etiology may rather it is constructed through human inter-
be in essence jurisdictional disputes (this is action.
perhaps clearest in the case of opiate addiction, The "discovery" of public facts is a process of social
presented in Chapter 5). As Erich Goode (1969) organization. Someone must engage in monitoring,
points out, "naming" itself has important polit- recording, aggregating, analyzing and transmitting
ical implications: "By devising a linguistic cat- the separate and individual events into the public
egory with specific connotations, one is design- reality of "auto accidents and deaths." At every
ing the armaments for a battle; by having it stage in this process human choices of selection and
accepted and used, one has scored a major vic- interpretation operate. Events are given meaning and
assumptions and values guide the selection. Public
tory" (p. 89). In our view, deviance designa-
"facts" are not like pebbles on the beach, lying in
tions are not ipso facto one type of problem or
the sun and waiting to be seen. They must instead be
another, and it is similarly not evident which picked, polished, shaped and packaged. Finally
social control agency is most appropriate. De- ready for display they bear the marks of their
cisions concerning what is the proper deviance shapers. (Gusfield. 1975. p. 291)
designation and who is the proper agent of con-
These facts may be part of claims-making activ-
trol are political questions decided frequently
ities of an agency or organization. Spector and
through political contest.
Kitsuse (1977) note that their perspective leads
Recent analyses of social problems present
them "to view scientific facts and knowledge
an analogous situation. We have already noted
about social conditions as products of that or-
that Spector and Kitsuse (1977) suggest that the
ganization, not as reflections of the phenomena
distinctive focus of the sociology of social prob-
they purport to explain" (p. 67). In this view,
lems and deviance should be the social proces-
public "facts" about social conditions that
sing of definitions. Sociologists need to focus
render deviance properly in one jurisdiction or
on the "claims-making activities" of the var-
another, even those claimed to be scientific
ious groups asserting their definitions of devi-
ones, are viewed skeptically as "social con-
ance and analyze "how categories of social
structions" that may support certain claims of
problems and deviance are produced, and how
legitimacy. * This perspective is particularly ap-
methods of social control and treatment are in-
propriate when "scientific evidence" is pre-
stitutionally established" (Spector & Kitsuse,
sented by an agency or organization in sup-
1977, p. 72). This latter task is analogous to the
port of their deviance designation or to refute
one we propose here: the examination of
the claims of others. In short, such data may
"claims-making" activities that lead to the es-
become vitally important ammunition in the
tablishment of a deviance designation and the
battle among competing groups and control
appropriate agent of social control. Joseph
agencies.
Gusfield (1975), in his analysis of the appro-
priate designation and control agent for auto-
*It is in this light that Goode (1969) notes that "em-
mobile accidents and deaths attributed to pirical reality. being staggeringly complex. permits
"drinking-driving," suggests we investigate and even demands factual selection. We character-
how one agency attains "ownership" of a so- istically seek support for our view: contrary opinions
cial problem and thus establishes its designation and facts are generally avoided. This opens the way
of deviance. For example, why are traffic fatal- for the maintenance of points of view which are con-
tradicted by empirical evidence. And there is invari-
ities and drinking-driving defined as an individ- ably a variety of facts to choose from. It is a com-
ual's alcohol problem rather than as a problem paratively simple matter to find what one is looking
in transportation (i.e., getting safely from one for in any moderately complex issue" (p. 87).
Some prestigious claims-makers or organized 6. It may produce a change in the mode of in-
collectivities have greater power than others to tervention. When opiate addicts are defined as
define what is true and false, respectable and criminals, they are given legal punishments;
disrespectable, normal and abnormal, etc. when they are defined as sick, they are given
Howard Becker (1967) suggests there are methadone.
"hierarchies of credibility" whereby presti- 7. It may operate as a road sign as to what
gious organizations such as the American Med- type of data to collect and on what to focus
ical Association, the American Bar Associa- one's attention. By defining drinking-driving as
tion, the Department of Health, Education and the "cause" of auto fatalities, we focus on
Welfare, the Justice Department, and represen- problem characteristics of the individual driver
tatives of these organizations have a greater and collect data about him or her, rather than
power to define and legitimate reality (and de- collecting data about the auto industry or ana-
viance designations) than do other groups. lyzing the transportation system. By defining
They often use scientific findings selectively to hyperactive children as sick, we tum our atten-
support their particular policies (see, for ex- tion from the school and the child's situation
ample, Chapter 5). and focus on the child's physiological charac-
Deviance designations and social teristics.
change. Changes in deviance designations 8. It may shift the attribution of responsibil-
have consequences beyond justifying the suit- ity. Sinful and criminal deviants are responsible
able social control agent: for their behavior; sick deviants are not.
l. It may change the legitimate "authority" All these changes and others should become
concerning a particular variety of deviant be- apparent in various combinations throughout
havior. In the late 17th century, physicians this book in our examination of changing devi-
rather than priests or magistrates became the ance designations.
experts on madness. When certain types of deviance become ac-
2. It may change the meaning of behavior. cepted and taken for granted as reality, we have
The behavior of restless, disruptive school- something analogous to Thomas Kuhn's con-
children is no longer rebelliousness or willful cept of paradigm (Le., a fundamental image of
opposition, but symptomatic of the illness the subject matter). Paradigms structure the
hyperkinesis. way the "faithful" construct and interpret the
3. It may change the legal status of the devi- world. When paradigms change, after a crisis
ance. The Harrison Act of 1914 created a new and the emergence of a new paradigm, views of
group of criminals-opium peddlers; the 1973 reality change also. According to Kuhn (1970),
Supreme Court decision made abortion a con- "though the world does not change with a
ventional medical procedure. change in paradigm, the scientist afterwards
4. It may change the contents of a deviance works in a different world" (p. 121). Different
category or the norm itself. Prohibition, the data are collected, the world is seen and inter-
Eighteenth Amendment, altered, at least sym- preted differently, and the new paradigm be-
bolically, the norm of acceptable drinking becomes the dominant manner by which to inter-
havior-there could be none. With repeal, only pret experience.
certain drinkers were defined as deviant-the We propose that three major paradigms may
underage and the chronic inebriate. be identified that have held reign over deviance
5. It may change the arena where identifica- designations in various historical periods: devi-
tion and labeling of deviance takes place, as ance as sin; deviance as crime; and deviance as
well as the vocabulary used. When homosexual sickness. Overlap and competition among these
conduct is viewed as a "crime against nature," "paradigms" are apparent over time, but they
labeling occurs in judicial processes; when it provide, nonetheless, distinct perspectives and
is defined as an illness, labeling takes place in images for constructing deviant reality. When
the psychiatric arena through medical pro- a theological world view dominated, deviance
cesses. was sin; when the nation-states emerged from
the decay of feudalism, most deviance became discoveries, claims-making activities, and ne-
designated as crime; and in our own scientifi- gotiation of jurisdictional boundaries. It is im-
cally oriented world, various forms of deviance portant to remember that deviance designations
are designated increasingly as medical prob- do not change by themselves; social action en-
lems. Thus we view the medical paradigm as gaged in by real people or collectivities is nec-
the ascending paradigm for deviance designa- essary to create definitional change. We aim at
tions in our postindustrial society. constructing a historical overview and staying
In a given society a particular paradigm may close to the data in each case, rather than trying
be dominant. In contemporary American socie- to fit all cases into a rigid model of medicali-
ty a tension exists frequently between the legal- zation. In a sense, we view each substantive
crime and medical-sickness paradigms, al- chapter as revealing some aspect of the process
though opponents can develop comfortable ac- of medicalization. In Chapter 10 we attempt to
commodations. Each paradigm has institutional integrate these into a theoretical statement on
supporters of relatively high status (i.e., law- the medicalization of deviance.
makers and judges, medical researchers and
physicians). In a world that views science as the DEVIANCE, ILLNESS, AND
ultimate arbiter of reality, deviance designa- MEDICALIZATION*
tions that can be supported by scientific re- Consider the following situations. A woman
search are more likely to gain credence. We say rides a horse naked through the streets of Den-
"more likely," since the factors in the politics ver claiming to be Lady Godiva and after being
of deviance designation are complex. However, apprehended by authorities, is taken to a psychi-
all other things being equal, medical concep- atric hospital and declared to be suffering from
tions of deviance are more likely to be proposed a mental illness. A well-known surgeon in a
in the name of science. When medical designa- Southwestern city performs a psychosurgical
tions of deviant reality are in competition with operation on a young man who is prone to
other designations, we may well witness a violent outbursts. An Atlanta attorney, inclined
hegemony of medical definitions; that is, a to drinking sprees, is treated at a hospital clinic
preponderant influence or acceptance of medi- for his disease, alcoholism. A child in Cali-
cal authority as the "final" reality and a dimin- fornia brought to a pediatric clinic because of
ishing of other potential realities. Needless to his disruptive behavior in school is labeled
say, there can be and are challenges to this hyperactive and is prescribed methylphenidate
hegemony, but some see a type of cultural and (Ritalin) for his disorder. A chronically over-
structural medical hegemony of deviance desig- weight Chicago housewife receives a surgical
nations as increasingly apparent in American intestinal bypass operation for her problem of
society (see Illich, 1976; Radelet, 1977a). obesity. Scientists at a New England medical
We use the approach just outlined in the center work on a million-dollar federal research
remainder of this book to study the changing grant to discover a heroin-blocking agent as a
designations of deviance, especially as designa- "cure" for heroin addiction. What do these
tions become medical and physicians are in- situations have in common? In all instances
volved in treatment and social control. In the medical solutions are being sought for a variety
next section of this chapter we identify some of of deviant behaviors or conditions. We call this
the more general issues in "the medicalization "the medicalization of deviance" and suggest
of deviance. " In all the following substantive that these examples illustrate how medical defi-
chapters (3 to 8), we try to be true to the com-
plexities of the changing definitions and desig-
nations of deviance for each particular case. * The remainder of this chapter is an extended and
This involves giving attention to such specifics amended version of "On the Medicalization of De-
viance and Social Control" by Conrad, P. In D.
as historical events, relevant settings of con- Ingleby (Ed.), Critical psychiatry. Copyright ©
flict and change, attributions of cause, political 1980 by Peter Conrad. Reprinted by permission of
conflict, social control mechanisms, scientific Penguin Books Ltd.
nitions of deviant behavior are becoming more something that exists "out there," apart even
prevalent in modem industrial societies like our from the human body, that may enter the body
own. The historical sources of this medicaliza- and do harm; ideas of avoiding viruses, germs,
tion, and the development of medical concep- and other "diseases" follow from this view. A
tions and controls for deviant behavior, are the systematized variant of a commonsense view
central concerns of our analysis. might be that disease is "a specific destructive
Medical practitioners and medical treatment process in an organism, with specific causes
in our society are usually viewed as dedicated to and specific symptoms" (Webster's New Ideal
healing the sick and giving comfort to the af- Dictionary). Sometimes disease is seen simply
flicted. No doubt these are important aspects of as a departure from health. Illness, if differen-
medicine. In recent years the jurisdiction of the tiated from disease, is taken as the condition of
medical profession has expanded and encom- being diseased, or more commonly, the state of
passes many problems that formerly were not being sick. Yet, as we will point out, disease
defined as medical entities. Ivan Illich (1976) and illness are highly complex entities, far more
has called this "the medicalization of life." problematic than these commonsense views
There is much evidence for this general view- indicate. It is not our goal here to settle a long-
point-for example, the medicalization of preg- standing academic controversy on the nature of
nancy and childbirth, contraception, diet, exer- disease and illness, but rather to sensitize the
cise, child development norms-but our con- reader to a number of approaches and to some
cern here is more limited and specific. Our in- characteristics of illness designations.
terests focus on the medicalization of deviant A positivist conception of illness is most sim-
behavior: the defining and labeling of deviant ilar to the commonsense view. Illness is the
behavior as a medical problem, usually an ill- presence of disease in an organism that inhibits
ness, and mandating the medical profession to the functioning, or, in Leon Kass's (1975)
provide some type of treatment for it. Concomi- terms, "well-working" of the physiological or-
tant with such medicalization is the growing use gans (in a most inclusive sense) of the organ-
of medicine as an agent of social control, typi- ism. This strict and limiting definition includes
cally as medical intervention. Medical interven- only malfunctioning organs as diseases. It con-
tion as social control seeks to limit, modify, tains an implicit assumption that there is some
regulate, isolate, or eliminate deviant behavior norm of functioning or well-working that can be
with medical means and in the name of health used as a standard and that this normal condi-
(Zola, 1972). The remainder of this book ex- tion is recognizable by the medical observer.
amines sociologically the medicalization of de- One need only think about the recent medical
viance and the development of medical social controversies surrounding tonsillectomies and
control. It presents an analysis of the transfor- what constitutes "healthy" or "unhealthy"
mation of deviance from badness to sickness tonsils to realize that the concept of "well-func-
and the adoption of the medical model for a tioning organs" is itself problematic. More-
number of specific categories of deviant be- over, does such a notion limiting illness and
havior. disease to organ malfunctioning include undis-
Before beginning our introduction to the covered diseases or organ changes that may be
medicalization process, we discuss two general adaptations to an environment (e.g., the sickle
sociological notions that pertain to the perspec- cell trait)? By focusing only on "objective" or-
tive developed here. These are the social con- gan conditions, the medical positivists (at least
struction of illness and the relationship of ill- in theory) limit their concept of disease. It is
ness and deviance. important to point out that most of the difficul-
ties we call mental illness, especially the so-
The social construction of Illness called functional disorders, do not match this
What are disease and illness? On the face of definition at all.
it they seem rather straightforward concepts. A Others have argued that disease and illness
commonsense viewpoint might see disease as are separate entities and can be so analyzed. For
example, Abram Feinstein has conceptualized notion that a universal condition exists that is
disease "health" is a mirage and that health and illness
are limited by cultural knowledge and adapta-
in purely morphologic, physiologic, and chemical
terms. What the physician directly observes in his tions to the environment. Certainly such a rela-
dialogue [examination] ... that he terms the illness tivist stance allows important insight, perhaps
consists of subjective sensations (symptoms) and especially with what we call mental illness, but
certain findings (signs). The illness is described as it is criticized easily for minimizing the organ-
the result of the interaction of the disease with the ic-physiological nature of illness and disease.
host or person, emphasis being given to the mech- Cultural relativists, however, do sensitize us to
anism by which the disease develops and "pro- the variability in the interpretation and defini-
duces" or is associated with the illness. (Feinstein, tion of physiological phenomena.
1967, as summarized and cited in Fabrega & Man-
Although all these approaches have some
ning, 1972, p. 95)*
utility and validity in the contexts in which they
According to this view, disease is a physiologi- are used, from a sociological perspective they
cal state, and illness is a social state presumably miss a crucial aspect of illness: they take for
caused by the disease. Although the pathologist granted how something becomes defined as an
sees the disease, the physician sees only signs illness in the first place. Illness and disease are
and symptoms of illness and infers disease. human constructions; they do not exist without
This allows, conceptually at least, for illness someone proposing, describing, and recogniz-
without diseases and diseases without illnesses. ing them. There are processes we commonsen-
Such a body/social dichotomy has the advan- sically call "disease," but that does not make
tage of permitting analysis on both the physio- them a priori diseases. As Peter Sedgwick
logical and social levels. (1972) points out, "the blight that strikes at
In sharp contrast to the positivist viewpoint is com or potatoes is a human invention, for if
the cultural relativist position: an entity or con- man wished to cultivate parasites (rather than
dition is a disease or illness only if it is recog- potatoes or com) there would be no 'blight,'
nized and defined as one by the culture. For but simply the necessary foddering of the para-
example, in one South American Indian tribe, site-crop" (p. 211). An animal may be feebled,
dyschromic spirochetosis, a disease character- have parasites, or be in pain but that in no way
ized by colored spots appearing on the skin, means it is suffering from an "illness." As
was so common that those who did not have it Sedgwick (1972) states,
were regarded as deviant and excluded from Animals do not have diseases either, prior to the
marriage (Mechanic, 1968, p. 16). Among the presence of man in a meaningful relation with them.
Papago Indians of the American Southwest, A tiger may experience pain or feebleness from a va-
obesity has a prevalence of nearly 100%. The riety of causes .... It may be infected by a germ,
Papago do not regard this condition as abnor- trodden by an elephant, scratched by another tiger, or
mal; in fact, they often bring babies whose de- subjected to the [aging] process of its own cells. It
velopment is normal by Western standards to does not present itself as being ill (though it may
the medical clinic and ask the physician why present itself as being highly distressed or uncom-
their baby is so skinny and sickly. To the Papa- fortable) except in the eyes of a human observer
who can discriminate illness from other sources of
go, obesity is not an illness; by Western stan-
pain or enfeeblement. Outside the significances that
dards nearly all the Papago are ill. Which
man voluntarily attaches to certain conditions, there
definition is more valid? Rene Dubos (1959), are no illnesses or diseases in nature. (p. 211)
an esteemed microbiologist, has argued that the
Another way of saying this is that there are no
*From "Disease, illness, and deviant careers," by illnesses in nature, only relationships. There
Horatio Fabrega, Jr. and Peter K. Manning, in Theo- are, of course, naturally occurring events, in-
retical perspectives on deviance, edited by Robert A.
Scott and Jack D. Douglas, p. 95, © 1972 by Robert cluding infectious viruses, malignant growths,
A. Scott and Jack D. Douglas, Basic Books, Inc., ruptures of tissues, and unusual chromosome
Publishers, New York. constellations, but these are not ipso facto ill-
nesses. Without the social meaning that humans illness and alcoholism. Biological aberration is
attach to them they do not constitute illness or neither necessary nor sufficient for something to
disease: be labeled an illness: a 7-foot basketball player
The fracture of a septuagenarian's femur has, within
is outside the normal biological range but not
the world of nature, no more significance than the considered ill. Early and late onset of puberty
snapping of an autumn leaf from its twig; and the in- are both biologically deviant conditions, yet
vasion of a human organism by cholera germs car- only late puberty is viewed as evidence for
ries with it no more the stamp of "illness" than the physiological abnormalities and disorders (Con-
souring of milk by other forms of bacteria. (Sedg- rad, 1976, p. 69). Nearly all functional mental
wick, 1972, p. 211) disorders have no or at best questionable phys-
Thus one could argue that biophysiological iological evidence, yet they are defined and
phenomena are what we use as a basis to label treated as diseases. In Western societies most
one condition or another as an illness or dis- illnesses are assumed to have some biophysio-
ease; the biophysiological phenomena are not in logical or organic basis (and most do), but this
themselves illness or disease. (As we shall see is not a necessary condition for something to be
in later chapters, however, a suspicion or hy- defined as an illness. Occasionally an undesir-
pothesis of biophysiological phenomena may be able physiological condition such as baldness is
sufficient to label something as illness.) not considered an illness. Most physiological
Illnesses represent human judgments of con- conditions found troublesome, however, are de-
ditions that exist in the natural world. They are fined as illnesses or medical disorders.
essentiall y social constructions - products of As Eliot Freidson (1970a) observes, calling
our own creation. "Illness," as Gusfield (1967) something an illness in human society has con-
has written, "is a social designation, by no sequences independent of the effects on the bio-
means given by the nature of medical fact" (p. logical condition of the organism:
180). The fact that there is high agreement on When a veterinarian diagnoses a cow's condition as
what constitutes an illness does not change this. an illness, he does not merely by diagnosis change
The high degree of consensus on what "objec- the cow's behavior: to the cow, illness remains an
experienced biophysical state, no more. But when a
tively" is disease is not independent of the
physician diagnoses a human's condition as illness,
social consensus that constructs these "facts"
he changes the man's behavior by diagnosis: a social
and renders them" important." For physical ill- state is added to a biophysical state by assigning the
ness, the consensus is so extensive and taken meaning of illness to disease. (p. 223)
for granted that we are inclined to forget that it
represents a reality wholly dependent on our Think for a moment of the difference in conse-
collective agreement (Freidson, 1970a, pp. quences if a person's inability to function is at-
214-215). tributed to laziness or to mononucleosis, seiz-
As illnesses are social judgments, they are ures to demon possession or epilepsy, or drink-
negative judgments. Can we think of any illness ing habits to moral weakness or alcoholism.
designations that are positive judgments or any Medical diagnosis affects people's behavior, at-
illness conditions that are viewed as desirable titudes they take toward themselves, and atti-
states? Common sense also tells us that an enti- tudes others take toward them.
ty labeled an illness or disease is considered In summary, illness is a social construction
undesirable. In the human world this is as true based on human judgments of some condition
for tuberculosis* and cancer as it is for mental in the world. In some fashion, illness, like
beauty (and like deviance), is in the eye of the
beholder. Although it is based partly on current
* Susan Sontag's (1978) recent characterization of cultural conceptions of what disease is, and
tuberculosis in the 19th century as having an ap- more often than not in Western society
pealing symbolic significance within a small circle
of literary and artistic figures appears to be an ex- grounded in biophysiological phenomena, this
ception that, when viewed from a more general social evaluative process is central rather than
social perspective, serves to support the rule. peripheral to the concept of illness and disease.
It follows logically that both diagnoses (as sys- ety. The sick role has four components, two
tematized classifications) and treatments are exemptions from normal responsibilities and
founded on these social judgments; they cannot two new obligations. First, the sick person is
be separated. Just as profound consequences exempted from normal responsibilities, at least
followed from the recognition of microorgan- to the extent necessary to "get well." Second,
isms as agents of "disease," so are there con- the individual is not held responsible for his or
sequences from recognizing illnesses as social her condition and cannot be expected to recover
judgments. Needless to say, the social construc- by an act of will. Third, the person must recog-
tion of illness designations for deviant be- nize that being ill is an inherently undesirable
haviors is subject to more ambiguity and in- state and must want to recover. Fourth, the sick
terpretation than manifestly biophysiological person is obligated to seek and cooperate with
problems. In this light it is understandable that a competent treatment agent (usually a physi-
conditions defined as illness reflect the social cian). * For sickness, then, medicine is the
values and general Weltanschauung of a so- "appropriate" institution of social control.
ciety. Both as legitimizer of the sick role and as the
expert who strives to return the sick to con-
Illness and deviance ventional social roles, the physician functions
As Talcott Parsons pointed out in his classic as a social control agent.
writings on the "sick role," both crime and In light of the socially constructed nature of
illness are designations for deviant behavior both crime and illness, it should not be sur-
(Parsons, 1951, pp. 428-479). Parsons concep- prising to find that there has been a fluidity or
tualized illness as deviance primarily because of drift between designations of crime deviations
its threat to the stability of a social system and illness deviations. One of the major con-
thrC'ugh its impact on role performance. Al- cerns of this book is to explore the factors con-
though both crime and illness are violations of tributing to the change from moral-criminal
norms (social and medical) and can be disrup- definitions of deviance to medical ones, what
tive to social life, the attributions of cause are we call the medicalization of deviance.
different. Deviance considered willful tends to
be defined as crime; when it is seen as unwill- MEDICALIZATION OF DEVIANCE
Jul it tends to be defined as illness (see Aubert Conceptions of deviant behavior change, and
& Messinger, 1958). Since crime and illness agencies mandated to control deviance change
are both designations of deviance, it becomes also. Historically there have been great trans-
necessary to distinguish between the two, es- formations in the definition of deviance-from
pecially with reference to appropriate mecha- religious to state-legal to medical-scientific.
nisms of social control. It is in this regard Emile Durkheim (1893/1933) noted in The
that Parsons developed his notion of the sick Division oj Labor in Society that as societies de-
role. velop from simple to complex, sanctions for
The social responses to crime and illness are deviance change from repressive to restitutive
different. Criminals are punished with the goal or, put another way, from punishment to treat-
of altering their behavior in the direction of con- ment or rehabilitation. Along with the change in
ventionality; sick people are treated with the sanctions and social control agent there is a cor-
goal of altering the conditions that prevent their responding change in definition or concep-
conventionality. Parsons further argues that tualization of deviant behavior. For example,
there exists for the sick a culturally available certain "extreme" forms of deviant drinking
"sick role" that serves to conditionally legiti- (what is now called alcoholism) have been
mate the deviance of illness and channel the
sick into the reintegrating physician-patient re-
* There have been a number of critiques and modi-
lationship. It is this relationship that serves the fications of the sick role. See, for example, Gordon
key social control function of minimizing the (1966), Mechanic (1968), Sigler and Osmond
disruptiveness of sickness to the group or soci- (1974), and Parsons (1975).
defined as sin, moral weakness, crime, and The effectiveness of physicians and modem
most recently illness. Nicholas Kittrie (1971) medicine in treating many illnesses has cer-
has called this change the divestment of the tainly contributed to the authority they are
criminal justice system and the coming of the given. This has been especially true in the case
therapeutic state. Philip Rieff (1966), in his of infectious diseases. With the mid-19th-cen-
sociological study of the impact of Freudian tury discovery of the germ theory of disease, a
thought, terms it the "triumph of the thera- "doctrine of specific etiology" developed
peutic. " (Dubos, 1959). This doctrine implied that each
In modem industrial society there has been a disease had a single, specific, external, and
substantial growth in the prestige, dominance, objectively identifiable cause that could be
and jurisdiction of the medical profession discovered and treated accordingly. The suc-
(Freidson, 1970a). It is only within the last cen- cess of this doctrine enhanced the prestige and
tury that physicians have become highly orga- reputations of medical professionals. However,
nized, consistently trained, highly paid, and as Freidson (1970a, p. 83) cautions, the repu-
sophisticated in their therapeutic techniques tations of the medical profession should not be
and abilities. Eminent American social scien- seen only as a result of actual achievement
tist Lawrence J. Henderson observed that but also as the product of negotiation, per-
"somewhere between 1910 and 1912 in this suasion, and impression management by
country, a random patient, with a random dis- powerful interests involved in health care (re-
ease, consulting a doctor chosen at random, call our discussion of the monopolization of
had,for the first time in the history of mankind, medicine in Chapter I). This distinction be-
a better than fifty-fifty chance of profiting from tween the reputation and reality of modem med-
the encounter" (quoted in Blumgart, 1964; em- icine is a point we return to in the next chapter
phasis added). This observation suggests the in our discussion of how madness became en-
poor state of medicine prior to the 20th cen- trenched in medical jurisdiction.
tury. With the apparent success of medicine in Medical treatments for deviant behavior are
controlling communicable diseases (Dubos, heralded frequently as examples of the "prog-
1959), the growth of scientific biomedicine, ress" typical of modem society, believed to
the regulation of medical education and licens- unfold in a linear fashion, leaving beneficial
ing, and the political organization and lobbying advances in its wake. Medical progress is par-
by the American Medical Association, the pres- ticularly likely to be seen as holding promise
tige of the medical profession has increased. for solutions to age-old human problems.
The medical profession dominates the organiza- What "progress" is, however, on inspection,
tion of health care and has a virtual monopoly is not as clear as it might initially appear.
on anything that is defined as medical treat- "Progress" is only meaningful in relation to
ment, especially in terms of what constitutes some other point in time and to a specific audi-
"illness" and what is appropriate medical inter- ence. Progress is a positive evaluation of some
vention. As Freidson (l970a) has observed, change. But social change is not clearly linear
"The medical profession has first claim to juris- and rarely totally beneficial or detrimental. So-
diction over the label illness and anything to cial change nearly always produces positive and
which it may be attached, irrespective of its negative effects that are distributed differential-
capacity to deal with it effectively" (p. 251). ly in the affected population (Corzine, 1977).
Rieff (1966) contends that the hospital has re- For plantation owners the development of
placed the church and parliament as the symbol- slavery was progress, but for the slaves it was
ic center of Western society. Although Durk- the beginning of oppressive bondage. Perhaps
heim did not predict this medicalization, per- in some respects the medicalization of opiate
haps in part because medicine of his time was addiction, deviant drinking, obesity, hyperac-
not the scientific, prestigious, and dominant tivity, madness, and the other behaviors dis-
profession of today, it is clear that medicine is cussed in this book was progress. But changes
the central restitutive agent in our society. defined as progress must be viewed as progress
for a specific audience; all do not necessarily scientific" progress; indeed, it often leads to
benefit equally from these changes. And to "humanitarian and scientific" treatment rather
have a more complete picture, it is important than punishment as a response to deviant behav-
to point out the accompanying problems and ior. As Barbara Wootton (1959) notes:
consequences created by the alleged progress.
Without question ... in the contemporary attitude to-
When the picture is more complete, change wards anti-social behavior, psychiatry [i.e., medi-
may not appear as clearly to be progress. cine] and humanitarianism have marched hand in
hand. Just because it is so much in keeping with the
Expansion of medical Jurisdiction mental atmosphere of a scientifically-minded age, the
over deviance medical treatment of social deviants has been a
When treatment rather than punishment be- powerful reinforcement of humanitarian impulses;
comes the preferred sanction for deviance, an for today the prestige of humane proposals is im-
increasing amount of behavior is conceptual- mensely enhanced if these are expressed in the idiom
ized in a medical framework as illness. As of medical science. (p. 206)
noted earlier, this is not unexpected, since med- There are, however, other, more disturbing
icine has always functioned as an agent of so- consequences of medicalizing deviance that
cial control, especially in attempting to "nor- will be discussed in later chapters.
malize" illness and return people to their func- A number of broad social factors underlie the
tioning capacity in society. Public health and medicalization of deviance. As psychiatric crit-
psychiatry have long been concerned with so- ic Thomas Szasz (1974) observes, there has
cial behavior and have functioned traditionally been a major historical shift in the manner in
as agents of social control (Foucault, 1965; which we view human conduct:
Rosen, 1972). What is significant, however, is
With the transformation of the religious perspective
the expansion of this sphere where medicine
of man into the scientific, and in particular the psy-
functions in a social control capacity. In the
chiatric, which became fully articulated during the
wake of a general humanitarian trend, the nineteenth century, there occurred a radical shift in
success and prestige of modern biomedicine, emphasis away from viewing man as a responsible
the technological growth of the 20th century, agent acting in and on the world and toward viewing
and the diminution of religion as a viable agent him as a responsive organism being acted upon by
of control, more and more deviant behavior has biological and social "forces." (p. 149)*
come into the province of medicine. In short,
This is exemplified by the diffusion of Freudian
the particular, dominant designation of devi-
thought, which since the 1920s has had a sig-
ance has changed; much of what was badness
nificant impact on the treatment of deviance,
(i.e., sinful or criminal) is now sickness. Al-
the distribution of stigma, and the incidence of
though some forms of deviant behavior are
penal sanctions.
more completely medicalized than others (e.g.,
Nicholas Kittrie (1971), focusing on decrimi-
mental illness), recent research has pointed to a
nalization, contends that the foundation of the
considerable variety of deviance that has been
therapeutic state can be found in determinist
treated within medical jurisdiction: alcoholism,
criminology, that it stems from the parens
drug addiction, hyperactive children, suicide,
patriae power of the state (the state's right to
obesity, mental retardation, crime, violence,
help those who are unable to help themselves),
child abuse, and learning problems, as well as
and that it dates its origin with the development
several other categories of social deviance.
of juvenile justice at the turn of the century. He
Concomitant with medicalization there has been
further suggests that criminal law has failed to
a change in imputed responsibility for deviance:
deal effectively (e.g., in deterrence) with crim-
with badness the deviants were considered re-
inals and deviants, encouraging a use of alter-
sponsible for their behavior; with sickness they
are not, or at least responsibility is diminished
(see Stoll, 1968). The social response to devi- * From Szasz, T. Ceremonial chemistry. New York:
ance is "therapeutic" rather than punitive. Doubleday & Co., Inc., 1974. Copyright © 1974
Many have viewed this as "humanitarian and by Thomas Szasz.
native methods of control. Others have pointed psychogenic agent or condition that is assumed
out that the strength of formal sanctions is de- to cause the behavioral deviance. The medical
clining because of the increase in geographical model of deviance usually, although not al-
mobility and the decrease in strength of tradi- ways, mandates intervention by medical per-
tional status groups (e.g., the family) and that sonnel with medical means as treatment for the
medicalization offers a substitute method for "illness." Alcoholics Anonymous, for exam-
controlling deviance (Pitts, 1968). The success ple, adopts a rather idiosyncratic version of the
of medicine in areas like infectious disease has medical model- that alcoholism is a chronic
led to rising expectations of what medicine can disease caused by an "allergy" to alcohol-but
accomplish. In modem technological societies, actively discourages professional medical inter-
medicine has followed a technological impera- vention. But by and large, adoption of the med-
tive - that the physician is responsible for doing ical model legitimates and even mandates medi-
everything possible for the patient-while ne- cal intervention.
glecting such significant issues as the patient's The medical model and the associated medi-
rights and wishes and the impact of biomedical cal designations are assumed to have a scientific
advances on society (Mechanic, 1973). Increas- basis and thus are treated as if they were moral-
ingly sophisticated medical technology has ex- ly neutral (Zola, 1975). They are not considered
tended the potential of medicine as social con- moral judgments but rational, scientifically
trol, especially in terms of psychotechnology verifiable conditions. As pointed out earlier,
(Chorover, 1973). Psychotechnology includes medical designations are social judgments, and
a variety of medical and quasimedical treat- the adoption of a medical model of behavior, a
ments or procedures: psychosurgery, psychoac- political decision. When such medical designa-
tive medications, genetic engineering, disul- tions are applied to deviant behavior, they are
firam (Antabuse), and methadone. Medicine is related directly and intimately to the moral
frequently a pragmatic way of dealing with a order of society. In 1851 Samuel Cartwright, a
problem (Gusfield, 1975). Undoubtedly the in- well-known Southern physician, published an
creasing acceptance and dominance of a scien- article in a pretigious medical journal describ-
tific world view and the increase in status and ing the disease "drapetomania," which only
power of the medical profession have contrib- affected slaves and whose major symptom was
uted significantly to the adoption and public running away from the plantations of their
acceptance of medical approaches to handling white masters (Cartwright, 1851). Medical
deviant behavior. texts during the Victorian era routinely de-
scribed masturbation as a disease or addiction
The medical model and and prescribed mechanical and surgical treat-
"moral neutrality" ments for its cure (Comfort, 1967; Englehardt,
The first "victories" over disease by an 1974). Recently many political dissidents in the
emerging biomedicine were in the infectious Soviet Union have been designated mentall~ ill,
diseases in which specific causal agents- with diagnoses such as •'paranoia with counter-
germs-could be identified. An image was cre- revolutionary delusions" and "manic reform-
ated of disease as caused by physiological dif- ism," and hospitalized for their opposition to
ficulties located within the human body. This the political order (Conrad, 1977). Although
was the medical model. It emphasized the in- these illustrations may appear to be extreme ex-
ternal and biophysiological environment and amples, they highlight the fact that all
deemphasized the external and social psycho- medical designations of deviance are influ-
logical environment. enced significantly by the moral order of
There are numerous definitions of "the medi- society and thus cannot be considered morally
cal model." In this book we adopt a broad and neutral.
pragmatic definition: the medical model of de-
viance locates the source of deviant behavior SUMMARY
within the individual, postulating a physiologi- This chapter has outlined the conceptual
cal, constitutional, organic, or, occasionally, framework that informs the remainder of this
book. We call it a "historical-social construc- thing akin to a paradigm exists. There have
tionist" approach to deviance. Of the two ori- been three major deviance paradigms: deviance
entations to deviance noted in Chapter I, it is as sin, deviance as crime, and deviance as
clearly interactionist and has its roots in the la- sickness. When one paradigm and its adherents
beling-interactionist tradition. In addition, it become the ultimate arbiter of "reality" in
employs a sociology-of-knowledge perspective society, we say a hegemony of definitions
to examine the emergence and change of defini- exists. In Western societies, and American
tions and designations of deviance. Rather than society in particular, anything proposed in the
focusing on individual deviants and the causes name of science gains great authority. In mod-
of their behavior, the focus is on the etiology of em industrial societies, deviance designations
definitions of deviance. In this sense it can be have become increasingly medicalized. We
viewed as a sociology of deviance designations. call the change in designations from badness
Deviance definitions are treated as products of to sickness the medicalization of deviance.
a political process, as social constructions usu- Illness, like deviance, is a social construction
ally implemented and legitimated by powerful based on social judgments of some condition in
and influential interests and applied to relatively the world. Although based partly on current
powerless and subordinate groups. cultural conceptions of what constitutes dis-
Even after a social definition of deviance be- ease, and (in Western societies) typically
comes accepted or legitimated, it is not evident grounded in biophysiological phenomena, the
what particular type of problem it is. Frequently social evaluative process of classifying some
there are intellectual disputes over the causes condition or event as a disease is central rather
of the deviant behavior and the appropriate than peripheral to the concept of disease and
methods of control. These battles about devi- illness. In this fundamental sense a disease des-
ance designation (is it sin, crime, or sickness?) ignation is a moral judgment, for to define
and control are battles over turf: Who is the ap- something as a disease or illness is to deem it
propriate definer and treater of the deviance? undesirable.
Decisions concerning what is the proper devi- Sociologists since Parsons have viewed ill-
ance designation and hence the appropriate ness and crime as alternate designations for de-
agent of social control are settled by some type viance. Deviance that is considered willful is
of political conflict. defined as crime; when it is considered unwill-
How one designation rather than another be- ful, it tends to be defined as illness. Thus when
comes dominant is a central sociological ques- illness is a designation for deviant behavior,
tion. In answering this question, sociologists medicine becomes the agent of social control.
must focus on claims-making activities of the Designations of deviance have increasingly
various interest groups involved and examine shifted from the moral to the medical sphere.
how one or another attains ownership of a given With the apparent success of medicine in con-
type of deviance or social problem and thus trolling communicable diseases, the growth of
generates legitimacy for a deviance designa- scientific biomedicine, the political organiza-
tion. Seen from this perspective, public facts, tion and lobbying of the American Medical
even those which wear a "scientific" mantle, Association, and the profession's control over
are treated as products of the groups or organ- medical education and licensing, medicine has
izations that produce or promote them rather become a prestigious profession in the 20th cen-
than as accurate reflections of "reality." The tury. The medical profession dominates the or-
adoption of one deviance designation or an- ganization of health care and has a virtual
other has consequences beyond settling a dis- monopoly over anything that is defined as an
pute about social control turf; these willi become illness or a "medical" treatment.
more apparent and will be articulated in subse- Although our portrayals of the social and his-
quent chapters. torical sources of changing deviance designa-
When a particular type of deviance desig- tions are painted with a broad brush, and cer-
nation is accepted and taken for granted, some- tainly cannot include all the contextual charac-
teristics involved in such complex shifts, clear his emphasis is on the symbolic qualities of chang-
outlines of the change and development of each ing designations, this paper exemplifies the ap-
proach outlined in this chapter.
deviance designation are delineated. In depict- IlIich, I. Medical nemesis. New York: Pantheon
ing these individual cases we use a finer brush Books, Inc., 1976.
and give attention to specific detail. Thus we A readable and controversial analysis of the place
give consideration to historical events, relevant of medicine in modern society. Illich argues that
settings of conflict and change, attributions of medicine has become more a threat to health than
a healing agent and needs to be dismantled, decen-
cause, social control mechanisms, scientific tralized, and replaced by various forms of self-
discoveries, and claims-making activities for help. The section on "social iatrogenesis" is most
each case presented in the following six chap- relevant to medicaIization of deviance.
ters. Kittrie, N. N. The right to be different: deviance and
enforced therapy. Baltimore: Johns Hopkins Uni-
versity Press, 1971.
SUGGESTED READINGS A superbly documented overview focusing on the
Freidson, E. Profession of medicine. New York: legal aspects of medicalization. Kittrie documents
Dodd, Mead & Co., 1970. the growth of the therapeutic state in relation to the
Considered a seminal and path-breaking sociolog- growth of 19th-century deterministic theories, em-
ical analysis of the profession of medicine. Of par- phasizes lack of legal "safeguards" for deviants,
ticular interest is the section on the social construc- and makes specific recommendations for action.
tionof illness (pp. 203-331). Parsons, T. The social system. New York: The Free
Gusfield, J. R. Moral passage: the symbolic process Press, I 951.
in the public designations of deviance. Soc. Prob., Parsons' major theoretical treatise. His analysis of
1967,15, 175-188. "the sick role" (pp. 428-479) is the classical so-
Builds on Gusfield's earlier (1963) work on the ciological discussion of the relation of crime and
Temperance movement and analyzes changing illness as deviance designations and medicine
public designations of deviant drinking. Although as an agent of social control.
3 MEDICAL MODEL
of MADNESS
THE EMERGENCE of MENTAL ILLNESS
T he roots of the medical conception of

madness run deep. * This chapter ex-
plores the historical origins of the con-
cept of mental illness, its ascendence
states but did not call them madness, and the
Cochiti Pueblos do not distinguish between
madness and physical illness at all (Kiev,
1964). The causes of madness are attributed
and expansion in Western society, and sub- variously to demon possession or spirit intru-
sequent domination of the medical model of sion, witchcraft or sorcery, soul loss or devine
madness in modem times. The concept of mad- retribution for taboo violation. What each cul-
an
ness as illness has a long history in Western ture views as the cause of madness is depen-
culture but has not been always the dominant dent on its world view. In a society with a
explanation of madness. We carefully review dominant spiritual or religious world view, one
the historical development of mental illness as would expect madness to be attributed to some
it is the exemplar for medical conceptions of spiritual offense or otherworldly beings. Cul-
deviant behavior. It is literally the original case tures that have had no contact with Western
of medicalized deviance. psychiatry rarely define madness as an illness.
All societies seem to recognize certain forms It is by no means obvious that madness is
of peculiar and unpredictable behavior as mad- mental illness or even a medical problem. In-
ness. Anthropologists have never discovered deed, one of the primary purposes of this chap-
that mythical idyllic culture where no idea of ter is to analyze how madness became defined
madness existed. Cultures define madness dif- as a medical problem in Western society. The
ferently, however. Grandiose ideas are accept- madness-as-illness concept is a product of 2000
able among the Kwakiutl, hallucinations among years of cultural and social development. We
Siberian Eskimos, and fears of persecution begin our search for roots in biblical Palestine.
among the Dobu; all are seen as symptoms of
madness by Western standards. The Yoruba of SMlnEN BY MADNESS:
Nigeria identify 20 separate types of madness, ANCIENT PALESTINE
the Iroquois recognized undesirable mental Madness was certainly recognized by the
ancient Hebrews. The Bible's Old Testament
serves as our best record of the era. For ex-
*Throughout this chapter we have used a number ample, Saul's madness is described in detail
of different designations to depict mad people
(maniacs, lunatics, insane, mental patients, mentally in the first book of Samuel. He believed, as did
ill), their healers and keepers (mad-doctors, physi- most Hebrews of the time, that madness was in-
cians of the insane, medical superintendents, medical flicted by a supernatural power or by an angry
psychologists, alienists, psychiatrists), and their in- deity as punishment for sin. •• Among the He-
stitutions (insane asylums, lunatic asylums, mad- brews, those presumed to disobey God's com-
houses, mental hospitals) in an attempt to capture the
appropriate terms of the era. The changing vocabu- mandments and to violate his ordinances were
lary of madness is itself symbolic of many of the threatened with dire retribution, including the
developments discussed herein. curse of madness" (Rosen, 1968, p. 28). There
38
MEDICAL MODEL OF MADNESS; THE EMERGENCE OF MENTAL ILLNESS 39
are several references in the Bible to madness and the mad person's to divine retribution.
as divine retribution. In Deuteronomy Moses From a sociological viewpoint, there is nothing
warned his people that if they "will not obey inherently mad or prophetic in Ezekiel's be-
the voice of the Lord your God or be careful havior; the prophecy was attributed by his fel-
to obey all his commandments . . . the Lord low Hebrews. Prophecy was an explanation
will smite you with madness and confusion of available to the Hebrews for certain types of ex-
mind." treme behavior and an available social role for
Although the objective criteria for identifying some deviants. It is interesting to speculate
madness among the Hebrews was "the oc- where the prophets are today, when we no long-
currence of impulsive, uncontrolled or un- er attribute hearing voices to God but to mental
reasonable behavior" (Rosen, 1968, p. 37), not illness.
all those who behaved abnormally were de-
fined as mad. The prophets also acted in strange ROOTS OF THE MEDICAL MODEL:
and sometimes bizarre ways, but in the context CLASSICAL GREECE AND ROME
of their society they were not considered mad. The genesis of many of the ideas and con-
Ezekiel, a sterling example, "was subject to ceptions in Western thought can be traced to
frenzies in which he clapped his hands, classical Greece. Perhaps most significant for
stamped his feet, uttered inarticulate cries and our discussion, the Greeks introduced an origi-
shook his sword to and fro" (Rosen, 1968, p. nal rational view of nature and humanity. This
53). He experienced trances and visions, as contrasted sharply with the dominant religious-
well as claiming to speak with God. Medical cosmological views of previous cultures and
historian George Rosen (1968) describes clear- allowed for the developments of a primitive
ly some of Ezekiel's peculiar behavior: "science" and a naturalistic medicine. The
Romans copied and expanded Greek knowl-
On receiving his prophetic call Ezekiel was com- edge, thus preserving it for future civilizations.
manded by Yahweh to eat papyrus scroll on which
Most historians consider modem medicine to
were written the words of lamentation and mourning,
have begun with the Greeks. Hippocrates (460-
symbols of the message he was about to deliver.
When he did so he had the sensation of eating hon- 377 Be), called the "Father of Medicine," com-
ey .... To forecast the famine and other horrors to bined the speculations of the philosophers of
which the seige of Jerusalem would lead, Ezekiel ra- medicine who preceded him with detailed bed-
tioned his food and drink and prepared it by using for side observations. He was the first to attempt
fuel human dung, which was considered unclean. As to explain consistently all diseases on the basis
a sign of the calamities that would befall Jerusalem of natural causes. The maintenance of a skep-
he cut off his hair and beard using a sword as a razor, tical insistence on rational knowledge and nat-
then burned one third, destroyed another third, and ural explanations, a pubescent scientific atti-
scattered the remainder to the four winds .... To in- tude, forms the basis of the Hippocratic tradi-
dicate the time during which Israel and Judah
tion of medicine.
respectively would be exiled, he was commanded by
Yahweh to lie down for two periods, once on his left
The Greeks had two explanations for mad-
side for 390 days ... and once on his right side for ness. The cosmological-supernatural explana-
forty days. (p. 44) tion - that madness was a possession caused
by the gods or inflicted by the spirit under-
Madness and prophecy both were abnormal world - was believed by most of the Greek
to the Hebrews. The Hebrew verb "to behave populace. It made sense, since the mythological
like a prophet" also means "to rave" or "to gods were considered part of everyday life. The
act like one is beside oneself' (Rosen, 1968, natural-medical explanation, the first elaborated
p. 42). Both were attributed to divine inter- medical explanation in recorded history, which
vention and socially ascribed to individuals. Al- defined madness as a disease with natural
though the mad person and the prophet alike causes, seems to have been adopted only by
engaged in peculiar and extreme behavior, the certain segments of the upper classes.
prophet's was attributed to divine inspiration Greek medicine, early in its history, rejected
the supernatural explanation, conceptualizing 1968). The Romans practiced a form of "elec-
madness as a disease or the symptom of a troshock" treatment by using electric eels ap-
disease with the same etiology as somatic dis- plied to the head. Variations on these remedies
eases (Rosen, 1968, p. 76). The causes of mad- for madness can be found through modem
ness were explained by the same general theory times.
of disease used to explain all illness, humoral Not all the Greek intelligentsia accepted fully
theory. The humoral theory, which held sway the medical definition of madness. Socrates,
in medicine from the time of Hippocrates until himself later considered a deviant, appears to
well into the 17th century, was deceptively sim- have been skeptical about the medical notions
ple in its physiological explanation. The theory of madness. With astoundingly profound in-
postulated the existence of four humors: blood, sight he wrote:
phlegm, black bile, yellow bile-bodily fluids [Most men] do not call those mad that err in matters
whose proportion and balance were significant that lie outside the knowledge of ordinary people:
to health. The four humors were thought to madness is the name they give to errors in matters
enter into the constitution of the body and deter- of common knowledge. For instance, if a man imag-
mine, by their relative proportions, a person's ines himself to be so tall as to stoop when he goes
health and temperament. One's disposition and through the gateways of the Wall, or so strong as to
state of mind were determined by the balance of try to lift houses or perform any other feat that every-
these humors. Madness was looked on as an im- body knows to be impossible, they say he's mad.
balance of humors, usually as an excess. For They don't think a slight error implies madness, but
example, melancholia or depression was caused just as they call a strong desire love, so they name a
great delusion madness. (Quoted in Rosen, 1968,
by an excess of black bile, which was generated
p.94)
by the liver; a sudden flux of yellow bile from
the spleen to the brain would bring on anxiety Madness in the Graeco-Roman era was
and produce a "choleric" temperament. The viewed largely as a family problem to be dealt
names Hippocrates used to depict madness with by kin. People who could not function in
are still common today: epilepsy, mania (ab- society and were not dangerous to others were
normal excitement), melancholia (depression), allowed to wander about and were cared for by
and paranoia (Zilboorg, 1941, p. 47). Indeed, family. Eventually some legal restrictions
a residue of this idea of mental health is pre- on the insane were enacted: Roman law forbade
served in our everyday language when we them to marry, acquire property, and to make or
refer to someone as being in a "bad humor." witness a will. Plato may have been influenced
As treatments follow from etiological or by the disease concept of madness. He wrote:
causal explanations, the medical treatments for "A man ... either in a state of madness, or
madness, though relatively uncommon among when affected by disease, or under the influ-
the Greeks, were attempts to rebalance the ence of old age, or in a fit of childish wanton-
humors. Both physical and what we might call ness, himself no better than a child" could not
psychotherapeutic methods were employed. be responsible for his crimes "unless he have
Physicians recommended rest, a limited diet, slain someone, and have within his hands the
and gentle massage, as well as bleeding and stain of blood" (quoted in Rosen, 1968, p.
cupping. If there was no improvement, non- 124). Even under these circumstances such a
specific stimulants such as irritant plasters, person was to be exiled for a year or have a
purges, vomitives, hot and cold baths, sun- guardian appointed to care for his other affairs.
bathing and other forms of heating were added Physicians on the whole did not playa large
to the regimen. When psychological factors role in the treatment of madness in ancient
were thought to be the cause, mental exercises, Greece and Rome. Rosen (1968, p. 135) notes
games, and recreation were used. Occasionally that there is no evidence that medical data or
extreme physical' 'treatments" were employed: opinion were required to treat manias or dike
severe physical restraint, violent purges, exces- paranoias. The pauper insane who wandered
sive bleeding, dunking the patient into cold the countryside received no medical care and
water and even Whipping and beating (Rosen, were ridiculed and stigmatized. Those who
MEDICAL MODEL OF MADNESS: THE EMERGENCE OF MENTAL ILLNESS 41
could afford it consulted physicians. Most did not flourish. By the ninth century the medi-
people, however, either because of their belief cal school at Salerno, building on the Hippo-
in the supernatural explanation or because relief cratic as well as other medical traditions, had
could not be obtained any other way, sought identified a number of types of mental dis-
religious and magical treatments for mad- orders. They called them stupor, pheresy, epi-
ness. lepsy, hysteria, idiocy, mania, and melancholy.
In Greece and later in Rome, competing The first four were considered to be physical
theories of madness existed side by side. In ret- diseases (Neaman, 1975, p. 14).
rospect, it appears that medical theories were The medieval physicians attributed madness
respected by the upper classes and intelligent- to either of two causes, the passions or an im-
sia, but supernatural-cosmological theories balance of humors. If the disease was primary,
were the favored explanations of the masses. that is, completely caused by physiological
Greek medicine, by introducing a theory that conditions, there was little hope for cure.
would remain the major medical explanation Medieval physicians believed also that two
for more than 15 centuries, actually laid the exotic forms of madness, love madness and
foundation for our present conceptions of mad- werewolfism (lycanthropy), were natural in
ness. Roman medicine, influenced heavily by origin and treatable by medical means. Love-
Galen, was more empirical and pragmatic, and sickness was treated as a genuine disease. A
expanded and synthesized the knowledge of medieval physician described its symptoms:
Greek medicine. After the fall of Rome, the
medical definition of madness became subor- Their eyes are hollow and do not shed tears and
appear to be overflowing with gladness; their eyelids
dinate to another supernatural view of madness
move more rapidly . . . . When they call to recol-
that arose in the medieval period.
lection the beloved object either from seeing or hear-
DOMINANCE OF THE ing, and more especially if this suddenly occurs,
then the pulse undergoes a change from the disorder
THEOLOGICAL MODEL: THE
of the soul. (Quoted in Neaman, 1975, p. 22)
MIDDLE AGES
The collapse of the Roman Empire in the Medieval physicians never believed that hu-
fifth century produced a general return to super- mans were actually changed into werewolves but
natural beliefs, mysticism, and mythology. rather that certain imbalances of humors caused
Many historians of the medieval period write as some maniacs to imitate wolves, especially at
if there were only theological and demonologi- night.
cal conceptions of madness, in a psychiatric The therapeutic methods used by medieval
"dark age." physicians were similar to the Greek and Ro-
man treatments, although they added herbal
On the whole . . . whatever little knowledge the remedies like "lettuces" and "poppies"
Greeks had established was lost and a tragic decline
(opiates). The first psychosurgery appears to be
to an earlier cultural level ensued. The clock was
the Byzantine physicians' treatment called
put back a thousand years. For a thousand years
the mentally ill were again regarded as possessed "trepanning," or incising of the skull, "to
by the devil or evil spirits, or considered to be permit compressed atoms of flesh to move
witches or sorcerers who could produce illness in apart and thus relieve the pressure on the brain,
others. (Ackerknecht, 1968, p. 18)* which they believed was causing these operable
cases of insanity" (Neaman, 1975, p. 25).
This is, however, an overstatement. Although The medical view was not the dominant
theological institutions and theories were cer- conception of madness in medieval times, how-
tainly dominant, medical conceptions of mad- ever. The dominant conception was a theologi-
ness did exist during this period, even if they cal view based on dogma of the Christian
Church. The Church reached its pinnacle of
*From Ackerknecht, E. H. A short history o/psychi- power during this period and was the dominant
atry. New York: Hafner Press, 1968. Copyright institution in defining much of human affairs.
1968, Hafner Publishing Co. Theological doctrines pervaded education, law,
medicine, and just about everything else. In the Church. Feudalism was beginning to crack and
theological view, which was based on the bibli- crumble; the Gutenberg printing revolution
cal tradition, all disease and other misfortune made self-education possible; the dogma and
had three principal interpretations. Disease was abuses by the Church were being attacked by
God's mode of punishment for sin, specifically the precursors of the Reformation; and severe
the sin offaithlessness; it was God's manner of plagues had decimated the population of Europe
testing an individual's strength, as with Job; or by nearly half. The dominance and authority of
it was a sign warning the individual, and others, the Church were being threatened and, accord-
that he had better repent. Medieval conceptions ing to Thomas Szasz (1970), a scapegoat was
of madness to a large degree followed from necessary around which theologian dogmatists
this. Madness was seen as a punishment for could unite.
sin . . Madness was not, as it is commonly The most spectacular and devastating Church
thought, depicted as sin itself but was rather response was the infamous Inquisition and the
caused by and a retribution for sin (Neaman, organized witch-hunts, which led to the burn-
1975, pp. 48-50). An interesting consequence ing, hanging, and drowning of perhaps half a
of the theological view of madness was that million people accused of being witches and
an individual was not held responsible for any agents of the Devil (Currie, 1968). Mad persons
behavior committed while mad, but was for the were not considered to be witches and subject
behavior that caused him to be smitten with to persecution until the 14th century. By the
madness. "The Church reasoned that insanity 15th century the Inquisition was a powerful
couldn't be the cause of sin but could be the social force, doggedly combating heresy and
result of sin" (Neaman, 1975, p. 99). other deviance. At the peak of this period the
For centuries the Church was the major in- Malleus Maleficarum (Hammer of Witches)
stitution of social control and the Devil its was published in 1487. Written by two Domini-
n~1T}esis. The Devil was powerful and ubiqui- can monks, Johan Sprenger and Heinrich Krae-
tous in medieval times. Medical conceptions had mer, and with papal approval, it became the
to account for this. Some suggested that the guidebook for the Inquisition. This handbook
Devil could enter the body and upset the humor- depicted most dissidents, mad people, deviants,
al balance. Mental diseases were seen as pun- and especially women, as "witches" who had
ishments for sin. Both theologians and physi- made a compact with the Devil and were then in
cians made clear distinctions between madness his employ. Anyone who showed psychologi-
and possession. Demonic possession was a cal, behavioral, or physical deviation was la-
spiritual illness, and therefore no medical treat- beled a witch or a sorcerer. The Malleus, which
ment could cure it; exorcism was more appro- Szasz (1970) calls a diagnostic manual for the
priate. Theological and medical views of witch-hunter, described in detail how to diag-
madness were not competing conceptions of nose witches, try them fn court, and handle
reality; medical views were subordinate to those convicted, usually by burning. The Mal-
theological ones. Most physicians agreed with leus contended that if organic cause could not
the theologians that the first cause of disease be determined for a disease, the disease must
was always God or the Devil. This produced a be caused by witchcraft. Furthermore, if the
complex intertwining of the medical and theo- reader was not convinced by the authors' argu-
logical conceptions of madness and created a ments, it was because he or she, too, was a
delicate division of labor that enabled the two victim of witchcraft (a 15th-century Catch-22!).
institutions to coexist and divide up the social A highly misogynic document, the Malleus
control turf. points out: "All witchcraft comes from a carnal
lust which in women is insatiable" (quoted in
WHchcraft. wHch-hunts. and Alexander & Selesnick, 1966, p. 98). For the
madne.. next 200 years in most of continental Europe,
By the late 13th century enormous social those considered insane were caught in the mas-
changes were' occurring in Europe, producing sive witchcraft net, and theological rationaliza-
reactions from the powerful and conservative tions caused many to be burned at the stake.
During the Inquisition period the medical fined and relabeled in medical terms, with med-
conception of madness was largely muted. icine replacing the church as the institution of
There was still an occasional strike for the social control. It "happened because of the
medical viewpoint. "For example, in Spain transformation of a religious ideology into a
the Inquisition as early as 1537 recognized that scientific one: medicine replaced theology; the
alleged witches might be insane, and there were alienist, the inquisitor; and the insane, the
several cases on record where such individuals witch" (Szasz, 1970, p. xx).
were transferred to hospitals" (Rosen, 1968, Szasz (1970) compares theological concep-
p. 12). By the 17th century, physicians were tions of witchcraft with medical conceptions of
beginning to collect detailed histories of "de- madness. His comparisons are elaborate and
monics" and to speak of physiology and pa- compelling: witchcraft and mental illness are
thology in such cases. myths "diagnosed" in terms of behavior by a
Johann Weyer, a German physician, was not professional diagnostician; they are ascribed
the first to espouse the view that the witches statuses based on deviant behavior that are con-
were really mentally ill, "but he was [its] ferred by the powerful on the powerless;
most explicit, most forceful and most success- witches and mental patients are scapegoats who
ful champion" (Ackerknecht, 1968, p. 21). suffer persecution by society, in one case justi-
Weyer is considered a central figure in the his- fied by religion and in the other by medicine;
tory of psychiatry because of his methodical witch trials and sanity trials both lack due
attempts to prove that witches were mentally ill process and fail to protect individual rights; and
and should be treated by physicians. A careful both reinforce the dominant ethic of society. He
observer and investigator who interviewed both argues further that institutional psychiatry, the
the accusers and the accused, Weyer collected kind practiced in mental hospitals, is a con-
data to support his case that the women perse- tinuance of the Inquisition. It, too, is an in-
cuted as witches were really mentally sick. His stitution to control deviants; and mental patients
research took 12 years, and in 1563 he pub- are the "witches" of today. One need not agree
lished De Praestigiis Daemonum (The Decep- completely with Szasz's notion of institutional
tion of Demons), a detailed rebuttal to the psychiatry as a replacement for the Inquisition
Malleus Maleficarum. Weyer, in a respectful to appreciate the spirit of his analysis. Szasz's
tone and still maintaining his belief in the argument by analogy is revealing and insight-
existence of witchcraft, argued that the ac- ful, and it highlights psychiatry as a social con-
cused were melancholy old women. He wrote, trol agent and mental illness as a conception
"Those illnesses whose origins are attributed to developed to explain certain types of behavior.
witches come from natural causes" (quoted in The labeling of deviants as witches was pos-
Alexander & Selesnick, 1966, p. 121). This is sible because an ideology, witchcraft, and a
depicted as a turning point by medical histori- powerful ecclesiastical and secular institution,
ans-the first stroke of a virtual renaissance, the the Inquisition, had been created and legiti-
new search for natural causes of madness. mized. This instrument of control had been de-
Weyer's immediate impact was not, however, vised to eradicate dissent and deviance and to
that great. "He did not acquire a true following protect the established order. The established
until almost a century after his death. In the order was changing, and new conceptions of
meantime the spirit of the Malleus Maleficarum deviance began to emerge.
was still alive and active" (Zilboorg, 1941, p.
235). THE EUROPEAN EXPERIENCE:
Medical and psychiatric historians (e.g., Zil- MADNESS BECOMES MENTAL
boorg, 1941) argue that psychiatry developed ILLNESS
as the persecution of witches declined and dis- The Renaissance brought a rediscovery of
appeared. Increasingly, enlightened physicians Greek and Roman art and science, including
realized that the alleged heretics were mentally medicine. While the Graeco-Roman model,
ill. Thomas Szasz rebuts this interpretation and based on humoral theory, provided physicians
suggests that the deviants were merely rede- with a basic medical conception of madness, it
was not the dominant one in society, nor was it criminals, libertines, beggars, vagabonds, pros-
the basis for state policies for dealing with mad- titutes, the unemployed, and the poor were
ness. In fact, physicians had relatively little to confined there. At one point it held I % of the
do with madness until the early 19th century. Paris population, about 6000 people. Over the
There are several significant changes that oc- course of its existence, the general hospital
curred between the 16th and 18th centuries that combined the characteristics of an asylum, a
affected the ascendance of the medical model workhouse, and a hospital. From the outset,
of madness to its dominant position and the social control was a major function of the
legitimation of physicians as the authorities to hospital. With the opening of H6pital General,
treat it. These include the great confinement of the period of "the great confinement" of the
lunatics and other deviants; the separation of poor and the deviant began (Foucault, 1965),
the able-bodied from the lunatics; the entrance and institutions for the deviant and "socially
of physicians; and the emergence of a unitary useless" emerged in all European countries.
concept of mental illness. Confinement became the new way to deal with
deviants.
The great confinement H6pital General and its sister institutions
Before the 17th century, harmless mad peo- were great moral and social edifices. Confine-
ple roamed the roads of countryside and town. ment was not for medical reasons but as an
Although they were occasionally abused and "imperative to labor" to prevent "mendicancy
driven from towns, they generally led a free- and idleness as a source of all disorders" (Fou-
wandering existence. Responsibility for the cault, 1965, p. 48). The obligation to work
mad was with the family and local community; was predominant in these institutions; indeed,
only in rare circumstances were obviously dis- through this they served an important function
turbed individuals "hospitalized" or formally for the new bourgeois society. They provided
excluded from the community. Dangerous and "cheap manpower in the periods of full em-
criminal mad persons were handled directly by ployment and high salaries; and in periods of
legal procedures. One interesting, although rel- unemployment, reabsorption of the idle and
atively uncommon, innovation was the Nar- social protection against agitation and upris-
ranschiff (literally, "ship of fools"). Ships ing" (Foucault, 1965, p. 51). It is significant
filled with mad people would sail the rivers and to point out that the emerging capitalist or-
the seas, stopping at various towns to load or der needed "willing" workers, and these insti-
unload some of their cargo of lunatics. Prior to tutions served also to "discipline the work
the 17th century, madness and folly were not force," that is, inculcate people with the value
hidden away and were part of everyday life; as of work and "proper" work habits, neither of
Michel Foucault (1965) points out, society's which could be assumed in the 17th century.
"debate" with madness over reality was a pub-
lic matter. Separation of the able-bodied
By the middle of the 17th century the rem- from the lunatics
nants of the feudal order were fading, and a new As the importance of a competent labor force
absolutist, capitalist order was emerging. This increased, it became increasingly necessary to
was a period of great changes in society; separate the able-bodied poor from the nonable-
among these was a shift in the treatment of bodied. After all, how could discipline and
madness and other deviance. In 1656 H6pital good work habits be instilled if lunatics were
General was opened in Paris by royal decree. around disrupting the order of the institution?
This was not a hospital in the sense we think of The 18th century saw a gradual separation of
hospital; there was no medical treatment and insanity from other forms of dependence and
nearly no medical involvement. It was essen- deviance. This gave rise, by the end of the cen-
tially a paupers' prison, constructed to rid the tury, to special institutions like the almshouse,
city of idlers and beggars and other socially the workhouse, the madhouse, and the prison.
useless individuals. Mad people, along with The mad were separated from other deviants,
not for the purposes of special treatment but curative and rehabilitative treatments, then it
rather to protect others from the "contagion" would be clear why medicine came to dominate
of madness (Foucault, 1965) and to impose the realm of madness. But this does not seem
order and discipline on the hospital and the to be the case. Most of the therapies used by the
workhouse. "The presence of the mad [in the 18th-century physicians were ancient ones:
institutions] appears as an injustice [not for the bloodletting, dunking, and purgation were pop-
mad] but for others" (Foucault, 1965, p. 184). ular treatments. Fear, restraint, starvation, and
In the early capitalist society, with its highly castration were also used as treatments, as were
unstable and fluctuating economy, it became diets and a few available drugs. New innova-
increasingly important to have an able-bodied tions, usually physical treatments, such as the
reserve labor pool who worked in the periods of "Darwin chair" (invented by Charles Darwin's
boom and were institutionalized or controlled in grandfather), were introduced. "In this chair
periods of bust. With the rise of industrialism the insane were rotated until blood oozed from
this becomes even more significant (Scull, their mouths, ears and noses, and for years most
1977b). successful cures were reported as a result of its
Lunatics were segregated increasingly into use" (Ackerknecht, 1968, p. 38). Althoughthis
special institutions. The first of these appeared primitive "shock therapy" may have aided a
in the 18th century. An extensive "trade in few disordered people, the 18th-century physi-
lunacy, " private madhouses owned and oper- cian's armamentarium and ability to "cure"
ated by physicians ("mad-doctors"), developed were limited.
in England (Parry-Jones, 1972). These mad- There was, however, considerable optimism
houses were "frequently a lucrative business concerning the promise of medicine to solve
dealing with the most acutely disturbed and problems of human suffering and pain.
refractory cases" (Scull, 1977b) and were the
precursors to the public asylums that developed The intellectual approach to the problems of health
a century later. Overall, from a sociological gave the illusion that in medicine, as in other social
viewpoint, the separation and segregation of the sciences, the Age of Reason would mark the begin-
mad from other deviants was accomplished ning of a new era. In fact, there was justification for
the optimism prevailing in medicine during the peri-
largely for social and economic reasons, not for
od of 1750-1800. Leprosy and the plague had all but
medical ones.
disappeared from Europe: smallpox, malaria and
Entrance of the physician summer diarrhea had been brought under control.
Condorcet envisaged an era when man would be free
As noted earlier, the early institutions for the from disease and old age and death would be in-
mad were not medical institutions. Through the definitely postponed; Benjamin Franklin made simi-
18th century, physicians played a small role in lar predictions. (Dubos, 1959, p. 18)
the confinement and provided little treatment.
In England it was not until 1774 that a physi- Undoubtedly some of this optimism was trans-
cian's certificate was required for commitment ferred to the physicians who treated madness.
to a madhouse; until then, the judgment of a Although limited in therapeutic ability, by the
magistrate was sufficient. It was not apparent end of the 18th century the physician had be-
to the judicial and political powers or to the po- come essential to the madhouse. Since medical
tential clientele that physicians had any special certificates were required for confinement of
expertise in the area of madness. Eighteenth- lunatics, the physician became the gatekeeper
century physicians did not have any explanatory of madness, in charge of entry. "The doctor's
theories or curative treatments that could have intervention is not made by virtue of a medical
made madness and the madhouse ipso facto skill or power that he possesses in himself and
their legitimate turf. How did physicians be- that would be justified by a body of objective
come the keepers of the madhouse and ulti- knowledge. It is not as a scientist that homo
mately the legitimate authorities on madness? medicus has authority in the asylum, but as
Certainly, if physicians could provide useful wiseman" (Foucault, 1965, p. 217). The phy-
sician was not healer of the sick, but guardian values and self-control, to remove obstacles
of the inept. that impeded the "natural" recovery process.
Perhaps one of the most dramatic images in "Moral treatment actively sought to transform
the history of the treatment of madness is Phil- the lunatic, to remodel him into something ap-
ippe Pinel, the great humanitarian director of proximating the bourgeois ideal of the rational
the French asylums at Bicetre and Salpetriere, individual" (Scull, 1975, p. 227). The rate of
removing the chains of the mad and liberating recovery (Tuke never used the word "cure")
them from physical bondage in 1794. In 1801 at York, largely due te> humane and kind treat-
he wrote a basic text in "psychiatry," Traite ment, was probably better than at most other
medico-philosophique sur l' alienation mentale English madhouses. Andrew Scull (1975) notes
ou la manie (Treatise on Insanity). Pinel em- that contemporary medical people viewed this
phasized the role of heredity as the first cause as a lay threat to their emerging control of the
of, and social and psychological factors as con- domain of madness.
tributory to, the development of madness. Pinel Since moral treatment seemed to work, the
presented a classification of mental disease: medical profession had to find a way to accom-
melancholia, mania, dementia, and idiocy. Ac- modate it. Physicians presented the argument
cording to him, these were located in the region that medical and moral treatments were neces-
of the stomach. Of greatest importance to Pinel sary for recovery, and since only physicians had
were the principles underlying the organization the legitimate authority to dispense medical
and administration of institutions, beginning treatments, they were the natural ones to em-
with the separation of different types of pa- ploy or at least oversee moral treatment also.
tients. He rejected chains, used minimum con- Since the physicians were relatively organized
straints, urged the importance of studying the and the moral treatment people were not, they
patient's personality, and believed in the main- were successful at convincing Parliament to
tenance of constant routine. He stressed the have their position officially legislated as the
benefits of moral treatment, which included dominant one. The mere fact that they had to
kindness, careful coercion, and work therapy. persuade the legislators is telling.
Pinel, and even more especially his favorite The single most effective ... [argument] would have
student, Esquirol, used careful clinical obser- been to demonstrate that insanity was in fact caused
vation and kept detailed statistics of "cure" by biophysiological variables. A somatic interpreta-
rates. Although some have seen this as the tion could place it beyond dispute within medicine's
"beginning of a new epoch" in the treatment of recognized sphere of competence, and make plau-
madness (Ackerknecht, 1968, p. 41), from a sible the assertion that it responded to medicine's
more sociological perspective the "asylum conventional remedies for disease. The trouble was
[became], in Pinel's hands, an instrument of that doctors could not show the existence of the
moral uniformity and social degradation' , necessary physical lesions, and this inconvenient fact
was already in the public domain. (Scull, 1975, p.
(Foucault, 1965, p. 208). In Foucault's terms
251)
Pinel's asylum was a religious domain without
a religion; a moral force for socializing people The fact that those administrating moral treat-
to values of bourgeois society-obedience, ment were already using a quasimedical vocab-
work, and the value of property. While releas- ulary- "patients," "mental illness," "recov-
ing physical restraints, Pinel substituted moral ery," "treatment," etc. -probably made it eas-
ones. ier. Through testimony, and one suspects lob-
A contemporary and admirer of Pinel was bying, physicians were able to ensure that they
Englishman William Tuke, a lay Quaker who themselves would regulate the madhouses by
founded York Retreat. Tuke developed his own the enactment of a variety of parliamentary acts
brand of moral treatment. His institution, run (e.g., requiring medical inspection) between
by lay people, represented an alternative to the 1816 and 1845. This solidified their legal posi-
ascending medical perspective. Therapy at tion as the official controllers of madness
York Retreat was much more of an educational (Scull, 1975). In a real sense they "captured"
process, a pragmatic attempt to teach moral madness as their domain, and clarified and ex-
tended their "authority in this area, so as to de- science, a concept of mental illness slowly
velop an official monopoly of the right to define emerged. Teresa of Avila provides an interest-
(mental) health and illness" (Scull, 1975). By ing example. An outstanding figure of this
1830 nearly all public mental hospitals had a period, she attempted to save a group of "hys-
resident medical director. In Eliot Freidson's terical" nuns from the Inquisition by arguing
(1 970b ) terms, they had established their pro- that these women were ill and that their behav-
fessional dominance and autonomy over mental ior could be explained by natural causes. As
illness. This was a coup for the medical pro- natural causes she suggested melancholy (as
fession, since at this point they had little better in humoral pathology), weak imagination, or
to offer in terms of treatments for insanity. drowsiness. Persons whose behavior could be
accounted for by natural causes were not evil,
Emergence of a unitary concept but rather comas enfermas -as if they were
of mental Illness sick, and thus not fodder for the Inquisition.
As we pointed out earlier in this chapter, the Hence physicians rather than priests were the
roots of medical ideas of madness run deep. experts who should legitimately handle the
However, a unitary, popular, and finally dom- problem. The social benefits to the nuns of de-
inant concept of mental illness developed only fining them as sick rather than evil are apparent.
in the late 18th century. It was not an overnight Sarbin points out that it was during this peri-
revolution, but rather a gradual development od of Western history that the concept of mind
over more than two centuries. A number of came into being. It was used to explain deviant
factors contributed significantly to its ascen- behavior that could not be attributed easily to
dance, including the separation and segregation events external to the person; deviants were
of the mad (discussed earlier) and the develop- seen as behaving as if the "state of mind" was
ment of the psychiatric profession (to be dis- causing the behavior. He suggests that "the 'as
cussed). It is difficult to point to any single if' was dropped, especially when Galenic [Ro-
causal agent most responsible for the change. man] classifications were reintroduced" and
Both Johann Weyer and the humoral physi- accepted uncritically (Sarbin, 1969, p. 13).
cians viewed madness as a natural phenomenon Thus any bit of peculiar behavior or reports of
with physiological causes, but the concept of strange images could be interpreted, like a
madness as mental illness was still diffuse and fever, as a symptom of an underlying disease.
vague. Their theories were esoteric and did not "Illness" came to include misconduct and the
enjoy much popular support. Clearly there was deviant behavior commonly known as madness,
little, if any, empirical evidence to support their first by its use as a metaphor that was later
medical contentions, and physicians themselves reified into a "myth," and second as a justifica-
were limited in their curing abilities. Although tion for the medical involvement and author-
medical historians (e.g., Ackerknecht, 1968; ity over madness (Sarbin, 1969; Szasz, 1961,
Alexander & Selesnick, 1966) suggest that with 1970). As Scull (l977b) points out, the emer-
the spread of the Enlightenment, madness could gence of medical "specialists" to deal with
be studied at last on a scientific basis, prog- madness and the lobbying of physicians buoyed
ress was, to say the least, slow. It is possible, the legitimacy of the mental illness concept:
of course, that some of the esoteric medical
"knowledge" that increasingly supported a dis- The growing power and influence of what was to be-
ease concept of madness "trickled down" to come the psychiatric profession helped to complete
and lend legitimacy to this classification of deviance;
the masses over a period of years so that by the
transforming a vague cultural view of madness into
late 18th century madness as a mental illness
what now purported to be a formally coherent, scien-
was a dominant concept. tifically distinguishable entity reflecting and caused
But Theodore Sarbin (1969) offers another by a single underlying pathology [mental illness].
interpretation. In the 16th century, with the re- (p. 344) (By permission.)
discovery and serious study of the classics, the
decline of the Church, and the humanistic thrust Regardless of which of these explanations one
of the Renaissance, as well as the rise of accepts, two points are clear. First, scientific
48 DEVIANCE AND MEDICAUZATION: FROM BADNESS TO SICKNESS
empirical knowledge of the origin of madness gerous "Iunatick," who was variously found in
and the physician's ability to "cure" mental stocks, pillories, and jails. The colonists
disease played at the most a small role in the "conceived of the family, the church and the
development of a popular concept of mental ill- network of community relations as important
ness. Second, by the late 18th century the con- weapons against sin and crime" and madness
cept of mental illness was becoming the domi- (Rothman, 1971, p. 16).
nant definition of madness. The first general hospital in America, Penn-
Although the mad were institutionalized, sylvania Hospital, was founded by the Quakers
certified by physicians, and more and more in 1756. There were some mad people among
were considered to be sick, there is little evi- the sick persons admitted, although they were
dence that anything resembling medical treat- confined to the cellar. The treatments employed
ment was carried out. An inspector general of were the medical treatments for insanity com-
French hospitals and prisons summed up the mon at the time. "Their scalps were shaved and
situation of lunatics in 1785 most succintly: blistered; they were bled to the point of syn-
Thousands of lunatics are locked up in prison without cope; purged until the alimentary canal failed to
anyone even thinking of administering the slightest yield anything but mucus, and in intervals, they
remedy. The half-mad are mingled with those who were chained by the waist or ankle to the cell
are totally deranged, those with rage with those who wall" (Deutsch, 1949, p. 60). It was a local
are quiet; some are in chains, while others are free in custom for townspeople to come and gaze at the
their prison. Finally, unless nature comes to their lunatics for a small fee. (This actually contin-
aid by curing them, the duration of their misery is ued in some fonn until 1822.) One suspects that
life-long, for unfortunately the illness does not im- this stigmatized the mad, at the same time pro-
prove but only grows worse. (Quoted in Rosen, viding a warning for those who psychically
1968, p. 151).
strayed from the straight and narrow path.
It is interesting to note that the disease concept The colonial governor of Virginia became
of madness was accepted as public policy even concerned with the treatment of madness and
though there was no medical treatment and no the "case of the poor lunaticks." Beginning
"evidence" to support biophysiological the- in 1766 he appealed regularly to the legisla-
ories. As Thomas Kuhn (1970) points out, ture to construct an asylum so that lunatics
"scientific revolutions" and associated para- need not be confined to the Williamsburg jail.
digm changes-in this case from madness to In 1769 the legislature passed an act' 'to make
mental illness-may occur for political reasons provision for the Support and Maintenance of
and not necessarily scientific ones. During this Ideots, Lunaticks and other persons of unsound
significant period of its ascendance, the mental Minds" (Deutsch, 1949, p. 70). In 1773 the
illness concept is better viewed as an ideology Public Hospital for Persons of Insane and Dis-
that a scientific achievement. ordered Minds (the Williamsburg Lunatic Asy-
lum) ,the first hospital exlusively for the insane,
THE 19th-CENTURY was opened in Williamsburg. Insanity was de-
AMERICAN EXPERIENCE: tennined by three magistrates, and no provision
THE INSTITUTIONALIZATION was made for a medical examination. The Wil-
OF MENTAL ILLNESS liamsburg Lunatic Asylum was meant to be a
In colonial America, much like contempo- last resort. Its primary task was to keep the
rary Europe, insanity was seen as a kinship or peace of the community and to constrain the in-
comrilUnal matter. The "harmless" dependent sane from wandering about. This remained the
insane were dealt with like other paupers, the only public lunatic asylum for 50 years.
well-to-do insane were cared for by their fam- The confinement of the insane has three
ilies, and the violent or criminal insane were sources of legitimacy in the Anglo-American
punished as criminals. Public provision for the political system (Kittrie, 1971). These princi-
dependent insane rarely included medical treat- ples were first developed in English law and
ment. Public concern was mostly about the dan- were adopted by the colonists and later by the
founders of the Republic as the basis of Ameri- raphy he wrote, "Chagrin, shame, fear, terror,
can law. They serve as the legal rationale for anger, unfit for legal acts, are transient mad-
involuntary incarceration. The first source of ness . . . . Suicide is madness . . . . Sanity [is
legitimacy is the' 'police power" of the state to an] aptitude to judge things like other men, and
protect the peace and ensure public welfare. regular habits, etc. Insanity [is] a departure
This was used with the violent and the "fu- from this" (quoted in Szasz, 1970, p. 141).
riously mad." The second source is parens Naturally he viewed physicians as the best jud-
patriae, the principle that the state could as- ges of insanity. Rush defined a variety of non-
sume guardianship of a person who was legal- conforming and deviant behaviors as medi-
ly "disabled" and declared incompetent and cal problems: he depicted lying, drunkenness,
could control his or her property. The third crime, and even opposing the Revolution as
source is the state's power over the indigent diseases (the latter he dubbed "revolutiona").
members of the pauper community. This is an He was an early and active abolitionist, al-
extension of the English concept of the Crown's though partly basing his conviction on his be-
responsibility for the destitute. Most confine- lief that blacks had a disease, "Negritude,"
ment in the 19th century was in the name of that was inherited from ancestors with leprosy
parens patriae, with the physician as wiseman and had turned their skins dark. Rush saw dis-
and guardian. ease in any behavior not complying with his
Benjamin Rush is widely considered the "Fa- particular world view. As Szasz (1970) notes,
ther of American Psychiatry. " He was a signer "His eyes thus beheld the world in terms of
of the Declaration of Independence, a respected sickness and health" (p. 140).
reformer, and a well-known physician when he
was appointed to Pennsylvania Hospital in- Asylum-building movement: a new
1783. He was firmly convinced that "the pa- "cure" for Insanity
tients afflicted by madness should be the first During the second quarter of the 19th century
objects of care of the physicians of the a virtual epidemic of state asylum building took
Pennsylvania Hospital" (Deutsch, 1949, p. place. In 1824 there were two state asylums, but
77). Rush's own theory was that madness was by 1860, 28 of the 33 states had public institu-
an arterial disease having its primary seat in the tions for the insane, a 14-fold increase. It seems
brain. Hence his treatments of purgatives, diets, that the asylum was an idea whose time had
hot and cold showers, and bloodletting were come; institutionalization became the treatment
aimed at affecting the circulation of blood. Ac- of choice for insanity. Why did this occur at
tually Rush was ambivalent about therapy and this time in history? And how does this relate to
punishment, often not clearly distinguishing the medical conception of mental illness?
between them. He believed that physicians had We first need to examine the perceived
to gain complete control, authority, and power causes of madness in early 19th-century Ameri-
over the mad person. Some of his writings ca. By the third decade the old order of Ameri-
make it apparent that he viewed the insane as can society was passing and was rapidly being
wild beasts who needed to be tamed with "wild replaced with a new one. The Jacksonian period
and terrifying modes of punishment. " At other (1828-1836) was characterized by an increase
times his writing takes on a flavor of Ute in social mobility and political participation,
kindness of moral treatment. Rush's crowning increased religious and intellectual freedom and
achievement was the publication in 1812 of enthusiasm, and a greater geographical mobil-
Medica/Inquiries and Observations Upon the ity for the population. These changes, accord-
Disease of Mind, the first American textbook ing to David Rothman (1971), created a per-
in psychiatry. This was the only American vasive anxiety in America. It was believed that
work of its kind for 70 years. the old social order was vanishing and that a
We can also consider Rush as the "Father of new, more fluid, potentially chaotic order was
the Medicalization of Deviance." He had a taking its place. Students of deviant behavior in
rather broad notion of madness. In his autobiog- this era thought that erosion in the discipline
and order of the family was the primary cause the insane. Reports of recovery rates from some
of deviant behavior. of the early asylums were astounding. A report
Insanity was viewed by physicians, and most issued by Hartford Retreat in 1827 announced
explicitly by the medical superintendents of that 21 of 23 new cases of insanity, an amazing
the new institutions, as a biological disease of 91%, had been cured. The newspapers publi-
the brain that was "socially caused" or at least cized the report, and this marked the beginning
precipitated by social forces. Such factors as of a curability craze that would last nearly two
lack of discipline, social mobility, disappointed decades. A "cult of curability" swept the mad-
ambition, or economic depression were cited ness world. The "asylum cure" was the rule,
frequently. Although these physicians were not the exception. Reports from medical super-
convinced that organic lesions existed, they, intendents of asylums regularly claimed 80%
unlike their European contemporaries, had no to 90% and even 100% cure rates. It was a vir-
interest in biological or anatomical. research. tual contest of figures. Interestingly, these sta-
The first cause was in the social system, not tistics went unchallenged until 1877, when
the body. Insanity was a disease of civilization; Pliny Earle, an asylum superintendent from
any man or woman could succumb to it. Luna- Massachusetts, pointed out that the figures were
tics were not considered a special breed of peo- reports of recovery of cases and not persons,
ple. One corollary of these doctrines was that and that some of the impressive cure rates rep-
if the source of madness resided in society resented the ratio of recoveries to patients dis-
rather than the individual, then society had a charged, not admitted (American Psychiatric
responsibility for these people. Social measures Association, 1976). One patient had been dis-
could and should be taken to alleviate and cor- charged 48 times with 48 cures.
rect the sufferer's condition. The "asylum cure" consisted of (1) removal
Theories of environmental cause of insanity of the insane from the community, the alleged
gave birth to a new belief that insanity was cause of mental disease; (2) confinement in an
curable. All that was required was to design a institution that was itself separate from the
proper curative environment to overcome the community (leading to the building of asylums
social order, tensions, and chaos. The needs of with big lawns on the rural fringes); and (3) cre-
the insane could be met by isolating them from ation of an order in the asylum to compensate
the community and developing a model soci- for the fluidity and disorder in society, an
ety, which would exemplify the advantages of an American version of moral treatment. As Roth-
orderly, disciplined routine. The physicians of man (1971) points out, the medical superinten-
insanity believed they had discovered its cure. dents designed their asylums as an attempt to
This was the invention of the insane asylum reconstitute the 18th-century virtues they per-
(Rothman, 1971). ceived lacking in the changing society:
The 1830s and 1840s was a utopian era in the They would teach discipline, a sense of limits and a
United States. Isolated "utopian communities" satisfaction with one's position . . . . The psychia-
such as the transcendentalist Brook Farm and trists . . . conceived of proper individual behavior
the Oneida community were founded as models and social relationships only in terms of a personal
of a more perfect community; the celibate Shak- respect for authority and tradition and an acceptance
ers lived in over a dozen flourishing settlements of one's station in the ranks of society. In this sense
during this peak period. The asylum movement they were trying to re-create in the asylum their own
sprang from similar utopian ideals, endeavoring vision of the colonial community. The results, how-
to create a model society. Those who cham- ever, were very different. Regimentation, punctual-
pioned it were believers in asylums as great re- ity, and precision became the asylum's basic traits,
and these qualities were far more in keeping with an
forms and vehicles for creating a better soci-
urban, industrial order than a local, agrarian one.
ety. Now, the reformers said, the asylum would (p. 154)
be the curative environment, not merely a pris-
on for the insane. Probably without knowing it, and certainly
This was an optimistic time for physicians of without intention, the physicians in the asylums
were preparing their charges for an impending exclusion of all other persons having no formal
order, rather than restoring them to past values. training and instruction in this specialty"
In America, as well as Europe, the asylum, (Grob, 1970, p. 312).
though humanizing the treatment of the insane, By the 1850s the optimism began to wane.
also became an institution that attempted to in- Many institutions had never reached the cur-
still the discipline necessary for industrial capi- ability rates claimed by others; "incurables"
talist labor. were backlogging and overcrowding asylums,
The ideas of the asylum and the asylum cure and some Eastern institutions were being
needed proponents to spread the word. Doro- flooded with immigrants who were considered
thea Dix, an energetic former schoolteacher, by some physicians as "incurable." Many de-
was "shocked" by the conditions of the men- ranged individuals who had resided in alms-
tally ill kept in almshouses and jails. She was houses were transferred to asylums. The pres-
undoubtedly the foremost champion of separate sures of rising admissions made moral treat-
public asylums for the insane. For many years ment increasingly difficult. By 1852 the popula-
after 1841 she toured the country, visiting insti- tion of Worcester State Lunatic Hospital in
tutions and lobbying with legislators for the Massachusetts had risen to 500 and the physi-
development of state hospitals. "Her formula cian-patient ratio had dropped significantly
was simple and she repeated it everywhere: first (Grob, 1970). Moral treatment, which was
assert the curability of insanity, link it directly possible and to some degree successful, in
to proper institutional care, and then quote pre- an asylum of 120 inmates, was impossible in
vailing medical opinion on rates of recoveries" an institution of over 500. Gradually most of
(Rothman, 1971, p. 132). Her success was re- the institutions reverted to custodial care and
markable. By 1880 there were 75 state asylums, the use of restraints for the "incurables," with
32 of which were founded as a direct result of the medical directors and legislators rationaliz-
her efforts. She also popularized the medical ing that it was better than jail. Drugs (e.g.,
concept of madness and championed the idea sedatives) and restraints became ends in them-
that medical psychologists, as they were called, selves, not adjuncts to a therapeutic program.
were the proper restorers of sanity. Some treatment was available for those recently
In 1844, 13 superintendents of insane asy- diagnosed insane, but if they did not recover in
lums organized the Association of Medical Su- a reasonable time, they were deemed incurable
perintendents of American Institutions of the and relegated to the custodial section of the asy-
Insane to aid in communication of knowledge lum. If the hospital could not be justified in
and information and set standards for treatment. terms of numbers of cured, then the easiest way
This organization was the forerunner of the to justify appropriations and the existence of the
American Psychiatric Association (the name institution to the legislature was to request
was changed in 1921) and served both as a po- funds for providing accommodations and care
litical force and a professional body. They pub- for the growing number of chronically insane
lished the American Journal of Insanity, which (Grob, 1970). By the late 19th century most
became the predominant journal in its field. asylums were largely custodial enterprises, with
American psychiatry developed very much as medical superintendents serving as gatekeepers
administrative psychiatry, and in its early years and guardians.
the association was more interested in asylum With the end of the cult of curability, somat-
architecture, vocational therapy, and cure rates ic or physiological pessimism replaced the more
than medical research. Nonetheless, it quickly optimistic theories of social causation espoused
became the authoritative voice of medical opin- by early asylum superintendents. The disillu-
ion on insanity. The association provided the sionment with the asylum cure and the rise of
legitimation of American psychiatry as a medi- Darwinian theory gave credence to a new
cal specialty. "By insisting that special skills idea-the degeneration hypothesis. This
and knowledge were required for treating men- hypothesis stated that there is a degeneration
tal illness, psychiatrists were able to justify the from the normal human type through genera-
tions, transmitted by heredity, which deterio- was viewed as a cause of insanity, but it was the
rates progressively toward extinction (Acker- weakening of the nervous system and the hy-
knecht, 1968). This rather pessimistic view of pothesized organic lesions produced by such
mental illness emerged largely in Europe, espe- "venereal indulgence" that were believed the
cially under the influence of Benedict Augustin source of insanity (see Englehardt, 1974).
Morel; but it serves well as an example of the The somatic approach, with one significant
type of medical theories of madness developed exception, was not particularly fruitful. The
at this time. Italian physician Cesare Lombroso discovery of general paresis, a type of madness
proposed his own ideas based on the degenera- caused by a neurological breakdown in third-
tion hypothesis in his writings on the "born stage syphilis, is considered by some as medi-
criminal" (see Chapter 8). cine's "greatest triumph in the field of behavior
In terms of the history of the medical concep- disorders" (White, 1964, p. 16), and by others
tion of madness, the 19th century was a signifi- as providing a rationalization for the disease
cant period. In the United States, as in England, concept of madness (Szasz, 1976). No doubt it
madness moved once and for all into medicai was a great achievement. It followed the dis-
turf. Alienists (as physicians of the insane were coveries of Pasteur, Koch, and Lister, which
called), with the aid of champions like Doro- had aided in the mastery of other infectious dis-
thea Dix, were able to gain a monopoly over eases. The "symptom complex" of this disor-
the definition and treatment of madness. All der was first described by Esquirol as early as
new asylums were run by medical superinten- 1805, but actual connection with syphilis as a
dents. Medical men did not have "scientific" causal agent was not made until 1894 and con-
evidence of mental disease, nor did their asy- firmed through a variety of clinical and microbi-
lum qua hospital offer a medical cure. In fact, al studies over the next two decades. When
both their causes and cures were specifically Noguchi and Moore in 1913 found Treponema
social. Medicine was embraced as much for its pallidum, the infectious agent of syphilis, in
humanitarian "moral treatment" as for any nerve-cell layers of the patient's cortex, any lin-
technical expertise. By the time the early opti- gering doubts that syphilis was the cause of this
mism of asylum cures had waned, medicine had type of insanity were erased. Medicine finally
secured control over the domain of insanity. had empirical evidence for the cause of at least
Again, we point out, this was accomplished one type of insanity. This provided "proof"
without physiological evidence for cause and that the medical concept of madness must be
before the advent of successful "medical" correct. If a physiological cause for one type of
treatments. In America as in Europe, medical insanity had been found, then modem medicine
dominance of madness was a social and polit- would, in time, discover the causes of all men-
ical rather than a scientific achievement. tal illness. This was undoubtedly a vindication
for the medical model of madness.
THE SCIENCE OF MENTAL DISEASE Late 19th-century psychiatry took its .cues
The science of mental disease developed in from its more successful sibling, somatic medi-
the asylum. The demise of the cult of curability cine. Alienists or psychiatrists needed only to
and the constricted morality of the Victorian era use more tools of somatic medicine and soon
supported the pessimism among the physicians they, too, would be able to discover physiologi-
of the insane. This pessimism, along with the cal causes for all mental disease, just as for gen-
apparent success of medicine in controlling in- eral paresis. Emil Kraepelin, a German alienist
fectious diseases and an increasing concern with a gift for observation and synthesis, en-
about the incurable immigrant insane, led psy- gaged in detailed studies of "natural histories"
chiatrists to abandon their environmental ap- of asylum patients. With the publication of Psy-
proaches and become heavily somatic. Physi- chiatrie, which went through several revisions
cians, armed with the microscope, looked in- between 1883 and 1913, Kraepelin changed the
creasingly to the brain, spinal cord, and nervous classification system of mental illness. His de-
system for the cause of madness. Masturbation scriptions of the symptom complexes of demen-
tia praecox and manic-depressive psychosis, the symptoms arose from conflicts between biogen-
two major categories of mental disorder, are ic drives such as sex and aggression and socio-
still used today. He believed that dementia cultural forces. These conflicts usually involved
praecox (literally, early senility) was charac- parents, occurred during early childhood, and
terized by progressive deterioration and that were repressed into "the unconscious." "He
manic depression (severe uncontrollable mood perceived his patients not as examples of brain
swings) tended to improve and recur spontane- disease, not victims of hereditary nervous
ously. Kraepelin, fully committed to the medi- weakness, but as troubled human beings whose
cal model, proposed only organic etiologies strivings, hopes, fears, daydreams, and inti-
for mental disorders and viewed them as physi- mate feelings were mixing them up and destroy-
cal diseases. Eugen Bleuler noted that all de- ing their health and happiness" (White, 1964,
mentia patients do not inevitably degenerate, p. 38). His method of treatment was psycho-
and in 1911 he created a modified and expanded analysis, a talking cure based on a series of con-
category he called schizophrenia. The great versations (an hour daily for several years) in
concern for classification of mental illness char- which the patient was encouraged to "free as-
acterizes the development of psychiatry. The sociate," say whatever came to mind, and re-
official psychiatric diagnostic manual, Diag- live and resolve past conflicts in the safety of
nostic and Statistical Manual of Mental Dis- the relationship with the therapist. This revela-
orders (American Psychiatric Association, tion and catharsis would enable the patient to
1%8), contains no less than 155 separate classi- develop "insight" into his or her difficulties,
fications of psychiatric disorders, and its latest understand the roots of the "illness," and hope-
revision, DSM-III, is expected to have twice fully have a "corrective emotional experi-
that many. ence." Freud was the first to systematically re-
open, in Foucault's terms, a dialogue with mad-
Freud, psychoanalysis, and ness. He gave an entirely new understanding to
medlcallzatlon human problems and substituted a psychogenic
In 1909 Sigmund Freud, a Viennese physi- explanation for a biogenic determinism.
cian and neurologist, delivered a series of five Freud's break with the medical conception of
lectures at Clark University in Worcester, Mas- madness was far from complete. In fact, the
sachusetts. He presented a theory of the human Freudian model of madness was grafted onto
mind that he had developed over the previous the existing medical model with little difficulty.
two decades. As a result of Freud's visit and Freud was trained as a physician-neurologist
ideas, American psychiatry has never been the and moved slowly from organic and physically
same. Freud's theory, which he based largely determined theories about mental illness to psy-
on his work with neurotic disorders such as hys- chological and, to a degree, sociocultural theo-
teria that are rarely seen in the asylum, appears ries of cause. No doubt his training as a physi-
at least on the surface to be a break with the cian affected the types of theories and treat-
medical concept of mental disease. * He sug- ments he developed. The people he saw were
gested that mental symptoms were intelligible "patients" and they had "illnesses, " albeit
but distorted results of the individual's struggles psychological ones, which therapy attempted to
with internal impulses. He assumed these cure. His theory located the source of problems
inside the patients' heads, and his treatment was
* We are concerned here only with the impact of individualistic. Treatment would occur in the
Freud on the medical conception of madness. The consulting room, with the patient on the couch
complexities of Freudian personality theory or psy- and the physician present in the room but not in
choanalysis are beyond the scope of this chapter, as the patient's sight. Freud himself never aban-
are the various schisms of his followers and revision- doned the notion that all psychological illness
ists. For a good introduction, see Freud's New In-
troductory Lectures in Psychoanalysis (1933) or must be attributable ultimately to neurological
Charles Brenner's An Elementary Textbook of Psy- process and could, like somatic diseases, some-
choanalysis (1974). day be treated with pills and injections. In
practice, however, because no such treatments nature of mental symptoms and psychological
were available, his work and practice were car- illnesses and by their attention to family and
ried out on a purely psychological level (Acker- childhood experiences. Yet because Freud-
knecht, 1968, p. 93). ian theory was grafted onto the existing medical
Freud and his early followers (e.g., Adler, model, it expanded greatly the notions of men-
Jung, Ferenczi) did not deal with the same types tal disease. This model of psychological illness
of madness that Kraepelin and the other asylum included all deviant behavior and emotional
alienists had. Asylum inmates were too dis- problems that were not organic in origin: essen-
turbed for Freud's theory. Most Freudians were tially all human behavior problems but general
concerned with what are called neurotic disor- paresis, senility, and organic brain syndrome.
ders such as hysteria, obsessions, compulsions, Madness, hysteria, obsessions, compulsions,
and phobias that kept people from optimal func- phobias, anxiety, homosexuality, drunkenness,
tioning. Freud did not investigate severely dis- sexual deviation, chronic misbehavior in chil-
turbed people suffering the insanity now called dren, and delinquency, among others, were all
psychoses (including schizophrenia and manic psychological illnesses and subject to medical-
depression), until his later years. When he did, psychiatric treatment.
he found these disorders inaccessible to psycho- The psychogenic movement, led by Freud
analysis and that these patients lacked "in- and his followers, infused psychiatry with a
sight" into their difficulties. Only in the 1930s new sense of optimism, replacing the somatic
did psychiatrists like Frieda Fromm-Reichmann pessimism of the late 19th century. Freud's the-
and Harry Stack Sullivan bring psychoanalysis ories and techniques for the first time made it
to the inmates of the asylum. possible for physicians to spend their time un-
The effect of Freud on American psychiatry derstanding the patient's psyches, rather than
was enormous. The first psychoanalytic insti- manipulating their bodies or creating moral
tute was founded in New York in 1931, and environments in asylums in which they resided.
eventually there were a dozen psychoanalytic The Freudian "revolution" was not, however,
centers in major cities. No one could study psy- supported by all psychiatrists. There were,
chiatry, psychology, or social work without more specifically, somaticists still to be heard
encountering his theories and techniques and from. The somaticism that developed in the
those of some of his followers. Psychoanalysts 1930s took three forms: "shock" therapies, lo-
became an elite of the American Psychiatric botomies, and genetic theories of mental ill-
Association. In fact, psychoanalysis became ness.
largely the property of medical psychiatry.
Freud had not wanted it that way. "He had Reappearance of the somatlclsts
'only unwillingly taken up the profession of Manfred Sakel, a German physician who
medicine'; in fact, Freud had a low opinion of had been using insulin to treat morphine addic-
physicians. They were merchants, trading in tion, in 1929 noticed some apparent psycholog-
the mitigation of miseries they scarcely at- ical improvement in a patient following a con-
tempted to understand" (Rieff, 1966, p. 83). vulsion and coma produced by an accidental
Freud spoke out several times in his life in sup- overdose of insulin. He extended his research
port of lay (nonmedical) analysis, but American and treatments to schizophrenia and reported
psychoanalysts created a medical monopoly and some success at reducing overt symptoms. Over
trained only physicians. * This further medical- the next two decades insulin shock therapy be-
ized psychoanalytic theory and therapy. came a common physiological treatment for
Freud and his followers both muted and ex- schizophrenia (Horowitz, W., 1959). Insulin
tended the medical model of madness. They shock had some inherent dangers, was rather
muted it by their emphasis on the intrapsychic expensive and time-consuming, since patients
needed continuous nursing care and observa-
* Some of the most distinguished psychoanalysts tion, and yielded unreliable results. In 1938
were lay analysts who were trained in Europe: for ex- two Italian physicians, Ugo Cerletti and L.
ample, Erik Erikson, Erich Fromm, and Anna Freud. Bini, introduced an "easier" technique, elec-
troconvulsive therapy (ECT), or, simply, elec- 1949 for his work. Supporters claimed cure in
troshock. This technique consists of applying a third and improvement in another third of lo-
electrodes to the patient's head and passing botomized patients (Freeman, 1959), but critics
moderate electrical currents (70 to 130 volts) claimed the "cure" was worse than the "dis-
through the brain for a few seconds. The patient ease." Many lobotomized patients showed
suffers a brief but violent convulsion, loses con- marked irreversible deterioration in personality,
sciousness, and on reawakening has an amnesia difficulty in generalizing and abstract thinking,
(memory loss) for recent events, which lasts for and an overall passivity, and remained institu-
several weeks or months. Shock treatments are tionalized; in short, they became "zombies."
given in a series over a period of weeks. Early For this reason, and because of the availability
medical practitioners of this method advocated of tranquilizing drugs, by the early 1950s lo-
it for patients with schizophrenia, but it has not botomy fell into disrepute. Up until that time,
proven particularly useful for this diagnosis. however, approximately 40,000 to 50,000 such
Some recent advocates limit its use to mood dis- operations were performed in the United States.
orders such as mania and depression. This crude In the late 1960s a new and more technological-
and violent treatment is used today and remains ly sophisticated variant of psychosurgery
controversial. There is no accepted explanation emerged, including laser technology and brain
of how it works. Some physicians are so zeal- implants, and was heralded by some as a treat-
ous about this physiological treatment that they ment for uncontrollable violent outbursts (see
have opened private institutions, referred to by Chapter 8).
critics as "shock shops," in which they are al- Psychiatrists and their precursors have long
leged to administer shock treatments to all their argued that madness runs in families. In this
patients. Others see it as a form of psychiatric view the question becomes whether it is psy-
barbarism (Szasz, 1976). chogenically or biogenically caused. The bio-
In 1935 Antonio Egas Moniz, a Portuguese genic hereditary theories of the late 19th cen-
neurologist, introduced the psychosurgery tury rose again with more sophisticated analy-
known as prefrontal lobotomy to the psychiatric ses beginning in the 1930s. Franz Kallmann, a
world. Moniz believed that the fixed ideas and German-born American psychiatrist, spurred a
repetitive behavior seen in some mental patients new genetic interest in mental illness etiology
were accompanied by abnormal cellular con- with the publication of Genetics of Schizophre-
nections in the brain. His theory suggested nia in 1938. He became the most influential
that ':morbid" thoughts were a result of brain proponent of the genetic hypothesis. Kallmann
disease and hence the appropriate treatment was (1938) examined the relatives of 1087 mental
brain surgery: patients who had been diagnosed schizophrenic.
He found that the expectancy of mental illness
In accordance with the theory we have developed, among relatives was higher than nonrelatives
one conclusion is derived: to cure these patients we
and that it increased with closeness of kinship.
must destroy the more or less fixed arrangements of
Several years later Kallmann (1946) published
cellular connections that exist in the brain, and par-
ticularly those which are related to the frontal lobes. another study which showed that the concor-
(Moniz, quoted in Freeman, 1959, p. 1521) dance of schizophrenia for identical (monozy-
gotic, or one-egg) twins was 86.2% and for
The method that Moniz conceived of as "cura- nonidentical (dyzygotic, or two-egg) twins
tive" for this supposed brain damage was lobot- 14.7%. He found that a subsample of identical
omy, a surgical procedure that severed some of twins who were "reared apart" still showed a
the neural connections between the frontal lobes 77.6% concordance, whereas those reared to-
and other parts of the brain. Although immersed gether were 91.5% concordant. Comparatively,
in controversy from the start, lobotomy became only about 1% of the population is diagnosed
a common treatment, and advocates such as as schizophrenic. Based on his research, and
American neurologist Walter Freeman operated especially the twin studies, Kallmann posited
on thousands of institutionalized mental pa- a genetic theory of mental illness.
tients. Moniz was awarded the Nobel Prize in This research has been amply criticized from
a number of angles, especially methodologi- show any great concern for "the mentally
cally (see Jackson, 1960). First, the psychiatric sick. " The idea that madness was a sickness
diagnosis is not reliable. A recent study by like any other sickness did not meet with a great
David Rosenhan (1973) demonstrates this dra- deal of public acceptance.
matically. In this study eight sane people pre-
sented themselves to the admitting units of a Reform and Institutionalization
variety of mental hospitals, claiming to hear Clifford Beers, a 32-year-old Yale graduate,
voices that saJd "thud," "empty," or "hol- in 1908 published a book, A Mind That Found
low." They did not alter their personal biog- Itself, detailing his 3 years in mental hospitals.
raphies in any other way. All were admitted and He related his experiences of treatment (which
each was diagnosed as schizophrenic. Once ad- he frequently called torture), his recovery, and
mitted, they resumed their normal identities, his determination to improve the care of the
and it took an average of 19 days before they mentally ill. He was outraged that people suf-
were discharged as "schizophrenia, in remis- fering from mental diseases were so shabbily
sion." Rosenhan (1973) concludes that "we treated. He set out to awaken the public con-
cannot distinguish insanity from sanity" (p. science. The book attracted considerable atten-
271). Furthermore, sociologists have pointed tion, and Beers began organizing a reform
out the many pitfalls of using the type of "offi- movement.
cial" hospital admissions data that Kallmann In 1909 Beers organized The National Com-
relied on (see Kitsuse & Cicourel, 1963). Final- mittee for Mental Hygiene to implement his
ly, Kallmann minimized the significance of dif- ideas. From the beginning Beers had close ties
ficult family histories (Coulter, 1973, pp. to the medical psychiatric profession; it had
15-28), and defined "reared apart" as living been Adolf Meyer, America's foremost psy-
apart for only the last 5 years. chiatrist, who had suggested the name "mental
No treatments evolved based on the genetic hygiene." In 1912 Thomas Salmon, another
hypothesis, but Kallmann (1959), echoing the prominent psychiatrist, became the Commit-
eugenicists of an earlier era, warned that soci- tee's medical director with Beers as secretary.
ety ignored the genetic basis of mental illness at Medical professionals have always been cen-
its own peril. Although Kallmann's research is trally involved. Twenty of the American Psy-
open to different interpretations, his work and chiatric Association presidents have been
similar studies by others lend some "scientific" actively involved in the Committee and its
support to the biogenic hypothesis and rein- successor, the National Association for Mental
force the medical conception of mental illness. Health (Mauss, 1975, p. 342).
To summarize briefly, the discovery of gen- The goals of the Committee included improv-
eral paresis symbolized medical vindication for ing the standard of care and treatment in mental
somatic bases of mental illness. Freud and his hospitals, encouraging prevention of mental ill-
followers both muted and extended the medical ness, promoting the notion that insanity was
model of madness, whereas Kraepelin and the curable, supporting research, and to the extent
"new" somaticists attempted to develop scien- desirable, enlisting government help. The Com-
tific theories and data to support medical con- mittee prepared lists of public and private
tentions. The total effect broadened and deep- mental institutions and of psychiatrists; com-
ened professional interest in the medical model piled a bibliography on nervous and mental dis-
of human problems and the commitment to eases; collected and analyzed laws pertaining
medical solutions for them. to the mentally ill; "and started a program of
public education, which included an exhibit,
MENTAL IUNESS AND THE PUBLIC and the preparation of four pamphlets, of which
Though the concept of mental illness was they distributed 91,000 copies [in the] first
well developed and recognized by the tum of working year" (Ridenour, 1961, p. 19). They
the 20th century, the insane were often still cooperated with what is now the American
treated severely, and the public did not seem to Psychiatric Association in the development of a
classification system for mental disease, and on a federal level. In 1917 a psychiatric division
along with the federal government, improved was established in the Surgeon General's office;
the collection of statistics. The Committee be- the object was to examine recruits for psychiat-
came both a reform movement and a public re- ric difficulties and to treat soldiers with mental
lations agency for psychiatry. Salmon himself problems, especially "shell shock." Psychia-
perceived psychiatry as "the Cinderella of med- trists participated even more fully in World War
icine," indicating its lack of prestige in the II. With William Menninger as head of the
medical world and its need for a more positive psychiatric division, the number of military
image. Both the Committee and Beers com- psychiatrists grew from 35 in late 1941 to 2400
pletely accepted the medical model of madness. in 1945. The psychiatrists were very busy. Be-
In fact, a primary goal was to establish the tween January, 1942, and June, 1945, an esti-
credibility of an illness interpretation for mad- mated 1,875,000 men (of 15 million) were re-
ness. In the 1950s the National Association of jected from the military for alleged psychiatric
Mental Health, which succeeded the Commit- disabilities (Mechanic, 1969, p. 55) and an-
tee, initiated campaigns with slogans such as other 750,000 more were eventually discharged
"Mental Health is Everybody's Business" and because of mental problems (Ridenour, 1961,
"Fight Mental Illness." They publicized ideas p. 60). Undoubtedly these high figures, along
such as "mental illness is an illness like any with lobbying by the National Committee of
other illness" and "half of all hospital beds are Mental Hygiene, contributed to the strong Con-
occupied by mental patients" to further spread gressional support in the passage of the 1946
the word. National Mental Health Act. It established a
Sociologist Kingsley Davis (1938), in a federal mental health agency, the National Insti-
brilliant analysis of the mental hygiene move- tute of Mental Health (NIMH), which began
ment viewpoint, notes that mental hygienists operation in 1949. NIMH would support re-
tacitly assume the Protestant open-class soci- search and psychiatric training and coordinate a
ety ethic, which is based on personal responsi- national effort to combat mental illness. Its
bility and individual achievement. He suggests budget grew steadily: from $9 million in 1950
that the psychological and individualistic view to $68 million in 1960 to $338 million in 1967
of mental disorder, completely ignoring how to $502 million in 1978. NIMH was dominated
social context may affect the human psyche, is by psychiatrists and thus committed to the med-
a product of the middle-class Protestant ethic ical model of madness from the start.
biases of its members. The Protestant ethic and Mental illness received some media attention
the individualism of the medical model are in the late 1940s. A spate of newspaper and
highly compatible. magazine exposes, in New York's PM, Read-
The psychiatric view of deviance was spread- er's Digest, Life, and other popular media, de-
ing in the 1920s. The medically inspired "child picted the overcrowded, decrepit, and inhu-
guidance movement," concerned with juvenile mane conditions of the state hospitals. A film,
delinquency, extended the illness concept to de- The Snake Pit, was shown widely, demonstrat-
linquent and troublesome children (see Chapter ing powerfully the situation of the mentally ill.
6). Out of this movement a multiprofessional These events brought the situation of the mad
organization, the American Orthopsychiatric into the public eye.
Association, was founded by prominent psy-
chiatrist Karl Menninger and 26 others. In late Public acceptance
1923 they sent a letter to their colleagues re- The public and professional definitions of
questing them to join a new organization of the what constitutes mental disorder are incongru-
"representatives of the neuropsychiatric or ent and probably have always been so. The pub-
medical view of crime" (quoted in Ridenour, lic has a much narrower conception of what
1961, p. 39). deviant behavior can be attributed to mental
The two world wars enhanced the acceptance illness than do psychiatrists. This has been
of psychiatry and led to its institutionalization demonstrated clearly in studies using descrip-
tions of deviant behavior developed by sociol- It is likely that the trend toward public adop-
ogist Shirley Star (1955) (see p. 59). Star had tion of the psychiatric viewpoint of deviant be-
meant these descriptive vignettes to serve as havior has continued. There is also some evi-
examples of the psychiatric categories of (1) dence of a greater tolerance or acceptance of the
paranoid schizophrenia, (2) simple schizophre- mentally ill themselves (Halpert, 1970; but see
nia, (3) anxiety neurosis, (4) alcoholism, (5) Sarbin and Mancuso, 1970). However, it is also
compulsive-phobic behavior, and (6) juvenile likely that the public still maintains a consider-
character disorder. In five different studies ran- ably narrower conception of what constitutes
domly selected people were asked to respond mental illness than does the medical profession.
whether each of the behavior descriptions was In short, public conceptions remain less medi-
indicative of mental illness. A group of 34 psy- calized.
chiatrists almost unanimously judged all these
descriptions as illustrating types of mental dis- Mental Illness and criminal law
order (Dohrenwend & Chin-Shong, 1967). A It is an old question whether mad people who
look at the results of the various surveys (shown commit crimes should be held responsible for
in the right-hand columns, pp. 59-60) indicates these acts. Mad persons accused of crimes have
that the public has a narrower view of what can been treated in various ways throughout history .
be attributed to mental illness than do psychia- For the most part they were treated like any oth-
trists. There is an incongruity with the medical er criminal and subject to criminal law, al-
definitions: only in the first two cases do the though there are some historical exceptions. In
majority of people define the behavior as mental ancient Israel a mad person "who caused bodily
illness. It appears that the public does not fully harm to another person could not be held legally
accept the medical model of deviant behavior, responsible" (Rosen, 1968, p. 66); in Greece,
although the two "psychoses" are much more under Plato's laws, crimes committed by the
commonly seen as mental illness (see p. 59, mad were subject to certain exemptions (p. 40);
cases 1 and 2). But the data seem to indicate and in the 17th century a person who did not
that public conceptions of mental disorder are know what he was doing any better than "a
changing in the direction of the professional wild beast" could escape punishment. In our
definition. That is, the notion of deviant behav- society the law has generally been guided by the
ior as mental illness is finding more public ac- principle that without mens rea or evil intent, an
ceptance. Whether this is due to the mental offender cannot be designated a criminal. This
health educational efforts, a more educated was enunciated most clearly in Anglo-Ameri-
populace, cultural drift, or some other factors is can law in the 1843 case of Daniel M'Naugh-
a matter of speculation. ten. M'Naughten shot and killed Edward Drum-
Since the public conceptions of madness are mond, the private secretary of Sir Edward Peel,
less medicalized than the psychiatric concep- believing him to be the Prime Minister. His
tions, it is not surprising to find that popular at- attorneys used insanity as a defense; medi-
titudes stigmatize the mentally ill. Public con- cal evidence was presented establishing that
ceptions tend to view the mentally ill more as M'Naughten was "laboring under an insane de-
"bad" than as "sick"; according to one land- lusion" of being hounded by his enemies, in-
mark study, this is largely because of the pub- cluding Peel. The jury found him not gUilty by
lic's lack of (psychiatric) information (Nunnal- reason of insanity. This set the precedent for
ly, 1961). The negative stereotype of the "dan- what became known as the "M'Naughten
gerous mental case," although not supported by rule," essentially, that he did not "know right
research evidence, is commonly held (Scheff, from wrong" at the time the act was com-
1966). One well-organized and well-financed mitted. This was the major test for the "insanity
study of the impact of mental health education defense" for more than a century.
in a small Canadian town found public attitudes In 1954 Judge David L. Bazelon, Chief Jus-
toward madness extremely difficult to change tice of the United States for the District of Co-
(Cumming & Cumming, 1957). lumbia, enunciated a new criterion for the in-
RESULTS OF STUDIES USING VIGNmES IN DEFINING PROBLEM BEHAVIOR

Year study was conducted and
percentage of respondents that considered
the behavior indicative of mental illness
1950· 1951t 1960* 1962§ 196411
1. I'm thinking of a man -let's call him Frank Jones- 75% 69% 91% 89% 90%
who is very suspicious; he doesn't trust anybody, and
he's sure that everybody Is against him. Sometimes
he thinks that people he sees on the street are talk-
ing about him or following him around. A couple of
times now he has beaten up men who didnl even
know him. The other night he began to curse his wife
terribly; then he hit her and threatened to kill her be-
cause, he said, she was working against him, too,
just like everyone else. ("Paranoid schizophrenia")
2. Now here's a young woman In her twenties, let's 34'7'0 36% 78% 77% 67%
call her Betty Smith ... she has never had a job, and
she doesnl seem to want to go out and look for one.
She Is a very quiet girl, she doesnl talk much to any-
one-even her own family, and she acts like she is
afraid of people, especially young men her own
age. She wonl go out with anyone, and whenever
someone comes to visit her family, she stays in her
own room until they leave. She just stays by herself
and daydreams all the time and shows no Interest In
anything or anybody. ("Simple schizophrenia")
3. Here's another kind of man; we can call him 18% NA~ NA NA 31%
George Brown. He has a good job and is doing
pretty well at it. Most of the time he gets along all
right with people, but he is always very touchy and
he always loses his temper quickly if things aren't
going his way or if people find fault with him. He wor-
ries a lot about little things, and he seems to be
moody and unhappy all the time. Everything is going
along all right for him, but he canl sleep nights,
brooding about the past and worrying about things
that might go wrong. ("Anxiety neurosis")
4. How about Bill Williams? He never seems to be 29% 25% 62% 63% 41%
able to hold a job very long because he drinks so
much. Whenever he has money in his pocket, he
goes on a spree; he stays out till all hours drinking,
and never seems to care what happens to his wife
and children. Sometimes he feels very bad about the
way he treats his family; he begs his wife to forgive
him and promises to stop drinking, but he always
goes off again. ("Alcoholism")
* Star (1955), national sample of adults in United States. Continued.

tCumming and Cumming (1957), a Canadian town.
*Lemkau and Crocetti (1962), Baltimore, Md.
§Meyer (1964), Easton, Md.
IlDohrenwend and Chin-Shong (1967), a multiethnic cross section in New York City.
~ NA = Not available; vignette not used in study.
RESULTS OF STUDIES USING VIGNmES IN DEFINING PROBLEM

