We now turn to sociological explanations of medicine and health. As usual, the major sociological perspectives that we have discussed throughout this textbook offer different types of explanations, but together they provide us with a more comprehensive understanding than any one approach can offer by itself. The Theoretical Perspectives Snapshot table below summarizes what they say.
Theoretical Perspectives Snapshot
| Theoretical perspective |
Major assumptions |
| Structural functionalism |
Good health and effective medical care are essential for the smooth functioning of society. Dysfunctions in social institutions and systems lead to poorer population health and disrupt societal harmony. Patients must perform the 'sick role' in order to be perceived as legitimately ill and to be exempt from their normal obligations. The biopsychosocial model of mental illness incorporates biological, psychological, and social features. |
| Conflict theory |
Social inequality characterizes the quality of health and the quality of healthcare. People from disadvantaged social backgrounds are more likely to become ill and to receive inadequate healthcare. Partly to increase their incomes, physicians have tried to control the practice of medicine and to define social problems as medical problems. |
| Symbolic interactionism |
Health and illness are social constructions: Physical and mental conditions have little or no objective reality but instead are considered healthy or ill conditions only if they are defined as such by a society. Physicians “manage the situation” to display their authority and medical knowledge. Labeling and stigma impact individuals who have been labeled as having a mental illness. |
Structural Functionalism
As conceived by American sociologist Talcott Parsons, the functionalist perspective emphasizes that good health and effective medical care are essential for a society’s ability to function. Ill health impairs our ability to perform our roles in society, and if too many people are unhealthy, society’s functioning and stability suffer. If health is vital to the stability of the society, illness is often seen as a form of deviance.
Parsons examined the functions of sickness and health in his book The Social System (1951), exploring the roles of the sick person and the doctor. The sick role is defined as patterns of expectations that define appropriate behavior for the sick and those who take care of them.
For a person to be considered legitimately sick, said Parsons, several expectations must be met. First, sick people should not be perceived as having caused their own health problem. If we eat high-fat food, become obese, and have a heart attack, we evoke less sympathy than if we had practiced good nutrition and maintained a proper weight. If someone is driving drunk and smashes into a tree, there is much less sympathy than if the driver had been sober and skidded off the road in icy weather.
Functionalist Talcott Parsons wrote that for a person to be perceived as legitimately ill, several expectations, called the sick role, must be met. These expectations include the perception that the person did not cause her or his own health problem.
Nathalie Babineau-Griffith – grand-maman’s blanket – CC BY-NC-ND 2.0
Second, sick people must want to get well. If they do not want to get well or, worse yet, are perceived as faking their illness or malingering after becoming healthier, they are no longer considered legitimately ill by the people who know them or, more generally, by society itself. Third, sick people are expected to have their illness confirmed by a physician or other health-care professional and to follow the professional’s instructions in order to become well. If a sick person fails to do so, she or he again loses the right to perform the sick role. If all these expectations are met, said Parsons, sick people are treated as sick by their family, their friends, and other people they know, and they become exempt from their normal obligations to all these people. Sometimes they are even told to stay in bed when they want to remain active.
Physicians also have a role to perform, said Parsons. First and foremost, they have to diagnose the person’s illness, decide how to treat it, and help the person become well. To do so, they need the cooperation of the patient, who must answer the physician’s questions accurately and follow the physician’s instructions. Parsons thus viewed the physician-patient relationship as hierarchical: The physician gives the orders (or, more accurately, provides advice and instructions), and the patient follows them.
Parsons was certainly right in emphasizing the importance of individuals’ good health for society’s health, but his perspective has been criticized for several reasons. First, his idea of the sick role applies more to acute (short-term) illness than to chronic (long-term) illness. Although much of his discussion implies a person temporarily enters a sick role and leaves it soon after following adequate medical care, people with chronic illnesses can be locked into a sick role for a very long time or even permanently. A long-term illness can make our world seem smaller, more defined by the illness than anything else. An illness can be a chance for discovery, for re-imaging a new self (Conrad and Barker 2007).
Second, Parsons’s discussion ignores the fact that our social backgrounds affect the likelihood of becoming ill and the quality of medical care we receive. Third, Parsons wrote approvingly of the power hierarchy implicit in the physician-patient relationship. Many experts say today that patients need to reduce this hierarchy by asking more questions of their physicians and by taking a more active role in maintaining their health. To the extent that physicians do not always provide the best medical care, the hierarchy that Parsons favored is at least partly to blame.
Regarding mental health, functionalist sociologists begin to layer social approaches to medical and psychological models. Functionalists look at the function that mental illness and mental health play in society. They look at how mental health functions in a person’s life. To this end, they developed psychosocial and biopsychosocial models of mental illness.
