MEASURE ONCE, CUT TWICE: IN DEFENSE OF SELF-HARM
10/2024 - full body autonomy and full communism now; cutters, unionize; for a wholesale rejection of psychiatry, addiction models, the DSM/ICD, and all systems of oppression.
Introduction
Navigating eating disorder treatment centers as a trans teen meant that I instinctively felt something I would spend the next years attempting to put into words: I knew more than every adult in the room – and I needed to hide it. Only two perspectives were offered to me at the time, neither of which got to the root of the issue. On one hand, power, in the form of psychiatrists and doctors, blamed my transgender delusions on my energy-deficient brain. On the other hand, well-meaning trans activists affirmed that transition was not mutilation, that wanting to change my body in this way had nothing to do with wanting to cut or to starve myself. Years before I approached any kind of antipsychiatry theory, I already struggled to wrap my head around the idea that some changes were allowed, and others were not; that there should be a clear separation between dysphoria and dysmorphia; that some feelings warranted external intervention, and others didn’t.
Much of the rhetorical struggle for trans rights is fought by emphasizing the positive effect transition has on people and opposing the common transphobic assertion that trans surgery is mutilation.1 For trans activists, this is an attempt to bring trans surgeries (and, to a lesser extent, hormonal therapy) within the conceptual umbrella of ‘socially sanctioned’ behaviors – without questioning the ideologies that form the scaffolding of this category in the first place. In Psyche on the Skin: A History of Self-Harm, Chaney exposes the complexity of a transhistorical definition of self-harm, since “the DSM definition, for example, states that [self-harm] does not include ‘socially sanctioned’ behaviours; however, it is largely left to individual psychiatrists to decide what is or is not socially sanctioned. Body piercing and tattooing are listed as examples, certainly; but what of other forms of body modification, acts defined as sexually masochistic or extreme performance art?”
Using the rhetoric of “mutilation” often proves itself very useful as a justification for social control, especially against populations that are already disenfranchised or judged unable to make their own decisions: children, women, trans people, disabled people. So many discussions about body autonomy revolve around defining what is and isn’t self-harm; which self-harming behaviors are allowed, if any; and if they aren’t allowed, what methods can be employed to prevent them. We must reject wholesale this distinction, this rhetorical dead-end; the parsing of any act committed by one person on their own body as inherently harmful, regardless of context, is a violation against body autonomy everywhere.
I want to argue that politics of body autonomy need to put the defense of self-harm (by which I mean any behavior that is considered as harmful against one’s own self by legislators, psychiatry, and power in a broader sense) front and center. In this perspective, self-harm, and the concept of harm in general, must be seen as a category defined differently in different contexts to include a wide array of behaviors, with various individual meanings and purposes, in order to justify social control; we must think of it as a morally neutral action where each individual, regardless of the behaviors in which they engage on their own body, deserves to be met where they are, and supported in the ways they need.
A word on materialism
First, it is crucial to note that this position must come specifically from a dialectical materialist perspective. The questioning of the category of self-harm is part of a project that affirms that there is no characteristic inherent to any behavior – only the material consequences of those behaviors in current circumstances. This project, as we will see later, also concerns behaviors that are not generally – or not anymore – seen as self-harm. In Seeking the Straight and Narrow: Weight Loss and Sexual Reorientation in Evangelical America, Gerber analyzes this dynamic in relation to sexual orientation and body size: “This conceptualization of change is connected to the essentialization of both sexual orientation and body size. Heterosexuality and thinness are depicted as ideal states, ones to which a person would revert if she or he realized God’s intentions. This ideal is sometimes seen in scientific terms and sometimes religious ones, but in both cases it renders these traits both normative and necessary.” The conception of a non-modified (and white, straight, thin, etc.) body as a template and an ideal (both in the sense of perfect and in the sense of made of ideas) is not a neutral one. It is used to enforce intervention on non-normative bodies and ensure compliance to white supremacist capitalist patriarchy.
Even among people who recognize (or claim to) the need to not treat the white, straight, thin body as a default, direct, physical intervention on the body is often parsed in a different category; self-harm is deemed an objective medical issue, which then justifies bypassing concerns about body autonomy. “The medical model and the associated medical designations,” write Peter Conrad and Joseph Schneider in Deviance and Medicalization, “are assumed to have a scientific basis and thus are treated as if they were morally neutral. They are not considered moral judgments but rational, scientifically verifiable conditions.” It is a basis tenet of materialist analyses of science and psychiatry that those systems of knowledge are constructed and are maintained because of the purpose they serve for the current political system; abuse, incarceration, and violence are not flaws or perversions of the system, but indeed the system working as intended. The ideological assumptions underpinning this system are all the less questionable because the prism of medicine serves to render them as neutral.
