Reflections on Asian American trauma , heteropatriarchal betrayal , and trans / gender-variant health disparities research

This article first examines the author’s positionality with reference to the historical and inter-generational transmission of Asian trauma, the contemporary plight of North Koreans, and the betrayal of anatomically-female individuals (including those who are sexual minority/gender-variant) within Asian heteropatriarchal systems. An analysis of the relevance of empirical research on low-income trans/gender-variant people of color is then discussed, along with an examination of HIV and health disparities in relation to the socio-economic positioning of low-income trans/gender-variant people of color and sexual minority women, and how social contexts often gives rise to gender identity, including transmasculine identities. What next follows is an appeal to feminist and queer/trans studies to truly integrate those located on the lowest socio-economic echelons. The final section interrogates concepts of health, well-being, and happiness and how an incorporation of the most highly disenfranchised/marginalized communities and populations challenges us to consider more expansive visions of social transformation.


I. Introduction
As a Korean American with immigrant parents I have experienced what Lisa Lowe has described as a "splitting off" from the histories of Asia.The political formation of Asian immigrants into American citizens has often entailed a "trade off," where in order to be represented as a citizen within the U.S. political sphere, Asian immigrants must "split off" from the "unrepresentable histories of situated embodiment that contradict the abstract form of [U.S.] citizenship" (Lowe, 1996: 2). 2 For instance, it is difficult for me to reconcile the immense poverty I witnessed growing up in South Korea from in the early 1970s 3 with the role of the "privileged subordinated" model minority as a Korean American in the U.S. 4 As a Korean American it is also difficult for me to reconcile that 4 I would say I occupy the status of the "privileged subordinated" as opposed to those that are "categorically marginalized" but also not belonging to the privileged Euro-American dominant stratum.The privileged subordinated are those that are elevated from the categorically marginalized to often occupy a middle stratum between the categorically marginalized and the dominant stratum.(For more explanation of these terms, see Cohen, 1999.)although I grew up comfortably middle-class, I am only one generation removed from both my maternal and paternal familial lineages that were historically working-and poverty-class.My parents and grandparents remained mostly silent about their unrepresentable histories of situated embodiment that they experienced in Korea where they often experienced little or no access to dominant institutions and resources and often struggled with basic survival. 5hese experiences were precipitated by the historical events of Japanese colonialism, the Korean War, U.S. military occupation, and a series of dictatorships.In fact, my parents and grandparents have never lived in a non-colonized, non-occupied, and non-traumatized politically "free" Korea with a stable economy, since they emigrated to the U.S. while South Korea was still politically unstable and one of the poorest countries in the world (Armstrong, 2006;Cumings, 1998;South Korea, 2006). 6he burden of unrepresentable ethnic Korean histories is further compounded/complicated by the "plight" of North Koreans, initially severed from the South due to U.S. initiative, and sequestered from the vast majority of the global economy through sixty years of trade embargoes enacted by a U.S. government in which I am complicit with as a U.S. citizen.Approximately one-third of all Koreans live in North Korea, in which reportedly two to three million North Koreans have died from starvation, 37% of North Korean children are stunted, 2/3 of the North Korean population do not know where their next meal is coming from, and North Koreans are 3 to 5 inches shorter compared to South Koreans due to malnutrition (Bialik, 2008;Topple, 2013;WiseGeek, 2013).In addition, North Korea has its own prison industrial complex of prison camps and reeducation camps in which up to 200,000 North Koreans are currently imprisoned and more than 400,000 have died in prison (Topple, 2013).Given these grave conditions, almost 300,000 North Koreans have migrated without documents to China, 80% of these migrants are female, and 70-90% of these undocumented North Korean girls and women in China are sex trafficked (Topple, 2013).If genocide is defined as the destruction of a people, culture, and/or community (Martinot, 2003), then the situation within North Korea can be described as a protracted "low-intensity" genocide, in which sixty years of famine and extreme (heteropatriarchal) post-colonial political repression has resulted in the decimation of a society of 22.7 million people.
Engaging with poverty-class/low-income and/or immigrant transpeople of color who have little or no access to dominant institutions and resources and are surviving their own versions of protracted genocide (Hwahng & Nuttbrock, 2007;Hwahng et al., 2012Hwahng et al., , 2013a, b, c) , b, c) inspires in me an empathetic resonance with their experiences that also galvanizes me to reach back and recover those formerly unrepresentable histories from my parents, grandparents, great-grandparents, historical lineage, as well as the historical and current genocide of one-third of my ethnicity that has been suppressed and tucked away within the U.S. imaginary that I have also internalized.These formerly unrepresentable historical and current situations are still embodied within me and the more I can recover and give meaning to them, the more I feel grounded and present as a Korean/Korean American, and as a "privileged subordinated" anatomically-female gender-variant person within this politically confusing, racially and economically stratified, globalized world full of vast social and health disparities that we find ourselves in. 7hrough the richness of information flow and feedback available in my face-to-face interactions with other transpeople, I have received information on an incredible variety of trans/gender-variant lives and experiences that has profoundly and continually moved me through my witnessing of their strength, grace, and beauty even within very harsh and painful circumstances.I imagine that my parents, grandparents, great-grandparents, ancestors, as well as North Koreans past and present, also witnessed and perhaps sometimes epitomized the depths of human strength, grace, and beauty within the harsh and painful events they experienced.As someone who grew up fully ensconced within the "racist social scripting" of Asian Americans as the "model minority" (Lowe, 1996), I have felt cut off from the richness of information flow that is possible from their embodiment as Koreans because of the suppression of their histories and realities. 8I.Asian American Trauma I am a 2 nd -generation Korean American fourth-sex (anatomically-female non-heterosexually-behaving gender-variant social role designations found in indigenous Asian and non-Western cultures)9 gender-variant person whose parents emigrated from South Korea.Therefore, Japanese colonization, the Pacific War, the Korean War, a series of dictatorships and extremely unstable political economies have directly impacted my parents and grandparents.Although it is probably understandable how these events affect/ed my parents and grandparents as survivors of wars, violence, and political and economic instability, I am also interested in how their experiences shape and inform who I am, including my gender identity and the research and scholarly work I engage in.
For instance, how have my father's and paternal grandfather's experiences as interpreters for the U.S. Army during the Korean War (in which they facilitated the perpetration of extreme violence against Koreans on the "other" Northern side not out of ideological fervor, but because this was employment and they believed this was the only way for themselves and their biological relatives to survive) and my maternal grandfather's possible business forays in trafficking during Japanese colonialism (along with mother's shame that my maternal grandmother, as third or fourth wife, was placed at the bottom of my maternal grandfather's hierarchized polygamy) influenced/affected my gender, masculinity, femininity, and sexuality?And how has the centuries-long historical legacy of Asian heteropatriarchal sexual exploitation of Korean girls and women that ultimately manifested in the licensed prostitution and military sexual slavery system of poverty-stricken Korean girls and women during minority" that I do not include Pacific Islanders, since Pacific Islanders are not viewed as the model minority in dominant U.S. discourse and often occupy socio-economic-political positionings more similar to other Indigenous people such as Native Americans, rather than Asian Americans (Asian-Americans, 2010; Model minority, 2010).
Japanese colonialism (Choi 1997;Fujime, 1997;Hwahng, 2009;Song 1997), forced prostitution of Korean girls and women for the U.S. military during U.S. neocolonization of South Korea (Cho, 2008;Moon, 1997;Sturdevant & Stoltzfus, 1993), and the widespread sex trafficking, rape, sexual abuse, and torture of North Korean women in both North Korea and China (Committee, 2009;Chung, 2009;Muico, 2005), affected my grandmothers, my mother, my other female relatives, and ultimately me?Why is it that for my mother there is such a deep fundamental connection between poverty, sexual exploitation/mutilation, 10 torture, and humiliation?These questions shape the context in which I was raised.
