Alex Edmonds “A Right to Beauty”

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A Right to Beauty

Alexander Edmonds

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.

In 1988 a newly democratic Brazil rati­fied an ambitious constitutional right to health care. Public hospitals, however, are poorly funded and often beset by long lines, crumbling infrastructure, and rude service. (My middle-class Brazilian friends, who pay enviably low premiums for private health insurance, generally would not set foot in one.) A right to beauty thus seems a rather frivolous concern in a country with more pressing problems, from tropical diseases, like dengue, to the diseases of civilization, like diabetes. Yet to an outsider trying to un­derstand a new society, such a view had a whiff of condescension. I remembered the remark of a Carnival designer: “Only intel­lectuals like misery; the poor want luxury.” I wanted to try to understand what this med­ical practice meant to the people who prac­ticed it and claimed they benefited from it.

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

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One Response

  1. Thank you Mr. Edmonds for sharing this anthropological piece. This was very compelling for it showcases the varying perspectives of how women and more so societies and cultures view beauty. I learned in my anthropology class that the difference between gender and sex is the difference between culture and biology. This concept speaks to a larger phenomenon of the differing ways women identify their self worth and how that relates to the society in which they live. In the same class I learned about gender and sex, I also learned about how gender roles pertain to the “economy of efforts” this concept explains the origins of gender roles and how it pertains to the necessary economical roles of women and men in traditional societies. When comparing the traditional origins of gender roles and the brazilian subculture of plastic surgery as outlined in your article, “A Right to Beauty”, it is easy to see how this subculture may be deemed a frenetic outgrowth of these gender origins. There is a stark contrast between separating women based on their worth and contribution to a family or town as outlined in the concept of the economy of effort with separating and judging a woman on her physical beauty. This evolution of how women perceive beauty and self worth speaks to the spark of globalization and the ability for women who would not usually be concerned with their looks having easy access to not only the media outlets that stem this physical consciousness but also the plastic sergeants who can “correct” their bodies.

    However, who is to say their new wave of physical consciousness is one to look down upon? I mean after all, anthropologists are merely suppose to observe and understand another sub culture right? But, this is where anthropology frustrates me. I understand that anthropologists are suppose to understand another culture but I am driven by action not mere observance. When I hear about women judging their worth merely on their beauty and risking their health and as I see it “wasting” their money on plastic surgery I get concerned and my emotional state wants me to take action. To somehow stop these women, tell them that they are worth more than just their looks and that cutting their bodies is not the only answer. But, as I live through this chain of events I see how this scenario can be compared to what may perceived as- someone from the outside trying to tell someone from the inside what they are doing is wrong. This approach is inefficient and also in my opinion ethically wrong. Change starts small and it starts from within. If the way women so freely turn to plastic surgery in Brazil concerns me I need to do more research of my own and try to approach what I see as a concern with a more holistic, relativistic approach and ultimately start by asking myself why am I concerned.

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