BEHAVIOR - cont'd
1950· 1951t 1960* 1962§ 196411
5. Here's a different sort of girl -let's call her Mary 7% NA NA NA 25%
White. She seems happy and cheerful; she's pretty,
has a good job, and is engaged to marry a nice
young man. She has loads offriends; everybody likes
her, and she's always busy and active. However, she
just can't leave the house without going back to see
whether she left the gas stove lit or not. And she al-
ways goes back again just to make sure she locked
the door. And one other thing about her: she's afraid
to ride up and down in elevators; she just won't go
any place where she'd have to ride in an elevator to
get there. ("Compulsive-phobic behavior")
6. Now, I'd like to describe a 12-year-old boy - Bob- 16% NA NA NA 41%

by Grey. He's bright enough and In good health, and
he comes from a comfortable home. But his father
and mother have found out that he's been telling lies
for a long time now. He's been stealing things from
stores, and taking money from his mother's purse,
and he has been playing truant. staying away from
school whenever he can. His parents are very upset
about the way he acts, but he pays no attention to
them. ("Juvenile character disorder")
sanity defense in the case of Monte Durham "divestment" from the criminal law of much of
(Durham v. United States). its traditional jurisdiction, resulting in the re-
The rule we now hold is simply that the accused is moval of blame and responsibility from individ-
not criminally responsible if his unlawful act was the uals for certain categories of illegal acts.
product of mental disease or mental defect. We use Although the Durham rule was subsequently
"disease" in the sense of a condition which is con- modified (see Bazelon, 1974; Kittrie, 1971, pp.
sidered capable of improving or deteriorating. We 42-43), and Judge Bazelon himself (1974) has
use "defect" in the sense of a condition which is not voiced reservations about the nature of psychi-
considered capable of either improving or deterio- atric participation in the legal process, the psy-
rating and which may be congenital or the residual chiatric mental illness definition is permanently
effect of a physical or mental disease. (Quoted in a part of the legal process and central to the in-
Halleck, 1971, pp. 148-149)
sanity defense.
This ruling, known as the "Durham rule," in- To sum up briefly, as evidenced by federal
stitutionalized the psychiatric definitions of legislation, changing public attitudes, and the
mental disease or defect into the legal process. Durham rule, by the 1950s in the United States
Not only could we have medical experts' testi- there was an increasing public acceptance of the
mony (as with the M'Naughten rule), but now medical model of madness.
the actual medical definitions and diagnoses be-
came in themselves reasons for the insanity THE THIRD REVOLUTION IN
defense. Judge Bazelon has continued to be a MENTAL HEALTH
champion of using psychiatry "to humanize" In the early 1950s psychiatry in the United
the legal process (Bazelon, 1974). Nicholas States was characterized by a "psychothera-
Kittrie (1971), among others, has cautioned us peutic ideology" (Armer & Klerman, 1968),
about the consequences of what he calls the based essentially on the Freudian principles that
madness is a result of childhood experiences utility of Thorazine. This extensive promotion

and rooted in intrapsychic conflicts. Psycho- campaign was highly successful* (Swazey,
therapy, though not often available in large 1974):
state mental hospitals, was considered the treat-
ment of choice. There were somatically ori- The drug impact ... was rapid and profound. Within
ented psychiatrists as well, who maintained a 8 months Thorazine was given to an estimated two
million patients. A stream of professional publica-
physiological model of madness and whose ma-
tions, now totaling over 14,000, began to describe
jor forms of treatment were insulin and elec-
the drug's "revolutionary" impact on mental hospi-
troshock therapies. The majority of patients in tals. The mass media hailed [it] ... as a "miracle
large, overcrowded state institutions received drug." (p. 160)
no treatment at all beyond custodial care and
were warehoused on "back wards." By 1955 Thorazine was soon joined by a sister medica-
this all began to change. tion, reserpine (and by 1969, 850 other psycho-
tropic drugs [Swazey, 1974, p. 30]). Under the
Psychotropic medication directorship of Henry Brill, an early and active
The use of drugs for madness has a long his- supporter of pharmacological treatment, New
tory. Vomitives, purgatives, narcotics, and York became the first state mental health sys-
others were used in the 19th century. The 20th tem to introduce the drugs en masse. By 1957
century saw the development of "sedatives" to the psychiatric response was enthusiastic.
control problem patients. But it was not until Wards became quieter, "delusions" decreased,
the middle 1950s that drugs became a central and institutions ran more smoothly. Perhaps
part of psychiatric treatment. The impact of the most important, more patients were being dis-
new psychotropic drugs on psychiatry and men- charged from mental hospitals.
tal hospitals has been termed by medical histo- A new feeling of optimism permeated the
rians the third revolution in mental health. psychiatric world. Because of the dominant
(Pinel's contribution is considered the first; psy- "psychotherapeutic ideology," many psychia-
choanalysis, the second.) trists in the early 1950s embraced drug treat-
In France in 1952 a newly synthesized drug, ment because they believed with the aid of
chlorpromazine, was developed. It was the first medications, "now we can really do psycho-
of the psychotropic drugs: chemicals that exert therapy with the mentally ill." As one promi-
their principal effect on a person's mind, nent psychiatrist noted after reviewing the bene-
thought, or behavior. They did not sedate in the fits of chlorpromazine, "thus, many patients
traditional sense. These drugs, also called who had previously been inaccessible to psy-
phenothiazines or major tranquilizers, were chotherapy [could now be reached] " (Overhol-
considered antipsychotic drugs because they ser, 1956, p. 198; quoted in Swazey, 1974).
did not impair consciousness as did sedatives. Mental hospital staffs developed an increased
They enabled, to varying degrees, mad people medical orientation in their work. In fact, psy-
to function better. The popularity of the drugs chiatrist Jerome Frank (1974) suggests that the
took hold slowly but soon spread rapidly, first greatest effect of the drug revolution was on the
in Europe and then in the United States. staff and not the patients. The staff developed a
In May, 1954, the pharmaceutical corpora- more optimistic outlook and became more will-
tion Smith, Kline & French (SKF) introduced
* Within a year Thorazine increased the company's
chlorpromazine under the trade name Thorazine sales volume by a third; and Thorazine was a major
in the United States. It was aggressively mar- component of SKF's phenomenal financial growth,
keted by a special SKF task force of 50 sales- with net sales increasing from $53 million in 1953 to
people, who, armed with promising research re- $347 million in 1970 (Swazey, 1974, p. 161). Psy-
choactive drugs in general have been the most rapid-
ports and testimonies from psychiatrists, set out
ly expanding component of the drug industry'S
to convince state legislatures (who were respon- growth. The drug industry has been either the first or
sible for the then minimal drug budgets for state second most profitable industry in the United States
hospitals) and hospital administrators of the each of the past 25 years (Goddard, 1973).
62 DEVIANCE AND MEDICAL/ZATION: FROM BADNESS TO SICKNESS
ing to interact with the patients. Talk of truly Fig. 1 shows clearly the dramatic decline in
therapeutic rather than custodial hospitals was inpatient populations of county and state mental
legion. Within a decade, however, the no- hospitals since 1955. The inpatient population
tions of "really doing psychotherapy" were re- had dropped to about 174,000 by 1977. Many
placed by the reality that the dispensing of have pointed out that it was the introduction of
drugs, called chemotherapy, would itself be drugs, enabling patients to function better and
the major form of treatment for most patients. be discharged from hospitals, that was responsi-
There were some critics of drug treatment ble for this decline (e.g., Brill & Patton, 1957,
who argued that drugs only masked the symp- 1962). Some have suggested that social science
toms and did not treat causes; others suggested research on the negative effects of institutional-
they were "chemical straightjackets," merely ization (to be discussed shortly) played a sig-
pharmaceutical social control mechanisms. As nificant role. Sociologist Andrew Scull (1977a)
one recent critic points out, there are important argues that economic and fiscal reasons, that is,
differences between the purposes of medical the expense of state mental hospitals, were pre-
and psychiatric drug treatments: dominant factors. All probably contributed to
the decline, with the introduction of drugs be-
The purpose of medical treatment is to alter the struc- ing most significant. Whatever the explanation,
ture and function of the body to influence favorably
one fact is clear: mental hospital inpatient pop-
the course of a physical disease. The purpose of psy-
chiatric treatment is to alter mood, thought and be- ulations have declined steadily since 1955.
havior (Leifer, 1969, p. 44). There were other consequences of drug treat-
ment and the decline in inpatient populations.
The critics of drug treatments were a distinct Fewer wards were locked, and mental hospi-
minority, however, and the declining popula- tals became more open institutions. Milieu ther-
tions of mental hospitals relegated their critique apy was introduced. The emptying of hospitals
to gadfly status. discouraged the building of new ones, and some
By the mid-1950s the psychopharmacologi- even closed-14 state hospitals closed between
cal revolution in mental health had been pro- 1970 and 1973 (Scull, 1977a, p. 72). "After-
claimed. Psychiatrists could now act like "real care" services increased, since some patients
physicians" and dispense medications for men- were able to remain in the community "stabi-
tal ills. The drug treatment itself lent support to lized" on medication. Hospital stays were
beliefs that madness was an illness that could be shorter, but the number of readmissions in-
treated by drugs. A few even viewed it as a cure creased. As we will discuss later, the pharma-
for mental illness. Drugs qua medications cological revolution and the decline in inpatient
suited perfectly the rhetoric of medicine in the populations encouraged the development of a
treatment of madness. new social policy, "community mental
health."
Decline In mental hospital
populations Sociological research
Before 1955 public mental hospitals' popula- The 1950s was the beginning of a growing
tions had been steadily increasing and had sociological interest in mental health. Due part-
quadrupled in the previous half-century (Joint ly to an increased availability of funding from
Commission on Mental Illness and Health, NIMH and partly to the belief that social factors
1961, p. 7). Most mental hospitals were large, were significant, if unexplored, elements of
overcrowded, and custodial; a few, like Pilgrim madness, sociologists and social psychiatrists
State Hospital in New York, approached popu- began turning their attention to mental health
lations of 12,000. The total county and state problems. This research focused generally on
mental hospital population reached a peak in three subjects: the mental hospital, social epi-
1955, with over 558,000 patients residing in demiology, and identifying mental illness.
such public institutions. In 1956 this trend re- The mental hospital proved a fertile site for
versed itself. sociological research. Between the 1954 publi-
700
600
500
.,c
0;;-
.
0
:>
0
-=.. 400
'E
.!!!
0Il.
300
'ECII
.,.;;;
CII
a: 200
100
0
1900 1920 1940 1960 1980
Year
FIg. 1. Inpatient populations, state and county mental hospitals. (Courtesy U.s. Department of
Health, Education and Welfare, National Institute of Mental Health, Biometry Branch, Washington,
D.c.)
cation of The Mental Hospital by Alfred A. to, and that patients' responses were institution-
Stanton and Morris S. Schwartz and the 1964 alized. Perhaps the latter is most devastating:
publication of Psychiatric Ideologies and Insti- the hospital "institutionalized" patients to the
tutions by Anselm Strauss et at. more than a needs of the hospital organization, engendering
dozen studies of mental hospitals were con- patient responses and behavior that were useful
ducted (e.g., Belknap, 1956; Caudill, 1958; in adjusting to the institution but totally detri-
Dunham & Weinberg, 1960; Goffman, 1%1). mental to "getting well" or readjusting to the
Nearly all studies used participant observation, outside world. Goffman and others di~covered
with the sociological investigator acquiring that mental hospitals provided little "therapy"
first-hand knowledge of the operation and social and were dangerous to mental health. This
life of a mental hospital. The most renowned marked the beginning of a sociological critique
and influential of these is Erving Goffman's of the medical model of madness.
Asylums. Goffman (1961) spent a year as a par- Sociologists traditionally have pursued the
ticipant observer at St. Elizabeth's Hospital in positivist search for social causes of deviant be-
Washington, D.C., a public institution with havior. This has been particularly true in the
7000 patients. Goffman described in vivid de- sociological investigation of madness. The
tail the underlife of the institution and the social major method of study has been some type of
life of the inmates largely from their perspec- "social epidemiology" in which patterns of
tive. He saw the hospital as a "total institution" incidence and prevalence of mental illness in
and found a sharp division between patients and a population are described. These patterns are
staff, a hospital culture that the patient adapted then correlated with social factors (e.g., social
class, residence, migration, race, sex) that ap- cial class position did affect diagnosed mental
pear to affect the likelihood of mental illness. illness and the type of treatment rendered. Al-
In the 1930s Chicago sociologists Robert E. L. though this study was largely completed before
Faris and H. Warren Dunham (1939) published the advent of drug treatment, subsequent stud-
their classic, Mental Disorders in Urban Areas. ies (e.g., Dohrenwend & Dohrenwend, 1969)
Examining the "natural areas" of a city, they have supported many of its conclusions.
discovered the highest incidence rates of treated Most of the epidemiological studies focused
mental disorder to be in the central city. They on treated mental illness; it was a much more
hypothesized that urban life in the central city, complex research task to ascertain the amount
with its isolation and "social disorganization," of untreated mental problems. A group of so-
caused the higher rates of mental illness. Myer- cial scientists and psychiatrists devised a meth-
son (1941) suggested, in contrast, that perhaps od to ascertain the amount of untreated mental
the central city, with its array of rooming symptoms in what has come to be known as the
houses and its anonymity, attracted people who Midtown Manhattan Study (Srole et al., 1962).
were already having psychological difficulties. They interviewed a representative sample of
Two decades later social psychiatrist Alexander urban residents, using a questionnaire designed
Leighton and his colleagues, in a series of care- to elicit responses concerning behaviors and
ful and sophisticated studies (Leighton, A. H., experiences that psychiatrists might consider
1959; Leighton, D. C., et al., 1963; Hughes, symptoms of mental problems. Psychiatrists
C. C., et al., 1960) found higher rates of mental tht';n rated these questionnaires from zero (no
symptoms (as defined by psychiatrists) in com- significant symptoms) to six (incapacitating
munities that were more socially "disorga- symptoms). Those whose symptoms were rated
nized. " "marked," "severe," or "incapacitated," the
Among the most influential sociological re- three categories for the most symptoms, were
search on madness is Social Class and Mental called "impaired." They found a remarkably
Illness, a study by sociologist August Hollings- high 23.4% of their sample to be impaired,
head and psychiatrist Frederick Redlich. Hol- 58.1% had mild or moderate symptomatology,
lingshead and Redlich (1958) attempted to col- and 18.5% were considered well. This high rate
lect data on all treated cases of mental illness in of people who were "impaired," at least by
New Haven, Connecticut. They surveyed all psychiatric definitions, was used by some to
the clinics, hospitals, and private practitioners argue for more psychiatric case finding and
in the northeastern United States that might expanded treatment facilities.
have been used by New Haven residents. Each Another type of sociological research fo-
patient was classified as a member of a social cused on identifying and labeling people as
class (designated I through V, with I the high- mentally ill. Perhaps the best-known study in
est), based on residence, occupation, and in- this tradition is Thomas Scheff's Being Mental-
come. The principal finding was that social ly Ill, a major work in the labeling-interac-
class varied inversely with diagnosed mental tionist approach. Scheff (1966) based his re-
illness, that is, the lower the social class, the search on data gathered at a state mental hospi-
higher the rate of mental illness and vice versa. tal and developed a theory of becoming mental-
Hollingshead and Redlich also found that indi- ly ill. He was not so much interested in etiology
viduals in lower classes (IV and V) were more of behavior as in the social process by which
likely to be diagnosed as "psychotic," where- a person became defined as mentally ill. Scheff
as individuals in higher classes (I and II) were shifted the attention from the patient to the
diagnosed more commonly as "neurotic." Fur- defining social audiences (especially psychia-
thermore, lower class patients tended to receive trists) who frequently commit individuals to a
custodial care or somatic treatments, and higher mental hospital. He suggested that mental
class patients were more likely to receive psy- symptoms are "residual deviance" for which
chotherapy. Class V patients, the lowest social we have no other appropriate labels and that
class, had by far the longest periods of hospi- they arise from a wide variety of sources. He ar-
talization. In all, they concluded that one's so- gued that most deviant acts never come to the
attention of psychiatrists; but when they are has proposed that "mental illness is a myth,"
identified and come to psychiatric attention, involuntary commitment is persecution in the
they are labeled as mental illness and the indi- name of mental health, mental hospitals are
vidual is cast into the role of mental patient. prisons for social deviants, and we should be
When in doubt, according to Scheff, psychia- aware of the dangers of the therapeutic state.
trists are more likely to see and diagnose We have already discussed some of these argu-
"illness" than health. In this view the social ments. Szasz's position is essentially a laissez-
contingencies that lead to the labeling are more faire critique: people ought to be allowed to be-
important than the psychiatric symptoms them- have as they wish as long as they do not break
selves. Scheff suggests that most patients' be- the law; if they break the law, they should
haviors are interpreted on the assumption that be treated as criminals. Psychiatry, through
they are mentally ill (see Rosenhan, 1973), and the use of involuntary hospitalization, deprives
"appropriate" illness behaviors are reinforced. people of their liberty without due process of
The patient-physician encounter, then, places law. To justify this, psychiatry, specifically
the former in the role of mental patient. institutional psychiatry, has created the myth
"Chronic" mental patients are created by that the individual is suffering from an illness
labeling and mental hospital treatment. It is that needs treatment. Szasz suggests that peo-
difficult to return to conventional roles in the ple have "problems in living," not illnesses,
face of the master status, "ex-mental patient," and that if people voluntarily seek help from
and this stigma makes "normal" interpersonal psychiatrists, contractual psychotherapy may
relations and employment more difficult. be appropriate. But even then Szasz views
Scheff's work has been the subject of con- individuals as responsible for their behavior;
siderable sociological controversy (e.g., Gove, for him, psychotherapy is a "moral dialogue,"
1970, 1975b; Scheff, 1974). Certainly Scheff's not treatment for a sick mind.
theory only tells part of the story of madness. R. D. Laing's (1960, 1967; Laing and Ester-
But it is clear that his work has sensitized us to son, 1964) critique comes from a very different
the fact that it is a profoundly social process angle. Whereas his earlier work is really an
that defines, identifies, and labels behavior as extension of psychiatric theory, his later work
madness. is quite sociological in nature. Laing's main
Although research by the social epidemiol- focus is on the etiology of "schizophrenia."
ogists essentially accepted medical psychiatric For him madness does not reside within the per-
definitions and looked only for "social fac- son, but rather is a response to the life situation
tors" involved in mental illness causation, their in which a person finds himself. The source
findings served to modify the medical model. or cause of the madness is in the family com-
Work like Goffman's and Scheff's explicitly munication system; the mad person is a victim
challenged the medical model of madness. of an oppressive or "sick" family system in
which he or she must operate. Far from being
Psychiatric critique illogical or irrational, madness is understand-
In this chapter we have tended to view psy- able from the viewpoint of the victim. It may
chiatry as a single entity or, perhaps better, be the only possible response to what Laing
as a dual entity with a tension between socio- terms "a checkmate situation." In this way
psychological views and somatophysiological his theory is similar to Bateson's (1956), which
views. Beginning in the 1960s another view hypothesizes that schizophrenia is the result
developed that we might call the psychiatric of "double bind" problems in family com-
critique: psychiatrists who criticized psychiatry munications. Mad people, in Laing's view, are
and the nature of psychiatric work. The two not sick but different; if anything is "sick,"
foremost examples of this minority viewpoint, it is the environment or social system in which
although different in their critiques, are those of they live. The social system is what needs
Thomas Szasz and R. D. Laing. changing. Short of that, Laing's treatment is to
Thomas Szasz (1961, 1963, 1970, 1976), help people go through experiences of mad-
in a number of analytic and polemic pieces, ness so they can grow from them. His empha-
sis on the phenomenological experience of phasis should be placed on prevention; a na-

madness still further opens the dialogue with tional recruitment program for mental health
madness that Foucault suggests was closed personnel on all levels should be established;
with the dawn of the age of reason. Laing views more funds were needed for training and basic
mad people as victims who may have a good research; mental health expenditures should
deal to tell us about the "crazy" society in be doubled in 5 years and tripled in 10; and
which we live. one community mental health clinic should be
In a sense we can view Szasz as a psychiatric established for every 50,000 persons in the
critic from the right and Laing as one from the population. President Kennedy was receptive
left. For Szasz, individuals are responsible to the report, although in his February, 1963,
for their behavior; for Laing, they are victims of message to Congress and in the legislation he
an oppressive society. Both, however, reject supported, he emphasized the development of
the medical model assumption that madness comprehensive community mental health cen-
is a mental illness and argue that all deviating ters (CMHC). These centers would enable
human behavior is not caused by diseases, the mentally ill to be treated in their own com-
mental or otherwise. munities and returned quickly to a useful place
To sum up briefly, the psychopharmacologi- in society. Kennedy declared, "We need a new
cal revolution, the decline in mental hospital type of health facility, one which will return
populations, and the interest in social aspects mental health care to the mainstream of Amer-
of mental illness laid a foundation for what ican medicine" (quoted in Szasz, 1970, p.
appeared to be a major policy change, the de- 319). In October, 1963, Congress passed the
velopment in the 1960s of community mental Community Mental Health Centers Act, pro-
health centers. viding financing for construction of facilities;
a 1965 bill provided funds for staffing the
COMMUNITY MENTAL HEALTH: centers. This was to be a "bold, new ap-
A BOLD, NEW APPROACH proach" in psychiatry, emphasizing preven-
By 1955, just before the impact of the tion and treating the mentally ill swiftly and
pharmacological revolution, there was a grow- surely in their own communities.
ing governmental concern with the problem A number of social conditions made the
of mental illness. World War II had brought to 1960s ripe for the development of the com-
light a sizable number of individuals with munity mental health center and its professional
psychiatric problems, public mental hospitals counterpart, community psychiatry. The Amer-
were overcrowded and largely custodial, and ican economy was secure and appeared to be
there was some disillusionment with psycho- growing steadily. There was an incipient con-
therapy as inpatient treatment for mental ill- cern for the poor, and public "welfare" pro-
ness. Congress enacted the 1955 Mental Health grams could deliver a certain amount of "out-
Study Act, with an appropriation of more than door relief." Civil rights activism, and later
a million dollars, and established the Joint antiwar activity, was conducive to the de-
Commission on Mental Health and Illness. velopment of an activist psychiatry. There was
considerable frustration with traditional ap-
Federal action and professional proaches to treatment in mental hospitals.
growth Sociological and social psychiatric research
The Joint Commission on Mental Health had demonstrated the importance of social fac-
and Illness, which consisted of representatives tors in mental illness (although it is question-
from a variety of professional organizations, able whether they had any direct impact on
presented its final report, Action For Mental policy; see Roman, 1971). Drug treatment
Health, in 1961. This document made sweeping had led to a decline in hospital populations
recommendations: no mental hospital should and enabled some individuals to remain in
have more than 1()()() beds; treatment programs the community. President Kennedy had a per-
for the acutely ill should be expanded; an em- sonal concern for mental illness, and the notion
of the CMHC aligned well with his own no- welfare authorities, can improve the "moral
tions of "a new frontier." atmosphere" of homes with children of un-
There was some psychiatric enthusiasm for wed mothers by encouraging these women "to
the new policies. As sociologist Warren Dun- marry and provide them with stable fathers"
ham (1976) suggests, in the case of community (Caplan, G., 1964, p. 59). Needless to add,
psychiatry it appears that "ideas followed "improvement" in the moral atmospheres
money." That is, whatever enthusiasm existed is dependent on whose moral view one adopts.
in the psychiatric world, it was fueled by the Although Caplan and others who presented
availability of extensive federal funds. In the similar views were well intentioned in their
first 6 years, $477 million was appropriated proposals, a sociologist may find them prob-
for construction and staffing grants (Chu & lematic. Aside from the expansive notions of
Trotter, 1974, p. 26). The number of psychia- psychiatric work, which will be discussed
trists grew from 17,047 in 1964 to 22,701 shortly, there are problems with the concepts
in 1973. Increases of psychiatric nurses, social of primary and secondary prevention. In terms
workers, and paraprofessionals were greater of primary prevention, we do not presently have
still. By 1973, 540 CMHCs had been funded sufficient knowledge about the etiology of
and 400 were in operation (Robin & Wagen- mental illness behavior to know how to elim-
field, 1977). inate it (Roman, 1971, p. 385). Reports of
intervention attempts in the anthropological
CommunHy psychiatry literature are far from promising (e.g., Paul,
The professional arm of the "bold, new 1955; Spicer, 1952). Moreover, there are
approach" was community psychiatry. A significant ethical issues involved in promoting
somewhat vague and amorphous subspecialty certain forms of human behavior (e.g., mar-
in psychiatry, this was an attempt to tum psy- riage for unwed mothers) in the name of mental
chiatric knowledge and techniques to com- health. Secondary prevention, with its early
munity problems, with a goal of preventing identification, runs a substantial risk of "label-
or minimizing mental disorder. Gerald Caplan's ing" what may be transitory life problems
(1964) Principles of Preventive Psychiatry be- (Dohrenwend & Dohrenwend, 1969) and cast-
came the gospel of the community psychiatry ing the individual into the role of mental pa-
movement. Caplan, relying heavily on public tient, thus stabilizing the deviance (see Lemert,
health as a model, conceptualized psychiatry 1972). The risks and benefits need to be
as preventing mental illness on three levels. weighed carefully.
Primary prevention focused on eliminating the Some conceptions of community psychiatry
causes of mental illness in the community; were less encompassing and expansive than
secondary prevention was aimed at "early Caplan's. A number of psychiatrists viewed
identification" of and intervention against treating individuals in the community as a
mental problems; and tertiary prevention was viable alternative. Demonstration projects
treatment and rehabilitation efforts that at- established that for many, "home treatment"
tempted to prevent long-term incapacities. He could be an alternative to hospitalization
suggested that psychiatrists should anticipate (Weiner et aI., 1967). Researchers showed that
crises and intervene, providing "anticipatory nearly three quarters of diagnosed schizo-
guidance and emotional inoculation, which phrenics slated for hospital admission could
help [people] cope with threatening events" be maintained in the community with medica-
in such situations as prenatal clinics, surgical tion and regular visits from public health
wards, divorce courts, and colleges (Mechanic, nurses (Pasamanick et aI., 1967). Other psy-
1969, p. 100). Caplan envisioned psychiatrists chiatrists saw community psychiatry as a means
consulting with legislators and other admin- of delivering mental health care to poor and
istrators in an attempt to create a mentally indigent populations. Indeed, the concept of
healthy environment. He even suggests that community psychiatry included a range of
psychiatrists, with the aid of legislators and viewpoints, from inclusive notions of seeing the
community itself as patient to narrower views TABLE 1

of delivering services to poorly served popula- ADMISSIONS TO STATE AND
tions. In general, community psychiatry meant COUNTY MEDICAL HOSPITALS*
for psychiatrists a shift away from one-to-one
relations with patients to new roles as con- Total First
sultants and administrators. Year admissions admissions Readmissions
The major role for the community psy- 1975 385,237 120,690 232272
chiatrist has been administrator of the CMHC. 1969 367,963 163,984 173245
CMHCs are intended to be comprehensive 1957 205,041 128,124 64,823
mental health facilities serving a •• catchment 1947 130,872 93)49 29,643
area" of 75,000 to 200,000 people. They have 1938 106,220 79,408 21,085
an interdisciplinary staff, frequently including * From Statistical Abstracts 1940, 1950, 1960 and National
a contingent of nonprofessionals from the com- Institute of Mental Health, Biometry Branch, Washington,
munity (Sobey, 1970), and provide a range D.C.
of services typically including aftercare, home
visits, day and night hospitals, outpatient
treatment, short-term inpatient treatment, a "voluntary" status, and fewer are committed
•• crisis intervention," consultation to schools indefinitely. There has been a continued rise
and other agencies, and the coordination of a in the number of admissions, but the number of
"continuity of care" for their patients. CMHCs readmissions has skyrocketed (Table I).
almost always are related to mental hospitals The statistics, however, do not tell the whole
and not infrequently located on the mental hos- story. Most mental hospitals have developed a
pital grounds. The hospitals themselves have "revolving door" policy, with patients ad-
endeavored to develop more "therapeutic" mitted for shorter but more frequent stays. In
environments, mainly through the adoption of addition, the psychiatric ward in the general
"milieu therapy." Milieu therapy, adapted hospital (a community psychiatry innovation)
from Maxwell Jones' (1953) work on thera- often treats the most "acute" difficulties, and
peutic communities, can be viewed as a return thus many patients never become state hospital
to a type of "moral treatment" for madness. statistics. Furthermore, many "chronic" pa-
It is an attempt to construct a therapeutic en- tients simply have been transferred to custodial
vironment for recovery, including combining nursing homes, rather than becoming well-
male and female wards, doing away with uni- functioning members of the community. More-
forms, and instituting patient government, over, there is increasing evidence that released
ward meetings, therapeutic teams, individual patients go "from back wards to back alleys,"
attention, group therapy, and patient involve- living meager existences in welfare hotels and
ment in the treatment process. Such innova- receiving little continuity of care (Chu & Trot-
tions, although they have-certainly humanized ter, 1974; Kirk & Therrien, 1975). Although
the mental hospital (Cumming & Cumming, more people are remaining in the community,
1966), have not been particularly effective in the question increasingly becomes, "Under
"curing" or even rehabilitating many long- what conditions?"
term mental patients. In some hospitals, how- Overall, community psychiatry has had
ever, there appears to have been little impact mixed results. More individuals are receiving
of community psychiatry, and custodial care treatment in outpatient facilities and fewer are
remains the rule (Fowlkes, 1975). becoming' 'institutionalized," a few previously
A major goal of community psychiatry has unserved populations are being served, some
been to place as many patients as possible reforms have taken hold in mental hospitals,
"in the community." Increased efforts at hospitalization is shorter, and tile team ap-
"decarceration" have intensified the trend proach has included more nonpsychiatrists
of decreasing mental hospital populations in treatment programs. But psychiatrists, per-
(Scull, 1977a). More patients are admitted on haps fortunately, have not treated communi-
ties; there has been no apparent success in pital. Such organizational ties made a break
preventing mental illness; difficulties have been from the past extremely difficult.
encountered in continuity of care; patients have Most significant to our discussion, however,
been "dumped" from mental hospitals without is that community psychiatry actually ex-
the availability of appropriate alternatives; panded the medical model of human problems
and rehabilitation has been minimal (Kirk & and the jurisdiction of psychiatry. Dunham
Therrien, 1975). Furthermore, community psy- (1976) calls it "the widening definition of
chiatry has still other consequences. mental illness." The domain of community
psychiatry includes not only traditional mental
Community psychiatry and illness conceptions, but alcoholism, drug ad-
the medical model diction, children's school and behavior prob-
Community psychiatry represents an attempt lems, predelinquency, bad marriages, job
by psychiatry to break from the past and orig- losses, and aging. Virtually any human prob-
inate a bold, new approach. Unfortunately, lem could be addressed by community psy-
such breaks are frequently limited by "ideolog- chiatry and, for the most part, through the lens
ical barriers" (Ryan, 1971b) and existing pat- of the medical model. Psychiatric "case find-
terns of organization. ing," a search for those in need of psychiatric
Community psychiatry never relinquished services, is a poignant example:
the medical model of mental disorder. For ex-
ample, the psychiatric focus on the individual The search for "hidden" deviants reflects the
dominance of the medical model in psychiatry-
remained evident. Patients were still considered
namely, the notion that "pathologies" are inde-
to suffer from diseases, qualitatively different pendent of social norms and can be located by epi-
from everyday problems in living, and were demiological methods. A consequence of such pro-
still "treated" under the aegis of a medical cedures may be a large increase in the proportion of
practitioner who typically was director of the the population regarded by psychiatry as "mentally
CMHC. Although some research prior to ill." (Roman, 1971, p. 384)*
"community psychiatry" showed that accep-
tance of the medical model among psychiatrists In short, community psychiatry has broadened
varied so that they ranged along a continuum the concept of mental illness and expanded the
from somatically oriented to socially oriented domain of psychiatric intervention in human
community psychiatrists (Strauss, A., et aI., problems.
1964), research after the launching of the com- One final point: some social scientists (Ken-
munity psychiatry movement showed that psy- niston, 1968; Leifer, 1966; Manning & Zucker,
chiatrists still tended to favor an organic or 1976, pp. 61-62) have pointed out the sociaf
individualistic model, rather than a commu- control aspects of community psychiatry. By
nity model (Rogow, 1970). This is not surpris- defining more people in the jurisdiction of
ing, given the individual orientation of medical psychiatry and providing treatment for these
education and medical practice and the history deviants, psychiatry plays an increased and
of psychiatry. active role in the maintenance of the social
Small organizational changes were made, es- order.
pecially the training and use of nonprofession- As we have seen throughout this chapter,
als, but much of the previous organization most reform movements in mental health begin
remained. Because of the psychiatric dom- with a high optimism that is eventually institu-
inance of the CMHC, the medical model of tionalized into business as usual. Largely be-
service and treatment still predominated. Some cause of fiscal constraints and an inability to
of the nonprofessionals had been long-time
aides in mental hospitals and maintained the *Copyright © 1971 by The William Alanson White
Psychiatric Foundation, Inc. Reprinted by special
institutional viewpoint. Many of the CMHCs permission of The William Alanson White Psychiat-
were physically tied to the past, since they ric Foundation, Inc., from Psychiatry (1971) 34:
operated in the shadows of the old state hos- 378-390.
fulfill its early and probably excessive expecta- parkinsonian-like syndrome that leads to loss
tions, community psychiatry as a social move- of muscular control.) There is also a resurgent
ment lost some of its vigor by the mid-1970s. interest in psychosurgery, although not yet with
mental patients (Chavkin, 1976).
MEDICAL MODEL OF One of the most interesting recent events
MADNESS IN THE 19705 concerning mental illness is the 1975 Supreme
This is still the era of community mental Court decision 0' Connor v. Donaldson. Ken-
health centers, but there are changes occurring neth Donaldson (1976) was involuntarily com-
in psychiatry and most especially in the medical mitted to a Florida state mental hospital in
model of madness. 1957 at age 49. He was never considered to
We have noted a general shift away from the be dangerous. For more than a decade he
1960s' concern with searching society or the repeatedly and unsuccessfully tried to secure his
community for the causes of madness back to own release, particularly through court action.
a focus on the individual. In actuality commu- In 1971, after nearly 15 years of custodial care,
nity psychiatry never strayed far from the indi- he was released. Donaldson sued for damages
vidual, medical model orientation, but the for being involuntarily confined without treat-
1970s brought a new concern for individual, ment. A lower court awarded him $38,500 in
especially organic, explanations and treatments compensatory and punitive damages. The case
of madness. The reasons for this reorientation was appealed through the judicial system to the
are complex; it can be explained in part by such Supreme Court. Some supporters had hoped
factors as a recession-prone economy that for a ruling that would state that confined pa-
contributed to the curtailing of numerous pro- tients have "a right to treatment." The Su-
grams, the waning optimism after a decade preme Court's opinion, however, was nar-
of community psychiatry, a backlash to the rower; nondangerous patients who are capable
politicization of the 1960s, and a professional of surviving outside the institution cannot be
attempt to "reintegrate" psychiatry into the confined against their will without some treat-
mainstream of medicine. ment. Justice Potter Stewart wrote: "The mere
There has been a renewed emphasis on presence of mental illness does not disqualify a
biological and organic models of madness. person from preferring his home to the com-
Biomedical research, especially in the areas of forts of the institution."
genetics and biochemistry, is capable of mea- The Court did not decide whether a non-
suring increasingly subtle variations between dangerous, mentally ill person could be con-
the mentally ill and others. Genetics in par- fined for the purpose of treatment or whether
ticular has captured the imagination of psy- mentally ill persons not considered dangerous
chiatrists. Many psychiatrists are increasingly to themselves or others have a right to treat-
convinced of some type of genetic component ment (Miller, K. S., 1976). Although the Court
in manic depression (Rainer, 1974) but are implicitly reaffirmed the medical designation
somewhat more equivocal about schizophrenia of mental illness, it limited what psychiatrists
(Rosenthal, 1974). Most believe that genetic and others could do about it against a person's
predisposition is a necessary but not sufficient will. Some feared the decision would lead
condition for the onset of madness. The use of fiscally pressed institutions to "dump" thou-
lithium carbonate, a naturally occurring com- sands of patients. Others acclaimed it as finally
pound, in controlling the severe mood swings giving mad people some rights.
of manic depression has reinforced biomedical The psychiatric profession has expressed
conceptions of madness (Fieve, 1970). Drug concern over the abuse of the mental illness
treatment is still psychiatry's most potent de- designation for political ends, especially in the
vice for making a short-term impact on mad- Soviet Union. Considerable evidence has ac-
ness. (It has been discovered that long-term cumulated showing that some Soviet political
usage of phenothiazine drugs can produce iatro- dissidents, who are sane by Western psychiatric
genic effects such as "tardive dyskinesia," a standards, have been declared mentally ill and
committed to mental hospitals. This medical- roots are found in Hippocratic medicine of
ization of dissent serves certain functions for classical Greece, although there were com-
the Soviet state. It permits swift commitment peting conceptions of the reality of madness
of dissidents without a trial, depoliticizes their among the Greeks. During the medieval period
dissent by declaring it ravings of madness, medical conceptions were subordinate and had
and allows for a retraction of statements to to accommodate the dogma of the Church.
be a sign of a "cure." American psychiatrists Medical conceptions of madness begin to re-
have decried this as an abuse of psychiatry and emerge partly as a response to the excesses of
a form of psychiatric repression. The Soviet witchcraft and the decline of the church.
example is an extreme instance of psychiatry Deviants were first confined in the 17th cen-
as an agent of social control and an explicitly tury, establishing the institutionalization of the
political use of the mental illness designation. mad. Physicians entered the institution not as
It nevertheless underlines the inherent vague- healers but as guardians or wisemen. Medicine,
ness and malleability of the mental illness con- symbolized by Pinel, was a humanitarian re-
cept and the potential, if not yet realized, use form in the treatment of madness. Psychiatrists
of psychiatry for political ends (Conrad, 1977). or medical psychologists did not have any
One final note about mental illness in the theories or treatments of madness that would
1970s. It seems likely that some form of Na- have made madness ipso facto a medical prob-
tional Health Insurance (NHI) will be enacted lem. The "capturing" of madness by the med-
within the next few years. NHI will probably ical profession was a social and political
be a type of expansion of Medicare and Medi- achievement rather than a scientific one.
caid to the popUlation not covered by these In 19th-century America, the medical super-
programs, providing payment for many medical intendents of asylums organized, and with
services. Treatment for mental illness will be the aid of champions like Dorothea Dix, cre-
included. It is an interesting question how NHI ated a virtual monopoly over the treatment of
will affect the medical model of madness. Two madness. In the early days they were highly
general possibilities exist. It may, because optimistic about the asylum cure, the American
payment for service is available for "medical" version of moral treatment, and scores of asy-
problems, expand the medical model of mental lums were built. By the 1850s social pressures
illness to include previously nonmedical prob- and therapeutic disappointments resulted in
lems. This would enlarge the psychiatric custodial care in the asylums. At the dawn
domain and medicalize nearly everything. On of the 20th century the medical profession had
the other hand, it may, primarily because of fis- a firm dominance over the conception and
cal constraints, encourage the adoption of a treatment of madness yet possessed no' 'success-
narrow traditional definition of mental illness ful' , medical treatment and no evidence of
including only schizophrenia, manic depres- organic causes of madness.
sion, and similar disorders. The economic sit- In the early 20th century the discovery of
uation and the spirit of Congress make the latter general paresis reinforced medical conceptions
perhaps a more likely possibility. of madness and gave rise to a hope that the
Overall, in the 1970s, individualistic solu- organic causes of all mental illness would be
tions to human problems abound (Schur, 1976). similarly discovered. The wide acceptance of
In mental health this has led to an increased Freudian ideas in the first half of this century
interest in technology-be it drugs, genetics, both muted and expanded the medical model of
or behavior technology (behavior modification) madness. A psychogepic model was grafted
-and an intensified emphasis on the medical onto the medical model. In the 1930s, with the
model of madness. advent of shock therapy, lobotomies, and ge-
netic theories, somatic conceptions of madness
SUMMARY reemerged. By the 1950s, partly through efforts
The development of the medical model of of the mental hygiene movement, public atti-
madness spans a period of 2000 years. The tudes toward mental illness changed in the di-
rection of medical ones. The public, however, long before there was any evidence that mad-
still maintained a narrower view of what con- ness had any biophysiological components
stitutes mental illness. The 1954 Durham deci- (and this is still controversial in some circles),
sion institutionalized the psychiatric concept and before any medical treatments, other than
of madness into the judicial process. the nonmedical moral treatment, made any
In 1955, because of the introduction of impact on madness. The development of the
phenothiazine drugs, mental hospital popula- medical model of madness was a social and
tions began to decline. The diffusion of drug political rather than a scientific achievement.
treatments aligned well with medical concepts
of madness, since psychiatrists could now give SUGGESTED READINGS
medications for the "illness. " The drug Alexander, F. G. and Selesnick, S. T. A history of
revolution, the declining hospital populations, psychiatry. New York: New American Library,
1966.
and an increased interest in the social aspects A comprehensive and well-written history by
of madness preceded a major change in social two psychoanalysts. They emphasize theories
policy: the development of community mental and therapies, not historic events. Written from
health centers. The community mental health the perspective of the development of modern
movement, and its professional arm, commun- psychiatry .
Foucault, M. Madness and civilization. New York:
ity psychiatry, were an attempt to turn psychiat- Random House, Inc., 1965.
ric concepts to community problems. Although An interpretive structuralist analysis that traces
community psychiatry encompassed a range of the conceptions and treatments of madness from
opinions, in its extreme forms it was the psy- 1500 to 1800. Foucault argues we broke the dia-
chiatricization of everything. The 1970s have logue with madness with the dawn of the age of
reason. It is difficult but fascinating reading.
seen somewhat of a decline in interest in com- Goffman, E. Asylums. New York: Anchor Press,
munity psychiatry and a resurgence of organic 1961.
and biomedical theories of madness. A classic sociological study based on participant
There are a few recurrent themes in our his- observation in a mental hospital. A precursor to
tory of the medical concept of madness. the labeling-interactionist tradition, Goffman de-
velops his conceptions of the moral careers of
Medical theories have located the source of mental patients, total institutions, and psychiatry
madness in a variety of somatic organs: the as a tinkering trade.
humors, the stomach, the nervous system, the Rothman, D. The discovery of the asylum. Boston:
brain. Every era seems to have its own reform Little, Brown & Co., 1971.
movements that lead to an increased optimism, An award-winning social history of the develop-
ment of institutionalization in 19th-century Amer-
which several years later, after the move- ica. Rothman analyzes the emergence of the
ments fail to live up to their promise, reverts asylum as a response to the changing social order
to a pessimistic view of madness. This has in the Jacksonian period.
often taken the form of a •• somatic pessimism," Szasz, T. The manufacture of madness. New York:
locating the causes of madness in the physiol- Harper & Row, Publishers, 1970.
A controversial and provocative analysis of the
ogy (e.g., the degeneration hypothesis). Med- emergence of institutional psychiatry from the In-
ical involvement with madness, historically quisition and mental illness from witchcraft. Al-
speaking, emerges more as a humanitarian re- though more polemical than analytic, Szasz's
form than as a biomedical accomplishment. arguments are seminal to the medicalization of
It is worth repeating that medical concepts deviance.
became the dominant conceptions of madness
4 ALCOHOLISM
DRUNKENNESS, INEBRIETY, and the
DISEASE CONCEPT
I n this chapter we discuss the origins and

rise of the idea that repeated alcohol in-
toxication should be thought of as a sick-
ness rather than a sin or crime. In contrast to
(p. 495)," then it may become a legitimate
topic for medical study and intervention. The
fact that one must put a chemical substance-
and one that has been defined as •'psychoac-
the case of mental illness discussed in the pre- tive" -inside one's body as a prerequisite to
vious chapter, the rise for the disease concept of deviant drinking immediately established med-
alcoholism illustrates that the process of collec- icine as having at least a prima facie interest
tive medical definition need not necessarily be and jurisdiction over the causes, consequences,
sustained primarily by medical personnel. The and control of such conduct. This jurisdiction
historical development of medical definitions of over the physiology of alcohol is what we call
deviant drinking involves powerful nonmedical the uncontested medical model of alcohol. By
groups, individuals, and organizations whose uncontested we mean that a political status quo
moral, political, status, and/or professional based on medical definitions and interventions
interests were served by such definitional has been achieved and is supported as legitimate
change. Although physicians were not hapless by most parties involved.
bystanders in this process, they were not the For example, no one argues about who
leading crusaders. should have the legitimate jurisdiction over the
definition and treatment of the symptoms of
PHYSIOLOGY OF ALCOHOL: acute intoxication or alcohol poisoning or of the
UNCONTESTED APPLICATIONS physiological consequences of chronic heavy
OF THE MEDICAL MODEL drinking, (e.g., physical withdrawal symptoms,
Unlike mental illness, the medicalization malnutrition, liver disease). These are identified
of deviant drinking behavior and opiate use, typically as the physiological, pharmacologi-
discussed in Chapter 5, rests importantly on cal, or medical consequences of such drinking
a long-established legitimate medical presence. (Butz, 1977; Greenberg, 1958; Lieber, 1976;
An absolutely necessary condition of deviant Seixas et al., 1975; U.S. Department of Health,
drinking is drinking itself. Before one can be- Education and Welfare, 1978). This has
come a "drunkard," "inebriate," or "alco- been called the "drug centered" perspec-
holic," one somehow has to get the substance tive on drinking, and it has influenced most
("chemical") alcohol into one's blood. This conventional as well as scientific work (Mac-
condition sets deviant drinking and opiate use Andrew & Edgerton, 1969; Young, Jock,
apart from all the other cases we discuss in 1971).
this book. That this bears great significance for The goal of medical treatment for such con-
a legitimate medical presence around "drink- ditions is detoxification-regardless of whether
ing behavior" becomes obvious when one re- for the acutely or chronically intoxicated and
calls Irving Zola's (1972) remark: "If any- whether it occurs in a general hospital or alco-
thing can be shown ... to effect the inner work- hol treatment center. Detoxification aims at
ings of the body and to a lesser extent the mind mollifying the toxic effects of alcohol on the
73
body. Abstinence is the first and most easily of alcohol when it is in effect. This treatment
achieved step under such controlled conditions. is premised on the behaviorist assumption that
Depending on the severity of the intoxication, drinking under such circumstances will be-
various heroic measures may be instituted if come associated with the negative experience
permanent damage or death appears imminent. of nausea and gradually will be extinguished
Short of such interventions, there is actually (see Chapter 8).
little that can be done to reverse the intoxicat- Contributing to the consensus that these are
ing effects of alcohol, except to allow the liver indeed "medical problems" is the fact that, in
to metabolize or remove the alcohol from the general, such treatments and interventions for
body. intoxication and its effects have "worked"-
For the chronically intoxicated, the next step physicians have been successful in solving or
involves attention to the symptoms of alcohol at least alleviating the problems of intoxication,
withdrawal. The medical concept of physical physical withdrawal, and the pathological con-
dependence on alcohol suggests that alcohol ditions associated with long-term heavy drink-
has become an integral part of body physiology, ing. The fact that this uncontested jurisdiction
that the body has adapted to a particular level of is nonetheless political should not be forgotten.
alcohol as a "normal" part of its operation. That is, physicians both have been given and
When alcohol is removed from the system, have taken control over these problems as part
then, physical symptoms ensue in reaction to of their expert "turf."
its absence as a kind of physiological trauma From time to time, medical-scientific con-
caused by the sudden change. For those whose troversies arise within this generally uncon-
bodies have become accustomed to alcohol, tested jurisdiction that serve to remind us that
several hours are usually required for these such control is indeed political. One of the most
symptoms to subside. They include moderate- recent examples is the medical-scientific de-
to-violent tremors or shaking, anxiety, nausea, bate surrounding what is called fetal alcohol
convulsions, hallucinations, and in the most syndrome (FAS), or the effects of alcohol con-
extreme form, delirium tremens. Severe alcohol sumption by pregnant women on the developing
withdrawal can be fatal if the individual does fetus. Such contests also remind us of Thomas
not receive medical attention. Medical treat- Kuhn's (1970) insights on the importance of
ments at this stage include anticonvulsant and politics and ideology in scientific work in gen-
sedative drugs to reduce stress, vitamin supple- eral. The fact that lay persons as well as
ments, rest, and supportive care. scientists consider the conditions we have
Once medical control of these short-term discussed to be "obvious" medical problems
effects of severe intoxication is achieved, a means only that such a view has become part
variety of less heroic treatments designed to of the taken-for-granted wisdom of alcohol.
retard or alleviate the more long-term effects Such "commonsense" wisdom is in large part
of drinking are used. In addition to attention due to the great influence of the natural science,
to problems involving gastrointestinal, car- drug-centered, pharmacological paradigm used
diac, and neurological complications, treat- to "make sense" of what alcohol is and what
ment at this stage often involves psychotherapy, it does to us when we drink it. Although the
including both individual and- group arrange- science of the physiology of alcohol may offer
ments, use of the so-called therapeutic com- us interesting political questions to pursue, our
munity, "reality therapy," and various be- interest in the medicalization of deviant drink-
haviorist techniques. The drug disulfiram, ing behavior directs our attention to the ques-
known commonly as Antabuse, is often used tion of the effects of alcohol on social con-
in conjunction with such treatment. Antabuse duct, or how people behave when they drink.
is given typically to outpatient drinkers when It is this question of alcohol's effects on be-
they are sober. The drug has no noticeable ef- havior that provides the arena in which the
fect when taken but produces extreme nausea contested application of the medical model
should the individual drink even a small amount may be defined more clearly.
ALCOHOLISM: DRUNKENNESS, INEBRIETY, AND THE DISEASE CONCEPT 75
ALCOHOL AND BEHAVIOR: from drinking. Aside from motivation, station

tHE QUESTION OF CONTROL in life, or cultural surroundings, it is believed
AND THE BEGINNING OF CONTEST that alcohol, as a result of its chemical action,
The consensus of the uncontested medical removes one's inhibitions and lessens the de-
model of alcohol begins to dissolve when at- gree of control over behavior. Such conduct is
tention shifts from internal and phannacologic assumed virtually always to be socially undesir-
processes to social conduct. By contested able and potentially disruptive-to be, in short,
medical model we mean that the question of at least rule-breaking and probably deviant
"turf," or jurisdiction, has not been settled behavior. This deviation is believed caused
with any general degree of consensus and that by the drug's indirect and "depressing" ef-
political negotiation continues about whether feet on the brain, which is generally consid-
and to what extent deviant drinking should ered to be the physiological seat of the
be defined and treated as a medical problem. self.
At the risk of oversimplification, we argue that People, if they drink "enough," are thought
the core proposition of these contested medical to say and do things they would "not nor-
definitions of alcohol use is that drinking, if mally" say and do. When "under the in-
done in sufficient quantity and under certain fluence" of alcohol, we are not considered
circumstances, causes people in varying de- to be our "true" selves. The deviant behavior
grees to "lose control" over their behavior. associated with such drinking is described
This is believed to occur either because of typically as irrational, bizarre, sometimes anti-
the inherently disinhibiting qualities of the drug social, and primitive, as a working out of some
itself or because certain people who drink have presumed essential and ever-present biological
some genetic or acquired vulnerability to alco- imperative-something that society, for the
hol that predisposes them to lose control over most part, effectively contains through a variety
drinking, once begun. The first explanation of social controls. This view of drug taking
is often called the "disinhibitor hypothesis" is what Jock Young (1971, pp. 59-60) has
and assumes a universal human vulnerability called the "absolutist monolith" and is an
to alcohol's effects; the second explanation extension of the uncontested, physiological-
is premised on the existence of some biophysio- phannacological view of alcohol into the
logical flaw in the individual that, when com- realm of behavior. Just as the internal "laws"
bined with alcohol, produces the disease of in- of bodily metabolism regulate the rate at which
ebriety, or alcoholism. This chapter is con- alcohol is decomposed into its parts, this view
cerned primarily with the origins and develop- assumes that the drug has similar universal ef-
ment of this latter idea, but the influence of the fects on the drinker's behavior. It assumes that
disinhibitor proposition has been so widespread social and cultural context are by and large ir-
in conventional thinking about the effects of relevant in understanding what happens to us
drinking that we must first discuss it briefly and when we drink.
the criticisms launched against it. In addition, The popUlarity of the disinhibitor hypothesis,
since it specifically links deviant behavior with however, predates the rise of the science of
drinking, the disinhibitor hypothesis serves to physiology itself. It has long been part of "what
reinforce the medicalization of deviant drinking everybody knows" about alcohol-influenced
itself. behavior. Deviant drinking, in other words, is
as old as drinking itself. T. D. Crothers (1903),
DlslnhlbHor hypothesis for example, suggests that as early as 2000 BC
Conventional lay and scientific wisdom, the Egyptian government proposed regulations
backed by centuries of tradition (but not banning drinking among soldiers, who were
necessarily rigorous evidence), holds that made ineffective by intoxication. In the famed
because of the physiology and phannacology of legal code of Hammurabi, dating from about
alcohol in the body, certain highly predictable 1800 BC, we find detailed restrictions on the
behavioral consequences follow inevitably sale, pricing, and use of alcoholic drink (Har-
per, 1904). In the 83rd letter of the Roman the antisocial consequences caused by its re-
lawyer-philosopher Seneca (1942), who lived moval of social and cultural restraints.
in the first century AD, we find a distinction be- Although the disinhibitor hypothesis-in a
tween "one who is drunk" and a "drunkard": variety of forms-has been popular in virtually
"in [one] case ... the man who is loaded with all ages and centuries, it has become part of
wine and has no control over himself; in the scientific wisdom only since the rise of the
other, of a man who is accustomed to get drunk, science of physiology and the growth of physio-
and is a slave to the habit" (p. 304). This is logical research in the second quarter of the
perhaps the earliest succinct distinction be- 20th century. One of the most influential and
tween one who has "lost control" of behavior prestigious proponents during this period was
as a result of intoxication and one who has' 'lost Leon Greenberg, a leading physiologist of
control" because of what came to be called alcohol. The following statement by Green-
"alcohol addiction." We will have consider- berg (1953) received wide currency in the
ably more to say about the latter in the rest of United States as an absolutely factual descrip-
this chapter. tion of what happens to our behavior when
In what may well be one of the most colorful we drink:
statements of the disinhibitor hypothesis,
The most pronounced physiological effect of alcohol
Seneca (1942) in this same letter counsels is on the brain .... A blood concentration of about
"good men" against drink: .05 percent of alcohol ... depresses the uppermost
How much better it is to arraign drunkenness frankly levels of the brain-the center of inhibitions, re-
and expose its vices! ... if you wish to prove that straint and judgment. At this stage the drinker feels
a good man ought not to get drunk, why work it that he is sitting on top of the world; he is "a free
out by logic? . . . Show how often the drunkard human being"; many of his normal inhibitions van-
does things which make him blush when he is sober; ish; he takes personal and social liberties as the im-
state that drunkenness is nothing but a condition pulse prompts; he is long-winded and can lick any-
of insanity purposively assumed. Drunkenness body in the country .... Contrary to old and popular
kindles and discloses every kind of vice, and re- belief, alcohol does not stimulate the nervous sys-
moves the sense of shame that veils our evil under- tem. The illusion of stimulation results from the
takings .... When the strength of wine has become removal of inhibitions and restraints. (p. 88)
too great and has gained control over the mind, every Finally, Marvin Block, a physician who has
lurking evil comes forth from its hiding-place.
been called "perhaps the American Medical
Drunkenness does not create vice, it merely brings it
Association's leading spokesman on alcohol-
into view; at such times the lustful man does not
wait even for the privacy of a bedroom, but without ism" (MacAndrew & Edgerton, 1969), writes
postponement gives free play to the demands of of the dis inhibiting effect of alcohol in words
his passions; at such times the unchaste man pro- that parallel those of Seneca almost 2000 years
claims and publishes his malady; at such times your earlier. Block (1965) writes:
cross-grained fellow does not restrain his tongue
Since alcohol depresses the powers of judgment,
or his hand. The haughty man increases his arro-
drinking may release inhibitions .... As far as sexual
gance, the ruthless man his cruelty, the slanderer behavior is concerned, it is well-known that alcohol
his spitefulness. Every vice is given free play and reduces the inhibitions of individuals and removes
comes to the front. Besides, we forget who we
the controls. The individual becomes careless and
are . ... (p. 306, emphasis added)*
will often do things under the influence of alcohol
Here we have the unmistakable image of the that he would not do if his judgment were not im-
powerful drug's triumph over the drinker and paired. Therefore, impairment of the judgment by
alcohol may cause sexual behavior that would
not occur were he not exposed to the loss of control
that alcohol brings about. (pp. 219-220)
* Reprinted by permission from Quarterly Journal of
Studies on Alcohol. Vol. 3, pp. 302-307, 1942, Given the commonsense and later profession-
Copyright by Journal of Studies on Alcohol, Inc., al support of the disinhibitor hypothesis, it is
New Brunswick, N.J. 08903. not surprising that challenges have been rather
late in coming. Interestingly, these challenges Sociologist Jacqueline Wiseman (1979) recent-
have come most effectively from social scien- ly has taken this analysis further, arguing that
tists who have taken this connection between among chronic heavy drinkers. even being sober
drink and behavior not as revealed truth but is a carefully orchestrated kind of intentional
rather as itself a problem for study. Among the rather than "natural" comportment.
most effective critics have been Alfred Linde- This social science criticism can be upheld
smith (1947, 1968), Howard Becker (1953, by even the most casual review of our own
1967a), Craig MacAndrew and Robert Edger- experience. It is clear that drinking alcohol is
ton (1969), and Jock Young (1971). We will not followed by the same behavior in all peo-
return to this work in our discussion of addic- ple-even among those from similar social and
tion later in this chapter, but we may summarize cultural situations. It is simply not true that al-
their critique as follows. Although the pharma- cohol, even in significant quantities, necessar-
cological-physiological model of alcohol may ily and inevitably "causes" drinkers to "lose
tell us something about the effects of alcohol control" over their behavior. In the face of such
inside the body, it produces faulty conclusions variety, and particularly considering the appar-
when applied uncritically to drinking (or drug- ent inability of some people to "hold their
taking) behavior. The major problem stems liquor," a new kind of explanation for drunken-
from what it ignores-the entire cultural and ness becomes necessary. Such an explanation,
social realm of meaning and definition. Es- unlike the drug-centered, disinhibitor hypothe-
chewing a simplistic chemical determinism, sis, centers only on those individuals out of all
these social science critics insist that the who drink alcohol (the majority of Americans
effects of drugs on social conduct cannot be report that they do drink some alcohol, but the
understood adequately without considering the majority are clearly not deviant drinkers [Ca-
questions of, for example, what "drink" halan, 1970]) who appear to "lose control"
means, how drinking is defined, social expec- both over their ability to regulate drinking and
tations for "drinking" and even "drunken" other conduct as well. The problem, then, be-
behavior, and the appropriate times and places comes one that appears to lie at the intersection
for such conduct. Short of the obviously limit- of the drug alcohol and the individual drinker.
ing conditions of unconsciousness and death Given the constant nature of the former and the
brought on by a high concentration of alcohol variable nature of the latter, attention is focused
in the blood, a complex set of social meanings particularly on the individual as one who is
influences drinking behavior. Anthropologists, somehow constitutionally susceptible to the ef-
in particular, have provided us with data that fects of alcohol.
demonstrate this in the cross-cultural variety To the extent that such "susceptible" drink-
of the impact of alcoholic beverages on beers seem impervious to emotional, rational, and
havior (see Cahalan et al., 1969; Everett et aI., even scientific appeal. we have a "puzzle" that
1976, Lemert, 1969; MacAndrew & Edgerton, invites solution (MacAndrew, 1969). If. there
1969). MacAndrew and Edgerton (1969, pp. are those "who can't hold their liquor" (Mac-
13-82) have addressed this question of the so- Andrew & Edgerton, 1969, pp. 13-36), there
cially constructed and interpreted nature of are, by implication, those who can. As religion
drinking behavior. They reject the pharmaco- was gradually replaced by science, and in
logical-physiological imperative of the disin- particular medical science, as the arbiter of
hibitor hypothesis as itself an inadequate expla- personal problems, the search was begun to dis-
nation of such conduct and suggest instead the cover how deviant drinkers differ from the
concept of "drunken comportment" -that "normal" drinking population. Deviant drink-
" drunken behavior is a complex combination of ers were no longer seen as possessed by threat-
physiological effects and individual interpreta- ening spiritual forms but by threatening med-
tions of these effects in light of cultural and ical ones; the behavior became evidence of
social contexts; that, in short, drunkenness is in disease rather than of sin or willful malice.
important respects intentional social conduct. For almost 200 years individuals who evi-
dence patterns of chronic and highly disruptive it was a clerical admonition, followed by more
intoxication have been identified by medical extreme sanctions such as suspension and,
labels. This is the history of the medicalization finally, excommunication as the ultimate, al-
of deviant drinking and the rise of the disease though probably infrequently used, religious
concept of alcoholism. With its rise has come a control. Civil authorities affirmed the church's
clear example of the political rather than scien- judgment and meted out various forms of public
tific contest that medicalization represents. It degradation, fines, ostracism, whippings, and
is to the origins of this development that we imprisonment* (Lender, 1973).
now turn. The colonists, not unlike their ancestors and
descendents, made a distinction between being
DEVIANT DRINKING AS DISEASE: drunk, or intoxicated, and "habitual" drunken-
HISTORICAL FOUNDATIONS· ness. The latter not only made the drinker a
The first systematic attempts to characterize public spectacle but had unmistakable negative
chronic and disruptive intoxication as a sickness consequences for self, family, and larger com-
or disease emerge in the last decades of the 18th munity. Historically, it is this pattern of re-
century in the United States and in England. peated and highly consequential drunkenness
We will be concerned with tracing the origins that demands explanation. It is like a puzzle
and meanings of such characterizations as they for observers that requires solution (Mac-
developed subsequently in the United States. Andrew, 1969). The particular solutions pro-
posed for such puzzles reflect the dominant
Colonial period interests and ideologies of the time. More spe-
Drinking in the American colonies in the cifically, such solutions will also reflect the par-
17th and particularly the 18th century was ticular definitions and world view of specialists
the norm. Although drunkenness was disap- charged with providing such answers (Holzner,
proved, it was far from rare (Keller, 1976; 1972, pp. 122-162). Toward the end of the
Lender, 1973; Levine, 1978; Paredes, 1976). colonial period, it was not the average citizen
If there were anything "bad" to be found in but the leading Puritan clergy-bolstered by
drinking, it certainly was not the drink itself. those more well-placed members of the com-
Such prominent Puritan clergy as Increase and munity who feared the spectre of the hostile,
Cotton Mather called alcohol a "good creature drunken "masses" -who were such specialists
of God," and churches and drinking houses and who were most concerned about drunken-
were often situated close to one another as ness.
social centers of the community. Most of the The religious heritage of the 17th and 18th
concern and social comment about public centuries defined drinking (and all forms of
drunkenness in the colonies was expressed by behavior) as a consequence of the actor's free
a relatively small number of scholarly, aristo- will. It was assumed that people behaved as
cratic church leaders who warned against the they did because of the enjoyment and profit
sin of drunken excess. It is important to note derived and that they avoided things unpleasant
that it was the excess-the responsibility for and detrimental. Being drunk, according to this
which rests with the drinker, not the drink-that hedonistic view, was the result of free choice.
concerned these church leaders. Such abuse This free-will philosophy is also apparent in the
of God's gift was sometimes attributed to the roots of classical criminology (see Chapter 8);
work of the Devil, and punishment for re- *These drunkenness laws were not uniformly or
peated drunkenness was consistent with the consistently enforced in early New England but
dominant institution of social control. Initially were likely to vary in their application by individual,
context, and governmental unit involved (Lender,
* The remainder of this chapter is a considerably ex- 1973). This selective enforcement of such laws has
panded and altered version of "From deviant drink- a long and continuing history. Jacqueline Wiseman
ing to disease: alcoholism as a social accomplish- (1970), in a study of skid row in a modem American
ment" (Schneider, 1978). © The Society for the city, found a similar pattern of selective and dif-
Study of Social Problems. ferential enforcement.
ALCOHOLISM: DRUNKENNESS. INEBRIETY. AND THE DISEASE CONCEPT 79
people broke laws not by accident but by intent. behavioral effects of alcohol and distilled spirits
One of the most eloquent spokesmen for this and provided a thorough and systematic clinical
free-will philosophy was Jonathan Edwards. picture of intoxication. Appended to the 1790
In his 1754 work, Freedom of the Will, he edition of this classic is what Rush called "A
argued: Moral and Physical Thermometer" (Fig. 2)
It cannot be truly said, according to the ordinary gauging these effects and the decline from
use of the language, that a malicious man ... can- temperance to intemperance with the increasing
not hold his hand from striking, or that he is not able strength of the alcoholic beverage. Most im-
to show his neighbor kindness; or that a drunkard, portant, Rush argued that those who apparently
let his appetite be never so strong, cannot keep the had "lost control" over their drinking-all of
cup from his mouth. In the strictest propriety of whom presumably were drinkers of distilled al-
speech, a man has a thing in his power, if he has it cohol-suffered from the "disease of inebri-
in his choice or at his election . . . . Therefore, in ety. " The list of symptoms of "this odious dis-
these things, to ascribe a nonperformance to the ease" provides insight into the deviant behavior
want of power or ability, is not just. (Quoted in
involved: unusual garrulity and silence, a dis-
Levine, 1978, p. 150)
position to quarrel, uncommon good humor
Colonial religious thought, however, did allow and insipid simpering or laughing, profane
that those who were repeatedly drunk and in- swearing or cursing, disclosing secrets, rude-
capacitated probably suffered from some kind ness, immodesty (especially in women), the
of moral degeneration. Although the idea that "clipping of words" in speaking, fighting,
such drunkards might be insane did exist in a swelled nose or black eye, and extravagant
Europe at about this same time, the prevailing acts indicating "a temporary fit of madness"
religious and social values of the New World (Rush, 1785/1943, pp. 325-336). Rush also
were inhospitable to such a notion (Wilkerson, enumerated signs of madness linked to in-
1966). ebriety: "singing, hallooing, roaring, imitat-
The Puritan free-will doctrine is also at odds ing the noises of brute animals, jumping, tear-
with the drug-centered perspective typical of ing off clothes, dancing naked, breaking glasses
the uncontested medical model of alcohol; in- and china and dashing other articles of house-
deed, it provides perhaps the clearest example hold furniture upon the ground, or floor" (p.
of an explicitly moral paradigm on deviant 326). This idea that repeated drunkenness
drinking. It was to give way to a new, decidely and associated deviant behaviors were a form
medical point of view toward the end of the of mental disease was more specifically elab-
18th century. Although both this moral view orated at about this same time by Thomas Trot-
and the emerging medical views on chronic ter, an English physician. Trotter's treatise
drunkenness were individualistic, the shift in on inebriety was written in 1788 as partial
the "ownership" (Gusfield, 1975) of chronic requirement for a medical degree at the Univer-
drinking problems incorporated decidedly new sity of Edinburgh and was published subse-
definitions of the drunkard and how he or she quently in 1804 as Essay, Medical, Philosophi-
should be treated. cal and Chemical, on Drunkenness.
The most significant element common to
The disease of Inebriety and the both Rush's and Trotter's descriptions of in-
concept of alcohol addiction ebriety was their identification of the connection
The idea that chronic drunkenness should be between drinker and drink as an "addiction"
considered evidence of a distinct disease entity to spiritous or distilled liquors. Rush believed
was first synthesized and championed by none that this addiction developed gradually and was
other than Benjamin Rush, the man we have progressive. The initial drinking behavior was
called "the father of the medicalization of de- not abnormal, but over time, drinking sub-
viance. " In his An Inquiry Into the Effects of stantial amounts of distilled alcoholic beverages
Ardent Spirits Upon the Body and Mind, first led to the diseased state. This stage was the
published in 1785, Rush catalogued bodily and disease inebriety in which the drinker no longer
A MORAL and PHY-5ICAL THERMOMETER:

Or, a. .scale of the H-ogref-{, of TJ:MPERANC£ and TNTEMPERANCE.
LJQUOR.5,witht~il' EpPE:CT.s,ill 'theit' vfval ORDER..
(.~ TEHPERANCE
70 -" WATER..
Heahh. We&hh,
~o
{Milk and Water. .!Sereni"ty of mind,
Yinegsr lind Water.
Molaffes Slid Water. Reputation, long life ,and
S" ,sma.Il beer. Happinefs.
-10 Cider. Cheerfulnefs,

30 Wine. Strength and
Nouriahment, 'When taken

ZO PorteJ'.
only a1: weah. and in
Jo Strong BeeT',
mod~ra.,e. CJ..uan-tiHes.
pvnCh{weaj N T E M P E RA NeE
" 81rong
VICeS. DlSEA3ES. PUNlSH-
M~NT.s.
IcUenefs, GO\..1'\,
10 Toddy, 8icknef.:,
Pnvifh_fs. Puking.and Deb't.,
Tremors of
Grog. Q,.u8rrel1ing t hi' hands in
themoN\'g Black eyes.
Bloa1:ecinaf/l,
30 Flip. InfJa", 'd eye-a R.ags,
~ying, Red %lole &f.
Sore and. Hunger.
+0 Swearing, fwelted legs,
Jaundiee. Ab~6 houfe,
Pains in-the
50 Bittllrs, infufea timbs, and Workhoufe,
in .)pirits "Fraud, burning in
the hands Jail.
Morning drsl'lS Anarchy Clh.d fe.e1:,
Dropfy, W"hipping
Ha"tTcd of Epilc.pfy.
70 Pc.p"er in Rum Melancholy, Pos1. ,
j ..f"t gov-t. Ideo1.ifm,
Mlilclnef.. , C aft,lelfland.,
Murde1', Paify.
Apoplcucy,
.sUICIDE. DEATH . GALLOWS.
Fig. 2. Benjamin Rushs conceptualization of the effects of alcohol and distilled spirits on the body
and mind. (From Rush, An inquiry into the effects of ardent spirits upon the body and mind, Boston,
1790, Thomas & Andrews)
had control over drinking itself; in short, the and drunkard; the notion of "love" of drink
drinker had become addicted. Rush called in- was supplanted by such physiological-sounding
ebriety a "disease of the will," based on the terms as "craving" and "insatiable desire"
then popular assumption that one's "will" (Levine, 1978).
and "desire" were quite distinct. It was one's This emerging medical and scientific con-
will that became weakened and ultimately de- ceptualization of chronic drunkenness as ad-
bilitated by successive bouts of heavy drinking diction had important and complicating impli-
of spirits. Trotter's view of inebrity was some- cations for assigning blame and responsibility
what less philosophical and more psychiatric. for the deviant behaviors often associated with
He argued specifically that "the habit of such drinking. If such persons are not willful
drunkenness is a disease of the mind" and in their drunkenness, as was previously thought,
advised his fellow physicians in their treatment then to punish them for it and various at-
of such persons: tendant wrongdoing is contrary to classic no-
tions of justice (Platt, A., & Diamond, 1966).
This disease, I mean the habit of drunkenness, is
Unclarified, however, was at what point the
like some other mental derangements; there is an
ascendancy to be gained over the person committed
inebriate becomes irresponsible, or "loses con-
to our care, which, when accomplished, brings him trol." Rush was willing to grant that initial
entirely under our control. (Trotter, 180411941, drinking was willful but argued that ultimately,
pp. 586-587) through the process of addiction, it became
something in which the drinker had no choice.
Both Rush and Trotter, however, were com- This issue of the determination of responsibility
mitted to the notion that the disease of inebriety for drunkenness among those identified medi-
had physical dimensions that distinguished it cally as "inebriates," "dipsomaniacs," and
from certain more "purely" mental conditions. later, "alcoholics" remains a point of legal
The last words of Rush's title, "on the body contention (Fingarette, 1970).
and mind," announce this conception of al- Aside from the question of legal responsibil-
cohol addiction as both a mental and physio- ity for drinking-associated deviance, this
logical state. Both these physician-founders of early conception of alcohol addiction was con-
the disease concept of deviant drinking held sistent with a developing trend whereby various
that the first and foremost step in treatment was categories of wrongdoers and deviants were
abstinence from all alcoholic drink. Incidental- redefined from willful and vicious to helpless
ly, it is this prescription, along with Rush's and sick. Although such individuals could cer-
general skepticism about the wisdom of drink- tainly be incarcerated and punished in the
ing distilled spirits, that has led some to identify alleged interest of community welfare, more
Rush and his American physician colleagues and more they were defined as victims of var-
as the "physicians' temperance movement" ious illnesses and diseases and subjected to
(Wilkerson, 1966). treatment and therapy. This is part of what has
Although Rush did riot elaborate the specific been called the "divestment" from the criminal
mechanisms or process through which this justice system of traditional categories of of-
"disease of the will" developed, his ideas did fenders and the rise of the "therapeutic state"
provide an alternate explanation to the tradi- (Kittrie, 1971; Rieff, 1966; Szasz, 1970). The
tional moral account offered by colonial reli- ideas of Benjamin Rush that common drunk-
gious leaders. In an attempt to shed new light ards suffered from a disease that incapacitated
on the puzzle of habitual drunkenness, Rush their will to avoid drink and that they should
and Trotter, along with a few English and therefore be treated as patients rather than
European medical colleagues such as John Lett- criminals represents the symbolic beginning of
som, Thomas Sutton, and Magnus Huss (Kel- this divestment process for habitual deviant
ler, 1966), adopted a scientific approach. They drinking behavior in America. Paradoxically
even avoided the traditional moral language it was the growing American temperance move-
used to describe the connection between drink ment, with its moral theme of abstinence and,
ultimately, of prohibition, that popularized the assumed that in the face of such esteemed
idea that inebriety was indeed a sickness or knowledge on the physical and social perils
disease. of distilled alcohol, all rational moderate or
temperate drinkers would be dissuaded effec-
DISEASE CONCEPT AND THE tively from excess.
AMERICAN TEMPERANCE A second important idea the "temperance
MOVEMENT physicians" (Wilkerson, 1966) provided the
The definition or identification of chronic movement was the very statement that repeated
intoxication as a disease was attractive to those intemperate drinking is itself a disease. The
who urged control and reason-temperance- assumption that such behavior is direct evi-
in drinking behavior (Levine, 1978). Although dence of disease rested (and continues to rest)
support of the disease view became less com- on the belief that no rational person, "in con-
mon with the rise of a more specifically pro- trol" of his or her will, would continue to drink
hibitionist stance after about 1870 (Gusfield, after learning these facts. This idea, that "in-
1963), the social movement for temperance ebriety is a disease," became a common theme
drew on and used the developing medical model of temperance literature and speeches until
of alcohol in two important ways. the final decades of the century. It was a widely
shared part of the middle-class view of the
An enemy and a weapon: perils of drinking.
disease and abstinence The plausibility of this disease interpreta-
First, the clinical descriptions of physiolog- tion requires the decline or tempering of the
ical effects of alcohol and intoxication avail- free will argument we discussed earlier. along
able toward the end of the 18th century pro- with an increased acceptance of the idea that
vided temperance reformers with compelling people could be compelled to behave in cer-
evidence against the use of distilled spirits. tain ways by forces beyond their control; that,
As Rush's comments and his "moral thermom- indeed, one's will, or ability to choose, and
eter" suggest, these "medical" descriptions one's desire were independent (Levine, 1978).
went well beyond physiological effects and in- Demonic or spirit possession was a competing
cluded a wide range of deviant behaviors be- explanation that had become a less acceptable
lieved to be caused by drink. Such characteriza- answer than it once had been. The apparently
tions reiterated the disinhibitor hypothesis and irrational nature of repeated intoxication, how-
became highly useful grist for the temperance ever, remained puzzling. An emerging medical
mill. These "medical facts" of alcohol were science slowly began to suggest new solutions.
early popularized for temperance purposes Although certainly crude by contemporary
by the French-American Quaker reformer, standards, medicine attempted to account for
Anthony Benezet (Krout, 1925, pp. 64-66). suffering and pain in terms of natural laws in
Benezet became aware of the problems asso- an "objective" rather than a mystical or
ciated with repeated use of distilled spirits transcendental fashion. The puzzle of habitual
through his welfare work with the American drunkenness began to be unraveled scientifical-
Indians. Shocked by what he had seen, Benezet ly. Loss of control over one's body and self
began to take note of similar kinds of behaviors was assumed increasingly to be the result of a
and effects of spirits among his peers. He pub- natural although still obscure disease process.
lished his observations in 1774 under the title Such an account brought some vague degree
The Mighty Destroyer Displayed. A few years of understanding to the behavior itself as well
later he distributed a pamphlet that drew to- as the ineffectiveness of traditional means of
gether prominent medical opinion of the day control. Theological and legal interventions
on the effects of spirits on the body. Need- had been unsuccessful because they were mis-
less to say, the medical consensus was gloomy guided. The problem was not seated in the soul
and thus served temperance interests well in or the free will, but rather somehow in the body
supporting restrictions on strong drink. It was and/or mind.
The identification of inebriety as a disease 1840, and the larger and more powerful Wom-
allowed temperance leaders to draw on a cul- en's Christian Temperance Union, founded in
tural universal. Disease, whatever it is de- 1874. The temperance stance of sympathy
fined technically to be, is undesirable; it should toward the addicted inebriate and the growing
be opposed, controlled, and, if possible, demand for control of alcohol that increasingly
eradicated. By logical extension, all known or typified the temperance movement during the
suspicioned causes of such conditions should 19th century reflected Rush's discussion of
be approached similarly. Probably unintention- inebriety. He agreed that initial drinking was
ally, although Rush was a temperance sup- most likely an act of will and that the drinker,
porter, the physicians who called inebriety a consequently, should be held responsible. Once
disease provided the movement with an evil the addictive process had begun, however,
perhaps more universal than sin itself. "In- Rush believed the drinker could not control
ebriety is a disease" became an important slo- whether he or she took a drink or how much
gan of the temperance movement. "Intemper- was drunk. Alcohol addiction was a condition
ance," a term whose meaning is sufficiently to which all drinkers of alcohol could in prin-
broad to include even a single instance of in- ciple fall victim (Levine, 1978). Even social
toxication, occasionally replaced inebriety in or moderate drinking of spirits was, therefore,
the slogan. Rush's and other physician's considered suspect and foolish.
prescription of abstinence as the first and
absolutely necessary step in treatment also was Rise of the Inebriate asylum
turned to temperance use as "the" solution for and the rush to Prohibition
the problems associated with drinking. As a A fascinating example of the congeniality
measure of the movement's appeal, the Amer- of these middle-class temperance ideals and the
ican Temperance Society reported that only 6 disease concept is found in the rise and pro-
years after being founded in 1826, it could liferation of inebriate asylums-special hos-
record over half a million people who had pitals for chronic drunkards-during the middle
signed a public pledge of abstinence from all and latter part of the 19th century. Partly as a
alcoholic beverages (Krout, 1925, p. 129). result of the hostile reception chronic drunk-
The use of the disease slogan and the abstinence ards and severely intoxicated persons received
prescription by temperance leaders to their own at general hospitals and partly in an attempt to
ends is a clear illustration of the rise and ac- succeed where traditional institutions such as
ceptance of ideas because of their political prisons, workhouses, and general and mental
and ideological-indeed, their moral-appeal hospitals had failed, a small group of concerned
rather than their substantive or technical physicians established "homes" and asylums.
significance (Christie & Bruun, 1969; Gusfield, These were special places where inebriates
1975). could receive needed physical and, more im-
An important consequence of temperance portant, moral care and supervision that temper-
strategy was that the idea that inebriety is a ance supporters believed essential to regenerate
disease was not evaluated critically as an intel- and support their defective wills, still believed
lectual or scientific claim during most of the to be at the heart of the disease itself.
19th century. As a moral slogan, however, it An early plea for such facilities is found in
allowed advocates to pity the sick inebriate an 1830 report of a committee of the Connecti-
who required treatment and support on the one cut Medical Society. The committee concluded
hand and to rail against "Demon Rum," "King that separate institutions for inebriates were
Alcohol" and so-called social, or moderate, necessary, where such persons would
drinking on the other. Joseph Gusfield (1963) be subjected to salutary discipline, and needful re-
documents the humanitarian factions of the straint. Where they shall have no access to in-
movement that sought to exert an uplifting, toxicating liquors . . . [and] be constantly and
ameliorative force in American society, such usefully employed. Where they shall not be con-
as the Washingtonian Movement, begun in taminated by evil associates, and where they shall
have no opportunity of exerting an unfavorable in- of the asylums became the "keepers" of in-
fluence upon others. Where they shall receive what- ebriety. Not only did the state support commit-
ever medical aid is necessary to restore their debili- ment to "medical" asylums rather than to
tated constitutions. . . . Where they shall receive workhouses but also such "therapy" required a
the benefit of moral precepts, correct examples, and
much longer "sentence." The prisonlike qual-
such instruction as will induce them permanently to
abandon their former vicious courses . . . . Where
ity of some of these hospitals is evidenced by
. . . by an enlightened system of physical and the barred windows, locked doors, and searches
moral treatment, they may be reformed; and of patient rooms typical of the New York State
whence, if reformed, they may be restored, wel- Inebriate Asylum at Binghamton, opened in
come guests of their families, and useful members 1858 (Corwin & Cunningham, 1944, pp. 15-
of society. (Quoted in Corwin & Cunningham, 16). The New York State institution was the
1944, pp. 12-13)* first bona fide special hospital for inebriates,
although the famed Washingtonian Home in
The committee continued, adding that the
Boston had been established almost 10 years
organization and arrangement of such facility
before, in 1857. The popUlarity of this medical-
"must be entirely devoted to the cause of indus-
moral solution to chronic drunkenness was
try and temperance" and that "much of [its]
great, and by 1900 there were more than 50
success will depend upon the character of the
such special facilities operating in the United
person to whose charge it is entrusted." Final-
States (Wilkerson, 1966, pp. 142-151).
Iy, committee members anticipated some slight
These hospitals for inebriates were, however,
legal obstacle that would need to be overcome
not received with universal enthusiasm among
for this interesting form of medical social con-
either temperance leaders or the medical com-
trol to be realized:
munity. The asylums were even more contro-
The only serious objection to the success of such versial in those states where laws were passed to
a scheme is that it will require a slight modification divert liquor or general tax revenues to their
of existing laws. Instead of sending a drunkard support (Corwin & Cunningham, 1944; Jelli-
to a work-house for punishment, we would have nek, 1960). Temperance leaders toward the lat-
him sent to an asylum for reformation; and instead ter decades of the century became more and
of thirty days' confinement, we would require him more skeptical about the potentially "soft" and
to devote at least a year to the great and important
tolerant attitudes of asylum officials toward
work of reformation. (Quoted in Corwin & Cun-
alcohol. It was not until the superintendent-
ningham, 1944, p. 13)*
physicians formed an association dedicated
The kind of moral therapy the committee specifically to the proposition that inebriety,
proposed was not original in their 1830 report. although a disease, was caused by sinful indul-
We noted in Chapter 3 that persons believed to gence in drink that temperance forces adopted a
be insane were regularly subjected to such mor- more supportive posture. In response, the Na-
al treatment in European and American asylums tional Temperance Society, the coordinator of
after the tum of the 19th century. The focus of temperance action, issued its reserved en-
these treatments was the patients' moral and dorsement in 1872, in which their priorities
mental rather than their physical constitutions. were clear: "The Temperance press has always
The Connecticut committee's reference to the regarded drunkenness as a sin and a disease-a
inebriate's "reform" signals this image of the sin first, then a disease; and we rejoice that the
kind of disease involved. Finally, as we have Inebriate Association are [sic] now on the
argued, such medical treatment is also a clear same platform" (quoted in Levine, 1978, p.
form of social control. The medical directors 157).
This same association of physician-superin-
tendents, along with a small number of inter-
*Reprinted by permission from Quarterly Journal of
Studies on Alcohol, Vol. 5, pp. 9-85, 1944. Copy- ested colleagues, began publishing a journal
right by Journal of Studies on Alcohol, Inc., New based on the premise that inebriety is a disease.
Brunswick, N.J.. 08903 It was called The Journal of Inebriety, and the
first issue appeared in 1876, continuing on a the then less-than-revered position of the medi-
limited and precarious basis until 1914. Its ap- cal profession in general in the public con-
proach was distinctly psychiatric and dedicated sciousness. Indeed, many of these considera-
to promoting the idea that "inebriety is a neu- tions provide rare insight into understanding the
rosis and psychosis and that alcohol is both an history and present status of the debate as to
exciting and contributing cause as well as a whether alcoholism is "really" an illness. Re-
symptom of conditions that existed before" gardless of the scientific quality of the work,
(Crothers, 1911). Not surprisingly, the Journal these late 19th-century conditions would seem
contributed to the idea that inebriety is a special to have precluded both professional and popular
kind of mental illness involving alcohol, but the acceptance of such ideas. Acceptance of the
clarity of such formulations barely went beyond disease concept turns not on its validity but
that assertion. The question of whether such be- rather its viability (Spector & Kitsuse, 1977).
havior is a symptom of a psychiatric condi- By the tum of the century, prohibition ad-
tion and hence less intrinsically important, or vocates had been able to focus attention on legal
whether it is itself a disease condition continues controls as the only solution to the alcohol prob-
to divide the medical and treatment communi- lem. The temperance movement became the
ties. The preference of the editors and authors "antialcohol movement," and the disease con-
in the Journal appears to have been the former. cept of inebriety (or alcoholism, as it was then
E. M. Jellinek (1960) quotes one of the leading occasionally called) was an issue too technical
students of this early 20th-century disease con- and esoteric to warrant serious attention. Many
cept to illustrate the moral and intellectual con- of the social, economic, and political changes
fusion surrounding this work: ushered in with the first decades of the new
century made alcohol and its "disinhibiting"
I have ... contended that inebriety is a condition of effects appear even more threatening to a
nervous weakness on which is engrafted a habit. This
smoothly running social order, and these di-
conception of the condition seems to me to qualify
the assertion that inebriety is a disease. While calling
mensions of drinking behavior became most
it a "disease" we do not by accepting such a defini- salient. With the passage of the Eighteenth, or
tion imply that the inebriate is irresponsible. (p. 5) Prohibition, Amendment in 1919, drinking,
drunkenness, and habitual drunkenness or in-
Neither the journal nor its parent association ebriety did not cease but became illegal for the
received the support of the psychiatric commu- next 13 years. This symbolic victory of temper-
nity or medical profession at large. There was a ance forces (Gusfield, 1963) effectively chilled
small group of citizens who took an interest in debate and work on the disease concept for
their work, but public opinion ranged from more than a decade.
skeptical to negative, particularly about the
public financial support and the suspicion that POST·PROHIBITION
such efforts were attempts to excuse vice and REDISCOVERY: THE YALE CENTER,
crime (Jellinek, 1960, pp. 2-7). ALCOHOLICS ANONYMOUS,
The medical profession's unenthusiastic re- AND THE JELLINEK
ception of these inebriate specialists may be FORMULATION
seen as a result of the relatively low scientific Although there was virtually no organized
quality of their work. We suggest, however, successful support of the disease concept from
that a good part of this skepticism and hostility the end of the 19th century until after Prohibi-
was due to political and social considerations. tion (Gusfield, 1975), there was a good deal of
Such analysis focuses our attention on the rela- interest and development in science and the
tively low stature of psychiatry in the hierarchy professionalization of scientific research in
of American medicine, the moral stigma at- American universities (Ben-David, 1971, pp.
tached to working with and in support of heavy 139 and 168). At roughly the same time that
drinkers and inebriates, the political contro- the moral crusade against alcohol was waning,
versy surrounding the inebriate hospitals, and science and scientific work were becoming
established. This was to have a great impact oratory were involved in alcohol metabolism
on the kinds of solutions Americans would sug- and nutritional research-studying the physio-
gest for a variety of problems. Since after 1933 logical and chemical effects of alcohol on the
alcohol was again legal and popular, it was not body. As this work at Yale became increasingly
likely to be defined as the primary source of interdisciplinary within the natural sciences,
deviant drinking behavior. Intoxication and Haggard became convinced that the proper
drunkenness, when they were deemed disrup- study of such problems required an even more
tive, were problems assigned to civil authorities comprehensive approach. He invited Jellinek
or the state. But the chronically drunk person re- to come to Yale as director of a multidisci-
mained a puzzle. plinary Center of Alcohol Studies. The physio-
In this context, even more than at Rush's logical research at Yale and the broadened ap-
time, science and medicine seemed to hold the proach to alcohol studies were communicated
promise. Three developments, all beginning through The Quarterly Journal of Studies on
within a decade after Repeal, provide the Alcohol, founded in 1940 by Haggard. This
foundation on which this renewed medical journal, which in 1975 became The Journal of
conceptualization of chronic drunkenness be- Studies on Alcohol, is perhaps the key inter-
havior was to rise during the middle years of national publication on alcohol research, its
the 20th century: the Yale research center; the tenure of continuous publication being second
self-help group Alcoholics Anonymous; and a only to The British Journal of Addiction, which
new medical specification of what it means to began publication in 1892 as The British Jour-
say "alcoholism is a disease." nal of Inebriety. The Yale center, its journal,
and the laboratory quickly became the intellec-
Yale Research Center of Alcohol tual core of American research on alcohol. The
Studies center continued successfully at Yale until
The major body coordinating support for 1962, at which time it was moved to Rutgers
scientific work on alcohol problems in the mid- University in New Jersey, where it remains
1930s was the Research Council on Problems one of the most prestigious of a small number
of Alcohol, established shortly after Repeal of such research centers in the world. *
(Keller, 1976b). The council was comprised One of the center's most significant early
disproportionately of physicians and natural contributions to the idea that alcoholism is a
scientists and apparently had grown out of some disease was its summer school program, begun
medical research in progress at Bellevue Hos- in 1943. These annual sessions were organized
pital in New York City. The group was inter- as educational programs for concerned citizens
ested particularly in studying the causes of involved in policy formulation in their local
alcoholism as an important social and personal communities throughout the country. A com-
problem. One member of the committee was mon concern was what to do about "alcohol-
Howard Haggard, the physician-director of the ism" and alcohol-related problems. Robert
Laboratory of Applied Physiology at Yale Uni- Straus (1976) and Morris Chafetz and Harold
versity. Although the council was unsuccessful Demone (1962) suggest that the slogan "alco-
in raising significant sums of money for alcohol holism is a disease" was introduced intentional-
research, the stature of its individual members ly by center staff at these summer sessions in an
did establish such work as scientifically respect-
able. One grant of financial support, however, *Robert Straus (1976) provides some fascinating
was consequential. It was for a review of the insight into the social and political history leading
scientific literature on the biological effects of up to this move. He suggests that the wide publicity
alcohol on humans. The council called on E. the Yale center received in its early days was an em-
M. Jellinek, who had been doing research on barrassment to that university because of the sub-
stance of its work, and that the interdisciplinary qual-
neuroendocrine schizophrenia, to administer ity of the center was perceived as inappropriate in
the project. the context of the traditional departmental structure
Haggard and his colleagues at the Yale lab- of the university.
attempt to reorient and "de-moralize" local parties in perpetuating and expanding this
and state government policy and popular think- growing number of organizations, both public
ing about people with drinking problems. This and private, dedicated to the diagnosis and
idea was not introduced to stimulate scientific treatment of alcoholism.
or technical discussions at these summer school The Yale center provided the prototype for
sessions. Rather, the school was seen more as such diagnosis in 1944 with the establishment
providing a good opportunity to disseminate the of the Yale Plan Clinics (Jellinek, 1943). These
idea and point out its practical moral and polit- clinics were intended as facilities where devi-
ical implications for treatment and cure. Al- ant drinkers could come for help with their
though only a small segment of the total summer drinking problems. The Yale Plan Clinics were
program was devoted to the disease question, it established as bona fide interdisciplinary but
was an idea supported by both Haggard and Jel- clearly medical facilities staffed by clinical per-
linek and soon became a topic of considerable sonnel who could accurately refer patients to
interest among the lay audience. the existing treatment facilities in the commu-
The appeal of this idea that alcoholism is a nity. One of the objects of these clinics was to
disease requiring treatment rather than a sin or "serve as experimental models for the develop-
crime calling for punishment must be under- ment of future large-scale procedures. " The re-
stood both in terms of the specific history of col- alization of this goal is seen most clearly in the
lective definitions of chronic drunkenness and recent phenomenal rise of the federal bureau-
the politics of medicalization in general. Not cracy established in 1971 to combat "alcohol
only did the idea that chronic drunkenness abuse and alcoholism," The National Institute
might be a disease offer a plausible solution to of Alcohol Abuse and Alcoholism (NIAAA). In
the apparent irrationality of such behavior-a a short time NIAAA has developed an annual
solution which, incidentally, the legalistic ap- budget of nearly $170 million, the largest single
proach represented by Prohibition and subse- portion of which goes to local centers for the
quent drunkenness laws does not address-but diagnosis, treatment, and rehabilitation of per-
also it was morally and politically appealing in sons identified as alcoholics. Calling alcoholism
the increasingly therapeutic and treatment-ori- "the third greatest health problem in this coun-
ented context of the American criminal justice try," a past director of the Institute, physician
system (Kittrie, 1971). Not only would the Ernest P. Noble, identified bringing "the treat-
courts and jails be relieved of a large and grow- ment of alcoholism into the mainstream of our
ing burden of cases involving alcohol (the most nation's health care delivery system" to be "a
common arrest of all those made by police), but central purpose and goal" of NIAAA.
also these and other officials would be freed Finally, the Yale center, and especially the
from the morally objectionable position of early summer sessions, provided a fertile orga-
righteous indignation and condemnation typical nizational foundation for growth of the National
of pre-Prohibition reactions to drunkenness. As Council on Alcoholism (NCA), a middle-class,
the chronic drunkard becomes the "alcoholic," voluntary association premised both on the
a sick person, those charged with control cease, validity and viability of the disease concept
at least overtly, to be moral crusaders and be- (Chafetz & Demone, 1962; Paredes, 1976). The
come humanitarian guardians, responsible for NCA, known initially as the National Com-
healing and recovery rather than reform. Final- mittee for Education on Alcoholism, was estab-
ly, as Harrison Trice and Paul Roman (1972) lished in 1944 as a direct result of the efforts of
suggest, this conception of chronic drunkenness three women: a former alcoholic, a journalist,
as disease calls forth the development of a vir- and a psychiatrist. Mrs. Marty Mann, who had
tual "industry" of professional and lay per- been a member of Alcoholics Anonymous, saw
sons charged with the identification, treat- the National Committee as supplementing the
ment, counseling, and study of such per- work of that organization in terms of public
sons. These "alcohologists" (Robinson, 1972; education and organization. In the spring of
Room, 1972, 1976b) become clearly interested 1944 these women met with Jellinek, and they
decided that the National Committee "plan" tings surrounding the notion of alcoholism,
should be introduced in the Yale summer school such diagnostic criteria provide practical an-
program. At the time of the original incorpora- swers to the everyday diagnostic problems cli-
tion of the National Committee in 1944, its nicians face. It is not surprising that they have
close connection with the Yale center was evi- been adopted widely.
denced by the committee's officers: Dr. How-
ard Haggard was named president; E. M. Jelli- Alcoholics Anonymous
nek was chairman of the board; Professor Sel- A second post-Prohibition development cru-
den Bacon of Yale was secretary; and Professor cially important for the viability of the idea that
Edward Baird, also of Yale, was the commit- alcoholism is a disease was the founding and
tee's legal counsel (Chafetz & Demone, 1962, subsequent growth of the self-help organiza-
p. 141). Although the NCA became organi- tion, Alcoholics Anonymous. AA, as it came to
zationally independent of the prestigious and be known, was begun in 1935 by two men, a
influential Yale center in 1950, the association stockbroker and a physician, who considered
was favorable for the idea that alcoholism is a themselves among the chronically intoxicated.
disease. The extent to which the NCA itself It was premised on the idea that such individ-
helped to carry this slogan is suggested by uals could help themselves and others like them
Chafetz and Demone (1962): to achieve sobriety by developing a supportive,
open, frank, and spiritual fellowship commit-
NCA then began to search for a formula, something ted primarily to that end. The collective and re-
which would translate the basic facts of alcoholism ligious nature of the AA program was inherited
into easily understood and remembered phrases.
directly from its early ties with the Oxford
This resulted in the well known concepts or credo:
Group, a religious movement that flourished
Alcoholism is a disease and the alcoholic a sick per-
son. The alcoholic. can be helped and is worth help- briefly during the 1930s and was characterized
ing. This is a public health problem and therefore a by "small discussion groups ... confessions,
public responsibility. (p. 142)* honesty, talking out of emotional problems,
unselfishness, and praying to God as personal-
The NCA remains today, through its nation- ly conceived" (Trice, 1958). One of the foun-
al office and many local affiliates throughout ders of AA, Bill W. * had himself experienced
the United States, perhaps the most force- a "spiritual awakening" (Alcoholics Anony-
ful nonpublic voice supporting the idea that mous, 1957, p. 63) through his exposure to
alcoholism is a disease. In 1972 it published an Oxford Group's fellowship. He believed this
the widely cited and used "Criteria for the spiritual experience, in which he submitted
Diagnosis of Alcoholism" in The American himself to a . 'power greater than myself," was
Journal of Psychiatry. These diagnostic crite- the key to gaining control over drinking and re-
ria, including physiological, behavioral, and maining sober.
psychiatric components, were created by a Bill W., during his many trips to the hospital
blue-ribbon committee of physicians organized for emergency treatment of severe intoxication,
and supported by the National Council for this had been treated by a sympathetic and interest-
task. The promulgation of such medical guide- ed psychiatrist, Dr. W. D. Silkworth. Through
lines obviously is premised on the disease def- the support of Dr. Silkworth and his own obser-
inition of at least certain forms of deviant vations and reading, Bill W. became convinced
drinking. They encourage physicians and other that such therapeutic insight could come only
clinical health workers to adopt this general after the drinker's life had become virtually
definition and the specific guides. Considering devastated and deflated by drink-only after he
the ambiguity and skepticism in medical set- or she had "hit bottom." Anxious to carry this
*The principles comprising this ideology had been *Consistent with the tenet of selflessness, anonymity
stated earlier by Dwight Anderson (1942), director of is a fundamental principle espoused and followed by
public relations for the New York State Medical AA members. Only first names are used to identify
Society, and subsequently the first public relations persons in AA publications, materials, and meetings.
director of the NCA.
message to others with similar experiences, he parently an effective way to prepare them for
engaged in a brief campaign to convert those the spiritual message AA provides. To con-
he believed ready for such insight. After a series vince such drinkers that they are sick and, in
of failures to reach his fellow drinkers, Bill W. fact, dying is to impress on them the gravity
was given some consequently important advice of their condition, quite aside, it appeared,
by his friend Dr. Silkworth (Alcoholics Anony- from any questions of morality. From the first,
mous, 1957); the only hope for triumph over this disease was
to stop drinking forever. Abstinence from all
You're having nothing but failure because you are
alcoholic beverages became the logical first step
preaching at these alcoholics. You are talking to
them about the Oxford Group precepts of being ab- in freeing oneself from the devastating effects
solutely honest, absolutely pure, absolutely unself- of the alcohol allergy. The AA slogans, "Once
ish, and absolutely loving. This is a very big order. an alcoholic, always an alcoholic" and "One
Then you top it off by harping on this mysterious drink away from a drunk," were learned by all
spiritual experience of yours . . . . Why don't you members and the general public alike as factual
tum your strategy the other way around? ... You've descriptions of alcoholism and alcoholics.
got to deflate these people first. So give them the Decades of testimonials and impassioned' 'sto-
medical business, and give it to them hard. Pour it ries" have cemented this prescription of absti-
right into them about the obsession that condemns nence firmly at the heart of AA ideology and
them to drink and the physical sensitivity or allergy
treatment. It is an absolutely nonnegotiable
of the body that condemns them to go mad or die if
proposition among AA faithful, including the
they keep on drinking. (pp. 67-68)*
leaders and founders of the NCA (Mann, 1958).
Silkworth and Bill W. agreed that only then The physical allergy conception of the disease
would the spiritual principles borrowed from concept offered an advantage over competing
the Oxford Groups be effective in giving guid- definitions of such drinking behavior as primar-
ance and strength to gain control over alcohol. ily a type of mental illness or psychiatric condi-
This notion of an obsessive craving for alco- tion. Although AA ideology agrees that a com-
hol linked to a physical allergy to this drug be- pulsion to drink drives the alcoholic, it rejects
came the fundamental proposition on which the the notion that such drinking behavior is merely
AA program developed, both in terms of self- a manifestation of an underlying psychiatric or
help and education. Many Americans, both mental problem (Cahn, 1970, pp. 139-144;
lay and professional, see alcoholism through Trice & Roman, 1970). This leads AA mem-
these AA ideas and principles. The themes that bers to take a dim view of psychotherapy in the
alcoholism is a disease and alcoholics are sick treatment of alcoholism. In addition, AA ideol-
people run through all AA publications and ogy has generally opposed the use of drugs in
speeches. The proposition that this condition treatment, insisting on the importance of the
rests on an allergy to alcohol occupies a central, spiritual awakening or experience as an alter-
if sometimes implicit, place in AA ideology. nate and preferable way for alcoholics to gain
Although medical opinion on this assertion control.
was then skeptical and subsequent research has The allergy metaphor identifies alcoholism as
failed to support it (Jellinek, 1960, pp. 86- a bona fide medical or "disease" condition.
88), the idea that chronic drunkenness is a This in effect legitimizes the medical definition
mark of physiological sensitivity rather than of such drinkers as "sick"; people with aller-
moral degeneration was appealing both to such gies are seen as victims who are not held re-
drinkers and those charged with their care. As sponsible for their conditions. The concept of
Dr. Silkworth suggested to Bill W., giving a purely mental illness or sickness has never
these drinkers "the medical business" was ap- held quite the degree of legitimacy or medical
stature of physiologically based pathological
conditions. Moral stigma and questions of
*From Alcoholics Anonymous Comes of Age, copy-
right © 1957 by Alcoholics Anonymous World Ser- blame and responsibility cling to problems de-
vices, Inc. Reprinted by permission of AA World fined primarily or wholly as emotional. Trice
Services, Inc. and Roman (1970) suggest that a good deal of
the apparent success of AA as a means to so- role. Norris' suggestion that "God" might be
briety involves the process of removing such interpreted to be a physician is perhaps not
stigmatized or negative labels from the drinker an extreme exaggeration in terms of the latter's
and relabeling the person with more socially control over the legitimacy of sickness and dis-
acceptable identities such as "sick," "repen- ease designation and admission to treatment.
tant," "recovered," and "controlled." The success attributed to the AA program in
This process of recovery that has come to rep- helping drinkers recover from alcoholism has
resent the essence of the AA program was first become part of popular wisdom, generally un-
codified in 1938 and published a year later in the challenged even though no comparative, sys-
famous book Alcoholics Anonymous (1939, pp. tematically collected empirical evidence ap-
71-72), a compilation of individuals' own life pears to be available. The effect of AA pro-
stories of their drinking and how AA helped grams and ideology on thinking about alcohol-
them stop. It centers around the well-known ism has been humanitarian and educational, and
"twelve steps" toward recovery. Two themes the generally high regard in which it is held
particularly relevant to the AA disease concept in local communities throughout the country
are found in the first and third steps. Prior to all serves to reinforce the disease concept implied
else, and derived directly from Bill W.'s in its program. This high regard is evidenced
spiritual experience and Dr. Silkworth's sug- by recent research on a sample of physicians.
gestion, the first step reads: "We admitted we A majority of those agreeing that alcoholism
were powerless over alcohol- that our lives had is a disease believed that referring drinkers to
become unmanageable." This is precisely the AA was the best professional strategy (Jones
concept "loss of control," a description of & Helrich, 1972). An additional interpretation
repeated intoxication that has been at the center of these results, and one not without support,
of the developing disease concept since Rush's is that such an attitude serves to free the physi-
writing over 150 years ago. It is, of course, con- cian from what is often considered the bother-
sistent with the conception of alcoholism as a some responsibility of treating the chronically
sickness. intoxicated.
The third AA step to recovery requires one
to have "made a decision to tum our will and Jellinek formulation
our lives over to the care of God as we under- The Yale center and AA contributed im-
stood Him." The question of just how religious portantly to the spread and popularization of the
AA should be has always been somewhat con- disease concept. It is, however, in the work of
troversial among its members. In an attempt E. M. Jellinek, early director of the Yale cen-
to broaden its appeal to include virtually all ter, and later in the writing of his associate,
spiritual experience, leaders were quick to point Mark Keller, that the disease concept was de-
out that although the language of these steps fined unequivocally as alcohol addiction. The
sounds traditionally religious, such terms as extent to which the assertion that alcoholism
"God" are to be interpreted loosely and on the is a disease gained scientific credibility at about
basis of the individual's own spiritual biog- midcenturyprobably rests on the work of Jel-
raphy. Attesting to the scope of this interpreta- linek and his associates at Yale. This formula-
tion, John L. Norris (1976), chairman of the tion codified the various meanings of the dis-
board of AA, says: ease concept as it had developed over the
previous century and a half. Its major author,
This turning over of self direction is akin perhaps to Jellinek, was already a known and established
the acceptance of a regimen prescribed by a phy-
medical researcher before his arrival at Yale.
sician for a disease. The decision is made to accept
reality, to stop trying to run things, and to let the
This, coupled with his position as director of
"Power greater than ourselves" take over. (p. 740) that prestigious university'S alcohol research
center, established his work as prima facie
This description of the AA role is clearly remi- worthy of serious consideration. Short of per-
niscent of Parsons' (1951) discussion of the sick haps Howard Haggard, no one of Jellinek's
stature since Rush had chosen to address this relieve tension and an increased tolerance to
question at such length. alcohol; the prodromal phase, initiated by "al-
Jellinek set out his understanding of what it coholic palimpsests" or blackouts and punc-
means to call alcoholism a disease in a series of tuated by their regularity; the crucial phase,
articles begun shortly after his arrival in New wherein loss of control over drinking begins,
Haven, culminating in a comprehensive and leading to personally disruptive consequences,
widely cited manuscript, The Disease Concept rationalizations, nutritional neglect, and di-
of Alcoholism. In an early paper in 1941 with minished sex drive; and, finally, the chronic
psychiatrist Karl Bowman as first author, Jelli- phase, begun by prolonged periods of intoxi-
nek resurrected the concept of alcoholism as cation, alcoholic psychoses, a decrease in toler-
an addiction to alcohol. A few years later, af- ance, obsessive drinking. Although the Criteria
ter persuing data from an AA questionnaire Committee of the National Council on Alcohol-
about alcoholics' drinking experiences, Jellinek ism (1972) does not cite Jellinek as a specific
(1946) constructed his well-known phase pro- source of their ideas, their criteria for the diag-
gression model of alcoholism. A revision and noses of alcoholism specifies "early," "mid-
extension of this paper published in 1952 and dle," and "late" manifestations of the disease
titled "The Phases of Alcohol Addiction" had in terms of a number of identifiable behavioral
appeared inti ally under the auspices of the Al- symptoms. Physician Max Glatt (1970, 1974)
coholism Subcommittee of the World Health specifically incorporated Jellinek's phases into
Organization (1952), of which Jellinek was an his own description of alcohol addiction and
influential and highly regarded member. Virtu- recovery. He proposed a U-shaped chart, with
ally all subsequent discussion of the idea that the base of the U representing the familiar AA
alcoholism is a progressive disease with rela- view of having to "hit bottom" before starting
tively distinct phases and symptoms of increas- on the road to "rehabilitation." This chart has
ing severity rests on this work by Jellinek. become an almost universal tool in alcoholism
This addictive process was said to occur in treatment centers throughout the world to de-
four major stages, identified by 43 specific scribe the "natural history" of the disease.
symptoms (Fig. 3): the prealcoholic phase, That Jellinek "discovered" these phases of
marked by the decided increase of drinking to alcohol addiction in the AA data is not surpris-
Purely symptomotic Additive phoses superimposed over

phoses symptomotic drinking
r---------~&~------~, ,r____________________ ______________________
--JA~ ~
Onset of Onset of Onset of

"alcoholic palimpsests" loss of control prolonged intoxications
Increase in 31
Decrease in
alcohol tolerance 23"567 32 33 34 3S 36 alcohol tolerance
~7 383940414243
Occasional Constant
relief I relief
drinking Idrinking
'-------.,V".----~I '--.r---' ~~------------.....v,--------------'I ,'-------......vr --------',

Prealcoholic Prodromal Crucial phase Chronic phase
phase phase
fig. 3. Phases of alcohol addiciton. Large bars denote the onset of majOr symptoms which initiate
phases. Short bars denote the onset of symptoms within a phase. Numbers above bars refer to the
identities of the specific symptoms, which may be found in the original Jellinek article. (Reprinted
by permission from Jellinek, E. M Phases of alcohol addiction. Alcohol, 1952, 13, 673-684. Copy-
right by Journal of Studies on Alcohol, Inc, New Brunswick, NJ 08903.)
ing. Not unlike the discoveries of hyperactivi- and the "dipsomaniac" or "inebriate," be-
ty and child abuse discussed in Chapter 6. lel- tween the social drinker who sometimes "goes
linek's view of alcoholism as a progressive dis- too far" and the "alcoholic," identifies the lat-
ease with definable phases is in part a prod- ter as qualitatively rather than merely quanti-
uct of the way he approached his data. The dis- tatively different from the former. Alcoholism,
covery of such diagnostic categories from a so- then, becomes a particular kind of deviant
ciology-of-knowledge perspective can be seen drinking behavior. As sociologist Selden Bacon
as a product of the values, knowledge, and be- (1958) has suggested, "alcoholics don't drink."
liefs held by their discoverers. The progressive What Bacon means is that when we speak of
and increasingly severe phases lellinek saw in alcoholism, inebriety, or chronic drunkenness,
the AA members' responses become then an al- we refer to only a relatively small segment of
most inevitable consequence of the disease- so-called deviant drinking behavior. Disease
addiction perspective he adopted at the outset. concept advocates were interested in making a
The concept of disease, particularly when clear distinction between drinking that results
used in clinical settings, conveys an image of in personal and even social problems (e.g.,
process and progression (Fabrega, 1972; Room, drunk driving. absenteeism on the job, etc.) and
1974). lellinek's discovery of the phases of drinking that is alcoholic. The first type of
increasingly "implicative" drinking in AA drinking problem was believed to be primarily
members' responses (people already convinced the product of "enough" alcohol-anyone
of the disease nature of alcoholism) is remi- could get drunk and become "disinhibited" or
niscent of Erving Goffman's (1961, p. 145) dis- irresponsible. It was, however, the latter set
cussion of the" obvious" mental illness hospital of drinking symptoms-repetitive, highly con-
staff sometimes see in case histories constructed sequential, impervious to all pleas of both emo-
for patients already diagnosed as mentally ill. tion and reason-that was to be given the label
Varieties of alcoholism: disease and "alcoholism." In his phase paper and subse-
non-disease types. Another major pur- quent work lellinek sought to reaffirm, once
pose of the phase paper was to reiterate and and for all, these important distinctions.
clarify an important distinction central to the lellinek argued that there are two subcatego-
alcoholism-as-disease perspective. Drinking ries of alcoholics: "alcohol addicts" and "ha-
that results in problems of living, or "problem bitual symptomatic excessive drinkers." Al-
drinking," while important in its own right, though both kinds of drinkers have "under-
had to be kept distinct from drinking that is to lying psychological or social pathology" that
be called a disease. This distinction is most im- leads to drinking, only the alcohol addict, after
portant to the viability of the disease view: first, a period of years of such drinking, develops a
because it serves to define the boundaries with- "loss of control" over drinking. Such persons,
in which medicine could (and should, accord- lellinek argued, are addicted to alcohol (as evi-
ing to lellinek) operate; second, it suggests that denced by their loss of control) and are there-
forms of deviant drinking not properly seen as fore clearly diseased. lellinek (1952)* attempts
diseases should be "managed only on the level to clarify this distinction:
of applied sociology, including law enforce-
ment" (Jellinek, 1952). These nondisease The disease conception of alcohol addiction does not
forms of drinking behavior are thus defined as apply to the excessive drinking, but solely to the
loss of control which occurs in only one group of
moral problems to be met on moral terms. Dis-
alcoholics and then only after many years of exces-
eased drinking, suggests lellinek, is rightfully sive drinking. (p. 674, emphasis added)
a medical problem that deserves the serious at-
tention of and treatment by the medical profes-
sion and public support for such treatment. *Quotations from Jellinek (1952) reprinted by per-
mission from Quarterly Journal of Studies on Al-
This long-time distinction between people cohol, Vol. 13, pp. 673-684, 1952. Copyright by
who get drunk and "common drunkards," Journal of Studies on Alcohol, Inc., New Brunswick,
between someone who is acutely intoxicated N.J. 08903.
Anxious to separate drinkers who suffer pri- according to Jellinek, the ability to control
marily from an underlying psychiatric condition whether he will begin to drink in any particular
from those whose major affliction is the uncon- situation. Laying aside the AA emphasis on al-
trolled drinking itself, Jellinek (1952) con- cohol's triumph over the drinker's will, Jellinek
tinues: says that such a notion deludes the addicted
alcoholic into believing that it is possible to re-
There is no intention to deny that the non-addictive
alcoholic is a sick person; but his ailment is not the gain control over drinking by mastering his
excessive drinking, but rather the psychological or defective will. "He is not aware," writes Jel-
social difficulties from which alcohol intoxication linek (1952) "that he has undergone a process
gives temporary surcease. (p. 674) which makes it impossible for him to control
his alcohol intake" (p. 680).
The precise nature ("psychopathological" or a This physiological view of alcohol addiction
"physical pathology") of the addictive process and loss of control over drinking reflects the
detailed in his phase progression was unclear,
dominant, "official" view of addiction held at
but Jellinek (1952) believed that the "fact that the time Jellinek developed his ideas. It was a
this loss of control does not occur in a large conception influenced heavily by the American
group of excessive drinkers would point toward legal and medical experience with narcotics and
a predisposing X factor in the addictive alcohol- opiates (discussed in the following chapter).
ics" (p. 674). Regardless of whether this factor Basic to this view of addiction were the physio-
were innate or acquired, such a view defines
logical elements of increased bodily tolerance
the source of drinking behavior to be an en- leading to increased intake (one must take more
tity seated in the individual's body and/or to get the same physical effects) and the devel-
mind. opment of a withdrawal syndrome at the end
This characterization of the disease of alco-
of a period of continued "heavy" drinking.
holism as alcohol addiction causing a loss of
The conventional understanding of how this
control over drinking gave a renewed buoy-
physical inevitability of addiction operated was
ancy to medical definitions of such drinking be-
that the addicted person, somehow knowing
havior. Similar to the physical allergy concept
automatically that he or she is addicted and
at the heart of AA ideology, Jellinek's discus-
must have continued amounts of the drug in
sion of addiction and loss of control rest on an
question, is driven by this physical inevitability
assumption that these were, at bottom, physi-
("compulsion"?) and therefore cannot control
cally based phenomena. Walking a careful line
his or her drinking. This is a clear example of
between his phychiatric and "medical" col-
the drug-centered model of drinking behavior in
leagues, Jellinek (1952) said loss of control
which the drug is portrayed as the "cause" of
means that "any drinking of alcohol starts a
the deviance or, in this case, the sickness of
chain reaction which is felt by the drinker as
addiction and loss of control. Ironically, it is the
a physical demand for alcohol" (p. 679). As
formulation of the disease concept as a physio-
to what holds the drinker to a pattern of con-
logically based alcohol addiction that was the
tinuing excessive drinking, Jellinek (1952) said
fertile soil in which subsequent and successful
that after
scientific attacks on these ideas were to grow.
recovery from the intoxication, it is not the loss of The distinction between the disease and non-
control-that is, the physical demand, apparent or disease varieties of alcoholism in terms of ad-
real-which leads to a new bout of drinking . . . . diction became the centerpiece of Jellinek's
The renewal of drinking is set off by the original (1%0) major work, The Disease Concept of
psychological conflicts or by a simple social situa-
Alcoholism, culminating nearly two decades of
tion which involves drinking. (p. 680)
research and writing. This work is in some
It is not, then, the loss of control that gives rise senses paradoxical. It provides an exhaustive
to new bouts of drinking. Once drinking is start- and critical review of relevant previous research
ed, however, the drinker "has lost the ability on the disease question; it contains a more care-
to control the quantity." The drinker retains, ful classification of types of alcoholism, Jelli-
nek's well-known Greek-letter typology; but it is characteristic of certain European countries,

also offers a definition of alcoholism that mol- particularly France.
lifies considerably any clarifications achieved As we noted earlier in this chapter, such
in other regards. lellinek (1960), ignoring his disease conditions could not develop without
own earlier caution against vague and inclusive alcohol drinking. Under the disease concept,
definitions, calls alcoholism "any use of alco- however, the initial causes of such drinking are
holic beverages that causes any damage to the not seen as particularly important in under-
individual or the society or both" (p. 35). One standing the disease entity itself. Stressful or
could hardly imagine a more inclusive defini- ambivalent social and cultural environments
tion. Selden Bacon (1976) has documented and personal problems deemed important by
such imprecise and careless conceptualization social scientists* seeking to explain drinking
as common to alcohol studies, but it must have behavior become only background information
been particularly disconcerting for lellinek' s of little significance in distinguishing the
supporters and colleagues that the 20th-century addicted alcoholic from the problem or even
master of the disease concept would have "social" drinker. The key explanatory mech-
stepped so explicitly into this trap. anism used to account for the puzzle of the
Definitional problems aside, lellinek's apparently irrational behavior of the alcoholic
(1960) Greek-letter typology of alcoholism did drinker is the vague, almost mysterious, con-
provide a clarifying foundation for future re- cept of addiction. Alcoholism (certain varie-
search and debate and an even stronger reitera- ties, at least) is a disease because it is an ad-
tion of the physical metaphor of addiction. He diction. Addiction involves the "loss of con-
identified four major types: Alpha, Beta, Gam- trol" over drinking (equally mysterious), which
ma, and Delta (pp. 36-39). Alpha is the ideal is direct evidence of the existence of a disease.
type of symptomatic drinking discussed in his It is a person-specific, circular, and medical
1952 essay; Beta refers specifically to all explanation for a pattern of deviant behavior.
physical disease conditions resulting from pro- Challenge and defense: Mark Keller
longed substantial drinking, what we have and the posf-Jelilnek era. Since lellinek's
called "medical consequences." lellinek ar- death in I %3 the leading advocate for the
gues that only the Gamma and Delta types qual- disease concept has been Mark Keller, a prod-
ify as diseases. These two types share three ele- uct of the Yale center and long-time associate
ments in common: (I) acquired increased tissue of lellinek, who has been influential in editing
tolerance to alcohol, (2) adaptive cell metabo- The Journal of Studies on Alcohol since its
lism, and (3) withdrawal symptoms. These inception. Keller, widely considered an "ex-
three conditions lead to "craving" or physical pert" on alcohol studies, does not occupy the
dependence on alcohol. In addition, Gamma al- stature of lellinek or Haggard. He is not a sci-
coholics display a loss of control over how entist by training, has no advanced degrees in
much is drunk, involving a progression from any special field, is described respectfully by
psychological to physiological dependence. his associates as a "scholar's scholar" (Bacon,
lellinek identifies this type as most typical of 1977), and is noted for his administrative and
the United States, as causing the greatest per-
sonal and social damage, and as the type of
alcoholism recognized by AA. Delta alcoholics *Edwin Lemert (1969) suggests that most tradition-
differ from Gammas in that they show no loss al sociocultural theories of deviant drinking adopt
a "symptomatic" approach. These theories-an-
of control over quantity of intake, but rather omie, status deprivation, anxiety reduction, and am-
over the ability to abstain for any significant bivalence-define such drinking as a personal
period of time. As a result, this type of alcohol- symptom of a prior social and cultural disturbance.
ic, while suffering from the disease of alcohol- They share with psychiatry a view of drinking pri-
ism, rarely experiences the devastating conse- marily as an indicator of more important underlying
problems. See Room (1976a) for a critical review of
quences of Gamma alcoholism and therefore the highly popular sociological explanation that devi-
presents a less urgent medical and social prob- ant drinking in the United States is caused by Ameri-
lem. lellinek suggests that this drinking pattern can social and cultural ambivalence about alcohol.
political skills as an archivist of the alcohol of control, the concept "addiction" -with its
literature and a tireless advocate of the disease earlier heavy emphasis on tolerance, increased
view. dose, withdrawal, and harm had been redefined
Keller, like Jellinek, argues that alcoholism by the World Health Organization (1964, 1969)
is a medical condition, a "psychogenic depen- as "dependence." In place of the earlier opiate-
dence on or a physiological addiction to" alco- influenced focus on the dangerous "hook"
hol. The defining characteristic of the condi- believed inherent in the drug, the new empha-
tion is "loss of control" over drinking. He sis was given to the user's "perceived need" to
translates this latter idea as follows: "when- continue using the drug (Davies, 1976, p. 61).
ever an alcoholic starts to drink it is not certain During this 20-year period, official definitions
that he will be able to stop at will." The "evi- of the "glue" believed to hold individuals to re-
dence" for such loss of control is found precise- peated drug use as physiological had been aban-
ly in the drinker not controlling that which doned (Room, 1973, pp. 1-6), and the link be-
should be controlled: tween such drug use and "harm" considerably
deemphasized. The anomalous idea of "con-
The key criterion, for all ill effects, is this: Would the trolled addiction" or "primary psychological
individual be expected to reduce his drinking (or give dependence" involving dependence but no de-
it up) in order to avoid the injury or its continu- viance (Davies, 1976; Seevers, 1968) had di-
ance? If the answer is yes, and he does not do so, luted further the importance of physical addic-
it is assumed-admitting it is only an assumption tion as the prototype of addiction.
-that he cannot, hence that he has "lost control
Social scientists, and particularly sociologists
over drinking," that he is addicted to or dependent
on alcohol. This inference is the heart of the matter. Alfred Lindesmith (1947, 1968), Howard
Without evident or at least reasonably inferred loss Becker (1953; 1967a), and Jock Young (1971),
of control, there is no foundation for the claim that had made convincing arguments that the physi-
"alcoholism is a disease," except in the medical cal dependence model of addiction is both over-
dictionary sense of diseases . . . caused by alcohol simplified and misleading. They held that an
poisoning. (Keller, 1960, p. 132)* understanding of both the drinker or drug
user and the cultural definitions surrounding
It is on the basis of such "reasonably inferred such use is essential to clarify the origins and
loss of control" that the disease status of alco- nature of addiction. Repeated drug taking is
holism rests. It is not surprising that scientists not the automatic consequence of the drug's
and physicians have been skeptical of the valid- pharmacological properties but rather a com-
ity of the idea that alcoholism is a disease, par- plex process wherein the individual learns to
ticularly in the hands of Keller. use the drug under particular circumstances.
So important is this loss of control idea to the Howard Becker (1967a) argues that such
life of the disease concept that Keller (1972b) learning is linked to the user's recognition and
wrote a subsequent essay devoted entirely to definition of physical withdrawal:
its defense. This and an even more recent article
One can only be addicted when he experiences physi-
titled ' 'The Disease Concept of Alcoholism ological withdrawal symptoms, recognizes them as
Revisited" (I 976a) , represent interesting and due to a need for drugs, and relieves them by taking
important attempts to simultaneously align the another dose. The crucial step of recognition is
disease concept with new and critical scientific most likely to occur when the user participates in a
knowledge and defend it as morally sound. culture in which the signs of withdrawal are interpre-
Keller (1972b) avoided what appeared to be the ted for what they are. When a person is ignorant of
most vulnerable part of Jellinek's formulation, the nature of withdrawal sickness, and has some
the emphasis on physical dependence as the seat other cause to which he can attribute his discom-
of loss of control over drinking. fort . . . he may misinterpret the symptoms and thus
escape addiction. (po 175)
By the time Keller wrote his defense of loss 0 0 0
This view emphasizes the importance of mean-

