GUT FEMI NISM
ELIZABETH A. WILSON DUKE UNIVERSITY PRESS
Durham and London 2015
© 2015 Duke University Press All rights reserved Printed in the United States o America Ame rica on acid-ree acid-ree paper ∞ Designed by Amy Ruth Buchanan Typeset in Quadraat and Gill Sans by Westchester Westchester Publishing Ser vices Ser vices Library o Congress Cataloging-inCataloging-in-Publication Publication Data Wilson, Elizabeth A. (Elizabeth (Elizabet h Ann), [date] Gut eminism / Elizabeth A. Wilson. pages cm—(Next cm—(Next wave : new directions in women’s studies) Includes bibliographical reerences and index. ���� 978-0-8223-5951-7 978-0-8223-5951-7 (hardcover : alk. paper) ���� 978-0-8223-5970-8 (pbk. : alk. paper) ���� 978-0-8223-7520-3 (e-book) (e-book) 1. Feminist theory. theory. 2. Mind and body. body. 3. Feminism Feminism and science. 4. Depression, Mental. �. Title. ��. Series: Next wave. ��1190.�548 2015 305.4201—dc23 305.4201— dc23 2015008324
Cover art: elin o’Hara slavick, Global Economy (slaughtered cow near SalvadorBahia, Brazil), 1996 (details). Chromogenic print. Courtesy o the artist. Duke University Press grateully acknowledges Emory College o Arts and Sciences and the Laney Graduate Gradu ate School, which provided unds toward the publication publica tion o this book.
CONTENTS
Acknow Ac knowledg ledgments ments vii Introduction: Depression, Biology, Aggression 1 RY P A R T I . F E M I N I S T T H E O RY CHAPTER 1.
Underbelly 21
The Biological Unconscious 45
CHAPTER 2.
CHAPTER 3.
Bitter Melancholy 68
PA R T I I . A N T I D E P R E S S A N T S CHAPTER 4.
Chemical Transerence 97
CHAPTER 5.
The T he Bastard Placebo 121
The Pharmakology o Depression 141
CHAPTER 6.
Conclusion 169 Notes 181 Reerences 201 Index 225
AC K N O WL E D GM E N T S
An early version o the second chapter o this book was published in 2004 in the journal differences under the title “Gut Feminism.” In the short acknow acknowledg ledgments ments at the end o that essay I stated that this was the �nal expression o an argument made at greater length in my 2004 book Psychosomatic: Feminism and the Neurological Body . At the time, i I recall correctly, correctly, I imagined that th at the questions o the gut that t hat had emerged late in the writing o Psychosomatic could be slightly extended, but that the differences article would bring those issues to a close. That is not what happened. In 2004 2004 I was was at at the beginning o a �ve�ve- year year ellows ellowship, hip, unded by the Australian Research Council, on neurology and eminism. That pro ject wasn wasn’t ’t primarily oriented to questions questions o the gut, but but as things have turned out, the t he gut and antidepressants have consumed all my attention. This book is the outcome o that research. The datum that 95 percent o the human body’s serotonin can be ound in the gut (something I �rst stumbled across across while writing Psychosomatic ) did not lose its grip on me. Exploiting these kinds o data, this book contains the best arguments I can currently muster or using the peripheral body to think psychologically, and or using depressive states to understand the necessary aggressions o eminist theory and politics. While eminist questions about biology and hostility will continue to be asked, I believe that I have now �nally brought this partic par ticu ular, much extended pro ject to a close. close. There are many institutions and colleagues who have sustained me as I have written. I have been very ortunate to be invited to speak to a number o inormed and animated audiences. Early versions o this
research were presented at the ollowing venues (in response to invitations rom these colleagues): the Diane Weiss Memorial Lecture, Wesleyan University (Victoria Pitts-Taylor); the Linda Singer Memorial Lecture, Miami Univers University ity (Gaile Pohlhaus); ���� (Rachel Lee and Hannah Landecker); Kings College College and the London School o Economics (Nikolas Rose); the University o Caliornia, San Diego (Lisa Cartwright and Steven Epstein); Concordia University (Marcie Frank); Women’s Studies, Rutgers University (Belinda (Beli nda Edmondson); Edmondso n); the Program Progra m in Women’ Women’ss Studies, Duke University (Ranji Khanna and Robyn Wiegman); the University o Illinois at Urbana–Champaig Urbana–Champaign n (Bruce (Br uce Rosenstock); Rosenstock); the Committee on Degrees in Studies o Women, Gender and Sexuality, Harvard University (Anne Fausto-Sterling); Fausto-Sterling); the Center or the Humanities, Wesleyan University (Robert Reynolds); the University o New South Wales (Vicki Kirby); St. Thomas Aquinas College (Charles Shepherdson); the ��� Program in Women’ Women’s Studies (Evelyn Fox Keller); Keller); the th e Rock Ethics Institute Instit ute and the Science, Medicine and Technology in Culture Program, Penn State Uni versity (Susan Squier); the Pembroke Center or Res Research earch and Teaching on Women, Brown University (Elizabeth Weed); the Centre or Women’ W omen’ss Stud Studies ies and Gender Gender Research Research,, Monash Universi University ty (Maryanne Dever; JaneMaree Maher; Steven Angelides); the Department o Gender Studies, University o Sydney (Elspeth Probyn); the Australian Women’s Studies Association; Association; the Society or Literature Literature and Science and the Arts. This book was begun with the support o an Australian Research