1. An intersectional feminist politics of shame for institutions

Feminist attention to shame stems largely from the inequitable distribution of shame across gendered bodies and the relationship of shame and power (Fischer Reference Fischer2018). This unequal distribution is no less relevant within the bounds of a specific institution than within broader social life and focusing on institutions enables attention to how a politics of shame might be concretely enacted. Institutions like, in this case, medicine, represent sets of rules and norms that dictate agential operation within a system. Organizations are instantiations of institutions, guided by institutional norms; together organizations and institutions aim to enact stability in social life (Meyer and Rowan Reference Meyer and Rowan1978). At the same time, institutions are made up of agents, and despite their seeming stability, institutions reflect shifts and changes over time. Agential participation in institutions like medicine is often bounded by credentialing or other markers of belonging, shrinking the participants who can enact institutional shifts from the inside. In the case discussed here, members of medical organizations enact one politics of shame in response to the norms and practices of their institution. Institutional life is not and should not be the endpoint of a social politics of gendered shame: institutions are normative structures which can occlude broader social movements toward justice. Nonetheless, a rich history of institutional change theory and the role of gendered actors within institutions suggests promise in better understanding how the political dimensions of shame operate within such bounded spaces and their specific histories of gendered and racialized shame (Parsons and Priola Reference Parsons and Priola2013; Meyerson and Scully Reference Meyerson, Scully and Price2009; Martin and Meyerson Reference Martin, Meyerson, Louis, Boland and Thomas1988).Footnote ²

To give an account of shame in this paper, I draw largely on Sara Ahmed’s affect theory, and on the long tradition of intersectional feminism. In The politics of emotion, Ahmed describes her theory as working to unsettle an idea of emotions as either “inside-out” (felt individually and then shared) or “outside in” (created in an individual by external factors) (2014, 9–10). Emotions, instead, move back and forth between—and constitute—individual bodies and their contexts. Ahmed is centrally concerned with how shame lets individuals “claim identity” in relation to larger groups; in her case, national identity, and in the case I will present, professional or institutional identity. Because shame is so linked to identity, an intersectional politics is key, following Kimberlé Crenshaw’s initial assertion that this framework can help to “[mediate] the tension between assertions of multiple identity and the ongoing necessity of group politics” (Reference Crenshaw1991, 1296). Intersectionality continues as a living theory and term in feminist work; following Patricia Hill Collins (Reference Collins2015), in this paper I aim to use intersectionality as a analytic strategy to clarify a social phenomenon—how gender, race, and the identity work forced within cultures of shame manifest in health and medicine.

Ahmed describes the feeling of shame as burning with “self-negation … an intense feeling of the subject ‘being against itself’” (2014, 103). Key to this account is that shame is, paradoxically, about both visibility and invisibility. An individual experiencing shame may feel globally flawed and desperate to disappear. In Gabriele Taylor’s work, shame is distinguished from other self-focused emotions like guilt because it skewers the whole self, while guilt more narrowly castigates an action (Reference Taylor1985). Ahmed similarly distinguishes between shame and guilt, describing shame as lacking the recognition in guilt of an action or next step; in shame, the object of focus is the flawed and negated self. But a shamed person may also be seeking reintegration into the fold, and longing for a re-making-visible of the self in a less damaging (or damaged) form. Ahmed’s theory of stickiness emphasizes how re-making of the self can be more or less challenging depending on one’s race, or other visible identities or signifiers to which one is attached. Ahmed’s theory begins with the notion that emotions work to “surface” differences, constituting a subject through the intersubjective movement of feeling (Ahmed Reference Ahmed2004, 112). These emotions work to attach individuals to communities, and signifiers to subjects. Following Ahmed, some signifiers are “stickier” than others; for example, one’s apparent ethnicity is more likely to influence how others judge you than your shoe color because your perceived ethnicity sticks to you in concurrence with long histories of racial and ethnic stereotyping (Ahmed Reference Ahmed2004, 126). I suggest that, in institutions, the stickiness of signifiers can conflict with the shame-as-pedagogy that is used to demand (or ideally teach) changes in the self.

