On Medical Domination

ABSTRACT

In this article, I propose and define the concept of medical domination by combining insights from political sociology, Bourdieu's theory of domination, and intersectional perspectives. Drawing on a multi‐sited ethnographic study of abortion services in France, I analyse how a set of legitimised and institutionalised power practices shape access to care despite growing emphasis on patient autonomy. This conceptualisation helps explain disparities in healthcare access and quality, showing how medical interactions reproduce social hierarchies beyond the clinical setting. The paper contributes to political sociology of health by examining both structural foundations of medical power and the socialisation processes through which professionals learn to exercise authority and patients learn to submit to it.

1. Introduction

Medical power has been constituted as a research object in health sociology through complementary perspectives. One examines the power of the medical profession in the political field (Hassenteufel 1997; Stevens 2001). Another emphasises medical authority over other professions within the division of labour in healthcare systems (Freidson 1970). A third studies medicine as a central component of biopolitics (Foucault 1977, 1978, 2008; Casper and Clarke 1998; Clarke et al. 2003) and the governance of bodies and behaviours (Conrad 1992; Rose 2007), particularly at the boundaries of life and death (Memmi 2003). And the fourth focuses on physicians' power over users through the lens of discrimination and the health inequalities it produces (B. G. Glaser and Strauss 1965; B. Glaser and Strauss 1968; Roth 1972), notably by considering care as the result of negotiation between individuals unequally endowed with resources (Strauss et al. 1985).

This article extends this latter perspective. It focuses on physicians' capacity to control users' behaviours, access to and modalities of care. Drawing on the political sociology of domination, it proposes an innovative conceptualisation of the medical domination relations articulating power dynamics within medical interactions with objective structures and incorporated dispositions that enable this power's success and reproduction. It demonstrates the value and scope of this theoretical proposition by applying it to abortion care.

2. Conceptualising Medical Domination

What is medical domination? I first provide a theoretical definition rooted in a tradition of political sociology. I then trace the foundations of this domination in the institutionalised dependence of laypeople on physicians. Finally, I describe what this conceptual proposition brings to an intersectional analysis of power relations at work in the medical relationship.

2.1. A Political Sociology of Medical Domination

Sociological analysis of health and medicine has long been dominated by the sociology of professions, delaying the mobilisation of other theoretical frameworks. With the exception of Foucault's analyses of biopower and medicalisation, classical works in the sociology of domination such as those by Marx, Weber, or even Bourdieu remain relatively underutilised. However, the application of Bourdieusian concepts to health analysis has been developing for 2 decades through dispositional analysis of doctors or patients (Luke 2003; Castro 2014; Darmon 2016), analysis of the medical field (Pinell 2005; Brosnan 2010; Collyer et al. 2017), or cultural health capital (Shim 2010). ¹ To theorise medical domination, I extend this movement by combining the work of Weber and Bourdieu. Max Weber dedicated an entire section of Economy and Society to the study of forms of power and domination. He defines power (macht) as the ‘possibility of forcing other people to modify their behaviour according to one's own will’ (Weber 2015: 44, my translation), and domination as a particular case—legitimate power, where the dominated person acquiesces, where the power relation is recognised as valid and can dispense with coercion. Considering medical domination from a Weberian perspective means examining not only doctors' power to control patients' behaviour but also its legitimation processes (Lagroye 1985). Pierre Bourdieu extends this analysis in two notable ways. First, by highlighting that processes of obedience and legitimation of power rest not only on explicit and rational justifications of power practices by actors (Boltanski and Thévenot 1991) but also on incorporated cultural schemes that conceal power relations, habituate people to them, and lead them to reproduce them in practical and unintentional ways. ² Second, by considering these power relations to which individuals are socialised through the functioning of fields—systems of positions occupied by individuals competing for capital (economic, social, cultural, as well as field‐specific capital). Field analysis allows for examining both the structural dimension of power relations, the communities of interest and collective strategies of those who occupy structurally similar positions, and their competition for power positions and the definition of valued capital.

From this, I derive my definition of medical domination, which has three dimensions. First, medical domination is power—the capacity to influence others' behaviour according to one's will. Second, it is exercised institutionally and collectively by physicians, who are united in reproducing their dominant position over laypeople whilst competing for positions within the medical field. Third, this power becomes invisible through legitimation processes encompassing both rational justifications and latent mechanisms of socialisation of both physicians and laypeople to the domination relationship. Medical domination is therefore the institutionalised and internalised social relation through which medical power is exercised legitimately.

2.2. Experts, Laypeople, and Domination‐Dependence

Medical domination is rooted in an asymmetric dependence of laypeople on physicians. Patients' dependence on physicians is the consequence of multiple processes: the possession of a specific form of cultural capital (scientific and technical) by a restricted portion of the population, the monopoly on access to health goods conferred by the state, and the vulnerability of laypeople and its intensification via (bio)medicalisation and the pathologisation of bodies.

