The Bad Feature

“Your daddy did my lips”

Lynn Hershman Leeson, Roberta's Construction Chart #2 (Suggested Alterations). 1975, chromogenic print. 26 × 33". Courtesy of the artist and Anglim Gilbert Gallery, San Francisco.

Body by Daddy

When I was 13 years old, as if overnight, a mole appeared on my right cheek, diagonal to the upper corner of my mouth. This seemed like a forbidding omen, though I did not yet know it was the beginning of the end. I had been put on attention-bending stimulants at the tender age of 8, and my baby fat had melted off in inverse proportion to my sudden increased ability to spend hours at the piano practicing Air on the G String. I spent my latency period seraphic, a tawny lanugo coating my long legs and arms. The geriatric greeters at Walmart smiled behind their support our troops buttons, complimenting my mother on her beautiful children. In the heat of the car ride home, my mother would rebuke me for vanity, but I didn’t experience my body as beautiful or unbeautiful. I was — and I cannot emphasize this enough — fucking high for the entire opening act of the millennium. But the mole was sudden and felt ugly, portending worse transformations to come.

I caught my father in the master bathroom one night shortly after the mark appeared. He was still in his blue scrubs, returning late from another complicated hospital birth. We both took in my face, not looking directly at each other but at our reflections in the large mirror over the sink. He told me it was like the beauty mark gracing Cindy Crawford, whom he called, within earshot of my mother in the adjacent bedroom, “the most beautiful woman in the world.” My father, the evangelical obstetrician-gynecologist, was for once on the same page as the puberty enchiridion published by American Girl, which I would read in the coming months crouched between the magazine racks in the public library, poring over cartoon diagrams of the vagina: You Are Beautiful the Way You Are. I was beautiful the way I was then, but it wouldn’t stay that way. 

In the years to come, as my face grew pocked and twisted with the precipitous growth spurt of my upper jaw, as my father became ashamed of my awkward body suddenly veiled in a chastity garment of ill-laid fat, I held this moment — my father and I regarding each other quietly in the mirror — as incorruptible. For years, I planned to tell this story at his funeral.

Things fell apart. I left home. Years later, I returned. My father had not exactly divorced my mother, but he had a new ultra-beige apartment and was sporting a puka-shell necklace procured as a memento of the most recent of his new indulgences, Caribbean cruises. I started telling friends, “My father is in his Gauguin phase.” His Gauguin phase, it turned out, was financed by a specialty dermatology clinic catering to women targeted by skin-care advertising terms like firming and tightening. After a long career birthing the lily-white evangelical children of our Lollardy southern town, my father’s gimlet eye lit upon the new needs of his aging clientele. He was determined to be a better man than his deadbeat Canadian father, and had spent the heady first months of Bush II’s sequel term devouring an investing-for-beginners book and tape series titled Rich Dad Poor Dad, which promised insight into the secrets of the wealthy, and possibly — secondarily — fatherhood. After a series of opaque real-estate deals tanked in the 2008 crash, Rich Dad returned his gaze to the oldest moneymaker, the female body. 

There are treatments that needle the entire face so that the body, mistaking itself as under violent attack, pumps blood to the epithelium. There are threads you can attach to the inside of the temple and pull up through the hairline, tightening the sagging skin. All this under local anesthetic, if any. The business in injectables alone — Restylane Lyft, Juvéderm Voluma, Bellafill — is brisk and easy money, at around $800 per syringe, with each multi-syringe procedure requiring an apotropaic annual repetition. “Almost everyone you know is having it done,” my father told me. After a few years at it, he’d developed a kind of craftsman’s appreciation for techne: inability to detect the art was the measure of excellence. Casting his diagnostic eye on the public and discreetly remarking “what she’d had done” — this woman at Chick-fil-A, that celebrity in the supermarket checkout tabloids — became one of his standard and most entertaining bits.

Almost everyone you know is having it done. The market for cosmetic surgery in the US climbed rapidly between 1992 and 2005, increasing by 725 percent, with over $10 billion spent in 2005 alone. The same period saw so-called noninvasive procedures, like peels and soft-tissue fillers, increase by 3,158 percent, as a raft of new products came to market. Over the next decade the injectables market outperformed even the most optimistic predictions of the American Society of Plastic Surgeons, hitting 9.92 million procedures annually in the US if you include Botox. The global market for facial injectables in 2016 was valued at $6.5 billion and is projected to reach $17.2 billion by 2025. (For comparison, the global statin market was valued at $19.2 billion in 2017.) The main cause behind these ever-increasing numbers is the rise of noninvasive procedures, purveyed by clinics that can book you last minute and have you back at your desk the same day. A new, younger demographic of people in their twenties and thirties is flocking to plastic surgeons and dermatologists, lured by the pied pipers of Instagram. “Invest in your skin,” one campaign reads, beside an image of a woman with radiant cheeks and bee-stung lips. “It’s going to be with you a long time.” 

