Print version ISSN 1414-3283
Interface (Botucatu) vol.3 no.se Botucatu 2007
A medicalização da beleza
La medicación de la belleza
Paulo Poli NetoI,1; Sandra N.C. CaponiII
IMédico; doutorando em Ciências Interdisciplinares; médico de Família e Comunidade, Prefeitura Municipal de Florianópolis, SC. <email@example.com>
IIFilósofa; doutora em Lógica e Filosofia da Ciência; professora, Departamento de Saúde Pública, Universidade Federal de Santa Catarina, Florianópolis, SC. <firstname.lastname@example.org>
Translated by Silvana Polchlopek
Translation from Interface - Comunicação, Saúde, Educação, Botucatu, v.11, n.23, p. 569-584, Sept./Dec. 2007.
Concern with body image and medical interventions related to physical beauty has greatly increased in the past few years. The purpose of this study is to investigate how medicine is dealing with the theme of beauty. The 2003/2004 editions of the periodicals Aesthetic Surgery Journal and Aesthetic Plastic Surgery were analyzed, in order to investigate the rationality buttressing their discourse. Three categories were prioritized for this study: definition of aesthetic plastic surgery's study object; beauty patterns guiding interventions; and understanding popular demand for aesthetic corrections. Discourse is sustained by biomedical rationality, structured around a disease theory and a dual construction between normal and pathological, with emphasis on biology. In the articles, the beauty patterns guiding therapeutic practices are anchored in biological norms defined through several anthropometric measures, which refer to abstract concepts of beauty, harmony, proportionality and symmetry. In this discourse, there are no references to patterns or to social norms of beauty; motivation for aesthetic intervention appears to be rooted in low self-esteem related to the aging process or to some bodily nonconformity. As per the meaning of 'medicalization' adopted herein, biomedical rationality appropriates variations or anomalies of physical appearance, thus allowing the theme to be dealt with in terms of health and disease, normal and pathological.
Key words: Medicalization. Surgery plastic. Beauty culture. Body image.
A supervalorização da aparência física é acompanhada pelo crescimento de uma medicina da beleza. Neste estudo investiga-se como a Cirurgia Plástica Estética aborda a aparência por meio da análise de discurso das revistas Aesthetic Surgery Journal e Aesthetic Plastic Surgery, em 2003 e 2004. Três categorias foram analisadas: como define seu objeto de estudo; em que padrões de beleza baseia a intervenção; e como explica a demanda pela cirurgia. A racionalidade que sustenta o discurso é a biomédica, que se estrutura em torno de uma teoria das doenças e de uma construção dual entre normal e patológico. Os padrões de beleza constroem-se com base em normas biológicas e de estudos antropométricos, e não de normas sociais de beleza. A motivação para as intervenções estéticas proviria de uma baixa auto-estima, naturalizada, resultante da desconformidade do corpo em relação às normas. No sentido emprestado à medicalização neste estudo, conclui-se que há uma apropriação de variações ou anomalias da aparência física pela racionalidade biomédica, o que permitiria discursar sobre o tema em termos de saúde/doença, normal/patológico.
Palavras-chave: Medicalização. Cirurgia plástica. Indústria da beleza. Imagem corporal.
La supervalorización de la apariencia física acompaña el crecimiento de una medicina de la belleza. En este estudio se investiga de qué modo la Cirurgía Plástica Estética aborda la apariencia física por medio del análisis de discurso de las revistas Aesthetic Surgery Journal y Aesthetic Plastic Surgery en 2003 y 2004. Se analizaron tres categorías: cómo definen su objeto de estudio, en que padrones de belleza basan la intervención y cómo explican la demanda de cirurgía. La racionalidad que sustenta el discurso es la biomédica, estructurada en torno de una teoría de las enfermedades y de una construcción dual entre normal y patológico. Los padrones de belleza se construyen a partir de normas biológicas y de estudios antropométricos y no de normas sociales de belleza. La motivación para realizar intervenciones estéticas se refiere a problemas de baja autoestima naturalizada, resultante de la disconformidad del cuerpo en relación a las normas. A partir del concepto de medicación según este estudio, se concluye que hay una apropiación de variaciones o anomalías de la apariencia física por la racionalidad biomédica; lo que permitiría discursar sobre el tema en términos de salud-enfermedad, normal-patológico.
Palabras clave: Medicalización. Cirurgia plástica. Indústria de la beleza. Imagen corporal.
The contemporaneous society in which we live in observes, astonished, the moving of "perfect bodies' which, progressively, invade all spaces in modern life. People's body expectations in relation to these beauty patterns is what probably interconnects a variety of phenomena that is more and more common, such as the major incidence of bulimia and anorexia, the excessive hard exercise practice and aesthetic plastic surgeries.
Among these phenomena, the increase of Aesthetic Plastic Surgery needs to be emphasized due to the impact that corporal alterations, proposed by the Beauty Medicine, cause in relation to the body image and also due to the role medicine takes in society that one of a spreader of "scientific truths".
There have been several studies about the medicalization of appearance although with a different perspective and methodology compared to the one adopted in this research. Gilman (1999), for instance, makes a historical analysis of the increase of Aesthetic Plastic Surgery since the XIX century giving emphasis to the ethnical surgery and its cultural outspreads. Davis (1995) and Gonçalves (2001) studies cosmetic surgery services and medical and patients discourse while trying to understand their motivations and comprehension in this process. Sullivan (2001) makes a sociologic draft of the construction of a demand for cosmetic surgery and the professionalization of aesthetic plastic surgeons associating it to what he calls 'commercialism', the predominance of economic aspects above all of the others. Wolf (1992) and Gillespie (1996) are more focused on genre aspects and relate the greatest demand of cosmetic surgery among women to a strategy used to take power from them.
