Peter Conrad

Types of medical social control

Abstract

In recent years there has been considerable interest in the social control
aspects of medicine. While medical social control lias been conceptualized in several ways, the concern here is with the medical control of
deviant behavior, an aspect of what has been called the medicalization
of deviance. Medical social control is defined as the ways in which
medicine functions (wittingly or unwittingly) to secure adherence to
siicial norms; specifically by using medical means or authority to
minimize, eliminate or normalize deviant behavior. This paper catalogues and illustrates a broad range of medical control of deviance,
and in so doing conceptualizes three major types of medical social
control: medical technology, medical collaboration, and medical
ideology. Numerous examples are provided lor each. These concepts
aid in revealing the breadth of medical social control and the extent
and limitations of professional dominance over the medical social
control of deviance.

In recent years there has been considerable interest in the social control
aspects of medicine. Medicine was first conceptualized as an agent of
social control by Parsons (1) in his seminal essay on the 'sick role'.
Freidson (2) and Zola (3) have elucidated the jurisdictional mandate
the medical profession has over anything that can be labeled an illness,
regardless of its ability to deal with it effectively. The boundaries of
medicine are elastic and increasingly expansive (4), and some analysts
have expressed concern at the increasing medicalization of life (5).
While medical social control has been conceptualized in several ways,
including professional control of colleagues (6) and control of the
micro-pohtics of doctor-patient interaction (7), the focus here is
narrower. My concern is with the medical control of deviant behavior,
an aspect of what has been called the medicalization of deviance (8, 9).
Thus, by medical social control I mean tlie ways in which medicine
functions (wittingly or unwittingly) to secure adherence to social
norms; specifically, by using medical means to minimize, eliminate, or
normalize deviant behavior. While there has been considerable research
on medical social control, there has been no attempt to order and
analyze the variety of medical controls. The purpose of this paper is to
cataglogue and illustrate the broad range of medical controls of deviance.
Sociology of Health and Illness Vo\. 1 No. 1 1979
R . K . P . 1979

0141-9889/79/0101-0001 $1.50/1

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conceptualize three major types of medical social control, and explicate

the relation of the medical profession to these types of social control.
On the most abstract level, medical social control is the acceptance
of a medical perspective as the dominant definition of certain phenomena. When medical perspectives of problems and their solutions become
dominant, they diminish competing definitions. This is particularly true
of problems related to bodily functioning and in areas where medical
technology can demonstrate effectiveness (e.g., immunization, contraception, anti-bacterial drugs), and is increasingly the case for behavioral
and social problems (10). This underlies the construction of medical
norms (e.g., what is healthy) and the 'enforcement' of both medical and
social norms. Medical social control also includes medical advice,
counsel, and infonnation that is part ofthe general stock of knowledge:
eat a well-balanced diet, cigarette smoking causes cancer, overweight
increases health risks, exercising regularly is healthy, teeth should be
brushed twice daily, etc. Such aphorisms, even when unheeded, serve
as roadsigns for desirable behavior. At a more concrete level, medical
social control is professional medical intervention qua medical treatment (although it may include some types of self-treatment). This
intervention aims at returning sick individuals to a state of health and
to their conventional social roles, adjusting them to new (e.g., impaired)
roles, or, short of these, making individuals more comfortable with
their condition [cf. 1,2). Medical social control of deviant behavior is
usually a variant of medical intervention that seeks to eliminate, modify,
isolate or regulate behavior, socially defined as deviant, with medical
means and in the name of health.
Traditionally, psychiatry and public health have served as modes of
medical control. Psychiatry's social control functions with mental illness, especially in terms of mstitutionalization, have been widely
analyzed (e.g., 11, 12). Recently it has been argued that psychotherapy
itself is an agent of social control and a supporter of the status quo
(13, 14). Public health medicine's mandate, the control and elimination
of conditions and diseases that are deemed a threat to the health of a
community, is more diffuse. It operates as a control agent by setting
and enforcing certain 'health' standards in the home, workplace, and
community (food, water, sanitation, etc.) and by identifying,
preventing, treating, and, if necessary, isolating persons with communicable diseases (15). The clearest example of the latter is the detection
of venereal disease. Indeed, public health has exerted considerable
coercive power in attempting to prevent the spread of infectious
disease.
There are a number of types of medical control of deviance. The
most common forms of medical social control include medicalizing

