The Body and Consent in Psychology, Psychiatry, and Medicine

A Therapeutic Rape Culture

Jemma Tosh

• Publisher: Routledge
• Year: 2019
• Print ISBN: 9781138078840
• eBook ISBN: 9781351627832
• Topic: Medicine
• Subtopic: History & Theory in Psychology

This groundbreaking text interrogates the constructed boundary between therapy and violence, by examining therapeutic practice and discourse through the lens of a psychologist and a survivor of sexual abuse.

It asks, what happens when those we approach for help cause further harm? Can we identify coercive practices and stop sexual abuse in psychology, psychiatry, and medicine? Tosh explores these questions and more to illustrate that many of the therapies considered fundamental to clinical practice are deeply problematic when issues of consent and sexual abuse are considered.

The book examines a range of situations where medical power and authority produces a context where the refusals and non-consent of oppressed groups are denied, dismissed, or ignored, arguing that key concepts and discourses have resulted in the production and standardisation of a therapeutic rape culture in the helping professions. Tosh uses critical intersectionality theory and discourse analysis to expertly highlight the complex interrelationships between race, class, gender, sexuality, and disability in our understanding of abuse and how we define survivors.

Drawing on a wide range of comprehensive examples, including experiences and perspectives from cisgender and transgender men and women, as well as nonbinary and intersex people, this is essential reading for students and researchers of critical and queer psychology, gender studies, as well as mental health practitioners and social workers.

1
INTRODUCTION

I am writing on the eve of the Ireland Abortion Referendum.¹ The question posed to those living in the South of Ireland² is whether or not the government should repeal the 8th Amendment of the Irish Constitution, which declares,

Admhaíonn an Stát ceart na mbeo gan breith chun a mbeatha agus, ag féachaint go cuí do chomhcheart na máthar chun a beatha, ráthaíonn sé gan cur isteach lena dhlíthe ar an gceart sin agus ráthaíonn fós an ceart sin a chosaint is a shuíomh lena dhlíthe sa mhéid gur féidir é [The State acknowledges the right to life of the unborn and, with due regard to the equal right to life of the mother, guarantees in its laws to respect, and, as far as practicable, by its laws to defend and vindicate that right].

(Eighth Amendment of the Constitution Act, 1983, Part I and Part II)

The rhetoric between pro-choice and pro-life perspectives (or ‘yes’ and ‘no’, respectively) has been passionate and at times hostile (Holland, 2018; Mullally, 2018). The country, diaspora, and many Irish immigrants like myself wait in eager anticipation of an end to the cruel law; a law that forces those with a womb to give birth against their will, delay lifesaving treatment to prioritise the life of the foetus, or travel to another country for an abortion – an option that is not only stressful but too difficult and expensive for many (O’Carroll, 2018; McDonald, 2014). Being forced to carry a foetus to term is traumatic in itself, however, combined with the complications of sexual and domestic violence (such as being impregnated against your will and other forms of reproductive coercion), as well as experiences of gender dysphoria³ (such as pregnancy being incongruent with your gender), we can see how strict abortion laws can exacerbate already difficult circumstances (Clark et al., 2014; MacDonald et al., 2016; Miller et al., 2010; Nikolajski et al., 2015; Obedin-Maliver and Makadon, 2015; Park et al., 2016; Silverman and Raj, 2014). This untenable situation has resulted in the development of several groups who work to make reproductive healthcare accessible to Irish people, as well as campaign to end the law itself.⁴

While justifications for this law are often framed as ‘protecting life’, Irish history repeatedly shows that some lives, and particularly some children, are viewed as ‘disposable’. Whether it is the mass graves of almost 800 babies and children found in a septic tank at the Tuam ‘Mother and Baby Home’ (Bohan, 2017) within the context of the country’s longstanding ‘architecture of containment’ for unmarried women (Luddy, 2011; Smith, 2007), or the deaths of young people in the Northern Irish conflict⁵ (Smyth et al., 2004), we can see that laws like this one are often more about controlling women’s bodies (Londras and Enright, 2018) and their sexuality than preserving life:

Irish women, especially those from the working classes and rural poor, who became pregnant outside of marriage during the greater part of the twentieth century, were considered a great shame; they were castigated as sinners, shunned, tainted and ultimately cornered. Removed from their families and communities and hidden behind the grey walls of ‘Mother and Baby Homes’ to give birth in secret. They were completely isolated and helpless when their children were taken from them … the children were neglected and starved and often died in alarming numbers while nobody noticed or cared.

