Sociology of Health & Illness Vol. 38 No. 1 2016 ISSN 0141-9889, pp.

73–89
doi: 10.1111/1467-9566.12342

On social plasticity: the transformative power of

pharmaceuticals on health, nature and identity
Johanne Collin
Research Group on Medications as Social Objects and Faculty of Pharmacy, Universite de
Montreal, Canada

Abstract This article proposes a theoretical framework on the role of pharmaceuticals in

transforming perspectives and shaping contemporary subjectivities. It outlines the
significant role drugs play in three fundamental processes of social transformation
in Western societies: medicalisation, molecularisation and biosocialisation. Indeed,
drugs can be envisaged as major devices of a pharmaceutical regime, which is
more akin to the notion of dispositif, as used by Foucault, than to the sole result
of high-level scheming by powerful economic interests, a notion which informs a
significant share of the literature. Medications serve as a key vector of the
transformation of perspective (or gaze) that characterises medicalisation,
molecularisation and biosocialisation, by shifting our view on health, nature and
identity from a categorical to a dimensional framework. Hence, central to this
thesis is that the same underlying mechanism is at work. Indeed, in all three
processes there is an evolving polarity between two antinomic categories, the
positions of which are constantly being redefined by the various uses of drugs.
Due to their concreteness, the fluidity of their use and the plasticity of the
identities they authorise, drugs colonise all areas of contemporary social
experiences, far beyond the medical sphere.
A video abstract of this article can be found at: https://www.youtube.com/watch?
v=djIBY7DHKW4&feature=youtu.be

Keywords: biomedicine, drugs and medication, medicalisation, norms and values,

pharmaceuticalisation, biopolitics

In contemporary Western societies pharmaceutical drugs are central to the lives of individuals.
From birth to death, these substances colonise every life phase. Since the 1980s the social nat-
ure of medicines has become a field of study, notably in pharmaceutical anthropology (van der
Geest 2006). Seminal work in this field (Nichter and Vuckovic 1994, van der Geest and
Whyte 1989) explored the meanings of pharmaceuticals, how their use conveys ideologies and
values, and the way they transform social dynamics. In anthropology (Nichter and Vuckovic
1994, Whyte et al. 2002) as in sociology (Cohen et al. 2001), scholars have proposed a bio-
graphical approach to the study of pharmaceutical drugs that considered these as both material
and cultural objects inherent to a lifecycle, from the starting point of their production (design
in the laboratory, development and marketing) to their distribution (prescription and dispensing
by professionals), and finally to their daily consumption by laypeople).1

© 2015 The Author. Sociology of Health & Illness published by John Wiley & Sons Ltd on behalf of Foundation for SHIL.
This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits
use and distribution in any medium, provided the original work is properly cited, the use is non-commercial and no modifications or
adaptations are made.
74 Johanne Collin

Recent key trends since the emergence of the concept of pharmaceuticalisation in sociologi-
cal and anthropological studies include the analysis of the pharmaceutical industry’s regulatory
practices (Abraham 2010, Abraham and Lawton 2003, Abraham 2010) as well as the study of
the unequal production and distribution of pharmaceuticals in developing countries (Petryna
et al. 2006). The focus on users as consumers has also raised the issue of how patient groups
engage with pharmaceutical companies (Conrad 2007, Williams et al. 2011). Furthermore, the
connections between new developments in bioscience and political debates raise questions on
the role of the pharmaceutical industry in biocapitalism (Bell and Figert 2015, Clarke et al.
2010, Rose 2007).
It goes without saying that drugs are fundamental to the theoretical framework of pharma-
ceuticalisation (Abraham 2011, Bell and Figert 2015, Williams et al. 2011, Williams and Gabe
2009). However, they are also paramount in theories of biomedicalisation (Clarke et al. 2010)
and biopolitics (Rose 2007). Indeed, they are central to the notion of molecularisation, as
described by Rose, through what he refers to as ‘neurochemical selves’ (Rose 2007: 187).
Likewise, Clarke et al. consider drugs to be the ‘most dominant and portable mechanisms of
biomedicalisation’ (2010: 44). Yet, in these theoretical frameworks pharmaceuticals tend to be
mainly conceptualised as material avatars of larger social forces. In fact, most studies on phar-
maceuticals within these theoretical frameworks focus on macro-analyses of structures, institu-
tions and collective actors that produce, market, dispense and use drugs.
Although these perspectives are sound and indispensable, to better grasp the extensive use
of pharmaceuticals beyond the medical sphere there is also a need to focus on drugs as living
objects and actors (Fraser et al. 2009, Martin 2006, Persson 2004). According to Fraser et al.
(2009: 124):

In framing and indeed shaping lives, drugs are social and political agents. In a strange way,
they too have lives – as much as we live through drugs, they live through us.