lypcs of mciiical social control

deviant behavior - i.e.. defining the behavior as an illness or a symptom

of an illness or underlying disease - and subsequent direct medical
intervention (9). This medical social control takes three general forms:
medical technology, medical collaboration, and medical ideology.*These
'ideal types' are not entirely discrete. We separate tlieni here in an
attempt to 'unpack' the elements of medical social control and catalogue the range of possible controls.
The growth of speciahzed and technological medicine and tlie concomitant development of medical technology has produced an armamentarium of medical controls. Psychotechnologies, which include
various forms of medical and behavioral technologies (16), are tlie most
common types of medical control of deviance. Since the emergence of
phenothiazine medications in the early 1950s for the treatment and
control of mental disorder, there has been a virtual explosion in the
development and use of psychoactive medications that control
behavioral deviance: tranquilizers like Librium and Valium for anxiety,
nervousness, and general malaise; stimulant medications for hyperactive
children; amphetamines for overeating and obesity; Antabuse for
alcoholism; Methadone for heroin, and many others.' These pharmaceutical discoveries, aggressively promoted by a highly profitable and
powerful drug industry (17), often become the treatment of choice for
deviant behavior. They are easily administered, under professional
medical control, quite potent in their effects (i.e.. controlling, modifying, and even elminating behavior), and are generally less expensive
than other treatments and controls (e.g., hospitalization, altering
environments, long-term psychotherapy).
Psychosurgery, surgical procedures meant to correct certain 'brain
dysfunctions' alleged to cause deviant behavior, was developed first in
the early 1930s as prefrontal lobotomy as a treatment for mental illness.
Early forms of psychosurgery fell into disrepute in the early 1950s
because the 'side effects' (general passivity, difficulty with abstract
thinking) were deemed too undesirable and many patients remained
institutionalized (and besides, new psychoactive medications were
becoming available to control the mentally ill). During this period,
however, approximately 40,000 to 50,000 such operations were performed in the United States. In the late 1960 a new and technologically
more sophisticated variant of psycho-surgery (including laser technology
and brain implants) emerged and was heralded by some as a treatment
of uncontrollable violent outbursts (18, 19). While psychosurgery for
violence has been criticized from both within the medical profession
and without (20) and relatively few operations have actually been performed, in 1976 a blue-ribbon national commission reporting to the
US Department of Health, Education and Welfare endorsed the use of

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psychosurgery as having 'potential merit' and judged its risks 'not

excessive'. This may encourage an increased utilization of this form of
medical control.^
Behavior modification, a psychotechnology based on B. F. Skinner
and other behaviorist learning tlieories, has been adopted by some
medical professionals as a treatment modality. A variety of types and
variations of behavior modification exist (token economies, positive
reinforcement schedules, aversive conditioning, operant conditioning,
etc.). While they are not medical technologies per se, these have been
used by physicians for the treatment of mental illness, mental retardation, homosexuality, violence, hyperactive children, autism, phobias,
alcoholism, drug addiction, and other disorders. An irony of the
medical use of behavior modification is that behaviorism explicitly
denies the medical model (that behavior is a symptom of illness) and
adopts an environmental, albeit still individual, solution to the problem.
This has not, however, hindered its adoption by medical professionals,
perhaps because physicians frequently have been only able to treat
'symptoms' rather than causes, anyway.
Human genetics is one of the most exciting and rapidly expanding
areas of medical knowledge. Genetic screening and genetic counseling
are becoming more commonplace. Genetic causes are proposed for such
a variety of human problems as alcoholism, hyperactivity, learning
disabilities, schizophrenia, mania-depressive psychosis, homosexuality,
and mental retardation. At this point in time, apart from specific
genetic disorders such as plieylketonuria (PKU) and certain forms of
retardation, genetic explanations tend to be general theories, with only
minimal (if any) empirical support, and are not the level at which
medical intervention occurs. The most well-publicized genetic theory
of deviant behaviour is that an XYY chromosome arrangement is a
determinant factor in 'criminal tendencies'. While this XYY research
has been severely questioned (21) the controversy surrounding it may
be a harbinger of things to come. Genetic anomalies may be discovered
to have a correlation with deviant behavior and may become a causal
explanation for this behavior. Medical control, in the form of genetic
counseling (22), may discourage parents from having offspring with a
high risk (e.g., 25 per cent) of genetic impairment. Clearly, the
potentials for medical control go far beyond present use; one could
imagine the possibility of licensing selected parents (with proper genes)
to have children, and further manipulating gene arrangements to
produce or eliminate certain traits.
Medicine acts not only as an independent agent of social control (as
above) but frequently medical collaboration with other authorities
serves social control functions. Such collaboration includes roles as

Types of medical social control

information provider, gatekeeper, institutional agent, and technician.

