Introduction

Medicalization occurs when an aspect of embodied humanity is scrutinized by the medical industry, claimed as pathological, and subsumed under medical intervention (Zola 1972). Numerous critiques of medicalization appear in academic literature, often put forth by bioethicists who use a variety of “lenses” to make their case. Feminist critiques of medicalization raise the concerns of the politically disenfranchised, thus seeking to protect women—particularly natal sex women—from medical exploitation. This article will focus on three feminist critiques of medicalization which offer an alternative narrative of sickness and health and will discuss both feminism and medicalization from a modern, developed-world perspective in the privileged sphere of academia. There are many limitations to this methodology, but in absence of sustained ethnographic interviews or extensive international archival work, this is the standard for academic, English-language journals.

I will first briefly describe the philosophical origins of medicalization. Then, I will present three feminist critiques of medicalization. Liberal feminism, trans feminism, and crip feminism tend to regard Western medicine with a hermeneutics of suspicion and draw out potential harms of medicalization of reproductive sexuality, gender, and disability, respectively. While neither these branches of feminism—nor their critiques—are homogenous, they provide much-needed commentaries on phallocentric medicine. I will conclude the article by arguing for the continual need for feminist critiques of medicalization, using uterus transplantation as a relevant case study.

Medicalization

MedicalizationFootnote 1 occurs when the person is told they can, or should, utilize medical treatment, even though there might not be a medical indication. Andy Miah and Emma Rich observe that “Medical language now permeates many everyday activities, including childbirth, sex, reproduction, exercise, drinking, eating, smoking and pregnancy… ‘having to put up with unpleasant social circumstances,’ now could provoke someone to ‘see a psychotherapist or a naturopath’” (Miah and Rich 2008, 20). Medicalization can also occur when human functioning becomes an object of medical scrutiny to be fixed by medical solutions rather than accepted as “normal” variation. In the words of Ivan Illich:

… the medicalization of life appears as…the addiction to medical drugs; it also takes form in iatrogenic labeling of the ages of man [sic]. This labeling becomes part of a culture when layman accept it as a trivial verity that people require routine medical ministration of the simple fact that they are… (in any state of life) (quoted in Oakley 1984, 275).

From a medicalized view, “Health is thus a highly personalized state of satisfaction or dissatisfaction determined by the patient [her]self” (Mitchell et al. 2007, 114).

Medicalization may not seem problematic, especially if we assume doctors are adhering to the Hippocratic Oath and the four principles of biomedical ethics. Medicalization is not the only objective of the healthcare industry. To be sure, in some cases medicalization has not occurred and the patient will be distressed about her health or in need of treatment and seek the offerings of the medical industry. While patient-driven medicalization, or “medicalization from below” (Szasz 2007, xvviii) is a reality, in the case that there is a clinical disease that can be treated, an appropriate course of medicine should be suggested.

Moreover, medicalization has certain social benefits such as moving criminal actions—like drug use and violence—from the law to the less punitive medical system (Conrad 2007, 152). Furthermore, medicalization vis-a-vis documenting and categorizing previously unrecognized mental disorders such as gender identity disorder, expands medical services and the use of health insurance to defray costs associated with treatment. Other benefits of medicalization include legal protection against discrimination and enhanced ability to find emotional support through friends or family or online. The debate about “good and bad forms of medicalization” (Parens 2013) is outside the scope of this paper, which is using a critical feminist hermeneutic to disavow medicalization.

Feminist Critiques of Medicalization

Feminists note that oftentimes the medical gaze has collided—and colluded—with the male gaze to impose normative standards of health on women. For feminist bioethicists, medicalization occurs when the medical gaze (Foucault 1973, xii) intersects with the male gaze (Mulvey 1975, 15) in healthcare. These are sharply critiqued as being antithetical to women’s well-being and clinically superfluous. Detrimental effects of medicalization include overprescription or unnecessary drugs, iatrogenic diseases, emotional distress, and financial burdens (Elliott 2003; Welch, Schwartz, and Woloshin 2011; Hadler 2008).

There are as many feminist perspectives on medicalization as there are divisions of medicine (Purdy 2001). Furthermore, there are as many feminist critiques of medicalization as there are branches of feminism. Three aspects covered in this article are a liberal feminist critique of the medicalization of women’s sexual and reproductive function, a trans feminist critique of the medicalization of gender, and a crip feminist critique of the medicalization of disability. These are not “the” only feminist critiques of medicalization within these tributaries of feminism. Moreover, my categorizations of feminism are debatable, but constructed along broadly accepted concepts and definitions. The categories I am using are not necessarily independent branches of feminism. Since there is overlap in feminist philosophy, one scholar might write using a liberal perspective, while self-identifying as separatist, for instance. Another feminist scholar might be viewed as conservative, while she is actually radical. These labels are moving targets. The academic equivalent of the “sound bite”—that is, the quote—cannot adequately represent the complexity of evolving intellectual thought, nor the scholar herself, who might adopt a distanced position for the sake of rhetoric.

