The Politics of Aesthetics

When we ask what the conditions of intelligibility are by which the human emerges, by which the human is recognized, by which some subject becomes the subject of human love, we are asking about conditions of intelligibility composed of norms, of practices, that have become presuppositional, without which we cannot think the human at all. Judith Butler (2001). “Doing Justice to Someone: Sex Reassignment and Allegories of Transsexuality”. GLQ: A Journal of Lesbian and Gay Studies 7 (4): 621-36.

Today I wore boxers. It felt transitively gender appropriate and maybe even, essential, since I was heading off to see the plastic surgeon about chest reconstruction. Recall, that this is the only plastic surgeon in British Columbia who does chest surgery for fTm trans folks AND who does breast reconstruction. This guy, I figured, would get my particularities. But still, I needed the performative insurance boxers might provide. After all, I would need to convince the surgeon that doing chest contouring would be, in my case, an genderqueerly appropriate form of post mastectomy/breast cancer “reconstruction surgery“.

Typically, chest, or “top surgery” is regarded by the medical professionals and the health care system in British Columbia as a form of fTm Sex Reassignment Surgery (SRS). The rules regarding SRS are archaic and extraordinarily discriminatory towards transgendered folks. They include proscriptive requirements, such as, for example, that a candidate for SRS “pass” successfully for a member of the “opposite sex” for a minimum period of two years PRIOR to approval for surgery and that this successful “passing” be observed and recorded by “qualified professionals”. It is also the case that candidates for SRS need to be interviewed and approved for surgery by two mental health professionals.

Step Two, if we are to think of Step One, as the deliberate selection of the Calvin Kleins, involved filling out copious forms. Dr. B wanted to know such a lot about me. There were 8 pages of questions about my sexual and gender identity in relation to temporality, as in, “Who were you when you were born?” (identification via biology), and “Who would you like to become?” (identification via surgery). I was asked to use the space inside of an empty circle to demarcate, with a single dividing line, just how much of ME was f or m at those two critical times - past and future - actual and virtual. All my circles were covered with lines going every which way, tartan-esque, and sported a lively mix of f and m. It was appropriately messy.

Complete these sentences: Gender Identity. I think of myself as a _____. Ideally, I would like to think of myself as a _____.

I experimented with playful answers, as in: How did others perceive your gender identity as a child? Answer: Simplistically. How do others perceive your gender identity now? Answer: Generously.

Step Three was the live interview with Dr. B, who was intelligent, informative and kind. Dr. B is a really stunning example of ethical medical sensibilities. He was emphatic about wanting to use respectful language in asking me about “personal aspects” of my life, and encouraged me to correct him if he went astray. Dr. B didn’t read my answers on the forms. That impressed me. He just chatted away and asked lots of questions. Medical protocol requires doctors to establish that patients seeking any form of SRS actually, seriously want surgery based on what is called, in transgender health discourse, the test of Real Life Experience (RLE). And so the performative criterion becomes, Can I establish that I have a stable and longstanding record of making successful choices in the world that are recognizable and public actions which would pass as Otherly gendered?

I knew that many of the queries were quite important to get right, no matter how casual they may have appeared, like, “Would your ideal gender identity include male genitalia?” If I sounded like I love being a woman “just the way I am,” including all my womanly parts, I would fail the necessary performance of some stable elements of gender dysphoria that would make wanting a male chest something other than totally pathological. Fortunately, “bottom surgery” (as we trannies call it) is a pretty risky biz, so I made some kind of blisteringly ironic statement about preferring a dick I could slam in a drawer to one that might whither away and drop off my body. It seemed persuasive. And I meant well. “Have you told your parents?” This was a tough question, on all kinds of levels, not the least of which is, “What’s to tell?”. Once again, humour was my friend. Most of the time, I was able to assert my stubborn attachment to a transitive relation to gender — a moving project with no fixed address. I insisted on standing in the space of gender queer, and of living a life that is about playful complexity, rather than having ever inhabited something as apparently simple as a tick box on a form.

