- News feature: Whose body is it anyway?
- Catherine Jackson
- ‘I think, over the years, women have a battle with their bodies as they change, different ages – they struggle with trying to accept it… and the fact that you can, it’s like, “Wow, so what, it’s a bit of money, let’s just change ourselves.”’
This woman, interviewed for a survey commissioned to support the recent independent review of cosmetic surgery, speaks for many millions of women, judging by the rapidly rising use of cosmetic surgery worldwide. A 16-year-old schoolgirl, also interviewed for the review, may be similarly speaking for her generation: ‘It’s your body and you can do what you want with it.’
The Review of the Regulation of Cosmetic Interventions, led by Sir Bruce Keogh, Medical Director of NHS England, for which the surveys were conducted, was commissioned by the Government in the wake of the PIP breast implant scandal. The review highlights widespread concerns among the public and the medical profession about the standards and regulation both of surgical/medical practices and the marketing techniques used by the cosmetic surgery industry. It calls for national standards and tighter controls on both and the Government is expected to publish its response to the recommendations this autumn.
Global surveys show a worldwide surge in demand for cosmetic surgery: from South Korea (leading the field in the number of cosmetic surgery procedures per head of population) to India (the least), women – and increasingly men – are buying new breasts and noses, having fat sucked from various parts of their bodies and injected into others, getting tummies tucked, eyes widened, jaw bones ‘shaved’ and vaginas ‘rejuvenated’. In 2011, according to the most recent figures from the International Society of Aesthetic Plastic Surgeons (ISAPS), 15 million people worldwide had cosmetic surgery or non-invasive procedures such as laser skin resurfacing, hair removal, botox and chemical peels. The UK ranked 16th, with just over 95,000 procedures; the US came top, followed by Brazil, China, Japan, Mexico and Italy. The most popular procedures by far are lipoplasty and breast augmentation, followed by blepharoplasty (eyelids), abdominoplasty (tummy tucks) and rhinoplasty (nose jobs). The American Society of Aesthetic Plastic Surgeons (ASAPS) reports a 64 per cent rise in vaginal rejuvenation procedures between 2011 and 2012.
The latest stats from the British Association of Aesthetic and Plastic Surgeons (the wonderfully acronymed BAAPS) show a slight leveling off in activity recently in the UK: procedures performed by its members in 2012 were just 0.2 per cent up on 2011, compared with a 5.8 per cent rise between 2010 and 2011, although the industry is still projected to reach a £3.6 billion turnover by 2015.
Cosmetic surgery has historically been less common among black and ethnic minority people. In the US, black people reportedly make up just 30 per cent of clients, but the numbers are growing fast.1 In South Africa, there has been a 780 per cent rise in non-invasive interventions and 128 per cent increase in breast procedures in the last 10 years, according to the Association of Plastic and Reconstructive Surgeons of Southern Africa – fuelled, it argues, by cheap prices.2 Growing affluence among black people is also likely to have played a part.
The cosmetic surgery industry is frequently criticised for its marketing tactics, which include claims that its procedures can deliver direct psychosocial benefits. A cosmetic surgery company’s website will typically promise (often without reference to any evidence other than anecdotal feedback from their own patients) ‘added self-confidence’, ‘increased self-esteem’, ‘much more confidence and a more fulfilling sex life’ from their procedures. The empirical evidence for such claims is, at best, mixed.
Deborah Sandler, who describes herself as a cosmetic surgery counsellor, is open about having had surgery herself; indeed, it was her personal experience that led her to launch an information and peer support website (see www.cosmeticsupport.com). Advertising has, she says, ‘taken cosmetic surgery out of the medical world and placed it in the world of luxury goods. It has trivialised it.’ More importantly, it also promises what it cannot deliver.
People have to go into surgery with realistic expectations, she believes. ‘People imagine that happiness and confidence will come more easily post-surgery. They expect other people to notice, to love them more, to give them that compliment they’ve never had. But that love has to come from within, in the form of self-love, self-acceptance.
‘Counselling can unblock this for them. It’s a journey and some realise they have to go on it and others don’t.’
She particularly decries the high-pressure sales tactics that offer cheap deals if people sign up immediately for surgery. She thinks there should be a statutory ‘cooling off period’ between having an initial consultation and making the decision to proceed, with at least one session of impartial counselling pre- and post-surgery. ‘It’s a life-changing intervention. People think they just need to take 10 days off work and everything will be fine but there are other things that need to be gone through to make that happen. Patients need to consent to the emotional as well as physical risks.’
