Confronting Health’s Normality Bias

In every aspect of society, the concept of normality is both ubiquitous and insidious. It is so often referenced that it rarely draws attention to itself in our thinking, speaking, and writing. In some instances, normality is used in a culturally unproblematic or benign manner. For example, normality could refer to what is common, usual, habitual, or the proper functioning of organs. It can also refer to normalcy at an individual level, such as when a doctor understands someone’s “normal” state or level of functioning.

While “normal” seems like an innocent term, its cultural baggage reveals complex and derisive implications. Regardless of the intention of the person using the term, normality inherently draws a distinction between the normal and the abnormal. Even more problematically, this binary elevates the normal over the abnormal, which places a value distinction on human existence.

Since medicine equates normality with health, this value distinction implies that sick people, people with disabilities, or otherwise “unhealthy” people are less worthy. In valuing some human beings over others, the term is misaligned with health justice, which is grounded in equity. The etymology of the term sheds light on how it became an instrument of marginalization and discrimination.

Normality’s Historical Significance

You want to watch out for [words] whose influence is felt everywhere, but whose location and operation remain somehow invisible.

Elizabeth Stephens, #notnormal

It is also crucial to point out that the term “normal,” not coincidentally, made the leap from mathematical to popular use while eugenics gained momentum.

Philosophers and historians trace the concept of normality to the 18th century when it functioned as a statistical concept. At that time, normality was used to reference the (normal) distribution curve. Accordingly, normal at the dawn of statistics merely referred to a range of variations or a probable outcome. Since medicine also relies on statistics, normality became a mainstay in medical discourse when Francis Galton combined the statistical conceptualization of the normal as the average and the medical conceptualization of the normal as the healthy.

The meaning of “normal” shifted to its more socially and culturally loaded form in the late 19th century. The term, as well as the constellation of synonyms and antonyms that codify its meaning, entered the English language between 1840 and 1860. At this point, rather than a mathematical term, normal came to mean regular, usual, or conforming to the common type or standard.

It is also crucial to point out that the term “normal,” not coincidentally, made the leap from mathematical to popular use while eugenics gained momentum. In fact, Galton, who is considered the originator of medical statistics, coined the term “eugenics” in 1883. Essentially, eugenic ideology created hierarchies that separated people closer to the societal norm at the time (desirables) from everyone else (undesirables).¹ Desirable people—who were also White, adherent to the gender binary, heterosexual, and perceived to have “normal” bodies and minds—were elevated in all areas of society. Desirables were also urged to procreate to pass on their “biological advantages” to future generations. Undesirables were removed from society through a variety of means, including restrictive immigration policies and institutionalization in mental facilities. Throughout most of the 20th century, this part of the population was discouraged from passing on their genes to future generations, leading to the forced sterilization of 62,000 people in the United States.

Since normality had become a standard reference point in science and medicine, it became a useful tool for eugenicists who sought justifications for racism, sexism, xenophobia, homophobia, and ableism. Though now considered a pseudoscience that justified centuries of human rights violations, the doctrine drew favor from both sides of the political spectrum in the early 20th century, ingraining it in America’s social, political, and cultural landscape.² The historical coemergence of normality and eugenics lays bare its tendency to degrade, dehumanize, and even legitimize violence toward people outside the so-called norm.

Modern Medicine and Normality

Today, the concept of normality is constantly reified in medicine and the health sciences, where medical doctors, psychologists, psychiatrists, and psychoanalysts use the term with disturbing frequency in their writing. In addition to the proliferation of normality in scientific discourse—due, at least in part, to the prominence of statistics and other quantitative methods—the concept of normality has also been incorporated into clinical guidelines and decision algorithms.

What is considered normal then functions as a hidden system of compulsory conformity and as an exclusionary tool for those labeled “abnormal.”

There are limits to normality in the medical profession; every commonly held trait is not accepted as a “normal” human condition. Regarding mental health, for instance, over time, doctors have exercised their authority to create a statically smaller and finite understanding of what is considered normal. Additionally, since normality is idealistic, it relies on an ideal of optimal functioning that is unrealistic. The shrinking nature of what is considered medically “normal” and its conflation with perfection has made normality, in the context of medicine, less and less achievable.

The diagnostic classification manuals, such as the Diagnostic and Statistical Manual of Mental Disorders (DSM) and the International Statistical Classification of Mental and Behavioral Disorders (ICD), have increasingly included the term “normal” as a baseline while designating any variations “abnormal.” “Normal” is used 19 times in the first edition of the DSM, published in 1952. But normal is used 366 times in its more modern adaptation, the DSM-5, released in 2013. The ICD-10, published in 1992, uses normal 259 times, while the ICD-11, published in 2020, uses it 1,445 times.