This inductive and ethnographical approach is seen as paving the way to a reflection on the
connections across the different arenas or dimensions of drugs trajectories: production, regula-
tion, marketing, dispensing or use. Yet this approach has so far mostly produced discrete case
studies of specific pharmaceuticals at different stages of their biography, while expressing
ambivalence towards any form of generalisation or theorisation about drugs, envisaged as both
subjects and objects. Indeed, we are warned that:

Medications must be analyzed . . . in their specificity, and any connections with other health
issues or generalizations about the action of medicine must be built outwards from each
specific case – carefully and with close attention to difference. (Fraser et al. 2009: 128)

Yet there must be some form of middle ground between these two major trends in the litera-
ture. The goal of this article is thus to invest this interzone by proposing a theoretical frame-
work that will shed some light on the role of medications per se in transforming perspectives
and shaping contemporary subjectivities. This article is programmatic in that it does not claim
to be exhaustive and should be envisioned as a first iteration of a wider research agenda. It
outlines the significant role played by drugs in three core processes of social transformations
in contemporary Western societies: those of medicalisation, molecularisation and biosocialisa-
tion.
The following pages discuss, using a series of specific examples, the manner in which medi-
cations play a significant role in those three central processes of contemporary social dynam-
ics. The article highlights the ways in which they operate to transform the social and medical
© 2015 The Author
Sociology of Health & Illness published by John Wiley & Sons Ltd on behalf of Foundation for SHIL
 The transformative power of pharmaceuticals 81

technology, would allow returning to a natural order of things, thus shifting the boundaries
between the natural and the artificial.
Elimination of the need for sleep by modafinil, a drug originally designed to treat nar-
colepsy, can also be considered appealing in the bio-capitalistic perspective of seeking hyper-
productivity and performance, and aiming to conquer the sleeping body as much as the waking
body (Coveney et al. 2009, Williams et al. 2008). Beyond an individual’s desire to free them-
selves from the limitations imposed by the need for sleep, an argument is developing in sup-
port of the mandatory use of this medication in the context of certain occupations requiring
around the clock alertness, for instance, in military operations (Eliyahu et al. 2007, Williams
et al. 2008). Indeed, a recent study indicates that off-label use of modafinil increased 15-fold
between 2002 and 2009 in the USA (Pe~ naloza et al. 2013).
In the case of suppressed menstruations or the elimination of the need to sleep, the process
at work reaches beyond a simple desire for optimisation or enhancement through micro-manip-
ulations aiming at transforming bodies and selves for lifestyle promotion. As bio-politics are
orchestrated to make these drugs not only accessible but potentially obligatory in certain con-
texts, namely in the workplace, one can envision a collective exemption from certain physical
limits progressively setting into place as it moves the boundary between the natural and the
artificial.
Pharmaceuticals then follow the same itinerary, whether the issue at hand is menstrual sup-
pression or sleep elimination. Initially approved for specific health problems, the demand for
these drugs quickly rises to support lifestyle and personal choices. Their mandatory use is then
contemplated in certain work settings while scientific arguments, justifying a generalised use
in the name of health, public safety and the good of society, proliferate. The extent to which
that drug-taking is systematised (organised, collective and mandatory) to extend the body’s
limits will ultimately have the effect of naturalising bodily states that would have been, until
then, considered artificial.

Biosocialisation: drugs and the tension between conformity and resistance

According to this model, biosocialisation may be conceived as a mechanism through which

there is a progressive superimposition of two antinomic conditions: inclusion in and exclusion
from society. While there has always been a tension between inclusion and exclusion, it is
increasingly common for individuals to be fully integrated in a community while simultane-
ously marginalised or stigmatised by society.
This dimension directly calls upon the concepts of biosociality (Rabinow 1996) and bio-citi-
zenship (Petryna et al. 2006, Rose and Novas 2005). As stated by several authors, there is a
reshaping of collective identities in contemporary Western societies through the genetic,
somatic or physical attributes that individuals share and around which they are mobilised
(Clarke et al. 2010, Rose 2007).
However, we can also envisage the shaping of collective identities through attitudes towards
pharmaceuticals and the ways in which individuals organise their shared experiences in rela-
tion to them (Hardon et al. 2013). Drugs serve as catalysts when they become the object
around which new socialities appear, be it through non-medical or illicit use, as in the case of
cognitive enhancers (also called smart drugs), or through the rejection of a diagnostic label
and subsequent treatment, as in the management of extreme shyness with psychotropic drugs.
Pharmaceuticals would then play a significant role in building collective identities through
individuals sharing their experiences related to consuming the drugs or, on the other end of
the spectrum, their refusal to use them.
© 2015 The Author
Sociology of Health & Illness published by John Wiley & Sons Ltd on behalf of Foundation for SHIL
76 Johanne Collin

Envisages life at the molecular level, as a set of intelligible vital mechanisms among molec-
ular entities that can be identified, isolated, manipulated, mobilized, recombined, in new
practices of intervention, which are no longer constrained by the apparent normativity of a
natural vital order. (Rose 2007: 6)

Through this other (and concomitant) transformation of the medical (and societal) gaze, a blur-
ring of boundaries occurs between living and non-living organisms, and by extension, between
what is considered to be natural from what is perceived to be artificial. It is my contention that
drugs play a major role in this process of transformation as to what is considered natural and
artificial in everyday life, and in shifting the limit that separates ethically acceptable extensions
of corporal limits from inacceptable ones.
Biosocialisation, finally, could be similarly envisaged as a transformation of the biomedical
and social gaze that blurs the boundaries between the mutually exclusive notions of integration
and exclusion, and of conformity and resistance to dominant social norms. Pharmaceuticals
would then play a significant role in the constitution of a technoscientific identity fashioned by
drug-taking as something to either embrace or reject.
Hence, central to this conceptualisation is the assumption that, through medicalisation,
molecularisation and biosocialisation, the same basic mechanism is at work: that of an evolv-
ing polarity between two antinomic categories, the positions of which are constantly being
redefined by the various uses of drugs, among other social forces. By examining the question
from this angle, I seek to understand how these polarities evolve and the role pharmaceutical
drugs play in the process. This phenomenon is far from unidirectional or tsunami-like; it nei-
ther follows a single direction nor is characterised by a regular, linear configuration.