For my father, the lateral move into the medicalized beauty market was a “Meet the new hysteric, same as the old hysteric” sort of situation. My father’s approach to the female body was, by and large, that of a sanguine auto mechanic dealing with a clientele he benevolently regarded as clueless. He was the first physician in our southern state to perform surgeries with the laparoscopic wonder dubbed the da Vinci system, a suite of high-tech gadgets the university hospital network introduced in the melee for patient-customers in the early 2000s. The system allows the surgeon to perform procedures via tiny incisions in the skin. A robot that looks like a praying mantis is inserted into the body cavity, its movements tracked by a camera, the whole thing leaving only a whisper of a scar.

As if to provide encyclopedic dispatches of the gore machine my prepubescent body was poised to become, my father shed magazine-size, high-def color photographs of innumerable uteri gleaned from his robotic labors into the maw of his new Miata’s passenger seat. This purchase my mother had greeted darkly with a tight-lipped quotation from Ecclesiastes, “All is vanity and vexation of the soul,” notwithstanding the fact that he had bought it secondhand, and that it was constantly sputtering what seemed to be its final protest. With Leonardine optimism, my father would coax it to continued efforts, prostrate under its body or hunched under its hood. As I helped him clean out the car during one such session, carrying armfuls of vivid glossies of women’s guts to dump in piles on his desk, from under the car came my father’s voice: “You wanna know what it’s like doing a vaginal hysterectomy? It’s like changing the engine through the exhaust pipe.”

“El da Vinci” was not the only innovation pioneered by my father in the wild early Aughts. After leaving a group practice of seven ob-gyns, my father struck out on his own, an American utopianist all the more American for being a Canadian refugee fleeing the penurious margins of socialized medicine. He was a man who believed in being smart so you could make money, so you could use that money to engineer solutions to problems caused by the sad fact that everyone in the world was a fucking moron. He was a man whose fight against the man turned out to involve, to his great regret, day-jobbing as the man. He had migrated south in search of a B-I-N-G-O of warmer climes, a privatized health-care system, and a community of believers who would honor the Holy Ghost while otherwise leaving him the hell alone. His late-career embrace of the out-of-pocket beauty industry was simply an extension of this earlier logic. After a series of weekend courses in the subtle arts of the needle, he was ready to set up shop. Under the golden sun of American capitalism, taking out a uterus was a mere shade of difference away from cool-sculpting the drooping fat of the upper arm, microblasting the depredations of fine webbing around the eye, hypodermically finessing the turgid lip into a sinuous, artisanal pout. 

To be a woman is to engage in constant revision of our horrific, obdurate bodies.

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And so, although he was not a man eager to acknowledge his shortcomings, my father offered amenities as if in tacit recognition that there had been faults meriting redress. Mistakes may have been made. When I met him for dinner over Christmas break after my first semester of graduate school, my father had his business partner in tow, a nurse practitioner my boyfriend at the time would later describe admiringly as “stacked.” She was more than stunning, the sort of woman you could imagine, if you didn’t know any better, feeling Beautiful the Way She Are. She beamed at me with a Pre-Raphaelite glow while fawning on his arm: “Your daddy did my lips.” Over the following years, my aunts would have their wrinkles blasted, their cheeks and lips plumped, their underarms de-flabbed, all gratis. My mother found it a dark business, and anyway it had been curtains for her. As we kissed goodbye after dinner, my father paused in the restaurant’s foyer light. Peering at the right side of my face, he noticed the mole as if for the first time. “You know, I could get rid of that mole real easily.” For free, he said, as a gift. 

He had forgotten, of course. A pang of fondness shot through me. I didn’t remind him. I knew he was just trying to help. Several nights later, we drove to the dark clinic, where I lay on the tissue paper–covered dais as he burned off the mole with workmanlike detachment. Pressing gauze to my face in the car on the way home, I thought, You Are Not Beautiful the Way You Are, But with Some Smart Investment, You Could Be Okay. By my early twenties, having seen the direct correlation of opportunities both social and professional with being hot, I was not not desperate. Most women are, if you ask me. Vanity and vexation of the soul. To be a woman is to engage in constant revision of our horrific, obdurate bodies. It often involves surgeries. 


The Bad Feature

In the years after the mole, I came to the realization of the Bad Feature. The Bad Feature waxed and waned in my mind on its own mysterious cycles, eclipsing my ability to think and then receding. Under its moon I became a monster, a lunatic. By the end of the worst year, the Bad Feature had ballooned cancerously to the size of a white whale. It was a year in which I could not stay sober from the intoxication of its shame, months on end in which my mind was occupied by it — not like a handicraft, but like a foreign army. It had become first hard, then impossible, to leave the house without white-knuckling my way through a handful of juiceless CBT routines. That this misery enveloped me so entirely was only an added mark in my own bad book. Wasn’t the political situation getting worse and more worthy of my attentions? I was shallow, stupid, bad, evil, hideous, vain. The language of shame has always been my natural grammar, but by the end any tensegrity of my mind had collapsed; I was speaking fully, ecstatically, in tongues. It sounds like a joke to say that for several years I seriously contemplated suicide in a pattern of reasoning that fastened to the unlivability of a life in which, in addition to everything else, I was grotesque; it sounds even more like a joke to say that I don’t anymore. The Bad Feature is the only changed variable.