There is also increasing evidence that it is the fourth-sex that was/is most sacrificed and coerced into survival sex work within both historical and modern transnational sex work systems in Asia precisely because the fourth sex had/has very little use value and exchange value in the political and representational economies of Asian patriarchal heterosexual consumption (Hwahng, 2011;Morris, 1994;Sinnott, 2004;Sturdevant & Stoltzfus, 1993).In fact, within some Asian heteropatriarchal systems, the sexuality of fourth-sex individuals has been successfully deployed to reinforce these heteropatriarchal systems, either through facilitating the preservation of (second-sex) cis-gendered women's11 virginity for their impending sexual partnerships to (first-sex) cis-gendered men (Hwahng, 2011;Sinnott, 2004) 12 , or fourth-sex individuals themselves being utilized as especially industrious sex workers par excellence precisely because of their emotional distance from the cis-gendered men with whom they participate in often coerced heterosexual acts (Morris, 1994;Sturdevant & Stoltzfus, 1993).Knowing all this has had a particularly acute effect on me in considering the historical and contemporary weight of Asian heteropatriarchal betrayals of the fourth sex.
Research has shown that severe traumas can cause neurobiological changes in survivors, although effective interventions can alter and/or repair these changes (Becker-Blease & Freyd, 2005;Siegel, 2003).However, when trauma remains unaddressed, as in my parents, grandparents, great-grandparents, ancestors, do the neurobiological changes in their bodies then transmit trans-generationally and transnationally into my body through our shared 10 Sexual mutilation refers to a series of bodily transformations that Korean sex slaves were forced to undergo by the Japanese military, including forced injections of the chemical compound No. 606, hack abortions, etc.For more information see Hwahng, 2009.heteropatriarchal culture as not "authentic" sex, but rather "playing with friends" (len phuan, 49-53, 115-118).In Thailand, one role of young toms, who are anatomically-female transmasculine fourth-sex individuals, is to partner with young feminine "normative" women (known as dees), so that the virginities of these young women/dees are preserved.Toms, as anatomically-female, are not able to de-virginize women because they do not possess an anatomical penis.Thus, the young toms are seen to merely be "playing with friends" with young dees in their romantic/sexual partnerships; thereby protecting the dees from entering into romantic/sexual relationships with cis-gendered men before the dees are fully "mature" for "authentic" heterosexual union.When dees fully "mature," it is then expected that they will break up with their tom partners, and enter into full-fledged heterosexual unions/marriages with cis-gendered men ("releasing" the dee partner, 99-105).This pattern also results in a "surplus" of single toms, middle-age and older, who reconcile themselves to their single tom status because, as Buddhists, many toms view their transmasculinity as "suffering" resulting from bad karma they had accumulated from negative actions in past lives (93-99).
blood; are they imprinted into my psyche through our socio-biological intimacy?So that I find my own body and psyche drawn to conduct research on those who are racially marginalized and sexually stigmatized, who often must engage in sex work to survive, who engage in illicit and/or injection drug use to ease the trauma of their own lives?
As previously mentioned the U.S. social scriptings often demand or coerce Asian Americans to "cut off" aspects of their histories and identities that do not correlate with assimilation into the U.S. in order to be constructed as the model minority.Many of these cut-off aspects often involve traumatic histories and experiences so that Asian Americans are construed as "safe" blank slates onto which U.S. desires and national narratives can be projected, unlike the perceived "dangerous" and traumatized groups of African Americans/Blacks, certain Latino ethnicities (such as Mexicans and Puerto Ricans) 13 , and Native Indigenous people.So do my research interests not only manifest from embodied traumas that are not recognizable in the U.S. imaginary, but can the recognition of my own embodied traumas be an opening and pathway to connect with the traumas of other people of color, along with the traumas of people of my own ethnic heritage who have been socio-politically cut off in the U.S. imaginary?Contemporary research on Asian Americans actually conclude that many Asian Americans have extensive histories of trauma including pre-immigration political and war trauma, childhood sexual and physical abuse, domestic violence, and rape, in addition to trauma experienced from (im)migration and racism (Abueg & Chun, 1996;Midlarsky et al., 2006;Mollica et al., 1987;Ng 2004;Tummala-Narra, 2001;Weingarten, 2004;Young et al., 1987).In fact, most Asian Americans are immigrants and thus may have survived and/or witnessed large-scale pre-U.S. immigration institutionalized forms of violence and abuse experienced in such armed conflicts and violent events such as the Pacific War, Hiroshima/Nagasaki, the Partition of India, the Korean War, the Cultural Revolution, the Laotian Civil War, the Bangladesh Independence War, the Vietnam War, the Cambodian genocide, Tiananmen Square, and in military dictatorships in many Asian countries during the 20 th and 21 st centuries.
Sexual atrocities were/are also widespread during many of these Asian armed conflicts, and violence taking the form of mass rape and systems of sexual exploitation were/are also historically and currently entrenched within Asian heteropatriarchal systems in which girls and women in poverty were/are the most vulnerable (Chang, 1998;Cho, 2008;D'Costa, 2010;Hicks, 1995).The 60-plus year Korean War has still not ended and increasing evidence, including female North Korean survivor testimonies, indicate the rampant sexual violence, exploitation, and abuse perpetrated against North Korean girls and women, especially those girls and women classified by the DPRK in the "hostile" and "wavering" sectors (Chung, 2009),14 by both the North Korean and Chinese nation-states (in which the and hostile.Members of the core class are those who are deemed most loyal to the North Korean government, whereas the wavering class has not demonstrated any exceptional loyalty, and the hostile class has demonstrated disloyalty to the North Korean government.The majority of the North Korean population is classified in the wavering and hostile sectors.In addition, one member of a biological family who has been categorized as hostile will render the members of the entire family as hostile, this designation will endure throughout generations, and it is nearly impossible for any citizen deemed hostile to move up to a more loyal (and less marginalized) status.Once deemed "hostile," it is these "hostile" North Koreans who are most likely to be generationally incarcerated within the vast prison industrial complex in North Korea (Chung, 2009).The U.S. nation-state is also implicated through its military and economic aggressions/sanctions that have resulted in a poverty-stricken North Korea). 15n addition, increasing militarization of the Asia/Pacific region since World War II has also manifested in the rampant sexual exploitation of Asian girls and women on U.S. military bases (Cheng, 2010;Moon, 1997;Sturdevant & Stoltzfus, 1993), while the widening global gap between wealth and poverty has manifested in increased sex trafficking of survival sex workers in Asia, including female North Korean survival sex workers in China.Given this evidence, it appears that Asian/Americans may actually be a highly traumatized group, contrary to the U.S. social scriptings of Asian Americans.These traumas, sexual and otherwise, have an impact on Asian Americans, not only as actual survivors of said traumas, but also as witnesses of these traumas (especially as witnesses of traumas of survivors of their own ethnic groups), 16 and as children and grandchildren of survivors.Despite this proliferation, there is a relative dearth of research on Asian American trauma.Reviewing what research is available on Asian American trauma, along with examining trauma research conducted in other ethnicspecific communities, however, can provide useful concepts and methodologies.For instance, Asian Americans who experienced pre-immigration trauma in Asia were subsequently re-traumatized through experiences of (im)migration, racism, violence, and/or surviving or witnessing human-made or natural disasters and armed conflicts in the U.S. Thus, pre-immigration traumas experienced even decades ago may still have an impact on persistent PTSD and neurobiological changes among Asian Americans (Trautman et al., 2002;Tummala-Narra, 2001, 2005, 2007).
