Looping Genomes: Diagnostic Change and the Genetic Makeup of the Autism Population

Regulating diagnosis-Molecular and regulatory sub-stratifications of lung cancer treatment

The sociology of diagnosis has shown that diagnosis not only serves to label the underlying cause of disease but also to provide access to services and resources. Elaborating on this double-affordance of diagnosis, this article examines how precision medicine reconfigures diagnosis as a label and as a process in regulatory and clinical settings. Reporting from an ethnographic case study of the introduction of immunotherapy for lung cancer, the paper unfolds the uncertainties involved in dissecting diagnosis into layers and examines the efforts and negotiations it takes to enable these layers to work both as clinical entities and regulative entities with the purpose of delineating access to treatment. I suggest that the work of subdividing diseases into molecularly defined categories for the purpose of delineating treatment-eligible populations can be labelled 'diagnostic sub-stratification' and argue that it is pertinent to understand the political capacity of this strategy. Diagnostic sub-stratification involves a push of diagnosis from the clinic 'up' into the regulatory system and 'out' into the laboratories, obscuring who is accountable for the diagnostic categories employed to define patients' treatment access.

Performative credibility: How opioid researchers sustain public trust during the opioid epidemic

Experts often face credibility challenges during times of crisis. However, opioid use disorder (OUD) researchers preserved their scientific credibility despite the increasing public scrutiny of medical knowledge during the opioid epidemic. Building on 30 in-depth interviews with OUD researchers, this article examines how researchers conduct scientific research, collaborate with non-expert stakeholders, and communicate research outcomes to the public. It distinguishes between performative credibility - a discourse enacted through languages, meanings, and symbols in constructing the reality of credibility, and descriptive credibility - the description, perception, and measurements of credibility under a given credibility discourse. It argues that the crisis of expertise is situational - it depends on whether and how performative credibility is sustained. This article finds that OUD researchers enact at least three credibility discourses: professional, data-driven, and community-centered. While researchers can have multiple discourses in mind, their choices of enacting a specific credibility discourse when interacting with non-experts and the public are contingent upon their rankings in the profession, medical training backgrounds, forms of patient interactions, and access to OUD medications. This case recenters sociological studies of expertise and trust on the enacting power of experts' statements and actions. It also reveals the relevance of social locations in understanding the formation of the credibility crisis. Finally, it provides a conceptual framework for understanding public (mis)trust in science and medicine.

What rare cancers have in common. The making of lists of (very) rare cancers and the coordination of medical work

This article aims to understand why medical actors recently published lists of rare and very rare cancers. It studies four lists of rare and very rare cancers based on interviews with the main actors on these lists and an analysis of medical articles in which these lists were published. It argues that these lists constitute boundary objects whose aim is to deal with the organizational challenges raised by precision medicine, which imply increasing the coordination work between various types of actors. Our work therefore allows a better understanding of the functioning of the recursive standardization process of a boundary object and, by analyzing how the category of rarity is built at the intersection of both professional and nosographic principles, shows the intertwining of the biomedical, organizational, and political aspects on which rests the practice of contemporary precision medicine.

Should We Continue to Tell Autistic People that Their Brains are Different?

Autism is often considered to reflect categorically 'different brains'. Neuropsychological research on autism spectrum disorder (ASD) however, has struggled to define this difference, or derive clear-cut boundaries between autism and non-autism. Consequently, restructuring or disbanding the ASD diagnosis is becoming increasingly advocated within research. Nonetheless, autism now exists as a salient social construction, of which 'difference' is a key facet. Clinical and educational professionals must influence this cautiously, as changes to autism's social construction may counterproductively affect the quality of life of autistic people. This paper therefore reviews ASD's value as both neuropsychological and social constructs. Although lacking neuropsychological validity, the autism label may be beneficial for autistic self-identity, reduction of stigma, and administering support. Whilst a shift away from case-control ASD research is warranted, lay notions of 'different brains' may be preserved.

