Okay, here’s a teaser, from one of my more ‘ethnographic’ chapters:
During a process that involves considerable prolonged experience of pain, the practice of care above all demands attention to a patient’s comfort. To offer comfort, of course, is distinct from the state of being ‘comfortable’: one does not guarantee the other. Neither is comfort merely a state that pertains to the corporeal—pillows, climate control, relief of hunger or thirst. It registers an affective disposition, and so does its antonym, discomfort. As those familiar with the previous Australian Prime Minister John Howard’s fantasy of [white] national subjects feeling “relaxed and comfortable” might recall, comfort may also settle on its intended bearers with more or less success according to the vicissitudes of racialisation. “If whiteness allows bodies to move with comfort through space,” Sara Ahmed writes,
and to inhabit the world as if it were home, then these bodies take up more space. Such physical motility becomes the grounds for social mobility.
To attend to the minute differentiations between comfort and discomfort within the gender clinic, then, might result in more than a register of citations of individual affect. Not all of those who would talk to me about their sojourns in Thai gender reassignment clinics professed to feeling comfortable there. Som, for example, told of difficulty with the aftercare procedures associated with her vaginoplasty, and also of a certain feeling that she could not expect the same service as would be proferred to non-Thai, or white, patients. Som was a Thai from the poor rural north who had moved to Bangkok. Her Australian boyfriend encouraged her to migrate to Australia to live with him, and paid for her gender reassignment surgeries at the clinic I described above. When I interviewed her in Sydney, ten months after surgery, she said initially that her experience of reassignment surgery had been excellent. During recovery, she said, she felt like a “princess”. Later we began to discuss the fact that 95% of her surgeon’s patients are non-Thai, the majority of them affluent American, British or European transwomen. Thailand is famous for its large population of sao braphet song or kathoey, male-to-female gender variant people. It seemed remarkable that non-Thais constituted the overwhelming majority of patients undergoing GRS at the most well-known clinics. As Som commented on the apparent disparity of this situation, she revised her previous narrative about the level of care at the clinic she had attended:
When I talked to Dr ____, he said that most of his patients are farangs [foreigners], some from Japan, some from Europe, American, Australia. But not many Thais.
Som: Because he is very expensive! He put his prices up!
Many of them put their prices up, I heard. Also Dr ____?
Dr ____, I didn’t like. He doesn’t even care about the Thais.
What surgeons do Thai kathoey or ladyboys go to?
Well, they can do [surgery] in a public hospital, which is quite a reasonable price, and the result might not be… Not so good. And sometimes I hear from Thai ladyboys and some people, they said that in photos, it looks weird, it’s not the same as… [Gesturing to herself]
Not the same as your surgery?
No. It looked terrible. Indeed.
What do you think about this, that the best [clinics] seem to be for farangs [foreigners], and some surgeons don’t seem to care about Thais?
Dr ____’s staff [at the clinic] too. When I come to meet them, they will be very nice to foreigners. But they forget about Thais… Because they think foreigners have lots of money, more than Thai. But we all pay the same price! So, we should deserve to have the same service. But we don’t have the right to say that.
Emma is Vietnamese and had been living in Australia for 12 years when she had gender reassignment surgery in Bangkok in 2006. She travelled to Thailand from Australia and stayed in one of Bangkok’s premier medical tourist hospitals, having surgery with the most well-known surgeon who practices GRS in Bangkok. However, she was travelling without a support person. By the time I met her at a the hospital in Bangkok where she was recovering from the operation, she had decided coming to Thailand was a bad idea. After her experiences, she said, she would advise transpeople in Australia to obtain surgery with Australian surgeons:
Dr _____ is very busy and it’s very difficult to get him to come to see me. I am very annoyed. Also, the nurses do not come to see me. I ring and it takes half an hour for them to come… I didn’t bring anyone with me to take care of me after the operation. They told me on the phone that the nurses would take care of me, but where are the nurses?
To place these comments in context: the vast majority of Australian transwomen involved in my project had been scathing about Australian surgeons’ technique. Most agreed that the hospital care available in Thailand far surpassed that available even in Australian private hospitals. Karen, a transwoman who obtained GRS in an equally well-resourced hospital in Phuket, commented that the hospital felt more like a hotel: “[There were] heaps of nurses, everybody always had lots of time… You could ask for something and five minutes later it was in the room.” Some surgeons performing GRS in Thailand will charge on a sliding scale: they will advertise a high rate (usually quoted in American dollars) for non-Thais, and on application may quote a much lower rate in baht for Thais. Som and Emma both told me with some pride that despite being Thai, and Vietnamese, respectively, they had paid the full advertised rate. And yet their stories did not correlate with the overwhelmingly positive narratives I was hearing simultaneously from Americans, Britons and Australians who attended the same clinics at the same time, underwent the same procedures and who were apparently paying for the same service.
Ahmed appends the lines I cite above on comfort and whiteness with a cautionary caveat: “This extension of white motility should not be confused with freedom. To move easily is not to move freely.” It is true that even white-skinned or affluent gender variant subjects are not guaranteed freedom in the world we live in. Across the globe, gender reassignment technologies such as hormones and surgery are notoriously difficult for gender variant people to access. With few exceptions, most governments refuse to cover gender reassignment under public health funding. Private health insurance corporations are equally reluctant to cover what is regarded as “elective” treatment. The majority of surgeons who perform gender reassignment surgeries, globally, work in semi-regulated private practices. The better reputation a surgeon gains, the more valuable the performance of such a skilled procedure becomes, and the more it assumes the magical properties of a commodity. One of the arguments I will make in this chapter is that gender reassignment surgery in Thailand has become (and perhaps always was) a niche medical tourism market, targeted to affluent citizens of affluent nations, and a precursor to the booming culture of medical tourism across South East Asia. Yet, this does not explain why, in a clinic that is reputed to provide the best care and clearly has the capacity to do so, Som felt that the staff cared more about foreigners than Thais. Neither does it account for why, in a similar situation at a different clinic, Emma felt that her needs were not valued. These stories highlight some critical questions: even when gender reassignment technologies are freely available to anyone who can meet the cost, which gender variant bodies carry more value than others? Within the growing neoliberal globalisation of biomedicine, of which gender transformation technologies are a part, which racialised subjects constitute the ideal to whom the labours of care, respect, surgical skill and affect are made available, and which subjects fall outside of that sphere of care and respect?