Reflecting on Cosmetic Surgery

Body image, Shame and Narcissism

Jane Northrop, Jane Megan Northrop

• Publisher: Routledge
• Year: 2013
• Print ISBN: 9781138020108
• eBook ISBN: 9781136327865
• Topic: Social Sciences
• Subtopic: Plastic & Cosmetic Medicine
• Index: Social Sciences

Cosmetic surgery represents an extreme form of modern grooming. It is the fastest growing medical specialty, yet misconceptions abound about those who undertake it and their reasons for doing so. With a grounded approach, engaging 30 women through in-depth interview, this study explores how they chose cosmetic surgery as an option. Their accounts frame a theoretical discussion, in which Northrop proposes that cosmetic surgery is initiated within the vulnerable and divisive relationship between the self and its poor body image.

Poor body image and the attempt at its reparation are examined conceptually through shame and narcissism. With compelling case studies and a multi-disciplinary approach, Reflecting on Cosmetic Surgery demonstrates that shame constitutes a framework through which we formulate appearance norms and learn the art of becoming socially embodied. Shame concerns the self, but manifests in response to perceived social phenomena. Through the evaluation and amendment of body image with cosmetic surgery, notions of self and social worthiness are played out.

Northrop argues convincingly for a review of the way in which we view narcissism and proposes that shame, and the discomforts arising from it, are implicated in its occurrence. This book will appeal to students and scholars across the social sciences, and particularly in women's studies and gender studies.

1 Evolving appearance norms and cosmetic surgery

Cosmetic surgery is one of the fastest growing and most lucrative of medical specialities (Haiken 1997, Sullivan 2001). This chapter considers the historical and social settings and trends that have evolved to provide such an extraordinarily fecund cultural climate in which the practice of cosmetic surgery most certainly thrives. The demand for cosmetic surgery, however, has arisen from within a particular set of social matrices emerging over many centuries. This chapter draws on the work of sociologists and social historians to identify these processes, and to argue that bodily appearance has persistently been used in systematic ways to organize and classify particular social groups. The earliest cosmetic surgery was instrumental in refashioning the features of physical appearance collectively deemed to be stigmatizing, but its more recent emergence as a major grooming industry has seen such surgery take on an increasingly significant role in determining the parameters of appearance, and the appearance of women in particular. Despite the evident growth in the cosmetic surgery industry, determining its actual size relies on estimation. Cosmetic surgery is sanctioned by institutional medicine, but functions largely outside its structures; consequently, it is difficult to establish the magnitude of the industry with any accuracy. This chapter begins by providing a brief overview of the recent growth in the cosmetic surgery industry, before considering the social and historical underpinnings of its formative development. It draws on the Cosmetic Surgery Report (CSR) undertaken by the Health Care Complaints Commission (HCCC) of New South Wales in 1999, and statistics provided by the American Society of Plastic Surgeons (ASPS 2008, 2010, 2011).

The CSR (Walton 1999) examined the cosmetic surgery industry in the most heavily populated Australian state of New South Wales (NSW). It found the way services were delivered to be far from ideal, leaving consumers vulnerable. The CSR defined cosmetic surgery as a surgical procedure undertaken to ‘reshape normal structures of the body, or to adorn the body, with the aim of improving the consumer’s appearance and self-esteem’ (1999:v). It observed that consumers themselves initiate treatments with a view to improving their appearance and promoting self-esteem. It also acknowledged that their judgments about their appearances were subjective. As found in many global settings, the CSR noted considerable variation in the training of those who practise cosmetic surgery.