To be clear, I’m not complaining. Even in the worst phases of a dysmorphia too mortifying to describe any further, I knew, rationally, that it was a politically conditioned tic of the mind, inseparable — like everything else — from its political-economic-historical conditions, but not inherently politically valorous for being so. Two months before my consultation with the surgeon, I had run the numbers. Surgery was cheaper than therapy, assuming as I did that it would take at least two years to get to the bottom of things by way of the couch. I didn’t want to stop wanting what I wanted. What I wanted was to be wanted in the way that I wanted. I wanted to change my appearance, not how I related to my own visibility. I was making a targeted strike.

I had found the practice of a doctor I’ll call William Fabriole through a website that advertised him with unsettling modesty as the best cosmetic surgeon in the “greater metropolitan area” of a midsize town. During the night car ride to my father’s clinic years earlier, swatting at the silence that seemed to be radioactively emanating from the mole, I’d asked him if his new profession had caused him to view his own face differently, as something with the potential to be improved. Had he ever been tempted to get high on his own supply? My father had eluded giving a straight answer, but Dr. William Fabriole was not a man who left you in any doubt on the question. It was hard to find what art historians call the “detail” in his face, which caused it to look like something that would melt if left in a hot car, but by the time we met for my surgical consult, I’d already decided that any change would be better than continuing as I had. And anyway, the consultation fee was nonrefundable. 

Perhaps I’d been half hoping that in the harsh light of the medical clinic, the professional gaze would size me up and tell me I was insane to think I needed any surgical help. Fabriole eyed my head like a secondhand purchase, turning it this way and that by the chin, and asked me to discuss my “concerns about my face.” I spoke in clipped sentences, as if describing troubles with a piece of machinery. “I definitely see what you mean,” he said, while in the background a nurse nodded silent amens. As in every instance of ritual humiliation, I felt myself to be in a state of grace. I left with a bill for the $4,000 I had scraped together and a surgery date, on which morning I arrived alone, was put under, awoke bedazed by painkillers, called a cab, and recovered in solitude in an Airbnb for several days. I told no one save my two closest friends where I was or what I was doing, considering this one of my weirder experiments, certainly no one else’s business politically or otherwise. The first rule of feminine labor is that you don’t talk about your feminine labor. 


The Sovereign Consumer

During my final battle with the Bad Feature, a significant piece about gendered body-modification surgery caught my attention. In an op-ed in the New York Times titled “My New Vagina Won’t Make Me Happy,” the author, a transgender woman on the eve of bottom surgery, argued that the question of whether or not someone should be able to get trans surgery should be decided simply by whether or not they want it, end of story.1

On its own terms, this holds water. If I could opt to have my Bad Feature addressed as I willed it, why not Andrea Long Chu or anyone else? As things stand, trans surgery is ghettoized within a bureaucratic hedge of medical ethics and specialist evaluation that arrogates to itself the power to decide whether a procedure will be “good for the patient.” Chu argues that this medicalization of trans surgery in the name of “patient outcomes” is rank paternalism masquerading as ethics. As I read Chu’s piece, laid up post-op through a veil of bandages, it did not escape me that it was possible that this was the dumbest thing I had ever done. I hadn’t asked anyone for advice because I hadn’t wanted any. Even including the sizing-up my Airbnb host’s lumpen boyfriend gave me as I staggered in from the cab, my face swollen as a bitten tongue, the only thing that could have made the process more humiliating would have been a state-licensed high inquisitor of my sanity asking me if I was sure I really needed what I wanted. My Airbnb host was a perfectly lovely woman dating a man who, as far as I could tell, spent most of his time playing a cacophonous video game involving dragons, and occasionally screaming invectives at the postal worker, and I was in a pink haze of Vicodin facing the reality that I had disfigured myself permanently; nobody was checking in on us to make sure “we knew best for ourselves.” Why start asking if women are sure they know what they want only when they get to the consultation chair for trans surgery?

At first blush, what’s so persuasive about Chu’s reasoning is that the decisionism vested in the physician in trans surgery is exceptional, one of the few remaining holdouts of a physician sovereignty that has by now become largely antique. In every genre of gendered body modification other than trans surgery, all that was solid in the physician’s little kingdom has melted into air. Chu’s demand is that the same standard of patient choice apply in trans procedures. Yet what’s missing from this political program is a sense of how the dethroning of the physician — whose completion Chu calls for — was achieved and how it ended with the recurring triumph of commoditized medicine and the great failed experiment of the current American health-care system.