Medicalisation and ‘semi-pathological pre-illness at-risk states’

Medicalisation is surely the most recurring subject in sociology of health. A great number of
studies have contributed to describing and analysing this phenomenon over the past 40 years.
In its simplest form, it is conceptualised as the extension and expansion of medical jurisdiction
through new spheres of social life. Medicalisation has been historically studied from two main
standpoints: from the angle of professional dominance and from a definitional approach. Origi-
nating from the radical theory of medical imperialism (Illich, 1974, Navarro 1988), the notion
of the professional dominance that bestowed on physicians a major role in the medicalisation
process, refined itself towards a rigorous analysis of professional dynamics (Freidson, 1970,
1988). Research interests included the issues of autonomy and clinical judgement in the con-
text of evidence-based medicine, as well as doctor–patient relationships (Collin 2010). The
definitional approach, first introduced by Zola and Conrad, is focused on a conceptualisation
and redefinition of the boundaries of illness and of the nosographic tools used in institutional
processes, together with technoscientific developments and their political and economical
underpinnings. Since Conrad and Zola’s foundational works were published, numerous studies
have followed this definitional path, exploring the medicalisation of aging, sexuality (perhaps
most notably pertaining to erectile dysfunction) as well as emotions and behaviour such as
depression, attention deficit and hyperactivity disorder (ADHD) and shyness. In this section of
the article, I focus on the definitional approach of medicalisation. My goal is not to provide a
synthesis of the studies related to this approach, but instead to focus on the mechanisms under-
lying the reconceptualisation of health and illness from a categorical to a dimensional perspec-
tive, using as an example the case of hypertension.

© 2015 The Author

Sociology of Health & Illness published by John Wiley & Sons Ltd on behalf of Foundation for SHIL
 The transformative power of pharmaceuticals 77

Against the backdrop of a series of transformations (including the worldwide growth of the
pharmaceutical industry, the development of medical specialties, the institutionalisation of
epidemiology and health promotion) and the proliferation of population health surveys, the
mid-20th century marked the beginning of a major reconfiguration of the relationship between
signs, symptoms and pathologies (Clarke et al. 2010, Conrad 2007). Normal curves soon pro-
vided statistical benchmarks for identifying at-risk groups (Armstrong, 1995, Greene 2007).
Before the 1970s, no effective treatment made it possible to control high blood pressure in
individuals.2 However, in the 1970s the publication of a randomised study, the first to be
founded on a large population survey, showed the positive impact of high blood pressure con-
trol on the morbidity and mortality associated with cardiovascular diseases (Veterans Adminis-
tration Cooperative Study Group Antihypertensive Agents 1970). This same period marked the
arrival on the market of therapeutic agents that effectively controlled high blood pressure.
Thus, screening rose to the top of medical concerns. What is considered high blood pressure
has changed since the 1960s (Wang and Vasan 2005) for two reasons. The first corresponds to
the progressive lowering of the thresholds that constitute abnormal blood pressure. The second
is the multiplication and increasingly complex assessment of risk factors accompanying hyper-
tension that are likely to lead to coronary disease (Will 2005). Both have contributed to pro-
gressively widening the arena in which medicine and public health intervene.
In 1999 High Blood Pressure Guidelines were published, distinguishing categories of hyper-
tension, which were established according to associated risks (World Health Organization-In-
ternational Society of Hypertension Guidelines Subcommittee 1999). Risk levels varied
according to the patient’s condition and were associated with each category of high blood
pressure, ranging from low (systolic blood pressure [SBP]: 140–159 or diastolic blood pressure
[DBP] 90–99 mm Hg), to moderate (SBP: 160–179 or DBP 100–109 mm Hg) to high
(SBP > 179 or DBP > 109 mm Hg). For example, a diabetic person showing high blood pres-
sure in the low category was nevertheless assigned a high level of cardiovascular risk. Increas-
ingly, however, a distinction was made between individuals who do not suffer from
hypertension and those who have optimal blood pressure (< 120/80), as well as from those
whose pressure is deemed to be normal (120–129/80–85 mm Hg) or high normal (130–139/
85–89 mmHg). In this last case there was also reference to pre-hypertension (Nesbitt and
Julius 2000).
Moreover, since the studies showed that there is no threshold above which the relationship
between the level of blood pressure and cardiovascular mortality is not statistically significant,
experts conclude that the lower the blood pressure, the lower the risk of cardiovascular inci-
dent (Moynihan 2010, Ritz 2007). Strictly following the recommendations issued in these
guidelines means that most of the population is considered to be above the norm, which is
established not according to the population’s normal distribution curve, but to an ideal target.
Immediately questioning whether average values should comprise the norm, the authors of an
article on this issue observed that the blood pressure values of isolated populations having
maintained a primitive lifestyle were much lower than those of contemporary Western popula-
tions: ‘This raises the question as to whether average Western values should be regarded as
normal’ (Law and Wald 2002: 1573).
Thus, although recent American High Blood Pressure Guidelines (James et al. 2014) recom-
mend less strict blood pressure goals for older adults, the category of normal blood pressure is
now defined as < 120/80 mm HG, and that of pre-hypertension (120–139 or 80–89 mm Hg)
including categories that were previously defined as normal and high normal in the 1999
Guidelines.
In fact, the idea that prevention – the first line against disease – can avoid the accumulation
of a confirmed health problem or even pre-empt its appearance serves as a starting point for
© 2015 The Author
Sociology of Health & Illness published by John Wiley & Sons Ltd on behalf of Foundation for SHIL
78 Johanne Collin