Tliese interdependent medical control functions highUght the interwoven position of medicine in tlie fabric of society. Historically, niedical
personnel have reported information on gunshot wounds and venereal
liisease to state autliorities. More recently, these have been extended to
reporting 'child abuse' to child welfare or law enforcement agencies.
The medical profession's status as official designator of the 'sick
role', which imbues the physician with authority to define particular
kinds of deviance as illness and exempt the patient from certain role
obligations, is a general gatekeeping and social control task. In some
instances the physician functions as a specific gatekeeper for special
exemptions from conventional norms; here the exemptions are
authorized due to illness, disease or disability. The classic example is
the so-called 'insanity defense' in capital crime cases. Other more
commonplace examples include: medical deferment from the draft or a
medical discharge from the military; requiring doctors' notes to legitimize missing an examination or excessive absences in school; and,
before abortion was legahzed, obtaining two psychiatrists' letters
testifying to the therapeutic necessity of the abortion. Halleck (13) has
termed this 'the power of medical excuse'. In a slightly different vein,
but still fonns of gatekeeping and medical excuse, are medical examinations for disability or workman's compensation benefits. Medical
reports required for insurance coverage and employment, or medical
certification of an epileptic as seizure-free to obtain a driver's license,
are also gatekeeping activities.
Physicians in total instutitons have one or two roles. In some
institutions, such as schools for the retarded or mental hospitals, they
are usually the administrative authority; in others, such as the military
or prisons, they are employees of the administration. In total institutions, medicine's roles as an agent of social control (for the institution) is more apparent. In both the military and prisons, physicians
have the power to confer the sick role and to offer medical excuse for
deviance (cf. 23, 24). For example, medical discharges and sick call are
available designations for deviant behavior. As physicians are in the hire
of and paid by the institution, it is difficult for them to be fully an
agent of the patient, engendering built-in role strains. An extreme
example is in wartime conflict when the physician's mandate is to
return the soldier to combat duty as soon as possible. Under some circumstances, physicians act as direct agents of control by prescribing
medications to control unruly or disorderly inmates or to help a
'neurotic' adjust to the conditions of total institution. In such cases,
'captive professionals' (23) are more likely to become the agent of the
institution than the agent of the individual patient.

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Under rather rare circumstances, physicians may become 'mere

technicians', applying the sanctions of another authority who hires
their medical skills. An extreme, although more complex, example
would be the behavior of the experimental and death physicians in Nazi
Germany. A more mundane example is physicians who perform courtordered sterilizations (24). Perhaps one could imagine sometime in the
future, if the death penalty becomes commonplace again, physicians
administering drugs as the 'humanitarian' and painless executioner.^
Medical ideology is a type of social control that involves defining a
behavior or condition as an illness primarily because of the social and
ideological benefits accrued by conceptualizing it in medical terms.
It includes adopting medical or quasi-medical imagery or vocabulary in
conceptualizing and treating the problem. Medical ideology uses metlical authority by way of language. The latent functions of medical
ideology may benefit the individual or the dominant interests in society
or both, but are quite separate from any organic basis for illness or any
available treatment. Waitzkin and Waterman (25) call one latent
function of medicalization 'secondary gain', arguing that assumption of
the sick role can fulfill personality and individual needs (e.g., gaining
nurturance or attention) or legitimize personal failure (25). One ofthe
most important functions of the disease model of alcoholism and to a
lesser extent drug addiction is the secondary gain of removing blame
from, and constructing a shield against condemnation of, individuals
for their deviant behavior. Alcoholics Anonymous, a non-medical quasireligious self-help organization, adopted a variant ofthe medical model
of alcoholism quite independently from the medical profession. One
suspects the secondary gain serves their purposes well.
Disease designations can support social interests and institutions.
A poignant example is prominent New Orleans physician S. W.
Cartwright's antebellum conceptualization ofthe disease drapetomania,
a condition that only affected slaves. Its major symptom was running
away from their masters (27). Medical conceptions and controls often
support dominant social values and morality: the 19th-century
Victorian conceptualization of the illness of and addiction to masturbation and the medical treatments developed to control this disease
make chilling reading in the 1970s (28). The recent Soviet labeling of
political dissidents as mentally ill is a further example of the manipulation of illness designations to support dominant political and social
institutions (29). These examples highlight the socio-political nature of
illness designations in general (30).
In actual operation, the types of medical social control described
above do not necessarily exist as discrete entities, but are found in
combination with one another. For example, court-ordered sterilization