In Australia the Fellows of the Royal Australasian College of Surgeons (FRACS) require surgeons who practise in public and most private hospitals to undergo six years of specialized post-graduate training and successfully pass two exams. A basic medical degree completed in Australia, however, comprises two undergraduate degrees, a Bachelor in Medicine and a Bachelor of Surgery. Therefore any doctor who is registered as a medical practitioner can call him or herself a surgeon and practise cosmetic surgery (Walton 1999:34). Hence, a broad range of medical practitioners, including those specifically trained to practise reconstructive, plastic and cosmetic surgery, as well as dermatologists, ophthalmologists, ear, nose and throat specialists, and general practitioners, are among those who currently perform cosmetic surgery and cosmetic procedures. In addition, nurses, under the supervision of medical practitioners, perform cosmetic procedures such as injecting collagen, laser treatments, dermabrasion and facial peels. To a lesser degree dentists also carry out cosmetic procedures. Most significantly, the cosmetic surgery industry currently functions outside the regulated framework of organized medicine, therefore offering few safeguards to consumers (Walton 1999:v). Much cosmetic surgery is performed in private hospitals, day surgery units or doctors’ rooms. Recent developments in local anaesthesia, nerve blocks and sedation have reduced the need for general anaesthesia, resulting in an increasing number of cosmetic procedures, like laser skin resurfacing and liposuction, being performed in doctors’ rooms. The shift to doctors’ rooms is not unique to cosmetic surgery – the development of less invasive techniques has facilitated a more general trend which has seen surgical procedures once conducted only in clinical settings increasingly performed in doctors’ rooms (Walton 1999:29).

The relocation from an institutional setting to private rooms frequently reduces the costs to consumers, but it also diminishes the protections otherwise available to them. Consumers are further exposed to risk because the doctors performing cosmetic procedures are not answerable to a particular professional organization, nor are they required to undergo specific training. They do not need to demonstrate competency and, away from larger clinical settings, safety issues are no longer subjected to regulation or peer review. In addition, while Medicare may cover some cosmetic surgeries in Australia, consumers can also self-refer without prior consultation or referral by a GP. The relationship between patient and cosmetic surgeon is, therefore, potentially exclusive. This is of concern because the clients themselves may already be vulnerable. They may be dealing with doctors whose skills are questionable and who operate outside established structures, which leaves them exposed. One cosmetic surgeon I spoke to during the course of this study said he understood why his peers had such a poor reputation, given that many of those performing cosmetic surgery were ‘shysters’ and ‘not far removed from used car salesmen’.

When the CSR presented its findings in 1999 it was not known how many people were undertaking cosmetic surgery, but it was estimated that one in eighty Australians had had a cosmetic procedure of some kind. In addition, the HCCC commissioned a study as part of the report which found that people undertaking cosmetic surgery came from a diverse range of age, geographic and income groups. Most people surveyed had initially been informed about the cosmetic procedure they undertook by media or advertising. Just less than half of the respondents reported having more than one cosmetic surgery (Walton 1999:v). The majority (more than 60 per cent) paid for their procedures from savings, 23 per cent paid by credit card or bank loan and 7 per cent were gifted money for their surgery. One quarter had procedures covered in part or full payment by a private health insurance fund and a similar number claimed payment through Medicare. Costs may be covered by Medicare if procedures are determined to have been done for therapeutic reasons (Walton 1999:13). Despite its inherent limitations in gauging the extent of the cosmetic surgery industry, the CSR provides insight into the problems existing within that industry which persist today, particularly in relation to regulating the competency of practitioners and the provision of safeguards to prospective clients.

The American Society of Plastic Surgeons (ASPS) was formed in 1931, and is now the largest organization representing certified physicians, plastic and reconstructive surgeons in the world. Its website, www.plasticsurgery.org, lists the surgeries and procedures its members have been performing since 1992, suggesting the trends and fashions in cosmetic surgery. Statistics for 1992–2007 indicate that the number of Americans having cosmetic surgery performed by ASPS members almost quadrupled (ASPS 2008:15). In 2007, ASPS members alone performed cosmetic surgery or a cosmetic procedure on 12 million Americans who spent almost US$12.5 billon for their services. Nearly 10 million of those cases were minimally invasive procedures and 1.8 million were cosmetic surgeries (ASPS 2008:3).