Council Fellowship (2004–2008) at the University o Sydney (Research Institute or Humanities and Social Sciences) and the University o New South Wales (School o English, English, Media and Perorming Arts). The Australian Research Research Council has been an enormously impor im portant tant source o unding or me, and I remain ver y grateul or their support o interdisciplinary work that no doubt made them anxious. The pro ject pro ject was also supported by a ellowship year at the Radcliffe Institute or Ad vanced Study Study, Harvard University (2011 (2011–201 –2012), 2), which provided provided me with with remarkable resources and great intellectual company. com pany. Some o the ollowing chapters have been published in the early stages o this research; these essays have have all been revised or this book. Chapter 1 appeared, in different orm, as “Underbelly” in differences: A Journall of Feminist Journa Feminist Cultural Cultural Studies 21, no. 1 (2010): 194–208. Chapter 2 was published, in different orm, under the title “Gut eminism” in differences: A Journal of Feminist Cultural Studies 15, no. 3 (2004): 66–94. Frag viii
ACKNOWL E D GM E N T S
ments rom “The work o antidepressants: Preliminary notes on how to build an alliance between eminism and psychopharmacology” (BioSocieties: An Interdisciplinary Journal for the Social Studies of Life Sciences 1 [2006], 125–131) and “Organic empathy: Feminism, psychopharmaceuticals and the embodiment o depression” (in Stacy Alaimo and Susan Hekman’s Material Feminisms [Bloomington: Indiana University Press, 2009], 373–399) 373–399) can be ound scattered through chapter 4 and beyond. An earlier version o chapter 5 was published, in different orm, with Australian lian Feminist Studies 23 (2008): 31–42. the title “Ingesting placebo” in Austra Chapter 6 was published, in different orm, as “Neurological entanglements: The case o pediatric depression, ����s and suicidal ideation” in Subjectivity 4, no. 3 (2011): 277–297. I have the very best o colleagues in the Department o Women’s, Gender,, and Sexuality Studies at Emory Universi Gender University. ty. My deepest thanks to two exemplary chairs (Lynne Huffer and Pamela Scully) who pro vided the conditio conditions ns or this this resear research ch to proceed proceed,, to a crack team o staff (Berky Abreu, April Biagioni, Linda Calloway, and Chelsea Long), and to my departmental colleagues Rizvana Bradley, Irene Browne, Michael Moon, Beth Reingold, Deboleena Roy, Holloway Sparks, and Rosemarie Garland Thomson. Special thanks to Carla Freeman, who provided excellent company company and chocolatechocolate-based based encouragement through a long summer when neither o us thought our books would ever be �nished. Ingrid Meintjes helped with the dreary drear y editing tasks right at the very end and was a liesaver li esaver.. Over the many years o this book’s ormation my thinking has continued to grow in the company company o great riends, supporters, and coconspirators: Steven Angelides, Karen Barad, Tyler Curtain, Guy Davidson, Penelope Deutscher, Richard Doyle, Anne Fausto-Sterling, Fausto- Sterling, Mike Fortun, Kim Fortun, Adam Frank, Jonathan Goldberg, Lynne Huffer, Annamarie Jagose, Lynne Joyrich, Helen Keane, Vicki Kirby, Neil Levi, Kate Livett, Elizabeth McMahon, Michael Moon, Brigitta Olubas, Isobel Pegrum, Marguerite Pigeon, Robert Reynolds, Jennier Rutherord, Vanessa Smith, Colin Talley, Nicole Vitellone, and Elizabeth Weed. I would particularly like to note the importance o the Mrs. Klein reading group that met over many years in Sydney. My thanks to Sue Best, Gillian Straker, and kylie valentine not just or their incisive thinking and great humor but also or understanding that cake is necessary or sustained discussions o the Kleinian underworld. Robyn Wiegman AC KNOWL E D GMENTS
ix
provided a crucial reading o the manuscript in the latter stages that helped clariy what this book is about. I greatly appreciate her enthusiasm or intellectual and politi po litical cal adventure. Carla Freeman, Michael Moon, and Vanessa Smith read �nal snippets o the manuscript; they are the very best o riends and interlocutors. Courtney Berger has been a supportive and sanguine presence throughout the writing writi ng and publication process, process, and Erin Hanas, Liz Smith, and Christi Stanorth have h ave very effectively guided the book into production. I remain very grateul or the support Duke University Press has shown to me over the years. Scott Conkright was an impor important, tant, energizing in�uence in the �nal years o this pro ject; his his understanding understanding that eeling eeling and and intellect intellect are happy happy bedbedellows repaired all kinds o problems. My New Zealand amily have al wayss been supportive way supportive o my intellectual intellectual endeavor endeavors. s. In partic particu ular, I have been especially grateul or a lively postal correspondence with Sarah Oram over many years. Ashley Shelden has a capacity capacit y or love that, that , daily, astonishes me. Let me say it as plainly as I can: she has brought me back to lie. In relation to this book her intellectual acuity has been vital. Our conversations have strengthened and intensi�ed the arguments presented here. My only wish is that the book could more ably re�ect her abiding intellectual and emotional in�uence on me.