The development of pharmaceutical and medical efficacy has led to medicine's disenchantment. This is manifested by the rationalisation of therapeutic power, its separation from sacred or political functions (Bloch 1924), and its de‐individualisation and professionalisation. The charismatic domination of the healer has largely given way to the rational and disembodied domination of the expert, based on the recognition of the medical profession's collective competence (Fassin 1996, 151). ³ Contemporary medical domination is primarily the consequence of medical technical progress and the division of labour through which a minority of individuals accumulates a particular form of cultural capital that enables them to provide care. It is therefore, above all, a form of cultural domination of experts over laypeople where cultural capital operates both through its distinctive dimension (Bourdieu 1979) and through the intrinsic value of medical knowledge. On one hand, medical degrees, lengthy studies, and selective entrance examinations legitimise physicians' economic and symbolic dominance; on the other hand, the content of medical knowledge itself creates the dependence that enables domination. Physicians maintain control over this capital by defining legitimate knowledge and practices while training new members of the profession (Freidson 1970).

If patients request services and follow physicians' instructions, it is partly because they are seen as experts capable of addressing their ailments. But it is also because physicians have a state‐conferred monopoly on controlling access to healthcare resources: prescription drugs, hospitalisation, and expensive medical infrastructure and equipment. The state grants this monopoly in exchange for biopolitical services and to ensure controlled allocation of public resources and quality of care, which can only be delivered by professionals whose competence has been validated by obtaining a degree.

Finally, patients' dependence stems from their vulnerability—acute or chronic illness, continued pregnancy, abortion, assisted reproduction, etc.—which leads them to seek medical help, often urgently. This vulnerability is partly shaped by medicalisation and biomedicalisation processes that expand what is commonly seen as pathological and requiring medical management (Zola 1972; Conrad 1992; Clarke et al. 2003), particularly prevalent regarding women's bodies, such as pregnancy or abortion.

Medical domination thus rests on an impersonal relation of dependence whereby physicians hold specific cultural capital and political rights of access to healthcare resources that enable and authorise them to provide care to vulnerable laypeople. Dependence grounds domination, meaning both physicians' propensity to impose and patients' propensity to obey. The medical domination relation resembles the profoundly unbalanced relationship between parents and children, which combines, to varying degrees, benevolence and assistance or even devotion on one hand, with authority, control, and inculcation—as well as, in some cases, violence and economic or sexual exploitation—on the other. The vulnerability of both child and patient favours and justifies self‐surrender to others. Medical domination involves assimilating patients to children—hence the terms medical paternalism, sometimes maternalism or infantilisation— and endowing them with a status of ignorance. Medical work thus appears to combine inseparably a care function with a socialising function (cultural transmission and behaviour normalisation).

2.3. A Distinct Form of Social Domination

Theorising medical domination as a distinct domination relation has important epistemological implications. It makes it possible to analyse how medical domination articulates with gender, class, and race power relations rather than simply serving as a resonance chamber for them.

Sociological and historical works have demonstrated medicine's role in producing gender both through binary sex categorisation (Fausto‐Sterling 2000) and through controlling women's bodies while enforcing heterosexual norms (Riessman 1983; Memmi 2003; Dorlin 2006; Gardey 2014). Research has also shown how class inequalities and racist discrimination translate into disparities in healthcare access and quality of care (Burgess et al. 2008; Goodman et al. 2017; Morel 2019).

‘Classic’ domination relations articulate with medical domination, reinforce it, and are recomposed according to their intersections. They also co‐construct each other: gender, race, or class positions are partly formed within medical interaction. However, the asymmetry between physicians and patients does not simply results from gender, race, or class relations. While physicians generally occupy a dominant position at the intersection of various power relations in relation to patients, physicians who are themselves dominated in terms of gender, race, class, age, or sexuality can nonetheless dominate in the therapeutic relationship. For instance, a young female physician treating an older man may well have the upper hand in the interaction.

An intersectional approach (Crenshaw 1991) that examines how medical domination articulates with other power relations—rather than dissolving into them—offers analytical advantages. It avoids hierarchising domination relations a priori, allows us to grasp the heterogeneity of social groups (particularly avoiding overly uniform approaches to gender) and to analyse the specific effects of medical contexts of power.

I will illustrate the value of this theoretical proposition using empirical data from the concrete case of abortion care in France.

3. Thinking Medical Domination to Understand Access to Care: The Case of Abortion

Literature on reproductive governance has demonstrated how states, international organisations, and social movements shape, monitor, and control reproductive behaviours (Morgan and Roberts 2012; Morgan 2019). Concerning abortion, inequalities between countries according to their legal frameworks (Center for Reproductive Rights 2024) and the effects of legal and institutional barriers are extensively documented (Shah and Ahman 2010; Ona Singer 2020; Stevenson 2021). France is one of 77 countries that allow abortion at a woman's request without medical justification, though with certain conditions such as pregnancy duration limits or mandatory counselling. Initially established in 1975, the French system of medical‐psychological supervision and dissuasion has been largely dismantled through 50 years of successive reforms (Bajos and Ferrand 2011). Unlike previous generations, French women no longer must wait for a ‘reflection’ week or see a counsellor or psychologist. They can obtain abortions from home, free of charge, as many times as they need and at later pregnancy terms than before. Non‐resident foreign women may now also access the procedure, and minors no longer need parental authorisation. While legal limits persist—notably a maximum 14‐week gestational term—the changes have been substantial.