The ideological scaffolding
Much of the knee-jerk opposition to a defense of self-harm rests on a set of assumptions that are so thoroughly immersed into our culture that many people struggle to look past them, despite being able (to some degree) to recognize those assumptions in other times and places.
The first assumption is the idea that those acts are harmful in and of themselves; that this harm is self-evident, and indeed that it is possible to define and quantify harm in an objective way. Many discussions around alcoholism take for granted that sobriety (or use only in specific circumstances and amounts) is the goal, and choose to focus instead on the roadblocks that make this goal unattainable. In the same vein, practices such as cutting are often considered (in treatment centers and interpersonal relationships) objectively negative behavior – a necessary evil required in order to cope, make pain apparent, etc. Cutting and alcohol use are only two examples here of a much broader social pattern. In Seeking the Straight and Narrow, Gerber discusses this construction of assumed pain as precondition for support in the context of weight loss: "Recognizing the pain that is assumed to underlie sin makes the object of judgment worthy of sympathy; compassion is thus dependent on the perception of pain. (…) The shift from repulsion to pity, in the form of tears or hugs, is seen as progress in the struggle with judgment, but the assumption that fat reflects pain (and that tears or hugs would be welcome responses) remains unchallenged." This assumption preemptively justifies any intervention that one would take towards someone thought to be self-harming.
The second assumption states that structures of power have more knowledge about what causes harm to an individual than the individual themselves. Indeed, many behaviors are seen as self-harm when committed against oneself, and not when done by others in a position of power (doctors, for example). According to this logic, members of those structures have knowledge that an individual could never have, and any action they might undertake based on this knowledge would be justified. Prescription of neuroleptics (“antipsychotics”), physical restriction, corrective physical or sexual violence, are common and normal practices in the framework of the doctor/patient relationship. Forcible sterilization is regularly carried out according to this logic (particularly towards immigrants, Indigenous people, intersex, and disabled people), often without the person’s knowledge,2 while others, who are actively seeking this surgery, are denied it. Since the body of an individual does not belong to them, the state and its agents (here, doctors) are the ones responsible for decisions regarding it. The crime of mayhem, originally, which forbade the ‘willful removal of healthy tissue’, referred to the act of self-mutilation to render oneself unfit for military service; the underlying message was that this prevented one from having their body employed as a resource for the exercise of sovereign power, and thus an affront on power itself. The individual must be actively barred from intervening directly on their own body in a way that could threaten their use to systems of re/production. The same idea is at play when harm that is being done to an individual (whether by other individuals or by wider structures) is instead framed as self-harm: engaging with upsetting news regarding political violence towards one’s community or seeking out partners who then proceed to abuse you is seen as damage that you are doing to yourself to redirect the responsibility to the individual.
Finally, disgust as a moral force is key and parcel of the conception of self-injury; it is “common sense” that some behaviors are bad, that they are repulsive to an imagined average person. This of course ignores the way that reactions of disgust and repulsion are shaped by the material forces of the base (which refers to relations of production), and are then used to reinforce and reify those forces. Publicly available support for cutters (even when it does not consist of straightforward privations of freedom) often comes in the form of looking for the underlying reasons why people self-harm, as nothing but pain could justify this behavior. This perspective assumes a return to "normal" after those reasons and needs are met. Moving away from those assumptions requires us to see beyond our gut reactions to critically examine what fits in and maintains the category or self-harm – what makes, for instance, cutting worthy of institutionalization, but not sleep deprivation for work purposes.
Delineating the category of harm
In this perspective, it is crucial to explore what behaviors the notion of self-harm has encompassed in different contexts, because the idea that there are standard meanings and standard manifestations to self-harm, that practices such as cutting must come with the goal of eventually stopping, is based on the idea of it being an objective, self-evident category. While cutting is seen in the current day in psychiatry as the quintessential form of self-harm, the term has been applied to many other practices. For most of these practices, the notion of harming one’s self often came with the unspoken assumption that harming your self also meant committing harm on your social circles and society at large and would therefore need to be banned.
