When doctors and therapists medicalized transsexualism in the 1970s, they played a large role in removing it from public debate, and smothered ethical and political discussion about it. The medical model had a profound influence on the way that people viewed transsexualism. Transsexualism as a medical specialty in a medical empire created the disease of gender dysphoria, and brooked no outside interference or public criticism. If one’s basic approach to gender identity is from a psychological and medical basis, then many moral issues, as well as sociopolitical, economic, and environmental problems are transformed into technical problems. And the kind of ‘health’ values it generates do not encourage a would-be transitioner to recognize that such ‘health’ may be unhealthy in the long run. (29)
The following essay by Donovan Cleckley was first published at Women Are Human on January 18, 2022.
“Freedom Is Slavery”
Transsexualism past and transgenderism present challenge us to think about the meaning of individual-as-object versus individual-as-subject. In her 1979 book The Transsexual Empire: The Making of the She-Male, Janice G. Raymond draws upon Ivan Illich’s analysis from his 1975 book Medical Nemesis: The Expropriation of Health. As her main point, Raymond argues that, in the medicalization of sex vis-à-vis gender, “the social situation” has not been considered—or, more precisely, it has been strategically ignored—with relation to the development of what has been diagnosed as gender “dis-ease” (1979/1994, 142). From adults undergoing social and medical transitioning, this strategic ignorance toward social facts has extended to what Heather Brunskell-Evans describes as “the medico-legal ‘making’ of ‘the transgender child.’” An ideal of ‘self-determination’ has been consistently prioritized over analyzing the phenomenon of sex-role stereotyping and its reinforcement by a medical-technical solution.
Illich’s Medical Nemesis: The Expropriation of Health, later reprinted as Limits to Medicine – Medical Nemesis: The Expropriation of Health, begins with the following sentence: “The medical establishment has become a major threat to health” (3). What Illich writes might appear to us as paradoxical: One expects health to be managed, even regulated, by medicine, not threatened by it. Indeed, one would believe, in opposition to Illich, maybe too naïvely, that the medical establishment must be one’s preserver and protector. While controversial in 1975, Illich’s critique grew to be, as he puts it, “trite,” by 1994—that is, nonthreatening (1975/2013, v). Illich does not reject all uses of medicine and technology; rather, he recognizes industrial civilization for its contradictions, one of these being un-health as ‘health.’ An industrial complex does exist in the making of more patients to produce more profits. Such a state of things is not a conspiracy theory, but rather a conspiracy; the former would be fantasy, while the latter is reality.
The Death Is in the Details
On the expropriation of death, Babette Babiche argues that Illich’s position can be regarded as paradoxical, for he does not hold the position of “pain medication for all on demand,” even if he also does not oppose pain management. In his concern for the life of the body as the self, Illich rejects the denial of pain embedded in the desire for transcendence. Alienation in the fear of the body, even the hatred of it, underpins the view that pain must be killed by its medicalization. One terrorizes the flesh, imagined as just meat, in the aim of finding the self underneath one’s skin. But there is nothing there but what one hopes to unearth from body as if dirt. Critical of this concept of body-as-thing, Illich’s point of view seems, as Babiche writes, “counterintuitive for us, palliatively minded as we are, anaesthetically, pain-management-minded as we are” (2018, 9). Gender medicine seems oriented toward a palliative and anaesthetic sense of being in nonbeing: one’s life to come that is one’s death.
On the state of the left, it seems that many, including those who declare themselves communists and even feminists, denounce the prison-industrial complex as oppression to be not only criticized but also abolished. The same who do so simultaneously refuse to even criticize the medical-industrial complex, much less note its existence in relation to social conditions. There seems to be the further denial of sexuality and sexual politics in relation to medicine. Other contradictions begin to emerge, observable in the commercial mainstreaming of the medicalization of sex vis-à-vis gender in our time and its increasingly uncritical acceptance on the left. Destroying the endocrine system and dismembering the body do not seem like the best methods of treating any mental health condition. Impairing one’s physical health for life, done in the hope of improving one’s mental health, makes sense in the context of medical nemesis. Therefore, Illich’s analysis seems applicable, maybe even more so now than it did in his time, for thinking critically about the making of gender medicine as both ideology and industry.