In this article, the purpose is to analyze the medical discourse within studies published in the principal magazines of aesthetic plastic surgery and relate it to the idea of medicalization in the sense of the incorporation of a new theme by the biomedical rationality, which means the organization of a new medical nosology, the creation of patterns of normality and the legitimization of therapeutic medical intervention.
For this study, approximately 130 articles of two of the main international magazines of Aesthetic Plastic Surgery, the Aesthetic Plastic Surgery and the Aesthetic Surgery Journal, published in 2003 and 2004 were analyzed. The method used was the content analysis which, according to Bardin (1977), allows the manipulation of the empirical material used, so that it can be analyzed based on another draft. In this research, the texts were approached through the theoretical referential of some authors of the health sciences philosophy area (especially Canguilhem and Foucault), aiming to characterize the biomedical rationality and to find overlaps and distances in relation to the approach of the Aesthetic Plastic Surgery over physical variations.
Some previous categories were selected in order to direct this study based on the following issues: how the Aesthetic Plastic Surgery sees its object of study and intervention; how it refers to beauty patterns: and how it understands the demand of the population by aesthetic corrections.
The birth of a beauty medicine
It is not intended here to say that only recently the medical discourse has expressed itself about beauty, but that, for the first time, it comes up as the unique and central object of the medical area instead. Before the origins of the Beauty Medicine, the appearance was appraised only by some medical areas in a marginal way as it is the case of the association between beauty and maternity, demonstrated by Rohden (2001,p.16) in a study about medicine of the XVII and XIX centuries:
The medical image of feminine beauty was misunderstood with the woman's representation as a good spouse and mother producer of many children. Her muliebrity would be reflected in a round and large body with generous breasts, developed hips associated as maternity characteristics. Physicians, impressed, 'note' how the ideal beauty of women is delineated by nature, due to the primordial function women have.
On its turn, the hygienist medical discourse of the end of the XIX century and beginning of the XX says that beauty is associated to the values of the catholic morality such as purity and cleanness. At this time, physical appearance is taken as a divine gift and not as an achievement or an individual possibility: "Out of this usage and beyond medical prescriptions that include the body hygiene and physical culture, the embellishment ruins the risk to denote a doubtful morality" (Sant'Anna, 1995, p.125).
The history of the aesthetic plastic surgery is imbricated with the reconstructive plastic one as the techniques used are very similar. However, during several years, the surgery for merely aesthetic purposes was understood as something immoral by regular plastic surgeons themselves. Sullivan (2001) demonstrates how the Aesthetic Plastic Surgery moves from a marginal practice, almost unknown in the 50s, to a recognized specialty in the USA, regulated and more and more intended by physicians. There are several aspects related to this change of perception about aesthetic surgery. One of them is that physical appearance begins to have another connotation in the western society at this time, which is called by Eco (2004) as the Consumption Beauty in which beauty ideals are determined by economical interests.
Numbers prove that the beauty appropriation by the market is impressing. The cosmetic and diet industry are among those with the highest increase in the world, similarly to what happens with the Beauty Medicine (Wolf, 1992).
In the USA, according to the American Society For Plastic Surgeons - ASPS (2004a), more than 8,7 million aesthetic procedures were carried out such as: almost three million shots of the botulinum toxin; 320 thousand liposuctions and 254 thousand breast implants in 2003. The tendency from 1992 to 2003 points to an increase in the number of cosmetic plastic surgeries: breast implants to about 657%; lift in the buttock to about 526%, liposuction to 412% and botulina shots 153%, from 2002 to 2003 (ASPS, 2004b). Another tendency is the increase of these interventions in more and more precocious ages. In the USA, 3.841 surgeries of breast implants in girls under 18 were carried out in 2003 revealing an increase of 24% in relation to these procedures in 2002. In the same year, American teenagers submitted themselves to 5.606 interventions for botulina shots, which represents 950% more in relation to 2002 (ASPS, 2004c).
Brazil is the third country in the world in number of plastic surgeries only behind the USA and Mexico. In 2003, 400,000 interventions were carried out and half of them were merely aesthetic ones. Among these, 40% were of liposuction, 30% of breasts and 20% in the face.
Independently of existing an economic justification for the increase and acceptance of a Beauty Medicine, that is, the hypothesis that an increase in the demand for aesthetical interventions, due to ignored reasons, have forced the development of this medical practice there must have been an adjustment of this object of intervention and knowledge, in the case, the physical appearance, when it is re-interpreted by medicine. If the medical knowledge from the XIX century is specially structured around a theory of diseases - as the prevention, diagnostic and treatment of such diseases, based on scientific research it will be necessary to get a re-adequacy of such discourse to enable the construction of a Beauty Medicine. Then, how this relation between this rationality and the physical beauty, that were not approached in terms of pathology or abnormality, going to be developed.