In research conducted on Native indigenous communities in North America, historical trauma is defined as trauma that is transmitted trans-generationally within a specific ethnic community and which bears an impact on subsequent health outcomes (Balsam et al., 2004;Duran & Walters, 2004;Simoni et al., 2006;Walters, 1997). 17esearch on the aftermath of the WWII Holocaust has also revealed the phenomenon of "secondary" or "vicarious" rationing of food, health, and welfare services is based on class status, and the vast majority of North Korean refugees to China are members of the wavering and hostile classes (Chung, 2009).Presumably the North Korean government renders a portion of its citizens as permanently hostile in order to maintain a labor force for the North Korean military industrial complex and to justify the extreme exploitation of said labor force while severely limiting food and services to members of this class.trauma, which is defined as trauma experienced by someone who witnesses trauma.A witness can be traumatized several ways, such as directly witnessing the event, by listening to a re-telling of the traumatic event by a survivor, or by being a child of a survivor and intuitively sensing the trauma experienced by their parents (Hesse et al., 2003;Rowland-Klein, 2004;Wallace, 1996;Williams, 2005).Research has shown that the more empathic a witness is to a survivor, the more vulnerable that witness is to secondary trauma (Amir & Lev-Wiesel, 2004;Bride et al., 2004;Feldman & Kaal, 2007;Hesse et al., 2003;Rowland-Klein, 2004;Wallace, 1996;Williams, 2005). 18Children, therefore, are often highly vulnerable to secondary trauma from their parents, which is sometimes termed "empathic traumatization" (Hesse et al., 2003;Rowland-Klein, 2004;Wallace, 1996;Williams, 2005).
Research on children of Holocaust survivors indicate that these children, similar to their parents, have more difficulties coping with stress, and are more susceptible to post-traumatic stress disorder (PTSD) symptoms such as intrusive images, nightmares, difficulty containing anger, restricted emotional range, fear of death, depression, and guilt.Children of Holocaust survivors also experience the desire to protect their parents, not wanting to burden their parents, feelings of mourning and loss, prevalent feelings of guilt and anxiety, and heightened sensitivity to suffering people.Since previous research has already determined that Asian survivors of war and political violence suffer psychological disturbances and PTSD symptoms (Abueg & Chun, 1996;Mollica et al., 1987;Ng, 2004;Tummala-Narra, 2001, 2005, 2007;Young et al., 1987), similar secondary trauma effects may be applicable to Asian Americans who are children of survivors.It can thus be hypothesized that these Asian American children may also be suffering similar symptoms to children of Holocaust survivors. 19he proliferation of trauma, sexual and otherwise, may have dire consequences for sexuality and sexual expression for both Asian American survivors of trauma, and those who experience secondary or empathic trauma.This could manifest in individuals experiencing stigma and shame regarding sexuality, the shutting down of their sexuality, a general absence of discourse of sexuality within Asian American communities, rigidification of gender and sexuality within Asian American communities, an inability to confront issues of sexual violence and trauma in Asian and Asian American communities, and a general intolerance of sexualities and genders that are considered "abnormal," gender and/or sexual minority and/or non-heterosexual.For survivors, "sex-negative" and sexintolerant attitudes and behaviors may be related to the actual trauma they experienced, especially if they survived or witnessed sexual trauma or violence.For those experiencing secondary or empathic trauma such as witnesses or children of survivors, sex-negative and intolerant attitudes and behaviors may also be related to desires to protect and not burden survivors or parents.
Therefore, how are sex-negative and intolerant attitudes in Asian American communities related to the Asian American positioning as the model minority? 20Are the unintelligible and repressed historical and contemporary Asian/Asian American traumas that give rise to sex-negativity and intolerance related to a passive Asian American complicity as the model minority and the tacit acceptance of Euro-American hegemony?How can recognizing and confronting these traumas also open up new spaces and opportunities for alliances with other traumatized groups of people of color and ultimately, for profound and sustainable social transformation?

III. Empirical Research
As someone who moved from engaging in mostly textual, archival, and some qualitative analyses in graduate school to qualitative and quantitative empirical research in my postdoctoral career, I seek to draw from and amalgamate/integrate all the training and methodologies I have been exposed to.However, I do find empirical research especially engaging, because I can apply my prior interdisciplinary analytic training to the empirical evidence, which hopefully enables a synergistic relationship that reinvigorates data collection, analysis, and dissemination.
Both the U.S. National Institutes of Health and the American Public Health Association state that they are striving towards more interdisciplinary methodologies and theoretical frameworks within research (Perrone & Simmons 2006;King 2006).In 2011 the U.S. Institute of Medicine issued a report on lesbian, gay, bisexual, and transgender health, which has galvanized more research funding and health care provision for LGBT populations (Institute, 2011).In the past few years the field of "transgender health" has exponentially expanded.Examples include the annual Philadelphia Trans-Health Conference, which is the largest conference on a transgender topic, with more than N=3200 attendees in 2013 (Callanan, 2013); the U.S. Centers for Disease Control and Prevention funding a Center of Excellence for Transgender Health at University of California at San Francisco (University, 2013); and the Open Society Foundation sponsoring an international seminar and report on international transgender health advocacy (Baker, 2013).
From 2004-09 I was involved in a quantitative longitudinal U.S. National Institute on Drug Abuse-funded study called the "New York Transgender Project," which measured gender identity, identity development, substance use, mental health, and HIV/STI risk among transwomen/transfeminine populations 21 in New York City (N=600, as opposed to these so-called Asian American "cultural norms" actually being manifestations of historical trauma (Scott et al., 2005). 21"Transfeminine" is to "transwoman" what "MSM" is to "gay men."Both "transfeminine" and "MSM" are descriptive (versus identity) terms, and "transfeminine" connotes a much broader spectrum beyond the identity term "transwoman," which often assumes a binary sex/gender system where an individual crosses over from one gender to the other, often through hormone therapy and/or sexual reassignment surgery.In addition, many transfeminine people/transwomen of color may not utilize the term "transwoman" as an identity term for themselves (Hwahng & Lin, 2009;Hwahng & Nuttbrock, 2007;Mazzoni Center, 2011).However, for transfeminine people of color, there is political saliency in situating themselves within the socio-political feminist rubric of "women of color," including the socio-structural/institutional/anti-racist/class inequity/anti-misogynist critiques and movements available in this socio-political feminist positioning.Thus, the term "transwomen of color" will be utilized throughout the majority of this article as a political gesture to align and intersect N=275 tracked for 3 years) and was involved in the outreach, recruitment, interview, data analysis, and write-up process.I also directed my own ethnographic study on socio-structural factors that influence HIV/STI risk behaviors among transwomen/transfeminine communities in NYC and have, to date, identified seven transwomen/transfeminine communities, six of which were poverty-class/low-income transwomen/transfeminine communities of color, with members of at least five of these communities of color actively involved in survival sex work (Hwahng & Nuttbrock, 2007).During the past few years I have also been involved in research projects on (N=100) poverty-class/low-income trans/gender-variant people of color funded by the U.S. Substance Abuse and Mental Health Services Administration, the New York State AIDS Institute, and the Keith Haring Foundation, in conjunction with a community-based organization and two major research institutes.

