Class & the Cost of Documentation

In the United States, the cost of medical care and insurance is regularly cited as a pressing public issue. Conflicts between "Obamacare" and individual-payer approaches to healthcare are rampant in media reports. This attention is duly justified. Based on 2016 data from the Centers for Disease Control and Prevention (CDC), 12.4% of adults in traditional college years are uninsured. Even with insurance, three in five American bankruptcies in 2014 were due to unpayable medical bills, making healthcare the leading cause of personal bankruptcy (Lamontagne, 2014). Americans with disabilities often require more healthcare services than their nondisabled counterparts, making them more likely to face financial burdens in the medical arena, as well as in the broader economic sphere due to increased unemployment rates (Rivera Drew, 2015).

The documentation requirement for college students with disabilities seeking accommodations adds to this financial burden. Physical illnesses that cause disabilities often take years to diagnose, and require substantial expenses for medical testing. Treatment aside, the diagnosis process is one that many Americans cannot even begin due to their financial limitations. Disabling physical illnesses, particularly invisible ones, regularly take multiple specialist visits to diagnose, and some tests cost several thousand dollars—not including doctors' fees to read the results (e.g., tilt table testing, genetic testing, MRIs). These costs leave many low-income people altogether undiagnosed, and thus unable to receive accommodations that make it possible for them to be successful as college students. Even being diagnosed with common, well-known learning differences and disabilities (LDs) such as attention deficit hyperactivity disorder (ADHD) can be costly. In Los Angeles, the average price for an ADHD evaluation is $1,634 (Consumer Reports, 2010). Such an evaluation does not ensure a diagnosis or accommodations recommendations, either. Further testing may be required, and this initial fee does not include future treatments or therapy sessions meant to ease the symptoms of the condition. Thus, the diagnosis process alone can inhibit students from accessing accommodations for their disabilities.

By contrast, students who come from places of socioeconomic privilege are far more likely to have their disabilities diagnosed prior to college years. This creates a "class gap" in which claims of disability are more often believed when they come from wealthy families and individuals. Some upper class students even claim to have duped the system and received false diagnoses for LDs (Mitchell, 2012). Researchers from the University of Kentucky found that false-positive diagnoses for ADHD are common, "particularly when students are motivated to convey symptoms," such as when their parents pressure them to get ahead (Sollman, Ranseen, & Berry, 2010, p. 325). Some parents express their distaste for alleged "fake" disabilities in elite schools: "All the uptown [Manhattan] parents claim disability. It's gross" (Mitchell, 2012). This frustration regarding the unfair advantage of students without disabilities receiving accommodations is common.

Despite this justifiable frustration, I caution claims that link socioeconomic privilege to having false diagnoses because this can be used to justify ableist oppressions against wealthy students who do indeed have disabilities. Instead, I bring this issue to light to underline how much of a role class can play in receiving disability accommodations. While some college students and/or their families can afford testing, others altogether cannot. This means that disabled students from low-income backgrounds are less likely to succeed than their wealthy peers, adding a layer of difficulty to the already dismal numbers of students with disabilities finishing baccalaureate degrees. Furthermore, being from a lower class background means that poor students with disabilities are more likely to be seen as "moochers" on the system than their wealthy peers, thus making them more susceptible to scrutiny when they receive accommodations. Stereotypes linking the poor to laziness, weak work ethics, and abuse of public systems and substances (Gorski, 2008) make the intersection of class important to address when considering the social situations faced by various people with disabilities.

In this socioeconomic arena, a biocultural lens such as crip theory (McRuer, 2006) encourages an understanding of disability as something that is socioculturally-induced by compulsory able-normativity. In other words, people's bodies and minds are not disabling them; the procedures and norms for receiving accommodations are the disabling forces at hand. The disabling impacts of socioeconomic class explained in this section are further exacerbated by histories of biomedical oppressions that harm other oppressed groups such as people of color, queer folks, women, trans people, undocumented individuals, and many of the intersections therein.