One functionalist model of mental illness is called the psychosocial model of mental illness. This approach focuses on how individuals interact with and adapt to their environment. Specific factors of interest might include a person’s relationships, past trauma, economic situation, outlook on life, and religious beliefs. For example, stress – both good and bad – can affect your mental health. Social scientists pay attention to where these stressful areas are. In fact, starting a new job is in the top three stressful things – but most people are happy to start new jobs. Happiness aside, the new expectations, roles, and attitudes you find at your new workplace cause stress. Of course, negative things can also cause stress, and psychologists help people develop resilience against this sort of stress so they can successfully navigate the stressful situation.
Another thing psychologists take into account are your social roles. Having conflicting social roles, such as being a parent during COVID-19 and having a full-time job, is a role conflict that can cause stress. There are several kinds of role strain, situations caused by higher-than-expected demands placed on an individual performing a specific role that leads to difficulty or stress. For example, being a student can take up too much time according to your boss at work.
As the name implies, the psychosocial model focuses on the importance of psychological and social factors in informing a person’s mental health. Rather than looking to a person’s brain for clues, a proponent of the psychosocial model of mental illness might look to a patient’s personal history, attitude, beliefs, and life circumstances to better understand their mental illness. But the psychosocial model is also limited because it doesn’t take biological or genetic factors into account.
To address this, sociologists, psychologists, and psychiatrists have developed the biopsychosocial model of mental illness, which addresses the idea that mental health problems are caused by a combination of biological, psychological, and social features.
For example, it can be true that a patient has a biological disposition to mental illness and has experienced trauma that is causing or exacerbating their symptoms. Similarly, many patients have discovered that a combination of psychotropic medication and talk therapy helps address their mental health issues. In fact, many mental health care providers integrate both approaches into a more holistic framework called the biopsychosocial model.
Conflict Theory
According to conflict theory, the dominant group in society – those people with power, money, and other resources – make decisions about how the healthcare system runs. Therefore, they ensure that they have access to quality healthcare. To ensure that subordinate groups stay subordinate, they restrict access to care. This creates significant healthcare and health disparities between the dominant and subordinate groups. Early conflict theorists emphasized that social class difference is the main cause of unequal outcomes, and today that may include health outcomes. However, single-determinant models are insufficient to explain our complex social problems, as power differentials and inequalities are intersectional.
The conflict approach emphasizes inequality in the quality of health and of health care (Weitz 2013). They highlight how society’s inequities along the areas of social class, race, gender, sexuality, and age are reproduced in health care and the institution of medicine more broadly. Health care institutions include thousands of doctors, staff, patients, and administrators, and are highly bureaucratic. They do not serve everyone equally, often because of structural systems of oppression (e.g., racism, sexism, cissexism, heterosexism). When health is a commodity, marginalized people are more likely to experience illness and live and work in unhealthy environments.
The conflict approach also critiques efforts by physicians over the decades to control the practice of medicine and to define various social problems as medical ones. Physicians’ motivation for doing so has been both good and bad. On the good side, they have believed they are the most qualified professionals to diagnose problems and to treat people who have these problems. On the negative side, they have also recognized that their financial status will improve if they succeed in characterizing social problems as medical problems and in monopolizing the treatment of these problems. Once these problems become medicalized, transformed from a behavior or condition into a medical problem, their possible social roots and thus potential solutions are neglected.
Obstetrical care provides a strong example. In most of human history, midwives were the people who helped deliver babies. In the nineteenth century, with the professionalization of medicine, physicians medicalized childbearing, claiming that they were better trained than midwives and winning legislation in the US giving them authority to deliver babies. Some may have honestly felt that midwives were inadequately trained, but they also fully recognized that obstetrical care would be quite lucrative (Ehrenreich & English 2005), and they strongly stigmatized midwives to make them seem inadequate.
The medicalization of childbirth in the US is so pervasive that most expectant parents in the US give birth in hospitals, with fetal monitors, medications, and other medical interventions that are unnecessary for most healthy pregnancies. In fact, severe complications among childbearers in the US have more than doubled in the last 20 years, rather than the reverse. In contrast, other Western nations continue to rely on midwifery. In Great Britain, midwives deliver half of all babies, including Kate Middleton’s first two children, Prince George and Princess Charlotte. In Sweden, Norway, and France, midwives oversee most expectant and new births, enabling obstetricians to concentrate on high-risk births. In Canada and New Zealand, midwives are so highly valued that they’re brought in to manage complex cases that need special attention.
