Globalization, Presentation, and Care: Preecha Aesthetic Institute over 10 Years

GNDR_ST 341 Final Exam

Carrie Hsieh • Maddy Kossick • Carrie Willis

Abstract Neoliberal globalization describes the increased reach of global trade and the opening of

domestic markets to foreign investors, informed by the neoliberal ideology of individual

responsibility and the fundamental right to free trade. We argue that neoliberal policies and the

institution of the global economy have directly impacted the degree of competition in the Thai

medical services market. The increased freedom of non-Thai consumers to engage in the Thai

medical market combined with the increasing use of Internet marketing made Thai clinics and

hospitals more accessible to a far larger consumer base than they had ever seen. This shifted

marketing strategies from the more loyalty- and networking-based strategy of word-of-mouth

and institutionalized the concept of “window-shopping,” or considering multiple clinics with no

real stake in any.

In an attempt to compete with other clinics’ and hospitals’ websites and appeal to the

large mass of “window-shopping” consumers, the Preecha Aesthetic Institute (PAI) has radically

transformed its website over time. By examining key pages of the website in 2004 and May

2014, one can see how PAI’s website simplified its language to make it more accessible to a less-

informed, non-medical audience and made its design more aesthetically pleasing to draw in its

mostly Western consumer base. To distinguish itself from its competition, PAI also actively

expresses warmth, understanding, and compassion for its disproportionately Western trans*

consumer base, using the strategy of communicating affect to express this sentiment. These

intentional and premeditated changes are reflected in the changes in PAI’s website over ten years

and are supported by interviews with the PAI webmaster and founder of the Institute.

Introduction: Medicine on the Global Stage

Globalization, often called neoliberal globalization, is a political and economic ideology

which assumes that “human well-being can best be advanced by liberating individual

entrepreneurial freedoms and skills” (Harvey 2 qtd in di Leonardo 5). The shift from Keynesian

social and economic policy to neoliberal ideology in the 1960s and 1970s introduced political

and economic policy which reflects this ideology, including the liberalization of trade, the

protection of private property rights, the reduction of “barriers to free trade” such as taxes and

tariffs, and the reduction of state intervention in the global economy (di Leonardo 5-6; Spade 57-

59).

Neoliberal economic policy relies heavily on the concept of comparative advantage, or

the idea that “nations should specialize in producing goods in which they have a natural

advantage and thereby find their market niche” (Ricardo in Ellwood 18). Thailand has

historically enjoyed a robust tourism market, due to its self-orientalization as a mystical, exotic

land as well as its enduring sex industry (Aizura, “Feminine Transformations” 426-427; Wilson

129-130). However, Thailand’s market niche can almost certainly be considered its medical

tourism industry.

To combat social and economic turmoil in the late 1990s through 2010s, the Thai

government instituted a dual-track health program which polarized healthcare consumers into

two groups: those who could afford more expensive privatized healthcare and those engaged in

the more affordable national healthcare system (Wilson 130). This former system attracted

foreigners with money, incentivized by lower healthcare costs and the reputation of Thai

surgeons as highly skilled and well-trained, as well as the eventual recognition and

popularization of medical tourism by the Tourism Authority of Thailand (Cohen qtd in Wilson

133; Aizura, “Feminine Transformations” 429; Wilson 132).

Between 1990 and 2010, the population of “foreigners” in the Thai medical services

market increased from 5 percent to 90 percent (Chokrungvaranont et al 4). Many of these

foreigners are Western trans*men and trans*women who come to Thailand for sex reassignment

surgery (SRS). Western trans* people choose Thailand for SRS due to the “friendliness” and

“respectfulness” of the surgeons compared to Western doctors, combined with the assumed

openmindedness of Thai society reflected in Thai popularization of kathoey, or Thai gender

variant individuals, through beauty pageants and popular media (Aizura, “Feminine

Transformations” 431-432; Chokrungvaranont et al 3).

As the global market for medical tourism emerged, media, including the Internet, became

an invaluable tool in broadening the reach of advertising to larger audiences and isolating target

populations for more intensive marketing (Aizura, “Performative Genders” 429; Wilson 123).

Prior to the internet boom, clinics and hospitals relied on word-of-mouth based marketing,

wherein loyal ex-patients popularized clinics and hospitals within their social circles and smaller

Internet discussion boards (Aizura, “Performative Genders” 429; Chokrungvaranont et al 3).

However, as more potential clients took to the internet and more clinics created web pages to

cater to them, internet competition between clinics and hospitals increased.

