A Right to Beauty
While living in Rio de Janeiro in 1999, I saw something that caught my attention: a television broadcast of a Carnival parade that paid homage to a plastic surgeon, Dr. Ivo Pitanguy. The doctor led the procession surrounded by samba dancers in feathers and bikinis. Over a thundering drum section and the anarchic screech of a cuíca (Brazilian friction drum), the singer praised Pitanguy for “awakening the self-esteem in each ego” with a “scalpel guided by heaven.”
It was the height of Rio’s sticky summer, and the city had almost slowed to a standstill, as had my progress on the research for my anthropology doctorate on Afro-Brazilian syncretism. After seeing the parade, I began to notice that Rio’s plastic surgery clinics were almost as numerous as beauty parlors (and there are a lot of those). New-stands sold magazines with titles like Plástica & Beauty, next to Marie Claire. I assumed that the popularity of cosmetic surgery in a developing nation was one more example of Brazil’s gaping inequalities.But Pitanguy has long maintained that plastic surgery was not only for the rich: “The poor have the right to be beautiful, too,” he has said.
The beauty of the human body has raised distinct ethical issues in different epochs. The literary scholar Elaine Scarry pointed out that in the classical world a glimpse of a beautiful person could imperil an observer. In his “Phaedrus” Plato describes a man who after beholding a beautiful youth begins to spin, shudder, shiver, and sweat. With the rise of mass consumerism, ethical discussions have focused on images of female beauty. Beauty ideals are blamed for eating disorders and body alienation. But Pitanguy’s remark raises yet another issue: Is beauty a right, which, like education or health care, should be realized with the help of public institutions and expertise?
The question might seem absurd. Pitanguy’s talk of rights echoes the slogans of make-up marketing (e.g., L’Oreal’s “Because you’re worth it” campaign). Yet his vision of plastic surgery reflects a clinical reality that he helped create. For years he has performed charity surgeries for the poor. More radically, some of his students offer free cosmetic operations in the nation’s public-health system.
After a long wait, I began new fieldwork among a “tribe” of Cariocas (residents of Rio) less familiar to me: socialites and their maids, divorced housewives, unemployed secretaries, aspiring celebrities, transvestite prostitutes, and other patients who were making Brazil, as a national news magazine bragged, the “empire of the scalpel.”
I first met Ester through her former employer, a successful plastic surgeon, for whom she’d worked as his personal cook. Ester lived near the surgeon in Vidigal, a favela flanking the brilliant white sand beach of Leblon. One day, after she’d prepared dinner for his family, she shyly told him in private, “Doctor, I want to put in silicone.”
After reading up on prosthetic materials in an Internet café, she’d settled on a mid-cost model of breast implant (1,500 real, or about $900), size (175 cm), and shape (natural), and convinced the doctor in a minute that she was a good candidate. Hesitant to perform the surgery on his domestic employee, he referred her to a young resident in Pitanguy’s clinic.
Ester left school at 14 to work beside her mother as a maid, and now has two young kids. While taking night classes to get her high-school diploma, she dreamed of “working with numbers.”� Job prospects were grim, however, and she said she’d take anything, even “working for a family” (a euphemism for domestic service). I asked her why she wanted to have the surgery. “I didn’t put in an implant to exhibit myself, but to feel better. It wasn’t a simple vanity, but a … necessary vanity. Surgery improves a woman’s auto-estima.”
Ester mentioned a key concept in Pitanguy’s vision of plastic surgery’s healing potential: self-esteem. A prolific writer, Pitanguy says he takes a “humanistic” approach to medicine. Most of his 800-plus publications are technical, but some cite thinkers, such as Michel Foucault and Claude Lévi-Strauss, rarely found in medical works (hence Pitanguy’s sobriquet, given by a colleague: the “philosopher of plástica”). With its wide-ranging reflections, this oeuvre has earned Pitanguy a place in Brazil’s prestigious academy of letters.
It also outlines a radical therapeutic justification for cosmetic surgery. Pitanguy argues that the real object of healing is not the body, but the mind. A plastic surgeon is a “psychologist with a scalpel in his hand.”