We might consider two passages: one from the notes of Illich’s 1974 lectures, republished in 2003, and the other from Raymond’s 1979 analysis:
By transforming pain, illness, and death from personal challenge into a technical problem, medical practice expropriates the potential of people to deal with their human condition in an autonomous way and becomes the source of a new kind of un-health. (919)
Transsexual surgery promotes the ethic that the problem of transsexualism cannot be confronted on an autonomous level but needs the intervention of the medical and surgical, as well as psychological, specialties. (167)
Between Illich and Raymond, we notice a shared consideration for an otherwise autonomous state of being. In her 1977 essay “Transsexualism: The Ultimate Homage to Sex-Role Power,” Raymond cites Illich, questioning if the medicalization of sex vis-à-vis gender manifests in “a renouncing of autonomy” (22). The paradoxical argument has been that greater dependence upon medicalization, in the form of hormone treatments and surgical interventions—that is, therapy as a way of life—in turn produces greater independence for the individual. But it does not seem to be so, as the reverse seems true: One would seem to become more dependent, object rather than subject, for life. In Medical Nemesis, Illich defines exactly this relation: “The patient is reduced to an object—his body—being repaired; he is no longer a subject being helped to heal” (1975/2013, 235). The body does not appear regarded as the self, which becomes seen as a thing to be excavated from the body. This dynamic would seem especially true for the children and young people subjected to puberty blockers followed by cross-sex hormones.
Gender Dysphoria as Cultural Iatrogenesis
Iatrogenesis derives from iatros, Greek for “physician” or “healer,” and genesis meaning “origin.” Illich uses iatrogenesis to describe what he calls “the sick-making powers of diagnosis and therapy”: ‘health’ as un-health (1975/2013, 3). A market becomes produced for the medicalization of life, defined by affirming pleasure and annihilating pain for the self and, by extension, for the society. Authoritarianism underlies this utopian desire, which, upon closer analysis, seems more dystopian in nature. Read alongside Illich, Raymond’s critique of the medicalization of sex vis-à-vis gender seems like a reasonable extension of his critique of cultural iatrogenesis. According to Illich:
Cultural iatrogenesis . . . consists in the paralysis of healthy responses to suffering, impairment, and death. It occurs when people accept health management designed on the engineering model, when they conspire in an attempt to produce, as if it were a commodity, something called ‘better health.’ This inevitably results in the managed maintenance of life on high levels of sublethal illness. (1975/2013, 33-34, qtd. in Raymond, 1979/1994, 181)
A medical-technical paradox appears in a ‘solution’ that is a problem; a cure for the mind, in this sense, is more sickness for the body. The patient comes to expect the medical authorities, those who technically authorize the ‘autonomy,’ to liberate and not oppress. One does not die instantly, but one dies over time, the individual being farmed by the industry. The killing of the masses becomes not hastened, but rather slowed, in order to paralyze and terrorize (iii).
Where one finds ‘the transgender child,’ one also finds the argument that pubertal development must be ‘blocked’ to ease or end the child’s suffering. Because we hear that the child would kill himself or herself anyway, impairment physiologically and psychologically for a lifetime becomes far less concerning. Or, at least, this framing makes it seem to be so. Medicalization becomes a religion for killing the pain, with the patient becoming faithful in any promise to end his or her suffering. The idea of avoiding going through the ‘wrong’ puberty appears with claims about this medicalization being necessary to stop depression and suicide. Indeed, ‘trans liberation,’ as a concept, has seemed inextricable from such lifelong medicalization over sex-role stereotyping. One becomes, as Raymond writes, “a lifelong patient” (1979/1994, 181). As others have done, it might be argued that, even while reduced to an object, the individual-as-object can imagine the self in the role of the subject, thereby escaping being the object.
However, this point of view seems far more idealistic than realistic, presenting an ideal of ‘self-determination,’ set above the reality of one’s social conditions. On the related issues of prostitution and surrogacy, a similar rhetoric of individual-as-subject, by fantasy, rather than reality, dominates contemporary analyses from the liberal point of view. One argues that adults can do with their bodies as they please, which does not seem objectionable in its simplicity, but this argument sidesteps important ethical and moral issues. Narcissism engenders this absence of the ethical and the moral in the personal and the political, where the other matters far less than the self. Caught in the contradictions of bourgeois individualism, the slogan of ‘sex work is work,’ for instance, likewise expresses the idea of liberation by oppression, not from it. The fantasy of autonomy in one’s choice presents itself, as if the end of the question—only to be negated by the reality of one’s social conditions. This utopia as dystopia is freedom as slavery: the negative hidden by the positive.