"Peas in a pod": Oral History Reflections on Autistic Identity in Family and Community by Late-Diagnosed Adults

In this paper, we report on a participatory oral history study documenting the lives of late-diagnosed autistic adults in Australia. We interviewed 26 autistic adults about their life history and the impact of late diagnosis. All were diagnosed after the age of 35, growing up in an era when autism was not well known. Using reflexive thematic analysis, we uncovered a rich body of reflections on shared Autistic identity and identified three major themes within that data set: 'conceptualising the Autistic family', 'creating Autistic community', and 'contesting Autistic identity'. Overall, the study provides insights into the active creation of shared Autistic identity and the importance of Autistic community to these late-diagnosed autistic adults.

Medicalizing risk: How experts and consumers manage uncertainty in genetic health testing

Given increased prevalence of direct-to-consumer (DTC) genetic health tests in recent years, this paper delves into discourses among researchers at professional genomics conferences and lay DTC genetic test users on popular discussion website Reddit to understand the contested value of genetic knowledge and its direct implications for health management. Harnessing ethnographic observations at five conferences and a text -analysis of 52 Reddit threads, we find both experts and lay patient-consumers navigate their own versions of “productive uncertainty.” Experts develop genetic technologies to legitimize unsettled genomics as medical knowledge and mobilize resources and products, while lay patient-consumers turn to Internet forums to gain clarity on knowledge gaps that help better manage their genetic risk states. By showing how the uncertain nature of genomics serves as a productive force placing both parties within a mutually cooperative cycle, we argue that experts and patient-consumers co-produce a form of relational medicalization that concretizes “risk” itself as a disease state.

Testing the talented child: Direct-to-consumer genetic talent tests in China

One controversial area of direct-to-consumer genetic testing in China is "genetic talent testing" for children. In this study, I show that while experts criticize genetic talent testing as unscientific, the persistence of genetic talent testing is not merely a product of parents' scientific illiteracy. Instead, genetic talent testing reflects parents' pragmatic use of technology in response to the parenting pressures in contemporary China. Parents see the results of genetic talent testing as offering an advantage for their children when combined with the intensive parenting strategy of precision education. Drawing on the sociology of testing, I argue how genetic talent testing in China is a product of broader concerns about population quality and can potentially reshape how parents imagine quality children through the theory of multiple intelligences. My study of this "off label" use of direct-to-consumer genetic testing also suggests that scientists need to broaden their imagination of potential misuses of their technologies.

Democracy underwater: public participation, technical expertise, and climate infrastructure planning in New York City

This article provides an explanation for how increased public participation can paradoxically translate into limited democratic decision-making in urban settings. Recent sociological research shows how governments can control participatory forums to restrict the distribution of resources to poor neighborhoods or to advance private land development interests. Yet such explanations cannot account for the decoupling of participation from democratic decision-making in the case of planning for climate change, which expands the substantive topics and public funding decisions that involve urban residents. Through an in-depth case study of one of the largest coastal protection projects in the world and drawing on global scholarship on participation, this article narrates the social production of resistance to climate change infrastructure by showing how the state sidestepped public input and exercised authority through appeals to the rationality of technical expertise. After a lengthy participation process wherein participants reported satisfaction with how their input was included in designs, city officials switched decision-making styles and used expertise from engineers to render the publicly-supported plan unfeasible, while continuing to involve residents in the process. As a result, conflict arose between activists and public housing representatives, bitterly dividing the neighborhood over who could legitimately claim to represent the interests of the "frontline community." By documenting the experience of participants in the process before and after the switch in decision-making styles, this article advances a sociological description of public influence in policy: The ability for participants in a planning process to recognize their own input reflected in finished plans.