Types of medical social control

or medical prescribing of drugs to unruly nursing home patients combines both technological and collaborative aspects of medical control;
legitimating disability status is both ideological and collaborative; and
treating Soviet dissidents with drugs for their mental illness combines
all three aspects of medical social control. We treat them as analytically
separate to explicate and clarify the various faces of medical social
control.
Medical social control and the medical profession

This section of the paper discusses the relation of the medical profession to each type of medical social control. Given the dominance of
the medical profession in western society (2, 31), one might suspect
that medical control of deviance was squarely in the hands of the
medical profession. A number of writers have assumed medical
hegemony, monopoly or imperialism in the expansion of the sphere of
medical control (4, 32). While in individual cases this may present an
accurate picture, upon closer inspection we find that the determination
and control of each of these controls varies considerably. We identify
three factors affecting the medical profession's control of medical
controls: the necessity of active involvement of medical professionals,
the ability of non-medical segments of society to limit or demand
medical social control, and the source of instigation of medical control.
Medical technology and collaboration both require the active participation of medical professionals. Only the medical profession has the
license and mandate to legally use behavior-controlling drugs and to
perform surgery. Without the involvement of physicians, medical
technology cannot be implemented. Medical ideology, on the other
hand, can exist without the active participation of medical professionals.
Frequently non-medical groups, such as Alcoholics Anonymous and the
early juvenile court (33), adopt a medical ideology or rhetoric in their
social control work. The involvement of the medical profession is
marginal at best, and more likely, non-existent. Fledgling professions or
semi-professions (34) may adopt a medical ideology in their work in
order to benefit from the prestigious cloak of medicine and enhance
their own professional status.
The ability of agents outside of medicine to require or limit the use
of medical controls varies for the three types of control. The application
of medical technology by and large belongs solely to the medical profession. This medical monopoly may be somewhat restricted by governmental regulatory agencies such as the Food and Drug Administration,
by the courts, or through special legislation. But the actual limitations

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on medical control by these agencies is limited - it is usually tlie result

of a specific controversy (e.g., XYY research witli newborns), the
specific restrictions of a specific drug, or a specific legal issue (e.g.,
informed consent and psychosurgery). Generally speaking, the professional dominance of medicine is most evident here, as the extramedical agents must engage in battle if they wish to limit the medical
profession's primacy in the use of medical technology. Medical collaboration by definition involves some relationship with another institution. In nearly all examples of medical collaboration cited above,
medicine performs reporting, definitional or technical tasks for another
institution. Physicians are significantly constrained by these relationships: they may be required to report information (as in child abuse) or
may have their range of medical judgment limited by the demands of
the 'collaborating' institution (as in the military). Medical dominance
and professional freedom in use of expertise is thus significantly
curtailed in collaborative social control. Medical ideology can be greatly
affected by non-medical agents in society. Althougli medical professionals may use medical ideology as social control, it is not the sole
property of the medical profession or its related professions. Self-help
organizations like Alcoholics Anonymous or weight-reducing groups
(35) can adapt or develop their own quasi-medical theories apart from
medical professionals. These theories may of course be challenged by
medical professionals, but here the challenge must come at the instigation of the medical profession." The medical profession claims, but
has no ownership of, medical rhetoric and vocabulary. It can be used by
other organizations independently ofthe medical profession. Physicians
may disown or challenge a particular use of medical vocabulary, but
they must challenge it through the media, courts, the legislature or in
some other public arena.
Finally, source of instigation varies for the three types of social
control. Medical technology includes surgical procedures, drugs and
technological innovations. While psychoactive dmgs and advanced
medical apparatuses are often invented and promoted by corporate
interests, they only can be implemented by medical professionals.
(This is why the pharmaceutical industry spends 25 percent of its
gross budget on physician advertising.) The implementafion of surgical
procedures by physicians is among the most laissez-faire of modern
medicine (36). Physicians may not be the original instigators of specific
medical technologies, but they are invariably in control of its
implementation. Medical collaboration is nearly always instigated outside the medical profession. Even in the case of child abuse where some
physicians championed the cause (37), it was the state's passage of
mandatory reporting laws that instigated the use of medical control.