Embodied Copresence
What I find completely engaging about participating in these empirical research studies is having embodied access within "face-to-face" interactions with participants who often comprise part of the lowest and most marginalized socio-economic echelons within U.S. society.I have found myself traveling through various geographies engaging and interacting with trans/gender-variant people of color in neighborhoods such as Corona Heights, Jamaica, and Jackson Heights in Queens; Bedford-Stuyvesant, Brownsville, Bushwick, Canarsie, East New York, and Coney Island in Brooklyn; Fordham, Hunt's Point, Mott Haven, Parkchester, and Tremont in the Bronx; and East Harlem, Financial District, Harlem, Midtown, and Gramercy in Manhattan.As Erving Goffman has stated, embodied information is comprised of a sender conveying messages through their own current bodily activity, the transmission occurring during the time the body is present to sustain this activity.Conversely, individuals receive embodied messages through their "naked senses," although messages may be qualified and modified by additional information.And of course, within situations of embodied copresence, there is simultaneous sending and receiving of messages between individuals that contributes to "the special mutuality of social interaction" (Goffman 1963: 14-16).
Inherent within the embodied copresence of face-to-face interactions is a richness of information flow and facilitation of feedback perhaps not as available in what Goffman terms disembodied research, which is when information is trapped and held long after the sender has stopped conveying messages (Goffman 1963). 22As a gender-variant-identified researcher, albeit one who is often more socio-economically privileged than the trans/gender-variant participants I am studying, it is extremely fulfilling for me to interact in close proximities to other trans/gender-variant people who have little to no access to dominant institutions and resources.Because this recalls and helps me reconnect to my own ethnic historicized past/present of Korean/Korean War/North Korean poverty and extreme marginalization, which, as part of the model minority in the U.S., I have been conditioned to transfeminine people/transwomen of color experiences and issues with women of color movements and discourses that are also often greatly engaged with poverty-class women of color experiences and issues (Incite!, 2006;Richie, 2012).
forget.It is through my own historical/transnational recollection that I am able to connect in the present moment with poverty-class/low-income trans/gender-variant people of color.

Trans/Gender-variant Research
Three important and memorable discoveries emerged from the panel "Research/Advocacy/Community: Trans Health Disparities Research" that I organized for the Trans Politics, Social Change and Justice conference at the City University of New York in 2005.First, was the amount of interest in this topic on trans/gender-variant health disparities research, which was somewhat unexpected at that time since trans/gender-variant health disparities research did not seem to be of wide interest or discussion among academics and activists in 2005.For those of us on the panel, we were not sure what to expect or who would attend because most panels and workshops at this conference were focused on more general community organizing or legal issues and concerns and not exclusively on health and/or medical issues.It was thus a pleasant surprise that there was full attendance and that the discussion after the panel seemed like it could have easily extended for at least another hour from the time we had to actually terminate discussion for the next workshop.
Second, many of the attendees were students with specific questions on the methodologies, logistics, and ethics of carrying out research among trans/gender-variant communities.Some concerns included outreaching to and recruiting from a diversity of trans/gender-variant communities that were often viewed as "hidden populations" (Gorman et al. 1997;Sterling et al. 2000;Sykes 1999), and the ethics involved in, say, a Euro-American economically privileged researcher conducting research among poverty-class/low-income people of color communities.I recall that innovative possibilities were raised during the discussion for collaborations between (privileged) researchers and (disenfranchised) research participants and their communities, such as mentorship and co-authorship.
And third, was the dearth of transwomen of color at this conference.A conference participant brought this up during the discussion in our panel and this was echoed at later points in the conference.Although I had taken care to assemble a panel that was majority people of color (five out of seven panelists), majority trans/gender-variant (five out of seven panelists), and included three trans/gender-variant people of color, two of whom were transwomen of color, I realized that during the organizing of this conference I had been concerned that transwomen of color would be underrepresented.What this reveals to me is the extent to which organizing and conferences like these are privileged sites.Many transwomen of color, in fact, struggle with basic survival issues such as food, housing, shelter, employment, and health on a daily basis and often comprise the lowest socio-economic echelons among trans/gender-variant communities (Clements-Nolle et al., 2001;Kenagy, 2002Kenagy, , 2005;;Kenagy & Hsieh, 2005;Nemoto et al., 1999Nemoto et al., , 2004aNemoto et al., , 2004b;;Nuttbrock et al., 2009;Weinberg et al., 1999;Valera et al., 2001).In light of the harsh day-to-day logistics many transwomen of color have to contend with, attending conferences like these, which do not seem to directly impact their lives, would probably not have been high priority for them.In retrospect, during the planning of this conference we did a great disservice by not engaging in comprehensive discussions of access and privilege, really mapping which trans/gender-variant communities would actually be in attendance and participating, and how to recruit participation from those communities who probably would not be present.Unfortunately for this conference, transwomen of color ended up only representing a tokenized presence.

IV. Feminism and the Lowest Socio-Economic Echelons
Speaking of transwomen of color, I am not sure which is worseto tokenize transwomen of color, or to exclude them altogether.It strikes me that in repeated discourses around "feminism" in relation to trans/gender-variant identities, transwomen of color have often been altogether ignored.Sometimes these "feminist" conversations may exclusively only engage with privileged (and mostly Euro-American) female-to-male trans/gender-variant/transmen identities, or else engage exclusively with "gender" with perhaps some "class" analyses but elide race, so that only Euro-American transwomen are actually being addressed.
I also noticed that in lesbian feminist discourses "low-income" is often equated as the "working-class" social echelon (Kennedy & Davis, 1994;Nestle, 1992), while members of the poverty-class23 who belong to the "underground economy" (Bourgois, 2002) of survival sex work and drug use/dealing are again marginalized and made invisible.The "working-class" is still within the legal economy, whereas the underground economy is socioeconomically more marginalized and below the "working-class"; those within the underground economy often experience quite different risks, vulnerabilities, and marginalizations compared to those who are working-class.The majority of low-income transwomen of color whom I have researched subsisted within this underground economy and are definitively not working-class, but rather poverty-class.
In addition, Euro-American lesbian discourse often valorizes "working-class" mostly White anatomicallyfemale-born/female-assigned-at-birth ("anatomically-female") lesbians who are able to enact sexual and lifetime partnerships solely with other women (Feinberg, 2004;Kennedy & Davis, 1994;Nestle, 1992).However, public health research has operationalized the category women who have sex with women (WSW)24 in part to examine the phenomenon of poverty-class/low-income drug-using anatomically-female WSW subsisting within the underground economy (many of whom may be gender-variant), and who frequently exchange sex with men for economic survival (Arend 2003;Bell et al. 2006;Diaz et al. 2001;Friedman et al., 2003;Hwahng & Lin, 2009;Hwahng & Ompad, 2012;Johnson 2007;Kral et al. 1997;Ompad et al. 2011).
Comparing the two groups of "WSW" is striking.Whereas the more privileged group of working-class Euro-American lesbian-identified WSW (who are often women who have sex with women only -WSWO) are considered at very low risk for HIV, poverty-class/low-income drug-using WSW (who are mostly women of color, and often women who have sex with women and men-WSWM) have been measured with HIV seroprevalence ranging from 12.8% to 53% (Diaz et al., 2001;Friedman et al., 1999;Ompad et al., 2011).The HIV seroprevalence of this latter group of WSW has often been measured to be even higher than the HIV seroprevalence compared to women who have sex with men only (WSWO) (Absalon et al., 2006;Diaz et al., 2001;Friedman, 1998;Friedman et al., 2003;Hwahng & Ompad, 2012;Magura et al., 1992;Ompad et al., 2011;Scheer at al., 2002;Young et al., 2005;Young et al., 2000;Young et al. 1992) and is even sometimes higher than the "high-risk category" of drug-using men who have sex with men (MSM) in similar social networks and communities of color (Diaz et al., 2001).