detecting and diagnosing potential problems as pre–problems or proto-diseases (Rosenberg

2007), as the very notion of pre-hypertension illustrates (Moynihan 2010).
The conceptualization of high blood pressure is very clearly seen here from a dimensional
rather than categorical perspective. Indeed, being increasingly used before health problems
appear, medications play a major role in blurring the boundaries between the normal and the
pathological and lowering the threshold for medical intervention. In fact, the risk itself
becomes a disease to target and on which prescription drugs will intervene (Dumit 2012).
The case of statins used in the treatment of hypercholesterolaemia further illuminates the
role played by medications. Indeed, there is a progressive lowering of the threshold for inter-
vention, that is, the recommendations to proceed, or not, with statin therapy. Guidelines for
the management of dyslipidemia published in 2013, which raised important debates among
clinicians, could lead to a significant increase in the number of patients for whom statins are
indicated (Park 2014). Many other examples can be found to illustrate the role of medications
in the management of risks and the lowering of thresholds for intervention, one of which being
HIV ‘treatment as prevention’ (Alert n.d.)
Once the problem is made public, the marketing of new medications catalyses the reorienta-
tion of the targeted population’s normative expectations and thus starts playing an integral part
in defining the boundaries of this nosological entity, paired with identifying and marketing its
solution. It is clear how drugs contribute to the blurring of the border between what is normal
and pathological in these situations where treatment thresholds for medical intervention are
steadily lowered.

Molecularisation: drugs and the extension of human limits

A similar process of dissolution of the great divide between two dichotomous categories
has occured through the molecular perspective that characterises contemporary societies.
Debates are numerous as to the breaking down of the boundaries between nature and cul-
ture or nature and artifice (Bensaude-Vincent and Newman 2007, Miah 2008, Rheinberger
2000, Rose 2007). In fact, it is increasingly harder to maintain that these are substantial
and antinomic categories in the face of developments in genetics, stem cell research and so
on. Franklin (2000) suggested that decoding the genomes of plants, animals and humans
and placing them under the aegis of corporate capital has lead nature to become denatu-
ralised. Thus, many authors suggest using the concepts of ‘nature-culture’ (Haraway 2004)
or ‘naturecultures’ (Latimer and Miele 2013) since these two categories are co-constitutive
entities and are defined only in relation to one another. Indeed, nature and culture can be
understood as two poles of orientation in an inhabited world, and not as discrete, alterna-
tive categories.
However, while for some authors the ontological distinction between nature and culture is
henceforth fictional; that is, if such a distinction ever existed, it must be acknowledged that
because of their philosophical and moral scope and their inevitable impact on our use of medi-
cal technologies, we cannot relegate these categories to the status of ‘popular prejudices or that
of an irrational nostalgia of the past’ (Bensaude-Vincent and Newman 2007: 3). Rather, nature
and culture are at opposite ends of a spectrum. Even though they may be fictional, they consti-
tute the poles of an evolving polarity that bind a society’s views on what is natural and what
is artificial.
The concept of molecularisation introduces a new dimension with regard to medicalisation,
which is intimately linked to Clarke’s theory of biomedicalisation (Clarke et al. 2003, 2010)
and to what Rose (2007) designates as the politics of life itself. According to these authors,
© 2015 The Author
Sociology of Health & Illness published by John Wiley & Sons Ltd on behalf of Foundation for SHIL
 The transformative power of pharmaceuticals 79

there is an epistemological rupture – or at least a ‘step-change’ (Rose 2007: 4) rather than a

simple accentuation of the phenomenon – between medicalisation, which characterises a large
part of the 20th century, and biomedicalisation in the era of vital politics that characterises the
21st century. According to Rose, this vital politics:

Is neither delimited by the poles of illness and health, nor focused on eliminating pathology
to protect the destiny of the nation. Rather it is concerned with our growing capacities to
control, manage, engineer, reshape, and modulate the very vital capacities of human beings
as living creatures. (Rose 2007: 3)