Cosmetic surgery can be beneficial if the person’s expectations are realistic. ‘You need to go into surgery thinking you will look the best you can. I don’t subscribe to the notion that you have to live in your body, to accept decay. I would be having a face lift today if I had the money. But it wouldn’t make me happier; it would make me look less old and if I looked less old I would feel less old and that would make me happier. If something is decaying or not looking as good as you feel it could, then fortunately we live in a world where we can do something about it.’
Evidence for benefits
The Keogh review commissioned a systematic review of the published evidence on psychosocial factors in relation to cosmetic interventions. The review team, at the Institute of Education, could draw only the weakest of conclusions as the quality of the primary research was so poor, and some studies were very dated. Overall, dissatisfaction with body image and improving self-esteem and confidence were frequent motivations for seeking surgery, but the pre-procedure self-esteem levels reported in the studies were no different from the general population. Post-surgery, evidence to suggest improved self-esteem and decreased anxiety was ‘limited’ and claims of positive psychological and social outcomes rendered suspect by the quality of the studies.
A very recent Norwegian study,3 published in 2012 and conducted by researchers at NOVA, the Norwegian social research institute, and the Norwegian Institute of Public Health, followed up some 1,500 men and women over 13 years, from school-age into adulthood, and found higher levels of anxiety, depression and suicidal feelings both before and after the intervention among the 4.9 per cent of women who had undergone cosmetic surgery. Their mental health problems and distress continued post-procedure, and sometimes got worse.
But another study, from Germany and reportedly the largest ever such comparative trial of the psychological effects of cosmetic surgery, found the opposite.4 The 544 first-time cosmetic surgery patients in the study declared themselves 80 per cent satisfied that the procedure had delivered what they wanted. Also, in comparison with 264 people who had considered but decided against surgery, they reported higher wellbeing, better quality of life, less anxiety and greater sense of attractiveness and body satisfaction. The researchers found no evidence of negative psychological effects post-surgery; indeed, there was a small decrease in depression and social phobia and findings to suggest, they say, that patients were ‘less preoccupied with their looks’. The study was funded by a large German cosmetic surgery company.
It has even been proposed that having botox can actually combat depression. According to Dr Eric Finzi, author of The Face of Emotion, dubbed by the New York Times as ‘the first authorized biography of botox’, paralyzing the muscles in the forehead can not only smooth the furrowed brow but also prevent people’s faces from expressing negative emotions such as sadness, fear, anger and distress. And, as Darwin argued back in the 17th century, facial muscles not only express emotion but also govern them: if we can’t physically frown, we don’t feel sad. Another dermatologist, Dr Patrick Bowler, has tested this, and found that the women who had botox were indeed ‘measurably less negative than their non-botoxed counterparts’.5
Cosmetic surgery remains a subject of deeply divided opinion, not least among counsellors and psychotherapists. While some cross their legs and wince at the thought of vaginal rejuvenation, others are more pragmatic. Sexual and relationship therapist Paula Hall says it isn’t a question of morality: ‘We shouldn’t make value judgments about people’s ideals of beauty. The days when people raised their eyebrows about boob jobs are long past; genital surgery is just the next stage. Men have been able to compare themselves with each other since time immemorial.
‘Women should have choice but it needs to be informed choice. It’s important that women explore what they believe will make them happy and that they don’t have false expectations that vaginal surgery will make them feel better about themselves or that it’s going to be a relationship fix.’
Researchers at the Centre for Interdisciplinary Gender Studies at the University of Leeds have just released preliminary findings from a two-year study of cosmetic surgery tourism titled Sun, Sea, Sand and Silicone. Led by Professor Ruth Holliday, the research team interviewed over 100 patients from the UK, Australia and China and 100 cosmetic surgery providers to explore people’s reasons for travelling overseas for cosmetic surgery. Principally it was cost: they simply couldn’t afford to have it done in their home country, she says.
‘There’s this media construction that cosmetic surgery tourists are glamour pusses who are only interested in looking sexy forever; that they’re all young women wanting really enormous breasts and doing whatever they can to get them. We found very few of them were like that. Mostly they are very ordinary people who have one thing they don’t like about their appearance and are desperate to sort it out.’