*From Keller, M. Definition of alcoholism. Q. J. ings and ideas as mediated by the interpretive
Stud. Alcohol. 1%0,21, 125-134. actor. This, and a variety of less symbolic
learning theory arguments, coupled with the by the drinker can prevent a bout of drinking. In
proliferation of the "abuse" of "good" drugs addition, the drinker is not likely ever to know
during this 20-year period, provided the intel- the precise nature of the critical cues and signals
lectual and political context in terms of which that set off his uncontrolled drinking. This is
Keller's earlier defense of "loss of control" why abstinence for the alcoholic is the most
was written. He chose to ignore all. such argu- prudent course; he does not know when or why
ments. his drinking may become uncontrolled.
Keller proceeded instead to deemphasize Although Keller suggests that he has clarified
Jellinek's focus on the physical dependence the confusion surrounding loss of control and
typical of the Gamma type of alcoholism. He its operation in alcoholism, he has in fact re-
argues that Jellinek was unduly influenced in treated into the circularity and mystery of his
such thinking by the AA ideology of an allergic previous definitions. Although the drinker is no
sensitivity to alcohol. Jellinek's idea that when longer at the mercy of physiological and phar-
an alcoholic drinks, there is some kind of auto- macological process, Keller has offered even
matic physiological chain reaction producing more obscure forces - unknown and almost
craving and an inability to stop drinking is mir- unknowable cues and signals-that, although
rored in the AA slogan "One drink away from a they are learned, are beyond the recognition or
drunk. " This idea had been fundamental to the control of the individual. It is apparent that he
disease concept. Since its early statement in has ignored the social science criticisms of the
Jellinek's works, however, scientific research physical dependence model of addiction. This
to test this proposition had been underway. The is evident in the language he uses to describe
accumulating evidence did not support this how these cues operate. They "impinge" on
idea, and Keller had little choice but to ac- the drinker, who is under their "impulse" and
knowledge these results. In summarizing this "influence" and who requires some "exter-
research, he says: "none of the subjects in these nal" circumstances to free him or her from their
experiments were precipitated into a bout of grip. Although Keller (l972b) cites a variety of
drinking by the first drink or even by a con- well-placed scientific criticisms, he concludes
siderable amount of drink" (Keller, 1972b, his defense sounding like a traditional advocate
p. 156). If alcoholic loss of control is not auto- of the disease concept: "There comes an oc-
matic on drinking, then it must involve mecha- casion when [the drinker] . . . is powerless,
nisms peculiar to the particular drinker and the when he cannot help drinking. For that is the
drinker's experience. The specific source of essence or nature of a drug addiction. And that
loss of control then varies from one drinker to indeed is why I am sure alcoholism is a dis-
the next. It is, in other words, drinker specific. ease" (p. 162). Keller warns that critics' asser-
Having dethroned physiological reactions to tions that alcoholics may exist who have not
alcohol as the primary form of diseased drink- lost control "can cause confusion in the public
ing, Keller (l972b, p. 160) reiterated his 1962 mind, loss of confidence on the part of pa-
definition of the concept: "if an alcoholic takes tients, erroneous jurisprudence, and misdirec-
a drink, he can never be sure he will be able to tion of effort by government agencies" (p.
stop before he loses control and starts on a 163).
bout." The trigger, or, as Keller says, the "cue It is this final caveat that is most revealing
or signal," that precipitates such loss of con- about the status of the ideas that alcoholism is a
trol may take any number of divergent forms, disease and alcoholics sick persons. These cau-
and the connection between such cues and tions are not based on evidence or scientific
drinking found in addiction' 'is thought of as a argument but rather on values, ideology, pub-
form of learned or conditioned response." lic opinion, politics, and control. In a society
Alcohol itself, or a "particular blood alcohol that holds persons responsible for behavior that
level," may even be such a cue. The important they presumably can control, the viability of the
thing, argues Keller, is that when such cues disease concept of alcoholism rests squarely on
are elicited, no amount of rational calculation the assertion that such drinkers lack such con-
trol and are therefore to be helped rather than idea. He is first a disciple who argues that the
blamed. Keeping this belief alive and well is a disease concept is revealed truth and that skep-
job for entrepreneurs and politicians, not tics, be they physicians or social scientists, are
scientists. It is toward this end that Keller's heretics. Such, of course, is the quality of ideo-
efforts are directed. logical debate.
This is perhaps most clear in Keller's (1976a)
latest response to critics, "The Disease Con- IS ALCOHOLISM A DISEASE?
cept of Alcoholism Revisited." In a tone of Whether alcoholism is a disease, given our
impatience and disdain for skeptics, buttressed discussion, is both a reasonable and inevitable
by circular reasoning and argument by analogy question. Our historical-constructionist per-
(Brandsma, 1977), Keller (1976a) attempts to spective on the medicalization of deviance al-
vanquish foes of the disease concept by a va- lows us to conclude that apparently it is, but not
riety of ad hominem arguments attacking the because we say so and not in the same sense
critics' motives: that Rush, lellinek, Keller, or AA have drawn
It is possible that some people look with envy-un-
such conclusions. Alcoholism is a disease be-
conscious, of course-at those fellows who are hav- cause it has been defined successfully as such,
ing an uproariously good time at everybody else's particularly since 1940. The high points of
expense, getting irresponsibly drunk and then de- this successful contest have, for the most part,
manding to be cared for and coddled-at public cost, been noted: the rise of the Yale center, the
yet. founding and growth of the international or-
Another motive is apparent in those who, not ganization AA, the active and successful cam-
being M.D. 's, think they know better than doctors paigns of the NCA, lellinek's and Keller's
how to treat alcoholism. . . . It is understandable work and the attention it has received, and,
that some people would feel uncomfortable-they finally, the rapid growth of an independent fed-
might even perceive it to be illegal-to be treating a
eral bureaucracy, the NIAAA, premised on the
disease without a license to practice medicine. But if
only it is not a disease-why, then, they are in busi-
ideas that alcoholism is a chronic disease and a
ness! (p. 1711)* major health problem.
We suggested at the beginning of this chap-
Not only are such critics of the disease con- ter that an interesting feature of the medicaliza-
cept misguided and even self-seeking, but they tion of such deviant drinking is that medical
become, at Keller's hands, obstructionist, anti- personnel and official medical organizations
medical, and unhumanitarian. Perhaps worst of have chosen to remain by and large on the pe-
all, they are cast ironically into the role of mod- riphery of this contest. Our historical overview,
ern-day moral crusaders against alcohol and however, does portray some physicians as ac-
drinking. tive supporters of this idea. For example, Rush
Keller's polemical reaction to critics is cu- and his temperance colleagues, the few physi-
rious. Why the emotional and moral tone of his cians who operated and supported the inebriate
defense? Clearly, challenges to the idea are asylums in the late 19th century, Dr. Silkworth
challenges to established and entrenched groups who gave AA its allergy concept, and those
and interests whose livelihoods depend on the physicians involved in research and writing at
viability of that idea. We have identified some the Yale center during the 1940s and 1950s
of these groups and interests in this social his- were central figures in this history. Although
tory of the disease concept. Keller's attempts some of these physicians had high professional
at "logic" to the contrary, he has become one and social prestige, they were few in number
of the last surviving crusaders on behalf of this and, more often than not, were psychiatrists-
practitioners of a specialty of relatively low
status in the medical community.
* Reprinted by permission from Journal of Studies
on Alcohol, Vol. 37, pp. 1694-1717, 1976. Copy- The success of the definitional change that is
right by Journal of Studies on Alcohol, Inc., New medicalization must rest ultimately on either
Brunswick, N.J. 08903. passive acceptance (mostly ignoring but not
challenging) or official recognition by the estab- "epileptics" and "blind persons," alcoholics
lished representatives of the medical profes- elicited the greatest intolerance and the least
sion. Prior to 1940 it appears that the disease favorable responses from her respondents. Ries
concept was either ignored or at least not chal- concludes that on the.basis of her analysis, "al-
lenged by the American medical establishment, coholism is not defined and reacted to 'just like
although there were a few physicians who any other illness.'''
treated the chronically intoxicated seriously as In another recent study replicating a 1963
patients. In addition, there were certain moral research (Mulford, 1964) on physicians' atti-
and social class stigmas associated with re- tudes toward alcoholics, Harold Bischoff
peated intoxication, particularly if it were pub- (1976) found that when asked their "personal
lic. Physicians, since the early 20th century, view" of the alcoholic, only 28% of the 198
have occupied a relatively high social class and physicians sampled described such persons
prestige position in America. They were, in the solely as "sick" (as opposed to "morally
language of the 1960s, members of the "Estab- weak," "weak-willed," "criminal," or other
lishment"; persons with a good deal invested in descriptions). When comparing his results to
the dominant social and economic status quo. those obtained from a similar sample in the
Public drunkards or "skid row" types were be- original study, Bischoff found that there had
lieved to be just the opposite. They were seen been a decided decline in the popularity of this
as unable to exert self-control, perhaps the "sick person" description as the most accurate
prime middle-class virtue, and were considered view of the alcoholic patients (from 45% in
irresponsible, lacking self-pride, and without 1963). Finally, on the subject of the alcoholic's
any motivation to mend their ways. responsibility for his condition, Bischoff found
Physicians' belief in this skid row stereotype, that 60% of his physician sample believed such
along with the personal and social differences persons were "totally" or "mainly" respon-
between them and their alcoholic patients, sible, whereas only 2% said they were "not at
were not conducive to establishing the rapport all" responsible for their condition.
thought so necessary for effective treatment. These attitudes, coupled with the common
A review of a series of studies on physicians' at- medical practice of referring detoxified alco-
titudes toward alcoholic patients beginning in holic patients to nonmedical organizations such
the mid-I940s (Riley & Marden, 1946; Straus, as AA, represent something less than enthusi-
1952; Wolf et aI., 1965; Corley, 1974; Bis- astic support among practicing physicians for
choff, 1976) provides evidence of this skeptical the idea that alcoholism is a "real" disease.
and often hostile stance. Common to all these These definitions and treatment strategies have
studies are various descriptions of the alcoholic prevailed for almost four decades in the United
patient as "weak," "weak-willed," "uncoop- States, despite the strength and successes of the
erative," "troublesome," "hopeless," and a alcoholism movement we have described. In
"waste of time." Endorsements of the idea that light of these and similar findings, it becomes
the alcoholic is a sick person were common, apparent that the "victories" in medical rec-
although rarely were such descriptions offered ognition of the disease concept claimed by
without qualifying negative moral judgments. movement leaders have been perhaps more
These findings are paralleled in two studies of symbolic than substantive (Gusfield, 1963).
attitudes toward the alcoholic in the general The most important symbolic medical recogni-
population. In a 1961 survey Harold Mulford tion is found in the official support given the
and Donald Miller (1964) found that although disease slogan by dominant medical organi-
65% of their sample agreed that the alcoholic zations.
was a "sick person," only 24% accepted the
sickness view without some kind of moral judg- Medical response to the disease
ment attached. In a more recent study, Janet concept
Ries (1977) found that alcoholics were defined One of the most frequent defenses of the
as "unpredictable" and "responsible" for their proposition that alcoholism is a disease is that
behavior. In comparison with the categories the medical profession recognizes it as such.
This argument usually makes reference to of- unspecified alcoholism." Although this latter
ficial resolutions, committees, or publications classification is somewhat reminiscent of Jelli-
of various medical organizations, most notably nek's phase progression, the primary identifi-
the AMA. A famous example of this argument cation of alcoholism as a mental disorder is
was proposed by Jellinek (1960) himself in an certainly not. Such a definition is also at odds
attempt to address this definitional problem: with AA ideology. Although inclusion in these
official registers of disease does give credibility
Physicians know what belongs in their realm . . . a
to the statement that alcoholism is a disease, it
disease is what the medical profession recognizes as
should not be seen as an unbridled endorsement
such . . . . the medical profession has officially ac-
cepted alcoholism as an illness, whether a part of the
of what we have called the traditional disease
public likes it or not, and even if a minority of the concept.
medical profession is disinclined to accept the idea. Another commonly cited example of the
(p.12) medical profession's alleged support of the dis-
ease concept is the formal resolutions contained
Jellinek was content to leave the issue at that in reports of the Board of Trustees of the AMA
and get on with specifying the nature and types to its House of Delegates. These statements
of this malady. have originated typically in the Committee on
The official acceptance to which Jellinek re- Alcoholism, formed in 1954 under the direction
fers has assumed two primary forms: the in- of the AMA Council on Mental Health. The
clusion of "alcoholism" in the official manuals first such resolution from this committee was
of medical diagnosis and classification used by issued in 1956 and was followed shortly there-
the medical profession, and specific AMA reso- after by a similar statement from the Ameri-
lutions and publications defining alcoholism as can Hospital Association. It addressed the prob-
a medical problem to which physicians should lem alcoholics face in gaining admission to gen-
direct their attention. The three major diagnos- eral hospitals for treatment of drinking-related
tic classifications of diseases usually noted in problems. It is cited commonly as evidence of
such discussions are the AMA's Standard No- the medical profession's "recognition" of the
menclature of Diseases and Operations (1961), disease of alcoholism and is the basis for Jelli-
the International Classification of Diseases nek's remarks quoted earlier. The resolution
(ICD) (1968), and their psychiatric counterpart, (1956) begins by identifying "excessive drink-
published by the American Psychiatric Associa- ing" as a "personality disorder" (consistent
tion, The Diagnostic and Statistical Manual with the official nomenclature), and goes on to
of Mental Disorders (DSM). These manuals give a vague characterization of alcoholism and
provide the medical community with adminis- the medical profession's responsibility toward
tratively useful classifications for diagnosis and it:
record keeping. They are organized into sec-
tions on the basis of the believed locations of When, in addition to this excessive use, there are cer-
tain signs and symptoms of behavioral, personality
the disease or disorder in the person. All these
and physical disorder or of their development, the
official publications identify alcoholism as a syndrome of alcoholism is achieved. The intoxica-
mental disorder. More specifically, it is a tion and some of the other possible complications
"personality disorder," including, in the ICD manifested in this syndrome often make treatment
and DSM-II, the classification "alcohol difficult. However, alcoholism must be regarded as
addiction." The Standard Nomenclature of the within the purview of medical practice. The Council
AMA (1961, p. 112) does not actually contain on Mental Health, its Committee on Alcoholism, and
the word "alcoholism" but rather uses the clas- the profession in general recognizes this syndrome
sification "OOO-x641 Alcohol addiction chron- of alcoholism as illness which justifiably should have
ic." The ICD (1968, p. 175) and DSM-II (1968, the attention of physicians. (p. 750)*
p. 10) manuals do use the word "alcoholism"
and subdivide it as follows: "Episodic exces-
sive drinking," "Habitual excessive drink- *FromJ.A.M.A., 1956,162,750. Copyright 1956,
ing," "Alcohol addiction," and "Other and American Medical Association.
This resolution continues and suggests one rea- being a victim of it does not free the sick person
son that some physicians may have been less from responsibility for deviant behavior com-
than enthusiastic about treating alcoholics: mitted when sick. Given our discussions of
hospitals often refuse to admit them as patients. mental illness (Chapter 3) and the history of
The committee encourages all general "hospital criminal responsibility (Chapter 8), it is appar-
administrators and the staffs . . . [to] look upon ent that alcoholism is seen here as a different,
alcoholism as a medical problem and to admit less incapacitating kind of sickness.
patients who are alcoholics to their hospitals for
treatment . . ." (p. 750). Supreme Court and the disease
Although this resolution is indeed a formal concept
recognition and reaffirmation of alcoholism as The explicit reference to the legal responsi-
a medical problem, it is perhaps most signifi- bilities of the alcoholic in the 1967 AMA reso-
cant in its vagueness about the condition and its lution was no accident. During the decade since
treatment. Noticeable by its absence is any the first resolution, three important court de-
mention of "loss of control" or "addiction," cisions were handed down that bore directly on
either in the quoted segment or anywhere else the viability of the disease concept. The first
in the report. It is, of course, this idea that is case,Robinson v. California, in 1962, involved
the heart of the traditional view. In addition, the the use of opiates and the issue of whether ad-
connection between drinking and the alleged diction produces a loss of control that prevents
disease is left obscure, the statement asserting the user from regulating use of the drug in ques-
only that the "behavioral, personal, and physi- tion. Its import for the disease concept is found
cal disorder" exists "in addition to" drinking. in the Supreme Court's argument that drug ad-
The traditionally important distinction between diction is indeed an illness, a key characteristic
medical consequences of drinking and some of which is loss of control over ingestion of the
specific disease entity called "alcoholism" is drug. The Court said it is a violation of the
omitted. Eighth Amendment to punish a person for dis-
A similarly obscure AMA resolution was playing the direct symptoms of an illness; that
made a decade later, in 1967. Premised on the such punishment is indeed ' 'cruel and un-
assumption that the medical profession could usual. " Two subsequent cases, both decided in
"attack" the "disease of alcoholism" in the 1966, involved men who had been medically
same successful fashion used with other dis- identified as alcoholics. The issue was whether
eases, it contains the following statements: they should be punished for public intoxication.
These are the well-known cases of Driver v.
Resolved, that the American Medical Association
identifies alcoholism as a complex disease and as Hinnant and of Easter v. District of Columbia
such recognizes that the medical components are (Kittrie, 1971, pp. 278-289). In both cases the
medicine's responsibility . . . . Such recognition is Court decided in favor of the defendants, argu-
not intended to relieve the alcoholic of moral and ing that since medical authorities considered al-
legal responsibility, as provided by law, for any acts coholism a disease, one of the defining charac-
committed when inebriated; nor does this recogni- teristics of which is uncontrollable intoxication,
tion preclude civil arrest and imprisonment, as pro- the sick alcoholic should not be punished as a
vided by law, for antisocial acts committed when criminal for such drunkenness. To do so, they
inebriated. (Quoted in Wilbur, 1969, p. 12) argued, is unconstitutional, based on the Eighth
Two important points about this position should Amendment protection. In the Driver case,
be made. First, the medical profession claims however, the Court made it clear that the deci-
only responsibility for treating the "medical sion in no sense exempted alcoholic persons
components" (medical consequences?) of alco- from responsibility for other deviant and unlaw-
holism, the determination of which they as ful behavior committed while intoxicated; the
medical experts control. Second, there is a protection extended only to public intoxication.
strong moral and legalistic reference to the ef- This, of course, is mirrored in the AMA reso-
fect that although alcoholism may be a disease, lution.
The Driver decision addressed specifically by proving both an "inability to abstain" from drink-
the question of how such publicly intoxicated ing in the first place and a total "loss of control"
sick persons should be treated. It argued, "Of over his conduct once he had commenced to drink.
course, the alcohol-diseased may by law be (p. 288)*
kept out of public sight" and that while confine- In addition, they argued that there were no ade-
ment in jail is unconstitutional, their ruling did quate facilities to provide medical treatment to
not preclude "appropriate detention . . . for alcoholics and that to strike down existing
treatment and rehabilitation so long as he is not practices of incarceration would result in
marked as a criminal" (quoted in Kittrie, 1971, "thousands of alcoholics . . . roving the
p. 281). The Easter decision, rendered a few streets." Finally, the justices were concerned
months later, directly affirmed the Driver argu- about the possible negative effects of such a
ments. The immediate effects of this latter deci- ruling on the constitutional doctrine of criminal
sion were to divert arrested alcoholics in Wash- responsibility. (Bacon, 1969).
ington, D.C., from the customary jail sentences ThePowell case was a decided setback in the
to medical treatment facilities. To the frustra- progress of the disease concept. Not only did it
tion both of the courts and medical personnel, it provide the opportunity for the Supreme Court
became immediately apparent that there simply to evaluate the idea and relevant evidence, it
were neither adequate facilities nor treatments also was the occasion for a number of critical
available for this newly created population of articles in which the disease concept was at-
"patients. " The practical solution of many tacked (see Fingarette, 1970). Perhaps most im-
judges was simply to set such persons free, with portant, the Court opinion contained a clear
neither punishment nor "treatment." Others criticism of the medical profession, both for the
used long-established civil commitment laws to poor state of its knowledge of the nature and
confine alcoholics in mental hospitals for obser- cause of alcoholism and for the limited number
vation and care. It was generally agreed by both of medical treatment facilities available for al-
legal and medical authorities that such a situa- coholics. Pressed between the demands of the
tion was undesirable. moral entrepreneurs of the alcoholism move-
A fourth and perhaps most important case de- ment and the less than laudatory remarks of the
cided 2 years after Driver and Easter signaled Supreme Court, the medical profession had
judicial dissatisfaction with the consequences of little choice but to accept the challenge, at least
the earlier rulings. In the 1968 case of Powell at a public and official level. t
v. Texas the Supreme Court was faced with the This tentative and somewhat uncomfortable
same issues it had addressed in the Robinson nature of medicine's embrace of the disease
decision, only this time it was alcoholism rather concept is evidenced in a speech given by the
than opiate addiction that was to be considered. president of the AMA before the 28th Interna-
Contrary to the favorable expectations of alco- tional Congress on Alcohol and Alcoholism in
holism movement advocates and civil liberties 1968. In his remarks President Dwight Wilbur
lawyers, in Powell the Court decided in a five- reiterated that alcoholism is a "disease," a
to-four vote against the alcoholic defendant.
Reacting both to the practical problems created
by the previous decisions and the controversy *From Kittrie, N. The right to be different: deviance
and lack of agreement among medical authori- and enforced therapy. Baltimore: John Hopkins Uni-
versity Press, 1971. © 1971 by the Johns Hopkins
ties on "what it means to say that alcoholism is University Press.
a disease," the Powell majority was not con- tWhen the NCA's committee of physicians issued
vinced by defense arguments. Nicholas Kittrie their statement on the diagnostic criteria for alcohol-
( 1971) highlights the justices' concerns: ism in 1972-attempting to refute the Powell opinion
regarding the poor state of medical diagnosis-an
editorial appeared in the Journal of the American
To permit alcoholism as a defense to prohibited con- Medical Association (1972) proclaiming that "alco-
duct, the Supre'me Court majority felt, an accused holism is a disease" and "applauding" the NCA for
would have to demonstrate a complete lack of fault, its action.
"sickness," an "affliction," and an "ill- FUTURE OF THE DISEASE

ness. He cited the AMA's development of
CONCEPT OF ALCOHOLISM
a "multifaceted program" on alcoholism The idea that alcoholism, or inebriety, or
that his organization adopted that same year. common drunkenness is a disease indeed has
This program consisted of attempts to encour- had a long history. Its fortunes as a definition
age and educate physicians to treat alcoholics, and explanation of repeated intoxication and
to urge general hospitals to admit them, to pro- associated "harm" have risen and fallen in the
vide better teaching about alcoholism in medi- United States now for almost 200 years. Since
cal schools, and to work toward further decrim- 1940 this fortune has been, for the most part,
inalization of public drunkenness. Most telling in ascendance. It has become the official polit-
about the position of the medical profession on ical definition of such drinking behavior in our
the alleged disease entity "alcoholism" are hiS country, as evidenced both by the power of the
remarks about treatment: NIAAA in influencing treatment and research,
and by such federal legislation as The Uniform
Physicians who undertake such a job . . . need all the Alcoholism and Intoxication Treatment Act of
help they can get from organizations that are con- 1974, which is a congressional endorsement of
cerned with this complex and difficult problem ....
whatever its degree, alcoholism is rarely-probably the assumptions on which the disease concept
never-exclusively a medical matter. The physician rests. In addition, private insurance carriers
cannot work alone and have much hope for success. such as Blue Cross and Blue Shield are begin-
He can only do his part in what must be a team effort. ning to cover alcoholism treatment costs, and
(Wilbur, 1969, p. 15) congressional committees deliberating various
national health insurance plans are giving seri-
This is an uncharacteristically modest position ous consideration to including coverage of such
for the medical profession to adopt. Not only is costs.
it implied that the physician needs help from
nonmedical organizations in treating the alco- A coming crisis?
holic, but Wilbur (1969) goes on to describe The advance of this disease model, or para-
the limited nature of this treatment: digm, however, has not been without contro-
versy. We have called it the "contested" med-
If medical attention has not been delayed too long,
the physician probably can restore the patient's ical model of alcohol. Even though this view re-
physical health. He might even be able to calm the mains the dominant political and social force in
patient, mentally and emotionally, sometimes just thinking about chronic alcohol problems, we
by offering the help. And he can at least contribute suggest that over the past decade and a half a
to finding the basic cause of the problem that is mani- "crisis" in the viability of the disease paradigm
festing itself in alcoholism .... (p. 15) has been developing. Whether this political
struggle between disease advocates and a small
Finally, having laid these modest responsibili- but growing band of critics will lead to the rise
ties at the physician's door, he argues that the of a new paradigm for chronic intoxication is
"ultimate" solution to the alcoholic's problem difficult to predict. We can. however, suggest
the nature of this crisis and what its short-range
may have to come from his religious counselor, his development might entail.
employer, his family, his friends, from social
The growing crisis for the disease concept of
workers or other dedicated people trained to deal
with this kind of person. I know of no other medical alcoholism is a product of two developments.
or health problem in which so many groups and so First, critics suggest increasingly that although
many individuals outside of the medical profession perhaps once a humanitarian and practical strat-
can contribute so much toward this solution. (p. 15) egy, it has now outlived its usefulness. One of
the oldest "friends" of the disease view, Sel-
As Selden Bacon (1973) has remarked, "That, den Bacon (1973)-himself a founder of The
to put it mildly, is strange medical practice" National Council on Alcoholism, a colleague of
(p. 23). Jellinek, Haggard, and Keller at Yale, and per-
haps the premier social scientist of alcohol concept presents perhaps the most serious threat
alive today-has said that the disease concept, to its future reign.
although once politically useful, has become an This scientific evidence has developed pri-
obstruction to progress in alcohol studies and marily during the last two decades. Paradoxi-
problem solution: cally, this development grew from an attempt
by disease advocates, especially lellinek, to
Twenty-five years ago this belief acted to tear
down the walls of avoidance, denial, ignorance,
provide a more precise and clear formulation of
cruelty, and hopelessness. Today, however, I see what it means to say that alcoholism is a dis-
signs of its being used as a cop-out. For example: ease. As Nils Christie and Kettil Bruun (1969)
"Let's turn the whole problem over to the doctors, have argued, one function of the "big, fat
it's a disease, isn't itT' This can be seen in efforts of words" so common in alcohol studies is to in-
law enforcement agencies to relieve themselves of sulate the status quo against critical evaluation
responsibility. This can be seen in terms of friends, and scrutiny. Targets cannot be hit unless they
associates, and relatives who can explain away their can be seen clearly. Vague and imprecise con-
possible responsibilities by this new magic just as cepts are particularly disabling of scientific
they could escape by such old magics as ideas of lack evaluation. Unless the terms and arguments of a
of will power, of sin, or of biologic inheritance. This
theory or point of view can be defined clearly
means that research shall be medical, that facilities
and measured empirically, science can offer
shall be medical. And this, of course, reduces the
need for other research, other training, other facili- little to enlighten debate. Such has been the
ties. In the past we turned over these problems to the case for the disease concept.
churches, to the schools, to legislative sales controls, Once the meanings of the claim that alcohol-
to policemen and jails. Now it will be medicine's ism is a disease were specified, however,
tum, and it looks like a nice new cop-out. (p. 24)* science was put to the task of establishing ex-
periments to test them. It is apparent in retro-
It is also possible that with the historical loosen-
spect that once such scientific evaluation be-
ing of moral prohibitions on a wide variety of
gan, it was only a matter of time before the dis-
behaviors, we no longer need to define the alco-
ease concept was under siege. Coupled with the
holic drinker as "sick" to adopt a rational and
practical and moral skepticism echoed by
supportive stance in helping individuals cope
Bacon and other critics (Seeley, 1962; Pattison,
with such behavior. These and similar argu-
1969; Room, 1972; Robinson, D., 1972, 1976;
ments undermine the practical and moral appeal
Pattison et al., 1977; Roizen, 1977), these sci-
of the traditional view, making it appear more
entific challenges to the validity of disease ideas
of an unncessary ruse than a useful guide to ef-
have become difficult for advocates to ignore. It
fective action. The functions it was created to
is ironic that the very vehicle that disease
serve having been largely met, the need for ad-
supporters of the 1940s and 1950s chose to
vocacy is reduced.
launch their argument, medical science, subse-
A second development that threatens the dis-
quently gave birth to the most serious chal-
ease paradigm comes from the accumulation of
lenge to its continued existence. To provide an
what Thomas Kuhn (1970) calls anomalous or
appreciation of the scope and seriousness of this
"difficult" findings that cannot be explained by
criticism, we review briefly its major elements.
the traditional, dominant paradigm. The anom-
alous quality of such evidence is heightened by Scientific claims
the existence of the dominant model itself, for it
First, the proposition that alcoholics have
is only in contrast to it that such evidence be-
predisposing characteristics that consistently
comes difficult, embarrassing, and challenging.
differentiate them from nonalcoholics simply
The accumulation of a growing body of scien-
tific research evidence contrary to the disease has not been supported by research evidence
(Pattison et al., 1977, pp. 61-64). Particularly
fruitless has been the search for an ~'alcoholic
personality" that might then be used to explain
* © 1973 by New York University. such drinking behavior. Even disease advocate
t04 DEVIANCE AND MEDICALIZATION: FROM BADNESS TO SICKNESS
Mark Kel1er (l972a, p. 1147) has remarked that learned, conditioned response. * We have de-
"alcoholics are different in so many ways that scribed the nature of such arguments in some
it makes no difference." Physician Mansel1 detail and, in Keller's 1960 argument, have
Pattison, Mark Sobel1, and Linda Sobell (1977 , pointed out the tautological or circular logic on
p. 62) have reviewed this research and con- which this loss-of-control argument rests. The
clude that "except for sharing alcohol prob- capacity to identify this condition comes pri-
lems, all alcoholics are not the same. " marily from a commitment to the idea that self-
There appear to be, then, no predisposing sys- injurious behavior is not rational and therefore
tematic distinctions between alcoholics and cannot be willful; that, for example, renewed
nonalcoholics, contrary to the disease con- "binge" drinking among alcoholics must there-
cept. fore be beyond their control. Having ruled out
A second proposition fundamental to the dis- moral explanations, advocates propose disease
ease view is Jellinek's idea that alcoholic drink- as the most plausible account. The scientific
ing is a progressive, inexorable process begin- hypothesis derivable from this position is that
ning with "implicative" and "symptomatic" once such drinking begins, it will not be subject
drinking and culminating in severe and "chron- to the drinker's will, and he or she will .stop
ic" alcoholism. This also has been challenged only when the body will not allow the continua-
directly by research evidence. Over two de- tion of drinking. Pattison et al. (1977) conclude
cades ago, Harrison Trice and Richard J. Wahl that whether one chooses the physiological or
(1958) found that there was no systematic clus- more psychological version of this argument,
tering of symptoms alleged to characterize such the scientific evidence has been devastating:
phase movement. These and other authors have "Over the past 15 yeras, an impressive number
offered devastating criticisms of Jellinek's 1946 of studies have robustly demonstrated that even
research on which the phase progression hy- the drinking of chronic, skid-row alcoholics is
pothesis is based. In an important series of lon- subject to their precise control under appro-
gitudinal studies of American drinking prac- priate circumstances" (p. 99). This evidence
tices, Don Cahalan and his colleagues (Cahalan has accumulated over a broad range of both
et al. 1969; Cahalan, 1970; Cahalan & Room, experimental and natural settings. There ap-
1974; Clark & Cahalan, 1976) have demon- pears at this time simply no sound support for
strated that contrary to the prediction of pro- "loss of control" as a valid account for pat-
gressively severe drinking symptoms, a sub- terns of continued drinking among so-called
stantial number of young men in their early alcoholics.
twenties who reported a variety of serious prob- Finally, even the most inveterate of all dis-
lems due to drinking turned out, in subsequent ease concept ideas, the absolute necessity of
interviews several years later, to be "normal" abstinence in the treatment of such drinkers, has
or "social" drinkers. This research has also come under scientific attack. This core idea
demonstrated a good deal of moving "in and has been defended most strongly and con-
out" of what might be called "deviant" drink-
ing behavior over the course of an individual
drinker's life. The progressiveness inherent in *The logically prior question of why an alcoholic
the clinical model of disease appears, then, to resumes drinking was addressed typically in early
versions of the disease argument by proposing the
be inconsistent with the facts of such deviant existence of a "craving," "irresistible desire," or
drinking behavior. compulsion to drink. These were believed to be
A third key hypothesis of the disease para- psychological forces that somehow were linked to a
digm is that if a sober, "dried out" alcoholic mysterious "cell hunger" for alcohol on the physio-
resumes drinking, he will not be able to choose logical level. So controversial and vulnerable were
these ideas (Clark, 1975) that even Jellinek urged
whether to stop drinking. He will, in effect, that they be abandoned in favor of a general social
"lose control" over drinking because of either psychological explanation focusing on the drinker
some physical sensitivity or unconsciously and the drinker's environment.
sistently by AA and the NCA followed faithful, from local AA members to the director
closely by the federal NIAAA bureaucracy. of the NIAAA. Ron Roizen (1977) suggests
It is voiced perhaps most clearly in the that such findings, quite aside from their scien-
aphorism "Once an alcoholic, always an al- tific or substantive implications, can breed
coholic." Second only to loss of control doubt among the many levels of treatment and
as a defining quality of alcoholics is the belief administrative personnel Who comprise the al-
that they simply cannot drink. This propo- coholism establishment. It is a potentially fatal
sition is perhaps most crucial to the contin- challenge to the orthodox ideology on which
ued viability of the disease view. If it can be this establishment rests.
shown that alcoholics could become con- Given the politically volatile nature of this
trolled, "social" drinkers, then the issue of proposition, it is not surprising to find that alco-
choice and responsibility reemerge from the hol scientists approach its evaluation cautious-
humanitarian protection afforded by the sick ly. In their general review of research evidence
role. Such data would refute directly the on the disease concept, Pattison et al. (1977,
mysterious notions of allergy and physiological pp. 120-164) are conservative in drawing their
sensitivity, and force the psychological, con- conclusions on this question of abstinence.
ditioned response version of loss of control After a review of 74 studies designed to test
into the realm of consciousness-as some- some aspect of this hypothesis, however, they
thing we do in fact choose for ourselves. conclude that it is not supported by existing
Diseases are not considered to be such phe- evidence. Some so-called alcoholics have and
nomena. will continue to learn to control their drinking.
The crucial importance of abstinence to the They conclude that this offers a new vista in
life of the traditional view is evidenced by the practical treatment alternatives that historically
typically polemical and emotional reaction of have been precluded by the dominance of the
advocates to scientific challenges of this argu- disease ideology.
ment. An example is the reaction following Contrary to such optimism, however, we
David Davies' 1962 research on what happened know from Kuhn's analysis of the development
to alcoholics after they were discharged from of science that entrenched paradigms do not
medical treatment. Davies innocently reported simply crumble in the face of contrary evi-
the finding that some of these people had actu- dence. Although such evidence is probably a
ally returned to social or normal drinking prac- necessary component of scientific revolutions,
tices. This finding, rather than being regarded it has to be organized and used as the basis for
as an interesting and important discovery, was an attack on the disease concept. Such scientific
attacked, and Davies' research regaled as in- claims against the disease paradigm must be
valid and premature (Davies, 1963). It was al- "pushed" or carried by some politically orga-
most as though one of the faithful had commit- nized group according to a carefully planned
ted an act of heresy rather than simply reporting strategy in order for them to threaten the dis-
an objective finding (Pattison et al., 1977, p. ease view. In short, a competing paradigm must
124). A more recent example is the alcohol- emerge that is (1) philosophically appealing,
ogists' response to the so-called Rand report (2) able to incorporate the existing anomalous
(Armor et al., 1976). This report was a product scientific data as well as the old puzzles the dis-
of the routine evaluation research that is part of ease concept seemed to solve, and (3) able to
NIAAA-funded research. One, but by no means draw converts and supporters to it. A glance to
the only, concern of the report was the finding the horizon of alcohol studies in the United
that some and perhaps a notable number of al- States reveals no threatening presence of this
coholics can and do return to controlled drink- stature.
ing. This caused a storm of controversy that The most likely alternative paradigm would
shook the disease establishment. The finding seem to focus on the concept of "problems"
and report were denounced by a variety of the caused by or associated with drinking. In this
approach, sick alcoholics become "problem tent to which values, ideologies, and vested in-
drinkers" whose patterns of drinking behavior terests contribute to the inertia of dominant
are documented carefully in longitudinal or ideas in scientific work. This insight informs
epidemiological studies. The problems ap- our understanding of the disease concept as the
proach, not unlike approaches typical of con- dominant paradigm in the study of repeated and
temporary writing in the sociology of deviance, negatively consequential intoxication. We have
is less etiological and correctional than the argued that scientists who marshall contradic-
disease paradigm. No underlying disease entity tory evidence must not be seen as the authorita-
or mechanism is assumed to account for the tive voice in the debate on the disease status of
drinking behavior under study. The first com- such behavior. Indeed, they must be seen as
mitment is to a careful description of patterns of only one of a large cast of interested parties in a
actual drinking and associated behaviors as they political and social contest over definitions and
occur over time. Causes, when they are ad- social control. Moreover, the medical profes-
dressed, are inferred cautiously from empirical- sion rarely has been in the vanguard of the dis-
ly established relationships. There is less of a ease forces. More commonly, physicians have
clinical concern with treating individuals and been pulled along by nonmedical interests to
more attention devoted to drinking behavior as provide the necessary legitimation for the lat-
an inextricably social and cultural phenome- ter's claims-making activities. They would
non - as something that must be understood and seem to occupy a particularly paradoxical posi-
influenced in context. The problem paradigm tion today.
has been reflected most explicitly in the work of The American medical establishment got on
Don Cahalan, Walter Clark, Robin Room, Ron the disease bandwagon not primarily because of
Roizen, and their colleagues cited here. These science but because of politics. As contradic-
individuals are social scientists associated with tory scientific evidence accumulates in opposi-
th"" School of Public Health of the University tion to the disease view, physicians would
of California at Berkeley. Although their appear to have two options. First, and least like-
writing and research could provide the basis ly, they could officially repudiate the idea that
for a new paradigm in alcohol studies, these alcoholism is a disease along with their past en-
social scientists are probably unlikely candi- dorsements of that idea. This would, in effect,
dates as vanquishers of the disease concept. amount to an admission of previous error. More
They are themselves linked, through research likely, physicians will continue to endorse the
funding and consultation, to the NIAAA estab- "health" approach to such drinking, carefully
lishment. * In addition, they are part of the omitting use of the term "disease." This is part
health' 'industry. " Although their contributions of the "reform" that the problems perspective
have done, and will continue to do, a good deal is already effecting. By jettisoning the vulner-
for the quality and clarity of our understanding able baggage of "disease," "loss of control,"
of drinking behavior, they are more likely to ef- and other "big, fat, words," this reform leaves
fect a reform rather than a revolution in the dis- much of the traditional alcoholism movement
ease paradigm. undisturbed under the expanding umbrella of
Although the disease concept of alcoholism medical definitions of deviant behavior. Wheth-
has been challenged increasingly over the past er alcoholism will continue to be a "disease"
two decades, it is far from dead. One of Kuhn's may well be in doubt. We suspect, however, its
greatest insights was to force us to see the ex- status as a "medical problem" is secure.
SUMMARY
*In 1978 these Berkeley social scientists were The medical model of alcohol and the disease
awarded a large grant from NIAAA to establish one concept of alcoholism add two important di-
of a handful of new research centers on alcohol use
and problems. Robin Room, one of the most effec- mensions to our understanding of the medical-
tive critics of the disease concept, is the director of ization of deviance. First, the social definitional
this new center. quality of medicalization is highlighted by the
distinction we draw between the contested and part of the same commonsense and scientific
uncontested medical models of alcohol. The un- knowledge used to support it. Much cross-cul-
contested model is organized around questions tural and experimental research has failed to
of what the chemical alcohol is and what it does document the universally disinhibiting effects
inside our bodies when we drink. The physio- of alcohol on behavior. The variety of common-
logical and medical consequences of sustained ly observed behaviors associated with drinking
drinking are defined for the most part as non- preclude the validity of this medicalized, drug-
controversial issues for medical definition and centered conception. Being wise, however, to
attention. Few would argue that this is a legiti- the intransigence of useful ideas, we have seen
mate piece of medical "turf." Our interest fo- that this conventional wisdom dies hard, if at
cuses more specifically on the contested mod- all. The idea that drinking-related deviance
el of alcohol and particularly on the medicaliza- comes from the drink rather than the drinker is
tion of certain forms of deviant drinking be- the premise on which most pre-20th-century
havior. The consensus on these medical defini- thinking about the disease concept rests.
tions and interventions historically has been far That chronic drunkenness should be consid-
from universal. ered a disease was first stated by Benjamin
A second dimension of medicalization this Rush in a 1785 treatise on the deleterious ef-
chapter addresses is the authorship and support fects of "ardent spirits" on the body and mind.
of such medical constructions. These need not The drug-centered medical model of alcohol
be solely or even primarily the work of medical provided the foundation of Rush's argument
personnel-although it is important that medi- that inebriety was a disease and the inebriate a
cine give such definitions legitimacy by at least sick person needing medical treatment rather
a symbolic endorsement. In the case of the dis- than moral scorn. Rush and a few other temper-
ease concept of alcoholism, the major moral ance physicians insisted that all who drink dis-
and intellectual entrepreneurs have not for the tilled liquor are subject to these overpowering
most part been physicians or representatives of and destroying effects; the wise person should
the medical profession. Rather, first a "move- abstain from such drinking completely.
ment" and subsequently an "industry" has These ideas were to become useful grist for
grown up around the disease concept, peopled the 19th-century temperance movement. Rather
by a variety of interested nonmedical persons than denying this medical construction, tem-
and groups. perance leaders throughout most of the 19th
The uncontested and contested medical century simply added it to the characterization
models of alcohol often overlap or interpene- of "Demon Rum" and "King Alcohol" as the
trate one another. A good example is the ques- moral poison of American life. Drinking be-
tion of alcohol's effects on social behavior. came dangerous medically as well as morally.
Centuries of carefully selected commonsense One interesting manifestation of this moral-
as well as expert wisdom has it that when we medical definition of common drunkenness
drink we "lose control" of our conventional was the inebriate asylums that grew up during
selves and our behavior; we become, as the the last half of the century. These special hospi-
drug accumulates in our bodies, "disinhibited" tals were intended as places where the sick in-
and "under the influence." We do and say ebriate could receive physical treatment for his
things we would not otherwise do and say. alcohol-related ailments. More important, how-
These things are seen typically to involve un- ever, the drinker could be morally rejuvenated.
toward, rule-breaking, or deviant behavior and Asylum superintendents walked a precarious
are believed to be the inevitable consequence of line between watchful temperance groups wary
sufficient drink. All who drink are potentially of "coddling" drinkers and skeptical medical
subject to this uncontrolling influence. Such de- and popular attitudes toward these facilities.
viant drinking thus becomes a pharmacological, They never received the approval either of the
drug-centered, and medical phenomenon. public or medical community, and as the waves
This construction has been challenged by a of prohibition sentiment grew strong after 1900,
f08 DEVIANCE AND MEDICALIZATION: FROM BADNESS TO SICKNESS
asylum personnel and others interested in the the idea that alcoholism is a disease rooted in an
disease concept could not withstand the force of allergy to alcohol, AA developed twelve steps
history. With passage of the Eighteenth by which the sick alcoholic could regain control
Amendment in 1919, Congress symbolically over drinking. Once recovered, one could re-
endorsed the century-long crusade against alco- main so only by complete abstinence, a logical
hol by making its production and sale illegal. consequence of the allergy idea. Although AA
Between 1920 and 1933, when Prohibition remained true to its loose organizational format
was repealed, no one "owned" or promoted the and principle of anonymity of membership, it
idea that such drinking behavior should be has been probably the most influential source
considered a disease. On repeal, however, a of Americans' thinking about deviant drinking.
new and promising day for this idea had Finally, the writing of E. M. Jellinek, Yale
dawned. pioneer and long-time center director, gave fo-
In the decades following the official reap- cus to what it meant to argue that alcoholism is
pearance of alcohol in America, three important a disease. Jellinek held that alcoholism is a pro-
developments gave the disease concept unpar- gressive condition with identifiable stages, that
alleled vitality: the establishment of a research there are important differences between alco-
center on alcohol at prestigious Yale Univer- holics and nonalcoholics, that certain forms of
sity; the founding and phenomenal growth of alcoholism are bona fide diseases, and that its
the self-help organization AA; and an increas- defining characteristic was the loss of control
ingly clear person-centered statement of what it over drinking. Jellinek's work, although not
means to say that alcoholism is a disease, found without problems, provided fellow scientists
in the work of Yale center leader, E. M. Jel- with a set of propositions on this person-specific
linek. form of addiction that they could begin to test.
The Yale Center of Alcohol Studies, founded On Jellinek's death, his colleague Mark Keller
in 1940, provided a supportive context in which became the leading advocate of the disease
scientific research and policy questions about view, reiterating and attempting to clarify some
alcohol could be pursued. As certain drinking of Jellinek's arguments.
behaviors were defined as important "social To answer the question of whether alcohol-
problems," the Yale center took the lead in at- ism is a disease, one must refer to the current
tempting to give humanitarian and progressive political status of these ideas. Since 1940, sup-
direction to public policy on alcohol and alco- porters of the disease concept have been suc-
holics. Its summer school program provided the cessful in sustaining its viability. Recent signifi-
impetus for a group of people, some of whom cant achievements include legal endorsement of
were themselves alcoholics, to formulate an its assumptions, the 1970 formation of a $170
educational and action plan to combat the dis- million federal bureaucracy, the National Insti-
ease. This plan, including the ideas that alco- tute on Alcohol Abuse and Alcoholism, pre-
holism is a disease and a public health problem, mised on the belief that alcoholism is a disease
was introduced intentionally in these summer and an important health problem, and a 1974
programs at Yale as an enlightened and non- congressional act that supports decriminaliza-
moral position that community leaders could tion of public drunkenness and mandates treat-
use to establish a treatment rather than punishment rather than punishment. Finally, the
ment approach to drinkers at the local level. American medical profession has given the
The authors of this plan, along with a collection symbolic endorsement required for these ideas
of Yale faculty, founded what was to become and definitions to attain legitimacy. In a series
the National Council on Alcoholism. The NCA of official statements since 1946, the AMA has
subsequently became the leading private lobby agreed that this condition is a disease and that
for the disease concept in the United States. its medical aspects should be treated by physi-
A second crucial post-Prohibition develop- cians and medical personnel.
ment of the 1930s was the formation of Alco- These victories, however, must be seen in a
holics Anonymous. Premised from the start on context of recent challenges. Both in terms of
practical utility and scientific validity, the dis- parallels our own discussion in that he speaks of
ease view has come under attack. Whether temperance as a moral crusade by one set of
these challenges will lead to a "crisis" in the claims-makers against a set of new values and con-
duct that they saw as threatening.
disease paradigm we cannot predict. We sug- Jellinek, E. M. The disease concept of alcoholism.
gest, however, that given the entrenched inter- New Brunswick, N.J.: Hillhouse Press, 1960.
ests behind these ideas, a more likely outcome A must for any student of the disease concept. Jel-
would be "reform" rather than "revolution." linek clearly had the greatest 20th-century impact
Instead of "disease" it is likely that alcoholism of any single medical model claims-maker on the
rise of the disease concept of alcoholism. In this
simply will become a "health problem." This readable book he not only lays out his understand-
subtle redefinition discards the vulnerable bag- ing of what that means but also provides a review
gage "disease" while leaving the traditional of virtually all other important research on alco-
definition secure under the ever-expanding um- holism to the time of his writing.
brella of medicalization. Pattison, E. M., Sobell, M. B., and Sobell, L. C.
Emerging concepts of alcohol dependence. New
York: Springer-Verlag, 1977.
SUGGESTED READINGS A recent, critical, and thorough review of the ar-
Alcoholics Anonymous: The story of how many gument that alcoholism is a disease. It is highly
thousands of men and women have recovered from readable, well organized, and documented care-
alcoholism. New York: Works Publishing Co., fully. These authors and other contributors paint
1939. a less than optimistic picture for the future of the
Spoken of as "the book" by members of AA. This disease concept as a scientific proposition.
fascinating work offers as nothing else can the Pittman, D. J., and Snyder, C. R. (Eds.). Society,
images and values by which AA thrives and, ap- culture, and drinking patterns. New York: John
parently, successfully helps alcoholics recover Wiley & Sons, Inc., 1962.
from their "disease." The social science "bible" of research and writing
Filstead, W. J., Rossi, J. J., and Keller, M. (Eds.). on drinking behavior. Although almost two de-
Alcohol and alcohol problems: new thinking and cades old, it still offers the introductory reader a
new directions. Cambridge, Mass.: Ballinger Pub- comprehensive view of how social scientists, as
lishing Co., 1976. opposed to medical and biological scientists,
A high-quality collection of cross-disciplinary dis- might approach the study of drinking. These edi-
cussions of where alcohol research has been and tors are currently considering revising this impor-
where it might go. It ranges from a historical paper tant book with the same ends and standards in
by Mark Keller to an invaluable critique of alcohol view.
concepts by Seldon Bacon, to research in the biol- Room, R., Ambivalence as a sociological explana-
ogy of alcoholism and alcohol problem prevention: the case of cultural explanations of alcohol
tion. problems. Am. Soc. Rev., 1976,42,1047-1056.
Gusfield, J. Symbolic crusade: status politics and the The most recent and perhaps best critique of the
American temperance movement. Urbana, Ill.: favorite sociological explanation of drinking prob-
Uni versity of Illinois Press, 1963. lems-the ambivalence hypothesis. Not only does
The best single sociological discussion of the his- the article offer a clear view of the weaknesses of
torical foundations of American thought and social this sociological explanation, but also it provides
action concerning alcohol. Gusfield's analysis, al- a good reference section for sociological work on
though not of the medical definitions of drinking, drinking.
5 OPIATE ADDICTION
THE FALL and RISE of MEDICAL INVOLVEMENT
T he history of medical involvement with

opiate addiction illustrates most clearly
the political conflicts involved in the de-
viance designation battles and the vicis-
them "good" or "bad" drugs. Similar to de-
viance, it is the social definition that separates
the reputable from the disreputable. Heroin and
morphine are two opiate drugs that have nearly
situdes of deviance definitions. This chapter identical pharmacological compositions and
traces a number of clear definitional changes of physiological effects, yet one is seen as a
opiate use: from a time when it was not consid- "killer" drug and the other a boon to medicine.
ered much of a problem, to its definition as a The largest difference between the two drugs is
medical problem, through its criminalization, that one is considered illicit and the other licit.
and again to its limited remedicalization. Since Rather than a drug's chemical nature or bio-
our focus is on definitional change and medical physiological effects making it licit or illicit, it
involvement, we are interested in drug traffic, is who prescribes or who denies the use of the
criminal activities, legal penalties, or drug sub- drug that creates the distinction (Horowitz,
cultures only as they affect medicalization and 1972). Thus a socially defined line has been
demedicalization. Our focus is on the politics of drawn between licit and illicit drugs, based on
deviance designation as seen in actions by Par- some dubious assumptions but having some real
liament, Congress, the Supreme Court, the consequences.
medical profession, and government agencies, The physiological effects of opiates are sub-
and on technological discoveries, published re- stantial. Opiates have depressant actions on the
search reports, official investigations, and human body that "include analgesia (relief of
propagandistic appeals. pain), sedation (freedom from anxiety, muscu-
Opium had no general appeal for the Western lar relaxation, decreased motor activity), hyp-
world until the middle of the 19th century, and nosis (drowsiness, lethargy), and euphoria (a
until then its use was not considered much of a sense of well-being and contentment)" (Ausu-
social problem or deviant behavior. As back- bel, 1958, p. 18). Opiates and synthetic opiate-
ground for our discussion of the politics of like substances (methadone, meperidine [Dem-
opiate addiction, we review briefly opiate use erol]) are the most effective analgesics, or pain-
prior to the 19th century when opium was used killers, known today (Ray, 1978, p. 309). Mor-
primarily for medicinal purposes and only oc- phine and heroin are most frequently taken
casionally as a recreational (i.e., used for plea- by injection (they can also be "eaten" or
sure) drug. Before beginning our history of the "snorted"). After injecting the drug, the user
definition and treatment of opiate addiction, usually feels flushed immediately, experiences
however, it is important to briefly describe a mild itching or tingling, soon becomes re-
opiates, their qualities and physiological ef- laxed and sleepy, and enters into what can be
fects. described as a euphoric state of reverie.
Continued use of opiates gradually produces
NATURE OF OPIATES a physical tolerance, and the dosage must be in-
Opiates are drugs derived from the white creased to maintain the same euphoric effect.
juice of certain species of poppy. There is noth- The body becomes increasingly dependent on
ing in the chemical nature of opiates that makes the drug for normal functioning. If the drug is
110
OPIATE ADDICTION: THE FALL AND RISE OF MEDICAL INVOLVEMENT 111
not taken, after a number of hours withdrawal (quoted in Brecher, 1972, p. 25). Its effect on
symptoms begin. These include, at first, tense- the mind seems equally noninjurious; there is
ness, restlessness, watery eyes, sweats, and no evidence for an increase of mental disorder
runny nose and, later, chills, gooseflesh, (psychosis) or decrease of intelligence with opi-
twitching of legs, stomach cramps, and vom- ate addiction. Most studies show that personal-
iting. They can last from less than a day to ity does not change from the physiological and
nearly a week, depending on a person's "hab- psychological addiction itself. In fact, as we
it. " A single dose of the drug will produce shall see later, the most harmful effects of opi-
relief. Opiate addiction is considered to be ate addiction have come from its criminaliza-
based on a physiological dependence on the tion and the attendant development of a crimi-
drug. nal narcotic underworld rather than from the
We noted in the previous chapter, however, opiate drugs themselves.
that such "addiction" can exist only when one
"experiences physiological withdrawal symp- A MIRACLE DRUG: PRE-19th-
toms, recognizes them as due to the need for CENTURY USE OF OPIATES
drugs, and relieves them by taking another The use of opium may be older than alcohol.
dose" (Becker, 1967a, p. 175). Recognition of The Sumerians, an ancient Middle Eastern cul-
the connection between taking the drug and re- ture thought to have flourished about 4000 BC,
lief of the symptoms appears most important. had an ideogram for the poppy plant that meant
Some researchers suggest that addiction is char- "joy" or "rejoicing" (Lindesmith, 1965, p.
acterized by the "hunger" for euphoria (Ausu- 207). Many writers date the first specific medi-
bel, 1958), whereas others (Lindesmith, 1968) cal use of opium at about 1500 BC based on the
posit the avoidance of withdrawal distress as Ebers papyrus reference to an opium remedy
central. "to prevent the excessive crying of children"
Although there has been little attempt to de- (Ray, 1978, p. 300).
termine the degree to which individuals are in- Opium was used by classical Greek physi-
capacitated by the effects of the opiate drug it- cians as a medicinal agent. Theophrastus, a
self (Horowitz, 1972), it is commonly believed Greek naturalist and philosopher, recorded
that sustained opiate use and subsequent addic- what is the earliest undisputed reference to the
tion is in itself harmful to the human body. use of poppy juice (Szasz, 1974, p. 171). Hip-
What little scientific evidence exists in this re- pocrates, although familiar with opium, cau-
gard tends to refute this belief. A study com- tioned against its use. However, Galen, the last
pleted in 1929 but still cited as authoritative great Greek physician, saw opium as a panacea.
showed "that morphine addiction is not charac- In his view, opium cured everything from
terized by physiological deterioration or impair- snakebites to "women's troubles," including
ment of physical fitness aside from the addic- "vertigo, deafness, epilepsy, apoplexy, dim-
tion per se" (Light & Torrance, 1929, quoted ness of sight, loss of voice, asthma, coughs of
in Brecher, 1972, p. 23). This is true for per- all kinds, spitting of blood, tightness of breath,
sons addicted as long as 20 years. Other stud- colic, the iliac poison, jaundice, hardness of the
ies have confirmed this. A more recent and spleen," and sundry other human ills (quoted in
often-cited study (Chein et aI., 1964) empha- Scott, J. M., 1969, p. Ill). It is not surprising
sized that opiate addiction does not produce any that Galen, a careful medical observer and a
known organic diseases-such as, for example, precursor to "scientific" medicine, was so im-
those produced by chronic smoking-and its pressed with opium's curing powers; in his time
annoying physiological effects (e.g., constipa- there were few other medical treatments with
tion, sexual impotence) are neither permanent such powerful effects, especially for pain,
nor disabling. Vincent P. Dole, a long-time coughs, or bowel disorders. Since medical use
and respected researcher of opiates, maintained of opiates was common, there may also have
that "cigarette smoking is unquestionably more been some recreational use of the drug. Galen
damaging to the human body than heroin" commented in his writings on the opium cakes
and candies that were sold everywhere in the abled physicians to perform cures that appeared
streets. The Greek knowledge of opium use almost miraculous and believed that "without
was lost with the decline of the Roman Empire opium, the healing art would cease to exist"
and did not influence the European use of opi- (Scott, J. M., 1969, p. 114). In 1762, Thomas
um until a thousand years later. Dover, who is thought to have been a student of
Opium was spread by the Arabs. Perhaps be- Sydenham, introduced a prescription for a
cause the Koran forbade wine and other alcohol, "diaphoretic powder," which he recommended
but not opium, it was more frequently indulged particularly for the treatment of gout. It became
in by Arabs both as a medicinal and a social known as Dover's Powder and was the most
drug. Opium was carried east and west by widely used opium preparation for the next 150
Mohammedan warriors and the merchants that years (Szasz, 1974). Although opium was a
followed them. "In the West, opium was in- mainstay of the medical armamentarium, some
cluded in the cargoes of spices imported by 18th-century physicians were cautious and con-
Venetian merchants in the Middle Ages. It had cerned that frequent use could result in habitu-
limited appeal. Opium was one of the products ation.
Columbus hoped to bring back from the Indies" There is no evidence at all of general addic-
(Scott, J. M., 1969, p. 11). Opium was used for tion in the 17th century, although opium drugs
medicine and recreation in the Far Eastern were increasingly prescribed and could be
countries, and eventually they began cultivating bought without any restriction (Scott, J. M.,
their own poppies. By the 10th century AD, opi- 1969). Although there had been incidental re-
um was referred to in Chinese medical writings. ports of tolerance to the drug since the Roman
An Arabian physician, Biruni, composed a period and occasional reports of discomfort on
pharmacology book shortly after 1000 AD that cessation of habitual use that could be relieved
included what may be the first written descrip- by ingesting more opium, no concept of addic-
tiO'l of addiction (Ray, 1978, p. 301). tion was yet delineated. It was not until the
By the ninth century, opium was used widely early 18th century that a clear association was
in China and the Far East. The Chinese used made between the discontinuation of regular
opium as a medicine, but to a limited degree, opium use and the appearance of certain (with-
and never by smoking it. Smoking opium was drawal) symptoms. One of the earliest known
only for recreational usage; by the 17th century descriptions, though not defined as addiction,
it was a fairly commonplace and popular activ- appears in John Jones' 1700 work The Mys-
ity in some circles. Several emperors' attempts teries of Opium. He warned that the
to control opiate use were largely futile, and
China remained a world center for recreational effects of sudden leaving off the use of opium after a
opium use until the 20th century. long and lavish use thereof [ were] great and even in-
European travelers to the Orient brought opi- tolerable distresses, anxieties, and depressions of
spirit, which commonly ended in a most miserable
um back to the West. Paracelsus, a 16th-century
death, attended with strange agonies, unless men re-
Swiss physician who traveled to the East, intro-
turn to the use of opium; which soon raises them
duced laudanum, or tincture of opium, into again, and certainly restores them. (Quoted in
medical practice. He, like Galen before him and Musto, 1973, p. 69)
others after, thought of opium as a panacea and
called it "the stone of immortality. " It soon be- But this viewpoint was not readily accepted by
came a staple of European medicine. Thomas the medical profession, and the debate over
Sydenham, an English physician considered the whether opium was addictive and whether only
founder of clinical medicine, regarded opium certain people were prone to addiction (e.g.,
as "one of the most valued medicines in the Orientals), raged well into the 19th century.
world [which] does more honor to medicine Prior to the 19th century, then, with the ex-
than any remedy whatsoever" (quoted in Mus- ception of China, opiates were generally lim-
to, 1973, p. 69). He believed that opium en- ited to medical uses. What came to be called
addiction was not considered much of a prob- use of opium was limited for many years to a
lem, although certainly many people must have select, elite group. Af~er a prohibition edict in
become physically dependent as a result of 1729, it became necessary to smuggle opium
medical treatment. The great controversies sur- from India. This illegal commerce proved very
rounding opium use were not to begin until the profitable for all parties (including customs of-
19th century. ficials); so it was tolerated (Scott, J. M., 1969).
This produced a lively international commerce
POLITICS OF OPIUM IN THE and two "opium wars."
19th CENTURY The history of the opium wars is a fascinating
During the 19th century the definitions and example of the ravages of Western imperialism,
uses of opium began to change. Opium became but it is much too long and involved to be told
an important item to trade and was alleged to here. However, a few points need to be made
have been the object of two wars; scientific and to understand how definitions of opiate use
medical discoveries made opiates more potent were to change in England and subsequently
and usable; the usage of opiates increased mark- elsewhere. In the late 17th century the port of
edly in the United States, especially in the sec- Canton was finally opened to foreign trade. Tea
ond half of the century; and opium became the was a major export, much desired in England.
center of increasingly clear political activities. What would be a suitable item of trade? Ac-
Yet, at the close of the century, opium use was cording to J. M. Scott (1969), "From the first,
not yet considered a significant problem in opium was the only export the Chinese custom-
American society. er took to" (p. 20). Beginning in the 18th cen-
tury, European nations traded increasingly in
Recreational use In England opium as a source of foreign revenue. Opium
and China became a major item of British trade. The Brit-
The first reports of European recreational use ish East India Company obtained a monopoly
of opium appear in the early 19th century, of Indian opium, considered the world's best,
emanating especially from literary circles. One and began exporting opium from India to China
of the most well-known users was Samuel Tay- in 1767. When opium became illegal in China,
lor Coleridge, who composed his exquisite the British created a complex smuggling net-
"Kubla Khan" while under the influence of work (in which they continually denied involve-
opium. The poet Elizabeth Barret Browning ment). It was a huge and profitable trade. In
was also addicted to opium. Thomas De Quin- addition to trading for tea, silks, and silver, the
cy's Confessions of an English Opium Eater, cultivation of opium financed the British colo-
in 1823, presented vivid accounts of his experi- nial administration in India. The Chinese were
ences with opium and offered a positive view of literally "force-fed" opium, and the supply
opium's recreational and aesthetic qualities. He continued to create its own demand (Helmer,
saw opium use as a habit, which must be 1975). In 1839 a Chinese commissioner ar-
learned like any other habit, but he also suf- rested opium smugglers and destroyed a con-
fered from long and unproductive periods at- siderable amount of opium. This led to a British
tributed to his habit. These writers and others, military reaction and the first opium war (1839-
sometimes referred to as members of an "opi- 1842). With the second opium war 15 years
um cult, " experimented with drugs and became later, the British extended their distribution of
well-known for their opiate habits, but they opium in China, and ill~gal British imports con-
were a distinct artistic minority. Their writings tinued. During the latter part of the 19th cen-
and reputations gave a romantic flavor to the tury, it was estimated that 8 million Chinese
image of opiate use, but recreational opiate use were addicted (Kittrie, 1971, p. 216). Although
in England was actually not widespread in the the British received considerable profits from
early 19th century. the opium trade, the primary motivation for the
In China the situation was different. Chinese wars was to open the potentially huge market
of China for international trade in general, not able" (Rothstein, 1972, p. 191). In the United
just an opium trade (Rar, 1978, p. 305). States the Civil War contributed to the spread of
opiate use. Morphine injections were given to
Medical uses: from a panacea soldiers to reduce pain and combat dysentery
10 a problem symptoms. So many veterans returned home
In 1806 Frederich W. A. Serturner, a 23- addicted that it was called the "soldier's dis-
year-old German pharmacist's assistant, ex- ease" (Lindesmith, 1965).
tracted a purer alkaloid from raw opium with a By the end of the Civil War, morphine was
potency 10 times greater and named it mor- commonly used in medical practice. Some phy-
phium after the god of sleep. Medical applica- sicians considered it safer than opium; more-
tions for morphine soon became obvious, and over, it was easier to ingest, since it could be in-
it was increasingly substituted for opium in jected by hypodermic needle. As medical his-
medical practice. In 1831 Serturner was torian David Musto (1973, p. 73) points out,
awarded a prize from the French Institute for mid-19th-century conventional medical wis-
this medical discovery (Scott, J. M., 1969). A dom tended to define opium by its therapeutic
year later other scientists isolated a second im- qualities, minimizing its dangers, except to the
portant alkaloid called codeine. lower classes. It was not until the 1870s that
The administration of morphine was facili- the addictive properties of morphine were rec-
tated greatly by the invention of the hypodermic ognized and warnings began to appear in the
syringe in 1853. Doses could be controlled, and medical literature.
action was quicker. Physicians thought that in- It appears that most addicts of this period
jected morphine was not habit-forming (addic- were literally recruited into addiction, albeit un-
tive) and used it for a variety of ailments. A intentionally, through the liberal and careless
standard British medical text, used widely in use of opiates in medical treatment (Linde-
America, recommended opium for a variety of smith, 1965, p. 129). Occasionally physicians
common medical problems: like Oliver Wendell Holmes, Sr., then dean of
Harvard Medical School, criticized the igno-
to mitigate pain, to allay spasm, to promote sleep, rance of physicians and blamed them for the
to relieve nervous restlessness, to produce perspira- prevalence of addiction. In a speech he said,
tion and to check profuse mucous discharges from
"The constant prescription of opiates by certain
the bronchial tubes and gastrointestinal canal. But
physicians . . . has rendered the habitual use of
experience has proved its value in relieving some
diseases in which not one of these indications can be that drug [in the Western states] very preva-
at all times distinctly traced. (Pereira, 1854, quoted lent" (quoted in Musto, 1973, p. 4). An 1885.
in Musto, 1973, p. 70) report to the Iowa State Board of Health
charged:
But some physicians also warned of the dangers
of opium smoking and were able to describe The habit in a vast majority of cases is first formed
addiction accurately. Physicians believed that by the unpardonable carelessness of physicians, who
"enslavement" to opiates was caused more by are often fond of using the little syringe, or relieving
every ache and pain by the administration of an opi-
the user's weak character than the drug itself
ate. (Hull, 1885/1974, p. 39)
and considered the lower classes to be particu-
larly vulnerable to it. They often described a de- But the drug continued to be prescribed freely
cline in moral character associated with chronic in the 189Os.
opiate use. Morphine was not only used for a variety of
Physicians were so taken with the pain-kill- medical ailments but was touted both as a treat-
ing qualities of opiates that they invented a new ment for opium addiction and alcoholism. Be-
disease called neuralgia (a term used today in a cause injection of morphine was thought to be
more restricted sense), for which opium was nonhabit-forming, many physicians saw mor-
the treatment. Neuralgia was used "to describe phine as a cure for addiction to smoking opium
pains, the origin of which is not clearly trace- and treated their addicted patients accordingly.
Morphine was also heralded as a treatment for every pharmacy and general store. By the tum
chronic drinking problems. In an article enti- of the century some concern was voiced about
tled "Advantages of Substituting the Morphia these medicines' addictive qualities, but literal-
Habit for the Incurably Alcoholic," published ly hundreds of thousands of people were al-
in 1889 in a medical journal, the physician-au- ready addicted, including many physicians,
thor claimed morphine was "less inimical to the who had thought themselves immune to addic-
healthy life than alcohol" and reported, "After tion (Goode, 1972, p. 164). The availability of
years of experimental trial and observation I ar- a regular supply of drugs allowed these addicted
rived at the conclusion that [morphine] is im- people to lead conventional lives.
measurably the best, or by far the least of the
two evils" (quoted in Ray, 1978, p. 307). Discovery of addiction as
Many physicians did in fact convert alcoholics a disease
to morphine (Brecher, 1972). This strategy of Physicians in the latter part of the century
treating one addiction with another occurs with began to recognize that morphine was addic-
regularity and almost with predictability tive, even when injected. Although there were
throughout the history of opiate addiction. increasing reports in the medical literature, the
Freud, for example, was fascinated with co- acceptance of these data by the medical profes-
caine as a cure for morphine addiction. This sion was slow. The first documented case of in-
game of unwitting "medical substitution" in jected morphine addiction was reported in
the treatment of addiction involves the medical 1864. But in an 1880 questionnaire most physi-
profession in a continuing, frustrating, and cians still doubted that injections produced ad-
largely fruitless search for a drug that will cure diction (Morgan, 1974). Thomas Szasz (1974,
drug addiction. p. 6) notes that the earliest edition of Kraepe-
Although physicians were partly responsible lin's 1883 psychiatric text made no mention of
for recruiting the mid-19th-century addict pop- drug intoxication or addiction at all, while later
ulation, by the latter half of the century another editions mention "chronic intoxication" and
quasimedical industry was increasingly impli- "morphism" but not "addiction" per se. The
cated in addiction recruitment. The manufac- category of drug addiction did not appear in
ture of "patent medicines" was a highly suc- Bleuler's renowned 1916 Textbook of Psychia-
cessful industry beginning about the time of the try. Warnings of addiction as a result of mor-
Civil War. There were few government regula- phine did not appear in medical texts until about
tions, and thus many "soothing syrups" and 1900 (Duster, 1970, p. 13).
"tonics" containing opiates were sold as home Although many physicians and psychiatrists
remedies. Such products as Mrs. Winslow's denied or ignored the addictive qualities of mor-
Soothing Syrup, Hooper's Anodyne, the In- phine until nearly the tum of the century, others
fant's Friend, Ayer's Cherry Pectoral, and God- demonstrated an increasing interest in addiction
frey's Cordial were actively promoted by the as a medical problem. These physicians devel-
growing drug industry, sometimes as "cure- oped both theories and treatments for what they
aIls" but more often for "women's troubles," believed increasingly was the disease of opiate
infant teething, diarrhea, coughs, or pain. Since addiction. An example is J. B. Mattison's The
ingredients did not have to be listed on the la- Treatment of Opiate Addiction. published in
bel, many users became physically dependent 1885. The most commonly accepted theories of
without realizing it. The drug companies also addiction emphasized its tendency to be in-
sold guaranteed "drug addiction cures," which herited:
were themselves addictive, thus merely trans-
Learned journals bristled with confident discussions
ferring the addiction to another drug (Young, of "high" and "low" brain centers that governed
James H., 1961). In a nation with a limited conduct; of poor nerve endowment, or genetic faults.
level of health care, such potent medicines were Social tensions, translated into personal imbalances
popular and, to a degree, useful treatments. in weak individuals, were also allegedly high among
They were available at customers' request in Americans .... (Morgan, 1974, p. 90)
Such ideas, coupled with the belief that lower- coveries like the hypodermic needle made in-
class people were susceptible to addiction, led gestion easier; and recognition of the "addic-
physicians to see addiction more as a problem tion as a disease" led to medical treatments.
of "weak people" rather than of strong drugs. Thus, in a real sense, 19th-century medical
It was largely the constitution of individuals practice created the very addiction problem it
that made them addictable, not the drug itself. was treating at the century's close.
These and similar theories lasted into the 20th
century and in fact provided the bases of some Addicts and addiction In a Iidope
of the greatest controversies concerning addic- fiend's paradlse"
tion. By the early 20th century, however, opi- The late 19th century has been called "a
ates themselves were also indicted by physi- dope fiend's paradise" (Brecher, 1972). Al-
cians in general as a "cause" of addiction. most no federal or state restrictions were in
Physicians treated opiate addiction when it ap- force, opiates were regularly available from
peared in their practice, and were generally physicians and in pharmacies, and no great
optimistic that withdrawal, medical care, and moral stigma was attached to opiate use or ad-
rest would cure addiction. diction. A wide variety of people were ad-
The late 19th century saw changes in medical dicted, and obtaining drugs was not much of a
practice that made opiates no longer necessarily problem.
a panacea. With the discovery of the germ the- Yesterday'. addlcll. For those of us who
ory of disease, infectious diseases like tubercu- are accustomed to thinking of the typical mod-
losis, caused by germs and bacteria, came to em-day opiate addict as young, male, urban,
dominate medical practice and became the lower-class, and a member of a minority group,
"model" of disease for medical practitioners. 19th-century addicts provide a sharp contrast.
Thus, by the end of the century, opiates had From all the data we have (which are somewhat
few medical uses beyond the relief of pain. limited by today's research standards), it ap-
They were no longer seen as cure-aIls or sooth- pears that the typical 19th-century addict was
ing agents but as a potential medical problem in middle-aged, female, rural, middle-class, and
themselves. white. The only exceptions were the opium-
At the close of the 19th century "many doc- smoking Chinese immigrants who were limited
tors believed that addiction was a disease, to be to the West Coast. An 1872 Massachusetts
treated with pragmatic therapy rather than mor- Board of Health Survey found many women
alism" (Morgan, 1974, p. 19). Medical the- and small-town residents among opiate users
ories hypothesized that if opiates changed nerve (Oliver, 1872/1974). A Chicago study in 1880
tissues and cellular activity, then the individ- reported that the model age of addicts was 30 to
ual's need for them was uncontrollable. Thus, 50, and only 12 of 235 addicts were "colored."
according to a physician addiction expert of the This study further suggested it was "among the
time, addicts used opiates "not for social enjoy- middle class that we find the great majority who
ment but for a physical necessity" because of are today opium eaters" (Earle, 1880/1974,
alterations in the body's physiology (Mattison, p. 56). The Iowa Board of Health survey noted
quoted in Morgan, 1974, p. 19). This became "the age at which the habit is most common is
an increasingly accepted medical view. By the fifty and sixty" (Hull, 1885/1974). It has been
tum of the 20th century, opiate addiction be- estimated that 60% to 75% of the addicts were
came defined as a disease and a bona fide medi- women, perhaps as a result of the "widespread
cal concern. medical custom of prescribing opiates for men-
In sum, the 19th century saw opium use strual and menopausal discomforts, and the
change from a central medical treatment to an many proprietary opiates advertised for female
emergent medical problem. Physicians were in- troubles" (Brecher, 1972, p. 17). Another
timately involved with opiate addiction at all probable factor was the strong negative sanc-
phases: people became addicted through medi- tions against alcohol drinking by women.
cal and quasimedical treatments; medical dis- Most addicts purchased their drugs at the
local phannacy. An 1880 Boston researcher to China began to suggest the opium trade
found that of "10,200 recipes taken in 34 drug- might have deleterious effects on the Chinese
stores, I found 1,481 recipes which prescribed people. Missionary W. H. Medheurst reported
some preparation of opium .... [In addition] I in 1840 in his book, China, that nearly 3 mil-
learned that proprietary or 'patent' medicines lion people were demoralized by the opium
which have the largest sales were those con- habit, their bodies debilitated, their families
taining opiates" (Eaton, 1880/1974, p. 182). ruined, and their life expectancies reduced by
The number of addicts during this period was 10 years (Inglis, 1975). One of the first times
probably greater than at any other time in the issue was publicly raised was in an 1842
American history. Estimates by recent research- lead article in The Times denouncing the trade.
ers range from 250,000 (Musto, 1973) to a A few voices condemned the trade in ensuing
prevalence eight times greater than today years, but the great debate did not become real-
(Duster, 1970). There is no doubt that opiate ly heated for nearly three decades.
addiction was widespread, perhaps encompass- The major adversaries in the debate about
ing "no less than 1% of the population" (Ray, opium were the opium interests and the anti-
1978, p. 308). Yet, despite such a high preva- opium crusaders. The opium interests were
lence of addiction, it was not considered espe- those who profited economically from the trade:
cially deviant or a major social problem. This the merchants, the traffickers, the Indian colo-
was partly because addicts could easily obtain nial government, and, to a degree, the British
their drugs and were thus able to function nor- government itself. The British government had
mally in society. This was facilitated by a dif- considerable vested interest in the trade: an esti-
ferent public definition of opiate addiction than mated 10% to 14% of the British-controlled In-
exists today in the United States; by 1920 this dian government's revenues came from the opi-
public definition had changed, drugs were no um trade (Johnson, B. D., 1975). The antiopi-
longer easily available, the addict population um groups included some moral reformers and
shifted drastically, and addiction became a ma- missionaries who organized themselves into a
jor social problem. variety of antiopium organizations. Predomi-
nant among these groups were the Society for
Entrepreneurs and the morality of the Suppression of the Opium Trade (SSOT)
opium: the creation of an evil and the Anti-Opium Society. The intensity of
Public moral definitions of behavior do not the debate developed slowly; in the first years
change by themselves. Moral entrepreneurs, in- when the issue was raised in Parliament, de-
terest groups, and other claims-makers work to fenders of the trade argued that its "evils" had
legitimate their versions of morality. Some- been greatly exaggerated. But controversy
times this politics of definition making is ob- grew, and over the years the sheer number of
scure. In the case of opiate addiction, how- words exchanged, both in and out of Parlia-
ever, the arenas of conflict are public, and the ment, was enormous. Scores of books, articles,
definitional politicking is fairly clear. In the letters, and pamphlets appeared extolling one
19th century we encounter moral entrepreneur- position or another; the Anti-Opium Society's
ship and interest group politicking in the British journal, The Friend of China, financed in its
Parliament's "great debate" over the opium beginning in 1875 by four wealthy Quakers,
trade. In the next century we see the conflict ex- eventually reached 32 bound volumes. The
panded to an international arena (and especially antiopiumists attempted to persuade both the
dramatically in the United States). public and Parliament of the justice of their
In the first half of the century the "opium cause.
question," to the extent there was one, was not The issues were fairly clear for both sides,
a particularly pressing moral issue for Euro- and the same arguments were repeated over and
peans (although it certainly was to the Chinese). over. The pro-opium interests argued that there
There were few voices questioning the British was a demand for the product-opium-and the
opium trade. A few missionaries who had been Chinese people wanted it, "free" trade should
not be hampered, the revenues were important tain individuals were more addictable than
to (Britain's) economic stability, and the drug others (already heard in the United States), was
was not dangerous and its "evils" were exag- also debated. Predictably, some physicians and
gerated. The antiopium crusaders claimed that others suggested it was not the drug but the Chi-
the trade had been forced on China and she had nese moral constitution that was the cause of
been consistently hostile to it, the market for any degeneration from opium. Antiopium
opium had been created by the supply, it was forces directly countered this argument with in-
immoral to trade this addicting and dangerous creasing evidence to suit the needs of its posi-
drug that leads inevitably to destruction and tion. Although medical people can be moral
demoralization of people, and self-interested entrepreneurs in their own right, nonmedical
profits from this immoral vice were immoral interest groups frequently select medical evi-
(Johnson, B. D., 1975; Scott, J. M., 1969). dence to support their particular claims.
Both sides drew on medical evidence to sup- Although opium had been mentioned in Par-
port their claims, usually concerning the effects liament before 1870, it was not until that year
of the drug. Pro-opium interests quoted medical that a motion to condemn the opium trade was
figures such as George Birdwood: introduced. It was soundly defeated. After a
I hold [opium] to be absolutely harmless. I do not
period of decreased public interest and several
place it simply in the same category with even tobac- defeats, antiopium crusaders managed to per-
co smoking ... but I mean that opium smoking, in suade Parliament to pass a motion in 1891 stat-
itself, is as harmless as smoking willow bark, or ining "that the system by which Indian opium
haling the smoke of a peat fire, or vapour of boiling revenue is raised is morally indefensible"
water .... I hold opium smoking, in short, to be a (Scott, J. M., 1969, p. 107). The motion,
strictly harmless indulgence, like any other smoking, however, never became a resolution; so it re-
and the essence of its pleasure to be not in the opium mained merely a symbolic moral stand, with no
in itself so much as the smoking of it. If something practical political implications.
else were put into the pipe instead of opium, that Under the direction of Prime Minister Wil-
something else would gradually become just as popu-
liam Gladstone, a royal commission was as-
lar as opium, although it might not incidentally
signed to study the problem. The commission
prove so beneficial. (Quoted in Scott, J. M., 1969,
p.99) was screened and picked by authorities in India;
so a critical report could hardly be expected. The
Antiopium crusaders would also quote well- Royal Commission on Opium published a mas-
known physicians such as D. W. Osgood, a sive seven-volume, 2500-page report in 1895.
medical missionary: The commission's major conclusions were that
Rich and poor find that the continual use of opium the dangers of opium had been exaggerated and
[smoking] interferes with digestion, diminishing the were no worse than those resulting from the ex-
secretions of the alimentary canal, producing consti- cess use of alcohol, that a limitation of produc-
pation, loss of appetite and the usual discomfiture tion was created by the monopoly in India, and
of dyspepsia. In nearly every case there is difficulty that if it was unsatisfactory to China, it was
in breathing, and in many chronic bronchitis and their responsibility to prohibit importation. It
asthma. The smoker becomes anemic and impotent. also pointed out that India's opium was the
(Quoted in Scott, J. M., 1969, pp. 99-100) world's best and that India's economy could not
Sometimes these medical claims became afford to lose the revenue from opium produc-
explicitly moralistic. Physician D. W. Moore, tion (Scott, J. M., 1969, pp. 107-108). In short,
an opium supporter, suggested "that in ancient opium was an important economic venture, and
times the Chinese were a very drunken people" associated dangers were considered minimal.
and if opium had not been introduced into The ensuing years were difficult ones for the
China, alcohol use would be more of a prob- antiopium movement. Numerous pamphlets
lem. Other physicians argued vehemently for and books attempted to refute the commission
the evil nature of the drug (Scott, J. M., 1969). and discredit the report. The main thrust of the
An extension of the controversy, whether cer- opposition to the report was an 1895 pamphlet
OPIATE ADDICTION: THE FAll AND RISE OF MEDICAL INVOLVEMENT 119
by Joshua Rowntree, "The Opium Habit in the ism. " Now that the addictive potential of the
East: A Study of the Evidence Given to the drugs became better known, they viewed opiate
Royal Commission on Opium." Rowntree addiction rather matter-of-factly. It was a dis-
showed conflicts of opinion and manipulation ease to be treated like any other disease; addicts
of evidence in the commission report. He were just "poor victims."
pointed out, for example, that although 49 out This was not necessarily the dominant public
of 52 missionaries from China had given evi- attitude. In some circles opium was viewed as
dence that condemned opium, the report had immoral-a vice akin to dancing, smoking,
quoted only the views of two of the three who theatergoing, gambling, or sexual promiscuity
had been less critical (Inglis, 1975, p. 92). (Brecher, 1972). Narcotics were seen as mak-
Within 10 years the report was discredited, and ing an individual a "slave," robbing the addict
today scholars generally agree that the commis- of free will. The popular stereotype of the ad-
sion had "whitewashed the opium problem and dict was an individual who "lacked both proper
rubber-stamped the opium monopoly and inhibitions and the stimuli of individual respon-
trade" (Johnson, B. D., 1975, p. 315). Parlia- sibility" (Morgan, 1974, p. 22). Late 19th-
ment did pass an antiopium trade bill in 1906, century Americans were beginning to view opi-
but the trade did not end finally until 1913. ate use as a "will-weakening vice" that they
In their efforts to end the opium trade with believed people of strong will could stop if only
China, the antiopium crusaders also changed they tried hard enough. Addiction was loathed,
public opinion about the drug and the defini- but "because of the connection between medi-
tions of opium use. Opium addiction became an cal therapy and addiction, the drug addict was
, 'evil. " Their arguments about the immoral and viewed as a helpless victim, an unfortunate sick
detrimental nature of opium use still echo in to- person in need of medical attention" (Goode,
day's society. As sociologist Bruce D. Johnson 1972, p. 189). Acquaintances felt somewhat
(1976) points out, sorry for the addict's dependence on medication
The main legacy of the British anti-opium movement
but did not disvalue the addict or his role. As
to modem times was the institutionalization of anti- we shall soon see, this all changed by the
opium, but scientifically dubious, beliefs that opiates 1920s.
cause almost immediate and life-long addiction, Although addiction was imbued with nega-
cause physical and moral harm to the user, cause tive values, there does not seem to have been
crime, prostitution, gambling, etc. (p. 21) the same hard-nosed public support for banning
opium as existed in the later stages of the tem-
American aHltudes toward opiate perance movement. This may be partly because
addiction: from empathy to anxiety the public considered opiates a medical con-
There was some ambivalence in the 19th- cern and because addiction was not viewed as
century American attitude toward opiate addic- a problem for society, whereas alcohol was.
tion. Because of their medical use and medical Nevertheless, these negative public views
connotation, some favorable images of opiates tended to undercut the more benign medical
were available. Addiction was not considered a position on opium. Most people developed a
major social problem, and there was no public basic fear of drug addiction (Musto, 1973),
moral devaluation of addicts, but as people be- a view which was increasingly promoted in
came aware of the addictive qualities of opi- the media and through other channels of propa-
ates, the seeds of public concern began to ger- ganda.
minate. Nineteenth-century addicts, however, A concern developed among the public and
generally aroused sympathy and were people to medical profession alike that addiction could
be pitied rather than scorned. weaken the key to America's strength: its young
As suggested, physicians were partly respon- and its middle class. After 1865 some anxiety
sible for these attitudes. They had been largely began to be voiced that women and the young
indifferent to addiction and tended to treat it may be particularly vulnerable to addiction
with "pragmatic therapy rather than moral- (they were likely candidates to have weak con-
stitutions), and many middle-class, respectable hostility, based partly on racial prejudices and
citizens were addicted. In 1902 a physician partly on their willingness to accept employ-
wrote, "morphism is one of the most serious ment at low wages. In 1875 the city passed an
addictions among active brain workers, profes- ordinance prohibiting opium smoking in the
sional businessmen, teachers, and persons dens of San Francisco. This was not a health or-
having large responsibilities" (quoted in Mor- dinance but rather a clear-cut attempt to regu-
gan, 1974, p. 14). It was especially worrisome, late the life-style of a minority. It was the first
since as long as the drug supply was main- of a number of racist laws aimed at restricting
tained, it was difficult to detect an addict. the Chinese use of opium. Prohibition pushed
But much of the concern with addiction came opium smoking underground. In the ensuing
from the association in the public eye of addic- years several states passed anti-opium-smok-
tion, opium-smoking dens, and Chinese immi- ing laws, but they were relatively ineffective.
grants. "By the 1870s the press reported often In 1887 Congress passed a law prohibiting opi-
on opium smoking, the first form of addiction um importing by the Chinese, and in 1890 it
to attain wide public notoriety" (Morgan, limited opium manufacture to American citi-
1974, p. 5). The anti-Chinese sentiment in the zens. Even with these local, state, and federal
United States became intimately tied to a fledg- efforts the amount of smoking opium legally
ling antiopium sentiment. The 19th-century imported in the United States continued to rise
press was silent on morphine medication and steadily. By 1909 legal importing of opium had
its addicting effects, despite the vastly larger risen sevenfold in 50 years. It was in that same
number of morphine addicts than opium smok- year that importation of smoking opium was
ers. Newspapers depended on advertising that prohibited altogether (Morgan, 1974).
included opium products, and' 'did not want to These laws were futile attempts to control
alienate the advertisers, because they were a opium smoking. They failed, as have other pro-
major source of revenue" (Duster, 1970, p. 8). hibitionary laws since, largely because opium
Thus the American view of opiate addiction smoking is a "crime without a complaint."
began to turn on anti-Chinese sentiments. Since the laws were aimed at private transac-
tions between willing sellers and willing buy-
First prohlbHlon of smoking opium ers, there was no individual complainant to
The amount of smoking opium imported into bring these "transgressions" to the attention of
the United States increased markedly after the authorities. Such laws also have other unin-
1860. The largest consumers were Chinese im- tended effects such as creating an illegal under-
migrants who had brought their opium habits ground and converting smokers to more hazard-
with them when they were recruited and im- ous but available substances.
ported as cheap labor to build the railroads.
One antiopium crusader estimated in 1900 that Discovery of heroin
35% of the Chinese immigrant population In 1898 the German Bayer Laboratory, a ma-
smoked opium with some degree of regularity jor pharmaceutical company, introduced a new
(Hamilton Wright, in Helmer, 1975). This esti- morphine derivative that had been discovered
mate may be too high, but even if there were two decades earlier. This new drug was three
only half or a third as many opium smokers, times as potent as morphine and was marketed
the number was substantial. Anti-Chinese senti- as a nonaddicting substitute for morphine or co-
ments ran high, especially on the West Coast, deine. It was named heroin for these "heroic"
since the Chinese were seen taking jobs from properties. Physicians writing in medical jour-
Americans and undercutting the American labor nals described it as a nonaddicting drug. A pa-
market. This culminated in the Chinese Ex- per in the Boston Medical and Surgical Journal
clusion Act of 1882, which suspended Chinese asserted that' 'there was no danger of acquiring
immigration. a habit" (cited in Szasz, 1974, p. 179). The
Many Chinese immigrant laborers migrated New York Medical Journal (Manges, 1900) dis-
to San Francisco. This engendered increased missed its addiction problems as minimal:
Habituation has been noted in a small percentage ... the connection of opium use to the prevalent
of the cases . . . . All observers agreed, however, anti-Chinese sentiment and the divorce of
that none of the patients suffer in any way from this heroin from any medical connotations, we see
habituation, and that none of the symptoms which the beginnings of a definitional transformation
are so characteristic of chronic morphinism have
and a hardening of the public view that became
ever been observed. On the other hand, a large num-
ber of the reports refer to the fact that the same dose
clear in the first two decades of the 20th cen-
may be used for a long time without any habituation. tury.
(Quoted in Ray, 1978, p. 308)
CRIMINALIZATION AND
Heroin was a popular drug, easy to administer, DEMEDICALIZATION
and available without prescription (Duster, The definition of opiate addiction and the
1970). Users frequently injected it with hypo- treatment of opiate addicts shifted radically in
dermic needles readily acquired by mail from the first two decades of the 20th century. By the
the Sears catalogue. middle of the 1920s, opiates were prohibited,
In its early years heroin was lauded as a cure addicts were seen as "dope fiends," and a
for opiate addiction. This, however, turned out criminal subculture emerged. Many of these
to be another case of wishful thinking and the changes in the definition and treatment of opiate
"medical substitution game" as reports of addiction remain in force today, although there
heroin add.iction began to appear in the medical has been a reemergence of medical definitions.
literature. Within 5 years of its introduction to International developments around the tum of
the market it was abundantly clear that heroin the century significantly affected a changing
was at least as addictive as morphine, and warn- American opium policy.
ings appeared in the medical journals (Pettey,
1902-1903, cited in Duster, 1970). A quest for International control
Following the reports of heroin's addictive and the UnHed States' response
qualities, the medical profession declared that Shortly after the tum of the century the
heroin had no value for medical treatment and United States government seemed suddenly to
called for a curtailment of its use in cough emerge on the international scene as a driving
syrups and other remedies. With this medical moral force championing world-wide control
repudiation, heroin was divorced from any re- of "evil" opiates. Although the United States
spectability and legitimacy. Unlike morphine took a strong and righteous moral stand, it was
and codeine, it had no medical definitions; it not a selfless one. In fact, the State Depart-
was a drug that had only "recreational" uses ment's leadership in the anti narcotics move-
and thus became quickly imbued with far ment "originated with one of the peaks of
greater negative connotations than either of its American imperialism, the seizure of the Phil-
sister drugs. Muckraking exposes of addiction ippine Islands from Spain and the drive for a
appeared in the popular press, which depicted share of the China market" (Musto, 1973, p.
heroin as the most threatening drug in history. 24).
It was portrayed as having special appeals and The United States annexed the Philippines
dangers for youth (Morgan, 1974). Stripped of from Spain after the Spanish-American War in
its medical respectability, heroin became de- 1898. The Philippines had an established gov-
fined as a drug with no redeeming value, a view ernment opium monopoly, and the United
which remains prominent today. States Philippine Commission soon created a
In sum, the late 19th century saw an in- special committee to study "the opium prob-
creased public concern with addiction. Yet ad- lem. " The committee consisted of the Commis-
diction certainly was not considered a major so- sioner of Public Health for the Philippines, a
cial problem, and little of the moral opprobrium Filipino physician, and an Episcopal bishop
we associate with addiction and addicts was ap- named Charles Henry Brent. Reverend Brent
parent; addiction was a medical problem, a dis- eventually became a leading international cru-
ease, and addicts engendered sympathy. With sader in the antiopium movement. The commit-
122 DEVIANCE AND MEDICALlZATlON: FROM BADNESS TO SICKNESS
tee reported in 1904, after an extensive inves- dent Roosevelt suggested convening an interna-
tigation of opium in the Far East. Their conclu- tional opium conference. The United States
sions were exactly the opposite of those pre- wanted to expand her interests in China and
sented by the Royal Commission on Opium a thus offered aid to the Chinese in dealing with
decade earlier (Taylor, A., 1969). The com- their opium problems. American policymakers
mittee's report stated that opium was an evil hoped this might predispose China to adopt a
influence, and it proposed governmental con- position favorable to United States' trade inter-
trol of opiates and the gradual decrease of in- ests (Platt, J. J., & Labate, 1976).
dividual opium rations toward the eventual goal Two Inlemallonal conferences. The
of prohibition except for medical purposes. United States, spearheading the new interna-
Hospital cures and the teachings of the evils of tional conference convened in 1909, was in the
opium also should be made available. rather embarrassing position of having no fed-
eral legislation limiting opium use. But in
The report's authors considered it in accord with con- 1909, just as the conference was beginning,
temporary medical opinion selected, no doubt, to
Congress passed legislation prohibiting the
make their point: the craving for opium is irrepressi-
ble and a habitue gradually increases his intake until
importation of smoking opium to the United
systematic intoxication leads to moral and physical States.
degradation. (Musto, 1973, p. 27) The Shanghai Opium Commission convened
in 1909 with 13 nations attending. The Ameri-
The American response was even more drastic can delegation consisted of Hamilton Wright, a
than the report's recommendations. In 1905 physician and enthusiastic antiopium crusader;
Congress ordered an immediate opiate prohibi- Charles Tenney, an expert on China and a
tion for Filipinos except for medical purposes. strong antiopium advocate; and Bishop Brent,
After 3 years prohibition would include non- who acted as chairman. The United States pro-
Filipinos. This report and legislation were sig- posed a prohibition of opium except for medi-
nificant because these prohibitionary measures cal and scientific purposes; other nations were
became more or less a model for future antiopi- interested but not enthusiastic. The commission
um legislation. In all cases prohibitionary leg- had no real power and was thus limited to mak-
islation carried the conditional phrase' 'except ing recommendations. There was general agree-
for medical purposes." The closing off of other ment that some controls were needed, but no
legal sources increased the medicalization of way to implement them was outlined. The com-
opiate addiction and brought more addicts un- mission's recommendations provided an impe-
der medical jurisdiction. tus and support for subsequent American legis-
China initiated legislation in 1906 to end all lation (Platt, J. J., & Labate, 1976). The main
opium production in 10 years. Britain agreed to result of the conference was to focus political
reduce Indian opium exports to China in pro- attention to the opium problem.
portion with her own reductions in cultivation A second conference was called for 1912.
and imports from other countries (Scott, J. M., Attempts in Congress to pass an opium-control
1969). American missionaries played a sig- bill before the second conference failed. The
nificant role in promoting an antiopium move- principal interest group involved in defeating
ment and inducing the United States to become the legislation was the drug industry, which
involved. For missionaries like Bishop Brent, would not accept the severe restrictions pro-
opium was a moral issue "and transactions in posed (Musto, 1973). The International Con-
the drug ... a social vice-a crime" (Taylor, ference on Opium at the Hague recommended
A., 1969, p. 37). He believed opium was ruin- governmental limitation on importing opium for
ing lives in many countries and could only be nonmedical purposes and governmental licens-
controlled with some international agreement. ing for all persons engaged in all phases of the
He wrote a letter to President Theodore Roose- production and distribution of opiates. No ad-
velt articulating his views and calling for some ministrative mechanisms were created to carry
international concerted action. In 1906 Presi- out the recommendations, however, and it took
the better part of two decades to finally create largely responsible for "discovering" the do-
some international controls on opium manufac- mestic "drug problem" (Reasons, 1974). In
ture and distribution. reaction to the agreements of the second in-
Although these international conferences did ternational opium conference, a bill restrict-
not directly affect the medicalization of opiate ing the manufacture and distribution of nar-
addiction in the United States, they had impor- cotics was introduced in Congress. Repre-
tant indirect ramifications. First, they were the sentative Francis Burton Harrison agreed to
prelude and impetus for the legislation that pro- shepherd this legislation through the House of
hibited nonmedical opiate manufacture and sale Representatives. He appeared not to have a
in the United States. Second, by restricting opi- particular interest in the specific philosophy of
ate supplies to medical purposes, they forced the legislation so much as in its political viabil-
opiate addicts to rely increasingly on physicians ity (Musto, 1973, p. 54). Among the champions
as their suppliers of the drug. of the bill was Secretary of State William Jen-
nings Bryan, a long-time prohibitionist and
Harrison Act: the crlmlnallzatlon supporter of missionary activities. He urged
of addiction prompt passage of the law to fulfill the United
The early 20th century was a "progressive States' obligations under the new international
era" in the United States, resulting in the in- treaty.
creased governmental regulation of industry The various components of the drug and
and commerce. Domestic concern about drugs pharmaceutical industry were still opposed to
was increasing. In response to the crusading of a very restrictive bill. The AMA at this time
Dr. Harvey W. Wiley and the "muckraking" supported the restrictive legislation. The Har-
journalism that exposed the patent medicine rison bill, which incorporated numt:rous com-
industry, Congress in 1906 passed the Pure promises of interested parties, was introduced
Food and Drug Act. This law required that in 1913. The Harrison bill's supporters had
medicines containing opiates (and certain other little to say about the evils of opiate addiction
drugs) have their contents clearly labeled. It in the United States (Brecher, 1972, p. 49).
appears that some addicts subsequently dis- Debate centered more on the necessity of
continued their use of opiate preparations. meeting our international obligations than on
Following the Flexner Report in 1910, which the morality or health hazards of opiate addic-
was a devastating indictment of the quality of tion, and the bill passed the House easily. More
medical education, the medical profession itself than a year later the Senate passed a version
began to exert tighter regulation on medical with amendments lobbied for by special interest
training and thus on who could become a physi- groups. On December 14, 1914, the Harrison
cian. The temperance movement had become Act was passed, and it was signed by the presi~
prohibitionist and by the end of the second dent 3 days later. The American government
decade succeeded in winning such an amend- had vindicated its moralistic international prom-
ment to the Constitution. ises: opiates and other narcotics would be
Passage of the Harrison Act. From 1885 brought under federal control.
to the commencing of the first international On the face of it, the Harrison Act did not
conference on opium, many states passed laws seem to be a prohibition law. Its official and
against opiate use, usually opium smoking. cumbersome title suggests its function as a
The first comprehensive narcotics law, the control law by tax and registration:
Boylan Act, was passed in 1914 by the New
An Act to provide for the registration of, with the
York state legislature. But with the exception collectors of internal revenue, and to impose a spe-
of the 1909 law on smoking opium, no federal cial tax upon all persons who produce, import,
legislation on opiates existed until the Har- manufacture, compound, deal in, dispense, sell,
rison Act. distribute, or give away opium or coca leaves, their
Dr. Hamilton Wright and a few others, salts, derivatives, or preparations, and for other pur-
mostly missionaries and physicians, were poses.
Physicians, pharmacists, and manufacturers the few minutes it took to write a prescription,
dealing in opiates would be licensed. Addicts and when the law allowed, they dispensed
were not mentioned (Lindesmith, 1965). The opiates. The public outcry against these physi-
act had three major provisions: (I) Through cians was minimal, perhaps because the public
registration and licensing it gave the govern- believed that since the addict was under a
ment precise knowledge of legal traffic; (2) it physician's care, there was little reason for con-
required all parties to pay a tax, therefore plac- cern. Most physicians, however, were reluctant
ing the responsibility for enforcement on the to maintain addicts and did not include them in
Bureau of Internal Revenue of the Treasury their practice. As Musto (1973) points out:
Department; and (3) it limited the purchase of
The rare physician who before 1919 favored the
narcotics (except for a few exempt small
maintenance of addicts pleaded with his associates
amounts) to those prescribed by physicians for
to cooperate, but the practitioner's interest in doing
legitimate medical use. Thus physicians reso, either initially or as anti-narcotic legislation
tained control over opiates and their distribu- gained ground, appeared to be rather small. (p. 92)
tion. The intent of the bill appears to have been
to place opiates and addicts completely in the Thus it does not appear that physicians, as a
hands of the medical profession (Duster, 1970) whole or as an organization, favored the main-
and to achieve a controlled and orderly mar- tenance of opiate addicts. On the other hand,
keting of opiates. This is not, however, what it is clear that they did favor the medical con-
happened. trol of opiates, largely through physician
Interpreting and Implementing the Har- prescription. From their viewpoint, so long as
rison Act. Although the Harrison Act was in- physicians controlled the substances, the prob-
tended to be a law aimed at the regulation, con- lems of abuse and addiction would be mini-
trol, and record-keeping of opiates, it was mized.
neither interpreted nor implemented in that The Treasury Department did not see it that
light. Rather, through a campaign by the Trea- way. They became concerned about addicts
sury Department and a series of Supreme Court who went to the physicians and the physicians
decisions, the Harrison Act became increasing- who prescribed them drugs. The Treasury De-
ly interpreted as mandating the complete pro- partment interpreted the Harrison Act in terms
hibition of nonmedical opiate use and the of a moral principle-that taking narcotics for
criminalization of addicts. How did this occur? other than bona fide medical purposes was
The Harrison Act's provision that permitted harmful and should be prevented (Musto,
the medical prescription of opiates if prescribed 1973). Possession of narcotics received from
in "good faith" in "the legitimate practice of unregistered sources, according to the Treasury
medicine" left physicians as the only legal Department's interpretation, would be in itself
suppliers of opiates. Thus the medical profes- a violation of the Act. Increasingly, specific
sion, somewhat unwittingly, obtained a legal Treasury Department regulations narrowed
monopoly over the treatment and maintenance and eventually forbade opiate maintenance.
of addiction. Many law-abiding addicts sud- Physicians and druggists who prescribed opi-
denly came to physicians' offices for their ates freely were harassed and prosecuted.
drugs. It seems that only a minority of physi- The Treasury Department adopted a dual
cians actually dealt with addicts. Some physi- strategy of disseminating (mis)information
cians developed methods of "treating" addic- to the public about the narcotics problem
tion, and a few operated medical sanitaria spe- and "degenerate" addicts and instigating court
cifically designed for curing addiction. A small proceedings against physicians who maintained
subgroup of physicians, uncomplimentarily addicts. They launched a major attack against
called "opium doctors," organized their entire the medical profession through court cases.
practices around prescribing opiate substances Although the medical profession was coming
to patient-addicts. Many opium doctors saw under attack for dereliction of duties in pre-
hundreds of patients daily, perhaps only for scribing drugs indiscriminately, physicians con-
OPIATE ADDICTION: THE FALL AND RISE OF MEDICAL INVOLVEMENT '125
tinued to prescribe opiates based on the 1974). The medical profession had only a lim-
"legitimate medical practices" clause (Rea- ited interest in addiction per se, and focused
sons, 1974). The conflict would be settled in its concern on the physicians' prerogative to
the Supreme Court. practice medicine in a manner they saw fit.
Supreme Court support of the criminal Only a few physicians actually championed the
designation of addiction. The Supreme medical model of .addiction. Musto (1973)
Court handed down a series of decisions be- suggests that the political atmosphere changed
tween 1915 and 1922 that effectively demedi- between 1915 and 1919, as did the public's and
calized addiction and upheld a criminal defini- the Treasury Department's views of narcotics
tion. In 1915 in United States v. lin Fuey Moy use:
the Court ruled that possession of narcotics by
unregistered persons was essentially a crime. What had been a respectable viewpoint by 1915,
although not the dominant attitude of the public-
This decision literally forced addicts to go to
the value of addict maintenance by physicians and
physicians as their only legal source of drugs.
others-by 1919 and 1920 had come to seem a great
Subsequent decisions further limited both the danger and folly. Advocacy for maintenance was
physicians' and the addicts' options. The cen- repressed as strongly as socialism. (p. 32)
tral issue became what constituted "legitimate
medical use." In 1919 the Court ruled in Webb By the time America entered World War I, drug
et al. v. United States that prescribing drugs addiction was not only viewed as immoral be-
for an addict "not in the course of professional cause it wasted people's lives but was also per-
treatment in the attempted cure of the habit, ceived as a threat to the national war effort. It
but being issued for the purpose of providing was seen as sapping the nation's energies. In
the user with morphine sufficient to keep him 1919 the Palmer raids against Bolsheviks and
comfortable by maintaining his customary use" anarchists took place, and Prohibition was rati-
was not in the realm of legitimate medical prac- fied. Opiate maintenance could not be de-
tice. Thus medical opiate maintenance became fended any more than alcoholism. It is not sur-
illegal. The Court decisions of lin Fuey Moy v. prising that the Supreme Court decisions re-
United States in 1920 and United States v. flected an increasing concern with controlling
Behrman in 1922 further narrowed the medical "degeneracy" and deviance. Thus the Court's
prerogative of prescribing opiates. In the latter decision to oppose opiate maintenance, as
case physicians were effectively denied the Musto (1973) points out, could be broadly
right to prescribe opiates to treat and cure ad- interpreted as a strike against activities that
dicts (Lindesmith, 1965). These decisions weaken a nation. *
made outpatient treatment of addiction impos- Narcotics clinics: the medical swan
sible. The Court softened its view considerably song. In 1918-1919 the Special Narcotic Com-
by 1925 in the Lindner v. United States de- mittee of the Treasury Department was con-
cision by deeming that "addicts are diseased vened to attempt to close the loopholes revealed
and proper subjects for [medical] treatment," by several court decisions. The committee pro-
but it was too late. By that time physicians had duced a report, "Traffic in Narcotics," which
largely adopted the dominant moral-criminal contained their analysis and recommendations.
definition of addiction and had all but aban- It presented unreliable and very inflated statis-
doned medical treatment of addicts. tics regarding the scope of the addiction prob-
But why did this dramatic shift in the defini-
tion occur when it did? Clearly the Treasury *Although sociologists like Richard Quinney (1974a,
Department championed the criminal definition p. 97) and John Helmer (1975) present Marxian
of addiction and claimed the addict as within its analyses of the passage of the Harrison Act, theories
legitimate social control turf. Their use of postulating class and power struggles or minority
oppression do not adequately explain this complex
judicial decisions, rather than legislative ac- phenomenon. Scotty Embree (1978) presents a plau-
tion, circumvented the strong medical and sible economic analysis but lacks data to support
pharmaceutical congressional lobbies (Reasons, her argument.
lem (it estimated that there were about a million autonomous section of the Prohibition Unit)
addicts at that time) and presented an optimistic adopted a view that addiction maintenance was
view of the "cure" rates of addiction. The re- only tolerable for medical reasons. A battle
port defined opiate addiction as having aspects with these federal agents ensued over who
of a disease-the addiction that resulted from should have legitimate control over this turf,
continued use of opiates and the addicts' subse- and many physicians, pharmacists, and even
quent use of the drug to remain "normal" - but clinic personnel were arrested.
also depicted addicts as weak creatures, lacking The operation of the clinics was uneven;
morality, who would resort to crime when de- some, like the Shreveport, Louisiana, clinic
prived of the drug. The committee believed may have been successful in treating addicts,
that an addict could not discontinue drug use controlling the spread of addiction, and limiting
without intervention and thus recommended the development of a criminal drug under-
the provision of medical care. However, it world. On the other hand, the New York City
did not specify which of the medical approaches clinic, probably the largest in the country, was
would be most suitable. By the time the re- run poorly and distributed drugs rather in-
port was released, the Supreme Court had al- discriminately. The Treasury Department fo-
ready handed down its decisions narrowing cused its attack on the clinics in New York:
medical discretion in the treatment of addic- it conducted an investigation and, with the
tion (Musto, 1973). aid of muckraking journalists, discredited nar-
Although the Treasury Department con- cotics clinics as a means of dealing with drug
sidered medical treatment a necessary step in problems. By 1923 all the clinics were closed.
addiction control, the United States Public The Treasury Department distorted evidence
Health Service did not see it that way. The (which actually was mixed) to brand the clinics
Public Health Service, the major government and the medical approach to addiction as un-
branch of medicine, stepped out of the opiate tenable and a total failure (Lindesmith, 1965).
treatment picture after 1919 and "excused it- The clinics received considerable bad press,
self from claiming knowledge of how to cure and this contributed to an increased public con-
addicts and drew the conclusion that the nation cern about addiction. The AMA in 1925 took
should rely on legal enforcement to control a firm position against ambulatory treatment
narcotic supply" (Musto, 1973, p. 146). The of addicts, suggesting that institutionalization
Treasury Department, frustrated in its attempts was the only alternative. The AMA passed a
to control addiction through enforcement, resolution calling on federal and state govern-
sought medical help and urged the establishments "to exert their full powers and authority
ment of local municipal narcotics clinics. to put an end to all manner of so-called ambula-
Between 1919 and 1920 about 44 narcotics tory methods of treatment" (quoted in Schur,
clinics opened in scattered cities across Amer- 1965, p. 159). The narcotics clinics were the
ica. They varied in size and organization, but swan song of the medical approach to addic-
all adopted a medical approach to treating drug tion; with their demise, physicians by and large
addiction. From their start, most clinics used abandoned treatment of opiate addicts. The
an outpatient or ambulatory maintenance ap- closing of the clinics marks the end of the
proach to addiction. The goal, ideally, would medical era: the medical approach to addiction
be to "cure" the addicts. In some clinics this was no longer a viable competing definition of
involved medical treatment and follow-up care, reality. All concerned seemed to agree that
but in others it amounted to merely giving out addiction was a criminal problem.
drugs to those who registered and requested There seem to be several reasons why
them. Although the clinics were always deemed physicians relinquished their jurisdiction over
to be a temporary measure, it appears that fed- opiate addiction. First, the medical profes-
eral officials quickly became disenchanted with sion's support of opiate maintenance had been
their operation. The Narcotics Division of the based more on a belief in the physician's pre-
Treasury Department (newly created as a semi- rogative to control medical treatment and a dis-
taste of government interference in medical criminal approach to addiction. Although in

practice than on any real commitment to the the short run a punitive approach may have re-
morality or efficacy of maintenance treatment. duced the number of addicts, several long-run
Few physicians were heavily invested in treat- consequences actually created new and more
ing addicts, and physicians still retained control difficult narcotics-related problems (Goode,
of opiates for "medical uses" (minus heroin, 1972). Cutting off the legal medical supply of
whose manufacture for any purpose was pro- drugs left addicts with two choices: they could
hibited in 1924). Second, by the 1920s most give up their habits and suffer greatly from
physicians no longer believed addiction was a withdrawal or tum to an expanding illegal net-
disease (Musto, 1973, p. 83), and their opti- work to procure their drugs. The prohibition
mism for achieving a cure was waning. Third, of opiates thus contributed to the creation of
the medical profession also may have had an addict subculture, an underworld where ad-
enough of the Treasury Department's harass- dicts could find protection and connections.
ment. One study estimated that in the 25 years Erich Goode (1972, p. 196) suggests that this
following the Harrison Act, 25,000 physicians subculture has been central in the "recruit-
were arrested on narcotics charges and 3000 ment" of new addicts. Moreover, the prohibi-
actually served prison sentences (cited in tion of opiates made narcotics a highly profit-
Goode, 1972, p. 191). Thousands more had able commodity, and an entire criminal industry
their licenses revoked. The state had effectively developed to market them. The drugs' illegality
recalled the medical profession's license to treat and subsequent scarcity inflated their price and
opiate addiction. made it nearly impossible for addicts to work
In sum, the medical profession relinquished at conventional jobs to support their habits.
its turf of opiate addiction. The Narcotics Divi- Many addicts therefore had to tum to crime
sion of the Treasury Department had success- as the only way to finance their addiction.
fully challenged medicine and staked out ad- There is undoubtedly a relationship between
diction as within its legitimate and exclusive addiction and crime; the important question is,
jurisdiction. As such, the Narcotics Division's however, what is the nature of this relation-
entrepreneurship had created an entire new ship? Many addicts resort to burglary and other
category of criminals, "drug addicts," and property crimes to pay the inflated prices of
manufactured a social problem where there black-market drugs. In places where drugs
had been none before. As Erich Goode (1972) are cheaply available, addicts are no more
points out, the result of this was criminal than nonaddicts. Thus the Narcotics
Division's prohibition of opiates amplified any
the dramatic emergence of a new criminal class opiate problems that may have existed previous-
of addicts-a criminal class that had not existed ly by setting conditions that gave rise to an
previously. The link between addiction and crime-
addict subculture and forcing addicts into a
the view that the addict was by definition a crimi-
nal-was forged. The law itself created a new class
world of crime to maintain their addiction.
of criminals. (p. 194) Along with the change in the definition and
designation of addiction, a shift occurred in
The social definition of opiate addiction as a the popUlation of addicts and in the moral con-
criminal problem became a self-fulfilling proph- demnation of addiction. Troy Duster (1970,
ecy. pp. 20-23) argues that certain social categories
are more easily morally condemned than others.
REIGN OF THE CRIMINAL As the population of addicts became typified
DESIGNATION by the young, lower-class black male, rather
In the wake of the Harrison Act and the than the middle-aged, middle-class white fe-
subsequent Court decisions that "clarified" it, male, American's moral hostility increased
the problem of opiate addiction was securely proportionately. The Harrison Act did not
on the Narcotics Division's turf. But there were create the strong moral judgments about heroin
some unanticipated consequences of taking a use per se but pushed addiction into an arena
populated by the lower classes and the crime tice Department became concerned with finding
underworld, groups about which strong moral some alternative to traditional imprisonment,
feelings already existed. As the addict popula- since addicts had become the largest class of
tion shifted, the image of the addict changed offenders in prisons (Musto, 1973, p. 204). A
from a sick to a contemptible deviant. bill was introduced in Congress that called
for the establishment of Federal Narcotics
AddlcHon becomes a "criminal Farms (later called hospitals); essentially these
menace" would be separate prisons run by the Public
The change of the addict's image did not Health Service. Hospital-farms were opened in
happen by chance. The Narcotics Division Lexington, Kentucky, in 1935 and in Fort
had institutionalized its definition of addiction Worth, Texas, in 1938. Run as prisons, they
as national policy and through "educational" provided segregation and limited medical
efforts changed the "image of the addict ... treatment. Although Anslinger reported that
from ailment to evil" (Reasons, 1975, p. 19). 64% of addicts treated at Lexington never re-
Its "success" was rewarded by increased bud- turned for treatment (Anslinger & Tompkins,
gets (Dickson, 1968) and by its being estab- 1953, p. 24), the "cure" rate was actually low.
lished in 1930 as a separate organization, the Anslinger's figures included only those who
Federal Bureau of Narcotics (FBN). Henry J. returned to Lexington; most addicts relapsed
Anslinger, a former Prohibition official, was and went to prison or other hospitals. More
named to head the new bureau. He came to rigorous studies suggest that the Lexington
have an enormous effect on national drug pol- success rate (as evidenced by nonprison absti-
icy for three decades. Anslinger viewed opiate nence from narcotics for several years) was a
addiction as a clearly criminal problem and the meager 2%, and at best, 7% (Hunt, G. H., and
addict as a moral degenerate. The FBN's propa- Odorhoff, 1962; Vaillant, 1965). Perhaps the
gandistic activities were central in creating and most significant contribution of the hospital-
popularizing the myth of the addict as a de- farms was as research centers and training
generate, violent "dope fiend" who is out grounds for future National Institute of Mental
to convert others to drugs (Lindesmith, 1940). Health (NIMH) people, who were disillusioned
Here was the source for the belief that heroin with the FBN and the criminal approach to ad-
itself "caused" crime and violence. In the late diction (Musto, 1973). They provided an in-
1930s the FBN, under Anslinger's leadership, stitutionalized setting for the ferment over
expanded its turf to include jurisdiction over medical approaches that would reemerge in
marijuana use (Becker, H. S., 1963). the 1950s.
The period before World War II saw little World War II interrupted the international
medical attention to addiction and nearly no heroin traffic, and as a result the addict popula-
claims-making activity. A few widely scattered tion in the United States may well have declined
physicians took issue with the criminal ap- (McCoy, 1973). For a short time, this mini-
proach to addiction. Dr. Charles E. Terry's and mized the FBN's problems with smuggling
Muriel Pellens' (1928) massive work, The and addiction. At the war's end there were only
Opium Problem, presented data at variance 20,000 known addicts in the United States
with FBN reports (Lindesmith, 1965). Dr. (Goode, 1972, p. 196). Few challenged the
Henry Smith's 1939 book, Drug Addicts Are criminal definition of addiction (an exception
Human Beings: The Story of Our Billion Dollar was sociologist Alfred Lindesmith, discussed
Drug Racket, indicted government officials later).
for intimate involvement in creating the drug By the 1950s heroin addiction was associated
problem. But such critiques were few, and the increasingly with ghetto life and organized
criminal definition of addiction became taken crime; public attention was again drawn to
for granted. the alleged "criminal menace" of addiction,
Large numbers of addicts were imprisoned especially as it threatened teenagers and school-
under the Harrison Act's provisions. The Jus- children. The Kefauver Committee on Crime,
in a series of televised hearings, focused pub- Several factors underlie this failure. First,
lic attention on narcotics problems. Popular there has been and continues to be a demand
magazines like Newsweek, Life, and Reader's for chemical substances that relieve pain, alter
Digest published articles on the drug evil with human consciousness, and provide recreation
such alluring titles as "New York Wakes Up and distraction from mundane experiences.
to 15,000 Heroin Addicts" and "Children in Explanations that hypothesize psychological
Peril," based largely on information from or physiological predispositions or "addictive
Anslinger and the FBN. Anslinger recom- personalities" miss the point; drugs are attrac-
mended that Congress pass laws with tougher tive to a large variety of people (witness the
penalties to combat the addiction "menace." popular use of cigarettes, alcohol, and mari-
In the McCarthy era the narcotics problem juana). Although social circumstances like op-
was linked with communism and deemed an pression, the availability of drugs, and cultural
agent of subversion, corruption (Reasons, meanings of drug-taking may increase or de-
1975), and a threat to the American way. crease the demand, such a demand exists in
Congress responded by passing two laws most societies. Second, opiates are drugs with
that strengthened and extended the criminal addicting properties (Brecher, 1972, pp.
approach. The Boggs Amendment of 1951 61-89). There is a great deal of evidence that
called for mandatory sentences for narcotics demonstrates the difficulty of terminating opiate
violations, with no suspended sentence or use. Relapse rates are high no matter what
parole for repeated offenders, and made prose- method of treatment or punishment is used.
cution of users and peddlers easier. The Nar- Rehabilitation has been largely a failure-
cotic Control Act of 1956 extended the Boggs prison has served to perpetuate drug use-and
law, eliminating parole for all but first of- addicts return frequently to the same environ-
fenders, and "combined the threat of death ment with the same problems that engendered
with mandatory minimum sentences for the addiction in the first place. Third, the black-
first conviction" (Musto, 1973, p. 242). Nu- market sales of heroin and other drugs have
merous states modeled their own laws after created a huge illegal industry. This industry is
these, and a few enacted legislation making ad- an international and highly profitable one and
diction per se a crime. The penalties for drug at times has been nearly monopolistic in its
offenses were more severe than for crimes like control of the market (Chambliss, 1977). Gov-
armed robbery and burglary (Lindesmith, ernment attempts to control the industry, usual-
1965). These "get tough" laws reinforced the ly through efforts at curtailing "smuggling,"
criminal definition of addiction. They represent have served to decrease supply and thus main-
the high-water mark of the FBN's philosophy, tain high prices. This has not, however, re-
which had emerged more than 30 years be- duced effectively the use' of opiates and other
fore-that if penalties were made severe drugs in American society. Fourth, the very
enough and enforced effectively, addiction laws that made opiates illegal ironically gave
would disappear. This, however, has not been rise to a criminal underworld that has nurtured
the case. the spread of drug use. The addict subculture,
which emerged in response to the criminaliza-
Why narcotics laws have failed tion of opiates, became a means by which in-
The criminal approach has failed to eliminate formation and drugs could be disseminated.
or even effectively control addiction. The Finally, despite the failure of criminal sanc-
number of addicts and the amount of illegal tions, certain groups in society, particularly the
opiate trade have increased substantially in the FBN and other law-enforcement agencies,
past 25 years. The 1960s saw addiction spread continued to promote the punitive approach to
to middle-class communities and college cam- the drug problem. Politicking in legislatures,
puses and become a major problem in the misleading publications and research (Linde-
armed forces. Why has the criminal approach smith, 1965, p. 121), and increased budgets for
failed? control and enforcement, along with a general
acceptance of punitive sanctions for lower-class of the drugs (e.g., who view them as a result
and minority deviants, kept the criminal ap- of a disease) escape addiction. Thus in Linde-
proach dominant. smith's model of addiction the fear of with-
In sum, the 1950s saw the criminal defini- drawal distress creates the "craving" for
tion reach a peak. But criticism was mounting drugs. *
that the harsh, punitive approach was not In a final section of Opiate Addiction Linde-
stemming the tide of addiction. It had not smith criticized the criminal approach for fail-
"worked." Murmurings of a reemergence of ing to deal adequately with the problem of
a medical definition of addiction could be addiction. He proposed that the law-enforce-
heard. ment approach be limited to controlling illegal
narcotics traffic and that the addict be handled
REEMERGENCE OF MEDICAL as a medical rather than criminal problem.
DESIGNATIONS OF ADDICTION This could be accomplished by reinterpreting
By the mid-1950s a small chorus of voices the Harrison Act to recapture its original intent
could be heard criticizing the punitive approach and by changing laws so "prescription of drugs
to addiction and calling for alternatives. Per- to addicts by a physician is defined as being
haps the premier and most articulate voice was within the field of medicine" (Lindesmith,
that of sociologist Alfred R. Lindesmith. 1968, p. 234). He pointed to the British system
Lindesmith, in a series of papers and most (discussed later) as a model of successful
specifically in his 1947 book, Opiate Addiction, medical control of addiction.
developed a sociological explanation of addic- The middle 1950s saw segments of the
tion that contradicted the conventional popular medical profession begin to reassert publicly
and medical wisdom that addiction was caused their claims that addicts are a medical problem.
by the euphoria -drugs produced. Lindesmith The Committee of Public Health of the pres-
concluded, on the basis of extensive, in-depth tigious New York Academy of Medicine as-
interviews with a large variety of addicts, that serted in a 1955 report:
opiate addiction (i.e., the continued use of
There should be a change in attitude toward the
opiates) was not caused by the search for addict. He is a sick person, not a criminal. That he
euphoria but by the usage of drugs to alleviate may commit criminal acts to maintain his drug sup-
withdrawal distress. In Lindesmith's (1968) ply is recognized; but it is unjust to consider him
words: as a criminal simply because he uses narcotic drugs.
(New York Academy of Medicine, 1955/1%6, p.
Addiction occurs only when opiates are used to al-
188)
leviate withdrawal distress, after such distress has
been properly understood or interpreted. . . . If the The report further maintained that to eradicate
individual fails to conceive of his distress as with- drug addiction, the profit must be taken out of
drawal distress brought about by the absence of drug traffic. To facilitate this, the committee
opiates, he does not become addicted, but, if he
proposed a federally controlled medical dispen-
does, addiction is quickly and permanently estab-
sary-clinic system whereby addicts could re-
lished through further use of the drug. (p. 191)*
ceive drugs at low cost. The goal of the clinics
This explanation emphasizes the importance would be to persuade addicts to undergo with-
of the cognitive element in addiction: the indi- drawal. If addicts could not be persuaded "de-
vidual's interpretation of the biological events
associated with drug use and disuse are cen- *Lindesmith's theory has been criticized by re-
tral to becoming addicted. According to Linde- searchers who posit more drug-centered, physiolog-
smith, those who experience withdrawal symp- ical models of addiction (e.g., Ausubel, 1958;
Duster, 1970, pp. 59-60). In a recent study, Mc-
toms and do not connect them to the ingestion
Auliffe and Gordon (1974) attempted to test
Lindesmith's withdrawal-versus-euphoria hypothe-
sis and claimed their findings refuted his theory. In
*Copyright © 1947, 1968 by Alfred R. Lindesmith. a reply Lindesmith (1975) points out that these find-
Reprinted, with permission, from Addiction and opi- ings, although valid in their own right, do not refute
ates (New York: Aldine Publishing Co.) his theory.
spite all efforts" and were "resistant to under- the long-dormant Lindner decision of 1925
taking therapy," minimum doses of drugs that accepted addiction as a disease. The deci-
should be legally and cheaply supplied. The sion compared addiction to other diseases:
central thesis of the report was that addicts
would be under medical supervision. A year It is unlikely that any State at this moment in his-
later, in 1956, psychiatrist Marie Nyswander, tory would attempt to make it a criminal offense
for a person to be mentally ill, or a leper, or to
who had treated addicts at the Lexington nar-
be afflicted with venereal disease . . . . a law which
cotic hospital and in private practice, published made a criminal offense of such a disease would
The Addict as Patient. She argued for accepting doubtless be universally thought to be an infliction
addicts as patients, not criminals, and suggested of cruel and unusual punishment. (Quoted in Kittrie,
that opiate maintenance might be the only 1971, p. 239)
feasible solution because none of the treatments
worked well. The decision proposed that rather than punish-
The most controversial and influential docu- ing addicts, states should compel them to
ment claiming addiction as a medical problem undergo treatment, presumably under civil
was a report by the Joint Committee of the commitment statutes. Although Robinson did
American Bar Association and the American not affect laws on possession, sales, or other
Medical Association on Narcotic Drugs. The narcotics offenses or make a therapeutic ap-
joint committee consisted of six well-respected proach imperative (Kittrie, 1971, p. 240), it
members of these associations, including Rufus added considerable legitimacy to the sup-
King, a lawyer well-known for his writings on porters of the medical approach.
narcotics. The Interim Report, published in Change in the definition and treatment of ad-
1958 in limited edition for use by the profes- diction was definitely in the air. In 1963 the
sional associations, made a number of recom- Presidential Comission on Narcotics and Drug
mendations: (I) The laws on narcotics need Abuse Report called for (I) the relaxation of
review, (2) qualified physicians should be al- mandatory sentences, (2) an increase in appro-
lowed to dispense narcotics, and (3) medical priations for research, (3) dismantling of the
treatment in outpatient facilities should be tried FBN and transfer of its functions to the Depart-
on a controlled experimental basis. The thrust ment of Health, Education and Welfare and
of the report was that a strict law-enforcement the Justice Department, and (4) reinstituting the
approach had not provided an answer to the ad- medical profession as the authority on what
diction problem. constituted legitimate medical treatment of ad-
The FBN reacted sharply to the ABA-AMA diction (Platt, J. J., and Labate, 1976, p. 28).
report. Their domain of drug addiction threat- Almost as if to mark a change in eras of drug
ened, the FBN retorted with a caustic rebuttal control, FBN Commissioner Anslinger, the
that amounted to "largely a vehement attack on author and staunchest defender of the punitive
the 'un-American' ABA-AMA committee approach to addiction, retired in 1962.
members, the sources cited in the report, and The late 1950s, then, saw a slight shift in
the Supreme Court" (Reasons, 1975; p. 33). the definition of addiction. Perhaps in response
When the report was about to be published by to the punitive peak reached by the Boggs law
the Indiana University Press, FBN chief An- and the Narcotics Control Act of 1956, a small
slinger sent a narcotics agent to Indiana Univer- group of claims-makers and supporters of
sity to "investigate" it (Lindesmith, 1965, medical definitions of addiction began to chal-
p. 246). The report was published in 1961 as lenge dominant criminal definitions. Addicts
Drug Addiction: Crime or Disease? were increasingly portrayed as sick rather than
evil. It is unclear exactly why this challenge oc-
Support for a medical designation curred at this point, but certain factors seemed
In 1962 the Supreme Court struck down a to support definitional change. There had never
California statute that had defined addiction as a been an unbending consensus in organizations
punishable crime. In this significant decision, like the AMA and the ABA that addicts were
Robinson v. California, the Court reaffirmed dangerous and pathological criminals (Rock,
1977). The apparent failure of punitive addic- of the law was necessary. The Ministry of
tion control and the increased isolation of the Health appointed a committee, headed by Sir
FBN from other professional viewpoints made Humphrey Rolleston, "to resolve what ap-
the time ripe for a challenge. The province and peared to be a conflict of views between phy-
status of psychiatry was growing as a result of sicians, who were in fact caring for addicts, and
the pharmacological revolution that began in law enforcement bodies, which thought the
1955. This may have ignited new hopes in 1920 statutes prohibited this" (Lindesmith,
medical approaches to deviance control. And 1965, pp. 167-168). The Rolleston Committee
by the early 1960s President Kennedy's "bold, issued a report in 1926 that was favorable to
new approach" in mental health treatment the physicians. Although eschewing the sup-
could easily be expanded to include addic- plying of drugs "solely for the gratification
tion. of addiction," the report stated:
This is not to say that criminal designations
morphine or heroin may properly be administered
of addiction disappeared. Rather, claims-
to addicts in the following circumstances, namely
makers were promoting a medical designation (a) where patients are under treatment by the gradual
of addiction that would challenge, and ulti- withdrawal method with a view to cure, (b) where
mately coexist with, law-enforcement agen- it has been demonstrated, after a prolonged attempt
cies' criminal approach. It sometimes appeared at cure, that the use of the drug cannot be safely dis-
that champions of the medical approach sup- continued entirely, on account of the severity of the
ported it more as a strategy for citicizing the withdrawal symptoms produced, (c) where it has
dominant punitive approach than out of a deep been similarly demonstrated that the patient, while
belief in the morality and efficiency of medical capable of leading a useful and relatively normal
interventions. Although they had no proven life when a certain minimum dose is regularly ad-
"answers" to propose as addiction policy, the ministered, becomes incapable of this when the
drug is entirely discontinued. (Quoted in Schur,
critics often pointed to the success of the
1962, p. 76)
British system of heroin maintenance as a
medical approach worthy of emulation. In effect, this ruling gave physicians final
authority in dealing with addiction and defined
EXCURSUS: THE BRITISH "treatment" as regularly providing drugs for
EXPERIENCE addicts. Thus the British never took the Amer-
American champions of medical designations ican route of trying to keep drugs away from
for addiction point frequently to the British addicts.
experience as an exemplar of the utility and For the first four decades of the medical ap-
success of a medical approach. The British approach to addiction, an addict could go to any
proach designates addiction as a sickness and physician and receive a prescription for opiates;
treats the addict almost entirely as a medical physicians voluntarily notified the Home Of-
concern. Treatment of addicts resides with fice of their addict-patients. This approach
medical practitioners and consists, in general, worked well; in 1935 there were only 700
of supplying opiates to addicts under medical known addicts in Britain; by 1950, the number
supervision. We will briefly explore the de- had dropped to about 300 (Brecher, 1972, p.
velopment and operation of the British ap- 121). Even if a small number were unknown to
proach to addiction. officials (which is likely), the British still
Great Britain responded to the international appeared to have the addiction problem well
conferences of the early 20th century in a man- controlled. Furthermore, no black market of
ner similar to the United States; in 1920, drugs had developed, there was virtually no
Parliament enacted the Dangerous Drug Act, drug-related crime (since addicts did not need
which, like the Harrison Act, was intended to to resort to crime to support their habits), and
limit opiate distribution to medical channels. many addicts were still employed and leading
But, as in the United States, a dispute over productive lives. It is little wonder that Amer-
jurisdiction developed, and an interpretation ican champions of the medical approach held
up the British system as a model (e.g., Linde- TABLE 2

smith, 1947; Joint Committee of the American NUMBER OF KNOWN ADDICTS
Bar Association and the American Medical IN GREAT BRITAIN*
Association, 1961).
Anslinger and the FBN, as well as other Number of Number of
supporters of the law-enforcement approach, Year known addicts Year known addicts
tried continually to discredit the British pro- 1945 367 1968 2782
gram. Much of the FBN critique is contradic- 1950 306 1969 2881
tory. At various times Anslinger depicted the 1955 335 1970 2661
British approach as a "nonsystem," and, 1960 437 1971 2762
incredibly, as the same as the American ap- 1961 470 1972 2934
proach (after all, according to his reasoning, 1962 532 1973 3021
they both included laws against opiate traffic 1963 635 1974 3254
and nonmedical opiate use). FBN officials 1964 753 1975 3427
charged that the British statistics were phony 1965 927 1976 3480
1966 1349 1977 3611
or at best unreliable and that the British ap-
1967 1729
proach worked in Britain because it was an
island and the British character was less addic- *"Throughput" figures calculated from data from the
Statistical Division of the Home Office.
tion prone. When the number of addicts rose
sharply in the early 1960s, FBN officials an-
nounced that the British approach was simply take advantage of the availability of high-qual-
a failure (Brecher, 1972, Lindesmith, 1965). ity, low-cost legal heroin (Brecher, 1972, p.
When a committee to evaluate the British 123). A new pattern of drug use also was dis-
policy toward addiction met in 1961 under the cernible among British youth. The rise of a
direction of Sir Russell Brain, it reported that teenage subculture with favorable attitudes
the system was working well, and no alterations toward drug experimentation created for the
in policy were necessary. But by July, 1964, first time a potential market for opiate-type sub-
the situation had changed sufficiently for the stances (Scull, 1972). The public's demand for
committee to be reconvened (Scull, 1972). punitive action and a delay in responding to the
Beginning in the early 1960s, the number of changed climate further exacerbated the situa-
opiate addicts in Great Britain rose sharply tion.
(Table 2). By the mid-1960s, the number of The Brain Committee's second report reaf-
new addicts was increasing at a rate that firmed the medical approach to addiction: "The
doubled the addict population every 16 months. addict should be regarded as a sick person, he
Black markets could be found in Soho and should be treated as such and not as a criminal,
Picadilly (May, 1971). When the Brain Com- provided that he does not resort to criminal
mittee reconvened, there was serious concern acts" (quoted in May, 1971, p. 348). The
that the British system was indeed breaking committee did, however, recommend a number
down. of changes, which finally went into effect in
The Brain Committee reported in 1965. 1968. These included: (I) that all addicts should
They attributed the rise in opiate addicts mainly be "notified" (reported) to the Home Office,
to a few irresponsible physicians who were (2) special treatment clinics should be estab-
overprescribing drugs to addicts, and to addicts lished, and (3) prescription of heroin and co-
who peddled these excesses on the street, caine should be limited to physicians at these
creating a "gray market." Other factors, clinics (other physicians could still prescribe
not specifically noted by the committee, also morphine or methadone). These simple mea-
undoubtedly had contributed to the increased sures seemed to be effective, since the number
addiction. In the early 1960s a small group of of new addicts began to decrease markedl y
Canadian and American addicts had migrated after 1968 (May, 1971) and the total addict
to England to escape repressive drug laws and population increased at a slower rate and
134 DEVIANCE AND MED/CALIZAT/ON: FROM BADNESS TO SICKNESS
appears to be relatively stabilized (Table 2). * Lilly Pharmaceutical Company marketed it as