Indeed, the suffix bio in biomedicalisation signifies the major influence that molecular biology
acquired, from the 1950s, on the body of knowledge and practices in the fields of life sciences,
medicine and therapeutics. The development of molecular biology set forth a change of scale
within the clinical and scientific gaze and a significant increase in our capacity to modify,
transform and improve our metabolism, organs, body and brain.
However, molecularisation, which is accompanied by an ensemble of political, economic,
cultural, social and identity-related mutations or transformations, also constitutes a style of
thought (Hacking 1992). In other words, molecularisation does not only drive the use of new
technologies or scientific knowledge; this process also introduces more fundamental transfor-
mations in manners of thinking, considering and interpreting phenomena and their respective
solutions (Hacking 1992).
Yet, some authors ctiticise the biomedicalisation or molecularisation thesis for being too
totalising (see specifically Latimer [2013] in The Gene, the Clinic and the Family, as well as
the debate on geneticisation between Kerr (2004) and Hedgecoe (2004). Latimer and Kerr
insist that the thesis over-emphasises changes in the clinic (clinical gaze and diagnostic reason-
ing) following advances in molecular biology and genetics. According to these authors, the
molecular era is more a continuation of than a rupture with the preceding one.
Nonetheless, through precise interventions at the molecular level, the delineations of what is
natural and what is artificial are constantly being redefined. According to Nikolas Rose: ‘In
principle, it seems, any element of a living organism – any element of life – can be. . . manipu-
lated and recombined with anything else’ (Rose 2007: 83). Imagining a society at a molecular
level entails the possibility of ‘remaking life and death’ (Franklin and Lock 2003) and extend-
ing human limits. New reproductive technologies (including artificial uteri), which permit the
reprogramming of the beginnings of life on one end and driving back the aging process on the
other, are emblematic of the transformation of the technoscientific and medical gaze on life
itself. Molecularisation is accompanied by a process of geneticisation, reflecting a promise of
customised and personalised medicine through pharmacogenetics (Hedgecoe and Martin 2003).
Paradoxically, the promise of hyper-individualisation through the genetic decoding of individu-
als coexists with complete depersonalisation. Indeed, bodily products (including cells, tissue
and DNA fragments), as well as organs, have become bio-objects detached from the social
identity of the bodies from which they are harvested and commoditised. Although many
authors have considered the processes of molecularisation and geneticisation – as well as the
possibilities of extending human capacities – as leading to the production of robotised bodies,
even cyborgs (Haraway 2004), Rose proposes that, within the dynamics of the politics of life
itself, the shaping of the bios must pass through interventions on the zo€e, rendering individuals
not less, but more biological:

© 2015 The Author

Sociology of Health & Illness published by John Wiley & Sons Ltd on behalf of Foundation for SHIL
Sociology of Health & Illness Vol. 38 No. 1 2016 ISSN 0141-9889, pp. 73–89
doi: 10.1111/1467-9566.12342

On social plasticity: the transformative power of

pharmaceuticals on health, nature and identity
Johanne Collin
Research Group on Medications as Social Objects and Faculty of Pharmacy, Universite de
Montreal, Canada

Abstract This article proposes a theoretical framework on the role of pharmaceuticals in

transforming perspectives and shaping contemporary subjectivities. It outlines the
significant role drugs play in three fundamental processes of social transformation
in Western societies: medicalisation, molecularisation and biosocialisation. Indeed,
drugs can be envisaged as major devices of a pharmaceutical regime, which is
more akin to the notion of dispositif, as used by Foucault, than to the sole result
of high-level scheming by powerful economic interests, a notion which informs a
significant share of the literature. Medications serve as a key vector of the
transformation of perspective (or gaze) that characterises medicalisation,
molecularisation and biosocialisation, by shifting our view on health, nature and
identity from a categorical to a dimensional framework. Hence, central to this
thesis is that the same underlying mechanism is at work. Indeed, in all three
processes there is an evolving polarity between two antinomic categories, the
positions of which are constantly being redefined by the various uses of drugs.
Due to their concreteness, the fluidity of their use and the plasticity of the
identities they authorise, drugs colonise all areas of contemporary social
experiences, far beyond the medical sphere.
A video abstract of this article can be found at: https://www.youtube.com/watch?
v=djIBY7DHKW4&feature=youtu.be

Keywords: biomedicine, drugs and medication, medicalisation, norms and values,

pharmaceuticalisation, biopolitics

In contemporary Western societies pharmaceutical drugs are central to the lives of individuals.
From birth to death, these substances colonise every life phase. Since the 1980s the social nat-
ure of medicines has become a field of study, notably in pharmaceutical anthropology (van der
Geest 2006). Seminal work in this field (Nichter and Vuckovic 1994, van der Geest and
Whyte 1989) explored the meanings of pharmaceuticals, how their use conveys ideologies and
values, and the way they transform social dynamics. In anthropology (Nichter and Vuckovic
1994, Whyte et al. 2002) as in sociology (Cohen et al. 2001), scholars have proposed a bio-
graphical approach to the study of pharmaceutical drugs that considered these as both material
and cultural objects inherent to a lifecycle, from the starting point of their production (design
in the laboratory, development and marketing) to their distribution (prescription and dispensing
by professionals), and finally to their daily consumption by laypeople).1