However, access to abortion cannot be explained solely by the legal framework. One must consider rights in action, not merely rights on paper. Public reports from the French High Council for Equality and media testimonies confirm this reality: in practice, access to abortion remains fraught with obstacles, and care quality is very unequal. These obstacles have multiple sources beyond the law itself—not just healthcare system resource constraints or anti‐choice activism (which remains relatively weak in France), but also the very structure of abortion provision. The law grants women access to abortion within 14 weeks of pregnancy but with one crucial requirement: the procedure must be performed by a physician. As with other public services—unemployment, family benefits, or immigration—rights depend on the professionals responsible for implementing them and their discretionary decisions (Lipsky 1980). Understanding abortion access necessitates examining medical professionals and their gatekeeping power.

Medical sociology and micro‐level analyses inspired by reproductive governance have examined physicians' gatekeeping role, demonstrating how care practices and medical attitudes affect abortion access across various national contexts. Existing research reveals contrasting professional responses. Some studies document feminist workers in specialised clinics (Simonds 1996) and physicians who attempt to enable or facilitate access within constraining legal frameworks (Freedman 2010; Mercier et al. 2015). Conversely, numerous studies highlight physicians' moral opposition as a barrier to access, particularly through conscientious objection (Autorino et al. 2020; de Londras et al. 2025; Millar 2023) and stigmatisation of women seeking abortions (Kimport et al. 2016). Beyond opposition or support, research shows how abortion care serves as a framework for governing conduct (Fassin and Memmi 2004) and normalising reproductive practices (Brandi et al. 2018; Biggs et al. 2020). Medical technologies, particularly ultrasound, shape abortion experiences (Kimport and Weitz 2015; Kimport et al. 2018) and access possibilities (Perrin 2025b). Provider stigma affects abortion practice and medical careers in various contexts—Australia (Ripper 2001), United States (Joffe 1996; Freedman 2010), Spain and Italy (De Zordo 2016), Colombia (Fink et al. 2016) etc. France presents a contrasting picture. Interviews for this study indicate that refusing to perform abortions, rather than providing them, risks professional stigmatisation. Conscientious objectors remain few and marginalised. Abortion is routine practice performed by both specialised professionals and gynaecologists alongside obstetric work. Yet my research reveals a paradox: within a legal context granting increasing reproductive autonomy, physicians favourable to abortion rights nonetheless limit access.

I conducted an observational study between September 2021 and July 2022 in three French maternity hospitals (72 days total). I observed abortion consultations and procedures in the hospitals' abortion centres. The sites were selected for their contrasting profiles. Centre A belongs to a university hospital in a large city. Five physicians (including two interns) and a midwife work there, performing 2500 abortions per year. Centre B is attached to a hospital in the prefecture of a rural department with few medical facilities and professionals performing abortions. A gynaecologist and a midwife work there, performing 300 abortions per year. Centre C is attached to a university hospital in a medium‐sized city. Nine physicians (including two interns) and a midwife work there, performing 1000 abortions per year. The centres differed in professional cultures. Centre C physicians —all general practitioners—embrace militant pro‐abortion identities, are politically left‐aligned, claim feminist positions, and advocate expanding abortion access through extending the time limit for abortion access. Centres A and B employ gynaecologists and general practitioners who, while supporting abortion rights, are politically centrist, reluctant to adopt feminist labels, and oppose extending gestational limits. All staff are white women except two male physicians at Centre C. The ethnographic issues and the gendered dynamics of this research—a male researcher studying a predominantly female profession—are analysed in detail elsewhere (Perrin 2023). Regarding the relationship with women seeking abortions, physicians typically introduced me minimally as ‘the colleague’, ‘a student’, ‘the intern’, or simply say ‘we're going to see you together today’, with little regard for women's consent. My medical uniform (white coat or scrubs) reinforced professional authority. I subsequently ensured backstage consent from women away from medical staff, thus minimising my reliance on the medical domination that this article analyses.

This ethnography was combined with interviews conducted between September 2020 and October 2022 with 88 physicians practicing gynaecology—both obstetrician‐gynaecologists and general practitioners who could perform or refuse to perform abortions. Interview participants were selected for diversity across gender, age, region, career stage, practice setting, and abortion positioning.

A key finding emerges from this research: access to abortion and care modalities vary considerably according to women's social characteristics and their consulting physicians. Care pathways differ dramatically—duration of the care pathway, consultation number, possibility of having an abortion at an early or late gestational term, performance of intimate medical examinations, choice of abortion methods ⁴ and contraception. Physicians most committed to women's autonomy enable abortion from the first consultation and at the very beginning of pregnancy, as French law now permits. Others, conversely, require two, three, or four medical visits, waiting periods of days or weeks, mandatory counselling, supervised medication ingestion, and unnecessary gynaecological examinations. In centres where physicians do not like to perform the procedure, women do not have a choice between different methods and must accept medication abortion. These variations reflect physician characteristics—gender, age, speciality, political views, feminist engagement, religious practice, and personal abortion experience. Care also varies by patient characteristics. With the same physician, women face differential treatment based on age, race, language, economic status, and whether they are seeking their first abortion or have had multiple procedures. Some receive prompt, respectful care with full autonomy over method choice. Others encounter pressure regarding contraception (particularly IUDs or implants), judgemental remarks about ‘irresponsible behaviour’, or denial of services. The legal right to abortion thus becomes stratified—universal in principle but unequal in practice.