Health disparities are often a result of specific structural and cultural factors that influence social, cognitive, behavioral, and psychological mechanisms.What an examination of health outcomes provides is an indication of how cognitive and behavioral patterns perform and reproduce themselves within specific social and cultural milieus, and how particular social structures and institutions perpetuate themselves through the reinforcement of social inequities and health disparities.
Among transwomen of color, then, HIV seroprevalence in the U.S. has been measured to be as high as 63% for African Americans, 50% for Latina/os, and 27% for Asian and Pacific Islanders (Nemoto et al., 1999(Nemoto et al., , 2004a(Nemoto et al., , 2004b;;Clements-Nolle et al., 2001;Kenagy, 2002Kenagy, , 2005;;Kellogg et al., 2001;Nuttbrock et al., 2009;Simon et al., 2000).Along with measurements indicating that transfeminine individuals/transwomen often engage in riskier sexual behavior within riskier sexual networks compared to MSM, cis-gendered women, and female-to-male trans/gender-variant people (FTMs)/transmen, the exorbitantly high HIV rates among transwomen communities of color point to structural and cultural factors that appear to continually marginalize and disenfranchise transwomen of color and limit their access to dominant resources and institutions.
On the other hand, HIV seroprevalence among FTM/transmen is fairly low and since most people who identify as "FTM" or "transmen" are Euro-American and economically and/or educationally privileged, it makes sense that Euro-American privileged FTMs and transmen would have such low HIV seroprevalence, even when these privileged transmen reported engaging in unprotected sex with cis-gender men, including sex work with cisgender men (Clements-Nolle et al. 2001;Kenagy & Hsieh 2005;Reisner et al., 2010;Sevelius et al., 2009).These health statistics merely reflect the inequities and marginalizations within U.S. society, with transwomen of color experiencing higher rates of incarceration, homelessness, unemployment, sex work, HIV/STIs, and having lower education compared to privileged and often white FTMs/transmen (Nemoto et al., 1999(Nemoto et al., , 2004a(Nemoto et al., , 2004b;;Stephens et al., 1999;Clements-Nolle et al., 2001;Kenagy, 2002Kenagy, , 2005;;Kenagy & Hsieh, 2005;Weinberg et al., 1999;Reisner, et al., 2010;Sevelius, 2009;Gwadz et al., 2004;Elifson et al., 1993;Modan et al., 1992;Valenta et al., 1992;Tirelli et al., 1988).These statistics on both transwomen of color and drug-using anatomically-female WSW of color are disturbing since they parallel or exceed HIV seroprevalence in other contexts such as in sub-Saharan Africa, where HIV has been universally acknowledged as a rapidly spreading epidemic.Interestingly enough, the Euro-American trans/gender-variant movement has not included members of the poverty-class/low-income drug-using WSW population as part of its trans/gender-variant movement nor discourse, even though a substantial percentage of poverty-class/low-income drug-using WSW could be considered gender-variant (Hwahng & Ompad, 2012;Lombardi et al., 2011).In addition Euro-American lesbian social service and policy networks have intentionally excluded poverty-class/low-income drug-using WSW because these relatively privileged lesbian networks have viewed drug-using WSW as too stigmatized to incorporate them (Friedman, 2010;Young et al., 2005).
It is particularly telling that anatomically-female individuals who are gender atypical or gender-variant and who have the least access to resources and capital may never have an opportunity to develop a cohesive or coherent transmasculine/gender-variant identity.This was certainly the case for Glenda, an anatomically-female-born Filipina who as an adolescent was attracted to women and identified as a "t-bird" but was born into poverty, raped at the age of 15 years by a much older cis-gender man, ostracized by her family, and economically coerced into the U.S. military sex industry.After an unsuccessful marriage to a Euro-American military soldier stationed in the Philippines in which she bore two children, one who died at a young age, she was finally able to partner with another anatomically-female Filipina sex worker and form a "family" of sorts.Since at the time of her narrative both her and her partner were U.S. military sex workers, it could probably be assumed that the social structure they created was fragile and highly vulnerable to the constraints of economic necessity and the whims of various U.S. military personnel and clients (in Sturdevant & Stoltzfus, 1993).
In the U.S. there also appears to be systematic aggression against anatomically-female individuals who are either sexual minorities and/or gender atypical, and such anatomically-female individuals who are the most socially (race/class) marginalized may also be the most vulnerable to this systematic violence.Psychological, social scientific, and public health research indicate that an underlying factor of multiple health disparities experienced by WSW may be heightened risk for childhood abuse victimization compared to women who have sex with men only (WSMO), and the reason for WSW's vulnerability to childhood and adolescent abuse as youth was due to their gender atypicality.In addition, the sexual, physical, and/or psychological abuse experienced during childhood and adolescence by WSW tended to be more chronic compared to the abuse experienced by WSMO (Austin et al., 2008;D'Augelli, 2003;Cooperman et al., 2003;Descamps et al. 2000;Saewyc et al., 1999;Scheer et al., 2003;Tjaden et al., 1999).
In fact, in a study comparing WSW with their WSMO siblings, WSW reported higher levels of psychological, physical, and sexual violence in both childhood and adulthood (Balsam et al., 2005).This research thus suggests that sexual minority/gender atypical anatomically-female youth are at greater risk for victimization compared to their heterosexually-behaving siblings, and in general, sexual minority/gender atypical (female) youth may be singled out by their parents, other family members, and neighbors for maltreatment (Austin et al., 2008;Balsam, 2003;Balsam et al., 2005;D'Augelli, 2003;D'Augelli et al., 2006;Hall, 1998;Roberts et al., 2012;Robohm et al., 2003;Saewyc et al. 2006).Research also indicates that WSW may experience adult abuse and victimization as a continuation of the cycle of childhood and adolescent abuse and victimization, in which adult victimization is actually a "re-traumatization" arising from prior trauma and abuse (Balsam et al., 2004;Balsam et al., 2005).Scientific literature also reveals that sexual minority/gender-atypical anatomically-male youth are also at greater risk for victimization compared to heterosexually-behaving male youth (Balsam et al., 2005;D'Augelli et al., 2006).Yet it is revealing that the rates of abuse among sexual minority/gender-atypical anatomically-female youth are still even greater than the rates of abuse among sexual minority/gender-atypical male (AMB/MAB) youth (Balsam et al., 2005;Friedman et al., 2011;Robohm et al., 2003;Tjaden et al., 1999). 25  For gender and sexual minority people of color, this cycle of abuse and victimization may have been originally initiated by racialized "historical trauma," in which inter-personal trauma experienced over the life course compounds the historical trauma.Racialized historical violence such as genocide, colonization, slavery, etc. has been measured to be transmitted inter-generationally, in which historical trauma particularly affects gender and sexual minorities more than heterosexuals (Balsam et al., 2004;Hwahng & Nuttbrock, in press).This may explain, in part, why WSW of color often experience higher rates of lifetime victimization and greater negative health outcomes compared to both White WSW and WSMO of color (Balsam et al., 2004;Cochran et al., 2007;Cooperman et al., 2003;Descamps et al., 2000;Hughes et al., 2003;Mays et al., 2002;Morris & Balsam, 2003). 25Researchers also acknowledge that childhood sexual abuse (CSA) does not "cause" homosexual behavior; rather, gay, lesbian and bisexual children/adolescents are more gender-atypical compared to heterosexual children/adolescents and perpetrators tend to target gender-atypical children/adolescents for sexual abuse (Austin et al., 2008;Balsam, 2003;Balsam et al., 2005;D'Augelli, 2003;D'Augelli et al., 2006;Hall, 1998;Roberts et al., 2012;Robohm et al., 2003;Saewyc et al. 2006).Among anatomically-female individuals, WSW have experienced more CSA compared to WSMO.Among WSW, WSWM have experienced more sexual abuse compared to WSWO (Austin et al., 2008;Balsam et al., 2005;Friedman et al., 2011;Scheer et al., 2003).For some groups of WSWM, then, sexual behavior with men may be a form of adult re-traumatization of CSA, since the vast majority of CSA perpetrators in many studies were/are cis-gendered boys/men (Balsam et al, 2005).