Although some addicts who obtain their drugs cough medicine. However, the main use for
from illicit sources never come to "official" methadone was in the detoxification of opiate
attention, the British addict population never addicts.
approached the estimated 150,000 to 250,000 Many hospitals, following procedures that
Americans addicted during the same time were developed at the Lexington research cen-
period. (In relative terms, the United States ter, used methadone to "detoxify" opiate ad-
has about to times the number of opiate addicts. The procedure was simple. Under med-
dicts as Britain.) American proponents of the ical supervision addict-patients had their ad-
law-enforcement approach to addiction had diction transferred from morphine or heroin
written a premature obituary, for the British to methadone. Then, over a period of about to
had at least slowed the increasing spiral of days, the daily dose of methadone was progres-
addiction. sively reduced until it reached a zero level.
There is no evidence, however, that British This procedure was intended to minimize the
physicians had any better success at "curing" suffering of withdrawal and was a common
addiction than had their American counter- practice by the early 1960s. In a sense, the
parts in the narcotics clinics in the early 20th medical involvement in these detoxification
century. For a variety of reasons, many already procedures occasioned the return of medical
mentioned, heroin maintenance never had practitioners to the treatment of opiate addic-
substantial official support in the United States. tion. Until the discovery of "methadone main-
Americans seem to want to "cure" by compul- tenance" in the mid-1960s, however, physi-
sion or a forced cure, whereas the British do cians nearly always exited from the treat-
not (Lindesmith, 1965, p. 169). However, ment process after withdrawal was accom-
there never were any "cures" that were very plished.
successful. But when methadone maintenance Methadone maintenance as a treatment for
was discovered in the early 1960s, many Amer- addiction was discovered accidentally by two
icans thought they had found that elusive cure medical researchers, Vincent Dole and Marie
for heroin addiction, and it was embraced Nyswander. Dole, a specialist in metabolic
accordingly. disease, became interested in heroin addiction
through his research on obesity. This research
METHADONE AND THE led him to conclude that relapses among some
REMEDICALIZATION OF obese patients were due to metabolic, biochem-
OPIATE ADDICTION ical causes, rather than simply a lack of "will-
Methadone is a synthetic opiate-like drug power" (Brecher, 1972, p. 135). Nyswander,
that possesses many of the same qualities of a psychiatrist with considerable experience
opiates, including addictiveness and analgesic treating addiction and addicts at Lexington and
action. Methadone was developed by a German in New York City storefronts, became Dole's
chemist and first used by physicians as an anal- associate for his heroin research. She was a
gesic in medical treatment when opium was long-time advocate of a medical approach to
scarce during the second World War. After the addiction, as evidenced by her book, The Drug
war a governmental team investigating Nazi Addict as Patient (1956). Together, at Rocke-
drug companies brought methadone to this feller University, they began research on the
country. Beginning in the late 1940s, E. J. metabolics of heroin addiction. In October,
1963, they placed two addicts on high doses
of methadone to compare morphine and meth-
*The actual number of addicts receiving medical adone metabolism. Much to their surprise,
treatment at anyone time is smaller. For example,
according to the Home Office, 1879 addict-patients when the addict-patients were on high doses of
were receiving drugs from physicians on January 1, methadone, unexpected changes in their be-
1977. havior and activity began to occur. Nyswander
reported, "The older addict began to paint the euphoric action of heroin, and they de-
industriously and his paintings were good. The scribed it as an "antinarcotic drug." Dole and
younger addict started urging us to let him get Nyswander (1967) developed a theory con-
his high school equivalency diploma" (Hen- ceptualizing opiate addiction as a metabolic
toff, 1969, p. 114). Both were allowed to live disease, with methadone as part of its "cure."
and attend school outside the hospital while Their theory was that opiate addiction created
being maintained on methadone. They became, a permanent biochemical change in the physiol-
apparently, effectively functioning human be- ogy-hence methadone maintenance can be
ings-and were essentially "cured" of their seen as necessary to the life of the addict. Meth-
cravings for heroin. The researchers soon adone stabilized the physiology of an addict
replicated these results with four additional much as insulin stabilized the diabetic. These
"hard-core" addicts. Thus, by accident, Dole scientific reports and the results from early
and Nyswander discovered that methadone demonstration projects and evaluations pro-
could be used as a maintenance drug that vided ammunition for the supporters of the
enabled addicts to engage in conventional pur- medical approach in the battle over the designa-
suits. tion and treatment of addiction. Between 1963
Dole and Nyswander published a series of and 1971, in the wake of a heroin "epidemic,"
articles reporting the results of their work with methadone maintenance went from an esoteric
methadone maintenance and proposing a theory accidential finding to a dominant position in
of how it worked. The first article (Dole & public policy.
Nyswander, 1965) reported striking improve-
ments in employment, education, and family "HerOin epidemic" and available
reconciliation for 22 patients receiving metha- treatment
done maintenance. According to the report, all The 1960s saw an increased public concern
the addict-patients had many previous treat- with "the drug problem," especially heroin
ment experiences and had been unable to addiction. The number of heroin users in-
remain drug free after withdrawal; they had creased dramatically; estimates ranged from
been treatment "failures." On methadone the 150,000 to 500,000 addicts. By the end of the
craving for heroin appeared to be suppressed. decade, writers in both the professional (Du-
Dole and Nyswander (1965) concluded: Pont, 1971) and popular (Newsweek, July 5,
1971) media were declaring a virtual "heroin
This medication appears to have two useful effects:
(I) relief of narcotic hunger, and (2) induction of
addiction epidemic" in America. (It is inter-
sufficient tolerance to block the euphoric effect of esting to note that in the 1960s the problem
an average illegal dose of [heroin]. With medication was designated in quasimedical terms as a drug
and a comprehensive program of rehabilitation, pa- "epidemic," whereas in the 1930s it had been
tients have shown marked improvement; they a drug' 'menace.' ') Not only was heroin use in-
have returned to school, obtained jobs, and became creasing, but it was no longer confined to the
reconciled with their families. Medical and psy- ghettos. Middle-class youth were experiment-
chometric tests have disclosed no signs of toxicity, ing with drugs-at first, marijuana and halluci-
apart from con.stipation. Methadone treatment needs nogens, and later, opiates and other drugs.
careful medical supervision and many social ser- Newspapers reported high rates of heroin addic-
vices. In our opinion, both the medication and the
supporting program are essential. (p. 646)*
tion among soldiers in Vietnam. "Drug abuse"
no longer was limited to poorer and minority
In another early report (Dole & Nyswander, elements of society; law-enforcement agen-
1966) they claimed that methadone "blocked" cies and legislatures were showing great con-
cern about the drug epidemic. Rising crime
rates were attributed to drug-related offenses.
*From l.A.M.A., 1965, 193, 646-650. Copyright President Nixon declared drug abuse to be
1965, American Medical Association. "public enemy number one" and "the most
serious threat this nation has ever faced" (Du- presuppose sickness so much as stupidity. . . .
mont, 1972). * Our starting point is not a hospital but rather
The Robinson Supreme Court decision in a school" (quoted in Yablonsky, 1967, p. 387).
1962 had vindicated the medical approach and Synanon was basically a self-help lay-run pro-
essentially mandated civil commitment and gram that eschewed the medical approach to
some type of treatment, rather than only im- addiction. It had some success getting and
prisonment, for addicts. But the two major keeping addicts drug free, especially when
forms of treatment available at the time, "de- members remained in the Synanon community
toxification" and therapeutic communities, and its related businesses for life. But if addicts
were not actually medical programs. Detoxi- left Synanon, the relapse rate was well over
fication programs, as mentioned earlier, in- 90% (Brecher, 1972, p. 78). Many therapeutic
volved physicians only in the early stages of communities based on the Synanon model or
treatment. Beyond that, civil commitment in- some variation of it began during the I 960s. A
volved some loose rehabilitation programs, but few used methadone detoxification, and several
as Lindesmith (1965, p. 292) points out, they had physicians associated with the program, but
functioned largely to segregate the addict and, nearly all rejected the medical approach to ad-
being compulsory, were implicitly a punitive diction.
measure. Little rehabilitation, much less treat- The detoxification and therapeutic commu-
ment, was accomplished. nity approaches were limited. Detoxification
The first and best-known "therapeutic com- had no program and little proven success; thera-
munity" for addicts was Synanon. It was peutic communities had modest success and
founded in 1958 in California by Charles E. limited appeal to addicts, and, being by neces-
Dederich, a talented former AA devotee and sity small, could take few addicts. A 1971 con-
businessman. Synanon emphasized withdrawal gressional committee recommended a "Man-
from drugs without medical help, as well as hattan Project" to develop "a drug which will
residential treatment, availability of 24-hour- effectively treat, prevent or cure heroin addic-
a-day care, and abstinence from drugs. The tion . . . . " (quoted in Nelkin, 1973, p. 141).
core of the treatment was daily seminars and With the "heroin epidemic" a problem of great
leaderless groups that met three evenings a public concern, the drug control turf was fertile
week to "release hostilities" (Yablonsky, for a drug program that "worked."
1967). Synanon members, however, defined
their approach as educational rather than thera- Adoption of methadone
peutic. As Dederich himself said, "We don't maintenance as public polley
The publication in medical journals of im-
pressive research results reporting a new treat-
*The late 1960s and early 1970s revealed a definite ment for an old social problem does not in itself
and distinct cleavage between the "Establishment" create or change public policy. Some indi-
and the antiwar youth culture. Students and other
youth were engaged in the most severe anti-Estab- viduals or groups must become the champions
lishment activities in three decades. Closely asso- of this particular treatment approach and con-
ciated with the youth culture was drug use. Although vince those with the authority and resources to
many young people used "soft" drugs such as mari- implement it of its viability before it is used
juana, the "Establishment" often did not dis-
as a solution to the problem. Often this process
tinguish between drugs in enforcing laws. Thus
President Nixon's proclamation of drug abuse takes many years or even decades. But the im-
as "public enemy number one" may have had a mediate and urgent nature of "the drug prob-
more generalized meaning. In a symbolic frame, lem" in the late 1960s compressed the pro-
drug abuse could be viewed as a symbol of process. Only 6 years after Dole and Nyswander's
testing youth. One might suggest that the protesting (1965) first publication, methadone mainte-
youth were really' 'public enemy number one," and
President Nixon could focus on "drug abuse" as nance had become public policy.
a symbolic vehicle for discrediting alienated pro- The champions of methadone maintenance
testors and controlling deviants. had to overcome some entrenched resistance to
any maintenance approach. For nearly 50 years gram grew rapidly. By 1970 New York City
the official policy toward opiate addiction ad- had 42 methadone maintenance centers with
vocated abstinence; all punitive and treatment nearly 3500 patients (Brecher, 1972, p. 140).
programs viewed a drug-free state as the only Reports of "success" permeated the scientif-
legitimate rehabilitative goal. As recently as ic and popular media. Perhaps the strongest
1963, a joint statement by the AMA and the scientific legitimation came from a series of
National Academy of Sciences reaffirmed the independent evaluations of the Dole and Nys-
1920s position on maintenance: "Continued wander program carried out by Francis Gearing
administration of narcotic drugs solely for of the Columbia University School of Public
the maintenance of dependence is not a bona Health. Gearing, a respected researcher, pre-
fide attempt at cure nor is it ethical treat- sented positive and optimistic evaluations of
ment except in . . . unusual circumstances" methadone maintenance to the First National
(quoted in Miller, R., 1974, p. 173). The Conference on Methadone Treatment in 1968
Bureau of Narcotics and Dangerous Drugs (the and in succeeding conferences over the next
BNDD, a :-eorganized and renamed FBN), the several years. These national conferences be-
major law-enforcement agency for drug abuse, came a showcase for research on methadone.
maintained an official stance until 1970 that The Journal of the American Medical Associa-
methadone maintenance was illegal under the tion published results from this first evaluation
Harrison Act (Nelkin, 1973). There was con- in late 1968. The major conclusions were im-
siderable resistance to medicalization among pressive:
law-enforcement agencies. Administrators and I. Of the 871 patients admitted to the pro-
clients in therapeutic community drug program, 86% remained in treatment.
grams were vocal in denouncing any main- 2. For patients who remained in the pro-
tenance approach as a sham because it failed gram at least 3 months, rates of employ-
to get addicts off narcotics. ment improved from a pretreatment 28%
New York City has the nation's largest to 45% after 5 months and a rather amaz-
heroin addiction problem. It has been estimated ing 85% after 24 months.
that between a fourth and a half the American 3. There was a notable decrease in criminal
addict population resides there. It was fertile arrests among the patients.
ground for experimental programs to control 4. None of the patients became readdicted
addiction. In 1965, Dr. Dole went to New York to heroin. *
City'S commissioner of hospitals, Dr. Ray Although some methodological criticisms
Trussell, with his early research results. He of the study were voiced, the overall thrust
hoped to obtain the use of six hospital beds to was clear: methadone maintenance "worked"
expand his methadone research. Dr. Trussell to reduce crime, keep people off heroin, and
was impressed with the preliminary findings get them reemployed. Subsequent reports by
and arranged for more than $1 million to imple- Gearing and his colleagues, as well as some-
ment the Dole and Nyswander program in New what less glowing reports from other programs,
York City (Brecher, 1972, p. 138). Until this confirmed these conclusions (Miller, R., 1974).
time the study and treatment of narcotics addic- Gearing's evaluations became "evidence"
tion had been solely in the domain of the Public that advocates used to promote methadone
Health Service, especially at the Lexington hos-
pital. The BNDD, which opposed any mainte- *Most subsequent studies of methadone mainte-
nance program and saw its turf threatened, ap- nance adopted these criteria for evaluation of a
parently "put pressure on the associate hos- program's effectiveness in treating addiction: (I)
pitals to shadow people, to obtain records, to the retention of clients in the program; (2) the
seize methadone prescriptions and to threaten number of clients employed; and (3) the reduction
of criminal activity, usually measured in terms of
the pharmacist who filled the prescriptions" arrest rates. Other criteria are also used, most
(Etzioni & Remp, 1973, p. 44). But with re- frequently abuse of other drugs, often measured
ports and evaluations of "success" the pro- by chemical tests of the patient's urine.
maintenance. These reports of the "success" on drug abuse. Jaffe soon became the head of
of treatment, in the hands of professional and the new Special Action Office for Drug Abuse
political claims-makers, stimulated the spread Problems (SAODAP), which would be the
of methadone treatment and softened resistance coordinating agency for drug policy. Under his
by critics and opponents. * direction SAODAP became a strong advocate
Any new and successful treatment for opiate for methadone treatment. In 1969 Jaffe said,
addiction would have been big news in the late "If I had a limited number of dollars to spread
1960s; so methadone maintenance received around Chicago . . . we would be expanding
substantial coverage in the news media. The our methadone program without any question"
popular press, however, presented methadone (quoted in Moss, 1977, p. 141). What seemed
in a rather misleading fashion. This was at to impress the Administration most was the
least in part because of the presentation by Dole decline in criminal activity among addicts
and Nyswander. For instance, Dole referred to on methadone. The obsession with lowering
his program in a New York Times article as the crime statistics focused the Administration
substitution of "pain-killing methadone" for on drug programs that would reduce heroin use
"crippling heroin." Press reports regularly and especially "drug-related crime" (Epstein,
avoided referring to methadone as a narcotic, 1977). Methadone maintenance seemed the
thus creating an image that it was a cure for most promising.
heroin (Etzioni & Remp, 1973). It is likely that Opposition to methadone was waning. The
much of the public was ready to see methadone FDA and BNDD in June, 1970, formally de-
as a solution to the heroin epidemic. The pub- fined methadone for maintenance as an investi-
lic and policymakers alike would increasingly gational new drug (IND)-literally, a research
view methadone maintenance as "the answer" drug. Methadone maintenance "was viewed as
to the problem of opiate abuse. a research technique which showed 'promise'
Nixon Administration as a champion of in management and rehabilitation but also had
methadone maintenance. President Nixon significant potential for abuse" (Miller, R.,
and his administration became both direct and 1974, p. 175). Later that year, following a cau-
indirect supporters of methadone maintenance tious AMA statement approving methadone
(Epstein, 1977). It was under the Nixon Admin- maintenance, the BNDD announced a limited
istration that methadone maintenance became acceptance of methadone treatment. The op-
a central part of public drug policy. With the position had retreated, but remained cautious
Administration's "law and order" stance and gave only limited approval to methadone
against "crime in the streets,"· drug abuse treatment. These cautions contrasted with the
could become public enemy number one. White House's embracing of methadone treat-
Physician Jerome Jaffe, a successful director ment. The Administration wanted to extend
of state drug programs in Illinois and an advo- drug treatment, consisting mainly of meth-
cate of a "multimodal" approach to addiction, adone maintenance, to the entire population
became the administration's special consultant of heroin users in America (Moss, 1977).
President Nixon's recommendation to Con-
gress had authorized SAODAP to spend about
* In addition to its apparent "success" as a treat- $1 billion in its first 3 years. The agency would
ment' methadone was easy to administer and was be directly under White House supervision.
regularly depicted as having numerous distinct treat-
ment advantages. First, it was addicting, so the Under Jaffe's direction the new agency's fa-
patient could not stop taking it. Second, it could be vorite approach to opiate addiction was meth-
given orally and produced no euphoric "highs." adone maintenance (Stevenson, no date).
Third, it was fairly long-acting; thus treatment could Some of the reasons for the Administration's
be organized on an outpaitent basis, with the pa- enthusiasm for this approach are clear. In a time
tient returning every I to 2 days. Fourth, patients
could be •• stabilized , " so that the drug did not of national concern with drugs and ·crime and
need to be continually increased. Finally, it cre- with an election year upcoming in 1972 (Ep-
ated a "blockage" of other opiate highs. stein, 1977), it appeared as a relatively simple
TABLE 3 policy, some entrenched resistance could be

ESTIMATED RELATIVE COSTS OF DRUG circumvented and the Administration's war
PROGRAMS PER ADDICT PER YEAR against heroin could be fought with double
(IN 1971 DOLLARS)* barrels: the BNDD continuing its law-enforce-
ment approach, with SAODAP becoming a
Program Cost proponent for methadone maintenance. In the
early 1970s it appeared that with the success
NIMH civil $10,000 to $12,000
of methadone maintenance the "medical sub-
commitment
Prison $8000
stitution game" might finally have found a
Therapeutic $4400 (plus welfare) winner.
communities
Methadone revisionists
Methadone $2000 (plus welfare)
maintenance Methadone maintenance became a popular
and common treatment for addiction. In 1973
*From Methadone maintenance: a technological fix by
methadone was formally labeled by the FDA
D. Nelkin, 1973, New York: George Braziller, Inc.
as a "treatment" drug. Comprehensive reviews
by the editors of Consumer Reports (Brecher,
technological solution to a perplexing problem.
1972) and by social scientists (e.g., Miller, R.,
Although a large amount of federal money
1974) were generally approving and optimistic
was allocated to the "war on drugs," the
about methadone maintenance. But meth-
cost per addict was low enough to appeal to the
adone's critics, who had been overshadowed
fiscally conservative Administration (Table 3).
by the reports of success and the methadone
Undoubtedly, redefining the problem as a
bandwagon, began to reemerge.
medical one and placing addicts in the jurisdic-
The first critique concerned the "diversion"
tion of medically run clinics appealed to the
of methadone into black markets. As early as
medically oriented leadership of SAODAP.
1973 there were reports of methadone diversion
From less than three dozen programs with
from clinics and clinic patients to the street and
several thousand addicts in 1970, methadone
to drug users; a methadone black market had
maintenance programs were begun by private
been created. Many clinics resorted to a "no
physicians, hospitals, and mental health cen-
take home" policy (Miller, R., 1974), and in
ters*; although sometimes they received sup-
1973 new regulations went into effect that at-
port from law-enforcement agencies, they were
tempted to control methadone diversion. These
clearly under medical jurisdiction. By 1974, the
policies appear to have had little success. Meth-
peak: year for methadone treatment, approxi-
adone became the most easily obtainable street
mately 80,000 addicts were involved. To coin a
drug in New York City and popular with addicts
phrase, there had been a virtual counterepi-
because it gave "good highs" (Agar, 1977;
demic of methadone programs.
Agar & Stephens, 1975). Methadone diversion
In sum, the Nixon Administration, taken
also created new addicts, as well as being regu-
with the early impressive results of methadone
lar fare for those already addicted. Many street
maintenance, became its prime champion. By
users "shot" methadone (rather than taking it
creating a separate agency to coordinate drug
orally), and these reported methadone "highs"
dealt the myth of the "heroin blockade" a
*Some of the private methadone maintenance pro-
grams proved to be lucrative and profitable ventures. severe blow.
B~t~een 197.0 and 1974, 24 private methadone Reports and papers presented at the Fourth
chmcs began In New York City alone. Investigations and Fifth National Methadone Maintenance
by City Councilman Carter Burden and the news- Conferences in 1972 and 1973 revealed many
paper The Village Voice reported the programs to- discrepant findings and raised important ques-
taIe~ between $2 and $3 million in profits per year
(Smith, 1978). Entrepreneurship and profitability tions about methadone maintenance. A paper
undoubtedly contributed to methadone maintenance's by Avram Goldstein, director of the Addiction
rapid spread. Research Laboratory at Stanford, cast doubt
on Dole and Nyswander's metabolic theory of sicians and counselors in rehabilitative pro-
addiction. Other reports presented data that grams (Epstein, 1977).
questioned the high retention figures of meth-
adone maintenance programs. Considerable [Proponents of methadone maintenance] stated that
skepticism was evident as to whether abstinence all the responsible doctors and social scientists in-
volved in the program viewed methadone simply as
was a realistic goal of methadone treatment.
a lure to entice addicts into treatment programs
Reports of serious problems with the street use where the real "rehabilitative effort" could take
of methadone were presented (Moss, 1977). place. (Epstein, 1977, p. 286)
Although few people probably read these tech-
nical reports, an article published in The Public Critics seized on this as using methadone overt-
Interest by journalist Edward Jay Epstein ly as a social control mechanism and not as a
(1974) made many of these "revisionist" find- treatment drug.
ings more widely available. This article, cited Rather suddenly during 1974, methadone
frequently by methadone critics, attacked the maintenance began to lose favor as federal pub-
claims made by methadone proponents. After lic policy. It is unlikely that this was a direct
reviewing much of the methadone research, result of scientific evaluations, since many of
Epstein concluded that (1) methadone does not them were published after 1974. Several factors
by itself reduce crime, (2) it does not block ad- seem to have led to a reversal of policy. Gen-
dicts against heroin (many still used heroin), erally, methadone maintenance had not made
and (3) there was no evidence that heroin addic- the major dent in crime statistics that the pre-
tion was a "metabolic disease" as Dole and election Nixon Administration had hoped for.
Nyswander hypothesized. This article raised The heroin epidemic may have tapered off by
doubts more publicly than before about the itself by this time. More specifically, a report
efficacy of methadone maintenance and gave by the Drug Enforcement Agency (the succes-
the antimethadone view some exposure. * sor of the BNDD, which never fully supported
Critics also voiced concern about the fact methadone maintenance) reported a sharp rise
that methadone was more addictive than heroin. in methadone-related deaths and a relatively
Why should the government and the medical high arrest rate among methadone users and
profession support the use of an addictive drug? suggested that "methadone is partially replac-
Supporters of drug abstinence saw it merely ing heroin as the drug of abuse" (quoted in
as another substitution and a worse addiction. Epstein, 1977, p. 248). Such reports may have
Dr. Peter Bourne, who for a time was head of made the Administration uneasy. One analyst
SAODAP, saw it differently: "The fact that suggests that in the Administration's policy
methadone .is addicting is essential to allow statement, "Federal Strategy for Drug Abuse
therapy to occur ... it develops a trust between and Drug Prevention 1974," "it appears to be
the patients and the doctor" (quoted in Steven- the government's intention to expand drug-free
son, no date, p. 5). In response to increasing treatment programs over the next 2 years, while
criticism of methadone's effectiveness, one allowing methadone maintenance programs
critic reports that some methadone proponents to shrink away" (Moss, 1977, p. 150). Presi-
shifted their claims to view the addiction of dent Nixon and his White House staff began to
maintenance as a "chemical parole." The disassociate themselves from the funding of
methadone addiction, in this view, had the methadone programs. The White House offi-
latent function of forcing addicts to report to the cially divorced itself from SAODAP, the agen-
clinic for methadone several times weekly, cy the President had created to oversee drug
where they would come into contact with phy- treatment; SAODAP was moved to the Depart-
ment of Health, Education and Welfare, where
it merged into another federal agency (National
*Other critiques, especially of Gearing's studies, ap-
peared also in the psychiatric (e.g., Maddox & Bow- Institute for Drug Abuse) (Epstein, 1977, p.
den, 1972) and sociological (e.g., Waldorf, 1973) 249). Thus, as the Nixon Administration extri-
literatures. cated itself from the drug treatment business,
methadone maintenance lost its chief source Dole and Nyswander themselves have con-
of financial support. cluded that their early projections were overly
Methadone maintenance programs, however, optimistic but cite administrative regulations
have not withered away. Only their expansion and errors as causes of methadone main-
seems to have been curtailed. Methadone pro- tenance's loss of effectiveness. With the in-
grams seem to have stabilized at about 80,000 credibly rapid expansion of programs that
addict patients, estimated to be about 15% of quickly grew too large and were placed under
the addict population (DeLong, 1. V., 1975). the jurisdiction of a government monopoly that
Scientific reports continue to point out the flaws imposed too many arbitrary controls, they sug-
in early evaluations of methadone main- gest that "the treatment programs have lost
tenance's "success," to question the validity their ability to attract and rehabilitate addicts."
of data used in evaluations, and to present a (Dole & Nyswander, 1976, p. 211). Yet meth-
more limited view of its treatment efficacy. * adone maintenance remains far less expen-
sive on a per patient basis than other treatments
*Validity problems include "the shrinking sample," and has proved to be no less successful. Thus
the unreliability of patient self-reports, and, most approximately 800 methadone clinics were in
critically, the criteria for measurement of "success" operation in 1977 at the cost of 50 million fed-
(Cohen, M., et aI., 1976). Major criteria used in
evaluating the programs were retention, employ- eral dollars (Newsweek, Feb. 7, 1977, p. 29).
ment, number of arrests, and drug abuse. These Some hold out hope that longer lasting heroin
revisionist studies found problems with the measure- substitutes (for example, LAAM) will alleviate
ment of all of these. The "shrinking sample," some of the problems of methadone mainte-
counting only those who remained in the program nance (Blaine & Renault, 1976). Others see the
for a specific period rather than the entire cohort
admitted to the 'program, inflated retention rates narcotic "antagonists" (that block opiate
(Cohen, M., et aI., 1976; Newman, 1976). As "highs"), such as naltrexone, as having great
many as three fifths of the patients terminated by potential for successful treatment (Lex &
the end of the second year (Kleinman et aI., 1977). Meyer, 1977), although they may bring prob-
Improved rates of employment may not have repre- lems similar to those in methadone treatment
sented the "success" of treatment. This criterion of
evaluation was bound to improve, since programs (Goldstein, 1976). Some consideration has
were often self-selective-an individual had to been given to long-acting narcotic antagonists
remain employed to remain in it. One 5-year study that could be implanted under the skin (Wil-
showed that employment improved for the two lette, 1976). A few have suggested medically
fifths of the original cohort who remained in the pro- controlled heroin maintenance. Even with the
gram for 2 years but not for others (Kleinman et aI.,
1977). These figures were further complicated by recent disenchantment with methadone mainte-
reliance on patients' self-reports and lack of differen- nance, medical approaches to opiate addiction
tiation between full- and part-time employment are alive and well.
(Cohen, M., et aI., 1976). The reduction of criminal
behavior was also less than first reported. The only A final note on methadone
real decline linked clearly to the availability of a and medlcallzatlon
heroin substitute was in drug-related arrests. Ac-
cording to one study, prosocial changes were limited Methadone was a medical technological
almost exclusively to the 23% who remained in the discovery that received extravagant early re-
program for more than 3 years. Overall, the results ports of success. Its promotion by the medical
of the studies depicted methadone maintenance as profession was limited mostly to the relatively
providing "modest help for a few" (Kleinman &
Lukoff, 1975). It appears to be most successful with few individuals engaged in methadone re-
older addicts who volunteer for the program and search or treatment programs. The adoption of
are motivated to remain in it for several years. In methadone maintenance by the Nixon Admin-
fairness to Dole and Nyswander, they always pointed istration as a way of combating the heroin epi-
out the need for supportive counseling and re- demic and an attempt to reduce crime statistics
habilitation. Their small program provided this;
most of the later programs were much larger was its greatest boost. In fact, from the original
and focused more on dispensing and controlling the Dole and Nyswander project to the creation
methadone. of SAODAP, it was politicians and govern-
ment administrators who were methadone's it was a policy adopted by an elected admin-
strongest champions. * istration to meet its own ends and was sup-
In its early days methadone was seen as a ported through legislative process. The medical
panacea. However, as in similar previous profession's mandat.e to treat addiction was
rounds of "the medical substitution game," directly dependent on the government's pol-
methadone was soon found not to be "the an- icies; the adoption of methadone maintenance
swer" to opiate addiction and to engender new placed medicine in the service of the govern-
problems. Presently it remains one of several ment. With noncriminal deviance, medical pro-
types of treatment available for opiate addiction. fessional dominance is an important factor
From the perspective of this book, the de- determining medicalization. However, in mat-
velopment of methadone maintenance offers ters related to criminal law, treatment by the
some significant insights into the process of medical profession is accomplished at the
medicalization. After a dormant period of over determination of the state, with medicine func-
40 years, a medical approach to addiction re- tioning as a social control agent for the state.
emerged in the 1960s. The introduction of Thus the medicalization of opiate addiction
methadone maintenance vindicated the medical highlights the connections between medical
approach and reengaged the medical profes- and legal social control networks, something
sion in the treatment of addicts. But it would we will explore further in Chapters 9 and 10.
be a mistake to view this as the medical pro- The criminal approach to deviance, however,
fession's attempt to expand medical jurisdic- has not been abandoned. Law-enforcement
tion; on the contrary, the rapid rise and dif- agencies continue to prosecute addicts for
fusion of methadone maintenance was accom- drug-related activities. The emergence of
plished with only minor contributions by the methadone maintenance and the medical con-
medical profession. There were few specific trol of addiction created some tensions between
medical entrepreneurs for methadone outside medical and criminal jurisdictions. For the
governmental agencies. Medical interest per- most part, in recent years an uneasy alliance
haps was limited, since most physicians did has been forged between the law-enforce-
not regularly come in contact with opiate ment and medical systems, with functional co-
addicts and because they had no access to operation on a local level (Lidz & Walker,
highly regulated methadone. On a theoretical 1977). We are left with a hybrid criminal-
level, no well-developed disease concept of medical designation of addiction: opiate addic-
opiate addiction was generated to justify med- tion is still criminalized, but addicts are
ical intervention (as had occurred with alcohol- deemed suitable for medical treatment.
ism). On a practical level, few physicians
wanted to deal with addicts. SUMMARY
The waxing and waning of methadone main- The history of medical involvement with
tenance was largely a political matter handled opiate addiction is long and marked with overt
by politicians and governmental administra- political conflict. A number of definitional
tors. This is no different from the Harrison changes are apparent: from a time when it was
Act's demedicalization of opiate addiction. not considered a problem, to its definition as a
The adoption of a medical approach was a poli- medical problem, to its criminalization, and
tical decision in a most conventional sense: again to its remedicalization.
Opiates are powerful analgesic drugs. Con-
tinued use creates a physiological dependence;
*Heroin addiction becoming more a middle-class when the drug is discontinued, withdrawal
rather than only a lower-class phenomenon seems symptoms commence. Opiate addiction stems
to have made medicalization a more likely and from a recognized physiological dependence
more acceptable policy. High prevalence of deviance
among the middle class (e.g., alcoholism, hyper-
on the drug. To the best of our knowledge,
activity) increases the likelihood of medicalization physical dependence on opiates is in itself not
and medical sanctions. particularly harmful to the human body.
The use of opium is at least 3000 years old. politicking both created addiction as a social
Prior to the 19th century it was used largely as problem and changed its definition. The "great
a medical agent. There is little evidence of debate" about the opium trade in the British
extensive recreational usage, except in China. Parliament lasted several decades; it pitted the
After it was brought to the West by travelers, antiopium crusaders against the opium inter-
it became an important remedy in European ests. Millions of words were exchanged. Both
medicine. There was little concern about addic- sides summoned medical evidence to support
tion, and it was not considered much of a their claims. After numerous defeats, the anti-
problem. opium forces won a Parliamentary victory in
Definitions and uses of opium changed 1906. The definitions of opium addiction were
during the 19th century. Imperialistic British changing: it was now considered immoral and
policies forced an opium trade on China. The an evil.
supply created its own demand, and millions In late 19th-century America, addicts
of Chinese were addicted to smoking opium. aroused sympathy and pity, but addiction was
Two "opium wars" were fought to ensure seen increasingly as will weakening and im-
the profitable British trade. moral. The first American opiate prohibition
Innovations and medical use facilitated the attempted to control opium smoking by Chinese
spread of opium. Purer forms of opiates were immigrants. Heroin was discovered and at first
isolated (morphine and codeine), the hypo- viewed as a cure for morphine addiction. It
dermic syringe was invented, and the medical was, however, soon defined as devoid of med-
use of morphine during the Civil War created so ical uses and a drug with no redeeming value.
many addicts that addiction was called the The American views of opiate addiction turned
"soldier's disease." In fact, nearly all the 19th in a negative direction on the axis of anti-
century addicts were recruited through some Chinese sentiment and fears of heroin.
medical channels: many physicians used opiates After banning opium in the newly acquired
with little regard to addiction, and a growing Philippines, the United States, under the leader-
patent medicine industry promoted nostrums ship of several moral entrepreneurs, spear-
that contained opiates. Tens of thousands un- headed two international conferences on con-
wittingly became physiologically dependent. trolling opium. As a domestic response, the
Unproven medical beliefs that only "weak" Harrison Act was passed. It was originally
individuals could become addicted and that intended to limit and regulate the marketing of
injected morphine could cure opium addiction opiates, giving physicians control of opiates
contributed to this dependence. The latter is the and placing addicts completely in medical
first instance of what we call the "medical hands. But the Treasury Department defined
substitution game." By the close of the 19th taking opiates for nontherapeutic purposes
century, medical practice had changed and as harmful and criminal. A battle over criminal
opiates had fewer medical uses. Addiction was and medical jurisdiction began, with the Su-
considered a diaease, to be treated by prag- preme Court supporting the Treasury Depart-
matic medical intervention. In a real sense, ment's definition, making medical treatment
19th-century medical practice had created of addiction impossible. After a short-lived era
the very problem it was treating at the cen- of narcotics clinics, the medical profession
tury's close. gave up all claims to treatment of addiction.
The typical 19th-century American addict Opiate addiction had been demedicalized.
was middle-aged, female, rural, middle-class, Opiate addiction remained securely as the
and white; she had become addicted either by FBN's turf for over three decades. But there
her physicians's treatments or from her use of were consequences of criminalizing addiction:
patent medicines. More addicts probably ex- an addict subculture emerged, a criminal drug
isted at this time than any other, but it still was underworld was created, the image of the addict
not considered a major social problem. as dope fiend was promoted, the population of
Moral entrepreneurship and interest-group addicts changed, and addicts began to fill the
prisons. Only a tiny percent of addicts were as a social control agent in the former's behalf.
rehabilitated. In the 1950s the criminal ap- The uneasy alliance between the law-enforce-
proach reached a high-water mark with in- ment and medical systems has created a hybrid
creased penalties for narcotics offenses. But the criminal-medical designation of addiction.
criminal approach had failed to stem the in-
creasing tide of addiction. SUGGESTED READINGS
By the mid-1950s, a small chorus of voices, Brecher, E. M. Licit and illicit drugs. Boston: Little,
including some medical professionals, began Brown & Co., 1972.
The best readily available single source on the
criticizing the punitive approach and calling history of drugs. It also includes an intelligent
for medical alternatives. They pointed to the evaluation of drug effects. Since it is written by
British system of heroin maintenance as a the editors of Consumer Reports, it contains no
model. The FBN attempted to discredit these sociological analysis.
critics. But the long-silent champions of med- Duster, T. The legislation of morality. New York:
The Free Press, 1970.
ical definitions would be heard; their view- A readable analysis of the changing definition of
point was echoed by a Supreme Court deci- addiction. Duster focuses on how legislation
sion and a presidential commission. contributed to the creation of a negative moral
The discovery of methadone maintenance judgment of addiction.
was the vehicle for the remedicalization of Lindesmith, A. The addict and the law. New York:
Vintage Books, Inc., 1965.
opiate addiction. In light of early reports of An outstanding sociological analysis of the crea-
success, supporters viewed it as a panacea. In tion of American drug policy. Highly critical of
response to the "heroin epidemic" and in an the criminal approach, Lindesmith calls for the
attempt to reduce crime statistics, the Nixon development of a truly medical approach to addic-
Administration embraced methadone for its tion.
Musto, D. The American disease. New Haven,
use in the' 'war" on drugs. Medical methadone Conn.: Yale University Press, 1973.
programs grew rapidly. Soon it became clear The most complete historical analysis of the
that the success of methadone maintenance definition and treatment of opiates in America.
had been overstated, and the Administration Written by a medical historian, it includes a good
withdrew its support. Overall, the introduction analysis of medical involvement.
Nelkin, D. Methadone maintenance: a technological
of methadone maintenance vindicated the fix. New York: George BraziIIer, Inc., 1973.
medical approach and reengaged the medical Analyzes the technological, social, and political
profession in the treatment of addicts. But since factors involved in the development of methadone
the medical profession's mandate to treat addic- maintenance. Nelkin critically evaluates meth-
tion is dependent on (and accomplished at the adone as a technological solution to a complex
social problem.
determination of) the state, medicine functions
6 CHILDREN and
MEDICALIZATION
DELINQUENCY, HYPERACTIVITY,
and CHILD ABUSE
C hildren are a special group of people

in our society: they are considered in-
nocent, dependent, and, because of
their immaturity, not wholly respon-
Through the latter parts of the Middle Ages,
children, soon after weaning, interacted, la-
bored, and played with adults in everyday life.
The child was viewed as a small version of an
sible for their deviant behaviors. Many deviant adult. For example, children in medieval paint-
behaviors by children, and some behaviors ings were depicted as miniature adults, little
that victimize them, have come under medical people with all the dress and features of adults
jurisdiction in American society. This medical- (Aries, 1962). Children were largely ignored
ization of childhood deviance has occurred in or exploited until a century or two after the
part because of the status of children in society Middle Ages and were not considered of par-
and the types of attention and reaction we are ticular importance. Infanticide was a regular,
able to give to childhood problems. To better if subterranean, form of birth control (Harris,
understand this special status of children, we 1977; Langner, 1974). Abandonment of chil-
first briefly review "the discovery of child- dren was a common practice (de Mause, 1974).
hood," focusing on the development of the This indifference to children (Empey, 1978)
modem conception of "child." We then is more understandable given the facts of
present discussions of the expansion of medical child mortality, or death rate. As late as the
jurisdiction to encompass three types of de- 17th century, from one half to two thirds of all
viance related to children: delinquency, hyper- children died before the age of twenty (Empey,
activity, and child abuse. Finally, we discuss 1978, p. 32). Into the 18th century the odds
the status of children and their "risk" for med- were two or three to one against a child living
icalization. to age 5 (Kessen, 1965, cited in Empey,
1978, p. 44). Under such conditions, with the
DISCOVERY OF CHILDHOOD child's great vulnerability and small survival
rate, people could not afford to invest a substan-
"Childhood" has not always been a separate tial amount of time and energy or become at-
and distinct stage in the life cycle. Clearly, tached to children: the prospects of return were
infants and children have always aged chron- not good. Those who did survive were often
ologically and, to a degree, biologically the boarded out, as young as at the age of 7, to
same way, but "childhood" as a special become apprentices or serve in the homes of
period or stage does not exist in nature. Child- other people (Aries, 1962).
hood is a social construction, an invention of Childhood was not discovered at anyone
the postmedieval period. Childhood, with its specific time. Rather, it was a by-product of the
special rights and privileges, is no more than Enlightenment, gradually emerging over two
a few hundred years old. to three centuries. As symbolic of its discovery,
145
Phillipe Aries (1962) points out that well-to-do children should be brought up to work diligent-
persons in the 16th and 17th centuries began to ly. Fifth, children were to respect and obey
commission individual portraits of their chil- authority (Aries, 1962, pp. 114-118; Empey,
dren and show them in special outfits designed 1978, pp. 54-55). From these, the modem
for children. These children for the first time notion of childhood as a special period of de-
resemble our conception of a child, rather than pendence had been created.
a miniature adult. Children were increasingly The sources of this change were both general
seen as having special characteristics and "on and specific. Although the infant mortality
account of [their] sweetness, simplicity and rate did not change greatly until after the
drollery, became a source of amusement and 19th century, children were becoming more
relaxation for the adult" (Aries, 1962, p. 129). important in families. Industrialization and
The two major attributes characterizing this urbanization created the nuclear family, and
new view of children were innocence and de- this drew more energy and attention to chil-
pendence. Although Christian moralists long dren and individual needs. At first, "coddling"
had emphasized the innocent natures of chil- of children became common in the family circle
dren (de Mause, 1974), they were paid little as children became a center of family amuse-
attention until the 16th century. The idea that ment. The principles and admonitions of a small
children are "innocent" and because of this group of champions of children's morality
innocence and sweetness need to be protected warned, however, of the dangers of "coddling"
from the harsh and sinful world has its roots in as opposed to disciplining children. These
the discovery of childhood (Empey, 1978, p. refonners, including moralists, educators, and
8). "The idea of childish innocence," Aries clergy, supported child-rearing philosophies
(1962) notes, that emphasized psychological control and
moral solicitude, in the name of benefiting the
resulted in two kinds of attitude and behaviour child (Aries, 1962, pp. 330-412; Empey, 1978,
towards childhood: firstly, safeguarding it against pp. 51-68). These ideas prevailed, and children
pollution by life, and particularly by the sexuality
came to be seen "as fragile creatures of God
tolerated if not approved of among adults; and sec-
ondly, strengthening it by developing character and
who needed to be both safeguarded and re-
reason. (p. 119) fonned" (Aries, 1962, p. 133). Eventually
this led to the creation of special institutions
Children were also increasingly seen as de- to educate children; soon much child-rearing
pendent beings who needed careful guidance would be taken over by schools. Thus the mod-
and direction. For the child's proper develop- em conceptions of childhood were forged:
ment "he must be stringently safeguarded, both children were innocent and dependent but
physically and morally, he must receive a corruptible and needed guidance and discipline.
carefully structured and special education, and, With the discovery of childhood the behavior
only after long years of preparation, will he and activities of children became worthy of
be properly prepared for adulthood" (Empey, attention in their own right.
1978, pp. 50-51). For a child to live in the
adult world "he had to be subjected to a special ORIGINS OF JUVENILE
treatment, a sort of quarantine, before he was DELINQUENCY
allowed to join the adults" (Aries, 1962, p. As we have pointed out throughout this
412). During this developmentally segregated book, new deviance designations do not emerge
childhood, children would be subject to a moral by themselves but are products of collective
education based on five principles. First, chil- enterprise and claims-making activities. The
dren must be closely watched, under constant "invention" of juvenile delinquency, as
supervision, and never left alone.Second, chil- Anthony Platt (1969) tenns it, is one such ex-
dren should not be pampered and must learn ample. Unlike most of the other fonns of
strict discipline early in life. Third, children deviance we discuss, delinquency never be-
must practice modesty and decency. Fourth, came a manifest medical problem, and the med-
CHILDREN AND MEDICALIZATION: DELINQUENCY, HYPERACTIVITY, AND CHILD ABUSE 147
ical professions' involvement with it was in severe cases were the fonnal mechanisms of
never more than peripheral. Yet the definition state or civil authority called on. The early
and treatment of delinquency shares many American colonists, for example, equated
attributes with the therapeutic-clinical ap- crime with sin and did not consider sinners re-
proach; in fact, those who crusaded for delin- habilitable; their deviance demanded retribu-
quency prevention adopted a medical rather tion and punishment, which was swift and usu-
than a punitive model of deviance. It is these ally severe.
aspects of a quasi medical approach that But even before the 17th century, children
we emphasize here, giving special atten- were sometimes differentiated from adults.
tion to the early medical analogies for delin- Societal response to children's deviance often
quency and the subsequent developments of turned on whether a child could be held respon-
the juvenile court and child-guidance move- sible for criminal or deviant behavior. The
ment. Code of Hammurabi, the earliest-known code
of laws, took specific note of children's duties
Childhood deviance Into to parents and prescribed punishments for viola-
the 19th century tions. Age became an important factor in de-
Many children's behaviors now considered fining responsibility for children's behavior.
deviant have a long history of being seen as Roman law defined children under 7 as inca-
common and conventional children's behavior. pable of mens rea (criminal intent) and there-
As late as the 17th century, children engaged in fore not responsible for criminal behavior.
behaviors that today would be defined as de- From the age of 7 to about puberty children's
linquency: most learned and used obscene lan- responsibility could be detennined by the
guage regularly, many freely engaged in a va- courts. If a child were deemed responsible, he
riety of sexual activities, some drank regularly or she was subject to adult laws and courts
in taverns, and few ever went to school (Em- (Short, 1968). Common law in England and in-
pey, 1978, p. 71). These behaviors, although fonnal practice in Europe and America did not
not condoned, were largely tolerated. Today hold children criminally responsible for their
these children could well be labeled delinquent. acts below the age of 7, but beyond that, the
Why has this occurred? One might suggest laws were open to interpretation and pennitted
that children engage in more deviant behaviors severe punishments by courts, parents, and
now or that today there are more troublesome apprentice masters (Empey, 1978, p. 42). Thus
children around. However, there is little evi- prior to the 19th century children received some
dence to support this contention. On the other special considerations under the law, but they
hand, there have been clear changes in how were limited.
these behaviors have come to be defined. The
discovery of childhood and the subsequent Child-savers and the
changes in the perception of children focused house of refuge
increased attention on children's behavior and As a result of the Enlightenment and the
welfare. Through the efforts of refonners and emerging ideas of individualistic and collective
child-saving crusaders, the definition and treat- progress, the colonial practice of equating
ment of children's behavior changed. Certain crime and sin lost favor, and the idea that the
behaviors became defined as delinquent. causes of deviant behavior were "inborn ten-
This is not to say that no childhood deviance dencies" and "the work of the devil" became
was condemned or punished in pre-17th-cen- less popular. By the early 19th century the
tury society. Children have always "misbe- causes of deviance were increasingly found in
haved," and social groups have always en- the environment. Urbanization and industriali-
deavored to control this deviance. But this zation and the breakdown of the traditional
control was, until the 19th century, largely in- social order were depicted as causing individual
fonnal. Families, the local community, and the deviant behavior. With childhood recognized
church took care of troublesome children. Only as a unique stage of development in the early
19th century, attention was paid to the plight jected to an ordered and disciplined model
of children in their own right. The Jacksonian routine, and in the words of a fund-raising ap-
reformers, among the first interested in saving peal from the Philadelphia House of Refuge,
children from "ruin," located the sources of would be "shielded from the temptations of
crime and delinquency in society. An inade- a sinful world" (quoted in Rothman, 1971, p.
quate family upbringing and the spread of 210). The house of refuge would be a "super-
vice through the community were believed parent" (Empey, 1978) restituting what re-
especially important in leading children astray. formers perceived as the loss of a tightly knit
Parental neglect was deemed the primary cause community and the laxity of family structure.
of deviant behavior, with the debilitating in- Superparent is an apt metaphor for such insti-
fluences of the environment, such as taverns tutions. The state's jurisdiction over these chil-
and houses of prostitution, seen as contributory dren was based on the concept of "parens
(Rothman, 1971, pp. 76-78). patriae," a term derived from the English con-
As we argued in Chapter 3, early 19th-cen- cept of the King's role as father of the country,
tury reformers viewed the "asylum" as the giving the state power to protect the rights of
cure for all social ills and deviant behavior. If these children and, if need be, assume the
the breakdown of social order was the cause of parental role. The houses of refuge would act
deviance, then a well-ordered environment in loco parentis, in place of parents, to trans-
would be its solution. This was also true with form socially dependent and deviant children
childhood deviance. Delinquency and pauper- into responsible adults, not with punishment
ism were subjects of considerable concern in but through treatment (Kittrie, 1971, p. 3).
the 19th century. They were seen as closely The reformatory superintendents endeavored
related; a delinquent was a potential pauper to replace parental authority and substitute their
(Finestone, 1976b). In 1823 the Society for the own. In an attempt to bring the child under as
Prevention of Pauperism reorganized itself as full control as possible, they frequently insisted
the Society for the Reformation of Juvenile parents transfer to them their legal rights on
Delinquents. This middle- and upper-class the child's admission (Rothman, 1971, p. 221).
group of "gentlemen reformers" saw delin- The well-ordered family was also the model
quency as a problem of the individual. Armed of reformatory organization. The institution's
with the best of intentions, their goal was to goal was to reform each individual child. Con-
reach the delinquent early, before he (or she) tact with the outside world and outsiders' con-
was too tainted by environmental influences, tact with the children were minimized. The
and provide a "correct" environment that children were subject to a carefully regulated
would lead to a responsible adulthood. The ve- and organized schedule, with an extraordinary
hicle for this was "the house of refuge. " emphasis on obedience and authority. Dis-
The first house of refuge opened in New cipline for the benefit of the child could not
York City in 1825, followed soon by many be too absolute. Although the family was the
others in various Eastern cities. The champions ideal model, historian David Rothman (1971,
of these child-saving institutions were con- p. 235) suggests that "a military tone seems to
fident that the incarceration of the juvenile have pervaded these institutions." The orga-
offender, the wandering street urchin, the child nization and routines more resembled an army
of impoverished parents, and the disobedient camp than a family.
child, could be nothing but beneficial for the By the 1850s some of the optimism had
child. They shared the intense faith of the asy- faded. The reformatories were overcrowded,
lum superintendents (see Chapter 3) "in the re- and the popUlation of delinquents had changed.
habilitative powers of a carefully designed More foreign-born and children from the
environment and were certain that properly "dangerous classes," deemed less suited for
structured institutions would not only comfort reform, were being sent to the reformatories
the homeless but reform the delinquent" (Roth- (Rothman, 1971, p. 261). New theories stress-
man, 1971, p. 206). The child would be sub- ing the powerful influences of heredity on
deviant behavior dimmed the belief in the resident family, and the training of youth in
viability of social reform. After the Civil War agricultural and industrial trades. As Anthony
a new generation of reformers criticized the Platt (1969) notes, the penal reformers advo-
harsh discipline and prisonlike atmosphere of cated nonurban, middle-class values for these
these institutions. In fact, the reformatories children yet taught lower-class skills. Although
had become increasingly custodial and in ac- undoubtedly sincerely concerned with their
- tuality much like "youth prisons." But even charges and the welfare of children in general,
when they could not reform, they found com- these child-savers had a turf to protect, the
munity support because at least they functioned reformatory, and thus aimed their reforms at
as a benevolent method of keeping child of- modifying the existing system.
fenders off the streets. The second group of child-savers was out-
With the development of the houses of side the system. They were charitable and phi-
refuge, the die was cast for the creation and lanthropic crusaders, largely women, who saw
treatment of juvenile delinquency. Children child-saving as an ethical and humanitarian
were a separate and dependent class of people calling. Their interest was in saving not just
who needed both protection and reform. The deviant children but all less fortunate children
state could intervene with delinquent or poten- from the afflictions of rapid urbanization. Their
tially delinquent children deemed in need and child-saving activity gained legitimacy partly
"treat" them in the children's own best inter- because it was taken to be a natural extension
ests. While the reformatories lost some favor of their female role as "caretakers" and "ex-
as a vehicle for reform, a new group of child- perts" in the welfare of children. They argued
saving crusaders proposed changes that led to that women should be involved in child-saving
the creation of another type of superparent to because they were "the better half" (Filene,
treat deviant children, the juvenile court. 1974), morally superior and endowed with a
temperament that was better suited for work
Child-savers and the Ideology with delinquents. Women as nurturers, it was
of child welfare * argued, would have a "civilizing" effect on
The post-Civil War period saw the emer- child penology. Many of these crusaders, how-
gence of a new and regenerated child-saving ever, were also feminists. The child-saving
movement. This movement, essentially com- movement gave feminists a cause that had
posed of two separate though overlapping broad-based support in society and gave women
threads of reform, developed a particular ide- an acceptable public role at a time when few
ology of child welfare that was eventually such roles were available. Most of the child-
institutionalized in the juvenile court system. saving women, such as Louise Bowen and Jane
The first thread of reform came from within Addams, were from rural and middle-class
the existing system. Numerous penal specialists origins, and they promoted a middle-class
and institutional superintendents became orientation toward delinquents. Although the
champions of penal reform, urging the re- child-savers' interests included removing chil-
vamping of the reformatory structure and or- dren from almshouses, private institutions, and
ganization. They proposed reforms, including jails, their major impact was not on the jails
a "simpler, more natural" life in the country or reformatories (Platt, 1969, p. 99). Their leg-
for delinquents, a reorganization of the institu- acy stems from their expansion of child-saving
tion into a smaller "cottage system" with a activities to all children in need and the par-
ticular view of child welfare they espoused.
The late 19th-century child-savers embraced
*The material in this section comes largely from and promoted a particular "ideology of child
Platt (1969). Since we select only elements of his welfare," the assumptions of which were ulti-
intriguing analysis that bear directly on children
and medicalization, the reader is encouraged to mately institutionalized in the juvenile court.
consult that volume for a more complete picture Their ideology was an amalgam of ideas drawn
of the child-saving movement. from available theories of deviance and de-
pendence of the period and was displayed disorganized families, and moral decay), most
in their child-saving claims. As David Matza believed early and proper social intervention
(1964) points out, nearly all theories of delin- could prevent or reform delinquency. One as-
quency are positivistic and deterministic, pect of the ideology, echoing Lombroso, was
assuming that psychological, social or biolog- a faith that delinquents could be identified,
ical "forces" rather than some type of "will" treated, and changed. "Crime, like disease,
determines the behavior of the child. He sug- was revealed 'in the face, the voice, the per-
gests that students of delinquency, including son and the carriage,' so that a skillful and
perhaps especially these child-savers, have properly trained diagnostician could arrest
developed an "ideology of child welfare." criminal tendencies" (Platt, 1969, p. 30). In
Because juvenile delinquency is seen always these cases medical intervention could be a
in a deterministic framework, Matza (1964) preventive measure. But it was the medical
argues that model and vocabulary, rather than medical
statements reinforcing the delinquents' conception intervention, that became the hallmark of juve-
of irresponsibility are an integral part of the ideok gy nile delinquency treatment. Delinquency could
of child welfare shared by social work, psychoanaly- be prevented by therapeutic intervention.
sis and criminology. This ideology presents a causal In sum, the child-savers made relatively
theory of delinquency which, when it attributes minor reforms in the reformatories themselves.
fault, directs it to parent, community, society, or But they made a lasting impact on the defini-
even to victims of crime. (p. 95).
tion and treatment of delinquency in three
This ideology, nascent and undeveloped be- more significant matters. First, they extended
fore the 19th century, took a particular form public concern for the general welfare of chil-
in the hands of these reformers, a form that dren (as dependent individuals) rather than
outlined the contours of the juvenile court. focusing attention on specific types of behavior
If the earlier child-savers of the house of engaged in by deviant children. This, as Platt
refuge era borrowed their rhetoric from social (1969, p. 99) observes, extended governmental
theories of environmental causation, the new control "over a whole range of activities that
child-savers borrowed their ideal from med- had been previously ignored or dealt with in-
icine. Since the child-savers were concerned formally." Second, they developed a particular
with humanitarian benefit and the welfare of ideology of child welfare, based on the medical
the child rather than punishment, the medical model of prevention and treatment. Third, they
therapeutic analogy was fitting. Taking their managed to institutionalize most of their re-
cues from physicians who had pioneered forms in the creation of the juvenile court.
positivist criminology (Platt, 1969, p. 29),
and perhaps impressed with the successes of Juvenile court
medical work in the late 19th century, the child- The "success" of the child-saving move-
savers updated social origin theories with the ment was the juvenile court. The first legisla-
new ideas of biological determinism and bor- tion establishing a juvenile court was passed
rowed the medical "imagery of pathology, in 1899 in Illinois. A result of many years of
infection, and immunization" (Platt, 1969, concern by child-saving and other humanitarian
p. 18)* as their strategy for handling delin- groups, the legislation created a special chil-
quency. Even if, as popular theories suggested, dren's court and established a new type of legal
heredity and biology played a role in causing machinery for handling juveniles outside the
deviant behavior (some child-savers challenged adult criminal justice system.
this with their own theories of urban slums, The mandate of the juvenile court was
broad-the welfare of children under 16 who
* Quotations from Platt (1969) on pp. 150 to 152 were in some kind of trouble. Based on the
from Platt, A., The child savers: the invention of de- traditional parens patriae concept, the court
linquency. Chicago: University of Chicago Press,
1969, Copyright 1969 by University of Chicago would "regulate the treatment and control of
Press. dependent, neglected and delinquent children"
CHILDREN AND MEDICALIZATlON: DELINQUENCY, HYPERACTIVITY, AND CHILD ABUSE 151
(Platt, 1969, p. 134). The juvenile court could lished with a separate judge, a special court,
gain guardianship over the child, not as a crim- confidential records, and infonnal sessions.
inal but as a ward of the state. A child could As mentioned, the court not only dealt with
be brought into the jurisdiction of the court lawbreakers but also with neglected and
for three types of problems: (I) for criminal of- dependent children. Prior to the creation of the
fenses (similar to adults); (2) for being ne- juvenile court, the "sick" (mentally ill) and the
glected by parents or guardians; and (3) for "bad" (criminal) were more or less separate
"status" offenses-offenses that came under categories (see Chapter 3). The juvenile court
legal control only because of the juvenile's blurred those distinctions for children, how-
age, including drinking, truancy, incorrigibil- ever, by developing a mechanism that was "to
ity, running away, begging, and being "in operate in the interest and protection of the
danger of immorality. " Both neglect and status child with the intent to understand the de-
offenses, neither of which would bring adults velopment of disturbing behavior" (Rafferty,
into the purview of the law, emphasized the 1977, p. 273). It was not important to estab-
court's claim over the dependent status of lish whether the child was "bad" (i.e., guilty
children. * And, as Platt (1969) points out, or innocent), because legally the child was seen
the status offenses reflected the child-savers' as incapacitated (Kittrie, 1971, p. 106) and
"concern" with the behavior of the poor, dependent, but to ascertain what could be done
since "they were primarily attributable to in the child's best interest to save him or her
children of lower-class migrant and immigrant from a criminal career. Like medicine and un-
families" (p. 139). like law, the etiology and development of the
Although the legislation did not invent delin- problem or difficulty was a central concern.
quency out of whole cloth (cf. Hagan & Leon, The focus was on the child's background and
1977), it expanded and consolidated the state's environment rather than on the offense.
control over youthful activities and institution- Although the juvenile court did not exactly
alized the dependent status of children (Platt, adopt the rhetoric of medicine, it borrowed a
1969). Many states shortly thereafter passed number of medical assumptions. It adopted the
juvenile justice legislation; by 1928 all but two medical model ideal of early diagnosis and
states had adopted a juvenile court system, preventive treatment. The court's procedures
and by 1932 there were 600 juvenile courts in were quasimedical, with private hearings,
the United States (Platt, 1969, p. 10). secret records, and an emphasis on therapeutic
The creation of the juvenile court actually intervention with "predelinquents." The judge
punctuated and institutionalized a change was depicted as a "doctor-counselor" and
that had been occurring for more than a cen- based his decisions "largely on social history
tury. The colonists had blamed deviant children reports by probation officers" (Sanders, 1976,
for their innate depravity. By the late 19th p. 183).
century, Americans largely externalized blame
by defining conduct as socially or biologically The role model for the juvenile court judges was
detennined and sought "treatment," not retri- doctor-counselor rather than lawyer. "Judicial
bution, for deviance (Empey, 1978, p. 93). To therapists" were expected to establish one-to-one
relationships with "delinquents" in the same way
accomplish this, the juvenile court was estab-
a country doctor might give his time and attention
*The juvenile court's jurisdiction over children was to a favorite patient. The courtroom was arranged
sweeping and comprehensive. The 1899 Illinois like a clinic and the vocabulary of the participants
law "made it possible for a youth to be held in was largely composed of medical metaphors. (Platt,
detention or sent to a state training school if he 1969, p. 142)
was destitute; or if he was homeless, abandoned,
or dependent; or if he had improper parental care; Like medical treatment, the court's interven-
or if he was begging or receiving alms; or if he was
living in a house of ill-fame or with any vicious or tion was assumed to be "good" and for the
disreputable person; or if he was in an unfit place" benefit of the child. An emphasis on "due
(Lerman, 1977, p. 286). process" of law-fonnal charges, legal couo-
sel, adversary proceedings, etc.-was seen as 17l). Ten years after the original legislation,
unnecessary and actually detrimental to the clinical expertise was brought to the juvenile
child's welfare. Critics have pointed out, how- court.
ever, that although the juvenile court was In the early 1900s Dr. William Healy, a
viewed as a therapeutic institution, children rather remarkable Chicago psychiatrist, began
were sometimes denied their civil rights and what would be a life-long study of the causes
treated arbitrarily in the name of "clinical and treatment of juvenile delinquency. In 1909,
treatment" and "moral development" (Kittrie, with the financial support of philanthropist Mrs.
1971; Platt, 1974, p. 372). W. F. Dummer, the Juvenile Psychopathic
The limitations of the court's capacity to Institute of Chicago was founded. The Institute
cause therapeutic change soon became ap- was established with a twofold purpose: first
parent. Well-meaning judges, probation of- and foremost, to engage in the scientific study
ficers, and reformatory personnel found that of delinquency and delinquency prevention,
many children's problems were beyond their especially its psychological and psychiatric
abilities. aspects; and second, to serve as a clinical re-
source for the Chicago Juvenile Court. Healy,
Many cases proved to be beyond the skills and re-
sources of probation officers; a substantial volume on the recommendation of reknowned psy-
of juvenile recidivism persisted despite all efforts chologist William James, was named its first
at treatment and control. The psychological sciences director (Finestone, 1976b). The institute under
were drawn upon to provide resources to deal with Healy's direction would endeavor to carry out
violators. (Finestone, 1976b, p. 8)* the child-saving goal of understanding delin-
quency.
From the juvenile court, with its jurisdiction
Healy was both a researcher and a clinician.
over dependent children, its emphasis on early
His first major piece of research, The Individual
diagnosis and treatment, its ideal of therapeutic
Delinquent, was published in 1915. Healy
intervention for the individual child, and its
analyzed 1000 case histories of repeated juve-
rhetoric of medical analogies, it was only a
nile offenders in an attempt to understand
small step to actual medical intervention. The
juvenile delinquent behavior. He included phys-
"psychological sciences" and medical-psy-
iological, developmental, social, and psycho-
chiatric expertise were brought to the juvenile
logical case histories of individual delinquents
court system by William Healy and the sup-
(Rafferty, 1977). He tested popular theories,
porters of the guild guidance movement.
such as Lombroso's physiological stigmata
William Healy. court clinics. and theory (see Chapter 8) and found them want-
the child guidance movement ing. He held that existing causal theories of
delinquency were inadequate and that delin-
Soon after juvenile courts began, it became
quency could be understood only by analyzing
evident to some people involved in delinquency
individual cases. He wanted to develop a better
work that many children had severe problems
theory, but he eschewed simplification. "Such
and that more professional expertise was neces-
statements as 'crime is a disease,''' Healy
sary. Social welfare pioneer Jane Addams
(1917) wrote, "appear dubiously cheap in light
"recalled that at last it was apparent that many
of our experience" (quoted in Finestone,
of these children were psychopathic cases and
1976b, p. 55). Although Healy did not appre-
they and other borderline cases needed more
ciate fully the sociological and social psycho-
skilled care than the most devoted probation
logical aspects of delinquency, beyond seeing
officer would give them" (Hawes, 1971, p.
the family as influential, his work was provoca-
tive and led to a cross-fertilization between the
*Quotations from Finestone (l976b) on pp. 152 to
behavioral and social sciences. Many of
153 taken from Victims of change: juvenile delin-
quents in American society by Harold Finestone and Healy's initiatives were later pursued by Clif-
used with the permission of the publisher, Green- ford W. Shaw from a sociological perspective
wood Press, Inc., Westport, Conn. (Finestone, 1976b, p. 19), and Shaw, in tum,
appears to have persuaded Healy to consider the clinics had originally been created as
sociological demographic analysis. adjuncts to the court, they soon broadened their
Healy also influenced delinquency treatment mission. The clinics expanded their domain
as a clinician. He was a leader in developing in an attempt to reach potential delinquents
clinical psychiatric procedures for diagnosing earlier and also to serve middle-class children.
and treating emotionally disturbed children They became known as "child guidance
(Finestone, 1976b, p. 75). Healy's perspec- clinics." The clinics were interdisciplinary,
tive as a clinician influenced his scientific with psychiatrists, psychologists, and social
work. He insisted on the intensive study of the workers working together as a treatment
individual as a necessary prerequisite to under- "team. "
standing delinquent behavior and strove to Professional psychiatric groups promoted
make his scientific work have clinical applica- the clinics as the first line of defense against
tions. "Altogether our task has not been so delinquency. The National Committee for
much [to] gather material for generalizations," Mental Hygiene (see Chapter 3) established
Healy (1917) wrote, "as ascertainment of the a new Division on the Prevention of Delin-
methods and facts which will help towards quency in 1922. Dr. Karl Menninger and
the making of practical diagnoses and prog- a number of other prominent psychiatrists
noses" (p. 4) (quoted in Finestone, 1976b: 55). founded the multiprofessional American Or-
Healy was influenced by psychoanalysis, es- thopsychiatric Association in 1924 to study
pecially the work of the Austrian August and promote "the neuropsychiatric or med-
Aichorn, and in the 1930s introduced a psycho- ical view of crime" (Ridenour, 1961, p.
analytic perspective to the study and treatment 39). It became a major vehicle for developing
of delinquency. Psychoanalytic concepts had ideas of preventive psychiatry, and prevention
a significant impact on the delinquency field. of delinquency was a principal theme (Finch &
In this framework, delinquents were seen as Green, 1977, p. 161). Appropriately, William
"acting out" underlying psychic conflicts and Healy served as the organization's first presi-
"antisocial impulses." Healy's research in- dent. In the late 1920s the development of chil-
creasingly centered on family life as the origin dren's clinics became the focus of a social
of the psychic conflicts that were the basis of movement, sometimes called "the child guid-
delinquent behavior. In a study comparing ance movement." Between 1927 and 1932,
delinquents and nondelinquents, conducted with the support of millions of dollars from phi-
with his colleague and wife, Augusta Bronner, lanthropic sources such as the Commonwealth
Healy (1936) concluded that the delinquent Fund, 27 cities set up child guidance clinics
child "had never had affectional identifica- and hundreds more established some type of
tion with the one who seemed to him a good part-time service (Ridenour, 1961, p. 38). The
parent" (p. 10) and found "the origins of child guidance clinics institutionalized the
delinquency in every case unquestionably to psychiatric approach to delinquency.
represent the expression of [internal and ex- Healy always remained true to his belief in
ternal] desires and urges which were other- the complexity of juvenile delinquency. By the
wise unsatisfied" (p. 2). The psychoanalytic mid-1930s, while still seeing child guidance
viewpoint, focusing on intrapsychic conflicts, as a valid and essential approach, Healy be-
aligned well with the ideology of child welfare came aware of its inherent limitations for the
and had a swift and profound influence on the prevention of delinquency.
diagnosis and treatment of juvenile delin-
Aside from the individuals who became delinquent
quency. mainly because of inner conflicts and frustrations,
The Juvenile Psychopathic Institute became it is plainly discemable that in the complex of factors
an exemplar for juvenile court clinics that which make for delinquency there are many social
sprouted up in a number of major cities. Healy elements, deprivations and pressures that cannot
himself moved to Boston in 1919 to head the possibly be bettered by clinic effort alone. (Healy,
Judge Baker Foundation (Clinic). Although 1934, p. 14, quoted in Finestone, 1976b, p. 123)
Healy brought both scientific study and clin- in re Winship, 1970-extended adult safe-
ical practice to the treatment of delinquency. guards to the juvenile court, giving delinquents
Although a physician and psychiatrist by legal rights and protections and providing some
training, Healy was more psychological than degree of due process. * These decisions limited
medical in his approach. His legacy and that the juvenile court's power to intercede on be-
of his followers was the dominance of the clin- half of delinquent children and eroded the
ical approach to delinquency prevention and "therapeutic ideal" of court intervention. t
treatment. * Although sociological studies of Although the medical model of the juvenile
urban life (Shaw & McKay, 1942), gangs and court appears to be waning, other innovations
gang subcultures (Thrasher, 1927/1936; appear to have expanded therapeutic-medical
Cohen, A., 1955), and opportunity structures intervention with deviant children. In early
(Cloward & Ohlin, 1960) subsequently chal- 1967 Congress passed the Early and Periodic
lenged and modified the purely clinical-indi- Screening, Diagnosis and Treatment Program
vidual approaches Healy espoused, the child (EPSDT) as part of the Medicaid package.
guidance clinics served as front-line troops in The bill, although not aimed at delinquent chil-
delinquency prevention for many decades. dren, mandates screening for physical, mental,
psychological, and behavioral deviations of
Medical-clinical model eligible children. It calls for
of delinquency today
such early and periodic screening and diagnosis of
Despite the spread of child guidance clinics, individuals who are eligible under the plan or are
juvenile delinquency showed no signs of under the age of 21 to ascertain their physical or
abating. The medical-clinical approach to mental defects, and such health care, treatment, and
delinquency was strongly challenged by socio- other measures to correct or ameliorate defects and
logical research in the 1950s and 1960s. Socio- chronic conditions discovered thereby as may be
logical studies clearly demonstrated the prom- mandated by the Secretary (Title XIX, Section 105
inence of sociocultural and socioeconomic [a] [4] [B]).
aspects of delinquency (see Gibbons, 1976, This modern-day medical child-saving venture,
pp. 89-141), giving rise to a variety of experi- passed surely with the good intentions of ex-
ments in social intervention and delinquency tending medical and psychiatric treatment to
prevention, including diversion from the juve- lower class children, may well increase the
nile court. But the severest challenge to the medicalization of children's deviance. As
"therapeutic" powers of the court was mounted psychiatrist Lee Coleman (1978, p. 67) notes,
by the legal profession. The lawyers charged the "EPSDT and similar schemes [of screening
that juveniles were denied "due process" and and intervention] require diagnosis of medicai
constitutional and legal protections and that the or quasi-medical disorders" for services to be
juvenile court had great potential for unfair-
ness and arbitrariness. Through a series of
*Kent v. United States, 1966, said that juveniles
Supreme Court decisions, some of the original, were entitled to a hearing, legal representation, and
informal procedures of the juvenile court's other rights in the instance of waiver to a criminal
therapeutic superparent approach were deemed court. The landmark in re Gault, 1967, decision
unconstitutional. These decisions by a Supreme ruled that juveniles must be given such legal pro-
Court concerned with offenders' rights-Kent tections as the right to counsel, notice of charge,
confrontation, and the right to cross-examine. The in
v. United States, 1966; in re Gault, 1967; and re Winship, 1970, decision stated the juvenile court
was obliged to apply the same standard of evidence
as in the adult criminal court.
*There was some tension as well as cooperation be- tThe New York state legislature recently passed
tween the juvenile courts and the child guidance a bill that would allow some juveniles to be tried for
clinics. The courts, although therapeutic and pre- murder and other crimes in adult courts. Although
ventive in orientation, were also legalistic and justice this bill still must be constitutionally tested, it ex-
oriented and did not accept completely the psychiat- emplifies a legislative "backlash" against a per-
ric approach to delinquency. ceived "soft" and coddling treatment of juveniles.
rendered. Coleman suggests that such programs Medical diagnosis of hyperkinesis

reinforce the medical model of deviance and en- Hyperkinesis, a behavior disorder, is prev-
courage the creation of medical diagnoses of alent in an estimated 3% to 10% of the ele-
behavior problems so that the child may be mentary school population. * It is a particularly
"covered" under the program. good example for investigating the process
EPSDT, unlike the juvenile court or the child of the medicalization of children's deviance,
guidance movement, was not a product of the since it is a relatively recent phenomenon as
lobbying of child-saving groups or the claims- a medical diagnostic category. Only in the
making of professional psychiatrists. It was, past two decades has it been available as a
rather, promoted by the federal bureaucracy recognized diagnostic category, and perhaps
and the educational establishment (Schrag & only in about the most recent decade did it be-
Divoky, 1975). With massive screening pro- gin to receive widespread notice and medical
grams like EPSDT, it is possible to establish popularity. However, as shown below, the
early diagnosis and intervention with deviant roots of the diagnosis and treatment of this dis-
children to an extent beyond the dreams of the order are found earlier.
19th-century child-savers. We do not suggest Hyperkinesis is also known as minimal brain
any sinister intentions in the passage of EPSDT dysfunction (MBD), hyperactive syndrome,
legislation-on the contrary, its passage at the hyperkinetic disorder of childhood, and several
peak of 1960s liberalism suggests the op- other diagnostic designations. Although oc-
posite-but rather point out that this program casionally the symptoms emphasized vary a
greatly expanded the potential of medical con- little from category to category, and the pre-
trol of children's deviance. While it has not yet, sumed etiology frequently varies by diagnosis,
to our knowledge, been used widely to identify the behaviors that are considered symptomatic
delinquent children, it demonstrates the federal of each are, in general, similar and overlap
government's faith in medical interventions considerably. t Typical symptom patterns for
and controls. But the potential for the medical- diagnosing the disorder include extreme excess
ization of delinquent behavior remains, as of motor activity (hyperactivity), short attention
exemplified by the Hutschnecker plan de- span (the child flits from activity to activity),
scribed later in this chapter. restlessness, fidgetiness, often wildly oscillat-
In sum, today's juvenile court relies less on ing mood swings (the child is fine one day, a
the therapeutic-medical analogy, but certain
forms of children's deviant behavior have be-
come defined as medical problems and shifted *Until recently there has been no methodologically
into medical jurisdiction. A classic example sound community-wide epidemiological research on
is hyperkinesis. hyperkinesis. Most of the estimates vary between 3%
and 5% of the elementary school populations, but
DISCOVERY OF HYPERKINESIS· there have been estimates as high as 20% (Huessy,
1973). It is likely that between 250,000 and 500,000
We now tum to a theoretical review and children have been identified as hyperkinetic. A
analysis of the development of hyperkinesis recent careful community study in California (Lam-
as a medical diagnosis. We describe the diag- bert et aI., 1978) suggests that epidemiology varies
nosis, review the pertinent literature relevant to by social system and who is diagnosing the disorder.
its development, and present a sociological A strict medical diagnosis yields less than 2% of
schoolchildren as hyperactive, whereas a school sys-
analysis of its discovery. tem count is over 12%.
tThe U.S. Public Health Service report (Clements,
*This section slightly amended and extended from 1966) included 38 terms that were used to describe
Conrad, Peter, Identifying hyperactive children: the or distinguish the conditions that it labeled MBD.
medicalization of deviant behavior: (Lexington, Although the literature attempts to differentiate
Mass.: Lexington Books, D. C. Heath and Com- MBD, hyperkinesis, hyperactive syndrome, and
pany, Copyright 1976, D. C. Heath and Company), several other diagnostic labels, it is our belief that in
and from Conrad, P. Social Prob., 1975, 23,12-21 practice they are almost interchangeable-especially
(Oct.). in terms of treatment.
terror the next), clumsiness, aggressive-like Bradley and his associates), the next significant
behavior, impulsivity, the inability to sit still contribution was the work of A. A. Strauss and
in school and comply with rules, a low frustra- his associates (Strauss, A. A. & Lehtinen,
tion level, sleeping problems, and delayed ac- 1947). Building on prior research, they re-
quisition of speech (Stewart, 1970; Stewart et ported that they found certain behavior (in-
aI., 1966; Wender, 1971). cluding hyperkinetic behaviors) in posten-
Most of these indications or symptoms for cephalitic children suffering from what they
the disorder probably would be considered called minimal brain injury. This was the first
deviant behaviors, although it is usually de- time that these behaviors (similar to those
fined as a physiological disorder found in chil- found in children reported by Bradley and
dren (with a prevalence six times as great others) were found to be caused by this new
among boys). Since we are more concerned organic distinction of minimal brain injury
with the sociological process than with the (or damage).
specific diagnostic criteria, we use the term This disorder still remained unnamed or at
"hyperkinesis" as representative of all the least went by a variety of names (usually simply
daignostic categories of this disorder. This term "childhood behavior disorder") and did not
is more descriptive and less assumptive of etiol- exist as a specific diagnostic category until
ogy than "minimal brain dysfunction" and Maurice W. Laufer and his associates described
more medically appropriate than the popular it as the "hyperkinetic impulse disorder" in
description "hyperactivity." In the remainder 1957. On finding that "the salient characteris-
of this chapter hyperkinesis and hyperactivity tics of the behavior pattern . . . are strikingly
are used interchangeably. similar to those with clear-cut organic causa-
tion," they went on to describe a disorder with
Discovery of hyperkinesis no clear-cut history or evidence for organicity.
In developing an analysis of the discovery They also presented a case for the possible
of hyperkinesis it is useful to distinguish what organic etiology of the disorder (Laufer et aI.,
might be called clinical factors (events directly 1957).
related to the diagnosis and treatment of hyper- In an attempt to clarify the ambiguity and
kinesis) from social factors (factors that are not confusion in terminology and symptomatology
directly related to hyperkinesis but are rele- in diagnosing children's behavior and learning
vant). Clinical and social factors do, of course, disorders, a task force sponsored by the U.S.
overlap, but such an analytic distinction will Public Health Service and the National Asso-
be useful in our discussion. ciation for Crippled Children and Adults
Clinical factors. In 1937 Charles Bradley presented a report in 1966. From over three
(1937) observed that recently discovered dozen diagnoses, they agreed on the term
amphetamine drugs had a spectacular effect in "minimal brain dysfunction" (MBD) as an
altering the behavior in a number of school- overriding diagnosis that would include hyper-
children who exhibited behavior disorders or kinesis and other disorders (Clements, 1966).*
learning problems. Fifteen of the 30 children Since this time, MBD has been the primary
he treated actually became more subdued in formal diagnosis or label, although many others
their behavior. Bradley termed the effect of this still remain in use.
medication "paradoxical," since he expected In the middle 1950s a new drug, methyl-
that amphetamines would stimulate the children phenidate (Ritalin), was synthesized. This drug
as they stimulated adults. After the medication
was discontinued, the children's behavior re- *The report stated, "The term minimal brain dys-
turned to premedication level. function will be reserved for the child whose symp-
Although there was a scattering of reports tomatology appears in one or more specific areas
of brain function, but in mild, borderline or sub-
in the medical literature in the next two decades clinical form, without reducing overall intellectual
on the utility of stimulant medications with functioning to the subnormal ranges" (Clements,
"childhood behavior disorders" (mostly by 1966, p. 9).
is a stimulant that has many qualities of am- TABLE 4

phetamines without some of the more undesir- ARTICLES ON HYPERACTIVITY IN THE
able side effects. In 1961 it was approved by the POPULAR AND EDUCATIONAL MEDIA
FDA for use with children. Since that time a 1966-1974*
large body of research has been published on
the use of Ritalin in the treatment of childhood Number of Number of
behavior disorders. This medication became articles in articles in
Year popular media educational media
increasingly considered the "treatment of
choice" (along with the older amphetamine, 1974 12 16
dextroamphetamine 504 [Dexedrine] and the 1973 7 20
more recent addition, pemoline [Cyclert]) for 1972 4 10
children with hyperkinesis. 1971 11 23
There has been a virtual flood of papers and 1970 6 7
research published since the early 1960s. The 1969 it 5
vast majority is medical research concerned 1968 1 1:1:
with etiology, diagnosis, and treatment of 1967 0 0
hyperkinesis (see Cole, Sherwood, 1975;
1966 0 0
Delong, A. R., 1972; Grinspoon & Singer, *Reprinted by pennission of the publisher, from Peter
1973). By far the largest number of these pub- Conrad, Identifying hyperactive children: the medicaliza-
lications (perhaps as many as three fourths of tion of deviant behavior (Lexington, Mass.: Lexington
them) are concerned with drug treatment of the Books, D. C. Heath & Co., Copyright 1976. D. C. Heath
& Co.). Infonnation from Reader's Guide to Periodical
disorder. There has been increasing pUblicity Literature, 1965-1975, and Educational Indn, 1965-1975.
of the disorder in the mass media as well. A tPrior to 1970, articles on hyperactivity were listed in the
perusal of the citations in the Reader's Guide Reader's Guide to Periodical Literature under "problem
to Periodical Literature showed no articles on children ...
:j:Prior to 1969, articles were listed in the Educational
hyperkinesis before 1967, one each in 1968
Index under "activity level."
and 1969, and a total of 40 for 1970 through
1974 (a mean of eight per year) (Table 4).
Hyperkinesis has become the most common
child psychiatric problem (Gross & Wilson,
1974, p. 142); special clinics have been estab- The pharmaceutical revolution. Since the
lished to treat hyperkinetic children, and sub- 1930s the pharmaceutical industry has been
stantial amounts of federal research monies synthesizing and manufacturing a large number
have been invested in etiological and treatment of psychoactive drugs; this has been part
research. Furthermore, outside the medical of a virtual revolution in drug making and
profession, teachers have developed a working drug taking in America (Silverman & Lee,
clinical knowledge of hyperkinesis' symptoms 1974).
and treatment (Robin & Bosco, 1973), and Psychoactive drugs are agents that affect
as articles appear regularly in mass circu- the central nervous system. Benzedrine (am-
lation magazines and newspapers, parents phetamine S04), Ritalin, and Dexedrine are all
often come to clinics with knowledge of this synthesized psychoactive stimulants that were
diagnosis. Hyperkinesis is no longer the rela- indicated for narcolepsy, appetite control (as
tively esoteric diagnostic category it may have "diet pills"), mild depression, fatigue, and,
been 20 years ago; it is now a well-known more recently, MBD. These drugs, which have
clinical disorder. all been used with hyperkinetic children, are
Social factors. The social factors affect- only three of the hundreds of psychoactive
ing the discovery of hyperkinesis can be divided drugs that have been synthesized since the
into three areas: (1) the pharmaceutical revolu- 1930s.
tion, (2) trends in medical practice, and (3) Until the 1960s there was little or no promo-
government action. tion and advertisement of any of these medica-
tions for use with childhood disorders. * It child psychiatric problems is related to the dis-
was at this time that two major pharmaceutical covery of hyperkinesis in children; if one does
firms (Smith, Kline & French, manufacturer not look for a disorder or has no way of concep-
of Dexedrine, and CIBA, manufacturer of tualizing it, it is likely that it will remain un-
Ritalin) began to advertise increasingly in identified or undiagnosed or even considered
medical journals, through direct mailing, and outside the purview of medical attention.
the "detail men" who call on physicians. Govemment action. Since the publication of
Most of this advertising and promotion of the the U.S. Public Health Service report on MBD
pharmaceutical treatment of hyperkinesis was there have been at least two significant govern-
limited to the medical sphere, but some of mental reports concerned with the issue of treat-
the promotion was targeted for the educa- ing schoolchildren with stimulant medications
tional sector also (Hentoff, 1972). This pro- for behavior disorders. Both of these inquiries
motion was probably significant in dissem- came either directly or indirectly as a response
inating information concerning the diagnosis to the national pUblicity created by the Wash-
and treatment of this newly discovered dis- ington Post report in 1970 that 5% to 10% of the
order.t 62,000 grammar schoolchildren in Omaha, Ne-
Trends in medical practice. Two recent braska, were being treated with "behavior
trends in medical practice have affected the in- modification drugs to improve deportment and
crease in the diagnosis and treatment of hyper- increase learning potential" (quoted in Grin-
kinesis. Probably the most significant is what spoon & Singer, 1973). Although the figures
has been called' 'the great pharmaceutical revo- were later found to be a little exaggerated, they
lution" in mental health: the use of psycho- nevertheless spurred a congressional investiga-
active medications (especially phenothiazines) tion (U.S. House Committee on Government
for the treatment of persons who are mentally Operations, 1970) and a conference sponsored
ill. Since 1955 the increasing use of these medi- by the Office of Child Development (1971) on
cations has made psychopharmacology an in- the use of stimulant drugs in the treatment of
tegral part of treatment for mental disorders. It behaviorally disturbed schoolchildren.
has also undoubtedly increased the confidence The Congressional Subcommittee on Privacy
of the medical profession in the pharmaceutical chaired by Congressman Cornelius E. Galla-
approach to mental and behavioral problems. gher held hearings on the issue of prescribing
In the past decade there also has been bur- drugs for hyperactive schoolchildren. In gener-
geoning interest in child mental health and psy- al, the committee showed great concern with
chiatry. It has been argued that children's men- the facility in which the medication was pre-
tal health was generally ignored or at least given scribed; more specifically, that some children at
a second-class position until recent years (e.g., least were receiving drugs from general practi-
see Task Force of Children Out of School, tioners whose primary diagnosis consisted of
1972). It is likely that this increased interest in teachers' and parents' reports that the child was
doing poorly in school. There was also a con-
*Part of this may have to do with the AMA's change cern with the absence of follow-up studies on
in policy in accepting more pharmaceutical adver- the long-term effects of treatment.
tising in the late 1950s. Probably more specifically The Department of Health, Education and
involved was the FDA approval of the use of Ritalin Welfare committee was a rather hastily con-
for children in 1961. It is interesting to note that
until 1970 Ritalin was advertised for treatment of vened group of professionals (the majority be-
"functional behavior problems in children." Since ing physicians), many of whom already had
then, because of an FDA order, it has only been commitments to drug treatment for children's
promoted for treatment of MBD. behavior problems. They recommended that
tThe drug industry spends fully 25% of its budget only physicians make the diagnosis and pre-
on promotion and advertising; so it is likely to be
effective. See James Coleman et al. (1966) for the scribe treatment, that the pharmaceutical com-
role of the detail men and how physicians rely on panies promote the treatment of the disorder
them for information. only through medical channels, that parents not
be coerced to accept any particular treatment, mandate to use drugs to modify human behavior
and that long-term follow-up research be done. in others (although to a certain extent, within
This report served as blue-ribbon approval for the limits of legality and availability, we can do
treating hyperkinesis with psychoactive medi- it ourselves), so that to justify the treatment,
cations. there had to be a medical label. In other words,
for medical social control mechanisms to oper-
A sociological analysis ate, deviance must be conceptualized in medi-
Three issues are discussed in this section: cal terms.
how children's deviant behavior became con- A second question that we can address is why
ceptualized as a medical problem, why this oc- this type of deviance became defined as a medi-
curred when it did, and what the present status cal problem when it did. Why did the label
is of hyperkinesis as a medical problem. "hyperkinesis" (and its treatment with psycho-
A primary question that this analysis ad- active medications) become so popular in the
dresses is how deviant behavior became con- 1960s and 1970s? In the first place, only in the
ceptualized as a medical problem. It is assumed late 1950s were both the diagnostic label and
that before the discovery of hyperkinesis this the pharmaceutical treatment available. Sec-
type of behavior was defined as disruptive, dis- ond, the pharmaceutical revolution in mental
obedient, rebellious, antisocial, or deviant (per- health and the increased interest in child psychi-
haps even the label "emotionally disturbed" atry provided a favorable background for the
was sometimes used when it was in vogue in the dissemination of knowledge about this new dis-
1960s) and was usually handled in the context order. The latter, in fact, probably made the
of the family or the school or, in extreme cases, medical profession more likely to consider be-
the child guidance clinic. How, then, did this havior problems in children within their clinical
constellation of deviant behaviors become a jurisdiction.
medical disorder? There were, however, agents outside the med-
What stands out to a sociologist is that the ical profession that were significant in "pro-
treatment was available long before the disorder moting' , hyperkinesis as a disorder that was
that was being treated was clearly conceptual- within the medical framework. These agents
ized. It was 20 years after Bradley's discovery might be conceptualized in Howard Becker's
of the "paradoxical effect" of stimulants on terms as "moral entrepreneurs," those who
certain deviant children that Maurice W. Laufer crusade for creation and enforcement of the
named the disorder and described its character- rules whose violation constitutes deviance
istic symptoms (behaviors). In terms of the (Becker, 1963).* In this case the moral entre-
sociological study of deviance this is most inter- preneurs were the pharmaceutical companies
esting. The social control mechanism (in this and the Association for Children with Learning
case, pharmacological treatment) preceded the Disabilities.
label (hyperkinesis) by 20 years. This presents The pharmaceutical companies spent a great
an interesting problem for a sociological per- amount of time and money promoting stimulant
spective: Do medical labels appear when med- medications for this new disorder. After the
ical social control mechanisms are available? middle 1960s it is nearly impossible to read a
In this case, an extremely cynical reading of the medical journal or the free "throw-away"
history of the development of medical control magazines without seeing some elaborate ad-
might be that the label was invented to facilitate
the use of a particular social control mecha-
nism, in this case psychoactive drugs. * In our * Eliot Freidson (1970a) also notes the medical pro-
society, only the medical profession has the fessional role as moral entrepreneur in this process:
'The profession does treat the illnesses .laymen take
to it, but it also seeks to discover illness of which the
* We do not necessarily endorse such an extreme laymen may not even be aware. One of the greatest
view, but it is a possible interpretation of the evi- ambitions of the physician is to discover and describe
dence. a 'new' disease or syndrome ... " (p. 252).
vertising for either Ritalin or Dexedrine. These cians, parents, teachers, and children have, for
advertisements explain the utility of treating a variety of reasons, come to accept this con-
hyperkinesis (or any of the other labels that are ception of deviant behavior. Physicians find
used such as MBD) and urge the physician to treatment to be relatively simple (medication)
diagnose and treat hyperkinetic children. The and the results sometimes spectacular. Hyper-
advertisements may run from one to six pages. kinesis minimizes parents' guilt by emphasizing
They often advise physicians that "the hyper- "it's not their fault, it's an organic problem"
kinetic syndrome" exists as "a distinct medical and allows for nonpunitive management or con-
entity" and that the "syndrome is readily diag- trol of deviance. Medication often makes a
nosed through patient histories and psycho- child less disruptive in the classroom and some-
metric testing" and "has been classified by an times facilitates learning. There are, however,
expert panel" of the Department of Health, some other, perhaps more subtle, consequences
Education and Welfare as MBD. These same of such medicalization of deviant behavior,
pharmaceutical firms also supply sophisticated which we discuss in Chapter 9.
packets of "diagnostic and treatment" informa- In recent years a few studies on the sociologi-
tion on hyperkinesis to physicians, pay for pro- cal aspects of hyperactivity have been reported.
fessional conferences on the subject, and sup- Most of this work takes a skeptical view of
port research in the identification and treatment hyperactivity. Some have argued that hyperac-
of the disorder. Clearly these corporations have tivity as a medical disorder is a myth (Schmitt,
a vested interest in the labeling and treatment 1975) and is merely a form of medical child
of hyperkinesis; it was reported that CIBA real- control (Schrag & Divoky, 1975). Other re-
ized $13 million profit from Ritalin alone in search has pointed out that physicians' diagno-
1971, which was 15% of its total gross profits sis of hyperactivity is based primarily on ob-
(Ct:arles, 1971; Hentoff, 1972). served behavior and reports from teachers and
The other moral entrepreneur, less powerful school (Conrad, 1976, pp. 51-70; Kenny et aI.,
than the pharmaceutical companies but never- 1971; Sandoval et aI., 1976), and some children
theless influential, was the Association for are defined as hyperactive in one social system
Children with Learning Disabilities. Although and not in another (Conrad, 1976, pp. 77-85;
its focus is not specifically on hyperkinetic Lambert et aI., 1978). But these "critiques" of
children, it does include it in its conception of the medical model of hyperactive behavior re-
lel'lrning disabilities, along with aphasia, read- main largely outside the mainstream of medical
ing problems such as dyslexia, and perceptual practice.
motor problems. Founded in the early 1960s by In another sense the definition of hyperactiv-
parents and professionals, it has functioned ity may be expanding. It has been suggested
much like the National Association for Mental that girls who suffer from the disorder are hypo-
Health does for mental illness: promoting con- active rather than hyperactive (Huessy, 1967).
ferences, sponsoring legislation, and providing Their symptoms are daydreaming and "spacing
social support. One of its main functions has out" in school. Some researchers have postu-
been to disseminate information concerning lated that hyperactive children may develop into
this relatively new area in education-learning juvenile delinquents (Berman & Siegal, 1976);
disabilities; although the organization does have that hyperactivity may be the precursor to adult
a more educational than medical perspective, sociopathy, alcoholism, and hysteria (Cantwell,
most of its literature indicates that at least with 1975). A few have claimed to discover adults
hyperkinesis it has adopted the medical model with the hyperactive syndrome (Mann, H. &
and the medical approach to the problem. It has Greenspan, 1976). The diagnosis of hyperactiv-
sensitized teachers and schools to the concep- ity appears to be slowly expanding beyond
tion of hyperkinesis as a medical problem. school-aged children to adolescents and adults.
The medical model of hyperactive behavior In sum, the discovery of hyperkinesis brings
(and associated treatment with medications) has up most clearly the question of whether the de-
become well accepted in our society. Physi- velopment of new medical mechanisms of so-
cial control (stimulant drugs) leads to the emer- paring the number of adult males to females)
gence of new categories or designations of devi- suggest that infanticide, especially of females,
ance and the expansion of medical jurisdiction. was not uncommon in Europe as late as the 16th
From the example of hyperkinesis, and to a less- century, despite its Judeo-Christian definition
er extent methadone, as discussed in Chapter 5, as murder (Harris, 1977). Death was common-
the answer appears to be a tentative "yes." ly attributed to "overlaying" -accidental suf-
focation caused by a mother's rolling over on
CHILD ABUSE AS A MEDICAL her infant in bed. Married women so accused
PROBLEM merely had to appear as a penitent in church;
The physical maltreatment of children has unwed mothers were often labeled witches and
become a recognized problem only in the last put to death (Harris, 1977).
century. "Child abuse" has become a medical A much more widespread form of child mal-
problem only in the past two decades. This is treatment in Western society was abandonment.
not to say that children did not suffer willful Foundling hospitals, institutions for abandoned
harm resulting in injury or death prior to the last children, first were organized in the 18th centu-
century; they certainly did. The history of child ry. Apparently they were busy places. "In
maltreatment, neglect, and physical injury is a France, admissions rose from 40,000 a year in
long one, but it is only in the past two decades 1784 to 138,000 in 1822. By 1830 there were
that child abuse became clearly defined 270 revolving boxes [in which one could place
as a social and medical problem. This section infants] in use throughout France, with 336,247
traces that development. infants legally abandoned from 1824 to 1833"
(Harris, 1977, p. 120). Most of these infants
Historical notes on the died in the first year of life. The first foundling
maltreatment of children hospital in the United States was established as
As noted earlier in this chapter, children were the New York Foundling Asylum in 1869 in an
not regarded highly or treated as "little dar- attempt to curb the high rate of infant abandon-
lings" until the most recent centuries. The de- ment and subsequent death. In 1873, 1392
gree of neglect and maltreatment varies from foundlings were left there (Radbill, 1968, p.
society to society, but for nearly every society 10). As late as 1892, 200 foundlings and 100
some evidence exists fUf what we would today dead infants were found on the streets of New
call child abuse. The physical abuse of children York City (Fontana, 1966, p. 236). This was
can be divided into two general types: infanti- probably only a small portion of the abandoned
cide and abandonment, and discipline and pun- and abused children, those who for some reason
ishment. came to the attention of social and medical
Infanticide, the killing of a newborn or infant authorities.
with the consent of the parents, was regularly The other major historic form of child mal-
practiced in many societies. Until the most re- treatment could be defined broadly as "child
cent centuries, it was a common and effective discipline." Child-rearing methods in Western
means of population control. This, along with society were often austere and severe; harsh
the inability of individual families to support punishments inflicted by parents and other adult
the child, illegitimate births, and, in some cul- authorities were commonplace, in fact, norma-
tures, ritualistic sacrifice (Radbill, 1968, pp. 6- tive. Parents had total sovereignty over their
7) are usually cited as causes of infanticide. For children. In colonial times physical punish-
virtually all recorded history, except among ments in the name of discipline rarely could be
Judeo-Christian societies, infanticide has been viewed as too harsh. The whipping and birching
an acceptable procedure for disposing of not of children was the prerogative of parents,
only deformed or sickly infants but any new- teachers, and the courts. Indeed, corporal pun-
borns who might strain the resources of the ishment was the regular disciplinary fare. The
family or the community (Langner, 1974). Re- dictum "spare the rod and spoil the child" cap-
cent historical studies of "sex ratios" (com- tured the child-rearing spirit. And there was
little a child could do about it. There was gener- to have Mary Ellen removed from her home.
al agreement that this was simply the way it Ironically, the ASPCA was able to intervene
was. "It was always taken for granted that par- because Mary Ellen was a member of the
ents and guardians had every right to treat their animal kingdom, and thus could be included
children as they saw fit" (Radbill, 1968, p. 4). under the laws which protected animals from
No doubt, serious injuries frequently occurred, human cruelty (Radbill, 1968, p. 13). As an
but no one called them "child abuse," nor outgrowth of significant journalistic publicity,
were they, short of murder, restricted by so- the Society for the Prevention of Cruelty to
ciety. Children was established. This was soon fol-
Through the 19th century, then, infanticide lowed by legislation that extended some pro-
and abandonment were prevalent, and severe tections to children. The SPCC, however, rare-
punishment was the norm of childhood disci- ly concerned itself with the maltreatment of
pline. Yet these were generally taken for children in their "natural" families, concen-
granted as part of the lot of the child's life. trating much of its effort on children mistreated
Even when "child protection" emerged as a by their employers or foster parents (Pfohl,
cause, the concern was largely children who 1977, p. 312). Natural parents were not con-
were neglected, not physically abused. sidered to abuse their children; their sovereignty
over child rearing remained nearly absolute.
Child protection By the beginning of the 20th century the ju-
Among the first forms of "child protection" venile court gained jurisdiction over dependent
were the houses of refuge discussed earlier in and delinquent children. As mentioned earlier,
this chapter. They frequently took charge of the juvenile court's concern was the prevention
neglected or even abandoned juveniles. But of delinquency; thus its focus was on neglected
these institutions dealt mostly with older chil- children who were viewed as potential delin-
dren. Younger children were shipped to orphan- quents rather than on the protection of physi-
ages or left to their own devices. Not until the cally abused children from their parents or guard-
foundling homes did infants and very young ians. Both the juvenile courts and the SPCC
children have an institution specifically man- often advocated the removal of neglected chil-
dated for their care. Again, these were for ne- dren from their homes, a perspective that
glected or abandoned children. There was liter- clashed with the emerging social work and child
ally no societal response to physically mal- guidance professions. These new "helping pro-
treated children. The first organization with the fessions" sought, at least ideally, to strengthen
explicit purpose of "protecting" and caring for the family (for a critical analysis of this, see
physically mistreated children was the New Lasch, 1977). The 1909 White House Confer-
York Society for the Prevention of Cruelty to ence on Children supported this emerging view-
Children (SPCC). point, declaring that poverty was not a suffi-
The founding of the SPCC is an interesting cient reason for removing children from their
story, and it highlights the lack of a social def- homes and calling for social services and finan-
inition of physical child abuse as a social prob- cial aid to bolster the home environment (Pfohl,
lem. In the early 1870s a 9-year-old child 1977, p. 313). Parents' physical abuse ofchil-
named Mary Ellen was being severely mis- dren was not yet defined as a particularly "im-
treated by her foster parents. Concerned church portant" kind of deviance.
workers brought her to various agencies who Stephen Pfohl (1977) points out that most of
refused to intervene, primarily because they the measures up to this time were essentially
viewed the right of parents to chastise their "society-saving" rather than "child-saving."
children as absolute, and there was no law Although the child was the focus of concern,
under which they could intervene to protect the the object was to save society from the long-
child. Finally, Mary Ellen was brought to the term burdens and hardships of dependent or
American Society for the Prevention of Cruel- delinquent juveniles who would grow up to be
ty to Animals, who took her case and was able dependent or criminal adults, rather than to save
the child from abusive parents. Parents were parents' nearly complete prerogative in raising
ignored as a source of deviant behavior or as and disciplining their children.
an object of sanction, reform, or treatment. The The first medical recognition of what is now
victim of abuse, not the perpetrator, was con- called child abuse appeared in an 1888 paper on
sidered the problem. acute periosteal swelling in infants by a Dr. S.
Specific medical intervention in child mal- West (Solomon, 1963, p. 774). It was not,
treatment, beyond marginal involvement with however, until 75 years later that child abuse
the foundling hospitals, was limited. To the ex- became a bona fide medical entity.
tent that physicians treated the casualties of Articles leading to the medical discovery of
child maltreatment, they were involved, but "child abuse," nearly all based on x-ray studies
they were treating specific physical injuries in by pediatric radiologists, appeared in medical
children, not cases of "child abuse." In fact, journals over a number of years. John Caffey
many physicians did not consider abuse to exist (1946) reported a frequent association of sub-
(Pfohl, 1977). It took certain organized inter- dural hematoma (a hemorrhage between the
ests in. medicine to discover child abuse as a brain membranes usually caused by trauma)
medical problem. and abnormal changes in the long bones re-
vealed in x-ray pictures. Other researchers
Medical involvement and the clearly defined the traumatic nature of the in-
discovery of child abuse juries and even suggested they resulted from
Undoubtedly physicians treated countless "parental conduct" (Silverman. 1953). Wool-
children's physical injuries sustained at the ley and Evans (1955) were the first to suggest
hands of their parents or guardians. But these specifically that these traumas might be will-
injuries were treated only as specific medical fully inflicted, the product of "indifference,
pathological conditions (a broken bone, a bum, immaturity and irresponsibility of parents."
a skull fracture), and the source of the injury What had been considered as "unspecific
was overlooked, ignored, or simply unknown. trauma" was redefined as "misconduct and
This is not to suggest that physicians were dere- deliberate injury" (Caffey, 1957). Reports
lict in their medical duty; many factors kept filtered into the media, and an increase in public
physicians (and others) from "seeing" the in- concern for abused children began to develop
juries as results of parental abuse. (Radbill. 1968, p. 16).
Medical practice frequently treats symptoms Probably the key work in defining and legiti-
rather than causes; child trauma was no dif- mizing child abuse as a medical problem was
ferent. Pfohl (1977, p. 13) suggests four bar- Kempe and associates' 1962 paper published in
riers that kept physicians from recognizing the the Journal of the American Medical Associa-
injuries as child abuse. First, many doctors tion (Kempe et aI., 1962). The appearance of
were simply unaware that "abuse" could be a the article "The Battered Child Syndrome" in
diagnosis; no clear diagnostic label was avail- the most prestigious and widely read medical
able. Second, physicians may have been psy- journal, complete with an editorial underlining
chologically unwilling to believe parents would the medical seriousness of the problem, gave
inflict such injuries on children. Third, physi- visibility and legitimacy to battered children as
cians were concerned that reporting such mal- a significant medical problem. Kempe and his
treatment would violate the norm of medical associates described the clinical manifestations,
confidentiality and create the possibility of psychiatric aspects, techniques of evaluation,
legal liability from the violation. Finally, many radiologic features, and management of phys-
doctors were reluctant to become involved in ically abused children and their families. They
a time-consuming criminal justice process that described a "syndrome" with characteristics
would also take the consequences of their diag- that included the victims being usually under 3
nosis out of their hands. There is, of course, no years of age and neglected, having traumatic
reason to assume that physicians should be any injuries especially to the head and long bones,
different from the society at large in granting and having parents who often themselves had
been battered as children and who denied the of injury in black-and-white x rays but little of
abuse of their own child. They exhorted physi- the bloody assault itself. The distance also min-
cians to find and report such cases to proper imized the radiologists' concern with confi-
authorities: dentiality or violating the physician-patient re-
lationship. They had less connection with par-
The principal concern of the physician should be to ents; thus it may have been easier for them to
make a correct diagnosis so that he can institute prop-
hypothesize parental fault. These factors neu-
er therapy and make certain that a similar event will
tralized many of the obstacles that kept other
not occur again. He should report possible willful
trauma to the police department or any special chil- physicians from attributing child injury to pa-
dren's protective service that operates in the com- rental abuse.
munity. (Kempe et aI., 1962, p. 247)* Pfohl (1977) posits further that the status of
pediatric radiology in the medical profession
With the publication of this article in a widely contributed to pediatric radiologists' discover-
read journal, physicians could now more easily ing child abuse. Pediatric radiology is a rela-
"recognize" child abuse when they encoun- tively marginal and low-prestige specialty with-
tered maltreated, injured children. The label in organized medicine. It has few of the charac-
"battered child syndrome" gave physicians teristics of more esteemed specialties such as
both a measure and a legitimacy for medical in- surgery and internal medicine: it has no face-to-
tervention. t face clinical interaction, is research oriented
The central figures in the discovery of "child with virtually no patient relations, and has little
abuse" were pediatric radiologists, whose re- of the life-and-death "risk and responsibility"
search reports, published in a variety of profes- of the high-prestige specialties. Pfohl suggests
sional journals for over a decade and a half, that the discovery of "child abuse" as a viable
demonstrates an increasing Willingness to medical entity was an opportunity for pediatric
"see" and define child abuse as a distinct med- radiologists to achieve some prestige in the
ical entity. Why pediatric radiologists? Why not medical community. "Child abuse" linked the
emergency room physicians, who frequently radiologists to the critical medical tasks of pa-
saw injured children, or surgeons or internists tient diagnosis; it enabled pediatric radiologists
who treated their injuries? Sociologist Stephen to publish their research in prestigious medical
Pfohl (1977) presents a suggestive analysis. journals, including the Journal of the American
Clearly, hospital physicians, espe~ially those in Medical Association, where pediatric radiologi-
emergency rooms, encountered abused children cal research reports rarely appeared; and it facil-
more directly than radiologists; should not they itated the development of medical coalitions
have discovered it first? Pfohl points out that the with more prestigious segments of medicine
four obstacles listed earlier for physicians kept such as pediatrics and psychodynamically ori-
the direct caretaking physicians from seeing in- ented psychiatry. Most of all, it gave pediatric
jury as "child abuse." The pediatric radiolo- radiology and its allied specialties the opportu-
gists, on the other hand, had a certain distance nity to discover a bona fide medical diagnosis,
from the abused children and their families. "the battered child syndrome." In all, Pfohl
This reduced or eliminated some of the obsta- points out that it was the distance from the
cles that kept the clinicians from discovering abuse and injury and the opportunity for ad-
"child abuse." All the radiologists involved in vancement within the organized medical com-
the discovery were researchers in children's munity that led these medical professionals to
x rays; they could see the radiological remnants discover and define child abuse as a medical
problem. Once it was conceptualized and dis-
*From l.A.M.A., 1962, 181, 17-24. Copyright covered in the professional medical community,
1962, American Medical Association. it found many champions in wider society. The
t As Gelles (1975) points out, "The Kempe article "battered child" became a national concern.
made physicians and medical practitioners aware of
the problem of child abuse, but none of this was new Following the 1962 report describing the bat-
to other agencies, which had for years been trying to tered child syndrome (Kempe et aI., 1962),
cope with the problem of abused children" (p. 369). both professional journals and the popular me-
dia carried an increasing number of articles on cated; child abusers were suffering from a psy-
battered children. Mass circulation magazines chopathological "sickness" that needed treat-
popularized the "syndrome" with such pro- ment. Medical practitioners had discovered the
vocative titles as "Cry Rises From Beaten problem, but it was through the legislatures that
Babies," "Parents Who Beat Their Children," it was diffused and institutionalized as a sanc-
and "Terror Struck Children," all heralding the tionable form of deviant behavior.
discovery of a new and terrible type of deviant
behavior and medical problem (cited in Pfohl, Child abuse as a medical and
1977, p. 320). social problem
The professional journals, echoed by the As we have suggested in previous discus-
popular media, essentially presented a "psy- sions, publication of scientific or professional
chopathological" model of child abuse. It be- articles, even in prestigious medical journals,
came widely accepted that "the parent who does not assure the recognition or acceptance
abuses his or her child suffers from some psy- of a particular deviance designation. Child
chological disease which must be cured in order abuse needed its champions and moral entrepre-
to prevent further abuse" (Gelles, 1973, p. neurs to bring the problem to public attention
611). The abusive parent became a psycho- and to carry the antiabuse banner in legisla-
medical problem; it was tacitly assumed "any- tures.
one who would abuse his child was sick" (Gel- It was not a difficult banner to carry. No one
les,,l973, p. 612). The cause of abuse was lo- is for child abuse. In fact, in the early 1960s a
cated in the pathological psyche or in the social- "child abuse-reporting movement" emerged,
ization experience of the parent. Sometimes promoting rapid passage of state laws on child
abusers were considered to have a mental dis- abuse reporting. * The only question was what
order; frequently they were assumed to have type of laws would be passed. Would they be
distinctive characterological traits typical of a oriented toward "treatment" or "punishment"
psychopathic personality. Clearly, the psycho- of the abuser? The supporters of the treatment
pathological-medical model of child abuse fo- orientation were most active. Social welfare
cused directly on the "sick" individual abuser; organizations such as the Children's Division
however, as with much medicalized deviance, of the American Humane Association, the Pub-
focusing on the "clinical condition" of the par- lic Welfare Association, and the Child Welfare
ent allowed the sociocultural aspects of child League, called for research on abuse and
abuse to be ignored. lobbied for "treatment based" (i.e., not puni-
In sum, "child abuse" was discovered and tive) legislation (Pfohl, 1977, pp. 319-320).
defined by pediatric radiologists. In a sense The Children's Bureau of the Department of
they functioned as a professional interest group, Health, Education and Welfare in 1963 pro-
promoting child abuse as a medical entity. posed model legislation on reporting cases of
Probably because of the tragic and critical na- physically abused children (Silver et aI., 1967).
ture of battered children, they met with little Medical interests, of course, supported child
resistance inside or outside the medical profes- abuse legislation, although organizations were
sion. Indeed, discovering child abuse may have divided about whether reporting should be
served as a vehicle for status gain within orga-
nized medicine and for professional collabora-
tion with higher status specialties (Pfohl, 1977). * Actually, prosecution of child abuse did not re-
quire new legislation: murder, assault and battery,
Defining child abuse as a bona fide medical even when committed by parents, are punishable
entity, the battered child syndrome, legiti- crimes in every state. Moreover, existing laws spe-
mized medical intervention with physically cifically forbade "cruelty to children" (Paulsen,
abused children. Moreover, by pairing deviance 1966, p. 42). The new laws, however, mandated re-
with sickness, the professional autonomy of porting of abuse and "treatment." The "punish-
ment" laws had been enforced in only the most
medicine was assured (Pfohl, 1977). By desig- severe cases; supporters of the new laws hoped to in-
nating abuse as illness, parents of maltreated crease reporting and intervention and to help the
children were for the first time clearly impli- child and family.
mandatory: the American Medical Association county or state department of welfare to handle
wanted physicians to be allowed discretion in the reports and cases. The ihtent of the child
reporting, the American Academy of Pediatrics abuse reporting laws was primarily to protect
supported mandatory reporting (Paulsen, 1966, the child, although they were premised on the
p. 46). Legislative committees concerned with notion that a crime had been committed and
abuse legislation were nearly always chaired by action might be taken against the parents (Bain,
a physician, usually a pediatrician associated 1963). In some states the results of legislation
with academic medicine (Pfohl, 1977); so un- were dramatic. In Florida, for example, the
doubtedly medical positions were well repre- passage of new statutes, buttressed by a media
sented. campaign and a 24-hour WATS line, led to a
Some nonmedical interests challenged the phenomenal increase of reported cases from 17
treatment of abusers as "sick." Several law- to 19,120 in a single year (Nagi, 1977).
enforcement groups argued that the abuse of But not all physicians readily "saw" the
Ghildren was a crime and abusers should be "battered child syndrome" or were aware of
tl-eated as criminals. Yet, as Pfohl (1977) notes, what they should do about it. Based on a survey
"nearly all legal scholars endorsed treatment of over 200 physicians most likely to be in con-
rather than punishment to manage abusers" (p. tact with abused children-pediatricians, gener-
320). Disagreement existed among the legal al practitioners, and emergency room physi-
profession as well about whether the reports cians-Silver et al. (1967) concluded, "A strik-
should be mandatory and to whom the reports ingly high percentage of the physicians sug-
should be made (Pfohl, 1977). All agreed, how- gested a lack of awareness of the battered child
ever, that reporters of abuse must be granted syndrome or a lack of knowledge about com-
immunity. munity procedures" (p. 67).
A major issue in the passage of legislation
was whether the reporting of child abuse should Social scientists' views of
be mandatory and, if so, for whom. The focus child abuse
increasingly became that it should be manda- Social scientists, with different training, in-
tory for physicians to report abuse either to law- tellectual frameworks, and tasks than physi-
enforcement or child welfare agencies, depend- cians, often present a variant view of a medical
ing on the state. phenomenon or at least point to social variables
that are glossed over by a clinical viewpoint.
The argument for focusing on the reporting by physi- Richard J. Gelles and David H. Gil are social
cians is very strong. Doctors face special confiden- scientists who have cast a critical eye on the
tiality problems arising from the physician-patient medical-illness view of child abuse. Their basic
relationship and are concerned about the threat of
critique is that the medical model of abuse, fo-
legal action. Actually, the chief aim of legislation
is to uncover cases which only medical skill can
cusing nearly exclusively on the abuser and the
detect in the course of a medical examination and a abuser's characterological makeup, is limited
review of the medical history. (Paulsen, 1%6, p. 46) and neglects the social context of child abuse.
They see child abuse as a multidimensional,
Focusing on physicians as reporters is not with- rather than singular, phenomenon. The focus of
out precedent: physicians were already required each analysis is somewhat different. Gelles sug-
to report venereal disease and gunshot wounds gests that social and sociological factors need to
to various government agencies. The reporting be taken into account in ascertaining cause of
mandate to the physician drew child abuse fur- individual child abuse, and, while Gil agrees,
ther into medical jurisdiction. he maintains the causes of child abuse are
Diffusion of child abuse laws was rapid, and rooted in our culture and social structure.
laws were passed easily in most state legisla- Get'~s (1973) criticizes the psychopathologi-
tures. In 3 years (1963 to 1965),47 of 50 states cal model of child abuse as narrow and incon-
had passed child abuse reporting laws (De- sistent. He argues that by locating the causes of
Francis, 1966). Although the laws varied, most child abuse in a single variable, the mental ab-
made reporting mandatory and designated the normality of the parent, we ignore other equally
important causal variables. He proposes a more abuse both in our culture, especially in our ap-
sociological approach to child abuse that in- proval of the use of force in adult-child rela-
cludes overlooked variables such as the social tions, and in our social structure, most particu-
characteristics of abusive parents and their larly in the existence of poverty. Moreover, Gil
children as well as the situational or contextual argues that "child abuse" is far more pervasive
properties of the act(s) of child abuse (Gelles, and subtle than the medical-clinical conception,
1973). After reviewing previous studies, Gelles which focuses only on severe physical mal-
notes, for instance, that the lower and working treatment, would lead us to believe. He claims
classes tend to be overrepresented among child that far more children are victims of societal
abusers, that abusers are often female (unusual forms of "child abuse" such as malnutrition,
in violent crimes), and that social stresses such poverty, poor education and medical services,
as unemployment or unwanted pregnancies may and physical abuse in schools and other child
play important causal roles in child abuse. He caretaking institutions (Gil, 1971). Thus, he
further suggests we investigate the social pro- calls for the application of a four-part "public
cess by which individuals are designated and health model of preventive intervention to phys-
labeled as abusers, with specific attention to ical abuse with children" (p. 392): (1) the out-
how the label is differentially applied (Gelles, lawing of corporal punishment in institutions,
1975). (2) elimination of poverty, (3) education for
Whereas Gelles essentially maintains an in- family life and comprehensive family plan-
dividual focus on the abuser, Gil (1970, 1971, ning, including the availability of abortion, and
1975) sees child abuse as a symptom of a great- (4) the availability of high-quality, neighbor-
er malady. Basing his analysis on a nationwide hood social and medical services. This could be
epidemiological survey of child abuse, he sug- called a social-structural approach to child
gests that the'incidence of the classic' 'battered abuse prevention.
child syndrome" is actually relatively infre- We have presented these social scientific cri-
quent (6000 to 7000 cases a year) and argues tiques in some detail not only because they
for a more sociocultural approach to child point up the limitations of a purely medical-
abuse. In the nationwide survey he found a clinical approach to child abuse but also be-
greater incidence of child abuse in families cause they present alternative models as well.
subject to social stress: lower class families, Gelles (1973) summarizes succinctly the sig-
broken families, and families with four or more nificance of a sociological viewpoint on child
children (Gil, 1970). * To Gil, child abuse is not abuse:
an isolated phenomenon; he finds its roots in
When a patient is diagnosed as sick, the treatment
the sociocultural configuration of our society. which is administered to him is designed to cure his
He maintains that violence against children is illness. Consequently, when a child abuser is diag-
rooted deeply in our theories and practices of nosed as a psychopath, the treatment which is given
child rearing. He locates the "causes" of child him is designed to cure his disease and prevent future
episodes which result from that disease .... So far,
treatment of psychopathic disorders of abusive par-
* So many writers and analysts have claimed that
child abuse occurs nearly equally in all classes that ents tends to be of limited effecti veness ... one rea-
a "myth of c1asslessness" can be said to exist. Leroy son may be that the [treatment] strategies are based
H. Pelton (1978) notes that nearly all studies show a on an erroneous diagnosis of the problem . . . . [It]
significantly higher incidence of child abuse in the is now necessary to stop thinking of child abuse as
lower class. He argues that this relationship is real, having a single cause: the mental aberrations of the
rather than being an artifact of selective public scru- parents. (p. 620)*
tiny and reporting. Viewing child abuse as a classless
phenomenon supports the medical model of abuse; it But sociological approaches, although they
is seen as a "disease" that can strike anyone regard- may be more comprehensive and focus more on
less of social class. This glosses over the possibility
that child abuse is a result of structured class-based
social stresses. It focuses attention on causes in the * Reprinted, with permission, from the American
individual, not in the social structure, thus supporting Journal of Orthopsychiatry: copyright 1973 by the
intervention with the abuser rather than the society. American Orthopsychiatric Association, Inc.
"root" causes of abuse, are largely disregarded Oct. 10, 1977, p. 112). Although the agency's
by those who have to deal with more practical director calls child abuse an "epidemic," it is
tasks at hand: reporting abuse, protecting chil- more likely that the recent publicity has encour-
dren, and treating abusers. aged more people to speak out about it. Still,
undoubtedly the pool of potential cases of
Changes In the definitions of what "child abuse" is large; a recent study (Gelles et
constHutes child abuse al., 1977) estimated that between l. 4 and l. 9
Child abuse has been institutionalized as a million children wt:re vulnerable to physical in-
social problem, the abuser defined as a psycho- jury from violence in 1975. The expanded def-
pathological deviant, and the "battered child inition has created a larger net for defining mis-
syndrome" established as a legitimate medical treatment of children as deviance. A more com-
problem. Like hyperkinesis, child abuse has prehensive approach to intervention, such as
become a well-known form of deviance. Mil- suggested by Gil, seems also to be necessary if
lions of federal dollars have been authorized for we are not simply to treat the casualties of child
research and treatment. In 1973, Congress maltreatment.
passed The Child Abuse Prevention and Treat- Yet not all signs point to an expansion in the
ment Act. This legislation created The National definition of child abuse. The Supreme Court
Center of Child Abuse and Neglect to function has recently defined some violence toward chil-
as a clearinghouse for child abuse research and dren as acceptable and as not constituting child
information and earmarked $85 million for abuse. In a 1977 case of two students who had
treatment of abuse. Included in the act was been beaten with a wooden paddle by school
a definition of child abuse that was more officials (Ingraham v. Wright et at.), the Court
comprehensive than the previous medical defi- ruled that school spankings, no matter how
nition: harsh, did not violate the constitution's ban on
cruel and unusual punishment. According to
Child abuse and neglect means the physical or mental Gil (1975), however, this type of decision en-
injury, sexual abuse, negligent treatment, or mal- courages child abuse:
treatment of a child under the age of eighteen by a
person who is responsible for the child's welfare when schools and other child care settings employ
under circumstances which indicate that the child's practices that are not conducive to optimal child de-
health or welfare is harmed or threatened there- velopment, e.g., corporal punishment and other de-
by .... (Cited in Gelles, 1975, p. 365) meaning and threatening, negative disciplinary
measures, they convey a subtle message to parents-
This legislation officially expanded the defini- namely that such methods are appropriate, as they are
tion of child abuse beyond physically battered sanctioned by educational authorities and "experts."
children. But what constitutes' 'mental injury," . . . Whenever corporal punishment in child rearing
"negligent treatment," "harm," or "threat" is sanctioned, and even subtly encouraged by so-
is not clear. How do we know when we have ciety, incidents of serious child abuse are bound to
happen, either as a result of deliberate, systematic
a mental injury? What is a threat? What is harm
and conscious effort on the part of the perpetrators,
and according to whom? In our judgment it is
or under conditions of loss of self control. (pp. 348
problematic to expand the definition of child and 352)*
abuse without expanding significantly the levels
of prevention and intervention. As long as inter- In sum, child abuse has found a place among
vention (and prevention) remains only at the medical maladies in our society. Since the med-
clinical-medical and child welfare agency level, icalization of child abuse, physicians have
such a comprehensive definition serves only to acted as significant "protectors" of children.
expand the clinical domain. And this seems to Yet intervention has not moved far beyond the
have occurred. In 1972, only 60,000 alleged
incidents of child abuse were brought to official * Reprinted, with permission, from the American
attention in the United States; by 1976 the num- Journal of Orthopsychiatry: copyright 1975 by the
ber was more than half a million (Newsweek, American Orthopsychiatric Association, Inc.
medical-clinical approach, and child abuse is pie (adults), even if such direction is carried out
still defined as only an individual's problem. in "the best interests of the child. " They are on
the short end of the archetypal paternalistic re-
CHILDREN AS A POPULATION lationship.
AT RISK" FOR
II
Over about the past century there has been an
MEDICALIZATION* erosion of parents' control of child rearing and
As we discussed earlier in this chapter, the discipline (Lasch, 1977). In part this is a result
discovery of childhood led to a differentiation of the increase in geographical mobility, ex-
and separation of children from adults. Child- ponential growth of communications, and a
hood became a distinct period in the life cycle, general decline in strength of traditional status
and children became a separate class of people groups such as the family and Church. But,
with distinctive characteristics, rights, and ob- more specifically, institutional forces such as
ligations. Children were defined as "fragile public schools, the juvenile court, and the child
creatures . . . who needed to be both safe- guidance movement and cultural forces such as
guarded and reformed" (Aries, 1962, p. Dr. Spock's baby books, more permissive child
133). Children were unlike adults and needed rearing, and television have eroded parents'
special attention. Among the most signifi- authority and control. Their sovereignty over
cant characteristics of this depiction of chil- child rearing has been considerably modified.
dren was that they were innocent and depen- In place of this parental authority a variety of
dent. extrafamily "resources" have emerged: school-
The innocence of children manifested itself teachers, day-care specialists, child experts,
in defining children as in need of protection guidance counselors, welfare workers, and pe-
from the harsh and sinful world. They required diatricians, among others. Medicine, in the
guidance and discipline to grow up into respon- form of the family physician, pediatrician, or
sible adults. Childhood became a special period medical clinic, has become a significant family
of dependence, "a sort of quarantine, before resource and a source of "authority. " As David
[children were] allowed to join the world of Mechanic (1973) notes, "As medicine has de-
adults" (Aries, 1962, p. 412). In fact, children veloped, it has increasingly taken over the func-
became a separate, dependent class of people. tions of care provided by the family and close
Parents had full sovereignty over this depen- associates ... " (p. 16).
dency; and if they faltered, the state via parens The combination of defining children as in-
patriae assumed parental control and responsi- nocent, dependent, and nonresponsible people
bility. Closely aligned with and as a conse- and the diminution of authority in the family
quence of viewing children as innocent and have made deviant children a population at risk
dependent, children were defined as people who for medicalization. Let us explore this assertion
were not fully responsible for their behavior. a little further, both theoretically and in partic-
This led to their exemption from certain types ular examples.
of criminal prosecution. In short, by being As Talcott Parsons (1951) pointed out nearly
relegated to a special status in society, children three decades ago, when deviance is seen as
became a special class of people: innocent, de- willful, it tends to be defined as a crime; when
pendent, and not fully responsible for their ac- it is seen as unwillful, it tends to be defined as
tions. sickness. In our society, because of the way
Children are also a relatively powerless children are defined and the status ascribed to
group in society. They are powerless because them, they are much less likely to have their
they are physically weaker, socially unorga- behavior defined as willful. It is much more
nized, politically disenfranchised, and econom- likely that they will be seen as not responsible
ically dependent. Children are most susceptible for their behavior or, literally, as incapacitated
to the rules and sanctions of more powerful peo- or not fully competent human beings. To come
full circle, when individuals are not considered
* We present this section in lieu of a summary in this to be responsible for their behavior, they are
chapter.
considered "sick."* This is not to imply the schnecker. In a memo submitted by way of a
absurdity that children are sick all the time but presidential advisor to the Department of
to point out that when children's behavior is de- Health, Education and Welfare in early 1970,
viant, it is more likely to be designated as an Dr. Hutschnecker proposed the massive admin-
illness or dysfunction. The status of "child" istration of psychological tests to schoolchil-
affects how the behavior will be defined. Con- dren between the ages of 6 and 8 to detect po-
sider the example of hyperactivity. Imagine that tential mental disturbances or tendencies toward
instead of a child in a classroom being identi- violent or antisocial behavior. According to
fied as hyperactive, it is a worker in a factory what the tests showed, children identified as
or a salesman in an automobile showroom. having "delinquent tendencies" would receive
Would they be referred to a physician for their "corrective treatments" - in day-care centers
deviant behaviors? Would a physician diagnose for the young, counseling for older children,
them as hyperactive and prescribe stimulant and special camps for incorrigible deviants.
medications for them on the basis of reports of After someone at the Department of Health,
a boss, a spouse, or a parent? How much is the Education and Welfare leaked the plan to the
identification and definition of hyperactivity a press, both medical and governmental officials
function of the dependent and relatively power- disavowed support of it. Dr. Hutschnecker was
less status of the child? surprised at the negative response: "My prem-
The dependent status of children increases ise is that we vaccinate children to prevent
the propensity of arousing a protective response physical disease, why not provide psychologi-
in society: for example, the houses of refuge, cal tests and treatment to prevent the problems
foundling hospitals, orphanages, juvenile court, of crime?" (quoted in Newsweek, April 20,
child labor laws, and child abuse laws. The 1970, p. 76).
medical ideal, perhaps most clearly demon- In sum, the definition and status of children
strllted in public health but also visible in clini- has facilitated and encouraged the expansion of
cal practice, is an ideal of prevention. In this medical jurisdiction to encompass more types
sense, medicine, too, is a protective institution. of children's behavior. * Although in part a
The child-protective response of society aligns protective response, medicalization also in-
with the protective-preventive response of med- cludes the identification and treatment of be-
icine. It encourages medical "child protection" haviors that would not be defined as medical
in the name of health. Moreover, in a demo- maladies in adults.
cratic society early "diagnosis" and interven-
tion "in the best interests of the child" is more SUGGESTED READINGS
easily justified by medical-therapeutic inter- Aries, P. Centuries of childhood. New York: Vin-
vention than with legal or civil intervention. tage Books, Inc., 1962.
An accessible and by now classic analysis of the
Thus we have a medical-protective response development of the modern image of children. Us-
with child abuse but not spouse abuse. The ing a variety of cultural and historical data, Aries
adult battering of other adult family mem- weaves a fascinating theory of the discovery of
bers has not been defined as a medical prob- childhood.
lem (see Martin, 1976; Steinmetz & Straus, Conrad, P. Identifying hyperactive children: the
medicalization of deviant behavior. Lexington,
1974). Mass.: D. C. Heath & Co., 1976.
An extreme example of potential vulner- Uses the labeling-interactionist frame and partici-
ability of children to medicalization was a plan pant observation at a medical diagnostic clinic to
designed by a physician named Arnold Hut- investigate parents' and physicians' constructions
of the medical entity of hyperactivity. Of special
*This may in part explain why Matza (1964) found * Normal child development has also become codi-
all theories of juvenile delinquency to be determinis- fied in medical terms; deviances from these de-
tic. If children are not considered responsible for velopmental norms are defined as disorders such as
their behavior, it must be determined by external or learning or developmental disabilities.
internal "forces."
CHILDREN AND MEDICALIZATlON: DELINQUENCY, HYPERACTIVITY, AND CHILD ABUSE 171
interest is Chapter 6, "Uncertainty and Medical found challenge to the medicalization of child
Diagnosis: The Social Construction of Hyper- abuse. In addition to reporting a nationwide epide-
activity ... miological study of child abuse, Gil argues per-
Empey, L. T. American delinquency: its meaning suasively for a sociocultural rather than medical
and construction. Homewood, Ill.: Dorsey Press, approach to the problem.
1978. Platt, A. The child savers. Chicago: University of
Approaches juvenile delinquency from a perspec- Chicago Press, 1969.
tive that complements ours. This is a comprehen- An excellent study of how middle-class champions
sive and readable text and a fine resource for stu- defined lower class deviance. Combining a label-
dents of deviance. ing and class analysis, Platt traces the "invention
Gil, D. G. Violence against children. Cambridge, of delinquency" to the work of 19th-century child-
Mass.: Harvard University Press, 1970. savers.
A provocative book and, if taken seriously, a pro-
7 HOMOSEXUALITY
FROM SIN to SICKNESS to LIFE-STYLE
T he subject of this chapter is the medi-