Histories of Biomedical Oppression as Exacerbating Documentation Difficulties

Beyond the issue of access and affordability, the Western biomedical field hosts a troubling history of oppression against racial, gendered, and sexual minority groups (see Szasz, 1997; Maines, 2001; Cohen, 2016; Reynolds, 2016). Many intersectional identities held by American college students with disabilities negatively impact their experiences with the process of obtaining documentation, and therefore accommodations, for their disabilities. In this section, I detail a few examples of how histories of biomedical oppression infiltrate contemporary experiences with medical diagnoses and care. Specifically, I outline some of the barriers faced by LGBTQ folks, people of color, and undocumented immigrants. Neatly separating these groups is unproductive due to the intersectional nature of identity (Crenshaw, 1989), so the overlap between these identities is duly noted. Addressing the experiences of, for example, trans women of color who are undocumented requires onlookers to see beyond traditional siloed views of identity, despite biomedical attempts to neatly categorize and separate bodies. In this section, however, some elements of non-intersectionality are present based on the rhetorics of biomedical documentation and history that reflect singular views of identity.

Within crip theory, the connection between queer and disabled people as Othered by compulsory normativities (hetero- and able-, respectively) is forefronted. This is because, like those with disabilities, queer people in the United States have long been oppressed by the biomedical field. Same-sex attraction ("homosexuality") was a diagnosable psychiatric condition listed in the DSM until 1973 (Krieg, 2013). The labeling of gay identities as medical disorders allowed medical providers to abuse queer individuals under the guise of health treatment. "Reparative therapies" designed to convert people to the social norm of heterosexuality included violent brain surgeries, chemical castrations, electric shock therapies, and other horrifying forms of alleged medical care (Dean, 2014). From a biocultural perspective, it is clear that the medicalization of sexuality in this case was built more upon hegemonic American values (i.e., heteronormativity, nuclear families) than the presence of corporeal illness. Many queer people in the United States still fear medical offices and care providers (Smith, Johnson, & Guenther, 2011), and often avoid seeking biomedical care as a result (Chance, 2013). This issue is compounded for Black queer men in particular, who often report negative encounters with medical institutions based on their sociocultural association with HIV/AIDS (Malebranche, Peterson, Fullilove, & Stackhouse, 2004). Since documentation for disabilities requires medical documentation, these trends suggest that queer students may be less likely to receive accommodations based on (fears of and/or actualized) biomedical oppression. Histories of violence in this field thus prevent queer people with disabilities from acquiring the documentation colleges require.

While same-sex attraction is no longer officially medicalized in the United States and is understood as a normal variant in humans, transgender individuals continue to face standardized medical oppression in contemporary times. Prior to 2013, the DSM characterized trans people as having "gender identity disorder" (American Psychological Association [APA], 1994). The current DSM shifted this language to "gender dysphoria" in order to shift from the much-resisted emphasis on identity as illness to instead emphasize experiences of bodily discomfort as diagnostic criteria to be given "treatment": hormones or surgeries for transition. Though this seems like a positive move, the contemporary DSM still links trans identities to pathology, and medical clinics serve as gatekeepers between trans individuals and physical transition procedures. Almost all clinics legally offering gender confirmation surgery or hormones require letters from psychiatric professionals who attest to the fact that their patients do indeed meet the diagnostic criteria for being trans (e.g., The Papillon Center, The Garramone Center).

The medicalization of gender identity evident in these procedures leaves many trans and gender nonconforming (GNC) individuals uncomfortable with seeking medical care—especially from psychologists or other professionals who study the brain. This issue is particularly pressing for trans and GNC students of traditional college age (young adults), who are even more likely to forgo medical care, treatment, or testing based on fear or anger toward the biomedical community (Clark, Veale, Greyson, & Saewyc, 2017). Such avoidance of biomedical spaces results in a barrier between trans and GNC students with disabilities and their accommodations, which regularly require medical or psychiatric documentation (see NACUA, 2013). In sum, the documentation requirement for obtaining student accommodations in American colleges and universities unwittingly acts as a queer-phobic entity in terms of both gender and sexual orientation. This oppressive nature of biomedical care is furthered by issues of racism within the healthcare field.

