Elena R. Gutiérrez, Fertile Matters: The Politics of Mexican-Origin Women's Reproduction. Austin, TX: University of Texas Press, 2008, 199 pages, ISBN 978-0-292-71682-7. Paper, $25.00.
Jonathan M. Metzl, The Protest Psychosis: How Schizophrenia Became a Black Disease. Boston, MA: Beacon Press, 2011, 288 pages, ISBN 978-080700127-1. Paper, $22.00.
INTRODUCTION
In March of 1969, a Black man from Detroit named Abdul-Rasheed Karim arrived at Ionia State Hospital for the Criminally Insane in Ionia, Michigan, after spending two years locked up in prison and a psychiatric ward for a fight that started when he was assaulted by three White boys, then brutalized by the police who responded. Mr. Karim, who suffered two broken ribs, a cracked tooth, and a deep skull laceration, made the mistake of hitting one of the officers who were beating him with clubs. As Metzl quotes, the clinical evaluation that led to Mr. Karim's transfer to Ionia noted “cultural retardation is thus a significant factor in his schizophrenic disease” because he had been “socialized toward ghetto survival” (p. 143) as a child. The doctor interpreted Mr. Karim's Islamic beliefs as “religious delusions,” writing, “his identification with the Black Muslim group is a projection of his feelings of inadequacy” (p. 143). Once at Ionia, doctors treated Mr. Karim's hostility toward authority figures by confining him to a maximum supervision ward where he was injected daily with escalating doses of antipsychotic drugs.
While Mr. Karim languished in Ionia, a Mexican immigrant woman named Helena Orozco, who received prenatal care at the Los Angeles County Medical Center (LACMC), was pressured repeatedly by nurses and doctors throughout her pregnancy to agree to surgical sterilization. Each time, Mrs. Orozco explained that she and her husband had decided against the procedure. But when hospital staff continued to harass her during the delivery as she cried from severe labor pains, as quoted in Gutiérrez, Mrs. Orozco broke down and signed the consent form they shoved at her because, in her words, “I just wanted them to leave me alone, sign the papers, and get it over with” (p. 42). No one explained to Mrs. Orozco that the sterilization procedure was irreversible; she intended to have her tubes untied in three years and only found out more than a year later that the doctors had stripped her of the ability to have children.
These disturbing accounts of medical abuse during the late 1960s and early 1970s powerfully illustrate the racial politics of medical practice and policy explored in two brilliant books—Elena R. Gutiérrez's Fertile Matters: The Politics of Mexican-Origin Women's Reproduction and Jonathan M. Metzl's The Protest Psychosis: How Schizophrenia Became A Black Disease. Gutiérrez, a professor of gender and Latino studies, examines the sociohistorical forces that created the popular stereotype portraying Mexican-origin women as “hyper-fertile baby machines” who “breed like rabbits” (p. xi) and construed their reproductive behavior as an urgent social problem to be remedied through medical and policy interventions. She demonstrates that the politics of reproduction has been shaped by immigration policy debates and has influenced the practice of doctors treating pregnant women. As the experience of Helena Orozco exemplifies, countless poor Mexican immigrant women were subjected to coercive sterilizations at the LACMC in the 1970s. Gutiérrez describes the failed class-action lawsuit, Madrigal v. Quilligan, 1978, brought by some of these women against the hospital, as well as a more successful campaign to revise state and federal guidelines governing sterilization procedures. Two decades later, the reproduction of Mexican immigrant women continued to dominate immigration politics, with California voters approving Proposition 187—placed on the state ballot in November, 1994, to bar undocumented immigrants from receiving public benefits and services, including prenatal care—and with calls to end birthright citizenship believed to lure Mexican women to cross the border illegally in order to obtain citizenship status for their children, now disparagingly labeled “anchor babies.”