Her subjects worked in administration, nursing, care work; they were hotel porters, hairdressers, beauticians, students, police officers and teachers. Less than one in 10 had a higher education qualification. Most said they would otherwise have spent the money on holidays or home improvements.
‘Mostly they simply wanted to look normal,’ Professor Holliday says. ‘There’s a lot of talk about the “designer vagina” but some of the people we talked to had some very nasty birthing injuries. Vaginal tightening can be the same technique used to repair prolapse. These things are very ambiguous. If you lose 10 to 15 stone, that’s lots of skin and it has an enormous impact on your body.’
People seeking anti-aging interventions were often motivated by the need to keep on top of their work. A woman prison officer had cosmetic dentistry because ‘she said she couldn’t look like someone’s granny if she was to keep her status with the prisoners’. Men were having hair transplants ‘to stay competitive at work’. For the Chinese patients travelling to South Korea to have their jawbones shaved and their eyes widened, cosmetic surgery was seen as an economic necessity to improve their career prospects and employability.
The primary drive is self-improvement, says Professor Holliday. ‘For working-class people, who don’t own a house or a fancy car, investment in your body is the only thing you can control. Cosmetic surgery is their way of showing “I am doing the right thing by improving myself and making myself better”. What we call self-esteem is as much to do with feeling you are excluded from the rest of society as it is with low confidence.’
At the other end of the spectrum of views are psychotherapists like Alessandra Lemma, Visiting Professor of Psychoanalysis at University College London and author of Under the Skin, a psychoanalytic study of body modification, and psychotherapist Susie Orbach, author of Fat is a Feminist Issue and, more recently, Bodies, which similarly explores what drives people to constantly perfect and literally ‘design’ their own bodies.
Both see the urge as rooted in a discomfort with being in the body, which itself comes from the lack of a positive, loving physical interaction between mother/caregiver and baby – in Lemma’s words, the lack of ‘a (m)other’s loving and desiring gaze’ – that is crucial to our feeling safe, or ‘at home’ in our bodies.
Orbach describes a growing epidemic of bodily distress – ‘a hidden public health emergency’. She argues that the internalisation of how a mother feels about her own body is transmitted to her child (her daughter) from birth. Thus her campaign, within the Endangered Bodies global movement (www.endangeredbodies.org) against body hatred, to persuade the Government to require all health visitors and midwives to be trained in body awareness – their own as well as that of the new mother – so they can support women to be more physically holding of their baby. We need ‘a theory of body development just as compelling as our existing theories of the mind’, Orbach argues.
Holli Rubin, a psychotherapist specialising in body image, works with Orbach on the campaign. ‘Women need to feel good about themselves and their own bodies before they can give that to their child. But many young mothers – not all – have this belief that they need to get back into their skinny jeans and exercise routines immediately after birth. It is symptomatic of the pressures on all women to live up to standards that are not attainable,’ she says.
She sees this reflected in the increasing popularity of cosmetic surgery. ‘People feel it’s going to make them feel better, be better, be accepted. If someone has a nose that they have wanted to fix for ages and they know it would make them happier about how they look, I have no issue with that. We are lucky enough to be able to do that these days. But for some, when they’ve had their nose fixed, then they don’t like their ears, their chin, their breasts… maybe if they changed that… People are trying to become what they think they need to be and it’s never good enough; the perfectionism gets out of control. As counsellors, we have to look at why.’
Psychotherapist Rima Sidhpara sees these same pressures within the UK Asian community. She works for the Rutland House counselling and psychotherapy service in Leicester, where there is a large Asian population. ‘The Asian culture has a specific perception of what is beautiful, which for Indian women is being thin, having long, thick hair and being fair skinned. Difference is seen as shameful, even disgusting. There are creams for Asians that promise to make your skin lighter and if you go to Indian beauticians they offer facials to lighten your skin. Mothers worry a lot about their daughters looking beautiful as if they are not, who will marry them? I have had clients choose surgery for weight loss, which was kept hidden from the family. Image is not something that can be spoken about – instead the young woman can be on the receiving end of rejection, anger, shame and humiliation by close family.’
Young women’s feelings of low self-esteem turn inwards to self-harm. ‘I have found young women experience low self-esteem and huge amounts of shame. They will tend to hide away their bodies and personality. They lack confidence and that affects how they interact and socialise with other people. They do not feel they fit in and can feel very isolated and there tends to be anger that then gets turned inwards on the self. These feelings are very enmeshed.’