Shame-as-pedagogy through training in the institution of medicine, and especially in the teaching hospital, has been well-documented and is growing more contested. Medical training in the US follows a basic structure: a student receives a bachelor’s degree, then undertakes four years of medical school. The first two years of medical school are primarily classroom-based instruction in the basic sciences, while the second two are the “clinical” years, when a student gets exposure to the workings of the hospital. Following medical school, newly minted MDs enter a residency, when they work as doctors-in-training and continue building specialized skills; depending on the field of medicine, residency and then optional additional fellowship training can be from four to well over ten years. This extensive training makes the doctor a participant in the institution, a “professional.”

In the clinical years of medical school and into residency, the most “classic” form of shame pedagogy in US medical education is “pimping,” a pedagogy marked by questioning of a learner with intent to “cause discomfort such as shame or humiliation as a means of maintaining the power hierarchy in medical education” (Kost and Chen Reference Kost and Chen2015, 21).Footnote ³ Pimping is controversial and not used by all or even necessarily by most teachers—but in nationally collected surveys on medical training, over 20% of students report experiencing public humiliation at the hands of medical school faculty, staff, or from their peers (Association of American Medical Colleges 2021). This pervasive sense of shame may stem from the high-stakes and high-pressure nature of medical training, the perfectionism expected from students, and the deeply hierarchical power structure of the hospital. “Pimping” as a shame practice is not an inherently gendered form of shaming, but must be understood in relationship to the “ubiquitous” nature of gendered shame; or in other words, the way that shame always underlies existence in a gendered body (Mann Reference Mann2018, 403). At the same time, shame is unpredictable: while a student may be expected to feel shame in response to such pedagogies, individuals may resist, refuse, or move quickly through shame reactions. Nonetheless, such pedagogies serve to illustrate what has been proposed as a “culture of shame” in medical institutions, and highlight the potential of enacting an intersectional politics of shame in this context (Sklar Reference Sklar2019).

2. Theorizing gendered shame as institutional discipline

Shame has a long history in educational organizations as both a social emotion and an explicit force of surveillance and discipline. To understand gendered shame as discipline, I center the subtle relationship between shame and power in the institutional context, using Ahmed’s account of shame alongside the work of Michel Foucault and Bonnie Mann. In Discipline and punish, Foucault describes a military school in which students are classified based on their “performance,” with the “best” students wearing silver epaulettes, the secondary wearing red and silver, the “mediocre” students wearing red, and the bad—the “shameful class”—wearing brown. As Foucault explains, this process of making shame explicit “existed only to disappear,” as students are intended to climb the hierarchy and lose their badge of dishonor. This model “exercised over [the students] a constant pressure to conform … so that they might all be subjected to subordination, docility, attention … and all the parts of discipline” (1995, 182). So, shame and public shame in the learning space have long been linked to mechanisms of power and discipline, forces leading to greater conformity. Following Ahmed’s account, shame exists to disappear such that the shamed person might reappear, visible again unmarked by shame. Within institutions, shame can be a racialized form of governmentality and manifestation of institutional power (Dar and Ibrahim Reference Dar and Ibrahim2019). Explicit shaming pedagogies reflect Foucault’s “disciplinary society” threaded by surveillance, classification, normalization, and manifestations of power (Foucault Reference Foucault1995, 209).

In The history of sexuality, volume I, Foucault triangulates the power-knowledge formation central to Discipline and punish into power-knowledge-pleasure. As bodies became objects of knowledge through the organizational and classificatory development technocratic society, power to wield knowledge meant power to control bodies. At the same time, power drives the creation of knowledge (Foucault Reference Foucault1995). Adding “pleasure” as a third point in the relationship between power and knowledge ties Foucault’s analysis of epistemically driven institutions like medicine and schools into his analysis of sexuality. It also opens space to consider the non-cognitive or non-linguistic elements of power-knowledge as part of the larger structures of discipline and surveillance shaping institutions. This formulation serves as a link between affective experience (though Foucault did not think in terms of affect) and the circulations of power. In his formulation, knowledge, power, and pleasure entangle as the creation of knowledge increases pleasure alongside power; or power begets knowledge which is itself pleasurable; or restricting knowledge is a form of power that is pleasurable.

