Biomedicalization from the inside out

In this historical project, we have explored changing and at times contested relations between the social and the biological by investigating medical interventions and technologies, as well as their problematisations, in three different case histories (1) histories of trans medicine, (2) histories of problematic drug use (3) histories of psychiatric diagnosis and the law and 4) histories of global social medicine. In the thesis The ephemerality of transgender medicine in the Welfare state, Scandinavia 1951-2001" , Ketil Slagstad showed that what we today understand as a new phenomenon, namely that people who do not feel at home in the gender they were assigned to at birth seek medical help, is not new. We have had hormone treatment for transgender people since the 1950s, while the first surgical treatment of the genitalia was carried out at Rikshospitalet in 1963. In the thesis, Slagstad found that the Scandinavian welfare state context shaped the care of trans people in significant ways. In Scandinavia, the "social" was an important framework - not market mechanisms and a far more specialized medical practice, as in the USA. The goal in Scandinavia was to integrate and adapt the patient to society, but also to protect the social fabric. At the core of gender-confirming practices was the concept of sex, and the boundaries of what constituted a gender changed in line with the political project of the welfare state. From the 1970s, patients were given more decision-making authority. Towards the end of the 20th century, transmedicine became more bureaucratised, and the monopoly at Rikshospitalet was established, among other things, on the basis of financial needs. Diagnostic tools and questionnaires led to the treatment becoming less discretionary, and treatment became reserved for people who wanted to change completely from one gender to another, i.e. the full package. It was not possible to wish for only hormone treatment or only breast surgery. You had to take the whole treatment package, and thus this approach also paradoxically led to overtreatment, since the patient had the choice between no treatment at all or everything. In the thesis "The Mask of Expertise: Hervey Cleckley, Psychiatry, and Law in 20th Century America" Samuel Scharff examined how legal frameworks both constructed and limited the influence of medical experts on whether an accused was sent to hospital, to prison or set free. He showed how medico-legal decisions became increasingly difficult as medical knowledge increased - not the other way around, as was thought. Central psychiatrists played a significant role in reforming the medico-legal systems. Michael Henley, who will defend his thesis this summer, has worked on how psychiatry's classification of psychiatric illness reflects wider philosophical and social political trends. Regarding the history of medicine's involvement in problematic substance use, we have shown how the appearance of a market for illegal substances led to major changes in the way drug disorders were perceived - from medical conditions to social conditions. These were to be solved partly by the legal apparatus, and partly by social-pedagogical treatment. A social approach formed the basis of treatment until the 90s, and there was great opposition to medical treatment, such as methadone. The HIV/AIDS epidemic ushered in a slow change in this thinking. It was not until 1998 that the first regular methadone program was started, albeit on a very small scale at first, much later than most countries in Europe. We have also found that patient/user associations emerged as significant pressure groups in the 2000s, not least because drug users gained patient rights with the drug reform in 2004, which transferred responsibility for the treatment of drug disorders from the social services to the health service. In all these fields, the subject of social medicine takes a part in Norway, as an alternative to the purely biomedical approach, concerned with social justice and health inequalities. It was important in the formation of the welfare state, which ensured the individual security from cradle to grave. Perhaps social medicine became a victim of its own success, because social medicine declined, both as an academic and medical practice. On the global scale Karl Evang and then Gro Harlem Brundtland played important roles. In the history of global social medicine, we have uncovered how the common narrative - which almost always starts with the German Virchow - is Eurocentric and imprecise. We have found how different forms of social medicine were created in Latin America and in Asia, which in turn influenced Europe and the US. The Covid pandemic showed that social medicine - understood as an interdisciplinary approach with a holistic perspective focused on social justice - is more important than ever.

BIO-prosjektet har vært med å vri forskningsfeltet i retning av biomedikalisering og sosialmedisin som tilnærming, både gjennom utstrakt konferansedeltagelse, en rekke workshops, våre publikasjoner og ikke minst gjennom sluttkonferansen, som "tvang" 280 forskere fra hele verden til å skrive inn sine abstracts i prosjektets kjerneområder. I tillegg har bio-prosjektet bidratt med historiske perspektiver i en rekke aktuelle situasjoner som har vært preget av polarisering - rusreformdebatten, debatten rundt kjønnsidentitet og kjønnsinkongruens, og debatten om sosial ulikhet under Covid-pandemien. Gjennom utstrakt samrbeid med stakeholders - både brukerorganisasjoner, klinikere og myndighter, har vi i oppnådd å sette dagens polariserte debatt i et historisk perspektiv. Vi har bidratt med råd inn mot utforming av helsepolitiske endringer, og erfart at rådene har blitt tatt hensyn til. Prosjektideene har vært tydelig tilstede i utdanning av morgendagens helsetjenesteutøvere, og mange av dem har uttalt i evalueringer at dette vil endre måten de vil agere på som helsepersonell. Vi har bidratt med åpningsinnlegg i flere store konferanser på rusfeltet og hos samfunnsmedisinere og opplever stor interesse for prosjektet, og har også hørt at brukerorganisasjonene har lært av oss og tatt perspektiver derfra inn i sitt arbeid.

In the 21st century, health problems and their interventions are increasingly understood in biological terms, by patients, families, governments, industry, and other actors well outside the sphere of clinical medicine. Disease causation has shifted to the molecular and genetic level, biomedical expertise and decision-making has been decentralized in an era of public internet access to biomedical publications, and medicine has been increasingly capitalized and corporatized. Sociologists have recently proposed the term “biomedicalization” to describe this shift (Clarke 2010, Clarke et al. 2003). Yet the changing use of biomedical frameworks to explain nature and culture by lay and professional bodies is itself the product of specific historical forces in the 20th and early 21st centuries. In this project, we will study this historical process by exploring the instruments, technologies and practices of biomedicalization across the last fifty years. However, we will do so not by focusing on the history of high-tech fields traditionally associated with this development, like cancer research or digital health. In order to grasp the complexity of the history of biomedicalization we have chosen as our empirical fields three domains traditionally perceived to be ‘border zones’ of biomedical practice, where these processes have had particular social effects and importance: (1) somatic interventions into sex and gender, (2) treatment of drug addiction and abuse and (3) psychiatric diagnosis in the courtroom. A fourth work package will chart the field of ‘social medicine’, which represented a continuous, if at times marginal perspective on viewing health as simultaneously biological and social. This is a transnational and interdisciplinary project, that combines historical investigation with cognate fields in the medical humanities and social sciences, along with close engagement in professional and lay interests in current dilemmas over the governance of health.