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AC KNOWL E D GMENTS
INTRODUCTION
DEP RE SSI ON, BIOL OGY, AGGRESSION
The connections between gut and depression have been known, in the West, W est, since since ancient ancient Greece. Greece. It was was the Hippocratic writers who gave gave the name melancholia to states o dejection, hopelessness, hopelessness, and torpor. They understood such states to be caused by an accumulation o black bile (in Greek, melaina chole), a substance secreted by the liver. For these writers, and or practi practition tioners ers o medicine or another two thousand years, melancholia was both the name o one o the enteric humors and the name or a disruption to emotional equilibrium (Jackson 1986). One o the Hippocratic Hippocr atic aphorisms makes m akes the affinit nityy between bet ween these two t wo modes o melancholia explicit: “The bowel should be treated in melancholics” (Hippocrates 1978, 217). The condensation o viscera and mood, exempli�ed in the term melancholia, is the subject o Gut Feminism. This book will explore the t he alliances o internal organs and minded states, not in relation to ancient texts but in the contemporary milieu where melancholias are orga organized nized as entanglements o affects, ideations, nerves, agitation, sociality, pills, and synaptic biochemistry. I am not proposing a theory o depression. Rather, I want to extract rom these analyses o depressed viscera and mood some gain or eminist theory. I have two ambitions. First, I seek some eminist theoretical gain in relation to how biological data can be used to think about minded and bodily states. What conceptual innovations innovati ons would be possible i eminist theory wasn’t so instinctively antibiological? Second, I seek some eminist theoretical gain in relation to thinking about the hostility (bile) intrinsic to our politics. What i eminist politics are necessarily necessa rily more destructive than we are able to bear? This introduction
offers some context or how eminist theory theor y might approach these tough questions o biology and aggression. In the �rst instance, this book makes an argument that biological data can be enormously helpul helpul or o r eminist theory theor y. By “helpul” I mean “arresting, transorming, taxing.” When the pro ject pro ject bega began n (with (with a paper paper titled “Gut Feminism” at the 2003 Society or Literature Lit erature and Science con vention) ven tion) my prima primarr y conc concern ern was to sho show w that emin eminist ist theory cou could ld �nd conceptual insight in the biological and pharmacological research on depression. depress ion. It had been clear to me or some time ti me that there were signi�cant gains to be made by reading biological, evolutionar evolutionaryy, and cognitive research more closely (E. A. Wilson 1998, 2004). I wanted to show that data about the pharmaceutical treatment o depression need not alway alwayss be the object o eminist suspicion; they could sometimes be the source o conceptual and methodological ingenuity. By 2003 many eminist science studies projects were expanding the ways in which biological data could be apprehended. In the wake o early in�uential work in eminist philosophy o science and biomedicine (e.g., Ruth Bleier, Donna Haraway, Sandra Harding, Emily Martin), Anne Fausto-Sterling’s Fausto- Sterling’s Sexing the Body (2000) and Evelyn Fox Keller’s Century of the Gene (2000) brought to a wide audience the idea that biology was a site o im por portant tant politi political cal and conceptual argumentation or eminism, and—in particular—that particular— that detailed understanding o biological processe pro cessess was crucial to such eminist analyses. What ollowed were a number o impor im portant tant and engaging monographs on eminism, sex, gender, sexuality, capital, biotechnology, and biology: Susan Squier’s Liminal Lives (2004), Catherine Waldby and Robert Mitchell’s Tissue Economies (2006), Sarah Franklin’s Dolly Mixtures (2007), Melinda Cooper’s Life as Surplus (2008), Marsha Rosengarten’ Rosengarten’ss ��� Interventions (2009), Hannah Landecker’s Culturing Life (2010), Rebecca Jordan Jord an-Young’s Young’s Brain Storm (2010), Michelle Murphy’s Seizing the Means of Reproduction (2012), Sarah Richardson’s Sex Itself (2013)—to (2013)—to name those most prominent on my bookshelves over this decade. decade. My interests in Gut Feminism are less to do with that body o literature, lit erature, which continues to �ourish (and to provide sustenance or my own thinking), and more to do with the broader �eld o eminist theory, where biology remains something o a thorny conceptual and po politilitical issue and where antibiologism is still valued as currency. This book is less interested in what eminist theory might be able to say about biology than in what biology might be able to do or—do to—eminist to— eminist 2
INTRODUCTION
theor y. How do biological data arrest, transorm, or tax theory t ax the theoretical oundations o eminist theory? Gut Feminism begins with the conjecture that despite the burgeoning work in eminist science studies there is still something about biology biology that remains troublesome or eminist theory. Take, or example, the eminist theoretical work on the body (which was very in�uential on my training and subsequent work). In the last thirty years, eminists have produced pioneering theories o the body—they body— they have demonstrated how bodies vary across different cultural contexts and historical periods, how structures o gender and sexuality and race constitute bodies in very partic particu ular ways, how bodies are being ashioned by biomedical and technological invention. Yet despite its avow avowed ed interest in the body, this eminist work is ofen reluctant to engage directly with biological data. Most eminist research on the body has relied on the methods o social constructionism, which explore how cultural, social, symbolic, or linguistic constraints govern and sculpt the kinds o bodies we have. These theorists tend not to be very curious about the details o empirical claims in gene ge netics, neurophy neurophysiology siology,, evolutionary biology, pharmacology, or biochemistry. This has been true even when biology is the topic at hand. Lynda Birke (2000), or example, provides a thorough overview o the early eminist work on the body body.. Like me, she is concerned that “the biological body has been peripheral peripheral to much much eminist theor theoryy. . . . The emphasis in our theory was on the social construction o gender; the body hardly eatured at all” (1–2). Like me, Birke expresses a desire to look inside the body, at the “blood and guts” (48). Nonetheless, and despite her training in neurophysiology and despite her desire to “bring the biological back to eminism” (175), Birke almost entirely avoids discussion o empirical data and ocuses her analysis analy sis on the gendered narratives, metaphors, meta phors, and represen representa tations tions that are “etched “etched deep” (41) into biological knowledges. This aversion to biological data is widespread in eminist theories o all stripes. It bespeaks an ongoing discomort with how to manm anage biological biological claims—as i biological data will overwhelm the ability abilit y o eminist theory to t o make cogent conceptual conceptual and politi political cal interventions. One thing eminist theory still needs, even afer decades de cades o eminist work wor k on the lie sciences, sciences, is a conceptual conceptual toolkit toolkit or reading reading biology biology.. In Psychosomatic: Feminism and the Neurological Body (2004) I thought at length about neurological data (the so-called so- called gay brain, the neurophysiology INTRODUCTION
3