In invoking the relationship between knowledge, power, and pleasure, I extend pleasure to a more general sense of affect—of feeling, desire, and all the ambient non-psychological and non-cognitive forces that impact bodies within institutions and social life. In the #MedBikini case, an article written as a contribution to the formal knowledge of the medical field served to spark shame; perhaps a sort of pleasure in the shaming of others; and certainly, to exert the power of professionalism as an arm of gendered authority in the field. Karen Adkins writes that shame within a community (like a profession) is both an ethical and epistemic act—for shame to “land,” there must be epistemic agreement about its root cause (Reference Adkins2019). There can be pleasure in that agreement and “rightness,” when shame is seen by some in the community as valuable; shame can be considered a “pro-social” emotion—sometimes it encourages adherence to norms that are positive, useful, or simply necessary for social interaction.Footnote ⁴ For others in the community, rejecting dominant emotional norms—what Xine Yao describes as “disaffection”—is the most salient option. As such, shame in medical education remains a tricky business: shame is not necessarily all bad (although for a shamed person it can feel this way) nor is it inherently a pedagogical good. Centralizing shame-as-discipline and the relationship between shame, knowledge, and power serves to sidestep, at least momentarily, some of the subjective experience of shame in service of understanding the way shame works to structure the institution.

Understanding shame as a social affect means understanding its role in self–other communications and in subjectification. Across feminist philosophies of emotion shame is a productive emotion—more specifically an identity-producing emotion. Shame can intensify and attaches to almost any trigger or phenomenon—there is no “thing” that is inherently shameful, but rather shame is a response which attaches itself to other things (Sedgwick Reference Sedgwick2002, 62; Tomkins Reference Tomkins2008). Shame’s sociality makes the relationships that we have with other people and, in doing so, creates the subject in relation to the social world—for both Ahmed and Mann, shame binds individuals in relation to the nation or national group. In Mann’s account, shame can bind to almost anything including gender performance, and in the reinforcement of gender-based shame, shame can build a gender identity (Mann Reference Mann2014, 115). Akin to Foucault’s structure of power, shame is a morphing force that does not necessarily come from above or from outside but can come from within or from below.

Shame and particularly gendered shame may play an outsized role in the formulation of power and knowledge in medical training and the functioning of the institution through its impact on identity. In Mann’s account of the shame to power conversion, a shamed male transforms his gender-based shame into a performance of masculinity and masculine power in a means of self-redemption. Mann writes, “Shame produces a turning inward of the self on the self. Its redemption in the shame-to-power conversion provides the relief of an ecstatic self, a self-outside-of-itself among others. It therefore establishes the conditions in which belonging, when it is achieved, will be the object of a kind of greater-than-life passion” (2014, 129). Contra, Mann argues elsewhere that gender shame for girls or femmes is often unredeemable—the self can never be relieved and the person can never regain belonging (2018). In the shame-to-power conversion, shame transforms the self—not necessarily into a more moral self, but into one more tied to the collective of a totalizing institution.

In constituting the self, shame can impact knowledge within the institution—knowledge of what is/is not acceptable, of what is/is not social, of what is/is not internal, and in Adkins’s sense, what is/is not epistemically secure (2019).Footnote ⁵ Shame is an affect that thrives at the intersection of visibility and invisibility. Shame under surveillance springs from the experience of being highly visible and can drive an individual to wish to be invisible. At the same time, being seen as a whole person can move people from a shameful, hidden position. Shame thrives in the shadows because shame itself is shameful: even the possibility of shame can drive someone from the spotlight. In Foucault’s example shame is meant to disappear; in Mann’s construction, it is meant to transmit into power. These experiences can fundamentally shape the way an individual sees themselves and how they interact with others. Drawing together Foucault, Ahmed, and Mann, shame-as-discipline functions at the fulcrum of visibility/invisibility, and within institutions shame is also possible power, rendering some bodies redeemable and others bereft. I suggest that power, knowledge, and shame (power-knowledge-shame) circulate together under, around, and through practices of shame-as-discipline in institutions. But there is a line between the shame that swirls and guides social interactions and explicit shaming practices, and that line was perceived to be crossed by the shame-as-discipline tactics of the Journal of Vascular Surgery article.

3. Shame, surveillance, and discipline in the Journal of Vascular Surgery

A team of vascular surgeon researchers created fake social media profiles to find and follow vascular surgery residents on various social media platforms, publishing an article: “Prevalence of unprofessional social media content among young vascular surgeons.” The researchers reported that of the 235 vascular surgery trainees who had public accounts, 26% of those accounts demonstrated unprofessional or “potentially unprofessional content” (Hardouin et al. Reference Hardouin, Cheng, Mitchell, Raulli, Jones, Siracuse and Farber2020). They defined unprofessional and potentially unprofessional content as:

Within these categories of unprofessional social media content, inappropriate attire was defined as swimwear, underwear, and provocative Halloween costumes, and politicized or religious commentary was specifically abortion and gun control. The authors did not find any significant difference in frequency of unprofessionalism between men and women (as gendered by the researchers).