A clinical regard at beauty
According to ASPS (2005), the aesthetic plastic surgery "is performed to reshape normal structures of the body in order to improve the patient's appearance and self-esteem". The sentence summarize what this study seeks to approach: 1) evaluate if a pathologization of aesthetic variations occurs in the Beauty Medicine discourse, 2) analyze what the phrase "improve appearance" refers to; which social or biological norms come up in such a discourse and what kind of influence the Beauty Medicine takes in establishing these norms and, finally, 3) how self-esteem occurs in such a discourse and what it deals with when used to justify aesthetic interventions.
Before that, however, we are going to work with the complex term of medicalization as it has several definitions, usages and possibilities as there are not enough attributes and convergence among theoreticians to define it as concept or an analytical tool according to Lowenberg and Davis (1994). It is important to specify the comprehension this term gains in this study which is the assimilation (involving capture or transformation) of anomalies and physical variations associated to the physical appearance through the biomedical rationality. There are also other definitions for medicalization such as: broaden of the medical jurisdiction in society, increase in the number of physicians and medical companies; major dependence of population over medical services or medicine, among others. Thus, it is important to present the characteristics of the biomedical rationality, the outline of this method of knowledge and practice and how it sees the physical appearance. Any medical rationality would be defined, according to Luz (1993), though a structured system composed by five fundamental theoretical elements: 1) a human morphology and anatomy; 2) a human vital physiology or dynamics; 3) a system of diagnostics; 4) a system of therapeutic interventions and 5) a medical doctrine.
According to Foucault (2003, p.10), the biomedicine or modern medicine comes, from the end of the XVIII century, from a moment in which medicine "...proposes a discourse with a scientific structure over the individual." The scientific logic used at the time remains the same nowadays and is marked by a mechanicist conception which is stimulated, especially, by two subjects: physics and astronomy. These would come to influence all the areas of knowledge by means of their principles of reproducibility, predictability, exactness and mathematization of events. This scientific rationality will then be adopted, from modernity, by the medical knowledge. Foucault (2003) calls this transformation a rupture as it is based on a new episteme:
The access of the medical view to the interior of the body is not the continuation of a movement of approximation, somehow regularly, that would have been developed from the day in which this view of the first doctor, which was becoming scientific, was directed from apart to the body of the first patient. It is the result of a reformulation to the very own level of knowledge and not to the level of accumulated knowledge, correlated, deepened and adjusted. (p.157)
For the author, this knowledge reformulation is associated with two fundamental and indissoluble bases: a new perspective regard and a new medical language. This new perspective or clinical regard results from a group of factors: 1) an institutional support: medicine was legitimized to take care of sick people, to enter the hospitals in which it is going to become better, to structure and replicate itself; 2) it is a broader view as it seeks all deviant signs (classificatory ones) and that gains depth with the pathological anatomy (see anatomo-clinical) and 3) a calculator view so as to delineate probabilities and risks (Foucault, 2003). The new language is, then, the transference of this new perspective to the enunciable and "the implicit labor of language in the description that authorizes the transformation of symptom into sign, the passage of the sick people to a disease, the access of the individual to the conceptual" (Foucault, 2003, p.129).
This regard as described by Foucault, was created at a time in which there was the predominance of classic diseases such as infect-contagious ones, which helped to build up a biomedical rationality that is characterized by this structure:
The medical doctrine has, implicitly, the idea that diseases are objects with an autonomous existence and are translatable by the occurrence of injuries that would be, on their turn, the result of a chain of events derived from one or multiple causes. The diagnostic system is, then, oriented to the identification of diseases from the characterization of its injuries; the therapeutics is hierarchical according to its capacity to reach the latest causes of diseases; morphology and vital dynamics act mainly as auxiliaries in the characterization of the morbid process. (Camargo Jr., 2003, p.110).
This structure is what we intend to search for in Beauty Medicine articles so as to perceive how the physical beauty theme is going to be adjusted to this medical doctrine and also to these characteristic systems of biomedicine. Below, there is an example of one of these articles:
Liposuction is an increasingly popular technique in the field of aesthetic surgery. Most patients seeking liposuction wish to correct a body contour deformity, usually caused by fat. The objective of liposuction is to decrease or remove these excessive subcutaneous fatty areas by means of metal cannulas placed through small skin incisions. (Bilgili et al., 2004, p.226)
In this speech it is possible to recognize the typical presentation of "cases" in biomedicine with their etiology, diagnostic, therapeutics and also epidemiologic profile. The pathologic anatomy is going to add itself to this clinical regard (temporal) in order to be correlated to what Foucault (2003, p.155) called "anatomo-clinical regard" which allows a new specialization of the disease. For the surgeon, it is not only the pathologic anatomy that allows this spatial reorganization of the disease as the surgery offers the "advantage of providing knowledge elements of diseases and their location in the live organism that moves itself [author's emphasis] in a different way from the pathologic anatomy that works with corpses" (Luz, 1988, p.89). In the articles analyzed, the aesthetic plastic surgeon's view also reveals this specialization, which means the encounter of a visible variation with a previously known anatomical substratum. An example of this anatomo-clinical regard is:
The basics of facial beauty are symmetry, balance, and proportion. The major forces responsible for facial aging include gravity, soft tissue maturation, skeletal remodeling, muscular facial activity, and solar changes. Aging in the upper third of the face manifests as rhytides and ptosis of the frontal, glabellar, and brow regions. Beginning in the mid and late thirties, changes become apparent all trough the face. Wrinkles and fine lines appear around eyes and mouth, and the upper and lower eyelids begin to sag. (Maio, 2004, p.295)
The search for causality in medicine is associated to a previous (and arbitrary) definition of an usually, undesirable event that ones want to study and intervene in. As Canguilhem (1982) says, it is necessary that the anomaly becomes arbitrarily defined as a problem for scientific studies: "the anomaly is only recognized by science if it has been, as first, felt in the conscience under the form of an obstacle to the exercise of the functions, a disturbance or as something harmful" (p.104).
