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As women all over the world came forward to talk about their experiences of sexual violence, old certainties about what constituted normal, acceptable behavior between men and women, between those with power and those without it, began to peel away like dead skin. Half a decade later, it's still happening. It's not just Hollywood, and it's not just Silicon Valley. It's not just in the White House or behind the scenes at Fox News. It's happening in the art world and in mainstream political parties. It's happening in the London radical left, in the US Democratic Party, in the Australian parliament and in the world of international aid. It's happening in academia and in the media and in legal and therapeutic professions. It's been happening for decades. It's still happening. Wandering hands and daily dehumanisation remain a weary assault course not just for women trying to make their mark in entertainment or finance or media or politics, but for the many millions fighting to survive in lower-paid, lower-status jobs. Shortly after the #MeToo movement broke, tens of thousands of domestic workers started speaking out about their experience of abuse. McDonald's workers declared that their bodies were not on the menu. The movement against male domination and sexual coercion appeared, for a brief moment, to bridge divides of race and class. Migrant agricultural labourers spoke out against domestic violence at the same time as Hollywood actors, journalists, politicians and technologists were organising to bring down serial predators in their industries. Defiance, for these women, began the only way workplace defiance ever does: at the point where people decide that the risk of staying silent is greater than the risk of speaking out. When people realise that their struggles aren't unique, that their pain is real and it matters, the sensation is terrifying and liberating at once. There is an exhilaration to realising that you are allowed to trust yourself, that it's not crazy to want another world, or that even if you are crazy, it doesn't mean you're wrong. A great many alleged abusers and their allies responded to these revelations with pleas for more understanding, with insistence that accusers consider the context of these crimes. Well, of course. Context is vital. It is crucial to consider the context in which this all-out uprising against toxic white male entitlement is taking place. The context is a historical moment where it has become obvious that white male entitlement is the greatest collective threat to the survival of the species. That isn't a metaphor. Political consent and sexual consent are not analogous. They are correlative. They feed one another. The search for a more human understanding of power and consent is not simply stage dressing for a bigger fight. It is the big fight. It's all about the grabby old men, and the young men groping for power in their wake, and it always has been. What will happen when women everywhere flick on every light in the house ... and men no longer have any darkness left to hide in?' asks writer Caitlin Johnstone at Medium. 'It is unimaginable. Power structures will be disrupted from the basic family unit all the way up to the highest echelons of influence.' This book deals directly with the implications of this seismic shift - and the threat it poses to traditional systems of power. Modern states are sexist and racist by their very nature, because their power structures are built on the exploitation of people of colour and of white women. Sexual violence and racist oppression are fundamental to how work, money and resources are organised in most modern societies. This is not a new idea. Theorists like Catharine A. MacKinnon have observed how fundamental gendered power is to the formation of the modern state. MacKinnon, however, believed that sexual violence is the source code of that power differential - that the state was constructed to facilitate male sexual violence against women. This book argues otherwise. Sexual violence is not the end goal of white supremacist patriarchy - it's an enforcing mechanism. The real point of maintaining hierarchies of gender and race, the hierarchies that scaffold most modern political systems, is not controlling sex, but controlling work. Our architectures of racist and sexist violence are designed to coerce people of colour and most white women into doing the hard, repetitive, essential labour of sustaining life so that a minority of white, wealthy men don't have to - an arrangement that is, ultimately, to everyone's detriment. Sex is part of this story. My generation inherited a world where Sex was cheap but not free. We inherited a culture of boring, violent, coercive heterosexuality. We grew up being warned that sex was something dangerous, something violent that boys did to girls, something that men needed and women controlled, something that strong men wanted and nice girls didn't let them have too easily. We grew up marinated in a flood of mainstream pornography that rephrased sex as a factory line of bodies battering each other into submission, of ritual violence being done to women and girls, of hammering, nailing, smashing, wrecking, choking, slapping, destroying, a language of sex that was as strait-laced, joyless and competitive as everything else in our lives. Modern society conflates sex and power, creating an environment where the idea of freedom is fetishised in theory and flattened in practice. Where every desire must become the desire to dominate. Where power, violence and authority are eroticised, sex itself becomes authoritarian. Authoritarian tendencies are baked into mainstream political culture. A more specific term for this tendencies are what some people call neoliberalism. Neoliberalism is, quite simply, a way of organising society - from politics to culture and commerce - so that the needs of the market and of private gain take precedence over everything else. It describes a specific form of global capitalism where nothing is more important than what can be sold, and to whom, and for how much. Where human life itself has no inherent value, where every human urge is channelled towards greater productivity and most of us spend most of our time working ourselves to the raw nerves for someone else's profit. More than anything else, neoliberalism is allergic to the idea of human beings living, organising and caring for one another collectively - instead, it imagines a world order where individuals and their families struggle alone in a world of ruthless competition where only the strongest and luckiest survive. This is why neoliberalism eventually becomes authoritarianism. And neoliberalism, like every form of authoritarianism, is not just about controlling what people do; it is about controlling how they think and feel. But eventually, something is bound to snap. Something usually does. Wilhelm Reich was one of the first philosophers to pay attention to the way in which sexual frustration was being whipped up and manipulated by the despots of the 1930s and channelled towards violent imperialist and racist ends. He observed in The Mass Psychology of Fascism that "the suppression of natural sexual gratification leads to various kinds of substitute gratifications ... Natural aggression, for example, becomes brutal sadism which then is an essential mass-psychological factor in imperialistic wars.' The same is true today, from Islamic State to the American far right: the strategic use of sexual frustration and weaponised misogyny in the radicalisation of young men is consistent across ideologies. Sadly, the entitlement that underlies it is not exclusive to fascist movements. The opposite of consent culture is not rape culture - it is authoritarianism. Sexual authoritarianism occurs when straight men can no longer count on women's sexual compliance. Again, this is more than a metaphor. Sexual repression is more than simply an analogy for political oppression. Sexual repression is real, and political oppression is real, and the two are related. Both tend to involve powerful men grabbing whatever they feel entitled to, whatever the cost, and getting away