Thus, poverty-class/low-income drug-using WSW of color, positioned as one of the groups that occupy the lowest socio-economic echelons, have been especially targeted for violence.Coming from contexts of multigenerational poverty and as anatomically-female people of color who were often gender-atypical as youth, they often experienced chronic childhood and adolescent abuse from a very young age, which was often sexual abuse accompanied by other forms of abuse (Hwahng & Ompad, 2012;Magura, 1992).As poverty-class/low-income anatomically-female youth and adults of color, they also often did not have access to resources and capital to adequately and comprehensively address and cope with the effects of their traumas, much less access to resources and capital to "reflect" or enter into comprehensive "discourses" on their gender identity.Nor did they have much if any opportunities to develop a cohesive or coherent gender-variant and/or transmasculine identity, especially an identity that would be recognizable by those within more privileged socio-economic echelons.
It is telling that in empirical research on low-income transwomen of color vs. transmen of color, lowincome transmen of color still appeared to have more access to resources and capital compared to low-income transwomen of color (Hwahng et al., 2013c).It is not that claiming a cohesive transmale identity somehow miraculously grants an anatomically-female individual more access to resources and capital; what is operationalized is that anatomically-female individuals must already have a certain amount of access to resources and capital in order to take on a transmale identity that is considered coherent, cohesive, and socially recognizable, especially by those located within more socio-economically privileged echelons, such as policymakers, educators, and social service/health service providers.Since within heteropatriarchal systems both in the U.S. and globally, masculinity is valued over femininity, anatomically-female individuals must somehow "purchase" and prove their masculinity and/or maleness through their access to resources and capital, because within heteropatriarchal logic they are claiming a more privileged status by claiming a coherent masculine/male identity. 26In contrast, anatomically-maleborn transfeminine individuals/transwomen within heteropatriarchal logic are viewed as losing status when taking on a feminine and/or female identity, and this loss of status could be considered as a punitive loss for their androphilia (i.e.attraction to men) and/or gender variance.Thus, unlike transmale individuals, transfeminine individuals/transwomen do not need to have access to resources and capital in order to claim a feminine and/or female identity, and many transfeminine individuals/transwomen come from the lowest socio-economic echelons, which are reflected in the extremely high rates of HIV seroprevalence, violence, and exploitation of this population.
26 Even in the middle-income country of Thailand, variation of privilege among anatomically-female individuals resulted in the level of coherence, cohesiveness, and social recognizability of their gendervariant/transmasculine identities.Sinnott (2004) writes that the socially recognizable transmasculine identity of "tom" was most evident and coherent among middle-class anatomically-female individuals.Sinnott also discusses the ostracization of a low-income anatomically-female individual who, out of economic necessity, was involved in sex work with cis-gendered men and was sexually partnering with a German cis-gendered man in order to gain access to education.Although this low-income anatomically-female individual self-identified as a "tom," she was socially rejected and ostracized by other more socio-economically privileged toms, who could not reconcile her participation in survival sex work with the transmasculine identity of tom (157-160).Thus, in this example, it is clear that only those anatomically-female individuals who had access to resources and capital to circumvent economically-coerced participation in sex work and were financially stable, often through inherited familial socio-economic privilege, were also able to fully claim a tom identity that was validated and socially recognized by other privileged toms.
We thus see that among the low-income anatomically-female people of color populations who are gender and sexual minority youth there are actually variation in access to resources and capital, which has influenced their gender expression and identities.Low-income anatomically-female people of color who had relatively greater access to resources, which may have manifested in the absence of childhood and adolescent sexual abuse, and relatively greater familial and social support, financial resources, educational opportunities, etc., may have also been able to develop more coherent, cohesive, and socially recognizable transmasculine and/or gender-variant identities such as transmen, aggressives/AGs, studs, stems 27 , or butches.
In contrast, low-income sexual minority/gender-atypical anatomically-female people of color who had the least amount of access to resources and capital were more likely to be poverty-class, suffer more severe and chronic forms of childhood and adolescent abuse (including sexual abuse), and had very little to no familial or social support, financial resources, educational opportunities, etc.Some individuals in this latter group may have thus taken the trajectory of illicit drug use (including injection drug use), survival sex with high HIV risk men, and vulnerability to chronic violence (often sexual) and incarceration (Saewyc et al., 2006), in which the development of a cohesive transmasculine/transmale gender identity was not able to occur nor was it encouraged.In this regard, this latter group had never developed their own internal sense of identifying and naming their gender, and have thus been categorized by public health outsiders as "WSW" for lack of a better term(s). 28  Although well-intentioned, queer/trans studies and feminist literature that have only focused on those anatomically-female individuals who have been able to claim a coherent and cohesive transmasculine/transmale identity that is socially recognizable within privileged socio-economic echelons without acknowledging the privilege that these anatomically-female individuals possess in order to make these transmasculine claims run the risk of valorizing this privilege.At the same time this valorization elides this privilege by focusing on the transmasculine gender presentations/identities (as opposed to their socio-economic-political contexts) as the overarching framework of these individuals' social positioning (Halberstam, 1998a;Prosser, 1998), and unwittingly sets up an implicit white supremacist construct of transmasculinity in which the racial group with the most privilege -Euro-Western whitesare able to construct, present, and perform the most cohesive forms of transmasculinity. 2927 "Stem" refers to someone who alternates between a "stud" and "femme" identity, and seems to be common vernacular among young low-income transmasculine people of color in New York City (Hwahng et al., 2013c). 28Although there has been some discussion in public health discourse of the limitations of MSM, MSMW, WSW, and WSWM terms (Young & Meyer, 2005), to date, more precise or meaningful terms have not been developed. 29For instance, according to Halberstam, 1998, the manifestation of a visible coherent anatomically-female masculinity (that does not include an identity as transmen) is somehow inherently liberatory, and exceeds institutionalized heteropatriarchal constrictions.Yet Halberstam does not engage in a reflexive socio-economicpolitical analysis of their "masculine female" subjects, therefore eliding much of the racial, class, and citizenship privilege (read: white, middle-class, and/or citizens of developed/First World/Global North countries) that allows these subjects to at least appear as if they are able to overcome heteropatriarchal institutions.In contrast, many toms in Thailand, by virtue of being middle-class, are able to present a coherent transmasculinity that is actually connected to a long history of transmasculinity within Thai culture, as Sinnott, 2004, discusses.However, because toms, as Thais, are located within a Southeast Asian country that has historically been a developing/low-income/Global South country, toms have historically not had the racial nor citizenship privilege that Halberstam's subjects have.Thus, the transmasculinity of tomness has actually been successfully deployed to reinforce Thai heteropatriarchy, as discussed in footnote 12.
In addition, greatly disenfranchised/marginalized anatomically-female gender-variant individuals who do not have access or opportunities to develop a cohesive/coherent transmasculine identity are re-marginalized and resilenced since they have not even been acknowledged within this literature.As if all anatomically-female individuals always already have the access and resources to claim a coherent and cohesive transmasculine and/or transmale identity if they so choose.And this valorization of the transmasculinity of privileged 30 anatomicallyfemale individuals almost seems to occur at the expense of ignoring and disregarding highly disenfranchised/marginalized sexual minority/gender atypical anatomically-female individuals who have not been able to develop a transmasculinity and/or gender-variance that is coherent, cohesive, and socially recognizable within socio-economically privileged contexts.