The association of a cause to the identification of an anatomo-physiologic substratum (as the loss of liquid in the interstitial space or the reduction of some tissue as the mammary glandule) represents to Canguilhem (1982, p.108) the process that takes to the pathologization of an anomaly: "...since the etiology and the pathogeny of an anomaly are known, the anomalous becomes pathologic". Following the same logic, it is possible to find a pathology of beauty in the articles which were studied. In these articles, the anatomic injuries come out as altered structures which are responsible for the unwanted external appearance, as in the example below: "Ptosis usually resulted from postdelivery and breastfeeding involution changes characterized by different degrees of atrophy of the mammary gland, skin flaccidity, and ptosis of the nipple-areolar complex" (Velasco et al., 2004, p.199).
In this case, the authors associate the cause of the mammary ptose, which is a consequence of childbirth or the breast-feeding, to a tissue injury of the mammary glandule, skin and tissues that sustain the nipple areolar complex. The idea of having an injury associated to the cause, a locus causal, as it has been already mentioned, is the foundation of the biomedical rationality. The search for the last location of a causal injury is a constant dispute in medicine, according to Camargo Jr. (2003). In the case of the Beauty Medicine, the majority of studies point out to an anatomical injury which can be the result of a genetic predisposition, cellular alterations or environmental influences.
Another characteristic of biomedicine that emerges in Beauty Medicine refers to diagnostic classifications and categorizations for unwanted variations. The organization of these variations in different degrees is what Foucault (2003) called primarily as spatialization and it can be fond in these, as well as other, examples: "We propose a classification of postpartum ptosis into 4 groups on the basis of anatomic findings and the appropriate surgical treatment for each group" (Velasco et al., 2004, p.199).
Besides having a classificatory table for the anomalies, another important point that characterizes biomedicine and that can be found in the Beauty Medicine is the creation of a nosology that not only defines a certain variation, but also enables it to exist; as Foucault says (2003, p.135) "it liberates a constant truth". Some examples of that are: "gluteal hipoplasia", "mammary ptosis", "contour defects", "nasolabial folds", "facial lines", "breast asymmetries", "body contour deformities", excessive fatty deposits". This is the association between the discourse and the regard which was pointed out by Foucault (2003) and which materialized this object called 'disease'.
Until now, we have presented biomedical rationality, its origin and principal characteristics and confronted it with excerpts from the articles of the Beauty Medicine area as well. It is possible to notice that the anatomo-clinical regard is present in these excerpts no matter the difficulties to label a theme as physical appearance into a disease theory. Placed against pathology, the biomedic rationality needs a biologic normality. They are dual references that characterize the construction of knowledge in medicine. In the case of a physical beauty, we will analyze how a biologic norm is created.
Biologic norms of beauty
The definition of biologic norms, which allows the classifications of physical variations, and the planning of physical aesthetic interventions are the object of several studies in Beauty Medicine and, by means of anthropometry, both attempt to search a pattern of normality.
Similarly to when we use a pattern curve to define the stature or normal weight, the Beauty Medicine searches for the measures that define a beauty pattern as in the following example:
No reports can be found in medical literature describing the anatomic details that make the buttocks beautiful, nor the defects in this region that can help the surgeon decide whether gluteal prostheses are necessary or not (...) The authors studied 1.320 photographs of nude women and measured 132 female patients ages 16 to 62 (...) On the basis of the information obtained, the defects of the gluteal region were classified into five types, resulting in surgical recommendations intended to achieve buttocks as close as possible to the standard of beauty, with the right volume and projection (...) The surgeon must be familiar with the "signs" of beauty so an attempt can be made to recreate them. (Cuenca-Guerra & Quezada, 2004, p.340)
In the study above, it is possible to observe the preoccupation of the authors in the Beauty Medicine to define a beauty pattern aiming to guide the therapeutic practice. Following this example, there are many other studies that carry out several measurements of anatomic points in people with different ages, seeking to understand which structures are altered within the years and to what things they are related to, in order to catalogue data to set a biologic norm. The article below demonstrates the importance to define the normality in order to allow some kind of intervention:
It is a reality that the normal anatomy of the nasolabial complex with its smooth fold and crease is a basic beauty of the face and should not be removed completely or distorted. Instead, an attempt to normalize the anatomy must be the gold standard for any planned operation. (Sen et al., 2004, p.308)
According to Canguilhem (1982), the normal concept in Biology is defined by the frequency of character which is qualified in this way. In the above example, the author takes this principle when classifying the creases and lines that frequently compose the nasolabial structure as something normal. However, he only does so to, later, subvert this idea, without considering the modification that these structures suffer within time as a normal issue. The normalization suggested by the author does not mean to transform that anatomy into the most frequent one, but in a beauty pattern instead and which is pre-determined.