Throughout histories of biomedical research, the bodies of people of color, particularly women, have been abused as unwilling subjects (e.g., the Tuskegee syphilis experiment, the use HeLa cells, Marion Sims' gynecological experiments on female slaves). These forms of physical violence were often justified by racist "sciences" that supported colonial power and white supremacy while lacking any sort of base in biological evidence (see Gonder, 2004; Robinson, 1983). In contemporary times, racial oppression continues to permeate biomedicine (Davis, 2013). People of color in the U.S. receive lower-quality healthcare than white patients, even when factors like age, socioeconomic status, and insurance coverage are taken into account (Smedley, Stith, & Nelson, 2003). Therefore, it can justifiably be assumed that this poor quality healthcare impacts students of color when they require documentation for their disabilities in order to receive adequate accommodations—in college or otherwise.

From primary and secondary schools onward, disabled people of color are less likely than their white peers to be identified as exhibiting disabilities, and therefore are less likely to be placed in special education programs that account for their needs (Morgan, Farkas, Hillemeier, & Maczuga, 2017). Blanchett (2010) explains that learning disabilities often serve as a "category of privilege for the privileged," meaning that they allow people with class privilege to benefit from higher quality education assistance while those without class privilege remain without accommodations. This notion of LDs as "for the privileged" is reflected in many statistics surrounding diagnosed disabilities. The number of boys diagnosed with LDs is triple that of girls (Hallahan & Kauffman, 2006), and an overwhelming majority of those boys are white (Blanchett, 2010). It is unreasonable to believe that this disparity is based on internal racial inferiority; rather, it reflects a failure of the biomedical system to adequately care for people of color—and thus diagnose them with LDs—based on racist assumptions of people of color as somehow inherently less able to succeed in scholastic pursuits. The complex web of poor quality care for racial minorities (Smedley, Stith, & Nelson, 2003), racial biases in diagnostic criteria (Davis, 2013), fears of medical care held by people of color (Malebranche, Peterson, Fullilove, & Stackhouse, 2004), and other factors make this issue of documentation for disability accommodations an unintentionally-racist requirement.

For undocumented disabled students of color (who may also be members of the LGBTQ community), all of these ropes of biomedical oppression are compounded. When tighter immigration laws are passed, undocumented individuals are less likely to use healthcare services, often for fear of being exposed or reported to immigration authorities (e.g., Toomey, Umaña-Taylor, Williams, Harvey-Mendoza, Jahromi, & Updegraff, 2014). Some undocumented patients facing long-term healthcare needs—as many with physical disabilities do—can be deported through a process called "medical repatriation," which transfers them to medical care facilities in their countries of origin (Donelson, 2015). This euphemistic deportation aside, since most undocumented individuals in the U.S. do not have access to health insurance or public medical services like Medicare or Medicaid (Donelson, 2015), undocumented folks are then less likely to be able to obtain the medical services necessary to receive diagnoses for their disabilities. Instead, many undocumented people avoid medical services altogether and work to exist under the radar of institutions. When these students enter college, therefore, they rarely seek "extra" services (like disability resources) even if they have previously been diagnosed with a disability.