The article used surveillance methodology—observing trainees’ social media platforms—to classify actions and actors as unprofessional (in opposition to professional), thus naming a “normal” and implementing discipline. That the article served as a public form of discipline reflects the public shaming practices historic in the institution of medical training. That the article was published in a peer-reviewed journal is constitutive of initial acceptance and support by the vascular surgery establishment. The article, as part of the broader phenomenon of shame and shaming in the institution, reflects the nature of affect-based surveillance and discipline in the profession. Bodies are surveilled and disciplined in part through shame.

The structure of shame-as-discipline and the intersections of power-knowledge-shame in the institution are not race or gender neutral but are mediated by the ways that race and gender have been pushed down and out of the profession. The legacy of power-knowledge in the American medical institution reflects the long history of “whiteness as property” in the US, or the ways in which whiteness has been constructed as something valuable and conservable by white people. Whiteness as property, as defined by Cheryl Harris, is reflected in the exclusionary legacy of medical school admissions—the opportunity to become-a-professional—which makes professional status a piece of property to which whiteness is entitled (1992, 1769).Footnote ⁶ Within a system already structured by white professional standards, methods of surveillance and discipline can then serve to continue to shape the groups that are/are not accepted under those standards. At the same time, professionalism doctrines are race and gender avoidant, propose an impossible neutrality, and have long sought to remove identifying characteristics of the body. Management of racialized bodies—so-called “diversity management”—is itself a tactic of institutions which shrinks attention to racism and to feminist of color critiques of institutions (Ahmed Reference Ahmed2012, 13). These premises shape the affective landscape into which the Journal of Vascular Surgery article entered, and the public discourse that followed.

In response to the article, swathes of healthcare workers posted bathing suit photos (and supportive Tweets without photos) using the #MedBikini. This case represents an example in which institutional shame tactics are publicly identified by members of the institution as unacceptable. The #MedBikini movement is a case of a small rupture in the medical institution which allows for a reconsideration of the way that affect and power circulate and are transmitted. The Journal of Vascular Surgery article, which one commentator described as “[saying] the quiet part out loud” does not produce but reifies power-knowledge-shame in the medical institution (Goldberg Reference Goldberg2020). The publication of the article in an online journal and then the quick Twitter response reflect the unique way that affect can travel through institutional norms into the virtual. Being online changes the way that shame can be spread or in fact resisted quickly and across borders or differences.Footnote ⁷ The Vascular Surgery article makes the nature of medical professional discipline visible, as it utilized surveillance and classification to manifest power and attempted to circulate gendered shame among trainees.

4. #MedBikini and resistance to shame-as-discipline and surveillance

Participants in #MedBikini clarified this case of shame as discipline through their response to the article. In doing so, they resignified bikinis (gendered attire) as not-shameful, even within a system of education in which shame in relation to discipline and norming seems nearly inevitable. In reconfiguring the locus of shame from the seat of academic production to online, community Twitter discourse, shame as a form of discipline is detached from bikini-wearing gendered bodies and is instead pointed toward the disciplinary tactics themselves. Recalling Mann’s (Reference Mann2014) shame-to-power conversion, while the article could have worked to convert gender-based shame into masculinized, institutionalized power, the respondents (largely women) redirected that shame, consolidating a different form of power and redemption. This shift reassigns group notions of shame and what is socially permitted to be shameful and worthy of disciplining within the institution.

Simultaneously, the initial #MedBikini movement was identified by interlocutors as initially race-avoidant and lacking attention to the ways that racialized attire (such as hijab) and racialized bodies are surveilled and disciplined in the profession. These nuances underscore the moving target of shame-based discipline in the institution and complicate the ultimate value of shame as the central analytic in gendered resistance to the institution. The online movement, while effective in bringing attention to one set of norms within knowledge creation and practice in medical education, does not necessarily address the experience of being an individual within the hospital itself—no one is wearing a bikini to work in the clinic.