o blushing, blushing, the peripheral neurology o neurosis) and their relation to eminist accounts o the body. However, I presumed too readily that lucid explication o biological detail would be enough to detach eminist theory rom its conviction that social and discursive analysis analy sis are the primary or most powerul power ul tools or or engaging biological claims. My introduction to that book ends on a buoyant note: “It is the presumption o this book that sustained interest in biological detail will have a reorga reorganiz nizing ing effect on eminist theories o the body—that body— that exploring the entanglements o biochemistry, affectivity, and the physiology o the internal organs will provide us with new avenues into the body. Attention to neurological detail . . . will enable eminist research to move past its depen de pendency dency on social constructionism and generate more vibrant, biologically attuned account o the body” (Wilson 2004, 14). What I touched on in that book but did not pursue with any vigor was how im impor portant tant antibiologism has been to the successes successes o eminist theory. There is a powerul power ul paradox in play: antibiologism antibiologism both places signi�cant conceptual limitations on eminist theory and has been one o the means by which eminist theory has prospered. Even as it restricts what eminist arguments can be made, antibiologism antibiologism still wields the rhetorical power to make a eminist argument seem right . Because eminist theory has credentialed itsel through these biological reusals, antibiologism is not something that can be easily relinquished. The opening two chapters o Gut Feminism tackle this problem problem directly. They describe this tendency to braid eminist theoretical innovation with antibiologism, and they discuss what legacies that leaves politi po litically cally and conceptually. Because antibiologism has done such impor im portant tant authorizing work or eminist theory, any intervention that takes a nonparanoid approach to biological and pharmaceutical claims is likely to breach long-standing, longstanding, dearly held eminist convictions. I anticipate that or many readers Gut Feminism is occasionally going to eel politi po litically cally erroneous, dangerous, or compromised. This book takes that path, assuming that risk, in order to examine the tangle o antibiologism and critical sophistication sophis tication that underwrites under writes so much eminist argumentation. As this pro ject unolded, another prob problem lem in relation to eminist theoryy and biology emerged. With the rise o the so-called theor so- called neuroscienti�c turn in the critical humanities and social sciences in the last decade decade (Fitzgerald and Callard 2014; Little�eld and Johnson 2012), eminists and other critics began to take biological claims more seriously. How4
INTRODUCTION
ever, they have ofen done so in a way that was overly credulous about the status o neuroscienti�c data. This is the coin o antibiologism �ipped verso. Where traditionally many eminists have preemptively dismissed biological biological claims, this new ne w breed o neurological neurologically ly inormed critics want to swallow biological claims whole: “We are living at the hour o neuronal liberation” (Malabou 2008, 8). In analyses like this, engagement with biology has more ofen meant betrothal than battle. Gut Feminism will intervene inter vene into this broad problematic problematic (not enough engagement gageme nt with biology; too much belie in biology) biolog y) by reading or what is peripheral in biological and pharmacological pharmacological theories o depress depression, ion, and or what the psychoanalyst Sándor Ferenczi called the biological unconscious. By ocusing on the neurological periphery (the enteric ner vous system that encases the gut) gut) I aim to show show that biology is much more dynamic than eminists have presumed and much less determinate than many neuro-critics neuro- critics currently suppose suppose.. Speci�cally, Speci�cally, this book contests the idea that neurological arguments are always about the central ner vous system (the brain, the spinal cord): the neurological is not synonymous with the cere ce rebral. bral. This is one place, it seems to me, where the new neuro-critics neuro-critics have been too compliant with the convention that the neurology that counts is all above the neck. I want to show how some biological and pharmacological data about depression help us think about minded states as enacted not just by the brain but also by the distributed network o nerves that innervates the periphery (especially the gut). My argument is not that the gut contributes to minded states, but that the gut is an organ o mind: it ruminates, deliberates, comprehends. These concerns about how to read biology biolog y were the �rst and explicit goal o Gut Feminism. These were the key problems that I researched and intended to analyze. The second major consideration o this book emerged rom the presen presenta tation, tion, revision, and rereading o the manuscript, and it is not something that th at I had anticipated in the early parts part s o the pro ject: I ound mysel making a strong case or the necessa necessarr y place place o aggression (bile) in eminist theory. There are some obvious intellectual antecedents or such a claim (eminist anger; deconstruction; Kleinian psychoanalysis), but the most prominent o these or me has been the so-called so-called antisocial thesis in queer theory. In the latter stages o this pro ject I have been teaching the now canonical queer work o Leo Bersani and Lee Edelman, and I have had to work especially hard INTRODUCTION
5
against the tendency in students to read sel-shattering against sel- shattering or negativity as an apoliti apolitical cal orce that works to simply undo the coherence o the social or the subje subject. ct. What Bersani and Edelman E delman propose is not the punk sentiment that wants “to ail, ail, to make a mess, to uck shit up” (Halberstam 2006, 824), a sentiment that speaks only to consciously accessible parts o the social abric and that sees negativity only in the realm o rebellion and antinormativity. One impor im portant tant pedagogical goal o these classes has been to make clear that negativity is intrinsic (rather than antagonistic) to sociality and subjectivity (Berlant and Edelman 2013), and this makes a world o difference po liti litically. cally. This queer work isn’t antisocial at all; rather, it wants to build theories that can stomach the undamental involv involvement ement o negativity in sociality and subjectivity. The idea that negativity is indeed negative has been a hard lesson to learn. Today Today (Friday, June June 13, 2014), as I sit down to rewrite re write this thi s introduction, there is a one-day one-day eminist emin ist and queer event e vent called “Radical “Ra dical Negativ Negativ-ity” at Goldsmiths College, University University o London (http:/ (http:///radicalnegativity .com). The byline or this event encapsulates a widespread conceptual conceptual problem prob lem with how to approach negativity and aggression. The conerence website describes the event as “an interdisciplinary conerence interrogating productive possibilities or negative states o being,” being,” and the description o the conerence describes a shared hope to “valorise negative states” in order to “provide the potential to open up new possibilities or politics and connection.” Against this idea that the negative can be made valuable (productive, valorized, connected), Gut Feminism makes a case that we need to pay more attention to the destructive and damaging aspects o politics that cannot be repurposed to good ends. Chapter 3 takes up this argument in depth. There I claim not only that depression is a more outwardly aggressive event than we usually think (it is not just the inward turn o aggression against onesel ), but also that this outward outward turn o hostility is the mark o ever everyy political politi cal action. In impor im portant, tant, unavoidable ways, eminist politics attack and damage the things they love. This encounter with a negativity that stays negative continues to be an impor im portant tant thread through chapters 4, 5, and 6, where the particulars o antidepressant treatment are examined. Feminist politics are most effective, I argue, not when they transorm the destructive into the productive, but when they are able to tolerate their own capacity or harm.