Midwives are far less prevalent in the US than in other affluent Western countries, attending around 10% of births, despite that birthing care shortages have reached critical levels, with nearly half of all US counties without a practicing obstetrician-gynecologist (OBGYN). In rural areas, hospitals offering obstetric services have fallen more than 16% since 2004. The extent to which they can legally participate in patient care varies widely from one state to the next. At times, the cultural stigmas regarding medical practices can cause people to seek medical services that don’t meet their needs.
In another example, many hyperactive children are now diagnosed with ADHD, or attention deficit/hyperactivity disorder. A generation or more ago, they would have been considered merely as active children. After Ritalin, a drug that reduces hyperactivity, was developed, their behavior came to be considered a medical problem and the ADHD diagnosis was increasingly applied, and tens of thousands of children went to physicians’ offices and were given Ritalin or similar drugs. The definition of their behavior as a medical problem was lucrative for physicians and for the company that developed Ritalin, and it also obscured the possible roots of their behavior in parenting, schools, or even gender socialization (Conrad 2008; Rao & Seaton 2010).
Critics say the conflict approach’s assessment of health and medicine is overly harsh and its criticism of physicians’ motivation far too cynical. Scientific medicine has greatly improved the health of people around the world. Although physicians are certainly motivated, as many people are, by economic considerations their efforts to extend their scope into previously nonmedical areas also stem from honest beliefs that people’s health and lives will improve if these efforts succeed. Certainly there is some truth in this criticism of the conflict approach, but the evidence of social inequality in health and medicine and of the negative aspects of the medical establishment’s motivation for extending its reach remains compelling.
When we look at inequality in mental health, the approach is typically grounded in conflict theory. We will provide an example of this approach to mental health our discussion of social class. You may notice that it takes a conflict approach because it ties wealth and poverty to rates of mental illness. In essence, The Chicago Schizophrenia Study found that people from poorer neighborhoods were more likely to develop schizophrenia than were people from middle-class neighborhoods. While Faris and Dunham had differing approaches to explain why this might be the case, the fact that poverty – a classist experience – is linked to health outcomes is a classic conflict theory approach to mental illness.
Symbolic Interactionism
Like all social problems, the concepts of health and illness are socially constructed. The social construction of illness is based on the idea that there is no objective reality, only our own perceptions of reality. In other words, various physical and mental conditions have little or no objective reality but instead are considered healthy or ill conditions only if they are defined as such by a society and its members (Buckser 2009; Lorber & Moore 2002). The theories surrounding the social construction of health emphasize the social and cultural aspects of the discipline’s approach to physical, objectively definable phenomena. This section examines a comprehensive framework that focuses on the cultural meaning of illness, the social construction of the illness experience, and the social construction of medical knowledge (Conrad and Barker 2010).
Most medical sociologists contend that illnesses have both a biological and an experiential component and that these components exist independently of each other. Dominant white culture influences the way we experience illness, dictating which illnesses are stigmatized, which are considered disabilities or impairments, and which are contestable illnesses (Conrad & Barker 2010).
Contested illnesses are those that are questioned or questionable by some medical professionals. Disorders like fibromyalgia or chronic fatigue syndrome are real physical experiences, but some medical professionals contest whether these ailments are definable in medical terms. This causes a problem for a patient with symptoms that might be explained by a contested illness – how to get the treatment and diagnosis they need in the face of a medical establishment that does not believe their symptoms are real.
Scholars disagree over the social construction of mental illness. The predominant view in psychiatry, of course, is that people have actual mental and emotional functioning problems. These problems are best characterized as mental illnesses or mental disorders and should be treated by medical professionals (Kring and Sloan 2009). But other scholars, adopting a labeling theory approach, say that mental illness is a social construction (Szasz 2008) because few are labeled as 'mentally ill' despite that all kinds of people sometimes act oddly or in diverse ways. If someone says they hear the voice of an angel, we often attribute their perceptions to their religious views and consider them religious, not mentally ill. Instead, if someone insists that aliens from Mars have been in touch, we are more apt to think that there is something mentally wrong with that person. We socially construct our concepts of mental illness, labeling some people but not others.
This intellectual debate notwithstanding, many people suffer serious mental and emotional problems, such as severe mood swings and depression, that interfere with their everyday functioning and social interaction. Other symptoms of mental illnesses include psychosis, which is the loss of contact with reality; hallucinations, which is seeing or hearing things that others cannot; and delusions, which is believing things that are not actually true. Sociologists and other researchers have investigated the social epidemiology of these problems. As usual, they find social inequality (Cockerham 2011).