The possibility of normalization, by means of the Beauty Medicine, can yet be understood as that one in which aesthetic interventions generates beauty norms. The image of the modified body by the Beauty Medicine ascend to a normal condition, as it is the one that takes place in the media as the most frequently seen and exposed bodies. As Bordo (1993, p.26) states there is a new norm "...reachable only trough continuous cosmetic surgeries in which the surface of the woman's body stops to get older physically as the body gets older chronologically."
The majority of the articles of Beauty Medicine propose some surgical intervention, which implies the definition of a purpose to the modification which, on its turn, is certainly supported by some beauty pattern. This pattern, however, is rarely explicit or the author usually focuses a certain theme, as the increase in breast implants, and proposes a specific intervention, such as the silicon implants, without explaining the reasons for his choice. He can yet refer to an abstract beauty by using terms, such as harmony and proportionality, as in seen in the excerpt below:
Surgical body modeling must be planned in conformity with anthropometric parameters. Before commencing work, the surgeon, like a sculptor, must draw up plans according to the principles of beauty. Remove and add, the two fundamental theorems inspiring figurative arts and aesthetic plastic surgery, are combined into an action whose goal is to restore the body's proportions. (Fruscella, 2004, p.44)
Besides the anthropometrical studies that aim to define beauty patterns and also unattractiveness, there are studies whose intention is to find a natural norm of beauty, that is, "...crowns physical beauty as an adaptive mechanism for the promotion and evolutionary advancement of our species" (Dayan et al., 2004, p.301). Or, according to Etcoff (1999, p.16): "...the passionate search for beauty reflects the action of a basic instinct". A similar statement is found in Dayan et al. (2004, p.304):
It appears that certain facial features such as symmetry, youthfulness, and averageness are universally found to be favorable. Evolutionary biologists argue that certain facial features are physical signs indicating health and well adjustment, thus leading to a selective advantage for mating and species propagation. Individuals with these features expected to be more (...) likely to manage the forces of natural selection favorably. Evolutionary biologists also point to animal models demonstrating that symmetry and average features are commonly found characteristic features in the fittest of a species.
Few are the studies in Beauty Medicine in which an explanation of what would be a biologic norm of beauty is found. In most cases, as in the previous examples, the authors generally research measurements of ideal parts of the body without explaining the reasons for their choice. In the above example, there is an attempt to justify the Beauty Medicine supported in an essential or natural need, that in which there are characteristics in human beings that are culturally valued and that would be a heritage to survival and reproduction. Social norms of beauty, that is, the influence or determination of culture in the appreciation of physical appearance are rarely approached in articles of Beauty Medicine, which also represents another biomedicine characteristic.
Social Norms of Beauty
When trying to establish biologic or natural norms of beauty, the Beauty Medicine reduces or denies the importance of culture in the formation of aesthetic patterns. To define physical beauty patterns and give them a status of something 'natural' means to eternalize something that "...is never ever absolute or immutable, but that has taken several facets according to a historical period and country", as stated by Eco (2004, p.14). Breton (2003) says that, in the western imaginary, the model of the body as a machine, a precarious and fallible enclosure that confines the essence of man, the cogito it is still present. The transposition of the body to the condition of an accessory to the person (as a business card) allows it to be
...submitted to a design that is sometimes radical and that does not leave anything uncultured (bodybuilding, corporal mark, aesthetic surgery, transexualism, etc.). Pointed out as a self representation, chop of a manageable identity, it becomes a self-assertion and evidence of an aesthetic of presence as well. (Breton, 2003, p.22) [Emphasis from the author]
As we have already mentioned, within the analyzed articles there are no references to a social determination in the conception of body. They seem to move from the principle that there is not a social norm of beauty and that the demand for an aesthetic intervention occurs due to a natural intent. Similarly, some articles point out results of satisfaction or benefits of those who have submitted themselves to these interventions without taking these norms into account, as if the results did not depend on a previously created necessity, many times, by technicization itself. As Dayan et al. (2004, p.306) has demonstrated:
First impressions are very much based on facial features, and psychological science has taught us that a more attractive individual is likely to receive better judgment and treatment. We present evidence that those who undergo facial plastic surgery improve the first impression they create on the basis of their photographic appearance alone.
The technicization of beauty, that is, the creation of new aesthetic possibilities through the instrumentalization of human being can impose some new norms. Breast implants, for example, are pretty recent (about 50 years only) but with the development of such technique, it is broaden and adjusted to the patients' needs according to these new possibilities as Jacobson says (1998, p.1255): "...the need was constructed as plastic surgeons have medicalized the size and forms of the breasts". Below, there is another example that evokes the debate between biologic and social norms and also the ethnical aesthetic surgery issue.
Many patients who present for rhinoplasty request changes that will bring them closer to the perceived norms for their particular ethnic groups. For patients of African-American and Hispanic backgrounds, this frequently necessitates augmentation rhinoplasty. Patients use popular-culture idols and media figures as sources of reference for their ideals, influencing their desires and aesthetic concepts dramatically. (Strauch et al., 2004, p.327)
In this study, at the same time authors make a reference to social patterns that are generated in the media or in the popular culture, they reassure they refer to perceived norms in ethical groups, that is, the physical peculiar characteristics of each group. Besides the emphasis in the biologic norm, another characteristic of the Beauty Medicine that emerges in this study and somehow denounces the influence of a social norm work with those surgeries that deals with ethical characteristics. Gilman (1999) demonstrates how the aesthetic surgery has been used for more than 100 years as a liberal eugenics. He also highlights the surgeries to modify the syphilitic, Jewish nose and the Afro-American nose. In the excerpt of plastic surgery selected above, the author emphasizes that "...the procedure should address the patient's specific concerns, allowing the preservation of characteristics in keeping with the patient's ethnicity rather than producing a more "Caucasian"-appearing nose..." however, the modifications proposed by the surgeon to the nose of an Afro-American person that is characterized by "...showing a flat, broad dorsum; poor tip projection; and wide alar bases" are closer to the Caucasian nose. (Strauch et al., 2004, p.328-9). Similar examples are found in articles that refer to Asian patients who have submitted themselves to surgeries that modify the eye lids and get them closer to the western pattern. These are examples that clearly break with the hypothesis of a biologic norm because they are modifications that are carried out by the Beauty Medicine and which put people away from the most frequent characteristics in their own ethnical groups.