(Daly, 2018, cited in Redmond, 2018, para. 3)

This historic referendum occurs at a time when reproductive rights are being restricted and threatened at an alarming rate (Andreou and Urry, 2018), and the fight for access and the decriminalisation of abortion continues, such as the ongoing protests in Argentina (Goñi, 2019). In the United States, while reproductive and sexual health services are closing down with ongoing threats to federal funding (Belluck, 2019; Richardson, 2017), the experiences of immigrants and refugees who have been detained and prevented from accessing abortion services reads like a nightmare from dystopian fiction (e.g. Amiri, 2018). Again, these examples defy arguments of ‘protecting life’ or ‘saving children’ because of the widespread trauma that has resulted from enforced family separations. This is in addition to the reports of sexual abuse, maltreatment, and deaths of children who have been detained by US Immigration and Customs Enforcement (ICE) (Durkin, 2018; Gomez, 2019; Gonzales, 2019). The experiences of these groups are alarming and painful, as they exist at the intersection of racial, colonial, and gender violence.

Even in situations when an individual wants to give birth, coercion during the reproductive process within medical settings can occur. For example, some who have experienced a traumatic birth describe the experience as birth rape, due to feeling powerless over the decisions made about their body, non-consensual genital touching, and non-consensual surgical procedures (such as cutting) (Kitzinger, 2006). As Elmir et al. (2010) state in their meta-ethnographic study of traumatic births:

It was also distressing for them when large numbers of people were invited to watch the birth without their consent: “nobody said to me … do you mind five or six complete strangers having a look at the most intimate parts of your body?” (Nicholls and Ayers, 2007, p. 496). Other participants talked of feeling like a ‘lump of meat’ or a ‘slab on a table’ when describing the dehumanizing way in which they were treated during birth, and described a total lack of acknowledgement of them as people.

(p. 2147)

Therefore, being able to make decisions about reproduction is only a very small part of the coercive culture around medicine, bodies typically considered feminine,⁶ and other intersecting systems of violence and oppression. Forcing unwanted procedures on someone, and denying procedures to others, both overrule the wants, needs, and consent of the individual in question. The message regarding how bodies are viewed is equally destructive: your body is not your own.

‘The body’

During my studies of sexual abuse, I noted that we often use familiar terms assuming that everyone agrees on their definitions. Whether it is ‘consent’, ‘sex’, or ‘rape’, these words are so frequently used in popular discourse that it can be easy to overlook the conflict, disagreement, and transformation of these emotive terms. I found that there are generally as many definitions and understandings of rape and abuse as there are people (Tosh, 2013, 2016a, 2017). Everyone has an opinion, and everyone thinks theirs is right, but few examine how they came to that conclusion or what assumptions they made in the process. The same can be said for how we think about the human body and how our definitions of bodies can impact on our understanding of their violation – or in other words, violence. Therefore, in this book I ask, what do we understand the body to be, where are its boundaries, what is its form, and how does that shape concepts like consent and abuse?

While bodies may appear more corporeal than abstract, philosophers have been theorising about what the body is and what it represents for centuries. Whether it is Plato’s framing of the body as a ‘soma-sema’ or a ‘tomb of the soul’ in Ancient Greece, St. Paul’s declaration “that your bodies are temples of the Holy Spirit…. You are not your own” in Corinthians, Descartes’ (1850/1637) view of the body as machine, or Sartre’s understanding that the body is ‘the self’ in Being and Nothingness (2018/1943) (Synnott, 1992, 2002; Wheeler, 2008), we can see that there is more to the human body than a solid collection of cells, and there is much debate over how it is defined and what its purpose is. As Akrich and Berg (2004) state, the body is “both discursive and material, both historical and real” (p. 2). This multitude of meanings and representations applied to material bodies and the conceptual body is influenced by social context, culture, and history. However, this multiplicity and complexity often gets overlooked and the body reduced to a solid, universally similar, and unchanging object within a context where biomedical discourses predominate (Williams, 2006).

The medical gaze

During the 18th and 19th centuries the body became increasingly under the purview of medicine and science, in place of historically predominant religious and spiritual discourse. In The Birth of the Clinic: An Archaeology of Medical Perception, Foucault (2008) analysed how the role of clinics and hospitals led to bodies coming under the medical gaze, and how this began the abstraction of bodies in terms of conditions, symptoms, and diseases that needed to be monitored and studied. By focusing on symptoms and disease classification systems based on similar developments in botany, the medical gaze subtracted the individual in an attempt to view disease in its ‘purest’ form, what Foucault (2008) referred to as primary spatialisation. In other words, clinicians had to separate what features and experiences the individual had that related to the disease, and what were irrelevant or coincidental and therefore potentially confounding an accurate understanding. This included a move from the embodied and theorised (i.e. hypotheses regarding potential causes or origins of disease) to the measurable and observable (i.e. symptoms and disease progression). There was also a qualitative gaze, referred to as secondary spatialisation, that differentiated between the qualities of different symptoms that Foucault (2008) considered to be “a more penetrating gaze” of the individual (p. 17). Tertiary spatialisation was where disease became isolated and divided into “cure centres”, which involved “a whole corpus of medical practices” in a social space where disease existed as “denatured” (i.e. influenced by the social context and not in its ‘pure’ or ‘natural’ state) (p. 17). For example,

Armstrong (1993), following Foucault, describes how disease was remapped during the twentieth century, from the inner organs of the body into the social spaces between people. Tuberculosis, for example, became seen increasingly as a social disease, indicating poor living conditions rather than a disease of the individual body. These changes helped to extend the medical gaze.