© 2015 The Author. Sociology of Health & Illness published by John Wiley & Sons Ltd on behalf of Foundation for SHIL.
This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits
use and distribution in any medium, provided the original work is properly cited, the use is non-commercial and no modifications or
adaptations are made.
 The transformative power of pharmaceuticals 81

technology, would allow returning to a natural order of things, thus shifting the boundaries
between the natural and the artificial.
Elimination of the need for sleep by modafinil, a drug originally designed to treat nar-
colepsy, can also be considered appealing in the bio-capitalistic perspective of seeking hyper-
productivity and performance, and aiming to conquer the sleeping body as much as the waking
body (Coveney et al. 2009, Williams et al. 2008). Beyond an individual’s desire to free them-
selves from the limitations imposed by the need for sleep, an argument is developing in sup-
port of the mandatory use of this medication in the context of certain occupations requiring
around the clock alertness, for instance, in military operations (Eliyahu et al. 2007, Williams
et al. 2008). Indeed, a recent study indicates that off-label use of modafinil increased 15-fold
between 2002 and 2009 in the USA (Pe~ naloza et al. 2013).
In the case of suppressed menstruations or the elimination of the need to sleep, the process
at work reaches beyond a simple desire for optimisation or enhancement through micro-manip-
ulations aiming at transforming bodies and selves for lifestyle promotion. As bio-politics are
orchestrated to make these drugs not only accessible but potentially obligatory in certain con-
texts, namely in the workplace, one can envision a collective exemption from certain physical
limits progressively setting into place as it moves the boundary between the natural and the
artificial.
Pharmaceuticals then follow the same itinerary, whether the issue at hand is menstrual sup-
pression or sleep elimination. Initially approved for specific health problems, the demand for
these drugs quickly rises to support lifestyle and personal choices. Their mandatory use is then
contemplated in certain work settings while scientific arguments, justifying a generalised use
in the name of health, public safety and the good of society, proliferate. The extent to which
that drug-taking is systematised (organised, collective and mandatory) to extend the body’s
limits will ultimately have the effect of naturalising bodily states that would have been, until
then, considered artificial.

Biosocialisation: drugs and the tension between conformity and resistance

According to this model, biosocialisation may be conceived as a mechanism through which

there is a progressive superimposition of two antinomic conditions: inclusion in and exclusion
from society. While there has always been a tension between inclusion and exclusion, it is
increasingly common for individuals to be fully integrated in a community while simultane-
ously marginalised or stigmatised by society.
This dimension directly calls upon the concepts of biosociality (Rabinow 1996) and bio-citi-
zenship (Petryna et al. 2006, Rose and Novas 2005). As stated by several authors, there is a
reshaping of collective identities in contemporary Western societies through the genetic,
somatic or physical attributes that individuals share and around which they are mobilised
(Clarke et al. 2010, Rose 2007).
However, we can also envisage the shaping of collective identities through attitudes towards
pharmaceuticals and the ways in which individuals organise their shared experiences in rela-
tion to them (Hardon et al. 2013). Drugs serve as catalysts when they become the object
around which new socialities appear, be it through non-medical or illicit use, as in the case of
cognitive enhancers (also called smart drugs), or through the rejection of a diagnostic label
and subsequent treatment, as in the management of extreme shyness with psychotropic drugs.
Pharmaceuticals would then play a significant role in building collective identities through
individuals sharing their experiences related to consuming the drugs or, on the other end of
the spectrum, their refusal to use them.
© 2015 The Author
Sociology of Health & Illness published by John Wiley & Sons Ltd on behalf of Foundation for SHIL
82 Johanne Collin

Thus, through the construction of individual and collective identities, there is also a tension
between conformity – via a standardisation and normalisation of behaviour and appearances –
and resistance to this homogenising force. Indeed, the relationship between these two poles is
made more complex in that it leads to a reflection on the tensions between specificity and