In 1992 when the ASPS first started monitoring what its members were doing, the most frequently sought surgery was an eyelid lift. Over the period from 1992 to 2007 the number of people having eyelid surgery more than quadrupled, but the most phenomenal increase was in the number of women having breast augmentation (ASPS 2008:15). In 2007 the most frequently sought surgery was breast enlargement (327,524 women) which represented more than a tenfold increase since 1992. The next most popular surgery was liposuction. While women sought surgery in the form of having their breasts enlarged and their bodies effaced with liposuction, men sought surgery to have their noses reshaped and their eyelids lifted. However, with 91 per cent of those seeking cosmetic surgery being women, modern cosmetic surgery remains an emphatically feminine pursuit (ASPS 2008:5, 2011:6). Significantly, 42 per cent of those seeking a cosmetic procedure, either surgical or minimally invasive, were repeat patients, and 42 per cent of all patients had several procedures performed at one time (ASPS 2008:13). The most prolific seekers of cosmetic surgery were aged 40–54 years (33 per cent of all those having such surgery), whereas liposuction, followed by eyelid surgery, were the most highly sought-after surgeries (ASPS 2008:10). Subsequent statistics from the ASPS (2011) for 2010 suggest the economic downturn in the USA has impacted cosmetic surgeries, down to 1.6 million from the 1.8 million surgeries recorded in 2007, whereas less invasive, less expensive, cosmetic procedures increased from nearly 10 million in 2007 to 11.6 million in 2010. An online survey of 2,148 people commissioned on behalf of the ‘cosmetic treatment community’ (ASPS 2010) found that enthusiasm for cosmetic surgery is nonetheless robust. More than two thirds of respondents declared they would have a cosmetic procedure, and a third of those indicated they would undergo surgical intervention if their finances permitted. Any data from the ASPS must, however, be considered as suggestive since the number of people actually undertaking cosmetic surgery in the USA is impossible to measure, much as it is in Australia, because a range of medical practitioners not registered by the ASPS practise cosmetic surgery. This aside, it is clear from the ASPS records that cosmetic surgery is big business, and those who have one procedure are likely to return for more.

Social to surgical bodies

The appearance of the body has always been socially significant. While there can be little doubt that the unadorned body is already a social body, inscribed for example by age, gender, pregnancy, illness and access to nutrition, the overlaying of grooming practices upon its surface unequivocally reiterates the body as a social object. Manipulating the body’s surface to alter its appearance has been integral to the cultural practice of all social groups throughout history and its more extreme manifestations have recently drawn the interest of social scientists (see Featherstone 2000, Pitts 2003). Similarly, as cosmetic surgery has slipped from marginal to mainstream, sociologists have increasingly directed their attention to its examination (see for example Sullivan 2001, Gimlin 2002, Pitts-Taylor 2007, Elliott 2008, Parker 2010). Although not generally designated as a theoretical category in its own right, appearance, the ways in which people manage the surface of their bodies and the considerable investments made in it, has long been of interest within the discipline.

Sociologists and anthropologists alike propose that physical appearances are primary sources of information which convey and guide social interaction. In 1934 Marcel Mauss (1973) argued, and Mary Douglas (1973) later concurred, that bodily inscription, dress, adornment, racial features, posture and gait were complex symbolic systems which could be interpreted as taxonomies subsequently disclosing social groupings. They proposed that the body could be read as an artefact, inscribed by cultural practice and imbued with meaning indicative of broader social mechanisms and processes. In Techniques of the Body’ Mauss (1973) nominated all aspects of corporeal function as acquired, rather than something that simply occurs as a result of natural behaviour. He reviewed a range of commonplace bodily activities and observed variation between societies, as well as differences within subgroups, which, he argued, could be correlated to variables such as class, status, education and fashion. Mauss (1973:73) emphasized that ‘the art of using the human body’ was something learned through socialization but, he contended, children will take their leads from significant others who demonstrate confidence and authority. Children, he added, do not merely imitate those around them, but choose to model the way they use their bodies upon those who appear to be the most socially successful. Mauss (1973:73) described the process as ‘prestigious imitation’. Body techniques can, therefore, be viewed as consciously assembled symbolic systems constructed in accordance with dominant social authority. Most importantly, Mauss believed that a cross-disciplinary approach was required to fully apprehend body techniques. He argued that understanding such processes could not be achieved by sociological endeavour alone and called for a tripartite approach which incorporated sociology, psychology and physiology. Mauss maintained that socialization processes integrate social elements, but the imitative dimension within socialization required engaging psychology and physiology to fully comprehend the way body techniques are subsequently adopted. His observations were invaluable in guiding the cross-disciplinary approach this project eventually took.