Genetics on the neurodiversity spectrum: Genetic, phenotypic and endophenotypic continua in autism and ADHD

How we ought to diagnose, categorise and respond to spectrum disabilities such as autism and Attention Deficit/Hyperactivity Disorder (ADHD) is a topic of lively debate. The heterogeneity associated with ADHD and autism is described as falling on various continua of behavioural, neural, and genetic difference. These continua are varyingly described either as extending into the general population, or as being continua within a given disorder demarcation. Moreover, the interrelationships of these continua are likewise often vague and subject to diverse interpretations. In this paper, I explore geneticists' and self-advocates' perspectives concerning autism and ADHD as continua. These diagnoses are overwhelmingly analysed as falling on a continuum or continua of underlying traits, which supports the notion of "the neurodiversity spectrum", i.e., a broader swath of human neural and behavioural diversity on which some concentrations of different functioning are diagnosed. I offer a taxonomy of conceptions of the genetic, phenotypic, and endophenotypic dimensionality within and beyond these diagnostic categories, and suggest that the spectrum of neurodiversity is characteristically endophenotypic.

Defending 'snake oil': The preservation of contentious knowledge and practices

How does belief in controversial ideas persist? I study a community of parents and practitioners who contend that autism spectrum disorder is caused by harmful environmental exposures - notably, early childhood vaccinations - and that there are worthwhile alternative or experimental treatments. Despite objections from dominant experts, these actors maintain their disputed ideas. This study identifies a set of strategies that help maintain internal legitimacy. In particular, actors protect internal legitimacy through professional alignment and contrastive boundary work. Professional alignment mobilizes resemblances to conventional counterparts (i.e. mainstream doctors) to defend unorthodox practices. Meanwhile, contrastive boundary-work performances convey the defining values and strengths that actors associate with their knowledge community and concomitantly, the weaknesses they ascribe to competing groups. Through these activities, actors respond to perceived threats and construct a distinct group identity anchored in shared knowledge, ways of knowing and practice.

Strategies of stratification: Regulating market access in the era of personalized medicine

Personalized medicine raises the stakes of pharmaceutical market regulation. Drawing on pragmatist valuation studies and science and technology studies literature on personalized medicine and pharmaceutical markets, this article demonstrates how complex negotiations about the value of a pharmaceutical can constitute a market in various ways, while also shaping the concerned patient populations. Tracing the path of a pharmacogenetic treatment, Spinraza, from its approval by the European Medicines Agency to its adoption in the publicly funded Danish healthcare system, we show how the market was formatted through particular stratifications of the patient population. We conceptualize these seemingly technical moves as strategies of stratification, that is, the application of techniques to assemble and divide data - and what data are meant to represent - into groups delineated by certain characteristics. We argue that stakeholders' use of strategies of stratification has important implications not only for market access, but also for the delineation of diseases and patient populations. Hence, it is crucial to make intelligible the mutual constitution of pharmaceutical markets and patient populations and the political efforts of delineating and connecting the two.

Going Beyond the Catch-22 of Autism Diagnosis and Research. The Moral Implications of (Not) Asking "What Is Autism?"

Psychiatric diagnoses such as Autism Spectrum Disorder (ASD) are primarily attributed on the basis of behavioral criteria. The aim of most of the biomedical research on ASD is to uncover the underlying mechanisms that lead to or even cause pathological behavior. However, in the philosophical and sociological literature, it has been suggested that autism is also to some extent a 'social construct' that cannot merely be reduced to its biological explanation. We show that a one-sided adherence to either a biological or a social explanation leads to a moral dilemma, a Catch-22, for autistics and for those living with them. Such explanations close the space for self-identifying as autistic and at the same time being considered to be in good mental health. They foreclose the possibility of making sense of the lived experience of (and with) autistics. In this paper we argue that such lack of space for moral imagination inherently leads to scientific stalemate. We propose that one can only go beyond this stalemate by taking an ethical stance in theorizing, one that enables better intersubjective understanding. Only on such a view can behavior and biology be linked without either disconnecting them or reducing the one to the other.