Following World War II, the vast expenditure of the American military state on applied sciences like medicine suggested that the state could replace the market and provide its citizens with universal health care. Spooked by the threat of national health plans in the style of Britain’s new National Health Service, American capitalists and the state struck a deal: the state would invest in health care, but health care would remain a commodity. Throughout the 1950s and 1960s, the US federal government invested dizzying amounts in medical science to sponsor research and fund hospitals. By the mid-’60s, medicine was reeling into what would be called the biological revolution, as cutting-edge technologies from genetic engineering to cardiac pacemakers sprang to life, nourished by federal funding aimed at maintaining the nation’s cold-war edge.

But the rapid pace of technological change throughout the 1950s and 1960s introduced an ever-widening knowledge gap between physicians and their patients. Soon patients began to grow suspicious of doctors’ unchecked power, and several radical civil rights and liberation movements coalesced to demand patients’ rights. The antipsychiatry movement railed against psychiatry’s medicalized imposition of social normativity, often implemented through underfunded state institutions that confined rather than treated patients. Simultaneously, the women’s health movement revolted against the lack of autonomy available for women in making decisions about their bodies, particularly reproductive decisions, while demands for medical justice were likewise key features of antiracist liberation movements, animating the Black Panthers’ campaigns for free health care and against medical experimentation in prisons, for example, and the Young Lords’ free medical clinics. 

At the same time that patients were seeking greater autonomy over their medical care, a crisis of unevenly distributed medical capacity was underway. Following the defeat of Harry Truman’s 1950 proposal for a national health plan, which left it to employers to provide health care to their employees, huge portions of rural, often agricultural populations were without coverage or care, and the majority of even the employed population had only inadequate fee-for-service — or nonexistent — benefits. (By 1960, three in four American workers were nonunion and thus lacked the ability to wrangle a strong contract.) The Lyndon Johnson Administration’s creation of Medicare and Medicaid in 1965 likewise did not succeed in resolving the health system’s central contradiction: that the most technologically advanced nation failed to deliver the benefits of its medical advances to the estimated fifty million Americans too poor to afford any type of medical care. The bitter irony of the situation was that by introducing a system of generous direct subsidies to hospitals and physicians without introducing effective price controls, Medicare and Medicaid only contributed to the runaway spiraling of health-care costs throughout the late 1960s, as hospitals and physicians jacked up their fees. Conservatives could have hardly asked for a better example of an alleged failure of central-government planning with which to argue that the solution to the health-care crisis could only be mediated by the information-processing functions of the market. 

By the mid-1960s, as the health-care system began to buckle into permanent crisis, patient suspicion toward doctors began to be normalized. Even the average citizen was skeptical of the kind of scientific “expertise” that authorized the Tuskegee scandal and human experiments in Nazi death camps and US prisons alike. The push to topple the dictatorship of the white coat was increasingly articulated not as a subsidiary of the civil, feminist, or environmental rights movements, where it had originated, but of the burgeoning consumer rights movement, whose assault on corporate power was by then propulsive enough to have procured Kennedy’s 1962 Consumer Bill of Rights. Reframing the problem of medical care as an issue of protecting buyers from unfair business practices gave everyone a partial victory: the patient would be empowered, but with the power of the consumer. 

Milton Friedman’s 1962 Capitalism and Freedom argued that professional medicine was a licensed guild that should be exposed to market forces. Instead of the state-backed profession limiting consumers’ choices by professional and ethical restrictions, Friedman argued that the consumer should be trusted to choose among any medical service offered for purchase — including from “crackpots” and experimentalists lacking good standing in the medical profession. The only consideration restricting what types of treatment and body modification are available to a patient should be whether party A is willing to sell it and party B is willing to buy. Friedman’s argument was an edgelord version of what was rapidly becoming common sense. The lesson seemed clear: the failure of federal planning demonstrated that only the market could discipline prices to calibrate demand and value. 

The result was that across the political spectrum, opinions converged in agreement that the proper role of the government was not to provide or subsidize services, but to guarantee that each individual was equipped with accurate information as they navigated the health-care market. The consumer’s discretion among services came with the condition that the patient shoulder moral responsibility for their choices. As John Knowles’s influential 1977 essay “The Responsibility of the Individual” argued, the consumer’s increased discretion correlated to a deeper responsibility for their own decisions: “The idea of a ‘right’ to health should be replaced by the idea of an individual moral obligation to preserve one’s own health — a public duty if you will.” 

The marketization of medicine was also attracting increased financial investment throughout the 1970s and early 1980s. In the wake of the Reaganite triumph — which spelled a clear end to any threat of a national health plan — Wall Street plunged into a health-care bonanza. Investors staked out markets in hospitals, commercial laboratories, and long-term care facilities while a suite of new biotech companies held IPOs. With health care launched through the financialized looking glass, the everyday decisions of patient care were increasingly governed not by sovereign physicians, but according to the terms worked out between for-profit health-care giants and insurance companies. 

