Beautyscapes

Mapping cosmetic surgery tourism

Ruth Holliday, Meredith Jones, David Bell

• Publisher: Manchester University Press
• Year: 2019
• Print ISBN: 9781526134257
• eBook ISBN: 9781526134271
• Edition: 1
• Topic: Social Sciences
• Subtopic: Sociology
• Index: Social Sciences

Beautyscapes explores the global phenomenon of international medical travel, focusing on patient-consumers seeking cosmetic surgery outside their home country and on those who enable them to access treatment abroad, including surgeons and facilitators. It documents the journeys of those who travel for treatment abroad, as well as the nature and power relations of the IMT industry. Empirically rich and theoretically sophisticated, Beautyscapes draws on key themes of interest to students and researchers interested in globalisation and mobility to explain the nature and growing popularity of cosmetic surgery tourism. Richly illustrated with ethnographic material and with the voices of those directly involved in cosmetic surgery tourism, Beautyscapes explores cosmetic surgery journeys from Australia and China to East-Asia and from the UK to Europe and North Africa.

1

CLINICAL TRAILS: RESEARCHING COSMETIC SURGERY TOURISM

When we began the research project on which this book is based, we were all too aware of the criticisms of international medical travel (IMT) and of cosmetic surgery. In the mainstream media IMT is largely represented as personally and socially selfish and reckless, especially when it involves cosmetic procedures. The stereotype is one of patients travelling abroad for procedures on the cheap, carried out by unqualified ‘cowboy’ medics who make big profits based on the promise of magical results that can never be achieved. Added to this are recurrent narratives of returning patients being patched up back home by domestic healthcare services after bungled surgeries, often at the taxpayers’ expense. On UK television screens, popular shows like Channel 5’s Botched Up Bodies Abroad vividly recount such horror stories. IMT is usually referred to in media and popular discussion as medical tourism – a term we both utilise and complicate in this book.

In most Western countries, at least, most people assume that doctors in their home country are qualified and belong to recognised and trusted institutions and professional organisations; whereas doctors abroad are imagined as underqualified, uncaring and only out to make a profit. The Western media is full of shocking stories of British or Australian (and subsequently Chinese) patients dying or being left disfigured as a result of these reckless journeys – to the point of moral panic. Meghann Ormond (2013a) conjectures that this, like all moral panics, betrays a deep anxiety: in this case about the neoliberalisation and globalisation of healthcare and the breakdown of the post-war consensus that health is an individual human right provided for citizens by their nationstate. IMT speaks to this fear of the end of national healthcare. This narrative, however, is flipped when international medical tourists come ‘here’: then they are represented as seeking to steal our own hard-won healthcare and access our excellent medical facilities without making social or fiscal contributions.

Those who seek cosmetic surgery, meanwhile, are most often represented in mainstream media in two different but interconnected ways. Firstly, there is the vanity model: rich (or seeking a rich husband), self-obsessed women who aspire to the goal of ultimate beauty and eternal youth. Secondly, there is the victim model: the hapless cultural dopes, victims (ironically) of the media, who are so unduly influenced by it that they aspire to emulate those ‘perfect’ celebrities that fit the first, vanity, model. The story goes that these TV viewers and consumers of advertising mistake Photoshopped perfection for normal bodies and are left feeling inadequate and lacking (Jones 2013). This line was taken to its logical conclusion in the UK in 2014 by the Conservative MP (and GP) Sarah Wollaston in an online comment piece for a British newspaper published the wake of the discovery that 50,000 women in the UK (and 400,000 in Europe) had been fraudulently sold faulty breast implants made from mattress filler instead of medical grade silicone. While questioning the profit motives of the businesses that made and sold the implants (and that refused to replace them when their toxic nature was uncovered), Wollaston also revealed her personal disgust at these women’s preferred bodily aesthetics, claiming they looked like ‘grotesque dolls’ (Wollaston 2012). Further, she suggested that

perhaps in future women who wish to undergo cosmetic breast enlargement should have to pay an additional premium to cover the costs of removal in the event that they regret their decision or the implants fail; it could also cover the cost of maintaining a national register. (Wollaston 2012)

Thus, Wollaston laid the responsibility for fraud and deception by a private company pursuing inflated profit margins firmly at the feet of the victims of these crimes. This Poly Implant Prosthèse (PIP) scandal, discussed in more detail in chapter two, was initially blamed on medical tourism by the British Association of Aesthetic Plastic Surgeons (BAAPS), who mobilised their press and PR leverage to point the finger at cheap breast augmentations performed in central and Eastern Europe (BAAPS 2011; Holehouse 2012), despite it later becoming clear that the vast majority were implanted in the UK. So, here we begin to see some of the interests at work in various media discourses – and via figures of authority and powerful institutions – impacting on how cosmetic surgery tourism is perceived. The discourses surrounding it are based on xenophobic, misogynistic and classed notions, and are also deeply protectionist.