This article does not primarily aim to describe these empirical findings but rather to understand the power mechanisms that enable them. Formally, regulatory frameworks leave little room for professional discretion. The diagnostic and prognostic dimensions are minimal, women should freely choose their abortion method, and physicians can only refuse through ‘conscience clause’ provided that they refer patients elsewhere. Yet medical power operates paradoxically in abortion care. It functions as a structural feature of doctor‐patient interactions without official recognition, persisting despite growing emphasis on patient autonomy and consent (Castel 2005), expanded patient knowledge (Clarke et al. 2003), and increased patient organisation (Reeder 1972; Quick 2017). This occurs alongside medicine's relative decline in prestige, trust, and professional autonomy (Furedi 2006). The contrast with other professions is striking. Police officers or prison guards exercise state‐legitimised power over bodies through explicit training and regulation. Physicians, conversely, impose abortion modalities despite their official service provider role and against legal provisions and health authority recommendations. This raises a question: how do physicians control abortion access without official coercive power? Understanding abortion provision requires analysing medical domination.

4. Medical Domination in Practice

4.1. Making Women Obey

How do physicians control abortion modalities without official mandate? Research reveals this control operates at two levels.First, through structural framework design. Physicians define care pathways, number and content of consultations. This framework appears objective and immutable concealing physicians' discretionary power and legal flexibility. It carries institutional weight, leading most women in observed cases to follow prescribed pathways without openly questioning them.

Second, through interactional management when (rare) women contest the framework—seeking faster access, refusing pelvic examination or counselling, rejecting contraceptive pressure, particulary for IUDs or contraceptive implants (Perrin 2025a). Unlike psychiatry, abortion care lacks legitimised constraint mechanisms through mechanical or drugs restraint. Unlike emergency medicine, physicians cannot impose treatment on unwilling unconscious patients. Abortion encounters are typically brief and singular, preventing the gradual consent‐building possible in long‐term care relationships.Yet physicians achieve compliance through a repertoire of power practices. They deploy strategies for rapidly producing consent—ranging from simple guidance to what B. G. Glaser and Strauss (1965) term ‘negative tactics’: the orders, reprimands, and threats used to shape patient behaviour. Often, simply stating what needs to be done suffices. In consultations, physicians express preferences, share enthusiastic or disapproving opinions, and provide directive guidance on contraception, on abortion method (‘For you, local anaesthesia is best’), on abortion timing (‘Take time to think’), on the opportunity of counselling (‘I think it would really be good to see the counsellor’). When guidance proves insufficient, physicians employ more coercive practices.

A common strategy involves instilling fear about health consequences or refusing to correct women's misconceptions about procedural risks. In Centres A and B, I repeatedly observed professionals claiming that repeat abortions could impair future fertility or were ‘dangerous.’ Yet abortion complications are very rare and repeated procedures have no proven negative effect on fertility—a fact most of these professionals know. This deliberate misinformation emerges clearly in the following exchange. When I asked a general medicine intern about women who declined contraception, she replied

Yes, Wednesday. I was doing the consultation with Olivia [gynecology intern]. An 18‐year‐old patient, already had two abortions. [Takes on a shrill voice:] ‘I don’t want contraception.’ She must think abortion is a form of contraception. You always feel a sense of failure as a caregiver, you feel like you’re not fulfilling your mission. […]

‐What did you tell her?

‐I told her that she needed to consider having effective contraception, that it was dangerous for her and that she would regret it later. There, 18 years old, already two abortions and no contraception… I used shock phrases, that if she wanted children later she could have problems, she wouldn’t succeed, she would regret it.

‐Does abortion cause problems for having children?

‐It can (Delphine, 27, intern, general practitioner).

When physicians' decisions directly confront women's wishes—imposing additional consultations, deferring or refusing abortion—professionals can turn to the institutionalised and crystallised form of their power: law and medical protocols, or rather their own interpretation of these. By referencing the authority of these norms, professionals can claim they have no room for manoeuver. Yet physicians follow rules they themselves have defined, individually or at the centre level. Although 2001 legislation made counselling optional, Centre C systematically imposes it while Centre A applies it selectively, depending on women (‘You will see the counsellor right after this consultation, it's mandatory, it's the procedure’). Women comply more readily with medical power because they believe in its legality. Centre B illustrates this pattern clearly. The midwife and gynaecologist impose complete gynaecological examinations (vaginal examination, screening smear, breast palpation) on all women seeking abortion, regardless of age, gynaecological follow‐up, or patient preference. This examination is neither legally required nor recommended by health authorities. The following interaction demonstrates how such requirements are imposed:

In silence, Laure (midwife, 52) indicates a line on her computer screen to me: ‘2020: delivery of pregnancy resulting from rape’. Mrs S., 20 years old, faces us in the Centre. The midwife asks if she is followed by a gynaecologist. She replies yes, she regularly attends the family planning centre since her son's birth.