For instance, are the supposed differentials between "butches" and "FTMs" in the "butch/FTM border wars" (Halberstam, 1998b;Hale, 1998) that are based on economically-privileged Euro-Western individuals and communities actually that vast and profound when also taking into consideration the lives of highly disenfranchised/marginalized sexual minority/gender atypical anatomically-female individuals of color who have not been able to develop a transmasculinity and/or gender-variance that is coherent, cohesive, and socially recognizable?Or does the full incorporation of disenfranchised/marginalized sexual minority/gender atypical anatomically-female individuals of color into this field of masculine of center/transmasculinity actually render the "butch/FTM border wars" as a phenomena that may be quite myopic and mostly relevant to economically-privileged Euro-Western sexual minority/gender atypical anatomically-female individuals?Which also begs the question of why so much attention, in certain areas of academia, was/is invested in this "border wars" phenomenon that clearly elides race and class and reifies "gender/sexual identity" as the primary category that is privileged over race and class?
If feminism is to have any significant political relevance, it must fully address and interrogate gender in relation to social inequities, and it thus seems almost socially irresponsible to exclude those trans/gender-variant people and WSW/sexual minority women who often suffer the greatest inequities.Feminism as an analytic framework could be highly useful and effective in discerning how structural and cultural factors influence social, cognitive, behavioral, and psychological mechanisms and patterns that manifest in extremely high HIV 30 Both Halberstam and Prosser examine either socio-economically privileged transmasculine individuals and/or privileged representations of transmasculine individuals who are often Euro-American.These include individuals who wrote their own autobiographies and memoirs that were published by literary presses, individuals who performed in venues located within high-end, gentrified, and mostly Euro-American urban neighborhoods such as the East Village in New York City, and Hollywood and/or blockbuster fictional and semi-fictional representations that may not accurately reflect actual people's lives.Even the extensive coverage of Brandon Teena, a young transmasculine individual who experienced a tragic homicidal death, in queer/trans/feminist studies literature begs the question that as a Euro-American working-class individual, did he still have enough racial and class privilege to elicit both a feature-length documentary and a feature-length fictionalized Oscarwinning film, along with the numerous essays and articles devoted to the analysis of his life?The answer seems to be affirmative, since there does not appear to be any poverty-class/low-income transmasculine, sexual minority, and/or gender-variant anatomically-female person of color -dead or alive -that has garnered anywhere close to the same amount of attention.Not to mention the dozens of young poverty-class transwomen of color who suffer homicidal deaths every month in the U.S.
seroprevalence among poverty-class/low-income gender and sexual minority people of color, such as the transfeminine/transwomen and WSW/sexual minority women populations I have discussed. 31Women of color feminist/womanist literature has often critiqued many forms of feminism as white supremacist (Collins, 1991;hooks, 1981;hooks 1984;Hurtado, 1996;Incite! 2006;Richie, 2012) and these types of critiques and interventions must also be carried forth into the realms of queer/trans/gender-variant theory, research, and academic literatures that reify the privileged at the expense and/or elision of the disenfranchised and marginalized.Women of color feminisms, in relation/addition to other social movements, have also examined and provided evidence that the most highly disenfranchised and marginalized sectors and members of societies are never fully included nor served within the current white supremacist heteropatriarchal capitalist administrative bureaucratic systems and structures of contemporary U.S. and other large societies, and a transformation of these systems and structures are urgently needed (Incite! 2006(Incite! , 2007;;Richie 2012).
In my research praxis, the attendant experiences of embodied copresence, the richness of information flow, and the recovery of the formerly suppressed past have helped me to reorganize and prioritize my own values within a cosmology that will remain incomplete until the lowest socio-economic echelons are not only addressed but also foregrounded and integrated within any conceptual, theoretical, or political framework or system, such as feminism, social scientific analysis, race/ethnic/Asian/Asian American studies, queer theory/studies, trans/gender-variant studies/research, and/or public health discourse.Perhaps it is often within the lowest socio-economic echelons that the particular vulnerabilities and resiliencies of humanity are most directly evident, thoroughly intersected by the multiple effects of poverty and survival.It is these vulnerabilities and resiliencies of humanity that I am sure my parents, grandparents, great-grandparents, ancestors, and the majority of North Koreans have had to experience and negotiate in their lives.I always sensed these vulnerabilities and resiliencies within situations of embodied copresence with my older relatives but could not give full meaning to them because the full expression of them were tucked away just out of my field of vision, but not quite out of my field of sensing.My participation in embodied empirical trans/gender-variant research has not only reaffirmed my commitment to those who are the most marginalized but has reaffirmed my commitment to humanity itself through deeply informing who I am and where I proceed in my life and my work.
V. On Health, Well-Being and Happiness Incorporating the various strains of transnational and inter-generational trauma, empirical research, mental and physical health disparities, sexual and gender minority victimization, and interrogations of (bio)power and privilege into the theme of this special issue on Translating Happiness: Medicine, Culture and Social Progress gives rise to this question: is happiness directly correlated to health and well-being?And what are health and well-being and how do we describe and measure them?Do we accept the standard medical/health definitions of health and or do these definitions diverge from an exploration of optimal health and well-being?And if there are divergences, how would optimal health and well-being manifest, be identified, or even measured?Both the economist/philosopher Amartya Sen and the epidemiologist Michael Marmot examine the concepts of happiness, health, and well-being, with Marmot elaborating on Sen's initial premises on these subject matters.Sen (1992) first describes "space" as a chosen focal variable and characteristics of inequality in different spaces (such as income, wealth, happiness, etc.) may deviate from each other (2).Sen also describes "functionings" as "beings and doings," in which an individual measures their achievement at the vector of these functionings (39).Functionings range from being adequately nourished, being in good health, avoiding escapable morbidity and premature mortality, to what he describes as "more complex achievements" such as being happy, having selfrespect, and taking part in the life of the community.Functionings are constitutive of an individual's being, and an evaluation of well-being has to assess functionings as constitutive elements."Capability" is a set of vectors of functionings and is a reflection of the freedom to achieve valuable functionings.Capability focuses on freedom, including the freedom to achieve well-being, and identifies the real alternatives available to an individual.
Sen also posits that measuring "well-being" through the "utilities" and "mental metrics" of pleasures, happiness, or desire-fulfillment can be erroneous and that the full range of capabilities cannot be ascertained within solely the metrics of these utilities (53-5).Although a utility such as happiness can count as an important functioning, it is not the only valuable functioning, and if well-being is only measured through the metric of happiness, then all other functionings would become deprioritized and be valued only to the extent they contribute towards the measurement of happiness (54).
Sen interrogates the duplicity of focusing solely on the measure of "happiness," by offering the example of a thoroughly deprived individual, in whom hardship has become so utterly normalized that this hardship is accepted with resignation, and perhaps a resignation that has also been so normalized and internalized that the individual is not even aware of their own resignation.When situations of continual deprivations have occurred over a long period of time, the "victims" of these deprivations "do not go on grieving and lamenting all the time, and very often make great efforts to take pleasure in small 'mercies' and to cut down personal desires to modest -'realistic'proportions" (55).Sen offers that through "prudential reasoning," "victims" focus their desires on those limited things they can possibly achieve, rather than fruitlessly pining for what is unattainable (55).And thus, the achievement of such "limited things" may lead to (short-lived?) pleasure, happiness, or fulfillment of desires, although personally, I question the sustainability of these functioning-utilities that have been derived from such a context of prudential reasoning.