6
INTRODUCTION
What is the nature n ature o contemporary melancholia? The ��� notes that the use o the word melancholy to denote ill temper, te mper, sullenness, and anger generated by black bile is obsolete. Contemporary melancholic states are less humoral, more molecular. Since 1987, when �uoxetine hydrochloride (Prozac) was approved approved by the t he US Food and Drug Administration (���) or use as an antidepressant, melancholias in the United States and its pharmaceutical outposts have been signi�cantly transormed. They have become more prevalent, more quotidian, more biochemical, more cere cerebral, bral, and (paradoxically) both more treatable and more intractable. There are some stable demographics to these post-Prozac post- Prozac depressions: depress ions: they tend t end to be diagnosed more requently in women than in men, and worldwide rates o depression are higher in the poor than in the wealthy. Yet melancholia has always been characterized more by mutability than th an by a stable set o symptoms. For example, early psychopsychoanalytic theories o melancholia were oriented toward bipolar conditions (the circular insanities), and these theories were more attentive to the signi�catory patterns in melancholic states than would be the case in the second, medicated hal o the twentieth century. These �rst psychoanalytic patients were despondent in partic par ticu ular kinds o ways: cannibalistic, ambivalent, lost (Abraham 1911; Freud 1917a). Afer imipramine (the �rst tricyclic tric yclic antidepressant, antidepressant, synthesized in the 1950s) and with the subseq subsequent uent revisions o the Diagnostic and Statistical Manual of Mental Disorders (���) away rom Freudian and toward biological etiologies, depressions began to look and eel different. The identi�cation and diagnosis o depression in medical environments underwent signi�cant revision (Healy 1997), and the orm and experience o our depressions changed accordingly. Despite being more biochemical, these later depressions were less vegetative vegetative (somatic) in character; and in the wake o Aaron Beck’s Beck’s (1967) in�uential cognitive cognitive theory o depression, depressions became more ideational in tone—the tone—the result o distorted thinking rather than disordered eeling or imagination or libido. These transormations are only the most recent change in a long historyy o metamorphoses: in prior centuries melancholia was variously a tor sin, a madness or monomania, a orm o love, an unabating ear, the stagnation o blood, a delirium o the brain, a dotage without ever, a temperamental trait, t rait, or degeneration (Radden 2000). Robert Robert Burton’ Burton’ss INTRODUCTION
7
Anatomy of Melancho Melancholy ly (1621/1989) amously �nds not one, but seemingly endless causes, symptoms, and orms o melancholic distress. In act, much o what we have come to take or granted about depression has been historically variable: the association o depression with women, or example, is a airly recent event—it emerges afer a ver veryy long history (rom Aristotle to Hamlet to Churchill) in which melancholia was a gauge o male genius (Schiesari 1992). Moreover, even in the current milieu there are signi�cant variations in how depression is experienced and treated: Arthur Kleinman ound culturally distinctive links between somatic symptomology and neurasthenia and depression in China (Kleinman 1986), and one o the most highly industrialized countries in the world, Japan, Japan, was unusually slow in taking t aking up new antidepressant antidepressa nt pharmaceuticals (Berger and Fukunishi 1996; Kirmayer 2002). Intrasocietal differences add to the complexity: or example, individuals o East Asian descent living in North America, Ame rica, Europe, Europe, or Australia are less likely than individuals i ndividuals o Euro Eu ropean pean descent to develop major depressive disorder (as described by the ���), despite the likelihood that they will experience more discrimination, a lower standard o living, and poorer medical care (Dutton 2009). Melancholia, then, �nds no one orm across time and place. This mutability is crucial to the arguments in Gut Feminism. The conceptual, politi po litical, cal, and methodological orientations o this pro ject pro ject emerge rom the presumption that depression is contingent . Even though melancholia has endured rom ancient Greece until the present, pre sent, it is not a condition underwritten by substrata that persist despite variation in historical, cultural, or discursive positioning. positioning. Such oundations (too easily designated “biological”) simply do not exist in that orm. But neither is melancholia just the effect o cultural trends, a ad (or weak ideologicall construct) that might be dispelled by incisive critique. This ideologica pro ject tries to t o demonstrate demonstrat e the inadequacy inadequac y o thinking thinkin g in such biurcated terms (Is depression biological or is it socially constructed? Is depression created by biochemical imbalances or historical injustices?). Those nature/culture debates presume a separation in the substrata o depression, as i biochemicals and cultural institutions are oil and water.. Gut Feminism disputes the compartmentalization o nature/culture water arguments in all their orms. It will be my presumption throughout that biology and culture are not separate, agonistic agonistic orces; that a po litical choice cannot be made between bet ween biological and cultural agency; that 8
INTRODUCTION
the interaction o biology and culture (nature/nurture) is an inadequate solution to the problem problem o etiology; that the relative weight o biological or cultural actors cannot be individually calculated; that biology is not a synonym or determinism and sociality is not a synonym or transormation. I use “contingency” “contingency” here (borrowed rom Barbara Herrnstein Smith [1988]) to mark that state o nature- culture entanglement that is almost impossible to articulate: coimplication, coevolution, mutuality, intra-action, intra-action, dynamic systems systems,, embeddedness (names given by the eminist philos philoso ophers o science whose work is oundational to this book’s claims: Karen Barad [2007], Anne Fausto-Sterling, Fausto- Sterling, Cynthia Garcia Coll, and Megan Lamarre [2012a, 2012b], Evelyn Fox Keller [2010], Susan Oyama [2000]). There are contingencies to melancholia that stretch across two thousand years, years, and there are contingencies that have h ave ound orm only in the wake o certain pharmaceutical interventions since the 1950s 1950s.. Gut Feminism is concerned primarily with the biological and pharmaceutical contingencies that shape depressions afer Prozac. I the ways in which depressions depress ions are diagnosed, experienced, experienced, and treated are all intralinked (that is, i how we talk about depressions, and how we treat them, and how they crystallize cr ystallize biologically, biologically, and what they eel like, are all mutually coimplicated), and i the pattern o this mutuality has been subject to recent