Rather than essentializing feminism or feminist bioethics, I highlight three non-discrete critiques of medicalization that retain an underlying commitment to better the lives of women, however “better” and “women” are defined. These critiques, which I will allow to speak on their own terms, are unified by a gynocentric epistemology. These may at times seem outdated, not “politically correct,” or non-standard for a particular country. Although feminism may at times contradict itself as an ideology, or be offensive, this diverse presentation of liberal, trans, and crip feminism avoids the colonization of attempting to force all feminist voices into uniformity.

Since liberal feminism is perhaps the most recognizable form of feminism in bioethics, it will be discussed first. In many ways, trans feminism and crip feminism both elaborate and critique liberal feminism. Therefore, the remainder of the article should be viewed as a dialogue, rather than a compartmentalized argument, between some constitutive feminists on medicalization in the capitalistic, developed, well-educated, overfed, modern world.

Liberal Feminist Critique of Medicalization

Doctors have historically been male and acted paternalistically in their medical treatment of female patients. Although today there are more female doctors than in previous centuries, the medical profession is still predominantly influenced by the collective tradition of “male medical experts [who] exert power over women’s bodies by defining certain physiological states experienced exclusively by women as disease or potential medical crises that should be controlled by (male) medical management” (Andolsen 1996, 343). These exclusively female experiences include menstruation, pregnancy, childbirth, nursing, and menopause. These are all somatic possibilities of the female body. When they are viewed as irregular or deficient, typically because a man deems them to be so, medicalization has occurred.

The patriarchal male gaze on a female body prescribes gender stereotypes, gender roles, gender scripts, and hegemonic notions of femininity. The colonization of the female body by making it undergo the chemical or silver knife in an effort to conform to what men determine is “normal” is rallied against by feminists who perceive that “the construction of gender dissatisfaction has been medicalized through promotion of breast implants, hormone replacement therapy, infertility hormones and reproductive procedures, and plastic surgery” (Raymond 1993, xiv).

Since sex is biological/chromosomal and cannot be changed, Margaret Farley rightly notes that medicalization focuses on gender expectations, which are socially constructed, normative descriptions about women (and men). Farley argues these “social and cultural stereotypes that promote hierarchal relations…do not, in the end, succeed in making us complements across a gender divide” (Farley 2006, 156–157). Her critique is particular salient for the glorification of biological determinism whereby femininity (gender) is conflated with reproduction (biological sex) and, consequently, heterosexual, fertile women are held to be the pinnacle of health.

Medicalization of Sexual Intercourse

Liberal feminists observe that women have been forced into medical models that are parasitic on socially constructed notions of the purpose of women as sex object for men. For instance, Kristina Gupta challenges the Diagnostic and Statistical Manual (DSM) categorization of low libido as a disorder. Claiming “hypoactive sexual desire disorder,” or HSDD, as problematic “pathologizes benign variations in women’s levels of sexual interest, increases pressure on heterosexual and bisexual women to live up to male partners’ sexual expectations, and inappropriately locates the cause of sexual dissatisfaction in the individual instead of society” (Gupta 2013). Although Gupta wrote this in 2013, her insight has gone largely unnoticed by those in the medical industry, and in 2015 the U.S. Food and Drug Administration approved the first pharmaceutical pill to “treat a lack of sexual desire in women” (Pollack 2015). Flibanserin, also called “female Viagra,” has side effects that include low blood pressure, fainting, nausea, and dizziness. Despite being called a treatment, there are no medical problems associated with a lack of heterosexual intercourse or heterosexual desire.

While it may seem idealistic to suggest that scholarship like Gupta’s can lead to policy change, scholars can and do influence policy, especially in biomedical ethics. However, feminist perspectives are often ignored, while male/masculine perspectives are taken seriously and codified into policy. Nonetheless, liberal feminists continue to question who is benefiting from the definitions and “cures” for women’s sexual and reproductive “underperforming” capacities. In most cases, it is not the women themselves, but heterosexist society that depends on women’s sexual availability, reproduction, and unpaid domestic labour.

Although women can sometimes escape these heterosexist traps through womenloving, even same-sex female relationships may be tainted by inequality and dominance, which typify all relationships in a patriarchal society (Jeffreys 2003, 12). Thus, even lesbians are pressured into reproductivity and sexual access. Teresa Delgado comments that “the particularity of ‘woman bodiliness’ entails the religious and cultural mandate to ‘give up’ our bodies for the sake of others: as mothers, objects of sexual exploitation, and commodities for sale” (Delgado 2009, 26). As sex objects, the primary function of women is to be available for coitus and reproduction. In patriarchal systems, heterosexual and bisexual men use women for coitus and heterosexual, bisexual, and homosexual men demand access to women for reproduction, for example, through surrogate motherhood. When women are unable or unwilling to fulfil these patriarchal imperatives, they fall under the male medical gaze (Richie 2013).