Many of these practices are related to sexual behaviors that go against the sexual standards of capitalist productivity – standards that depend on the needs of the relevant social context. The term “self-abuse” referred in the early eighteen century to masturbation, conceptualized as a disease that harmed the self, and needed to be morally mandated against.3 In much of contemporary Christian anti-gay rhetoric, gay sex is considered a form of self-harm; though the person might not realize it, engaging in homosexual activity is inherently damaging to the soul and the body (the possible transmission of STD being a physical manifestation of this damage).4 In Irreversible Damage: The Transgender Craze Seducing Our Daughters, Abigail Shrier explicitly compares the “transgender craze” with the “anorexia and bulimia” of previous decades. The visual value of double mastectomy (often referred to as top surgery), in which a “healthy” mass is removed surgically, allows obvious rhetorical parallels with cutting.
Many forms of body intervention are also associated with the non-Christian subject. In From psychiatric symptom to diagnostic category: self-harm from the Victorians to DSM-5, Gilman refers to the case of circumcision as a practice treated as culturally marked: "Can a circumcised (male) Jew be an Englishman? (Endelman, 1999). The general consensus was that he could not. Genital self-mutilation as part of a vocabulary of cultural images is clear. It is a sign of the primitive as opposed to the civilized." Once again, the concept of "socially sanctioned behaviors" at the heart of the idea of self-harm is problematized by thinking of its treatment of non-Christian and/or non-Western cultures and individuals. We’ve seen that tattoos and piercings are not counted as self-harm in the modern DSM. However, their origin and cultural associations are with colonial anthropological explorations of non-European peoples (as well as, in later times and for the same reasons, with criminals in the imperial core). Self-mutilation is seen in the Victorian times as a “primitive” behavior set in opposition to the “English proper”, in a process that mirrors the similar construction of madness.
Chris Millard summarizes it thus in Making the Cut:
Behavioural patterns, diagnoses and illness categories are made by human beings, in specific contexts through specific intellectual and practical processes of sense-making. Behaviours/diagnoses such as ‘self-harm’ are not some kind of surface expression of monolithic deep causes such as ‘distress’ or to be collapsed into the esoteric languages of genetics, biology, or neurochemistry – or the now unfashionable ego, Oedipus complex, or ‘penis envy’.
As mentioned, much of the pushback against this rhetoric as part of sexual liberation movements has aimed to sever these practices (transitioning, gay sex, masturbation) from the realm of self-harm. In the US, gay liberation movements celebrated the complete removal of mentions of homosexuality from the DSM in 1987. However, attempts to depsychiatrize homosexuality and transsexuality while not questioning the foundation of psychiatry and medicine puts gay and trans people in the position of constantly needing to reaffirm this difference, reifying the psychiatric institution in the process. Similar conversations have been had about the existence of a “gay”, “trans”, or “alcoholic” gene; instead of destigmatizing the behavior, they present it as something that is justified only insofar as it is impossible to change.
This is where the tools and analyses of antipsychiatry and disability studies approaches come in useful. In disability studies, the concept of Dignity of Risk refers to a person being allowed to make decisions that might cause them harm. The concept was specifically designed to be applied to people with mental disabilities, and was not initially conceived in an approach that rejects psychiatry altogether. However, it can prove relevant to explain why someone might wish to engage in activities that could cause them bodily harm. Indeed, we have seen that this dignity is (if temporarily, and with conditions) allowed as long as it does not impede functioning under capitalistic society, after which it gets parsed into deviant behavior.
And what of care? If we question everything that is implied, all the discursive weight put on the concept of harm, then we must proceed in the same way with care. Under this pretense, any act that a doctor performs can be and is justified5. Under this pretense, the family isolates, abuses and controls its children. The construction of deviant behavior – particularly behavior that renders one unfit for capitalistic productivity – was essential in consolidating medical authority as a means to correct these behaviors This notion of self-harm as a deviant behavior, one that renders someone unfit for work and must therefore be criminalized, medicalized, or both, is visible in the treatment that is given to behaviors like alcohol consumption or calorie restriction. Both are socially acceptable (even encouraged) until they start affecting one’s ability to function, appear sane to the general public, and be productive. Past this point, the same behaviors start being referred to as anorexia or alcoholism, thus justifying forced intervention, hospitalization, institutionalization, etc. It is important, however, to mention here that not all practices currently parsed as self-harm have the same weight and the same social consequences. Each come with different discursive ideas, different social value, and different punishments. However, they all have in common that they are envisioned as something that must have a cause, with the assumption that resolving those dynamics would inevitably lead to the path of recovery, and that preventing those behaviors justifies any forced intervention.