We moved on to Step Four, because I passed Step Three. OMG. Who was born of this moment - this institutionalized accomplishment of intelligibility?

Dr. B told me enthusiastically that he would not require me to be evaluated by a psychiatrist, because it seemed like I “had a really stable and healthy identity in relation to my complex gender”. And so I learned about the various options for my chest reconstruction, which include several variations, from fixing the problems residual to the bilateral mastectomy, to a full chest contouring operation. I have lots to think about. At the end of today, I was fixated on two thoughts:

If I had been talking about using reconstruction to get a 36DD chest, I would not have been required to disclose whether I felt like I had been born, secretly, as Dolly Parton, and now needed surgery to correct a lack of fit between the inside feeling and the outward appearance.

Maybe everyone should have to read Foucault as a right of passage into adulthood, and yearly thereafter. There might even have to be a test.

I am left with enormous respect for a doctor who has learned so very much about how to care under conditions of institutionalization, uncertainty and risk. I am, also, so very proud that I found within myself the courage to insist on speaking truth to power about a kind of complexity of intelligibility for which there are so very many punishments, sanctions and harsh measures.

 

Re/Construction: How to Queer the Alchemy of Intelligibility

“Gender is always posthuman, always a sewing job which stiches identity into a body bag.” J. Halberstam

Yesterday I went to see one of the surgeons who operates in the local Breast Reconstruction program. Do you remember when my GP told me that she would sign me up for breast reconstruction because I was “in denial” when I declined reconstruction at the time of my bilateral mastectomy? Well sure enough, the surgeon’s office called me because they had a cancellation, and I went to see Dr. N because I thought I should explore all the options available to me. And yes, I have been rethinking this reconstruction business generally, and in particular, my strong resistance to the whole thing.

I learned two things yesterday. First, I am sad to say that I am so shallow, and so marked by cultural norms around fat phobia, that I was thrilled to hear that “you don’t have enough abdominal fat to make breasts”. Having grown up as a tormented fat child, this was my very first adult experience of being told that I wasn’t fat enough! <OMG that is SO sick> But seriously folks, I also knew for sure, feeling absolutely alienated by the various breast implants littering Dr. N’s desk, that I could no more voluntarily submit to attaching breasts to my body than to wear a dress. Not me.

As I have commented upon in previous blog posts, breast reconstruction is narrated entirely un-self-consciously as the reparation of a state of injury to restore a woman to a previously uncompromised state of femininity. There are many normative investments in this line of reasoning, including but not limited to a view of the female body as equivalent to the feminine body, and a view of the female body as being made up, symbolically, of essential parts, such as breasts. On this view, there is a whole which can be radically compromised by the subtraction of specific parts. And so most texts about breast reconstruction take for granted that the stigma of mastectomy will involve an injury to femininity that can be corrected surgically. The degree to which this is a symbolic restoration is underscored by the things that are left out of these accounts, like the fact that using the best of current techniques, breast reconstruction can not repair the nerves that provide sensation to the breast.

However, for me (and many others) the fundamental problem with what I will call, the Restoration Story, is that it incorrectly identifies my gender identification in general, and in particular, the role of breasts in my gender identification. And so a refusal of, or resistance to, “breast reconstruction” is, in fact, often not a desire to refuse a reparation to the damage of surgery, but rather, a refusal of the notion that there ever existed a normative relationship with breasts. How do you reconstruct what was never there? It’s one thing to co-exist with breasts that never felt like they belonged on my body. But how could I ever choose to undergo surgery in order to “restore” what never was — which I could simply define as a state of normative femininity?