Oftentimes these medicalized “solutions” offer a deeply incongruous notion of what women’s bodies should do. A survey of these contradictory sexual and reproductive medical offerings include pills to increase libido, such as “Hot Plants for Her,” and “Libido Max,” and numbing creams to stop “persistent sexual arousal syndrome” like the antidepressant paroxetine. The birth control pill has been used to regulate or start menstrual cycles, but in the last few years the product Seasonale has been marketed as a way to eliminate a majority of one’s menstrual cycles. Contraception is given to prevent pregnancy, while artificial insemination and assisted reproductive technologies are options for obtaining a pregnancy. Surgical, chemical [mifepristone, also known as RU-486], and herbal abortions can terminate a pregnancy, while tocolytic medicines such as terbutaline, indometacin, nifedipinine, and magnesium sulfate sustain pregnancy by stopping premature labour. Epidural anesthesia blocks pain in vaginal childbirth, while a caesarean section may increase pain following recovery (Burrows 2012). The medical solution, of course, is more medicine. “Technophilia’s tendency to create a demand for more technology also masks a misguided desire to seek medical or technical solutions to decidedly nonmedical problems” (Traina 1999, 327).

Medicalization Post-Partum

Medicalization also encourages women to “restore” parous bodies to virginal states through “laser vaginal rejuvenation,” and other vagina tightening techniques like vaginoplasty, hymenoplasty, and labiaplasty (Groskop 2008). Tummy tucks, (abdominoplasty), breast lifts (mastopexy), liposuction, varicose veins elimination, and skin pigmentation “repair” are also marketed to postpartum women to erase the effects of being pregnant. Then, at the end of a woman’s reproductive life, fertility can be artificially prolonged, symptoms of menopause can be masked by “hormone replacement therapy,” and women can be more accommodating to male penetration with vaginal lubrication suppositories. Other forms of medical manipulation of women’s bodies include female genital mutilation (FGM), elective genital cosmetic surgery, and genital reassignment surgery (for intersex or transgender individuals). The pathologization of women’s bodies treats their flesh and function as machinery. Many feminists would exclude all such medical invasions in the female body as a “glaring pollution of women” (Raymond 1993, 134).

Physically healthy women are being diagnosed as sick by the medical industry. The medicalization of the experience of being an embodied woman manifests in a plurality of harmful treatments that have lasting side effects. Physical harm occurs to women when they are told that they need technological intervention to “correct” a problem of their bodies. Iatrogenic disease is a major cause of pain and mortality. In contrast, affirming the diversity of physical experiences of women and a non-gender essentialist view of womankind does away with medical models that compel women to squeeze into the same box. Not all women can—or should—menstruate, have heterosexual sex, become pregnant, or desire men. Recognition of medicalization empowers women to reject medically unnecessary treatments at their discretion. It furthermore protects the dignity—and even health—of the person who accepts herself without medical intervention. The liberal feminist critiques of the medicalization of sex and reproduction have been integrated into the healthcare industry in selected circles, while other aspects of medicalization receive attention from additional feminist branches.

Trans Feminist Critique of Medicalization

Trans feminism builds on the liberal feminism’s resistance to medicalization, without necessarily adhering to the philosophical foundations of liberal feminism itself. Particularly since the foremothers of liberal feminism in America were generally white women—with womanism and black feminism developing subsequently (hooks 1989)—liberal feminism has not enjoyed the wealth of perspectives that trans feminism has. Because race and racism have been pernicious characteristics of American medicine, criticisms of medicalization from non-white trans feminist perspectives are particularly important (Snorton 2017). In adding these narratives, the trans feminist critiques of medicalization become complicated and more disparate. In any case, trans feminism addresses the medicalization of gender from a feminist perspective.

Gender is separate from sex (Hausman 1998). Sex is biological, chromosomal, and manifests in secondary sexual characteristics. All animals, including humans, have a sex (XX, XY, intersex). However, only humans have gender. Gender is a highly inflected concept that is specific to race, ethnicity, geographical location, era, age bracket, education, ability, religion, and other demographics. For instance, in Greenland, Inuit women (XX) of the female gender wear pants because it is cold. However, Orthodox Jewish women (XX) of the female gender are prohibited from wearing pants by religion. Both are women by sex, with different gender expectations for femininity.