The #MedBikini Twitter movement responded to surveillance with visibility, proposing a defiance of wanting to be seen. There is no way to say if the subjects of the study itself (who remained anonymous) responded to the movement. Instead, it was a group response, built not on the affective experience of any one individual who was explicitly shamed, but rather by the shaming forces within the institution. Shame lives in the tension between visibility and invisibility; it thrives in the shadows, serving as a sort of “present absence” in influencing persons even when it is not explicitly recognized or felt. Shame can lead persons to hide to keep their shamefulness invisible, but shame also often arises from the actual experience of being seen. As in Foucault’s example of the school with the shameful class, badges of shame (in this case, ostensibly the bikini) carry shame through their visibility, and are intended to disappear through discipline. Making them instead more visible inverts the impetus of shame-as-discipline. Broadly, this form of visibility can connect to discourses of pride, political defiance, and stigma-reduction for gendered bodies.

In this case, the authors of the Journal of Vascular Surgery article assigned the badges of shame in social media themselves but garnered legibility, validity, and power through their association with institutional structures. The authors follow the Accreditation Council for Graduate Medical Education and American Board of Medical Specialties in holding professionalism as a central competency for medical trainees and physicians. They align themselves with the American Medical Association, which has published social media guidelines for medical students. These institutional powerhouses create the guidelines for medical training—they shape the epistemologies of medicine, acting as a power-knowledge structure.Footnote ⁸ The article reflects the way that surveillance and discipline function within the profession, arguing that “Unprofessional social media content not only reflects poorly on the individual, but also the medical profession as a whole” (Hardouin et al. Reference Hardouin, Cheng, Mitchell, Raulli, Jones, Siracuse and Farber2020, 671). In other words, the authors fear not just the significance of a bikini on a body, but what that significance could do to the public perception of medicine and its institutional standing. Implicitly, they may also fear their own shaming, loss of reputation, or discreditation through the public repudiation and ultimate retraction of their article.Footnote ⁹

The bikini is only one badge of shame noted in the article, and per the results section, “inappropriate attire” is not even the most common signifier of unprofessionalism. That would be holding or consuming alcohol in photographs. But the affective-activist response that arose to the article focused specifically on bikinis and on their gendered nature. Yes, a bikini does not have feelings and a bikini does not necessarily have any inherent value—but in this article, the bikini has been assigned value. Furthermore, the person wearing the bikini does have feelings, and bodies can be actively disciplined, through biopolitical self-surveillance and through explicit educational pedagogy and policy. The signs of “unprofessionalism,” generated from the social movement of shame, displeasure, righteousness, and (in)appropriateness, attach as well to those bodies. In turning to the #MedBikini “movement” that arose in response to this article, emotion is reconscripted by those who have been surveilled and disciplined, as the forces of power-knowledge-shame shift targets to shine a light on the discipliners.

5. Calling out surveillance: what institutional resistance is possible?

When the article was published and backlash began, Twitter became a central point for discourse around not just the article, but professionalism, medicine, and social media. One of the authors of the article—identified as the only woman on the team—Tweeted a response: “People get judged everyday by what is available on social media in all forms. It is the reality of today’s world in medicine or any other profession—like it or not. These impressions and the SM [social media] content stick and are hard to eliminate” (Leith Mitchell Reference Leith Mitchell2020). She appeals to the “real world” as a justifier for discipline and surveillance in the profession—if judgment exists outside of the profession broadly on social media, then it is acceptable for the profession to maintain those same norms. As the author notes, it can be very hard to “unstick” negative perceptions from actions, proposing a justification for forms of surveillance and discipline in the field. While this use of the term “stick” is not technical in the Ahmedian sense, it implies the same concern: certain signifiers (in this case, social media posts) will glue a person to feelings already glued to those signifiers (in this case, mistrust, or negative feelings toward “bad” doctors). And, implicit in the author’s comment, badges of shame arise in many settings, institutionally mandated or not. In defending her work, the author sets up the conundrum of power-knowledge-shame. There is no universal standard for professionalism within the teaching hospital, and professional attire itself has changed and been pressured for decades across institutional settings.Footnote ¹⁰ Even as standards and laws shift, definitional knowledge and rule changes are not sufficient to change practices of discipline and sources of shame within the educational setting; the racialization and gendering of bodies and communities continues to persevere. This Tweet reflects that perseverance of disciplinary tactics, and the affective dimensions underlying it: fear of judgment is fear of shame, embarrassment, humiliation.

