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Medicalization and Epistemic Injustice: The Case of Premenstrual Dysphoric Disorder

This week on Imperfect Cognitions, we showcase a couple of posts by authors with papers published in a special issue from the European Journal of Analytic Philosophy (EuJAP). The special issue is on the Philosophy of Medicine with guest editors Saana Jukola and Anke Bueter. 

In today's post, Anne-Marie Gagné-Julien discusses her paper in the special issue, which you can read here. Anne-Marie is a postdoctoral fellow at the Biomedical Ethics Unit at McGill University and also affiliated with the École normale supérieure (ENS). She works on philosophy of psychiatry and medicine, social epistemology, and epistemic innocence. 

Anne-Marie Gagné-Julien

Medicalization is the process through which nonmedical problems are conceptualized and treated as medical problems (Conrad and Slodden 2013). It has become a controversial topic both within and outside psychiatry, especially since the publication of the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Several critics have argued that the DSM-5 medicalizes conditions that should only be considered “normal life problems”, “dangerous gifts”, or minoritized ways of being. Some specific revisions in the DSM-5 have been received with great suspicion, such as the diagnoses of major depressive disorder, bipolar disorder in children, personality disorders, and premenstrual dysphoric disorder. 

From a philosophical point of view, this raises the question of how to assess the medicalization of these diagnoses. Although medicalization in psychiatry is generally discussed from a critical perspective, the term itself is neither positive nor negative in itself: sometimes medicalization can bring good consequences, such as access to resources and decreasing blame associated with medicalized conditions. Sometimes it can lead to bad consequences, such as seeing all humans’ problems through a biomedical framework and spawning unnecessary clinical interventions. Therefore, what appears problematic are the bad forms of medicalization, or what I call “wrongful medicalization”. Regarding the many consequences and implications of medicalization, identifying cases of medicalization that are wrongful is a difficult undertaking. In other words, “what is a wrongful medicalization?” is a complex question.

In the paper, I propose to explore these issues with the philosophical framework of epistemic injustice (EI, e.g., Fricker 2007). EI are the harms suffered by individuals belonging to socially oppressed groups in their capacities to produce, access and/or share knowledge because of prejudicial identity stereotypes (e.g., racism, sexism, ableism, etc.) or because of their social marginalization. Where medicine is concerned, Kidd and Carel (2017) have depicted a particular form of EI that concerns prejudices associated with the experience of illness. It occurs when the knowledge of ill persons is dismissed, not even looked for, or confined to a purely biomedical discourse. As some have argued, the risk of encountering this type of EI is even greater in psychiatry because of widespread negative stereotypes associated with mental illness.

Using this framework is useful to think about what wrongful medicalization is. In the paper, I focus on Kaczmarek’s (2019) promising pragmatic approach to assessing medicalization. Using EI, I argue that Kaczmarek’s proposal lacks guidance concerning the procedures through which we are to assess medicalization (e.g., what model of discussion is the most fruitful to think about wrongful medicalization? Who should be included in these discussions and why? etc.). 

I demonstrate that the EI framework should complement Kaczmarek’s account in order to reduce the risk of epistemic injustices induced by medicalization, and therefore the risk of wrongful medicalization. To illustrate the relevance of my proposal, I apply this conclusion to a case study: the medicalization of Premenstrual Dysphoric Disorder (PMDD) in DSM-5. This leads me to defend more inclusive decision-making procedures regarding medicalization of PMDD in the DSM. I argue that Kaczmarek’s account complemented with the EI framework can help us achieve better forms of medicalization in psychiatry.

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