calization and demedicalization of homo-
sexual or same-sex sexual conduct (here-
after, simply "same-sex conduct"). We
is true not only for same-sex conduct but for
virtually all sexual behavior; indeed, Western
culture has been called "sex negative" (Chur-
chill, 1967).
place this discussion toward the end of our Social historian Vern Bullough (1976, p. ix),
case examples because it allows us to reiterate in his exhaustive Sexual Variance in Society
several of the key themes of our medicalization and History, concludes that although the par-
argument as well as providing a clear illustra- ticular forms of these judgments have changed,
tion of demedicalization of deviance-a topic to the essential morality has not. From its origins
which we have thus far only alluded. as primarily a religious transgression, a sin,
The origin and rise of the medical definitions same-sex conduct had become by the end of
of same-sex conduct and those who engage in the medieval period, a matter for state control,
it provide us with a clear-cut example of the a crime, and ultimately was redefined in mod-
historical complementarity and continuity of em society as a sickness.
religious, legal, and medical definitions and ex- Some historical evidence suggests that even
planations of deviance. It also demonstrates before it became a sin, same-sex conduct was
how these three institutions of social control disapproved because it might interfere with ful-
typically reinforce each other in the general filling one's reproductive responsibility to the
moral definitions and prescriptions they cham- community. This included ensuring oneself
pion. In addition, the medicalization of same- of care during old age, continuing the
sex conduct portrays physicians as moral entre- family line, and the proper performance of
preneurs for sickness definitions of "undesir- ritual responsibilities (Bullough, 1976). In
able" conduct and persons. Finally, the case of the Mesopotamian culture of the Tigris-Eu-
homosexuality allows us to address the pro- phrates valley, dated about 3000 BC, anal in-
cess of demedicalization and to raise impor- tercourse was apparently common (involving
tant questions about the possible consequences both male-male and male-female partners).
of removing medical (and in a sense, protec- This tolerance, however, depended on such ac-
tive) definitions from certain kinds of behavior tivities neither precluding progeny nor being
within an essentially disapproving moral uni- exploitive.
verse. The connection between heterosexual repro-
duction and species-community survival be-
MORAL FOUNDATIONS: came a kind of practical standard against which
THE SIN AGAINST NATURE other forms of sexual as well as nonsexual con-
It is, of course, too simple to claim that duct might be judged. This biological premise
homosexual conduct has been always and for attitudes toward homosexuality (and other
everywhere despised and prohibited. At the forms of nonprocreative sex) is one important
same time, it is essentially accurate to foundation for the common reference to such
argue that at least in the West, the overwhelm- behavior as "unnatural," with heterosexual,
ing pattern has been one of disapproval if not especially reproductive, sex being "natural."
condemnation (Bullough, 1976, 1977). This It is clear that such a distinction represents the
172
HOMOSEXUALITY: FROM SIN TO SICKNESS TO LIFE-STYLE 173
same kind of social construction process we might do together irrelevant to the reproductive
have discussed throughout this book. Never- potential of the community. This indifference
theless, this natural-unnatural designation has toward female same-sex conduct is reflected
been taken generally as both a biological and not only in historical records of the ancients but
moral absolute throughout human history and for all societies. Although we speak of homo-
has profoundly influenced social definitions sexual conduct in this chapter, both the histor-
of and actions toward same-sex behavior. ical and contemporary writing on homosexual-
ity concentrates overwhelmingly on males.
Ancient origins: The Persians and Regardless of the reasons, same-sex conduct
Hebrews among women simply has not engendered the
By the time the Persians conquered the same social reaction as similar conduct among
Egyptians and established their culture about men.* As long as women's behavior did
the sixth century BC, negative attitudes toward not interfere with carrying, bearing, and rear-
nonprocreative sex outside marriage were ing children, it received comparatively little
common. The Persians, influenced by Zoroas- attention.
trian religious doctrines, believed that although Condemnation of such behavior among
sexual activity should not be forbidden (elim- males, however, has been rarely ambiguous.
inating vital progeny), it harbored great poten- Vern Bullough (1976, p. 82) locates the first
tial for social disruption if not carefully con- specific biblical prohibition in Leviticus 18:22,
trolled and channeled toward "higher" virtues. dating probably from before the seventh cen-
Doctrines of divine preordination and prescrip- tury BC: "Thou shalt not lie with mankind, as
tion became superimposed on evolutionary with womankind: it is abomination"; and later:
arguments supporting heterosexual conduct "If a man also lie with mankind, as he lieth
as the norm. The Persians believed that male with a woman, both of them have committed
sperm or "seed" had particularly unique and an abomination: they shall surely be put to
wondrous generative powers (an idea that con- death; and their blood shall be upon them"
tinued to influence thinking on sex for cen- (Leviticus 21: 13). This bibilical prophecy was
turies). To "waste" or "spill" it voluntarily to be interpreted subsequently as a religious
outside the nurturing body of a woman was sanction for capital punishment and torture.
repudiation of a divine gift. To do so in homo- By far the most influential of all biblical
sexual conduct was to mock both "Nature" stories used to condemn homosexual conduct
and its creator. It was, in short, an abomination is the Old Testament story of Sodom, from
assuring damnation. which comes the term "sodomy." According
The Hebrews were by far the most influential to Genesis 19: 1-11, God vows to destroy
of the ancient Middle Eastern peoples in shap- Sodom and several other cities because of the
ing Western attitudes toward sex. They were sins of their inhabitants. Abraham pleads with
a male-centered society (which was typical of God to spare the innocent who would perish
that and subsequent historical periods). Women unjustly. God sends two angels into Sodom
enjoyed perhaps certain marital (including sex- to determine the true state of affairs. The angels
ual) and family prerogatives, but outside their (presumably male figures) are met by Abra-
roles as wives and mothers they received little ham's nephew, Lot, who invites them to his
attention. Marriage was expected of everyone house. During their stay, the men of the city
who had reached puberty, and remarriage on assemble outside and call on Lot to present his
the death of a spouse was assumed. Children,
and especially males, were important assurance *It is important to remember that those who made
of social and religious continuity. male same-sex conduct so important a transgres-
sion-a sin, a crime, and later a sickness-were
Sexual liaisons between women were re-
themselves males. This dearth of information on les-
garded as considerably less significant than bians has only recently begun to give way to popu-
those involving men. Doctrines of male su- larly available works and public discussion of the
premacy in procreation made what women topic.
guests to them so that they might "know Greek culture, the content of this symbol
them. " Lot refuses but offers to present his changed to reflect that which they found most
daughters instead. The crowd, however, per- heinous in the Hellenic world. The homosexual
sists and is struck blind by the visiting angels. interpretation has become so entrenched that
The next morning Lot and his family are led it is accepted uncritically not only by Christians
from Sodom, after which God destroys it by and Jews but also by generations of historians,
fire. philosophers, and scholars. It has become, in
The common interpretation is that the fore- effect, part of the revealed wisdom of the West,
most sin of the Sodomites was homosexual providing an almost unimpeachable condemna-
conduct and that such behavior brings damnation of same-sex conduct.
tion and destruction both to those who pursue
it and those who tolerate it. The irony of this Contributions of the Greeks
interpretation is that the Sodom story contains The actual prevalence of homosexual con-
no specific references to homosexual acts. In- duct in ancient Greece is impossible to deter-
deed, the sins for which the city was destroyed mine, the distinction between Greek values
are specified as wickedness, inhospitality, and practice forever obscure. There is, how-
pride, slothfulness, and "abomination" -in- ever, evidence sufficient to conclude that cer-
terpreted most accurately as idolatry rather than tain forms of such behavior were institutional-
same-sex conduct (Bailey, 1955, pp. 9-10). The ized firmly in Greek culture and practice, and
linguistic justification for the homosexual inter- to speculate with some confidence that certain
pretation turns on the two meanings of the He- kinds of same-sex liaisons between males were
brew word ylidha (to know). Beyond its con- common, particularly between the eighth and
ventional usage, meaning to become acquainted second centuries BC (Dover, 1978). This accept-
with, the word also can be used to mean "to ance derived from two cultural ideals: male
have sexual knowledge of' or sexual relations superiority and an ideal of love that was be-
with. Presuming that both the angels and those lieved to uplift the human spirit and strengthen
outside Lot's house were males, selecting the community solidarity. To the extent that prac-
latter usage implies that the Sodomites were tice approximated these ideals, the Greeks
interested in homosexual acts. Such an interpre- believed such sexual conduct was neither un-
tation, however, would have to be chosen natural nor bad.
against the conventional and more likely one. Greek culture and social life were penetrated
Given the historic popUlarity of the homosexual by testimonies to the superiority of the male
interpretation, it is important to speculate on and his diverse potential for moral, physical,
its source. and intellectual perfection. The phallus sym-
Biblical scholar Derrick Bailey (1955, pp. 9- bolized strength, power, and wisdom and was
28) and historian Vern Bullough (1976, pp. 82- believed to possess special religious properties
85) review the historical record carefully and that could nullify evil (Licht, 193211963, p.
conclude that such interpretation was added by 369; Vanggaard, 1972, pp. 59-62). The Greek
the ancient Hebrews some considerable time ideal of physical and spiritual beauty was male
after the original story was written, probably rather than female, and the nude youth in ath-
some time around the first century AD. The letic contest occupied a central and frequent
story, as elaborated and used by the Jews of place in art (Dover, 1978) and writing. Greek
this period, may be in large part a reaction mythology and lyric poetry provide important
against the rise of paganism and Greek culture. insights into cultural values and contain many
Bailey (1955) argues that Sodom became a references not only to the male's exalted posi-
"symbol for every wickedness which offended tion but to heroic figures who championed and
the devout Jewish spirit-pride, inhospitality, excelled in homosexual love. Women were
adultery, forgetfulness of God and ingratitude defined as bound naturally to their childbearing
for his blessings" (p. 27). As the ancient He- functions (except for prostitutes, whose sexual-
brews felt more threatened by the expansion of ity was for male pleasure) and were considered
neither worthy nor capable of serious male ment of manly social and military skills and
companionship (Symonds, 1931, pp. 85-87). responsibilities, including marriage, hetero-
Although sensuous and particularly sexual sexual life-style, and procreation on completing
pleasures were important and desirable, the cul- this education period (at about age 19), were
tural foundations of Greek homosexuality ap- its primary aims. Later, when these men be-
pear in fact to rest primarily on a spiritual rather came established and respected, they were
than a physical level. Sexual relationships be- expected to select a free youth of the commu-
tween males were idealized to the extent that nity, pursue him, and repeat the process (Lacey,
they were an expression of this more noble 1968).*
bond. The most important example of the insti- Outside these socially and personally en-
tutionalization of these ideas is the Greek hancing contexts, boy love and homosexual
system of education. conduct were officially disapproved (although
At the core of this system was the ideal of probably not uncommon). Sexual assault of
paiderasty. the Greek term meaning the love of young boys still in primary school was against
boys. This "love" was the complex, spiritual- the law. Male (as well as female) prostitution
emotional bond just described rather than was disapproved. Sexual relationships between
simply physical stimulation and orgasm. It adult males were not encouraged, and it was
was precisely this kind of relationship between thought degrading for a male much beyond his
an adult male and a pubescent boy, in which the teens to play the passive role in anal inter-
former took virtually total personal and social course. Although the Greeks institutionalized
responsibility for the youth and his develop- a positive attitude toward sensual pleasure in
ment, that was the homosexuality approved human relationships, they also imposed con-
most by the Greeks. This student-teacher, be- trols against homosexual conduct they be-
loved-lover bond drew heavily on the processes lieved threatening to the family and larger so-
of emulation and admiration on the one hand, cial fabric.
and example and mentorship on the other. The One particular form of such deviant homo-
responsibility of this tutelage was believed most sexual conduct is identified as "effeminate."
directly beneficial for the youth, but, in addi- The approved sexuality was called "virile."
tion, it was to motivate the adult to high levels Plato described an idealized form of love con-
of moral, intellectual, and physical perfor- sistent with typically "masculine" rather than
mance. The social and personal benefits of this "feminine" pursuits. "Effeminate" homo-
reciprocal pederastic relationship were praised, sexuality apparently refers to males, in their
perhaps most eloquently by Plato in his Sym- sexual conduct, acting or assuming the cultural-
posium (178C-179B). ly prescribed role of the female. There is some
The Greeks were not, however, insensitive evidence to suggest that such men-and wom-
to the existence of less spiritual forms of same- en who "acted" sexually like men-were
sex conduct. It must be remembered that the thought to be "unnatural" and, in fact, suffer-
pederastic ideal was just that, an ideal. As such, ing from a disease or sickness. Aristotle, for
the Greeks took pains to distinguish it from less example, proposed a prescientific explanation
lofty sexual activity. This latter, "deviant" of this sexual deviance based on the premise
kind of homosexual relationship was considered that accumulated semen in the genital or anal
more purely sexual and less spiritual. The one areas predisposes men to pursue either the
was for "pleasure," the other "beauty"; one an active or passive role, respectively. The "nat-
"involuntary sickness," the other healthy; ural" or normal male was believed to experi-
one "virile, " the other "effeminate'" one
Greek, the other barbarous (Symonds, 1931, *Sappho, the legendary sixth century BC queen of
the island of Lesbos, was said to be a lover of young
p. 16). women. There are no records of her being reviled
Homosexual sex was socially approved only for this preference, which was, as in Greece, a
when embedded in a complex set of personally spiritual as well as physical attraction (8ullough,
and socially redeeming norms. The develop- 1976, pp. 111-112).
ence variation in the relative concentration they regarded such conduct as a shameful as-
of semen in these areas over his lifetime. Ef- pect of Greek life. Pederasty was not an institu-
feminate males, however, tionalized part of either the educational or
are unnaturally constituted; for though male, they military systems, and although Roman fighting
are in a condition in which this part of them is nec- units were pervaded by a strong sense of com-
essarily incapacitated. Now incapacity may involve panionship and loyalty, this did not include
either complete destruction or else perversion; the intimate fraternization. Homosexual conduct
former, however, is impossible, for it would involve between both men and women probably oc-
a man becoming a woman. They must therefore be- curred, but the Romans either gave official and
come perverted and aim at something other than the legal disapproval or chose to ignore it. Their
discharge of semen. The result is that they suffer sexual ideal was staunchly heterosexual.
from unsatisfied desires, like women .... (Aristotle,
Problemata: 879B-880A)* FROM SIN TO CRIME: EARLY
CHRISTIANITY AND THE
The following medical explanation of effemi-
MIDDLE AGES
nacy in males offered by the Greek physician
Soranus during the second century AD expands By the time Roman influence began to wane,
Aristotle's proposition: a new asceticism was being reflected in a variety
of religious and civil prohibitions. In the en-
People find it hard to believe that effeminate men
suing centuries of the Middle Ages the "nat-
or pathics ... really exist. The fact is that, although
uralness" of heterosexual reproductive sex
the practices of such persons are unnatural to human
beings, lust overcomes modesty and puts to shameful within marriage was reaffirmed with a ven-
use parts intended for other functions. That is, in the geance. At the hands of clerics such as the fifth-
case of certain individuals, there is no limit to their century figure St. Augustine, Western Chris-
desire and no hope of satisfying it; and they cannot tianity defined sex of any sort as base at best.
be content with their own lot, the lot which divine The "goodness" of marital sex was contingent
providence had marked out for them .... They even on conception - the promise of progeny re-
adopt the dress, walk and other characteristics of deeming an essentially lustful act. "Unnatural"
women. Now this condition is different from a bodily sexual urges were clearly beyond the bounds
disease; it is rather an affliction of a diseased mind. of membership in the official Christian com-
(Quoted in Bullough, 1976, p. 143, emphasis added)
munity-even though actual practice and this
Such persons were "perverted" because of a ideal, from Rome to 16th-century England,
physiological and/or mental disablement. were rarely aligned.
These may well be the earliest medical explana- Christian fathers and sympathetic rulers
tions for deviant homosexual conduct. The often cited homosexual conduct throughout
"puzzle" that these accounts were intended to this period as posing a serious threat to com-
solve was not so much the fact of same-sex con- munity welfare. Harsh prohibitions and formal
duct but rather the' 'perversion" represented by civil penalties for the guilty resulted. Celibacy
men who wanted to be or act like women. This and chastity, particularly in Western Europe,
simply did not "make sense"; thus the source became the ideal and most spiritually pure state.
of sense, the mind, must be troubled. This remained largely unchallenged until Mar-
This distinction between "natural" and "un- tin Luther's 16th-century reforms held out
natural" homosexual conduct became irrele- heterosexual marriage as an even greater good.
vant in Rome. Indeed, the rarefied spiritual It was this general cultural prescription of
and philosophical distinctions that supported asceticism, control, and the denial of pleasure
Greek pederasty were lost on the Romans, for that became the centerpiece of developing
Christianity and particularly its Western Cath-
olic and Protestant forms.
*From Aristotle. The works of Aristotle (Vol. VII).
W. D. Ross (Ed.), E. S. Forster (trans.). Oxford, Specific New Testament references to
Clarendon Press, 1927. By permission of Oxford homosexual acts, although few in number,
University Press. leave no doubt as to their moral status in
Christendom. In I Corinthians (6:9-10), the the precise nature and moral seriousness of
"effeminate," along with "fornicators," "unnatural" sex during the medieval period
"idolators," "adulterers," and "abusers of were enshrined in what came to be known as
themselves with mankind," were precluded canon, or Church, law.
from heaven. Two other references to homo- This separate system of rules and punish-
sexuality, one from I Timothy (1 :9-1 0) and ments emerges from the penitential writings
the other from St. Paul's letter to the Rom- of English and Welsh clerics about the sixth
ans (1:26-27), offer equally clear judgments: century. These penitentials were practical
"the law is not made for the righteous man, manuals by which clergy-confessors could
but for the lawless and disobedient, for the determine proper penance for people's sins.
ungodly and for sinners, for the unholy and the Explicit attention was given to sexual trans-
profane . . . for them that defile themselves gressions. Such writings offer insight into how
with mankind . .. (emphasis added)." And the early Western Church judged homosexual
acts. Interestingly, although there is great vari-
For this cause God gave them up into vile affec- ety in seriousness and penance, there is little
tions: for even their women did change the natural distinction made between so-called natural and
use into that which is against nature:
unnatural sexual sins. Fornication and adultery
And likewise also the men, leaving the natural use
of women, burned in their lust one toward another;
(and other heterosexual sins) and sodomy, in-
men with men working that which is unseemly, and cluding fellatio, kissing, and interfemoral inter-
receiving in themselves that recompense of their course, were often regarded as of roughly equal
error which was meet. seriousness (Bailey, 1955, pp. 100-110). In
short, canon law incorporated a good deal of
Other New Testament passages are sometimes ambiguity not only about the moral serious-
interpreted as condemnations of homosexual ness of such conduct but indeed about what
conduct, but their terms are ambiguous (e.g., such conduct actually entailed.
"shameful," "abomination," "unnatural," This confusion was later translated into civil
and additional references to the "sin of Sod- statutes when the vague "sin against nature"
om"). There is, however, no unimpeachable became the equally vague but more conse-
evidence to support such claims (Bailey, 1955, quential "crime against nature." This devel-
pp. 29-63); most likely, they reflect the same oping criminalization of same-sex conduct
hostility to and fear of Hellenic and pagan prac- throughout the medieval period culminated in
tices revealed in the Old Testament. the 1533 English statute, enacted under the
Part of this confusion derives from the diffi- reign of Henry VIII, making the "crime against
culty the Christian fathers faced in deciding nature" a capital offense. It was through this
just what was and was not in accord with nature statute, along with its subsequent versions,
and God's plan. Given St. Augustine's narrow that the moral condemnation of such behavior
definition of natural sex, the "sin against common in the Middle Ages came to exert such
nature" variously included anal intercourse, an important influence on Western social and
masturbation, bestiality (sex with animals), legal definitions (Gigeroff, 1968, pp. 1-7).
mouth-genital contact involving either sex, and Church punishments, however, were directed
even heterosexual intercourse in positions toward spiritual renewal rather than corporal
other than face-to-face with the man on top. sanctions. Variously long periods of atone-
St. Thomas Aquinas attempted to clarify this ment including prayer, self-imposed isolation,
somewhat in the 13th century. He insisted that special diet, and introspection were common.
a distinction was necessary between same-sex The ultimate punishment was excommunica-
and cross-sex sins. In effect, Aquinas argued tion, banishing the nonrepentant sinner to eter-
that homosexual "unnatural" sex was more nal damnation. There is apparently no evidence
heinous than heterosexual "unnatural" sex, that the medieval Church ever executed any-
such as fornication and adultery (Bullough, one for anything-including homosexual acts.
1976, pp. 380-381). These confusions about What did happen, and particularly during the
11th and 12th centuries, is that the accused a period of 70 years for which records are extant,
would be tried by the ecclesiastical court and, there were often several hundred accusations in one
if found guilty, turned over to the state for year .... The accused were brought before the offi-
proper secular punishment. In effect, this in- cials, testimony was given, and a verdict was
volved the state as a kind of henchman for the rendered. (p. 417)
Church. We do not suggest that the state neces- Florentine convents and their environs were
sarily occupied a subservient position here, but the objects of particular attention by these of-
rather that, particularly after the 11 th century, ficials, suggesting that the medieval concem
these two institutions were rarely in conflict on with "unnatural" sex was not limited to males,
questions of sexual morality. Increasingly, so- although discussion and edict focused pri-
called unnatural sexual sins became transgres- marily on them. Among the most celebrated
sions against the state. This criminalization of of the accused in Florence was Leonardo da
homosexual conduct in the West may be seen Vinci in 1746 (Vallentin, 1938, pp. 35-39).
as the continuation of a precedent established By the end of the 16th century in the West
centuries earlier among the Eastern faithful in the Church seemed to be losing some of its
Rome and Constantinople. moral dominance. This did not, however,
One of the most dramatic examples of such herald a change in the content of official moral-
political-religious cooperation is the Inquisition ity but only a shift to and consolidation of civil
of the 13th and early 14th centuries. Threatened or state control. The power of the Church
by what appeared to be a veritable wave of bureaucracy was thereby lessened, but its moral
heresy and revolt inspired by the forces of dark- precepts about sex-control, the "natural-
ness, Pope Gregory in 1233 appointed an order unnatural" dichotomy, and the key importance
of clerics as official detectives in behalf of the of reproductive sexuality - were preserved
Roman Catholic Church to rout out heretics intact in the new secular regulations of the
and bring these sinners either to God or de- 17th and 18th centuries. For example, Elizabeth
struction. Charges of unnatural, and specifi- I attempted to supersede the Church of England
cally homosexual, acts were sometimes in- and appease Puritan critics in 1558 by estab-
cluded in accusations against such persons. lishing the Court of the High Commission to
Some historians suggest (Bullough, 1976; Lea, punish sexual offenses that threatened orderly
1911; Lerner, 1972) that a good many of the married life. Unsatisfied with this capitula-
accusations brought during this period were tion, Puritan reformers persevered until in
motivated by both politics and personality 1650 under the leadership of Oliver Cromwell,
rather than religion alone. Once the spiritual Parliament passed the Act of May 1, which,
status of an individual or group was brought among other things, reiterated the 1553 decree
into question, charges of sexual deviance often that sodomy was an offense punishable by
were added on the slimmest of evidence. Per- death (Bullough, 1976, p. 464). That these legal
haps the most famous case is that of the Knights judgments were not merely idle threats is seen
Templars and their Grand Master, Jacques de from official records of the 17th century that
Molay. indicate several persons were in fact executed
A final example of this medieval criminal- for (probably open or public) homosexual con-
ization is the Italian sodomy courts, estab- duct (Bingham, 1971).
lished in Florence and Venice during the first At about this same time, there was an in-
half of the 15th century. A public office, the crease in popular, and particularly upper-class,
Ufficiali de notte. was created in 1432 with the interest in sex. The late 17th and 18th centuries
avowed purpose of purging the city of sodomy. were a time of rapid social, political, and intel-
Vern Bullough (1976) describes the peculiar lectual ferment. What had once appeared to be
justice of this institution: universal standards of right and wrong conduct
officials set up boxes (Iamburi) in various prominent were gradually recognized by some as relative
locations around the city and encouraged citizens to social and cultural locale. It was indeed
to drop anonymous accusations in these drums. Over the Age of Enlightenment-a time of ques-
tioning, discussing, and pursuing answers ac- most influential in America-continued until
cording to the tenets of reason and examination the latter half of the 19th century to define
of the empirical world rather than on the basis homosexual acts as inherently detestable crimes
of tradition alone, and sex was a topic included punishable, at least in principle, by death. Sex-
for study. Guided by reason into a new age of ual "excess" -indeed, excess of any sort-was
tolerance and investigation, it was a time (as soundly disapproved as beyond reason and
are all) wedded inextricably to its past. Para- order. The particular forms of sexual behavior
doxically it was the leading force of this ra- that came to be defined as excessive were in-
tionalism and tolerance-science-that was evitably those which had been morally dis-
to provide the new form for the old sexual approved. Deviant sex, including of course
morality. homosexual conduct, was therefore clearly
excessive.
NEW MORAL CONSENSUS: The new theories of health and illness that
SIN BECOMES SICKNESS emerged in the 18th century made this dis-
Medicine and moral continuity trust of moral excess their scientific center-
In the 18th century piece. Early in that century and throughout
The Enlightenment affected sexual attitudes the next, a handful of physicians and their
and behavior in important ways. Increas- popularizers promoted conceptions of health
ingly the Church had to contend with secular and illness that viewed the body as a closed
authority; a growing popular interest in sex system of vital nervous energy. Health was
and sexuality is evidenced in literary and defined vaguely in terms of nervous system
pornographic materials and more specifically stability, balance, and equilibrium, which, in
in the numerous and highly popular sex man- tum, were thought to be products of the indi-
uals available, most notably those bearing the vidual's integration with (read "conformity
name of the great philosopher, Aristotle*; there to") the larger moral and social environment.
was probably also an increase in the incidence To the extent that one's activities in the latter
of variant sexual practice, although it remained realm were "healthy," that is, morally proper,
largely covert, and systematic documentation internal physiological and nervous system func-
is impossible. London and Paris sported tion would follow accordingly. Conversely,
brothels supplying homosexual favors for pay activities that made repeated, unusual, and
(Bullough, 1976, p. 480). This tolerance to- "unhealthy" (immoral) demands on one's body
ward sexual variety even received the official would lead inevitably to its depletion, debility,
sanction of the French government under wasting, and disease (Rosenberg, 1977). Thus
Napoleon in the famed but short-lived 1810 immorality, as evidenced by social behavior,
criminal statutes bearing his name. The Napo- was believed causal of sickness and disease.
leonic Code decriminalized homosexual con- Sexual behavior became immediately a focus
duct between consenting adults in private. for such explanation. As had been clear for
We must not, however, overstate the scope centuries, sexual orgasm expends energy and is
of Enlightenment tolerance or the extent to followed by a period that might be described
which traditional moral principles-particularly as mild fatigue. These observations, coupled
regarding sex-were swept aside. This new with the new medical theories, yielded the
beacon of tolerance on the continent was only conclusion that too much sexual activity, and
a faint glimmer in England. English thought particularly deviant sexual activity, could be
and laws on deviant sexual conduct-those detrimental to one's health (see Graham, 1834/
1837, p. 49).
*Otho Beall (1963) has analyzed these enormously Proponents of these theories were not, of
popular works and concludes that virtually none of course, prepared to prescribe abstinence. Argu-
them were faithful either in letter or spirit to Aris-
totle's work. Although his name lent them credibil- ments that sex was a natural part of life had
ity and moral legitimacy, Beall concludes they were become too firmly entrenched. In addition,
clearly products of 17th-century thought. some medical theories warned that retention
of "seed" in the male could itself be hannful save the youth of America from the physical
to health. The solution was to recommend a and moral consequences of improper sexual
course of careful moderation. This reflected activities; a prime focus of these guardians of
clearly the traditional moral heritage of Chris- social and political stability was the male youth,
tianity. Procreative sex, judiciously pursued, the "hope for tomorrow." Although homosex-
was somehow believed to be less debilitating ual conduct was mentioned only rarely, its
to one's nerves than sex for its own sake. It existence and alleged link to masturbation and
followed that those fonns of sexual activity sexual excess were used to nuture a widespread
which had been and continued to be sins-in- fear that the one indulgence would lead inevita-
cluding homosexual conduct-were even more bly to the other.
threatening. The warriors in this battle consisted mainly
Sexual activity, and most particularly of middle-aged, middle-class medical men and
deviant sex, became medicalized precisely at popular medical writers of the mid-19th
the time in history when religious prohibitions century (Smith-Rosenberg, 1978). Their au-
were becoming less dominant. Medicine, al- dience was the postpubescent-to-young adult
though only beginning to emerge as an effica- male of the middle class, as the titles of some of
cious technology, became a new system of these works attest: The Young Man's Guide
social control for sexual behavior (Bullough, (Alcott, 1833), Lectures to Young Men on
1976; Bullough & Bullough, 1977; Comfort, Chastity (Graham, 1834/1837), and Hints to
1967; Haller & Haller, 1974; Smith-Rosen- Young Men on the True Relations of the Sexes
berg, 1978). Although "badness" thereby be- (Ware, 1850/1879). An important theme in this
came "sickness," the moral principles on writing was that masturbation could easily lead
which this translation were based remained es- to homosexual experimentation and subsequent
sentially unchanged. involvement. Carroll Smith-Rosenberg (1978)
suggests that given the middle-class restrictions
Masturbation and threatened on public speech about sex, masturbation
manhood: a crusade in defense may have been a "code" for unexpressed con-
of moral heaHh cerns about homosexuality. * This fear is seen
The rallying point for this medicalization in veiled references to "threatened masculin-
of variant sexual activity in the 18th and par- ity" (and occasionally, femininity), expressed
ticularly 19th centuries was masturbation, var- typically in conjunction with discussions of
iously called "onanism" (after the biblical chronic masturbation (Fowler, 1857, p. 28).
story of the sin of Onan), the "solitary vice," The portrait of the youthful devotee of sexual
"secret sin," "self-pollution," and "self- indulgence was a person who is
abuse." Throughout this period, and particular-
timid, afraid of his own shadow, uncertain . . . nor
ly during the Victorian era in America, mas- will he walk erect or dignified as if conscious of his
turbation was defined by both medical and pop- manhood and lofty in his aspirations, but will talk
ular writers as a major cause of physical and with a diminutive, cringing, sycophantic, inferior,
particularly mental illness. One especially mean, self-debased manner . . . . This secret prac-
threatening consequence was feared to be a tice has impaired both his physical and mental
"morbid interest" in others of one's own sex. manhood, and thereby effaced the nobleness and ef-
These claims against masturbation became ficiency of the masculine and deteriorated his soul.
so foreboding and consensual among the rising . . . (Quoted in Smith-Rosenberg, 1978, p. S226)
middle class that today's historians of sexuality
have named the period the "age of masturba-
tory insanity" (Bullough, 1976; Comfort,1967; *Bullough and Voght (1973) show that "onanism"
Englehardt, 1974). and "the secret sin" were terms used often to in-
clude a variety of deviant sexual practices, and
By the middle of the 19th century, middle- specifically same-sex conduct. Physician James
class champions of purity and the Christian life Foster Scott, (1908, p. 419) offers a particularly
(Pivar, 1973) began organizing a crusade to clear example of this expansive usage.
The parallel between this description and the and evolution. These ideas had gained wide
effeminate homosexual stereotype that was yet currency among the American middle and
to emerge is apparent. Indeed, the chronic upper classes of the latter 19th century in the
masturbator is depicted in the writings of these form of social Darwinism. Physicians who ad-
moral crusaders as representing the antithesis dressed the "problem" of same-sex conduct
of what we now call traditional male sex role proposed that it was the product of a heredi-
characteristics. tary predisposition, "taint," or congenital
The setting most commonly believed to en- "degeneration" in the central nervous system.
courage masturbation and such "unnatural" Sexual deviance was somehow produced by
same-sex liaisons during the latter part of the the operation of physiological mechanisms
19th century was the English public or boarding largely impervious to environmental influ-
school. It was in such sexually homogeneous ence, although masturbation, reading "dirty
settings that boys, thrown together and freed books," and association with those already
from moral guidance, were thought most vul- accustomed to such practices were still thought
nerable to such practices. The mechanism unwise, if not dangerous, to one's sexual nor-
whereby masturbation and same-sex conduct mality. Even in cases where such behavior ap-
develop was somewhat vague, but it was peared to be acquired, it was explained com-
spoken of in a kind of contagion model. Older, monly as due to the hereditary weakness of the
more experienced boys were believed to induct individuals in question; they did not have the
the younger, innocent but interested boys (see constitutional stamina sufficient to withstand
Graham, 1834/1837). These schools were environmental pressures.
sometimes scandalized by allegations and One of the early representatives of this
stories of homosexual conduct between the general view was French physician Paul
youthful residents and between school person- Moreau, who in 1887 proposed that same-sex
nel and those under their charge (Bullough & conduct was the consequence of a perverted
Bullough, 1978). genital sense, a "sixth sense" to accompany
the traditional ones of sight, hearing, smell,
CONSOLIDATING touch, and taste. Just as the person born blind
THE MEDICAL MODEL: or deaf may be described as having an
THE INVENTION impaired sense of sight or hearing, homosex-
OF HOMOSEXUALITY uals were, according to Moreau, afflicted with
Hereditary predisposition an impaired sense of sexuality. Physician
By the tum of the century the idea that "im- Cesare Lombroso, the father of scientific crim:
moral" behavior might make people sick was inology, offered an explanation of such con-
losing support among both popular and medical duct that incorporates both acquired and in-
audiences. Subsequent research on the physiol- herited hypotheses. According to Lombroso,
ogy of human sexuality has, of course, under- "sexual perverts" were the inevitable products
mined these notions completely. * As phy- of a physical and moral constitution typical of
sicians turned away from masturbation as the an earlier, more primitive evolutionary period.
primary cause of sexual deviance, they turned They were, in effect, "survivals" of less moral
increasingly toward the principles of heredity civilizations that had since become extinct.
Such persons were born "morally insane" and
*William Masters and Virginia Johnson (1966, could benefit neither from penal sanction nor
p. 210), in their pathbreaking research on human specific medical treatments. The only reason-
sexuality, however, report that a significant number able solution was confinement. Lombroso be-
of men expressed concern about the possibility that lieved these people should be treated kindly
excessive masturbation might affect their mental and not blamed, but that all necessary steps-
functioning. Twenty-six percent of a 1970 United
States sample of adults said they believed masturba-
including sterilization-should be taken to pre-
tion was "wrong" (Levitt & Klassen, 1974, p. vent them from perpetuating their kind and
30). "infecting" others (Bullough, 1977, p. 32).
Crlmlnallzatlon and medlcallzatlon that religion, law, and medicine are all sys-
The late 19th century was also a time of re- tems of morality. The rise of one in any par-
newed criminalization of same-sex conduct ticular historical period is not necessarily ac-
in Germany, England, and the United States. In companied by the decline of another. In fact,
the late 1860s in Germany, the Second Reich as the preceding discussions attest, they are
proposed a considerably more harsh penal code commonly superimposed on and concurrent
against men found gUilty of mutual sexual with one another.
activity. This particular section of the code Such is the case with same-sex conduct. In
was called "Paragraph 175" (Lauritsen & fact, the rise of legal-criminal definitions to-
Thorstad, 1974). When sodomy was removed ward the end of the 19th century may well have
from the list of capital offenses in England in stimulated medicalization. The logic of this
1861, prosecutions of same-sex conduct in- argument derives from the therapeutic alterna-
creased. With less harsh penalties, convictions tive that medical definitions and interventions
were more common (Bullough, 1976, p. 569). represent over more punitive, legal mecha-
Data from the United States Census Office nisms of control. As same-sex conduct was at-
document a dramatic increase in the number of tributed to biological-genetic roots, blame was
persons in American prisons for "crimes lifted from the actors' wills and relocated in
against nature." Between 1880 and 1890 (Katz, their biology and heredity. The concept of free
1976, pp. 37, 39) this number more than choice and its attendant responsibility was be-
tripled while the increase in population was lieved applicable only in persons whose wills
only about 25%. Crusades against female were healthy and mature. If same-sex conduct
prostitution in England and the United States were the consequence of hereditary or con-
produced, ironically, movements for legislation genital degeneration, such persons became
against homosexual conduct. In the late 1880s less likely candidates, as Kittrie (1971) has
in London, middle-class crusaders interested argued, for criminalization.
in stamping out "white slavery" -the recruit- In the face of movements toward increased
ment of naive young girls into prostitution- prosecution and arrest in late 19th-century En-
produced a law prohibiting "gross indecency" gland and America, medical definitions and
between "male persons" in both private and interventions offered a particularly viable
public places. * In 1909 the Chicago Vice intellectual and philosophical alternative. It is
Commission, formed originally to study prosti- probable that this criminalization, given the
tution, reported on what its members believed growing promise of medicine, produced a
to be the alarming number of "sex perverts" in strong supportive climate for medicalization
the city and the existence of an underground of same-sex conduct. * Indeed, it appears that
community, including public meeting places it was precisely at this time that homosex-
and special symbols whose meanings only in- uality as a medical diagnosis began to emerge.
siders understood. Calls for legal control fol-
lowed, and several states formulated harsh and
*We speculate that this was particularly true for
restrictive laws (Bullough, 1976, pp. 570-571, male homosexual conduct. It appears that the late
578,609). 19th-and early 20th-century repressive laws against
This simultaneous medicalization and crim- such behavior were aimed primarily, if not exclu-
inalization of same-sex conduct may appear sively, at men rather than women. This may well
contradictory; we have suggested that these have contributed to a greater medical interest in
and subsequent medicalization of such conduct
two historical processes represent the rise to among men. American physicians at the tum of the
dominance of different institutions of social century were perhaps primed to concentrate on prob-
control. It is important, however, to remember lems of male rather than female sexuality, given
the crusade against male masturbation. Virtually all
those charged under the new laws were males.
Physicians may simply have assumed that men
*It was not a child molester that became the most were most commonly afflicted with this condition.
celebrated victim of this law but rather the noted Finally, those "criminals" which physicians de-
English author Oscar Wilde. fended as "patients" were in fact men.
Homosexuality as a medical was not a consciously chosen preference. He

pathology called the condition' 'contrary sexual feelings."
The term "homosexuality" was invented in Westphal's treatment of this case is important
1869 by Hungarian physician K. M. Benkert, in that it gave a certain degree of medical
who wrote (presumably for his own protec- legitimacy to the topic. Several similar cases
tion) under the pseudonym of Kertbeny (Lau- were contributed to European medical liter-
ritsen & Thorstad, 1974). He argued against ature over the next decade.
the growing legal repression of same-sex con- In 1883 American physicians J. C. Shaw and
duct and the harsh punishments contained in the G. N. Ferris published an important article in
Prussian legal code, Paragraph 175. Such treat- The Journal of Nervous and Mental Disease en-
ment, he insisted, was both unjust and ineffec- titled "Perverted Sexual Instinct." Shaw and
tive inasmuch as homosexuality was congenital Ferris, stimulated by a patient who had come to
rather than acquired. He described the condi- the former for help, reviewed all the published
tion, homosexuality, as follows: medical cases of this condition they could find.
Most of these were in German or French, and
In addition to the nonnal sexual urge in man and their review introduced to their American col-
woman, Nature in her sovereign mood had endowed leagues an area of medical study neither com-
at birth certain male and female individuals with the mon nor understood widely in this country.
homosexual urge, thus placing them in a sexual The moral tone of the review is decidedly more
bondage which renders them physically and psychi-
neutral than the earlier medical writings on
cally incapable-even with the best intention-of
masturbation, but there is no doubt that the
nonnal erection. This urge creates in advance a
direct horror of the opposite [sex] and the victim authors considered the condition undesirable,
of this passion finds it impossible to suppress the describing it as "a most interesting pathological
feeling which individuals of his own sex exer- sexual phenomenon" typified by "abnormal
cise upon him. (Quoted in Hirschfeld, 1936a, p. desires. "
322) The most important physician-psychiatrist
whose cases Shaw and Ferris discussed is the
It was not, as some normals feared, a conta- late 19th-century German student of deviant
gious or communicable disease. Quarantine sexuality, Richard von Krafft -Ebing. More
and confinement were unnecessary, except in than any other physician of the period, Krafft-
those cases involving bodily threats to others. Ebing established same-sex conduct and the
In the same year, Berlin psychiatrist Karl von mental states from which it was presumed to
Westphal published a case history of a young flow as a physiologically based psychiatric
woman he examined in a local asylum. The pathology. His most influential work, Psycho-
woman reported a fondness for boys' games pathia Sexualis, was published first in 1886
when growing up, liked to dress as a boy, pro- and contained many case histories of various
fessed strong physical and emotional attrac- "sexual abnormalities." Written primarily for
tions for certain other women, and said that his medical colleagues, the work enjoyed an
she had been successful in realizing these enormous success and ran into many printings
desires on a number of occasions. She indi- and editions. Each successive edition seemed to
cated virtually no sexual interest in men. The include more case histories of sexual pathology
patient expressed anxiety and sorrow over this collected from associates, his own practice,
condition and "wished to be free of it." West- and police and court records. By the 11th edi-
phal reported that the woman appeared to be tion, published in 1894, they numbered over
a physically normal female, evidenced no 200 in all (Bullough, 1977). Krafft-Ebing's
delusions or hallucinations, and displayed no book became the definitive source of de-
notable peculiarities other than her sexual scriptive material on sexual variety and may
desires and activities (Shaw, J. C., & Ferris, well continue to be "the most comprehensive
1883). He concluded that the problem was con- collection of case histories of sexual deviation
genital, did not necessarily indicate insanity, available" (Van Den Haag, 1965, p. 12). A
and should not be considered a vice, since it gauge of this popUlarity with medical and sub-
sequently lay audiences (much to the author's and, more significantly, Krafft-Ebing) were
chagrin) is that it is still in print today. called on often to give expert testimony. The
Krafft-Ebing has been called a pivotal and latter testified that homosexuals could not
transitional figure between 19th- and 20th-cen- change the direction or the expression of their
tury medical study of sexuality (Bullough, sexual desires and that such persons were sick
1976; Robinson, P., 1976). The 19th-century and therefore should be treated therapeutically
face of his work is seen in his allegiance to a rather than punitively. He called not for sym-
Victorian moral code that defined heterosexual pathy but understanding. Finally, Krafft-Eb-
procreative sex as a standard. Sexual acts and ing's case histories and analyses contributed to
intimate emotional attachments between mem- the emergence of homosexuality as a medical
bers of the same sex were considered unequiv- entity and the homosexual as a distinctive kind
ocally abnormal in Krafft-Ebing's work. In of person.
addition, although he gave greatest causal em- As we have argued, a medical case history
phasis to a "hereditary taint," a congenital is not constructed in an intellectual vacuum.
weakness of the nervous system, he agreed that Rather, it is usually developed by clinicians
repeated masturbation and sexual excesses of attempting to solve people's "problems" with-
various types could excite or precipitate this in the context of the medical model. The ac-
condition. In all cases of "sexual inversion," cumulation of case histories around the diag-
however, physicians were instructed to presume nostic labels "invert," "sexual pervert," and
the existence of a constitutional susceptibility. "homosexual" gradually gave support to the
Krafft-Ebing regarded sex as the most powerful notion that these names represent a disease
and potentially devastating force with which entity, a "thing" people can "have" or "get"
human beings had to cope; to overcome the (Cassell, 1976). As medical consensus around
desires of sexual lust required a vigilant fight. such diagnoses grew, it also became part of the
At the same time, however, he previsions a popular, lay understandings about what the
20th-century approach to variant sexuality in condition "is" and what "kinds of people"
his willingness to address it openly and directly. the afflicted "are." Krafft-Ebing presented the
This was not, as we have noted, common at the typical features of this condition:
first publication of Psychopathia Sexualis, and Congenital absence of sexual feeling toward the op-
some of his medical colleagues chided him posite sex . . . . This defect occurs in a physically
for what they considered unnecessary frankness completely differentiated sexual type and normal
on such morally detestable practices (Bullough, development of the sexual organs. [There is] ab-
1976, p. 643). He brought attention to what sence of the psychical qualities corresponding to the
had been up to then, at least in the West, a sub- anatomical sexual type, but [rather] the feelings,
merged and dark comer of human experience. thoughts, and actions of a perverted sexual instinct.
Aside from whether he approved or disapproved Abnormally early appearance of sexual desire. Pain-
ful consciousness of the perverted sexual desire.
of such behaviors (and he did disapprove),
Sexual desire toward the same sex . . . . There are
his work effectively broke this Western, Chris- symptoms of a morbid excitability of the sexual
tian, and middle-class conspiracy of silence desires, together with an irritable weakness of the
about unconventional sexual behavior. At mini- nervous symptoms. . . . The perverse sexual im-
mum, he enlightened both medical and lay pulse is abnormally intense and rules all thought
audiences to the incredible variety of sexual and sensation. The love of such individuals is exces-
expression of which human beings are capable. sive even to adoration, and is often followed by
Having done so, there was no denying this di- sorrow, melancholy, and jealousy. People afflicted
versity; thereafter it had at least to be recog- with this abnormality frequently possess an instinc-
nized. tive power to recognize one another. (Quoted in
He is also a specifically pivotal figure in the Shaw, J. C., & Ferris, 1883, pp. 203-204)
medicalization of homosexuality. In the face of Although perhaps not as dramatic as some of
late 19th-century criminalization of variant the discoveries of medical science earlier in the
sexual practices, physicians (e.g., Benkert century, the accumulating case histories of
"such persons" gave credence to the proposi- others. Indeed, Freud posited that as children
tion that another medical mystery was being we all pass through a stage of sexual "latency"
solved, another battle about to be won. It is in during which these homoerotic desires and
terms of the repeated images of pathology, attachments are perfectly normal yet largely
pain, anguish, and the bizarre contained in covert. He characterized such sexuality as
these case histories that homosexuality and the "infantile." As children pass through puberty,
homosexual emerged as medical entities in the however, they typically transfer their sexual
20th century. attentions to peers of the opposite sex and
thereafter pursue the goal of heterosexual re-
RISE OF THE PSYCHIATRIC productive sexuality. This was "mature" and
PERSPECTIVE "complete" sexual development in the Freud-
Contribution of Freud ian scheme. It was not, however, the product
We pointed out in Chapter 3 that the work of of any predisposition other than that imposed
Sigmund Freud revolutionized the way med- by cultural rules and socialization. Such cul-
icine and psychiatry in particular defined and tural influences were usually effective in
treated a broad range of patient problems. That "making" heterosexuals, but Freud argued
was certainly true for homosexuality, although that all "normal" adults retained the "latent"
his work on this topic defies simple classifica- remnants of their homosexual desire. These
tion. For our purposes, Freud's most significant were "repressed" into the unconscious mind
contributions are paradoxical: he explained from which they were then expressed in "sub-
homosexuality by a general theory of sexuality limated" or disguised forms consistent with
that rejected the notions of congenital etiology conventional sexual standards (e.g., same-sex
and hereditary degeneration; this explanation, "best friends," poker clubs, sports).
in effect, "normalized" homoerotic desires Homosexual adults were described as per-
by making them part of "normal" sexual de- sons who had not fully completed this sexual
velopment and a "latent" dimension of hetero- development or who had "regressed" to an
sexuality; he argued that homosexuality is not immature stage. They were depicted as casual-
best understood as a disease, yet his work ties of the various "complexes" and conflicts
strengthened considerably medical dominance typical of the Freudian childhood. Among the
over the definition and treatment of this "con- most important of these is the Oedipus complex
dition." In short, Freud expanded and clarified wherein children, during puberty, must manage
the medical definition of homosexuality, but it socially prohibited and threatening incestuous
became a considerably different condition than desires for opposite-sex parents. Difficulties
had been described before. in relationships with one or both parents almost
First, Freud embedded his discussion of always assume great importance in Freudian
homosexuality in a more general theory of discussions of homosexual conduct. Whereas
psychosexual development that eschewed both the sexually mature adult weathers these
biological and environmental determinism - the traumas on the way to heterosexuality, the
two common explanatory contenders to that homosexual's attention to same-sex others
date. He argued that adult sexuality was a com- represents an inappropriate and immature solu-
plex product of the dynamic tension between tion to such crises. Although clearly undesir-
physiological sexual desires-the "libido," or able, homosexuality under Freud became in-
sexual appetite-on the one hand and social timately linked with the sexually "normal."
and cultural prescriptions and proscriptions on As part of his criticism of past congenital
the other. A distinctive feature of Freud's explanations, Freud attempted to counter the
theory was that the most crucial period for adult negative image of homosexuals conveyed by
sexuality was childhood. All people were be- the notion of "hereditary degeneration."
lieved born with a "polymorphous perverse" He insisted that
sexual capacity that included the potential for inversion is found in people who otherwise show no
stimulation by and attraction to same-sex marked deviation from the normal. It is found also
in people whose mental capacities are not disturbed, and contrary opened up an entirely new realm
who on the contrary are distinguished by especially of study and debate. *
high intellectual development and ethical culture. In 1935, Freud unwittingly made one of his
(Freud, 1905/1938, p. 556)* most famous statements on the nature of homo-
sexuality. In a letter to a mother who had writ-
Neither was homosexuality a monolith; homo-
ten to him regarding her son, Freud (1935/
sexuals were not all alike. There were, for
1960) summarized the major themes in his writ-
example, the "absolutely inverted" (exclusive-
ing on the subject:
ly homosexual in feelings and action), those
whose sexual object choice could be either male I gather from your letter that your son is a homo-
or female (the "psychosexually hermaphro- sexual. I am more impressed by the fact that you do
ditic"), and the "occasionally inverted," who not mention this term yourself in your information
engaged in same-sex conduct because of en- about him. May I question you, why you avoid it?
Homosexuality is assuredly no advantage but it is
vironmental isolation or limited access to cross-
nothing to be ashamed of, no vice. no degradation.
sex others (those we might call "situational
it cannot be classified as an illness; we consider it to
homosexuals"). Freud reported that inverts' be a variation of the sexual function produced by a
feelings about their "condition" ranged from certain arrest of sexual development. Many highly
matter-of-fact defense and demands for equal respectable individuals of ancient and modem times
treatment to a consuming struggle against what have been homosexuals, several of the greatest men
was seen as a "morbid compulsion." among them .... It is a great injustice to persecute
Linked closely to the proposition of "poly- homosexuality as a crime and cruelty too . . . . (pp.
morphus perverse" sexuality was Freud's idea 423-424, emphasis added)
of a universal biological predisposition to We must reiterate. Freud here argues that
bisexuality. He .believed that people were not homosexuality is a variation rather than a
simply "masculine" or "feminine," but that deviation; it is not something particularly
both men and women displayed such qualities "bad" but rather something that is merely
and characteristics: "different." One would search long for such an
there is no pure masculinity or femininity either in unequivocally nonjudgmental statement on this
the biological or psychological sense. On the con- topic among physicians before, during, or after
trary, every individual person shows a mixture of his Freud. t His letter continues by addressing the
own biological sex characteristics with the biological question of "cure." It reflects an early pessi-
traits of the other sex and a union of activity and mism about what psychiatric intervention can
passivity; this is the case whether these psycholog- and indeed should attempt (see also Freud
ical characteristic features depend on biological ele- 1920/1959):
ments or whether they are independent of them.
(Freud, 1905/1938, p. 613) By asking me if I can help, you mean, I suppose,
if I can abolish homosexuality and make normal
This confounded further the traditional simplic-
ity that depicted "normal" heterosexuality *Robert Stoller (1968) suggests that Freud's distinc-
as clearly distinct from "sick" homosexuality. tion between biological and psychic sexuality rep-
If the subjects and objects of sexual attraction resents the origins of the idea of gender as distinct
were themselves blurred, how could one be from sex as a physiological condition. Although this
idea existed prior to Freud's specification of it, the
sure which behaviors and feelings were normal location of homosexuality as primarily a problem
and which perverse? Indeed, the very notion of gender identity rather than genetic or physio-
that there were physical and psychological logical predisposition became the official psychiatric
dimensions of sexuality that could be distinct as well as popular position in subsequent decades.
tThe paradoxical nature of Freud's ideas on homo-
sexuality are evident, however, in a recent argu-
ment by Stephen Mitchell (I 978). He asserts that
the concept of pathology is itself inherent in the
*Quotation from Freud (1905/1938) reprinted by very theory and therapy that Freud proposed: psycho-
permission of Gioia Bernheim and Edmund Brill. analysis.
heterosexuality take its place. The answer is, in a the point, those who engaged in it. Although
general way, we cannot promise to achieve it. In such conduct was still "criminal" in the United
a certain number of cases we succeed in developing States and England, enforcement was uneven
the blighted germs of heterosexual tendencies which and seemed to occur primarily as a result of
are present in every homosexual, in the majority of
complaints in the name of "common decency"
cases it is no more possible. It is a question of the
quality and of the age of the individual. The result and "protection." Its intellectual boundaries
of treatment cannot be predicted. (p. 424) as a category for medical attention had ex-
panded decidely; homosexuality was not only
What Freud says here about the effectiveness of a question of what one was or did but also of
psychiatric treatment that attempts to "cure" what one thought-including unconscious de-
homosexuality could be taken as a summary sires only the trained psychiatrist could identify.
of the history of such treatments in the 20th Freud's reasoned caution regarding therapy
century. It is indeed probable that this lack of was compromised in subsequent psychiatric
a successful medical technology for solving the writing on homosexuality. Indeed, considering
"problem" of homosexuality was a major some of the medical interventions during and
factor giving support to its demedicalization. after Freud's time, such as hormone therapy,
Finally, Freud previsions what psychiatric aversive conditioning using electric shock and
treatment might best aim for in persons present- drugs, electroshock therapy, lobotomy, and
ing problems associated with same-sex conduct: "therapeutic castration" (Katz, 1976, pp. 129-
What analysis [meaning psychoanalysis] can do 207), psychoanalysis must be considered rela-
for your son runs in a different line. If he is un- tively benign. These "treatments" or attempts
happy, neurotic, tom by conflicts, inhibited in his to control homosexuals were premised in all
social life, analysis may bring him harmony, peace cases on a vision of this condition ali a consider-
of mind, full efficiency, whether he remains a homo- ably more serious problem than Freud proposed.
sexual or gets changed . . . . (p. 424, emphasis His equivocal position on the disease status of
added) homosexuality and homosexual conduct and
Rather than aiming primarily for a "cure," his pessimism about medical cures were sup-
with its implicit image of sickness, medical planted by a growing consensus in American
intervention might best facilitate the individ- psychiatry that the condition is a serious psy-
ual's life as that of one whose sexuality repre- chopathology, that it in all cases produces an-
sents a variation rather than a moral blemish. guish and unhappiness for those so afflicted,
that it is clearly abnormal (not a variant of nor-
Sacrificing Freud:* the mal sexuality), and that, like all diseases, it
reestablishment of pathology should and could be cured. * The kinds of vio-
and the promise of cure lent medical interventions noted were probably
One important consequence of Freud's work linked in a reciprocal way to the reservoir of
for the medicalization of homosexual conduct revulsion that was the general cultural inheri-
was that it was established first and foremost tance regarding same-sex conduct in the West.
as a psychiatric condition and psychiatrists There was, in other words, considerable non-
became the medical experts-the new "priests" medical support for such medical practices and
in charge of its diagnosis and treatment. The ideas, which in tum reinforced popular thought
therapeutic had triumphed over the religious on the subject.
and legal as the official language to define and
explain homosexual conduct and, more to *The Freudian analysis of homosexuality-albeit in
a variety of altered formulations - was pursued most
specifically after Freud by Adler, Bleuler, Coriat,
*We are indebted to Christopher Lasch (1976) for Ferenczi, lekels, lones, Ortvay, Sadger, and Senf.
this heading. It captures not only what happened See Ellis (1936, pp. 305-306) and Bullo/lgh (1977)
to Freud's more general theory but also the fate of for brief synopses of and reference to some of this
his proposition that homosexuality is not necessarily work. See Freud (1914) for a more general discus-
pathological. sion of the history of the psychoanalytic movement.
These nonmedical definitions sometimes took psychoanalytic psychiatry, was given new life
precedence over the more "humanitarian" in the late 1930s and again in 1952 in the work
stance of medicine, and medical rhetoric was of Franz J. Kallmann (see Chapter 3). Extend-
used sometimes in the service of other institu- ing a perspective developed in earlier work on
tions of social control. One of the clearest ex- the genetics of schizophrenia, Kallmann (1952)
amples is the American armed forces during reported the results of a study of 85 twins, 40
and after World War II. The military bureau- monozygotic (products of a single fertilized
cracy during the war provided not only an arena ovum) and 45 dizygotic (two fertilized ova)
for wholesale psychiatric and psychological pairs. The sets of monozygotic twins were
screening but also a set of circumstances all homosexual, and Kallmann reported this
in which the "problem" of homosexuality re- pattern had developed independently of each
ceived considerably increased attention. In other's socialization, cooperation, or knowl-
their review of sexual behavior and the military edge. Half the dizygotic twins were homosex-
law Louis J. West and Albert Glass (1965) ual, but the co-twins showed no dispropor-
conclude that homosexual conduct is the area tionate signs of overt homosexuality. Kallmann
of sexuality of primary concern to military concluded that this evidence supported the im-
officials. During World War II such persons portance of genetic factors in the origin and
were classified as "psychopathic" and received development of homosexuality.
a dishonorable or "blue" discharge. Military Kallmann's findings and conclusions have
psychiatrists typically provided the official diag- been cited and debated widely. Subsequent
nosis on which this action was taken. Soon after research (Sawyer, 1954; Pare, 1956; Money et
the war, official military policy toward homo- aI., 1957; Hampson & Hampson, 1961) has,
sexuality hardened, and its boundaries ex- however, raised serious questions that both
panded. In addition to their mental problems, undermine Kallmann's conclusions and cast
homosexuals became ' 'security risks, ' , doubt on the genetic explanation itself. Al-
"threats to morale," and highly "unreliable." though the hope for a genetic etiology of homo-
So concerned with the threat of homosexuality sexuality continues to be nourished in certain
were the American government and military medical-scientific circles (Evans, 1973; and
after 1947 that they moved to discharge not see Behavior Today, Nov. 15, 1976), it remains
only those who had engaged knowingly in a theory with highly inconclusive empirical
such conduct but also those "who exhibit, pro- support. It was, in any event, rejected and
fess, or admit homosexual tendencies or asso- hence not "owned" by the psychoanalytic
ciate with known homosexuals" (Williams psychiatrists who had become by midcentury
and Weinberg, 1971, p. 28, emphasis added). the experts on homosexuality.
Psychiatrists reluctantly became involved in Most influential in supporting the pathology-
what could be called an official campaign to treatment definition of homosexuality have
separate such persons from service; although been practicing clinical psychiatrists who have
they protested what they considered overly adopted various psychodynamic versions of the
punitive policies, their claims had little impact Freudian scheme. Among the most influential
until the late 1950s (see West et aI., 1958).* American advocates (and there have been
Medical definitions of homosexual pathology many) are Edmund Bergler, Irving Bieber, and
were used in the name of politics and ideology Charles Socarides. *
(Menninger, 1967, pp. 451-562; Szasz, 1965). Edmund Bergler.t Bergler, a psychoana-
The congenital explanation of homosexuality,
although challenged by the growing power of *An additional candidate might be Albert Ellis
(1965).
*The failure of these military psychiatrists to suc- tPages 189 to 190 contain selections from Homosex-
cessfully exert professional dominance and authority uality: disease or way of life? by Edmund Bergler,
on this question provides a specific example of the M.D. Copyright © 1956 by Edmund Bergler. Re-
larger proposition that in the face of the state the printed with the permission of Hill and Wang (now a
power of medicine is tentative and conditional. division of Farrar, Straus & Giroux, Inc.).
lytic psychiatrist trained at the University of 2. Male homosexuals* are terrified of wom-
Vienna who subsequently established a private en and flee from them to other men.
practice in New York City, held that homo- 3. They typically "obliterate" the person-
sexuality is a mental disease characterized by alities of their love objects-sex is impersonal
"oral regression," masochism, and (in males) and contempt-ridden.
an irrational fear of women. Lesbian relation- 4. "The typical homosexual is perpetually
ships were believed distortions of the mother- on the prow I," and the constant "cruising"
child bond, wherein one woman becomes self- for sex partners represents the masochistic
destructively dependent on the other, parent- desire to be caught and punished.
figure partner. All such persons manifest 5 . Homosexual relationships are often
"trademark" unconscious characteristics, ac- "camouflaged" as "husband-wife" bonds,
cording to Bergler (1956, p. 15). with one member attempting to escape into
Bergler's published work on homosexuality the argument of "biological femininity" to ac-
began with a few articles in the early 1940s count for his effeminate ways.
and culminated in several major works roughly 6. These persons are characterized by "an
a decade later. He framed the essential ques- unfounded megalomaniacal conviction" that
tion in a 1956 book, Homosexuality: Disease they are superior persons and the false belief
or Way of Life? His answer was unequiv- that "at bottom everybody has some homo-
ocally the former. He was one of medicine's sexual inclinations."
most vocal critics of the famous Kinsey studies 7. Despite an outward flippancy and casual
of male homosexual conduct published in 1948. air, all homosexuals suffer from a "deep inner
Bergler (1948) challenged Kinesy's generaliza- depression." "Scratch a homosexual and you
tion that one out of every three adult males in find a depressed neurotic." This outward
America had had a homosexual experience veneer is characterized also by an "exagger-
after adolescence. He believed the popular ated and free-flowing malice," which, under
dissemination of such alleged "findings" was a psychiatric gaze, becomes "pseudo" or irra-
cause of a new population of "statistically in- tional aggression.
duced homosexuals" -those "borderline" 8. All homosexuals experience a deep
cases swayed to full membership by this sense of gUilt from their "perversion," which
picture of supposed incidence. He rejected the "denotes infantile sex encountered in an adult
concept of "bisexuality" as a "flattering de- ... leading to orgasm. In short, a disease."
scription of the homosexual who is at times 9. Irrational and violent jealousy as a mas-
capable of mechanical heterosexual activity"; ochistic mechanism is common.
he insisted that "every 'bisexual' ... is a true 10. "Unreliability, ranging from a trace to
homosexual" who uses this label as an "alibi" a pronounced trend, is the rule and not the ex-
(Bergler, 1956, p. 8). Finally, although he ception among homosexuals" and is often
agreed that heterosexuality was no assurance justified by the rationalization that "I've suf-
of mental health, healthy heterosexuals do fered so much."
exist. There are, Bergler (1956, p. 9) insisted, The components of this portrait become
"no healthy homosexuals. ' , common themes in subsequent psychoanalytic
On the basis of "30 years" of clinical prac- work.
tice. Bergler (1956, pp. 16-28) provided the Summarizing his professional experience
following picture of the typical homosex- with homosexuals, Bergler (1956) asserts that
ual: although he has "no bias" against them, "if I
1. Such persons are "injustice collectors"
and "psychic masochists" who strive for "de-
feat, humiliation, and rejection" because of *Bergler (1956, pp. 261-290) discusses female
homosexuality in a separate section of his book.
their early failure to master the oral stage of His description and alleged origins of the condi-
psychodynamic development; they are "re- tion in women are, however, essentially the same as
gressed personalities." those offered for men.
were asked what kind of person the homosexual Bieber and his associates in Homosexuality: A
is, I would say: 'Homosexuals are essentially Psychoanalytic Study, published in 1962. Much
disagreeable people, regardless of their pleas- more reserved in its moral tone than Bergler's
ant or unpleasant outward manner'" (emphasis writing, it is based on a systematic study of 106
added). Although they ought not be held ac- male homosexual patients under psychoanalysis
countable for their condition, their personalities and a comparison group of 100 heterosexuals
are also under psychiatric care, but not for homo-
a mixture of superciliousness, fake aggression, and sexuality. The research was the product of a
whimpering . . . . they are subservient when con- committee formed in 1952 within the Society of
fronted with a stronger person, merciless when in Medical Psychoanalysts. Bieber was the found-
power, unscrupulous about trampling on a weaker ing chair of the nine-person group, initiated
person. The only language their unconscious under- specifically to pursue the study of homosexual-
stands is brute force . ... you seldom find an intact ity. Eight of its members were psychoanalysts,
ego (what is popularly called "a correct person") and they were joined later by a clinical psychol-
among them. (pp. 28-29, emphasis added)
ogist. Data were collected by sending ques-
One is struck immediately by the similarity be- tionnaires to the members of the society asking
tween these remarks and the traditional moral them to complete one for each of the male
judgments about same-sex conduct we have homosexuals currently in their care and for a
reviewed. Bergler's writing is perhaps one of comparable number of their other, nonhomo-
the best examples of how thinly guised by the sexual, male patients. Analysis of the data was
rhetoric and professional status of medicine in terms of relationships between patients and
this traditional hostility can be. It is clearly parents, psychosexual development, so-called
grist for the nonmedical mill of hostility toward latent homosexuality, and treatment.
such conduct and persons. The Bieber report provides a review of pre-
In an article titled "What Every Physician vious psychoanalytic work on homosexuality
Should Know About Homosexuality" Bergler since Freud, as well as research premised
offers some advice to his psychiatrist col- on hereditary theories. It identifies several op-
leagues. Facing on the one hand growing num- ponents to the view that homosexuality is a
bers of homosexuals claiming to be "normal" pathological condition: the Wolfenden Report
and on the other another group of heterosexuals from England, Kinsey's research, the anthro-
demanding harsh punishments, what, Bergler pological studies of Ford and Beach, and the
asks, is the "poor psychiatrist . . . caught in psychiatric evidence of Hooker, and Chang
the middle and attacked by both sides ... " to and Block (Bieber et aI., 1962, pp. 3-18). The
do? His prescriptions are insightful: profes- committee concludes this review, however,
sional and public education that homosexuality with the following terse remark: "All psycho-
is a neurotic and severely damaging, yet cur- analytic theories assume that adult homosexual-
able, disease and not "just a way of life"; ity is psychopathological and assign differing
encouraging outpatient services for treatment; weights to constitutional and experiential de-
opposition to and reversal of the "conspiracy terminants" (Bieber et aI., 1962, p. 18, em-
of silence" maintained by the media; "pub- phasis in original). The determinants of this
licity" that will assure homosexuals and "po- pathology are rooted in childhood and the
tential homosexuals" that there is no "gla- family.
mour" in "being different"; and assistance to The research of Bieber et ai. has been cited
"horrified parents" in handling the problem widely and the subject of several medical for-
of homosexuality in the family (Bergler, 1956, ums and popular discussions (Beiber, 1964). It
p. 690). The psychiatrist should, according to is taken typically among sympathetic physi-
Bergler, become an activist on behalf of the cians as a major empirical support for the
medical "truth" about this disease and its cure. disease view. Briefly, the conclusions of this
Irving Bieber et al. The most ambitious research are as follows: heterosexuality is the
psychoanalytic defense of the pathological "biologic norm" from which homosexuality
status of homosexuality has come from Irving represents a pathological deviation; it is the
result of "hidden but incapacitating fears of of Medicine, 1964; Socarides et al., 1973). He
the opposite sex"; these specific fears include subsequently became one of the staunchest
anticipated threats to the male genitals, aversion defenders of the definition of homosexuality
to female genitals, and anxiety about actual or as a serious medical pathology and, along with
anticipated heterosexual conduct. As a result, Bieber, the premier medical "expert" on this
sexual gratification is sought in members of topic. *
one's own sex. Homosexuality is not a "variant Socarides' major contribution to this view
of 'normal' sexual behavior" and is not the of homosexuality appears to be primarily as a
product of universal "latent" homosexual compiler of previous psychoanalytic theory and
desires. Homosexuality frequently flows from research, an experienced clinician, and a vocal
pathological "close, binding, and possessive" defender of the pathology perspective. His ma-
relationships between boys and their mothers jor work, The Overt Homosexual (1968), offers
and from "detached and hostile" fathers. In a literature review and critique, case histories,
fact, "a constructive, supportive, warmly and the elaboration and extension of selected
related father precludes the possibility of a themes from the psychoanalytic tradition. Much
homosexual son." The consequences of these of what we have discussed from Bergler and
early relationships are subsequently supported Beiber is reiterated by Socarides: homosexual-
in peer and play groups in a kind of self- ity is a form of mental illness with "pre-
fulfilling cycle, leading the young man into Oedipal" origins; it is an infantile and re-
supportive groups of other similarly disturbed gressed or fixated form of sexuality based on
individuals (Bieber et aI., 1962, pp. 303-319). profound fears and/or hostilities to one or
The committee members held, however, that both parents, and reflects a "pathological
therapeutic evidence (37% of the 106 homo- family constellation"; it is aggressive, self-
sexuals under analysis became "exclusively destructive, and typified by paranoid feelings,
heterosexual") is optimistic, particularly if a "masquerade of life" in which the actors
(as Bergler recommended) patients were care- are "tormented" individuals. Socarides (1968,
fully selected. * One of the important criteria p. 91) reiterates his own version of the tra-
for success is that the patient is "motivated ditional psychiatric distinction between "true"
to become heterosexual." Bieber and his col- or "obligatory" homosexuality and situational,
leagues urged psychiatrists to strive for a cure "utilitarian" or "episodic" homosexuality. It
(heterosexuality) rather than an "adjustment" is only the former, wherein perversion arises
(the "happy" homosexual) in their treatment from childhood trauma and conflict, that should
of these patients. be the subject of medical and psychoanalytic
Charles Soearldes. A third important intervention. The latter, presumably less dis-
psychoanalytic advocate of the disease view eased type of homosexual, is so by choice,
of homosexuality at midcentury is Charles stemming from motivations of "power, gain,
Socarides. A student of homosexuality and protection, security, vengeance, or specialized
other "perversions" for more than two de- sensations" or the temporary unavailability of a
cades, Socarides began publishing professional partner of the opposite sex. Socarides (1968,
discussions of the former in the early 1960s. He p. 216) calls psychoanalysis the "treatment of
was instrumental in initiating discussion of choice" for homosexuality, provided the pa-
homosexuality in 1958 at the first panel held tient expresses a degree of gUilt for uncon-
on the topic by the American Psychoanalytic
* Dr. Socarides has asked that, in conjunction with
Association and subsequently was a major par- our discussion of his work, we point out that, to
ticipant in various interdisciplinary and med- quote his correspondence, he has "never been
ical study groups on homosexuality that sup- against the decriminalization of homosexual acts oc-
ported the disease view (New York Academy curring between consenting adults" and that he "was
in the vanguard of promoting this, even before 'gay
rights' became an issue in this country." He cites
*One of the most widely cited psychodynamic dis- the 1973 Task Force Report of the New York County
cussions of interest is Lawrence Hatterer's (1971) District Branch, American Psychiatric Association
Changing Homosexuality in the Male. (Socarides et aI., 1973) as a reference.
scious wishes and comes to therapy volun- clude unequivocal statements that homosexual-
tarily. * ity is an emotional illness that "may cause such
In 1970 Socarides published an article titled grave disruption to the . . . individual that all
"Homosexuality and Medicine" in The Journal meaningful relationships in life are damaged
of the American Medical Association. He chal- from the outset and peculiarly susceptible to
lenges what he and others perceive as a spread- breakdown and destruction" (1970, p. 1201).
ing and grievous misperception of homosexual- He ends his almost impassioned plea for
ity on the part of some in the medical profes- medical control with some cautions and en-
sion, certain lay groups defending the "nor- couragements to fellow physicians:
mality" of the condition, and many homosex-
We practice today in the atmosphere of a sweeping
uals themselves. It is a call to action and a de- sexual revolution. Together with the mainstream
fense of expert medical authority. He begins heterosexual revolt has come the announcement that
by asserting that homosexuality is publicly ab- a homosexual revolution is also in progress and that
horrent and that "the majority of the public" homosexuality should be granted total acceptance
favors legal punishment for such conduct, even as a valid form of sexual functioning, different from
if private. t At the core of the confusion about but equal to heterosexuality. Such acceptance ... is
homosexuality is the fact that some have lost naive, not to say grounded in ignorance. (p. 1202)
sight, or refuse to recognize, that it is first and That such "fantasies" have been accepted as
foremost a "medical problem." In unmistak- truth is evidenced by the following ominous
ably turf-defending remarks, Socarides:j: (1970) example:
writes: "Only in the consultation room does
the homosexual reveal himself and his world. colleges can be pressured to charter homosexual
No other data, statistics, or statements can groups on campus with all the privileges of other
scholastic and social organizations, thereby lending
be accepted as setting forth the true nature
tacit approval. The implications of such trends are
of homosexuality" (p. 1199). The well-mean- profound. (p. 1202)
ing but "unqualified" defender of homosexual
normality is "misguided" because of the ab- He closes, however, optimistically, buoyed by
sence of clinically trained medical insight nec- the invincible armor of medical science:
essary to "discern the deep underlying ... dis- The whole issue of homosexuality must be trans-
order" homosexuality represents. Rather than formed into one more scientific challenge to med-
their being subjected to harsh punishments icine which has time and again been able to alleviate
based on a moral-criminal model, Socarides the plaguing illnesses of man. With this respected
insists such true homosexuals be helped by leadership on the part of the physician, we will see
medical treatment. Although he supports de- a surge of support for the study and treatment of the
criminalization, Socarides believes that without disorder by all the techniques and knowledge avail-
able through the great resources and medical talent
simultaneous medicalization such measures are
of the United States. (p. 1202)
dangerous. Such legislation should always in-
The battle lines drawn and the call to arms
*The sense in which any such therapy for homosex- made, only the ignorant, the ill, and the ma-
uality is "voluntary" is of course clouded consider- levolent can fail to join the fight.
ably by the widely negative cultural definitions that A final piece of evidence for the dominant
attach to such conduct and persons. The choice status of the pathology definition of homosex-
here is rather clearly not free of strong predisposition
in favor of treatment. uality comes from the official classification of
t A 1970 survey of the United States adult population psychiatric disorders of The American Psy-
found that approximately 59% of the representative chiatric Association, its Diagnostic and Statis-
sample thought that "homosexuality is a social tical Manual of Mental Disorders (DSM), and
corruption that can cause the downfall of a civiliza- its parent document, the World Health Orga-
tion" (Levitt & Klassen, 1974, p. 34).
* Quotation from Socarides fromJ.A.M.A., 1970,1,
1199-120i. Copyright 1970, American Medical
nization's International Classification of Dis-
ease (leD). These manuals, and particularly the
Association. former, represent the professionally approved
diagnostic labels for virtually all mental dis- of "normal" reasons, engage in homosexual
orders with which American psychiatrists are conduct. According to both DSM-I and DSM-
concerned. It is, so to speak, the "blue book" II, as well as the manuals of the World Health
of mental illness and not only serves for statis- Organization, homosexuality is a mental disor-
tical and operational classification but also pro- der, a psychopathology. A 1970 survey of pub-
vides the official list of what is and what is not lic attitudes toward homosexuality found that
considered a psychiatric condition. By review- about 62% of American adults agreed, calling it
ing the place of homosexuality in this manual, a "sickness that can be cured" (Levitt & Klas-
we can determine the extent of professional sen, 1974).
organizational support for the notion that it is a
bona fide mental illness. DEMEDICALIZATION: THE
The first edition of DSM was published by CONTINUING HISTORY OF A
The American Psychiatric Association in 1952 CHALLENGE
and was patterned after ICD-6, the sixth edition As is apparent from this book, the history of
of the International Classification. This and the medicalization of deviance is both longer
subsequent editions are the work of a special and more "rich" in detail that that of
committee within the association called the demedicalization. That this discussion comes as
Committee on Nomenclature and Statistics. the final section of this last historical chapter
In DSM-I the diagnostic label "homosexual- reflects both what has been-and probably will
ity" is identified as one of several forms of continue to be-the growing dominance of
"sexual deviation" and falls under the more medical definitions of and interventions in "so-
general psychiatric category "Sociopathic cial problems" and "deviant behavior" in
Personality Disturbance." The more clinically American society. Although we have discussed
distinct and medically significant conditions are specific criticisms of medical definitions and
assigned individual numbers according to a sys- practice (e.g., "mental illness," "addiction,"
tematic scheme. In DSM-I, homosexuality was "alcoholism"), it appears that only in the case
one of many unnumbered conditions under this of homosexuality do we find a clear challenge
larger sociopathic umbrella. to basic assumptions of the medical model it-
The second edition of DSM was published in self. *
1968 and is a reflection of ICD-8. In DSM-II, The origins of this challenge derive, para-
homosexuality assumed new significance as a doxically, from the very expansion of medi-
medical pathology. Under the major category cine at about the tum of the 20th century
"Personality Disorders and Certain Other Non- into various behavior problems. Most turn-of-
Psychotic Mental Disorders" (301-304), and the-century physicians saw homosexuality,
specifically under "Sexual Deviation" (302), although a sickness and no cause for blame, as
we find "Homosexuality" (302.0) (American a congenital (inborn) pathology. A small but
Psychiatric Association, 1968, p. 10). In a sec- respected number of physicians, in the face of
tion of the manual on definitions of terms, no legal repression and criminalization, pressed for
specific definition of homosexuality is offered a slight variation on this theme: although homo-
beyond that for "sexual deviations": "This sexual preference was probably congenital, it
category [302] is for individuals whose sexual was not pathological. It was understood best
interests are directed primarily toward objects not as a deviation but rather as a variation from
other than people of the opposite sex .... It is
not appropriate for individuals who perform
deviant sexual acts because normal sexual ob- *Although the Harrison Act and subsequent court
jects are not available to them" (American decisions did effectively "demedicalize" opiate
Psychiatric Association, 1968, p. 44). This re- addiction, this condition was never defined clearly
as a medical disorder (Le., it was the subject of
affirms the important distinction in the psycho- no well-regarded medical theory or treatment),
analytic literature between "true" homosexuals and there were few champions for such medical
and homosexuality and those who, for a variety definition.
typical sexuality, produced by natural forces. An important nonphysician advocate of this