In contrast, in much of the academic literature we read as we embarked on our research, IMT was viewed through the lenses of postcolonialism, critiques of orientalism or as neoliberalisation, resulting in the asset-stripping and exploitation of ‘less developed’ populations – as a ‘reverse subsidy for the elite’, as one paper’s title bluntly put it (Sengupta 2011). Often read as a manifestation of ‘bad globalisation’, IMT is characterised as an elite practice whereby wealthy patients (whether from the Global North or South) off-shore their own healthcare, abandoning health systems at home in search of better care or a better deal. While literature from a tourism management perspective largely sidesteps these ethical dimensions of IMT in favour of developing business models, much of the critical literature is grounded in an ethical position that begins from the assumption that IMT is a dubious practice. Of further worry to us was the fact that much of this literature is based around and very much influenced by readings of the media discourses we have sketched above.

Cosmetic surgery has itself been the subject of a long lineage of academic work, and today is often interrogated via feminist approaches to demonstrate the gendered power relations that disproportionately value women in terms of their bodies, or seek to extract value from women’s bodies, and also in terms of neoliberal attempts to make the self into a project (Shilling 2012). From de Beauvoir ([1949] 2011) to Bordo (1993), women’s investments in their bodies have been seen variously as symptoms of false consciousness or subjugation to patriarchal discourses of women’s beauty, whether they be circulated in person, in advertising and the media or via the Internet. Such is the dominance of this understanding that not only are the feminist frames through which cosmetic surgery is viewed limited but they also offer very little room for male patients of cosmetic surgery to be investigated (Holliday & Cairnie 2007).

However, it is important to note that when feminists began to write about cosmetic surgery – some thirty years ago – ‘the conglomeration of global, media, technological, and aesthetic conditions [that now make up cosmetic surgery tourism] was the stuff of science fiction’ (Heyes & Jones 2009: 1), and that while the dominant feminist discourse has presented cosmetic surgery as damaging and disempowering, some feminist scholars have ‘always evinced a certain flexibility and curiosity about what cosmetic surgery might mean to individuals’ and their social contexts (7). How we think about cosmetic surgery now requires acknowledgement that local fashions and logistics intersect in complex ways with an ever-changing global landscape. Later in this chapter we outline the more nuanced (but less popular) feminist theoretical approaches to cosmetic surgery that we are building upon, and we also discuss this in more detail in chapter two. First, however, we provide a brief overview of cosmetic surgery tourism as a phenomenon, before moving on to discuss the way we approached researching it.

Cosmetic surgery tourism: the basics

Cosmetic surgery tourism can be defined as travel to access procedures that enhance appearance. It is a distinct segment of IMT with a distinctive patient profile, a particular set of geographies and a set of drivers (or motives) that share some commonalities with other forms of IMT but which in other ways diverge from them. It is a phenomenon made up of diverse actors, including those we focus on in Beautyscapes: patients, surgeons, facilitators and intermediaries, hospitals, governments, health systems, airlines, hotels, websites, social media and many more. As we show in chapter three, these diverse actors are assembled in particular places and times – and that assemblage is what we know as cosmetic surgery tourism.

As we also discuss in chapter three, the ‘cosmeticness’ of cosmetic surgery tourism positions this group of patient-travellers as distinct from those travelling out of medical necessity – and this shapes both discourses and practices that surround the journeys patients undertake. As we recount in this book, the patients we met were ordinary people, propelled for various reasons to seek treatment abroad. They came from particular places and they travelled to particular places. While extrinsic factors such as exchange rates and airline flight paths have a role to play in shaping this map, as do policy decisions made by governments and healthcare providers, the map of patient flows for cosmetic surgery tourism can partly be understood by looking at the drivers that are behind these journeys, principal among those being cost, quality, access and availability (Holliday & Bell 2015). Price differentials between home and abroad can be substantial, and cost is especially significant for patients who are paying out of pocket for treatment – as cosmetic surgery patients are. In IMT marketing, the cost savings of treatment are a major selling point – patient-travellers (and their travelling companions) can add travel and a holiday and still be paying less than they would at home for treatment alone.

Yet not everyone we met was looking to save money. Sometimes the quality of either the procedure or the medical care was more important. While quality and cost might be wrapped together, we also found cases where quality mattered more: Chinese patient-travellers going to Seoul were willing to pay more than they would at home, and their decision-making was driven by quality (Holliday et al. 2017). Access as a driver here means physical access – proximity or ease of travel – but it can also mean cultural proximity: the attraction of going somewhere that is familiar enough to lessen the estrangement of travel. Availability is also a driver when procedures and treatments are unevenly distributed around the world. Experimental treatments in particular might be concentrated in particular places, while certain treatments may be illegal or heavily restricted in some countries, making travel necessary for citizens wishing to access them. In the broader IMT field this can range from assisted conception to assisted dying, and from stem cell treatments to xenotransplantation.