Gutiérrez places the sterilization epidemic in California hospitals in the context of growing fears about overpopulation and immigration after World War II, marked by the Reference Erlich1968 publication of Paul Ehrlich's Population Bomb, warning that out-of-control population growth threatened global disaster. She traces the link between population-control, environmentalist, and anti-immigration ideologies by featuring the campaigns of John Tanton, a former president of Zero Population Growth, Inc., and the founder of Federation of American Immigration Reform. Gutiérrez also scrutinizes the emergence of demographic research on the fertility patterns of Mexican-origin women during this same period to highlight academia's role in casting their reproductive behavior as a social problem. Her focus on Mexican immigrant women extends the literature on the relationship between racial domination and reproductive regulation that analyzes policies directed at African American (Roberts Reference Roberts1997) and Asian immigrant women (Park Reference Park2011). A chapter devoted to Chicanas organizing against sterilization abuse gives voice to the resistance of women of color against these repressive policies and their alternative vision of reproductive justice that respects all women's equal right to bear children.
In The Protest Psychosis, Metzl, a professor of psychiatry, traces how schizophrenia became a Black disease in the 1960s when psychiatrists began to explain Black urban unrest as a symptom of mental instability. Schizophrenia was first considered a psychological malady that afflicted primarily White intellectual men and middle-class housewives. The race of the disease radically morphed as the Civil Rights Movement erupted. “Many leading medical and popular sources suddenly described schizophrenia as an illness manifested not by docility, but by rage,” writes Metzl. “Growing numbers of research articles from leading psychiatric journals asserted that schizophrenia was a condition that also afflicted ‘Negro men,’ and that black forms of the illness were marked by volatility and aggression” (p. xiii). Black male accusations against the White power structure were diagnosed as signs of paranoia, delusion, and hostility. Metzl borrowed the title of his book from an article in the prestigious Archives of General Psychiatry by Bromberg and Simon (Reference Bromberg and Simon1968), wherein the authors described schizophrenia, in Metzl's summary, as:
a “protest psychosis” whereby black men developed “hostile and aggressive feelings” and “delusional anti-whiteness” after listening to the words of Malcolm X, joining the Black Muslims, or aligning with groups that preached militant resistance to white society. According to the authors, the men required psychiatric treatment because their symptoms threatened not only their own sanity, but the social order of white America
(p. xiv).Accompanying articles like this in leading psychiatric journals, calling for chemical management of Black male antagonism, were advertisements for antipsychotic medications that showed, Metzl writes, “angry black men with clenched, Black Power fists” (p. xv). The White press popularized the racial diagnosis by warning the public about violent Black men crazed by schizophrenia and assigning the label even to leading Black activists like Roy Wilkins, executive director of the NAACP. Schizophrenia became a metaphor for any Black dissatisfaction with racial inequality. Most shocking, state mental institutions began to fill with young Black men arrested for minor offenses who were confined indefinitely when psychiatrists diagnosed them with schizophrenia. The locked wards at Ionia outside Detroit, once an asylum for “neurotic” White women, swelled to more than one thousand Black “patients,” like Abdul-Rasheed Karim, thought to have gone mad from their anger at White people. There, a Black man's complaint that his civil rights were being violated or “tough guy attitude towards white authority figures” were noted in medical charts as evidence of mental illness.
Read together, Fertile Matters and The Protest Psychosis provide complex and important insights into the way medicalized explanations of racial inequality function as mechanisms of social control, reinforce negative stereotypes about people of color, relieve Whites' anxieties about minority protest and encroachment, and obscure the persistence of an unjust racial order. In this review, I want to highlight three themes about the conflation of biological and social issues that emerge from these books: the political nature of racialized medicine; the intersection of race and gender in the medicalization of inequality; and the relationship between individual diagnosis and structural inequality.
MEDICALIZING RACIAL INEQUALITY
Fertile Matters and The Protest Psychosis unveil a medical magic trick—the conversion of racial hierarchy into a biological issue that diverts the blame for racial inequities from White domination to minority pathology. Just as the reasons for immigration problems were attributed to Mexican-origin women's irrational fertility, so the reasons for urban unrest were attributed to Black men's mental disorders. These two books examine this sleight of hand from opposing angles. Gutiérrez is interested in how the biological matter of Mexican-origin women's childbearing got converted into a social problem, while Metzl investigates how the social protests of the civil rights era got converted into a psychiatric diagnosis. Black men's schizophrenia turned a social issue into a medical condition; Latina women's hyperfertility turned a medical condition into a social issue. Both perspectives help to explicate the way biological explanations for social inequality concretely work to normalize the oppression of people of color while justifying brutal state practices of containment.