We also see the social construction of health and illness when we try to measure and treat pain. Individual and cultural perceptions of pain can make it difficult for healthcare workers to treat illnesses since they cannot be measured using a device. A person’s experience of pain is subjective, and a physician’s response to treating pain is highly variable. In addition to individual and cultural differences in the response to pain, the medical system’s response to pain varies by race. Women of color are less likely to receive adequate pain medication during childbirth (Lange, Rao, and Toledo 2017) and the postpartum period (Badreldin, Grobman, and Yee 2019). If you would like to learn more, the website How We Fail Black Patients in Pain explores some reasons why physicians may give less pain medication to Black and Brown people than to white people.
In addition to pain, it can be challenging to come to a shared understanding of physical activity. Assessment tools like the Rating of Perceived Exertion (RPE) Scale attempt to measure exertion at the individual level using accessible language and visual cues. This RPE chart includes the Wong-Baker FACES pain assessment tool, which is used often in healthcare settings because it works for a variety of ages, ability levels, and can be understood by those whose primary language is not English. The Rating of Perceived Exertion (RPE) chart (below) gives a more complete view of an individual’s actual exertion level, since heart rate or pulse measurements may be affected by medication or other issues (Centers for Disease Control 2022).
In another example, in the late 1800s opium use was quite common in the US, as opium derivatives were included in all sorts of over-the-counter products. Opium use was considered neither a major health nor legal problem. That changed by the end of the century, as prejudice against Chinese Americans led to the banning of the opium dens (similar to today’s bars) they frequented, and calls for the banning of opium led to federal legislation early in the twentieth century that banned most opium products except by prescription (Musto 2002).
The symbolic interactionist approach has also provided important studies of the interaction between patients and health-care professionals. Consciously or not, physicians “manage the situation” to display their authority and medical knowledge. Patients usually have to wait a long time for the physician to show up, and the physician is often in a white lab coat. The physician is also often addressed as 'Doctor,' while patients are often called by their first name. Physicians typically use complex medical terms to describe a patient’s illness instead of the more simple terms used by laypeople and the patients themselves.
Critics fault the symbolic interactionist approach for implying that no illnesses have an objective reality. Many serious health conditions do exist and put people at risk for their health regardless of what they or their society thinks. Critics also say the approach neglects the effects of social inequality for health and illness. Despite these possible faults, the symbolic interactionist approach reminds us that health and illness do have a subjective reality and that reality itself is constructed through social interaction.
In regard to mental health, symbolic interactionism focuses on meanings, experiences, and consequences of mental illness. Michaels MacDonald, historian of psychiatry, observed that mental illness "is the most solitary of afflictions to the people who experience it; but it is the most social of maladies to those who observe its effects" (1981: 1). Psychiatry generally focuses on the suffering individual while sociologists study the social aspects and implications of an individual’s mental disturbance on friends, family, community, and society. Sociologists ask questions like:
- How can we define and draw boundaries around mental illness and distinguish it from eccentricity or mere idiosyncrasy?
- Who determines what is “normal” difference and what is pathological?
- Who has the privilege to make such decisions? Why? Do such things vary across time and cross-culturally?
- How have societies responded to the presence of those who do not seem to share our commonsense notions of reality?
As part of the answer to these questions, the social construction theory of mental illness states that mental illnesses, mental health, normality, and abnormality are all social constructions and are not based in biological reality. One socially constructed concept is the idea of what is 'normal.' People in power say that normal is being happy and productive. If you are not these things, you are deemed 'abnormal' or 'sick.' The National Alliance for Mental Illness, or NAMI, challenges this idea and argues that people with mental illnesses are indeed 'normal,' although they may be different than others. Differences are to be celebrated, not labeled as dangerous or damaged.
At the same time, mental illness has profoundly disruptive effects on individual lives and on the social order we all take for granted. Erving Goffman (pictured below), whose mid-twentieth century writings still constitute some of the most provocative and profound sociological meditations on the subject, is perhaps best known for his searing critique of mental hospitals as total institutions: Residential institutions that cut off individuals from wider communities or society. Total institutions often have the goal of resocialization: The learning of new cultural norms, values, and expectations. However, total institutions often attempt to break down the very personality and sense of self of an individual, forcing a revised, more obedient personality and selfhood.
Erving Goffman, a Canadian-born, Jewish sociologist researched mental health and mental illness. His book Stigma: Notes on the Management of Spoiled Identity is essential in understanding the social construction of difference.