transormation, then my critical approach to understanding the pharmaceutical treatment o depression must be able to adapt to these new circumstances. In partic par ticu ular, this pro ject presumes that the politi po litical cal commitments o antipsychiatry that �ourished in the period between the �rst generation o antidepressants in the 1950s and the arrival o the selective serotonin reuptake inhibitors ( ����s) in the 1990s are usually ill suited or the current melancholic landscape. There are a number o reasons that antipsychiatric politics have less purchase now than one might expect. In the �rst instance, the deinstitutionalization o psychiatric patients that began in the United States, the United Kingdom, Europe, Europe, Australia, and New Zealand rom the 1960s onward led to signi�cant decreases in people incarcerated in psychiatric care (Fakhoury and Priebe 2002). For example, in 1955 in the United States (as antidepressants and antipsychotic drugs were �rst coming on the market), 559,000 people were institutionalized in state mental hospitals; by 1971 this number had dropped to 275,000, and by 1994 this number had dropped again to 72,000 (Bachrach 1976; INTRODUCTION
9
Lamb 1998). The politics o the asylum—so cogently pursued by R. D. Laing and others—have others—have less relevance as psychiatric inmates become outpatients. Attempts to apply antipsychiatric politics to post-Prozac post- Prozac depressions (e.g., Breggin and Breggin 1994; Cvetkovich 2012; Davis 2013; Griggers 1997, 1998) have been much less compelling than earlier work in large large part because because the most most intensive sites sites o depressive depressive action in these deinstitutionalized countries are no longer hospital wards. Instead depressions have become extensively entangled with everyday lie: support groups, talk shows, memoir, sel-help sel- help books, op-ed pages, personal anecdote, blogs, social media, direct-todirect- to-consumer consumer advertising. Analysis Analy sis o these phenomena doesn’t ollow directly rom critiques o institutionalized psychiatry psychiatry.. Second, the prescription o antidepressants has moved out o the hands o psychiatric specialists in hospitals and into the hands o different kinds o health practi prac tition tioners. ers. In Australia in 2000, or example, 86 percent o prescriptions or antidepressants were made by general practi prac tition tioners, ers, who do not have extensive psychiatric or psychotherapeutic training (McManus (McManus et al. 2003). In the United States, nurse practition ti tioners ers and (in some states) clinical psychologists are able to prescribe antidepressant medications (Shell 2001). For better or or worse, the treatment o depression is no longer under the direct control o psychiatric expertise. Few o the sources that I turn to in this pro ject pro ject are psychiatric; instead, Gut Feminism ocuses on psychological and psychoanalytic theories o depression, especially as they relate to the use o pharmaceuticals and as they engage biological data. While psychological and psychoanalytic research increasingly draws on biological (usually neurological) data, it is not primarily ocused on biological explanations and is not wedded to the disease model o depression that exempli�es psychiatry. This means that biological data in psychological and psychoanalytic theories are ofen less sequestered rom interpersonal, intrapsychic, social, economic, or historical events; as such, these theories are ofen well positioned to engage the logic o entanglement that I am pursuing here. The third reason antipsychiatry has less leverage than it had in the past is that there has been massive growth in the population in deinstitutionalized countries that consumes antidepressant antidepressant medications. Nikolas Rose (2003) calculated that prescriptions or ���� pharmaceuticals in the United States increased by 1,300 percent rom 1990 to 2000. It is 10
INTRODUCTION
my hunch that what underwrites the increase o antidepressant use is neither a malevolent intensi�cation o psychiatric in�uence nor a miraculous leap or orward ward in terms term s o pharmaceutical pharmaceut ical efficacy (the (t he newgeneration antidepressants are about as clinically effective as the older ����s and tricyclic drugs). In large part, what made these new drugs more palatable to patient and practitioner pr actitioner alike is a decrease in aversive side effects. Tricyclic antidepressants (like imipramine) can provoke a variety o distressing side side effects (dry (dr y mouth, blurred vision, constipation, dizziness, sedation, weight gain), and the ���� antidepressants orce patients into a strict diet, as some common oods (e.g., chicken and cheese) can react atally with the medication. When Prozac was released into the US market, it promised effective symptom relie with ew side effects. For this reason ���� pharmaceuticals were prescribed to people who had more minor orms o depression (e.g., (e.g., what was then known as dysthymia, chronic and debilitating low mood)— mood)—conditions conditions that previously would not have been considered serious enough to warrant psychiatric medications and their possi possible ble adverse effects. It is not clear, then, that corporate and biomedical duress have been the most impor important tant mechanism or the expansion o antidepressant use, or that struggles over corporate and biomedical maleasance (crucial as these battles are) generate the best avenue ave nue o approach to the treatment o contemporary depressive states. I am hypothesizing that i recent shifs in the treatment o depression have been made not on the back o an antidepressant’s therapeutic effect, but on the basis o its so-called so-called secondary effects—effects effects—effects that pharmaceutical companies and medical practi practition tioners ers and patients alike attempt to minimize— then questions o politi political cal and biological in�uence as they have been thought in antipsychiatry need to be comprehensively reconsidered. A drug’s side effects run athwart not just therapeutic effects but also the institutions and the personal treatment regimes that attempt to manage man age dru d rug g efficacy. For this reason Gut Feminism will be intensely interested teres ted in the agency o what is i s allegedly ancillary ancillar y to pharmaceutical action act ion (e.g., placebo placebo). ). Chapters 5 and 6 will will expand these claims in relarelation to placebo and pediatric use o antidepressant medication. It is my eeling, then, that the insurrection that th at powers antipsychiaantipsychiatry is mismatched to the post-Prozac post- Prozac landscape. This mismatch has been particularly debilitating or eminist critique. Despite a robust women’’s health women health movement movement dating dating back to the late 1960s 1960s (Morgen (Morgen 2002) 2002) INTRODUCTION