New starts at New Start: Recovery and the work of hikikomori

Defined by psychologist Tamaki Saito as a period of social isolation in the absence of any other clear mental health issues for a period of six months or longer, hikikomori (social withdrawal) emerged as a condition among Japanese youth in the late 1980s. Used as both a noun to identify those afflicted, as well as describe their condition, the word immediately captured the attention of the Japanese and international public. According to various government and third-party surveys, hikikomori number from approximately 500,000 to two million people. Thus, while hikikomori are understood to struggle with long bouts of loneliness and isolation from their peers and parents, due to constant anxiety over their inability to perform among Japan's competitive capitalist-oriented social expectations, both academics and professionals continue to struggle to comprehend exactly who hikikomori are and how to help them. Based on fieldwork at New Start, a non-profit organization located just outside the city limits of Tokyo that helps hikikomori recover, this article examines the ways residents at New Start navigate this uncertainty and gain moral agency. Drawing from over a dozen interviews with parents, clients, and staff conducted while working as a volunteer at New Start, I focus on three representative trajectories that demonstrate how residents navigate the competing discourses surrounding the clinical and social categories of hikikomori and NEET (Not in Education, Employment, or Training), through which they embark on a journey from economically unproductive recluses, to productive capitalist citizens pursuing their own version of a "nearly normal" life. I argue that the various accomplishments of hikikomori, as individuals and as a social category, which both support existing social relations and provide an alternative mode of fitting within them, is "the work of hikikomori."

Expanding boundaries in psychiatry: uncertainty in the context of diagnosis-seeking and negotiation

Psychiatric diagnosis has become pervasive in modern culture, exerting an increasing influence on notions of personhood, identity practices and forms of self-governing. The broadening of diagnostic categories and increasing awareness regarding popular diagnostic categories has led to an increased demand for formal diagnosis within clinical encounters. However, there is continuing 'epistemological uncertainty' (Fox 2000) surrounding these entities, in part due to their lack of associated clinical biomarkers and their 'fuzzy boundaries'. Meanwhile, this diagnostic expansion has encountered resistance from those concerned with the alleged 'over-pathologisation' of emotional distress. Drawing upon the concepts of 'diagnostic cultures' (Brinkmann 2016) and the 'looping effects of human kinds' (Hacking 1995), this article considers some of the competing forces acting upon the contested boundaries of diagnostic categories as they play out within diagnostic interactions. The study involved ethnographic observations of diagnostic encounters within several UK-based mental health clinics. By focusing on interactions where diagnosis is negotiated, findings illustrate the role played by different kinds of diagnostic uncertainty in shaping these negotiations. It is argued that diagnostic reification plays a key role in the moral categorisation of patients, particularly where there is uncertainty regarding individual diagnostic status.

The many meanings of autism: conceptual and ethical reflections

Autism is a polysemous concept. It is defined as a neurodevelopmental disorder that is diagnosed based on an assessment of behaviour and dysfunction. Autism also refers to a specific way of information or sensorial processing. For those diagnosed with autism, it is a real and shared experience. In this paper, I sketch the moral work that biological conceptions of autism perform. They help to conceptualize the diagnosis and associated challenges as real and they remove some of the blame from the diagnosed person and/or their parents. But such approaches also risk neglecting the role of behaviour as a meaningful reaction to experiences. In thinking about the ethics of autism research, diagnosis of autism, and autism care, the recent findings of epigenetics and systems biology may help us overcome the dichotomy between biology and psyche, and point the way to a more nuanced and ethical view. WHAT THIS PAPER ADDS: The meaning of 'autism' has different layers and as such autism is a polysemous concept. The lived experience of autistic people matters in research.