This effectively describes our situation now, the result of a political bait and switch. The patient has been empowered, sure, but only because she is paying. Getting our heads around how the present state of affairs came about means grasping that capitalism is the sine qua non of modern American medicine’s historical development. The logic of the market was grafted into its DNA, and its essential character is that of a commodity, not a juridical right.

Chu’s case for the sovereign right of the individual to modify their body in accord with their desires is the clear-sighted and internally consistent extension of the logic that has come to govern health care in the United States. On these terms, Chu’s reasoning is not just persuasive, but the ineluctable extension of a dialectic in which the radical critique of the patriarchal institution of medicine was coopted by the neoliberal transformation of medical science into a marketplace. If medical care is a purchasable commodity, and if the consumer is not harming other people, then what right does the physician have to interfere in the workings of the market? 

It can feel so much like sickness that you agree to suspend the quotation marks around “sick” if it will get you the “cure.”

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Of course, not all body modification procedures are privatized. In the US, twenty-one states plus Washington DC provide Medicaid coverage for transition therapies. Only eighteen states have Medicaid programs that explicitly include hormone replacement therapy and both genital and chest modification. Of these, six states provide coverage for hair removal, and three provide surgery for facial feminization or masculinization. The long legal struggle to secure these provisions relied on establishing transition as “medically necessary,” a technical term that hinges on qualifying the mental anguish trans individuals often suffer because of gender dysphoria as a kind of sickness. In consequence, procedures that would be cosmetic for someone cisgendered are medically necessary to mitigate intense psychological distress. As the World Professional Association for Transgender Health argues, “Although it may be much easier to see a phalloplasty or a vaginoplasty as an intervention to end lifelong suffering, for certain patients an intervention like a reduction rhinoplasty [a nose job] can have a radical and permanent effect on their quality of life, and therefore is much more medically necessary than for somebody without gender dysphoria.” The case for the state’s coverage of trans surgery is predicated on the medicalization of dysphoria as being different in kind from everyday cosmetic dysmorphia. By this logic, the role of the physician in rationing state resources is to sort the cosmetic from the medically necessary, the aesthetic from the political.

Which brings us to the paradox of trying to hold Chu’s position while also imagining socialized medicine: you can either demand sovereignty over the body as a customer investing in your human capital, or you can make the case for the state rationing resources to provide medical care. What you can’t do is try to have it both ways, both appealing to professionalized medicine to underwrite the legitimacy of desires for bodily transformation as “medically necessary” while stripping the physician of precisely the authority your claim annexes. 

But of course, when you really want something, contradictions matter less. Everyone knows that. As many trans people have argued, acceding to the medical narrative that being trans is a sickness is simply making a deal with the devil. That’s one thing I’ve learned about desire: it can feel so much like sickness that you agree to suspend the quotation marks around “sick” if it will get you the “cure.” That’s what it means to want something.

Desire doesn’t say yes or no; it holds two irreconcilables and says “and yet . . .” I’ve learned to call this a dialectic: I want to want to not want to be beautiful, and yet I want to be beautiful; I am a woman, and yet I am not really a woman; I don’t believe plastic surgery is or should be necessary, yet I needed plastic surgery. For some time now I have kept my whole story a secret, thinking I could never survive the humiliation of anyone knowing, and yet there’s something I can’t stop myself from telling you. Desire is the Bad Feature.


Plastic Desire

It’s become a fashionable gesture to call things “neoliberal,” a gambit raised to a coup d’éclat if the speaker’s target has pretensions to liberatory politics, preferably feminism. That’s not what I’m up to here. Neoliberalism is not something to be revealed by scanning the zeitgeist and picking off X but not Y cultural phenomenon (Hillary Clinton but not tenant organizing, Instagram but not blood donation). It doesn’t work that way; neoliberalism is a historically specific infrastructure — of central banks, software, language, policing, kinship, and so on — that conditions contemporary social reality, infusing its logic into the most intimate zones of everyday life. What I am describing is the development of a historical condition: the rise of medicalized body modifications aimed at making gender performances “better,” undertaken within the subsumption of health care into neoliberalism’s ontology of the market. 

Is being trans in 2020 conditioned by neoliberalism? Understood historically, yes. So is being a nurse, taking an evening course in graphic design, signing up for food stamps, quitting Instagram and then signing back up for it, apologizing to Dad so he’ll sign your FAFSA, going another year without seeing the dentist — in short, so is everything we do within the political horizons and ordinary calculus of everyday life. 