Taxonomies of Gender

Gender has at least three components: social stereotypes, personal identity, and public presentation. Social gender stereotypes depend on sex. For instance, “because women are able to carry children” (based on biological sex) … “they are more caring towards all people” (social gender stereotype).” Or “because men are bigger than women” (based on biological sex) … “they are more suited for military service” (social gender stereotype). These stereotypes rely on binaries that are complementary and incommensurate. Heteroreproductive society depends on dichotomous gender in order to prevent same-sex attraction, which would violate compulsory heterosexuality and could not result in biological procreation. Men (XY) must behave, look, and act as masculine (socially determined); women (XX) as feminine (socially determined).

Personal gender identity is the way a person accepts or rejects the social gender stereotypes specific to her or his own culture and natal sex. Cisgender people are those who identify with the social gender stereotypes that have been set forth by their culture for their sex. Transgender people are those who do not identify with the social gender stereotypes that have been set forth by their culture for their sex. The Transgender Law Center writes, “The term ‘transgender’ is used to describe people whose gender identity does not correspond to their birth-assigned sex and/or the stereotypes associated with that sex” (2011, 1–2). This definition accurately locates gender within a socially constructed arena. One can identify as transgender without significantly or intentionally altering gender presentation. For example, a very feminine-looking natal sex woman could identify as transgender on the basis of her career ambitions, fascination with automobiles, or degree in biochemistry since these are stereotypically masculine characteristics. Transgender—since it encompasses emotional, mental, social, psychological, and physical stereotypes—is a very broad term.

Public gender presentation is the way one adopts gender stereotypes to acquiesce to—or rebel from—social gender stereotypes. Women have significantly more latitude in flouting gender conventions than men in most Western countries, particularly in matters of appearance. This inconsonance is often more troublesome for natal-sex men. For instance, American society permits women (XX) to wear typically male clothing such as pants, collared shirts, and flat shoes, but typically forbids men (XY) from wearing dresses, make-up, and high-heels. Restrictive norms surrounding public gender presentation may force a person to self-identify as transgender, when they actually are cisgender but enjoy cross-dressing. Cross-dressing is medicalized when transvestites are encouraged towards medical intervention, such as sex reassignment surgery (SRS), in order to validate their gender presentation. It should not be assumed that all transgender people want SRS. Transgender people can and do live without medical intervention. For the purposes of this article, public gender presentation—achieved through the medical industry and not through non-medical means, such as clothing—is the object of trans feminist critique. This critique of medicalization thus requires a medical diagnosis, leading to the use of the medical industry.

Medicalization of Gender Presentation

Transgender people have been labelled mentally ill by the Diagnostic and Statistical Manual of Mental Disorders (DSM). Their diagnosis: gender identity disorder (GID) / gender dysphoria. Gender identity disorder (GID) was the term used in the DSM-IV, but it was removed from the later DSM-V and replaced with the term “gender dysphoria.” The criteria for diagnosis are similar for both terms (American Psychiatric Association 2013). The social, medical, and policy implications of this change, as well as the history of the evolving definitions, are topics for another article (see Serano 2013). Suffice it to say, the DSM diagnosis was not based on first-hand experience, but rather exists as an observational tool of doctors and is therefore part of the medical gaze. Under the medical gaze, “cures” and “treatments” are imposed rather than solicited since the preferences of people who are experiencing these “symptoms” are removed.

In her oft-referenced work Changing Sex, Bernice Hausman claims that the medical construction of gender variance—rather than individual subjectivity—shaped the early transsexual medical narrative that still retains its hold in popular imagination. Hausman writes, “by demanding technological intervention to ‘change sex,’ transsexuals demonstrate that their relationship to technology is a dependent one…demanding sex change is therefore part of what constructs the subject as a transsexual: it is the mechanism through which transsexuals come to identify themselves under the sign of transsexualism” (Hausman 1995, 110). This medical intervention into gender presentation this is precisely what Sandy Stone describes in her trenchant essay “The ‘Empire’ Strikes Back: A Posttranssexual Manifesto.”

Stone observed that the medical construction of gender dissatisfaction, and therefore medical solution of gender satisfaction, focused on the body, and specifically the genitals, which are part of sex and not gender. The historical diagnostic tools for assessing an appropriate candidate for sex reassignment surgery used the sex organs as a proxy for gender. Stone recounts that under a circumscribed lexicon “so much of these discourses revolves around the phrase ‘wrong body.’ Under the binary phallocratic founding myth by which Western bodies and subjects are authorized, only one body per gendered subject is ‘right.’ All other bodies are wrong” (Stone 2004, 15). That is, a female-presenting person should not have a penis, and sex reassignment surgery was endorsed.

Rather than emanating from within the individual, the identity of transgender and actualization of transsexual came from the doctor. Judith “Jack” Halberstam contends that this taxonimizing of transgender and transsexual by sexologists—instead of the individuals themselves—has resulted in a problematically narrow categorization of people within the spectrum of gender expression. This leads to a contracted conception of gender identity, acceptable gender presentation, and sexual orientation (Halberstam 1989, 47). Still, in the United States and other industrialized countries, sex reassignment surgery became the medical industry’s solution to gender aberration.