Shame and gendered shame were evoked through the article, but the #MedBikini movement activated a different sort of righteousness through resistance to gendered shame in the profession. Where the article and the author’s Tweet show a righteousness on behalf of the profession and broad professional norms, those using the #MedBikini hashtag demonstrate a sense of anger and indignation on behalf of women in the profession. As one Tweet, which received over 8,000 “likes,” read, “If you are a true #heforshe then you must speak up against this disturbing study/3 men created fake social media accounts to purposefully spy on applicants/Worse they are shaming our women physician colleagues for wearing bikinis” (Chowdhary Reference Chowdhary2020). This Tweet invokes the HeForShe campaign, a United Nations project which invites “men and people of all genders” to stand with women against gender inequality (United Nations, n.d.). The Tweet activates us/them dichotomies: the “true” male allies of gender inequality in opposition to all those who would stand with the male authors of the study who utilize surveillance and shaming to subjugate women in the profession. Here the position of righteousness—and arguably, the position of disciplinarian—switches from those who are defending the profession to those who are speaking up for the cause.

In response to these mechanisms of surveillance and shaming, the #MedBikini hashtag saw healthcare workers post their bikini and swimsuit pictures with the hashtag and often commentary about their lives outside of the hospital. For some of the posters, this act of resistance was radical and satisfying, as discussed in a New York Times interview with a medical student at the historically Black Meharry Medical College:

Shame is an emotion of visibility, judgment, and surveillance. Professionalism itself acts as a norming force, which can be shaming in and of itself. The #MedBikini response demonstrates one form of protest against those normative forces and the many layers of discrimination faced by gendered and racialized physicians and students. Such movements gesture toward an ethical response to shame as dedicated “looking,” to holding and seeing painful or shameful moments in an act of care and reparation (Love Reference Love2018). These acts of protest seek to shift the shame and negative value attached to the bikini and in doing so to lighten the load of living under institutional surveillance.

The #MedBikini hashtag and discourse was picked up by the news and by the public as a feminist movement. Medical schools drafted public responses to the movement. The ability for a hashtag to reassign bikinis from shameful and unprofessional to signs of protest, righteousness, and even pride represents the potential for resistance aimed directly at shame-as-discipline to clarify and shift social values underlying disciplinary tactics. Identifying the paper as a force of shame undermined that shame, marking it as inappropriately directed. As Sedgwick declares shame constitutive and productive, here shame—and shame on a broad scale, not directed at any one individual but at a class of individuals, bikini-wearers—constituted a new sort of identity, an identity of protest and rejection of norms. In that identity one can sense a sort of pleasure—the pleasure of being in the right, of creating a new set of knowledge, of reshaping shame, of resisting power, of disciplining the discipliner.

The original paper was retracted by the Journal of Vascular Surgery, an institutional rejection of its own sanctioned norms in response to community outrage. The journal published a detailed apology for the publication of the article, citing ethical breaches in the data collection, as well as “methodology [in part] predicated on highly subjective assessments of professionalism based on antiquated norms and a predominantly male authorship supervised the assessments made by junior, male students and trainees” (Hardouin et al. Reference Hardouin, Cheng, Mitchell, Raulli, Jones, Siracuse and Farber2020). The retraction letter further noted that “The goal of professionalism in medicine is to help ensure trust among patients, colleagues and hospital staff. However, professionalism has historically been defined by and for white, heterosexual men and does not always speak to the diversity of our workforce or our patients” (Hardouin et al. Reference Hardouin, Cheng, Mitchell, Raulli, Jones, Siracuse and Farber2020). While disagreement within the profession is a valuable tenet of academic freedom, the retraction statement accounts for both ethical and scientific breaches in the article. Further, it ties them specifically to gendered research practices (male supervisors with male research assistants assessing women trainees). This letter also reemphasizes the aspirational purpose of professionalism standards—to ensure trust—but centers those standards explicitly within the systems of whiteness and heterosexism that situated the article’s publication. This response comes not from the medical profession at large, as many of the Tweets did, but from within the field of vascular surgery—an institutional self-repudiation.