“Erving Goffman” from the American Sociological Association is included under fair use
From the late nineteen-sixties through the nineteen-eighties, the intellectual distance and even hostility between sociologists and psychiatrists often seemed to be growing. Within five years of the appearance of Goffman’s groundbreaking book Asylums, the California sociologist Thomas Scheff had authored a more radical assault on psychiatry. Scheff dismissed the medical model of mental illness altogether and attempted to replace it with a societal reaction model, where mental patients were portrayed as victims – victims of psychiatrists (Scheff 1966).
Scheff noted that despite centuries of effort, "there is no rigorous knowledge of the cause, cure, or even the symptoms of functional mental disorders," and we would be better off adopting "a [sociological] theory of mental disorder in which psychiatric symptoms are considered to be labeled violations of social norms, and stable ‘mental illness’ to be a social role." And, "societal reaction [not internal pathology] is usually the most important determinant of entry into that role" (1966: 25).
During the 1960s and 1970s, the societal reaction theory of deviance enjoyed broad popularity and acceptance among many sociologists. Scheff’s was one of the principal works in that tradition. In the face of an avalanche of well-founded objections, Scheff was eventually forced to back away from many of his more extreme positions. By the time the third edition of his book appeared (Scheff 1999), most of its bolder ideas had been quietly abandoned.
Labeling and stigmatization of the mentally ill have remained important subjects for sybmolic interactionists. This stigmatization of illness is when shame or disgrace is aimed at a person with a physical or mental illness or condition. Stigma can exacerbate the experience of having a mental illness. The idea of stigmatization is powerful, even if culturally the stigma associated with mental illness has been weakening.
Other Theoretical Perspectives
In addition to the three classical theoretical perspectives, other theories have framed and explained problems of health and medicine. We will discuss two examples below, including important points regarding the intersection of race and social class.
The Hispanic Paradox
Healthcare researchers who explore health outcomes for Latinx or Hispanic people describe these outcomes as the Hispanic paradox. Hispanics make up the largest and fastest-growing racial minority group in the US (Funk and Lopez 2022). For decades, health services researchers have puzzled over a paradox among them. Hispanics live longer and have lower death rates from heart disease, cancer, and many other leading causes of death than non-Hispanic white people despite having social disadvantages, including lower incomes and worse access to health coverage, and experiencing racism and sometimes nativism or xenophobia.
There are many theories about why this might happen. The possibilities include stronger social networks, healthier eating habits, and lower smoking rates among some Hispanic groups, particularly newer arrivals. However, focusing on national data can mask important differences. It also matters if people have health insurance, speak primarily Spanish or English, or grew up in the US or another country. The very heterogeneity of the Hispanic population makes it hard to pinpoint problems, including high rates of diabetes, liver disease, and certain cancers and poor birth outcomes among some Hispanic groups. Some were born here and others come from more than 20 countries, with widely differing experiences and social circumstances, including immigration status. The same diversity challenges the validity of the Hispanic paradox (Hostetter and Klein 2018).
Racism and Weathering
When we consider the causes of poor health outcomes, a common theory about why people of color have poor health outcomes is because they are disproportionately poor. They don’t have the money or health insurance that they need to get the needed level of medical care. This theory is partially true, and thus highlights the need for attention to the intersection of race and social class.
However, researcher Arline Geroniumus (pictured below) argues that racism itself can impact health outcomes. She coined the term weathering to describe the impact that social location can have on health. More specifically, weathering is the concept describing how chronic exposure to social and economic disadvantage leads to an accelerated decline in physical health outcomes (Geronimus 2023).
Arline Geronimus is a public health researcher who argues that the harm of racism itself is a cause of health inequality for people of color.
“Photo of Arline Geronimus” © University of Michigan is included under fair use
As a student at Princeton, Geronimus worked with pregnant teenagers in Trenton, New Jersey. She noticed that many of these young moms had serious chronic conditions, even though they were still young, and she wondered why. This curiosity led her to do extensive research (Demby 2018). She discovered that the physical body breaks down faster when you are exposed to chronic racism. The stress of wondering whether the police will stop you in traffic, or whether your children will come home safely, causes a stress overload in the body, when in turn causes physical deterioration (Geronimus 2021).
While she originally did her research with Black people and focused on racial weathering, she has expanded her concept. During the COVID-19 pandemic, she found that marginalization of oppressed populations related to race, class, gender, and other areas of social location was likely to lead to poorer health outcomes related to COVID-19 (Geronimus 2021). Weathering partially explains racial and other disparities in a wide array of health conditions (Forde et al. 2019).
For example, structural racism leads to disproportionate houselessness for Black people in particular. Safe housing is one of the social determinants of health. Partially because Black people have less access to safe housing, they experience poorer health outcomes. This again highlights the intersection of racism and classism. This NPR episode explains the weathering concept if you would like more details.
