RESHAPING

THE
FEM AEE
BODY
This page intentionally left blank
RESHAPIN G
TH E
FEMAL E
BOD Y
THE DILEMMA OF
COSMETIC SURGERY

KATHY DAVIS

ROUTLEDGE NEW YORK AND LONDON

Published in 1995 by

Routledge
29 West 35th Street
New York, NY 10001

Published in Great Britain by

Routledge
11 New Fetter Lane
London EC4P4EE

Copyright © 1995 by Routledge, Inc.

Printed in the United States of America on acid free paper

All rights reserved. No part of this book may be reprinted or reproduced or utilized in any form
or by any electronic, mechanical or other means, now known or hereafter invented, including
photocopying and recording, or in any information storage or retrieval system, without per­
mission in writing from the publisher.

Library of Congress Cataloging-in-Publication Data

Reshaping the female body: the dilemma of cosmetic surgery / Kathy Davis,
p. cm.
Includes bibliographical references and index.
ISBN 0-415-90631-8.— ISBN 0-415-90632-6 (pbk.)
1. Surgery, Plastic— Psychological aspects. 2. Self-perception in women. 3. Women—
Health and hygiene— Sociological aspects. 4. Feminist theory. I. Title.
RD119.D385 1994 94-19290
617.9'5'0082— dc20 CIP

British Library Cataloguing-in-Publication Data also available

Material from Chapter 2 has appeared in different forms in Kathy Davis, "Remaking the She-
Devil: A Critical Look at Feminist Approaches to Beauty," in Hypatia 6,2 (Summer 1991 ):21—43;
Kathy Davis, "Het recht om mooi te zijn. De vele gezichten van cosmetische chirurgie," in Lover
18,1 (1991): 4-9; Kathy Davis, "Cultural Dopes and She-Devils: Cosmetic Surgery as Ideolog­
ical Dilemma" in Negotiating at the Margins: The Gendered Discourses of Power and
Resistance, ed. Sue Fisher and Kathy Davis, (New Brunswick: Rutgers University Press, 1993).
 CONTENTS

ACKNOWLEDGEMENTS vii

INTRODUCTION COSMETIC SURGERY 1

AS FEMINIST DILEMMA

ONE THE RISE OF THE SURGICAL FI X 14

TWO BEAUTY AND THE FEMALE BODY 39

THREE PUBLIC FACE/PRIVATE SUFFERING 68

FOUR FROM OBJECTIFIED BODY 93

TO EMBODIED SUBJECT

FIVE DECISIONS AND DELIBERATIONS 115

SIX CHOICE AND INFORMED 137

CONSENT REVISITED

SEVEN FACING THE DILEMMA 159

NOTES 182

BIBLIOGRAPHY 197

INDEX 207
FOR Μ I E KE
ACKNOWLEDGEMENT S

lc o sh mi s e t ibc o sou kr g e ar yb oisu tb a s we do om n e inn st e r ve ixe pwe sr i we ni tc he ss u rwg ei trhy

r e c ip ie n t s , p h y s ic ia n s , p la s t ic s u r g e o n s , a n d m e d ic a l
in s p e c t o r s , a n d o n f ie ld w o r k in m e d ic a l s e t t in g s . T o
p r e s e r v e c o n f id e n t ia lit y , I c a n n o t t h a n k t h e in t e r v ie w
s u b je c t s b y n a m e . H o w e v e r , t h e b o o k o w e s a d e b t o f
g r a t it u d e to e a c h o f t h e m , in c lu d in g t h e m e d ic a l
p r a c t it io n e r s w h o s h a r e d t h e ir in s ig h t s (a n d , in s o m e
c a se s, d o u b t s ) a b o u t c o s m e t ic s u r g e r y w it h m e a n d w h o
g a v e m e p e r m is s io n to d o f ie ld w o r k . I w o u ld e s p e c ia lly
lik e to t h a n k Im a n B a a r d m a n , w it h w h o m I s e t u p a n d
c o n d u c t e d t h e c lin ic a l s tu d y , f o r a s t im u la t in g a n d e n jo y a b le
c o lla b o r a t io n . A n d , f in a lly , m y m o s t h e a r t - f e lt t h a n k s a r e d u e t o
R E S H A P I N G THE F E M A L E BODY