They strived to separate heritability of the congenital-variation argument was German
"condition" from pathology. Being inborn, jurist Karl Heinrich Ulrichs, himself a homo-
homosexual preference could not be a product sexual, who authored a wide range of polemi-
of will. We have noted throughout this book cal, analytic, and theoretical discussions on
that the notion of disease or pathology is implic- the topic for over a decade beginning in 1864.
it particularly in the clinical model of medicine. Most significantly, he proposed a congenital
Although these tum-of-the-century medical re- theory that homosexuals, or "Urnings" as he
formers wished to leave the moral protection called them, were persons whose physical sex
provided by congenitality undisturbed, they simply did not correspond with their own sexual
challenged the moral proposition of pathology. instinct. Urnings were men who had a "femi-
This is, we believe, the origin of what later nine soul enclosed in a male body"; later
was to become a growing challenge to the medi- medical writers adapted this to a "female brain
cal model itself. in a male body. " They were a "third sex" mid-
In about 100 years' time, from the closing way between males and females. Ulrichs in-
decades of the last century in Germany to the sisted that the condition was not pathological
early 1970s in the United States, we have wit- and that legal repression was both unfair and ir-
nessed this growing (although not linear) attack rational (Bullough, 1976; Symonds, 1931). His
on negative definitions of homosexual conduct ideas were widely influential in medical circles,
and preference. The church and state both have and many physicians (e.g., Krafft-Ebing) cited
been arenas for such challenges. In the latter his work.
half of the 20th century, medicine remained not The most consequential medical defender of
only steadfastly opposed to "normalization" the period was German physician Magnus
but in fact, as we have shown, advocated an Hirschfeld. Hirschfeld (1936b, p. 318) theo-
even stronger sickness view. It is not surpris- rized that the "sexual urge, normal and ab-
ing, then, to find psychiatry as the prime target normal, is the result of a certain inborn goal-
of such attacks. As we will show, the most striving constitution, influenced by the glands
successful battle was fought in 1973-1974, but of secretion." He reiterated Ulrich's notion
the war had been declared a century before. that homosexuals were' 'sexual intermediates. "
These first salvos, however, could hardly be Like Benkert and Ulrichs before him, Hirsch-
considered grave, since they came from a feld vigorously opposed legal and moral per-
friendly source: other physicians. secution of homosexuals and argued that the
cool wisdom of science be used to direct a more
The armor of pioneering defense: just and socially useful policy. He often testi-
"nature," knowledge, and fied in trials involving sex crimes and is
mediCine credited with "saving" many from prison and
The earliest physician-proponent of the view even death. Hirschfeld founded what might
that homosexuality was not pathological was be called the first homosexual civil rights orga-
the Hungarian Benkert, whom we identified nization in 1897, the Scientific Humanitarian
earlier as the inventor of the term "homosex- Committee. This body, whose motto was "Jus-
uality." He spoke out publicly as early as 1869 tice through Science," published an annual
against the growing Prussian repression of Yearbook for Intermediate Sexual Types that
males found gUilty of homosexual acts. In an contained a wide variety of information about
open letter to state jurists, he criticized impris- homosexuality and other forms of variant sex.
onment and fines for such persons as not only a The committee's goals were (1) to influence
contradiction of the most basic principles of legislatures to repeal the repressive Paragraph
human justice but scientific knowledge as well. 175 of the German Penal Code; (2) public
He named a long list of important historical education about homosexuality; and (3) "inter-
figures who were homosexuals as evidence of esting the homosexual himself in the struggle
its nonpathological nature (Lauritsen & Thor- for his rights" (Lauritsen & Thorstad, 1974,
stad, 1974). p. 11). Aside from his reputation as a scientist,
Hirschfeld-and the committee itself-was precluded equality. Friedlander's fear was in-
known widely as devoted to political action. deed realized during roughly this same period.
The most vigorous example was a 25-year When medical treatments for homosexuality
campaign that gained wide medical and pop- proved repeatedly unsuccessful, the congenital
ular support to repeal Paragraph 175. Signed theory was used as the foundation for the
by more than 6000 leading figures of the day, pessimistic notion of "hereditary degenera-
it was finally presented to the Reichstag in tion." Treatment based on this view tended
1922, from where it never emerged. The rise toward confinement and control. This concept
of Nazism in Germany signaled an even came to assume major explanatory significance
greater repression, and the movement for in the work of Krafft-Ebing and other physi-
homosexual normalization was brought to a cians supporting the pathology view.
standstill during this period. The last major tum-of-the-century challenger
Hirschfeld put great stock in the assumption to medical pathology (with the exception of
that knowledge was the key to progressive Freud) was English physician Henry Havelock
and humane attitudes toward homosexuals and Ellis, described as the first truly modem thinker
sexuality in general. He conducted what was on sexuality in the 20th century (Robinson,
the first nonclinical study of sexual attitudes 1976). Ellis sought first and foremost to de-
and practices in which he sent questionnaires scribe sexuality rather than to judge it. He was
to over 10,000 men and women (Hirschfeld, confident that homosexuality or "sexual in-
1936b, p. 318). The diversity of the responses version" was a congenital, inherited condi-
convinced him even more firmly that the meta- tion, and although he admitted the possibility
phors of sickness and pathology were, more of "exciting" environmental events, he re-
often than not, inappropriate descriptions of jected the weight placed on such experiences
sexually variant ,behavior and caused him to by Freud and psychoanalysis. His medical
question whether, indeed, there was even some- training is reflected in the taken-for-granted
thing that could be defined unequivocally as descriptions of inversion as "unfortunate,"
sexually "normal." Hirschfeld founded the In- "abnormal, " and an "anomaly." Ellis in-
stitute for Sexual Science in Berlin in 1918, sisted, however, that it was not itself a "mor-
which, until it was destroyed by the Nazis in bid" condition, except insofar as social hos-
1933, was a world center for information and tility could render it so. He found the doctrine
study of sex. of organic bisexuality a plausible but crude
All Hirschfeld's colleagues in the Scientific explanation of the emergence of homosexual-
Humanitarian Committee did not agree with his ity. It would give way ultimately, he believed,
etiological theory of homosexuality. One of to a more precise hormonal theoryl. True inver-
the most vocal critics, Benedict Friedliinder, sion was not amenable to medical treatment
established a splinter group in 1907 called The aimed at cure. The physician served best as a
Community of the Special. Friedlander rejected counselor who encouraged patients toward reo
Hirschfeld's theory of the biological origins of straint and self-discipline in a negatively pre-
homosexuality, and considered it "degrading disposed social world. It was "outside the
and beggardly . . . pleading for sympathy" province of the physician to recommend his
(quoted in Lauritsen & Thorstad, 1974, p. 50). inverted patients to live according to their
He cited anthropological evidence to support homosexual impulses . . . . " (Ellis, 1936, p.
a more culturally relative view of sexual prac- 1936, p. 342).*
tice in opposition to what he saw as the prison Ellis appreciated the influence of context
of biological determinism proposed by Hirsch- and intellectual-political predisposition in the
feld and others. The involvement of medical definition of inversion. After enumerating
authorities as experts on homosexuality of- various such definitions ranging from vice to
fended Friedlander, and he warned that con-
genital arguments brought with them more *Quotations from Ellis (1936) by permission of the
than a protection from political oppression: to Society of Authors as the literary representative of
be biologically "different" from the majority Havelock Ellis.
benefit, and from disease to "sport," Ellis uality were important advocates of social and
(1936) concludes insightfully: political reform. Their argument that homosex-
uality was a congenital condition, however,
There is probably an element of truth in more than
one of these views. Very widely divergent views was used by opponents as the basis for in-
of sexual inversion are largely justified by the posi- creased legal and medical controls. Ellis him-
tion and attitude of the investigator. It is natural self recognized this problem, although he at-
that the police-official should find that his cases are tempted to mitigate the evaluations inherent
largely mere examples of disgusting vice and in such medical terminology. "All ... organic
crime. It is natural that the asylum superintendent variations," he noted, "are abnormalities"
should find that we are chiefly dealing with a form (Ellis, 1936, p. 318). The argument that homo-
of insanity. It is equally natural that the sexual in- sexuals are organic anomalies but not patholog-
vert himself should find that he and his inverted ical simply did not win the favor of those in
friends are not so very unlike ordinary persons. We
charge of official legal and medical definitions.
have to recognize the influence of professional and
As medicine expanded its boundaries to include
personal bias and the influence of environment.
(p. 302)
a variety of deviant behaviors, the optimistic
hopes of these sympathetic reformers were
He might have added that physicians are also sacrificed (just as were Freud's ideas on pathol-
predisposed to "discover" inversion as a condi- ogy) in the name of "treatment," "cure," and
tion emerging from the body and that that is the "protection" of "normal" society.
itself an additional kind of "bias" - but such
comment would have perhaps dulled the in- Spreading skepticism: social
tended theme of moral tolerance for "natural change and social science
abnormalities" that he hoped to convey. research
Like his medical colleagues, Ellis used the Physicians were not the only ones speaking
case history to present data on the condition about homosexuality in the early decades of the
of sexual inversion. Unlike virtually all other 20th century, although their voices were the
such medical case histories, however, Ellis loudest and increasingly most respected. Grad-
chose to display people who, quite aside from ually, literary figures and historians not only
their homosexuality, were generally healthy, raised questions about homosexual civil rights
happy, successful, intelligent, and sensitive but also presented images of such persons that
human beings rather than the tortured and questioned the tenets of pathology and congeni-
neurotic figures that emerged from Krafft- tality. Paul Brandt in Germany, Edward Car-
Ebing's work. The people Ellis described were penter and John Symonds in England, and
not, on the average, consumed with the goal Irenaeus Stevenson (also known as Xavier
of "cure," that is, of becoming heterosexual, Mayne) in the United States addressed homo-
and they defended their moral character as sexuality sympathetically in their work (Bul-
equal-if not superior-to that of so-called lough, 1976, pp. 643-644; 1977).
normals. Ellis pointed out that the generally Public as well as professional interest in
positive picture of the inverts in his cases was sexuality increased dramatically in the first
probably due to the fact that none of them had third of the century, and a series of social
come from police files or psychiatrists' offices. changes created a growing awareness that sex-
They were drawn, in effect, from that "other" ual activity need not always be linked to pro-
population of homosexuals who rarely if ever creation. Vern Bullough (1977) suggests the
become known to the variety of "experts" following as providing particularly important
charged with their control. This contrast served arenas in which this independence could be
to emphasize the highly selective and unrep- seen and debated: developments and applica-
resentative nature of the clinical case history tions of contraceptive techniques and ideology;
as the basis for knowledge about larger popula- serious scientifi c, and gradually popular, study
tions. and appreciation of the virtually ignored sexual
These early medical apologists for homosex- interests and capacities of women; even more
dramatic scientific discoveries about the nature an unbridgeable gap between statements of
and control of venereal disease (syphilis, in fact and statements of value. He was particu-
particular); and an appreciation of the ominous larly disdainful of the traditional medical cate-
implications of overpopulation. In light of this, gories "normal," "abnormal," and "patho-
Bullough suggests the stage was set historically logical" and their effects on scientific under-
for more serious consideration and tolerance of standing:
alternatives to traditional sexual values and ac-
Nothing has done more to block the free investiga-
tivities. tion of sexual behavior than the almost universal
The KInsey studies. It was against the back- acceptance, even among scientists, of certain aspects
ground of these developments that Alfred C. of that behavior as normal, and of other aspects of
Kinsey and associates Wardell Pomeroy, Clyde that behavior as abnormal . . . and the ready accep-
Martin, and, later, Paul Gebhard, published tance of those distinctions among scientific men may
their monumental and sensational studies of provide the basis for one of the severest criticisms
sexual behavior in America. The first volume, ... of the scientific quality of nineteenth and early
Sexual Behavior in the Human Male, appeared twentieth century scientists. This is first of all a re-
in 1948, followed 5 years later in 1953 by Sex- port on what people do. which raises no question of
what they should do. or what kinds of people
ual Behavior in the Human Female. These pub-
do it. (Kinsey et al. , 1948, p. 7, emphasis
lications have had (and in many regards, con-
added) *
tinue to have) an enormous impact on what
Americans think about sex. Although similar It is this nonjudgmental spirit of the Kinsey
research had been conducted before Kinsey, * research that was such a dramatic break not
nothing of its scope or detail had been at- only from Freud and other psychoanalysts but
tempted. Kinsey and associates collected data even from his predecessor Ellis. The medical
from 16,392 men and women through an inter- heritage of pathology was simply inappropriate
view and survey (statistical analysis was done to understand the variation in social behavior:
on only 11 ,240-5300 males and 5940 fe- The term "abnormal" is applied in medical pathol-
males). Although Kinsey was criticized subse- ogy to conditions which interfere with the physical
quently because his sample was not completely well-being of a living body. In a social sense, the
representative of the American adult popUlation term might apply to sexual activities which cause
(Cochran et aI., 1954), never before had so social maladjustment. Such an application, however,
many people provided so much information involves subjective determinations of what is good
about their sexual lives outside the clinic or personal living, or good social adjustment; and these
the church. Even the authors of these studies things are not as readily determined . . . . It is not
were unprepared for the incredible variation possible to insist that any departure from the sexual
mores ... always, or even usually, involves a neuro-
in and incidence of sexual practice that they
sis or psychosis, for the case histories abundantly
found. Indeed, this theme of the infinite variety
demonstrate that most individuals who engage in
in human sexual response became central to taboo activities make satisfactory social adjustments.
their work. Kinsey (1948, pp. 638-639) argued (Kinsey et aI., 1948, p. 201)
that the traditional categories "heterosexual,"
"homosexual," and "bisexual" were but syn- Kinsey and his colleagues spoke with confi-
thetic mental constructs that covered an infinite dence, for they had thousands of ostensibly
variety of actual behavior. "healthy," functioning, sexual "deviants" to
Kinsey was first and foremost a scientist support them.
committed to painstakingly careful description
and classification. He believed that there was *Paul Robinson (1976) points out that Kinsey did
labor under a few preconceptions, some of which
were clear (e.g., a commitment to tolerance, the
norm of biologic naturalism, and science itself) and
*See Kinsey et al. (1948, pp. 21-34) for a review and others that were less so (e.g., Kinsey occasionally
evaluation of previous studies on sexual practices displays his own preference for the heterosexual
and attitudes. norm).
The Kinsey research addressed a variety of certain of these sources. Kinsey's data showed
sexual activities, but the data and conclusions that this cultural learning and socialization was
about homosexual conduct were among the not foolproof. Contrary to age-old social norms,
most consequential (their discussions of mas- a significant number of people, and apparently
turbation and female sexuality might follow in without dire psychological consequences, had
a close second and third place). They rejected engaged in a variety of such forbidden, homo-
the mysterious psychic processes and sexual sexual conduct.
"identities" that were the stock-in-trade of Following directly from this explanation was
psychiatry: homosexual conduct is any physical one of Kinsey's most startling conclusions
sexual contact that involves a person of the about homosexuality: it simply did not exist.
same sex (Kinsey et al., 1948, pp. 615-617). There were only homosexual acts and homo-
To their own admitted surprise, they found such sexual relationships; as an "identity" or a dis-
behavior considerably more common than they ease entity-as a "thing" independent of those
had expected. On the basis of the white male who constructed it as a category-it did not
sample, Kinsey (1948, pp. 650-651) concluded exist (Kinsey et al., 1948, pp. 616-617). It was
that 37% of the adult male population of the (in particular) a medical artifact rather than
United States had "some overt homosexual either a congenital or psychic condition of the
experience to the point of orgasm between human species. It followed directly that if ho-
adolescence and old age"; that 50% of the mosexuality did not exist either in people's
males who were still unmarried at age 35 had heads or bodies, it certainly could not be a prob-
had such experience; and that 4% of the white lem for explanation, unless such explanation
adult male population is "exclusively homo- would be of its origins and rise as a diagnosis or
sexual throughout their lives." That means, of social and cultural reactions to the conduct
Kinsey (1948, p. 623) interpreted, more than involved. What did exist was same-sex beha-
one male in every three that one passes on vior, which one could attempt to explain. *
the street has had an adult homosexual expe- Kinsey summarized what he and his colleagues
rience. Predictably, the incidence data for wom- (1953) believed to be the most important fac-
en were lower: 13% had had such an adult tors in such an explanation:
experience to orgasm; 26% still single at age 45 (I) the basic physiological capacity of every mammal
reported a, homosexual orgasm, and less than to respond to any sufficent stimulus; (2) the accident
3% of the women were exclusively homosex- which leads an individual into his or her first sexual
ual throughout their lives (Kinsey et aI., 1953, experience with a person of the same sex; (3) the con-
p. 487). The immediate effect of these data ditioning effects of such experience; and (4) the in-
was, of course, to hail such conduct as a fact direct but powerful conditioning which the opinions
of sexual life; quite aside from cultural ideals, of other persons and social codes may have on an in-
homosexual behavior clearly was not rare. dividual's decision to accept or reject this type of
Having documented such incidence, Kinsey sexual contact. (p. 447)
offered what he considered to be the only legiti- In short, homosexual conduct was learned and
mate explanation: it was a perfectly natural therefore a question of "choice" (Kinsey et al. ,
phenomenon. Human beings possess, like their
mammalian relatives, the biological capacity
for sexual stimulation. The particular source of *Kinsey himself, however, had difficulty avoiding
that stimulation (e.g., male, female, animal, usage of the terms "homosexuality" and "homo-
sexual" as typifications of individuals. His well-
self) in no way precludes and is biologically
known seven-point continuum ranging from "exclu-
independent of that capacity. The fact that we
sively heterosexual" to "exclusively homosexual"
develop strongly held ideas about the proper (Kinsey et aI., 1948, pp. 636-641) also contributes
nature of this source of stimulation is a testi- to what he elsewhere tried to avoid-the character-
mony not to nature but to culture and social ization of persons as types of sexual beings rather
values. Through learning cultural proscriptions, than reserving the use of such terms as adjectives to
we effectively come to deny the suitability of describe behaviors.
1948, p. 661). The fact that we are called on to special committee called to investigate homo-
provide an "explanation" of it is more a re- sexual "offenses" and prostitution. After meet-
flection of these larger social and cultural con- ing for over 2 months, hearing over 200 "ex-
straints than a testimony to its inherent patho- pert" witnesses, and considering the extant
logical nature. scientific research, the committee concluded
The conclusions of the Kinsey research did that "legislation which covers ... [homosexual
not stand alone. By midcentury a growing body acts in private between consenting adults] goes
of social science research took up the challenge beyond the proper sphere of the law's concern"
to the traditional morality of medicine. Support (Wolfenden Report, 1963, p. 43). The com-
was gathering for the proposition that sexual be- mittee added, significantly, that whatever ho-
havior on the one hand, and the way people mosexuality might be, it most probably is not a
choose to construe or define it on the other, are disease and that it fails to meet standard medi-
independent questions. Anthropological re- cal criteria for such designation (Wolfenden
search, in particular by Devereaux (19371 Report, 1963, p. 31). Although the essence of
1963), Ford and Beach (1951), Malinowski the committee report was not adopted officially
(1932,1955), and Margaret Mead (1949), dem- for about 13 years, * its moral tone signified and
onstrated that homosexual conduct both was contributed to a gradual redefinition of such
more common than had been suspected and, in conduct and how it should be regarded by the
some cases, was an institutionalized part of so- state. At about this same time, the progressive
ciallife. It became clear that such behavior was American Law Institute issued its Model Penal
"bad," "criminal," or "sick" only when Code that recommended similar decriminaliza-
judged so by certain sets of cultural or domi- tion of private consensual adult homosexual
nant subcultural values and norms. conduct.
In 1956 clinical psychologist Evelyn Hooker The seeds of a new, more tolerant, and popu-
(1956, 1957) directly addressed the question of lar rather than expert-controlled definition of
the psychological normality of homosexuals homosexual conduct had been sown and were
compared to heterosexuals. Using results from growing in America. They were about to
psychological tests and life histories, a panel of emerge into the sunlight and fresh air of public
psychiatrists was unable to distinguish the ho- view in the form of a political movement that
mosexuals from the heterosexual controls in demanded not only respect and equality before
terms of their emotional health. Hooker con- the law but also an official repudiation of what
cluded tentatively that homosexuality may be its advocates saw increasingly as the last barrier
"within the normal range psychologically" of to normalization: the medical argument that to
human sexual behavior. Chang and Block be a "homosexual" is itself a pathological con-
(1960) drew similar conclusions using scores dition. It is to the origins and development of
from a self-acceptance inventory. They con- this political movement that we now tum.
cluded that homosexuals were not suffering a
psychiatric pathology. * Rise of gay liberation:
The 1950s also witnessed the famous Wolf- Homosexually as Identity
enden Report in England. The report was pre- and life-style
sented to Parliament in 1957 as the result of a The rise of "gay liberation" as a cultural
theme and social movement in the United States
*This tradition of social science research on homo- similar to the struggles waged by women
sexuality has been extended significantly by recent and blacks may have been inevitable. Al-
work from The Institute for Sex Research (source of
the Kinsey studies). Weinberg and Williams (1974) *Decriminalization of private consensual homosex-
and Bell and Weinberg (1978) draw on an enormous ual acts between adults became law in England on
amount of observation and interview data to nullify July 21, 1967. See Alex Gigeroff (1968, pp. 82-95)
the simplistic assumptions inherent in traditional for a detailed recapitulation of the political life of
medical descriptions and explanations of such be- this committee recommendation and the debate that
havior and its authors. surrounded it.
though larger "enabling" social change must popular philosophy of personal freedom,
not be ignored, the seeds of this social and po- choice, and introspection: "Do your own
litical protest derive most probably from the thing"; ''I'm OK, you're OK." Indeed, "be-
particular contradiction of democratic ideology ing" a homosexual, rather than one who simply
and actual experience found in this country. engages in Kinsey's "homosexual acts," has
The irony of social movements is often such: become the core of an identity that is both
the preconditions for their emergence derive source and consequence of the political chal-
from the segregating, isolating, and discredit- lenge gay liberation represents. As sociolo-
ing definitions and treatment persons face from gists have long suggested (see Goffman, 1963;
the majority and those who steer its "official" Becker, 1973), and more recently demon-
morality. For homosexuals, this "different- strated specifically for "homosexuals" (Warren
ness," a sense of depravity, rejection, and in- & Johnson, 1972; Warren, 1974; Weinberg,
feriority ascribed by centuries of righteous, T. S., 1977; Ponse, 1978), identity and com-
law-abiding, and "healthy" heterosexuals, had munity are inextricably linked. The "healthy
produced covert enclaves of people who were, homosexual" (see Weinberg, G., 1972), just
at least intellectually, ready to challenge these as the morally flawed one we have discussed,
ideas and their guardians. This challenge and an is a social construction, a product of concerted
attempt to redefine homosexuality and homo- and conscious political activity. We will now
sexuals is what "gay liberation" in America discuss the origins and development of that
has been about. What had been historically a activity.
moral "cancer," homosexuality, was to be- Origins of the "homophile movement."
come at the hands of a largely self-interested The first groups of self-proclaimed homosex-
minority something natural, worthwhile, and uals in America were small, secret, and self-
good. The s~igma of the old meanings sur- help oriented. They used euphemistic names to
rounding "homosexual" had to be removed protect their real purposes. Although some of
and a new, more positive definition substituted. these existed in the United States before 1945,
Under these circumstances, homosexuals would they were short-lived. Between 1945 and 1950
gradually become "gay" and "proud" and several organizations dedicated to helping peo-
public (see Dank, 1971). ple arrested for homosexual conduct were
Underlying this transformation, however- founded that provided counsel and support.
and this is perhaps the center of the irony in- The membership of these service organiza-
volved-is the assertion that indeed there are tions was not exclusively homosexual but in-
homosexuals and there is something called cluded various professional and religious per-
"homosexuality" -the entity on which most sons committed to helping those in need. A
traditional moral opprobrium rested. But it has social-recreational group of homosexuals
become an entity morally transformed. Leaders (something then considered dangerous) existed
of movement organizations, supported by a in New York beginning in 1945. It was called
much larger population of sympathetic others, The Veterans Benevolent Association, had a
have deemphasized questions of etiology. They total membership of about 75, and lasted for
argue that, short of academic and rarefied sci- roughly 9 years. The West Coast witnessed
entific debates about sexuality in general, there similar developments, the first being the
is no particular importance in searching for the "Friendship Circle" in 1947. This group con-
cause of something that is good. Although the sisted of a few women who circulated a mimeo-
question of cause may remain important at the graphed paper called Vice Versa in the Los
individual, biographic level, redefinition has Angeles area. A somewhat larger and more
turned attention to what homosexuality is. It diverse organization, The Knights of the Clock,
has become a "sexual preference," an "iden- formed in 1949 and was committed both to ho-
tity" (or "role" [McIntosh, 1968]), and a mosexual and black equal rights (Humphreys,
"life-style. " 1972).
Such formulations capture and reflect the The early 1950s might be called the begin-
ning of "homosexual consciousness." In 1950 Evelyn Hooker (1967) and sociologists John
five men established The Mattachine Founda- Gagnon and William Simon (1967) contributed
tion in Los Angeles. They chose the name additional detailed portraits of the "homosex-
"Mattachine" in reference to medieval court ual community." Edwin Schur (1965), in his
jesters who spoke the truth to the royalty of the highly popular and influential Crimes Without
court from behind masks that protected their Victims, argued forcefully that the criminaliza-
identities (Humphreys, 1972). Such secrecy was tion of homosexual conduct in America led not
indeed important, for it was the period of the only to personal tragedies but also to police
Cold War, anti-Communism, and Senator corruption and a general lack of respect for the
Joseph McCarthy. Persons who engaged in law. The topic of homosexuality was becoming
homosexual acts were considered serious se- an increasingly salient one among the American
curity risks by the government and prime tar- middle class.
gets for Communist manipulation. The House Representatives of established religious de-
Un-American Activities Committee scrutinized nominations such as the Episcopal and Uni-
carefully the past records of those suspected tarian churches lent their support to the move-
of such conduct. ment for respect and equal rights for the homo-
Internal dissension about issues of national sexual. The Council on Religion and the Homo-
"loyalty" fractured the Mattachine Founda- sexual was formed in San Francisco in 1965,
tion. In 1953 it gave birth to the Mattachine and by the end of the decade some of these
Society and a smaller group that became orga- religious leaders became the strongest external
nized around publication of a magazine called advocates of legal and social reform (Bullough,
One. This magazine subsequently developed a 1976; Martin & Lyon, 1972). Organizations
rather wide and successful national circulation. concentrating on legal assistance and reform,
The Mattachine Society began publishing its such as Philadelphia's Homosexual Law Re-
own journal, The Mattachine Review, in 1955, form Society, Los Angeles' Homosexual In-
and a few chapters were established in larger formation Center, and New York's Council on
cities across the country. In 1955 the Daughters Equality for the Homosexual (Teal, 1971, p.
of Bilitis was founded by eight women in San 44), began at about this same time. Local, self-
Francisco. Organized to serve the interests of interested groups of homosexuals patterned
lesbians, the DOB (its popular acronym) grew after those in California and New York emerged
slowly and privately, supportive but indepen- in many of the middle-sized to larger cities
dent of male-dominated homosexual organiza- across the country, and a nationally circulated
tions. Soon, DOB began publishing The Lad- newspaper for the gay community, The Advo-
der, a magazine of information and support for cate, began publication in 1967. Even a special
lesbian women by lesbian women. The maga- religious organization, the Metropolitan Com-
zine and the organization, even more so per- munity Church (MCC), was founded in 1968
haps than The Mattachine Society, were suc- by a young fundamentalist minister in Los
cessful beyond their founders' most optimistic Angeles. A diverse, loosely-knit social move-
expectations (Martin & Lyon, 1972). ment for homosexual rights and respect was
These and similar kinds of activities through- growing. The first national coordinating orga-
out the United States became characterized as nization, The North American Council of Ho-
the "homophile" (meaning love of same) mophile Organizations (NACHO), was estab-
movement. The first popular (although some- lished in 1964, and The Society for Individual
what apologetic) attempt to describe the con- Rights (SIR) was formed in· 1966 by Mat-
ditions faced by homosexuals in the United tachine members in California impatient with
States was published in 1951, The Homosexual the cautious strategies of the parent body. SIR
in America: A Subjective Approach, by Donald began publishing a newsletter called Vector
Webster Cory (pseudonym of Edward Sagarin that carried analysis and criticism of treatment
who later became a sociologist-expert on homo- of homosexuals in American society (Hum-
sexuality and sexual deviance). Psychologist phreys, 1972).
As the 1960s drew to a close, the first chap- particular event is cited frequently as the dra-
ter in the story of gay liberation in the United matic crucible in which this new militancy was
States had been written. It was a period of im- forged: the "Stonewall rebellion" in New
portant organizational, and identity-forming York's Greenwich Village.
work by homosexuals in their own behalf. Al- PolHlcl of confrontation. The Stonewall
though the homophile movement, not unlike Inn was a small gay bar on Christopher Street
most social movements, was by no means with- off Sheridan Square in Greenwich Village,
out internal dissension (see Humphreys, 1972; sometimes called the "Mecca" for homosex-
Teal, 1971), there was agreement at least on a uals on the East Coast. On June 27, 1969, po-
highly positive, new definition of what it meant lice conducted a raid on the Stonewall premised
to be a homosexual. Franklin Kameny (1969), a on alleged liquor code violations. It was gen-
respected leader in the movement, captures erally believed in the gay community that such
the essence of this new socially constructed raids were in fact to harass and frighten homo-
identity: sexuals (Teal, 1971). The typical scenario was
for the management to be arrested, liquor con-
it is time to open the closet door and let in the fresh
fiscated, and the patrons unceremoniously and
air and the sunshine; it is time to doff and to discard
the secrecy, the disguise, and the camouflage; it is sometimes violently ushered out. Also typical
time to hold up your heads and to look the world was the patrons' passive cooperation. The re-
squarely in the eye as the homosexuals that you are, action of those in the Stonewall that night was
confident of your equality, confident in the knowl- dramatically different. They, quite literally,
edge that as objects of prejudice and victims of dis- fought back in the face of what they perceived
crimination you are right and they are wrong, and as unfair, corrupt, and inhumane treatment. In
confident of the rightness of what you are and of the a battle of fists, rocks, bottles, fire, and even a
goodness of what you do; it is time to live your ho- parking meter used as a battering ram, homo-
mosexuality fully, joyously, openly, and proudly, sexuals forced police to barricade themselves
assured that morally, socially, physically, psycho-
inside the bar until reinforcements arrived. It
logically, emotionally, and in every other way: Gay
is good. It is. (p. 145)* was a resistance for which police were clearly
unprepared. Over the course of the next several
The change from "homosexual" to "gay" in nights, street demonstrations and some violence
Kameny's passage is instructive. It represents between police and homosexual protesters and
a larger change in meaning and definition that their allies filled Sheridan Square. To the cheers
was taking place. "Gay" was used increas- of "Gay Power!" a new, aggressive, politi-
ingly to refer to a total life-style and a way of cally attuned, and youthful homosexual pres-
thinking about oneself and others (Teal, 1971, ence in America was born.
p. 44). Not unlike the change in usage from Two highly influential organizations grew
"Negro" to "black," and from "lady" to out of the Stonewall experience: the Gay Liber-
"woman," "gay" was intended to deempha- ation Front (GLF) and the Gay Activist Alliance
size the one-dimensional image imposed by (GAA). The GLF was organized about a month
traditional and particularly medical definitions. after Stonewall; it was avowedly militant and
In many regards, "homosexual" could be seen politically radical to revolutionary. Its aims
as itself an oppressive term that grew out of a were to "liberate" not only homosexuals but
need to defend rather than assert one's human all "oppressed" people suffering under the
rights. It was the eve of a new, considerably dominance of the "capitalist state." Many of
less deferential, and more militant struggle for the members of GLF were veterans of the some-
normalization. Although this mood did not times violent student antiwar movement of the
begin suddenly at the end of the decade, one 1960s. They argued that the condition of homo-
sexuals in American society was part of a gen-
*Franklin E. Kameny, "Gay is good," The same
sex: an appraisal of homosexuality, ed. Ralph W. eral exploitive relationship between American
Weltge (New York: The Pilgrim Press, 1969), p. economic and political interests and "the peo-
145. Copyright © 1969 United Church Press. Used pie." They insisted that only by drawing the
by permission.
various groups supporting "people's libera- "Gay Power" and was a product and reflec-
tion" together-gay people, black people, tion of the activist political climate of the late
prisoners, women, third-world people-could 1960s. It was celebrated on the first anniversary
true freedom be won. The revolutionary themes of the Stonewall confrontation by a public pa-
in GLF speeches and pamphlets were clear rade in New York, from Sheridan Square to
(see Teal, 1971). Central Park, in which several thousand homo-
The GAA was born about 5 months later, sexuals and their supporters participated. The
and although billing itself as "militant," its event became institutionalized as Gay Pride
leaders and members pursued a course devoted Day, and by 1971 it had attracted an estimated
to nonviolent confrontation and working "with- 5000 to 10,000 people in New York City (Hum-
in the system" for political and social change. phreys, 1972). It was a celebration but also a
It was devoted exclusively and solely to the public statement that the new definition of
realization of complete and equal homosexual homosexuality-at least according to these par-
civil rights in American society. Open to any- ticipants-was here to stay.
one sympathetic to this goal and structured Evidence that this new presence was being
around an active committee system, GAA's recognized and endorsed outside the gay com-
constitution delineated the specific rights these munity began to accumulate soon after Stone-
"liberated homosexual activists" demanded: wall. In September, 1969, the American So-
ciological Association adopted a resolution
The right to our own feelings .... to feel attracted condemning discrimination against persons on
to the beauty of members of our own sex and to em-
account of sexual preference (Teal, 1971). The
brace those feelings as truly our own, free from any
American Library Association formed a Task
question or challenge whatsoever by any other per-
son, institution, or moral authority. The right to Force on Homosexuality in 1970 to formulate
love .... to express our feelings in action ... pro- a change in library classification to remove the
vided only that the action be freely chosen by all topic of homosexuality from its then current
the persons concerned. The right to our own bodies. location under "Sexual Perversion." This
... to treat and express our bodies as we will, to change followed shortly thereafter (Spector &
nurture them, to display them, to embellish them Kitsuse, 1977). New college courses on homo-
. . . independent of any external control whatsoever. sexuality were being offered in a variety of
The right to be persons . . . . freely to express our disciplines across the country (Humphreys,
own individuality under the governance of laws 1972), and the National Institute of Mental
justly made and executed, and to be the bearers of
Health had at about this same time called a
social and political rights . . . guaranteed by the
special task force of experts, chaired by Evelyn
Constitution of the United States and the Bill of
Rights . . . and grounded in the fact of our common Hooker, to investigate and reevaluate existing
humanity. (Quoted in Teal, 1971, p. 126) knowledge and research on homosexuality (Na-
tional Institute of Mental Health, 1972). By the
Avowedly more liberal in philosophy than the end of 1971, five states-Colorado, Connecti-
GLF and dedicated to a single issue, GAA was cut, Idaho, Illinois, Oregon-had passed laws
to become the more popular and probably more to decriminalize private consensual homosexual
influential of these two organizations. Both acts between adults. In its December 31, 1971,
quickly became established in California and issue, Life magazine, a chronicle of popular
Chicago. Within a year's time five new news- taste in America, devoted 10 pages to pictures
papers emerged to reflect and extend this new and a story titled "Homosexuals in Revolt. "
sense of consciousness and community: Gay, An important component of the new defini-
Gay Power!, Come Out!, Gay Sunshine, and tion-that gay is good and healthy-was in
Gay Flames (Teal, 1971). By 1972, over 1000 direct conflict with the official medical view
local gay organizations existed throughout the and the vocal public statements of a handful of
United States. active psychiatric opponents. Given the de-
This new homosexual presence in America velopment of what appeared to be a trend away
was based on the slogans of "Gay Pride" and from such thinking coupled with the confronta-
tion strategy of GAA, it was only a matter of conference. A gay activist addressed the be-
time before this important bastion of tradi- haviorists, pointing up the significance of what
tional morality would be attacked. had happened:
Official death of pathology: large meetings such as the one you have had here
the American Psychiatric today happen in Los Angeles each year. Most of
them come and go and nobody but the families of
Association decision on
those involved know that they came . . . [but] we
homosexuality noticed you-and the Associated Press and United
Challenging professional control. With Press noticed you, and this little episode that we had
effective challenges to traditional religious and with you this morning is going out on the wires right
legal definitions of homosexual conduct under- now, and everybody in the country is being told that
way, gay activists began to focus attention on psychologists and homosexuals were talking together
the "helping" professions-those who for so and we think that's news. I would like to thank ...
the kind people who had the good sense to send the
longhad attempted to "cure" this illness. Pur-
police away. It would have been ... inconvenient
suing its dramatic strategy of public confronta- for us to have been in jail this weekend, but we were
tion, or "zapping" as it came to be called, gay prepared to do so. . . . We would, in tum, have
activists "liberated" (a movement term mean- charged you with disturbing our peace, as you have
ing to disrupt and reconstitute in "more appro- disturbed our peace 10 these many years. Because we
priate" form) a session of formal papers at the cannot and will not allow it to be disturbed any more.
annual meeting of the American Psychiatric This is the unique thing that the Gay Liberation Front
Association on May 14, 1970, in San Francisco does. We no longer apologize because we have noth-
(Teal, 1971). The particular target of this attack ing to apologize for. When we say "We're Gay and
was a presentation on "aversion therapy," a We're Proud," we mean it. We are proud! (Quoted
in Teal, 1971, p. 300)
popular form of behavior control used in the
clinical treatment of homosexuals. This treat- These challenges continued and were focused
ment in effect punishes emotional responses on the major spokesmen of the pathology view:
toward same-sex others (typically, with electric psychiatrists Bieber and Socarides and their
shock) and rewards positive responses toward supporters.
opposite-sex others. In a later session at the As a result of the 1970 American Psychiatric
same meeting, a gay activist shouted from the Association (APA) confrontation, five homo-
audience at Irving Bieber and his colleagues: sexual activists were invited to participate in the
panel "Life-Styles of Nonpatient Homosex-
You are the pigs who make it possible for the cops to
uals" at the annual meeting the following year
beat homosexuals: they call us queer; you-so polite-
in Washington, D.C. Coordinated by Kent
ly-cali us sick. But it's the same thing. You make
possible the beatings and rapes in prisons, you are Robinson, a Baltimore psychiatrist, the panel
implicated in the torturous cures perpetrated on des- consisted of Frank Kameny of the Washington
perate homosexuals. (Quoted in Teal, 1971, p. 295) Mattachine Society; Jack Baker, newly-elected
(and homosexual) president of the student body
This initial challenge to the medical establish- at the University of Minnesota; Larry Littlejohn,
ment view of homosexuality was clearly not to past president of the Society for Individual
be on its own "rational," scientific terms. Rights (SIR); Lilli Vencenz, active in lesbian
Similar confrontations were staged that year organizations on the East Coast; and Del Mar-
at meetings of the American Medical Associ- tin, a founder of the Daughters of Bilitis and
ation against Dr. Charles Socarides, a nurses' representing the Council on Religion and the
seminar on the East Coast, the national conven- Homosexual (Martin & Lyon, 1972, p. 249). In
tion of American psychologists held in Los addition to the panel, which as expected pro-
Angeles, and a conference on behavior modifi- duced stinging denunciations of the pathology
cation (real, 1971). Donn Teal, in his book The and cure doctrines, gay activists made their
Gay Militants, gives a detailed account of the presence known in a discussion of a paper by
closing of the "liberated" session at this last Dr. Bieber, a seizure of the podium by Kameny
at a general session at which time he outlined in homosexuals' lives is Thomas Szasz. In his
the implications for homosexuals of the disease 1970 The Manufacture of Madness, Szasz re-
view, and an attack on a company advertising pudiates such psychiatric diagnosis as a self-
and selling its aversion therapy technology serving facade for social control:
(Martin, 1971).
In stubbornly insisting that the homosexual is sick,
Dissent from within the psychiatric es- the psychiatrist is merely pleading to be accepted
tablishment. Dissent to the illness view did as a physician .... psychiatric opinion about homo-
not come from gay liberationists alone. Sig- sexuals is not a scientific proposition but a medi-
nificantly, some psychiatrists themselves were cal prejudice. (pp. 173-174)
beginning to challenge the views of Bieber,
Socarides, and others. Highly respected and He continues, using the metaphor of the Inqui-
influential psychiatrist Judd Marmor had edited sition to represent the parallel between psychia-
a scholarly collection of scientific writings in trists and inquisitors on the one hand and pa-
1965 called Sexual Inversion. The volume con- tients and heretics on the other, suggesting that
tained some classic works on homosexuality the disease view will not be relinquished with-
and represented the full range of scientific opin- out a struggle: "For an inquisitor to have main-
ion. In his editorial remarks Marmor (1965) tained that witches were not heretics and that
wrote the following: their souls required no special effort at salvation
would have amounted to asserting that there
we must conclude that there is nothing inherently was no need for witchhunters. . . ." (1970, p.
"unnatural" about life experiences that predispose 176). Seymour Halleck (1971), in his critique
an individual to a preference for homosexual object- of psychiatry, The Politics of Therapy, enumer-
relations except insofar as this preference represents ates the injustice done by the "myth" that
a socially condemned form of behavior in our cul- homosexuality is a disease:
ture and consequently carries with it certain sanc-
tions and handicaps. . . . In a very basic sense, Psychiatrists insist that homosexuality should be
therefore, our psychiatric approach to the problem treated as an illness [footnote to Socarides (1968)]
of homosexuality is conditioned by whether we come yet there is no convincing evidence that the homo-
to it as pure scientists or as practical clinicians. The sexual differs in any profound biological or psycho-
scientist must approach his data nonevaluatively; logical manner from the heterosexual .... there ...
homosexual behavior and heterosexual behavior are is no justification, even in terms of social expedi-
merely different areas on a broad spectrum of human ency, for thinking of consenting adult homosexual-
sexual behavior . . . . The clinical psychiatrist, on ity as an illness .... This behavior should be con-
the other hand, is by the very nature of his work, sidered a problem only if the homosexual wants to
deeply involved in concepts of health' and disease, see it as a problem. (pp. 107-108)
normality and abnormality. These concepts, how-
Finally, psychiatrist Richard Green (1972) con-
ever, are not absolutes, particularly in the area of so-
cludes his carefully reasoned scientific evalua-
cial behavior. (pp. 16-17, emphasis in original)*
tion regarding the illness status of homosexual-
ity:
Marmor argues, in effect, that what homo-
sexuality "is" depends primarily on cultural What I question . . . is the given state of "knowl-
and social context. To the clinician in Western edge" that homosexuality is by definition a "dis-
society, therefore, it becomes immediately an order," a "disease," or an "illness" ... that or-
undesirable condition at variance with the gasms between males and females are by definition
healthy norm of heterosexuality; that is, it is a better than between females and females or males
and males, that the components comprising the
pathology.
major factor, "love," are by definition superior be-
A considerably more harsh and irreverent tween males and females to between males and males
critic of psychiatric diagnosis and intervention or females and females. I am not convinced we have
the data by which to base these judgments. I question
* From Sexual inversion: the multiple roots of homo- them because they are not proved. (p. 95)
sexuality, edited by Judd Marmor, pp. 16-17, ©
1965 by Basic Books, Inc., Publishers, New York. These and other professional writings of the
late 1960s and 1970s make it clear that psychi- havior therapists at which a session was dis-
atric opinion on the question of homosexuality rupted and "liberated" by members of the Gay
was considerably more diverse than the pa- Activist Alliance, including a man named Ron-
thology advocates' work suggested. This disen- ald Gold. As the result of an encounter
chantment within psychiatry, coupled with (and with Gold after the meeting, Spitzer began a
likely in part as a response to) gay activists' series of discussions that culminated in a
confrontations and a growing public awareness presentation to nomenclature committee mem-
of homosexuals' experiences with psychiatry bers by a contingent of gay activists, including
(see Hoffman, 1968; Miller, M., 1971; Wein- Gold, in February, 1973. It is important to note
berg, G., 1972), set the historical and political that this presentation was tailored for its
stage for the official repudiation that was near audience: it was based on a careful and thor-
at hand. ough review of existing medical and scientific
After the 1971 meetings of the American research and writing; it was sensitive-even
Psychiatric Association, vice-president Judd empathetic-to the increased 20th-century
Marmor began to raise informally the question demand on psychiatry to solve a broad range
of dropping the diagnosis of homosexuality as of personal problems (the medicalization of
a psychiatric condition from the Diagnostic and personal troubles as well as deviance), and it
Statistical Manual. The 1972 annual meetings was offered in a polite but critical manner (see
of the association brought a dramatic event: a Silverstein, 1976). In what must have been a
gay psychiatrist, masked to protect his identity, rather embarrassing situation for the APA com-
spoke at a session on homoseXUality. That fall mittee members, GAA representative and psy-
two important developments began that were chologist Charles Silverstein (1976) catalogued
aimed directly at'removing homosexuality from the flaws in scientific methodology of most past
the APA nomenclature (Spector, 1977). medical research. The psychiatric disease theo-
PoIHlc. of official nomenclature. The ries simply had not been supported by systemat-
Social Concerns Committee of the Massachu- ic evidence, and treatment technologies, rang-
setts Psychiatric Society, a committee that rou- ing from standard psychotherapy to aversive
tinely had been considering such issues as conditioning* (see Chapter 8), had not been
drugs, the war in Vietnam, and abortion met evaluated critically. In a plea couched in the
to consider the question of homosexuality. Dr. language of reason and science itself, Silver-
Richard Pillard, a counselor of homosexuals stein (1976) concluded:
who had just recently announced his own homo-
I suppose what we are saying is that you must choose
sexuality to colleagues (Brown, 1976, p. 205), between the undocumented theories [and treatments]
urged the committee to adopt a statement in that have unjustly harmed a great number of people,
strong support of homosexual civil rights that, and which continue to harm them, or the controlled
in addition, stipulated: "Homosexuality per se scientific studies cited here and in our previous report
should not be considered an illness and APA to you. It is no sin to have made an error in the past,
nomenclature on this subject should therefore but surely you will mock the principles of scientific
be altered" (Spector, 1977, p. 54). The Massa- research upon which the diagnostic system is based
chusetts Society approved the committee's res- if you tum your backs on the only objective evidence
olution early in 1973, as did a regional associa- we have. (pp. 157-158)
tion, clearing the way for its appearance before These gay claims-makers were playing sophis-
all regional representatives at the national meet- ticated politics. By deciding to use not their
ing in May. At that time a controversy about own but rather their opponents' rules, that is,
wording arose, and the resolution was with- reason, science, and data, they risked being
drawn for more work. Sponsors, however, dis-
covered a simultaneous but independent devel- *Gerald Davison and G. Terence Wilson (1973)
opment aimed in the same direction. found in a 1971 study that among behavior therapists
(who in general are not physicians), some form of
Robert Spitzer, psychiatrist-member of the aversion therapy was the most preferred technique
APA Committee on Nomenclature and Statis- in attempting to change "homosexuals in the direc-
tics, had attended a Fall, 1972, meeting of be- tion of heterosexuality. "
challenged as amateurs in a professional world. their comments had been directed to and heard
The fact that their strategy was successful can by medical ears and, apparently, taken to heart.
be understood, we think, as a result of two con- After the nomenclature committee meeting,
ditions that characterized psychiatric definition chairman Henry Brill reportedly agreed that in-
and treatment of homosexuals at the time. deed some change seemed in order (Spector,
First, the scientific evidence for psychiatric 1977).
disease theories was indeed sketchy and incon- At the 1973 APA meetings in May, Spitzer
sistent. With the focus on this fundamental cri- organized a panel addressed specifically to the
terion of scientific evaluation and judgment- question "Should homosexuality be in the APA
evidence-the challengers knew their psychiat- nomenclature?" Participants, in addition to
ric audience would have to listen. When they Spitzer as presider, were three psychiatrists
pointed out the morally based nature of the sympathetic to the removal of the diagnosis:
medical diagnosis of homosexuality, this im- Robert Stoller, Judd Marmor, and Richard
balance between facts and values became pain- Green. Representing the disease view were Bie-
fully clear. Second, although they did not ber and Socarides. The only nonphysician was
address it specifically, we believe that an im- Ronald Gold, representing himself as well as
portant key to the successful challenge to psy- other gay people. The presentations by Stoller,
chiatric diagnosis was the lack of any notably Marmor, and Green were strongly in favor of a
effective treatment. Although the disease pro- changed classification. They were scholarly, in-
ponents we discussed along with others had tellectual, and premised on the legitimacy of
cited various "cure" rates as "significant," scientific argument and evidence. Marmor held
rarely did such rates approach or exceed 50% of that the "pathology" of the homosexual qua
those treated. Psychiatrists were, compared to homosexual came down to its contradiction of
their medical colleagues, relatively ineffective a culturally preferred pattern: heterosexuality.
in solving the problem of homosexuality, even Homosexuality in the absence of bona fide men-
when it was presented to them by guilt-ridden, tal disturbance was best conceived as a "life-
unhappy patients. Gay activists knew this, if style," and psychiatric diagnosis of it as a
only intuitively, and their keen political judg- treatable illness "puts psychiatry clearly in the
ment is seen in the brand of politics they chose role of an agent of cuLturaL controL rather than
to play with APA officials. It was the politics of a branch of the healing arts" (Marmor, 1973,
of science. Their strategy is a good example of p. 1209, emphasis added). The papers by Bie-
how the medicalization of deviance is political ber and Socarides were predictable. They gave
in both an obvious sense (e.g., lobbying, "log unequivocal support to homosexual civil rights
rolling," the use of influence) and in a more but held steadfastly to their earlier interpreta-
subtle, "expert" sense (e.g., adherence to the tions. They, too, appealed to evidence, objec-
rules of scientific evidence, winning the ap- tivity, and research. Activist Gold captured the
proval of an audience of scientific peers, and theme of his presentation in its title: "Stop It,
success in the practical task of solving people's You're Making Me Sick!" Gold said that his
problems). The ultimate success of gay critics only "illness" had come from what psychia-
may have been much more in doubt if the chal- trists had told him about "the way I love" and
lenge could have been launched only on the from social elaborations and amplifications of
former, more "crass" political plane.* But those dour medical judgments. Gold (1973, p.
1211) says. "It is amazing how I could have
* We speculate that if there were some highly effec- kept on believing this nonsense about homo-
tive medical technology by which the deviance of sexuality when so little of it had anything to do
homosexuality could be changed into heterosexual- with my life," and that "the worst thing
ity, gay activists would have been forced into a con- [about a psychiatric diagnosis] is that gay peo-
test of much less specialized and influence-domi-
ple believe it." In spite of this, he described
nated politics that they probably would have lost.
In addition, they would have been faced with the himself and many other homosexuals as happy
popular conclusion that if physicians could cure it, and healthy people due, in no small part, to the
homosexuality must then be a disease. gay liberation movement. He encouraged those
psychiatrists who opposed the disease view is one form of sexual behavior and, like other forms
to be as vocal and outspoken as its sup- of sexual behavior which are not by themselves psy-
porters. chiatric disorders, is not listed in this nomenclature
of mental disorder .... (Quoted in Spector, 1977, p.
In November, 1973, these papers appeared in
53)
the APA's American Journal of Psychiatry. In
the interim Spitzer had written a statement of The new diagnosis was to be Spitzer's "Sexual
his own that was also published. Although he Orientation Disturbance (Homosexuality)" and
was sympathetic to gay activists' and others' would replace line 302.0 "Homosexuality" in
calls for change, Spitzer (1973, pp. 1214-1216) the official diagnostic manual of the associa-
was not a crusader and did not himself hold the tion. * Gay activists hailed the decision as a
view that homosexuality is as "normal" as "major step" in the right direction, but oppo-
heterosexuality. Neither was he prepared to en- nents Bieber and Socarides had been working
dorse the "life-style" view of Marmor. In- actively in opposition to the change and were
stead, Spitzer chose to define homosexuality as prepared to continue the struggle.
"an irregular form of sexual behavior" and In the spring of 1973, Bieber had formed a
stated that, as such, it should not be considered committee of psychiatric colleagues sympathet-
a psychiatric diagnosis. He proposed instead ic to the illness view. He criticized the no-
the term "sexual orientation disturbance" to menclature committee for addressing a topic on
refer to such persons who are "troubled by or which none of its members were "experts."
dissatisfied with their homosexual feelings or His committee also denounced a report issued
behavior." He believed that the proposed by the National Institute of Mental Health Task
change would help mitigate the charge of some Force on Homosexuality (1972) on the same
psychiatrist-critics that psychiatrists were "act- grounds. Pathology proponent Socarides re-
ing as agents of social control" and that the sponded to the trustees' decision with a petition-
diagnosis itself had been the basis for the supported demand that it be subjected to a ref-
abridgement of homosexual civil rights. Steer- erendum of the entire association membership.
ing a course of appeasement, Spitzer closed by This relatively rare event (it had been used just
insisting that the proposed change would in no once before involving a position statement on
way repudiate "the dedicated psychiatrists and the war in Vietnam) was newsworthy and
psychoanalysts who have devoted themselves brought a good deal of embarrassing publicity
to understanding and treating those homosex- to psychiatrists across the country. Perhaps
uals who have been unhappy with their lot." never before had it been made so clear that dis-
They could now simply help those same ease is first and foremost what the medical pro-
"troubled" people under his proposed new fession says it is (Freidson, 1970a). The public
diagnosis. had a rare opportunity to witness the politics of
When the APA Board of Trustees met in disease designation in action.
December, 1973, to consider the nomenclature Three months of political campaigning by
committee's resolution (essentially Spitzer's both sides followed. A letter, drafted by Spitzer
position), they voted to adopt it with slight but and Gold and paid for by the newly formed Na-
important modifications, the most significant tional Gay Task Force (NGTF), was sent to
being that they simply deleted Spitzer's word all APA members. It endorsed the proposed
"irregular" in describing homosexuality. The DSM change, opposed the Bieber-Socarides
final text of the approved change of DSM-II view, and was signed by all candidates for APA
read as follows: offices. The referendum was part of the regular
election held in April, 1974. Slightly more than
This category is for individuals whose sexual in-
terests are directed primarily toward people of the
same sex and who are either disturbed by, in con-
* Robert Spitzer was chosen to direct the preparation
flict with, or wish to change their sexual orientation. of DSM-III, scheduled for publication in 1980. In
This diagnostic category is distinguished from homo- this newest version, "Sexual Orientation Distur-
sexuality which by itself does not necessarily con- bance" apparently has been changed to "Homo-
stitute a psychiatric disorder. Homosexuality per se sexual-Conflict Disorder" (Goleman, 1978).
58% of the 18,000 APA membership voted. Of Conflict Disorder" (Goleman, 1978). There is
those, 58% favored the trustees' proposed no comparable "Heterosexual-Conflict Disor-
change, 38% opposed it, and 4% had no opin- der" diagnosis, and it was never suggested seri-
ion (Hite, 1974). At this same election, Judd ously that being unhappy with one's sexuality-
Marmor, proponent of the life-style view of ho- except if it is homosexual sexuality-might be a
mosexuality, was elected association president. psychiatric diagnosis, a sickness. The bounda-
The National Gay Task Force, a newly formed ries of medical social control thus have not been
and middle-class movement organization, pub- erased, but rather more unequivocally drawn. *
licly endorsed the outcome as "strengthening The proposed "tonic" for such illness remains
our position all around" and urged that this new becoming heterosexual, that is, sexually nor-
medical position on homosexuality be used to mal. t And were the members so inclined, noth-
fight for complete human rights for gay men ing in the APA decision precludes a reversal at
and women. At least officially, preferred same- some later time; they retain final control over
sex conduct was by itself no longer to be con- official medical definitions and interventions
sidered an illness. It was a political victory that while at the same time receiving praise from
had indeed been a long time coming. liberal humanitarians and gays for their "sen-
sible" action.
Beyond sickness, what? One wonders also how widespread is the
Although these events must be regarded as popular support for the decision among Ameri-
still recent and their significance therefore dif- can psychiatrists. In a recent survey of 2500
ficult to judge, we comment on what this offi- psychiatrists, 69% said that they usually con-
cial change might mean for the social control sidered homosexuality a "pathological adapta-
of "homosexuality" and "homosexuals" in tion" rather than a "normal variation" (Lief,
American society. First of all, and somewhat 1977). In contrast to the optimism of Bieber
counterintuitively, it could be argued that the and Socarides, only 3% of this sample of psy-
APA decision does not represent demedicaI- chiatrists said that "in most cases" homosexual
ization as much as a more careful and patients could become heterosexual through
therefore more secure specification of legiti- treatment. Harold Lief (1977, p. Ill) provides
mate medical turf. As Thomas Szasz (1977) three possible interpretations: first, the APA
has suggested, the decision was made after all vote was cast in the name of homosexual civil
on APA terms-it was the activists that spoke
"scientese" to psychiatrists; who were invited * A common response to the referendum by psy-
by psychiatrists to speak. A gay psychologist, chiatrists, including those who supported the change,
was that now they and their colleagues could be
Brad Wilson, wrote and another gay psycholo- more effective in helping homosexuals who really
gist, Charles Silverstein, presented to the no- "need" and "want" help. Socarides is reported to
menclature committee the scientific case for have said that one good thing about the decision
changing the diagnosis. The decision was hailed was that more psychiatrists were aware of the prob-
as a "victory," a "major step" by gay leaders. lem of homosexuality and might therefore be more
willing to treat it rather than ignoring it as they had
But Szasz (1977) argues, "I think the homo- often done in the past (Hite, 1974).
sexual community is making a big mistake by t Treatment has now become the central theme of the
hailing the APA's new stance . . . as a real professional debate over homosexuality. Not surpris-
forward step in civil liberties. It's nothing of ingly, Bieber (1976) and Socarides (1976) counsel
the sort. It's just another case of co-opta- cure (heterosexuality), whereas a new set of oppo-
nents are considerably more skeptical (see Begelman,
tion" (p. 37). Critic Szasz (as well as Socarides 1977; Coleman, E., 1978; Davison, 1976; Freund,
[1976] himself) believes that the decision was 1977; Halleck, 1976; Silverstein, 1977). Even the
intended to get homosexual activists off psy- recently published and widely reported research on
chiatrists' backs. In fact, he continues, "they homosexuality by Masters and Johnson (1979), al-
have merely relented on where they draw the though giving unequivocal support to the nonpatho-
logical nature of homosexuality, devotes almost half
boundaries around homosexuality" (Szasz, of its pages to the question of treatment for "dys-
1977, p. 37). This is, of course, true. The new functional" and "dissatisfied" homosexual men and
diagnosis for DSM-III is to be "Homosexual- women.
rights rather than medical substance; second, Supreme Court allowed to stand a Virginia
those responding to the survey are an unrepre- court ruling based on an 18th-century law pro-
sentative group of psychiatrists; and finally, hibiting "crimes against nature" (Kittrie,
"psychiatrists' opinions on the matter have 1976). The case involved an adult male homo-
changed since 1974." sexual couple who argued that the law and its
Despite claims that the APA decision would enforcement against them was an unconstitu-
bring dramatic improvements in the social and tional invasion of privacy. Refusing even to
legal status of homosexuals, we suggest that hear the legal arguments of the contending par-
although there are notable signs of more permis- ties, the justices indicated that the state's pro-
sive attitudes, these changes have been less than tection of privacy simply does not extend to
dramatic. Although the data are as yet limited, such persons and conduct. There are only 23
certain information and events may be noted. states that have statutes specifically decriminal-
Sociologists Kenneth Nyberg and Jon Alston izing consenting adult homosexual conduct in
(1976) r.eviewed public attitudes toward homo- private.
sexual behavior in a 1974 representative sample Entertainer and religious crusader Anita
of United States adults. They found that 72% of Bryant has been catapulted into the national
their sample said that such conduct was "al- consciousness in her drive against the moral
ways wrong. "* Based on comparable data from "threat" of homosexuality. Aiming her initial
a 1960 study, they conclude that negative atti- 1977 crusade against a Dade County, Florida,
tudes toward homosexuality and homosexuals regulation prohibiting housing discrimination
have remained essentially unchanged despite on the basis of sexual preference, Bryant has
the increased public awareness and official re- led and/or inspired similar successful cam-
definitions that occurred during that period. paigns against gay people in St. Paul, Minne-
Norval Glenn and Charles Weaver (1979) com- sota; Wichita, Kansas; and Eugene, Oregon,
pared national attitudes toward homosexual and again in Miami under the banner "Save
relationships between adults from four surveys Our Children." In 1978, the city council of
between 1973 and 1977. In none of the sur- New York City defeated, for the seventh time
veys did the percent saying homosexual rela- in as many years, a gay rights amendment (The
tions are "always wrong" drop below 75%. Advocate, Dec. 13, 1978). Such campaigns
Glenn and Weaver (1979) conclude that "there appeal to ancient fears and ignorance about
is no indication in the data that a majority of same-sex conduct while glossing their inherent
American adults are likely to consider homo- violence with the patina of "Christian love";
sexual relations to be morally acceptable in the Bryant says, for example, "I love homosex-
near future" (p. 115). Journalist Grace Lichten- uals, but I hate their sin." Such "hardening"
stein (1977) reports the result of a July, 1977, (if in fact they were ever "soft") of attitudes
United States Gallup poll of adults in which toward homosexuals was epitomized in the
43% said "homosexual relationships between 1978 California elections by the Briggs Initia-
consenting adults should not be legal." Fifty- tive, or "Proposition 6." John Briggs, a con-
six percent of the respondents said they believed servative state senator, introduced a bill that
homosexuals should have equal job rights, but would have prohibited any public, self-defined
for the occupations of teachers and clergy, this homosexual from holding a position in the pub-
dropped to 27% and 36%, respectively. Final- lic school system. Until Californians began to
ly, Lichtenstein reports that 53% of the sample realize that the Briggs Initiative was a scan-
believed that homosexuals cannot be good dalous infringement of freedom of speech
Christians or Jews. In 1976 the United States (school personnel supporting homosexual rights
and freedom of sexual preference were also
threatened) and saw virtually every public figure
*The degree of this negative judgment decreased across the entire political spectrum oppose it,
rather dramatically with increased education of re-
spondents, their being of Jewish or no religious they apparently thought Proposition 6 might
preference, and among young, urban respondents well be a good idea. As late as August before
(Nyberg & Alston, 1976). the November election, a Field Company poll
showed approximately 60% of Californians in and others have pointed out, certain protec-
support of the Briggs legislation (The Advo- tions in being considered "sick" that simply
cate, Nov. 15, 1978). In the end, although it do not extend to the categories "criminal" or
was defeated, 42% of California voters agreed "sinner" -although the latter offers some hope
with John Briggs. These events can hardly be for the repentant. Our historical review shows
said to represent a widespread popular accep- that one of the greatest "buffers" between
tance of homosexuals as "healthy," nonthreat- homosexuals and state control at the tum of the
ening people. 20th century was physicians willing to argue
It is, of course, true that the ,APA decision that such persons suffered a disease over which
has made "homosexual" and "sick" no longer they had no control. In a social and cultural en-
"per se" (as the APA text reads) synonymous. vironment where same-sex conduct and its au-
It is public knowledge that psychiatrists, as rep- thors are fundamentally disapproved-where
resented by their major professional associa- moral judgments are made against them-a
tion, have voted the disease of homosexuality medical diagnosis, albeit itself oppressive, pro-
out of existence. Since physicians remain very vides nevertheless an official or Establishment
much in charge of what and who is "sick," protection against hostile crusaders and an in-
groups challenging unequal legal and social sensitive state. In short, if a behavior is demed-
practices can cite the authoritative APA deci- icalized but not vindicated (absolved of im-
sion in their defense. A new set of sympathetic morality), it becomes more vulnerable to moral
psychiatric "experts" on homosexuality have attack. As our discussions suggest, medicali-
emerged from the APA struggle while those zation has apparently increased in the face of
defeated appear to be losing their popular as political and moral repression of same-sex
well as professional appeal (see Spector, 1977). conduct; it may well be that as medical defini-
These new leaders can be expected to say that tions are detached from such still "unnatural"
homosexuality is "not necessarily" an illness, behavior, openly gay people may face political
but that only certain kinds of homosexuality fall controls that arise from the ballot box and legis-
within official medical jurisdiction-the types latures rather than the clinic. As Edward Saga-
that causes people "conflict." Finally, it rin (1976) suggests, the personal "costs" of be-
appears that more homosexuals are "coming coming a public homosexual may indeed be
out," perhaps encouraged by what the psychi- high. Some of the events of the late 1970s
atrists have done. The Advocate (Aug. 9, 1978) would appear at least to make this interpretation
reported that' 'literally hundreds of thousands" plausible. The image of the wise and knowing
marched, rallied, and celebrated during the physician treating the personal casualties of this
annual Gay Pride Week in 1978. New York "new era" as patients suffenng "Homosexual-
City mayor Edward Koch (a long-time defender Conflict Disorder" is one that brims with bitter
of gay rights) issued an official proclamation irony and paradox. We hope it remains only an
of these events in that city. Even the APA has image.
recognized its gay members. Begun in 1977,
the Task Force on Gay, Lesbian and Bisexual SUMMARY
Issues of the APA was an official part of the The moral prohibitions against homosexual
APA meetings in 1978 (The Advocate, Sept. 6, conduct are age-old. We have argued that this
1978). moral continuity has remained largely intact for
We must ask, however, what gay people over 2000 years, although its particular forms
have "won" in this alleged victory of demedi- have changed to reflect historical shifts in dom-
calization. What does it imply for an increas- inant institutions of social control. First, such
ingly visible minority (the gay movement urged behavior was sinful, then criminal, and then for
homosexuals to "Come Out!' ') that had been about the last 100 years, a sickness. Only re-
considered widely as sick and criminal and im- cently has this latter designation been chal-
moral to be declared no longer "sick"? We lenged by a movement striving for yet another
suggest that it leaves such persons still "im- definition, that of "life-style" or personal
moral," "bad," or "wrong." There are, as we choice. We have attempted to trace the his-
2t2 DEVIANCE AND MEDICALIZATION: FROM BADNESS TO SICKNESS
tory of this medicalization and challenges gress with one another." In other words, mas-
to it. turbation could lead to homosexual experimen-
Although religious proscriptions against tation and a life of ruin, disease, and vice. A
same-sex conduct date from the sixth century flood of popular medical pamphlets emerged to-
BC, its foremost spiritUal opponents were the ward the middle of the 19th century that offered
ancient Hebrews and early Christians. Much of "advice for the young" and their parents on
what is "sex negative" about Western culture how to curb this grave threat to manhood and
may be traced rightfully to the ideals and values national destiny.
espoused by these groups. All sexual conduct By the end of the 19th century a more careful
was defined against the only fully approved medical formulation of the causes of same-sex
standard: heterosexual procreative intercourse. conduct had been fashioned out of the popular
Homosexual conduct was clearly far off the hereditary ideas of the age. "Homosexuality,"
mark. It was "unnatural" because it contra- a term invented by a Hungarian physician in
vened God's obvious intent; it was sinful be- 1869, was believed to be the product of a con-
cause it was pleasure for pleasure's sake. It genital, hereditary weakness, a "degenera-
was, in short, a grievous wrong and has re- tion" of the nervous system that could be nei-
mained so throughout Christendom. ther remedied nor reversed. Although such per-
Canon law forbade same-sex conduct, and sons should not be punished for this pathology,
gradually as the Church and state became in- they should most certainly be prevented from
tertwined, the force of the latter was placed reproducing their kind. Increasingly, physicians
behind such norms. Throughout the Middle became the experts on same-sex conduct to
Ages such behavior became a "crime against whom others deferred. They portrayed such
nature" as well as a sin. The state, in persons as sad and tortured victims of a "trick"
effect, gave these religious rules "teeth" and of nature. Among the most influential of these
provided the machinery for controlling such be- empathetic but not sympathetic apologists was
havior in the name of these values. As early as forensic psychiatrist Richard von Krafft-Ebing.
1533 Henry VIII of England decreed such of- The medical model of homosexuality was
fenses to be capital and prescribed the supreme given new intellectual vitality in the 20th-
penalty. This tradition of harsh legal punish- century writings of Sigmund Freud. Freud op-
ment for "crimes against nature" -a category posed the congenital explanations of the 19th
that remained only vaguely specified-became century and proposed instead a psychogenic
the official inheritance of the West. theory based on the sexual experiences and re-
The 18th century witnessed the rise of a third lationships of childhood. Freud believed that
system for defining and controlling same-sex homosexuality was the product of an incom-
conduct: medicine. Crude by modern standards, plete or arrested psychosexual development in-
medical theories proposed that one's physical volving unresolved conflict between parents
and mental health were intertwined intimately and child. Most important for our purposes,
with one's morality. Sinful, and particularly Freud deemphasized the pathological quality
sexually sinful, behavior became not only of homosexual preference and conduct. Al-
wrong but also unhealthy. The moral strain though he agreed it was "no advantage," he in-
from knowingly engaging in immoral conduct sisted it was not a disease. His many followers
made such conduct doubly taxing. Throughout in psychoanalysis chose, by and large, to ignore
the latter part of the 18th century and particular- this conclusion and fashioned a set of medical
ly in 19th-century Victorian America, the sym- definitions and explanations that reemphasized
bol of this dangerous sexual excess was mastur- pathology and urged cure, which, of course,
bation. Masturbation was believed to cause all meant heterosexuality.
manner of physical and mental ailments, in- Among the most vocal and influential advo-
cluding insanity, if practiced habitually. One of cates of this pathology-cure view in the middle
the dangers of such activity among young men of the 20th century have been Edmund Bergler,
was that it could lead them into' 'the filthy con- Irving Bieber, and Charles Socarides, all clini-
cal psychoanalytic psychiatrists. Although all was the oppressive medical model of pathology
urged "humane" and "just" treatment for and medical treatment. Members of the Gay
homosexuals, they described them as "injustice Activists Alliance and Gay Liberation Front de-
collectors," "psychic masochists," living a manded that these physicians remove the label
"masquerade of life," and "handicapped." of sickness from their lives; they were "gay,
They voiced their positions in both scholarly happy, and proud. " After 4 years of confronta-
and popular media and were legitimated by tion and dialogue the American Psychiatric As-
the official support of the American Psychiatric sociation voted in 1974 to remove homosexual-
Association. ity "per se" from its diagnostic manual. In its
Resistance to the medical concept of pathol- place they would put "Sexual Orientation Dis-
ogy began almost as soon as homosexuality was turbance (Homosexual)" to refer only to those
invented as a medical diagnosis at the end of homosexuals who were unhappy with their
the 19th century. A small number of physicians sexuality. An old disease had been laid to rest,
argued that although it was true that the condi- but a new disorder had been created.
tion was inborn, it was incorrect to call it pa- The APA vote might well be seen as a victory
thological. It was rather best seen as simply a for gay people and as an instance of demedi-
natural variation. German physician Magnus calization. There are, however, persistent ques-
Hirschfeld and English physician Havelock tions that remain several years after this event.
Ellis made perhaps the most influential scien- First, homosexuality is still mentioned in the
tific arguments on behalf of this view. It was APA diagnostic manual; so the sense in which
not until after World War II, however, that demedicalization has occurred is somewhat un-
significant opposition to the medical pathology clear. Although the decision was hailed as a
view began to arise. Foremost among this op- blow for civil rights, the official political situa-
position was publication of the Kinsey studies tion for openly gay people in America has not
in the United States. Not only had Kinsey and improved dramatically. And although there are
his colleagues found much more adult homo- new experts to speak for the nonpathological
sexual conduct than they or others expected, nature of same-sex preference, the removal of
they argued that the medical notions of "natur- the protective cover of the sick role leaves the
al" /"unnatural" and "pathology" were sim- status of such conduct and persons in doubt. If
ply inappropriate to describe same-sex con- it is not a sickness, then what is homosexuality?
duct. It was merely a reflection of a natural and Whatever else it may be, we suggest it is still
universal human capacity. A growing number considered "wrong" or "deviant" by a sizable
of social science studies and social changes proportion of the popUlation. Self-interested
that encouraged appreciation of sexuality as an advocates of the life-style view are Jeft to de-
end in itself combined with Kinsey's research fend their position in a political world where
to create a new climate of nonmedical interest they enjoy only limited resources. The possibil-
and discussion around same-sex behavior. ity that the old definitions of such conduct and
At about this same time, and no doubt in re- persons might reemerge and be championed by
sponse to the stigma and repression we have powerful opponents should not be ignored.
discussed, homosexuals began to form self-
SUGGESTED READINGS
help and support organizations. In 1950 the
Mattachine Society was founded in California, Bullough, V. Sexual variation in society and history.
New York: John Wiley & Sons, Inc., 1976.
followed 5 years later by the Daughters of Bili- A detailed, encyclopedic historical discussion of
tis. This was the beginning of the "homophile "variant" sexuality from the origins of human
movement" - for dignity, equality, and civil societies to the present. Although various forms
rights. Buoyed by similar movements of the of such sexuality are discussed, most attention is
1960s, gay liberation was born. By the end of paid to homosexuality. It is an invaluable re-
source.
the decade, new, more militant groups of ho- Levine, M. P. (Ed.). Gay men: the sociology of male
mosexuals pursued strategies of confrontation homosexuality. New York: Harper & Row, Pub-
and challenge. Among their foremost targets lishers, Inc., 1979.
A collection of recent sociological writing and relate 1960s and early 1970s. Long quotations from
search on male homosexuality. Although it does movement people and publications provide the
not address the issue of medicalization at length, clear sense of ethos and direction of activist gays
it provides a well-organized review of some of the during this time. Unfortunately, it is out of print.
best sociological work on the topic. Weinberg, M. S., & Bell, A. P. Homosexuality:
Marmor, J. (Ed.). Homosexual behavior: a modern an annotated bibliography. New York: Harper &
reappraisal. New York: Basic Books, Inc., 1979. Row, Publishers, Inc. 1968.
An updated version of the important 1965 book Over 1200 bibliographic entries with brief, concise
also edited by Marmor. It is a collection of articles descriptions of content and findings. Although
from a wide variety of disciplines and professions slightly dated, this is a valuable resource.
and is intended to review the state of our present Wolf, D. G. The lesbian community. Berkeley: Uni-
knowledge about homosexuality and indicate diversity of California Press, 1979.
rections for future research. An ethnographic study of a lesbian-feminist com-
Teal, D. The gay militants. New York: Stein & Day munity on the West Coast. In addition to inter-
Publishers, 1971. esting insights about the contours and history of
A useful and highly detailed picture of the ori- this community, the book provides an up-to-date
gins and development of the most militant phase bibliography of important writings on lesbians in
of the gay rights movement as it developed in the America.
8 MEDICINE and CRIME
THE SEARCH for the
BORN CRIMINAL and the MEDICAL
CONTROL of CRIMINALITY
Richard Moran
INTRODUCTORY NOTE der. To obtain his release from prison, he

Medical and biological approaches to crime agreed to "reclamation treatment," a program
came into prominence in the middle-ta-Iate 19th designed to rehabilitate him in less than 2
century and continue to have their advocates weeks. The prison warden opposed the new
today. In this chapter Richard Moran traces the
"Ludovico Technique," which was said to
historical development of the medical and crimina-
logical search for the "born criminal." While the "tum the bad into the good." He believed in
early theories have been soundly discredited, Moran "an eye for an eye" and thought that the new
finds contemporary biomedical theories of "criminal treatment was unduly soft on criminals. But the
types" strikingly similar, although much more tech- orders had come from above, and he was
nologically sophisticated. He explores the emer-
powerless to resist them.
gence of medical and "therapeutic" methods used
to "treat" and control criminality, including various The aim of the new technique was to impel
forms of biotechnology, behavior modification, and a person toward the good by turning his natural
mind control. Although his discussion goes beyond inclination for evil against itself. Each time the
explicitly medical controls to include various psy- subject intended to behave criminally he would
chological technologies, we believe the latter are
also examples of the medicalization of deviance
become severely ill. The only way he could
and social control. Most significantly, he discusses regain a feeling of well-being was to change
the therapeutic or rehabilitative ideal in the treat- his behavior. In this way, the criminal would
ment of criminals and recognizes the potential for its be turned into the perfect citizen-the person
ascendance in the future. This chapter serves, in who must obey the law: the perfect Christian-
effect, as a transition from our historical perspective
the person who must turn the other cheek. Even
of the past five chapters to the more conceptual
analyses of the final two. the thought of killing a fly would make him sick
to his stomach. Speaking through the prison
P. C. and J. W. S.
chaplain, a weak and lonely figure, Burgess
In A Clockwork Orange, Anthony Burgess' drew the moral and ethical problem presented
by the new therapy. In the following passage
futuristic novel, Alex, an ultraviolent criminal,
the chaplain is addressing Alex (also known as
had been given a life sentence for rape and mur-
6655321) just prior to the reclamation treat-
ment:
DExpanded version of an article published in Con-
temporary Crises, 1978,2, 335-357, reprinted with It may not be nice to be good, little 6655321. It may
pennission of Elsevier Scientific Publishing Co., be horrible to be good. And when I say that to you I
Amsterdam. realize how self-contradictory that sounds. I know
215
I shall have many sleepless nights about this. What THE THERAPEUTIC IDEAL
does God want? Does God want goodness or the AND THE SEARCH FOR THE
choice of goodness? Is a man who chooses the bad BORN CRIMINAL
perhaps in some way better than a man who has the
good imposed upon him? Deep and hard questions, The notion that the state should function in
little 6655321. But all I want to say to you now is a parental and therapeutic role probably origi-
this: if at any time in the future you look back to
nated in the English common law concept of
these times and remember me, the lowest and
humblest of all God's servitors, do not, I pray, think
parens patriae. The king, through his chancel-
evil of me in your heart, thinking me in any way lor, the keeper of the King's conscience, was
involved in what is now about to happen to you. responsible for the care and protection of all
And now, talking of praying, I realize sadly that those unable to look after themselves because
there will be little point in praying for you. You are of physical or mental infirmities. The king's
passing now to a region where you will be beyond law included sanctions against behavior that of-
the reach of the power of prayer. A terrible terrible fended the public welfare and morals, as well
thing to consider. And yet, in a sense, in choosing as behavior that directly harmed individuals.
to be deprived of the ability to make an ethical In 17th- and 18th-century England, both the
choice, you have in a sense really chosen the good. criminal and the pauper were subject to the law;
So I shall like to think. So, God help us all, 6655321,
those convicted of a crime were sent to prison,
I shall like to think. (Burgess, 1963, pp. 97-
98)*
and those found to be paupers were sent to the
workhouse (Kittrie, 1971, p. 357).
Hence Alex, deprived of the ability to make The parens patriae power of the state re-
moral choices, ceased to remain a person. Some mained relatively unchallenged until the epoch-
may argue that what happened to him was making work of an untrained Italian jurist,
merely the consequence of his choice to commit Cesare di Beccaria. In July, 1764, Beccaria
a crime, that he got what he deserved. But published an essay, Trattato dei delitti e delle
it was much more than that. Government func- pene (Essay on Crime and Punishment), in
tionaries, who cared little for the "subtleties" which he made an extraordinary plea for the
of ethical questions, had used these so-called reform of European criminal law. So devastat-
therapeutic techniques for political purposes. ing was the 26-year-old Beccaria's challenge
As Dr. Brodsky, the chief technician, said in to the existing criminal justice system that he
response to the chaplain's complaint about decided to publish his now-famous essay
Alex's loss of moral choice: "We are not anonymously (Paolucci, 1963, pp ix-xi). In
concerned with motives, with higher ethics. We Trattato dei delitti e delle pene Beccaria, rely-
are concerned only with cutting down crime. ing heavily on the work of the French rational-
... " To which the minister of interior added: ists Montesquieu, Rousseau, and Voltaire,
"And ... with relieving the ghastly congestion proposed equal application of the law and the
in our prisons" (Burgess, 1963, p. 128). In the development of procedural safeguards. Al-
process of appealing to the public's fear though the Church of Rome denounced Bec-
of crime and violence to win reelection, caria for sacrilege and heresy, and officials in
they turned Alex, and by extension an en- Milan accused him of sedition, his essay was an
tire society, into "a clockwork orange"- immediate success. Its tightly reasoned argu-
something mechanical that only appears or- ments and its commonsense approach to the ad-
ganic. ministration of criminal justice engendered
enormous public support. Beccaria believed
that an individual could determine his own des-
*A clockwork orange, by Anthony Burgess. Copy-
tiny through reason and knowledge and that
right © 1962 by Anthony Burgess. Copyright © the desire to avoid pain and pursue pleasure
1963 by W. W. Norton & Co., Inc. With the pemlis- was the strongest motivational force (Mona-
sion of W. W. Norton & Co., Inc. chesi, 1955). Beccaria's Classical School of
MEDICINE AND CRIME 217
Criminology was concerned with the legal contour of the skull, it was possible to index the
concept of crime and punishment, not the study various mental characteristics of an individual.
of the criminal as a biological or social type. Gall originally catalogued 26 psychological
Placed against a background of a rampantly characteristics (Spurzheim expanded this to
abusive and blatantly arbitrary application of 35) that made up the emotional and intellectual
the criminal law, equal protection and the lim- portions of the brain. The emotional, or lower,
itation of penal sanctions to punish overt ac- propensities, such as combativeness, amative-
tions, rather than to enforce public standards ness, and destructiveness, were dominated by
of morals and virtue, became the wave of prog- the higher intellectual faculties of friendship,
ress for the next century. veneration, and firmness. Crime and violent
Becarria's dream was never to be fully real- behavior occurred, however, when one of the
ized. Biological explanations of crime and lower propensities, through an imbalance of
human behavior that had been popular since forces, came to dominate the personality, for
antiquity began to reassert themselves. Physi- example, the domination of amativeness led to
ognomy, the pseudoscience that judged a per- rape, and the domination of destructiveness
son's character by the structure and appearance led to arson (Fink, 1938, pp. 1-19).
of his face, was perhaps the first "scientific"
attempt to understand human behavior in terms Lombroso and the emergence of
of biology. It can be traced to Aristotle's (1809) a biological criminology
History of Animals of Aristotle and A Treatise Although phrenology enjoyed a tremendous
of Physiognomy. Aristotle argued that a person popularity in scholarly circles during the early
who had facial features resembling an animal's, part of the 19th century, by the middle of the
also had the temperament commonly associated century it had been eclipsed by psychiatry. The
with that animal. For example, if a person research for the "born criminal" received a major
sembled an owl, he was wise; if he resembled a push, however, with the work of Cesare Lom-
bulldog, he was tenacious; if he resembled a broso. * In 1864, while working as a physician
weasel, he was sneaky. At the end of the 18th in the Italian Army, Lombroso observed that
century John Caspar Lavater developed this many of the disruptive soldiers were tattooed.
concept to its fullest. He believed that the mind He wrote: "From the beginning I was struck
and body were interdependent and that the na- by a characteristic that distinguished the
ture of a person's soul was written on his face. honest soldier from his vicious comrade:
Lavater (1804) produced a detailed map of the the extent to which the latter was tattooed
human face, relating various shapes and struc- and the indecency of the designs that covered
tures to personality and character traits. Today his body" (quoted in Lombroso-Ferrero,
physiognomy is no longer given any scientific 1972, p. xii). Drawing on contemporary
credence-it is mostly practiced by fortune- scientific theories, Lombroso believed that
tellers at carnivals-but the notion the "face physical characteristics could be correlated with
mirrors the soul" is still held to, at some level, inward psychological traits. Therefore he
by a significant portion of the American popula- concluded that tattoos reflected the "primitive
tion (Dion, 1972). nature" of the troublesome soliders. Lombroso
At the beginning of the 19th century Franz was so stimulated by his initial observations
Joseph Gall and John Caspar Spurzheim pub- that he later conducted a thorough anthropo-
lished a two-volume work on the new science of metric study of convicts in Italian prisons.
phrenology. * Gall and Spurzheim theorized These early studies led him to conclude that the
that the brain controlled mental capacity and criminal could be distinguished from the non-
temperament, and by measuring the shape and
*For a description of the intellectual antecedents of
*For a description of Spurzheim's and Gall's work, Lombroso's work, see Gina Lombroso-Ferrero
see Fink (1938). (1972, pp. v-xx).
criminal by certain physical characteristics, America. In 1877 he published his famous

which he called stigmata: study, The Jukes: A Study in Crime, Pauper-
ism, and Heredity in which he traced the
deviation in head size ... asymmetry of the face;
genealogy of a so-called degenerate family.
excessive dimensions of the jaw and cheek bones;
eye defects and peculiarities; ears of unusual size, or While inspecting the county jail system for the
occasionally very small, or standing out from the state of New York in 1874, Dugdale noticed
head as do those of a chimpanzee; nose twisted, up- that many of the prisoners were blood relatives.
turned, or flattened in thieves, or aquiline or beak- On inquiring, he learned of a particular family
like in murderers, or with a tip rising like a peal (whom he called the Jukes) that seemed to have
from swollen nostrils; lips fleshy . . . excessive an unusual number of criminals, paupers, and
length of arms, supernumerary fingers and toes; degenerates. Dugdale traced the origin of this
imbalance of the hemispheres of the brain (asym- family back 150 years. Regarding their history,
metry of cranium). (Quoted in Wolfgang, 1960, p. he wrote:
181)
Between the years 1720 and 1740 was born a man
Because Lombroso believed that these stig- who shall herein be called Max. He was a descendant
mata closely resembled the characteristics of of the early Dutch settlers, and lived much as the
primitive people, he theorized that the criminal backwoodsmen upon our frontiers now do. He is
was a biological throwback, an atavistic being described as "a hunter and a fisher, a hard drinker,
unable to avoid criminality in a modern world. jolly and companionable, averse to steady toil,"
His theory of atavism was given apparent sup- working hard by spurts and idling by turns, becom-
ing blind in his old age, and entailing his blindness
port when in 1876, while working in the foren-
upon his children and grandchildren. He had nu-
sic laboratory at the University of Pavia, Lom- merous progeny, some of them almost certainly il-
broso performed a postmortem examination on legitimate. (Dugdale, 1910, p. 14)
a famous Italian bandit named Vilella. On com-
pletion of the examination Lombroso reported By 1874 Max Juke had approximately 1200
finding a peculiar depression at the base of the progeny, but only 709 could be fully traced.
skull, which he named, because of its location, More than 25% (I 80) had been paupers,
the median occipital fossa. This depression receiving state welfare benefits for a cumulative
was ordinarily found in the lower animals, total of over 800 years. At least 140 of the Jukes
being most developed in birds. In recalling the were convicted of crimes. Of these, 60 were
effect this examination had on his subsequent thieves, 7 murderers, 50 prostitutes (40 had
understanding of criminals, Lombroso wrote: venereal disease and were believed to have in-
fected 440 persons), and 30 had been prose-
This was not merely an idea, but a revelation. At the cuted for bastardy (Dugdale, 1910, p. 68).
sight of that skull, I seemed to see all of a sudden, From his study of the Jukes Dugdale con-
lighted up as a vast plain under a flaming sky, the cluded that although "hereditary criminality,"
problem of the nature of the criminal-an atavistic "hereditary pauperism," and "hereditary de-
being who reproduces in his person the ferocious
generacy" existed and were transmitted from
instincts of primitive humanity and the inferior ani-
mals. (Quoted in Wolfgang, 1960, p. 184) one generation to another, they were by no
means beyond the ability of the environment to
With the publication of L' Uomo delinquente modify and ultimately eliminate. And since
(Criminal Man) in 1876 Lombroso succeeded "vigor" was what separated the criminal from
in shifting attention away from the criminal law the pauper, hereditary crime was more amena-
and toward the scientific study of the individual ble to environmental manipUlation than heredi-
offender. The criminal became identified as a tary pauperism. Despite Dugdale's emphasis
"subspecies" or "type" distinct from rational on the role of the environment, the thrust of his
man, destined or born to be a criminal. study seemed to demonstrate that crime was
The search for the born criminal was taken inherited, and it was widely interpreted as
up the following year by Robert L. Dugdale, an such. Much to his chagrin, Dugdale's Jukes
Englishman who as a child had immigrated to lent considerable support to the eugenics
movement, which wanted to eliminate "un- were egotistic, and those convicted of violence
desirable stock" before they inflicted fur- had bad tempers. It was with respect to in-
ther economic and moral hardships on the telligence, however, that criminals were
country. most easily distinguished from non-criminals.
In 1913 Charles Buckman Goring, phys- With the exception of those convicted of fraud,
ician of His Majesty's Prisons, published The the criminal population was decidely inferior in
English Convict, a biometric study of more intelligence. Goring concluded his study by
than 3000 British prisoners. Although he stating that "in every class and occupation of
stressed the biological aspects of criminal be- life it is feeble mind and the inferior forms of
havior, Goring took particular issue with Lom- physique which tend to be selected for a
broso's concept of the "born criminal." Goring criminal career" (p. 268).
believed that criminals differed in degree but Johannes Lange approached the question of
not in kind from the general population. This the inheritance of crime by studying the crimi-
view led him to postulate the existence of a nality of twins. In 1929 he published Crime
"criminal diathesis" of "a constitutional pro- as Destiny. With the cooperation of the Ba-
clivity either mental, moral, or physical, varian Ministry of Justice, Lange located
present to some degree in all men, but so potent 30 pairs of twins, at least one of whom was
in some as to determine for them, eventually, in prison. In his sample Lange had 13
the fate of imprisonment" (1913, p. 26). In his monozygotic pairs (single-egg), or identical
exhaustive 12-year study Goring compared his twins, and 17 dizygotic pairs (double-egg), or
convicts to control groups of Cambridge and fraternal twins. If heredity did not play a role
Oxford students, University of London profes- in criminality, Lange theorized, then a com-
sors, and British Royal Engineers (soldiers), parison of identical and fraternal twins should
among others. He found that the prisoners did reveal no difference in their criminal behavior.
not differ strikingly from the controls: they If, however, identical twins were found in
showed no evidence of the physical stigmata prison together more often than fraternal twins,
associated with the Lombrosian criminal type. this would indicate that crime was inherited.
Such differences as did appear could be at- Furthermore, if not all the fraternal twins were
tributed to social class and occupational imprisoned, then a three-way comparison
choices. Goring found, however, that his among identical twins, fraternal twins, and
prisoners' heads were slightly narrower than ordinary siblings would yield a measure of the
those of the soldiers. He also found that relative importance of heredity and environ-
prisoner's (90% of whom were property of- ment in producing criminal behavior (Lange,
fenders) were shorter in stature and lighter in 1931, pp. 38-48).
weight than the general population, except Lange's findings seemed to confirm the
violent offenders who were taller and more heredity hypothesis. Of the 13 identical twins,
muscular (p. 175). Lange found in 10 cases that they were in prison
Goring took these differences in physique together. For the 17 fraternal twins, the other
to indicate that the criminal population was twin had been imprisoned in only two cases.
physically inferior. He attempted to explain These data led Lange (1931, p. 41) to conclude
the criminal's "inferior" physique by postulat- that "as far as crime is concerned, monozy-
ing that the physically weak would have less gotic twins on the whole react in a definitely
chance of avoiding the law by escaping appre- similar manner, dizygotic twins behave quite
hension. In addition, he argued that the sons of differently"; that, in short, "innate tendencies
criminals would inherit the "diminutive stat- play a preponderant part" in the causes of
ure" of their fathers. "In the course of genera- crime. This conclusion was apparently further
tion this would lead to an inbred physical differ- confirmed by the fact that both fraternal twins
entiation of the criminal classes" (1913, p. were only slightly more likely to be criminals
200). In relation to "mental" characteristics, than ordinary siblings. Since fraternal twins
Goring found that offenders convicted of fraud would probably have a greater uniformity of
220 DEVIANCE AND MEDIALIZATION: FROM BADNESS TO SICKNESS
social environment (if crime was predominantly As most textbooks in criminology have
influenced by environment), and one of the pointed out, professional reviews of The Amer-
twins was already in prison, it would be ex- ican Criminal were extremely critical. Although
pected that the other would be in prison as well. Hooton's 107 different anthropometric char-
Twenty-six years after Goring had repudiated acteristics were properly measured, they did not
Lombroso's doctrine of a criminal type, Ernest provide an adequate basis from which to theo-
A. Hooton, a Harvard physical anthropologist, rize. Hooton failed to establish an independent
published The American Criminal (1939). measure of the "inferiority" or "superiority"
Hooton introduced his 12-year-Iong study of of any of the traits he examined. He simply took
13,873 male prisoners in 10 states with an at- those traits which were more often found
tack on Goring's work, charging that it was in the prison population and labeled them infe-
based on unscientific research methodology. rior. He then used this measure of inferiority
According to Hooton (1939, p. 17), Goring had to explain criminality-an elementary research
distorted "the results of his investigation to error, and one not easily overlooked by pro-
conformity with his bias" and so he had not, fessional critics. For example, Edwin Suther-
in fact, repudiated Lombroso. Hooton argued land (1939a) lau nched an immediate attack
that the criminal population was biologically on Hooton's methodology, charging that The
inferior and that crime and antisocial behavior American Criminal "proves nothing and leaves
were almost exclusively caused by physical the controversy [over the role of heredity] just
and racial factors. where it was twenty years ago." Yet, Harvard
Much of Hooton's work was devoted to ex- University Press published a condensed ver-
plaining racial differences. He believed that the sion of the massive three-volume work for pub-
reason races differed in criminality was that lic consumption entitled Crime and the Man.
they differed psychologically, and psychologi- Hooton's lively style and the book's amusing
cal differences were the result of physical or ra- illustrations caught the public's imagination,
cial differences. For example, after dividing and his "scientific" confirmation of popular
Caucasians into nine racial types, he concluded prejudices against blacks and the lower classes
that the Pure Nordic type is "an easy leader in added greatly to its success.
forgery and fraud, a strong second in burglary In 1940 Hooton's colleague at Harvard, Wil-
and larceny, and last or next to last in all crimes liam H. Sheldon (with S. S. Stevens and W. B.
against persons" (Hooton, 1939, p. 249). The Tucker) published The Varieties of Human
dark-haired, round-headed, Alpine type ranked Physique. Building on the work of the German
first in robbery, whereas the East Baltic type psychiatrist Ernst Kretschmer, Sheldon sought
(Russians and Polish-Austrians) "takes first to chart the assumed relationship between the
place in burglary and larceny, and is notably human physique and personality and ability.
low in offenses against the person, except Like Kretschmer, Sheldon believed that peo-
rape." Among the Old American type, sex ple could be placed in one of three general cate-
offenders contain "a majority of shrivelled gories according to body type. The three cate-
runts, perveted in body as in mind, and gories were the endomorph, the mesomorph,
manifesting the drooling lasciviousness of se- and the ectomorph. According to Sheldon et
nile decay" (Hooton, 1939, p. 374). Both al. (1940), the endomorph had a "relati ve
Negroids (blacks with "white" blood) and predominance of soft roundness through the ...
Negroes "commit a great deal of homicide, body"; the mesomorph had a "relative pre-
they are parsimonious in sex offenses, and dominance of muscle, bone, and connective
perpetuate a modest amount of robbery. . . ." tissue"; and the ectomorph was characterized
As is true with Old American criminals, black by a "predominance of linearity and fragility. "
murderers tended to be "bigger and brawnier," Each type had an accompanying temperament.
whereas thieves were smaller, and bootleggers The endomorph was viscerotonic, that is, he
were "bulky, square-jawed, thick-necked, and was "characterized ... by a general relaxation
broad faced" (Hooton, 1939, pp. 385-386). of the body .... He loves comfort, soft furni-
ture, a soft bed." He was an extrovert with a works, and criminologists are not intellectually
"fondness for fine food." On the other hand, free from the legacy of the early attempts to
the mesomorph was somatotonic, that is, "weed out" the delinquent before he (for it is
"energetic . . . a person addicted to exercise usually boys that most people have been wor-
and relatively immune to fatigue." He was ried about) becomes an adult criminal.
often loud and aggressive, meeting adversity Although criminology has moved far beyond
with direct action. Finally, the ectomorph was such fledgling biological theories, the bio-
cerebrotonic, that is, an introvert. He kept his medical approach itself has evidenced a
problems to himself and was unable to relax marked resilience as researchers continue to
and "let go." He often suffered from "al- search for the so-called criminal type. During
lergies, skin trouble, chronic fatigue, and in- the past century the classical notion of "let the
somnia .... He is not at home in social gather- punishment fit the crime" gave way to the
ings and he shrinks from crowds" (p. 236). positive notion of "let the punishment fit the
In his later work, Varieties of Delinquent criminal." Instead of concentrating on the
Youth, Sheldon (1949) attempted to relate these development of a system of criminal justice
body types and accompanying temperaments in which the arbitrary powers of the courts
to delinquent behavior. He studied the somato- could be substituted for "the proper quantum
types of 200 juveniles at the Hayden Good- of punishment ... meted out for each quantum
will Institute, a rehabilitation center for de- of crime" (Geis & Bloch, 1967, p. 86), crimi-
linquents in South Boston, Massachusetts. nologists have searched for the causes of crime
From extensive testing of the boys, Sheldon in the environment or in the criminal's biologi-
(1949, p. 294) developed an "index of delin- cal endowment. The control and prevention of
quency." The index included such measures as crime has been sought in social welfare pro-
IQ insufficiency, medical problems, psychotic grams, often aimed at the detection, treatment,
problems, psychoneurotic traits, cerebrophobic and rehabilitation of offenders, both real and
delinquency (alcoholism and drug use), gyn- potential.
androphrenic delinquency (homosexuality), During the last 100 years the biomedical
and primary criminality (legal delinquency). understanding of crime has defined criminal
Sheldon quantified those factors according to deviation more and more in terms of illness.
degree. A composite score indicated a juve- With the absence of moral guilt, the definition
nile's scale of shortcomings or' delinquency of the criminal offender has changed from
potential. Sheldon (1949, pp. 107-108) related someone who has done bad (morally guilty
these scores back to the young boys' physiques; conduct) to someone who is bad or defective.
since both differed markedly from college Hence the offender must be treated rather
males, he drew the dubious conclusion that than punished. Yet, as Nicholas Kittrie (1971)
delinquency was inherited through the inher- has written: "As more groups of people
itance of predisposing physiques and temper- are exempted from the criminal law because
aments. they are too sick . . . to posses a mens rea
Sheldon's work led to a long progression of [what he calls "divestment"], the less effec-
prediction studies designed to identify potential tive the criminal law is in providing society
delinquents at an early age. Eleanor and Shel- with protection . . . " (p. 35). To protect the
don Glueck (see Wolfgang et aI., 1975) de- state from those "dangerously ill," it was nec-
voted a lifetime to unraveling the meaning of essary that the civil and administrative systems
prediction tables. Although they were the most of removal be expanded. Because these sys-
frequently quoted authors during the years 1945 tems, like the juvenile court, are supposedly op-
to 1972, the utility of their work has not been erated for the "good" of the individual as well
demonstrated. Today there is general agreement as the welfare of the state, the ordinary safe-
that criminality cannot be predicted with any guards built into the criminal law were consid-
reasonable degree of accuracy. The search con- ered inappropriate. The rights to counsel, jury
tinues, however, for a prediction table that trial, and protection against hearsay and illegal-
ly obtained evidence were not included. Crime appear to offer a more humane approach to the
became viewed as a medical or scientific prob- problem of crime. However, a brief look at
lem, in which the state employs medical experts penal history reveals that it was under the ban-
to control crime. This Kittrie (1971) has called ner of humanitarian concerns that involuntary
"the rise of the therapeutic state." Crime, sterilization of the mentally ill, the mentally
rather than being primarily a question of moral- defective, the epileptic, the sex offender, the
ity or politics, becomes a problem to be solved "degenerates," the syphilitic, and the so-called
by applying the allegedly neutral technology of hereditary criminal were undertaken. Lobot-
medical practice. omy, electric shock, and preventive incarcera-
tion of the "dangerous classes" were likewise
DANGER OF THERAPEUTIC practiced as preferable penal substitutes (Kit-
TYRANNY trie, 1971, p. 314). In an important and widely
The gradual transformation of crime into ill- cited paper, Edwin Sutherland (1950) recog-
ness opened up new possibilities for prevention nized the punitive and capricious nature of
and control. With medical science and tech- sexual psychopath laws, arguing that per-
nology acting for the state in the parens pa- sons were often incarcerated for life in security
triae (parental) role, seeking not to discipline hospitals under vague and futile mental health
through punishment but to rehabilitate or re- statutes. The danger of a therapeutic tyranny
make through treatment, the individual offender lies in the complete obfuscation and circum-
can be handled more in harmony with the re- navigation of the political, social, moral, and
qUirements of social defense. The new thera- religious conflicts that characterize a non-
peutic solutions to the age-old problem of crime totalitarian state. In place of this diversity a
were superior to social condemnation and penal monolithic health standard by which to judge
retribution as tools of social control and coer- human deviation is offered. Just as the criminal
cive conformity. In a non totalitarian state, law reflects clearly the values and interests of
political, social, moral, and religious values certain dominant groups in society, the emerg-
have served to moderate the operation and goals ing therapeutic state can be expected to pro-
of the criminal justice system through the tect the standards of "appropriate" or "nor-
recognition of individual rights. The rise of the mal" conduct and values of these same dorni-
therapeutic ideal made the "major point of con- nan t groups.
frontation between the parens patriae power To conceive of crime in medical terms is to
[of the state] and the rights of indi viduals . . . depoliticize and remove moral judgment from
less visible" (Kittrie, 1971, p. 303). The fact the behavior in question. Much as the label
that crime is a by-product of the conflict be- "crime" allows no attention to the social en-
tween those who make and enforce laws and vironment, "sickness" removes the offending
those whose behavior violates such laws will act and actor even farther from any political and
become further obscured by an overriding con- ethical context. Under this definition, crime
cern for the "health" and "cure" of the law becomes a question of the individual's ability
violators. Concern for health, especially com- to "adjust" ultimately to the status quo. Mal-
munity health, might justify governmental in- adjustment (crime) signifies illness; successful
tervention and the employment of coercive adjustment or conformity signifies health, and
corrective measures. As Thomas Szasz (1963) rehabilitation means readjustment. With the
notes: employment of the health-illness metaphor, a
person becomes accountable for who he is,
Health values are ... treated differently than ordi- rather than responsible for what he did: "crim-
nary moral, political, or religious values . . . . The
inal" becomes an identity rather than a be-
American people approve of the right of the
government to compel people to be vaccinated
havior. This was precisely the goal of Carl
against smallpox, for the unvaccinated person is a Schmitt, Nazi Germany's leading constitution-
potential danger to the community. (p. 5) al lawyer, when he proposed the theory of
a priori cUlpability. According to Schmitt, a
On the surface the therapeutic solution may criminal was not necessarily one who commit-
ted an illegal act, but one whose character and in corrections can be explained largely by its
personality rendered him a criminal (Schwab, failure to "correct" the criminal. When eval-
1970). Under a therapeutic approach to crime uated in terms of recidivism, the rehabilitative
the criminal law in Nazi Germany became approach has been an unquestionable failure.
little more than a tool for political coercion and In the past several years, however, advance-
oppression. As Stephen Schafer (1974) has ments in medical science and rapid tech-
observed: nological developments generated by the aero-
This approach attempted to find what was called
space program and the war in Vietnam have
the "normative type" of criminal, and the penal increased greatly the state's potential capacity
consequences of his responsibility would be de- to prevent crime and remake the criminal.
cided by the deviation of his personality-and not The development of biomedical techniques to
his actions-from the ideologically saturated and control crime is still in the experimental stage.
politically interpreted norm. Capital punishment Once such techniques become available for
under this concept would not necessarily be in- large-scale application, however, it is probable
flicted on a person who actually committed a murder, that the 'rehabilitative idea in corrections will re-
but on any individual who, in view of his total assert itself. The current antirehabilitation
personality, should be regarded as a "murderer forces are sure to raise their voices in protest,
type," regardless of whether he committed a homi-
and the "nothing works, lock 'em up" people
cide or not. (p. 23)*
are certain to become more adamant. Both
The danger of therapeutic tyranny lies in the groups will be silenced, however, by the prag-
fact that under a purely therapeutic approach matists, who, in pointing to the capability of
to crime, health standards and regulations can biotechnics to "correct" the criminal, will
become little more than tools for political coer- argue, "but it works."
cion and oppression. For example, the Nazi Since an exhaustive account of current bio-
leaders apparently believed it necessary to medical research might require several vol-
first define political opponents as mentally ill umes, it is perhaps best for our purposes to
before ordering their extermination. Psychiatric select a few areas that are particularly signifi-
experts diagnosed political offenders and mem- cant. A sociological and scientific critique will
bers of racial minorities as "inveterate German be presented, although no real attempt to weigh
haters" and dispatched them to killing centers or evaluate the relevant biomedical and bio-
(Alexander, L., 1949). This was, of course, technological evidence will be undertaken.
merely part of a larger policy of exterminating Instead, they will be described as a way of
all those who were deemed physically or men- calling attention to the capacity and skill the
tall y unfit. medical profession possesses for the modifica-
tion of our biosystem and to the technological
A CENTURY OF BIOMEDICAL capability of the state to monitor and alter
RESEARCH human behavior. Current biomedical and bio-
The therapeutic approach to the problem of technological research will be examined.
crime has met with limited success. Although The century-old belief in the efficacy of the
it allowed the state to expand its control therapeutic ideal has created a new branch of
of behavior by extending its parens patriae science called behavioral medicine. Funda-
power over juveniles, "defective delinquents," mentally this discipline involves the movement
"sexually dangerous persons," and others os- of the medical practitioner into the diagnosis,
tensibly in need of care, the therapeutic ap- prediction, and control of actions formerly con-
proach failed to prove an effective means of sidered to be social and behavioral problems.
rehabilitation. In fact, the current disillusion- Just as Philadelphia physician Benjamin Rush
ment with the therapeutic or rehabilitative ideal entered into the care and treatment of the
mentally ill with reckless abandon in the 18th
*From Schafer, S. The political criminal. New York:
Macmillan Publishing Co., Inc., 1974. Copyright
century (Baines & Teeters, 1943, p. 759),
1974 by The Free Press. A division of Macmillan today's medical practitioners are similarly mov-
Publishing Co., Inc. ing into the field of crime with the correspond-
ing overshadowing or ousting of the socio- modifying human behavior. In the insane
logically and philosophically oriented. This asylum at Prefargier, Switzerland, Dr. Burck-
medicalization of problem behavior, as has hardt removed a small section of the brains
been argued, has gained tremendous public and of six dangerous and psychotic patients to
governmental support. render them harmless to themselves and others
In attempting to explain why biological ex- (Chorover, 1974a). Burckhardt claimed success
planations of crime were so enthusiastically for his new surgical technique, but ethical ques-
met at the turn of the 19th century, Lindesmith tions raised by his colleagues forced him to dis-
and Levin (1937) pointed to their ideological continue his operations.
efficacy: Psychosurgery apparently disappeared as a
For more than a century before criminal anthropol-
medical procedure until 1935, when two Portu-
ogy came into existence society's responsibility guese physicians, Antonio Egas Moniz and Al-
had been recognized and embodied in the legisla- meida Lima, inspired by the work on chimpan-
tion of all civilized countries. It may be, that the zees by Americans Jacobsen and Fulton, per-
theory of the born criminal offers a convenient formed 20 prefrontal lobotomies in less than a
rationalization of the failure of preventive effort 3-month period (Chorover, 1974b). A year later
and an escape from the implications of the danger- Walter Freeman and James W. Watts intro-
ous doctrine that crime is an essential product of our duced psychosurgery into the United States.
social organization. (p. 670)* The two Americans developed the technique of
These comments are equally applicable today. cutting the frontal lobes of the brain by inserting
By encouraging the view that the problem of an ice pick-like surgical instrument through the
crime is rooted in the biological makeup of eye socket. Freeman and Watts' technique was
the individual criminal, the biomedical ex- termed a success, since it reduced the opera-
planation of human behavior-currently em- tion's mortality rate to 1.7% and markedly
bodied in the work of the sociobiologists-has limited the debilitating effects associated with
provided a scientific rationalization for the fail- earlier surgical procedures (Kittrie, 1971).
ure of the ameliorative programs of the 1960s. The medical profession gradually began to
Not only were the War on Poverty and the accept brain surgery as a possible treatment
crime-prevention programs it spawned destined for psychosis and severe depression. By the
to fail, but, as some have argued, it was a cruel early 1950s more than 50,000 people had been
trick to play on people who, because of their subject to irreversible destructive brain lesions
biological limitaitons, could never hope to to relieve symptoms thought to be associated
"measure up." with mental illness. The introduction of new
In addition, medicine was a prestigious behavior-modifying drugs into mental hospitals
mantle under which to introduce new theories and penal institutions in the middle 1950s,
and programs of intervention. For many years however, greatly reduced the amount of psy-
the public has assumed that coincident with the chosurgery. Today neurosurgeons perform
recognition of crime as illness there would fewer than 600 lobotomies a year (Breggin,
come obvious cures. Like the problem of polio 1973b).
in children, medical science would solve the During the past 5 years, both scientific and
problem of crime in the criminal; it would be ethical pressure have been directed toward the
only a matter of time and money. goal of establishing a moratorium on all
psychosurgery, especially on prisoners, mental
Psychosurgery and the control patients, and children under 10 years of
of violence age. In response to public and congressional
In 1890 Gottlieb Burckhardt performed the criticism, the National Commission for the
first modem brain operation for the purpose of Protection of Human Subjects of Biomedical
and Behavioral Research was created. The
*From Lindesmith, A., & Levin, Y. Am. J. Social. commission's charge was to recommend pol-
1937,42. Copyright 1937 by The University of Chi- icies outlining under what conditions, if any,
cago. psychosurgery was permissible. According
to Barbara Culliton (1976), writing in the pres- It is important to realize that only a small number of
tigious journal Science, most members of the millions of slum dwellers have taken part in the
Congress were against such brain operations: riots, and that only a sub-fraction of these rioters
"And it is probably fair to say that several, have indulged in arson, sniping, and assault. Yet,
perhaps most, of the 11 members of the Com- if slum conditions alone determined and initiated
riots, why are the vast majority of slum dwellers
mission approach their study of psychosurgery
able to resist the temptations of unrestrained vio-
with a negative bias" (p. 299). Yet the com-
lence? Is there something peculiar about the violent
mission adopted a report that encouraged the slum dweller that differentiates him from his peaceful
Department of Health, Education and Welfare neighbor? (p. 895)*
to support further research. Apparently im-
pressed by the increased efficacy of recent According to Mark, Sweet, and Ervin, the "real
surgical techniques in which only selected lesson" of the urban riots was the need to
areas of the brain tissue are destroyed, the "pinpoint, diagnose, and treat those with low
commission took the position that recent violence thresholds before they contribute to
advancements in the science of brain surgery further tragedies." They called for "early
had reduced the ethical problems normally warning tests" to screen the violence-prone
introduced by such a procedure. In sum, the from the normal popUlation.
commission argued that it was ethical to destroy The human species now dominates the earth. Our
a portion of a person's brain (1) if it is effec- greatest danger no longer comes from famine or
tive, (2) if it serves the advancement of science, communicable diseases. Our greatest danger lies in
(3) if the patient has been chosen for the right ourselves and in our violent fellow humans. In
reasons (his own good), and (4) if there is in- order to reverse the trend of human violence, we
formed consent. must set certain basic standards of behavior (e.g.,
Although psychosurgery has been known for "golden rule" or "Ten Commandments") that
any individual with a normal brain can follow. In
almost a century, it was not until the late 1960s
addition, we need to find some way to detect those
that it became openly advocated as a technique individuals with brain abnormalities who are un-
to quiet political protest and racial unrest in likely to be able to follow those standards. In other
America. In 1970, physicians Vernon Mark words, we need to develop an "early warning test"
and Frank Ervin published Violence and the of limbic brain function to detect those humans
Brain, in which they theorized that an unde- who have a low threshold for impUlsive violence,
termined number of recurringly violent people and we need better and more effective methods of
are suffering from undiagnosed brain damage. treating them once we have found out who they are.
Probably a minor form of epilepsy that cannot Violence is a public health problem, and the major
be detected by ordinary neurological examina- thrust of any program dealing with violence must
tions, this damage keeps the brain's deep limbic be toward its prevention-a goal that will make a
better and safer world for all of us (Mark & Ervin,
structures volatile and ready to erupt at minor
1970, p. 160, emphasis added).
provocations. Although little evidence is of-
fered to support their theory, the notion of a dis- Apparently the view that violence is a public
ordered temporal region in the brain being health problem is gaining recognition. The re-
responsible for violent fits of rage in a few indi- search reported in Violence and the Brain was
viduals is certainly feasible and worthy of supported by grants from the Department of
further research. When the authors apply their Health, Education and Welfare (The National
theory to social phenomena and begin to ad- Cancer Institute, The Social and Rehabilitation
vocate a government-supported program of Service, The National Institute of Mental
detection and surgical intervention, a problem Health), the U.S. Public Health Service, and
arises, and one with obvious political appeal. the Dreyfus Foundation; in short, the mental
For example, in 1967, Mark, Ervin, and a third health establishment (Mark & Ervin, 1970).
colleague, Sweet (1967), wrote to the Journal Since 1970 the Neuro-Research Foundation,
of the American Medical Association concern-
ing the more "subtle" causes of urban riots, *From l.A.M.A., 1967,201, 895. Copyright 1967,
that is, brain dysfunctions in the rioters: American Medical Association.
which is devoted to the "diagnosis and treat- The physical stigmata thought to be associated
ment of persons with poor control of violent with the XYY chromosome carrier were not
impulses" (Mark, Ervin and Sweet are its cited merely for their intrinsic interest. As will
trustees), has received a half million dollars become evident, these observations are impor-
to do the kind of research proposed in Mark tant to a historical critique of present biological
and Ervin's book (Breggin, 1973a). understandings of crime and the types of inter-
vention programs they suggest.
The XYY chromosome carrier The growing relationship between the men-
In 1965 Patricia A. Jacobs and her colleagues tal health and law enforcement establishments
at the Western General Hospital in Edinburgh is demonstrated in the work of Lawrence Raza-
published their findings on 197 mentally abnor- vi, a cytogeneticist from Massachusetts Gener-
mal inmates in a prison hospital in Scotland. al Hospital, whom Mark and Ervin acknowl-
Their work brought into prominence the theory edge for significant help in preparing the text
of a relationship between the XYY karyotype and bibliography for their chapter "Genetic
and crime. Although all the institutionalized Brain Disease." Razavi was the principal in-
inmates were described as "dangerously vio- vestigator for a I-year, $79,000 Law Enforce-
lent, .. only seven of the male inmates examined ment Assistance Act (LEAA) grant to study
were found to be of the XYY chromosomal whether dermatoglyphics (i.e., fingerprints,
constitution. The 3.5% was considered highly palm prints and footprints) can be correlated
significant because the general population is with abnormal chromosome constitution (XXY,
thought to contain only 1.3 XYY s out of every XYY) and violent behavior in prisoners (Hunt,
1000 live births (Jacobs et aI., 1965). J., 1973). The scientific rationale for such an
The Y chromosome was theorized to possess investigation is the fact that the skin and brain
an elevated aggressiveness potential, whereas originate from the same embryological source,
the X chromosome was thought to contain a the ectoderm. There is evidence among carriers
high gentleness component. Consequently, the of Down's syndrome that a unique and identifi-
addition of an extra Y chromosome presents a able palm print is associated with an abnormal
double dose of aggressiveness. The XYY male chromosomal constitution and mental retarda-
was considered a "double male," who is by tion. Hence screening dermatoglyphics may be
virtue of his chromosomal constitution doubly a way of detecting abnormal genetic constitu-
aggressive. In a carefully worded statement, tions. The LEAA was interested in Razavi's
Jacobs et a1. concluded that the presence of an work because "screening via fingerprints offers
extra Y chromosome appeared to increase the a cheap and efficient method to establish the in-
chances of an individual being institutionalized. cidence of chromosome aberration" (Hunt, J.,
Research has described such XYY males as 1973, p. 4).
being unusually tall (Jacobs et aI., 1965) and
mentally dull (IQ between 80 and 95) and hav- The Lombroslan recapltulallon
ing facial acne, abnormal electroencephalo- These current investigations are reminiscent
graphic recordings, and a relatively high occur- of the work of Cesare Lombroso. Although the
rence of epilepsy. Disorders of the teeth such as techniques and methods available today are su-
discolored enamel and malocclusion have also perior to the anthropometric methods available
been reported (Amir & Berman, 1970). Mary to Lombroso, current belief in the "born crimi-
Tefler has described the outward XYY symp- nal" does not differ markedly. Mark and Er-
toms as the following: vin's diseased amygdala has its Lombrosian
extremely tall stature, long limbs with strikingly counterpart in the median-occipital fossa. Mark
long arm span, facial acne, mild mental retardation, and Ervin (1970, p. 108) contend that because
severe mental illness (including psychosis), and ag- artificial electrical stimulation of the amygdala
gressive, anti-social behavior involving a long his- initiates rage and aggression in human patients,
tory of arrests, frequently beginning at an early age. those with a malfunctioning amygdala have a
(Quoted in Fox,. Richard, 1971, p. 62) "low threshold for impulsive violence." Both
theorists point to epilepsy as a cause of crime. In nature, through the processes of natural selection,
Lombroso believed that epilepsy was the "bond the penalty for lack of adaptation is elimination. The
that unites . . . the moral imbecile [the insane true criminal by the absence or deficiency of the basic
criminal] and the born criminal in the same altruistic sentiments similarly demonstrates his "un-
fitness" or lack of adaptation to his social environ-
natural family" (Wolfgang, 1960, p. 188).
ment. Elimination from the social circle is thus the
Mark and Ervin (1970, p. 65) believe that tem-
penalty indicated. In this way, the social power will
porallobe epilepsy is "causally related to poor effect the artifical selection similar to that which na-
impulse control and violent behavior." Dr. ture effects by the death of individuals inassimilable
Razavi's dennatoglyphics are similar to the an- to the particular conditions of the environment in
atomical measurements that characterized the which they are born or to which they have been re-
works of Gall, Goring, Hooton, Sheldon, moved. Herein the state will be simply following the
Spurzheim, and others. Jacobs' and Tefler's example of nature. (Allen, 1960, p. 265)
work invites comparison with the physical stig-
Similarly, Ernest Hooton (1939) contended
mata of Lombroso. that prisoners showed a definite physical in-
All three approaches are theoretically close
feriority that makes it necessary that the "crim-
to the so-called bad genes studies at about the
inal stock" be eliminated. Only by sterilizing
turn of the 19th century, inasmuch as they pos-
these "defective types" and breeding a better
tulate an inherited or genetic predisposition to race is it possible to check the growth of crim-
crime and violence. Dugdale's The Jukes, pub- inality. Charles Goring (1913) believed that the
lished in 1877, and The Kallikak Family by
"real cure" for crime lay in the regulation of
Henry H. Goddard, published in 1912, are per-
the reproduction of those traits associated with
haps the two most famous examples. In his re- the criminal diathesis, namely, feeble-minded-
port Goddard argued that feeble-mindedness,
ness, epilepsy, insanity, and defective social
not criminality, is inherited, but the feeble- instinct.
minded are well-fitted by nature to commit In this tradition Mark and Ervin (1970) called
crime. Similarly. the "new Lombrosians" be- for the establishment of a prison hospital in
lieve that many criminals are biologically pre- which to study the sociobiology of violent per-
disposed to crime and violence and that modern sons. They write:
scientific technology can provide the means for
their identification. This "sign" of criminality, In our view, the best way to go about gathering the
contrary to Lombrosian theory, is not engraved information we so desperately need about violence
on their countenances, but rather is outlined in is to start with a sociobiological study of violent per-
sons. This study must be aimed at (1) establishing
their fingerprints, footprints, and palm prints,
the physical and social causes for such behavior; (2)
or in the temporal lobe region of their brains, or developing reliable early-warning tests for violence;
in the constitution of their sex chromosomes. (3) assessing presently available methods of treat-
Science can thus tell the good people from the ment, including medical and surgical therapies; and
bad, but more sophisticated instruments than (4) establishing community facilities to help violent
the naked eye are required. persons-facilities that also might be used for med-
In a sense, all theories of criminal behavior ical and sociological studies.
contain the assumptions from which programs Two kinds of facilities are necessary for any such
of social control and defense may emerge. investigation. One is a place to house the individuals
Medical understandings ordinarily give rise to being studied; the other is a medical center staffed
biomedical programs of intervention. For ex- with specialists in the field of neurology, psychiatry,
neurosurgery, psychology, and genetics. Of necessi-
ample, Lombroso's disciple Raffaele Garofalo
ty, these two institutions should co-exist-as they do
grounded his suggestions to combat crime in not today-and must be set up so that the safety of
social Darwinism. His emphasis on the biolog- the community is not jeopardized by the violent pa-
ical deficiency of the criminal resulted in a pol- tients. This means a building with a particular kind of
icy of punishment and treatment that made physical construction, and a staff of physicians,
eliminating the criminal of primary impor- nurses, and attendants who are capable of dealing
tance. with the violent behavior of the inmates.
Ideally, this kind of study would be made on two to treat behavioral problems (Roblin, 1975).
groups: Individuals self-referred to the general hos- This procedure will undercut the experimental
pital because of inability to control destructive im- validity of the study, rendering its research find-
pulses; and individuals who appear before the courts ings almost meaningless. Even if a higher inci-
who have committed violent anti-social acts. (pp.
dence of violence and sexual deviance is found
156-157)
among the XYY and XXY individuals, there
Likewise, the XYY chromosome theory has would be no way of telling whether it was
given rise to newly proposed programs of early caused by a chromosome aberration or if it was
warning and corrective thearapy. For example, merely the result of self-fulfilling prophecy.
in 1970 Dr. Arnold Hutschnecker, one of Presi-
dent Nixon's personal medical advisors, pro- BEHA VIOR MODIFICATION
posed a massive program of chromosomal In 1913 American psychologist John B. Wat-
screening and psychological testing for every 6- son published "Psychology as the Behaviorist
year-old in the country. The policy was aimed Views It," in which he argued that human be-
at detecting evidence of criminal potential. He havior occurs in response to stimuli from the
suggested that "hard-core 6-year-olds" be sent environment, conditioned over a period of time.
to "therapeutic" camps where they could learn Watson believed that since behavior was the re-
to be "good social animals." The White House sult of external stimuli, it could be predicted
sent the plan to Elliott Richardson, Secretary of and controlled without reference to internal
Health, Education and Welfare (HEW), for mental states or processes. In the early 20th
consideration and polishing. HEW turned down century, professional psychology was exclu-
the proposal because it was not feasible to im- sively the study of consciousness, with the
plement on a national scale at that time (Hunt, method of introspection its primary tool. Wat-
J, 1973). son asserted, however, that a knowledge of
In 1968 Stanley Walzer, a psychiatrist at the such subjective states was not necessary for an
Harvard Medical School, and a colleague, Park adequate understanding of human behavior.
Gerald, a geneticist at the Boston Hospital for He urged psychologists to redefine their disci-
Women, began karyotyping the sex chrom- pline as the study of overt behavior, with exclu-
osomes of all newborn male infants. Their tag- sive attention devoted to the examination of ob-
ging of the newborn males continued until June servable acts.
20, 1975, when public pressure brought to bear As the first explicit statement of the doctrine
by the Boston-based organization Science for of behaviorism, Watson's work attracted con-
the People and the Washington-based Chil- siderable attention. In 1920 he founded the be-
dren's Defense Fund forced the curtailment of haviorist school of psychology and began work
the screening portion of the study. Walzer and on a number of important experiments, the best-
Gerald, however, plan to continue the psycho- known of which were on an II-month-old baby
logical testing and behavioral analysis. For the he called "Little Albert." While the child was
next 20 years researchers will visit the homes of amusing himself, Watson introduced a white rat
the so-called affected children two or three into his play space. Little Albert's "natural"
times a year to record the parents' detailed de- response was to pick up the rat and cuddle it.
scriptions of their son's behavior and to admin- After Little Albert had played several times
ister a series of psychological tests to these chil- with the rat, Watson began to aversely condi-
dren. In addition, teachers will be asked to tion him. Each time the infant was allowed to
complete a questionnaire concerning the child's see the rat, Watson made a loud and frightening
sexual and aggressive behavior (Roblin, 1975). noise. Soon the child came to associate the aw-
The project is distinguished by the fact that it ful noise with the appearance of the rat and
combines scientific research with a program of would cry when the animal appeared. In this ex-
therapeutic intervention. Parents will be in- periment Watson (1930) believed that he had
formed if their child carries a sex chromosome demonstrated the new principles of condition-
abnormality, and they will be counseled on how ing.
In Russia, Ivan Pavlov, a contemporary of logical gambler exemplifies the result. Like the pi-
Watson, developed what became known as geon with its five responses per second for many
classical conditioning. In a number of famous hours, he is the victim of an unpredictable contin-
experiments on dogs, Pavlov showed that not gency of reinforcement. The long-term net gain or
loss is almost irrelevant in accounting for the effec-
only voluntary responses like Little Albert's,
tiveness of this schedule. (p. 104)*
but involuntary responses as well, could be con-
ditioned. Pavlov began by observing that dogs Skinner extended his experiments to the higher
would salivate when food was placed in their animals, eventually eliciting from them almost
mouths. He called food an unconditioned (nat- any behavior he desired. Taking his cue from
ural) stimulus that elicited the unconditioned Watson's notorious statement "Give me the
(natural) response of salivation. Pavlov found baby, and I'll make it climb and use its hands
that when the bell was rung before the dogs in constructing buildings . . . . I'll make it a
were given food, eventually the sound of the thief, a gunman, or a dope fiend. The possibili-
bell alone would evoke salivation. In Pavlovian ties ... are almost endless," Skinner decided
terms, the originally "neutral" stimulus of the to apply his techniques to the socialization of
bell became a "conditioned" stimulus that elic- children. He constructed the famous "Skinner
ited the "conditioned" response of salivation box," or baby tender. So strong was his belief
(Pavlov, 1927). in the efficacy of the baby tender for bringing
Beginning in the 1930s, Burrhus Frederick up children that he committed his daughter to it
Skinner, an American psychologist, introduced for most of her early years. Skinner's success
the theory of operant conditioning. The central with his daughter was more limited than his
concept of operant conditioning is that of the success with his pigeons. She was reported to
"reinforcer." In its most common form, a rein- have been rebellious in school and to have ex-
forcer or reward is given to the subject each perienced considerable emotional difficulties
time he produces the desired behavior. The re- during adolescence (Bowart, 1978).
inforcer is made contingent on the correct re- Programs of behavior modification have be-
sponse. The response is known as the operant. come a significant part of the biomedical con-
The person must "operate" on his environment trol of crime and social deviance. Although be-
to receive the reinforcement Operant condi- haviorism denies that crime is caused by psy-
tioning is based on the premise that behavior chological or physiological problems, it treats
which is reinforced tends to be repeated, where- socially unacceptable behavior much as a phy-
as behavior that is not reinforced tends to be sician treats the symptoms of a disease he can-
eliminated (Skinner, 1953). not cure. It has been integrated into the thera-
Skinner's early experiments involved con- peutic framework and becomes part of the bio-
ditioning pigeons to move through a maze and medical armamentarium. Short of "cure," the
to press various levers. As a reward, or rein- alleviation of the outward and debilitating
forcer, the birds would receive food. After the symptoms of a disease is considered an impor-
behavior was conditioned, the pigeons contin- tant function of medicine (see Chapter 9).
ued to perform the task even when the food was Behavior modification differs in a number of
not forthcoming. Skinner soon learned that the significant ways from traditional psychologi-
reinforcer need not be given after each success- cally based therapies. In the latter, behavior is
ful task completion. Intermittent rewards were considered symptomatic of underlying causes
sufficient to maintain the behavior. Concerning (e.g., feelings or emotions). It is these causes
the application of this principle to human be- which must be treated if the behavior is to be
havior, Skinner (1953) has written: successfully altered. In contrast, behavior mod-
The efficacy of such schedules in generating high
ification does not concern itself with uncon-
rates has long been known to the proprietors of gam-
bling establishments. Slot machines, roulette wheels, * From Skinner, B. F. Science and human behavior.
dice cages, horse races, and so on payoff on a sched- New York: Macmillan Publishing Co., Inc., 1953.
ule of variable-ratio reinforcement. . . . The patho- Copyright © 1953 by The Macmillan Company.
scious motivations. Actions, not feelings, are personality of another through the use of consciously
important. Consequently, changes in behavior applied psychological, medical and other technologi-
need not involve expensive and time-consum- cal methods. Because it is not based upon the rea-
ing congnitive exchanges with a therapist. soned exchange of information, behavior modifica-
tion is not a traditional learning process. Analogous
Since behavior is the result of conditioned re-
to a surgeon operating to remove a tumor, the be-
sponses to environmental stimuli, understand-
havior therapist attempts to remove an undesirable
ing human behavior merely requires an evalua- aspect of an individual's behavior through direct
tion of the individual's response to the environ- intervention into the latter individual's thought pro-
ment, and changing behavior necessitates ma- cesses. The aim of behavior modification is to re-
nipulation of the stimulus and/or response. In structure personality and the methods range from
Beyond Freedom and Dignity, Skinner has il- gold-star-type awards to psychosurgery. The ob-
lustrated the fundamental difference between jective of behavior modification, whatever its fonn,
behaviorism and the more traditional forms of is that the individual will no longer act in a manner
psychology. The italicized phrases in paren- previously detennined to be unacceptable. (p. I,
theses represent the behaviorists' way of look- emphasis added)
ing at human behavior. The Senate subcommittee's definition includes
techniques that are not generally considered
He lacks assurances or feels insecure or is unsure of
applications of the principles of conditioning,
himself (his behilvior is weak and inappropriate); he
is dissatisfied or discouraged (he is seldom rein-
such as psychosurgery, chemotherapy, and elec-
forced, and as a result his behilvior undergoes ex- trode implantation. These techniques, which
tinction); he is frustrated (extinction is accompanied involve physiological changes, will be dis-
by emotional responses); he feels uneasy or anxious cussed in the following section. This section
(his behilvior frequently hils unavoidable aversive will employ the more limited definition of be-
consequences which hilve emotional effects); there is havior modification used by the U.S. Senate
nothing he wants to do or enjoys doing well, he has Subcommittee (1974): "The systematic appli-
no feeling of crastsmanship, no sense of leading a cation of psychological and social principles to
purposeful life, no sense of accomplishment (he is bring about desired changes, or to prevent de-
rarely reinforced for doing anything); he feels guilty velopment of, certain 'problematic' behavior
or ashamed (he has previously been punished for
and responses" (p. 1).
idleness or failure, which now evokes emotional re-
sponses); he is disappointed in himself or disgusted Positive reinforcement
with himself (he is no longer reinforced by the ad-
miration of others, and the extinction which follows Positive reinforcement is the most commonly
hils emotional effects); he becomes hypochondriacal used technique of behavior modification. In an
(he concludes thilt he is ill) or neurotic (he engages effort to increase the occurrence of a desired
in a variety of ineffective modes of escape); and he behavior, positive reinforcements, or rewards,
experiences an identity crises (he does not recognize are given each time the behavior occurs natural-
the person he once called "f"). (Skinner, 1971, ly. For example, Bednar et al. (1970) used
pp. 146-147) money to reinforce or improve reading skills
Recently behaviorist principles have been among delinquent boys. Hayes et al. (1975)
employed in "therapeutic" settings to modify paid inmates of a federal prison money and
or alter human behavior. This type of therapy privileges to pick up litter. Marked pieces of
is known as behavior modification. The term it- litter were exchanged for money. Not surpris-
self often encompasses all techniques used ingly, Hayes found that there was less litter in
to change or control behavior. In a 1974 areas where the inmates were paid to clean up
investigation of federal involvement in behavior than in areas in which they were not. Most be-
modification programs, the U.S. Senate Sub- havior modifiers agree that money is the most
committee on Constitutional Rights (1974) effective positive reinforcer. Social reinforcers
stated that the common features were: such as praise, smiles, or offers of friendship
can often be rendered ineffective by the individ-
each employs methods that depend upon the direct ual's peer group who apply the same reinforcers
and systematic manipulation by one individual of the to the undesired behavior.
Token economies. The token economy is the acquisition of tokens the boys can "earn"
a clinical outgrowth of operant conditioning. their way out of the token system and return
Based on the priciple that behavior is strength- to their parents' or foster parents' home. The
ened or weakened by its consequences, token parents, who are schooled in the techniques of
economies shape behavior by controlling the behavior modification while the boy is away,
environmental feedback that a person receives. closely monitor his progress, with the help of
Several conditions define the token economy in individuals from the juvenile center. Should the
total institutions, where they have been used boy regress, he can reenter the residential facil-
extensively. First, institutional authorities des- ity. In time, theoretically, the boys will be
ignate desired behaviors through a process of weaned from the token system, and the parents
value judgments and identification of the pro- will be able to rely on more natural reinforcers
gram's goals. In a prison or juvenile home, de- such as parental, academic, and peer approval
sired behaviors might include cooperativeness plus an occasional ice cream cone (Milan &
and a no-troublemaking attitude. Second, a McKee, 1974).
medium of exchange must exist (known as the Tier systems. Like a token economy, the tier
secondary reinforcer), such as money, tokens, system seeks to motivate the individual to work
beads, or performance points. The individual is his way through the system by earning more
rewarded for conforming to desired behaviors and more privileges. In a tier system each par-
by earning a certain number of tokens. Loss of ticipant is initially assigned to the bottom tier
tokens occurs for behavior that is contrary to where his privileges and obligations to behave
those desired by authorities. This general, or properly are at the lowest level. The participant
secondary, reinforcer is used because a specific can move to a higher tier only by performing
reward system would require a knowledge of the behavior expected by the authorities. Each
each individual's prized privileges. The token successive tier carries with it greater privileges,
system operates in a manner similar to that of but it also requires more stringent behavior.
a market economy, where the token is a medi- Completion of the program requires the partici-
um for obtaining a privilege or benefit chosen pant to fulfill the requirements of the highest
and therefore prized, by the individual. The tier, and it is possible to lose ground by being
third condition that must exist to define a token put back for inappropriate behavior (U.S. Sen-
economy is access by individuals to privileges, ate Subcommittee on Constitutional Rights,
commodities, and benefits (known as primary 1974, p. 267).
reinforcers) for which they can trade the tokens The most controversial tier system has been
they have earned (see Kazdin & Bootzen, the Special Treatment and Rehabilitation Train-
1972). ing (START) program begun in 1972 at the
Achievement Place is a residential center lo- Medical Center for Federal Prisoners in Spring-
cated within the Lawrence, Kansas, community field, Missouri. START, as described by the
that provides a program of behavior modifica- U.S. Bureau of Prisons, was intended to "pro-
tion for predelinquent boys through the use of a mote change" in "disruptive" offenders' be-
token economy. The residents of Achievement havior toward the goal of allowing them greater
Place are boys who have a history of trouble- control (U.S. Senate Subcommittee on Consti-
making but have not as yet been adjudicated tutional Rights, 1974, p. 263). The program
delinquents. The goals of the program include was based explicitly on the principles of operant
the modification of undesirable and antisocial conditioning proposed by Skinner.
behavior- in conjunction with the development In its final form START combined a tier
of "new and appropriate forms." On arrival system with a token economy. Difficult-to-
at Achievement Place the boys enter a highly manage prisoners were selected from the segre-
structured token economy in which specific de- gation units of several federal penitentiaries
sired behaviors such as class attendance, im- and administratively transferred into the pro-
proved grades, and reduced unpleasant contact gram. The tier system had eight levels, with
with the police are rewarded by privileges and movement to higher levels contingent on earn-
increased self-control over their time. Through ing "good days," determined by assessing the
232 DEVIANCE AND MED/CALIZATION: FROM BADNESS TO SICKNESS
individual's performance in the three major hardly an acceptable experimental design" (p.
subgoals of the program: (1) personal hygiene, 419). The total START group would have to be
(2) work performance, and (3) social interaction compared with a control group of prisoners in
with others. These subgoals were measured by segregation to yield statistically significant re-
a 12-item checklist, which included: sults.
Willingness to participate; neat and clean appear- The START program was controversial from
ance; accepted a "no" or other reasonable response its inception. In a criticism similar to others of
when making requests; made requests in a non-abu- token economies and tier systems (see Johnson,
sive manner; settled differences without fighting, V. S., 1977), Richard Singer (1977) found that
wrestling, striking, or other overt, physically ag- START
gressive acts toward another person. (U.S. Senate
Subcommittee on Constitutional Rights, 1974, p. neither focused on the original offense . . . nor
267) sought to enhance [the prisoner's] chances for return
to the outside world; instead START was explicitly
Level one of the program consisted of con- designed to make the prisoner more 'adaptable' to
finement in a solitary cell with 1 hour of daily the general prison environment. (p. 35)
exercise and two showers per week. A good day
could be earned by fulfilling 9 of the 12 criteria The methods used to encourage START pris-
on the checklist; 20 good days were necessary oners to conform have been criticized as arbi-
to move to the second level. At level two the trary and coercive. The program actually used
inmate was expected to maintain level one be- punishment and aversive conditioning rather
havior plus pursue education and treatment than positive reinforcement. The prisoners re-
goals. He was also expected to work cleaning ceived fewer privileges than they had in segre-
the START unit. Twenty-five good days were gation units and, at the lowest levels, existed
necessary to move to level three. At the third in abysmal conditions. In addition, advance-
and subsequent levels, behavior requirements ment came to be contingent not solely on be-
were more stringent (11 and then all of the 12 havior but largely on the subjective assessments
criteria have to be met to earn a good day). and "whims" of prison personnel. Like so
Once the inmate had accumulated 195 good many other "therapeutic" programs, START
days and had demonstrated himself to be a co- rapidly degenerated into an excuse to use sen-
operati ve prisoner, he had "earned" his way sory deprivation and other punitive measures on
out of the START unit (U.S. Senate Subcom- "unruly" inmates. When in 1974 the Supreme
mittee on Constitutional Rights, 1974, p. 266). Court ruled that the selection procedure was
In a follow-up study of START participants, unconstitutional because it violated the right to
Scheckenbach (1974) found that of the 19 in- due process, START was stopped.
mates who began the program, only 10 com-
pleted it. Of these, three were eventually re- Negative reinforcement
leased from prison and "adjusted" to the com- A second major form of behavior modifica-
munity, three were living in prison outside of tion is negative reinforcement. As with positive
segregation, and four were back in segregation reinforcement, this form uses operant condi-
units. These figures compare favorably with tioning to increase the incidence of desired be-
the nine prisoners who did not complete the havior. Escape training and avoidance learning
program. Of these, only one was out of segre- are the two major techniques. Escape training
gation, two had committed additional offenses uses an aversive stimulus that is applied con-
in prison, and six were still in segregation. The tinuously until the subject performs the desired
fact that more than 60% of those inmates who behavior. In avoidance learning, a person can
completed START were no longer in segrega- learn a response that enables him to avoid a
tion seemed to indicate a limited success. V. S. negative stimulus. For example, in Somers pris-
Johnson (1977), however, has pointed out that on in Connecticut, child molesters were shown
"comparison of those who completed the pictures of children and adults in sexually sug-
START program with those who did not is gestive poses. When a picture of a child was
flashed on the screen, the inmate could request punishment) or by having his allowance with-
to have the picture changed. If he did not within held (negative punishment).
3 seconds, he received a "harmless but pain- Evaluation of behavioral changes in the light
ful" electric current close to the genitals. The of positive punishment has posed ethical ques-
inmates received no shock when viewing the tions. Researchers are limited by the amount of
adult pictures. After several months the inmate pain they can inflict on subjects in a laboratory
should have "repress [ed] completely the abil- setting. Most clinical studies are fraught with
ity to think of children as sex objects" (Coc- difficulties in identifying the effects of positive
kerham, 1975, p. 78). In addition, sexual rela- punishment on the studied behavior. Conse-
tions with a man or a woman were reinforced. quently, no conclusive results have been ob-
In the words of psychologist Roger Wolfe: "It tained. Instead, the advocates of positive pun-
doesn't really matter which as long as it's an ishment have relied on theoretical works for
adult" (quoted in Cockerham, 1975, p. 80). substantiation of their views. For example, in
The effectiveness of avoidance learning in 1944, Estes explained the effects of punishment
treating child molesters has not been empirical- on behavior in terms of operant conditioning.
ly verified. Such programs must be considered He said that the effect of punishment was to
experimental and therefore require higher stan- evoke emotional reactions that were condi-
dards of informed consent. The American Civil tioned in a classical manner to environmental
Liberties Union (ACLU) has claimed that the stimuli during the punishment. He further held
Connecticut program is coercive. Even though that later exposure to a similar situation would
inmates can decline to participate, they are inhibit the punishment response.
aware that such a decision would be looked on From what little empirical evidence exists,
with extreme disfavor by the state's Board of this theory would not seem to be validated. Cor-
Parole (Cockerham, 1975, p. 80). The side ef- poral punishment, a positive punishment, was
fects of this type of therapy remain unknown. used in both schools and prisons until the 20th
The ACLU is concerned about its possible con- century with little success. In 1845 in a 250-
sequences. Will the former child molester be- pupil school near Boston, 65V2 whippings on
come a child murderer when he seeks relief the average occurred each day. In the same
from the pain associated with seeing a half- year, 400 Massachusetts schools were broken
clothed child? Will the patient or his physician up by disruptions. Today, corporal punishment
be criminally responsible? Will this condition- is seldom used, and the behavior of the children
ing produce a phobia as in the case of a former is no worse (Andenaes, 1968). Until recently,
male homosexual who became nauseated every flogging, mutilation, branding, and other phys-
time he had to shake hands with another man? ical punishments were used in American pris-
Watson's Little Albert was conditioned to the ons. A study by Caldwell (1974) of public
point where he reacted to all fur-bearing ani- Whipping in Delaware between 1900 and 1942
mals with equal terror. found that 62% of those offenders whipped
Punishment. Punishment is the oldest were later reconvicted. In comparison, 65% of
known form of behavior modification. Al- those sent to prison were reconvicted, and only
though negative reinforcement and punishment 35% of those paroled were reconvicted. Allow-
are often equated, they are not, strictly speaking for the fact that those paroled were prob-
ing, the same technique. Negative reinforce- ably the least serious offenders, positive pun-
ment involves removing an unpleasant stimulus ishment (corporal punishment) was not more ef-
to encourage the continuation of a desired be- fective than negative punishment (imprison-
havior, whereas punishment seeks to stop an ment) in reforming offenders.
undesired behavior through the application of Aversive conditioning. From a learning
a negative reinforcer (positive punishment) or theory perspective the primary problem with
by removing a positive reinforcer (negative punishment is the time lag between the occur-
punishment). For example, a disobedient child rence of the unacceptable behavior and the ap-
can be punished by being spanked (positive plication of punishment. This delay reduces the
effectiveness of punishment as a means of cor- patient is given an emetic such as apomorphine

recting behavior. Aversive conditioning has al- and just before vomiting, he is required to look
lowed researchers to eliminate the lag between at alcohol, sexually suggestive pictures, or
the behavior and its punishment. In aversive other stimuli.
conditioning an actual or proxy stimulus for a The success of this treatment is difficult to
targeted behavior is paired with a stimulus that evaluate. It is especially hard to devise care-
elicits a noxious, unconditioned response. fully constructed control groups against which
Based on the principles of classical condition- to test its effectiveness vis it vis other therapies.
ing, the central objective is to develop in the In several studies dealing with alcoholics, aver-
patient a conditioned, unpleasant reaction to the sive conditioning using emetics seems to have
undesired behavior. Electric shocks and drugs been as ineffective as psychotherapy. In other
are most frequently used to evoke the uncondi- research the techniques have increased rather
tioned response. than decreased the frequency of the targeted
Shock therapy has been most commonly used behavior. A general problem is that aversive
to "treat" sex offenders. Schwitzgebel (1971) conditioning often appears to decrease but not
identified 26 studies dealing with the use of eliminate the behavior. The patient often re-
aversive conditioning on this group, most of quires frequent "refresher" treatments and also
which used shock therapy. As in the Somers appears to benefit greatly from other forms of
prison project discussed previously, shock ther- therapy (Schwitzgebel, 1971). As with other
apy usually involved showing the offender sex- behavior modification methods, aversive con-
ually stimulating pictures followed by the ad- ditioning can produce a wide variety of side
ministration of a shock. Unlike avoidance effects, including extreme anxiety, skeletal
therapy, the inmate-patient does not have the fractures, and destruction of brain tissue (Sage,
option to avoid the shock by requesting that 1974).
tbf' picture be changed. In aversive conditioning Aversive conditioning methods have been
there is no such option. This procedure has also used on inmates without their consent, fre-
been used in the treatment of alcoholism, sa- quently to punish rather than rehabilitate. At
dism, fetishism, and transvestism (Schwitz- Atascadero State Hospital in California, Anec-
gebel, 1971). Recently, offenders convicted of tine was used on black militants as well as other
property crimes such as bank robbery and shop- inmate-patients whose behavior was found to
lifting have also been subject to shock therapy, be "uncooperative" or "disruptive." At Atas-
with limited success (Singer, 1977). cadero, electroconvulsive shock therapy (ECT)
Perhaps the most notorious form of aversive was employed "not for medical reasons, but
conditioning has been that which uses drugs. as a punishment for violation of ward rules"
A commonly used drug is succinylcholine chlo- (Jackson, 1973, p. 44). Similar uses of aversive
ride, also called Anectine. Within 30 to 40 conditioning methods have been fully docu-
seconds of being injected with this drug, a per- mented at other so-called therapeutic institu-
son experiences paralysis of the diaphragm and tions, including Vacaville Rehabilitation Center
cardiovascular system, creating a sensation that in California and the Iowa Security Medical
has been compared with death, drowning, Facility (Jackson, 1973; Singer, 1977). At
and suffocation (Sage, 1974). While in this Vacaville, in 1971, fluphenazine dihydrochlo-
paralyzed state, the patient is told that his con- ride (Prolixin), a highly potent behavior-modi-
dition is the consequence of the behavior that fying drug, was administered to 1093 of the
preceded the injection. For example, in the 1400 inmates (Jackson, 1973) for ostensibly
treatment of alcoholism, the drug is injected therapeutic reasons. The side effects of Pro-
just after the patient takes a drink. This pairing lixin, as listed by the manufacturer, include
causes the dying sensation to be associated with "nausea . . . the induction of a catatonic
drinking. Emetics (nausea-producing drugs) state . . . blurred vision . . . liver damage . . .
have also been used to modify behavior, most impotency . . . hypotension severe enough to
usually with alcoholics, narcotics addicts, and cause fatal cardiac arrest ... " (Singer, 1977,
sexual offenders (Schwitzgebel, 1971). The p.35).
A number of court cases have ruled that the reversible. Researchers have attempted to solve
use of behavior modification methods without these problems by simulating the "real world"
consent of the individual involved is uncon- in the laboratory or by bringing the patient in
stitutional because it violates the Eighth for periodic "refresher" treatments. These
Amendment protection against cruel and unusu- strategies have met with limited success. Be-
al punishment (Singer, 1977). In 1973, a Michi- cause biotechnology allows technicians to mon-
gan court ruled (Kaimowitz v. The Michigan itor and control the patient while he lives in the
Department of Mental Health) that the inherent- community, it appears more promising in con-
ly coercive nature of mental hospitals made it trolling potential offenders.
impossible for a mental patient to give truly Essentially, biotechnology involves the im-
voluntary consent to experimental procedures plantation of electrodes into the brain through
(Singer, 1977). Since the Detroit decision the a hole or holes in the skull. The brain is then
trend has been toward outlawing nonconsensual stimulated electrically until the unwanted be-
experimental programs in total institutions. havior is elicited. Once the unwanted behavior
However, given past experiences, it seems rea- is located (e.g., fits of rage, depression, eu-
sonable to assume that such programs will not phoria), that area of the brain is coagulated
be eliminated. (As one researcher told me, "If with electricity. The goal is a carefully titrated
the government stops funding behavior modifi- lobotomy that blunts the emotional responsive-
cation programs we'll just call them by a dif- ness associated with the unwanted behavior
ferent name.") Prisoners will probably con- without otherwise incapacitating the individual.
tinue to be coerced into signing consent forms, Although the technology is highly sophis-
if only by the promise of early release. It must ticated, the method rests on the dubious, out-
be remembered that the constitutionality of be- dated theory that behavioral problems can be
havior modification programs themselves has reduced to foci of disordered brain tissue
never been ruled on. Rulings have only con- (Breggin, 1973b). Regardless of its theoretical
cerned their application in a closed institution validity, the technological capability to blunt
and only because these techniques are currently the emotions and thereby control or eliminate
considered experimental. the unwanted behavior appears impressive.
If the behavior modifiers solve the problem It is not difficult to imagine the potential for
of correcting the criminal, they will have cre- political manipulation of such advances in mind
ated a more vexing problem. What kind of ex- control. Physician Jose M. R. Delgado (1969),
offender will be produced? Is the juvenile who former professor of physiology at Yale Univer-
learns to manipulate his token economy any sity, has outlined a nationwide program of
more "moral" for his experience? Has he be- mind control in his book, Physical Control
come a "better" person or simply more clever of the Mind: Toward a Psychocivilized Society:
at getting the environment to serve his own
National agencies should be created in order to co-
ends? As Bedau (1975) has aptly noted: ordinate plans, budgets, and actions just as NASA
It has been said by some doctors closely associated in the United States had directed public interest and
with the use of these techniques that they will trans- technology, launching the country into the adven-
form a person into a "model citizen," a "respon- tures and accomplishments of outer space. (p. 259)*
sible, well-adjusted citizen." One is inclined to doubt The mass media must be mobilized for this pur-
whether Locke, Rousseau, Kant, Jefferson, and pose, and preparation of entertaining and informative
Mill would have agreed that these techniques can programs should be encouraged and promoted by
have such results. (p. 662) the neurobehavioral institutes. (p. 262)
BIOTECHNOLOGY * Specified excerpts from Physical control of the