Laure (enthusiastically): ‘We're still going to do a gynaecological exam!’

Mrs S. (worried): ‘Er… I don't really like gynaecological exams.’

Laure says nothing and heads to the adjoining examination room. She indicates the examination table, tells her to undress and position herself in the stirrups.

Mrs S.: ‘Is it compulsory?’

Laure: ‘Oh yes! We can walk on the moon, but we still don't know how to examine otherwise!’

She announces that after the gynaecological examination, she will perform a vaginal ultrasound.

Mrs S.: ‘Oh I don't like that!’

Laure: ‘You've only had ultrasounds on the belly? Yes, but that's because those were more advanced pregnancies. Here, we have no choice. Come on, relax your buttocks so I can place the speculum. (She struggles to insert it) Relax! Imagine you're at the beach. Am I hurting you?’

Mrs S.: ‘A little bit.’

Laure: ‘Alright. (Continues) Is that okay?’

Mrs S.: (groans in pain): ‘Hmm…’

Despite the woman's timid but repeated refusals—and the presence of a third party, a male non‐medical researcher—the healthcare professional performs an intrusive and visibly painful examination, devoid of medical utility in this context. To do so, she presents it as ‘compulsory’. Medical power in abortion centres also operates through control of timing. By controlling the care schedule, physicians impose abortion modalities. They determine not only pathway timing in the service—consultation frequency, duration, and imposed delays between appointments—but also when to deviate from standard practices: accelerating care or, conversely, introducing delays. The following example illustrates this temporal manipulation. Laurence (65, gynaecologist, Centre A), emerging from a pre‐abortion consultation, approaches the nurse who is about to schedule the procedure. She suspects the woman has a desire for a child and instructs: ‘Don't schedule her too soon! She needs time to advance in her reflection. Tell her there are no slots available at the moment.’ Unable to directly oppose the woman's decision, the physician ensures delayed access through administrative deception.

These power practices rely primarily on physicians' control of information, including lying—a phenomenon documented beyond abortion care (Fainzang 2006). Due to information asymmetry and physicians' symbolic capital, their statements go unquestioned in the consultation setting: no woman I encountered suggested doubting whether the physician might have lied about pregnancy term, service schedules, medical risks, or legal requirements.

Medical power can operate without official mandate precisely because it takes invisible forms. Observations reveal both the frequency and scope of power practices through which physicians—and sometimes subordinate professionals—control care modalities. In practice, consent becomes mere absence of formal opposition rather than the ‘free and informed’ agreement theorised in medical ethics. As with sexual relations, power asymmetry blurs the question of consent (Mathieu 1989). Consent is not often openly violated but is largely produced within and through medical encounters, sometimes manipulatively. Most fundamentally, consent's ‘freedom’ is compromised from the start by women's structural dependence: law requires physician involvement and time pressure intensifies vulnerability. In hospital settings, compliance becomes consent.

However, power techniques are not mobilised uniformly. Women are not simply constrained or not, do not simply consent or not—rather, they experience varying degrees of both. In abortion care, physicians judge requests as more or less ‘legitimate’ (Kimport et al. 2016). Certain women face greater restrictions: those seeking repeat abortions, presenting at advanced gestational age, refusing physician‐recommended contraception (pill, IUD, or implant), or failing to demonstrate appropriate distress. These women receive fewer choices regarding abortion method, intrusive examinations, counselling, or contraception.

Social distance and low ‘cultural health capital’ (Shim 2010) intensify this differential treatment. Racialised women, poor women, young women, and those categorised as having psychiatric conditions face particular scrutiny. Professionals translate social characteristics into psychological categories they use amongst themselves to designate patients—contrasting the ‘mess‐ups’, the ‘nutters’, with those deemed ‘mentally structured’ and ‘nice’. This stratification manifests in concrete practices. Physicians routinely offer marginalised women only contraceptive implants rather than describing available options—a restriction never applied to white, middle‐ or upper‐class women judged psychologically stable. Women with lower social value’ are deemed incapable of informed decision‐making, making paternalistic intervention appear professionally justified, even when contradicting explicit patient requests.

Control over abortion modalities relies on collective power practices. Observations revealed the choral dimension of advice, lies, and attempts to instil fear of complications, repeated at different stages of the abortion pathway by physicians, midwives, nurses, family planning counsellors, and secretaries. Because making patients comply constitutes ‘dirty work’ (Hughes 1971) incompatible with official requirements to respect consent, physicians delegate power exercise to subordinate professionals. This delegation is sometimes explicit: ‘tell her we have no more slots’, ‘she doesn't want the counselling interview, could you try pushing a bit more?’. Medical domination must therefore also be analysed at the collective service level. Power practices vary in frequency and acceptance according to local institutional cultures. Centre C recruits mostly specialised, militant, feminist, left‐aligned physicians. This centre demonstrates significantly less discriminatory care. Practices deemed inappropriate by centre standards face peer disapproval (notably imposing intimate examinations). Organisational mechanisms shape these cultures: staff selection, on‐the‐job training, and peer monitoring create homogenisation in how medical power is exercised and transmitted.