with it - because the laws that ought to hold them accountable were written by and for people just like them. This is the very essence of privilege, a word which literally means ‘private law'. To challenge sexual exploitation is ultimately to challenge male privilege on every level, from the political to the personal. It is to insist on the right of all bodies not just to equality before the law, not just to dignity and agency, but to self-mastery and pleasure and adventure. This book argues that the sexual revolution, and its urgent demands for a reorganisation of care and labour, is a threat to the modern economic order. And it is a challenge to sexual repression. This sexual revolution is a revolution in redefining terms - an exercise in taxonomy. It is about naming and nailing down the contours of a world of violent incoherence. Words matter in sexual politics. In 2018 the actress Alyssa Milano suggested a 'sex strike as a way for women to escalate the #MeToo movement - denying men sex so long as they deny the rest of us basic bodily autonomy. This was the right instinct, but the wrong strategy. A general sex strike is a stupid idea as well as a socially conservative one, given that female sexual desire is a real and active thing that requires extensive social and economic strategy to repress. Priests and politicians have been trying to squash women's sexuality for centuries. However, one specific sex strike - the one that chauvinists are afraid of - is already well underway. A widespread adoption of consent practices is the 'sex strike' that the chauvinists are afraid of. What has been happening, quietly and for quite some time, is women and girls opting out of the old patriarchal bargain whereby we traded our sexuality and the work of our lives for security and protection. Today, fewer women are obliged by economic necessity, social pressure, isolation or fear to enter or stay in relationships they don't want. It's all well and good to say that feminism is about women having choices, but what happens when we start making choices - en masse - that men don't approve of? What happens is a fundamental disturbance in the 'sexual contract', which, according to theorist Carole Pateman, is the very basis of what we think of as democratic freedom. Interrogating the idea of the Hobbesian 'social contract', Pateman explains" that the fundamental assumptions of Enlightenment liberation rely on an enforced power differential between men and women-an unspoken sexual contract whereby women owe men a duty of care, attention, sexual access and unpaid domestic labour. If women break the terms of that contract by refusing subservience, they deserve to be punished for it - and in the course of writing this book I spoke to countless women who have been punished for it, who carry wounds that ache in relentless reminder of the cost of non-compliance. In order to heal injustice in the future, it is necessary to name and claim the hurts of the past. This is one of the greatest challenges when it comes to constructing cultures that value human life and building human lives that resist oppression. Most of us would prefer the version of the story where we were in control the whole time, where all the hurt and disappointment we have suffered was our fault, because that way it's easier to own the horrible things that have happened to us and make sense of the way they make us feel. It is terribly human to want to avoid reliving the pain of the past. It can often feel as if denying past atrocities is the only way to fully survive them. But acknowledging harm that has already happened is often what it takes to stop it happening again. We cannot have sexual liberation without freedom from abuse, and we cannot be free from abuse without naming it. A great deal of the work of social change is about giving people permission to tell the truth about their own experiences, to articulate the hurt they have suffered so that others might not have to suffer the same. That's what happened in the 1960s and 1970s when feminists first began to speak about the sexual abuse and domestic violence that were and remain the ugly secrets gnawing at the core of our communities, families and political institutions. It was a brave and dangerous thing to do then, just as it is now. The shame of abuse was supposed to be borne by the survivors, largely women and children, who were expected to stay silent about what had happened to them, shielding their abusers from the consequences of their actions and - more importantly - protecting everyone else from the discomfort of other people's pain. Today, we're moving from a culture that tacitly permits the rape and abuse of women and children but criminalises homosexuality, abortion and birth control, and considers female sexual pleasure to be fundamentally suspect, to one where the important thing isn't who you have sex with, or how often, or with how many, but whether or not everyone wants it. More broadly, sexual revolution imagines a world where people are free to have sex and form relationships and build families in whatever way they choose, so long as they are not hurting or violating anyone else. It imagines a world where the moral schematic is not how much sex is being had, or what kind, but whether it's wanted, whether it's fun for everyone involved. And that schematic or consent doesn't just apply to sex. These ideas are an affront to current orthodoxies of work and love and sex. They are an affront to the assumption that men are owed something by women. To the assumption that women owe men sex, affection, emotional labour and domestic service. These assumptions are disturbed when women, girls and children come together to insist that, in fact, powerful men are not automatically entitled to have access to the bodies of others. And when a woman finally finds herself able to question whether she really owes men anything at all, whether she might be the one that's owed something by the world, that is an act of resistance. I've learned the hard way what happens when I make men uncomfortable. When I refused to make myself small and powerless so that men could feel large and in charge, there were consequences. But there are also consequences for staying clenched and closed, for forgetting your own selfhood. There are consequences for hollowing out your heart. Consequences for putting up with violence and disrespect. The most immediate is that the violence and the disrespect keep happening. To you, and to others. Karah Frank, who finally left a violent and abusive relationship, said in a letter that was presented during the court case against her abuser: In Judith [Lewis] Herman's now-foundational text "Trauma and Recovery", she outlines the process of psychological domination. The final stage in this process is known as total surrender, where the victim becomes utterly complicit in their own abuse? Herman explains the necessity of this 'in the mind of the abuser' using a quote by George Orwell, from 1984: We are not content with negative obedience, nor even with the most abject submission. When finally you surrender to us, it must be of your own free will. We do not destroy the heretic because he resists us; so long as he resists us we never destroy him. We convert him, we capture his inner mind, we reshape him. We burn all evil and all illusion out of him; we bring him over to our side, not in appearance, but genuinely, heart and soul. This, in Judith Lewis Herman's estimation, is also how abusers work, the creation of a cowed and complicit loyalty being 'necessary for the justification and continuation of the abuse cycle. The perpetrator insists on total loyalty; mind, body and soul.?25 Complicity can curdle anyone's courage. It is extremely uncomfortable to acknowledge historical violence that has been done in your name. That's one reason why women and girls, gay and trans people, Black and brown and Indigenous people remain bit-part players in the notion of history as it is simply and collectively understood. That matters. It matters because if we don't know our history, we can't learn from it, and those who can't learn from history are doomed to speak in ignorant clichés and to live them, too.