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and despite intensive criticism o pharmaceuticals like Viagra (Tieer 2010), 201 0), there has been surprisingly little eminist commentary on Prozac and its sibling pharmaceuticals. Judith Kegan Gardiner (1995) begins a review o Listening to Prozac, Talking Back to Prozac , and Prozac Nation with an anecdote that encapsulates this impasse between the popularity o pharmaceutical treatments on the one hand and the preerence or antipsychiatric (socially constructed) theories o depress depression ion on the other: I recently attended an interdisciplinary eminist meeting that assumed a consensus about social constructionism and criticized scholarly work that was perceived as “essentialist, “essentialist,”” because it implied a biological basis or gender attributes. During meals and breaks, however, I heard a different story stor y. Several women were taking Prozac or similar drugs or depression. Some o their children, who had been difficult, “underachie “un derachieving,” ving,” or disruptive in school, sch ool, were also being bein g medicated. These inormal discussions centered on symptoms, side effects, and relie. They implied but did not discuss a view o personality as biochemically in�uenced. . . . The potential contradiction between such private solutions and the publically avowed ideology o social constructio constr uctionism nism was never voiced. (Gardiner 1995, 501–502) 501–502) It seems that our best accounts o psychological politics have developed inde in depen pendently dently o biological data, and also—i we accept the veracity o Gardiner’s story—independently story—independently o everyday lie. Somewhat surprisingly, this de�cit is also visible in the cultural commentary on depression and loss (where the ubiquitous use o antidepressants might be the object o critical investigation): the leading edge o work on melancholia in the critical humanities is largely mute about the questions o pharmaceutical use and pharmacological action (e.g., Eng and Kazan jian 2003). The conundrum that underwrites under writes Gut Feminism is this: how to engage pharmaceutical data about the treatment o depression without simply acquiescing to the idea that biomedical research provides the actual oundation on which interpretations are built (on the one hand) or routinely repeating the doxa o social constructionism (on the other). My method is to take contemporary biomedical data about depression and read them through the peripheral body—speci�cally, body— speci�cally, the gut: that is, to push the serotonin hypothesis about depression out past the central ner vous ner vous system, and likely out past the limits o its
12
INTRODUCTION
coherence. I will take the biomedical data seriously but not literally, moving them outside the zones o interpretive comort that they usually occupy. My goal is to draw in the periphery o the body as psychological substrate and deisolate brain rom body, psyche rom chemical, neuron rom world. In concert with (and greatly indebted to) the work o Karen Barad (2007) and Vicki Kirby (1997, 2011), I am interested in the entanglements and patternment that generate depressive states. To this end Gut Feminism is not an argument or the gut over the brain, or drugs instead of talk, talk, or biology but not culture; culture; rather, it is an exploration o the remarkable intra-actions intra-actions o melancholic and pharmaceutical events in the human body.
Let me give an example o how I will read biological data in the chapters that ollow: abdominal migraine. The name itsel is something o a catachresis—aa condition ordinarily known to be in the head has ound catachresis— its way to the gut. Overseer and underbelly are already conused. The clinical characteristics o abdominal migraine are somewhat diffuse. It is commonest in children, and is characterized by acute and incapacitating midline abdominal pain, lasting hours or perhaps even days. days. The pain is dull and poorly localized in the epigastric or umbilical regions; attacks are recurrent. These days abdominal migraine is classi�ed as one o the unctional pediatric gastrointestinal disorders, meaning that (along with inant rumination, rumin ation, cyclic vomiting, and irritable bowel syndrome in children) the condition has no known organic etiology (Rasquin- W Weber eber et al. 1999). When afflicted the child will usually exhibit a deathly pallor and will shun ood; she or he may also have the symptoms o classical migraine (prodromal aura, headache, photophophotophobia, vomiting). In between attacks the child is healthy. The symptoms tend to diminish as the child grows and many children spontaneously recover afer a ew years, although although these individuals may be more prone to migraine as adults (Dignan, Abu-Araeh, Abu-Araeh, and Russell 2001). There is, unsurprisingly, some disagreement in the clinical literature lit erature about whether abdominal migraine ought to be thought o as a psychogenic affl icti iction on or as a conditi condition on caused by biochem biochemical ical abnorabno rmalities. The biologically oriented studies tend to think o abdominal migraine as a “migraine equivalent” (Dignan, Abu-Araeh, Abu- Araeh, and Russell
INTRODUCTION
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2001, 55): it is a classic head migraine, but with variant symptomology. Like classic migraine, these researchers researchers argue, it is the dynamics o vasoconstriction/vasodilation and neurotransmitter irregularities—all irregularities—all located in the central ner vous ner vous system— system—that that underpin the symptoms o childhood abdominal migraine. This literature lit erature thinks o abdominal migraine as a cere cerebral bral attack, exiled to the periphery peripher y. What I will argue in Gut Feminism is not that the periphery is a site o abandonment (a maligned ringe, a desolate border), but rather that the periphery is a site o intense biological, pharmaceutical, and psychological psychological agency on which the center is alway alwayss vitally dependent. Which is to say say,, the periphery is interior to the center; the stomach is intrinsic to mind. Sometimes the biological studies about abdominal migraine hint, inadvertently, at this kind o tangle between psyche and soma, head and gut. David Symon and George Russell (1986), or example, are clear that abdominal migraine should not be conused with a psychogenic condition; they see it as a “distinct clinical entity” that can be “easily distinguished” (226) rom other patterns o childhood abdominal pain. They see abdominal migraine as more head- y head- y,, less enteric, ent eric, than its name implies. They support this hypothesis with a treatment study o children with abdominal migraine. Twenty children were treated prophylactically with the drug pizotien, an antimigraine medication, or two to six months: 70 percent experienced complete remission o their symptoms, compared with 15 percent in the control group who “received “receiv ed no treatment other than explanation and reassurance” (225). (225). Symon and Russell conclude that these data provide evidence that abdominal migraine is less a psychogenic condition (that would respond to the palliatives o explanation and reassurance) and more like classic migraine, seemingly a disease whose etiology can be located above the neck. These data are very ver y persuasive. The etiology o abdominal migraine seems to be heavily weighted toward biology. But let’s keep looking. What is the nature n ature o the drug dr ug with which Symon and Russell treated these children? Pizotien is a serotonergic antagonist. The logic that underlies its use in this study is that it inhibits the action o certain serotonin receptors, thus blocking the effects o serotonin in the ner vous ner vous system that prece precede de classi classicc migr migraine aine atta attacks cks (vaso (vasoconst constricriction and vasodilation). Symon and Russell give no speci�c bodily lo-
