“You might not notice it … but I do”: Shame and Cosmetic Surgery

Augmenting the Body: Disability, Care and the Posthuman is an interdisciplinary research project that explores practices of bodily augmentation, from caring robots to prosthetic limbs, across the fields of English, Engineering, Healthcare, Philosophy, and Robotics. The project, led by Professor Stuart Murray and funded by a Wellcome Trust Seed Award, involves collaborators from the University of Leeds, the University of Exeter, and Sheffield Robotics.

In this post, one of the collaborators working on the project—Dr Luna Dolezal (University of Exeter)—offers a snapshot of her work on the relationship between bodily augmentation through cosmetic surgery and beauty demands.

It is only very recently that elective cosmetic surgery has entered the mainstream as a routine and socially acceptable way to alter appearance. In the 1950s, for example, aesthetic plastic surgery was a largely marginal and unknown medical practice. Just a few decades later, it is a recognized medical speciality, not to mention a highly lucrative multi-billion dollar global industry. As cosmetic surgery has proliferated, it has also become more democratic. No longer the privilege of the wealthy or elite, procedures are increasingly more affordable and cosmetic surgery is now a pursuit of the middle and more affluent lower classes.
Although cosmetic surgery is regularly performed on men, it is by and large a female practice. In 2013, for instance, in the United States, just over ninety per cent of surgical and non-surgical cosmetic procedures were performed on women, and only nine per cent on men. (Interestingly, although women are by and large the primary recipients of cosmetic surgery, eight out of every nine cosmetic surgeons are male.) These figures are mirrored precisely in the UK, where women make up about 90% of cosmetic surgery recipients.
It is widely reported in the academic literature on cosmetic surgery that women sometimes see cosmetic surgery as a means to take control of their bodies and lives, exercising their agency in order to alleviate psychological distress. As a result, despite the (obvious) focus on the physical body in cosmetic surgery practices and the promise of ameliorating physical flaws, a common justification by doctors and patients for the medical need for cosmetic surgery is not about the physical body, but instead related to the alleviation of psychological distress—significantly, they argue that cosmetic surgery will alleviate shame, anxiety and suffering arising as a result of perceived flaws in one’s body and the perceived threats to one’s social standing that this may incur.
Hence, it is commonly reported that women see cosmetic surgery as a means to alleviate or circumvent shame about the body, while ensuring a sense of social acceptance through impression management. Indeed, medical advocates of cosmetic surgery argue that as one of medicine’s primary goals is to reduce suffering, insofar as cosmetic surgery can offer relief to psychological distress then it should be considered a viable medical treatment. It is by this logic that cosmetic surgery is sometimes seen as medically justified rather than merely an enhancement of already ‘normal’ functioning, and is sometimes funded by national health services, such as the NHS.
In fact, concerns around appearance management are far from trivial and can indeed have serious consequences for one’s experience and sense of well being. The sort of psychological distress that individuals feel when appearance management comes to be dominated by chronic feelings of body shame can shrink one’s world, disrupting on-going activities and life projects as the self turns attention inwards on itself. This may result in a state of confusion or inaction, and perhaps an inability to engage meaningfully with projects in the world—and there is plenty of literature that corroborates that when attention is directed to the body and one is made to feel insecure, then this can have profound consequences on attention and performance. This sort of experience can lead to social withdrawal, rendering one fragile, insecure, timid and emotionally vulnerable.
It is clear from ample research and anecdotal evidence that cosmetic surgery is not simply an expression or manifestation of excess vanity in contemporary Western women, but rather it is sometimes utilized as a means to achieve a ‘normal’ appearance in order to avoid body shame. Hence, it seems that for some if not many women, cosmetic surgery is not about becoming beautiful or exceptional, but about merely ‘passing.’ Sought out in response to body shame that can perhaps range from minor to severe to completely unbearable, these women hope cosmetic surgery will help them become ‘unnoticeable,’ ‘invisible,’ and ‘ordinary’ to use some of the terms employed by the women in research interviews. In these contexts, arguably, cosmetic surgery can be seen as something beneficial for the subject where exercising one’s choice to have surgery can improve one’s quality of life, self-esteem and psychological functioning.
Transforming body shame into pride is, in fact, central to the drama of cosmetic surgery: shame drives women to seek out surgeons; surgeons cultivate it in order to acquire and maintain their clients; and, ultimately, surgeries are performed in order to alleviate it. In fact, doctors prey on shame and offer diagnostic language and a therapeutic narrative to alleviate the shame cycle that many women feel regarding their concerns with appearance, where the advice and attentions of a medical expert legitimates what might otherwise feel like a shameful preoccupation. A reassuring doctor will alleviate your shame, recasting what you feel might be mere vanity or narcissism into a serious medical concern. A perceived physical flaw is no longer a shameful secret or a personal failure, but part of a medical problem.
Diagnostic language is powerful. As critics writing about gender, race, sexual orientation and disability, among other embodied states that carry stigma, have noted, a medical diagnosis can alleviate shame and stigma, empowering and enabling an individual or group. As against feeling different, ashamed and alone, belonging to a medically classified group can be a positive and even life-changing experience, validating and endowing recognition to a subjectivity that was previously politically or socially marginalized, invisible and ignored. Not only is one’s shame alleviated, but often the medical model provides avenues and options for treatment and perhaps even a ‘cure.’
However, once these diagnoses or classifications are accepted and perceived as reality, it is difficult to resist the dictates of biomedicine and the normalizing ideology which underpins it. As a result, although doctors are key in alleviating the shame and embarrassment that one might feel about the body, they are also in a prime position to incite it.
There are numerous accounts in feminist literature on cosmetic surgery of doctors who, in consultation, routinely make women ‘see’ that parts of their bodies, for which they had not even considered surgery, are in fact also defective and in need of intervention. This has profound consequences for one’s self-perception and self-esteem. Susan Bordo cites this example:

