Merrick Daniel Pilling. (2022). Queer and Trans Madness: Struggles for Social Justice. Palgrave MacMillan, 2022. ISBN: 9783030904135
Reviewed by Andrew McEwan, PhD
School of Disability Studies, Toronto Metropolitan University
In this monograph, Merrick Daniel Pilling theorizes the importance of mad studies insights to queer and trans experiences of psychiatric institutionalization and pathologization. In forwarding this assertion, Pilling details a comprehensive overview of the overlapping concerns of mad and queer activism, and articulates a “mad-queer-trans” critical space. Pilling then provides evidence and analysis of the ways that the current psychiatric system not only fails to help queer and trans people, but actively harms them. The book provides a damning critique of the implicit cisheteronormativity and white supremacist ideology of current psychiatric treatment settings, and argues for an intersectional mad-queer-trans model of care for distress. Pilling draws upon interviews with queer and trans individuals in psychiatric in-patient settings, as well close readings and analyses of this demographic’s medical charts. Importantly, Pilling details how a mad-queer-trans critical lens must be invested in critiquing colonial, racist, and white supremacist power, and the way these are intertwined ideologically with sanism and cisheteronormativity.
Queer and Trans Madness serves as an opening prompt for interdisciplinary theoretical consideration of mad, queer, and trans marginalization. Provocatively, Pilling writes that “There is something queer and trans about madness” (29), gesturing towards a rich theoretical resonance, without flattening this comparison to a simplistic equivalence. This provocation promises a lot for theorizing queer and trans madness, but Pilling balances theoretical elaboration with a focus on lived experiences of psychiatric institutions.
In grounding theory in historical context, the early sections of Queer and Trans Madness describe the limitations and failures of past targeted demedicalization efforts in queer activism. Taking the example of the depathologization of homosexuality, Pilling argues that the lack of an entry in the DSM for queer desire does not preclude the pathologization of queer and trans lives and identities in practice. Although it might have been a pragmatic historical choice to argue for queer depathologization in a limited capacity, Pilling shows that the subsequent broader critique of psychiatric power never materialized from this movement. Pilling notes that contemporary queer and trans activism aimed at reforming psychiatric services to make them more queer and trans friendly will continue to fall into this same impasse, as revisionism supports a psychiatric system that is inherently cisheteronormative. Pilling convincingly argues that that pathologization of queer and trans individuals extends beyond limited DSM categories of homosexuality and gender dysphoria, and thus activism must incorporate a broader perspective of cisheteronoramtive psychiatric harm offered by mad activism and theory.
Quotations from interviews, conducted by Pilling in Winnipeg and Toronto between 2010 and 2012, prove especially informative in Pilling’s theorization. They show the real-world language used to convey the deep ambivalence that queer and trans people, broadly, feel towards psychiatry and the medicalization of our distress. Readers experience the often ambiguous and contradictory language used by folks attempting to navigate care and support as they show varying levels of acceptance of and resistance to the biomedical model of mental illness, its use of a mind-body separation, and diagnostic authority. Many interviewees express criticism of the ways in which psychiatric disciplines pathologize their experience, and many also resist pathological terms. Nevertheless, Pilling’s interview quotations show the ubiquity of the biomedical model of mental illness in even the most critical interviewees, who often employ pathologizing terms due to lack of an alternative language for their experience. These moments of ambiguity and ambivalence as individuals navigate mental health systems provide the field of mad studies with an informative and valuable perspective from within an institutional setting and the way that critical and activist language disseminates to those who need it most.
Pilling’s close-reading of psychiatric medical charts offers a compelling, if disturbing, view into the ignorance that mental health care practitioners have about queer and trans lives. Indeed, Pilling describes the difficulty of narrowing charts down to queer and trans patients since their demographic information is, on the whole, unreliably reported. Pilling quotes doctors’ notes about patients’ gender presentation, notation of preferred pronouns in scare quotes to indicate doubt of their validity, and the inconsistency, between doctors, of maintaining correct patient information for queer and trans individuals. Pilling points out that healthcare practitioners’ ignorance of queer and trans identities, gender expressions, and experiences of trans- and queerphobic discrimination and violence, becomes a rationale for diagnoses of mental disorders and individualization of distress. Pilling illustrates the broad iatrogenic harm of psychiatric settings for queer and trans individuals, including deadnaming, misgendering, notation of gender presentation as symptom, and noting experienced harassment and harm as delusional. These forms of harm and violence in patient charts reflect only the recorded ways that psychiatric settings not only fail to help queer and trans people in distress, but actively harm them through widespread misunderstanding of LGBTQ2IA+ issues.
As a critical project dedicated to helping improve the lives of institutionalized and psychiatrized people, Queer and Trans Madness offers much needed practical applications for theoretical insights. Pilling directs much of this text’s work towards an audience of queer and trans theorists and activists, and offers them the critical model of madness studies as a way to broaden and strengthen their advocacy and critique. The language of mad studies’ analysis of the biomedical model of mental illness, psychiatric authority and power, and the broad harms of psychiatrization of distress prove vital for those invested in depathologizing queer and trans lives. Pilling illustrates how seeds of this discourse already exist in the language that institutionalized queer and trans folks use to describe their experience, and to navigate their lives as they seek care under the current medicalized institutions.
Despite a strong focus on the utility of madness studies for queer and trans scholars and activists, Queer and Trans Madness also offers a needed provocation to madness studies to think closely about intersectional and co-informing oppressions. Theorizations of queer and trans madness are shown to be vital in considering the effects of psychiatric harm, and the pathologization of non-normative gender and sexuality. Further, this text consistently provides proof that Black, Indigenous, and people of colour (BIPOC) queer and trans individuals face increased harm in psychiatric settings. Pilling argues that the analysis of patient charts “showed. . . beyond a shadow of a doubt that BIPOC and trans, non-binary, and queer people cannot safely rely on the mental health system as a means to address their mental distress” (3). As a field, madness studies, like many disciplines, has begun to reckon with its predominant whiteness, and this text provides clear evidence for centering queer and trans BIPOC identities and their specific positions of marginality when developing critical insights.
In the final section of this book, Pilling shifts to a discussion of ways forward from the harms of present institutional and carceral psychiatric practices. First, Pilling discusses what would be required for the psychiatry, social work, nursing, and other “helping” professions to reduce the harm of medicalized supports for distress. This includes a shift towards a non-hierarchical model of care in which labourers in medical settings think of themselves as practicing ongoing allyship with patients. Queer and Trans Madness also advocates for increased learning about the ways that these professions practice cisheteronormativity. Yet, Pilling also notes that even the most dramatic changes to the medical mental health care system fall short of meeting the needs of queer and trans folks, especially BIPOC queer and trans individuals. As an alternative, Pilling surveys the peer support, non-coercive, non-carceral, collective care organizing currently supporting the needs of queer and trans people. These include the Project LETS (Let’s Erase the Stigma), and Trans Lifeline, among others.
Queer and Trans Madness: Struggles for Social Justice fills an important gap in mad, trans, and queer theory by bringing them into close conversation, and by articulating a broader critique of co-constituting medical, cisheteronormative, and white supremacist harm. Pilling points the way towards an important, though undertheorized, sub-field and maps this intersection in an institutional setting. This text queers madness studies, and maddens queer theory in a very exciting way. It will, no doubt, prove an inspiration for many more queer-trans-mad critical works to come.