This idea led Pitanguy to argue for the “union” of cosmetic and reconstructive procedures. In both types of surgery beauty and mental healing subtly mingle, he claims, and both benefit health. Pitanguy still makes a distinction between cosmetic and reconstructive operations. Santa Casa—which is run with a mix of charity and state funding—offers the latter for free, but charges a small fee to cover the costs of anesthesia and medical materials for cosmetic operations. But other surgeons, including some of Pitanguy’s students, have gone further, offering free cosmetic surgery in public hospitals.
We might ask: if you’re psychologically suffering, why not have psychological treatment? One doctor had this response: “What is the difference between a plastic surgeon and a psychoanalyst? The psychoanalyst knows everything but changes nothing. The plastic surgeon knows nothing but changes everything.”
He was joking, but he hit on a change in Brazil’s therapeutic landscape.
Psychoanalysis and plastic surgery, both once maverick medical specialties, overlap closely in their historical development. While the “talking cure” treated bodily complaints via the mind, plastic surgery healed mental suffering via the body. Historian Sander Gilman called plastic surgery “psychoanalysis in reverse.” In Brazil, as in Argentina, psychoanalysis enjoyed extraordinary popularity among wealthier Brazilhans.
“The poor prefer surgery.”
ians. But many veterans of Freudian or Lacanian therapy have supplemented or supplanted it with plástica. For the patients at public hospitals, psychoanalysis had never been “an option,” a psychologist who worked in Pitanguy’s clinic told me. Echoing the words of the mischievous Carnival designer, she explained, “The poor prefer surgery.”
Pitanguy’s ideas would have had little influence if it were not for his reputation as a skilled surgeon. Starting in the 1940s Pitanguy trained with leading plastic surgeons in Europe and the United States. One of his mentors in Britain was Sir Harold Gillies, who pioneered techniques in modern plastic surgery while operating on mutilated World War I veterans. His long career thus spans the 20th-century transformation of the specialty from primarily reconstructive techniques to primarily cosmetic improvements. Over the last five decades, Pitanguy has trained over 500 surgeons. His students have in turn trained new generations of surgeons, spreading their mentor’s techniques and “philosophy” as they open up practices around the country and abroad.
Pitanguy’s views of plastic surgery are in some ways no different than those of the wider specialty. Plastic surgery gained legitimacy in the early 20th century by limiting itself to reconstructive operations. The “beauty doctor” was a term of derision. But as techniques improved they were used for cosmetic improvements. Missing, however, was a valid diagnosis. Concepts like psychoanalyst Alfred Adler’s inferiority complex—and later low self-esteem—provided a missing link.
Victorians saw a cleft palate as a defect that built character. For us it hinders self-realization and merits corrective surgery. This shift reflects a new attitude toward appearance and mental health: the notion that at least some defects cause unfair suffering and social stigma is now widely accepted. But Brazilian surgeons take this reasoning a step further. Cosmetic surgery is a consumer service in most of the world. In Brazil it is becoming, as Ester put it, a “necessary vanity.” Or as one surgeon said, “Faced with an aesthetic defect, the poor suffer as much as the rich.”
Oddly enough for a plastic surgeon, Pitanguy is an aesthetic relativist. Some plastic surgeons cite Greek mathematicians to argue there is a universal beauty ideal based on classical notions of proportion. But Pitanguy, whose patients often have mixed African, indigenous, and European ancestry, stresses that aesthetic ideals vary by epoch and ethnicity. What matters are not objective notions of beauty, but how the patient feels. As his colleague says, the job of the plastic surgeon is to simply “follow desires.”
Yet, such desires are not simply a matter of psychology. Brazil’s pop music and TV shows are filled with talk of a new kind of celebrity: the siliconada. These actresses and models pose in medical magazines, the mainstream women’s press, and Brazilian versions of Playboy, which are read (or viewed) by female consumers. Patients are on average younger than they were 20 years ago. They often request minor changes to become, as one surgeon said, “more perfect.” Unlike fashion’s embrace of playful dissimulation and seduction, this beauty practice instead insists on correcting precisely measured flaws. Plastic surgery may contribute to a biologized view of sex where pleasure and fantasy matter less than the anatomical “truth” of the bare body.