I have similarly shown how population-control ideology and stereotypes of Black female sexual and reproductive irresponsibility attribute social inequities to childbearing by poor Black women, thereby legitimizing punitive regulation of their reproductive decisions (Roberts Reference Roberts1997). By identifying procreation as the cause of deplorable social conditions, reproductive punishments divert attention away from state responsibility and the need for social change. In the late 1980s, for example, Black mothers' crack use became a primary explanation for high rates of both Black infant mortality and child poverty, although these disparities long predated the crack epidemic. This erasure of social causes and solutions reinforces privatization, the hallmark of a neoliberal state that seeks to reduce social welfare programs while promoting the free-market conditions conducive to capital accumulation. Thus, reproductive regulation plays an important role not only in upholding the racial order but also in the neoliberal state's transfer of services from the welfare state to the private realm of family and market (Park Reference Park2011; Roberts Reference Roberts2009).
Constructing Social Problems and Diagnoses
Defining social inequities in biological terms makes them seem natural—the result of inherent racial differences instead of societal injustices. As science historian Evelynn Hammonds (Reference Hammonds2006) notes, “The appeal of a story that links race to medical and scientific progress is in the way in which it naturalizes the social order in a racially stratified society such as ours.” Gutiérrez and Metzl show that the supposedly objective medical categories involved in racial repression are actually socially constructed. Thus, the seemingly biological concepts of “fertility” and “schizophrenia” are not natural conditions that are neutrally diagnosed and treated by medical experts in hermetically sealed clinics. Rather, they are pliable and porous containers fashioned by medical experts under the influence of racist stereotypes, government policies, and political debates circulating in the broader society. “Cloaking our observations under the seemingly objective rubric of biological science,” writes Metzl, “renders these ideological functions all the more difficult to discern or critique” (p. i). The authors prove the constructed nature of these medical categories by tracing their revision over time. Gutiérrez points out that the social-scientific and demographic literature prior to 1970 rarely mentioned the fertility rates of Mexican-origin women, but by 1980 began to develop a subfield on the topic (p. 55).
Similarly, Metzl documents the remarkable diagnostic and demographic transformation at Ionia: while patient charts from the 1930s–1950s, when the population was majority White, do not associate schizophrenia with aggression, “[f]rom the 1960s onward, patients described by doctors as African American, paranoid, delusional, and violent had disproportionately high chances of being diagnosed with schizophrenia” (p. 57). Besides this statistical evidence, Metzl provides visual proof of the diagnostic metamorphosis from patient records. In the 1960s, clerks literally crossed out the diagnosis of “Psychopathic personality” on Black patients' charts and replaced it with “Schizophrenia.” Conversely, the chart of a White woman originally diagnosed with “Schizophrenia, paranoid type” was changed to “Involutional melancholia” (pp. 93, 164). Thus, African American men, Metzl concludes, became schizophrenic not because of any changes in their symptoms, but because of changes in the larger, national tumult over their civil rights (pp. 94, 106).
Racial Diseases
Defining disease in racial terms has played an essential part in this biological strategy to legitimize the racial order. The notion of “racial diseases”—that people of different races suffer from peculiar diseases and experience common diseases differently—is centuries old (Roberts Reference Roberts2011). According to Lundy Braun (Reference Braun2002), it was precisely “by locating disease in physiologic difference—be it susceptibility or resistance—that medicine served to mark blacks as deserving of their inferior social status in society” (p. 161).
White slaveholders argued that the biological peculiarities of Blacks made enslavement the only condition in which Blacks could be productive and disciplined. Dr. Samuel Cartwright (Reference Cartwright1851), a University of Pennsylvania Medical School graduate and well-known expert on Negro medicine, championed the claim that slavery was beneficial to Blacks for medical reasons. The physical labor that White slaveholders forced upon naturally slothful Blacks helped their lungs to “vitalize” blood. “It is the red, vital blood, sent to the brain, that liberates their mind when under the white man's control; and it is the want of a sufficiency of red, vital blood, that chains their mind to ignorance and barbarism, when in freedom” (p. 691), he explained in a medical journal. By converting race into biological difference, Cartwright could ingeniously turn enslavement of Africans into a form of freedom and turn Black freedom into slavery.