Life Is a Fatal Disease
Criticism of Raymond’s Transsexual Empire has seemed to default to autonomy—which facilitates the perception of the human body as a thing for disassembling and reassembling at will. One might call it mind-body dualism—the split self. Any critique becomes dismissed as moralism against the ‘free’ use of the body. A similar bodily concept appears in discourses around prostitution and surrogacy: body-as-commodity. The more simplistic framing of these issues revolves around personal choice, typically also seen as indicating political consciousness, romanticized as resisting the system. One performs a spectacle of radical and revolutionary politics lacking in substance. But a problem here appears to be that one reinforces the system that one claims to resist.
A question that Illich raises, which Raymond explores in her writing, has been how medicine influences everyday life, to the point that it becomes ritualistic. In her 1982 essay “Medicine as Patriarchal Religion,” Raymond writes: “Medicine has advanced the ideology that life is a disease that has to be cured or, at best, prevented” (213). Like Illich, Raymond does not seem to reject all medicalization, but she nevertheless considers it vital that we think about medicalization. As sickness, life becomes not something worth living, but rather something to be done away with. A child for whom life has become a sickness cannot grow up—indeed, must not grow up—demanding a cure, for life is a fatal disease. From Illich’s Medical Nemesis, we might consider the relation between cultural iatrogenesis and medical civilization as medical colonization. He writes:
The recovery from society-wide iatrogenic disease is a political task, not a professional one. It must be based on a grassroots consensus about the balance between the civil liberty to heal and the civil right to equitable health care. During the last generations the medical monopoly over health care has expanded without checks and has encroached on our liberty with regard to our own bodies. Society has transferred to physicians the exclusive right to determine what constitutes sickness, who is or might become sick, and what shall be done to such people. Deviance is now “legitimate” only when it merits and ultimately justifies medical interpretation and intervention. The social commitment to provide all citizens with almost unlimited outputs from the medical system threatens to destroy the environmental and cultural conditions needed by people to live a life of constant autonomous healing. This trend must be recognized and eventually be reversed. (Illich, 1975/2013, 6) (emphasis added)
Medical civilization is planned and organized to kill pain, to eliminate sickness, and to abolish the need for an art of suffering and of dying. This progressive flattening out of personal, virtuous performance constitutes a new goal which has never before been a guideline for social life. Suffering, healing, and dying, which are essentially intransitive activities that culture taught each man, are now claimed by technocracy as new areas of policy-making and are treated as malfunctions from which populations ought to be institutionally relieved. The goals of metropolitan medical civilization are thus in opposition to every single cultural health program they encounter in the process of progressive colonization. (Illich, 1975/2013, 132)
Illich underscores the importance of what he identifies as “the civil liberty to heal” and “the civil right to equitable health care.” The model for gender medicine does not seem to be about either of these. Consumerism seems to be its driving force, culminating in the idea, now applied to hormonal and surgical intervention, that ‘the customer is always right.’ Even within a culture of self-diagnosis, medical interpretation and intervention seem to hold dominion over the flesh. To be gender-nonconforming, especially for children and young people, is to be a potential object for management by medicine. The notion of the affirmation of one’s identity by medicalization being a life-or-death issue seems to illustrate this stranglehold. Being gender-dysphoric has appeared to require medicalization or else one will die, especially for children and young people. This popular argument that children and young people must be ‘saved’ from the ‘wrong’ puberty underpins modern transgender rights activism. In other cases, however, self-declaration alone makes one transgender, most often for adults rather than children—and that it requires little to no medicalization. The idea of ‘saving’ children and young people from the ‘wrong’ puberty appears to be predicated on the idea that they can be made into more convincing images of the idealized opposite sex. Technocratic ‘health’ values seem embodied in the idea that one can make a technological fix to not undergo pubertal development, ‘blocking’ one’s puberty, to become other than the body as the self.
