Kane Race is a Senior Lecturer in Gender and Cultural Studies at the University of Sydney.

PLEASURE CONSUMING MEDICINE

Duke University Press

Contents

Chapter One

An Introduction

My drugs require me to dance with no fewer than ten thousand people at a time. DAVID HALPERIN

This book explores multiple declensions of three seemingly incompatible terms: pleasure, consuming, and medicine. At first glance, "pleasure consuming medicine" is a queer conjunction. It doesn't seem to refer to any obviously recognizable form of experience. It is difficult to discern what it might properly mean. We are far more likely to consider medicine a bitter pill to swallow. Indeed, the austere advice to stop eating rich foods, exercise more, keep out of the sun, or give up smoking could well support the impression that medicine and pleasure are antithetically opposed. It is rare, in the presence of such advice, for pleasure to be treated as a valid exception to the medical rule. It tends to be cast instead as a gratuitous enticement that the individual must overcome in a dutiful struggle for health and self-mastery. From this perspective-and in ways that range from mildly irritating to thoroughly devastating-the imperatives of medicine can seem entirely pleasure-consuming.

Perhaps this loggerhead relation of medicine and pleasure has been felt most acutely in our time in the context of the aids crisis. Abruptly, many found their most intimate, exciting, or otherwise meaningful practices on the wrong side of (frequently punitive and distorted) health edicts. But while one very common response to this crisis might be summed up in the phrase "where safety prevails, pleasure must submit," HIV education has in fact been most effective when it has foregrounded and incorporated the embodied pleasures of endangered groups. The history of HIV prevention may be understood as a series of struggles on the part of affected groups to elaborate bodily practices capable of mediating between pleasure and safety. Here, health does not stand in opposition to pleasure. Rather it is something that has to be collaboratively negotiated and produced through the careful interaction of bodies. What can be drawn from this history is a better understanding of the critical agency of pleasure when devising practical logics of care and safety.

In general terms, though, the proposition that one might actually experience pleasure while consuming medicine seems slightly absurd. Indeed, it's easy to arrive at the conclusion that pleasure is precisely what should not be had in such activity. It is as though the two terms act, or should act, to cancel each other out. The clinician warns "this may feel a little uncomfortable" before engaging in procedures that can actually produce some not-entirely-unpleasant sensations. To acknowledge pleasure here would seem to betray the self that medicine must contain in its effort to produce a properly objective body, so pleasure is performatively banished from the clinic. Likewise, medical procedures are routinely demarcated from the realm of aesthetics. Reconstructive surgery is distinguished from cosmetic surgery, for example, on the basis of medical need and with reference to structures of the body that are classed as abnormal (in need of repair) rather than normal (and desiring adornment). In each of these instances, it seems important that health be not contaminated by more specific modes of desire-that it be basic, unmarked, and devoid of any affective connotation. To introduce particular affects into these contexts would be to excise health from medicine's recuperative function. Medicine concerns itself with the grave task of restoring life to its proper order. It is not, first and foremost, about optimizing particular attributes and sensations. Of course, pleasure might be experienced as a corollary of restoring health. One could even be excused for feeling good at such a prospect. But taking medicine for pleasure, without the intermediary goal of restoring health in all its generality? Such a qualified and instrumental reassignment of medical priorities and values would initially seem impossible to admit.

What are we to make then of the popularity of a class of medicines whose utility can well be framed in terms of enhancement, rather than merely treatment? In Listening to Prozac, psychiatrist Peter Kramer uses the term cosmetic pyschopharmacology to describe the sort of clinical and biochemical mechanisms at work in some applications of the antidepressant fluoxetine. Though initially his description frames the transformations enabled by this drug as superficial ("a neurochemical nosejob") and even socially dangerous ("steroids for the business Olympics"), Kramer demonstrates in the course of his discussion the far-from-trivial ways in which they can also transfigure the suffering of some patients. His account transfers clinical labor from a paradigm of restoration to one of transformation. Out of his careful discussion of numerous case studies, a picture of efficacy emerges that is not so much one of returning patients to a prior or extraneous state of normality, but rather one in which medicine produces quite specific sets of modifications to mood and behavior, with both beneficial and adverse effects. The effects can be-and in many cases are-critically evaluated in new forms of relation between clinician, patient, and their associates. Kramer displays some caution in characterizing medicine in these terms, but his book stands as an intelligent account of how biochemistry is being enfolded, through drugs, in new practices of ethical self-formation.