Douglas (1973), following Mauss, uses the metaphor of two bodies, the physical body and the self located within the broader social body, to elaborate a more fluid, interactive, but ultimately limited corporeal relationship between the social group and the individual. She writes:

The social body constrains the way the physical body is perceived. The physical experience of the body, always modified by the social categories through which it is known, sustains a particular view of society. There is a continual exchange of meanings between the two kinds of bodily experience so that each reinforces the categories of the other. As a result of this interaction the body itself is a highly restricted medium of expression.

(Douglas 1973:93)

Erving Goffman (1971) adds to the discussion, drawing attention to individual agency and highlighting the ways in which available body techniques are used as a repertoire from which individuals choose to construct performative social identities in the attempt to exercise some control over how others perceive them. Frank (1991), however, cautions, ‘Body techniques are socially given – individuals may improvise on them but rarely make up any for themselves … these techniques are as much resources for bodies as they are constraints on them; constraints enable as much as they constrict’ (1991:48, original emphasis).

When considering a sociological examination of the body three themes come into focus concerning, firstly, the way in which the body is constructed socially and culturally, secondly, the way social control and the regulation of bodies is enacted and, thirdly, the way these themes relate to, and inform, self-surveillance. The last theme cannot evade the psychosocial dimension of embodiment, as Mauss (1973) forewarned, and will be considered in Chapter 3. The remainder of this chapter addresses the first two of these themes to examine how appearance norms have evolved and have, subsequently, been impacted by the burgeoning cosmetic surgery industry. To understand cosmetic surgery’s emergence as an optional ‘body technique’, it is useful to consider the way these themes might be understood within the context of the historical development of the speciality.

The arrival of modernity and the ensuing social differentiation it inaugurated, as well as the globalization of mediated images, meant individuals began to rely increasingly upon systematic classification to establish a perceptual ordering of their expanding social worlds. Classification functions as a form of visual shorthand required to interpret and process the vast array of visual data to which individuals are exposed on a daily basis. Visual literacy has become integral to informing the construction of personal identity, to the way in which we cognitively understand the world around us, and in defining and controlling social groups (Douglas 1987). Classificatory systems delineate groups on the basis of characteristics such as gender, class and race, where inclusive membership is defined in opposition to ‘otherness’. Gilman, the author of Making the Body Beautiful: A Cultural History of Aesthetic Surgery (1999), claims that physical categories are increasingly constructed in ‘unambiguous antithesis’ (1999:23), for example, young and old, fat and thin, black and white, etc. These categories are defined in terms of appearance and attribute social advantage to belonging to a positive category and disadvantage to belonging to a negative category. The values attached to physical appearance are far from universal and vary from culture to culture. Nor are they temporally static, since the parameters of the body deemed fashionable have fluctuated historically. One characteristic that has seemingly endured, however, relates to the way we read bodies and an omnipresent belief that external appearance accurately reflects the character, the soul or the inner self. The provenance of these beliefs can be traced back to antiquity (Finkelstein 1991, Gilman 1999).