As the ease and variety of Internet searching replaced word-of-mouth based marketing

strategies, confidence in the quality of clinics and hospitals was no longer assured by a personal

and trusted contact. Consumers were no longer biased toward any particular clinic, and had more

freedom to “window shop,” or superficially consider multiple clinics and weigh their pros and

cons. Thus, it became much more important that these institutions’ websites reflect an experience

which the target audience would consider both high-quality and welcoming.

This phenomenon can be seen clearly in the transition of the website for the Preecha

Aesthetic Institute (PAI) from 2004 to May 2014, prior to its most recent update. PAI’s website

takes steps to make itself both more aesthetically pleasing as well as ideologically pleasing to

one of its largest consumer bases - Western trans* people, particularly trans*women. Through

the replacement of medical jargon with simple language, the integration of Western terminology,

concepts, and medical standards into webpage text, and the active expression of compassion,

understanding, and warmth toward Western trans* people, PAI markets itself not only as a

competent establishment within the trans* medical industry, but a supportive community of well-

informed individuals with respect for their patients.

Affect through Accessibility

In 2004, the website for Preecha Aesthetic Institute was largely textual and information-

based, and the tone of its content was impersonal and clinical. Some pages of the website

included long lists of hyperlinks to different websites and articles, directing potential patients to

seek outside knowledge from other locations. In 2014, the PAI website is comparably much

more self-contained and comprehensive. This change is in deliberate response to growing

competition from other websites, leading PAI to intentionally contain its information within the

website itself and provide more explanatory content, so that PAI could serve as the sole resource

potential patients would need. Before, in 2004, most information about clinics was spread word-

to-mouth; with word-of-mouth marketing, there is less pressure for a website to make an

immediate first impression, as a trusted friend had already done that by sharing their own

experience. Additionally, since the online consumer base for gender reassignment clinics is much

higher now than in the past, competition leads to clinic websites revamping their layouts and

making sure their pages are as visually appealing as possible. This accounts for the 2004 PAI

website being less aesthetically pleasing and more text-based, while the 2014 website takes

action to be more aesthetically pleasing and comprehensive.

An example of these changes can be seen in the differences between the 2004 and 2014

male-to-female SRS surgery pages: On the 2004 website, PAI redirects visitors seeking

information about SRS to outside sources. The specific 2014 male-to-female SRS surgery page

shown below – not even the general SRS page – provides a careful definition of SRS: “Sex

reassignment surgery (initialized as SRS; also known as genital reconstruction surgery, sex

affirmation surgery, sex realignment surgery or sex-change operation) is a term for the surgical

procedures by which a person’s physical appearance and function of their existing sexual

characteristics are altered to resemble that of the other sex” (parentheses in original).

As is illustrated below at right, the 2004 male-to-female SRS surgery page does not define SRS

at all, only providing information about service additions, facts about the procedure, preparation,

and details about the surgery schedule.

The 2014 website is

far more experience-based

and gives off a more

welcoming impression to

potential patients. Peera,

PAI’s webmaster, stresses

that making content

understandable and taking

care of patients are the main

priorities of the website.

From 2004 to 2014, the

reduction in medical jargon is

clear and deliberate. For

example, on the 2004 page

about the tracheal shave

surgical procedure, the

website states: “The thyroid

cartilage is reduced, usually by carving at the most prominent area and the rim of its superior

border…This procedure is often done in conjunction with a Cricothyroid approximation.” On the

other hand, the 2014 page on the same procedure uses much less complicated language in order

1 The 2004 Male-to-Female Sex Reassignment Surgery page at the Preecha

Aesthetic Institute website.

to make procedural details accessible to a non-medical audience: “After an anesthetic is

administered to the patient, a small, horizontal incision is made on the bottom of the Adam’s

apple…the protruding cartilage is shaved down with a scalpel, thus making the throat appear

smoother and less angular.”

Additionally, the tone of the 2014 website seems to exhibit genuine compassion, and it

also demonstrates a high degree of understanding, empathy, and warmth for the situations that

potential patients might be going through. This change in tone and content reflects the interview

with Dr. Preecha, who emphasized how much he cares for his patients and how critical

transgender rights are to him. In regard to PAI’s shifting tone, the GRS description page begins

with this quote from Harry Benjamin: “The difference between sex and gender. Sex is what you

see. Gender is what

you feel. Harmony

between the two is

essential for human

happiness.” This

quote emphasizes

individual emotion

and feeling, seeking

to resonate with

potential patients and

establish a connection

of understanding with

them. This quote 2 The 2014 Male to Female Surgery page of the Preecha Aesthetic Institute website.