 “Writing for New York magazine, 28-year-old, 5-foot 6-inch, and 118-pound Lily Burana describes how a series of interviews with plastic surgeons—the majority of whom had recommended rhinoplasty, lip augmentation, implants, liposuction and eyelid work—changed her perception of herself from ‘a hardy young sapling that could do with some pruning … to a gnarled thing that begs to be torn down to the root and rebuilt limb by limb.” (Bordo, 2009, p28)

In this manner, cosmetic surgeons can play out the common formula of consumer culture: they cultivate profound anxieties about the body and then present themselves and their services as the only means to eliminate or alleviate the very shame and guilt they have themselves helped to produce.
Arising from the inherent discrepancy in the power relations between doctors and patients, compounded by the highly gendered landscape within which cosmetic surgery practices play out, is an endless ground to invent new defects and, correspondingly, new interventions to correct them, inciting further anxieties in already existing clients while simultaneously broadening its markets to younger women, adolescents, men and diverse ethnic groups.     
Hence, what is interesting is that despite numerous testimonials that cosmetic surgery is sought out as a means to alleviate psychological distress caused by perceived flaws in appearance, there is ambivalent evidence on the overall positive psychological and social impact of cosmetic surgery, nor any clear evidence on how long any reported positive impacts will last. Evidence suggests that cosmetic surgery may offer a superficial fix targeting a particular instantiation of body shame, while, at the same time, ultimately exacerbating overall body dissatisfaction.
            In fact, the argument that cosmetic surgery is psychologically beneficial is extremely problematic and fraught with contradictions. Surgeons are regularly advised not to operate on those who suffer from mental health issues, especially Body Dysmorphia Disorder (BDD) which is characterized by chronic body shame and dissatisfaction with appearance or body image. These individuals are unlikely to be satisfied with the results of their surgeries, nor to experience any relief from their psychological suffering, and, moreover, they are the most likely to become litigious. However, while rejecting those with BDD as potential candidates for surgery, some surgeons simultaneously encourage BDD-like behavior in their ‘healthy’ and ‘suitable’ patients who turn to surgery as a result of dissatisfaction with minor or even imperceptible flaws in otherwise normal appearance. As a more honest surgeon remarks: “Plastic surgery sharpens your eyesight … You get something done, suddenly you’re looking in the mirror every five minutes—at imperfections nobody else can see.” (Bordo, 2009, p26). Indeed, a common mantra for women who undergo these sorts of procedures is: “You might not notice it … but I do.” (Wiseman, 2010, emphasis added).

Luna Dolezal is a lecturer in Medical Humanities and Philosophy at the University of Exeter. She discusses shame in the context of cosmetic surgery practices in her recent book The Body and Shame: Phenomenology, Feminism and the Socially Shaped Body (Lexington Books, 2015). Luna is a collaborator on the Augmenting the Body: Disability, Care and the Posthuman interdisciplinary research project. She is also the co-PI of the Shame and Medicine Project (www.shameandmedicineproject.com) which explores shame dynamics in all aspects of healthcare.

Bordo, S. (2009) Twenty Years in the Twilight Zone. In C. Heyes & M. Jones (eds.) Cosmetic Surgery: A Feminist Primer (pp.21-34). Farnham, UK: Ashgate Publishing

Wiseman, E. (March, 2010) Would Madam Like a Nose Job with Her Sandwich? The Observer Magazine


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