Thus, it is important to discuss how a norm of beauty reaches people. How does an explanation about the demand for these interventions occur in these articles? Such a theme goes through the encounter or distance between a corporal beauty and the personal experience of one's own body, generating bad feelings, shyness, shame or lowering self-esteem, which "...get stronger the greatest the disproportion between the socially demanded body and the practical relation with one's own body imposed by the views and the relationship with others is ." (Bourdieu, 2002, p.81).
Motivations for the Intervention of Beauty
In the articles of Beauty Medicine or in other studies about the same topic, it is common to find a feeling of motivation to be submitted to an aesthetic plastic surgery, within the increase in self-esteem. There are no explanations in these articles about the meaning of self-esteem, but we understand that it is a good feeling, happiness, a more positive self-evaluation. These are all subjective sensations, from the field of psi, leading the Beauty Medicine to consider some psychological reparation as a result from its own intervention. Such a thing took the Brazilian Society of Plastic Surgery (BSPS) to alter its former nomination (Brazilian Society of Aesthetic and Reconstructive Plastic Surgery) which used to separate Plastic Surgery in sub-specialties, Aesthetic and Reconstructive, to adopt its current name when considering that both areas deal equally with reconstructions no matter physical and/or psychological, as demonstrated by Gonçalves (2001, p.78).
In a private clinic, physicians can also take into account the psychological reparation of the patient, putting into practice that concept of a broader plastic surgery in which all aesthetic surgery is reparatory as it repairs "psychic problems" (traumas, inhibitions, complexes) and not only physiologic ones.
Similarly, in the example below, the editorial of one of Aesthetic Plastic Surgery editions, the author mentions the legitimization of this speciality facing physicians of other areas, thanks to a psychological benefit from the aesthetic plastic surgeries:
Plastic surgeons today no longer need to debate the benefits of aesthetic surgery with patients or colleagues in other fields as did our teachers. (...) Whereas the surgery of appearance (nonrestorative, nonreconstructive) improves the quality of life, it seldom saves life. It is not as necessary to physical survival as it is to psychological betterment. (Goldwyn, 2004, p.357)
This is one more step towards the process of adjustment of the theme of physical appearance to the biomedical rationality, a medical discourse about the demand for it to be accepted by the peers and that, for this reason, must be structured around the ideas of health-disease. People who go through an aesthetic plastic surgery are psychically suffering because they have some "defect" in their bodies but, after going through some intervention, they get "healed' of this bad feeling.
In the analyzed articles, the Beauty Medicine does not present any explanations about the origin of this low self-esteem as bad feelings regarding physical appearance. There are some attempts to explain about the "defects" of physical appearance; however, not about the origin of such physic suffering. Nevertheless, what ends up motivating people to search for an aesthetic correction, increase breasts, remove creases and wrinkles or modify their nose?
If the Aesthetic plastic Surgery considers the search for beauty as a basic instinct (as it is observed in some articles), it is possible to understand this psychic suffering as derived from an appearance opposite to a "biologic norm", that is, as something natural. All of us will suffer, up to some level, with aging, asymmetries or with the darkening of the skin that occurs along the years. When social norms that influence or determine beauty patterns are taken into account, it is the experience of difference between an ideal of beauty and the image of the body itself that may be in the origin of a low self-esteem or bad feeling, in other words, the psychic suffering. To understand how the internalization of these norms occurs means to understand, according to Jacobson (1998), the way how the need for an aesthetic intervention is constructed as part of an individual intent.
To Elias (1994, p.153) internationalization means "...to turn a socially intended behavior into something automatic, a self-control issue, so that one can see it as a result of his or her free will, besides being the interest of his own health or human dignity." The internalization of norms will make the disciplinary practices (and biomedicine is one of them) more efficient, as they will seem to be part of the behavior or the biologic side of the individual. In the case of medical norms, Foucault (1998) demonstrates how internalization occurs and how it may end up reinforcing, later on, the medical act itself:
It implies a physical approximation and a game of intense sensations from what medicalization (...) is at the same time both an effect and instrument. Engaged in the body and transformed into the individuals deep character (...) they overlap health and pathologic technology. And, inversely, from the moment in which it comes to be a medical "thing" or something medicalizable such as an injury, dysfunction or symptom, they will be overtaken in the depth of the organism or over the surface of the skin or among all the signs of behavior. (Foucault, 1998, p.44)
Regarding the beauty norms specifically, Costa (2004) demonstrates how the corporal image replaced feelings moving from the transition of a 'moral of feelings' to a 'moral of sensations'. The psychic suffering does not derive much from the weakness of the spirit or the character of the defects of corporal appearance. He says:
Today it is in the "exteriority" of the body, in the countenance of the egoic corporal sphere that the abject and the refractory threat to emerge. It is in this new place, the place of the wrinkles, stains, stripe, laxity, bellies, obesity, unintended texture of the skin, muscle tension, vicious osseous conformation, fats and more or less hair that the abject and the recalcitrant are exhaustively and implacably observed, investigated and feared in a phobic, obsessive, hysterical and persecutory way. (Costa, 2004, p.78-9).