Problematic Normalities 

 To normalize is to “impose a requirement on an existence.”

Georges Canguilhem, On the Normal and the Pathological

Throughout our society, normality operates as a standard that prescribes how a person ought to be and marginalizes those defined as “others.” Therefore, what is considered normal then functions as a hidden system of compulsory conformity and as an exclusionary tool for those labeled “abnormal.” Subsequently, the unreflective and uncritical use of normality perpetuates harm in different, domain-specific contexts:

• The Normal Brain

Due to shifting social structures and the expectations associated with them, some behaviors that were once considered within the realm of ordinary human variation are now viewed through the lens of abnormality. For instance, shyness could be the catalyst for a medical intervention. However, rather than labeling shyness as an “abnormal behavior,” we could change societal expectations of how people behave in novel situations.

The idea of the normal brain works to pathologize and (dis)qualify individual human brains, to justify medical and behavioral interventions that can be damaging, and to legitimize status quo educational practices. When normality is centered on mental health, certain types of cognitive processing, emotion regulation, and behaviors are seen as deficient rather than different, even though, as advocates have long argued, there is no such thing as a normal human brain.

• The Normal Body

The “normal body” is closely tied to Victorian notions of the ideal body, which reflects the beauty norms of that time. Constrictive gender norms—based on a heteronormative, binary understanding of femininity and masculinity—are also part of the concept of the normal body. Additionally, the notion imposes standards that threaten the bodily integrity of intersex people, stigmatizes a variety of bodily proportions, and rejects people of color as “others.”

The idea of the normal body has also promoted unjust narratives about differently abled people. In medicine, the normal body is also strongly linked to medicalization—the process by which nonmedical problems become defined and treated as medical problems—which very literally imposes the physical expectations associated with normality on otherwise healthy people.

• The Normal Family

The concept of a normal family renders less “traditional” family structures invisible or deviant. Throughout American history, the concept of the normal family, which has always been synonymous with the traditional nuclear family, has been used as a political tool to disparage other family types. Several of these family types—such as same-sex couples, same-sex parents, single parents, parents who are not biologically linked to their children, and other types of nonbiological familial structures—have been socially and politically undermined by laws and policies that delegitimize their existence.

Moving beyond Normality to Embrace Our Common Humanity  

Homo sum, humani nil a me alienum puto: I am a human being, nothing human can be alien to me.

Maya Angelou

Normality has become a common, often unquestioned term in science and medicine. In addition to its professional use, it is also a culturally loaded and diffuse term in the Western consciousness.

Cultural theorists, historians, social scientists, philosophers, and medical professionals have done the important work of shedding light on the problematic nature of normality as a concept and how it operates in our society. These thinkers have specifically taken issue with the overuse of the term in medicine because when the concept is imposed on patients, it fails to honor the lived experiences of those systematically excluded by the social, cultural, and medical authority of the normal. Normality as a concept also draws on the authority of medicine to control socially undesired behavior. Therefore, due to the hidden costs associated with the term and the ideas it represents, health professionals should exercise caution before using the term with patients.

When it comes to buying into the concept of normality and its covert meanings, medical professionals and healthcare workers should conduct a risk-benefit evaluation of the term’s use. As many theorists and clinicians have argued, there is little benefit to using the term in medicine, but there are significant risks. When normality is used as a synonym for health, it minimizes and demeans people in ways that entrench social inequalities and perpetuates care disparities. Research has identified mental illness-related stigma, for instance, as a major barrier to recovery. And people stigmatized by mental illness are more likely to receive poorer quality physical care. Furthermore, health-related stigma—physical, mental, social, or some combination thereof—deteriorates people’s health by triggering stress and other damaging emotional and behavioral responses.

Of course, abstaining from the term and the set of standards and assumptions accompanying it is a good first step toward realizing the diverse humanity of all people regardless of their unique mental, physical, and social attributes. This first step was embodied by the Ban Any Normality project, an effort by the Swiss National Science Foundation and the Institute for Biomedical Ethics at the University of Basel. The project challenged the public to be critical of using the term normal and the asymmetrical power relations it sustains, and to stop labeling people abnormal.

Though reminding ourselves that normality is a concept that simultaneously reflects and reinscribes systems of power and privilege, we need to move beyond omission to access frames of mind that more fully support humanity in all its forms. We can take cues from Maya Angelou, for instance, whose legacy reminds us to use language for its constructive power rather than its destructive nature and to approach all other human beings from the perspective of commonality and understanding.   

Notes

1. Daniel J. Kevles, “Eugenics and Human Rights,” British Medical Journal 319, no. 7207 (1999): 435–8.
2. Ibid.