While Pitanguy views plastic surgery as part of mental health, it is also becoming a routine intervention in women’s health. As elsewhere in the world, the majority of patients in Brazil are female. Ester said, “I was a mother twice. I had an enormous belly and it never returned to normal. Plástica can give you a muscular correction, they stretch the skin, cut it.” Happy with the results of her breast surgery, she was now saving up for abdominoplasty and liposuction. Some women (and plastic surgeons) blame pregnancy and breast feeding for breasts that are “fallen,” “shrunken,” or “shriveled like a passion fruit left in the refrigerator drawer,” and which can be corrected with cosmetic surgery.
In the United States, the growth of the “mommy job” has provoked a medical and cultural controversy. Bloggers have vehemently denounced “yuppie yummy mummies,” while the New York Times warned about the “pathologization” of motherhood. But in Brazil, such postpartum body contouring is in many ways becoming integrated into mainstream reproductive and sexual health practices.
Some ob-gyns and psychologists refer patients to plastic surgeons. Ob-gyns may also counsel expectant mothers how to manage weight gain, balancing between health and aesthetic factors. News media run features on women’s health that juxtapose advances in dieting pills and breast implants next to improvements in techniques for breast cancer screening. Brazil also has a highly interventionist tradition of medical managing of women’s health. It is perhaps not coincidental that Brazil has not only high rates of plastic surgery, but also high rates of Cesarean sections (70 percent of deliveries in some private hospitals), tubal ligations, and other surgeries for women. Plástica can be seen as a means to correct a scar or flaccidity following a C-section, or else more subtly as a “gift to the self” after the sacrifice of childbirth and the pain of other surgeries. Other women see elective surgeries as part of a modern standard of care, more or less routine for the middle class, but only sporadically available to the poor. One favela resident remarked: “If a girl from Ipanema can have a 5,000 reals breast job, then I have the right, too.”
|As plastic surgery becomes a more routine aspect of women’s health, risks may be overlooked. A botched liposuction can cause intestinal lesions or pulmonary edema. Tissue around breast implants may harden. Facelifts can result in necrosis of skin and infections. And coma and death are, of course, always a risk in procedures requiring anesthesia. At public hospitals, despite often aging equipment and infrastructure, surgeons claim that the rate of complications is low. And in fact, most of the deaths due to cosmetic surgery result from liposuction performed outside a hospital, leading one magazine to warn its readers against playing “Russian Roulette” with plástica. Higher risks in the private sector may be due to aggressive cost cutting in a highly competitive market. One successful surgeon, Dr. Lívia, said that clinics could only offer such remarkably low prices by cutting corners, “for example, by reusing a silicone implant, sterilized of course.”|
Brazil also provides a “good working environment,” surgeons say, compared to the United States or Europe. One resident remarked, “Patients here do not feel they have the right to pursue a malpractice suit.” He linked this to a cultural trait: “The Latin patient is friendly, more open, more sentimental. This is better for us because even if the patient is not satisfied, she is less likely to sue.” In the United States, patients must sign a form saying they understand the risks of surgery—a formality often dispensed with in Brazil. In public hospitals, which often have very short consultations, some patients were uninformed about the possibility of complications or unaware that operations would leave a scar. When complications do occur, surgeons sometimes blame the patient’s “response to surgery.” Or else, patients simply blame themselves. One woman said, “Plástica is a lottery. Because of the first operation I had to do others, and others, and others. They cut the nerves. It was an elaborate and sad road. … I was one of the rare ones who failed with plástica.”
While the rate of complications may be low, a surprising number of patients I meet are seeking a touch-up. Due to the subjective nature of body-image, it’s not always clear whether a resident botched the job, or the patient is simply disappointed with the results. But aside from the quality of the surgery, the “popularization” of plastic surgery raises another question: Are scarce public healthcare funds being diverted from other purposes?