standardisation, a late modern version of Norbert Elias’ 
civilizing process (Elias, 1994), where
the requirements of conformity to the ways of relating to others are an inherent paradox. The
valorization of autonomy that characterises contemporary Western societies implies that indi-
viduals must be themselves as much as possible (Ehrenberg 2010). They have to constantly
re-edit their image, and perform and obtain recognition for their distinctiveness. However, at
the same time, they have to conform to social norms. Georg Simmel aptly captures this
ambivalence in his analysis of fashion (Simmel and Wolff 1950). According to Simmel, fash-
ion incarnates the tension between social imitation on the one hand – being fashionable means
following the trends – and, on the other, being concerned with individual distinction – build-
ing, preserving and developing one’s image, and expressing it through fashion. Aspiring to be
as much oneself as possible, in fact, means meeting social expectations for performance and
autonomy. In societies where the somatic is a powerful dimension for uniting individuals
around a common identity, conformity – via a standardisation and normalisation of behaviour
and appearances – and resistance – to this homogenising force – are the two ends of a contin-
uum underlying the process of biosocialisation.
This tension between inclusion and exclusion, as well as between conformity and resistance
is exemplified by the cases of extreme shyness on one end, and of the non-medical use of cog-
nitive enhancers on the other.
Extreme shyness first appeared in the Diagnostic and Statistical Manual of Mental Disor-
ders (DSM) III in 1980 under the label of social phobia. The prevalence of social phobia (la-
belled social anxiety disorder (SAD) in more recent editions of the DSM) was then estimated
to be between 1.2 and 2.2 per cent of the total population (Horwitz 2010). Ten years later this
was revised to 13 per cent. This rise is partly due to a reduction of diagnostic criteria – in
numbers as in severity, making them more inclusive – but also to the marketing of antidepres-
sants approved for the treatment of social phobia (Collin and Otero 2015). Wide commerciali-
sation of these drugs confers a deep social resonance, a tangible reality, to extreme shyness,
bolstering its public awareness. Social phobia is a good example of the co-construction of a
new ‘disease’ via the mutual influence of psychiatrists, patient groups and pharmaceutical
companies (Horwitz 2010, Lane 2007, Scott 2006).
However, the medicalisation of this condition does not constitute its most intriguing aspect.
Rather, it is this tension between conformity and resistance. While some people find a new
social space in patient support groups, allowing for collective learning from the personal expe-
riences of others, numerous websites aim to resist the label of SAD or even of shyness – and
to assert the specificity of its followers as introverts. Interestingly, the mediatised translation of
this concept in popular discourse is no longer extreme shyness, but simply shyness. The issue
today is how to distance oneself from the stigma of the shy label and embrace the introvert
identity. Websites providing information and support are indeed very important in forging a
collective identity that redefines shyness or introvert behaviour outside the realm of medicine.
For introverts, the plague is not the illness but the necessity to conform to the norm of extro-
version, sociability and loudness. Enjoying solitude and quiet endeavours is not what is cur-
rently socially valued, as this quote, taken from a website where patients and physicians share
information and experiences, demonstrates:

So, the ex’s have it. Extraversion IS the norm. Introverts are the outsiders, struggling to fit
into a world set up for the numerical majority. (McManamy 2010)
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 The transformative power of pharmaceuticals 83

Redefining identity in physiological and molecular terms, through describing how the brain
works differently for introverts and extroverts, is rather common on blogs and support web-
sites:

Introverts have more brain activity in their frontal lobes and when these areas are activated
through solitary activity, introverts become energized through processes such as problem
solving, introspection, and complex thinking. . . There’s a deeper science to this that
involves differences in the levels of brain chemicals such as acetylcholine and dopamine in
extroverts and introverts, but I won’t get into that. (ProperlyChastised, n.d.)

Thus, introverts would also define themselves as neurochemical selves, albeit of a different
neurochemical kind, and seek social approval of that difference. Even further, the idea is to
convince others that society needs introverts, that they can make it a better, more balanced
place. This movement is unmistakably expanding, with the publication by former lawyer-
turned-writer Susan Cain’s (2012a) book Quiet: The Power of Introverts in a World That
Can’t Stop Talkin). The TED Talk she presented in 2012 has attracted 9 million views and
earned a place among the top 20 most viewed talks (Cain 2012b). The author also manages a
webpage and a blog on introvert empowerment (Cain n.d.) and has 49,000 followers on twit-
ter. According to Cain, introverts think more deeply, concentrate better, are more inventive,
more insightful, and more sensitive and moral than extroverts. Several other support groups
sites (such as Quietly Fabulous, n.d.) and self-help books adopt a similar direction (Ancowitz
2010, Wagele 2006).
In this case, there is much more than a process of medicalisation or de-medicalisation at
play. Both the social critique and the affirmation of a radically different and marginal identity
vis-a-vis the norm accompany a claim for integration into society. However, this identity is
also forged in opposition to the one defined by the DSM and widely disseminated through
direct-to-consumer-advertising for prescription drugs.
With regard to the case of cognitive enhancers or smart drugs, it is not the refusal of medi-
cal use but rather the non-medical use of medications that is of concern. Among the pharma-
ceuticals that are used as cognitive enhancers, methylphenidate, amphetamine salts and
modafinil are most often referred to. Over the last decade an increase in the use of psychostim-
ulants among college and university students has been observed, notably to improve academic
performance, comply with expected standards, facilitate social interactions and better answer
cultural norms concerning behaviour and appearance, for example, by using psychostimulants
to lose weight (DeSantis et al. 2008, Quintero 2009). Most ethical debates on the use of smart
drugs raise the question of the normative and moral boundary between students who take part
in such practices and those who do not (Cakic 2009, Greely et al. 2008). However, other
issues are also directly related to this phenomenon, such as the multiple sources of information
available on drugs and drug use, as well as the influence of peers on the construction of prac-
tices. DeSantis et al. (2008) observed that most illicit users of ADHD medications had limited
knowledge about these drugs and their effects. Their main sources of information were the nar-
ratives of their peers’ experiences and their accounts of these medications as ‘miracle’ or
‘study’ drugs.
Yet, it is warranted to contemplate the phenomenon of non-medical use of psychostimulants
through the lens of body projects that must lead to academic success in the context of a com-
petitive ethic. In contemporary Western societies, the body is the path though which identities
are exposed and expressed (Rose 2007). The project of the self is in many respects also a
body project, which is related to self-management and embodied control. The logic of perfor-
mance and the requirements for control that exist in the academic setting seem to converge
© 2015 The Author
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84 Johanne Collin