The tensions between treatment and enhancement play out particularly passionately in the case of a series of drugs that have acquired the nickname "lifestyle drugs." The term encompasses medications aimed at reversing baldness and losing weight as well as some applications of this class of antidepressants, such as reducing inhibition and shyness. But it inspires a particular level of excitement when it comes to drugs that target matters sexual. Strains begin to show, it seems, when the pathological imagination is applied to a domain so firmly identified with pleasure. In an article published in the British Medical Journal in 2003, Ray Moynihan reported on recent initiatives to clarify a category of female pathology. Keen to reproduce the massive profits of Viagra, drug companies were revealed to be sponsoring meetings between researchers and the pharmaceutical industry to determine the definition and measurable characteristics of "female sexual dysfunction" (FSD) as required for credible clinical trials. Data were being gathered to determine the "normal physiologic responses" for women in particular age groups. "The corporate sponsored creation of a disease is not a new phenomenon," Moynihan wrote, "but the making of female sexual dysfunction is the freshest, clearest example we have." The article provoked a flurry of responses, both for and against. For some, FSD was a genuine disorder, a pathology that feminists everywhere had a duty to affirm. To get the condition recognized and achieve equality in the field of pharmaceutical production, women had to cast their claims in the language of essential pathology: women's sexuality really can be impeded by physiological deficiencies. The fight for recognition required a proliferation of testimony on the realness of the condition: moving accounts of the plight of those with the disorder, anger and resentment that the validity of women's claims was once again being put in question. To achieve a just outcome, the normative determinations of medicine were to be affirmed, and the inventive character of its taxonomic labor denied. For others, though, FSD was "nothing more than a figment of corporate America's financial imagination," as Shere Hite put it, a cynical ploy of greedy multinationals bent on colonizing everyday life with biomedical artifacts and categories. FSD was not a "real" disease but a "construction"-a fact made all the more sinister by the involvement of industry. Hite, for example, complained that the pharmaceutical industry had "wilfully misunderstood the basics of female sexuality in its lust for blockbuster drugs." In their bid to sell product to gullible consumers, the makers of "female Viagra" were imposing an individualizing and masculinist frame on female sexuality. In so doing, they were selling women the fantasy that the interpersonal, social, and material problems affecting women's lives and sexualities could be resolved by taking a pill. Not only was FSD based on a normative conception of female sexuality, obviating as a consequence the cultural and performative differences in this sphere; but once it was in circulation, it would also set new universalizing standards, reducing women's experience to the humiliating and coercive terms of functionality and dysfunction.

Without entering into a detailed discussion of this example, it seems necessary to insist that yes, there is a physiological dimension to a realm of experience known as sexuality-a realm whose existence must be acknowledged in the case of women as well as men-and yes, medical categories are constructed and arise out of a questionable blend of scientific and commercial resources, a blend whose concrete manifestations require critical attention. It is not enough, for example, to claim that because this category of disorder is constructed, it is therefore false-unless one is willing to posit some pure and preconstructed realm of actual experience. It is telling in this regard that it falls on female sexuality to provide the "freshest, clearest example" of the artificial machinations of capitalist medicine. Women's sexuality is thereby constructed as pure, natural, and essentially nonexistent-something that reveals more about the traditional status of female sexuality than any of the ethical implications of this instance. To claim, on the other hand, that this pathology is real, plain and simple-as some proponents do-is to ignore the consequential nature of scientific and epistemological production: the impact of its practices, its constitutive effects. How quickly the argument congeals into a rhetorical division between a realm of experience that is supposedly real, natural, and therefore needs to be constantly reaffirmed as the single and incontestable standard of experience and value, and the view that what is constructed is artificial, and thus duplicitous (a set of assignments whose unsettling character seems almost entirely pre-validated in existing suspicions surrounding the category "drug"). Yet what this example must reveal most powerfully is the enormous discursive and scientific labor, both within and outside medicine, that goes into characterizing the purpose of medicine neutrally (in terms of repairing disorder) rather than positively (as enhancement). Assuming the drug in development does have some tangible and even desirable effects for some, irrespective of pathology, what this example reveals quite clearly is how intent medical morality is on disavowing its own active involvement in creation and re-creation.