I have been thinking about my options. I know that they don’t include the recreation of breasts. However, I also know that I am pretty sure that I don’t want to live out the rest of my life with a chest that is entirely unintelligible as a chest. Or at least, I am drawn to the notion that “body alchemy” involving a potent mix of feminine and masculine identifications creates a kind of “gender trouble” with which I feel a deep and familiar affinity. So now what? Well one of the options that I have been thinking about is the form of body modification that f>m transgendered folks call, Top Surgery. Loren Cameron’s gorgeous book of photographs, including his own self-portraits, document this Body Alchemy as practiced by f>m trans folks, wherein breasts become a chest.

I didn’t feel like I could talk about this with Dr. N, whose desk was covered with an array of breast implants and nice diagrams of busty beaming women. There is a plastic surgeon in town who does most of the f>m top surgeries. I have to wait a year to see him, but maybe I can just hunker down and be patient. It is SO not my best trick, but it may be the only trick in my book. It wouldn’t be something to undergo without a lot of thought, in any case. All very interesting to contemplate. I wonder what our public health plan will say to f>m chest surgery in lieu of breast reconstruction. Or in my case, chest surgery as the only genderqueerly-intelligible form of reconstruction. Think the logic will work with the billing bureaucrats?

 

Dumb Fairy Tales and other Discourses of Femininity

I now look at myself every morning, every evening, naked, in the mirror, equanimously, as I always did, and what I see is not a maimed body. Some might call this denial. Yet - I look at this flat expanse of my chest and I do not find it ugly, or repellent. My face, somehow, “goes” with this chest, there is a harmonious continuity from my face all the way down my body. There is, in all human beings, when they are bare-chested, a touching symmetry between the eyes and the nipples, and this symmetry, of course, in my case, is gone. Yet, and this may sound scandalous, absurd, or even mad: this breast-less body is not devoid, in my eyes, of a certain pure and abstracted beauty. If it is indeed monstrous, it is so in the manner of some magical, not quite human creature - a fairy, a mermaid - an Amazon. Anne-Marie de Grazia

Likely you know the fairy tale of The Princess and the Pea. A prince is looking for a bride. A woman appears at the gate of his castle who claims to be the real deal but she looks, well, pretty disheveled. Old ma knows how to tell the difference, and so places a pea under the pretending princess’ twenty mattress bed. When the parvenu wakes up she whines incessantly about having slept so poorly because there was something amiss with the bed and BINGO everyone knows she’s the real deal. The prince marries his newly authenticated bride. The pea is put in a museum.

As a child, I felt deeply ambivalent about this story. The fetishization, in women, of useless knowledge seems to me epitomized by the positive spin placed on the princess’ ability to find the pea. And when the possession of that useless knowledge is the litmus test for jubilant heterosexuality, well, then its existence, let alone cultivation, is most assuredly far from innocent.

How then, to feel about the fact that it is now my task, imposed by the medical establishment, to effect local control of a breast cancer recurrence by finding the pea. “When it comes back” my surgeon explained patiently, the other day, “it almost always feels like a pea.” Keeping track of the pea is not a new job for me. My family tree is chock-a-block with breast cancer, which is why I have been dutifully going for yearly mammograms since the age of 42.

Little did I know that mammograms are a very unreliable method for tracking early breast cancer in women under the age of 50, and that this lack of accuracy is even more pronounced for women with what are known as “dense breasts” - small, prone to cysts… After all, I had a “good” mammogram just ten months before my cancer was diagnosed. It had been missed the time before. It is also the case that I did not know that MRI’s are considered by some to be a much more reliable tool for detecting early breast cancer in women under 50.

I wonder about how my chances of finding that pea would be affected by reconstruction. There is a lot of pressure on women to undergo reconstruction after a mastectomy. Audre Lorde talks about this phenomenon in her Cancer Journal. When I went to visit my GP about a week prior to my double mastectomy, she asked me which surgeon was going to do my reconstruction. She guffawed when I told her that I had decided against reconstruction. “You’re in denial” she proclaimed. “I am going to sign you up. The waiting list is two years anyway. By then, you’ll be more than ready.”