towards what Davis (2009: 40) calls the ‘enterprising of the self’. This refers to the logic of
productivity within which an individual must develop their capacities to the maximum and
become successful in every sphere of their life, be it social, academic or related to health and
the body.
Thus, having control over one’s health, body and performance can signify, for some, not
having to take any medications (Collin et al. 2012). Conversely, for others, the use of pharma-
ceuticals allows the attainment of maximum performance levels and, consequently, control
over body and health. Through pharmaceuticals the body becomes instrumentalised. It can be
put to sleep or stimulated at will; it can be reprogrammed in a way that allows individuals to
answer to the performance requirements that weigh them down. Thus, while illicit users of
ADHD medications are those who most intensely adhere to the competitive ethic found in aca-
demia, can they truly be considered deviant and marginal or are they rather more closely
assimilated to the neoliberal ideology of productivity and performance that characterises Wes-
tern societies? In the case of smart drugs, as with shyness, pharmaceuticals reveal themselves
as powerful devices for shaping identities and blurring the boundary between inclusion and
exclusion, as well as between conformity and resistance.

Conclusion

In this article I have suggested that drugs are major devices of the dispositif of the pharmaceu-
tical regime that characterises contemporary Western societies. Pharmaceuticals play a signifi-
cant role in the transformation of perspective (or gaze) that characterises medicalisation,
molecularisation and biosocialisation. They achieve this by shifting our views on health, nature
and identity from a categorical to a dimensional framework. Thus, central to this conceptuali-
sation is the assumption that the same basic mechanism is at work in these three processes.
This does not entail that pharmaceuticals are the only devices able to act on our conception of
nature, illness and identity. However, the reason they play a crucial role in this process is that
they colonise every sphere of contemporary social experiences, reaching far beyond the medi-
cal realm. Therefore, I would like to conclude by proposing that three characteristics distin-
guishing drugs from other medical technologies significantly contribute to the colonisation of
all social spheres by pharmaceuticals.
The first is their materiality (their concreteness), which provides them with a metonymical
function (van der Geest and Whyte 1989). In other words, the medical and scientific expertise
is incorporated into the object itself: the pill. This is different from other medical technologies
that require a medical setting (medical instruments and experts) to implement them. Both the
concrete and the metonymic nature of prescription drugs allow the layperson to re–appropriate
their uses and effects. This democratisation of technology bestows drugs with enormous poten-
tial for social transformation, as it facilitates shifting their use towards enhancement, such as
in the case of cognitive enhancers, or other nonmedical outcomes, for example, improving
one’s lifestyle or answering to the demands of productivity, as in the case of menstruation and
sleep suppression. Thus, this materiality increases the potential for the autonomisation of tech-
nology.
This also implies that the same molecules have different end uses (and even effects) depend-
ing on the contexts in which they are consumed. Indeed, the very same drug can be taken, as
Conrad and Potter (2004) have shown, to repair, normalise or enhance. This second character-
istic plays an important part in redefining the limits not only between normality and pathology,
but also between the natural and the artificial as well as between inclusion and exclusion. The
multiple end uses of drugs contribute to opening up the social spaces in which they circulate.
© 2015 The Author
Sociology of Health & Illness published by John Wiley & Sons Ltd on behalf of Foundation for SHIL
 The transformative power of pharmaceuticals 85

Finally, the third characteristic – temporality – is directly connected to identity. Drugs act
on the individual’s spatial and temporal configuration by shaping identities through practices,
as we have shown in reference to biosocialisation. It is also achieved through a shift in the
boundary between what is normal and pathological, while the marketing of new pharmaceuti-
cals contributes to the creation of new ‘ill in the making’ identities. Moreover, the significant
prevalence of chronic disease means that most medications are taken on a daily basis to con-
trol rather than to cure diseases. The positive effect disappears as soon as the medication is
stopped, for instance, in the case of hypertension. The effect is thus temporary, as opposed to
the permanent effects of other medical technologies such as stem cells. In this perspective,
pharmaceuticals introduce a plasticity of identities because they make a certain reversibility of
effects and conditions possible.

Address for correspondence: Johanne Collin, Faculty of Pharmacy, Universite de Montreal,

C.P. 6128 Succ Centre-Ville Montreal Quebec H3C 3J7, Canada. E-mail: johanne.collin@
umontreal.ca.

Acknowledgements

The author would like to thank the anonymous reviewers as well as the editors for their thoughtful com-
ments. She also wishes to express her gratitude to Hugo C. Desrosiers for providing valuable comments
on previous versions of this article. This work was supported by the Quebec Research Fondation on Soci-
ety and Culture (FRN 2014-SE-171506) and by the Canadian Institutes of Health Research (FRN
115165) and (FRN 98739).

Notes

1 Of course, there have also been an important number of anthropological studies on drug efficacy and
its perception by laypeople that also emphasise the importance of context in shaping pharmaceutical
efficacy, but this is not the focus of this article (see Schlosser and Ninneman 2012).
2 The situation is certainly more complex and, according to the American National Health Examination
Survey (NHES), concern over high blood pressure began growing since the early 1960s. However, it
was only in the mid-1970s that a real leap both in the awareness of the problem and a call to action
occurred. For further details, see Greene (2007), Wang and Vasan (2005).

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