Types of medical social control

Witli medical excusing or gatekeeping tasks, as well as with mucli

medical work in institutions, medical control occurs at the instigation
of agents outside the medical profession. Medical ideology may be
instigated eitlier inside or outside tlie medical profession: physicians'
entrepreneursliip of new diagnoses or disorders, or non-medical
adoption of medical definitions, rlietoric or vocabulary may extend
medical ideology.
To summarize, while many analysts liave written of the professional
dominance of medicine, our analysis reveals that only in terms of
medical technology does the medical profession maintain dominant and
monopolistic control. When medicine operates in a collaborative role, it
shares control with otlier institutions or performs work in the service of
another institution. Medical ideology may arise independently from the
medical profession; for the medical profession to maintain dominance
over this form of social control, it must publicly cliallenge those groups
utilizing medical ideology.

Conclusion
This paper presented medical technology, collaboration and ideology as
three types of medical social control. It suggests that the dominance of
the medical profession in tlie utilization of medical social control is
limited to medical teclinology and that the medical profession's power
and control are shared or diminished with medical collaboration and
ideology.
It is clear that the enormous expansion of medicine in the past fifty
years has meant that the number of possible ways in which problems
could be medicalized has increased. Yet, we can only Speculate on the
amount of medicalized deviant behavior and the extent of medical
social control. We need further examination of the 'natural history' of
the emergence and decUne of medical social control mechanisms, tlie
'battles' over social control turfs between medicine and competing
control agencies, and the extent to which there is actual utilization of
medical social control. It is important to discover and explicate the
linkages between medicine and other social control agencies and how
they support one another. We will then have a better understanding of
iiiedicine's jurisdication over deviant beliavior and its operation as an
agent of social control.
Department of Sociology
Drake University

10

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Notes
My thanks to Joseph W. Schneider and anonymous reviewers for comments on an
earlier draft of this paper.
1. Another pharmaceutical innovation, birth control pills, also functions as a
medical control; in this case, the control of reproduction. There is little doubt
that 'the pill' has played a significant part in the alleged sexual revolutions
since the 1960s and the redefinition of sexual deviance.
2. A number of other surgical interventions for deviance have been developed in
recent years. Surgery for 'gender dysphoria' (trans-sexuality) and 'intestinal bypass' operations for obesity ".re both examples of the medicalization of
deviance and surgical intervention. The legalization of abortions also has
medicalized and legitimated an activity that was formerly deviant and brought
it under medical-surgical control.
3. It is worth noting that in the recent Gary Gilmore execution, a physician was
involved; he designated the spot where the heartbeat was loudest and measured
vital signs during the execution.
4. If these non-medical practitioners overextend their work to include that
which is part of the legislated medical monopoly, they may be subject to
prosecution for practicing medicine without a license.