Note both the quote from Harry Benjamin and the explanation of Sex Reassignment

Surgery.

starkly contrasts the detached and information-based language of the earlier website; it offers

affirmation and support to the clinic’s Western trans* base who might identify with its

sentiments.

In “The Romance of the Amazing Scalpel: ‘Race,’ Labour, and Affect in Thai Gender

Reassignment Clinics,” Aren Aizura’s discussion on affect might help account for the increased

emotional and experience-based rhetoric on the PAI website. Aizura mentions PAI specifically

as a clinic housed within a private hospital with large proportions of non-Thai patients; these

clinics serve “large proportions of non-Thai patients” and “constitute a destination for many

people globally who cannot…access gender reassignment surgeries close to where they reside”

(Aizura, “Romance of the Amazing Scalpel” 144). Here, Aizura highlights gender reassignment

clinics as international centers and points of access into Thailand for non-Thai visitors. As clinics

compete with each other to gain visibility and status as successful international centers for

medical tourism and travel, they must use different tactics to distinguish themselves from their

competition.

PAI’s expression of affirmation and affect help differentiate it from other clinics. Aizura

defines affect as “bodily capacities to affect and be affected or the augmentation or diminution of

a body’s capacity to act, engage, and to connect” (Aizura, “Romance of the Amazing Scalpel”

147). A body’s capacity to act, engage, and connect is based in feelings and emotions, and so

affect relates to the changing, experiential states of bodies and whatever influences its feelings or

emotions. PAI’s affirming and understanding tone helps the clinic “gain a reputation” by paying

“careful attention to patient care” and “attention to a patient’s comfort;” comfort is not just a

corporeal state, but also one that “registers an affective disposition” (Aizura, “Romance of the

Amazing Scalpel” 144). This can be seen in the image below, a header on one of the 2014

surgery pages:

Thus, PAI’s expression and affirmation attempts to build comfort for patients at the level

of affect, concerning itself with establishing emotional connections with patients and engaging

with them at a level of internal

understanding. The images at right,

which are included in the rotation of

images on the May 2014 home page,

depict affective labor practiced at the

clinic that PAI wants to underscore. All

three images present a sense of

“emotional work” and “the care, the

nurturing, and the transmission of

affect” that clinic staff expends for

patients (Aizura, “Romance of the

Amazing Scalpel” 147).

PAI visually and textually

highlights their affective work in images

3 A website header graphic from the 2014 Preecha Aesthetic Institute website.

4 Images from the rotating header graphic on the May 2014

Preecha Aesthetic Institute website.

of the 2014 homepage. As seen below, the images in the 2004 homepage are comparably more

clinical, professional, and dispassionate, less warm, and less engaged with feeling and emotion.

Building a Community of Care

Examining key pages of the Preecha Aesthetic Institute website 10 years apart illustrates

a dramatic change in the overall feel of the website, and in addition from transitioning from an

information-based website to an experience-based website, the website also changed the type of

information it provided and how it provided that information. Appeal to Westerners was moved

to the forefront of PAI’s marketing strategy. Thailand has a history of strategically incorporating

Western norms into broader Thai culture in order to prevent radical Western restructuring

(Jackson 38). Elements of this selective Westernization appear in the transition from the 2004

and May 2014 iterations of the Preecha Aesthetic Institute website.

Making Western trans* clients feel comfortable is a major goal in the layout and content

of the May 2014 edition of PAI’s website. Surgery pages, informational videos, and the

Frequently Asked Questions page refers to the standards of care of the World Professional

Association for Transgender Health (WP ATH), reassuring clients that “[PAI] is not a straw-

village clinic with rusty scalpels” (Economist 2008 qtd in Wilson 122). Language itself changed

in the updates between 2004 and May 2014. In addition to being primarily information-based,

the 2004 website also featured a lot of information that was categorized in a way that would

make trans* people feel uncomfortable or put-off. There are many examples throughout the site

where aspects of GRS surgery are categorized under “cosmetic” or “aesthetic” surgery, and in

the “Knowledge Base” section of the website at right, SRS is classified under the umbrella term

of “cosmetic plastic surgery.”