"Viagra is a recreational drug," writes Germaine Greer. "Ask the gay guys who keep Trade's club floor jumping and fill the pages of Attitude. They should know-they've been using it for months. And health is the least of their concerns. In hyper-gay circles, it is getting difficult to steer clear of Viagra. Any guy who would prefer to walk and talk, wine and dine, cuddle and kiss his significant other rather than keep him impaled for 48 hours is a sissy. When you can have a whole weekend of synthetic priapism, what red-blooded male would settle for anything less? Viagra weekends could vanquish football as we know it." The concern over lifestyle drugs arises, in part, from a concern over public subsidization. Those aiming for subsidization must cast their claims in the language of essential injury and its repair, while opponents use the tag of "lifestyle" or "recreation" in order to dismiss the drug in question as trivial, its effects indulgent and, in the final instance, expendable. This is why Greer wants to characterize Viagra as recreational. Concerned about the state of care for "women, children, the elderly and the actually sick," she wants to question, in the case of erectile difficulty, the purchase that the medical determination of disorder has on the public imagination. One need not disagree with Greer's priorities here to query the terms she uses to make her argument. Viagra is coded as recreational by associating it with gay life, located squarely in the zones of leisure. This in turn works to separate out a domain of "necessity" from a domain marked "lifestyle," and the distinction gets mapped onto lives and identities in culturally consequential ways. While some grading of need is unavoidable when it comes to the allocation of public resources for medical interventions, the way Greer deploys this distinction illustrates why the sexually minoritized have good reason to be suspicious of its cultural overtones. The distinction bears traces of gay men's already ambiguous status in the public sphere proper. Thus when, at a meeting on global treatment access, a pharmaceutical company representative responds to a demand made by aids activist Mark Harrington by asking, "Do you want us to leave the field and just work on lifestyle drugs?" I can't help reading this threat as, unconsciously or not, double-barrelled.

One of the issues here is that the medical construction of pathology cannot be relied upon to provide an infallible guide to public, let alone global, need. This is why terms like "lifestyle" pop up repeatedly in the pharmaceutical domain: they attempt to patch over the gap between medical and state or insurer determinations of what counts as necessary repair. The capitalization of the life sciences has meant that the logic of financial returns and market share now dominates which products get developed. As well as indicating a situation of massive geopolitical disparity-in which research and development for the major diseases affecting the world's poor is left languishing while minor problems that are expected to attract large financial returns are pursued-this situation exposes a peculiarity of the contemporary medical gaze: the attribution of disorder cannot be regarded as an accurate measure of social or collective need, but references a generic body, extracted from any relational context, to whom the category of need can be infinitely and arbitrarily applied so long as there is the desire, prospect, and normative precedent for some form of enhancement. If the image of medicine cataloguing norms of everyday pleasure in order to authorize the development of marketable product evokes a more disturbing sense of pleasure consuming medicine, it also crystallizes a problem in the sphere of regulation. Because authorizing new drugs demands the endorsement of new pathologies, the only thing medicine may produce, in this discourse, is a return to a putative state of normality. But what is also reproduced in this move is the regulative power of medicine to determine what can count as normal and therefore properly and publicly desirable.

(Continues...)

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