Oncological research appears to indicate no impact of reconstruction on detection of recurrence. But there is a clear set of normative assumptions at work in this research, which go something like this: (1) breasts constitute a vital marker of femininity, (2) women will benefit from the restoration, post-mastectomy, of their “spoiled identity” (E. Goffman) and therefore (3) reconstruction should be made widely available to all women undergoing mastectomy.

This is what the official story regarding reconstruction and mastectomy sounds like:

“Deciding on Mastectomy Making the decision to have a mastectomy can be very difficult. It can be hard to imagine living without your breast, and you may feel like your identity or femininity is being threatened. The procedure can often be made easier by having breast reconstruction after mastectomy. This helps to reshape your breast and reduce any disfigurement, and may help you to feel more comfortable choosing mastectomy. Ask you health care provider for more information about this option.”

No where in all of this research are the side effects and complications of reconstruction clearly delineated. Reconstruction surgery involves an initial long and very painful operation followed by several additional surgical procedures. The impression of breasts is created either by means of implants or the use of a woman’s own tissue (abdominal) which is relocated to the chest area.

So what is the medical establishment’s priorities in relation to breast health, cancer, and morbidity amongst women? Clearly, millions, if not billions of dollars is going to the improvement and funding of breast reconstruction. And it is equally obvious that virtually no money is being directed to programs that would improve the reliability of cancer detection in populations at-risk of mammogram failure. Whose job is it, actually, to find that pea? How terribly convenient for medical discourse inappropriately to relocate responsibility to women to find that pea, and in so doing, exaggerate the agency possessed by individual women in determining the likelihood of survival in relation to early stage breast cancer.

What a different world it would be if we decided to spend all of the breast cancer research dollars on the (a) identification (and elimination) of the actual causes of breast cancer, (b) widespread availability of accurate methods of early detection, (c) appropriate methods to deal with post-surgical complications (e.g., lymphedema, which is very common and extraordinarily challenging), and of course, (d) a cure for cancers of all kinds. Hallelujah!

 

Living in Pink

I have yet to detect a familiar or comforting level of gender trouble in what I have come to think of as “breast cancer world”. And no. Breast cancer world is not gender neutral. Think about the pink ribbons. Pink is the colour of this cultural enclave, and cultural diversity in respect of gender has so far been very elusive. Granted, my time in this universe is not extensive and who knows what I will find. But as a queer women with a very distinctively transitive relationship to her own gender, the lack of play with gender makes me really nervous. I can’t really do pink. My first observation of this phenomenon was my initial visits to the mammogram clinic. They do other kinds of medical imaging there, and there is a special room for the mammogram folks with a door that says “Ladies Only”. Inside, one is immediately handed a pink gown and told to “put it on and sit in the waiting room with the other ladies”. Never having identified as a lady, it’s all rather disconcerting. But now that I am a person fighting cancer directly, my experiences are not so fleeting. The other day, when I went for my preoperative breast MRI, the technician told me, as I was leaning down over the frame that would hold my breasts for the imaging, to “put your girls in there.” My girls. Ok, so it’s maybe kind of cute depending on the mood you’re in, but in my case, my breasts have never been “girls” and pink has never been my colour. This lack of “gender trouble” becomes, of course, much more serious in the dialogues and discourses around “breast conservation” and/or “reconstruction” surgery. Audre Lorde, in her Cancer Journals provides a really good analysis of the role of gender in the cultural shaping of medicalized practices related to the insistence, post-mastectomy, on wearing a prosthetic and then the various and complex medical debates about the relative safety of various forms of breast augmentation as part of reconstruction (e.g. silicone implants). If breast cancer treatment is in some critical way organized structurally around a deep and enduring (and some would say, mannic) commitment to the preservation of the breast at all costs - any breast whether real or fake, how is this shaping what would presumably be the primary goal — saving life and improving quality of life?