After slavery ended, White scientists blamed the deteriorating health of the American Negro on a biological incapacity to adjust to freedom. As quoted in Metzl, “After he became a free man,” wrote government psychiatrist Arrah Evarts in 1913, “the conditions under which he must continue his progress became infinitely harder” (p. 31). Locating Blacks' inferior status in their diseased bodies provided a reason for retaining White supremacy and discredited the need for radical social transformation. Instead, Whites argued that the best way to improve the condition of emancipated Blacks was through either benign neglect or coercive medical intervention.
Just as Whites explained the symptoms of Black oppression as caused by disease, so they explained Black resistance as a symptom of disease. Metzl compares contemporary psychiatrists' diagnosis of Black protest as schizophrenia to Cartwright's identification of insanity among enslaved Blacks. Cartwright coined the term drapetomania—combining Greek words for “runaway slave” and “crazy”—to describe the mental disorder that caused Blacks to abscond from bondage. Psychiatrists in the 1960s did not generally ascribe mental illness to the Black psyche, but, like Cartwright, interpreted Black men's accusations against White oppressors in particular as delusions. This move mirrors the more recent conservative dismissal of Black people's charge that racism persists in America as playing the race card or petty complaints (Blow Reference Blow2012; Crenshaw Reference Crenshaw2011).
The very long history, with many recent examples, of concocted diagnoses reminds us that understanding disease in racial terms inevitably involves social understandings of race and reflects current debates about racial politics. Whites have always turned their anxieties about race mixing, immigration, and resistance into medical findings of minority disease (Ikemoto Reference Ikemoto2005; Wailoo Reference Wailoo2001). Black men's peculiarly aggressive schizophrenia and Latina women's peculiarly excessive fecundity locate threats to the racial order in the bodies of subordinated people.
Scientific Authority
Both books highlight the role of medical professionals in developing and implementing the biological strategy of social regulation. Well-respected members of the mainstream medical establishment at LACMC and Ionia were responsible for inflicting atrocious injuries on their patients under the guise of helping them. As Gutiérrez writes, “Some physicians believed their professional status and resources granted them the authority and responsibility to protect the public welfare by taking deliberate actions to reduce high rates of population growth” (p. 20). Metzl similarly notes, “In a host of explicit and subtle ways, psychiatry thereby positioned itself as an authority that made sense of the crisis posed by angry, protesting black men during the civil rights era” (p. 108). It is precisely their position of assumed professionalism, objectivity, and benevolence that makes doctors especially formidable purveyors of racial control, for it grants them permission for practically unrestrained inhumanity.
What would ordinarily be deemed illegal assaults in clear violation of constitutional and human rights—forced sterilization, indefinite confinement without due process, and involuntary administration of mind-altering drugs—becomes legitimized by the medical profession not only as remedies for social problems but, more insidiously, as for the victims' own benefit. Metzl includes a heartbreaking chapter entitled “Rashomon” that consists of excerpts of correspondence between Abdul-Rasheed Karim's brother, Gerald James, and Ionia's Medical Superintendent, A.A. Fairman. In response to James's pleas for Karim's release or transfer to a hospital closer to home, Fairman replies with Kafkaesque assurances that “we will continue to give your brother the best possible care and treatment while he is on our hospital” (p. 168).
RACIALIZED AND GENDERED BODIES
Although Gutiérrez and Metzl concentrate on the racial politics behind the medical policies and practices they examine, both also offer considerable insights into the important role gender played in the social control of the Latina women and African American men at the center of their investigations. The sterilization abuse of Mexican-origin women entailed both the gendered regulation of their childbearing and the racist stereotypes that portrayed their childbearing as excessive. The schizophrenic profile morphed from docility to aggression when applied to African American men because of the gendered stereotype of violent Black masculinity. As intersectionality theory reveals, structures of privilege and disadvantage such as gender, race, and class inextricably interact in the lives of all people, depending on their particular identities and social positions, and work together to form a system of interlocking oppressions (Collins Reference Collins2000; Crenshaw Reference Crenshaw1989; Dill Reference Dill1983).