This issue is compounded by intersecting identities that undocumented people may hold. For example, undocumented LGBTQ folks face interlocking oppressions that frame them as deviants in sexuality, gender, and citizenship status. Thus, they can be framed as ultimate Others in ways that straight and/or cisgender undocumented folks are not. While it is unproductive to attempt to quantify oppression, addressing intersectionality is key to understanding the lived experiences of college students with disabilities, especially in their quests to receive accommodations. Outlining how race, gender, sexual orientation, citizenship status, and socioeconomic class intersect with ability to form highly variant experiences with disability services in college is important to understanding how some groups are barred access from ADA accommodations. When disabled students beat all of these odds and do manage to acquire accommodations, their struggles with social oppression are not over. Ableism becomes the guiding force.

To be clear, ableism cannot be separated from other forms of social oppression. This is because many other forms of oppression such as racism and sexism are fundamentally built upon ableist logics. As Bantyon (2001) explains, "the concept of disability has been used to justify discrimination against other groups by attributing disability to them" (p. 33 [emphasis in original]). For example, the suppression of women's right to vote in the U.S. was built upon the framing of women as feeble-minded or otherwise unable to make rational decisions. Likewise, anti-immigration policies in the U.S. have often relied upon the framing of immigrants as inherently less-able than American citizens to act in moral ways (i.e., Trump's discussion of Mexicans as rapists) or contribute to American society due to their alleged cultural or biological impairments. The ableism underlying these sexist and racist practices runs unchecked because oppression based on disability is, in essence, considered justifiable. With this understanding of ableism as the core of all other forms of oppression (Baynton, 2001), I now shift from the discussion of obtaining academic accommodations to a rhetorical analysis of the term "accommodation" and its implications.

The Damaging Discursive Power of "Accommodations"

From a discursive standpoint, the term "accommodations" attaches a negative connotation to disabled students in the American university setting. The U.S.'s hegemonic ideologies revolve around neoliberal values such as the "myth of meritocracy" (see Shome, 2000), which claims that each person is responsible for their own individual successes, and by extension, that no one should receive special services which "unfairly" aid some but not others. Neoliberal ideology therefore encourages nondisabled others to see disability accommodations as threats to American values and economic equality (Dolmage, 2017). Additionally, these dominant neoliberal ideologies in the U.S. frame college years as a time for independence and moving away from outside/parental aid. Social norms perpetuated through countless media texts suggest that American young adults (unlike their counterparts in other regions around the globe) of the traditional college age (18-24) should move out of their parents' homes and into dorms or other independent living situations (see Cugnon, 2015) while also doing many other adult activities for the first time. Having a disability makes this idealistic American College Experience unrealistic for many students. In a time of celebrated newfound independence, the fact that students with disabilities must be "accommodated"—that they depend on others for assistance to complete normative college tasks—means these students violate neoliberal norms for radical independence and self-sufficiency (see Harvey, 2005). They become doubly Othered by the social norms for their age that are shifted by disability.

Furthermore, the word used by the ADA (and thus college and university disability services offices) to describe how the college experience may be adapted for disabled students is a central part of this stigmatized issue. "Accommodations" implies something given out of luxury or generosity, not necessity. Merriam-Webster (2018) primarily defines "accommodation" as "something supplied for convenience," and gives examples related to travel and hospitality. Though words often have multiple definitions, the linkage between "accommodations" for wealthy cruise-goers (i.e., free beverages or room upgrades) and college students with disabilities (i.e., in-class note takers or the opportunity to have unpenalized absences) cannot be ignored because the overlap encourages people to think of accommodations as optional—as "extras" that are gifts instead of requirements. This connection to charity also further perpetuates infantilizing images of disabled people as unable to meet basic American norms.

As crip theory exposes, the idea of accommodation as charity relies upon logics of compulsory ableness that undergird American society. This gift-like framework normalizes able-bodied/minded people as the gatekeepers who can decide whether or not disabled students are able-enough to enter academic institutions. And if these gatekeepers decide a person with disabilities is allowed to enter, they still hold the power to control how that person exists in the academy by defining what sorts of accommodations are justifiable. Much like the discussion of Baynton (2001) and his theorization of sexism and racism as rooted in ableism (women and trans people as irrational; people of color as immoral or unintelligent) depicts, compulsory ableness can stretch, but only to extents that hegemonic, able-normative forces deem acceptable.