Medicalization and Sex Reassignment Surgery

Sex reassignment surgery describes the range of chemical, technological, and surgical procedures by which a person’s physical appearance and secondary sexual characteristics are altered to resemble that of the other sex. Sex reassignment surgery may involve “top” (mastectomy, breast implants) or “bottom” (penectomy, vaginal construction, penile construction, etc.) surgery, aesthetic contouring surgery on the body or face (Richie 2019a), hair removal or transplant, hormonal ingestion, Botox injections, and other medical offerings that do not have a clinical indication since gender presentation does not have a medical aetiology. SRS is still considered the standard cure for gender dysphoria in many countries. However, sex reassignment surgery is also used for people without gender dysphoria who want to live as the other sex. It should not be assumed that a person undergoing SRS has gender dysphoria.

Upon using the medical industry for cross-gender presentation, a person becomes a transsexual. Although this word is somewhat anachronistic, transsexual is a useful term to distinguish between those who have physically altered their appearance by surgical or chemical means to conform to normative ideas of what men or women should look like and those who have not. It is the bodies of transsexuals that are impacted by the medical industry (Transgender Law Center 2011) since they depend on medical interventions. The purpose of this classification is not to praise or marginalize one group, but rather to more narrowly identify the place of critique (i.e., the medical industry) for trans feminists, who otherwise might accept or encourage transgender personal identification and transgender public presentation without medical intervention. To be clear: the trans feminist critique of medicalization is aimed at medical diagnosis and use of the medical industry for gender presentation, and not individual transsexuals or non-medical transgender lifestyles.

Some lesbian, gay, bisexual, transgender (LGBT), and allied groups have advocated to have sex reassignment surgery covered under health insurance, claiming that it is the only solution to, and the best standard of treatment for, their “condition.” The “pro-surgery” strain of medical intervention for gender dysphoria is over-represented in medical discourse, evidenced in numerous articles supporting treatments for adults and minors (Baril 2015; Hewitt et al. 2012), as well as successful lobbying for sex reassignment surgery to be covered under Medicaid (Department of Health and Human Services 2014) and for prisoners in the United States (Parker 2015).

However, the technological solution should not be assumed to be the most beneficial for the patient. There is still a lack of consensus on political, medical, policy, and social transgender issues. Trans feminism is not homogenous and the applications of trans feminism are not uniform. In particular, the trans feminist critique of the medicalization of gender is often subdued or ignored. This counter-discourse focuses on the physical, psychological, and social harm of the medicalization of gender while also repudiating heteronormativity and gender binaries. Trans feminism thus points out that sex reassignment surgery and other medical interventions into gender have significant physical risks.

Harmful side effects of the medicalization of gender may include unpredictable outbursts of violence from male hormones, complications and painful recuperation from elective mastectomies, infections, or prescription of anti-depressants for dissatisfaction with surgical outcomes of “gender reassignment” (Purdy 2015, 4–7). In one case, extreme dissatisfaction with SRS led to a petition for euthanasia. The request was granted in 2013 (Miller 2013). The medical industry has even advocated that children who display gender dysphoria be subjected to “puberty suppression” via injections of hormones so that they can avoid being bullied because of ambiguous gender presentation and make the “inevitable” surgical sex transition easier later in life (De Vries et al. 2014). But high-tech solutions often lead to further problems down the road (Hurst 2017). In one study, over 70% of transmen undergoing pedicled pubic phalloplasty had “major complications,” including “neourethra (75%) with stricture formation (64%) and/or fistulae (55%)” (Bettocchi, Ralph, and Pryor 2005). Prolapse, infection, necrosis, and stenosis are risks with vaginoplasty for transwomen (Horbach et al. 2015). Although medical techniques in SRS continue to improve, the experimental procedures come with a human cost. The price transgender and gender non-conforming people pay is with their bodies, as they submit to invasive, life-altering, cancer-inducing hormone “therapies.”

There are psychological ramifications of the “gender dysphoria” label and subsequent technological intervention of SRS as well. Judith Butler cautions, “we not underestimate the pathologizing force of the diagnosis (of gender dysphoria), especially on young people who may not have the critical resources to resist this force” (Butler 2004, 77–78). It should not be the default to “cure” a “disorder” listed in the DSM with extensive, invasive, and oftentimes not fully successful outcomes in terms of patient satisfaction, sexual function, or “social passing” (Lawrence 2003). Medicalized “treatments” for transgender people have additional negative social outcomes.