4.2. From Medical Domination to Medical Violence

Medical domination sometimes takes brutal and explicit forms. Research on obstetric violence has described a continuum of practices that may occur around childbirth, ranging from disrespectful treatment and non‐consensual procedures to physical or sexual abuse, verbal humiliation, and care refusal (Sadler et al. 2016; El Kotni 2018; Smith‐Oka 2022). This has been appropriately analysed as gender‐based violence, revealing its structural dimension and the extent and frequency of that suffered by women. Building on these insights, an intersectional medical domination framework offers complementary analytical value (Perrin et al. 2025). Empirically, it extends analysis beyond obstetrics to other medical contexts. Theoretically, it highlights the specific expert‐layperson power dynamic that characterises medical relationships. This approach helps explain why medical interactions across specialities can facilitate violence—just as gender domination perspectives help understand sexual or domestic violence.

Social distance intensifies medical domination's brutal manifestations. When medical domination intersects with other power relations, physicians need not maintain egalitarian pretences. Patient compliance can rely more openly on coercion rather than genuine consent, enabling discrimination and abuse.

Most people who have abortions identify as women. Medical domination takes its most brutal forms with those occupying dominated positions—women distant from legitimate femininity, racialised women, working‐class women, and minors. During consultations observed with these women, physicians routinely ignore questions, reproach contraceptive irresponsibility, order silence, or speak curtly. In Centres A and B, young women face mocking judgements about appearance—platform trainers deemed ridiculous, false nails called ‘hideous’ and impractical, or waist chains regarded as absurd. This brutal familiarity can take on a racist dimension. In Centre A, nurses frequently greet women whose names have African consonance with songs inspired from 1980s hits with sexist and racist lyrics. A Black woman saying her name was Awa heard the two nurses facing her emit a long guttural cry: ‘Awawawawawa’. She remained silent. Healthcare professionals frame these humiliations as relational work to create levity. However, they follow patterns according to the power relations at play: infantilisation, mockery, or ‘maternal telling‐off’ (as one interviewee puts it) for young women; exoticisation and essentialisation for racialised women seeking abortion; sexualisation and sometimes sexual assault when medical domination intersects with gender dynamics.

I attended consultations by Mathieu (55), one of only two male physicians in the three centres studied, working at Centre C and presenting himself as an abortion ‘militant’. With patients, he transgresses professional boundaries, justifying this as ‘de‐dramatising’ abortion. He speaks loudly and extensively, sings, swears, describes the most effective contraceptive methods as ‘bazookas’… and sexualises patients through comments and ‘jokes’. When a 25‐year‐old mentions performing both urine and blood pregnancy tests, he exclaims: ‘Such an insatiable girl!’ Learning her partner is a farmer, he declares: ‘You like your men with heavy machinery!’ He is one of the few physicians to ask explicit questions about sexuality (‘Do you have orgasms?’), spontaneously suggests cosmetic vulvar surgery during an examination, and until recently performed vaginal examinations without gloves. ⁵

Mathieu's case illustrates how the medical framework reinforces gender domination and enables sexual assault. Physicians, particularly gynaecologists, access women's bodies in private interactions. Medical justification for intimate contact can be difficult to verify. Beyond sexual violence, physicians' symbolic capital, professional solidarity, and weak oversight mechanisms make filing complaints difficult and convictions very rare. Patients' dependence on physicians makes resistance risky, as it could delay or compromise access to care.

5. Becoming a Physician Also Means Learning to Dominate

In the history of sociology, the medical profession has served as the idealtypical case study of professional socialisation (Darmon 2023). Medical socialisation is a massive and enveloping process: learning medicine is lengthy, occurs within relatively closed institutions (hospitals), and requires subjective and objective commitment—because studying medicine, especially during competitive exams, means doing (almost) only that. American functionalists and interactionists have analysed how the layperson transforms into a physician, via the internalisation of the constitutive norms of ‘medical culture’ (Merton et al. 1957) or via a succession of moments of initiation and conversion—what Hughes terms ‘passage through the mirror’ (Hughes 1955). For Robert Merton, medical school socialisation teaches students to ‘become physicians,’ by reconciling contradictory professional demands: spending as much time as possible at patients' bedsides while staying informed about the latest medical advances; showing empathy while maintaining emotional distance, etc. Interactionists critiqued this approach as overly speculative. Their student‐focused research analysed peer socialisation as an evolving, discontinuous process varying across training stages (Becker et al. 1961). Recent scholarship emphasises emotional regulation in medical training—learning when and how to express emotions according to professional contexts, particularly regarding intimacy and death (Crowe and Brugha 2018; Underman 2015, 2020).

Medical socialisation remains a field of research yet to be fully explored. This article examines a neglected aspect: how people internalise their place in medical power relations. For physicians, this means learning to exercise power and feel legitimate doing so. For laypeople, it means incorporating dispositions to submit to medical authority.

I focus on the physicians' side. How do doctors in abortion centres come to impose gynaecological exams when women object? To claim that abortion can cause infertility to push contraception? To delay procedures or force counselling sessions? Medical students do not exercise power as easily as qualified physicians. This power is learnt during medical training. Fieldwork allowed me to watch the semester rotation of interns, observe their training, and see how their practices changed over weeks.