The connection between sexual oppression and social repression has been explored by philosophers for centuries. Oscar Wilde reportedly wrote that ‘everything is about sex, except sex. Sex is about power.’ The conversation being had right now is about the place where sex and power meet. It’s not enough to just reframe the rules, to ask how precisely flirting and fucking should work now that women are asking to be treated at every stage like people, rather than status objects or receptacles for men’s pleasure and pain. To change the culture of consent, we need to move on from talking about rules and start talking, instead, about ethics – about what sort of society we want to live in, and what it will take to get there. Consent culture, first named by activist and sex-critical feminist Kitty Stryker, is the alternative to all this. Resisting a culture of rape and abuse must involve more than insisting on the individual right to say no, although that’s both a decent starting place and a difficult concept for some people to wrap their foreheads around. There’s a reason for that. The reason that the notion of the real, continuous, enthusiastic sexual consent is so outrageous is that the concept of female sexual agency – let alone active desire – is still a fearful one. Our culture still has very little room for the idea that women and queer people, given the chance, want to enjoy sex just as much as men do. We must get to grips with the idea of consent as ongoing and negotiable, rather than consent as an object, a one-time contract that can be fudged or debated in court. If people of all genders are going to stand a chance of living in this weird new world together without destroying one another, consent is going to have to mean more than that. Consent is more than the absence of no. It is possibility of a real yes. It is the presence of mutual human agency. It is lust and lusciousness and shamelessness. It is the horizon of desire. We are teetering, as society, on the edge of a powerful transformation – but we could just as easily collapse back into the petty, violent certainties of the past. We could stop talking about ending ritual sexual violence in colleges, in schools, in religious and political institution. We could stop insisting on the importance of consent as a baseline for pleasure and desire. We could stop calling out rapists and abusers. We could keep bullying and pressuring and isolating survivors until it’s just too much pressure to speak out, until once again the impact of a rape accusation on a man’s life is considered more important than the impact of rape itself on a woman’s. We could stop all of it and pretend – if we can – that none of it ever happened. Or we could try something new. We could try being better than we’ve been before. We could decide to do better than just trying not to get in trouble, trying not to actively commit rape and assault. We could start to talk about desire and consent as if they matter.