In this sense, it is important to ask what role Beauty Medicine takes at a time in which the corporal image is so appraised, other than reinforcing the meaning of appearance? Doesn't it bring, more and more, to the surface the creases, wrinkles, skin, fats and, consequently, shame, suffering and sadness? Such a discussion, however, is not present in the analyzed articles, as if it did not exist.
The phenomenon we have studied here and to what we suggest a medical appropriation is that of the physical appearance, which has had an increasing importance not only to society, but also to the medical environment. The Aesthetic plastic Surgery served as an example to this study of the medicalization process that has several definitions and theories; however, it emerges here as an assimilation of the physical appearance theme through the biomedical rationality. In this sense, the observation of the way as the Beauty Medicine appreciates its object points out to an appearance medicalization.
Despite the statement of ASPS (2005) that aesthetic plastic surgery is used to offer a new form of normal structures to the body, what one can observe in the discourse of the two major international magazines of the area is an approach showing that the variations were related to physical appearance in terms of normality and pathology, from the biomedical point of view.
In the articles of the Aesthetic Plastic Surgery, certain variations related to physical appearance gain visibility and also emerge facing the clinical regard that temporarily traces all its biologic development cause, characteristics and evolution. At the same time the authors go deeper into the physical body, searching for smaller structures that are responsible for each alteration, there is no questioning about the way these variations are transformed into abnormalities, not even about the historical process that enabled its construction. When certain physical alterations related to aging or in disagreement with the current social norm of beauty are categorized as harmful, it points out to a possibility of research the generated causes and injuries. According to Canguilhem (1982), it is a process that represents the pathologization of an anomaly. In the case of the physical appearance, it means the pathologization of some of the differences that characterize us in relation to the others.
Besides a biological deeply comprehension that these physical challenges, which become visible, deserve diagnostic and treatment, there is an attempt to formulate a theory about biologic norms in the Aesthetic Plastic Surgery discourse. Measurements, distances, angles, curvatures and ideal saliencies that may define beauty patterns supported only within anatomic studies or in public opinion surveys about physical appearance, but also that would refer to biologic patterns of beauty that are accepted by being natural, a-historicals, effects of the human evolution, that is, that are not socially determined. The focus on the biologic determinism allows Beauty Medicine to discuss about beauty patterns without being confronted to its own practice, as if it was just one more technique of restoration of what is supposed to be normal and not of the creation of new norms.
The usage of self-esteem as a legitimization of this medical practice follows the same logic. It does not explain how people turn to be unhappy with their own body, but the aesthetic plastic surgery restores the self-esteem and brings the person back to his or her psychic normality with its intervention. Thus, Beauty Medicine is legitimized by its own peers as its discourse is structured in the logic of the health/disease process.
The notion of integrality in health, that involves the physic, psychic and social good feeling, makes it easier to accept a practice that notably makes people feel better soon after the intervention is carried out. On the other hand, something the Aesthetic Plastic Surgery does not demonstrate, within the analyzed articles, is that there is an former movement to interventions and increase in self-esteem, which is the lowerness of self-esteem and that its practice certainly has a connection with it as new corporal drafts define new norms that increase the intent for an aesthetic surgery.
These observations are not only important to a Beauty Medicine, but also to medicine as a whole as they serve as a demonstration of how these new issues, even the less probable ones, are incorporated by the structure of biomedicine.
AMERICAN SOCIETY FOR PLASTIC SURGEONS. ASPS. What is the difference between cosmetic and reconstructive surgery? Disponível em: <www.plasticsurgery.org/FAQ-What-is-the-difference-between -cosmetic-and-reconstructive-surgery.cfm.>. Acesso em: 15 mai. 2005.
AMERICAN SOCIETY FOR PLASTIC SURGEONS. National Plastic Surgery Statistics. Cosmetic and reconstructive procedure trends 2000-2003. Disponível em: <http://www.plasticsurgery.org.>. Acesso em: 20 jul. 2004ª.
AMERICAN SOCIETY FOR PLASTIC SURGEONS. National Plastic Surgery Statistics. Cosmetic surgery trends 1992, 1998, 2002, 2003. Disponível em: <http://www.plasticsurgery.org.>. Acesso em: 20 jul. 2004b.
AMERICAN SOCIETY FOR PLASTIC SURGEONS. National Plastic Surgery Statistics. Cosmetic surgery age (18 or younger). Disponível em: <http://www.plasticsurgery.org.>. Acesso em: 20 jul. 2004c.
BARDIN, L. Análise de conteúdo. São Paulo: Martins Fontes, 1977.
BILGILI, Y.; TELLIOGLU, A.T.; UNAB, B.; KARAEMINOGULLARI, G. Quantitative analysis of liposuction with B mode ultrasound. Aesthet. Plast. Surg., v.28, n.5, p.226-7, 2004.
BORDO, S. Unbearable weight: feminism, western culture and the body. Berkeley: University of California Press, 1993.