Blunt-force harm prevention
The question of a defense of self-harm might, for the general public, bring to mind attempts that have been made in the past to question whether or not self-harm (and often suicide) should be legal.6 This essay, however, does not aim to delineate the question of self-harm using a liberal rights-based framework. It is a misguided idealistic position to use rhetoric of identity-based oppression to explain these interventions: it is not because we are self-harmers that we are punished, institutionalized, controlled by the state; this control aims at its core to reinforce capitalistic productivity and produce obedient citizens, and it is often through the prism of preventing self-harm (in all its forms) that those mechanisms of control are justified post hoc, medicalizing them as a means of enforcing them.
Indeed, framing a behavior as harmful (as self-harm) allows institutions to justify banning access to services and criminalizing practices; laws restricting body autonomy are often presented as aiming to prevent self-harm. In the USA, 25 states now have bans over transgender healthcare for minors. The recent Cass Review in the UK has caused material harm to access to transgender healthcare, banning, for example, the use of puberty blockers.7 The mere construction of the legal category of minor (whose limit at 18 in many countries is a recent invention) aims to form a category of individuals, children, who are excluded from crucial decisions regarding their life and body. In parallel, the threat of institutionalization (and/or criminalization, depending on other factors, notably race and class) is always present when one is identified as engaging in self-harming behavior. Much has been written about the carceral role of the psychiatric hospital and psychiatry in general to define, control, monitor, incarcerate, diagnose, medicate, or otherwise exert power over people. Classifying an act of body intervention as “with suicidal intent” often allows to restrict even further the freedom and autonomy of the patient, and increase the monitoring of their behaviors, regardless of the severity of the wound, its threat to the patient’s health, or the intention behind it. No longer being considered a “danger to [yourself] or others” is often a prerequisite to the recovering of (some of) this freedom and autonomy. The same logic underpins the treatment of substance users, where courts can mandate an individual to attend Alcoholics Anonymous, or follow specific rules regarding sobriety, in order to remain out of jail, obtain custody or visiting rights, remain housed, etc.
Beyond the legal framework and medical system, one is encouraged to apply this surveillance to their own self. The sobriety model – both for substance use and cutting – encourages intense attention paid to the number of days, the amount drank, the regularity of the cuts, etc. It then encourages the patient to report these findings to authority. Many applications exist to track this “progress” (which, incidentally, often encounter data breaches regarding users’ personal information)8, seen as an unavoidable aspect of recovery. A heavy emphasis is also put on calorie-counting and exercise-tracking in eating disorder recovery. Failing to adequately perform this self-monitoring has severe social costs: anorexics in treatment are never given unconditional permission to eat, with the specter of “over-eating” always being wielded by doctors, especially in the case of fat patients. No place is given to the patient’s setting of their own goals, which are considered misguided due to going against the medical knowledge available. Structures of power and authority which enact this monitoring are also not limited to government institutions: other structures crucial to the functioning of capitalistic production, such as church groups, outpatient programs, or the family, also contribute to this, with members often encouraged, implicitly or explicitly, to also monitor each other – in everyone’s best interest.
People's self-image and self-narration then increasingly come to resemble the ones that are presented to them, indirectly in popular culture and directly by healthcare providers, as a means to affirm autonomy and avoid the more carceral dangers of the psych system. In Scripting Addiction: The Politics of Therapeutic Talk and American Sobriety, Carr refers to it as a "semiotic entanglements: clients worked to effectively represent themselves and their problems, and therapists worked to script, or set the terms of these representations. Because of the institutionalized ties between therapists and other social service professionals, a variety of resources—from temporary housing, transportation vouchers, and job training to medical care, legal protection, and therapeutic acknowledgment—hung in the balance of these intensive verbal transactions."
It is irrelevant how genuine any individual’s concern towards another’s behavior which they perceive as self-harming might be. Applying models of sobriety as a mandate or the sole solution to a behavior (as well as models that conceive of addiction as a lifelong illness against which one must be constantly vigilant) reproduces these structures of surveillance. Christian groups, for instance, often mention a moral duty to “help” people perceived to be self-harming: "Lydia told me of her hopes of recruiting a fat man in her church for the [weight loss] group. Some found this recruitment tactic off-putting and offensive, while others found it benign or an expression of Christian care."9 The central role that these groups occupy in the social life of their members encourage them to resist any attempt to stop this monitoring and disciplining. As with many other means of social control, the goal of this discipline is not to construct a body that does not harm itself (as we have seen, amounts of alcohol use, restrictive eating behaviors, or sleep deprivation, are tolerated and even encouraged) but to construct a compliant capitalist citizen.