In both books, White middle-class women enter the scene to provide an enlightening contrast to experiences of the non-White protagonists. In Fertility Matters, Gutiérrez recounts tensions between Chicana rights groups that joined together to petition California's Department of Health for stricter sterilization regulations, including informed consent requirements, counseling on other forms of birth control, and a waiting period following consent, and White-led feminist organizations like National Organization for Women that opposed what they saw as restrictions on women's access to the procedure (pp. 102–107). Evelyn Martinez of Comisión Femenil Mexicana National recalled, “Even to this day when I think of NOW, I always think of their not supporting this issue and we were always expected as Latinas to just jump on their bandwagon” (p. 105).
White middle-class women in the 1970s confronted medical attitudes that were diametrically opposed to the sterilization abuse of Latinas: many found it almost impossible to find a doctor who would sterilize them (Roberts Reference Roberts1997). The disparate experiences of women of color and White women resulted in clashing agendas concerning sterilization in other parts of the country as well. In the late 1970s, when the Committee to End Sterilization introduced in the New York City Council guidelines designed to prevent coercive sterilization, representatives of the National Abortion Rights Action League (NARAL) and Planned Parenthood testified against the guidelines (Roberts Reference Roberts1997).
Metzl tells the story of a White housewife named Alice Wilson who was treated at Ionia for schizophrenia in the 1940s, before the illness became associated with Black male aggression and before the facility came to house primarily angry Black men. As Metzl writes, her hospital chart explained the reason for her admission as “Disturbing the Peace. Got Confused and Embarrassed Husband” (p. 21). At the time, psychiatric literature and popular magazines portrayed White middle-class women as “driven to insanity by the dual pressures of housework and motherhood” (p. 37). Mrs. Wilson was clearly institutionalized for violating patriarchal rules confining women to the domestic sphere where they were subservient to their husbands. When doctors at Ionia recommended her release, one noted, “It would seem to me that the husband knows how to handle her” (p. 44).
Mrs. Wilson was subjugated by sexist norms, but I disagree that her case “is an individual tragedy on par with any in this book” (p. 175). Rather, she was privileged by her White race in a way the Black men diagnosed with schizophrenia were not privileged by their male gender. Newly diagnosed with depression, she was released in 1972 after a second stint at Ionia with a prescription for Valium and an “active friendliness” treatment approach, while the Black men she left behind were condemned to a lifetime of inhuman violation. Because race marks a particular kind of inequality, schizophrenia's conversion from a White to a Black disease was not just a matter of switching the diagnostic label on patient charts. When associated with Black men, schizophrenia took on a new meaning that required harsher treatment and indefinite confinement. Similarly, Latina women shared the experience of gendered reproductive regulation with White middle-class women who were denied access to sterilization. But the dominant society denied Latina women's childbearing the value granted to White women on account of race, thereby making Latina women more vulnerable to medical abuse.
Legal scholar Kimberlé Crenshaw (Reference Crenshaw1989) shows that the “single-axis” framework of discrimination analysis not only ignores the way in which identities intersect in people's lives, but also erases the experiences of some people. As a result, she argues, “Black women are sometimes excluded from feminist theory and anti-racist policy discourse because both are predicated on a discrete set of experiences that often does not accurately reflect the interaction of race and gender” (p. 315). Metzl encountered an erasure of Black women in the patient files, media accounts, and advertisements he gathered. While White women composed up to 20% of Ionia patients before 1960 and Black men became the dominant group after 1960, Black women were virtually absent. The invisibility of Black women in medical treatment records and narratives, Metzl observes, “suggests that, for better and mostly for worse, these women suffered in silence” (p. 61).
STRUCTURAL AND INDIVIDUALIZED VIOLENCE
By exploding the myth of medical objectivity, Gutiérrez and Metzl highlight the importance of placing clinical decision-making in the political context of institutionalized racism. Metzl builds on the concept of structural violence, developed by medical anthropologist Paul Farmer, to describe how psychiatric diagnoses can “define, circumscribe, and contain” vulnerable populations despite their intended purpose to aid afflicted individuals. As a result, he argues, the cultural competency approach to eliminating medical bias, based on the idea that “cultural differences can be resolved through individual interactions,” is doomed to fail. By focusing on the two actors in the doctor's office, “it practically trains doctors to remain blind to the ways in which the diagnoses themselves convey profoundly racial and cultural meanings” (pp. 202–203).