Sex Reassignment Surgery and Social Normativity

Sex reassignment surgery is a social—not clinical—solution constitutive of the patriarchy. This is especially pertinent when idiosyncrasies are medicalized and people are offered physical treatments for what is tantamount to a socially objectionable lifestyle. SRS perpetuates transphobia by marginalizing those who present themselves as genderqueer or genderplural. Endorsing medicalization of gender and offering SRS reifies heterosexism by forcing ambiguous or androgynous bodies into “normal” states of being. Halberstam records:

…in bulletins offering tips for FTM (female to male transsexuals) … most of these lists seem to place no particular political or even cultural cause upon the kinds of masculinities they mandate, but they obviously steer transsexual men away from transgressive or alternative masculine styles and towards a conservative masculinity (Halberstam 1998, 298).

The accepted practice for transgender people—proffered by both the medical industry and society—is gender conformity in the form of clear, binary gender stereotypes that facilitate heterosexual partnership.

Heteronormativity via sex reassignment surgery brings the “disordered” individual under a paradigm that assumes “healing” if they conform to gender essentialist standards. Halberstam continues, “posttransition… many formerly lesbian FTMs become heterosexual men, living so-called normal lives” (Halberstam 1998, 299). Instead of this route of conformity, which requires a substantial technological investment, the trans feminist perspective is acceptance of the variations in human gender expression. Trans feminism would further argue that it is not within the purview of the medical industry to create labels like “gender dysphoria” for “gender outlaws” who transgress socially accepted—and constructed—norms (Bornstein 1994).

Ethicists Kristen Voigt and Harald Schmidt regard it as “clearly problematic when people resort to surgical procedures to escape stigma, bias, and discrimination” (Voigt and Schmidt 2011, 1000).Footnote 2 While it is not always the case that surgery is sought in response to negative social reactions, when it is the case, Voigt and Schmidt persuasively argue, “it would be far preferable to address stigma and discrimination directly, rather than have people undergo surgical procedures” (Voigt and Schmidt 2011, 1000). Medicalization places the burden of conformity on already marginalized individuals, while failing to protect the same vulnerable individuals from the recovery time, pain and discomfort, logistical barriers, poor outcomes, or sequelae of medical intervention. Rather than yielding to social normativity, recognizing diversity in embodiment provides the best social—and ecological—environment for the transperson, who is not really ill.

Trans feminist critiques of the medicalization of gender may also draw on principles of green bioethics, which examine the sustainability of medical developments, techniques, and procedures (Richie 2019b). It is far better for the patient and the planet not to regard gender presentation as a problem to be cured by the medical industry. When a highly inflected gender presentation that focuses on an “ideal” body type or a particular piece of anatomy is obtained through the medical industry, carbon emissions are expended unnecessarily, which cause climate change related health hazards (World Health Organization 2009, 24).

Anti-essentialist feminists have long claimed that there is not one single unifying feature that all sexes or genders share. Julia Serano writes, “an example of essentialism is when people [say] that all women have a womb” (Serano 2013, 11). Trans feminists like Serano have fought against fictional essentialism as a way of separating gender from sex. Indeed, trans feminism recognizes we are all transgender (cf Halberstam 1999), regardless of our sex. That is, gender is constructed, and each person has pieces—even if it is the smallest bit—of both (all?) genders within them. When gender transgression is removed from the medical industry’s axis of power, it will mitigate medical resource use and carbon emissions. In doing so, gender can be established without use of the medical industry and its noxious, polluting, high-carbon resources (Chung and Meltzer 2009). Erasing gender fiction is environmentally sustainable (Richie 2015). Creating gender fiction is not.

Trans feminism recognizes and endorses transgender personal identity and offers approaches to gender presentation that do not harm the individual, society, or the planet. Non-surgical feminization or masculinization through altering socially determined gender markers like hair length, dress codes, hobbies, activities, self-identification through referencing pronouns, manner of speaking, and choice of romantic partner are included here. But in all cases, it should not be assumed that prolonged, extensive surgeries and interventions will ease personal or social dysphoria. Sex reassignment surgery as a “routine treatment” for transgender people must be re-evaluated. Medicalization of gender furthers the aims of patriarchal society. Thus, Halberstam calls upon society to “produce ever more accurate or colorful or elaborate…‘nonce taxonomies’” (Halberstam 1989, 47) for the gendered self. Drawing on Eve Sedwick for inspiration (Sedwick 1990), Halberstam emphasizes multiplicity over singularity, the mosaicked over the monochromatic.

Crip Feminist Critique of Medicalization

Crip feminist critiques of medicine often parallel radical feminism (Kafer 2013) and queer theory (McRuer 2006) and refuse to comply with “compulsory able-bodiedness” by creating internal standards for health and sickness, which usually prioritize being disabled. “Crip” is an abbreviated form of “crippled” (McRuer 2010). The term, like “queer,” is self-chosen, but may be considered offensive if used by someone outside of the community (Richie 2016). Crip feminists force the medical industry to confront its prejudices and myopic viewpoints on well-being. Crip feminism traces to crip theory for criticism of medicalization.