Modern cosmetic surgery emerged in Europe during the 1890s at a time when the ‘science’ of physiognomy enjoyed widespread popularity. Physiognomy deemed that facial features reflected the innermost character of the individual and represented a mirror to the underlying self or soul (Finkelstein 1991, Gilman 1999). Physiognomy has a long history dating back to De Physiognomia, written by Aristotle in the third century BC. Here physical appearances were classified by resemblance to animals, and human character itself was accorded the nature of the corresponding animal. Subsequent texts, written in a range of languages over the centuries to follow, reworked these themes, at times combining astrology and palmistry to create theoretical frameworks which formulated predictions and provided templates through which health and character were interpreted. The evident proliferation of texts is significant testimony to the enduring fascination of physiognomy (Finkelstein 1991). The face, usually visualized and accessible, became the conveyer of symbolic meaning imbued with moral significance. In its most simplistic form beauty reflected goodness and ugliness forewarned a bad character. A ‘behavioural determinism’ which ‘foretold and reflected the moral characteristics of the individual’ (Finkelstein 1991:21–22) underpinned the beliefs of the physiognomists. Such was their authority that prominent eighteenth-century advocate Johann Lavater, and a century later Cesare Lombroso, detailed the facial characteristics of criminal types and proposed they be identified and tattooed to prevent them embarking on criminal careers (Gilman 1999:27). The beliefs of the physiognomists were remarkably pervasive and have maintained a level of cultural currency. Indeed, as Goffman (quoted in Finklestein 1991:50) could write, ‘“the person who falls short” of “certain moral, mental and physiognomic standards” is forced into a secondary status’.

With the beliefs of the physiognomists so entrenched, enhancing ones features was always going to appeal to those who felt marginalized by their appearance. Technological advances in anaesthesia and asepsis in the late eighteenth century minimized surgical pain and the risk of infection, making the option of surgery much more accessible to those contemplating cosmetic surgical alteration. However, these developments alone were not enough to initiate the emergence of modern cosmetic surgery. Gilman (1999:18–19), borrowing from Kant, posits that the Enlightenment motto ‘Dare to use your own reason’, and the ideology of individualism, autonomy and self-transformation in the pursuit of happiness which the Enlightenment platform proclaimed, underpins the acceptance and subsequent growth of cultural bodily practices like cosmetic surgery. Thomas Jefferson added the pursuit of happiness to his list of Enlightenment ideals for the modern citizen. Happiness and the fulfillment of patient desires, claims Gilman (1999:18–19), are the underlying theses upon which aesthetic surgical practice is founded. Here group membership based on physical attributes is considered central to personal happiness. Within this framework the specific unhappiness that aesthetic surgery treats concerns the exclusion from a desired social group on the basis of a stigmatizing physical attribute. Gilman explains the history of aesthetic surgery through the model of passing. He accounts for the body in physical, emotional and social terms when he writes:

The pursuit of happiness through aesthetic surgery presupposes decisive categories of inclusion and exclusion. Happiness in this instance exists in crossing the boundary separating one category from another. It is rooted in the necessary creation of arbitrary demarcations between the perceived reality of the self and the ideal category into which one desires to move. It is the frustration or fulfillment of this desire that constitutes “unhappiness” or “happiness.”

(Gilman 1999:21–22)

Of course, other attributes such as a distinctive accent may also suggest ‘otherness’ but, for the most part, physiological differentiation is evaluated primarily in terms of appearance, and patients seeking surgical alteration perceive their exclusion from a desired category and inability to ‘pass’ as determined by their physical appearance. It is, therefore, their exclusion on the basis of appearance that is the cause of ‘psychological “unhappiness”’ (Gilman 1999:22). Passing not only involves moving from a negative to a positive category when appearance is transformed, but also implies that the moral meanings of character associated with physical appearance will likewise be transformed. Here cosmetic surgery is not undertaken to allow on...

Table of contents

• Cover
• Halftitle
• Title
• Copyright
• Contents
• Acknowledgements
• Introduction
• 1. Evolving appearance norms and cosmetic surgery
• 2. Women, appearance and cosmetic surgery
• 3. The mirrored self
• 4. Shame and the social self
• 5. Shame and subjective experience
• 6. Evaluating body image
• 7. Shame and cosmetic surgery
• 8. Just look at yourself
• References
• Index