This is transmitted through explicit pedagogical action via advice or reproaches during informal discussions following consultations. Interns commonly tell qualified physicians about recent consultations, expressing regret that women made what they consider poor choices. The senior physicians then encourage them to adopt practices of deception or constraint. ‘You should have lied. Told her it's a contraindication. Sometimes you shouldn't be too nice,’ commented Laurence (65). Lying is not deviant behaviour: it can be a conscious, assumed, and taught professional practice.

Another observed episode demonstrates this process: ‘WHEN YOU CONSIDER ONLY ONE ORGAN INSTEAD OF THE PATIENT AS A WHOLE, YOU’RE DOING SHITTY WORK! A PATIENT IS NOT JUST A UTERUS!’ In the centre's corridor, Armelle (55), the most influential nurse in the service, shouts at Olivia (26, gynaecology intern). She criticises her for failing to impose counselling on a woman who refused it, despite the old self‐harm scars spotted on her arm. Later, Olivia debriefs with the psychologist and me in the break room, visibly ashamed. She acknowledges that she must learn to set aside her scruples:

Armelle did well to notice the scars and send her to you. She spots things well. I need to be more… well, it’s a job! (Smiles) But I need to better see those who need it and those who don’t. The nurses are good at that. […] It’s not easy to force patients, because we’re no longer in patriarchal medicine.

Following the nurse's reproaches, Olivia seeks guidance from Juliette, the gynaecologist in charge of the abortion centre. Juliette urges her to find the right words to convince women to undergo counselling, particularly when dealing with women who have ‘chaotic lives—multiple abortions, no contraception, multiple sexual partners’. When necessary, she should force them by stating that counselling is part of the abortion pathway, even though the law has not required it since 2001. As Olivia progresses through her internship, her practice changes. She increasingly insists on long‐acting contraception and, depending on her patients, now omits to specify that counselling is optional. Within months, she has learnt to practice the paternalistic medicine she once rejected. Young physicians learn that imposing on patients is legitimate. For medical students, this becomes a requirement, one competency among others on which they are evaluated.

Bourdieu highlights another modality of socialisation, besides explicit transmission (Durkheim 1973 [1922]): the discreet, unconscious, and non‐strategic internalisation of structures through practice (Bourdieu 1980, 124). First, medical education acts as a ‘rite of institution’ (Bourdieu 1982). The competitive selection and long studies create a sense of excellence and exceptionality among medical students, which authorises the practice of power. This seclusion of the dominant aims not only at transmitting knowledge but at symbolic separation, establishing boundaries that both laypeople and physicians accept.

Second, socialisation occurs through imitation, where action and thought schemes pass ‘from practice to practice’ (Bourdieu 1980). In the three abortion centres, the training of interns and new physicians operates primarily through ‘companionship,’ as is common in medicine.

Finally, there is the routine following of local norms that frame the work by determining access to abortion. Through daily practice, these norms habituate interns to impose on women seeking abortion gestures, medication, or a temporality of care that they do not wish. One modality of internalising medical domination schemes through practice appears particularly effective: the experience of medical complications. In abortion centres, these are very rare. Only two occurred during my investigation—bronchospasms ⁶ caused by general anaesthesia. While frequent for anaesthesiologists, these events trigger agitation that contrasts with the usual calm of abortions. Complications play a key role in medical socialisation. They attest to the legitimacy of medical power, justified by the vital dangers patients face. They inscribe it in bodies—both physician and patient—through the effervescence and emotions they generate. While occurrences are rare, past complications are frequently recalled and recounted within services as justification for power practices and as a means of educating newcomers.

Becoming a physician thus involves more than learning technical skills and accumulating knowledge, or controlling emotional expression. It also means learning to dominate. The practical socialisation of medical students contradicts the official consent norms taught during the theoretical phase of their studies. Students learn not only to dominate, but to exercise this domination differently depending on the patients they encounter. They learn to categorise patients. They become accustomed to considering that racialised people lie and exaggerate their symptoms, ⁷ that black women have more ‘risky’ sexuality, that contraceptive methods requiring regular intake or use during intercourse are unsuitable for women in extreme poverty, that women are unreliable decision‐makers, and that even when requesting abortion, they often harbour hidden desires for children. Students learn medical power by exercising it on the most dominated.

Such practices, beliefs and attitudes become incorporated and naturalised to the point of becoming invisible to professionals. This helps explain how professionals who advocate for kindness in care can simultaneously discriminate, demonstrate paternalism, or commit acts that patients experience as violent.

6. Conclusion

The theoretical framework of medical domination is a fruitful tool for the political sociology of health and illness, complementing existing analytical frameworks. It enables articulated analysis of objective and institutionalised structures of medical power, interactional micro‐techniques of power, and incorporated dispositions. It emphasises the processes and reproduction of power by examining the concrete mechanisms of socialisation to medical domination and how they render it invisible, even in its most violent forms. This framework enables fine‐grained analysis of intersecting power relations in care contexts and their consubstantiality (Galerand and Kergoat 2014): medical domination is exercised and learnt by drawing upon other domination relations, while these are partly formed within medical relationships. Medical domination participates in constructing social hierarchies that go beyond the medical context alone. Alongside institutions such as schools, churches, police, or justice systems, medicine contributes to producing and internalising social order by making differences of gender, class, race, or age into markers of superiority or inferiority, and by socialising patients accordingly.