Behavior modification can never be com- mind: toward a psychocivilized society by Jose M.
R. Delgado, M.D. Vol. 41 of World Perspectives
pletely successful in controlling crime, either
Series, Planned and Edited by Ruth Nanda Anshen.
because reinforcers that work in a laboratory Copyright © 1969 by Jose M. R. Delgado. Re-
setting may differ from those in the community printed by permission of Harper & Row, Publishers,
or because the effects of the treatment are often Inc.
Delgado is currently working on direct control He becomes quite specific . . . when he talks about
of the brain by computer. He points out that drug addiction. Is the root of the problem poverty
one can open garage doors from a distance, ad- and racism, since drug addiction around the world
just a television set without leaving one's seat, and in America is overwhelmingly a problem of the
and direct orbiting spacecraft from earth. Why poor? No, it's not that. Is the new phenomenon of
drug addiction among the middle class youth re-
not remote control of humans by computers?
lated to the disaffection of youth from the society?
A two-way radio communication system could be No. Does it relate to the tremendous profits made
established between the brain of a subject and a com- by criminal groups from promoting drugs among the
puter. Certain types of neuronal activity related to poor? No. What then is the problem of drug addic-
behavioral disturbances such as anxiety, depression, tion, according to Dr. Heath? Drug addiction, he
or rage could be recognized in order to trigger stim- says, is an attempt at self-medication for pleasure in
ulation of specific inhibitory structures. The delivery people who have a neurologic defect in their pleasure
of brain stimulation on demand to correct cerebral centers. His cure then is corrective surgery or a
dysfunctions represents a new approach to thera- better, more efficient pleasure producing compound.
peutic feedback. While it is speculative, it is within (p. E1609)
the realm of possibility, according to present knowl-
edge and projected methodology. (p. 200) Heath's suggestion of electrical self-stimu-
lation is in concert with the recent shift in penal
The direct political potential for the control
practice to community-based treatment pro-
of society by those who program such com- grams. These programs extend treatment and
puters becomes explicit when Delgado de-
counseling to offenders during a temporary ~r
scribes experiments conducted on monkeys. By conditional release from the institution. The
using computerized remote control techniques,
treatment of criminal offenders in the commu-
he has been able both to stimulate the followers
nity, however, presents the problem of a poten-
to revolt against and overthrow the leaders, and
tial escape and increased risk to the community.
to activate the leaders to be more aggressive in
This problem has plagued these programs since
punishing the followers.
they were first inaugurated. The public has
If Delgado's proposal for an educational pro- somehow required a 100% success rate.
gram to instill respect for physical control of the In recent years there has been considerable
mind proves successful, the "afflicted" person research conducted on telemetry as a means of
may come to participate voluntarily in a "ther- solving the 100% problem. A prototype moni-
apeutic" program of mind control. Robert G. toring system called an "electronic rehabilita-
Heath (1963), in his article "Electrical Self- tion system" has been developed. This new
Stimulation of the Brain of Man," describes electronic system is capable of continual moni-
experiments that involve individuals who wear toring of a parolee's location, voice, blood
self-stimulation units. Such units allow people pressure, brain waves, and even penile erec-
to voluntarily and selectively control their own tion. R. K. Schwitzgebel (1968) has described
emotional response and behavior. His experi- the system:
ments involve research into the pleasure and
pain centers of the brain. He postulates that As presently designed the electronic rehabilitation
many mentally ill persons suffer from "inap- system is capable of monitoring the geographical
propriate anxiety." The cure is "instantaneous location of a subject in an urban setting up to 24
replacement of irrelevant anxiety with positive hours. The subject wears two small units approxi-
pleasure feelings" (Heath, 1970, p. 87), volun- mately 6 inches by 3 inches by 1 inch in size, weigh-
ing about 2 pounds. As the wearer walks through a
tarily activated by the patient. Heath, in a recent
prescribed monitored area, his transmitter activates
presidential address to the Society for Biologi-
various repeater stations which re-transmit his signal,
cal Psychiatry, contended, for example, that with a special location code, to the base station. The
drug addiction is a problem of a neurological repeater stations are so located that at least one is al-
defect in the addict's pleasure center. Psycho- ways activated by the wearer's transniitter.
surgery critic Peter R. Breggin (1973b) com- This prototype system as now used extends only a
ments on Heath's address: few blocks during street use and covers the inside
of one large building. The primary purpose of this his chance of being hijacked at the airport. Be-
system is to demonstrate the feasibility of larger, cause of the fear of hijacking but not bank
more complete systems and gather some preliminary robbery, the individual gladly undergoes a
data. Through the use of carefully placed repeater search by airport authorities who, because they
stations in each block, the system is theoretically are not public police, hold broader powers of
duplicable such that large geographical areas may be
search and seizure.
covered with a large number of subjects each trans-
mitting a unique signal. The range of the system and
Nicholas Kittrie (1971) has used the analogy
the specificity with which a person can be located of astronauts who will some day live and work
depend largely upon the number of repeater stations in orbiting stations to illustrate the point that
used. (p. 99) if the environment is viewed as hostile enough,
people will come to depend on constant sur-
It is conceivable that in the near future all veillance for their security:
parolees, as well as those who have had their
Recently a man was placed on the moon. Plans are
sentences suspended, might come under the
being made for the establishment of a space station
guardianship of an electronic rehabilitation sys-
where men could live and work in orbit around the
tem. Preventive measures could be taken to
earth. In these hostile environments, it is essential
render any parole violation or further criminal- that the men involved be under constant environ-
ity impossible. Hidden cameras could clandes- mental, physical, and mental surveillance, for one
tinely watch the business district of our urban error or miscalculation could endanger not only the
centers, as is already the case in Smyrna, Dela- indi vidual but the entire miniature society. The men
ware; San Jose, California; Hoboken, New who are involved in this work must be able not only
Jersey; and Mount Vernon, New York (Garth, to cope with the hostile environment but literally
1974). Citizens could be licensed to carry min- to thrive under the constant watchfulness of some
iature radio transmitters, which, when worn as controllirrg authority. That men are undertaking such
a watch, pendant, or belt buckle, could signal tasks under such constant scrutiny suggests-al-
though the analogy is not exact-that man might
the wearer's location, in the event of an attack,
adapt himself to live under the conditions of total sur-
to a central communication unit operated by
veillance that must prevail in a therapeutic society.
security police (LEAA, 1974). This alert sys- (p.35l)
tem is currently being tested in public housing
projects with plans for 5000 to 10,000 devices In a perceptive footnote to the above, Kittrie
to be in operation within a year. Vandalism, added:
arson, and robbery in public schools could In a telecast from Apollo 10, Ground Control at
be reduced by adapting the public address sys- Houston used the epigram, "Big Brother is Watch-
tem for use in audio monitoring, and by install- ing" to describe its source of information about the
ing closed-circuit television to patrol corridors, space craft. One of the astronauts replied, "And
classrooms, and lavatories, as in the Alexan- we're glad he is!" (p. 351)
dria, Virginia, school district (LEAA, 1975).
The ease with which the 100% problem can CIA and mind control
be adapted to include clandestine surveillance In the late 1940s and early 1950s the CIA
in public places of the entire population is ap- launched a 25-year covert project to develop
parent. If the public's fear of falling victim to techniques of mind control. The project in-
crimes of violence continues to grow, it might volved the "research and development of
be all too willing to trade its right to privacy chemical, biological, and radiological materials
for increased security. Witness the ease with capable of employment in clandestine opera-
which metal detectors, body searches, and bag- tions to control human behavior."* The multi-
gage inspections were introduced into our million dollar project was a closely guarded
nation's airports. The public's fear of hijacking
took precedence over its desire for privacy. An * From an unpublished memorandum from the CIA
individual's chance of being in a bank during a Inspector GerneraI to the CIA Director, July 26,
robbery is approximately 100 times greater than 1963, communicated privately to me.
secret; neither Congress nor the executive 1977b). In addition, the Smithsonian Institu-
branch knew of its existence. Because of pos- tion was used as a cover to fund a study of the
sible political and diplomatic repercussions, the possible use of migratory birds in germ war-
agency channeled its funds through private fare. The National Institute of Mental Health
medical research foundations. In all, the CIA conducted a study of the effects of hallucino-
sponsored behavior control experiments by genic drugs at its rehabilitation center in Lex-
185 privately employed scientists at 80 different ington, Kentucky. In the initial phase of the
institutions (Horrock, 1977a). study, only volunteer inmates who were re-
Project CHATIER, the initial mind control warded with the drug of their addiction were ex-
program, was begun by the u.s. Navy in 1947. perimented on. By the final stages of the study,
At that time CIA officials believed that some however, LSD was being administered surrepti-
American prisoners of war in North Korea had tiously to unwitting human subjects, the details
been brainwashed. Project CHATIER was de- of which have been outlined in the Church
signed to test "truth drugs" for use in inter- Committee Report (1976).
rogations by rendering an individual "subser- There is little question that the CIA was inter-
vient to an imposed will or control" (The New ested in the political uses of biomedical re-
York Times, 1977, p. 16), and to develop a search. The agency conducted medical experi-
drug that would prevent CIA agents from being mentation that often violated the Nuremburg
brainwashed (Szu1c, 1977). The project in- code of ethics. In its drugging of unwitting
cluded the laboratory testing of substances such patrons of bars in New York and San Francisco,
as Anabasis aphylla, scopolamine, and mes- the LSD experiments on prisoners at federal
caline "in order to determine their speech- penitentiaries, and the knockout drug testing
inducing qualities" (Church Committee, 1976, on unknowing terminal cancer patients, the
p. 387). During the Korean War the project agency evidenced a fundamental disregard for
grew enormously, but for reasons that remain the value of human life. Two American citi-
unclear it terminated in 1953. zens died as a direct result of these programs,
In 1950 Project BLUEBIRD/ARTICHOKE thousands had their constitutional rights vio-
was added to the CIA's programs of mind con- lated, and an undetermined number suffered
trol. Like Project CHATIER, its objectives permanent debilitations (Church Committee,
were to preven t the "extraction of information" 1976).
from agency personnel and the development of Although there is little available evidence
"special interrogation techniques" involving that the CIA used its mind control techniques
hypnosis and chemical and biological agents. against internal political opponents, the recent
The CIA has claimed that the original research history of the agency would suggest that this is
was necessary to defend its agents against So- a definite possibility. Yet it must be remem-
viet and Chinese techniques of brainwashing. bered that the search within the scientific com-
By August, 1951, however (when BLUEBIRD munity to find biomedical causes and biotech-
.vas renamed ARTICHOKE), the agency, with nological controls of human behavior is essen-
its research on inducing people to perform tially independent of CIA involvement. If the
acts against their will, was clearly looking to the CIA has, in fact, terminated its mind control
development of offensive capabilities (Church experiments, there is reason to believe that bio-
Committee, 1976). medical research will continue to be supported
Projects MKULTRA and MKDELTA by private and governmental agencies. Some of
(MKDELTA was the name given to MKULTRA the main proponents of large-scale mind con-
abroad) were the broadest and most compre- trol (e.g., Mark and Ervin and Delgado) appar-
hensive of the CIA programs to alter human ently conducted their research and promoted
behavior through the use of chemical and bio- its use to control "target" populations with-
logical agents. Such techniques as electric out CIA monies. Similarly, Dr. Robert Heath,
shock, radiation, and psychosurgery were em- who has often advocated the wide-scale appli-
ployed to control human behavior (Horrock, cation of his research on the pleasure centers
of the brain, refused CIA funding for a pro- muts, 1972). In fact, the introduction of pro-
ject to study its pain centers. One suspects that cedural safeguards may make the violation of
funding for such research in the future will be substantive rights more politically acceptable.
only too easy to find. In the case of juvenile diversion the net effect
has been to increase the web of state control
SUMMARY AND IMPLICATIONS over juveniles, not to lessen it (Morris, 1974).
We have examined the origins and prolifera- In addition, juvenile diversionary programs
tion of the therapeutic ideal, selected research have begun to erode the fundamental principle
in biomedics, behavior modification, biotech- on which the criminal law is founded-innocent
nics, and associated programs of crime con- until proven gUilty. Under those programs,
trol. It has been noted that the Italian physician juveniles are often diverted into the mental
Cesare Lombroso laid the scientific foundation health system for treatment without a judicial
for the development of biomedics in criminolo- determination of their guilt or innocence.
gy, thereby making possible the extension of As stated previously, the antirehabilitation
the state's parens patriae power over those ex- forces have been successful in demonstrating
hibiting aberrant behavior. If the past is an ac- the moral bankruptcy of an ideal that failed to
curate indicator of the future, it is not difficult rehabilitate criminals or cure mental patients.
to chart the course of biomedical research in The main thrust of their criticism has been that
criminology. it is immoral to tinker with the "whole" per-
Currently there is widespread dissatisfaction son, that the law should concern itself only with
with the rehabilitative ideal. Some writers the person's criminal behavior, not his values,
(e.g., Kittrie, 1971; and Lewis, 1953) view re- attitudes, or personality (American Friends Ser-
habilitation as essentially coercive and believe vice Committee, 1971). This is a tenable phi-
that under its guise the state has been able to losophy, but it is only palatable to policymakers
extend its punitive powers. Others (e.g., Norval when it is coupled with the fact that rehabilita-
Morris, 1974) maintain that rehabilitation does tion has not worked. Today it simply is not
not work, that the "noble lie" should be aban- practical to attempt to rehabilitate criminals.
doned, and that people should be locked up as There is a growing conservatism in the na-
punishment. The combined criticism of these tion, which is reflected in the research and writ-
two groups has all but killed the rehabilitative ings of those who study crime. Policymakers
ideal in corrections. In the process of pursuing have lost interest in attempting to alleviate the
their divergent assault, the antirehabilitation underlying causes of crime. Instead they now
group has managed to extend constitutional demand short-term, prophylactic methods of
rights to mental patients and juveniles. The crime prevention. Sociologists, who for the
so-called nothing works, lock 'em up faction, most part are hesitant about giving simple an-
exemplified by Robert Martinson et al. (1975) swers to a problem as complex as crime pre-
and James Q. Wilson (1975), has supported vention, have not responded to this new de-
passage of death penalty statutes in many states, mand. Consequently, policymakers have turned
introducing programs to crack down on career to those whose transient knowledge of crimi-
offenders, and instituting mandatory minimum nology makes them more able to deliver the
sentences. "easy" answer.
Yet it would be a mistake to conclude that the At the moment, policymakers are looking to-
rehabilitative ideal is completely dead or that ward political scientists and economists for
its effects will be short-lived. Although some cost-effective answers. Once biomedics and
procedural safeguards such as due process and biotechnological control of crime has been
equal protection under law have been intro- demonstrated to be effective and practical, it is
duced into the mental health and juvenile justice probable that the rehabilitative ideal, or some-
systems, with the single exception of juvenile thing close to it, will reassert itself. This re-
status offenses, none has challenged the state's emerging ideal may not be known as rehabili-
right to intervene in noncriminal matters (Klap- tation, it may be called habilitation or simply
correction, but behind it will probably b~ a bio- SUGGESTED READINGS

medical model of causality and a biotechno- Fink, A. E. Causes of crime: biological theories in
logical program of control. The antirehabilita- the United States, J800- J9 J5. Philadelphia: U ni-
tion forces will undoubtedly protest, but with- versity of Pennsylvania Press, 1938.
out evidence of rehabilitative failure to support A comprehensive and detailed discussion of late
19th- and early 20th-century theories of crime
their moral argument, they will not exert much causation in the United States. Not only is it fasci-
influence. The "nothing works, lock 'em up" nating reading, but it makes clear how important
people can be expected to embrace the new the medical point of view was during that period in
methods as the first really effective means providing explanations and treatments for var-
society has developed to protect its citizens ious forms of criminal conduct.
Fox, R. G. The XYY offender: a modem myth? 1.
against criminal trespassers. Crim. Law Criminol. Police Sci., 1971,62 (I),
For over 100 years the rehabilitative ideal 59-73.
has been the companion of biomedical research. A clear review and critique of the research and
At first glance the "new pragmatism" in cor- methodology surrounding the XYY hypothesis.
rections may appear to threaten the role of bio- Fox traces the history of the proposition and con-
cludes that the data simply do not support this
medical research in criminology. Classical most recent form of the biological explanation of
criminology, with its roots in Bentham's util- crime.
itarianism, is generally viewed as opposed to Mannheim, H. Pioneers in criminology. Chicago:
the rehabilitative ideal. There is, however, a Quadrangle/The New York Times Book Co.,
point of intersection of purpose. Both purport Inc., 1960.
A fine compilation of key pieces of work from
to have the "greater good" as their aim. The the founders of the science of criminology.
rehabilitative ideal, which emphasizes the pa- This convenient source book allows the reader to
tient's good and presents its arguments in terms see the fundamental differences between classi-
of morality, humanity, and therapy, still de- cal and positivist schools of criminology discussed
p(>nds heavily on its practical utility. The clas- in this chapter.
Sutherland, E. H. Book reviews of Crime and the
sical approach, which emphasizes the protec-
Man and The American Criminal: An Anthro-
tion of society, presents its arguments in terms pological Study, Vol. I, by Ernest Hooton. 1.
of utility, practicality, and justice. Both agree Crim. Law Criminal., 1939,29,911-914.
that the state should pursue the" greater good" Reviews of Hooton's book. Sutherland draws
and that this means developing a mechanism to carefully and clearly the line between a sociologi-
cal and biological-medical view of crime; they
control aberrant behavior. The point of dis-
provide a good opportunity to see the contrast
agreement is on which strategy to employ in the between these two highly divergent ways of con-
control of crime. Bentham's Panopticon Prison sidering such conduct.
or Inspection House is no more nor less humane U.S. Senate Committee on the Judiciary, Subcom-
than Mark and Ervin's prison hospital. The mittee on Constitutional Rights. Individual rights
and the federal role in behavior modification.
question is which approach is more effective in
93rd Congress, end session. Washington, D.C.:
controlling crime. According to the New Prag- U.S. Government Printing Office, 1974.
matists, this is the only question. A thorough and objective review of the ethical
and civil rights issues posed by the development
of behavior modification technology to con-
trol deviant (and other) behavior. It details the
nature of such technology and its various ap-
plications.
9 MEDICINE as an
INSTITUTION of SOCIAL
CONTROL
CONSEQUENCES for SOCIETY
I n the final two chapters we leave behind the

specific cases and focus on some general
features of the medicalization of deviance.
These are important chapters, for together
Physicians have been endowed with some of the
charisma of shamans. In the 20th century the
medical model of deviance has ascended with
the glitter of a rising star, expanding medicine's
they outline the sources and consequences of social control functions. In earlier substantive
medicalizing deviance in American society. chapters we focused on the changing definitions
Chapter 9 examines medicine as an institu- and designations of deviance, frequently allud-
tion of social control, and Chapter 10 offers ing to medical social control. In this chapter we
a statement of what a theory of medical- focus directly on medicine as an agent of social
ization of deviance might look like, based on control. First, we illustrate the range and vari-
the cases presented in earlier chapters. We at- eties of medical social control. Next, we ana-
tempt, in essence, to provide a more succinct lyze the consequences of the medicalization
sociological analysis of the medicalization of of deviance and social control. Finally, we ex-
deviance. amine some significant social policy questions
In our society we want to believe in med- pertaining to medicine and medicalization in
icine, as we want to believe in religion and American society.
our country; it wards off collective fears and re-
duces public anxieties (see Edelman, 1977). In TYPES OF MEDICAL SOCIAL
significant ways medicine, especially psy- CONTROL
chiatry, has replaced religion as the most Medicine was first conceptualized as an
powerful extralegal institution of social control. agent of social control by Talcott Parsons
(1951) in his seminal essay on the "sick role"
o This -chapter is an adapted, amended, and ex- (see Chapter 2). Eliot Freidson (1970a) and
tended discussion from Conrad, P. Types of social Irving Zola (1972) have elucidated the juris-
control. Soc. Health & Illness, 1979,1, 1-12,byper- dictional mandate the medical profession has
mission of Routledge & Kegan Paul Ltd.; and Con- over anything that can be labeled an illness,
rad, P., The discovery of hyperkinesis. Social Prob-
lems, 1975,23, 12-21. Portions of this chapter also regardless of its ability to deal with it effec-
taken from "Medicine" by Conrad, P., and Schnei- tively. The boundaries of medicine are elastic
der, J., in Social control for the 1980s: a handbook and increasingly expansive (Ehrenreich &
for order in a democratic society edited by Joseph S. Ehrenreich, 1975), and some analysts have ex-
Roucek, 1978, pp. 346-358, and used with the per- pressed concern at the increasing medicaliza-
mission of the publisher, Greenwood Press, Inc.,
Westport, Conn., and our forthcoming article in
tion of life (Illich, 1976). Although medical
Contemporary Crises, reprinted by permission of social control has been conceptualized in
Elsevier Scientific Publishing Co., Amsterdam. several ways, including professional control
241
of colleagues (Freidson, 1975) and control of comfortable with their condition (see Freidson,
the micropolitics of physician-patient interac- 1970a; Parsons, 1951). Medical social control
tion (Waitzkin & Stoeckle, 1976), the focus of deviant behavior is usually a variant of med-
here is narrower. Our concern, as is evident ical intervention that seeks to eliminate, mod-
throughout this book, is with the medical con- ify, isolate, or regulate behavior socially de-
trol of deviant behavior, an aspect of the med- fined as deviant, with medical means and in
icalization of deviance (Conrad, 1975; Pitts, the name of health.
1968). Thus by medical social control we mean Traditionally, psychiatry and public health
the ways in which medicine functions (witting- have served as the clearest examples of medical
ly or unwittingly) to secure adherence to social control. Psychiatry's social control functions
norms-specifically, by using medical means to with mental illness, especially in terms of insti-
minimize, eliminate, or normalize deviant tutionalization, have been described clearly
behavior. This section illustrates and catalogues (e.g., Miller, K. S., 1976; Szasz, 1970).
the broad range of medical controls of deviance Recently it has been argued that psychotherapy,
and in so doing conceptualizes three major because it reinforces dominant values and ad-
"ideal types" of medical social control. justs people to their life situations, is an agent
On the most abstract level medical social of social control and a supporter of the status
control is the acceptance of a medical perspec- quo (Halleck, 1971; Hurvitz, 1973). Public
tive as the dominant definition of certain health's mandate, the control and elimination
phenomena. When medical prespectives of of conditions and diseases that are deemed a
problems and their solutions become dominant, threat to the health of a community, is more
they diminish competing definitions. This is diffuse. It operates as a control agent by setting
particularly true of problems related to bodily and enforcing certain "health" standards in the
functioning and in areas where medical technol- home, workplace, and community (e.g., food,
ogy can demonstrate effectiveness (e.g., im- water, sanitation) and by identifying, prevent-
munization, contraception, antibacterial drugs) ing, treating, and, if necessary, isolating per-
and is increasingly the case for behavioral sons with communicable diseases (Rosen,
and social problems (Mechanic, 1973). This 1972). A clear example of the latter is the de-
underlies the construction of medical norms tection of venereal disease. Indeed, public
(e.g., the definition of what is healthy) and the health has exerted considerable coercive power
"enforcement" of both medical and social in attempting to prevent the spread of infectious
norms. Medical social control also includes disease.
medical advice, counsel, and information that There are a number of types of medical con-
are part of the general stock of knowledge: for trol of deviance. The most common forms of
example, a well-balanced diet is important, cig- medical social control include medicalizing
arette smoking causes cancer, being overweight deviant behavior-that is, defining the behavior
increases health risks, exercising regularly is as an illness or a symptom of an illness or un-
healthy, teeth should be brushed regularly. derlying disease-and subsequent direct med-
Such directives, even when unheeded, serve ical intervention. This medical social control
as road signs for desirable behavior. At a more takes three general forms: medical technology,
concrete level, medical social control is en- medical collaboration, and medical ideology.
acted through professional medical interven-
tion, qua medical treatment (although it may Medical technology
include some types of self-treatment such as The growth of specialized medicine and the
self-medication or medically oriented self-help concomitant development of medical technol-
groups). This intervention aims at returning ogy has produced an armamentarium of medical
sick individuals to compliance with health controls. Psychotechnologies, which include
norms and to their conventional social roles, various forms of medical and behavioral tech-
adjusting them to new (e.g., impaired) roles, nologies (Chorover, 1973), are the most com-
or, short of these, making individuals more mon means of medical control of deviance.
MEDICINE AS AN INSTITUTION OF SOCIAL CONTROL: CONSEQUENCES FOR SOCIETY 243
Since the emergence of phenothiazine medi- lent outbursts (Delgado, 1969; Mark & Ervin,
cations in the early 1950s for the treatment 1970). Although psychosurgery for violence
and control of mental disorder, there has has been criticized from both within as well as
been a virtual explosion in the development outside the medical profession (Chorover,
and use of psychoactive medications to con- I 974b) , and relatively few such operations
trol behavioral deviance: tranquilizers such as have been performed, in 1976 a blue-ribbon
chlordiazepoxide (Librium) and diazepam (Val- national commission reporting to the Depart-
ium) for anxiety, nervousness, and general ment of Health, Education and Welfare en-
malaise; stimulant medications for hyperac- dorsed the use of psychosurgery as having' 'po-
tive children; amphetamines for overeating tential merit" and judged its risks "not exces-
and obesity; disulfiram (Antabuse) for alco- sive." This may encourage an increased use
holism; methadone for heroin, and many oth- of this form of medical control. *
ers. * These pharmaceutical discoveries, ag- Behavior modification, a psychotechnology
gressively promoted by a highly profitable based on B.F. Skinner's and other behaviorists'
and powerful drug industry (Goddard, 1973), learning theories, has been adopted by some
often become the treatment of choice for de- medical professionals as a treatment modality.
viant behavior. They are easily administered A variety of types and variations of behavior
under professional medical control, quite po- modification exist (e.g., token economies, tier
tent in their effects (i.e., controlling, modify- systems, positive reinforcement schedules,
ing, and even eliminating behavior), and are aversive conditioning). While they are not med-
generally less expensive than other medical ical technologies per se, they have been used
treatments and controls (e.g., hospitalization, by physicians for the treatment of mental ill-
altering environments, long-term psycho- ness, mental retardation, homosexuality, vio-
therapy). lence, hyperactive children, autism, phobias,
Psychosurgery, surgical procedures meant to alcoholism, drug addiction, eating problems,
correct certain "brain dysfunctions" presumed and other disorders. An irony of the medical
to cause deviant behavior, was developed in use of behavior modification is that behaviorism
the early 1930s as prefrontal lobotomy, and explicitly denies the medical model (that be-
has been used as a treatment for mental illness. havior is a symptom of illness) and adopts an
But psychosurgery fell into disrepute in the environmental, albeit still individual, solution
early 1950s because the "side effects" (general to the problem. This has not, however, hindered
passivity, difficulty with abstract thinking) its adoption by medical professionals.
were deemed too undesirable, and many pa- Human genetics is one of the most exciting
tients remained institutionalized in spite of such and rapidly expanding areas of medical knowl-
treatments. Furthermore, new psychoactive edge. Genetic screening and genetic counseling
medications were becoming available to control are becoming more commonplace. Genetic
the mentally ill. By the middle 1950s, how- causes are proposed for such a variety of
ever, approximately 40,000 to 50,000 such human problems as alcoholism, hyperactivity,
operations were performed in the United States learning disabilities, schizophrenia, manic-
(Freeman, 1959). In the late 1960s a new and depressive psychosis, homosexuality, and
technologically more sophisticated variant of mental retardation. At this time, apart from
psychosurgery (including laser technology specific genetic disorders such as pheylketonu-
and brain implants) emerged and was heralded ria (PKU) and certain forms of retardation,
by some as a treatment for uncontrollable vio- *A number of other surgical interventions for de-
viance have been developed in recent years. Sur-
*Another pharmaceutical innovation, birth control gery for "gender dysphoria" (transsexuality) and
pills, also functions as a medical control; in this "intestinal by-pass" operations for obesity are both
case, the control of reproduction. There is little examples of surgical intervention for deviance. The
doubt that "the pill" has played a significant part legalization of abortions has also medicalized and
in the sexual revolution since the 1960s and the legitimated an activity that was formerly deviant
redefinition of what constitutes sexual deviance. and brought it under medical-surgical control.
genetic explanations tend to be general theories ability. A classic example is the so-called in-
(i.e., at best positing "predispositions "), with sanity defense in certain crime cases. Other
only minimal empirical support, and are not at more commonplace examples include compe-
the level at which medical intervention occurs. tency to stand trial, medical deferment from the
The most well-publicized genetic theory of de- draft or a medical discharge from the military;
viant behavior is that an XYY chromosome requiring physicians' notes to legitimize
arrangement is a determinant factor in "crimi- missing an examination or excessive absences
nal tendencies." Although this XYY research in school, and, before abortion was legalized,
has been criticized severely (e.g., Fox, 1971), obtaining two psychiatrists' letters testifying
the conu:oversy surrounding it may be a har- to the therapeutic necessity of the abortion.
binger of things to come. Genetic anomalies Halleck (1971) has called this "the power of
may be discovered to have a correlation with medical excuse." In a slightly different vein,
deviant behavior and may become a causal but still forms of gatekeeping and medical ex-
explanation for this behavior. Medical control, cuse, are medical examinations for disability
in the form of genetic counseling (Sorenson, or workman's compensation benefits. Medical
1974), may discourage parents from having off- reports required for insurance coverage and
spring with a high risk (e.g., 25%) of genetic employment or medical certification of an epi-
impairment. Clearly the potentials for medical leptic as seizure free to obtain a driver's license
control go far beyond present use; one could are also gatekeeping activities.
imagine the possibility of licensing selected Physicians in total institutions have one of
parents (with proper genes) to have children, two roles. In some institutions, such as schools
and further manipulating gene arrangements for the retarded or mental hospitals, they are
to produce or eliminate certain traits. usually the administrative authority; in others,
such as in the military or prisons, they are em-
Medical collaborallon ployees of the administration. In total institu-
Medicine acts not only as an independent tions, medicine's role as an agent of social con-
agent of social control (as above), but fre- trol (for the institution) is more apparent. In
quently medical collaboration with other both the military and prisons, physicians have
authorities serves social control functions. Such the power to confer the sick role and to offer
collaboration includes roles as information medical excuse for deviance (see Daniels,
provider, gatekeeper, institutional agent, and 1969; Waitzkin & Waterman, 1974). For
technician. These interdependent medical con- example, discharges and sick call are available
trol functions highlight the extent to which medical designations for deviant behavior.
medicine is interwoven in the fabric of society. Since physicians are both hired and paid by the
Historically, medical personnel have reported institution, it is difficult for them to be fully an
information on gunshot wounds and venereal agent of the patient, engendering built-in role
disease to state authorities. More recently this strains. An extreme example is in wartime
has included reporting "child abuse" to child when the physician's mandate is to return the
welfare or law enforcement agencies (Pfohl, soldier to combat duty as soon as possible.
1977). Under some circumstances physicians act as
The medical profession is the official desig- direct agents of control by prescribing medica-
nator of the "sick role." This imbues the tions to control unruly or disorderly inmates
physician with authority to define particular or to help a "neurotic" adjust to the conditions
kinds of deviance as illness and exempt the pa- of a total institution. In such cases "captive pro-
tient from certain role obligations. These are fessionals" (Daniels, 1969) are more likely to
general gatekeeping and social control tasks. In become the agent of the institution than the
some instances the physician functions as a spe- agent of the individual patient (Szasz, 1965; see
cific gatekeeper for special exemptions from also Menninger, 1967).
conventional norms; here the exemptions are Under rather rare circumstances physicians
authorized because of illness, disease, or dis- may become "mere technicians," applying
the sanctions of another authority who pur- Disease designations can support dominant
chases their medical skills. An extreme ex- social interests and institutions. A poignant
ample would be the behavior of the experimen- example is prominent 19th-century New Or-
tal and death physicians in Nazi Germany. A leans physician S. W. Cartwright's antebellum
less heinous but nevertheless ominous example conceptualization of the disease drapetomania,
is provided by physicians who perform court- a condition that affected only slaves. Its major
ordered sterilizations (Kittrie, 1971). Perhaps symptom was running away from their
one could imagine sometime in the future, if masters (Cartwright, S. W., 1851). Medical
the death penalty becomes commonplace again, conceptions and controls often support dom-
physicians administering drugs as the "humani- inant social values and morality: the 19th-cen-
tarian" and painless executioners. * tury Victorian conceptualization of the illness
of and addiction to masturbation and the medi-
Medical ideology cal treatments developed to control this disease
Medical ideology is a type of social control make chilling reading in the 1970s (Comfort,
that involves defining a behavior or condition as 1967; Englehardt, 1974). The recent Soviet
an illness primarily because of the social and labeling of political dissidents as mentally ill
ideological benefits accrued by conceptualizing is another example of the manipulation of
it in medical terms. These effects of medical illness designations to support dominant po-
ideology may benefit the individual, the domi- litical and social institutions (Conrad, 1977).
nant interests in the society, or both. They exist These examples highlight the sociopolitical na-
independently of any organic basis for illness ture of illness designations in general (Zola,
or any available treatment. Howard Waitzkin 1975).
and Barbara Waterman (1974) call one latent In sum, medicine as an institution of social
function of medicalization "secondary gain," control has a number of faces. The three types
arguing that assumption of the sick role can of medical social control discussed here do
fulfill personality and individual needs (e.g., not necessarily exist as discrete entities but
gaining nurturance or attention) or legitimize are found in combination with one another.
personal failure (Shuval & Antonovsky, For example, court-ordered sterilizations or
1973). t One of the most important functions medical prescribing of drugs to unruly nursing
of the disease model of alcoholism and to a home patients combines both technological
lesser extent drug addiction is the secondary and collaborative aspects of medical control;
gain of removing blame from, and constructing legitimating disability status includes both
a shield against condemnation of, individuals ideological and collaborative aspects of med-
for their deviant behavior. Alcoholics Anony- ical control; and treating Soviet dissidents with
mous, a nonmedical quasireligious self-help drugs for their mental illness combines all three
organization, adopted a variant of the medical aspects of medical social control. It is clear that
model of alcoholism independent of the medical the enormous expansion of medicine in the
profession. One suspects the secondary gain past 50 years has increased the number of pos-
serves their purposes well. sible ways in which problems could be medical-
ized beyond those discussed in earlier chapters.
*It is worth noting that in the recent Gary Gilmore In the next section we point out some of the
execution a physician was involved; he designated
the spot where the heartbeat was loudest and mea-
consequences of this medicalization.
sured vital signs during the execution ceremony. A
few states have actually passed death penalty legis-
SOCIAL CONSEQUENCES OF
lation specifying injection of a lethal drug as the MEDICALIZING DEVIANCE
means of execution. Jesse Pitts (1968), one of the first sociologists
t Although Waitzkin and Waterman suggest that to give attention to the medicalization of de-
such secondary gain functions are latent (i.e., un-
intended and unrecognized), the cases we have dis- viance, suggests that "medicalization is one
cussed here show that such "gains" are often inten- of the most effective means of social control
tionally pursued. and that it is destined to become the main mode
ofJormal social control" (p. 391, emphasis in tributed to medicalization. We review briefly
original). * Although his bold prediction is far- the accepted socially progressive aspects of
reaching (and, in light of recent develop- medicalizing deviance. They are separated
ments, perhaps a bit premature), his analysis more for clarity of presentation than for any
of a decade ago was curiously optimistic intrinsic separation in consequence.
and uncritical of the effects and consequences First, medicalization is related to a longtime
of medicalization. Nonsociologists, especially humanitarian trend in the conception and con-
psychiatric critic Thomas Szasz (1961, 1963, trol of deviance. For example, alcoholism is
1970, 1974) and legal scholar Nicholas Kittrie no longer considered a sin or even a moral
(1971), are much more critical in their evalua- weakness; it is now a disease. Alcoholics are
tions of the ramifications of medicalization. no longer arrested in many places for "pub-
Szasz's critiques are polemical and attack the lic drunkenness"; they are now somehow
medical, especially psychiatric, definitions and "treated," if only to be dried out for a time.
treatments for deviant behavior. Szasz's analy- Medical treatment for the alcoholic can be seen
ses, although path breaking, insightful, and as a more humanitarian means of social control.
suggestive, have not been presented in a par- It is not retributive or punitive, but at least
ticularly systematic form. Both he and Kittire ideally, therapeutic. Troy Duster (1970, p. 10)
tend to focus on the effects of medicalization suggests that medical definitions increase tol-
on individual civil liberties and judicial pro- erance and compassion for human problems and
cesses rather than on social consequences. they "have now been reinterpreted in an almost
Their writings, however, reveal that both are nonmoral fashion." (We doubt this, but leave
aware of sociological consequences. the morality issue for a later discussion.) Med-
In this section we discuss some of the more icine and humanitarianism historically de-
significant consequences and ramifications of veloped concurrently and, as some have ob-
defining deviant behavior as a medical problem. served, the use of medical language and evi-
We must remind the reader that we are examin- dence increases the prestige of human pro-
ing the social consequences of medicalizing posals and enhances their acceptance (Wootton,
deviance, which can be analyzed separately 1959; Zola, 1975). Medical definitions are im-
from the validity of medical definitions or diag- bued with the prestige of the medical profes-
noses, the effectiveness of medical regimens, or sion and are considered the "scientific" and
their individual consequences. These variously humane way of viewing a problem. (Concern-
"latent" consequences inhere in medicalization ing the actual scientific basis for medical defini-
itself and occur regardless of how efficacious tions, recall our discussion of the disease con-
the particular medical treatment or social concept of alcoholism in Chapter 4.) This is
trol mechanism. As will be apparent, our especially true if an apparently "successful"
sociological analysis has left us skeptical of treatment for controlling the behavior is avail-
the social benefits of medical social control. able, as with hyperkinesis.
We separate the consequences into the "bright- Second, medicalization allows for the exten-
er" and "darker" sides of medicalization. The sion of the sick role to those labeled as deviants
"brighter" side will be presented first. (see Chapter 2 for our discussion of the sick
role). Many of the perceived benefits of the
Brighter side medicalization of deviance stem from the
The brighter side of medicalization includes assignment of the sick role. Some have sug-
the positive or beneficial qualities that are at- gested that this is the most significant ele-
ment of adopting the medical model of deviant
behavior (Sigler & Osmond, 1974). By de-
*From Pitts, J. Social control: the concept. In D. fining deviant behavior as an illness or a result
Sills (Ed.), International encyclopedia of social
sciences (Vol. 14). New York: Macmillan Publish- of illness, one is absolved of responsibility for
ing Co., Inc., 1968. Copyright 1968 by Crowell one's behavior. It diminishes or removes blame
Collier and Macmillan, Inc. from the individual for deviant actions. Alco-
holics are no longer held responsible for their The deviant, in essence, is medically excused
uncontrolled drinking, and perhaps hyperactive for the deviation. But, as Talcott Parsons
children are no longer the classroom's "bad (1972) has pointed out, "the conditional legiti-
boys" but children with a medical disorder. mation is bought at a 'price,' namely, the
There is some clear secondary gain here for the recognition that illness itself is an undesirable
individual. The label "sick" is free of the state, to be recovered from as expeditiously
moral opprobrium and implied culpability of as possible" (p. 108). Thus the medical
"criminal" or "sinner." The designation of excuse for deviance is only valid when the pa-
sickness also may reduce guilt for drinkers tient-deviant accepts the medical perspective
and their families and for hyperactive children of the inherent undesirability of his or her sick
and their parents. Similarly, it may result in behavior and submits to a subordinate relation-
reduced stigma for the deviant. It allows for ship with an official agent of control (the phy-
the development of more acceptable accounts sician) toward changing it. This, of course, ne-
of deviance: a recent film depicted a child gates any threat the deviant may pose to so-
witnessing her father's helpless drunken stupor; ciety's normative structure, for such deviants
her mother remarked, "It's okay. Daddy's just do not challenge the norm; by accepting de-
sick. "* viance as sickness and social control as "treat-
The sick role allows for the "conditional ment," the deviant underscores the validity of
legitimation" of a certain amount of deviance, the violated norm.
so long as the individual fulfills the obligations Third, the medical model can be viewed as
of the sick role.t As Renee Fox (1977) notes: portraying an optimistic outcome for the de-
The fact that the exemptions of sickness have been viant. * Pitts (1968) notes, "the possibility that
extended to people with a widening arc of attitudes, a patient may be exploited is somewhat mini-
experiences and behaviors in American society mized by therapeutic ideology, which creates
means primarily that what is regarded as "condi- an optimistic bias concerning the patient's fate"
tionally legitimated deviance" has increased . . . . (p. 391).t The therapeutic ideology, accepted
So long as [the deviant] does not abandon himself in some form by all branches of medicine,
to illness or eagerly embrace it, but works actively suggests that a problem (e.g., deviant behavior)
on his own or with medical professionals to im-
can be changed or alleviated if only the proper
prove his condition, he is considered to be respond-
treatment is discovered and administered. De-
ing appropriately, even admirably, to an unfor-
tunate occurrence. Under these conditions, illness fining deviant behavior as an illness may also
is accepted as legitimate deviance. (p. 15):j: mobilize hope in the individual patient that
*It should be noted, however, that little empirical
with proper treatment a "cure" is possible
evidence exists for reduced stigmatization. Derek (Frank, J., 1974). Clearly this could have
Phillips' (1963) research suggests that people seek- beneficial results and even become a self-
ing medical help for their personal problems are fulfilling prophecy. Although the medical
highly at risk for rejection and stigmatization. model is interpreted frequently as optimistic
Certain illnesses carry their own stigma. Leprosy,
epilepsy, and mental illness are all stigmatized about individual change, under some circum-
illnesses (Gussow & Tracy, 1968); Susan Sontag stances it may lend itself to pessimistic inter-
(1978) proposes that cancer is highly stigmatized in pretations. The attribution of physiological
American society. We need further research on the cause coupled with the lack of effective treat-
stigma-reducing properties of medical designations ment engendered a somatic pessimism in the
of deviance; it is by no means an automatic result of
medicalization.
tOn the other hand, Paul Roman and Harrison Trice
(1968, p. 248) contend that the sick role of alcoholic *For a contrasting viewpoint, see Rotenberg'S (1978)
may actually reinforce deviant behavior by removing work, discussed in the next chapter.
responsibility for deviant drinking behavior. tFrom Pitts, J. Social control: the concept. In D.
:j:Reprinted by permission of Daedalus. Journal of Sills (Ed.), International encyclopedia of social
the American Academy of Arts and Sciences, Bos- sciences (Vol. 14). New York: Macmillan Pub-
ton, Mass. Spring 1977, Doing better and feeling lishing Co., Inc., 1968. Copyright 1968 by Crowell
worse: health in the United States. Collier and Macmillan, Inc.
late 19th-century conception of madness (see tions, may dramatically improve after treatment
Chapter 3). with medications. Medical controls circumvent
Fourth, medicalization lends the prestige of complicated legal and judicial procedures and
the medical profession to deviance designa- may be applied more informally. This can have
tions and treatments. The medical profession a considerable effect on social control struc-
is the most prestigious and dominant profes- tures. For example, it has been noted that de-
sion in American society (Freidson, 1970a). fining alcoholism as a disease would reduce
As just noted, medical definitions of deviance arrest rates in some areas up to 50%.
become imbued with the prestige of the medical In sum, the social benefits of medicalization
profession and are construed to be the "scien- include the creation of humanitarian and non-
tific" way of viewing a problem. The medical punitive sanctions; the extension of the sick
mantle of science may serve to deflect defini- role to some deviants; a reduction of individual
tional challenges. This is especially true if an responsibility, blame, and possibly stigma for
apparently "successful" treatment for control- deviance; an optimistic therapeutic ideology;
ling the behavior is available. Medicalization care and treatment rendered by a prestigious
places the problem in the hands of healing phy- medical profession; and the availability of a
sicians. "The therapeutic value of professional more flexible and often more efficient means of
dominance, from the patient's point of view, is social control.
that it becomes the doctor's problem" (Ehren-
reich & Ehrenreich, 1975, p. 156, emphasis in Darker side
original). Physicians are assumed to be bene- There is, however, another side to the med-
ficent and honorable. "The medical and icalization of deviant behavior. Although it
paramedical professions," Pitts (1968) con- may often seem entirely humanitarian to con-
tends, "especially in the United States, are ceptualize deviance as sickness as opposed to
probably more immune to corruption than are badness, it is not that simple. There is a
the judicial and parajudicial professions and "darker" side to the medicalization of de-
relatively immune to political pressure" (p. viance. In some senses these might be con-
391).* sidered as the more clearly latent aspects of
Fifth, medical social control is more flexible medicalization. In an earlier work Conrad
and often more efficient than judicial and legal (1975) elucidated four consequences of med-
controls. The impact of the flexibility of medi- icalizing deviance; building on that work, we
cine is most profound on the "deviance of ev- expand our analysis to seven. Six are dis-
eryday life," since it allows "social pressures cussed here; the seventh is described separately
on deviance [to] increase without boxing the in the next section.
deviant into as rigid a category as 'criminal''' Dislocation of responsibility. As we have
(Pitts, 1968, p. 391).* Medical controls are seen, defining behavior as a medical problem
adjustable to fit the needs of the individual pa- removes or profoundly diminishes responsibil-
tient, rather than being a response to the deviant ity from the individual. Although affixing
act itself. It may be more efficient (and less responsibility is always complex, medicaliza-
expensive) to control opiate addiction with tion produces confusion and ambiguity about
methadone maintenance than with long prison who is responsible. Responsibility is separated
terms or mental hospitalization. The behavior from social action; it is located in the
of disruptive hyperactive children, who have nether world of biophysiology or psyche. Al-
been immune to all parental and teacher sanc- though this takes the individual officially "off
the hook," its excuse is only a partial one. The
*From Pitts, J. Social control: the concept. In D. individual, the putative deviant, and the un-
Sills (Ed.), International encyclopedia of social
sciences (Vol. 14). New York: Macmillan Publish- desirable conduct are still associated. Aside
ing Co., Inc., 1968. Copyright 1968 by Crowell Col- from where such conduct is "seated," the sick
lier and Macmillan, Inc. deviant is the medium of its expression.
With the removal of responsibility also treat an individual problem but how and when.
comes the lowering of status. A dual-class cit- (p. 86)*
izenship is created: those who are deemed Defining deviance as a medical phenomenon in-
responsible for their actions and those who are volves moral enterprise.
not. The not-completely-responsible sick are Domination of expert control. The med-
placed in a position of dependence on the fully ical profession is made up of experts; it has
responsible nonsick (Parsons, 1975, p. 108). a monopoly on anything that can be con-
Kittrie (1971, p. 347) notes in this regard that ceptualized as an illness. Because of the way
more than half the American population is no the medical profession is organized and the
longer subject to the sanctions of criminal law. mandate it has from society, decisions related
Such persons, among others, become true "sec- to medical diagnoses and treatment are con-
ond-class citizens." trolled almost completely by medical profes-
Allumpflon of file moral neutrality of sionals.
medicine. Cloaked in the mantle of science, Conditions that enter the medical domain are
medicine and medical practice are assumed to not ipso facto medical problems, whether we
be objective and value free. But this profoundly speak of alcoholism, hyperactivity, or drug ad-
misrepresents reality. The very nature of med- diction. When a problem is defined as medical,
ical practice involves value judgment. To call it is removed from the public realm, where
something a disease is to deem it undesirable. there can be discussion by ordinary people, and
Medicine is influenced by the moral order of so- put on a plane where only medical people can
ciety-witness the diagnosis and treatment of discuss it. As Janice Reynolds (1973) succinctly
masturbation as a disease in Victorian times- states,
yet medical language of disease and treatment The increasing acceptance, especially among the
is assumed to be morally neutral. It is not, and more educated segments of our populace, of techni-
the very technological-scientific vocabulary of cal solutions-solutions administered by disinter-
medicine that defines disease obfuscates this ested and morally neutral experts-results in the
fact. withdrawal of more and more areas of human ex-
Defining deviance as disease allows behavior perience from the realm of public discussion. For
when drunkenness, juvenile delinquency, sub par
to keep its negative judgment, but medical
performance and extreme political beliefs are seen as
language veils the political and moral nature
symptoms of an underlying illness or biological de-
of this decision in the guise of scientific fact. fect the merits and drawbacks of such behavior or
There was little public clamor for moral beliefs need not be evaluated. (pp. 220-221)t
definitions of homosexuality as long as it re-
The public may have their own conceptions of
mained defined an illness, but soon after the
deviant behavior, but those of the experts are
disease designation was removed, moral cru-
usually dominant. Medical definitions have a
saders (e.g., Anita Bryant) launched public
high likelihood for dominance and hegemony:
campaigns condemning the immorality of
they are often taken as the last scientific word.
homosexuality. One only needs to scratch
The language of medical experts increases
the surface of medical designations for de-
mystification and decreases the accessibility of
viant behavior to find overtly moral judg-
public debate.
ments.
Medical social control. Defining deviant
Thus, as Zola (1975) points out, defining a
problem as within medical jurisdiction *Reprinted with permission from Pergamon Press,
Ltd.
is not morally neutral precisely because in estab- tFrom "The medical institution: the death and dis-
lishing its relevance as a key dimension for action, ease-producing appendage" by Janice M. Reynolds,
the moral issue is prevented from being squarely first published in American society: a critical analy-
faced and occasionally from even being raised. By sis edited by Larry T. Reynolds and James M. Hen-
the acceptance of a specific behavior as an un- slin. Copyright © 1973 by Longman Inc. Reprinted
desirable state the issue becomes not whether to by permission of Longman.
behavior as a medical problem allows certain in an individual lends itself to the individualiza-
things to be done that could not otherwise be tion of social problems. Rather than seeing cer-
considered; for example, the body may be cut tain deviant behaviors as symptomatic of social
open or psychoactive medications given. As we conditions, the medical perspective focuses on
elaborated above, this treatment can be a form the individual, diagnosing and treating the ill-
of social control. ness itself and generally ignoring the social sit-
In regard to drug treatment, Henry Lennard uation.
(1971) observes: "Psychoactive drugs, especial- Hyperkinesis serves as a good example of
ly those legally prescribed, tend to restrain in- this. Both the school and parents are con-
dividuals from behavior and experience that are cerned with the child's behavior; the child is
not complementary with the requirements of difficult at home and disruptive in school. No
the dominant value system" (p. 57). These punishments or rewards seem consistently ef-
forms of medical social control presume a prior fective in modifying the behavior, and both par-
definition of deviance as a medical problem. ents and school are at their wits' end. A med-
Psychosurgery on an individual prone to violent ical evaluation is suggested. The diagnosis of
outbursts requires a diagnosis that something is hyperkinetic behavior leads to prescribing stim-
wrong with his brain or nervous system.Simi- ulant medications. The child's behavior seems
larly, prescribing drugs to restless, overactive, to become more socially acceptable, reducing
and disruptive schoolchildren requires a diag- problems in school and home. Treatment is
nosis of hyperkinesis. These forms of social considered a medical success.
control, what Stephan Chorover (1973) has But there is an alternative perspective. By fo-
called "psychotechnology," are powerful and cusing on the symptoms and defining them as
often efficient means of controlling deviance. hyperkinesis, we ignore the possibility that the
These relatively new and increasingly popular behavior is not an illness but an adaptation to a
forms of medical control could not be used social situation. It diverts our attention from the
without the prior medicalization of deviant be- family or school and from seriously entertaining
havior. As is suggested from the discovery of the idea that the "problem" could be in the
hyperkinesis and to a lesser extent the develop- structure of the social system. By giving medi-
ment of methadone treatment of opiate addic- cations, we are essentially supporting the ex-
tion, if a mechanism of medical social control isting social and political arrangements in that
seems useful, then the deviant behavior it mod- it becomes a "symptom" of an individual dis-
ifies will be given a medical label or diagnosis. ease rather than a possible "comment" on the
We imply no overt malevolence on the part of nature of the present situation. Although the in-
the medical profession; rather, it is part of a dividualization of social problems aligns well
larger process, of which the medical profession with the individualistic ethic of American cul-
is only a part. The larger process might be ture, medical intervention against deviance
called the individualization of social problems. makes medicine a de facto agent of dominant
Individualization of social problems. social and political interests.
The medicalization of deviance is part of a DepolHlclzation of deviant behavior.
larger phenomenon that is prevalent in our so- Depoliticization of deviant behavior is a result
ciety: the individualization of social problems. of both the process of medicalization and the
We tend to look for causes and solutions to individualization of social problems. Probably
complex social problems in the individual rath- one of the clearest recent examples of such de-
er than in the social system. William Ryan politicization occurred when political dissidents
(1971 a) has identified this process as "blaming in the Soviet Union were decared mentally ill
the victim": seeing the causes of the problem and confined to mental hospitals (Conrad,
in individuals (who are usually of low status) 1977). This strategy served to neutralize the
rather than as endemic to the society. We seek meaning of political protest and dissent, render-
to change the "victim" rather than the society. ing it (officially, at least) symptomatic of men-
The medical practice of diagnosing an illness tal illness.
The medicalization of deviant behavior de- cause of the exclusion of evil, but it shrouds
politicizes deviance in the same manner. By conditions, events, and people and prevents
defining the overactive, restless, and disruptive them from being confronted as evil. The roots
child as hyperkinetic, we ignore the meaning of of the exclusion of evil are in the Enlighten-
the behavior in the context of the social system. ment, the diminution of religious imagery of
If we focused our analysis on the school sys- sin, the rise of determinist theories of human
tem, we might see the child's behavior as a pro- behavior, and the doctrine of cultural relativity.
test against some aspect of the school or class- Social scientists as well have excluded the
room situation, rather than symptomatic of an concept of evil from their analytic discourses
individual neurological disorder. Similar exam- (Wolff, 1969; for exceptions, see Becker, E.,
ples could be drawn of the opiate addict in the 1975, and Lyman, 1978).
ghetto, the alcoholic in the workplace, and Although we cannot here presume to identify
others. Medicalizing deviant behavior pre- the forms of evil in modem times, we would
cludes us from recognizing it as a possible in- like to sensitize the reader to how medical defi-
tentional repudiation of existing political ar- nitions of deviance serve to further exclude evil
rangements. from our view. It can be argued that regardless
There are other related consequences of the of what we construe as evil (e.g., destruction,
medicalization of deviance beyond the six dis- pain, alienation, exploitation, oppression),
cussed. The medical ideal of early intervention there are at least two general types of evil: evil
may lead to early labeling and secondary devi- intent and evil consequence. Evil intent is simi-
ance (see Lemert, 1972). The "medical de- lar to the legal concept mens rea, literally, "evil
cision rule," which approximates "when in mind." Some evil is intended by a specific line
doubt, treat," is nearly the converse of the legal of action. Evil consequence is, on the other
dictum "innocent until proven guilty" and may hand, the result of action. No intent or motive
unnecessarily enlarge the population of deviants to do evil is necessary for evil consequence
(Scheff, 1963). Certain constitutional safe- to prevail; on the contrary, it often re-
guards of the judicial system that protect in- sembles the platitude "the road to hell is paved
dividuals' rights are neutralized or by-passed by with good intentions." In either case medical-
medicalization (Kittrie, 1971). Social control ization dilutes or obstructs us from seeing evil.
in the name of benevolence is at once insidious Sickness gives us a vocabulary of motive
and difficult to confront. Although these are (Mills, 1940) that obliterates evil intent. And
all significant, we wish to expand on still anoth- although it does not automatically render evil
er consequence of considerable social impor- consequences good, the allegation that they
tance, the exclusion of evil. were products of a "sick" mind or body rele-
gates them to a status similar to that of "ac-
Exclusion of evil cidents. "
Evil has been excluded from the imagery of For example, Hitler orchestrated the greatest
modem human problems. We are uncomfort- mass genocide in modem history, yet some
able with notions of evil; we regard them as have reduced his motivation for the destruc-
primitive and nonhumanitarian, as residues tion of the Jews (and others) to a personal
from a theological era. * Medicalization contrib- pathological condition. To them and to many of
utes to the exclusion of concepts of evil in our us, Hitler was sick. But this portrays the hor-
society. Clearly medicalization is not the sole ror of the Holocaust as a product of individual
pathology; as Thomas Szasz frequently points
out, it prevents us from seeing and confronting
* Writing in the early 1970s, Kittrie (1971) noted, man's inhumanity to man. Are Son of Sam,
"Ours is increasingly becoming a society that views Charles Manson, the assassins of King and the
punishment as a primitive and vindictive tool and
is therefore loath to punish" (p. 347). Some recent Kennedys, the Richard Nixon of Watergate,
scholarship in penology and the controversy about Libya's Muammar Kaddafi, or the all-to-com-
the death penalty has slightly modified this trend. mon child beater sick? Although many may
well be troubled, we argue that there is little MEDICALIZATION OF DEVIANCE

to be gained by deploying such a medical AND SOCIAL POLICY
vocabulary of motives. * It only hinders us from "Social policy" may be characterized as an
comprehending the human element in the deci- institutionalized definition of a problem and its
sions we make, the social structures we create, solutions. There are many routes for developing
and the actions we take. Hannah Arendt (1963), social policy in a complex society, but, as John
in her exemplary study of the banality of evil, McKnight (1977) contends, "There is no great-
contends that Nazi war criminal Adolph Eich- er power than the right to define the question"
mann, rather than being sick, was "terribly, (p. 85). The definition and designation of the
terrifyingly normal." problem itself may be the key to the develop-
Susan Sontag (1978) has suggested that on a ment of social policy. Problem definitions often
cultural level, we use the metaphor of illness take on a life of their own; they tend to resist
to speak of various kinds of evil. Cancer, in change and become the accepted manner of
particular, provides such a metaphor: we depict defining reality (see Caplan, N., & Nelson,
slums and pornography shops as "cancers" in 1973). In a complex society, social policy is
our cities; J. Edgar Hoover's favorite metaphor only rarely implemented as a direct and self-
for communism was "a cancer in our midst"; conscious master plan, as, for example, oc-
and Nixon's administration was deemed "can- curred with the development of community
cerous," rotting from within. In our secular mental health centers (see Chapter 3). It is far
culture, where powerful religious connotations more common for social policies to evolve from
of sin and evil have been obscured, cancer (and the particular definitions and solutions that
for that matter, illness in general) is one of the emerge from various political processes. Indi-
few available images of unmitigated evil and vidual policies in diverse parts of society may
wickedness. As Sontag (1978) observes: conflict, impinge on, and modify one another.
The overall social policy even may be residual
But how to be ... [moral] in the late twentieth cen-
tury? How, when ... we have a sense of evil but to the political process. The medicalization of
no longer the religious or philosophical language to deviance never has been a formalized social
talk intelligently about evil. Trying to comprehend policy; as we have demonstrated throughout
"radical" or ""absolute" evil, we search for ade- this book, it has emerged from various com-
quate metaphors. But the modern disease metaphors binations of turf battles, court decisions, scien-
are all cheap shots ... Only in the most limited sense tific innovations, political expediences, medical
is any historical event or problem like an illness. It entrepreneurship, and other influences. The
is invariably an encouragement to simplify what is medicalization of deviance has become in effect
complex .... (p. 85) a de facto social policy.
Thus we suggest that the medicalization of so- In this discussion we explore briefly how
cial problems detracts from our capability to some changes and trends in medicine and crim-
see and confront the evils that face our world. inal justice as well as the recent "punitive back-
In sum, the "darker" side of the medicaliza- lash" may affect the future course of the medi-
tion of deviance has profound consequences for calization of deviance.
the putative or alleged deviant and society. We
Criminal Justice: decrlmlnalizaHon.
now turn to some policy implications of medi-
decarceratlon. and the therapeutic
calization.
state
* We do not suggest that these individuals or any Over the past two decades the percent of
other deviants discussed in this book are or should be officially defined deviants institutionalized in
considered evil. We only wish to point out that medi- prisons or mental hospitals has decreased.
calization on a societal level contributes to the exclu-
sion of evil. To the extent that evil exists, we would There has been a parallel growth in "commu-
argue that social structures and specific social con- nity-based" programs for social control. Al-
ditions are the most significant cause of evil. though this" decarceration" has been most dra-
matic with the mentally ill, substantial deinsti- mental patients are located in other institutions,
tutionalization has occurred in prison popula- especially nursing homes (Redlich & Kellert,
tions and with juvenile delinquents and opiate 1978). Here they remain under medical or
addicts as well (see Scull, 1977a). Many devi- quasimedical control. In short, decarceration
ants who until recently would have been institu- appears to increase the medicalization of devi-
tionalized are being "treated" or maintained in ance.
community programs-for example, probation, Decriminalization also affects medicaliza-
work release, and community correctional pro- tion. Decriminalization means that a certain
grams for criminal offenders; counseling, voca- activity is no longer considered to be a criminal
tional, or residential programs as diversion offense. But even when criminal sanctions are
from juvenile court for delinquents; and meth- removed, the act may still maintain its defini-
adone maintenance or therapeutic communi- tion as deviance. In this case, other noncriminal
ty programs in lieu of prison for opiate ad- sanctions may emerge. Alcohol use and devi-
dicts. ant drinking provide a useful example. We
This emerging social policy of decarceration noted in our discussion of the definition of de-
has already affected medicalization. Assuming viant drinking (Chapter 4) that the disease mod-
that the amount of deviance and number of de- el of alcoholism did not begin its rise to prom-
viants a society recognizes remains generally inence until after the repeal of Prohibition, that
constant (see Erikson, 1966), a change in policy is, after alcohol use in general was decriminal-
in one social control agency affects other social ized. More specifically, we can examine the re-
control agents. Thus decarceration of institu- sponse to the decriminalization of "public
tionalized deviants will lead to the deployment drunkenness" in the 1960s. A recent study has
of other forms of social control. Because medi- shown that although alcohol and drug psycho-
cal social control is one of the main types of so- ses comprised only 4.7% of the mental health
cial control deployed in the community, decar- population (inpatient and outpatient) in 1950,
ceration increases medicalization. Since the in 1975 "alcoholism accounted for 46 percent
Robinson Supreme Court decision and the of state hospital patients" and became the larg-
discovery of methadone maintenance the con- est diagnostic category in mental hospitals
trol of opiate addicts has shifted dramatically (Redlich & Kellert, 1978, p. 26). It is likely
from the criminal justice system to the medical that the combination of the declining popula-
system. Control of some criminal offenders tions in state mental hospitals and the decrimi-
may be subtly transferred from the correctional nalization of "public drunkenness" (e.g., po-
system to the mental health system; one recent lice now bring drunks to the mental hospital in-
study found an increase in the number of males stead of the drunk tank) is in part reflected in
with prior police records admitted to psychiatric this enormous increase of alcoholics in the
facilities and suggested this may be an indica- mental health system.
tion of a medicalization of criminal behavior Medicalization allows for the decriminaliza-
(Melick, Steadman, & Cocozza, 1979). There tion of certain activities (e.g., public drunken-
is also some evidence that probation officers, in ness, some types of drug use) because (1) they
their quest for professional status, adopt a medi- remain defined as deviant (sick) and are not
cal model in their treatment of offenders (Chal- vindicated and (2) an alternative form of social
fant, 1977). Although some observers have control is available (medicine). If an act is de-
suggested that the apparent decarceration of criminalized and also demedicalized (e.g.,
mental patients from mental hospitals and the homosexuality), there may well be a backlash
rise of community mental health facilities has at and a call for recriminalization or at least reaf-
least partially demedicalized madness (see firmation of its deviant status rather than a vin-
Chapter 3), this is an inaccurate interpretation. dication. We postulate that if an act is de-
Moreover, the extent of decarceration has been criminalized and yet not vindicated (i.e., still
exaggerated; many of the former or would-be remains defined as deviant), its control may be
transferred from the criminal justice to the med- a total of over $130 billion spent on medical
ical system. * care. Since 1963 health expenditures have risen
In the 1960s and early 1970s considerable more than 10% yearly, while the rest of the
concern was voiced in some quarters concern- economy has grown by 6% to 7%. In other
ing the "social policy" that was leading to the words, medicine is the fastest expanding part
divestment of criminal justice and the rise of of the service sector and one of the most ex-
the therapeutic state (Kittrie, 1971; Leifer, pansive segments of our economy. In one sense
1969; Szasz, 1963). As pointed out in Chapter we might see these increasing expenditures
8, there has been some retreat from the "re- themselves as an index of increasing medicali-
habilitative ideal" in criminal justice. On the zation. But more likely, the increasing econom-
other hand, both decarceration and decrimi- ic resources allocated to medical care create a
nalization have increased medicalization. Thus substantial pool of money to draw from, there-
we would conclude that although the "thera- by increasing the resources available for medi-
peutic state" is not becoming the dominant so- cal solutions to human problems. It should be
cial policy as its earlier critics feared, neither is noted, however, that the inflation of medical
it showing signs of abating. We would suggest costs could ultimately become a factor in de-
that to the extent that decarceration and decreasing the medicalization of deviance, simply
criminalization remain social policies, medical- because medical solutions have become too
ization of deviance can be expected to increase. costly.
Much of the rising cost of medical care has
Trends In medicine and been attributed to the growth in third-party pay-
medlcallzation ments (i.e., when medical care is paid not by
The medicalization of deviance has been the patient or the provider of the care but by
influenced by changes in the medical profession a third party). The major source of third-party
and in social policy regarding medical care. The payments has been Blue Cross and Blue Shield
prestige of medicine has been growing since and the health insurance industry, and, since the
the tum of the century. Medical practice has enactment of Medicare and Medicaid in 1965,
become increasingly specialized; whereas only also the federal government. More than 51 % of
20% of physicians were specialists in 1940, by medical costs was paid directly by the patient
the early 1970s nearly 80% considered them- in 1966; by 1975 this figure had dipped to less
selves specialists (Twaddle & Hessler, 1977, p. than 33% (Coe, 1978, p. 387). The largest in-
175). This is in part the result of the increas- crease in third-party payments has been the
ingly technological nature of medicine. The amount paid by the federal government; in
number of personnel employed in the medical 1975, 27.7% of medical costs was borne by
sector has increased considerably since the Sec- the federal government, and this is expected
ond World War. But the most spectacular to continue to increase. What this all means
growth has been in the cost and investment in for the medicalization of deviance is that "third
medical care in the past three decades. parties" are increasingly deciding what is ap-
In 1950 the expenditures for medical care propriate medical care and what is not. For
comprised 4.6% of the Gross National Product example, if medical insurance or Medicaid will
(GNP); by 1976 they accounted for 8.3%, for pay for certain types of treatment, then the
problem is more likely to be medicalized. Al-
* The decriminalization of abortion has led to its though the medical profession certainly has
complete medicalization. It is interesting to speculate influence in this area, this removes the control
whether the decriminalization of marijuana, gam- of medicalization from medical hands and
bling, and prostitution would lead to medicaliza- places it into the hands of the third-party pay-
tion. It is likely that with marijuana and gambling,
"compulsive" and excessive indulgence would be
ers. Although 90% of America's Blue Cross
defined as "sick"; with prostitution, medical certifi- plans provide some hospital coverage for al-
cation might be required, as is presently the case in coholism, less than 10% of the cost of treatment
several European countries. is currently covered by private insurance and
health-care protection programs (Behavior To- cal personnel could be an increase in the num-
day, June 21, 1976). Although many physi- ber of problems that become defined as medical
cians consider obesity to be a bona fide medical problems (after all, we have all these highly
condition, virtually no health insurers will pay trained professionals to treat them). Although
for intestinal by-pass operations as a treatment the greater number of physicians could result in
for obesity. Clearly, changes in policies by better delivery of medical services, it could also
third-party payers can drastically affect the increase medicalization as new physicians at-
types or amount of deviance medicalized. tempt to develop new areas of medical turf as
Until about the past two decades, the domi- old ones become saturated. David Mechanic
nant organization of medical practice was pri- (1974, p. 50) suggests, for instance, that for
vate, solo practice. There has been a growing "family practice" to become a viable disci-
bureaucratization of medical practice. The pline in medicine, family practitioners would
hospital rather than the private office is behave to develop a "scientific and investigatory
coming the center for health care delivery. stance" toward common family practice prob-
These large modem hospitals are both a result lems such as "alcoholism, drug abuse, difficul-
of, and an inducement for, the practice of high- ties in sexual development, failure to conform
ly specialized and technological medicine. to medical regimen and the like." The potential
Hospitals have their own organizational priori- for the expansion of the medical domain here is
ties of sustaining a smoothly running bureau- great.
cracy, maximizing profitable services, justi- But there are also some countertrends in
fying technological equipment, and maintaining medicine. There is an emphasis on both self-
the patient-bed load at near full capacity. Al- care and individual responsibility for health (see
though bureaucratic organizations reduce medi- Knowles, 1977). Health is becoming defined
cal professional power, the institutional struc- as more of a personal responsibility. As Zola
ture of the hospital is better suited to function (1972) observes, "At the same time the label
as an agent of social control than the singular 'illness' is being used to attribute 'diminished
office practice. Hospital medicine can be prac- responsibility' to a whole host of phenomena,
ticed at a high biotechnological level, is less the issue of 'personal responsibility' seems
client dependent (because of third-party pay- to be re-emerging in medicine itself" (p. 491).
ments), has less personal involvement, and is Increased personal responsibility for sickness
more responsive to demands of other institu- could cause the responsibility for the behavior
tions, especially the state, on whom it is in- to return to the individual. For instance, alco-
creasingly dependent for financial support. holics would be deemed responsible for deviant
For many years American medicine was drinking, obese people for their deviant bodies,
considered to be suffering from a shortage of and opiate addicts for their habits. This could
physicians. In the 1960s federal programs to ultimately spur some demedicalization. *
expand medical schools increased greatly the But the most important social policy affect-
number of physicians being trained. We have ing the future of medicalization hinges on the
just begun to experience the effects of the rising notion of a "right to adequate health care" and
number of physicians. Between 1970 and 1990
we can expect an 80% increase in the number * Renee Fox (1977, pp. 19-21) contends that the
of physicians-from about 325,000 to almost recent trends of viewing patients as consumers, the
emergence of physician extenders such as nurse
600,000. And if present population and medical practitioners and physicians' assistants, and "the
trends continue, as we expect they will, by increased insistence on patients' rights, self-therapy,
1990 there will be one physician for every 420 mutual aid, community medical services and care by
people in the United States and an even greater non-physician health professionals" constitute evi-
enlargement in the number of nurses and allied dence for demedicalization. We think Fox is mis-
taken. Demedicalization does not occur until a prob-
health workers (U.S. Department of Health, lem is no longer defmed in medical terms and medi-
Education and Welfare, 1974). cal treatments are no longer seen as directly relevant
One result of the growing number of medi- to its solution. Fox confuses deprofessionalization
with demedicalization.
the development of a National Health Insurance the convergence of illness and deviance. At
(NHI) program. The proposal of an NHI pro- this point, it is difficult to predict which, if any,
gram has become a significant political issue. of these scenarios might result from the en-
In the past decade dozens of bills advocating actment of NHI.
different NHI plans have been submitted to
various congressional committees. No specific Punitive backlash
NHI plan as yet has emerged as the most prob- Since about 1970 there has been a "back-
able candidate for passage, but there is a high lash" against the increasing "liberalization" of
likelihood that some type of NHI plan will be the treatment of deviance and the Supreme
enacted within the next decade. Because of the Court decisions that have granted criminal sus-
recent fiscal crunch and the strong lobbying of pects and offenders greater "rights." This pub-
powerful vested interests (e.g., the health insur- lic reaction, coming mostly from the more con-
ance industry, the medical profession, the hos- servative sectors of society, generally calls for
pital associations), it is unlikely that it will be more strict treatment of deviants and a return
an NHI program providing comprehensive to more punitive sanctions.
coverage. More likely, NHI will not alter the This "punitive backlash" takes many forms.
present structure of the medical system and In 1973 New York passed a "get tough" law
will resemble present insurance programs (al- with mandatory prison sentences for drug deal-
though with increased public accountability); ers. Other legislative attempts have been made
it will be at least partly federally financed and to impose mandatory minimum sentences on
extend insurance coverage to all Americans. offenders. There is considerable public clamor
Regardless of which NHI bill is enacted, it will for the return of the death penalty. A current
have an effect on medicalization. What the New York state law has allowed juveniles
effect will be, however, is uncertain. There are between ages 13 and 15 to be tried as adults
at least three possible scenarios. for some offenses. The antiabortion crusade has
made inroads into the availability of abortions
SCENARIO ONE: Because the cost of paying for treat-
ment is high and deemed prohibitive, fewer devi- and is aiming for the recriminalization of abor-
ant behaviors are defined as medical problems. tion. Recently antihomosexuality crusades have
Perhaps alcoholism, marital problems, drug addic- appeared from Florida to Oregon, defeating
tion, psychosurgery, and treatment for obesity will antidiscrimination referenda and limiting the
be excluded from NHI coverage. rights of homosexuals.
SCENARIO TWO: Because NHI will pay for the treat- This swell of public reaction may be in part
ment of anything defined as a medical problem, a response to the therapeutic ideology and the
more deviance becomes medicalized. Gambling, perceived "coddling" of deviants. Should this
divorce, boredom, narcissism, and lethargy will be backlash and other recent public reactions such
defined as illnesses and treated medically.
as California's Proposition 13 taxpayer revolt
SCENARIO THREE: Individuals are not considered re-
continue to gather strength and grow in popu-
sponsible for their illnesses; so activities that are
seen as leading to medical problems become de- larity, they well may force a retreat from the
fined as deviant. Smoking, eating poorly, get- medicalization of deviance.
ting insufficient exercise, or eschewing seat belts
all will be defined as deviant. Certain medical
Some SOCial policy
problems could be excluded from NHI coverage recommendations
because they are deemed to be willfully caused Our examination of the medicalization of
(i.e., "badness"). deviance in American society has led us to
This final scenario takes us full circle, as we some conclusions related to social policy. In
would develop the notion of "sickness as this discussion we briefly outline some social
sin. "* Scenarios two and three would further policy recommendations.
I. The medicalization of deviance needs to
*Paradoxically this could also encourage demedi- be recognized as a de facto social policy. Rec-
calization, for the medical model then becomes less ognized as such, issues like those pointed to in
functional in removing the culpability for deviance. this chapter could be raised and debated. It is
important that public discussion by physicians, Every person who lives in a society is accountable
politicians, and lay persons alike be encouraged to it for his anti-social behavior. Society, in return,
and facilitated. In recognition of the salience of may seek to curb his future misdeeds, not as a pun-
medicalization and its consequences, perhaps ishment for the improper exercise of free will but
"medicalization impact statements" should be as a remedy for his human failings.
required of social policy proposals affecting Although the notions of guilt, moral responsi-
medicalization. For example, It IS important bility, and accountability are profound philo-
to weigh the impact of NHI on medicaliza- sophical (and political) questions that cannot
tion. begin to be addressed here, we believe they
2. Research is needed on the extent of medi- must be directly discussed and reevaluated,
calization, its benefits, and its costs. This in- since many people's lives are profoundly af-
cludes research into the efficacy, the financial fected by them.
and social costs, and the extent of actual medi- Presently our society's only "no blame"
calization. We need continued research into the model for deviant behavior is the medical mod-
politics of medicalization and further investi- el. We need to develop new models of deviance
gation into the areas of medicalized deviance that do not assume ultimate individual moral
covered in this book as well as those not cov- responsibility and yet do not define those who
ered, such as the medicalization of suicide, old are not considered responsible as "sick." Pres-
age and senility, obesity, abortion, and mental ently the only alternative to the criminal-
retardation. We need to compare these with responsibility model is the medical-no-respons-
uncontested medical problems that were at one ibility model. It is imperative that we free our-
time defined as deviance, such as epilepsy and selves from the dichotomous crime or sick-
leprosy. Close attention needs to be given to the ness models that create largely either-or situa-
efficacy, costs, and benefits for each type of tions, as well as from unworkable and contra-
medicalization. Hopefully such knowledge and dictory crime-sickness hybrids, as with sex of-
understanding will better guide social policy fenders.
decisions concerning medicalization. New models of deviance need to be recon-
3. Medicalization removes the constitutional ciled with social scientific knowledge about de-
safeguards of the judicial process (see Kittrie, viance. There is considerable evidence that
1971). Because of this, it is important to create economic, social, and family factors contribute
some type of medical due process or redress to deviant behavior, and it is important to un-
for putative deviants who are the objects of derstand that the individual has 9nly limited
therapeutic interventions. Since this type of due control over these factors. Yet it is also im-
process would probably be resisted by the medi- portant, because of our understanding of hu-
cal profession and labeled antitherapeutic, we man behavior, not to completely neglect its
propose the development of some type of voluntary components. Thus we concur with
"counterpower" to medical social control. This Robert Veatch (1973) that rather than as-
could take the form of patient or deviant advo- suming that human behavior is caused by
cates, intervention review organizations, or biophysiological elements ("sickness"), "it
even a Nader-type watchdog group. This would is preferable to make clear the missing cate-
help ensure that individual rights were not cir- gories-namely nonculpable deviancy caused
cumvented in the name of health. psychologically, socially and culturally, for
4. It is our belief that we need to develop example, by lack of various forms of psycho-
social policies toward deviance that hold people logical, social, and cultural welfare" (p. 71).
accountable for their actions but do not blame We need to create a "no blame" role for de-
them. This is a delicate but possible balance. viants that still holds the individual accountable
One proposal is bypassing such slippery con- for his or her action. We need to create a social
cepts as responsibility and guilt, substituting an role analogous to the sick role that does not
assumption of human fallibility combined with assume sickness or remove responsibility and
accountability for human action. As Kittrie yet reconciles our understanding that there are
(197 I) suggests, "forces" beyond the scope of the individual
that affect human behavior. For example, one medications for hyperkinesis; and the medical
can envision the conception of a "victim role"; discovery of child abuse may well increase ther-
the individual is viewed as a "victim" of life apeutic intervention. Medicalization in general
circumstances; these circumstances are known has reduced societal condemnation of devi-
to increase the probability for certain types of ants. But these benefits do not mean these con-
"deviant" behavioral responses as well as ditions are in fact diseases or that the same re-
attributions, yet because the behavior is not sults could not be achieved in another manner.
regarded as "determined" by the circum- And even in those instances of medical "suc-
stances, the individual is accountable for de- cess," the social consequences indicated in this
viant behavior. In other words, given the cir- chapter are still evident.
cumstances, the individual is accountable for The most difficult consequence of medicali-
the behavioral strategies chosen in a situation. zation for us to discuss is the exclusion of evil.
Needless to say, this is a complex and sticky In part this is because we are members of a
issue, replete with philosophical and pragmatic culture that has largely eliminated evil from in-
pitfalls. It provides an important challenge tellectual and public discourse. But our dis-
for social scientists and philosophers. We pre- comfort also stems from our ambivalence about
sent this example only to suggest the possibility what can meaningfully be construed as evil in
of alternatives to the medical-criminal model our society. If we are excluding evil, what ex-
dichotomy. As Clarice Stoll (1968) observes, actly are we excluding? We have no difficulty
our "image of man" is central in determining depicting such conditions as pain, violence,
our social response to deviance; we call for the oppression, exploitation, and abject cruelty as
development of an alternative image that recon- evil. Social scientists of various stripes have
ciles societal response with the understandings been pointing to these evils and their conse-
of social and behavioral science. quences since the dawn of social science. It is
Finally, because social control is necessary also possible for us to conceive of "organiza-
for the existence of society, we urge the de- tional evils" such as corporate price fixing,
velopment of alternative, noncriminal and non- false advertising (or even all advertising), pro-
medical modes of social control appropriate to moting life-threatening automobiles, or the
the new model of deviance. wholesale drugging of nursing home patients
to facilitate institutional management. We also
MEDICALIZING DEVIANCE: have little trouble in seeing ideologies such
A FINAL NOTE as imperialism, chauvinism, and racial suprem-
The potential for medicalizing deviance has acy as evils. Our difficulty comes with see-
increased in the past few decades. The increasing individuals as evil. While we would not
ing dominance of the medical profession, the adopt a Father-Flanagan-of-Boys-Town attitude
discovery of subtle physiological correlates of of "there's no such thing as a bad boy," our
human behavior, and the creation of medical own socialization and "liberal" assumptions as
technologies (promoted by powerful pharma- well as sociological perspective make it difficult
ceutical and medical technology industry inter- for us to conceive of any individual as "evil."
ests) have advanced this trend. Although we re- As sociologists we are more likely to see people
main skeptical of the overall social benefits of as products of their psychological and social
medicalization and are concerned about its circumstances: there may be evil social struc-
"darker" side, it is much too simplistic to sug- tures, ideologies, or deeds, but not evil people.
gest a wholesale condemnation of medicaliza- Yet when we confront a Hitler, an Idi Amin, or
tion. Offering alcoholics medical treatment in a Stalin of the forced labor camps, it is some-
lieu of the drunk tank is undoubtedly a more hu- times difficult to reach any other conclusion.
mane response to deviance; methadone mainte- We note this dilemma more as clarification of
nance allows a select group of opiate addicts to our stance than as a solution. There are both
make successful adaptations to society; some evils in society and people who are "victims"
schoolchildren seem to benefit from stimulant to those evils. Worthwhile social scientific
goals include uncovering the evils, understand- nation of expert control; (4) powerful medical
ing and aiding the victims, and ultimately con- techniques used for social control; (5) the indi-
tributing to a more humane existence for all. vidualization of complex social problems; (6)
the depoliticization of deviant behavior; and (7)
SUMMARY the exclusion of evil. It is this darker side that
In the 20th century, medicine has expanded leaves us skeptical of the social benefits of
as an institution of social control. On the most medicalizing deviance.
abstract level medical social control is the ac- The medicalization of deviance has become a
ceptance of a medical perspective as the domi- de facto social policy. Changes in other" social
nant definition of certain phenomena. Medical policies" affect medicalization. Decarceration
social control of deviant behavior usually takes leads to the increasing deployment of medical
the form of medical intervention, attempting to social control, since it is one of the most effec-
modify deviant behavior with medical means tive social controls "in the community." De-
and in the name of health. We identify three criminalization may also increase medicaliza-
general forms of the medical social control of tion because medicine provides an alternative
deviance: medical technology, medical collabo- social control mechanism. We postulate that if
ration, and medical ideology. Medical tech- an act is decriminalized and not vindicated,
nology involves the use of pharmaceutical or its control may be transferred from the crimi-
surgical technologies as controls for deviance. nal justice system to the medical system. Al-
Medical collaboration emphasizes the inter- though the therapeutic state has not become the
woven position of medicine in society and oc- dominant social policy, neither does it show
curs when physicians collaborate with other any signs of withering away. Medicalization
authorities as information providers, gate- is also influenced by changes and trends in
keepers, institutional agents, and technicians. medicine. Medical practice is becoming in-
Medical ideology as social control involves creasingly specialized, technological, and bu-
defining a behavior or condition as an illness reaucratic. Society'S economic investment (in
primarily for the social and ideological benefits terms of percentage of GNP) in medical care
accrued by conceptualizing it in medical has nearly doubled in the past three decades.
terms. Although these three "ideal types" This is both an index of and incentive for med-
are likely to be found in combination, they icalization. Bureaucratic medical practice re-
highlight the varied faces of medical social con- moves some definitional power from the medi-
trol. cal profession and places it in the hands of
There are important social consequences of third-party payers (including the state) and
medic ali zing deviance. The "brighter" side hospital administrators. The number of physi-
of medicalization includes (1) a more humani- cians and other medical personnel will double
tarian conception of deviance; (2) the extension by 1990; this may well cause further medical-
of the sick role to deviants, minimizing blame ization. On the other hand, the increased em-
and allowing for the conditional legitimation phasis on self-care and individual responsibility
of a certain amount of deviance; (3) the more for health, as well as the "fiscal crisis" of rap-
optimistic view of change presented by the idly rising medical costs, may limit medicaliza-
medical model; (4) lending the prestigious tion and spur demedicalization. The passage of
mantle of the medical profession to deviance a National Health Insurance program may have
designations and treatments; and (5) the fact a profound effect on medicalization, although
that medical social control is more flexible and it is difficult to predict precisely what it will
sometimes more efficient than other controls. be. If the "punitive backlash" to perceived
However, there is a "darker" side of med- liberalized treatment of deviants gains strength,
icalization, which includes (1) the disloca- it may force some retreat from the medicaliza-
tion of responsibility from the individual; (2) tion of deviance.
the assumption of the moral neutrality of medi- We conclude with some brief social policy
cine; (3) the problems engendered by the domi- recommendations:
1. The medicalization of deviance needs to 4. A new model of deviance that holds peo-
be recognized as a de facto social policy. ple accountable for their actions but does not
2. More research is needed on the extent, blame them needs to be developed, perhaps as a
politics, benefits, and costs of medicalizing de- "victim" model. We need to be freed from the
viance. dichotomous crime or sickness models that
3. Some form of "counterpower" to medical create limiting either-or situations.
social control needs to be created.
10 A THEORETICAL
STATEMENT on the
MEDICALIZATION of
DEVIANCE
T his chapter serves as both a conceptual

summary of the various cases discussed
in this book and as a theoretical state-
ment about the medicalization of devi-
HISTORICAL AND CONCEPTUAL
BACKGROUND
As is evident in the various chapters of this
book, the medicalization of deviance has a long
ance in American society. In essence, we pro- history, beginning at least as early as ancient
pose here a general sociological account, Greece. The ideas that disease can cause devi-
grounded in the historical data we have pre- ant behavior, that deviant behavior can lead to
sented and drawing on common themes and pat- disease, and that such conduct is itself an ill-
terns. The chapter offers not a formal, positivist ness or a symptom thereof have existed in var-
"explanation" but rather an attempt to draw out ious forms for thousands of years. It is, how-
what we perceive to be the major analytic or ever, only in the 19th and 20th centuries that we
theoretical insights about the social and histor- see medical designations of deviance become
ical processes we have discussed. the dominant definitions of deviant behavior.
In this theoretical statement we attempt to We must, then, first examine the general condi-
account for the rise and fall (but mostly the rise) tions in these centuries that appear to have cre-
of medical designations of deviance. Any such ated an environment fertile for medicalizing de-
general sociological understanding of medi- viance. Although many factors contributed to
calization should also, of course, include de- the emergence of medicine as the dominant de-
medicalization, although there is considerably finer of deviance, we believe the most impor-
less historical data about the latter on which to tant for the modem medicalization of deviance
base generalizations. Thus we propose that our were the rise of rationalism, the development
•• theory" is neither definitive nor exhaustive but of determinist theories of causation that arose
rather that it represents an attempt to specify in the 19th century, and the growth and success
what general lessons we may learn about the of medicine in the 20th century.
rise and dominance of, and occasional chal- The European Enlightenment of the 17th and
lenge to, medical definitions and controls of 18th centuries nurtured the ideas of individual
deviant behavior. We divide the chapter into and collective progress. The dominance of
three parts: a review of the general histori- theological definitions and explanations for
cal and conceptual background of medical- human behavior, including deviance, were
ization, an inductive theory of medicalization, seriously challenged by thinkers who posited
and, finally, a section containing some of rational and scientific principles by which to
our more speculative hunches and hypoth- understand and then govern individual behavior
eses. and society. Rousseau, Voltaire, and Cesare di
261
Becarria made important contributions to the forms of traditionally "criminal" conduct-and

new rational philosophy. The criminal in Becar- has occurred in the United States over the past
ria's classical criminology was depicted as a century (Kittrie, 1971).
rational actor and considered to have free will As we pointed out in the first chapter, medi-
(see Chapter 8); in short, to be responsible for cine did not become a dominant, prestigious,
his or her own behavior. In this view of rational and successful profession until the turn of the
action, behavior was generally seen as turning 20th century. Medicine's own determinist the-
on a pleasure-pain calculus; people were be- ory, the germ theory of disease, became pop-
lieved to seek pleasure and avoid pain. ular and dominant after about 1870 and pro-
The Enlightenment also nurtured the develop- vided medicine with some of its greatest clinical
ment of science as a method for understanding achievements. It proved to be the key that un-
the world. By the 19th century, scientific theo- locked the mystery of infectious disease and
ries advanced the idea that behavior, and even provided the major perspective in terms of
society, were determined by , 'forces' , over which physicians viewed illness. It was, how-
which individuals had little control. Classical ever, the actual control of infectious disease
criminology was challenged by the develop- (which, incidentally, had little to do directly
ment and ascendance of determinist theories of with the discovery of the germ theory [Dubos,
criminality and deviance. These theories took 1959]), along with the consolidation and mo-
two general forms: social (environmental) de- nopolization of medical organization and prac-
terminism and biophysiological determinism. tice about the turn of the century that enabled
Social determinism, such as the theories of the medical profession to achieve a position of
environmental cause postulated by the Ameri- social and professional dominance.
can asylum superintendents (see Chapter 3), Many analysts and students of Western socie-
and later theories based on the work of Marx, ty have suggested the great importance of cer-
gained considerable popularity. Toward the tain major historical transformations in shap-
middle of the 19th century, biophysical theories ing the nature and contours of modern society.
such as that of Lombroso echoed the new dis- These various developments are used com-
coveries of Darwin and proposed that the causes monly to account for a broad range of other
of deviance could be found in one's constitution social and cultural changes. The list is some-
and/or biological heritage. These determinist what standard and includes industrialization,
theories, in their many forms, became the dom- the decline of religion, the demise of the ex-
inant explanation of deviant conduct and per- tended family, the loss of traditional authority,
sons. People were "bad" not so much because increased geographical mobility, the develop-
they chose to be but rather because they had no ment of technology, the professionalization of
alternative; they became "objects" at the mercy society, and the increased value of humanitari-
of powerful social or biophysiological forces. anism. Medicalization, too, has been explained
These determinist scientific explanations at least in part by reference to some of these
"made sense" of deviance in such a way that historic shifts. One difficulty with such explana-
punishment for such conduct became somewhat tion is that it often provides only limited under-
less important as a strategy for controlling devi- standing of how in fact a certain change in
ant behavior. It was considered incapable of practice or policy took place. Saying, for
affecting this social or biophysiological fate example, that medicalization is caused by the
by which the deviant was believed to be deprofessionalization of society leaves us wonder-
termined. "Treatment," rather than punishing just what that might mean. These global
ment, became increasingly popular as the more developments that are themselves used to define
humane and preferred way of controlling crime. modern society could be used to account for vir-
As we have noted, this change has been called tually any changes that followed them in time.
the divestment of the criminal law - the re- This is not to argue that they are meaningless or
linquishing of legal jurisdiction over many that they should be ignored in attempting to
A THEORETICAL STATEMENT ON THE MEDICALIZATION OF DEVIANCE 263
understand the medicalization of deviance and The United States, more than its European
its rise. Rather, we have attempted in the chap- counterparts, has a strong heritage of experi-
ters of this book to give these abstractions a de- mentation and utopianism. Some have called
gree of life by identifying them as values used America itself a "noble experiment." It has
by real people making claims for a certain been a society regularly open to new ideas and
change, or at least by trying to define them on a innovative ways of doing things and solving
more empirical level. We have tried to show problems. One might even suggest that the
that changes, even such massive ones as these, "new" -the latest and the best-has become a
do not just happen; they must be championed, fetish with many Americans. In addition, the
their themes invoked and defended against chal- value of humanitarianism is deeply ingrained
lenges, and renegotiated. in the American ethos. Indeed, Americans have
With this in mind, we can say that the rise been espousing this value of humanitarianism
of rationalism, science, and the popularity of since the Declaration of Independence, al-
determinist theories of deviance, as well as the though not following it consistently as a socie-
professionalization and monopolization of med- ty. But along with idealism and humanitarian-
icine, were general social conditions that appear ism, Americans have shown a strong penchant
to have given impetus to medicalization. That for pragmatism and particularly for pragmatic
is, people who championed these and related solutions to human problems. Rather than en-
ideas tended also to support and sometimes to gaging in philosophical or even scientific debate
actively promote medicine as a way of defining toward a more full understanding of such prob-
and dealing with personal problems and deviant lems, Americans are more likely to ask, "What
behavior. In terms of the history of ideas, medi- can be done about it?" Another dominant value
cal theories of deviance grew out of the same used to describe life in the United States is
materialist determinism that spawned the work individualism. Although all societies and social
of Darwin, Marx, and, later, Freud. And the groups must strike some balance between the
medicalization of deviance in particular flour- individual's needs and those of the collectivity,
ished in the United States. In the following disin America the balance usually is tipped in
cussion we explore some features of American favor of the individual. Certainly in terms of
society that have been supportive of medical solving social problems, typical solutions are
theories of deviance. nearly always those which involve intervention
not in the established institutions of the society
American society as fertile ground but rather in individuals' lives. Such a strategy is
for medlcallzatlon based on the dubious assumption that the source
The medicalization of deviance has been of the problem in question rests somehow in the
nowhere more pervasive than in the United person rather than in the diverse and often con-
States. This is not to say that medicalization is flicting social and cultural environment (see
unknown elsewhere; numerous instances can be Ryan, 197Ia). In a general sense, the American
cited. For example, we have alluded to the values of experimentation, newness, humani-
medicalization of madness and opiate addiction tarianism, pragmatism, and individualism have
in Great Britain and to the 19th-century medi- all contributed to a nurturing crucible for medi-
calization of homosexuality by German physi- calization, for the medical perspective on devi-
cians and of crime by European positivist crim- ance contains elements of all these values.
inologists. American society, however, and Max Weber (1904-1905/1958) argued per-
especially since the late 19th century, has suasively for the importance of the Protestant
provided a particularly hospitable environment Ethic in the development of capitalism and the
for the medicalization of deviance. In this dis- rationalization of Western society. He located
cussion we point to some general cultural and the root of the Protestant Ethic in early Protes-
organizational features of American society that tant asceticism, and particularly in the Calvinist
have contributed to this nurturant context. doctrine of predestination. Predestination, in
Calvinist tenns, meant that those who were Rotenberg contends there is a historical link be-
among the "elect" and would thus be "saved" tween the damnation metaphor and the contem-
had been identified or selected by God when porary medical model of deviance. He observes
they were born. Nothing that one did on earth that the latter, which classifies people as healthy
could change this divine ordination. Hard work, or sick, reflects the same dichotomous assump-
frugality, and thrift, however, were important tions as do the Calvinist notions of elect and
values of Puritan life, and it was believed that damned. Furthennore, the Protestant ethic of
certainly those whom God would choose would predestination is at least partly "responsible
be those who lived their lives according to such for the belief in man's inability to change,"
desirable standards. Such conduct, if followed which underlies much of the biophysiological
devoutly, also led ultimately to material success detenninism of the medical model (Rotenberg,
and accumulation, and although one could in 1978, p. 2). One could also suggest that both
no sense "work" one's way into heaven, such the notions "damned" and "sick" focus atten-
material achievement was believed to be a rea- tion on the individual's condition apart from
sonably good sign that a person was one of social context and portray deviance as innate,
God's chosen. No one, of course-at least none detennined, and largely irreversible. To the ex-
of the respectable members of the community- tent that the Protestant Ethic pervades American
wanted to be considered among the damned; society (see Merton, 1957), it can be argued
so Calvinists in general worked hard and ac- that it is a cultural condition conductive to the
cumulated much. Work, thrift, and material ac- medicalization of deviance.
cumulation thus became important ends in American society has cultivated an extra-
themselves. This, according to Weber, pro- ordinary faith in science, both as a way of mak-
vided the "spirit" conducive to the developing sense of experience and as a source of daz-
ment of capitalism. zling and problem-solving technology. As a
Mordechai Rotenberg (1978) suggests that way of understanding human behavior, this
Weber's thesis may be extended to account scientific legacy has been almost wholly posi-
for the Western, and especially American, way tivist-it has involved adopting natural science
of defining and treating deviance. He suggests assumptions to understand and account for the
that the Protestant ethic of predestination leads way human beings behave in the social world.
to a fundamental division of people into two As one might suspect, that has produced a good
camps: the righteous-elect and the wicked- deal of misunderstanding in social science and
damned. Since their selection is predetennined, particularly in the sociology of deviance. This
there is little confidence in the possibility of positivist heritage has also been the kind of
change. In these tenns, failure or deviance is science adopted by nonsociologist officials,
the converse of success, as damnation is the politicians, and bureaucrats, as well as the pub-
opposite of election. Rotenberg suggests that lic at large, to define and "explain" deviant
the Protestant Ethic creates a "spirit of failure' , behavior. David Matza (1969) has called this
that profoundly affects the manner in which we the affinity model of explaining deviance-
think about deviants and the techniques we use where conduct is portrayed as detennined by an
to treat them: individual's affinity or "predisposition" to it.
Such predisposition (sounding suspiciously like
More specifically, I have posited that just as the "predestination") is believed to be a product
Protestant Ethic had a general impact on the Western
of the circumstances in which deviant actors
world in terms of economic development and in-
find themselves and over which they have little
creased achievement behavior-as Weber [1904-
1905/1958] and others have posited-the covert be-
control. Deviant actors have been seen by sci-
lief that deviance and failure are symptoms of an inence as in general the product of various kinds
nate and irreversible state of damnation is equally of "forces" - not at all unlike the medical de-
pervasive in Western culture, since both tenets are tenninist theories just discussed. In short, this
traceable to Calvin's influential doctrine of predesti- positivist view of social behavior and specifi-
nation. (p. 23) cally deviant behavior reinforces the rigid and
categorical thinking that is the heritage of the terion for defining activities as deviant (e.g.,
Calvinist idea of predestination. Deviants and cigarette smoking and alcohol drinking). For
their conduct may be explained, then, not only some, a commitment to health has become al-
by God's will but by "natural laws" as well. most a "leg up" on immortality or salvation.
Science also has enabled us to do things and It is perhaps not surprising to find that in a so-
solve problems much more easily-more effi- ciety where such a high value is placed on
ciently, with less effort and time. It has, in health, the sick are considered "deviant" and
short, allowed the development of an amazing the deviant are considered "sick." In both
array of sophisticated technologies, including cases, this commitment to health serves as a
electricity, automobiles, airplanes, radio, tele- justification for the treatment and control of
vision, computers, and space satellites. Medi- such undesirable persons.
cine's technological achievements have been Finally, medicine can be highly profitable in
no less spectacular. Americans have been pio- a capitalist society. Medicalization can create
neers in technology and have adopted a per- new markets for products and services. This is
vasive belief in science as both "good" and true not only for medical practitioners but, per-
essential to "progress." haps more important, for entire industries. The
Our society pays official tribute to democrat- pharmaceutical, health insurance, and medical
ic political participation and public debate. This technology corporations, as well as other medi-
allows for challenges to dominant viewpoints cal industries, have achieved phenomenal
and established interests, both in and out of growth in the past three decades. Although we
conventional political arenas. Challenges to make explicit connections to the pharmaceutical
criminal and medical definitions of deviance industry in three of our cases (madness, opiate
may emerge under such conditions. Since the addiction, and hyperkinesis), we contend that
Progressive era, however, more influence and the profitability of medicine in American so-
"credibility" have been given to those desig- ciety has contributed in both specific and gen-
nated as "experts." As Richard Hofstadter eral ways to the medicalization of deviance.
(1963) notes, "In the interests of democracy In summary, important American values
itself, the old Jacksonian suspicion of experts align well with the medical model of deviance.
must be abated" (p. 197). In the rush to the de- In recent years health itself has become a pre-
pendence on various kinds of experts that we dominant value. American society, with its
have witnessed in this century, perhaps the democratic system, is open to challenges of
leading example has been the physician as the new definitions of deviance. Medical practice
expert par excellence on matters of health and is independent and expansive. In a capitalist
illness. Translated into less abstract terms, this society, medicalization can create new markets
means the physician has become the premier and be highly profitable. In short, in Ameri-
expert on personal problems, both of the body can society medical conceptions of deviance
and the mind. have a cultural resonance both with dominant
As we discussed in Chapter 1, the monopoly values and the organizational apparatus to pro-
of medical practice and the development of mote and sustain them, creating a fertile envi-
medicine as a profession gave physicians rela- ronment for medicalization. In the following
tive independence and functional autonomy discussion we begin to develop a model of how
(Freidson, 1970b). The "miracles" of modem this medicalization of deviance occurs.
medicine and the growing status of the physi-
cian-expert brought a considerable charisma to AN INDUCTIVE THEORY OF THE
the medical profession. At the same time, and MEDICALIZATION OF DEVIANCE
perhaps not unrelated to this, health has become Social conditions conducive to medicaliza-
a primary value in American society. Health is tion are alone insufficient to produce new defi-
used as a justification for controlling powerful nitions of deviance. New deviance designations
corporations (e.g., through air pollution and do not emerge by themselves but are the prod-
occupational safety regulations) and as a cri- uct of collective enterprise and claims-making
activities (Spector & Kitsuse, 1977). As we Third, our sequential model of medicaliza-
argued in Chapter 2, the process can be tion takes as its point of departure the recent
called "the politics of deviance designation." work of Malcolm Spector and John Kitsuse
Throughout this book we have emphasized the (1977) on the sociology of social problems
socially constructed nature of deviance defini- (recall our discussion in Chapter 2). We use,
tions and designations and the role of individ- for example, Spector and Kitsuse's concept of
uals, organizations, social movements, and claim in two related yet distinct ways re-
other interests in creating and implementing garding the medicalization of deviance. First,
them. In this section we outline an inductive after these authors, we consider a claim to
theory of the medicalization of deviance be a medical demand, contention, or asser-
grounded in the cases we have examined. * tion, such as claiming that opiate addiction
Given the variety of cases, actors, and circum- should be treated by physicians. Our second
stances we have discussed, it is not possi- usage, going beyond this first meaning, defines
ble to construct a theory that accounts for claim in the metaphor of a miner engaged in
all aspects of every case. We attempt rather prospecting land. Like the miner claiming that a
to develop a theory of the medicalization of portion of the land is his or her own, a medical
deviance that can be maximally generalized, yet "claim" of legitimate jurisdiction may be
that does not do violence to the empirical reality "staked" over a particular segment of social,
of our cases. In our discussion we will make personal, or even geographical "turf" as
note of cases that deviate or vary from the mod- something that "belongs to" medicine and
el proposed. We present our theoretical outline physicians as a professional group. An example
in two parts: a sequential model and grounded of this latter use of claim would be the early
generalizations. 19th-century official medical control of access
to and regulation of asylums in England. The
A sequential model first kind of claim is primarily a matter of
Before our s'equential model is presented, words and images; the second more a question
three points need to be made. First, we caution of "making good" such definitions by usurping
the reader to keep in mind that it is a theoretical or taking charge of a particular procedure or
model, and the stages delineated are not always territory as medicine's own.
distinct and separated clearly in practice. We propose a five-stage sequential model
Second, it is important to understand what we for the medicalization of deviance: (1) defini-
mean by medical "deviance designation." tion of behavior as deviant; (2) prospecting:
When we say claims-makers promote a new medical discovery; (3) claims-making: medical
deviance designation, we do not necessarily and nonmedical interests; (4) legitimacy: secur-
mean that the claim is presented in this manner, ing medical turf; and (5) institutionalization of a
that is, by claiming that the deviant behavior is medical deviance designation.
"sickness, not badness." Rather, medical Definition of behavior as deviant. In
claims are couched in terms that attempt to nearly all the cases we examined, the behavior
conceptualize deviance as a medical problem or activity in question was defined as deviant
and may be presented as a medical diagnosis or before the emergence of medical definitions.
etiology and/or treatment for the deviant and Madness, chronic drunkenness, homosexual
the deviant's behavior. conduct, delinquency, and criminal activities
were all defined as highly undesirable before
* Conrad (1976, pp. 93-97) presented an initial state- any medical writings or perspectives appeared.
ment toward a theory of the medicalization of devi- Prior to the Harrison Act, for example, opiate
ance based largely on his study of hyperkinesis. In addiction was, by and large, not considered par-
it he outlines five antecedent and two contingent ticularly deviant. The Harrison Act criminal-
conditions of medicalization. Although that state-
ized, and thus made deviant, opiate addiction.
ment may still h!lve some utility, the one presented
here, drawing on comparative and historical data, is Opiate addiction was thus deviant prior to at-
more broadly based and theoretically developed and tempts to remedicalize it in the 1960s. Child
modifies some of the earlier tenets. abuse and hyperactivity are somewhat more am-
biguous cases. Most likely, child battering, number of physicians, generally researchers,
when it was so defined, was considered deviant. who are specializing in the problem and who of-
Yet among physicians and the general public ten are professional colleagues.
alike it was rarely recognized or construed as We call this stage "prospecting" for two
such (Pfohl, 1977). This suggests that the medi- reasons. First, many articles about medical
cal discovery of child abuse was at least in part conceptions and treatments of deviance are
the invention of a new form of deviance. Hyper- published in professional journals but never
kinesis presents a similar situation. Restless, subsequently become ammunition in claims-
disruptive, and overactive children are surely making activities. They may be ignored,
defined as deviant in most school classrooms; buried, or quietly refuted. Second, such articles
yet it was the discovery and promotion of the are, by and large, formal and informational and,
medical label that gave shape to this vague form although they represent a viewpoint, constitute
of deviant behavior. To recapitulate, behavior is a "challenge" only in the most academic
generally defined as deviant before medical sense.
designations arc proposed. * As Erich Goode As we pointed out in earlier chapters, publica-
(1969, p. 88) observes, negative evaluations of tion of scientific and professional articles, even
behavior precede explanations of it, or, put dif- in prestigious medical journals, does not assure
ferently, explanations follow attitudes. We a new deviance designation's recognition or ac-
might suggest that medical designations of devi- ceptance. It needs champions and moral entre-
ance reflect and give shape to commonly held preneurs to carry the banner and bring the new
definitions of deviance, rather than defining problem or definition to public attention. When
deviance anew out of whole cloth. In a sense, this happens, the claims-making stage begins.
medical designations validate commonsense Claims-making: medical and nonmedi-
definitions of deviance. This highlights the con- cal Interests. This is a key stage in the emer-
tinuity between badness and sickness designa- gence of new deviance designations. It is at this
tions: they are both negative moral judgments. point that champions, moral entrepreneurs, and
Prospecting: medical discovery. The organized interests begin actively to make
"discovery" of a medical conception of devi- claims for a new deviance designation and at-
ant behavior is first announced in a professional tempt to expand the medical social control turf.
medical journal (or, more rarely, in a book or at Both medical and nonmedical interests engage
a conference). It appears in the form of a de- in claims-making activities.
scription of a new diagnosis (hyperactivity, The medical professional interests involved
child abuse), the proposal of a medical etiology in making claims for a new deviance designa-
of deviant behavior (alcoholism, homosexual- tion usually comprise a specialized group. They
ity), or the report of a new medical treatment for are either medical researchers of a specific
problem behaviors (methadone, psychosur- problem (as in stage 2) or are administratively
gery). Any of these may be used to promote a involved in treating the deviant behavior in
medical deviance designation. These articles question. By "administratively involved" we
are usually the product of the work of a limited mean that these physicians either operate a
special clinic treating the behavior in question
or are attached to an institution mandated to
deal with the problem. These physicians are
* In the 19th-century example of abortion, summa- not typical of the medical profession in gen-
rized in Chapter I, although not a case of medicaliza-
tion, it appears physicians were instrumental in de- eral, and their activities and concerns are far re-
fining that activity as deviant. However, in the case moved from the rank and file of medical doc-
of masturbation in Victorian times, physicians clear- tors. The latter are rarely if ever involved at this
ly medicalized commonsense deviance definitions of stage. In fact, aside from receiving information
this activity (see Englehardt, 1974). George Becker about "important discoveries" and claims pub-
(1978) notes that the negative and deviant definitions
of "mad" genius preceded the development of the lished in journals or presented at professional
medical definitions. These cases seem to support our meetings, most physicians are completely re-
contentions in stage I. moved from such claims-making activities.
The small group of active medical claims- the professional organization, but physicians'
makers are, by and large, not organized specif- claims-making is generally not that organized
ically around the promotion of a new medical or politically overt. If the champions of a partic-
deviance designation but come together pri- ular viewpoint are successful in convincing
marily because of their similar professional their professional organization to support their
interests and viewpoints. Although medical claims, the professional society itself becomes
professional claims-making may seem like an an important force for staking a claim.
organized activity, in its early stages it is com- Professional investigatory committees are
posed generally of individuals or small groups often established to evaluate the claims about a
engaged in promoting the new designation. new deviance designation. Professional so-
Their activites are more parallel than in concert. cieties establish such committees in response
One type of concerted claims-making that med- to its member-champions requesting that the or-
ical champions do engage in is the organization ganization support a particular claim or in re-
of professional forums and conferences at sponse to outside criticism and public pressure
which to display their claims. These include to take a professional stand on the issue. Some-
institutes, seminars, workshops, and various times these committees are initiated at govern-
meetings designed to publicize and promote ment request and organized under the auspices
their views to others, especially the nonmedical of an agency such as the Department of Health,
personnel who deal regularly with the problem Education and Welfare (e.g., in 1970 for hyper-
behavior. Exemplars include the Yale Center kinesis and 1975 for psychosurgery). The peo-
Summer School program on alcoholism and ple chosen to serve on these investigative com-
the series of National Conferences on Metha- mittees are designated •• experts" on the subject
done Treatment. and not infrequently include those most active
This loose alliance of claims-makers with in claims-making activities. The investigatory
similar interests is at first primarily an intel- committee's report, regardless of whether it
lectual or professional one, but as claims-mak- was professionally or bureaucratically initiated,
ing in and out of the profession progresses- is often supportive to the new deviance desig-
sometimes in response to the rise of an opposi- nation (with qualifications) and becomes im-
tion-the alliance becomes increasingly polit- portant ammunition in the promotion of the
icized. One aspect of this politicization may be new medical claim.
an attempt to prevail on their professional or- The activities of nonmedical claims-makers
ganization (e.g., the American Medical Asso- are more overt. 'Usually drawing on already-
ciation, the American Psychiatric Association) made professional medical claims, nonmedical
to support their claims. * To the extent that champions and vested interests play an impor-
medical claims-making is organized, those tant role in the promotion of new medical devi-
making claims for a deviance designation at- ance designations. Nonmedical claims-making
tempt to use the existing professional organi- groups in the cases we have examined include
zations for their own benefit (e.g., securing corporations (e.g., the pharmaceutical com-
passage of a supportive resolution or getting panies), professional and lay organizations
the organization to issue a position statement (e.g., the Association for Children with Learn-
substantiating the claim). Occasionally physi- ing Disabilities, the National Council on Alco-
cians organize themselves into special interest holism), government bureaucracies, (e.g., De-
"caucuses" to promote their viewpoint within partment of Health, Education and Welfare),
and self-help groups (e.g., Alcoholics Anony-
*Occasionally the professional claims-makers may mous). These groups, in different ways, pro-
start their own organization to represent their view- mote new designations by engaging in publicity
point; for example, the American Orthopsychiatric campaigns, lobbying in legislatures, and sup-
Association to promote the medical view of crime
and the American Society of Bariatric Physicians to porting litigation and judicial challenges. These
promote a medical conception and treatment of organizations are generally already in exis-
obesity. tence, and either publicize or expand on the
medical claim and become its most ardent sup- this, the politics of deviance designation moves
porters. These groups have a direct interest, be to the next stage.
it economic, moral, administrative, or thera- Legftlmacy: .ecurlng medical turf. This
peutic, in the adoption of the medical perspec- stage begins when proponents of the medical
tive of deviance. They align and intertwine with deviance designation launch an instrumental, as
medical claims and claims-makers; for exam- opposed to merely rhetorical, challenge to the
ple, by frequently calling on the medical cham- existing deviance designation. This usually
pions to lend "scientific" credence to their involves some type of appeal to the state, as
claims. arbiter of jurisdictional disputes and "official"
These nonmedical claims-makers are impor- legitimater of deviance designations, to recog-
tant in establishing new deviance designations, nize the medical viewpoint. The arenas of
since they initiate activity with the public, leg- challenge, or "battlegrounds," include legisla-
islatures, and in court in a way that medical tures, special investigatory committees, federal
professionals usually do not. They are perhaps bureaucracies, and courts. Often confronta-
freer to promote their position and challenge tion occurs simultaneously on a number of
their opponents, less constrained by "profes- fronts. Some challenging deviance designations
sional ethics" or "scientific" credibility. In of course never reach this stage, withering
short, they use the medical claims as ammuni- in the verbal battles and challenges of stage 3.
tion to battle for the new deviance designation In some cases, such as homosexuality, appeals
and become its foremost advocates. This allows to the state play only a minor role, and the
physicians to take the more dignified role as arenas of challenge lie elsewhere. In the face of
"experts" rather than overt partisans. active resistance, however, most medical
Although claims-makers may use the popular claims-makers must seek state legitimacy.
media to advance their cause, publicity seems The most common arenas of conflict are leg-
to play a less significant role in the politics of islatures and courtrooms. Legislatures, includ-
deviance designation than in the successful ing Congress, may hold hearings on deviance
emergence of social problems (see Spector & designations (in relation to proposed legisla-
Kitsuse, 1977), large! y because the politicking tion) and hear arguments from the designation's
occurs on a professional, administrative, or leg- champions and opponents. A "victory" here
islative rather than a public level. * The popular for the medical designation means passage of
media can playa role in disseminating informa- laws supportive of the medical viewpoint and
tion or creating public pressure for a new desig- not uncommonly granting medicine official
nation of deviance (or creating a demand for a jurisdiction over the question of social control
new medical treatment), but, generally speak- (e.g., madness, child abuse, juvenile delin-
ing, this is peripheral rather than central to the quency). Judicial decisions, especially from
political struggle. Although the media may oc- the Supreme Court, may affirm the dominance
casionally take editorial positions supporting of one designation over another and, in effect,
one designation over another, this influence ap- at least partially legitimize the designation
pears to be limited. The media playa more sig- (e.g., madness, opiate addiction, alcoholism).
nificant role later in this stage and the next by Special investigatory committees, organized by
"reporting" the challenges and the "victories" legislatures or part of the state bureaucracy, can
in the designation battle. weigh evidence and present a report more or
The supporters of a medical designation of less favorable to a deviance designation (e.g.,
deviance must, in most cases, appeal to the hyperkinesis, psychosurgery). This can be seen
state for legitimation of their perspective. With as an "official" recognition of one viewpoint
over another. In our metaphor of prospecting,
it is somewhat akin to being given the "deed"
*The recent •'gay rights" referenda are something of to an identifiable and bounded piece of •'prop-
an exception, although they are not per se battles erty." Needless to say, however, such "vic-
about deviance designations. tories" are rarely total, such "deeds" not with-
out conditions and being shared with other tion, we can say that a claim has been success-
"owners" of the property in question. In fact, fully staked. Although such claims are of
most cases involve grafting the challenging course open to new challenges, if they become
"sickness" designation onto some parts of institutionalized, they are more resistant to
older "badness" designations. Winning these challenge.
"battles" does not necessarily mean achieving InstHutionalizatlon of a medical devi-
exclusive control or jurisdiction over the deviance designation. When a deviance designa-
ance in question, but medical claims, for the tion is institutionalized, it reaches a state of
reasons stated earlier, have become increasing- fixity and semipermanence. The medical view-
ly dominant. The battles to define and redefine point has been legitimated and now becomes
deviance, however, will continue. an accepted category in the official order. We
It is important to note the connection between find two general types of institutionalization:
the rise of medical deviance designations and codification and bureaucratization.
the state. Generally speaking, in the face of en- When a deviance designation is codified, it
trenched criminal definitions of deviance, the becomes an accepted part of the official medi-
medicalization of deviance cannot occur with- cal and/or legal classification system. It is writ-
out some type of approval by the state. The ten into law, supported by court decisions, or
professional dominance of medicine does not is included as an official diagnosis in official
extend to the authority to override existing manuals such as the American Psychiatric As-
criminal definitions of deviance; thus successful sociation's Diagnostic and Statistical Manual.
appeals to the state are necessary for legitima- This provides both a symbolic and instrumental
tion. It is the state that grants medicine the acceptance of deviance as a medical category.
right to a particular social control turf. * Bureaucratization, the creation of large-
Medicine, in fact, may become the agent of scale organizations, is another form of institu-
social control for the state, as with opiate ad- tionalization. Large social control bureaucra-
diction and child abuse, or replace problematic cies are constructed that in effect provide in-
parts of the state control apparatus, as with stitutionalized support for medicalization. Ex-
chronic drunkenness. This highlights the com- amples include the federal agencies such as the
plex interface of medical and legal social con- National Institute of Mental Health and the
trol agencies. National Institute of Alcohol Abuse and Alco-
When the significant battle or battles are won holism, special programs such as SAODAP, in-
and medical claims-makers and their supporters formational "clearing houses" such as the
achieve legitimacy for their deviance designa- National Center of Child Abuse and Neglect,
and, in a different way, the state mental hos-
pital system itself. These bureaucracies support
* This is unnecessary when there is no prior criminal medicalization in one sense by providing re-
claim to a social control turf, as with hyperkinesis. search monies, technical assistance, and other
Similarly, when a particular form of social control
is only rarely deployed (e.g., arrest for homosexual institutional benefits to supporters of a particu-
behavior), the proponents of the new designation may lar viewpoint of deviance. On the other hand,
bypass appeals to the state. It is important to remem- they are bureaucratic "industries," with large
ber, however, that the state maintains ultimate con- budgets and many employees, that depend for
trol over this resource of legitimacy. Indeed, medical their existence on the acceptance of a particular
practice is itself premised on the continued viability
of this state-issued mandate. Moreover, in those deviance designation. They become "vested
cases in which there has been a distinction between interests" in every sense of the term. A desig-
"criminal" and "sickness" behavior, physicians nation with such a supportive bureaucracy is
have often adopted a position that explicitly more securely anchored against challenges
supports the state's system of criminal categories and becomes more resistant to change.
(e.g., public homosexual behavior is against the
law, as is driving under the influence of alcohol), When a deviance designation is institutional-
quite aside from whether such illegal activity is ized, one could say, adopting Thomas Kuhn's
thought to be a product of sickness. (1970) terminology, it has become the reigning
paradigm for viewing deviance. It is, of course, traced the definition of same-sex conduct from
open to new challenges, especially when immorality to sickness to its symbolic demedi-
anomalous data become available as ammu- calization (followed, apparently, by a resur-
nition for new claims-makers with a differ- gence of an antihomosexual moral crusade).
ent definition or designation of deviance. In In Chapter 3 we saw a series of more subtle
the model we present here, when new chal- changes, an oscillation between "social" and
lengers begin to make their claims, we may re- "biological" emphases in medical designations
turn to stage 2 or 3 and continue to observe the of madness. Thus we can say that the move-
politics of deviance designation. ment of deviance designations has a cyclical
To make one final point, in most cases of quality.
medicalization of deviance, public acceptance We ought not be surprised at the fluidity be-
"lags behind" professional and bureaucratic tween badness and sickness designations, since
support. The public remains more skeptical this ebb and flow occurs in a common sea of
about medical designations than professionals, "immorality." As we argued earlier, to define
especially in the cases of alcoholism, opiate a deviant activity as sickness leaves its negative
addiction, and homosexuality. This skepticism moral evaluation intact. Because the direction
provides a reservoir of potential support for of the moral evaluation of the behavior does
future challenges to medical deviance designa- not change-it is still disreputable and unto-
tions. ward-under proper circumstances sickness can
be redesignated as badness. Unless a behavior
or activity is vindicated and no longer defined
Although this sequential model proposes to as deviant, both medicalization and demedicali-
explain "how" deviance is medicalized, it zation take place on a moral, or more properly,
does not directly confront the questions of why an immoral continuum.
or when. We begin to address these questions This ebb and flow of deviance designations,
in the generalizations we have drawn from the although played out in various arenas of con·
cases presented earlier. flict, sometimes creates jurisdictional compro-
mises and marriages of convenience. Deviance
Grounded generalizations designations may become hybrid badness-
In this discussion we present five theoretical sickness amalgams, such as with opiate addicts
statements that could be called grounded gen- and sexual offenders, and the social control turf
eralizations in as much as they emerge from is then shared or divided.
our analysis of the cases in Chapters 3 to 8. We What factors spur a cyclical shift in deviance
offer these as propositions that seem to us to be designations? It seems that medical-sickness
suggested in our data. deviance designations emerge as a dialectical
Medlcallzatlon and demedlcallzatlon response to extreme criminal-badness designa-
of deviance are cyclical phenomena. We tions. A clear example is the reemergence of
have argued that the medicalization of devi- medical designations of opiate addiction at pre-
ance, as reflected in this book's title, is increas- cisely the same time in the 1950s that the se-
ing in American society. Although we believe verest criminal penalties for addiction were
this represents the dominant trend, our investi- passed into law. Other examples include (1)
gation also has revealed a cyclical dimension the appearance of medical designations of ho-
to medicalization. In other words, the changes mosexuality during the same period in the 19th
in deviance designations do not all flow in one century that saw a sustained drive against ho-
direction; there is a movement back and forth mosexual conduct and (2) the recent reascen-
between badness and sickness designations. dance of a "biological" model of madness after
Let us recall a few examples. In Chapter 5 the domination of "social" definitions during
we described the change in opiate addiction the 1960s community mental health movement.
from a medical problem to a crime and back Perhaps similarly, the disease concept of alco-
again to a medical entity. In Chapter 7 we holism emerged right after the repeal of Pro-
hibition. The cyclical nature of deviance desig- medical claims, to which we have alluded many
nations has a distinctly dynamic and dialectical times.
quality. In short, the extreme of one designation Only a small segment of the medical
creates fertile conditions for the challenge and profession Is Involved In the medlcallza-
emergence of counterclaims. This is related lion of deviance. In nearly all the cases ex-
clearly to our next generalization. amined, only a small specialized segment of the
Medical designations of deviance are medical profession is ever involved in the poli-
more often promoted as a "foil" against tics of deviance designation and the promotion
criminal definitions than as ends In them- of medical definitions of deviance. Although
selves. Since medical designations arise at an these claims-making physicians are few in
extreme point in criminalization, their emer- number, their participation is central and criti-
gence appears to be related to this criminaliza- cal to successful medicalization. It is their con-
tion. Medical designations have been used re- ceptualization of the behavior or condition as
gularly to mollify the harshness of criminal a medical problem that provides the rationale
definitions of deviants and in general as a foil and justification for medical designations of
against such designations. deviance, as well as supplying ammunition for
In many of the cases examined, we found claims-making battles. The nonmedical cham-
the champions of medical designations present- pions rely on and use these medical claims and
ing their claims specifically as a critique of the formulations in their own claims-making activi-
dominant or ascending criminal definition. K. ties.
M. Benkert, the Hungarian physician who pro- The debates about deviance designations are
posed a congenital theory of "homosexuality, " far removed from everyday medical practice.
argued directly against the growing legal re-. Rank and file physicians, for the most part, are
pression and harsh punishments for homosexual uninformed about the debates and battles and,
behavior contained in the Prussian legal code. furthermore, do not much care about them.
The mid-20th-century critics of America's Most of the "deviance" discussed in this book
criminalization and harsh treatment of opiate simply is not a significant part of the majority
addicts used the medical model of addiction, of medical practices, and, by and large, most
especially as evidenced in the British system of physicians do not wish to deal with such prob-
addiction control, as a foil with which to attack lems.
the injustice of the criminal treatment of ad- This requires modification of such general
dicts (e.g., Lindesmith, 1947; Nyswander, notions as "medical imperialism" as an expla-
1956; Schur, 1965; Duster, 1970). The 19th- nation of the medicalization of deviance. Med-
century champions of the asylum movement as ical imperialism, to the extent that it exists, is
well as the late 19th-century child savers used not usually initiated or even supported by the
medical rhetoric to promote their causes. Time medical profession en masse. The nonmedical
and again, medical and, perhaps especially, interests, be they political, economic, or "mor-
nonmedical reformers championed medical ai," aligned with a small segment of the medi-
conceptions as a critique of harsh and punitive cal profession, constitute the major claims-
practices. These claims-makers often promoted makers of new medical social control turfs.
medical definitions, not for their own sake as It is only when a medical claim is successfully
more "valid" or "true" conceptions of reality, staked and becomes part of standard medical
but as "humanitarian" challenges to what they practice that most physicians have much to do
saw as excessively punitive practices. * This, with it.
of course, underlines the political nature of the When medical designations of devi-
ance are proposed, they most likely will
be based on the notion of "compulslvlty."
* One reason reformers chose the medical model
as a critique is because it is the only reduced-blame For most cases examined, definitive and uncon-
and nonpunitive alternative model of deviance avail- testable evidence of biophysiological causa-
able (recall our discussion in Chapter 9). tion does not exist. In lieu of such evidence, or
in addition to ambiguous organic data, some organic cause. With the exception of opiate
type of "compulsivity" is proposed as the addiction, where the notion has been demys-
cause of the deviant behavior. The notion of tified and unmasked as rational behavior to re-
compulsivity is a central justification for the duce withdrawal pain, most medical claims for
medical claim. compulsivity have not been subjected to rigor-
All concepts of addiction have this notion of ous scientific testing. Indeed, it is not entirely
compulsion at their core. Medical explanations clear how such a scientific "test" of the com-
of homosexuality and psychopathology, and, to pulsion hypothesis might be constructed, given
a lesser degree, of hyperkinesis and child abuse, the vague and circular definitions of it that have
indicate the idea of compulsion in their concep- been offered (e.g., alcoholism as a product
tualizations. * Compulsivity denotes that the of "loss of control").
individual "cannot help it," since the behavior The historical sources of compulsivity as a
is caused by forces beyond his or her control. medical explanation for deviance are many and
Compulsivity, in effect, removes motivation or diverse. For example, 18th-century physician
cause from the will and locates it in the body or Benjamin Rush called inebriety a disease of the
mind. By proposing that the behavior is caused will; physicians in the 19th-century depicted
by "forces" beyond both a person's under- masturbation as a compUlsive disease; and
standing and control, and is therefore not the Freudian theorists have composed several varia-
individual's fault, compulsivity aligns well with tions on this theme. Yet compulsivity and loss
our sociological understanding of what consti- of control are not by themselves medical or
tutes sickness. biophysiological concepts-jurisdiction over
Let us explore for a moment the notion of compulsions must still be "won" by medical
compulsivity in a cultural context. In Western claims-makers.
society, moderation and control are important Medlcallzatlon and demedlcallzatlon
moral values. To be immoderate, excessive, are political and not scientific achieve-
and "out of control" is to be potentially devi- ments. We have mentioned the political as-
ant, regardless of the effects of one's behavior. pects of medicalization so frequently through-
Extreme immoderation is viewed as irrational out this book that it seems almost redundant
behavior. Our rational orientation to the world to say it again here. We would like to review
makes understanding such conduct difficult and what this means and draw out a few additional
puzzling. This quasimedical conception be- significant points.
comes then an explanation for the "puzzle" Medical designations of deviance that have
of immoderate and irrational conduct: the be- been proposed either challenge existing claims
havior is caused by a compulsion, which is or seek to carve out new deviance territory.
itself an illness. Furthermore, compulsivity While the medical claims are proposed in
posits an explanation that is determinist, indi- the name of science, they have not been in gen-
vidualistic, and has a scientific aura, all con- eral subject to the scientific rules of evidence.
sistent with the important American values Although science and medicine add prestige
discussed earlier. and authority to any claim, supporters must
Compulsivity, then, becomes a useful and still engage in the contests necessary to get their
significant part of medical designations of de- claim recognized. This is always a political
viance, since it allows for a medical explana- process. Because medical claims are couched in
tion without requiring conclusive evidence for the language of science, yet rarely subject to
empirical evaluation, scientific research can
threaten as well as support medical deviance
* Recently obesity and gambling have engendered designations. With methadone maintenance, for
medical explanations of compulsivity. George example, early reports were highly supportive
Becker (1978, p. 76) notes that in the 19th-century
medical conceptions of the "mad" genius "the im- of its efficacy in treating heroin addiction; later
age of the creative process was to acquire a decidedly reports, based on more rigorous research, were
compUlsive and irrational characteristic." increasingly critical. Proponents and opponents
of deviance designations may use scientific tion. This is not to say that medical technique
evidence to support their claims. In such situa- was not offered as evidence to support medical
tions it is ironic to see scientific research used claims, but rather that it cannot be seen as the
against medical claims that were themselves singular explanatory variable for medicalization
proffered in the name of science. that some have suggested. We believe, how-
Let us briefly recall several examples that ever, that with increasing research and reliance
highlight the political nature of the medicali- on medical technology, especially in the form
zation and demedicalization of deviance. The of drugs and technological medical practice
19th-century contest for the control of moral (especially surgery), technique will play an in-
treatment and regulation of madhouses can be creasingly important role in the medicalization
seen as a key "victory" for the medical con- of deviance. A few medical claims for deviance
ception of madness. The physicians were or- based on technique were pointed out in Chap-
ganized and were able to convince Parliament ter 8, and one need not go far to include drugs
to support their definitions over lay definitions, and surgery for obesity and tranquilizers for
although these physicians essentially had no everyday anxieties as additional examples.
specific or unique knowledge about or ability This leads us directly to study who is promot-
to treat madness. It was in every sense a "po- ing medical technique and with what conse-
litical" achievement. The modem disease con- quences (see the discussion of hunches and hy-
cept of alcoholism was intentionally proposed potheses later in the chapter).
by its champions at the Yale center not for its
scientific validity but for its moral and political Sociologists as challengers
implications. The two cases of demedicaliza- It seems fitting to include in this discussion
tion we examine in some detail, opiate addic- a reflexive note on the role of sociologists in the
tion in the early 20th century and homosexual- politics of deviance designation. Sociologists,
ity in the 1970s, underline with special clarity rather than being "objective" bystanders in the
the political nature of deviance designations. contests about deviance designation, are some-
The Harrison Act, and the subsequent chal- times active participants. Not only do sociol-
lenges by the Treasury Department (supported ogists collect data about deviance and chroni-
by a variety of Supreme Court cases), success- cle the claims-making activities of others, they
fully "defeated" the medical designation of often become active challengers in these ac-
opiate addiction. The recent American Psy- tivities. With one exception, sociologists in
chiatric Association decision that homosex- recent years have challenged rather than pro-
uality is no longer officially an "illness" was moted medical deviance designations. Sociol-
achieved in large part by the overt politiciza- ogists such as Alfred Lindesmith (1947), Ed-
tion of the issue by gay rights activists and a win Schur (1965), and Troy Duster (1970),
few psychiatric sympathizers. In our judgment, among others, supported the medical designa-
defining behavior as an illness is always a po- tion of opiate addiction against the dominant
litical achievement, although the actual politics criminal designation. But in most of the other
are sometimes subtle or obscured and difficult cases reviewed here-including, for example,
to sort out. madness (Goffman, 1961; Scheff, 1966), al-
We wish to make one final observation in coholism (Gusfield, 1967; Schneider, 1978),
this section. We were surprised at the apparent- child abuse (Gelles, 1973; Gil, 1970), and
ly small significance of medical technique or hyperkinesis (Conrad, 1975, 1976)-sociolo-
technology in the politics of deviance designa- gists' analyses and viewpoints stand as clear
tion that we have studied. Medical technol- challenges or at least alternatives to medical
ogy-drugs, surgery, or other medical treat- deviance designations. Although many other
ments-played a relatively minor role in the sociologists do adopt the medical model in
cases we examined. Only for hyperactivity their research, sociological analyses represent
and the remedicalization of opiate addiction a consistent potential challenge to medical
(with methadone) did technology playa domi- claims. The social and contextual nature of the
nant role in the political contest about designa- sociological perspective, perhaps most espe-
cially in its interactionist and Marxian modes, it becomes evident that it is also a middle-class
is in fundamental ways opposed to the more phenomenon, it is likely to be defined as sick-
individualist and reductionist medical perspec- ness. * When chronic drunkenness was thought
tive. common only to the lower-class skid row al-
coholic, badness designations prevailed. But
Hunches and hypotheses: notes as increasing research evidence and public
for further research recognition found problem drinkers in re-
In this discussion we note briefly a number spectable middle-class homes, it became diffi-
of "hunches and hypotheses" that emerge cult to maintain the skid row image of drunk-
from our investigation of the medicalization of enness. As more middle-class people were de-
deviance. Although we do not presently have fined as deviant drinkers, the notion that al-
sufficient data to call them conclusions, these coholism is a disease increased in acceptance
propositions are based on our analysis and are and popularity. Similarly, when opiate addic-
presented both as "informed" speculations tion left the ghetto and became a middle-class
and directions for further research. We separate problem in the late 1960s, there was a rapid
them for the sake of clarity. increase in its medicalization. Some existing
I. It appears that the medicalization of de- evidence indicates that hyperactivity is a diag-
viance increases after a failure or crisis in pre- nosis disproportionately used for middle-class
vious systems of social control. Although we and suburban schoolchildren. Perhaps poorer
must be somewhat cautious about generaliz- inner-city children are expected to be overac-
ing, our examination reveals several instances tive, restless, and distracted, but when subur-
where this occurred. In the 19th century, ban children behave this way, they are deemed
when asylums were becoming greatly over- "sick." Finally, we suggest that the medicali-
crowded, the degeneration hypothesis was pro- zation of abortion resulted partly because mid-
posed as a medical explanation and a justifica- dle-class women were among the largest reci-
tion for custodial care. Following the repeal of pients of abortions in the 1960s. In short, as
Prohibition, which could itself be seen as a public perceptions move from a lower-class
crisis in social control, the disease concept of problem to a middle-class problem, deviance
alcoholism was proposed. As the "drinker" designations tend to change from badness to
rather than the "drink" became the object of sickness.
social control, alcoholism as a disease became 3. Medicalization increases directly with its
an idea that attempted to justify a more hu- economic profitability. This is a significant
manitarian control of alcohol-related deviance. dimension of the medicalization of deviance
In the activist 1960s , "drugs" became a sym- that we have touched on several times in this
bol for rebellious and alienated youth. By the book but have not pursued in depth. We can
end of the decade "hard" drug use was spread- isolate three ways in which profitability en-
ing rapidly in middle-class communities. The courages medicalization. First, medicalization
extant social controls-resident self-help groups can create new and profitable markets for large
and imprisonment-had had only small success and powerful medical industries. As we noted
and were too limited to accommodate the in- in earlier chapters, the pharmaceutical cor-
creasing number of addicts. A social control porations garnered considerable profits from the
crisis was partly averted by "sentencing" ad- medicalization of hyperkinesis and opiate ad-
judicated opiate offenders to a variety of newly diction and from the increased use of medica-
created outpatient methadone maintenance tions for madness. We can extend these ex-
clinics. amples to include the promotion of psycho-
2. As a particular kind of deviance becomes active drugs for everyday anxieties (Radelet,
a middle-class rather than solely a lower-class 1977b), obesity, "senility," and other human
"problem," the probability of medicalization problems. The corporate profits from medical-
increases. There seems to be a historical pro- izing deviance are yet uncalculated but un-
clivity to define deviance that is thought en-
demic to lower-class life as badness, but when *We are indebted to Ralph Childers for this insight.
doubtedly enormous (based on the little data we First, general historical and cultural condi-
do have available). Second, the medicaliza- tions that have provided a foundation for the
tion of deviance can be a highly profitable en- medicalization of deviance were reviewed.
terprise for specialized groups of physicians. The most important factors appear to be the rise
For example, in the Newsletter of the American of rationalism, the development of science,
Society of Bariatric Physicians (a professional the emergence of determinist and biophysio-
organization of physicians specializing in treat- logical theories of causation, and the growth
ing obesity), advertisements appear offering and apparent success of medicine. American
bariatric practices for sale with six-figure sala- society has proven particularly hospitable to
ries and short working hours. Third, the medi- medicalization. The medical perspective of de-
calization of deviance indirectly supports cer- viance aligns well with a number of dominant
tain corporate interests. The alcoholic beverage American values, including experimentation,
industry, for example, vigorously supports the newness, humanitarianism, pragmatism, and
disease concept of alcoholism, which focuses individualism. Furthermore, the cultural con-
attention on the individual drinker and away ceptions related to the Protestant Ethic, an
from the industry's advertising and marketing abiding faith in science, a democratic political
techniques. The health insurance industry is system, the organization and monopolization
playing an increasing role in medicalization of the medical profession, and the profitabil-
politics. The role of the corporate sector and ity of medical treatment under capitalism are
the profitability of medicalization, only touched all facilitating social conditions for the medi-
on here, are fertile areas for research. Although calization of deviance. But, as we have noted
the necessary data are difficult to acquire, stu- numerous times, deviance designations do not
dies directed at a more specific understanding emerge by themselves but rather are a product
of the political economy of medicalizing de- of collective enterprise and claims-making
viance could provide an important extension activities.
to our analysis as well as evaluating the specu- In the second part of this chapter we pre-
lations presented here. sented an inductive theory of the medicaliza-
tion of deviance. Basing our analysis in the
A CONCLUDING REMARK politics of deviance designations described in
The medicalization of deviance is an abiding Chapter 2, we develop a sequential model of
feature of contemporary American society. It medicalization and offer five grounded gen-
will not disappear or even decrease perceptibly eralizations. The stages are analytically dis-
in this century and, indeed, is likely to expand. tinct and describe the process of medicaliza-
Medical definitions and treatments for deviance tion. The grounded generalizations begin to
undoubtedly will continue to be proposed, and provide a sociological explanation of the medi-
contests in the politics of deviance designation calization of deviance.
will persist. Barbara Wootton's (1963) re- In the final discussion in this chapter we pro-
marks nearly two decades ago remain poignant pose three hunches or hypotheses as directions
today: for future research: the medicalization of de-
We may well be on the brink of an age in which the viance increases after a failure or crisis in pre-
power of science to influence behavior will achieve vious social control; as a particular kind of de-
a new dimension. Yet the question of what behavior viance becomes a middle-class rather than sole-
is to be influenced, and in what directions, remains, ly lower-class "problem," medicalization in-
and will remain, as obstinate as ever. (p. 202) creases; and medicalization increases directly
with economic profitability. We note the impor-
SUMMARY tance of developing an analysis of the politi-
In this chapter we presented a theoretical cal economy of medicalization.
statement on the medicalization of deviance. It Our concluding remark suggests that the
serves as a conceptual summary of our analysis medicalization of deviance will continue and is
and as an inductive and historical sociological likely to expand and that the questions raised
explanation. in this book will remain pertinent in the future.
AFTERWORD
DEVIANCE and MEDICALIZAYION:
A DECADE LAYER
S ince Deviance and Medicalization was