In the narrower sense of upholding research ethics and acknowledging gender bias in research, the #MedBikini movement was a success. But insufficiency in the institutional response to acknowledge the politics of shame-as-discipline, of the stickiness of that shame, and of disaffection leads me to call again for the need for an intersectional and feminist lens on this aspect of medical culture. As the hashtag movement swelled, it was simultaneously critiqued by those in the institution who noticed its centralization of gender without race, a whitening of shame-as-discipline that overlooked interlocking patterns of shame, surveillance, and discipline broadly. While the journal retraction messages notes the intersection of power between whiteness and maleness, apologies hold only as much weight as their follow-up impacts; the number of articles and commentaries from within the profession demonstrate the eagerness to move toward justice. So, what is the potential of identifying shame-as-discipline when the ability to reshape shame, to carry out discipline, and to resist power is consolidated in the hands of only some agents, and when that potential may not spread from the internet into the social and institutional spaces where it acts on embodied experiences in the institution?

6. Embodiment, racialization, and resistance to gendered shame

Although participation in the #MedBikini movement was diverse, the initial hashtag use was described by participants as avoidant of race and other identities outside of gender; the gendered shame of the bikini was attached to mythic non-racialized (white-coded) women. This response to discipline and this rejection of shame in surveillance possibly codes the bikini as a shameless piece of clothing. More meaningful is the encoding of a gendered body in a bikini as not just shameless but included or unexceptional in institutional life—and if in doing so, the experience of embodiment changes. The bikini itself does not have feelings—it is the person inside the bikini who will either experience the shame and judgment assigned to them through that attire, or instead identify their embodied self as resistant to that shame. But that opportunity for resignification is not equally distributed, nor equally meaningful as a call for action. As one physician Tweeted as part of a thread about being Black at work, “#medbikini wasnt my movement b/c it focused on option of posting a bikini pic/Race, hair & facial features, names, body frames arent optional for WOC. They cant be turned off like privacy settings on social media. Our identity is always at risk of being called unprofessional” (Landry Reference Landry2020). In other words, the discipline enacted against the bikini is not comparable to the disciplining of racialized bodies. And more crucially, the ability to wear a bikini and to not be shamed for wearing that bikini is not comparable to pervasive racism and discrimination within institutions. Returning to Collins (Reference Collins2015), an analytical framework of intersectionality within this politics, then, emphasizes how the project of created knowledge is linked to the project of creating race—in my analysis, through the mechanisms of shame.

Where surveillance of sexualized gendered clothing like the bikini can be disentangled from disciplinary shame and judgment in the discourse around professionalism, racialized bodies—and racialized attire—remain under watch, reflecting the long history of racism and the legacy of whiteness as property and race avoidance in institutions in the US and similar cultures. A medical student used the hashtag to tweet: “Hey, were you a #medbikini advocate? Then read this!!!/CMAJ [Canadian Medical Association Journal] recently published an anti-hijab letter (written by someone who isn’t Muslim of course) in response to a photo of a little girl wearing hijab. Hijabi women are speaking up against the letter and getting backlash” (Kumte Reference Kumte2021). Where the bikini as a gendered piece of attire can be made impervious to surveillance and even represent a source of pride and positive identity in the profession, this Tweet recognizes that the hijab is not given the same attention by broad reactions to shame in the institution.

The sexism underlying the gendered institutional shame-as-discipline in this case was initially framed as a race-avoidant sexism. The initial upswell of response to the article centers sexism via the bikini—as opposed to underwear, or provocative Halloween costumes, or commentary on gun violence or abortion. The bikini is a sign associated with gendered bodies, but also with fit, abled, normatively appealing bodies. The bikini is risqué in that it is associated with pleasure and the pleasure of enjoying normative beauty, gender, and normatively “good” bodies—bodies in which society invests care. This study does not undertake a rigorous semiotic and aesthetic view of the movement and the images associated, but such a next step would add nuance to the specific meaning of the “bikini body” in context. While the movement was meant to appeal to broad feminist ideals and indeed many people of color participated, the ensuing critiques of #MedBikini exemplify increasing (gender) diversity in the institution without meaningful attention to not just racial diversity but racism (Ahmed Reference Ahmed2012). Through negotiating participation in the movement through the meeting point of racialization and gendering, individuals reframed the conversation toward an intersectional politics of shame.

