SOCIAL CONSTRUCTIONISM
How Illness and Disease are
Constructed
Illness and Disease :What’s the
difference?
Disease: refers to pathological changes
within the body which are expressed in
various physical signs and symptoms.
Illness: an individual’s subjective
interpretation and response to these signs
and symptoms.
Sociological Perspectives
Previously disease remained the concern of doctors and the
experience of illness was examined by social scientists.
The boundary between the two has been challenged , what
were formerly seen as “natural” categories – disease and the
body - are now also studied by sociologists.
Sociologists argue that these ‘natural’ categories are the
products of social activities and do not simply reflect
unchangeable biological facts.
Sociology argues that all knowledge, including medical and
scientific knowledge, is socially dependent i.e. that all
knowledge is socially constructed.
The 18th Century Woman, The
Prince and the Pins
The 18th Century Body in a Doctor‘s Diary
“[She] was standing in front of the mirror
with a bunch of pins in her mouth when she
was startled by a prince who approached her
from behind and slapped her on the back,
whereupon all the pins fell into her throat.
However, she felt no pain from the pins, and
on the third day she passed all of them
through her urine.”
Duden, B. (1991) The Woman Beneath the Skin: A Doctor’s Patients in Eighteenth Century
Germany. London: Harvard University Press pg. 70
Understanding the 18th Century Body
Duden (1991) argues that the body we know today is
fundamentally different from the body we would find
in the 18th century.
The difference is not only how the working of the
body is understood but also how the body was
actually experienced.
Duden argues, therefore, that the body is a cultural
construction and how it is understood, and more
importantly, how it is experienced must be related to
the historical context in which it lives.
The Body, Illness and Disease in 18th
Century Germany
Most illnesses and treatments were related to the
general idea of internal and external bodily fluids or
‘flux’.
Fluids such as blood, milk or pus both moved around
the inner body and were excreted from it.
Bodily fluids were all essentially the same but they
could be transformed in terms of their form, colour
and consistency so milk could resemble diarrhea.
The Body, Illness and Disease in 18th
Century Germany
Integral to physical health and well-being was the flow of
these fluids, their obstruction would result in illness and
disease.
If a woman’s menstrual blood was blocked it could cause
illness but this would not be problematic if the menstrual
blood was secreted in another form such as diarrhea
(Duden 1991:109).
“Inner flux” was the most common complaint people
presented to the doctor and it was connected to a range of
ailments such as headaches, ringing in the ears,
rheumatism and the loss of sight.
The Body, Illness and Disease in 18th
Century Germany
When “inner flux” did not circulate, it became hard
and began to stagnate. There were various
treatments to ensure that “flux” could escape from
the body :
“blister raising plasters” : would divert the fluid so it
could be drawn out of the body and
“fontanels” : were small artificial wounds through
which the fluids could drain.
The Body, Illness and Death in 18th
Century Germany
The Body, Illness and Death in 18th
Century Germany
“The wife of a shoemaker, forty years of age, ‘has an
oozing and sometimes foul-smelling sore under the breast
for many years. Having dried up in 1721, it moved to an
untoward place, namely to the genitals, ad muliebra.’ The
pains, especially when passing urine, were so intense that
the woman tried to soothe them with cold washes. This
bottled up the flux, upsetting the stomach and the guts,
causing great anxiety in the stomach and the lower body.
During the next years, whenever the flux, having returned
to its old place, dried up, she immediately requested help,
for ‘fear of dangerous ill effects’.
Illness and Death in 18th Century
Germany
Treatment was a mustard plaster:
“She placed the plaster under her breast, it dissolved
the skin, and already within an hour ‘the flux could be
lured out again, and the woman soon felt…relief’.
The woman died thirteen years later and the
cause of death was this:
“After she had fallen down the cellar stairs, the flux
under the breast subsided and failed to return,
whereupon all the matter got stuck in her head”
(Duden 1991: 107-108).