the women who, by generously sharing their experiences with me,

helped me understand what cosmetic surgery is about. I hope that they
are not disappointed in the outcome of our conversations.
In the course o f working on this project, many people kept me sup­
plied with a stream o f newspaper clippings, pictures, references, and
articles. In particular, I would like to thank Marlou Boots, Sandera
Krol, and Juliette Zipper.
Lively and often heated discussions with friends, students, and col­
leagues have contributed enormously to the development of this book.
I would like to thank the participants in the post-graduate course
“Interpreting Gender” which was held at Utrecht University in 1993,
and the members of the ongoing seminar on text analysis at the Wom­
ens Studies Department there for their insights and helpful comments.
I owe warm thanks to the following people for their careful reading
and constructive critique of various chapters: Anna Aalten, Jan Davis,
Sue Fisher, Lena Inowlocki, Mary Lommerse, Joan Wolffensperger,
and Dubravka Zarkov. The copyeditor Neill Bogan was an authors
delight who not only polished up the text and kept me on track, but
issued the occasional, timely warning against using dubious rhetorical
strategies to make my point.
I am indebted to Lorraine Code for encouraging me on several
occasions to engage with my critics, and Nina Gregg for reminding
me that conflicts— especially among feminists— are worth confronting.
An extra note o f thanks goes to Lena Inowlocki for her friendship,
her humor, her sensitive commentary, and her numerous impromptu
lessons on how to do biographical analysis.
W ieneke Matthijsse spared me the hassle o f having to cope with
recalcitrant printers and produced a polished manuscript, for which I
am grateful.
Most o f all, Willem de Haan was the person who read all the drafts,
was my toughest but most encouraging critic, and helped me through
all the rough patches. He showed me, once again, why I don’t ever
want to write a book without him.

Amsterdam, May 1994

Kathy Davis

1010
I N T R O D U C T I O N _________
COSMETIC SURGERY AS FEMINIST D ILEM M A

This book is about how women account for

their decisions to have cosmetic surgery. What kinds of
experiences make them want to have their appearances
altered surgically? How do they explain the decision
and how do they view it in light of the outcome?
Like every book, it is also a personal story. It is the
story of how I— a feminist with a long-standing con­
cern about the gendered inequities of medical
encounters—became interested in understanding why
women want to have their bodies altered by surgical
means. What began as my rage at the horrors being perpe­
trated on womens bodies by the medical system turned to a
profound puzzlement after I talked to women who were eager
R E S H A P I N G THE F E M A L E BODY

to undergo cosmetic surgery. My inability to put these two emotions

together in a meaningful and acceptable way created such a strong
sense of unease that I had no other recourse but to tackle my discom­
fort head on. Being someone who enjoys a challenge, I decided to put
my experience to work, using it as a resource rather than an impedi­
ment for a feminist analysis of cosmetic surgery.
Several years ago, I attended a conference on body image and iden­
tity at the Dutch medical faculty where I had been working for some
time in the field o f medical sociology. The audience was composed
primarily of physicians and medical academics, along with a few social
scientists like myself One of the speakers was a well-known plastic sur­
geon. This particular surgeons talk was all about the wonders of
cosmetic surgery in helping people overcome a negative body image.
He explained that doctors in his specialty had some unique difficulties
in diagnosing their patients. In most medical specialties, patients don’t
know what their problem is, and leave it to the specialist to figure out.
N ot so with cosmetic surgery. Here, it is the patient who knows what’s
wrong and the surgeon who often has a hard time seeing it. This leaves
him with a dilemma: either he has to send the patient home empty-
handed or he has to find some medically acceptable reason for an
intervention as drastic as surgery. To illustrate this point, the speaker
gave a slide show with— what else?— before and after pictures. To my
surprise, the patient was not a middle-aged woman with wrinkles who
wanted a face lift, but a fifteen-year old M oroccan girl who wanted
her nose done. According to this surgeon, this girl was only one
among many similar cases: second-generation immigrant adolescents
who were getting harassed at school for having “noses like that.” They
became miserable, antisocial, and developed feelings of inferiority, he
explained. It became difficult for them to become assimilated into
Dutch society.
Now, what did this man o f science conclude? He decided that he
had stumbled upon a new syndrome and, being an enterprising scien­
tist, he immediately gave it a name: inferiority complex due to racial
characteristics. Thus, a new diagnostic category was born, many more
noses could be “fixed,” and, presumably, many unhappy young Moroc­
can women were enabled to live happily ever after. End o f story.
My initial reaction to this incident was outrage. I saw it as a partic­
ularly dramatic illustration o f the dangers o f the medical profession’s
meddling with women’s bodies. This was medicalization and racism in
technicolor— under the knife for the sake o f white, Anglo-Saxon
beauty. A blatant instance o f the victimization of women through their

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 C O S M E T I C S U R G E R Y AS F E M I N I S T D I L E M M A