Transcendence beyond the body presents a hope that, in this life, is broken. One receives bodily reminders of it constantly—mind cannot truly enslave matter. Fantasy becomes reality that must be maintained by forcing it upon others. The desire for transcendence has remained true in the consumption of technology to escape the flesh. One seeks to become one’s true self by denying the body as the self. Raymond’s 1982 essay raises the issue of medicine and its multiple false promises, with its lies being especially appealing to women. She writes:
Whether the problem be gynecological, dietary, or even one of appearance calling for the wonders of plastic surgery, more women have come to depend upon medical science and technology to transcend themselves. Medicine has consistently made attempts to ‘improve’ the biological female, offering her a new lease on life through such techniques as prophylactic hysterectomies, reconstructive breast surgery, and ‘love surgery.’ The technological fix has become the transcendental fix. What medicine ultimately offers is transcendence by technology. And it is women, for the most part, who seek such transcendence. (Raymond, 1982, 199) (emphasis added)
Practices for ‘improvements’ on the biological female body have a history of not ending well. For too many, the harm ends up already having been done, but they need care in the aftermath. And, for others, they might be able to avoid the harm of the technological as the transcendental altogether. What Raymond writes, read here alongside Illich, makes clear the importance of thinking about the ethical and the moral, which go beyond the personal and the political. Prior to critiquing transsexualism, Raymond had done work critical of psychosurgery—or, as we might also know it, the lobotomy—and behavior control as they impacted women’s bodies and women’s minds. It seems relevant that Raymond’s understanding of technological fixes, such as psychosurgery, as transcendental fixes informed her more critical position toward using hormonal and surgical methods to remake the body in an idealized manifestation.
Illich’s Self-Criticism on the Concept of Coping
Although, in 1975, Illich had conceptualized “health” as “the intensity of autonomous coping ability,” in the preface to the 1995 edition of Limits to Medicine – Medical Nemesis, he writes:
I was unaware that by construing health in this self-referentially cybernetic fashion, I unwittingly prepared the ground for a worldview in which the suffering person would get even further out of touch with the flesh. I neglected the transformation of the experience of body and soul when well-being comes to be expressed by a term that implies functions, feedbacks and their regulation. […] You can obliterate the experienced sensual body of the past by conceiving of yourself as a self-regulatory, self-constructing system in need of responsible management and, in spite of this disembodiment, claim that you stand within the tradition of the art of suffering and the art of dying. (1975/2013, iii)
As soon as you understand suffering as coping, you make the decisive step: from bearing with your flesh, you move towards managing emotions, perceptions and states of the self conceived as a system. (1975/2013, vi)
Self-perception in systems terms dissolves the kind of flesh that could practise either the art of enjoyment—the sunny phase, or the art of suffering—the shady side. Medical Nemesis was an attempt to vindicate the art of living, the art of enjoyment and suffering, even within a culture shaped by progress, comfort, care and insurance providing entitlement to pain killing, normalization and, ultimately, euthanasia. (1975/2013, viii)
To become, as Illich writes, “further out of touch with the flesh” means not the body-as-self, but rather the body-as-thing. The reality of being disembodied contradicts any fantasy of embodiment. As what Illich calls “the experienced sensual body” becomes denied, one finds oneself mechanized. Gender medicine can be characterized as subjecting the flesh to further disembodiment, done so for the object of embodying the self.
Two other passages from Illich seem of particular relevance to the present conversation around gender medicine. Concerning malpractice, we have seen a move from the ethical to the technical. Illich writes:
Doctor-inflicted pain and infirmity have always been a part of medical practice. Professional callousness, negligence, and sheer incompetence are age-old forms of malpractice. With the transformation of the doctor from an artisan exercising a skill on personally known individuals into a technician applying scientific rules to classes of patients, malpractice acquired an anonymous, almost respectable status. What had formerly been considered an abuse of confidence and a moral fault can now be rationalized into the occasional breakdown of equipment and operators. In a complex technological hospital, negligence becomes ‘random human error’ or ‘system breakdown,’ callousness becomes ‘scientific detachment,’ and incompetence becomes ‘a lack of specialized equipment.’ The depersonalization of diagnosis and therapy has changed malpractice from an ethical into a technical problem. (29-30)
Patients are told ever more frequently by their doctors that they have been damaged by previous medication and that the treatment now prescribed is made necessary by the effects of such prior medication, which in some cases was given in a life-saving endeavor, but much more often for weight control, mild hypertension, flu, or mosquito bite or just to put a mutually satisfactory conclusion to an interview with the doctor. (228)
If the issue of the medicalization of sex vis-à-vis gender remains framed as being purely technical, then it cannot be analyzed for its ethical and moral relation to human life. Returning to an observation Illich makes in the 1995 preface, we might consider how he altered his emphasis. Whereas the issue he found most pressing in 1975 had been the ethical, he later considered it to be the epistemic—that is, “a question of truth” (viii). One might ask what the individual should do and how the individual knows. Which direction one takes must depend upon what one desires and how it impacts both the self and others as well as one’s knowledge, or lack thereof, of factors, including moral and ethical ones. Of the increasingly medicalized way of living, Illich adds, critically, that “what is done in the pursuit of health boomerangs as an interpretation of the self” (viii). Perhaps, or so it has seemed, the contradictions of disembodiment for embodiment have yet to be given proper thought.