Emerging from disability rights advocacy, a first step in the development of crip theory was the recognition that “diseases” or “conditions” which are not harmful to the body become medicalized when they are seen as socially problematic. By way of illustration, Plato recounts an anecdote in the Republic that Asclepius:

…prescribed drugs or surgery [to the ill] and then counselled them to continue their customary activities so as not to deprive the city of their services. But for those whose bodies were riddled by disease he did not try to prolong a wretched existence with diet or infusions or excavations (Plato 1985, book III, 407, d.).

The utilitarian view of health and ability predominates the medical mentality. Current standards of medical care work towards avoiding (Savulescu and Kahane 2009) or correcting disability or other impairments. People who cannot work due to illness, age, or disability are either convinced to seek medical treatments or else pushed aside as useless.

Deconstructing Disability

Michel Foucault observes that one of the purposes of medicine was to ensure that society was filled with productive labour, therefore illness was not only a concern of the patient, but through and through, a community concern. He states, “the sick man is no doubt incapable of working, but if he is placed in a hospital he becomes a double burden for society” (Foucault 1973, 18). Disorders that are costly—either because of lost worker productivity or because of social disruption—get priority government funding. Such is the case in “depression” and “schizophrenia” (Szasz 2007, 23, 25).

Disability rights advocacy also points out that Western medicine tends towards capitalistic values like conformity, production, and high-performance. Children are conscripted into the medical model when they cannot perform in class and are unproductive in their schoolwork and social skills (Parens and Johnston 2011, S2). Women are expected to fortify themselves and achieve mental equilibrium (Kendler and Prescott 1999). People with acquired or congenital disabilities are faced with media images of success, prowess, and tenacity, because of—not in spite of—disability (Kafer 2013). Paralympic athletes/models Oscar Pistorius and Aimee Mullins are sexualized and admired as “not really disabled.” These narratives imply that overcoming disability is available to anyone who works hard enough. Susan Wendell describes this as the disabled hero phenomenon, where “people with visible disabilities… receive public attention because they accomplish things that are unusual even for the able-bodied” (Wendell 1989, 116). At the same time, the medical industry presents competing messages about the undesirability of disability, which disability rights advocates have been keen to address.

Pre-implantation genetic diagnosis, genetic screening of embryos and fetuses, and amniocentesis are acceptable and routinely offered medical options. But the eugenic overtones of correcting or preventing disability are taken as an affront to those committed to equality, particularly in the disability rights movement. For disability advocates, the medicalization of disability marginalizes individuals and denigrates the unique diversity of humankind. Medical technology is not value-neutral. Eric Parens and Adrienne Asch argue that “prenatal diagnosis reinforces the medical model that disability itself, not social discrimination against people with disabilities, is the problem to be solved” (Parens and Asch 1999, S2). Reproductive technologies assure parents that their future offspring will not be marred by disability. Even as women accept these technologies for themselves, they simultaneously foreclose the opportunities to give their disabled daughter the same choice. For feminists, the essentialism narrative, whereby those with a disability have been predetermined to have a “diminished quality of life” or “be unable to do certain, normal things” runs too closely parallel with the way women have been viewed historically. Although gender essentialism is repudiated by feminists, disability essentialism may be accepted by the same women (Rothman 1986, 26).

Medicalization and Disability

By dismantling the structure of medicalization by objecting to “the master’s tools” (Lorde 1979) and defining itself, disability advocates echo Michel Foucault, who reminds us “the form of the composition of the being of the disease is a linguistic type. In relation to the individual, concrete being, disease is merely a name” (Foucault 1973, 119). “Disease” is sometimes the term we give to a great many things which vary from person to person, culture to culture, and even among sexes, ages, and races. This critical approach to disability rightly notes that the sign is not always the thing signified (de Saussure 1983, 67). Everything from “infertility” to “depression” is linguistically constructed, limited by language, ephemeral. While certainly maladies of the body—cancer, AIDS, and heart disease—are real, objective, scientifically observable phenomena, even these are not the identically manifested or experienced in the same way by individual persons.