This doesn’t mean there is no outside to neoliberalism, but that — like neoliberalism itself — the outside is nowhere in particular. To find the outside you have to look at people who think they’re disagreeing, then follow the logic of both parties to its terminus of secret agreement: the shared paradigms, language, values, and logic forming the consensus required for them to understand what they’re disagreeing about in the first place. That’s where neoliberalism lives, in the secret back laboratory of politics, the place where the molecular units of common sense are concocted. 

In this secret laboratory, neoliberalism breeds its synthetic life-form, a parasitic hybrid of Homo economicus and financialized postindustrial capitalism that Foucault called the entrepreneur of the self. After centuries of interminable struggle between labor and capital, the parasite got wise: she sees that the body of the host organism — its health, intellect, physical attractiveness, knowledge — is itself a form of capital whose value must be maximized through investment. Once the parasite has hacked the organism, activities that used to look like very different sorts of things — namely, production (or labor) and consumption — are now a single genre: all activity becomes investment in the human body the parasite has taken over in order to maximize returns on its human capital. 

Monetary returns are only one potential form that dividends might assume. “Not all investment in human capital is for future earnings alone,” Theodore Schultz, an early theorist of human capital, explained in 1962. “Some of it is for future well-being in forms that are not captured in the earnings stream of the individual in whom the investments are made.” Seen this way, incels who fail to compete in the Darwinian sexual marketplace can invest in “chad surgery” to generate returns on their “sexual capital,” and the enormous global market for cosmetics becomes a rational ramification of women’s savvy investment in what economists by 1997 were calling “beauty capital,” the advantage bestowed by good looks.

This is to say, nature is a sentimentality the parasite cannot afford, though the illusion of it can lend value as superadded artifice. As proprietor of its host’s body, the parasite takes a cool, ecumenical approach to augmenting and optimizing the organism and has no qualms about becoming cyborg, provided the likelihood for return on investment is there. It manages the body as a privatized investment property, responsible to no one for its life and, it follows, imbued with the right to do whatever it likes to that body. 

The equivocal status of the cyborg as private investment property has prompted some contemporary feminists to wonder what became of the political potential of biotechnology heralded by feminists at the end of the biological revolution in the 1970s. In a recent essay, Jia Tolentino sketches the imperative for feminized self-valorization under postindustrial capital — barre class, orthorexia sponsored by Sweetgreen, dermal-injectable-plumped features — before homing in on the early works of Donna Haraway, the paladin of an earlier generation’s techno-optimist feminist school. In the 1980s, Haraway sized up the hippified romanticization of the natural among feminist second-wavers — think Gaia, menstrual cups, and trans exclusion — and concluded that liberation would not ramify out of continued enthrallment to the idea of an unreconstructed nature. Instead, in her 1985 “A Cyborg Manifesto,” the most-likely-to-be-abused essay in critical theory since Marx’s “Fragment on Machines,” Haraway argued that because the construct “woman” is already constitutively artificial, feminist politics shouldn’t be afraid of abandoning nature. There is no natural essence of woman to be faithful to in the first place. Since woman is already cyborg, feminists could torque technology toward liberation, even if the technological marvels of the day were the offspring of the US military-industrial complex and the consumerization of medicine.

But while in 1985 Haraway thought that by 2020 women would be using technology to biohack their way out of oppression, the feminine cyborg these days seems to use technology only to get a leg up within the game patriarchal capitalism has set up for her. Visions of radical gestational engineering to free women from the division of labor chaining them to the home have given way to global commercial surrogacy markets that keep Mommy’s tummy flat. Cyberspace is less a zone of radical freedom from political hierarchy than a panopticon that relentlessly quantifies and transacts social capital. Woman is born cyborg, yet she is everywhere Instagramming. 

In a further weird turn of the dialectical screw, the cyborgification of women’s bodies seems to tend toward a virtuosic augmented performance of the natural. The contemporary fashioning of woman is notable not for the embrace of the artificial that marked Haraway’s Eighties woman — the camp-artificial silhouette of jutting shoulder pads and the no-holds-barred conspicuous makeup — but for its recommitment to “the natural.” We get injections now so we can meet beauty ideals without seeming to wear any makeup at all. Now, we not only have to look hot but to conceal the artificiality of hotness, to veil the labor required to achieve the effect. Under this politics of reenchanted nature, the entire political spectrum agrees that women should not spend a lot of time or money looking hot — or if they must, they should be discreet about it, because making your complicity in your own oppression obvious is in bad taste. Camp is dead, or at least kind of gross. If you want to be a woman now, you had better mean it without the quotation marks, regardless of your genitals at birth. For someone who had been resistant to doing either for years, I found it less personally or politically embarrassing in polite left-liberal society to come out as queer than to admit to having had plastic surgery. The supposedly liberatory insouciance of the woman who “woke up like this” is the structural isomorph of the queer who was “born this way,” two claims that only function, like the commodity fetish, by occluding the conditions of their production. 