This rhetorical slippage toward charity and gatekeeping is further perpetuated by the addition of the prefix term "reasonable" to disability accommodations. The omnipresent existence of the "reasonable" caveat holds significant implications for who is [un]welcome on college campuses based on who places an "undue hardship" or burden on the community. The ADA's rhetoric surrounding the gaps between reasonable accommodations and those that put undue hardship upon institutions seems logical for a capitalist, neoliberal system; employers and schools shouldn't be held responsible for accommodations that drastically decrease their money-making efforts (see Dolmage, 2017). But the underlying tone and assumption behind this capitalist logic is that some people with disabilities are "worth" being parts of society, while others are not.

This notion echoes the work of Marxist biocultural scholars (e.g., Cohen, 2016; Davis, 2013) who highlight the ties between personhood and consumer power. In the context of the neoliberal academy, Saunders (2007) explains that education is understood as "extrinsically good as it enables the student (customer) to purchase a product that will increase his or her human capital and thus allow the student to secure a better job, as defined by salary and wealth" (p. 5). This position of college education as job training means that students with disability accommodations are unimportant because they may not produce the same amount of capital in the "real world"; they will be burdens on future employers. This discursive harm perpetuated by the "reasonable" caveat for accommodations is not simply rhetorical or linguistic, however; it directly affects the health and bodies of students with disabilities.

Harm on Material and Corporeal Levels

Based on the social stigmas discussed above, disabled individuals face discrimination and harm on a deeply material, corporeal level. The World Health Organization (2018) states that disabled people of all ages are confronted with higher risks of physical violence than their nondisabled peers in any given context. When placed in institutions, this threat increases further. Undergraduate female students with disabilities report sexual assault at almost twice the rate of their nondisabled peers (National Council on Disability, 2018). Intersectional data would likely also reveal disparities for disabled women of color and/or disabled LGBTQ folks regarding sexual assault. This issue is compounded by the fact that college sexual violence prevention and education programs are rarely, if ever, inclusive of students with disabilities, and are often staffed with employees who lack proper training in helping these individuals (National Council on Disability, 2018).

Part of this lack in training stems from the breadth of disabilities in existence. The term "disabled" is broad-stroked and includes a number of physical, medical, intellectual, and emotional impairments—some of which are visible, while others are not. The process of asking for accommodations renders those "invisibly-disabled," visible. This observability often causes significant fear for students. Garland-Thompson (1997) asserts that the physically disabled body—and I argue, the invisibly-disabled body rendered visible—becomes "a repository for social anxieties" (p. 6). On college campuses, students with disabilities thus can be conceptualized as sites of projection for the fears of others. In crip theory terms, they are the reminders of the fallibility of compulsory ableness.

Perhaps the most salient of these fears includes omnipresent worries of "failure"—failure to meet neoliberal expectations for proper individual success (a common worry for college students). As Ahmed (2015) explains, "the fear of degeneration, decline and disintegration as mechanisms for preserving 'what is,' comes associated more with some bodies than others" (p. 78). On college campuses, the rhetorics of "reasonable accommodations" mean that the constant threat of "unreasonability" is a line toed by disabled students, who are thus the ultimate symbols of ever-looming decay. Due to their status as symbols of "degeneration" for temporarily able-bodied individuals who may become disabled at a moment's notice through accident or injury, disabled college students are often targets of violence based on externalized projections of fear. This does not justify violence in any sense; rather, it points to the systemic nature of violence against disabled people as stemming from dominant sociocultural ideologies—not mere individual outbursts. Between discursive and corporeal forms of harm, the rhetoric of "reasonable accommodations" thus intertwines with the histories of biomedical oppression to make the processes of acquiring college accommodations and living as "accommodated" an unequally-difficult pursuit.