Medical anthropologist Ann McElroy states that illness “is the experience of impairment or distress, as culturally defined… and disability also occurs in a social and cognitive matrix” (McElroy 1996, 5). For instance, defining an otherwise healthy blind person as “ill,” forces a medicalized social paradigm on them. A blind person is, of course, disadvantaged in some ways by the inability to see, but perhaps the larger hurdle to overcome is the stigma surrounding blindness and the way that society is set up only for visually unimpaired people. This critical approach to the medicalization of disability importantly locates physical and mental “problems” firmly in culture and not the individual, thus removing personal shame and social disgrace. On the other hand, the medicalization of selected incapacity simultaneously mainstreams other disabling conditions. As Mary Jo Iozzio argues, “the medical model denies and minimizes, through a variety of remedial accommodations, the manifold disabilities that are ‘acceptable’ in polite society, such as aging, hearing loss, and loss of visual acuity” (Iozzio 2005, 863). Going beyond disability rights advocacy, crip feminism—in keeping with disability rights and feminist philosophy—problematizes naturalistic notions of health and illness and calls others to acknowledge the many ways those with different bodies are oppressed in society (Hamraie 2015).

Crip feminists may regard disability as a place of privilege, where, constrained to the sanctuary of “crip time” (Kuppers 2014), which is a slow and private experience, an excavation of self is deeply drawn upon. “Cripepistemologies” build on the work of feminism and philosophy (Sedgwick 1990) to propose an alternative, and superior, way of knowing oneself (Johnson and McRuer 2014). Crip feminism has produced definitive art (Cachia 2014), creating tributaries that flood conventional notions of what the good life is. Not all conditions that the medical industry has dubbed “disease” or “disability” are, in actuality, such. Indeed, sometimes disability is chosen or preferred (Clare 2017). Crip feminists are opposed to medicalization of all kinds. However, there is a mischievous Machiavellianism underlying voluntary use of the medical industry to construct “disability” in line with one’s own body project. An accidental disability can be an opportunity for enhancement (Keenan 2013). In some cases, “disability” might be sought proactively.

Constructing Disability

The work of Alexandre Baril underscores the social interplay of gender and ability by arguing that sometimes proactively seeking a “disability” is the only way to achieve ego-synchrony (Baril 2015). Baril includes amputation for apotemnophilia, along with sex reassignment surgery, as desired and “disabling” procedures. Baril encourages critical reflection about health and gender presentation as concepts. Paradoxically, “highlighting how ableism and cisnormativity shape our conceptions of both sexuality and identity opens ways to imagine the possibility of body modifications pursued for diverse and overlapping ‘legitimate’ reasons” (Baril and Trevenen 2014). While the medical gaze is rejected, crip feminism is not opposed to medical intervention, especially when voluntarily undertaken to achieve desired aims. Since it is voluntarily adopted, it is not viewed as medicalized in relation to oneself.

Crip feminism continues to develop as a philosophy within bioethics (Elman 2012). As it does, it critiques itself and its roots, not only in bioethics, but in theory as well (Johnson 2015). It could be considered, in this way, in an adolescent stage of rebellion and discovery of identity apart from its progenitors. Like feminism and crip theory, critiques from crip feminism will continue to be levelled at the medical industry, the patriarchy, and any other structure that obstruct women’s flourishing.

Conclusion

Medicine, through the observation of the sick and the healthy produces a “model man [sic]… a normative posture, which authorizes it not only to distribute advice as to the healthy life but also to dictate the standards for physical and moral relations of the individual and of society” (Foucault 1973, 34). Standard taxonomies of healthcare marginalize individuals, while placing others firmly within the bounds of “health.” Feminists justifiably fight against medicalization on the behalf of all women. This protection is maternalistic in the sense of an ethics of care for women (Gilligan 1982), but unlike paternalism, feminist critiques of medicalization offer women the tools for self-direction.

Through the multiple and various modes of feminism, a much-needed critical distance has been established between the (often male) physician and the (female) patient. Nonetheless, with every new medical advancement and each novel application of technological healthcare, a “woman’s work is never done.” Medical errors account for approximate 400,000 deaths per year (Makary and Daniel 2016). Thousands of women are victimized by Western medicine. Very real border wars regarding the nature of sickness and health leave collateral damage on the flesh of women. Taken in tandem with an increasingly eager patient population, the stakes are simply too high to risk complacency in feminist resistance.

As bioethics and the medical industry confront new developments, the concerns of liberal, trans, and crip feminists must be addressed. For instance, the growing interest and excitement of uterus transplants is not shared by all. Liberal feminists might comment on how this continues to increase pressure on women to be reproductive and when they are done, sacrificially donate their uteruses (Arora 2017). Trans feminists might caution against the focus on biology as constitutive of gender and reject womb transplantation as just one more way the medical industry will conscript the genderqueer into heteronormative paradigms (Kalender 2010). Crip feminists might question how intersex individuals without a womb could be considered disabled (Holmes 2008) and “corrected” through this new technology. There will be ample room for other critiques of medicalization from postcolonial feminists, eco-feminists, conservative feminists, and mujerista feminists, to name a few. With the present medicalization of reproductive sexuality, gender, and disability, which seeks to colonize the bodies of women and pathologizes the experiences of female embodiment, there is—and will be—a continual need for critiques of medicalization, particularly from feminists.