Why has the cyborg collapsed as a political figure? If the Harawayan project was to use technology to facilitate nonnormative desires, why does the expression of those desires look like a relentless drive toward self-optimization? It is as if desire is itself a kind of hybrid, both plastic and organic. It is as if the desires for transformation that enlist technology are formed in the conditions of technocapitalism. The cyborg, it turns out, was easily colonized: it has no desires, and the parasite does.

This is the problem with the politics of desire. The parasite is already within us, and our desires are not our own. It’s not that a “real” self has been colonized by the infrastructures of desire, but that the very thing that we call “self” is composed of that colonization; the self does not exist without it. The politics of desire that undergird both the private transformation I pursued and Chu’s argument hinge on an idea of “rights” without referent to the constructions of both subjectivity and social collectivities as the transparent outcome of nature. With their framing of desires as natural rather than artificial — an expression of essence rather than the historical contingencies of power — the politics of desire end up reanimating the very carcass of romanticized nature that Haraway attacked. As in so many post-’68 political impulses that unwittingly reinscribe the politics of natural law that they claim to revolt against, here desire comes to stand in as nature, in the sense both of “that which could not be otherwise” and “that from which our politics must be deduced.” 

Extracting political projects from this naturalized desire — as if it were impossible to want anything other than what we want — plays the same card as any other naturalization of politics: from the neofascists, it looks like blood-and-soil racism linking arms with evolutionary biological notions of gender; from the center, the idea that political constructs like queerness or “mental health” can be found in the folds of the cerebellum or the gene. The entire ideological project of neoliberal governance hinges on this gambit’s success: Will we buy into the illusion that the desires of the parasite are inevitable? This is what Foucault meant by saying that the entrepreneur of the self is “eminently governable”: the apparatus of power doesn’t have to resort so much to open coercion or violence. It is already on the inside, pulling the levers of the individual’s desires with an invisible hand.


The Ethical Body

Some private medical insurance will cover bottom surgery, mostly after putting the applicant through a grotesque bureaucratic stations of the cross, but balks at covering anything beyond getting the genitals or chest to make the quantum leap onto the other side of the gendered binary opposition. Aetna’s policy language on coverage for transitioning is a litany of denials: blepharoplasty, body contouring (liposuction of the waist), breast enlargement procedures such as augmentation mammoplasty and implants, face-lifting, facial bone reduction, feminization of torso, hair removal, lip enhancement, reduction thyroid chondroplasty, rhinoplasty, skin resurfacing (dermabrasion, chemical peel), and voice modification surgery, which have all been used in feminization, are considered “cosmetic.” The same goes for the tools of masculinization, whether chin implants, lip reduction, breast reduction, or nose implants. In other words, after bottom surgery, for the rest of the long slog toward woman- or manhood, you’re on your own, fighting your fat hips or square jaw like the rest of us.

In terms of achieving acceptance as your identified gender, it’s arguable that so-called cosmetic procedures are a priority on par with genital surgery. After all, most people won’t be looking below the belt. The tragedy of public violent attacks and discrimination against trans people would conceivably be better addressed by cosmetic surgery that facilitates “passing,” not to mention the payoffs of the “beauty premium” that pays dividends in social, monetary, and sexual capital. Improving the normative performance of gender is an effective strategy in the arsenal of human capital’s self-valorization. As a 2017 Columbia Law Review article noted, both hair removal and facial transformation procedures can offer significant benefit to transgender patients, and it seems arbitrary to offer coverage of certain gender-affirming procedures yet deem others to be cosmetic. But by insurance companies’ logic, reductive gender biopolitics are what keep them from going belly-up. If insurers started covering the myriad forms of bodily modification beyond those of the genitals, the infinite optimizations that make one’s gender performance more “real,” who wouldn’t take out a policy? 

Decommodifying health care requires decommodifying the human being.

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With the world that we have, Chu is right to demand that trans surgery be treated as all other forms of bodily modification, as nobody’s business but the patient’s. But it’s telling that exactly the loss of such autonomy is held up as a bête noir by conservatives and neoliberals alike in the face of demands for socialized medicine, from the specter of “death panels” to the ability to “see your doctor.” It’s not for nothing that opponents of single-payer programs reach for the plastic surgery market first as an example in their arguments against universal coverage. Because costs in the plastic surgery market are borne directly by the customer-patient, they argue, cosmetic surgery markets have been immune to the ballooning costs otherwise prevalent in health care. Demanding the extension of the regnant logic of privatized medicine only punts on the question of what bodily modification and its medicalization would look like under the conditions of collective, socialized medicine.