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INTRODUCTION
cation or pizotien’s effects; but their citation o several established studie stu diess about the drug’s dr ug’s cognitive efficacy, along with their lack l ack o interest in peripheral neurology, imply that they see the neurology o abdominal migraine as centrally (cere (ce rebrally) brally) controlled. We might call this “listening to pizotien” (Kramer 1993): i the condition responds to an antimigraine treatment then, properly speaking, it is a migraine o the head. However, some o the studies that Symon and Russell cite to support their use o pizotien as a treatment suggest a more distributed, less neurologically circumscribed character to migraine—abdominal migraine— abdominal and other wise. For example, example, one o their t heir citational sources (Hsu et al. 1977) ound increased levels o catecholamines (speci�cally, noradrenalin) in the blood plasma o migraine sufferers. Noradrenalin acts as a neurotransmitter in the human ner vous ner vous system, system, so it tends to circulate discursively as a sign o central ner vous ner vous action, urther consolida consolidating ting the cere cerebral bral reputation o migraine. However, while noradrenalin is released by a region in the brainstem (the locus coeruleus) coer uleus) in response to stress and acts on a variety o brain structures (amygdala, hippocampus, neocortex), so too is it released by the peripheral (sympathetic) ner vous system and the adrenal glands as part o the body’ body’ss �ght�ght-oror�ight response. This means that noradrenalin is a chemical generated by,, and widely distributed through, the central and peripheral ner vous by ner vous systems o the human body. Elevated levels o noradrenalin in the plasma o migraineurs (extracted rom a vein in the arm) indicate body wide neurotransmission neurotransmission in migrainous attacks. These data no more indicate the authority o the central ner vous ner vous system over the peripheral ner vous ner vous system than they do the reverse. Abdominal migraine is no more a variant o classical cere ce rebral bral migraine than classical migraine is a deviation rom abdominal pain. In both o these studies, the locus o the migraine remains an open question— unexplored in Symon and Russell, and clearly dislodged rom its conventional home inside the cranium by Hsu et al. (who see a wider network o migrainous agency: plasma–sleep– plasma–sleep–stress– stress–noradrenaline– noradrenaline–personality– personality– somatization–nutrition– somatization– nutrition–diet– diet–agitated agitated mood). My suggestion is not that the question o migraine’s character has yet to be empirically resolved (is it o the head or o the gut?), but rather that the character o migraine is truly open and distributed. Situated athwart our usual
INTRODUCTION
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expectations that the biology o mind will be central centr al and locatable, migraine is an engaging conceptual object or eminist theor y. An older study (that speaks more directly to the psychological and perhaps depressive aspects o abdominal migraine) helps elucidate what is at stake conceptually. conceptually. Farquhar Farquhar (1956) summarizes 112 cases o abdominal migraine in children and documents the emotional state o children with abdominal migraine (data that tend to drop out o more recent literatures): liter atures): “worriers,” “obsessional, “obsessional,”” “ner vous “ner vous”” (1084). (1084). He also also notes that “the relationship between migraine and liver dysunction has long been recognized” (1084). This comment is made in relation to migraine and diet (atty oods may aggravate abdominal pain in these children), and could be read simply as an organic aside. However, the question o the liver connects elsewhere in his paper to one o the most common maniestations o abdominal migraine in children: biliousness. biliousness. In these literatures, bilious is sometimes simply a synonym or abdominal migraine (“bilious attacks” [1082]). However, the term (like the humor rom which it emerges etymologically) etymologically) also reers to emotional states—peevishness states— peevishness and ill-temper ill-temper (the ��� de�nes bilious equally as “o diseases and temperament”). Biliousness, in the context o abdominal migraine, is undecidably both o the liver and o the mind—a mind— a condensation o ailment and disposition. Like melancholia, its humoral cousin, a bilious attack brings our attention to t o the psychic character o the gut and to the enteric character o mood. Abdominal migraine encapsulates the problems that eminist theory encounters when it reads biology. The interpretation o biological data in biomedical research ofen splits mind rom body, body, locates mind only in the brain, and so thinks o the biological periphery as psychologically inert in ert.. It is also difficult to know kno w what to do conceptually conceptu ally with bile and aggression. The next three chapters take on these issues in detail. They argue that depressive rumination is as visceral as it is ideational, and they track some circuits o hostility in eminist politics. With these these analyses o antibiologis antibiologism m and aggression aggression in hand, the �nal three chapters ocus o cus on o n the effi cacies and an d ailures ai lures o antidepr an tidepressant essant medications. These �nal chapters outline how ���� medications work biologically, and they explore one o the core contradictions in critical accounts o the pharmaceutical treatment o depression—that depression— that ����s are both ineffec ineffective tive (no better than placebo) and harmul (especially to children and adolescents). These twin problematics (biology and ag16
INTRODUCTION
gression) structure the arguments that ollow. In relation to depression, I argue ar gue tha thatt eminist theor y could engage the contempor contemporar aryy landscape more potently i it was able to read biology more closely and tolerate the capacity or harm. While the ocus o the book is the pharmaceutical treatment o depression, I am hoping that a general orientation to the reading o biology and hostility emerges rom these pages. I have provisionally called this method “gut eminism”—a eminism”— a eminist theory that is able to think innovatively and organically at the same time.
INTRODUCTION
17