The five features of a radical queer sexual politics are not yet accomplished facts; they are still tasks to be tackled, dimensions to be fleshed out. While queer radicalism is inherently a politics of sexual liberation – which is the queerest thing about it – a queer politics has to involve more than being visibly, defiantly sexual in queer ways. Each of the five tasks for a queer politics has to take shape in organising tactics, as well as changes in personal and community life. To achieve full sexual liberation, a queer politics has to challenge and win power at the level of the economy, state and other sites where power is concentrated. Without a strategic project, queer radicalism dooms itself to perpetual marginality. Queer politics in this sense has barely begun to be invented. Defining queer politics in this way contradicts common-sense thinking about sexuality, and what has largely become common sense even among radical queers. For capitalist cultures organised around the divide between public and private, the sexual is pre-eminently private. Radical queers disagree, of course; we understand that heterosexuality is publicly ‘flaunted’ every day, and that genuine queer equality demands bringing queer sex into the public sphere and insisting on its public recognition.1 But most queers see the sexual as predominantly cultural. Disgusted with what passes for politics under neoliberal hegemony and leaning towards a wholesale anarchist rejection of the politics of large-scale organisations and state institutions, many queers see sexual politics as a domain of individual or small-group action and cultural production. Inventing a true queer politics must begin by challenging this dichotomy and refuting this fallacy. The cultural and the personal do not exist in a separate realm apart from the economic, the political and the social; they are constantly deployed and manipulated by the powers that be to produce economic, political and social outcomes that are in their interests. ‘Neoliberalism was constructed in and through cultural and identity politics’, as Lisa Duggan has pointed out. Moreover, radical cultural and personal change is only possible by transforming the state, economy and other structures that form the foundation of cultural and personal life, at both the micro level of individuals and small groups and the macro level of the city, nation, region and planet. Transformation will not be possible as long as ‘cultural and identity issues are separated, analytically and organizationally, from the political economy in which they are embedded’.2 An agenda for a radical sexual politics therefore has to address multiple cultural, social, economic and political issues. In subverting gender, it has to be closely connected to a socialist feminist programme for reproductive freedom. In practising queer inclusion and global and anti-racist solidarity, it needs to focus on cutting-edge struggles like those of queer youth and trans people, and solidarity campaigns against Islamophobia, cuts in aid to poor countries and the ‘pinkwashing’ of Israel as a pro-gay state. At the same time, it should start from visions of queer intimacy and ‘families of choice’ to define a radical yet unifying approach to the issue of same-sex partnership. This means opposing the privatisation of care and the transmission of class privilege, while exploring new ways of supporting parents and creating flexible forms for intimate relationships. Blurring the Boundaries Today there is a push in many countries to incorporate lesbian, gay, bisexual and even trans people into the prevailing sexual and family order. That order is structured under gendered capitalism by having the vast majority of children raised and socialised by at least one biological parent in families formed by sexually and romantically linked heterosexual couples. Particularly in regions where the nuclear family has been consolidated as the predominant capitalist household form, these are the families in which the great majority of lgbt children grow up. This means that at best, even in the most supposedly enlightened enclaves, lgbt people are bound to face a period of differentiation and alienation in coming to terms with their distinct identity. Their own process of family formation is bound to be exceptional and complex. In short, the best this order can offer lgbt people is a kind of second-class citizenship. lgbt lives in this situation entail a constant choice between, or more accurately a varying combination of, adaptation and ghettoisation. Most lgbt people can only survive, let alone prosper, by doing waged work in heteronormative companies or institutions. Their survival is made easier if they find steady partners who also have steady jobs, and even easier if they both have reasonably supportive heterosexual family networks to fall back on. But work and family life of this kind involves a constant process of adaptation, of having or failing to correct spoken or unspoken assumptions and weighing one’s own words and gestures. Even the places where most people spend their free time are heteronormative – witness the hostility evoked by queer kiss-ins in straight bars and sometimes by any public signs of same-sex affection. This is not necessarily a reflection of straight people’s prejudice or unwillingness to understand; it is simply the result of the heteronormative ways in which life is structured. So most lgbt people escape from the dominant forms of work, family and leisure or complement them with life in a separate lgbt world, made up of more or less mainstream gay bars, clubs and associations, and more or less alternative queer and trans scenes. Even in the absence of prejudice or discrimination, this is what gay normality consists of: a combination of life in a heteronormative world and retreat into an lgbt ghetto. In contrast to the homonormative model of lesbian/gay people as a minority caught between adaptation and ghettoisation, a queer radical politics can look to a future beyond the gay/straight binary. This is in keeping with the early objectives of lesbian/gay liberation, and with Herbert Marcuse’s vision of a generalised freeing up of human eroticism. It is in lgbt people’s interests to contest the heteronormative order and develop alternatives to it: not just a queerer ghetto, but communities beyond norms and ghettos. Radical queers challenge the social frontiers between gay and straight in different ways. One way is simply acting sexually in ways or settings that transgress society’s heterosexual norm – same-sex tongue-kissing in straight singles bars, for example. They assert what Scott Tucker once called ‘our right to the world’.3 The full range of issues and adversaries that they take on comes across in the list of focus groups that Queer Nation San Francisco had at its height: the streets; the media; the military; government institutions; universities; suburban malls; communities of colour; other countries.