BOURDIEU, P. A dominação masculina. Trad. Maria Helena Kühner. 2.ed. Rio de Janeiro: Bertrand Brasil, 2002.
BRETON, D.L. Adeus ao corpo: antropologia e sociedade. Campinas: Papirus, 2003.
CAMARGO JUNIOR, K.R. Biomedicina, saber & ciência: uma abordagem crítica. São Paulo SP: Hucitec, 2003.
CANGUILHEM, G. O normal e o patológico. 2.ed. Rio de Janeiro: Forense Universitária, 1982.
COSTA, J.F. O vestígio e a aura: corpo e consumismo na moral do espetáculo. Rio de Janeiro: Garamond, 2004.
CUENCA-GUERRA, R.; QUEZADA, J. What makes buttocks beautiful? A review and classification of the determinants of gluteal beauty and the surgical techniques to achieve them. Aesthet. Plast. Surg., v.28, n.5, p.340-7, 2004.
DAVIS, K. Reshaping the female body: the dilemma of cosmetic surgery. New York: Routledge, 1995.
DAYAN, S.; CLARK, K.; HO, A.A. Altering first impressions after facial plastic surgery. Aesthet. Plast. Surg., v.28, n.5, p.301-6, 2004.
ECO, U. (Org.). História da beleza. Trad. Eliana Aguiar. Rio de Janeiro: Record, 2004.
ELIAS, N. O processo civilizador: uma história dos costumes. Rio de Janeiro: Jorge Zahar, 1994. v.1.
ETCOFF, N. A lei do mais belo: a ciência da beleza. Rio de Janeiro: Objetiva, 1999.
FOUCAULT, M. O nascimento da clínica. Trad. Roberto Machado. 5.ed. Rio de Janeiro: Forense Universitária, 2003.
FRUSCELLA, P. Morphodynamics and surgical correction of the body's creases, folds and wrinkles. Aesthet. Plast. Surg., v.28, n.1, p.37-44, 2004.
GILLESPIE, R. Women, the body and brand extension in Medicine: cosmetic surgery and the paradox of choice. Women Health, v.24, n.4, p.69-85, 1996.
GILMAN, S. Making the body beatiful: a cultural history of aesthetic surgery. Princeton: Princeton University Press, 1999.
GOLDWYN, R.M. Who can have aesthetic surgery? Aesthet. Plast. Surg., v.28, n. 6, p.357-8, 2004.
GONÇALVES, I.L. Cortes e costuras: um estudo antropológico da cirurgia plástica no Rio de Janeiro. 2001. Dissertação (Mestrado) - Antropologia Social, Universidade Federal do Rio de Janeiro, Rio de Janeiro.
JACOBSON, N. The socially constructed breast: breast implants and the medical construction of need. Am. J. Public Health, v.88, n.8, p.1254-61, 1988.
LOWENBERG, J.S.; DAVIS, F. Beyond medicalization-demedicalization: the case of holistic health. Sociol. Health Illness, v.16, n.5, p.579-99, 1994. Disponível em: <http://www.blackwell-synergy.com/toc/shil/16/5>. Acesso em: 15 mar. 2005.
LUZ, M.T. Natural, racional, social: razão médica e racionalidade científica moderna. Rio de Janeiro: Campus, 1988.
LUZ, M.T. Racionalidades médicas e terapêuticas. Rio de Janeiro: Gráfica da UERJ, 1993. (Estudos em Saúde Coletiva, n.62)
MAIO, M. The minimal approach: an innovation in facial cosmetic procedures. Aesthet. Plast. Surg., v.28, n.5, p.295-300, 2004.
ROHDEN, F. Uma ciência da diferença: sexo e gênero na medicina da mulher. Rio de Janeiro: Fiocruz, 2001.
SANT'ANNA, D.B. (Org.). Políticas do corpo: elementos para uma história das práticas corporais. São Paulo: Estação Liberdade, 1995.
SEN, C.; CEK, D.I.; REIS, M. Direct skin excision fat rand repositioning for correction of prominent nasolabial fold. Aesthet. Plast. Surg., v.28, n.5, p.307-11, 2004.
STRAUCH, B.; ERHARD, H.A.; BAUM, T. Use of irradiated cartilage in rhinoplasty of the non-caucasian nose. Aesthet. Surg. J., v.24, n.4, p.324-30, 2004.
SULLIVAN, D.A. Cosmetic surgery: the cutting edge of commercial medicine in America. New Jersey: Rutgers University Press, 2001.
VELASCO, M.G.; ARIZTI, P.; TOCA, R.G. Surgical correction of the "small" postpartum ptotic breast. Aesthet. Surg. J., v.24, n.3, p.199-205, 2004.
WOLF, N. O mito da beleza: como as imagens de beleza são usadas contras as mulheres. Trad. Waldéa Barcellos. Rio de Janeiro: Rocco, 1992.
1 Travessa dos Imigrantes, 135, Centro de Saúde dos Ingleses
2 These data refer only to those productions of physicians who are certified by the American Society for Plastic Surgeons; therefore, underestimated in relation to the whole.
3 According to Canguilhem anomaly "is an individual variation that prevents two beings to replace each other fully"; it is not, however, a pathology.
4 The term 'biomedicine' is used within a close relation between medicine and the scientific knowledge which is, on its turn, produced in the Biology field (See: Camargo Jr., 2003, p.101).