References
1. Parsons. T. 1951 The Social System. New York: Free Press.
2. Freidson, E. \91Q Profession of Medicine. New York: Dodd, Mead.
3. Zola, I. K. 1975 'In the Name of Health and Illness: On Some Socio-political
{ onsequences of Medical Influence.' Social Science and Medicine, 9:83-87.
4. Ehrenreich, B. and Ehrenreich, J. 1975 'Medicine and Social Control.' In
Welfare in America: Controlling the 'Dangerous' Classes (edited by B. R.
Mandell), pp.138-167. Englewood Cliffs, N.J.: Prentice-Hall.
5. Illich, I. 1916 Medical Nemesis. New York: Pantheon.
6. Freidson, E. 1975 Doctoring Together. New York: Elsevier.
7. Waitzkin, H. and Stoeckle, J. 1976 'Information Control and the Micropolitics of Health Care: Summary of an Ongoing Project.' Social Science and
Medicine, 10:263-76.
8. Pitts, J. 1968 'Social Control: The Concept.' In International Encyclopedia of
Social Sciences, No. 14 (edited by D. SUls). New York: MacmUlan.
9. Conrad, P. 1975 'The Discovery of Hyperkinesis: Notes on the Medicalization
of Deviant Behavior.' Social Prohlems, 23:1 2-21.
10. Mechanic, D. 1973 'Health and Illness in Technological Societies.' Hastings
Center Studies, 1:7-18.
1 1. Szsaz, T. 1970 Manufacture of Madness. New York: Harper and Row.
12. Miller, K. 1976 Managing Madness. New York: Free Press.
13. Halleck, S. 1970 The Politics of Therapy. New York: Science House.
14. Hurvitz, N. 1973 'Psychotherapy as a Means of Social Control.'youA-wa/ of
Consulting and Clinieal Psychology, 40:232-39.

Fypes of medical social control

11

15. Rosen, G. 1972 'The Evolution of Social Medicine.' In Handbook of Medical

Sociology (edited by H. K. Freeman, S. Levine and L. Reeder), pp.30-60.
Hnglewood Cliffs, N.J.: Prentice-Hall.
16. Chorover, S. 1973 'Big Brother and Psychotechnology." Psychology Todtty,
43-54.
17. Goddard. J. 1973 'The Medical Business: Scientific American, 229;161-68.
18. Mark, V. and Ervin. F. 1970 Violence and the Brain. New York: Harper and
Row.
19. Delgado, J. M. R. 1971 Physical Control of the Mind. New York: Harper and
Row.
20. Chorover, S. 1974 'Psychosurgery: A Neuro Psychological Perspective.'fioifo/;
University Law Review, 74:231-48.
21. Fox, R. G. 1971 'The XYY Offender: A Modern Mythl'Journal of Criminal
Law, Criminology and Police Science, 62:1-15.
22. Sorenson, J. 1974 'Biomedical Innovation, Uncertainty, and Doctor-Patient
Interaction.'Jour^a/ of Health and Social Behavior, 15:366-74.
23. Daniels, A. K. 1969 'The Captive Professional: Bureaucratic Limitation in the
Practice of Military Psychiatry.'yourna/ of Health and Social Behavior,
10:25 5-65.
24. Kittrie, N. 1971 The Right to be Different. Baltimore: Johns Hopkins Press.
25. Waitzkin, H. K. and Waterman, B. 1974 The Exploitation of Illness in Capitalist
Society. Indianapolis: Bobbs-Merrill.
26. Shuval, J. T. and Antonovosky, A. 1973 'Illness: A Mechanism for Coping with
Failure.' Social Science and Medicine, 7:259-65.
27. Cartwright, S. W. 1851 'Report on the Diseases and Physical Peculiarities of the
Negro Race.' A'evv Orleans Medical and Surgical Journal, 7:691-715.
28. Englehardt, H., jr. 1974 'The Disease of Masturbation: Values and the Concept
of Disease.' Bulletin of History of Medicine, 48:234-48.
29. Conrad, P. 1977 'Soviet Dissidents, Ideological Deviance, and Mental
Hospitalization.' Paper presented at Midwest Sociological Society Meetings,
April.
30. Zola, I. K. 1972 'Medicine as an Institution of Social Control.'Socio/o^ica/
Review, 20:487-504.
31. Freidson, E. 1910 Professional Dominance. Chicago: Aiding.
32. Radelet, M. 1977 'Medical Hegemony as Social Control: The Use of Tranquilizers.' Paper presented at the meetings of the Society for the Study of Social
Problems.
33. Platt, A. 1969 The Child Savers. Chicago: University of Chicago Press.
34. Chalfant. P. 1976 'Unindicted Co-Conspirators in the Medicalization of
Deviance: The Role of a Semi-Profession.' Paper presented at the meetings of
the American Sociological Association.
35. Millman, M. Personal communication.
36. Millman, M. 1977 The Unkindest Cut: Life in the Backrooms of Medicine.
New York: William Morrow.
37. Pfohl,S. 1977 'The "Discovery" of Child Abuse.' Social Problems, 24:310-23.