(De)hegemonizing Heteronormativity Let us begin with the term ‘heterosexual matrix’, which is employed by Butler to designate ‘the grid of cultural intelligibility through which bodies, genders, and desires are naturalized’ (1999: 194n6). The matrix can be described as an assemblage of norms that operates to produce ‘intelligible’ subjects whose sex, gender, sexual practice and desire all cohere (Butler 1999: 23). Normative ideals of sex and gender determine who can be conceived of as a legitimate subject by constituting certain bodies, desires and actions as legible or natural. Not always enforced coercively, norms are most visible in the effects they produce (Butler 2004: 41–2). These regulatory practices manufacture and constrain ‘gender intelligibility’ by structuring the social, political and cultural worlds not just through influencing ideas, values and beliefs but also materially through institutions (Chambers and Carver 2008: 147). From insurance to taxes, from adoption to immigration, one can trace how heteronormativity secures privileges for those who consent to hegemonic norms, while non-normative behaviours, relationships and practices are stigmatized, illegitimated and rendered illegible (Chambers and Carver 2008: 147). First coined in 1993 in the now canonical book Fear of a Queer Planet, Michael Warner employs the term heteronormativity to describe how heterosexuality is taken to be normative. It is interesting to note that as early as 1975, a Dutch feminist group called ‘The Purple September Staff ’ published an article titled ‘The normative status of heterosexuality’. Here, they argued that heterosexuality is a ‘normalized power arrangement that limits options and privileges men over women and reinforces and naturalizes male dominance’ (qtd. in Ingraham 2002: 74). The term heteronormativity is useful in understanding how heterosexuality achieves hegemony. But before we engage with ‘hegemonic heteronormativity’, it is necessary to first clarify our understanding of hegemony. Introduced in Antonio Gramsci’s Prison Notebooks, hegemony is a key term in understanding operations of power. Given that Gramsci was making notes to himself and did not provide a systematic, precise definition, the term hegemony remains controversially discussed. The most commonly accepted understanding of hegemony is that instead of direct domination, it is the ‘spontaneous consent’ given by the masses to bourgeois ideas, values, norms, perceptions, beliefs, sentiments and prejudices, which are all historically produced as ‘common sense’ (Gramsci 1971: 12). A consensus emerges in which the working class identify their own interests with the interests of the bourgeoisie, thereby accepting the status quo rather than challenging it. Raymond Williams elucidates that ‘common sense’ is the sphere where dominant ideology is naturalized and exercised so that the values of the hegemonic group become values applicable to all (1977: 100). Consent to the general direction imposed on social life by the dominant class is historically manufactured. According to Gramsci, subordinated groups agree to hegemonic norms partly because of the prestige and moral authority that the dominant group enjoys. ‘Through their presence and participation in various institutions, cultural activities, and many other forms of social interaction, the dominant classes “lead” the society in certain directions’ (Buttigieg 2005: 44). Thus, for Gramsci, hegemony is a combination of economic domination plus intellectual and moral leadership. Rule by hegemony is maintained through moral authority in conjunction with the ‘free’ consent of dominated masses to the existing social order (Lears 1985: 568). This functions through the successful legitimizing strategies of dominant discourses and institutions accompanied by the delegitimization of alternative visions. Consent, for Gramsci, involves a ‘“contradictory consciousness” mixing approbation and apathy, resistance and resignation’ (Lears 1985: 570). It is important to point out here that within liberal political theory, consent is a fundamental ground for the legitimacy of political authority (Mehta 1999: 59). Those marked as unable to exercise reason either permanently (for example ‘the mad’) or temporarily (for example children) can be excluded from the political constituency (Mehta 1999: 59). In other words, those unable to exercise consent by virtue of lacking the qualified capacity to reason may be governed without their consent. Gramsci elucidates how the State, comprising political and civil society, functions to advance the interests of the ruling class in the name of promoting the greater common good (1971: 12). Political society includes the armed forces, police, courts of law and prisons, together with the governmental administration including taxation, finance, trade, industry and social security. These all function as an apparatus of the State’s coercive power that legitimately enforce discipline. However, coercion is only employed if efforts to manufacture consent are unsuccessful. Civil society is the sphere within which the State creates and consolidates hegemony. This includes organizations such as the church, schools and the media, which are all typically thought of as benevolent and non-political. Social institutions of civil society secure certain norms and practices consistent with the hegemonic social order through complex and constantly changing processes and mechanisms (Buttigieg 1995: 7). Herein the traditional intellectuals are ‘deputies’ and ‘functionaries’ of the dominant group, and thus invaluable in the production of consent. Gramsci argues that occasionally civil society is even more influential than the State in sustaining hegemony (1971: 238). It is important to note that the production of consent is not a one-time event but a recurrent process that engenders contradictory and incalculable effects. It is exactly here that space for counter-hegemony emerges. Thus, the notion of hegemony problematizes a straightforward topdown model of social control and transformation; it also explicates how actions and perceptions of a group of people are shaped by exercising power over them without explicit compulsion. Since it functions subtly, hegemony can be even more violently coercive in its effects to shape and regulate thought and action than more explicit forms of domination. The production of hegemony in civil society involves regulating everyday activities and interactions sustained over time so that it is no longer perceived as an operation of power. Through repetition, it becomes so deeply inscribed in the everyday that it is invisible as a form of control. ‘Hegemony … represents itself everywhere in its saturating silences or ritual repetitions’ (Comaroff and Comaroff 1991: 30). Undeclared and unspoken, hegemony only becomes a site for contestation when its invisible power is made transparent. And because hegemony must constantly be made, by the same token, it may be unmade. Intrinsically unstable and shifting over time and space, hegemonic orders are vulnerable. This brings us back to our initial question, namely, how does heterosexuality become hegemonic? It is important to clarify that heteronormativity is not a simple account of the fact that the majority of the population is ‘heterosexual’; rather it is a critical term that unfolds how heterosexuality operates ‘within social practices as the implicit standard of normalization’ (Butler 2004: 41) inciting each of us to conform to heterosexual standards. Another important aspect of heteronormativity is the mutual constitution of normative heterosexuality and the rigid binary gender order, whereby there are only two genders and one can only belong to one category at a time. As an intrinsic aspect of ‘normalizing society’, heterosexuality may be coercively implemented through an edict or law but generally operates much more subtly as a ‘disciplinary norm’ affecting every aspect of daily life, informing social relations and influencing public policy (Foucault 2003: 39). Heteronormativity as a concept is not simply the detection of discrimination against non-normative sexualities and bodies; rather it unpacks the extent to which everyone, straight or queer, is expected to consent to the heterosexual norm, so that ‘heterosexual desire and identity are not merely assumed, they are ... rewarded and privileged’ (Chambers and Carver 2008: 145). Here it is instructive to bear in mind Foucault’s insightful analysis on processes of production of consent. He argues that we should not ask why and how subjects agree to being subjugated but rather should focus on how hegemony manufactures subjects (Foucault 2003: 45). How are certain bodies, gestures, desires and pleasures identified and constituted as heterosexual and thereby as normative? How do diverse operations of hegemony support and reinforce one another, thereby guaranteeing that they function (2003: 45–6)? Here, subjects are not ‘inert or consenting targets of power’; rather, as Foucault argues, ‘power passes through individuals. It is not applied to them’ (2003: 29). This unfolds how politics governs social and sexual relations; it also determines the mechanisms of regulation of that which is to be regulated. Any attempt to denaturalize gender through the critique of heteronormativity is deeply linked to uncovering the ‘normative violence implied by ideal morphologies of sex and to uproot the pervasive assumptions about natural or presumptive heterosexuality’ (Butler 1999: xx). Normative violence is the violence of particular norms that determine not only who ultimately counts as human, but also regulates what is legible and intelligible within a specific framework. Those vulnerable to not being recognized as legitimate subjects risk ‘social death’ (Mills 2007: 137). In our everyday understanding, violence is seen to be exerted on an autonomous subject, whereby it is condemned precisely because it violates the subject’s sovereignty. In contrast, normative violence is not exerted on preformed subjects but exercised in the formation of subjectivity. Gender norms exert violence on those bodies that violate such norms (Chambers and Carver 2008: 76), whereas those who conform to the norms profit. The body does not exist prior to violence; instead it is constituted through it, thereby being an effect rather than simply a recipient of violence. Furthermore, Butler’s notion of normative violence does not attribute the agency of violence to erring homophobes but to the norms themselves, so that normative violence both enables typical physical violence, while simultaneously erasing the trace of the violence (2008: 76). Thus the capacity of norms to exert violence is twofold: On the one hand there is the occasional and incidental violence that relates to the particular manifestation of the norm. On the other hand is the violence internal to norms by virtue of their constitutive ‘worldmaking’ and ‘reality-conferring capacity’ (Mills 2007: 140). One of the biggest challenges lies in the difficulty of making normative violence visible – unfolding how ‘norms of recognition function to produce and to deproduce the notion of the human’ (Butler 2004: 32), thereby making some lives ‘impossible’ and ‘unlivable’ (1999: viii). Certain forms of violence are deemed as legitimate and permissible, since those at the receiving end fall outside the hegemonic norms of recognition. The threat of violence in the face of non-compliance with hegemonic norms is a constant reminder that to defy norms is to court death (2004: 34). The very possibility of a ‘lived life’ depends on being recognized as a legitimate and legible subject. Normative intelligibility is deeply linked to survival, as ‘we continue to live in a world in which one can risk serious disenfranchisement and physical violence for the pleasure one seeks, the fantasy one embodies, the gender one performs’ (2004: 214). Norms not only normalize but also valorize by rewarding compliance and punishing deviance. Thus norms are inextricably linked with incentives and consent that are produced and legitimized in the social, religious, economic and cultural spheres. Butler’s approach shifts the focus on the question of the relationship between sanctions and norms on two important points. Firstly, power in Butler’s thinking is not understood only negatively as something that prohibits or represses. She moves away from a juridical understanding of power where one subject harms another. Instead, she sees the power of norms as productive; they produce certain pleasures and desires while delegitimizing others. Secondly, Butler’s argument marks a shift away from the liberal conceptions of the subject as a rational being who makes informed choices about which norms to conform to. Rather, norms produce subjects and bodies even as they regulate them, á la Foucault. Liberal readings, which understand normativity only in terms of deliberate choices made by autonomous subjects over which norms to comply to, ignore the issue of survivability of non-normative bodies. Challenging the fiction of the sovereign subject, Butler foregrounds instead the vulnerable subject because of its dependency on norms (Mills 2007: 134). Moving away from a voluntarist notion of resistance, she unpacks how norms are a site of political agency, even as the vulnerability of the subject is closely related to normative regulations. Political attempts to dehegemonize heteronormativity usher in a conceptual shift from minoritarian identity politics aimed at social inclusion to challenging the ‘normative violence’ of heterosexuality. Within liberal theory, the problem of sexual orientation has been resolved by making discrimination against queers illegal (Chambers and Carver 2008: 145). The promise being that this will guarantee equality and freedom. But critique of heteronormativity is not only about individual acts of discrimination or overcoming the prejudice of the heterosexual majority. Heteronormativity sustains itself through constant iteration, so that subversion becomes possible precisely because regulatory practices have to be endlessly repeated to sustain themselves. As the iteration of norms is crucial for their sustenance, there is the possibility that norms can be ‘deterritorialized through ... citation’ (Butler 2004: 52). By virtue of being vulnerable to disruption, normative orders can be resignified through subversive iteration (2004: 223). However, deviation from the norm does not automatically entail subversion, because norms depend on deviations for their continued existence (Butler 2004: 149). Challenging the norm is still being defined in relation to the norm. Following Foucault, Butler argues that norms both limit and enable what humans can be (2004: 42). Foucault for his part learns an important lesson from Kant’s analytic of finitude – that we are indebted to limits for they are not only constraints but also conditions of possibility, namely, ‘enabling limitations’ (Simons 1995: 14). Norms are not frozen in time, nor can they be challenged in the same way at all times. The analysis of the historical conditions in which norms emerge and in which they regulate is crucial for a counter-hegemonic politics. Thus, the line between subversion and a mere imitation of norms is not easy to draw. Subversion does not happen automatically and its effects cannot be predicted in advance. Counter-hegemonic practices do not lie in the mere empirical chance that numerous individuals undermine gender norms by participating in the mimicry of heterosexual norms. Thus, there is no guaranteed way to contest heteronormativity, whereby subversion is an incalculable effect. Butler resists offering criteria to judge if a practice is subversive, instead arguing that an act may prove to be more subversive through its capacity to irritate hegemonic norms of recognition; that is, because of its illegibility (1994: 38). Heteronormativity makes sexuality legible through the coding of everyone as heterosexual. Those who do not comply with heterosexuality are expected to declare their deviance from the norm clearly and explicitly through ‘coming out’. Accordingly, to subvert heteronormativity would therefore be to render sexuality less legible and to undermine the practices of reading sexuality produced by heteronormativity (Chambers and Carver 2008: 155). Butler notes that ‘the affirmation of homosexuality is itself an extension of a homophobic discourse’ (1993: 308), so that ‘I come out only to produce a new and different closet’ (309). This is not a straightforward disclaiming of queer identities but rather a question of developing strategies for subverting the heteronormative norm without stabilizing homonormativity, even as ‘judgements on what distinguishes the subversive from the unsubversive … cannot be made out of context [and] cannot be made in ways that endure through time’ (Butler 1999: xxi). The ability to critique existing norms is linked to the capacity to articulate ‘alternative, minority versions of sustaining norms’ (Butler 2004: 3). Survivability depends both on being recognized by others as a legible subject and also on the ability to render one’s speech intelligible to others (Mills 2007: 142). Normative violence does not mean that norms are non-negotiable – though the negotiability of norms does not imply that norms cannot be violent and/or coercively implemented. The contingency of norms makes room for creative political agency. Even as subjects are dependent upon and emerge from within normative orders, they are not fully determined by them, so that ‘norms do not exercise a final or fatalistic control’ (Butler 2004: 15). Thus norms at once enable and hinder the subject’s legibility and intelligibility. This reveals the normative dilemmas we face, namely, that ‘although we need norms in order to live, and to live well, and to know in what direction to transform our social world, we are also constrained by norms in ways that sometimes do violence to us, and which, for reasons of social justice, we must oppose’ (Butler 2004: 206). This indicates the ‘constitutive and regulatory effects of norms’ as well as their ‘aspirational and destructive dimensions’ (Mills 2007: 134). Instead of the common sense understanding of the normative as action guiding, Butler unfolds the nexus of violence, norms and subject constitution (Mills 2007: 134). Norms enable and hinder survival through normative constitution of ‘lives worth living’. Furthermore, Butler isolates the force of the norm by exploring the effects normative regulations induce. Norms as a ‘form of social power’ or ‘apparatus’ (Butler 2004: 48) do not possess an independent ontological status; rather, norms operate as an ideal against which actions are rendered legible or illegible (Mills 2007: 138). Instead of being imposed from the ‘outside’, the norm produces its field of application (Mills 2007: 139). Political contest resides in exceeding and reworking the norm; it rests on negotiating normativity. If there are norms of recognition by which the human is constituted and these norms encode operations of power, then it follows that counter-hegemony entails a contest over the power that works in and through such norms (Butler 2004: 31). The capacity to challenge hegemonic norms presupposes an ability to re-imagine our relation to norms. Against this background, let us turn to the politics of same-sex marriage, in order to explore whether it serves as an extension of the heteronormative order and/or whether it holds the potential for counter-hegemony.