1. See Brunskell-Evans, “The Medico-Legal ‘Making’ of ‘The Transgender Child,’” pp. 641, 645-649, and 656-657, and, in particular, “Girls’ Bodies,” in Brunskell-Evans, Transgender Body Politics, pp. 41-81.
2. See, in particular, “The Killing of Pain,” in Illich, Limits of Medicine – Medical Nemesis: The Expropriation of Health, pp. 133-154.
Babiche, Babette. “Ivan Illich’s Medical Nemesis and the ‘Age of the Show’: On the Expropriation of Death.” Nursing Philosophy, vol. 19, no. 1, 2018, pp. 1-14. https://doi.org/10.1111/nup.12187
Brunskell-Evans, Heather. “The Medico-Legal ‘Making’ of ‘The Transgender Child.’” Medical Law Review, vol. 27, no. 4, 2019, pp. 640-657. https://doi.org/10.1093/medlaw/fwz013
—. Transgender Body Politics. Spinifex Press, 2020.
Illich, Ivan. Limits to Medicine – Medical Nemesis: The Expropriation of Health. Marion Boyars Publishers, 1975/2013.
—. “Medical Nemesis.” The Lancet, vol. 303, no. 7863, 1974, pp. 918-921. https://doi.org/10.1016/S0140-6736(74)90361-4
—. “Medical Nemesis.” Journal of Epidemiology and Community Health, vol. 57, no. 12, 2003, pp. 919-922. http://dx.doi.org/10.1136/jech.57.12.919
—. “The Medicalization of Life.” Journal of Medical Ethics, vol. 1, no. 2, 1975, pp. 73-77. http://dx.doi.org/10.1136/jme.1.2.73
Raymond, Janice G. Doublethink: A Feminist Challenge to Transgenderism. Spinifex Press, 2021.
—. “Medicine as Patriarchal Religion.” The Journal of Medicine and Philosophy, vol. 7, no. 2, 1982, pp. 197-216. https://doi.org/10.1093/jmp/7.2.197
—. The Transsexual Empire: The Making of the She-Male. Teachers College Press, 1979/1994.
—. “Transsexualism: The Ultimate Homage to Sex-Role Power.” Chrysalis, no. 3, 1977, pp. 11-23.
Brunskell-Evans’s 2019 essay “The Medico-Legal ‘Making’ of ‘The Transgender Child’” can be accessed via her website at the following link:
Raymond’s 1977 essay “Transsexualism: The Ultimate Homage to Sex-Role Power,” from Chrysalis, can be accessed via JSTOR at the following link:
Raymond’s 1979 book The Transsexual Empire: The Making of the She-Male and her 1982 essay “Medicine as Patriarchal Religion” can be accessed via her website at the following link:
Raymond’s 2021 book Doublethink: A Feminist Challenge to Transgenderism can be purchased from Spinifex Press at the following link:
Stella Perrett (Radical Cartoons) illustrated the image accompanying this essay. More of her work can be visited at the following link to her website:
Her YouTube channel, where she posts workshops and other videos on cartoons and illustrations, such as for the above image, can be visited at the following link:
Here is Perrett’s cartoon workshop video for the illustration created for this essay:
By Donovan Cleckley
I won’t tell you where the place is, the dark mesh of the woods
meeting the unmarked strip of light--
ghost-ridden crossroads, leafmold paradise:
I know already who wants to buy it, sell it, make it disappear.
- Adrienne Rich, “What Kind of Times Are These” (1991), Dark Fields of the Republic: Poems 1991-1995 (1995)
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