The inadequacy of an individualized approach is also seen in the trial judge's decision in Madrigal v. Quilligan, 1978, the class-action lawsuit brought by Latina victims of sterilization abuse in Los Angeles. In his decision, Judge Jesse Curtis absolved the physicians of any wrongdoing by attributing the sterilizations to a “communication breakdown” between the doctors and the women owing to their cultural differences. Noting that the Mexican-origin plaintiffs had a culture “somewhat foreign to ours,” as Gutiérrez reports, Judge Curtis concluded:
So, I do not think it is surprising that you might find a doctor who believes that people who are inclined to have big families shouldn't, and particularly for good medical reasons, undertakes to persuade a person not to have a large family. And if that person agrees and is willing to be sterilized, then I cannot see anything wrong with the doctor having suggested it or having convinced the patient, so long as he does not use his powers, his ability, his circumstances to override what would be a reasonable decision on the part of the patient
(pp. 46–47).The recognition of institutionalized racism and structural violence does not discount the devastating impact of racist regulation on the bodies of individual human beings. Both Fertile Matters and The Protest Psychosis are distinguished by their attention to the physical and emotional toll experienced by the victims of racialized medical abuse. Explicit in her aim to show how repressive reproductive policies affect individual women's lives, Gutiérrez details the unscrupulous techniques used by doctors to pressure Mexican-origin patients to sign sterilization consent forms while in the throes of labor. Metzl punctuates his scholarly analysis with poignant case studies of several Ionia patients based on their hospital records. The excerpts of patient charts reproduced in the book are almost too tragic to read.
CONCLUSION: THE NEW RACIAL SCIENCE
Fertile Matters and The Protest Psychosis might be seen solely as historical accounts of a White backlash against Mexican immigration and Black civil rights in the early 1970s, but their insights about race, biology, and social problems hold lessons that are just as relevant to today's political landscape. In Fatal Invention: How Science, Politics, and Big Business Re-create Race in the Twenty-first Century (Roberts Reference Roberts2011), I document the emergence of a new form of racial politics that relies on re-inventing the political system of race in biological terms using cutting-edge genomic science and biotechnologies. Nicholas Wade (Reference Wade2012) in the New York Times reported on a study that explained the higher risk of diseases like hypertension and prostate cancer among African Americans as a genetic adaptation by their enslaved ancestors to the novel environmental challenges they encountered in the New World. The modern-day notion that the pressures of enslavement caused African Americans to acquire a peculiar susceptibility to disease bears an eerie resemblance to the pseudoscience of past eras, but today's racial scientists claim to measure biological distinctions across races and “admixed” populations with greater precision and without social bias.
The pharmaceutical and biotech industries are exploiting race as a convenient proxy for genetic difference to market new drugs and other gene-based products. While waiting for the promise of gene-tailored medicine to materialize, race has become an avenue for turning the vision of tomorrow's personalized medicines into today's profit-making commodities. In 2005, the federal Food and Drug Administration approved the first race-specific drug, a heart failure therapy for self-identified African Americans. The FDA's press release celebrated the pill as “a step toward the promise of personalized medicine” (U.S. Food and Drug Administration 2005), even though the drug's developers had conducted no genetic research, suggesting that race could serve as a surrogate for some yet undiscovered genetic variation in heart disease or drug response. In fact, the inventor originally developed the drug and prescribed its ingredients without regard to race but later decided to market it to Black patients as a way to extend his patent and gain FDA approval (Kahn Reference Kahn2004).
Race does have medical significance—because social inequality affects people's health, not because race is written in our genes. Like the racialized construction of Mexican immigrant women's fertility and African American men's schizophrenia, the explanation of racial diseases at the molecular level helps to obscure racial injustice at the social level. At the very moment that science, government, and business are promoting race-based genomics, the idea that we are living in a “postracial” America is gaining traction, despite enduring inequities in health, wealth, education, and incarceration. Gutierrez and Metzl unveil the political work done by medical experts who convert reproduction into a social problem and social protest into a mental disorder. We should be equally wary when scientists and doctors insist that their use of race is purely biological.