JJ: It seems that in the media Medicare and Medicaid are mostly mentioned as a kind of in-one-breath tag-on to Social Security, when a story is giving a thumbnail of so-called “entitlements”; these programs are rarely center stage. I wonder if you could tell us about how this Republican plan, from what we know of it, would affect Medicare and Medicaid, and, along the way, remind us of what those programs do?

NA: The so-called Trumpcare, this new healthcare plan that the Republicans have just rolled out, is very destructive to both Medicare and Medicaid. The Republicans ran against the Affordable Care Act, the so-called Obamacare, but no one ran against Medicare and Medicaid, because the programs work very well and they’re very popular. Both programs were enacted in 1965. The idea behind Medicare—it’s a part of Social Security—is that you cannot really be economically secure if you’re one illness away from bankruptcy. So Medicare provides basic health insurance for those 65 and over who are receiving Social Security.

Social Security enrolls you in Original Medicare (Part A and Part B).

• Medicare Part A (hospital insurance) helps cover inpatient care in hospitals (including critical access hospitals) and skilled nursing facilities (not custodial or long-term care). Part A also pays for some home health care and hospice care and inpatient care in a religious non-medical health care institution.

“In America, your health and your longevity should not be dependent on your bank account or your stock portfolio,” Sanders said. “Health care is a human right, not a privilege.

“Over 85 million people are uninsured or underinsured. As we speak, there are millions of people who would like to go to a doctor but cannot afford to do so. That is an outrage.

Good things are in the works! This week in good news: Democrats take another shot at passing universal healthcare, a Minnesota bill targets Amazon’s warehouse labor violations, electric bus factory workers vote to unionize thanks to new federal policies, Chicago acknowledges environmental racism, and climate activists hold Shell accountable.

Medicare For All Is In The House (Again)

For the past 46 years, the Employee Retirement Income Security Act (ERISA) has preempted state regulation that “relates to” employer-sponsored health benefits.

Much has changed in health care and society over that time; but ERISA’s preemption abides — widely maligned, yet unaltered. An ERISA preemption waiver thus presents a long-overdue update to health care regulation with a lot to recommend it to the Biden Administration’s health care agenda: it enables states to “strengthen and build on the Affordable Care Act,” it offers a modest incremental step that could pave the way for bigger structural change, it prompts no federal spending, and it has bipartisan political support.

The Patient Protection and Affordable Care Act (ACA) was signed into law in 2010. 1 The aims of the ACA are to reduce the number of uninsured individuals in the United States, to reign in rising healthcare costs, and to improve healthcare quality' In 2017, the ACA's State Innovation Waiver (5 1332) will enable states to waive many of the ACA's provisions and to create their own Innovative solutions to control healthcare spending. However, the Employee Retirement Income Security Act of 1974 (ERISA)4 presents a number of significant legal hurdles to true innovation in healthcare. ERISA's original purpose was to encourage employers to sponsor benefit plans and minimize potential conflicts with existing state laws. Because of ERISA, the regulation of employee benefit plans, including health plans, falls primarily under federal jurisdiction for the forty-eight percent of the U.S. population insured through their employers. State laws cannot directly refer to ERISA, nor influence the benefits, administration, or structure of an ERISA plan. Also, if a state law limits employer choices too much, it will likely violate ERISA. 8

The most aggressive innovation in combating high healthcare costs is the implementation of a single-payer health insurance system. However, in order to comply with ERISA, states would need to leave the employer-based health insurance market intact, which stymies true healthcare reform. Any innovation that is too coercive and leaves employers with little choice but to modify their plans, or requires that an ERISA plan be administered in a specific way or through a single processor, would likely violate ERISA. II Additionally, under 1332, state statutes will be required to provide that employers offer coverage that is as "comprehensive" as is offered under the ACA. These mandated benefits would also violate ERISA. This Note explores the ways in which ERISA is a significant legal roadblock to meaningful state-level healthcare reform under the ACA's 2017 State Innovation Waiver. In order for states to truly innovate and reform their healthcare systems under 1332, ERISA needs to be waived, amended, or repealed by Congress, or overridden by executive order.

The main goal of this law, the Employee Retirement Income Security Act of 1974 (ERISA), was to provide uniform, federal regulation of pensions and employee benefit plans (including health care). But the law has had a far more dramatic impact on health policy beyond what Congress ever contemplated. Because ERISA pushes aside state regulation of these plans, it has impeded the states’ ability to partner with the federal government to achieve key health policy goals. ERISA has also stymied some of Congress’s goals under the Affordable Care Act, and may prove an even greater obstacle to Republican efforts to return more authority over health policy to the states.

ERISA and health reform have not meshed well. For instance, the ACA’s attempt to create greater uniformity of benefits is at odds with the way ERISA creates a special class of protected plans and blocks states efforts to regulate them. When you ask yourself why the ACA’s guarantee of essential health benefits applies to some health plans but not to others, the answer is deference to ERISA. When you ask yourself why some health plans are subject to state-mandated benefit laws but some remain exempt, the answer is ERISA.

Industry leaders say the impact of a state- or regional-level single-payer system on self-insured large group plan holders and Medicare beneficiaries would make choosing uniform plans difficult, raising the issue of some beneficiaries receiving more comprehensive coverage than those in other states.

James Klein, president of the American Benefits Council, says that any reform of the U.S. health coverage system should build on the employer-sponsored system covering nearly 180 million Americans to ensure that employees of multi-state companies receive the same benefits as co-workers in other states.