The structures of medical domination and identified micro‐techniques of power extend beyond abortion centres. Emergency departments, oncology or general medicine appointments, gastroenterology or cardiology hospitalisations are characterised by the same dependence to obtain care, waiting periods, information asymmetry, trust in the veracity of physicians' statements, health threats when medical choices are contested, and the promotion—sometimes imposition—of ways of living deemed good, from both a moral and health perspective.

I observed very few instances of explicit resistance by women seeking abortion to medical domination. Complementary research conducted directly with patients would refine this analysis by examining their relationship to medical domination—including resistance, strategic compliance in contexts of care dependence, internalisation of stigmatising representations of abortion (Cockrill and Nack 2013), and internalisation of dominated positions. I can nonetheless hypothesise that laypeople learn to be patients through repeated contact with medical institutions throughout life. Contrary to Strauss et al. (1985), medical encounters are not constantly renegotiated. Instead, physicians and patients arrive already knowing their respective roles and positions. Medicalisation would then encompass not only the expansion of medical care to different life aspects, as typically analysed (Conrad 1992), but also the medicalisation of habitus—the diffusion of dispositions to act (exercising power or conforming to it through habit, strategy, or adherence) and dispositions to perceive and be perceived as medicalised beings: some as vulnerable, pathological, sometimes guilty; others as competent and altruistic.

Unlike aristocrats or the upper bourgeoisie, physicians do not appear quite as dominant, particularly in their own eyes. The indirect and deferred nature of financial transactions between physicians and patients masks the economic motivation of the former and creates an appearance of disinterested service. Medical work appears not merely useful but sacrificial, obligating those who benefit from it. However, gentle domination is costly for those who exercise it, as the work of denial requires the dominant to ‘pay with their person’ (Bourdieu 1980, 221). The French physicians encountered often mention their long and difficult studies, their trying working conditions, the deteriorating healthcare system of which they claim to be primary victims, and sometimes—especially among hospital physicians—inadequate remuneration. They often present themselves as targets of patient violence, lamenting their loss of authority in consultations, declining trust in medicine, and what they perceive as media persecution of gynaecologists in recent years. Some of these statements are partially true; study and work can be harsh for some physicians, particularly women who suffer harassment and violence from peers. ⁸ However, the supposed erosion of medical power is largely mythical, and physicians derive substantial material and symbolic benefits from their position. In France, the average net income private practitioners increases annually—by 1.2% between 2005 and 2017 (Dixte and Vergier 2022), reaching €9980 monthly in 2017 (nearly 6 times the median income). Hospital medical personnel in full‐time equivalent (excluding medical students) earned an average of €6500 monthly in 2022, 2.5 times more than non‐medical staff (Ntamakuliro Inema et al. 2024). Physicians' social status provides privileged access to political power, from local office to parliament: with 34 deputies and 33 senators who were physicians in 2020, medicine remains one of the most represented professions in French national institutions. Medical careers continue serving as strategies for upper‐class reproduction, though less favoured today than finance or high public administration.

The emergence of a movement denouncing medical violence, primarily in gynaecology and obstetrics, signals a relative stumbling of medical domination and partial and localised erosion of its legitimacy. Professional norms and practices in gynaecology are indeed evolving towards gentler modes of governmentality; overtly visible or brutal manifestations of power are deemed unacceptable, and increasing attention is paid to women's cause and formal respect for consent. However, these evolutions are mainly confined to gynaecology and obstetrics and do not challenge the objective and subjective dependence of laypeople on physicians. Everything must change so that nothing changes: the civilisation of medical domination also serves to maintain its legitimacy.

Regarding abortion access, analysis through the lens of medical domination emphasises concrete care practices rather than abstract rights. It suggests not viewing medicalisation as the endpoint of the struggle for abortion, and considering the political stakes of abortion beyond mere legalisation. While abortion has been framed as a global public health problem requiring Global South countries to align with Global North standards, this article suggests to draw inspiration from feminist practices of non‐medical abortion accompaniment in countries where abortion is forbidden or heavily restricted (McReynolds‐Pérez et al. 2023) to explore forms of demedicalisation in countries where it is legal.

Funding Statement

This study was supported by Université Paris 1 Panthéon Sorbonne, Paris, France.

Ethics Statement

The research plan was approved by the Institut national de la santé et de la recherche médicale (INSERM)'s ethics evaluation committee. This study comes under methodology MR004 of the Commission Nationale de l’Informatique et des Libertés (CNIL) relative to ‘the treatment of personal data for study, evaluation, or research purposes not involving the human person.’ In accordance with its requirements, prior verbal consent to a recorded interview was obtained. The research plan was also submitted to hospital management and discussed and accepted by all staff at the abortion centres and gynaecology departments where the study took place. Centres' information has been changed so they could not be identified.

Conflicts of Interest

The author declares no conflicts of interest.

Data Availability Statement

Research data are not shared.