published in 1980, a great deal has
been written not only about the gen-
eral process of medicalization and the
zation of deviance published in the past
twelve years in preparation for writing this
addendum. The result of such a review can
be found in a recent essay by Conrad (1992).
medicalization of deviance but also about the Instead, we address various issues and ques-
particular cases we took up in the book. Many tions that seem significant in light of our
of the studies published in the last decade original work and our sense of it as part of a
would be relevant to a new, expanded edition particular historical moment in U.S. sociol-
of the text. We decided against such a ogy. Our goals are modest and focused: (1)
rewriting, however, for a number of rea- to note some of the conceptual issues that
sons. First, we concluded that the new stud- were implicit but not discussed in the origi-
ies would not lead us to alter fundamentally nal book; (2) to comment on some of the
our basic argument and analysis. We have recent critique surrounding the social con-
little new to add to the theoretical position structionist approach; (3) to "update"
about medicalization that we outlined more briefly some of the cases examined in the
than a decade ago. Moreover, we believe book; and (4) to speculate on emerging
the text can still stand as a useful resource issues and areas of study in the medicaliza-
for students of the medicalization of devi- tion of deviance.
ance. Finally, in view of our own subsequent
paths of intellectual experience and work, SOME CONCEPTUAL ISSUES
we feared that a full revision would yield a Just before Deviance and Medicalization
new book that would not necessarily cohere was published, P. M. Strong (1979, pp.
as well as the original one. In short, we 199-200) wrote a thoughtful and wide-
decided, instead, to affirm and extend the ranging critique of what he called the "medi-
original text and its arguments. cal imperialism" thesis-that there was an
At the same time, we wanted to mention "increasing and illegitimate medicalization
and comment on some of the new studies of the social world." Strong argued that
because it was precisely from the examina- while much of the criticism of medicalization
tion of such detailed cases that we built our written by sociologists was insightful, he
initial argument. In addition, the publication found little evidence of the advancement
in the last decade of some important criti- and power of medicalization at the level of
cisms of constructionist theory has encour- "what doctors actually control and do"; the
aged us to write something more than a brief arguments about medical imperialism
preface to a reprinted volume. In conse- seemed to him both "exaggerated and self-
quence, we chose this afterword as a way to serving." Moreover, he charged that socio-
reflect and comment on new developments logical critiques of medicine and medicaliza-
in various issues discussed in Deviance and tion were self-interested and that one could
Medicalization. We did not do a comprehen- speak of "sociological imperialism."
sive review of all literature on the medicali- While important, Strong's article was
271
actually more a critique of bourgeois sociol- is used to "order" or define the problem at
ogy than a demonstration of how the hand; few if any medical professionals need
medicalization thesis was "exaggerated." In be involved, and medical treatments are not
consequence, his conception of "medical necessarily used. The archetype here is the
imperialism" misunderstood much about Alcoholics Anonymous (AA) approach to
the medicalization process (Conrad & alcoholism, but compulsive gambling and
Schneider, 1980). We took issue with his other addictions have also been conceptual-
interpretation of medicalization as primarily ized in medical terms (cf. Rosencrance,
about "what doctors do and control" at the 1985). Organizations may adopt a medical
level of patient-physician interaction. We approach to the particular deviant behavior
argued, and maintain still, that medicaliza- in which they specialize. At this level, physi-
tion is primarily a definitional phenome- cians may function as gatekeepers for bene-
non-that is, one of how a problem is fits that are only legitimate in organizations
collectively defined, by whom, and with that adopt a medical definition and ap-
what consequences. Usually, the objects of proach to the problem, yet the routine work
attention somehow enter the jurisdiction of of processing the illness/deviance is accom-
the medical profession, and doctors become plished by nonmedical personnel. Most
involved in their specification and treat- medically directed alcoholism programs in
ment. Direct physician involvement, how- the United States operate on this model.
ever, is not a necessary condition for medi- Medicalization is often achieved in and
calization. Indeed, the medical profession through interactions between doctors and
may be quite divided on whether a particular patients; for instance, a physician gives a
phenomenon is really a medical one; it may medical diagnosis (i.e., defines a problem as
be laid at the doorstep of medicine by medical) or treats a "social problem" medi-
interested laypersons. Our view of the cally (e.g., prescribes tranquilizer drugs for
medicalization thesis is that it is essentially an unhappy family life; and see Waitzkin,
about culture, focusing on the creation and 1991). The concept of "levels" helps make it
use of categories and how this process clear that medicalization is a definitional
constitutes, shores up, or challenges existing process that mayor may not directly include
notions of reality. We need to examine physicians and medical treatment (although
carefully the nature of medical knowledge/ it often does) and that it can occur in several
power: where and how it is deployed; and different sites or arenas (Schneider & Con-
who is deploying it. We must also, of course, rad, 1980; cf. Hilgartner & Bosk, 1988).
consider the historically specific economic Medicalization is not an either/or phe-
and organizational context of this process. nomenon; it is better seen in terms of de-
But the emphasis of the medicalization the- grees. Often medicalization is not complete:
sis remains on the production of definitions, some aspects or instances of a condition may
their use, and the consequences of that use. be medicalized while others are defined
We argued that demedicalization can be nonmedically, or remnants of older defini-
studied along the same lines but, in effect, in tions may linger and make meanings equivo-
reverse (see Chapter 9; and see Winkler & cal. Examples of this are discussed in our
Winkler, 1991). original text, although not specifically in
In our response to Strong we offered the terms of degrees. Some deviant behaviors
notion of "levels of medicalization" (Con- are nearly completely medicalized (e.g.,
rad & Schneider, 1980), which helps us to madness); others are partly medicalized
see the process of medicalization as a defini- (e.g., opiate addiction); and still others are
tional one that can and usually does involve minimally medicalized (e.g., sexual addic-
conceptual, organizational, and doctor- tion, spouse abuse). By using the concepts
patient interactional considerations. Con- of levels and degrees, we can be alerted to
ceptually, a medical vocabulary (or model) the possibility that medicalization at differ-
A DECADE LATER 279
ent levels may vary somewhat indepen- analysis required, the most exciting theme
dently and that, even at anyone level or in for us was the general proposition from this
one arena, medical definitions may domi- view that what appears to be "natural" and
nate to different extents. Indeed, one of "given"-namely, in our context, medical
Strong's points seems to have been that a and scientific realitie~an be seen as social
behavior or problem may be medicalized on products, social accomplishments with par-
one level (e.g., conceptual), but hardly at all ticular histories and situated biographies
on another (e.g., interactional). claiming "universally valid" discoveries and
While we don't yet have a thorough un- accomplishments. That is, the approach al-
derstanding of what determines the degree lowed us to take medical claims, culture,
of medicalization of a particular concern, we and discourse as objects for study.
can identify some factors that are likely to be This was surely a heady intellectual posi-
significant: state and popular support of the tion in the face of medicine, medical knowl-
medical profession; availability of and ac- edge, and, of course, the positivist traditions
cess to medical and clinical interventions or in sociology as well. We felt ourselves part
treatments; the existence of alternative, of a much larger, although, for us, then only
nonmedical definitions and institutional dimly understood, paradigm shift in the
"owners" that can be seen as competing and human sciences that would call into question
self-interested; the extent to which the cost the idea of science as a privileged kind of
of medical (and paramedical) involvement is knowledge (see Kuhn, 1970; Mulkay, 1979;
covered by insurance. Medicalization is Woolgar, 1988b). This headiness lent our
most insightfully seen as a continuous pro- writing a tone of criticism and debunking
cess of defining problems or deviant behav- that by today's lights might seem somewhat
iors more or less in medical terms as situa- naive. For instance, we often imply, and
tions and contexts change. As we will note sometimes state explicitly, that a medical
later, this view includes the notion that category, diagnosis, or fact is "merely" a
medicalized categories can expand or con- "social construction." At times, we write as
tract (see the example of hyperactivity, dis- though we ourselves stand on a ground that
cussed below). somehow is not also constructed, his-
toricized, relative. For instance, a common
DEVIANCE AND MEDICALlZArlON practice in constructionist texts, including
AND SOCIAL CONSTRUCTIONISM our own, has been to raise the issue of
A major conceptual issue embedded in whether the phenomenon under study
the analysis presented in Deviance and Med- should be seen as created--constructed-or,
icalization is the validity and viability of the by contrast, as "discovered."
social constructionist approach to social While enthusiasm for this social con-
problems, which, broadly speaking, is the structionist argument has been notable (see
book's theoretical foundation. The social Schneider, 1985), applications-including
constructionist argument has become the ours-have not been as reflexive as one
object of spirited criticism and debate within today might hope; that is, they have not
sociology and the human sciences. We can- sufficiently applied social constructionist as-
not attempt to settle these issues here (in- sumptions to their own arguments. In a
deed, perhaps they cannot and should not be major and telling criticism of the con-
settled), but it is important to alert readers structionist argument (Woolgar & Pawluch,
to their existence and relevance to this text. 1985), Deviance and Medicalization was
When we wrote the book, we were only cited as one of many studies committing
beginning to understand the complexity of "ontological gerrymandering": a practice of
the emerging constructionist viewpoint, and argument and writing in which the analyst or
although we drew on diverse sources to offer observer is allowed a privileged place from
our sense of what a social constructionist which to see "truth" and against which
participants '--constructors '--constructing In light of this critique of constructionism,

activities stand out in relief (see also Pollner, Strong's paper (1979) deserves a rereading
1991, Schneider, 1992). that situates it primarily as a criticism not of
An upshot of the Woolgar (1983) and the medicalization and "medical imperial-
Woolgar and Pawluch (1985) line of criti- ism" thesis but rather of sociology itself.
cism of the constructionist argument is that Although Strong does not make the kind of
the distancing and ironicizing use of quota- philosophically based critique Woolgar and
tion marks must be disallowed. The ques- others have made, he does insist that we
tion, of course, is on what sort of ground one sociologists not be allowed to see our own
must stand in order to use quotation marks, "scientific" work as disinterested or as with-
which imply an Archimedean point from out desire for a more secure place in the
which "the Truth" may be specified. A deployment of powerlknowledge of which
stronger position would be to take as given Foucault (1980) has written (see also Res-
the constructed nature of discovery, among tivo, 1988; Aronowitz, 1988).
other things, and to examine in detail just
how discovery (like objectivity) is done, is REFLECTIONS ON MEDICALIZED
brought about. This is precisely the direction DEVIANCE A DECADE lATER
in which ethnographic and network analysis While we do not aim to present here
studies of scientific and laboratory work comprehensive literature reviews of the case
typical of the social studies of science have for medicalization or demedicalization of
gone (see, for instance, Latour & Woolgar, deviance that we originally addressed, we
1986 [1979]; Knorr-Cetina, 1981; Latour, use this section as an opportunity to com-
1988). The crucial "last" move, of course, is ment on some changes that have occurred
to complete this reflexivity by incorporating around these cases during the past decade.
one's analysis of this analysis into one's own
analysis (see Woolgar, 1988a). Mental Illness
Pursuing this debate here is perhaps not to In general, the relevant issues in mental
the point. Suffice it to say that anyone today illness remain consistent with our original
making a constructionist argument needs to analysis. That is, deinstitutionalization of
pay careful attention to the issues that Wool- mental patients continues and is abetted by
gar and Pawluch (1985), Woolgar (1988a), a policy that encourages noninstitution-
and others (e.g., Bury, 1986; King, 1987) alization whenever possible. The emphasis
have raised. These criticisms bear not just on biomedical research and interventions
on constructionism, but on all interpretive (e.g., drugs) is at least as strong as it was in
and positivist-indeed, on all human sci- 1980; new "wonder drugs" such as Xanax or
ence-arguments; they raise fundamental Prozac are marketed and used. In this sense,
questions about certainty (epistemology), madness remains conceived of and treated
about theory (see Seidman, 1991), and primarily as a medical phenomenon.
about the authority of the analyst (Schnei- But, as one reviewer of the book asked,
der, 1991; Clough, 1992). One highly unset- can we say that madness remains medical-
tling outcome of this criticism is that it does ized if the state continues to empty its
not auger well for sociology's place as a institutions without providing services for
center of privileged criticism of the society discharged patients and thus increases the
of which it is a part, a role at the very heart marginality of living conditions and the
of what Mills (1959) called "the sociological homelessness of these people (see Joffe,
imagination." The implications of these and 1982)? While the question is an important
similar critiques for the arguments in Devi- one, we think the provision of services for
ance and Medicalization were important de institutionalized persons and the
considerations in our decision not to revise characterization of problems from which
the original text. they suffer are two quite distinct issues.
A DECADE LATER 281
Madness remains in the medical domain biomedical view of madness. Socially and
(certainly, other community institutions psychologically oriented etiologies have
have not claimed it) quite aside from the been reduced~.g., the manual no longer
nature or extent of the care that is provided. uses terms such as neuroses-and medical-
The fact that the needs of people with ized terms have been increased-e.g.,
serious "problems in living" (to use an old "dysphoric disorder" is substituted for the
phrase) are neglected does not mean that earlier "depression." With the advent of the
their problems are no longer considered Human Genome Project-a huge, two-
medical. They still are seen as having "men- decade effort to map the entire human
tal" or "emotional" or "affective" problems genetic structure-it is very likely that more
that are, for the most part, properly genetic grounds of mental disorders will be
"owned" or served by medicine. It is possi- uncovered (see Collins, 1991). This, of
ble to argue that madness remains under course, very likely will lead to a reaffirma-
medical surveillance even though medical tion of the medicalization of madness.
control, at least in terms of institutionaliza-
tion, is less dramatic and complete than in Alcoholism
the 1960s. And, at the same time, certain The medicalization of deviant or problem
other areas of mental health treatment re- drinking remains firmly in place, despite
main as medicalized or are even more highly continuing criticism of the disease concept of
medicalized than a decade ago, especially in alcoholism (see Fingarette, 1988). Alcohol-
terms of the use of drug therapies, in, for ics Anonymous (AA) appears to be thriving
example, problems such as agoraphobia, and is now approaching 2 million members
panic disorders, and anorexia. (Institute of Medicine, 1990). While AA still
Three additional points suggest a con- takes a dubious view of medical treatment
tinuing medicalization of madness. First, the for alcoholism, the varieties of actual medi-
major social movement of the 1980s in cal treatment have grown'in the last decade.
mental health has been the National Alli- A recent article in the New England Journal
ance for the Mentally III (Mishler, 1991; of Medicine presented evidence that three
McLean, 1990). This organization, made up weeks of in-hospital treatment plus manda-
mostly of people with mentally ill family tory AA participation was more effective
members, advocates the medical model of (i.e., more clients still sober after 2 years)
madness. Indeed, its view aligns directly than just mandatory participation in AA
with the biomedical model of madness, see- (Walsh et aI., 1991). If this finding is borne
ing it as a disease of the brain. It claims that out by subsequent research and examina-
medical treatment of the severely mentally tion, it could both encourage increased
ill has been neglected and that these patients medical treatment of people with drinking
need more rather than less medical care. problems and move such treatment more
Second, acute mental health problems have firmly under medical insurance coverage. In
moved further into the mainstream of the turn, medical care of alcoholism would be-
medical care system as evidenced by an come more pervasive.
increase in the number of psychiatric units in Among the most interesting develop-
general hospitals (Brown, 1985) and, to a ments in response to drinking problems have
degree, broader in-hospital insurance cover- been the emergence and growth of em-
age of mental health care. Third, psychiatry ployee assistance programs or EAPs (Ro-
has moved further in the biomedical direc- man, 1980; Sonnenstuhl, 1986) and the ex-
tion; for example, the most recent edition- pansion of the alcoholism concept to include
the third revised-of the American Psychi- people associated with the alcoholic, such as
atric Association's Diagnostic and Statistical children and other family members (Peele,
Manual of Mental Disorder (DSM-IIIR), 1989). The enormous dissemination of the
reflects a consolidation and expansion of the discourse of "codependency" (Lichtenstein,
1988), spread in part through alcohol, drug, ideas and understandings of alcohol prob-
gambling, and related addiction treatment lems and deviant drinking behavior would
programs, would seem to widen the scope of seem certainly not to be less today than in
the medicalized view of alcohol problems to the recent past. Rather, the "natural" status
include a larger and potentially unlimited of the idea that such drinking is a medical
number of persons who regularly interact problem is possibly even more widespread.
with the key "dependent" person. Family In a recent paper, Roman and Blum (1991,
members of alcoholics have already been p. 780) suggest that the prevalence of
partially medicalized by being labeled as "health warning labels" on alcohol products
"enablers," "codependents," and "adult may "increase perceived risk associated with
children of alcoholics." One aspect of the alcohol consumption" in such a way as to
dissemination of medical or quasi-medical increase the association between alcohol use
ideas and interpretations of addiction is that and medical outcomes.
deviant drinking, which is not often man-
aged by people with medical credentials, is Opiate addiction
still unmistakably located within what might The focus of attention on drug use has
be called a quasi-clinical medical model (see changed over the past 15 years from opiates
Chapter 4). to cocaine and crack. The official response
Some researchers continue to hope that a to such drug use seems to have become
genetic predisposition to alcoholism will be predominantly punitive (perhaps with the
found. While new diagnostic techniques for exception of limited needle-exchange pro-
uncovering genetic markers that may iden- grams linked to transmission noted below of
tify persons at risk for alcoholism have been human immunodeficiency virus [HIV] and
reported (Tabikoff & Hoffman, 1988; Blum acquired immunodeficiency syndrome
et al., 1990), they are not without contro- [AIDS]). The criminal justice system in the
versy (Cloninger, 1991). But undoubtedly United States routinely processes large
the search for a biomedical cause of alcohol- numbers of substance-abuse charges; Amer-
ism will continue and will have potentially ican prisons have become crowded with
significant implications for the medicaliza- drug-related offenders (Holbert & Call,
tion of alcoholism. 1989). U.S. public policy primarily has been
Two of the most public social movements directed toward stopping the supply of
around alcohol problems in the last decade drugs, either at their domestic sites of pro-
have been the EAPs in industry (Roman, duction or at key border areas known to be
1980,1988; Sonnenstuhl, 1986) and Mothers common points of entry (Inciardi, 1992).
Against Drunk Driving (MADD). The for- Drug dealers are treated as criminals, and to
mer invokes a medical model of response a degree, so are drug users. Medicalized
and intervention and is generalized to prob- approaches such as methadone maintenance
lems beyond "alcoholism." It is estimated have lost some of their appeal, especially
that more than 10,000 EAP programs now because of reduced efficiency rates and re-
exist in workplaces in the United States ports of continued drug abuse by methadone
(Roman, 1988). The MADD approach re- patients (McCarthy & Borders, 1985). A
lies on punitive and educational action and recent government report concluded that
depicts drunk drivers as "violent criminals" many methadone maintenance centers are
without completely rejecting the disease not effective in weaning addicts from opiates
concept (see Reinarman, 1988). In spite of (New York Times, 1990).
continuing criticism of the disease concept of The advent of AIDS has had conse-
alcoholism (e.g., Peele, 1989; Fingarette, quences for the way in which intravenous
1988) and what might be called a growing (IV) drug users are defined and responded
criminalization of drunken driving (Reinar- to as objects of public opinion and policy
man, 1988), the predominance of medical intervention. The particular place of medi-
A DECADE LATER 283
calized themes in this larger image and ers, persons making insanity defenses, and
response is not clear. Since it is well known homosexuals). Cross-national comparisons
that needle sharing among IV drug users is a of official policies and public attitudes
risk behavior for the transmission of HIV, toward drug use, especially in Western Eu-
one might expect the prestige and power of rope, might help us to see whether medicali-
the medical profession to weigh in on the zation fares better in environments less le-
side of greater medical involvement in the gally hostile to it.
definition and treatment of (at least this
aspect of) drug addiction. But this does not Homosexuality
seem to be the case. Although programs Homosexuality remains, in our view, a
teaching users about the dangers of sharing lively topic for productive thinking about the
"dirty" needles and how to clean needles nature and consequences of the medicaliza-
with bleach have met some success, in gen- tion of deviance. It provided us one of the
eral they have not been enthusiastically clearest cases of medicalization in the face of
endorsed by local governments or medical an increasingly hostile political context (in
officials. In at least one case such a program late 19th-century Germany); of aggressive
faced enormous difficulties in gaining credi- intervention by psychiatry (Le., the mid to
bility among various target groups in a local late 20th-century theories and therapies
community (Broadhead & Margolis, 1992). advocated after Bergler, Bieber, and Socar-
In short, more "medicalized" approaches adies, [see entries under these names in
such as exchanging needles or providing main Bibliography] and the official illness
sterile ones have been rejected in most designation by the American Psychiatric
communities in the United States where Association); and the dramatic pOliticization
they have been tried or proposed. It appears in the late 1960s of gay and lesbian life that
then that even in the face of the threat of led to the demedicalization of homosexual-
AIDS, the medicalization of drug addiction ity as evidenced in the 1974 American Psy-
has not increased, something that likely chiatric Association vote (see also Bayer,
reflects the great moral opprobrium that has 1981; but see Stevens & Hall, 1991).
been nurtured around "drugs" in the United The impact of AIDS, beginning in the
States. Peyrot (1984) and Johnson and Wal- early 1980s, on gay people and their commu-
etzko (1991) have noted, as we did in our nities and identities has been enormous,
original analysis, that medical social control partly because the public definition of ho-
does not preclude the simultaneous and mosexuality has changed in light of AIDS,
even coordinated operation of legal con- which was seen initially (and, for some, is
trols. Indeed, medical control operates still seen) as "the gay plague." Even within
within and by the endorsement of legal the more subtly marked designation "risk
control. group" (and, later, "risk behavior"), the
Drug addiction is theoretically interesting connection between homosexual behavior
in that it appears to offer another opportu- and contagion, morbidity, and death could
nity to examine the conditions under which easily be read. To the extent that the efforts
medicalization receives support or has to and aims of the gay rights and gay liberation
compete with alternative moral paradigms movements of the late 1960s and the 1970s
for ownership and control of a problematic lessened the stigma associated with homo-
behavior. Our original text contains a num- sexuality, one feels it is at least plausible, if
ber of instances in which medicalization was not fully documented empirically, to argue
popularly seen as an "excuse" for people that AIDS has enabled a restigmatization of
whose undesirable conduct should be seen, homosexuality and especially of gay men
rather, as chosen and thus irresponsible or (see Altman, 1986; Shilts, 1987; Murray &
criminal and should lead properly to punish- Payne, 1985). While the issues of the gay
ment rather than treatment (e.g., child abus- movements of the 1970s and early 1980s
were politicization, coming out, and pride, leagues found that the particular group of
by the late 1980s much of the gay community neurons thought to regulate male sexual
seemed to have turned its energies to re- behavior was twice as large in heterosexual,
sponding to AIDS in American society. compared with homosexual, subjects. They
While pride remained an important issue, hypothesized that this difference might indi-
and protests of the ever-present "gay bash- cate a physiological basis for sexual orienta-
ing" continued, a central focus of movement tion. While it is not clear whether this
activity-particularly as seen in the Gay finding is a cause or an effect of homosexual
Men's Health Crisis (Perrow & Guillen, conduct (all the gay men examined had died
1990) and even in ACT-UP (AIDS Coalition of AIDS), this kind of argument and re-
to Unleash Power) (Berkowitz, 1991; Gam- search stimulates further similar research
son, 1989)-has been to urge greater gov- and research funding as well as an inclina-
ernment and institutional support for taking tion toward the simpler and more "elegant"
AIDS seriously and for committing more of explanation from biology. Another recent
the society's substantial resources toward study (Bailey & Pillard, 1991) found that
AIDS prevention and treatment research. monozygotic twins had a much higher con-
The U.S. military, insurance companies, cordance of homosexual orientation (52%)
and some other organizations have begun than either dizygotic twins (22%) or nontwin
HIV testing with the result that increasingly siblings (9%). The authors suggest that this
homosexuals can be seen as objects of offi- finding supports a genetic basis of homosex-
cial, even legal, discrimination to protect uality. Clearly, studies such as these might
"society" against further contagion and con- further erode demedicalization.
tamination (Bayer, 1989; also see Stoddard The question seems to be, if there are
& Reiman, 1991). biogenic differences between homosexual
Fear of AIDS easily translates into fear of and heterosexual people, how will these dif-
homosexuals and homosexuality (Conrad, ferences be characterized (see Conrad,
1986). And while AIDS has not created the 1977)? How will this kind of data and argu-
same sort of medicalization that existed in ment be used to reconfigure homosexuality?
the 1970s and before, the definition of male Some irony enters the discussion from the fact
homosexuality as an alternate (read "and that LeVay is a self-defined gay man who sees
equal") lifestyle has suffered with the ad- his scientific results as offering a positive
vent of "risk" and "death" (see Gamson, moral alternative to the interpretation that
1989). One might say that these events homosexuality is a choice one makes. As
constitute not so much a new medicalization Greenberg (1988, pp. 406-11) notes in his
as a new ground for disreputability and the historical review of medical theories of homo-
imputation of irrationality (even compul- sexuality, medical and physiological explana-
sion) to the pursuit of erotic interest in tions for homosexuality do not necessarily
same-sex others. It is of course still possible directly influence public policy.
that widespread medical surveillance (in
terms of mandatory screening for AIDS) Hyperactivity, child abuse,
could further medicalize homosexuality, but and family violence
this currently seems unlikely. One of the earliest topics for medicaliza-
Very recently we have witnessed an inter- tion of deviance research was deviant and
esting reemergence of scientific claims for a disruptive behavior by children, usually in
biogenic cause of homosexuality in men. the context of primary school classrooms.
Simon LeVay (1991), of the prestigious Salk Within the middle-class and controlled con-
Institute, published a paper reporting com- fines of the school, some children couldn't or
parisons of the anterior hypothalamus in wouldn't "behave." Troublesome school-
brains of gay men with those of a control, children who are active, fidgety, and don't
presumably straight, group. LeVay and col- pay attention have always been a problem
A DECADE LATER 285
for teachers and parents. What was new with Another phenomenon that has become
the advent of the diagnosis of hyperkinesis, central to the lives of schoolchildren and
Conrad (1975) argued in an early paper, was their parents, not to mention professionals,
the growing belief that this behavior was is learning disability. Although a more com-
symptomatic of a disorder that could be plicated category than hyperactivity, the
treated by available stimulant drugs. Some diverse diagnoses that fall under this um-
troublesome school kids thus became candi- brella term work in the predictable ways to
dates for medical diagnosis (hyperactive deflect attention from the central place that
syndrome or minimal brain dysfunction) and context and convention play in the very
treatment, and these children, their parents, creation of diagnostic categories. Using a
and teachers experienced all the definitional critical sociology of knowledge approach,
and practical changes that follow upon the Carrier (1983, p. 952) argues that learning
medicalization of deviance. disability theory "misrecognizes and thus
Since the emergence of hyperactivity as a masks the effects of social practices and
diagnosis, some interesting changes in the hierarchy" and focuses narrowly on the
scope of its application raise the more troublesome or troubled individual. This
general issue of the elasticity of medical decontextualization is typical of the medical-
categories applied to conduct previously ization process (see also McGuinness, 1985;
considered morally problematic. Initially, Coles, 1987). Erchak and Rosenfeld (1989,
hyperactivity applied only to overactive, p. 80) underline the enormous expansive-
impulsive, and distractible children (espe- ness of the diagnostic category by quoting
cially boys). In the 1980s the diagnostic from a 1984 guide for parents published by
focus shifted from overactivity to the inabil- the Foundation for Children with Learning
ity to pay attention, and the problem was Disabilities: "Virtually every child exhibits
reconceptualized as attentional deficit disor- some symptoms of learning disabilities at
der (ADD) or attentional deficit disorder one time or another." They argue that the
with hyperactivity (ADD-HA). By and five-stage sequential model of medicali-
large, the treatment of hyperactive children zation we offer (Chapter to) is useful in
stayed the same, but the diagnostic category understanding how learning disabilities have
expanded and became more inclusive. Now, become an institutionalized part of U.S.
ADD can include more teenagers, adults, education (Erchak & Rosenfeld, 1989; pp.
and hypoactive girls (Wender, 1987). De- 85-92).
spite, or perhaps because of, evidence that Child abuse has become institutionalized
ADD is an inadequately specified, rather as both a criminal and a medical phenomenon
vague category (Rubinstein & Brown, with a wide range of conventional responses:
1984), labeling and treatment seem to be medical diagnosis of the child, mandatory
increasing. One study found a consistent reporting, probable legal intervention in the
doubling of the rate of treatment for ADD family, and possible treatment for the abuser
children every 4 to 7 years, so that in 1987, (see Nelson, 1984). In many ways, the par-
6% of all public elementary school students ticular amalgam of legal/criminal and medical
were receiving stimulant medications (Safer definitions surrounding child abuse and bat-
& Krager, 1988), and the rates rose faster in tering would seem still to offer potential for
secondary than in elementary schools. It is observing how the different kinds of moral
worth noting that the medicalization of such categorizations are used in institutional set-
conduct has increased internationally; one tings through which people and families
report suggests that in China thousands of move. In the past 15 years, child abuse
children experiencing school-related diffi- definitions have expanded beyond battering
culties are diagnosed with "minimal brain and neglect to include emotional and sexual
dysfunction" and treated with stimulant abuse and denial of life support to severely
medications (Earls, 1981). handicapped infants (Newberger, 1991).
While physicians still provide the medical search (1984) suggests that, paradoxically,
diagnosis and identification, "in recent years there has been some medicalization of bat-
there has been a trend toward the criminaliza- tered women who stay with men who abuse
tion of child abuse," including more involve- them. Loseke and Cahill note that experts
ment of law enforcement personnel and the on battered women take as a central ques-
judicial systems (Dubowitz & Newberger, tion why women in battering situations
1989, p. 85). However, pediatricians remain choose to stay rather than leave. One kind of
key players in identification and reporting of account the experts offer points to the "ex-
child abuse. ternal constraints" of social and economic
The case of domestic violence against dependence: the women cannot leave be-
women offers an interesting comparison cause they have no money and no place to
with respect to how behavior definitions can go. But another, favored account suggests
be invoked and used. While some have that women who stay suffer "internal con-
claimed that wife battering is a medical straints" that prevent them from behaving
problem (Goodstein & Page, 1981), there is rationally, that is, from leaving the men who
evidence that it is only minimally medical- abuse them. It is only a very short step from
ized (Kurz, 1987; and see Loseke, 1987). this characterization to the familiar emo-
This is particularly interesting in view of the tional-psychiatric diagnoses so familiar in
relatively central position of medical per- the literature of the medicalization of devi-
sonnel, definitions, and interventions in ance. In fact, Loseke and Cahill (1984, p.
cases of child abuse. Gusfield's concept 306) note that such diagnoses have in fact
(1981) of "ownership," coupled with com- been offered: "battered wife syndrome"
peting definitions and a lack of medical (Morgan, 1982; Walker, 1983) or the "adult
involvement or entrepreneurship, offers maltreatment syndrome" in section 995.8 of
possibly helpful interpretations. the International Classification of Diseases.
The dominant definition of wife abuse or And one of the experts Loseke and Cahill
battering is not medical but political. Do- (1984, p. 309) cite writes, in the journal
mestic violence against women (not only Victimo!ogy, about "female masochism and
against wives) has emerged as a "social the enforced restriction of choice." So, to
problem" defined and owned by the the extent that the phenomena surrounding
women's movement-rather than a form of abuse of women in domestic settings have
"deviant behavior." It has been given a been medicalized, it appears to be the
feminist interpretation that turns on a theory women who stay in such relationships who
of gender relationships and dominance; the are considered first deviant and then sick.
theory portrays violence against women
partners as both relatively common and NEW AREAS OF STUDY AND FUTURE
rooted in the patriarchal structure underly- ISSUES
ing male-female relations. The treatment for When we reflect on the work done in the
battered women, beyond immediate medi- decade since we wrote our book, one gen-
cal care for acute injuries, has been to locate eral question that emerges is whether medi-
victims in the community in centers or "shel- calization is on the rise or the decline. Over
ters" and, in some cases, to use the courts to the years a few social scientists have sug-
enforce separation of the husband or male gested to us in conversation that, due to the
partner from the beaten women (see Tierney, dismantling of the welfare state and the
1982; Wharton, 1987; but see Ferraro, 1989). constraints from rising medical costs, medi-
While medical definitions of battering have calization may be on the decline. While this
been proffered, the frame for the problem may be true in a few specific areas (e.g.,
and response remains more feminist and drug addiction), our brief review of materi-
explicitly political than medical. als does not suggest a wholesale retreat from
Nonetheless, Loseke and Cahill's remedicalization. In fact, there is some evi-
A DECADE LATER 287
dence that more deviance is medicalized expanding the definition of AD has shrunk
today than a decade ago. Although few the range of effects deemed to constitute
studies have actually attempted to measure normal aging (Robertson, 1990) and has led
the amount of medicalization of deviant to neglect of social causes of cognitive decline
behavior> the weight of studies published (Lyman, 1989).
suggests expansion rather than contraction. We want briefly to point to several issues
In part this can be seen in analyses published that are relevant to understanding the future
in the last decade. trajectory of the medicalization and demedi-
Since Deviance and Medicalization was calization of deviance. We raise these issues
published, researchers have used elements as questions for continued investigation.
of the arguments we and others made to Medicine in the United States is changing:
examine new topics and cases and some- medical authority is declining (Starr, 1982);
times to extend the more general issues increasingly, physicians are employees (Mc-
raised earlier. Problems examined have in- Kinlay & Stoeckle, 1988); corporate struc-
cluded eating disorders and anorexia (Brum- tures have increased power as third parties
berg, 1988); compulsive gambling (Rosen- and as "buyers" of health services. These are
crance, 1985); transsexualism (Billings & fundamental changes in the organization of
Urban, 1982); menopause (MacPherson, medicine. What impacts are they having and
1981; McCrea, 1983; Riessman, 1983; Bell, might they have on the medicalization of
1987a, 1990) and premenstrual syndrome or deviance? Similarly, what are the impacts of
PMS (Bell, 1987b; Riessman, 1983); infertil- dismantling the welfare state and subsequent
ity (Greil, 1991); suicide (MacDonald, cutbacks in government subsidy of health
1989); "impaired physicians" (Stimson, care? Will behavioral problems be redefined
1988; Johnson, 1988; Morrow, 1982); "ex- as "badness" rather than sickness?
cessive" emotional reactions to combat dur- What is the relationship between the eco-
ing war-post-traumatic stress disorder nomic infrastructure of health care-
(Scott, 1990); chemical executions in the primarily insurance reimbursement-and
death penalty (Haines, 1989); and aging medicalization? What is the effect of contin-
(Estes & Binney, 1989). All of these studies ued rising health costs and subsequent policy
draw on tenets of the medicalization of concerns with cost containment? Do they
deviance argument to examine details of fuel or constrain medicalization, and how?
particular cases. What impact could universal health insur-
In a related area of study, what historically ance have on medicalization? Comparative
was called senility has become defined as studies of other industrialized health sys-
Alzheimer's disease or AD (see Gubrium, tems would be useful here.
1986; Fox, 1989; Halpert, 1983). An obscure Few authors have examined in detail the
disorder that was virtually unheard of two influence of the AIDS epidemic on the
decades ago, Alzheimer's disease is now con- medicalization of deviance. While it clearly
sidered one of the top five causes of death in has an impact on the definition and treat-
the United States. Fox (1989) suggests that ment of homosexuality, and probably on
the key issue in the change in conceptualiza- drug addiction as well, we know little about
tion of AD was the removal of age criterion, this impact. And does AIDS, which affects
which ended the distinction between AD and medicine and society in many ways, affect
senile dementia. The pool of potential cases other aspects of medicalization? For exam-
of AD now effectively includes cases of senile ple, what does HIV testing mean with re-
dementia in patients more than 60 years old. spect to medical surveillance and control?
Cognitive decline and the many associated The area of medical knowledge most
"deviant behaviors" are defined as results of likely to affect medicalization in the next
a specific disease rather than as inevitable decade is probably genetics. The Human
aspects of aging. Some have suggested that Genome Project is a 15-year project with the
goal of mapping the human genetic structure baugh, 1982; Littlewood & Lipsedge, 1987;
(Watson, 1991). While the purpose is to find Johnson, 1987), but how does medicalization
the chemical basis for the 4000 or so genetic interplay with culture-boundedness? What
diseases that afflict humans, it will also types of cultural and structural factors in
uncover new relationships between genetic societies encourage or discourage the medi-
structure and deviant behavior. While "be- calization of life's problems?
havioral genetics" and genetic intervention A few specific issues call for attention.
have thus far had a limited impact on medi- Even after nearly two decades of writing, we
calization, it seems inevitable that new dis- know rather little about the extent of medi-
coveries of genetic "markers" or predisposi- calization. In one of the few medicalization
tions will result in new medical diagnoses of studies that has taken the question of extent
and interventions in human behavior (see seriously, the authors found that menopause
Nelkin & Tancredi, 1989). The specific im- is medicalized on the conceptual level but
plications for the medicalization of deviance probably not widely in practice on the doc-
are not yet clear, but they are worthy of tor-patient level (Kaufert & Gilbert, 1986).
continued attention (e.g., see Duster, 1990). We need now also to attempt to analyze
While conditions such as obesity and variations in the medicalization of different
"chronic fatigue syndrome" have only be- problems and to make more detailed, care-
gun to be studied as instances of medicaliza- ful comparisons of the process across prob-
tion, we need to go beyond the accumulation lems. More careful comparisons of medical
of examples to investigate more carefully with other types of social control could be
the process of medicalization. Previously included. Two recent publications
undetected dimensions of medicalization (Waitzkin, 1991; Dull & West, 1991) have
need to be unearthed in an effort to formu- presented glimpses of practicing doctors'
late a more integrated theory. views of medicalization. Because some stud-
Medicalization has been most studied in ies have suggested that less medicalization
the United States and by Americans. It is not may occur at the doctor-patient level than at
clear whether it is more advanced in Ameri- other levels (Strong, 1979), research on the
can society or whether other societies have medicalization of perceptions and practices
not yet been adequately studied. More in everyday medical practice could be illumi-
crossnational and comparative studies, such nating. In sum, the medicalization of devi-
as Lock's examinations of aging (1984) and ance is as rich and vital an area for study
menopause (1987) in Japan, could be very today as when we first wrote our book.
enlightening. For example, how are anorexia, Some areas call out for continued investiga-
hyperactivity, obesity, and PMS defined and tion, particularly the structural underpin-
treated in other cultures? Anthropologists nings of medicalization, in view of the
typically conceptualize these conditions as enormous changes occurring in the organiza-
Western, "culture-bound syndromes" (Riten- tion of medicine and its powerlknowledge.
January 1992
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AUTHOR INDEX
A Bergler, E., 188n, 189-190

Ackerknecht, E., 41, 43, 46-47, 52, 54 Berman, A., 160
The Advocate, 210-211 Berman, Y., 226
Agar, M., 139 Bieber, I., 190-191, 209n
Alcoholics Anonymous, 88-90, 109 Bingham, C., 178
Alcott, W., 180 Bischoff, H., 98
Alexander, F., 42-43, 47, 72 Blaine, J., 141
Alexander, L., 223 Bloch, H., 221
Alford, R., 15 Block, J., 199
Allen, F., 227 Block, M., 76
Alston, J., 210 Blumer, H., 22
American Friends Service Committee, 239 Blumgart, H., 33
American Medical Association (AMA), 99, lOin, 192n, Bootzen, R., 231
225 Bosco, J., 157
American Psychiatric Association, 50, 53, 99, 193 Bowart, W., 229
Amir, M., 226 Bowden, c., 140n
Andenaes, J., 233 Boyer, P., 3n
Anderson, D., 88n Bradley, c., 156
Anslinger, H., 128 Brandsma, J., 97
Antonovsky, A., 245 Brecher, E., III, 115-116, 119, 123, 129, 132-134, 136-
Arendt, H., 252 137, 144
Aries, P., 145-146, 169-170 Breggin, P., 224, 226, 235-236
Aristotle, 176, 217 Brenner, C., 53
Armor, D., 60, 105 Brill, H., 62
Aubert, V., 32 Brown, H., 206
Ausubel, D., 110-111, 130n Bruun, K., 83, 103
Buckner, H., 8
B Bullough, B., 180-181
Bacon, S., 92, 94, 102-103 Bullough, V., 172-174, 175n, 176-184, 187n, 194, 196,
Bailey, D., 174, 177 201,213
Bain, K., 166 Burgess, A., 215-216
Baines, H., 223 Burnham, J., 13
Bateson, G., 65 Butz, R., 73
Bazelon, D., 60
Beach, F., 199 C
Beall, 0., 179n Caffey, J., 163
Becker, E., 251 Cahalan, D., 77, 104
Becker, G., 267n, 273n Cahn, S., 89
Becker,H.,6, 18-20,22,27,77,95, III, 128, 159,200 Caldwell, R., 233
Bedau, H., 235 Cantwell, D., 160
Bednar, R., 230 Caplan, G., 67
Begelman, D., 209n Caplan, N., 252
Behavior Today, 254-255 Cartwright, F., 9
Belknap, I., 63 Cartwright, S., 35, 245
Bell, A., 199n, 214 Cassell, E., 184
Ben-David, J., 85 Caudill, W., 63
Benedict, R., 6 Chafetz, M., 86-88
Berger, P., 21 Chalfant, P., 253
311
312 AUTHOR INDEX
Chambliss, W., 18,25, 129 Dole, Y., 135-136, 141

Chang, J., 199 Donaldson, K., 70
Charles, A., 160 Douglas, J., 30n
Chavkin, S., 70 Dover, K., 174
Chein, I., III Dubos, R., 13-14,30,33,45,262
Chin-Shong, E., 58,59-60 Dugdale, R., 218
Chorover, S., 35, 224, 242-243, 250 Dumont, M., 135, 136n
Christie, N., 83, 103 Dunham, H., 63-64, 67, 69
Chu, F., 67-68 DuPont, R., 135
Church Committee, 238 Durkheim, E., 5, 32-33
Churchill, W., 172 Duster, T., 115, 117, 120-121, 124, 127, 130n, 144,246
Cicourel, A., 56 272,274
Clark, W., 104
Clements, S., 156 E
Cloward, R., 154
Earle, c., 116
Cochran, W., 197
Eaton, Y., 117
Cockerham, W., 233
Edelman, M., 241
Cocozza, J., 253
Edgerton, R., 73, 76-77
Coe, R., 10, 254
Ehrenreich, B., 15,241,248
Cohen, A., 154
Ehrenreich, J., 15,241,248
Cohen, M., 141n
Ellis,A.,188n
Cole, S., 157
Ellis, H., 187n, 195-196
Coleman, E., 209n
Embree, S., 125n
Coleman, J., 158n
Empey, L., 145-148, 151, 171
Coleman, L., 154
Englehardt, H., 35, 52, 180,245, 267n
Comfort, A., 35, 180,245
Epstein, E., 138, 140
Conrad, P., 23, 28n, 31, 35, 71, 155n, 157t, .160, 170,
Erikson, K., 3n, 4-6, 16, 18, 253
241n, 242, 245, 248, 250, 266n, 274
Ervin, F., 225-228, 243
Corley, M., 98
Esterson, A., 65
Corwin, E., 84
Etzioni, A., 137-138
Corzine, J., 33
Evans, R., 188
Coulter, J., 56
Evans, W., 163
Crocetti, G., 59-60
Everett, M., 77
Crothers, T., 75, 85
Culliton, B., 225
Cumming, E., 58,59-60, 68 F
Cumming, J., 58,59-60, 68 Fabrega, H., 30, 92
Cunningham, E., 84 Faris, R., 64
Currie, E., 6, 18, 42 Feinstein, A., 30
Ferris, G., 183-184
D Fieve, R., 70
Daniels, A., 244 Filene, P., 149
Dank, B., 200 Filstead, W., 109
Davies, D., 95, 105 Finch, S., 153
Davis, F., 18 Finestone, H., 148, 152-153
Davis, K., 18n, 57 Fingarette, H., 81, 101
Davison, G., 206, 209n Fink, A., 12,217,240
DeFrancis, Y., 166 Fontana, Y., 161
Delgado, J., 235-236, 243 Ford, c., 199
DeLong, J., 141, 157 Foucault, M., 34, 44-46, 72
deMause, L., 145-146 Fowler, 0., 180
Demone, H., 86-88 Fowlkes, M., 68
Deutsch, A., 48-49 Fox, R., 247, 255n
Devereux, G., 199 Fox, R. G., 226, 240, 244
Diamond, B., 81 Frank, J., 61,247
Dickson, D., 22-23, 128 Freeman, W., 55, 243
Dion, K., 217 Freidson, E., 14, 16, 19-20,23,31,33,37,47, 159n, 208,
Divoky, D., 155, 160 241- 242, 248, 265
Dohrenwend, B. P., 58,59-60. 64, 67 Freud, S., 53, 185-187
Dohrenwend, B. S., 64, 67 Freund, K., 209n
AUTHOR INDEX 313
G Hollingshead, A., 64
Gagnon, J., 201 Holzner, B., 78
Galliher, J., 23n Hooker, E., 199,201
Garth, J., 237 Hooton, E., 220, 227, 240
Geis, G., 221 Horowitz, I., 110-111
Gelles, R., l64n, 165-168,274 Horowitz, W., 54
Gibbons, D., 154 Horrock, N., 238
Gigeroff, A., 177, 199n Huessy, H., 155n, 160
Gil, D., 167-168, 171,274 Hughes, C., 64
Glass, A., 188 Hull, J., 114, 116
Glalt, M., 91 Humphreys, L., 200-203
Glenn, N., 210 Hunt, G., 128
Goddard, J., 61, 243 Hunt, J., 226, 228
Goffman, E., 63, 72, 92, 200, 274 Hurvitz, N., 242
Gold, R., 207
Goldstein, A., 141
Goleman, D., 208n, 209 lIIich, I., 28-29, 37, 241
Goode, E., I, 16,20,26,115,119,127-128,267 Ingleby, D., 28n
Gordon, G., 32n Inglis, B., 117, 119
Gordon, L., 13
Gordon, R., 130n J
Goring, c., 219, 227 Jackson, D., 56, 234
Gove, W., 65 Jacobs, P., 226
Graham, S., 179-181 Janowitz, M., 7
Green, J., 153 Jellinek, E., 85, 87, 89,91. 92-94,99, 109
Green, R., 205 Jewson, N., 9
Greenberg, L., 73, 76 Johnson, B., 117-119
Greenspan, S., 160 Johnson, J., 200
Grinspoon, L., 157-158 Johnson, V. E., 181n, 209n
Grob, G., 51 Johnson, V. S., 232
Gross, M., 157 Joint Commission on Mental Illness and Health, 62
Gusfield, J., 17-18,22,24-26,31,35,37,79,82-83,85, Joint Committee of the American Bar Association and the
98, 109, 274 American Medical Association, 132
Gussow, Z., 247n Jones, M., 68
Jones, R., 90
H
Hagan, J., 151 K
Halleck, S., 60, 205, 209n, 242, 244 Kallman, F., 55-56, 188
Haller, J., 180 Kameny, F., 202
Haller, R., 180 Kass, L., 29
Halpert, H., 58 Katz, J., 182, 187
Hampson, J. G., 188 Kazdin, A., 231
Hampson, J. L., 188 Keller, M., 78, 81, 86, 95-97, 104, 109
Hansen, C., 3, 5 Kellert, S., 253
Harper, R., 75-76 Kelman, S., 14
Harris, M., 145, 161 Kempe, C., 163-164
Halterer, L., 191n Kenniston, K., 69
Hawes, J., 152 Kenny, T., 160
Hayes, S., 230 Kiev, A., 38
Healy, W., 152-153 Kinsey, A., 197-199
Heath, R., 236 Kirk, S., 68-69
Helmer, J., 113, 120, 125n Kitsuse, J., 19,26,56,85,203,265-266,269
Helrich, A., 90 Kittrie, N., 33-34, 37, 48, 60, 81, 87,100-101,113, 131,
Hentoff, N., 135, 158, 160 148, 151-152, 182,200,216,221-222,224,237,239,
Hessler, R., 254 245-246, 249, 251, 254, 257, 262
Hills, S., I Klapmuts, N., 239
Hirschfeld, M., 183, 194-195 Klassen, A., 181n, 192n, 193
Hite, C., 209 Kleinman, P., 141n
Hoffman, M., 206 Klerman, G., 60
Hofstadter, R., 265 Knowles, J., 255
314 AUTHOR INDEX
Krout, J., 82-83 Mark, V., 225-228, 243

Kuhn, T., 27, 48, 74, 103,270-271 Marmor, 1., 205, 207, 214
Martin, D., 170,201,204-205
L Martinson, R., 239
Labate, c., 122, 131 Masters, W., 181n, 209n
Lacey, W., 175 Matza, D., 1,18,150, 170n, 264
Laing, R., 65 Mauss, A., 22, 56
Lambert, N., 155n, 160 May, E., 133
Lange, J., 219 McAuliffe, W., 130n
Langner, W., 145, 161 McCaghy, c., 21
Larson, M., 10, 14 McCleery, R., 15
Lasch, C., 162, 169, 187n McCoy, A., 128
Laufer, M., 156 McIntosh, M., 200
Lauritsen, J., 182-183, 194-195 McKay, H., 154
Lavater, J., 217 McKee, J., 231
Lea, H., 178 McKeown, T., 13
LEAA,237 McKinlay, 1., 15
Lee, P., 157 McKnight, 1., 252
Lehtinen, L., 156 Mead, M., 199
Leifer, R., 62, 69, 254 Mechanic, D., 15,30, 32n, 35, 57, 67, 169,242,255
Leighton, A., 64 Melick, M., 253
Leighton, D., 64 Menninger, W., 188,244
Lemert, E., 67, 77, 94n, 251 Merton, R., 264
Lemkau, P., 59-60 Messinger, S., 32
Lender, M., 78 Meyer, J., 59-60
Lennard, H., 250 Meyer, R., 141
Leon, J., 151 Milan, M., 231
Lennan, P., 151n Miller, D., 98
Lerner, R., 178 Miller, K., 70, 242
Levin, Y., 224 Miller, M., 206
Levine, H., 78-79, 81-84 Miller, R., 137-139
Levine, M., 213-214 Mills, C., 251
Levitt, E., 181n, 192n, 193 Mitchell, S., 186n
Lewis, C., 239 Mohr, 1., 11-12
Lex, B., 141 Monachesi, E., 216
Licht, H., 174 Money, 1., 188
Lichtenstein, G., 210 Moran, R., 215
Lidz, c., 142 Morgan, H., 115-116, 119-121
Lieber, C., 73 Morris, N., 239
Lief, H., 209 Moss, A., 138, 140
Lindesmith, A., 77, 95, Ill, 114, 124-126, 128-134, 136, Mulford, H., 98
144, 224, 272, 274 Musto, D., 18n, 112, 114, 117, 119, 121-129, 144
Lofland, J., 21 Myerson, A., 64
Lombroso-Ferrero, G., 217
Luckmann, T., 21 N
Lukoff, I., 141n Nagi, S., 166
Lyman, S., 251 National Council on Alcoholism, 91
Lyon, P., 201, 204 National Institute of Mental Health, 63. 68t, 203, 208
Neaman, J., 41-42
M Nelkin, D., 136-137, 139t, 144
MacAndrew, C., 73, 76-78 Nelson, S., 252
Maddox, J., 140n New York Academy of Medicine, 130, 191
Malinowski, B., 199 New York Times. 238
Mancuso, J., 58 Newman, R., 141n
Manges, M., 120 Newsweek. 135,141,168,170
Mann, H., 160 Nissenbaum, S., 3n
Mann, M., 89 Norris, J., 90
Mannheim, H., 240 Nunnally, J., 58
Manning, P., 30, 69 Nyberg, K., 210
Marden, C., 98 Nyswander, M., 135-136, 141,272
AUTHOR INDEX 315
o Room, R., 87, 92, 94n, 95, 103-104, 106n, 109
Odorhoff, M., 128 Rosen, G., 12, 34, 38-40, 43, 48, 58, 242
Office of Child Development, 158 Rosenberg, C., 179
Ohlin, L., 154 Rosenhan, D., 56, 65
Oliver, F., 116 Rosenthal, D., 70
Orcutt, J., 21 Ross, E., 7
Osmond, H., 32n, 246 Rossi, J., 109
Overholser, W., 61 Rotenberg, M., 247n, 264
Rothman, D., 48-51, 72, 148
p Rothstein, W., 9-10,114
Paolucci, H., 216 Roucek, J., 7, 241n
Pare, c., 188 Rubington, E., 16
Paredes, A., 78, 87 Rush, B., 79, 80
Parry-Jones, W., 45 Ryan, W., 69, 250, 263
Parsons, T., 7, 32, 36-37, 90,169,241-242,247,249
Pasamanick, B., 67 S
Pattison, E., 103-105, 109 Sagarin, E., 211
Patton, R., 62 Sage, W., 234
Paul, B., 67 Sanders, W., 151
Paulsen, M., 165n, 166 Sandoval, J., 160
Pavlov, I., 229 Sarbin, T., 47,58
Pellens, M., 128 Sawyer, G., 188
Pelton, L., 167n Schafer, S., 223
Pfohl, S., 23, 162-166, 244, 267 Scheckenbach, A., 232
Philipps, D., 247n Scheff, T., 58, 64-65, 251, 274
Pittman, D., 109 Schmitt, B., 160
Pitts, J., 7, 35, 242, 245-248 Schneider, J., 78n, 241n, 274
Pivar, D., 180 Schrag, P., 155, 160
Plato, 175 Schur, E., 18,71, 126, 132,201, 272, 274
Platt, A., 18, 81, 145, 149-152, 171 Schwab, G., 223
Platt, J., 122, 131 Schwitzgebel, R., 234, 236-237
Ponse, B., 200 Scott, J. F., 180n
Scott, J. M., 111-114, 118, 122
Q Scott, R., 30n
Quinney, R., 21, 24, 125n Scull, A., 23, 45-47, 62, 68, 133,253
Sedgwick, P., 30-31
R Seeley, J., 103
Radbill, S., 161-163 Seevers, M., 95
Radelet, M., 28, 275 Seixas, F., 73
Rafferty, F., 151-152 Selesnick, S., 42-43, 47,72
Rainer, J., 70 Seneca, 76
Ray, 0.,110-112,114-115,117,121 Sharp, H., 12-13
Reasons, C., 123, 125, 128-129, 131 Shaw, C., 154
Redlich, F., 64, 253 Shaw, J., 183-184
Reiser, S., 9, 15 Sheldon, W., 220-221
Remp, R., 137-138 Short, J., 147
Renault, P., 141 Shryock, R., 9
Reynolds, J., 249 Shuval, J., 245
Ridenour, N., 56-57, 153 Siegal, A., 160
Rieff, P., 33, 54, 81 Sigerist, H., 13
Ries, J., 98 Sigler, M., 32n, 246
Riley, J., 98 Silver, L., 165-166
Robin, S., 67, 157 Silverman, M., 157
Robinson, D., 87, 103 Silverman, S., 163
Robinson, P., 184, 195, 197n Silverstein, C., 206, 209n
Roblin, R., 228 Simon, W., 201
Rock, P., 131 Singer, R., 232, 234-235
Rogow, A., 69 Singer, S., 157-158
Roizen, R., 103, 105 Skinner, B., 229-230
Roman, P., 66-67,69, 87, 89, 247n Smith, M., 139n
316 AUTHOR INDEX
Smith-Rosenberg, C, 180 u.S. Senate Committee on the Judiciary, Subcommittee on

Snyder, C, 109 Constitutional Rights, 230-232. 240
Sobel!, L., 104, 109
Sobeli, M., 104, 109 V
Sobey, F., 68 Vaillant. G., 128
Socarides, C, 191-192, 209 Vallentin, A., 178
Socrates, 40 Van Den Haag, E., 183
Solomon, T., 163 Vanggaard, T., 174
Sontag, S., 31n, 247n, 252 Veatch, R., 257
Sorenson, J., 244 Voght, M., 180n
Spector, M., 19.26.85.203,206-208.211,265-266,269
Spicer. E., 67 W
Spitzer, S., 20n. 208 Wagenfield, M .. 67
Srole. L., 64 Wahl, R., 104
Star, S., 58,59-60 Waitzkin, H .. 242, 244-245
Starkey. M., 3-5 Waldorf, D., 140n
Starr. P.• 10 Walker, A .• 23n
Steadman, H., 253 Walker. A. L., 142
Steinmetz, S .• 170 Ware, J., 180
Stephens, R .• 139 Warren. C, 200
Stevenson, J., 138, 140 Waterman, B., 244-245
Stewart. M., 156 Watson, J., 228
Stivers, R .• 18 Weaver, C, 210
Stoeckle, J .• 242 Weber, M., 263-264
Stoll, C. 34. 258 Weinberg, G., 200, 206
Stoller, R., 186n Weinberg, M., 16, 188, 199n. 214
Storer, H., II Weinberg. S .• 63
Straus. R .• 86. 98, 170 Weinberg. T., 200
Strauss, A .. 69. 156 Weiner, L., 67
Sutherland, E., 18n, 220, 222, 240 Wender, P.• 156
Swazey. J., 61 Wertz. D .. 9. 16
Sweet. W., 225 Wertz, R., 9, 16
Symonds. J., 174-175. 194 West. L.. 188
Szasz, T., 18n, 34. 42-43. 47. 49.52,55,65-66.72.81. White, R .. 52-53
111-112,115,120,188.205.209,222,242.244,246, Wilbur, D., 100, 102
254 Wilkerson, A., 79, 81-82, 84
Szulc. T., 238 Willette. R .• 141
, Williams, C, 188, 199n
Wilson, G., 206n
Task Force of Children Out of School. 158 Wilson. J .• 239
Taylor. A., 122 Wilson. W .• 157
Taylor, I.. 21 Wiseman, J., 77. 78n
Teal, D .• 201-204. 214 Wolf. D., 214
Teeters. N., 223 Wolf. 1..98
Temkin. 0 .. 13 Wolfenden Report, 199
Terry, C .• 128 Wolff, K. 251
Therrien, M .• 68-69 Wolfgang, M .. 218.220,227
Thio, A., I Woolley. P .• 163
Thorstad. D .• 182-183. 194-195 Wootton. B .• 34. 246, 276
Thrasher, F.. 154 World Health Organization. 91, 95
Tompkins, W., 128
Tracey, G., 247n y
Trice, H .• 87-89, 104. 247n Yablonsky. L.. 136
Trotter. S .• 67-68 Young. 1.. 73. 75. 77, 95
Trotter, T .• 81 Young. J. H., 115
Twaddle. A., 254
Z
u Zilboorg. G .• 40. 43
u.S. Department of Health, Education and Welfare. 63, Zola. I.. 29. 35. 73. 241, 245-246, 249. 255
73, 255. 268 Zucker. M .• 69
U.S. House Committee on Government Operations. 158 Zurcher, L.. 22
SUBJECT INDEX*
A Alcohol-cont'd
Abortion, 1,6, 10-13,22,27 and loss of control, 77, 82, 100, 104
decriminalizlJtion of, 254n medical consequences of drinking, 73
medicalization of, 275 and medical model, 73-74, 81
Abstinence, 74, 81, 82-83, 89, 104, 105 physical dependence on, 74
Achievement Place, 231 and physicians' temperance movement, 81, 82
Addict, stereotype, 119 physiology of, 73-74
Addiction and problem drinking, 105-106
alcohol, 76, 79-82, 90, 100 Prohibition crusade, 24-25, 83-85
and compulsion, l04n Quarterly Journal of Studies on Alcohol. 86
and craving, 81, l04n Research Council on Problems of, 86
and loss of control, 77, 79, 82, 100, 104 withdrawal from, 74
phases of, 9/ and work of B. Rush, 79-82
concept of, III, 112 Yale Center, 86-88
controlled, 95 Alcoholics Anonymous, 35, 87, 88-93, 97, 136, 245
criminalization of, 121-130 Alcoholism, 25, 28, 31-32, 34-35, 58, 243, 245, 249, 269,
demedicalization of, 121-130 273
as dependence, 95 and abstinence, 104, 105
drug, 25, 243, 245, 249 as alcohol addiction, 93
in Great Britain, 132-134 and alcoholic beverage industry, 276
heroin, 28, 135-136 and Alcoholics Anonymous, 88-90
masturbation as, 35 and Blue Cross and Blue Shield, 102
medical designations of, 130-132 and compulsion, l04n
from medical treatment, 114 and craving, l04n
morphine, 54,114-115 as deviant drinking, 92
opiate; see Opiate addiction diagnosis of, 88
opiates as cause of, 116 as disease, 92-94, 97-102, 246, 248, 253, 271
physical dependence model of, 96, 130n disease conc~pt of; see Disease concept of alcoholism
and physical withdrawal, 95 National Council on Alcoholism (NCA), 87-89, 91, 97,
Adler, A., 54 lOin, 105
Advocate. 201 National Institute of Alcohol Abuse and Alcoholism
Alcohol; see also Alcoholics Anonymous; Alcoholism; Dis- (NIAAA), 87, 97, 102, 105-106
ease concept of alcoholism; Drinking; Drunkenness; and problem drinking, 92
Inebriety Uniform, and Intoxication Treatment Act, 102
abstinence from, 74,81,82-83,89, 104 and Yale Center Summer School, 268
addiction to, 76, 79-82, 90, 100 Alcoholism treatment
and loss of control, 79 abstinence, 104-105
allergy to, 89 detoxification, 73
in American colonies, 78-82 disulfiram (Antabuse), 74
and behavior, 75-78 inebriate asylum, 83-85
and fetal alcohol syndrome (FAS), 74 moral,84
and inebriate asylum, 83-85 morphine, 114
and intoxication, 76 Yale Plan Clinics, 87
Journal of Studies on Alcohol. 86 Alcohologists, 87
American Academy of Pediatrics, 166
American Bar Association, 27
* Italicized numbers indicate illustrations. An "n" indi- American Bar Association and American Medical Associ-
cates information in a footnote, and a "t" indicates infor- ation loint Committee on Narcotic Drugs, 131
mation in a table. American Civil Liberties Union (ACLU), 233
317
318 SUBJECT INDEX
American Hospital Association, 15 Bini, L., 54

American Journal of Insanity, 51 Biotechnology, 235-239
American Library Association Task Force on Homosexual- Bleuler, E., 53
ity, 203 Blue Cross and Blue Shield, 102, 254
American Medical Association (AMA), 10-15, 27, 158n, Boggs Amendment, 129, 131
268 "Born criminal," search for, and therapeutic ideal, 216-
and alcoholism, 76, 100-102 222
and American Bar Association, Joint Committee on Nar- Bowman, K., 91
cotic Drugs, 131 Boylan Act, 123
and child abuse, 166 Bradley, c., 156, 159
and homosexuality, 204 Brain Committee, 133
and methadone maintenance, 137, 138 Briggs, J., 210-211
and opiate addiction, 123, 126, 131 British Journal of Addiction, 86
political organization and lobbying, 33, 36 British Journal of Inebriety, 86
American Orthopsychiatric Association, 57, 153, 268n Bryant, A., 210
American Psychiatric Association, 51, 268 Burckhardt, G., 224
and decision on "homosexuality," 204-209, 274 Bureau of Narcotics and Dangerous Drugs (BNDD), 137,
and homosexuality, 192-193,206 138
and mental hygiene, 56 Bureaucratization
and psychoanalysis, 54 and medicalization of deviance, 270
American Society of Bariatric Physicians, 268n, 276
American Society for the Prevention of Cruelty to Animals, C
162 Cahalan, D., 106
American Sociological Association, 203 Cancer, 31
American Temperance Society, 83 Carnegie Foundation, 14
Amphetamine SO. (Benzedrine), 157 Central Intelligence Agency, 237-239
Anslinger, H. J., 22, 128, 129, 131, 133 Cerletti, U., 54
Antabuse; see Disulfiram Child abuse, 6, 23, 34, 266, 273
Anti-Opium Society, 117 battered child syndrome, 163-164, 166
Antiopium movement, 118-119 changes in definitions of, 168-169
Association for Children with Learning Disabilities, 159, legislation, 165-166, 168
160, 268 medical discovery of, 267
Association of Medical Superintendents of American In- medical involvement in discovery of, 163-165
stitutes of the Insane, 51 as medical problem, 161-169
Asylum(s) as medical and social problem, 165-166
building movement, 49-52 psychopathological model of, 165, 166-167
as custodial enterprise, 51 and reporting laws, 165-166
and Darwin's theory, 51 social scientists' views of, 166-168
inebriate, 83-85 Child Abuse Prevention and Treatment Act, 168
as insanity cure, 49-52 Child abuse- reporting movement, 165-166
Atascadero State Hospital, 234 Child guidance movement, 57, 152-154
Child protection, 162-163
B and houses of refuge, 162
Badness, In, 9, 17-37 Child-savers, 147-149
and responsibility for deviance, 34 Child-saving movement, 18
Battered child syndrome, 163-164, 166; see also Child Child Welfare League, 165
abuse Child welfare movement, 149-150
Beccaria, C. di, 216 Childhood
Beers, c., 56, 57 concept of, 145-146
Behavior modification, 243 deviance, medicalization of, 145, 155
and aversive conditioning, 233-235 and hyperkinesis, 155
and crime, 228-235 Children
and negative reinforcement, 232-233 historical maltreatment of, 161-162
and positive reinforcement, 230 and medicalization, 169-170
and punishment, 233 Children's Bureau of the Department of Health, Educa-
Behaviorism, 228 tion and Welfare, 165
Benkert, K. M., 183, 194,272 Children's Division of the American Humane Association,
Benzedrine; see Amphetamine SO. 165
Bieber, I., 190-191,204,205,208 Chlorpromazine (Thorazine), 61
Bill W., 88-89 Church, 8, 9, 33, 41-43, 47
SUBJECT INDEX 319
CIBA-GEIGY Corporation, 158, 160 Delirium tremens, 74

Claims-making activities, 19, 26-27, 267-269 Demedicalization,IIO,121-130,142,193-21I,255n.270-
Clockwork Orange, A, 215 271
Community mental. health, 66-70 and deprofessionalization, 255n
and comprehensive community mental health centers and medicalization, 273-274
(CMHC), 66-69 politics of, 273-274
Community Mental Health Centers Act, 66 Detoxification, 73, 136
Community psychiatry, 67-70 Deviance
and CMHC, 68 as attributed designation, 17
and decarceration, 68 as badness, 17-37
and medical model, 69-70 categories of; see Deviance designation(s)
and social control, 69 as collective action, 18-20
Compulsion, l04n as contextual, 5, 7
Confinement childhood
of insane, 48-49 medicalization of, 145, 155
and parens patriae, 49 definition of, 3, 22-25, 36
Conflict perspective, 21, 22 definition, politics of, 22-25
deviance designations and, 21-22 medicalization of; see Medicalization of deviance
laws in, 21 orientations to
and Marxian theorists, 21 historical-social constructionist, 17-20
and pluralist theorists, 21 interactionist, 2-3
Connecticut Medical Society, 83 labeling-interactionist, 18, 20
Cory, D. W., 201 Marxian, 20n, 21, 24, 25
Counseling, genetic, 243, 244 positivist, 1-2, 262
Craving, 81, l04n relativist, I, 6-7
Crime, 34,128-129,137,244,253,266,271 sociological, 1-3
and behavior modification, 228-235 power in defining, 5, 7, 8, 13
and biomedical research, 223-228 as sickness, 17-37
and biotechnology, 235-239 as socially defined, 2, 5, 6
and CIA mind control, 237-239 socially structured nature of, 266
and danger of therapeutic tyranny, 222-223 as universal, 5-6, 7
and heredity, 218-222 unwillful, 32, 169
and heroin, 128 willful,32, 169
and Lombrosian recapitulation, 226-228 Deviance definitions, etiology of, 36
and psychosurgery, 224-226 Deviance designation(s)
and XYY chromosome carrier, 226, 228 and claims-makers, 19
Criminal law conflict perspective of, 21-22
divestment of, 33, 81,262 development and change of, 19-28,32-34
failure of, 34 etiology of, 19,25
and interest group model, 24 medical, 23, 28, 266, 270
and mental illness, 58-60 of addiction, 130-132
and opiate addiction, 127 paradigms of, 27, 28
Criminalization phenomenological perspective on, 20
of addiction, 121-130 politics of, 25-28, 266
of homosexuality, 176-179 and power, 17,20-21,27
Criminology and social change, 27-28
Classical School of, 216-217, 262 sociology of, 36
emergence of biological, 217-222 knowledge analysis of, 20
Cultural relativist conception of disease, 30 and state, 270
Devil, 3, 4, 8,42
D Dexedrine; see Dextroamphetamine sulfate
Dangerous Drug Act, 132 Dextroamphetamine sulfate, 157, 158, 160
Daughters of Bilitis (DOB), 201, 204 Diagnostic and Statistical Manual of Mental Disorders
Decarceration, 68, 252-254 (DSM), 52, 99, 192-193,206,209,270
Decriminalization, 34, 179,252-254 Diet, 29, 45, 49
Dederich, C. E., 136 Disease(s); see also llIness; Sickness
Definition, politics of, 22-25 addiction as, 25
gay rights, 22, 269, 274 cultural relativists' view of, 30
Degeneration hypothesis, 51-52 definition of, 29
Delinquency, 18,266; see also Juvenile delinquency as deviance label, 23
320 SUBJECT INDEX
Disease( s) - cont' d Durham v. United States, 60

deviant drinking as, 78-82 Dyschromic spirochetosis, 30
germ theory of, 14,33, 116
God as cause of, 42 E
and health approach to drinking, 106 Earle, P., 50
humoral theory of, 9, 39 Early and Periodic Screening, Diagnosis and Treatment
inebriety as, 79-82 Program (EPSDT), 154-155
infectious, 35, 52 Easter v. District of Columbia, 100
insanity as, of brain, 50 Eighteenth Amendment, 24, 85
International Classification of Disease (ICD), 99 Electroconvulsive therapy (electroshock; ECT), 55, 234
medical positivists' view of, 29 Ellis, H. H., 195-196
Negritude as, 49 Epilepsy, 13,31,40,41
opiate addiction as, 115-116 Etiology, 2, 6, 25, 26, 36
as punishment for sin, 42 doctrine of specific, 33
as social construction, 30 Eugenics movement, 12
Standard Nomenclature of Disease and Operations, 99 Evil, medicalization and exclusion of, 251-252
and theological model, 41-42
Disease concept of alcoholism, 82-85, 271, 274, 275 F
and Alcoholics Anonymous, 90 Federal Bureau of Narcotics (FBN), 22, 128, 129, 131,
future of, 102-106 133, 137
lellinek formulation, 90-97, 104 Federal Narcotics Farms, 128
and loss of control, 95, 96 Ferenczi, S., 54
medical response to, 98-100 Fetal alcohol syndrome (FAS), 74
and politics of medicalization, 87 First National Conference on Methadone Treatment, 137
scientific claims about, 103-106 Flexner, A., 14
and Supreme Court, 100-102 Flexner Report, 14, 123
and Yale Center, 90 Food and Drug Administration (FDA), 138, 157, 158n
Disinhibitor hypothesis, 75-77, 82 Freud, S., 53-54, 56, 195
Disulfiram (Antabuse), 35,74, 243 and American psychiatry, 53-54
Dix, D., 51 and homosexuality, 185-187
Doctrine of specific etiology, 14 and medical concept of mental disease, 53
Dope fiend, 128
Drapetomania, 35, 245 G
Drinking; see also Alcohol; Alcoholics Anonymous; Alco- Galen, c., III
holism; Disease concept of alcoholism; Drunken- Gay Activist Alliance (GAA), 202-204
ness; Inebriety Gay Liberation Front (GLF), 202-204
deviant, 8, 27, 31-33 Gay rights, 22, 269, 274
alcoholism as, 92 General paresis, 52, 54, 56
as disease, 78-82 Genetic counseling, 243, 244
medicalization of, 73, 74, 97-98 Genetic engineering, 35
sociocultural theories of. 94n Germ theory of disease, 14,33,116
and disinhibitor hypothesis, 75-76, 82 Glueck, E., 221
challenges to, 76-77 Glueck, S., 221
driving, 26, 27 God, 42, 88
drug-centered perspective, 73, 93 Gold, R., 207, 208
and free will, 78-79
health approach to, 106 H
and loss of control, 75, 77, 82, 92, 104 Haggard, H., 86-88, 90
problem, 105-106 Harrison, F. B., 123
Driver v. Hinnant, 100 Harrison Act, 27,123-127,130,132,137,266,274
Drug addiction, 25, 243, 245, 249 and demedicalization of opiate addiction, 142
Drug Enforcement Agency, 140 and medical control of opiates, 124-125, 130
Drunkenness; see also Alcohol; Alcoholics Anonymous; Healy, W., 152-154
Alcoholism; Disease concept of alcoholism; Drink- Heredity
ing; Inebriety and crime, 218-222
decriminalization of public, 253 and homosexuality, 181-182
and disease concept, 73-109 Heroin, 110
as social conduct, 77 and crime, 128
Dummer, Mrs. W. F., 152 as cure for opiate addiction, 121
Durham rule, 60 illegal, industry, 129
SUBJECT INDEX 321
Heroin-cont'd Homosexuality -cont' d

legal, 133 and social science research, 196-199
and medical treatment, 121, 142n and Stonewall rebellion, 202
as nonaddicting drug, 120-121 and story of Sodom, 173-174
Heroin addiction, 28 as unnatural, 172, 175-176, 177
epidemic of, 135-136 and U.S. Supreme Court, 210
Hippocrates, 9, 39, 40 and Wolfenden Report, 190, 199
Hirschfeld, M., 194-195 among women, 173
Homosexuality, 6,172-214,243,253,266,269, 270n, 271 House of refuge, 147-149, 162
and American armed forces, 188 Humanitarianism, 34, 52, 60, 83, 246
and American Law Institute's Model Penal Code, 199 Humoral theory of disease, 9, 39
American Library Association Task Force on, 203 Huss, M., 81
and American Psychiatric Association, 192-193 Hutschnecker, A., 170,228
American Psychiatric Association decision on, 204-209 Hyperactive behavior, 28, 155-161
ancient explanations of, 176 medical model of, 160
in ancient Greece, 174-176 Hyperactive children, 243, 248
among ancient Persians and Hebrews, 173-174 Hyperactivity, 33, 34, 92, 249, 266, 274; see also Hyper-
and APA Diagnosric and Srarisrical Manual of Menral kinesis
Disorders (DSM), 192-193,206,209 articles about, 157t
biblical prohibition of, 173-174, 177 Hyperkinesis, 23, 27, 246, 250, 267, 268, 270n, 273; see
and canon law, 177 also Hyperactivity
and Chicago Vice Commission, 182 and Benzedrine, Ritalin, and Dexedrine, 157
congenital explanation of, 188,272 discovery of, 155-161
and contribution of Freud, 185-187 clinical factors in, 156-157
as crime against nature, 27, 177 social factors, 157-159
criminalization of, 176-179 and hyperactive syndrome, 155
and medicalization of, 182 and hyperkinetic disorder of childhood, 155
and C. Socarides, 191-193 medical diagnosis of, 155-156
decriminalization of, 179 medicalization of, 275
in England, 199n and minimal brain dysfunction (MBD), 155, 156, 158,
and demedicalization, 193-211, 274 160
in early Christianity and Middle Ages, 176-179 and moral entrepreneurs, 159
and E. Bergler, 188-190 and pharmaceutical industry, 157
and "gay liberation," 199-204 a sociological analysis of, 159-161
and heredity, 181-182 symptoms of, as deviant behavior, 156
and House Un-American Activities Committee, 201
and I. Bieber et aI., 190-191
as identity and life-style, 199-204, 209-211 Illness; see also Disease(s); Sickness
and the Inquisition, 178 cultural relativist conception of, 30
invention of, 181-185 definition of, 29
and Kinsey studies, 190, 197-199 and deviance, 23, 28-32, 47
and masturbation in 19th century, 180-181 madness as, 38, 47
as medical pathology, 183-185, 187-193 masturbation as, 245
medical treatments for, 187 mental, 18,21, 28, 29
medicalization of, 179-193,263 as metaphor, 252
and medicine in 18th century, 179-180 positivist conception of, 29
in Mesopotamian culture, 172 psychological, and deviant behavior, 54
and Napoleonic Code, 179 social consequences of, 31
National Institute of Mental Health Task Force on, 203, social construction of, 29-32
208 as social judgment, 31
and Nazism, 195 In re Gaulr, 154
normalization of, and medical science, 194-196 In re Winship, 154
and origins of homophile movement, 200-202 Inebriety; see also Alcohol; Alcoholics Anonymous; Alco-
and "Paragraph 175," 182, 183, 194, 195 holism; Disease concept of alcoholism; Drinking;
and politics of confrontation, 202-204 Drunkenness
and politics of official nomenclature, 206-209 disease of, 79-82
and psychiatric dissent, 205-206 and disease concept, 73-109
and rise of psychiatric perspective, 185-193 as disease of the will, 81, 273
and "sexual excess," 179-180 Journal of Inebriery. 84-85
as sin against nature, 172-176 and loss of control. 79
322 SUBJECT INDEX
Inebriety-cont'd Knights Templars, 178

as mental illness, 85 Koch, R., 13,52
Trotter's treatise on, 79 Kraepelin, E., 52, 54, 56
Ingraham v. Wright et al., 168 Krafft-Ebing, R. von, 183-185, 195
Inquisition, 8,42,43,47
Insane asylum; see Asylum(s) L
in Colonial America, 48 Laboratory of Applied Physiology at Yale University, 86
as cure for insanity, 49-52 Ladder. 201
insanity as disease of brain and, 50 Lange, J., 219
insanity as socially caused and, 50 Laufer, M. W., 156, 159
Insulin shock therapy as treatment for schizophrenia, 54 Law
Interest politics and class interests, 25
as definer of deviance, 23, 24 conflict in origin of, 24
law, and deviance definitions, 24 and deviance definitions, 24
and morality, 25 pluralist conception of, 24
and theory of criminal law, 24 theory of criminal, 24
International Classification of Diseases (ICD), 99 Law Enforcement Assistance Act (LEAA), 226
International Conference on Opium, 122 Leprosy, 13,49
Iowa Security Medical Facility, 234 Life. 57, 129
Italian sodomy courts, 178 Lilly Pharmaceutical Company, 134
Lima, A., 224
J Lindner v. United States. 125
Jacksonian period, 49 Lombroso, C., 52, 181,217-218,226-227,262
Jaffe, J., 138
Jellinek, E. M., 86-88, 104 M
and Jellinek formulation, 90-97 Madness, 23, 27, 33, 253, 266, 269, 271; see also Insanity;
Joint Commission on Mental Health and Illness, 66 Mental illness
Journal of the American Medical Association, 164, 192, in ancient Palestine, 38-39
225 as arterial disease, 49
Journal of Inebriety, 84-85 and asylum cure for, 50
Journal of Studies on Alcohol, 86 biological and organic models of, 70
Jung, C. G., 54 in classical Greece and Rome, 39-41
Juvenile court, 150-152 in Colonial America, 48
and child guidance movement, 152-154 contagion of, 45
and court clinics, 152-154 cosmological-supernatural explanation of, 39
and medical model, 151-152 and cult of curability, 50, 52
and status offenses, 151 as culturally defined, 38
and W. Healy, 152-154 explanations for, 39-41, 51
Juvenile delinquency, 6, 57 and general paresis, 52
and child-savers, 147-149 as illness, 38, 47
and child welfare movement, 149-150 inheritability of, 55
concept of, 146-155 medical conception of, 52, 274
and house of refuge movement, 147-149 Freud's influence on, 53
and juvenile court, 150-152 medical dominance of, 52
medical-clinical model of today, 154-155 medical model of, 38-72
and parens patriae, 148 as mental illness, 43-48
Juvenile delinquents, 253 natural-medical explanation, 39
Juvenile Psychopathic Institute of Chicago, 152, 153 somatic approach to, 52, 54, 56
theological model of, 41-43
K treatment of, 41,43,44,49
Kaimowitz v. The Michigan Department of Mental Health, asylum, 49
235 moral treatment, 46, 50-52, 68
Kallmann, F., 55, 188 and witchcraft, 42-43
Kameny, F., 204 and witch-hunts, 42-43
Kefauver Committee on Crime, 128-129 Malleus Maleficarum, 42
Keller, M., 90, 97 Marijuana, 7, 18, 22-23
and the post-Jellinek era, 94-97 Marijuana Tax Act, 18, 22
Kent v. United States. 154 Martin, D., 204
Kinsey studies, 197-199 Marxian analyses of opiate legislation, 125n
Knights of the Clock, 200 Marxian view of deviance, 20n, 24, 25
SUBJECT INDEX 323
Masturbation, 7, 35, 52, 180-181 Medicalization of deviance-cont'd

as disease, 273 and costs of medical care, 254-255
illness of, 245 and decarceration, 252-254
Mattachine Foundation, 201 and decriminalization, 252-254, 272
Medicaid, 254 and demedicalization, 270-271
Medical care, costs of, 254-255 and depoliticization of deviant behavior, 250-251
Medical collaboration as social control, 244-245 and deviance definitions, 266-267
Medical deviance designation, 266, 267, 270-271 disadvantages of, 248-251
Medical excuse, 244, 247 and dislocation of responsibility, 248-249
Medical expertise, 13-14 and domination of expert control, 249
Medical ideology as social control, 245 and economic profitability, 275-276
Medical imperialism, 272 and exclusion of evil, 251-252
Medical jurisdiction, expansion of, 34-35 and grounded generalizations, 271-274
Medical model and health insurance, 276
contested, 75 historical and conceptual background of, 261-265
and moral neutrality, 35 and humanitarianism, 246
19th century, 48 and hunches and hypotheses, 275-276
and responsibility for behavior, 81 and increased efficiency, 248
roots of, 39-41,47 and individualization of social problems, 250
uncontested, 73 inductive theory of, 265-276
Medical police, 12 and "loss of control," 273
Medical positivists' conception of disease, 29 and medical deviance designation, 270-271
Medical practice, 9, 14-16 and medical discovery, 267
Medical profession and medical prestige, 248
and deviance in America, 9-16, 23 and medical profession, 272
dominance, 13-14 and medical social control, 249-250
emergence of in America, 9 and moral neutrality of medicine, 249
history of, 9-16 and number of medical personnel, 255
jurisdiction of, 29, 33 and optimism, 247-248
expansion, 34-35 and "punitive backlash," 256
medicalization of life, 29 and responsibility, 246-247
as monopoly, 10-13, 14,33,47,52 and responsibility for health, 255
and politics of definition, 23 and "right to medical care," 255-256
Medical science; see Medicine and scenarios for National Health Insurance, 256
Medical sects, 10 and securing medical turf, 269-270
Medical social control, 29, 249-250 and sick role, 246-247
Medical technology, 15, 35, 274 and social class, 275
as social control, 242-244 social consequences of, 245-252
Medicalization and social policy, 252-258
of abortion, 275 and social policy recommendations, 256-258
and demedicalization, 273-274 and sociologist challengers, 274-275
and determinist theories of deviance, 263 and therapeutic ideology, 247-248
of deviance; see Medicalization of deviance and therapeutic state, 252-254
and Freud, 53-54 Medicare, 254
and industrialization, 262 Medicine
and monopolization of medicine, 263 as agent of social control, 9, 13, 26, 29, 32, 35
and morality, 271 as arbiter of personal problems, 77
politics of, 273-274 classical, 39-41
and professionalization, 262, 263 as definer of deviance, 23
and psychoanalysis, 53-54 and humanitarianism, 246
and rationalism, 263 medieval, 41-43
and science, 263 as moral entrepreneur, 23, 159n
of Western society, 33 moral neutrality of, and medicalization of deviance, 249
Medicalization of deviance, 2n, 7, 17-37, 57, 258-259 optimism concerning, 45
and American society, 263-265 as restitutive, 33
"benefi ts" of, 246-248 scientific, 14, 33
and blaming the victim, 250 and sociology, 274-275
and bureaucratization, 270 and technological imperative, 35
and claims-making, 267-269 Menninger, K., 57, 153
and compulsivity, 272-273 Menninger, W., 57
324 SUBJECT INDEX
Mens rea, 58 Mental iIIness-cont'd

Mental disease political use of, 71
and asylum, 52 as problems in living, 65
classification of, 46 and public, 56-58
medical concept of, and Freud, 53 public acceptance of, 57-58
science of, 52-56 as r:esidual deviance, 64
Mental disorders and social class, 64
official manual of, 53, 99 and social disorganization, 64
surveys concerning, 58, 59t and sociological research, 62-65
treatment of somatic explanation of, 54-56
brain implant, 55 and stigma, 65
drug therapy, 60-66, 70 and theological model, 41-42
electroconvulsive therapy (electroshock), 55 unitary concept, 47-48
institutions, 56, 63 Methadone, 35, 134-142
insulin shock therapy, 54 as antinarcotic drug, 135
lasers, 55 and medicalization, 141-142
milieu therapy, 68 National Conference on Methadone Treatment, 137,268
psychosurgery, 55 Methadone maintenance, 273
psychotropic medication, 61 and crime, 13 7
tranquilizers, 55 criticisms of, 139-141
types of National Methadone Maintenance Conferences, 139,268
alcoholism, 58 and Nixon Administration, 138-139
compulsive-phobic behavior, 58 as public policy, 136-138
dementia, 46 Methylphenidate hydrochloride (Ritalin), 28, 156-158, 160
dementia praecox, 52 Metropolitan Community Church (MCC), 201
epilepsy, 40, 41 Meyer, A., 56
general paresis, 52, 56 Middle Ages, 8, 9, 41,176-179
hysteria, 41 Mind, concept of, 47
idiocy, 41, 46 Minimal brain dysfunction (MBD), 155, 156, 158, 160
juvenile character disorder, 58 M'Naughten, D., 58
love sickness, 41 Monitz, E. M., 55
mania, 40-41, 46 Moniz, A. E., 224
manic-depressive psychosis, 52 Moral crusaders; see Moral entrepreneurs
melancholia, 40-41, 43, 46-47 Moral entrepreneurs, 18,22,23, 117-119, 159
neurosis, 58 Moral treatment
paranoia, 40 in inebriate asylum, 84
pheresy, 41 of madhouses, 274
schizophrenia, 53-56, 58 Mor:phine, 54,110,114-115,120
stupor, 41 and alcoholism treatment, 115
werewolfism (lycanthropy), 41
Mental Health Study Act, 66 N
Mental hospitals, 62,63 Napoleonic code, 179
as total institution, 63 Narcotics clinics, 125-127
Mental hygiene movement, 18, 56, 57 Narcotics Control Act, 129, 131
and Protestant ethic, 57 Narcotics laws, failure of, 129-130
Mental illness, 18, 21, 28, 31, 34; see also Insanity; Mad- National Academy of Sciences, 137
ness National Association for Crippled Children and Adults, 156
classification system, 52 National Association for Mental Health, 56, 160
and criminal law, 58-60 National Center of Child Abuse and Neglect, 168, 270
degeneration hypothesis of, 51-52 National Committee for Mental Hygiene, 56-57, 153
and drug therapy, 60-66 National Council on Alcoholism (NCA), 87, 89, 91, 97,
and mental hospitals, 62 lOin, 105, 268
psychotherapeutic ideology, 61 and diagnosis of alcoholism, 88
emergence of, 38-72 National Gay Task Force (NGTF), 208, 209
inebriety as, 85 National Health Insurance (NHI), 71, 256, 257
institutionalization and, 48-52 scenarios for, and medicalization of deviance, 256
Joint Commission on, 66 National Institute of Alcohol Abuse and Alcoholism
and lobbying of physicians, 47 (NIAAA), 87, 97, 102, 105-106,270
madness as, 43-48 National Institute of Mental Health (NIMH), 57, 238, 270
as myth, 65 and medical model, 57
SUBJECT INDEX 325
National Institute of Mental Health (NIMH)-cont'd Opiates-cont'd

relation of, to hospital-farms, 128 physical tolerance of, III
and research, 62 physiological effects of, II 0-111
Task Force on Homosexuality, 203, 208 quest for international control of, 121-122
National Mental Health Act, 57 recreational use of, 112, 113-114
National Methadone Maintenance Conferences, 139 Opium
National Temperance Society, 84 International Conference on, 122
Nazi Gennany, physicians in, 245 medical uses of, 114-115
North American Council of Homophile Organizations politics of in 19th century, 113-121
(NACHO), 201 Royal Commission on, 118, 122
Shanghai Opium Commission, 122
o Society for the Suppression of the Opium Trade (SSOT),
Obesity, 28, 33, 34, 243, 273, 274, 275, 276 117
and Papago Indians, 30 Opium doctors, 124
O'Connor v. Donaldson, 70 Opium wars, 113
Office of Child Development, 158 Oxford Group, 88-89
Opiate addiction, 6, 18, 26-27, 33, 110-144, 248, 250,
266, 269, 271, 272, 275 p
American attitudes toward, 119-120 Parens patriae, 49, 148, 222
American view of, and anti-Chinese sentiment, 120 Pediatric radiology and discovery of child abuse, 163-165
and antiopium movement, 118-119 Pharmaceutical industry, 15, 157
and British experience, 132-134 Phenomenological perspective, 20-22
cost of treatment programs, 139t and language, 21
and crime, 127 and typifications, 20
criminal designation of, 125, 127-130 Physician(s)
criminalization of, 121-130 as alienists, 52
definition of, 121 as "mad-doctors," 45
demedicalization of, 121-130, 142 as medical crusaders, 10-12, 13,23
description of, 114 medieval,41
as disease, 115-116 in Nazi Gennany, 245
and Harrison Act, 27, 123-127, 142 Physicians' temperance movement, 81, 82
heroin as cure for, 121 Pinel, P., 46
medical approach to, 126, 128, 133 Political dissidents
medical designations of, 130-132 and mental illness, 35
medical involvement in, 110-144 in Nazi Gennany, 223
medical jurisdiction over, 126-127, 132 in Soviet Union, 35, 245, 250
as medical problem, 115, 124-125 Powell v. Texas, 101
medicalization of, 134-142 De Praestigiis Daemonum (The Deception of Demons), 43
and methadone, 27, 134-142 Prefrontal lobotomy, 55, 224, 243
and narcotics clinics, 125-127 and tranquilizing drugs, 55
physiological models of, 130n Problem drinking, 105-106
politics of, 110, 113-121 Professionalization, medical, 10, 12, 15
and remedicalization, 274 Progress, humanitarian and scientific, 33, 34
sociological explanation of, 130 Prohibition, 22, 87, 272, 275
support for medical designation of, 131-132 Amendment, 85
and Supreme Court, 125 crusade for, 24-25
treatment of, as symbolic crusade, 24
detoxification, 136 Protestant Ethic, 263, 264
therapeutic communities, 136 Psychiatry
Opiate legislation, Marxian analyses of, 125n American, 49
Opiate use, definitional changes, I 10 criticism of by psychiatrists, 65
Opiates and Freud, 53-54
chemical nature of, 110-111 institutionalization of, 57
as evil, 117-119 as medical specialty, 51
heroin, 110 and World War II, 57
and medical practice, 111-113 community, 67-69
medical treatment and addiction to, 114 as medical control, 242
and moral entrepreneurs, 117-119 Society for Biological, 236
morphine, 110 Psychoactive medications, 35, 157,243,250,275
and patent medicines, 115 Psychoanalysis, 53-54
326 SUBJECT INDEX
Psychosurgery, 35, 55, 243, 268, 269 Social control-cont'd

and control of violence, 224-226, 250 confinement as, 44
and mental health establishment, 225 formal, 7, 8
and U.S. Department of Health, Education and Welfare, informal, 7
225 institutions of, 8, 32
Psychotechnology, 250; see also Medical technology mechanisms of, 32
Psychotropic medication, 61 medical, 241-245, 249-250
Public health and medical collaboration, 244-245
as agent of social control, 34 and medical ideology, 245
as medical control, 242 medicine as agent of, 13,241-245
Public Health Service, U.S., 126, 137, 156, 158 as political mechanism, 21
Public Interest, 140 psychiatry as agent of, 34, 71
Public Welfare Association, 165 public health as agent of, 34
Pure Food and Drug Act, 123 Social policy and medicalization of deviance, 252-258
Puritan colonies, 4, 5, 6, 18, 78-82 Society for Biological Psychiatry, 236
Society for Individual Rights (SIR), 201, 204
Q Society for the Prevention of Cruelty to Children (SPCC),
Quarterly Journal of Studies on Alcohol, 86 162
Society for the Prevention of Pauperism, 148
R Society for the Reformation of Juvenile Delinquents, 148
Rand report, 105 Society for the Suppression of the Opium Trade (SSOT),
Reader's Digest, 57, 129 117
Reality construction; see Social construction of reality Sociology of knowledge, 18
Reformation, 42 analysis of deviance, 20
Research Council on Problems of Alcohol, 86 definition of, 20
Ritalin; see Methylphenidate hydrochloride and social construction of reality, 20
Robinson v. California, 100,131,136,253 Sociology and medicine, 274-275
Roizen, R., 106 Sodomy, 173-174, 178, 182
Rolleston Committee, 132 Soviet dissidents, 35, 245, 250
Room, R., 106 Soviet Union, 35, 70
Royal Commission on Opium, 118, 122 Special Action Office for Drug Abuse Problems (SAODAP),
Rush, B., 49, 79-82, 83, 90, 97, 223, 273 138-141,270
"A Moral and Physical Thermometer," 79,80 Special Treatment and Rehabilitation Training (START)
program, 231-232
S Spitzer, R., 206, 207, 208
Salem Village, 3-8 Standard Nomenclature of Diseases and Operations,
Schizophrenia 99
etiology of, 65 State, the, 17, 34, 270
insulin shock therapy as treatment for, 54 and parens patriae, 49
Scientific revolutions, 48 and police power, 49
Sexual psychopath laws, 18 Status politics, 24
Shanghai Opium Commission, 122 Storer, H. R., II
Shock treatment, 55 Supreme Court, U.S., II, 12,256,269,274
for sex offenders, 234 and abortion, 27
Sick role, 32, 90,169,241,244,246-247 and child abuse, 168
Sickness, 9, 15, 27; see also Disease(s); Illness and respon- and disease concept of alcoholism, 100-102
sibility for deviance, 34 and homosexuality, 210
Silkworth, Dr. W. D., 88-89, 97 and juvenile delinquency, 154
Smith, Kline & French, Inc. (SKF), 61,158 and mental illness, 70
Smithsonian Institution, 238 and opiate addiction, 124-125, 131, 136
Snake Pit, 57 Sutherland, E., 24
Socarides, c., 191-193,204,205,208 Sydenham, T., 9, 112
Social change, 27-28 Synanon, 136
and medical progress, 33 Syphilis, 52
Social construction of illness, 29-32
Social construction of reality, 20-28 T
Social control, 7-9 Temperance movement, 12, 24-25
agents of, 8, 9, 17,25,26,34,71 American, 82-85
changing designations of, 17-37 as "antialcohol movement," 85
and community psychiatry, 69 Theological model, dominance of, 41-43
SUBJECT INDEX 327
Therapeutic state, 34, 81, 252-254 w

Thorazine; see Chlorpromazine Washingtonian movement, 83
Treasury Department, 124-127 Webb et al. v. United States, 125
Trotter, T., 79-81 White House Conference on Children (1909), 162
Wilde, 0., 182n
u Wilson. B .• 209
Uniform Alcoholism and Intoxication Treatment Act, Witchcraft, 5, 6, 8, 18.42-43
102 Wolfenden Report. 190, 199
United States Philippine Commission, 121 Women's Christian Temperance Union (WCTU), 18. 22.
United States v. Behrman, 125 24,83
United States v. Jim Fuey Moy, 125 World Health Organization, 91, 95
V x
Vacaville Rehabilitation Center, 234 XYY chromosome. 226, 228, 244
Vagrancy laws, 18,25
Veterans Benevolent Association, 200 y
Vice Versa, 200 Yale Center of Alcohol Studies, 86-88, 90. 97, 274
Village Voice. 139n summer school program. 86. 268
Vinci, L. da, 178 Yale Plan Clinics. 87

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DEVIANCE AND MEDICALIZATION

FROM BADNESS TO SICKNESS

Foreword by Joseph R. Gusfleld

Recipient of 1981 SSSI

TEMPLE UNIVERSITY PRESS

Copyright © 1992 by Temple University

All rights reserved

Copyright © 1980 by The C. V. Mosby Company

Printed in the United States of America

The paper used in this publication meets the minimum

Library of Congress Cataloging-in-Publicafion Data

Conrad, Peter, 1945-

my fellowmen as a prophet, and I bow to their

*Freud, S. Civilization and its discontents. New

1 Deviance, definitions, and the medical profession, 1

2 From badness to sickness: changing designations of deviance

3 Medical model of madness: the emergence of mental Illness, 38

The science of mental disease, 52

4 Alcoholism: drunkenness. Inebriety. and the disease concept. 73

5 Opiate addiction: the fall and rise of medical Involvement. 110

American attitudes toward opiate addiction: from empathy to anxiety, 119

6 Children and medlcallzatlon: delinquency. hyperactivity. and

7 Homosexual"y: from sin to sickness to life-style. 172

Consolidating the medical model: the invention of homosexuality, 181

9 MediCine as an institution of social control: consequences for

10 A theoretical statement on the medlcallzatlon of deviance, 261

Author Index, 311

Subject Index, 317

A slow but steady transformation of de-

T his chapter departs from the historical

T he roots of the medical conception of

RESULTS OF STUDIES USING VIGNmES IN DEFINING PROBLEM BEHAVIOR

* Star (1955), national sample of adults in United States. Continued.

RESULTS OF STUDIES USING VIGNmES IN DEFINING PROBLEM

6. Now, I'd like to describe a 12-year-old boy - Bob- 16% NA NA NA 41%

madness is a result of childhood experiences utility of Thorazine. This extensive promotion

sis on the phenomenological experience of phasis should be placed on prevention; a na-

community itself as patient to narrower views TABLE 1

I n this chapter we discuss the origins and

ALCOHOL AND BEHAVIOR: from drinking. Aside from motivation, station

A MORAL and PHY-5ICAL THERMOMETER:

S" ,sma.Il beer. Happinefs.

-10 Cider. Cheerfulnefs,

Nouriahment, 'When taken

Purely symptomotic Additive phoses superimposed over

Onset of Onset of Onset of

'-------.,V".----~I '--.r---' ~~------------.....v,--------------'I ,'-------......vr --------',

nek's well-known Greek-letter typology; but it is characteristic of certain European countries,

This view emphasizes the importance of mean-

"sickness," an "affliction," and an "ill- FUTURE OF THE DISEASE

T he history of medical involvement with

taste of government interference in medical criminal approach to addiction. Although in

up the British system as a model (e.g., Linde- TABLE 2

appears to be relatively stabilized (Table 2). * Lilly Pharmaceutical Company marketed it as

TABLE 3 policy, some entrenched resistance could be