Santa Casa and some public hospitals house residency programs that provide extraordinary opportunities for training in cosmetic procedures. In the United States, plastic surgeons usually get experience in cosmetic surgery through a lengthy apprenticeship in a private practice. In Brazil, residents—some of whom receive scholarships—do cosmetic operations beginning in their first year. One resident who performed ninety-six surgeries in one year said, “There is nowhere else in the world where I could have gotten that kind of experience in so short a time.” Such opportunities attract doctors from around the world. At Santa Casa, I met residents from Italy, Switzerland, India, Mexico, Peru, and Colombia.
This experience is a valuable resource for the novice surgeon. Many plastic surgery residents later find work in the private sector, where pay is much higher. Brazilian cities have some of the highest densities of plastic surgeons in the world, which creates downward pressure on prices. Younger surgeons often open practices in smaller cities or in the interior of the country. Landlocked Minas Gerais now has more plastic surgeons than the state of Rio de Janeiro. Cheaper prices and reputation for quality is also luring medical tourists from North America, the Middle East, and Europe. What these patients may not realize is that their surgeon’s expertise—offered at a competitive price—was gained through an opportunity to perform state-subsidized cosmetic operations.
Pitanguy’s philosophy is disturbing for many reasons, yet it suggests a point about the significance of attractiveness often overlooked in academic discussion. Pierre Bourdieu argued that nearly all aspects of taste reflect social class. He extends his argument to the body itself: posture, gesture, even habits of chewing food. Curiously, and almost in passing, he makes an exception for physical attractiveness. Bodies “should,” he writes, “be perceived as strictly corresponding to their ‘owners’ position in the social hierarchy.” And yet they aren’t. “The high and mighty,” he argued, “are often denied the “bodily attributes of their position, such as height or beauty.” In other words, attractiveness is a quality that is at least partially independent of other social hierarchies. For
In poor urban areas, beauty often has a similar importance for girls as soccer (or basketball) does for boys: it promises an almost magical attainment of recognition, wealth, or power.
Beauty is unfair: the attractive enjoy privileges and powers gained without merit. As such, it can offend egalitarian values. Yet, while attractiveness is a quality “awarded” to those who don’t morally deserve it, it can also grant power to those excluded from other systems of privilege. It is a kind of “double negative”: a form of power that is unfairly distributed but which can disturb other unfair hierarchies. For this reason it may have democratic appeal. In poor urban areas, beauty often has a similar importance for girls as soccer (or basketball) does for boys: it promises an almost magical attainment of recognition, wealth, or power.
In Brazil’s favelas many dreams for social mobility center on the body. NGOs offer free lessons in fashion modeling. Marriage is often seen as an out-of-reach luxury, seduction a means of escaping poverty. Powerful attractions that cross class lines are a favorite theme in telenovelas. And working-class women face long lines at public hospitals to have cosmetic surgery. These social facts stem from the lack of other opportunities for many women. Yet, they also reflect an accurate, not deluded, perception of the role of physical attractiveness in consumer capitalism.
For many consumers, attractiveness is essential to economic and sexual competition, social visibility, and mental well-being. This “value” of appearance may be especially clear for those excluded from other means of social ascent. For the poor, beauty is often a form of capital that can be exchanged for other benefits, however small, transient, or unconducive to collective change.
Winner of the 2001 Miss Brasil contest. After she divulged she’d had multiple cosmetic surgeries, the Brazilian media dubbed her “Miss Siliconada.”
This article is adapted from an essay titled “A Necessary Vanity”that was first published in the New York Times series on philosophy, “The Stone,” on August 13, 2011.
Alexander Edmonds is assistant professor of anthropology at the University of Amsterdam. He is the author of Pretty Modern: Beauty, Sex and Plastic Surgery in Brazil (Duke University Press). More about his work can be found at http://home .medewerker.uva.nl/a.b.edmonds/.
Image from http://www.riobookings.com