In Western discourse, trans* people are often described as feeling

that they were born into the wrong body, that who they are does not

match the body they were given, and thus the completion of SRS surgery

is important to their emotional well-being. Sarah, also known as “The

Beautiful Boxer” was quoted as saying, “from an early age, I didn’t feel

like I belonged in the male body I had been given” (Sereemongkonpol

157). The classification of SRS or elements of SRS as “aesthetic” or

“cosmetic” surgeries makes them seem optional or elective, like breast

enhancement or getting a “nose job,” but due to the emotional, physical,

and mental toll SRS procedures take on the patient, the last thing a

potential client would want is to see their surgery classified as “cosmetic”

or “aesthetic.” The website’s classification of SRS and related surgeries as

cosmetic or aesthetic may seem like a small issue, simply different titles for

a list of links or tabs, as above at right, but it conveys a lack of understanding and empathy with

potential clients as to the reasons that trans* people get surgery and how vital they feel their

surgery is.

In addition to the fundamental misunderstanding of trans* identity reflected in the

classifications of GRS and related surgeries as cosmetic, the website’s language also betrays an

ignorance of the language used to describe trans* people in Western countries. In the website the

word transsexual is used, as shown below.

5 A sidebar menu from

the 2004 Preecha

Aesthetic Institute

website, listing both

gonioplasty and

labiaplasty as "Aesthetic

Plastic Surgery."

In Western discourse, the term “Male Transexual” [sic] would not be used to refer to a trans*

person who was born male, and could easily be taken as ignorant or potentially offensive when

read by a trans* person.

In the examples shown above, the incorrect classifications and use of language could

potentially give Western trans* people the impression that PAI is uncaring, but they do not

reflect the views of Dr. Preecha himself. In a 2011 interview, Dr. Preecha expressed sympathy

and understanding for trans* people who came to PAI for surgery, even showing frustration and

anger when discussing problems Vietnamese trans* people and Thai kathoey faced getting

appropriately-gendered ID cards after their surgeries (Preecha 2011). The lack of ideas and

language considered “appropriate” to Westerners did not reflect a lack of care on part of Dr.

Preecha, but rather that he did not know the vernacular that conformed to Westerners’ beliefs and

made them feel accepted and comfortable. This problem is clearly rectified in the 2014 website.

The contrast between the 2004 and 2014 websites is stark. For example, in 2014 there are

separate sections for “Aesthetic Plastic Surgery” and “Gender Reassignment Surgery,” as shown

below:

6 Information about Sex Reassignment Surgery, in which trans*women are referred to as "male

transexuals" [sic].

This separation shows that PAI staff understand the problems trans* people have with

listing their surgeries as “aesthetic,” and the change in labelling SRS (sexual reassignment

surgery) as GRS (gender reassignment surgery) reflects an understanding of Western concepts of

the sex/gender dichotomy. Additionally, the quote from trans* medical advocate Harry Benjamin

on the GRS splash page not only convey PAI’s desire to express affect and create an

environment in which patients feel understood, but that they comprehend Western ideologies and

concepts about what it means to be trans* and their part in their patients’ own transformation.

Conclusion

Between 2004 and May 2014, the website for Preecha Aesthetic Institute changed

aesthetically and textually to appeal to this consumer base, making medical information easier to

understand and appealing to Western perceptions of trans* identity to manufacture an

environment which is simultaneously competent and warm. The website markets itself as

welcoming to a Western trans* consumer base, consistently referring to well-known and trusted

Western trans* advocacy groups such as the World Professional Association for Transgender

Health (previously the Harry Benjamin International Gender Dysphoria Association), and the

May 2014 website uses terminology such as “transgender” rather than “transexual” [sic] as it did

in 2004.

7 Click-through links on the May 2014 Preecha Aesthetic Institute homepage,

clearly separating cosmetic plastic surgery and "Gender Reassignment Surgery."

The intentional aesthetic and ideological changes made between 2004 and 2014 reflect

the increased competition between clinics to engage in a global medical services market. As

Western neoliberal ideology stresses the responsibility of the individual as agent, consumers in

the healthcare market understand their ability to make choices about where and how to receive

healthcare as their fundamental right (Wilson 122). As the Internet became a more valuable

resource for clinics and hospitals to engage with a previously inaccessible, increasingly global

consumer base, consumer loyalty became less ensured, as word-of-mouth marketing was

replaced by “window-shopping” consumers with less of a personal stake in any particular clinic.

The calculated strategies of self-representation which PAI’s website utilizes to create a

personal connection with a large, overwhelmingly Western consumer base reflects not only that

PAI staff understand their audience on a personal level, but the increased importance of

presentation itself. The effort PAI takes to make its website more accessible to a much broader

audience while also catering to one of its most lucrative and important class of clients illustrates

the importance of affect in a market which has increasingly become a competitive global arena.

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