THE SOCIOLOGICAL INTERPRETATION
1.
2.
Duden argues that:
the way in which we experience our own body now
is influenced by the ideas of human anatomy and
physiology which became established at the end of
the 18th century.
the history of medical knowledge does not involve
the gradual unfolding of the ‘truth’ about the body
and disease, but that these categories are
dependent on their social, cultural, and historical
context.
In other words, they are socially constructed.
FEATURES OF THE SOCIAL
CONSTRUCTIONIST DEBATE
The social constructionist debate is one of the most
important in social science analyses of health and
illness.
It is part of a critical approach to biomedicine and
biomedical knowledge that emerged in the 1970s.
Many of the assumptions and values of the medical
profession and biomedicine were challenged and
criticised for being consistent with the patriarchal and
capitalist structures of the society in which they were
located.
FEATURES OF THE SOCIAL
CONSTRUCTIONIST DEBATE
From this emerged an anti-psychiatry movement which
argued that much of what was labelled a mental illness was
simply a social construction created by psychiatrists who
acted as powerful agents of social control.
Diagnosing someone as schizophrenic for example, enabled
psychiatrists to declare that person unfit to participate fully in
social life.
Diagnostic categories were called into question and the
application of medical knowledge was seen as being
political and not just a technically neutral act.
Themes in the Social Constructionist
Debate
These ideas in the social constructionist debate have
been applied to question the assumptions on which
biomedicine’s autonomous and extremely powerful
position in society is based.
There are several different aspects to the social
constructionist debate, two of the most important are
“problematisation” and “medicalisation”
The Problematization of Reality
This approach
states that diseases
are not simply real
but are products of
social reasoning and
social practices.
Calling a set of
symptoms
“bronchitis” does
not mean that a
discrete disease
exits as an entity
independent of
social context.
The Problematization of Reality:
Bronchitis
That is how medical science at a given place
and time with the aid of laboratory tests and
theories has come to define it.
Someone with bronchitis will experience pain
and suffering but the interpretation of it will
vary between time and place.
The Problematization of Reality
In this sense then the idea of medical discoveries
is misleading.
There are no fixed realities of the human body
waiting to be discovered.
There are fabrications or inventions by
biomedicine which implies that the disease was
established through certain investigations which
confirmed its reality.
Constructing Mental Illnesses: The Jerusalem Syndrome
Constructing Mental Illnesses: The Jerusalem Syndrome
Since the 1980s there has been an
increasing number of tourists who, on
arriving in Jerusalem have some kind
of psychotic episode or breakdown.
Tourists now treated in one central
facility and between 1980-1993, 1,200
tourists with have been referred there.
On average about 100 tourists are seen
annually and about 40 of them require
hospitalisation.
Three main types of patients have been
identified.
Jerusalem Syndrome: Type 3 Patient
Main diagnostic criteria:
•
First criterion: no previous history of psychiatric
illness.
•
Second criterion: “Subjects” usually arrive with
friends or family or part of an organised tour of
Mediterranean countries.
•
Third criterion: On arrival subjects develop an
acute psychotic reaction that develops in seven
identifiable stages.
7 Stages of Type 3 Patients
1. anxiety, agitation, other unspecified
reactions;
2. declaration of the desire to split away from
the group or family;
3. a need to be clean and pure, obsession
with taking baths and showers, compulsive
fingernail and toenail cutting;
7 Stages of Type 3 Patients
4. using hotel bed-linen to make an ankle
length, toga like gown which is always white;
5. the need to scream, shout or sing out loud
psalms, verses from the Bible, religious
hymns or spirituals;
7 Stages of Type 3 Patients
6. a procession or march to one of Jerusalem’s holy
places;
7. delivery of a ‘sermon’ in a holy place - this is
usually very confused and based on a unrealistic plea
to human kind to adopt a more wholesome, moral,
simple way of life.
Bar-El, Y. et al (2000) Jerusalem Syndrome. British Journal of Psychiatry 176: 86-90.