And perhaps, that is how the capitalist bureaucratic structure of U.S. society, as well as many other societies, sustains itself.That within a society ensconced within a context of prudential reasoning the normalization of resignation has led to members of society to be not even aware of both their individual and collective resignation, much less the prudential reasoning that arises from such resignation.And thus the provision of "limited things" and "small mercies" that an individual can or "must" procure in order to achieve the functioning-utilities of pleasure, happiness, and desire-fulfillment that are always already highly limited in temporality, remains unquestioned and perceived as fundamental to the sustenance of life itself.Hence, life sustenance is then conflated with the continual provision of such "limited things" and "small mercies," in which this provision must be continual because the attendant functioning-utilities of pleasure, happiness, and desire-fulfillment expire so quickly.And the market demand for such continual provision then obviously buttresses the (white supremacist and heteropatriarchal) capitalist administrative bureaucratic complexes. 32en thus concludes that the nature of entrenched inequalities and deprivations can be more clearly elucidated by focusing on socially generated differences in important capabilities, including those capabilities that the chronically deprived dare not covet (55).In another monograph, Sen (1999) describes poverty as capability deprivation and that low income is only instrumentally, not intrinsically, important, because income is not the only instrument in generating capabilities.Furthermore, the instrumental relation between low income and low capability is variable between different communities, families, and individuals (88).What is intrinsically important to understanding the nature and characteristics of poverty, then, is the deprivation of capabilities, i.e. a deprivation of the freedoms to achieve valuable functionings, such as adequate nourishment, good health, education, community engagement, political participation, happiness, and self-respect.
If income is a "means" to achieve certain "ends" of valuable functionings, Sen argues that it is more constructive to focus on the "ends" themselves, and the freedom to achieve these ends (90).For example, "real poverty" as capability deprivation may be even more "intense" than what appears in the income "space," measured by income metrics (88).And an individual with high income but no opportunity for political participation is not poor in terms of income but "poor" in terms of an important freedom (93-4).This latter example appears to be pertinent to the discussion of the largely unaddressed Asian American trauma I interrogated at the beginning of this article.Could it be that this unaddressed Asian American trauma limits the political capabilities of Asian Americans, such that Asian Americans remain highly politically capability-deprived despite performing the racist social scripting of the socio-economically privileged model minority? 33And in regards to the poverty-class transwomen of color and poverty-class drug-using sexual minority anatomically-female women of color I have discussed, are their capabilitydeprivations even more "intense" than a low income metric could ever indicate?34And for all three groups mentioned in this paragraph, how do these capability-deprivations then limit their freedom to achieve health, wellbeing, and yes, even happiness?Extending Sen's premises more fully into discussions of health, Marmot (2004) argues that lack of social participation and inadequate control over one's life leads to chronic stress and behaviors that negatively impact health.Marmot's fundamental proposition is that the status position that an individual occupies within a socioeconomic hierarchy is what determines that individual's health.And that even minor differences in positions within this "social gradient" can result in measurable differences in health outcomes (38)(39)(40)(41)(42)(43).Marmot also correlates the level of happiness to an individual's position within the socio-economic hierarchy, in which happiness is perceived as "subjective well-being" (85).Marmot's propositions, then, would appear to somewhat contradict Sen's premise that members of highly socio-economically marginalized may measure as deceptively "happier" compared to a full assessment of their capabilities.Yet, perhaps, what may be occurring is that at least for some highly socioeconomically marginalized individuals, despite possibly measuring at inflated levels on the "happiness" scale, will still measure as less happy compared to individuals with even incrementally greater status and socio-economic privilege.
In addressing inequality, Marmot writes that, "A society that excludes high proportions of its population from full social participation is one that does not value all its people equally highly… [and] is likely not to provide the conditions that favor good health" (80).What I posit here is that in a society that is highly inequitable such as the U.S., as manifested in "conditions that [do not] favor good health" and the consequent severe health disparities that arise from such conditions, that it is perhaps all members of such a society that do not experience optimal health, even those who are positioned at the top of the status and socio-economic hierarchy.Chandra T. Mohanty's (2003) discussion of the importance of locating and asserting knowledge outside the parameters of the dominant in order to fully perceive, support, and serve the highly disenfranchised (figured as "Third World Women" in Mohanty's discourse) is also an appeal for the "rethinking of sociality itself " (83).Imbricating this appeal for the "rethinking of sociality" with women of color feminist critiques of the medical, health, social service, and non-profit industrial complexes (Incite!, 2009;Richie, 2012) thus calls for the unpacking, deconstruction, and further interrogation of such concepts as "happiness," "health," and "full social participation."Although Marmot advocates for the "improvement of social conditions" (46) for the disenfranchised, I question if some of the recommended steps in his book (259-71) that seek improvements within a white-supremacist, heteropatriarchal capitalist administrative bureaucratic system would result in major positive transformations of health for the disenfranchised, especially because Marmot provides ample evidence that an individual's status position within a socio-economic hierarchy relative to the position of others will then determine positive or negative heath outcomes.Even if highly marginalized individuals and communities were to experience an improvement of their social conditions within the current systems, wouldn't they still be positioned lower than many other individuals and communities of much greater status and socio-economic privilege?And, thus, are these recommended steps the best social and health outcomes we can imagine or is this "improvement" approach arising from (an unconscious) prudential reasoning on the part of some scientific researchers?In which, perhaps, scientific researchers have experienced such continual apparently insurmountable difficulty and "hardship" at attempting to re/solve the "plights" of the disenfranchised and marginalized that these scientific researchers have unwittingly internalized their resignation and dare not strive for full resolution of these challenges?And instead these researchers settle for the "little things" and "small mercies" of possibly minor and temporally-limited improvements within a white-supremacist, heteropatriarchal capitalist administrative bureaucratic system that is set up to always already fail, especially, the most vulnerable members of a given society?
In a society such as the U.S. in which many consider, perhaps with resignation, that vast social inequities are inevitable, are the scientifically-measured high levels of "happiness" and "health" experienced by the privileged few at the top of the socio-economic hierarchy actually the optimal levels of happiness and health these individuals could experience?Or through layers of historical sedimentations of normalized and internalized resignation and prudential reasoning, have we come, as a society, to "settle" for sub-optimal levels of both happiness and health that are now (possibly delusionally?)measured as "high" levels of happiness and health because we must set the bar fairly low in an inequitable society?And in unpacking Marmot's conceptualization of a "full participation in society" that is supposedly available to those individuals at the top of the status/socio-economic hierarchy, how much can these individuals really "fully participate" if they cannot wholly interact with many sectors of a society so thoroughly dissociated by vectors of race, class, gender, and sexual orientation, such as in the U.S.? What is full social participation if even the most highly socio-economically privileged individuals cannot really cross these vectors of power and privilege, cannot really engage with all sectors of society?(Although, granted, the highly privileged would have the greatest access to dominant institutions and resources.)Would a rethought, reorganized, more equitable and transformed society always already enable greater latitude for a fuller social participation by more members of this society, including a fuller social participation for even the most privileged?And what would be the ramifications for health, well-being, and happiness in a society with greater social participation for all?Consider the various strains of marginalized and disenfranchised lives and experiences explored in this article, such as North Koreans, immigrant Asian American war survivors, poverty-class transwomen of color, and poverty-class sexual minority women of color.Through a careful consideration, it appears that the "small mercies" of "improvements" within the white supremacist heteropatriarchal capitalist administrative bureaucratic system that may have initially emerged from resignation and prudential reasoning has now become the "norm" for many public health recommendations, interventions, and policies.The "small mercies" that constitute the reductionist "norm" of public health praxis must give way to larger and more expansive contextual and practical visions of social transformation, including those visions informed by women of color feminisms, if we are to continue towards optimal health, well-being, and happiness.