The rare and the common: scale and the genetic imaginary in Alzheimer's disease drug development

In this paper I examine how the promissory value of genetics is constituted through processes of scale and scaling, focussing on the relationship between "rare" and "common" forms of disease. I highlight the bodies and spaces involved in the production of post-genomic knowledge and technologies of Alzheimer's disease and the development of new disease-modifying drugs. I focus on the example of the development of a monoclonal antibody therapy for Alzheimer's disease. I argue that the process of therapeutic innovation, from genetic studies and animal models to phase III clinical trials, reflects the persistent importance of a genetic imaginary and a mutually constitutive relationship between the rare and the common in in shaping visions of Alzheimer's disease medicine. Approaching this relationship as a question of scale, I suggest the importance of attending to how and where genomic knowledge is "scaled" or proves resistant to scaling.

Doing Abstraction: Autism, Diagnosis, and Social Theory

Recent decades have witnessed a dramatic upsurge in the prevalence of autism spectrum disorder (ASD). As researchers have investigated the responsible sociohistorical conditions, they have neglected how clinicians determine the diagnosis in local encounters in the first place. Articulating a position "between Foucault and Goffman," we ask how the interaction order of the clinic articulates with larger-scale historical forces affecting the definition and distribution of ASD. First, we show how the diagnostic process has a narrative structure. Second, case data from three decades show how narrative practices accommodate to different periods in the history of the disorder, including changing diagnostic nomenclatures. Third, we show how two different forms of abstraction-Type A, which is categorical, and Type B, which is concrete and particular-inhabit the diagnostic process. Our analysis contributes to the sociology of autism, the sociology of diagnosis, the sociology of abstraction, and social theory.

Informing materials: drugs as tools for exploring cancer mechanisms and pathways

This paper builds on previous work that investigated anticancer drugs as 'informed materials', i.e., substances that undergo an informational enrichment that situates them in a dense relational web of qualifications and measurements generated by clinical experiments and clinical trials. The paper analyzes the recent transformation of anticancer drugs from 'informed' to 'informing material'. Briefly put: in the post-genomic era, anti-cancer drugs have become instruments for the production of new biological, pathological, and therapeutic insights into the underlying etiology and evolution of cancer. Genomic platforms characterize individual patients' tumors based on their mutational landscapes. As part of this new approach, drugs targeting specific mutations transcend informational enrichment to become tools for informing (and destabilizing) their targets, while also problematizing the very notion of a 'target'. In other words, they have become tools for the exploration of cancer pathways and mechanisms. While several studies in the philosophy and history of biomedicine have called attention to the heuristic relevance and experimental use of drugs, few have investigated concrete instances of this role of drugs in clinical research.

The maternal body as environment in autism science

Research on autism and environmental risk factors has expanded substantially in recent years. My analysis draws attention to the regimes of perceptibility that shape how the environment is materialized in post-genomic science. I focus on how more complex narratives of autism's causes and social anxieties surrounding child development have helped situate autism risk in women's bodies before and during pregnancy. This has resulted in what I call the maternal body as environment in autism science. I show that this figure involves three characteristics: the molecularization of the environment, an individualization of risk, and the internalization of responsibility. I argue that these three features point to a new spatial and temporal politics of risk and responsibility that may heighten social and medical surveillance of women's bodies and decisions, eclipsing larger questions about the uneven distribution of exposures in society and more holistic understandings of health that include neurodiversity. I conclude by considering what the maternal body as environment signals for women, social justice, and the politics of environmental health in the post-genomic era.

ASD Validity

ASD research is at an important crossroads. The ASD diagnosis is important for assigning a child to early behavioral intervention and explaining a child’s condition. But ASD research has not provided a diagnosis-specific medical treatment, or a consistent early predictor, or a unified life course. If the ASD diagnosis also lacks biological and construct validity, a shift away from studying ASD-defined samples would be warranted. Consequently, this paper reviews recent findings for the neurobiological validity of ASD, the construct validity of ASD diagnostic criteria, and the construct validity of ASD spectrum features. The findings reviewed indicate that the ASD diagnosis lacks biological and construct validity. The paper concludes with proposals for research going forward.