MEDICALIZATION THESIS
It is indirectly related to social constructionism - it
does not question the basis of medical knowledge as
such but challenges its application.
It draws attention to the fact that medicine operates
as a powerful institution of social control.
It does this by claiming expertise about matters of life
which had previously not been regarded as medical
matters e.g. ageing, childbirth, alcohol consumption
and childhood behaviour.
MEDICALIZATION‘S CRITIQUE OF
BIOMEDICINE
 Medicine constructs or redefines aspects of
‘normal’ or accepted everyday life as medical
problems.
 Professionals tend to offer technological or
biomedical solutions to what are inherently
‘normal’ aspects of everyday life or social problems.
 Medicine has become a major institution of social
control and this has been related to an increasing
complex and bureaucratic system which encourages
a greater reliance on experts.
MEDICALIZATION‘S CRITIQUE OF
BIOMEDICINE
High-tech modern medicine has become increasingly
dangerous to the population’s health by:
 reducing their autonomy and their ability to cope with
their problems;
 making them dependent on the medical profession;
 damaging their health by the side effects of drugs
and surgical interventions;
The medical system operates in close relationship
with the manufacturers of pharmaceuticals and
medical equipment, and this relationship is not
necessarily in the patient’s interest.
Illich, I. (1977). Limits to medicine: Medical nemesis: the Exploration of health.
NY: Penguin
Theoretical Basis of Medicalization
Inherent in the medicalization thesis are Marxist and
Phenomological approaches to health and illness.
This thesis considers definitions of illness to be products of
social interactions or negotiations which are unequal
because people do not have equal influence on the social
construction of reality.
Medical professionals are more able to define what counts as
sickness than ordinary people.
Medical professionals, therefore, have great scope for social
regulation because if matters have to be defined as medical
concerns, then health professionals have the authority to
monitor, intervene and pass judgements upon them.
MEDICALIZATION OF CHILDBIRTH
The idea of
medicalization has
been most
developed in relation
to childbirth.
The control of
pregnancy and
childbirth has been
taken over by a
mainly male medical
profession.
Hans Sachs, Eygentliche Beschreibung Aller
Stande auf Erden (1568).
MEDICALIZATION OF CHILDBIRTH
Childbirth is surrounded
by a whole range of
technologies and
women are closely
monitored from the
acknowledgement of
conception until after
the baby is born.
MEDICALIZATION OF CHILDBIRTH
In many countries women
who have straightforward
pregnancies are subjected
to:
 routine intravenous infusions;
 they are encouraged to have
electronic fetal monitoring;
 and epidural analgesia;
 labour will be in the dorsal
position.
Medicalization of Childbirth: Increase in
assisted delivery rates and major surgery
 Caesarean section rates in the United States,
Canada, Italy, and the United Kingdom are about
20%.
Paranjothy S, Thomas J, (2001) Royal College of Obstetricians and Gynaecologists Clinical Effectiveness Support
Unit. National sentinel caesarean section audit report. London: RCOG Press
 Brazil, with a 36% caesarean section rate, is often
portrayed as a country where there is an unusually
high demand for caesarean sections, especially
among more affluent women.
 Research has found that doctors were active
participants in decision making and used their
expertise and authority to convince women to
`choose” a caesarean.
Hopkins K. (2000)Are Brazilian women really choosing to deliver by cesarean? Social Science & Medicine 51:72540.
Medicalization of Childbirth
In Spain, obstetric care includes routine enemas,
pubic shaving, and episiotomy, procedures that are
not evidence based and which ignore the WHO's
guidelines on the care of women in labour.
The extent of medicalisation in Spain is reflected in:
 some of the highest caesarean section rates in
Europe (26.4% in Catalonia with a 40% increase over
five years);
 obstetricians have been criticised for not allowing
women to participate in decisions about their
maternity care.
Bosch X. (1998) Spanish doctors criticised for high tech births. BMJ 317:1406.