The socialization of medicine is not simply a process of installing a government payer to pick up the tab for a system that remains otherwise intact, but a transformation of the ethical relationship between the individual body and a collectivity. The ethical premise of the welfare state is that statistical risk to the individual should be borne by the body politic as a whole. In return for insurance against the risk of accident or injury, the citizen’s body is not her own; her body is sponsored by a collectivity whose lives are bound up in each other’s. In many senses, the story of the late 1970s is the story of how social institutions were dismantled in the name of freeing the individual to fulfill their desires: in place of the institutions of collectivity, the libertarian imagination promised infinite freedom from the repressive mores of the welfare state. But if neoliberalism is found not in one specific entity or phenomenon but in the fabric of a way of life, the way out is the disintegration of the paradigm that provides the individual with absolute sovereignty over the body in the name of private property and the freedom to invest in her own human capital. Decommodifying health care requires decommodifying the human being.

What this means is that there is a fundamental anachronism in attempting to transact the political projects of the neoliberal subject within the framework of the welfare state. The welfare state disciplines the individual into the political imagination of a collectivity as the price of its care for her life. By contrast, the politics of the sovereign consumer in the era of neoliberal medicine are predicated on taking one’s own desire so seriously that it forms the core of a political project that is coterminous with investment in the self. The marketplace seems to be the supervenient structure that conditions all possible realities in which bodies relate to each other and transform. If the rallying phrase “My body, my choice” originated as a call for women’s liberation, its cooptation by astroturfed protesters calling for the post-Covid economy to be flung back open is no surprise: the rights of the individual over her body reach a limit in the ethical relation of the individual to a political body. The medicalized aesthetic projects of the body can make us hot; they can aid in chasing the asymptote of becoming woman, no scare quotes; but they cannot get us out of the fundamental paradigm of the neoliberal subject: the ownership of the self as private property to self-optimize. It’s every woman for herself out here under the unforgiving glint of the needle, the scalpel, the credit card chip. 

If we conjure the political will to create socialized medicine under the argument that health care is a human right, what forms of becoming gendered will be covered? To say that only bottom surgery would qualify is to reinscribe precisely our enemies’ reductive biopolitics of genital obsession. But what if becoming woman is a process not simply of jumping across a gendered binary, but one constantly occurring within gender itself? Do we then lean into or out of the medicalization of the gendered body? Do we have a right to be hot? Why should the socialist state cover one woman’s acquisition of breasts and not another’s augmentation of them? What is the space of nonequivalence between these two visions of “rights,” the right to purchase a commoditized medical service and the rights of an individual within a sociopolitical collectivity? If the welfare state is staked on the ethical wager that the plastic body is sponsored by the collectivity to help realize a collective vision of the good, what is the relation between rights and desires? And if the body is not private property to be managed as an investment, then how do we relate to it? 


Epilogue

If you’re wondering whether my surgery worked, the answer is yes and no. Yes, in that I am no longer tortured, and no in the sense that I don’t look particularly different from how I did before, certainly not hotter. Truth be told, I was disappointed in the surgical results, and sank into a brief state of nigh-psychotic despair, arriving at my one-month follow-up appointment ready to wage war. Like all the most dangerous lunatics, I was cunning. “I think it’s important for us to have honesty in the surgeon-patient relationship,” I said, citing the highest principle I reckoned I could force Dr. Fabriole to pretend to agree to. “And if I’m speaking honestly, I feel that we” — a lesson from Rich Dad, when negotiating always use we — “haven’t achieved the results I was hoping we would.” 

He understood my gambit perfectly and adapted without a downbeat. “Sure, OK,” he concurred, hauling out his phone from the back pocket of his scrubs and holding it at a farsighted arm’s length as we inspected the pre- and post-op photos, side by side. “And if we’re being honest, your befores aren’t so hot either.” Point and counterpoint. There was nothing to say to this but to revert to the first principle of negotiating, Dwell on Common Ground, in this case that we both agreed on that. In the following weeks, our therapeutic relationship fell apart precipitously in the course of an email thread whose critical juncture was my suggestion that “Just keep hoping and praying for the best” was not confidence-inspiring medical advice. By the end, he suggested that if I wasn’t happy, I was free to take my cash to a new physician, or pay him four thousand more dollars, preferably the former, as far as he was concerned. That’s how the marketplace works.

  1. Conventions for referring to medical treatments related to gendered performance vary, among them: gender affirmation surgery, sexual reassignment surgery, gender reassignment surgery, genital reconstruction surgery, sex change operation, and gender confirmation surgery. Normative debates about which phrasing should be used index that differences in language implicitly posit different theories of what gender is, and what it is that the medical procedure is doing (e.g., transitioning or affirming). For the purpose of this piece, I use the phrase “trans surgery” to refer to the surgeries one undergoes as a trans person in the process of transitioning. I choose this term in order to blackbox the questions of essence (that is, whether the surgery transitions or affirms), and to indicate a specific set of social and medical practices that occur in a particular socio-historical-political moment — the present . I made this choice with two aims in view: the first is to respect the robust debate within the trans community on these complex and key questions, and the second is to fasten my analysis to a set of actually occurring social practices in contemporary American medicine. 

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