A vexed question in all work on IMT concerns patient volume: how many people are travelling for treatment? This issue is complex because data sources are uneven and at times unreliable, not least because data are collected and disseminated with particular motives at work – for example, those with commercial interests wanting to maximise the numbers apparently travelling in order to boost business. The most widely reported figures for IMT are also the most contested (Horsfall & Lunt 2015a). In Beautyscapes we do not claim to be able to say how many people are undertaking these journeys; we focus instead on the stories told to us by those people who we met and talked with.

Research, selves and investments (a sort of epistemology)

The two discourses of medical tourism and cosmetic surgery outlined above unite to form a powerful prohibition against cosmetic surgery tourism – and, unsurprisingly, the cosmetic surgery tourists we spoke to were acutely aware of this. To comprehend the phenomenon of cosmetic surgery tourism we needed to find an approach that navigated the different investments and interests at work for patients, for IMT industry workers and for ‘home’ cosmetic surgery organisations and professional associations, and which could respond critically to dominant media and academic discourses. Beautyscapes represents this navigation, embedded in the extensive empirical work that this project is centred upon.

At the outset we want to discuss two issues that frame our analysis in this book. Firstly, our patient-consumers were aware, from media discourses, of the negative associations attached to their desire for cosmetic surgery and their choice to seek it abroad.¹ Adapting Hollway and Jefferson’s (2009) work on ‘defended subjects’ we show that our participants are responding to a discourse in which they are embedded, rather than offering a disinterested account of their surgical journeys. This made them, to some extent, ‘defensive subjects’. On the other hand, unlike Hollway and Jefferson, we also think about the unconscious investments of researchers in such a politically fraught field and attempt to position ourselves ‘nearby’ our participants (Trinh 1989), understanding things from their perspective (albeit that this attempt is doomed to fail) rather than playing the ‘god trick’ of judging them from our own (often distant) locations (Haraway 1988). While this understanding can never be transparent, and we can only access knowledge that is situated by our own identities and theoretical preferences, we try to avoid the privilege of ‘partial perspective’ invested in us as middle-class white people whose jobs and relationships require little attention to embodied appearance. Secondly, given that so much work on cosmetic surgery – partly because it mostly comes from a feminist perspective – focuses only on women’s experiences, we also wanted to interview and follow male patient-consumers in order to avoid focusing on what Robyn Wiegman (2012) calls ‘identity knowledges’ (we elaborate on these key terms below).

Defensive subjects

In their investigation of fear of crime, Wendy Hollway and Tony Jefferson (2009) argue that an interviewee’s answers should not be accepted at face value as automatically representing that person’s truth. Rather, they suggest that interviewees are not at all ‘transparent to themselves’ and are instead ‘defended’ (298): motivated by unconscious anxieties, not least about what they think the interviewer would like them to talk about. To circumvent this problem, Hollway and Jefferson recommend that interviewers keep the number of questions to a minimum and maximise the openness of questions to make more room for interviewees’ own understandings, narratives and affective associations.

While there is certainly plenty of food for thought in Hollway and Jefferson’s free association narrative interview technique, our participants were not defended against their own fears, rather we found that they were defensive, given their acute awareness that the practice in which they were involved is so maligned in public consciousness. In a sense, then, their answers to interview questions represented a defence of their choice to undertake cosmetic surgery tourism against what they presumed would be accusations of irresponsible vanity, rather than uncomplicated and transparent accounts of the facts. That is not to say that the whole of each interview progressed according to this pattern, but defensiveness nevertheless emerged recurrently in interview beginnings, with statements such as ‘I didn’t do this because I wanted to look like a celebrity …’; ‘I tried to live with my [faulty body part] for many years before taking the decision to have cosmetic surgery’; ‘I just wanted to be normal’; ‘I spent a very long time researching my surgeon’; and, perhaps most tellingly, ‘I’m not like those girls who go to [perceived unsafe destination] and get a boob job on a whim to look like Jordan’.² On one occasion we were talking to a surgeon in a hospital waiting area about how long people waited before they had surgery, and afterwards a patient approached us and said:

I heard you saying that people take a long ...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright
• Dedication
• Contents
• List of plates
• Acknowledgements
• 1 Clinical trails: researching cosmetic surgery tourism
• 2 Cosmetic investments
• 3 Locating cosmetic surgery tourism
• 4 The work of cosmetic surgery tourism I: caregiving companions and medical travel facilitators
• 5 The work of cosmetic surgery tourism II: health workers and patients
• 6 Community and little narratives
• 7 Decentring and disorienting cosmetic surgery tourism
• 8 Cosmetic convivialities and cosmopolitan beginnings
• 9 Conclusions
• References
• Index