To finance these universal and comprehensive benefits, state single-payer bills use several strategies to capture health expenditures from the existing multipayer system, while navigating a number of financial and legal impediments. First, the state bills would consolidate federal funds from Medicare, Medicaid, and the ACA exchanges into the state single-payer plan using  in those federal programs. The Department of Health and Human Services has considerable discretion to  state applications for each of these federal waivers; however, and the state bills generally lack fallback plans for capturing federal funds should the agency deny the waivers. Nor do the state single-payer bills confront financial obstacles from state constitutional prohibitions on , which constrain state plans when tax revenues fall during economic recession. 

Second, but perhaps more crucially, state single-payer bills must find ways to redirect the  that currently cover 49 percent of Americans—a daunting legal task under ERISA. ERISA  all state laws that “relate to” employer-sponsored benefits, so states cannot simply mandate that employers cease offering health benefits. States do retain broad power to regulate health care providers and health insurers, but ERISA preempts the application of state insurance regulations to employers’ self-funded health plans, which now comprise more than  of all employer-sponsored health benefits. ERISA challenges states’ abilitiesto capture employer health spending—a source of funding that would be critical to the viability of a single-payer system.

In health care, there are numerous political, economic, and historical reasons to prefer federal reforms. Politically, state “health reform” cuts both ways—some states aim for universal coverage and patient protections, others pass health laws restricting access, perpetuating discrimination, and responding to inaccurate assumptions.283 Though federal legislation is not inherently prone to protecting access, federal baseline protections can guard against discrimination and codify evidence-based solutions, counteracting local prejudices.284 Economically, federal reforms enjoy the advantages of economies of scale and deficit spending, as well as cost-control power in interstate markets.285 Historically, the decades before the ACA witnessed the widespread failure of state regulation to rein in costs and expand access to care, with the exception of Massachusetts’s bold universal coverage experiment and a handful of other state reforms.286 The ACA then built comprehensive federal reforms on the results of Massachusetts’s experiment.287 The decade since the ACA’s enactment has also witnessed some of federalism’s pitfalls, as a shift in the federal Executive has undermined the ACA’s core protections and encouraged states to pursue variations that contradict the purposes of federal laws, while receiving funding provided by those laws.288

Realizing the benefits of single-payer reform entails many challenges and potential pitfalls. As the CBO report noted, the effects on the economy and individuals would depend on key features of the design of the program, such as how it paid clinicians and what services were covered. While single-payer reform could simplify bureaucracy and free up hospital resources and physicians' time to meet the increased demand for care, poorly designed legislation might perpetuate Medicare's burdensome payment and monitoring strategies. Even in a well-designed system, waiting time for care might increase; however, the Affordable Care Act, which covered 20 million uninsured individuals, did not significantly increase waiting time or compromise access for previously insured individuals. Nonetheless, enhanced funding for training programs might be needed to ensure an adequate supply of clinicians, particularly in primary and behavioral health care and in regions with physician shortages. In addition, as with Medicare, politics could affect decisions regarding coverage in a single-payer system.

Most individuals would have an insurance transition, but they could keep their physicians and would be spared future transitions. Although patients would not be able to choose among insurers, they would no longer face network restrictions and, in many cases, could have improved benefits. To protect innovation, some drug price savings could be used to augment federal research funding.

While the point is often exaggerated, it is true that wait times are somewhat longer in Canada and the U.K. than they are in this country. In the age of three-second Google searches, however, no one has any excuse for believing that this is because socialized health systems suffer from “doctor shortages.” Canada and the U.S. have exactly the same rate of physicians per capita (2.6). The British rate is a bit higher (2.8). And the highest rate in the world (8.2!) can be found in Cuba.

The reason wait times are higher in countries with socialized health systems isn’t that there aren’t as many doctors. It’s that there are more patients.

Diamond (2009) predicts “The ultimate toll of a single-payer system will be a reduction in the quality of healthcare that Americans may be unwilling to bear” (p 921).

The most extensive study on the quality of healthcare among 11 first world countries is by Schneider, Sarnak, Squires, Shah, and Doty (2017). These authors synthesized 72 indicators of healthcare which they categorized in five domains. Their data is from the international surveys by the Commonwealth Fund, the Organization for Economic Cooperation and Development, the World Health Organization, and the European Observatory on Health Systems and Policies. The U.S. ranked last on overall healthcare when the five domains were combined, ranked last in four of the five domains when examined separately, and ranked last in the most important domain— Health Care Outcomes.

As “Medicare for all” gains steam in the Democratic primary, many physicians are concerned about reduced revenues from the program compared with private insurance. Even an expansion of the program, as many candidates’ plans call for “Medicare for more,” causes angst. Inevitably, some physicians will threaten to opt out of Medicare and refuse to see patients.

Such calls are, for the most part, bluffs. We need only examine how many physicians have followed through on past threats to see that.

Are such concerns supported by evidence? The nonpartisan Congressional Budget Office (CBO) recently estimated payments to physicians in 2030 under current policies and five options for Medicare for All. It projects that without reform the weighted average of public and private payments to physicians will increase to 116% of the 2019 weighted average, versus between 108% and 117% under the various Medicare for All options analyzed.1 But because the CBO expects Medicare for All to increase society-wide utilization of care, it also predicts that providers’ total revenues would increase, even if fee levels were to decline.

More specifically, the CBO projects that in 2030 providers’ total outpatient revenues would be between 5 and 9% higher under Medicare for All than without reform; physician services currently account for 78% of such revenue.1,2 These estimates assume that Medicare for All would not significantly alter the supply of physicians, which is currently limited by the supply of residency and medical school spots.1

U.S. physician organizations are shifting positions toward a single-payer healthcare system to benefit both doctors and patients. The single-payer system is a streamlined financing mechanism where one entity administers funding and payments.

After robust protests from medical students in 2019, the American Medical Association left the Partnership for America’s Healthcare Future, a lobbying group that spent more than 100 million dollars annually opposing both public option and universal single-payer proposals in federal election campaigns.