(Birke, 2002, p. 42)

Disease, epidemics, and their treatment and management became of increasing interest to, and under the control of, the state (Foucault, 2008). This extended medical gaze, then, can be considered a part of a broader biopolitics that “concern[ed] itself with addressing problems of mass and with regulating the life of a population” (Gougelet, 2010, p. 45). Thus, the body became ‘the patient’, who was the indirect focus in the surveillance of disease (Foucault, 2008), or from the perspective of the doctor, “I had minimal sense of the patient and the experience of illness, but rather felt obsessed with the notion of disease” (Radomsky, 1995, p. 1). The medical gaze had this objectifying and biologically reductive aspect to it, of divorcing body and person, but it was also framed as having the power to make the invisible visible, such as the inner processes of the body (Foucault, 2008). This seemingly miraculous capability influenced the belief that medicine would one day remove all disease from society through its production of knowledge, and therefore eliminate ‘deviant’ bodies.

‘Deviant’ Disabled bodies

The clinic, with its focus on pathology and armed with the tools of classification and measurement, produced a ‘normative’ body (Rose, 1979); a discourse comprising “sterile ideals of the body based on statistical averages and on an investment in the diagnosis of biological differences as deviance” (Snyder and Mitchell, 2001, p. 689). This ‘norm’ was based on research and theories that centred the experiences and bodies of white, non-disabled, cisgender⁷ men and consequently positioned different bodies as ‘abnormal’:

From the eighteenth to the mid-twentieth centuries, the great historical constructions of gender, race, and class were embedded in the organically marked bodies of woman, the colonized or enslaved, and the worker. Those inhabiting these marked bodies have been symbolically other to the fictive rational self of universal, and so unmarked, species man, a coherent subject.

(Haraway, 1999, p. 210)

In this framework, the body is described as if devoid of subjective/emotional experience, and positioned as separate from consciousness or self; as if bodies are simply a container in which people live. The body is compared to a machine (Descartes, 1850/1637), being a mechanical object with biomechanical functions, or like a computer with inputs and outputs (e.g. Johnson, 1987). Consequently, illness becomes a malfunction to be fixed.

Constructions of bodies as in a constant and fixed state did not apply to those who experienced chronic illness (Moss and Dyck, 2003). Rather than have a fixed state that has a sudden and temporary change (such as a short-term illness), their body can be in constant flux, disrupting the ‘norms’ of everyday life (Bury, 1982), as symptoms change day to day, minute to minute, and the highs and lows of changes in treatment and recovery and relapse. As Moss and Dyck (2003) explain:

women with chronic illness experience the material limits of their body, not as solid, impervious boundaries, but as fluid, permeable borders. Like chronic illness itself, these borders wax and wane, briefly congealing to form limits, then quickly dissolving so as to permit a new border to take shape. In order to contend with this fluctuating pattern of bodily border formation, women with chronic illness forged spaces to negotiate the discursive and material limits of the body. They moved with the uneven expansion and contraction of these borders, taking up the unpredictability of form and shape by living these spaces.

(p. 130)

Within this ‘norm’ there is an assumption that there is a universal experience of health and similar physical and mental attributes and abilities for most people, or a ‘compulsory able-bodiedness’ (Orr, 2018), which therefore excludes disability and neurodiversity.⁸ As Davis (2016) argues, “the ‘problem’ is not the person with disabilities; the problem is the way that normalcy is constructed to create the ‘problem’ of the disabled person” (p. 1). People were disabled by a medical system that classified bodies and compared them to a constructed ‘norm’, a norm that was based on a particular, narrow, and unachievable ideal. Therefore, within the process of medicalisation was the ‘social process of disabling’ (Davis, 2016): the creation of a discursive category that positioned groups of people as ‘less than’ others based on their bodily difference, or framed the disabled body as ‘lacking’ (Goodley and Runswick-Co...

Table of contents

• Cover
• Half Title
• Title
• Copyright
• Dedication
• CONTENTS
• Acknowledgements
• 1 Introduction
• 2 Intersex youth: non-consensual surgeries and nosocomial sexual abuse
• 3 Queer and trans youth: ‘sexual rehearsal play’ and reparative therapies
• 4 ‘Sex’ as treatment: consent, coercion, and sex therapy
• 5 Penetration as ‘treatment’: the pathologisation of sexual avoidance and pain
• 6 Phallometrics: quantifying sexuality and sexual violence
• 7 Conclusions: a therapeutic rape culture
• References
• Index