Conclusion
At the core of the concept of self-injury is a tautology: you self-harm because you are sick, you are sick because you self-harm. This rhetorical move makes the category porous enough to be easily shaped by the contexts in which it is used, and amenable enough to be applied to a great variety of circumstances and behaviors. A parallel can be found in the Borderline Personality Disorder (BPD) diagnosis, in its modern iteration (a diagnosis heavily associated with self-injury, with two of the diagnosis conditions being “Impulsiveness in two potentially damaging areas” and “Suicidal gestures”). The borderline patient self-harms because they are borderline, and are borderline because they self-harm. This builds a base understanding of something as negative and harmful, and pushes many mental health advocates to work against one of the two conjunctions of the tautology (arguing, for example, that borderline patients are not inherently manipulative or abusive) instead of questioning the terms of the statement in the first place.
Similarly to substance use, it is self-evident in any materialist analysis of those behaviors that any suffering incurred from cutting or other forms of self-injury is almost always beyond the sufferer’s control. It is caused by abuse; poverty; oppression; all of which are social forces within white supremacist capitalist patriarchy. Placing a negative value on the manifestation of this suffering – or indeed, assuming it must be a manifestation at all – does nothing to address any issues that psychiatrized people might be working on solving, in their personal life and in the world. This is not to mean that all body modifications or interventions must thought of in a “positive” lens. This conception remains in the realm of idealism by attributing an inherent quality to behaviors that encompass a variety of severity, concepts, causes, and meanings. Neither is the aim of this approach to integrate self-harm into the list of socially sanctioned behaviors of capitalist society. Chaney asks: “Self-harm cannot be socially sanctioned; it is a taboo act. Yet what happens when what is socially sanctioned expands?”; this question only serves to further move the goalposts that the removal (in some instances) of homosexuality or masturbation from the category already started.
No, the goal is to envision a different approach, which rejects in full the terms of the category of self-harm; promotes access to clean supplies for all users, regardless of the intent of those users to stop engaging in these behaviors; avoids moralizing; and puts emphasis on dismantling the structures that facilitate this surveillance and of which self-harming is, at times, only a corollary manifestation of distress.
Bibliography
Chandler, A. (2016). Self-Injury, Medicine and Society: Authentic Bodies. Palgrave Macmillan.
Chaney, S. (2017). Psyche on the Skin: A history of self-harm. Reaktion Books.
Chaney, S. (2011). ‘Self-control, selfishness and mutilation: how 'medical' is self-injury anyway?’. Medical history, 55(3), 375–382.
Conrad, P., Schneider, J.W. (1992). Deviance and Medicalization: From Badness to Sickness. Temple University Press.
Gerber, L. (2011). Seeking the Straight and Narrow: Weight Loss and Sexual Reorientation in Evangelical America. University of Chicago Press.
Gilman, S. L. (2013). ‘From psychiatric symptom to diagnostic category: self-harm from the Victorians to DSM-5’, History of Psychiatry, No.2, p. 148-165.
Lewis, A. J. (2016). ‘“We Are Certain of Our Own Insanity”: Antipsychiatry and the Gay Liberation Movement, 1968–1980.’ Journal of the History of Sexuality, vol. 25, no. 1, p. 83–113.
Millard, C. (2013). ‘Making the cut: The production of ‘self-harm’ in post-1945 Anglo-Saxon psychiatry’. History of the Human Sciences, 26(2), 126-150.
Summerson Carr, E., (2011). Scripting Addiction: The Politics of Therapeutic Talk and American Sobriety. Princeton University Press.
Stryker, S., Sullivan, N. (2009). ‘King's member, queen's body: Transsexual surgery, self-demand amputation and the somatechnics of sovereign power.’ Somatechnics: Queering the Technologisation of Bodies, (pp. 49-63).
Wolpert, J. (1980). ‘The Dignity of Risk’. Transactions of the Institute of British Geographers, 5(4), 391–401.
Chaney, S., 79.
Gerber, L., 64.
See Primum non nocere.
See What are the key findings of the NHS gender identity review?, and also fuck The Guardian.
Gerber, L., 50.
This piece is eye-opening. Endless thanks to you for writing this
Thank you for this 🙏