The growth of an enacted intersectional politics of shame is reflected in the formal professional responses to the article and its retraction. In the wake of the retraction, numerous editorial letters referenced the sexist standards of professionalism in surgery and suggested different approaches to reforming it. The editor in chief of the World Journal of Surgery wrote a letter noting that the definition of professionalism in 2020 was being “appropriately” debated, and committed to increasing gender, racial, ethnic, and class diversity in the editorial staff and reviewer pool of the journal, while also seeking to avoid levying a “minority tax” of responsibility on these individuals (Sosa Reference Sosa2020, 3587, 3588). A group of women vascular surgery trainees published a piece calling for specific reforms for both the journal and its associated society (Society for Vascular Surgery). The article called for the journal to increase representation in reviewers and incorporate ethics review of articles, and for the Society to increase pipeline support, mentorship, and bias reporting. The group wrote, “As female vascular surgery trainees, we will not be silent in our support for our female, underrepresented minorities, and LGBTQ+ vascular trainees. We, as a group, are multiracial/ethnic, LGBTQ+, international, and multilingual and actively seek to make a difference in the lives of our patients” (DiLosa et al. Reference DiLosa, Drudi, Hata, Devrome, Yang Yang and Blakely2020). In Karen Adkins’s terms, these trainees—while not explicitly aiming to shame the profession or individuals within the profession—are bidding for epistemic and social authority in the field. This response reflects intersectional feminist politics and a strong commitment from within the profession to push forward change at different levels—for trainees’ experiences and for knowledge production. But this politics is not necessarily reflective of the experience of racialized persons in the field and highlights a tension between institutionally oriented activism in response to shame-as-discipline and forms of resistance as affective withdrawal.

Shame is a racialized force in institutions and can be used to create difference and subjugation as governmentality among racialized participants in the institution (Dar and Ibrahim Reference Dar and Ibrahim2019). The Tweeter who described #MedBikini as not being “her movement” as a Black woman physician invokes another response to shame-as-discipline, which I draw from theorist Xine Yao’s concept of “disaffection.” Yao critiques sympathy, sentimentality, and the politics of emotional recognition as tools of whiteness in creating an affective regime through which Black and indigenous people and people of color are made “unhuman” through being “unfeeling.” Yao explains that, within this affective regime, “The demand to sympathize can be coercive, making the rejection of identification a political decision that may be the first step toward shifting existing structures of feeling. To choose not to care, not to be moved, pushes against the expectations of affectability” (Yao Reference Yao2021, 16). Inverting the expectation that women would monolithically care about a white-coded feminist resistance to sexism layers another form of affective nuance into the movement. Karen Adkins also notes the real risk of backlash to women of color when attempting to corral epistemic and social authority through redirecting shame at institutions (2019, 86).

This level of affective nuance questions not only the responses and the commitments, but the underlying affects which require activism and response. In other words, shame-as-discipline does not necessarily produce shame in an individual. For some people participating in this discourse, the shame associated with institutional norms of professionalism attached to bikinis could be read as not an affective priority. Other forms of discipline, surveillance, and knowledge-power structures may be more affectively relevant. Some of the calls for change from within the institution, like the women vascular surgeon trainees’ request to support pipeline programs in STEM (DiLosa et al. Reference DiLosa, Drudi, Hata, Devrome, Yang Yang and Blakely2020) do hold promise for meaningful institutional change cognizant of intersectional priorities. As is often within feminist activism, the tensions of which reforms are most valuable and from where and which perspectives those reforms should originate remain in the debates around #MedBikini.

Returning to Ahmed’s work on shame, the feeling only grows so long as the subject remains interested in and cares for the thing at hand, expressive of emotional investment. In some cases, shame serves to call an individual back into the moral community, which then opens the space for negotiation within the community, as opposed to demoralization. This phenomenon, in context of Yao’s work, is suggestive of both a need to recognize who is experiencing shame and why—if for example the journal had refused to show remorse, demonstrating shamelessness, their refusal of feeling would hold a different political valence than the refusal of targeted students to feel shame. Mann draws on a similar tension, noting that, for male subjects avoiding gender shame by turning to violence, “the reparative action required in the restorative conversion of the humiliated subject to sovereign manhood requires an antiethics; it can only become effective through hyperbolic displays of agency that trump all moral concern” (2014, 117). If a subject aims to transform their shame into power, they run the risk of rejecting wholeheartedly the moral or social commitment that led to their shame. Maintaining rigorous feminist analysis on the “who” and “why” of shame-as-discipline in institutional life is thus key to navigating the way that shame and power intersect. The response of disaffection itself then can create productive tension within resistance to institutional power, highlighting the way that an intersectional feminist politics of shame can focus on which (or whose) feelings receive recognition and priority, with potential to impact the way the institution acts and moves.