She always felt ‘too dark’ when she was young. ‘It was only when my white friends at university kept telling me how nice my skin was and other compliments that I began to change my own perception of how I looked.’ With clients, she tries to provide that same positive experience. ‘I explore with them what it is like to feel the way they do, the cultural demands made of them and what beautiful means for them. I try to offer the mirroring that was lacking from their parents and family, to provide that corrective emotional experience.’
In her book Alessandra Lemma proposes that our relationship to our body ‘is probably the most concrete marker we have of how we feel about ourselves and about others’. Her views, she says today, have not changed since she wrote those words in 2009. ‘Body modification is driven by the need to manage a range of unconscious anxieties, about intrusion, dependency on others or lack of desirability,’ she says. ‘As our existential anxieties increase in a world that is perceived as under threat and where we lack the holding structures that we could once turn to within our communities to support each other, the body has become a project that creates an illusion that its modification can be a solution to problems that are less tangible and felt to be completely out of control.’
She argues that normalising body modification allows us to avoid having to think about our motives for having cosmetic surgery. ‘Society reinforces the belief that you can find external solutions to internal psychic pain. It becomes harder to engage people in thinking what lies behind their pursuit of beautifying processes. The psychotherapeutic project is about learning to live within reality and accepting ourselves and our lives and their disappointments. The beauty industry represents the complete opposite. It’s about making the impossible possible and that is very seductive because it speaks so directly to the fantasy of reinventing the self. And it also provides solutions to the difficulty in coming to terms with ageing, and so with death.’
Lemma’s concerns about cultural normalisation are shared by child and adolescent psychotherapist Jeanine Connor, who is deeply concerned by the subtle cultural grooming of young girls that she sees in the media, from the reality TV show The Only Way is Essex (TOWIE), where the participants flagrantly parade their cosmetic procedures, to computer games. ‘Young people don’t take it seriously because it is so commonplace. I’ve heard of games aimed at under-11s where the aim is to create a perfect body for your avatar. You win points to buy a boob job or hair extensions. That horrifies me. I wouldn’t rule out surgery as an option but, if there is something about a child’s body that has an impact on how they feel about themselves, it is their sense of self that needs to be worked on first, not their body. Cosmetic surgery feels like a superficial response.
‘It’s a solution for families that can afford it and should be a last resort, in the same way that hospital admission or medication should be the last resort when a child is depressed. Paying money to have something physical and permanent changed in your body isn’t a fix-all.’
Lucy-Jean Lloyd, a counsellor who works with young people in educational settings, argues that the body carries a very particular weight of significance for adolescents, so the decision to have any form of body modification, whether it’s cosmetic surgery or just a tattoo, is likely also to be heavily loaded. ‘One of the tasks of adolescence is differentiating yourself from your parents – that separating out of what is me, what is mine and what is located within me. I think ambivalence about the body may well relate to feelings of ambivalence about those on whom we depend.’
In adolescence the body changes rapidly, in ways that can feel out of control at a time when so much else is also out of your control. ‘Cosmetic surgery may feel like you are taking charge of the body, almost taking revenge on it for its irreversibility. It gives you an illusion of control, of omnipotence,’ she suggests. She recalls one young client who had surgery to reduce the size of her breasts. ‘She had a very slight frame and they were causing her backache. But she had also had a troubled relationship with her mother. She felt she was not the daughter that her mother had wished for; there was a wish to get away from her. We talked a lot about the aftercare she would receive. There was something about the way she talked about the removal of the bandages that seemed to me to be about being born into herself again, almost reborn; as if she was saying “This is my body, not my mother’s”.’
Another client, a young woman in her early 20s, had a nose job. ‘She was someone who was full of very aggressive, hating feelings that were difficult for her to acknowledge. I still have a mental image of her face after the operation. It was very shocking; it looked as though she had been attacked. She had previously said that she thought her mother hated her but didn’t ever show it and I remember thinking it might have been a relief for her if her mother had been able to be in touch with her hatred.
‘I sensed she felt triumphant about having the nose job. Winnicott said that triumph is important for adolescents and certainly this young woman seemed to find it liberating. It was as if getting the body that she wanted through shock and force and violence freed her to be who she wanted to be. It felt very shocking but also maybe it felt necessary to her.
‘My experience of working with people who have cosmetic surgery has changed my view. Before I used to be more judgmental; now I see it as having a not necessarily negative function: we all seek transformative experiences as a flight from what we experience as unbearable.’