bodies and of the racialized aspects o f such repression, it confirmed all

o f my worst feminist suspicions about the dangers o f the beauty sys­
tem. Women are instructed that their bodies are unacceptable: too fat,
too thin, too wrinkled, too old and, now, too ethnic.
At the same time, however, I was somewhat taken aback by the fact
that a plastic surgeon would reveal such an incident in the first place.
As a clinical psychologist with a sociological research interest in deci­
sions concerning w om ens health, I knew that physicians are noto­
riously reluctant to admit that their practices are based on anything
but objectively derived scientific criteria (Davis 1988). I had never
encountered such a public display o f medical accountability. The fact
that a plastic surgeon would go to such lengths to explain his diagno­
sis indicated that cosmetic surgery was not an entirely unproblematic
endeavor— even for the medical profession.
A second experience occurred several months later and involved a
luncheon date with a friend whom I had not seen in awhile. She was
an attractive, self-confident, successful professional woman. She was
also a feminist. To my surprise, she told me over coffee that she was
about to have her breasts enlarged. I must have looked fairly flabber­
gasted, as she immediately began defending herself. She said that she
was tired of putting up with being flat-chested. She had tried every­
thing (psychoanalysis, feminism, talks with friends), but no matter
what she did, she simply could not accept it. She saw no other solu­
tion but to do something about it. Finally, she said, she was going to
“take her life in her own hands.”
My friend was well informed about the dangers and side effects of
breast implants. She knew, for example, that she had a forty percent
chance o f some side effects— ranging from lack o f sensation in the
breasts to scarring to encapsulation o f implants (which is very painful
and makes the breasts as hard as rocks). She also knew that she had a
twenty percent chance that the implants would become infected or
rejected by her body and have to be removed and redone. This could
leave her in worse shape than she was before the operation. She had
even conducted a small study on her own by putting an ad in a local
feminist journal and talking to more than twenty women about their
experiences, many o f which were quite negative.
My friend was a feminist and as a feminist she was very critical of the
suffering women have to endure because their bodies do not meet the
normative requirements o f feminine beauty. She found such norms
oppressive and believed that women in general should accept their bod­
ies the way they are. However, she still felt compelled to have cosmetic

3
R E S H AP I NG THE F E M A L E BODY

surgery for herself. Despite all the drawbacks of cosmetic surgery, she saw
it as her only option under the circumstances. So, here, to my amaze­
ment and— I must admit— distress, was a feminist who was actively and
knowledgeably opting for the “surgical fix.”
As a feminist, I could have rejected my friends explanation for why
she wanted to have cosmetic surgery as the deluded imaginings of
another casualty of the beauty craze— an instance o f what used to be
called “false consciousness.” This would have been in line with cur­
rent feminist thinking about the beauty system as an oppressive way to
discipline or normalize wom en through their bodies. I did not find
that approach very satisfactory in the case o f my friend, however.
After all, she was just as critical as I of the beauty norms and she knew
a lot more than I did about the risks and dangers of cosmetic surgery.
And, yet she still saw it as the only step she could take under the cir­
cumstances. I began to w onder why it was so difficult for me, as a
feminist, to hear my friend’s account o f why she wanted cosmetic
surgery as anything other than one more instance of a woman being
duped by the beauty system. If she had used the very same rhetoric to
justify, say, a divorce (“My marriage is awful. I’ve had it. I’m going to
do something about it. I’m getting a divorce.”), I would have heard
this as “ideologically correct.” In the first case, she is the victim of
manipulation and in the second, just another feminist who is taking
her life in hand.
Cosmetic surgery was clearly more complicated than I had imagined.
I had previously associated it either with well-to-do American house­
wives who were bored with their suburban lives and wanted to have a
face lift or with the celebrity “surgical junkies” who couldn’t seem to
stop remaking their bodies— Madonna with her collagen-inflated lips
(“kiss bumpers”) or Cher, who had had so many operations that it was
hard to know where the original left off and the artificially constructed
began. I hadn’t expected to find much cosmetic surgery in The
Netherlands and was very surprised to discover that it was not only
popular here, but that my own feminist friends were going in for it.
These two experiences formed the backdrop for the present book.
The first experience— the surgeon’s speech— indicated that cosmetic
surgery had become a widespread medical practice with its own dis­
course o f justification— a discourse which seemed to be begging for
feminist analysis. It indicated that it was worth looking into how wom­
en’s bodies became defined as appropriate objects for this particular
kind of medical intervention. Understanding such a process, moreover,
would require an analysis o f the cultural norms o f femininity as well as

4
 C O S M E T I C S U R G E R Y AS F E M I N I S T D I L E M M A

of the specific constraints imposed upon women to “improve” or alter

their appearance. The second experience— my talk with my friend—
showed that cosmetic surgery is not simply imposed by misogynist,
knife-happy surgeons upon women who blindly follow suit. O n the
contrary, cosmetic surgery is fervently desired by its recipients. Despite
myriad dangers and drawbacks, wom en willingly opt to have their
bodies so altered. My puzzlement at my friend s decision convinced
me that understanding why women engage in a practice which is
painful, dangerous, and demeaning would have to take wom ens own
explanations as a starting point.
In order to make sense of womens involvement in cosmetic surgery,
I have attempted a kind o f feminist balancing act. My analysis is situ­
ated on the razor s edge between a feminist critique o f the cosmetic
surgery craze (along with the ideologies of feminine inferiority which
sustain it) and an equally feminist desire to treat women as agents who
negotiate their bodies and their lives within the cultural and structural
constraints o f a gendered social order. This has meant exploring cos­
metic surgery as one of the most pernicious expressions of the Western
beauty culture without relegating women who have it to the position
of “cultural dope.” It has involved understanding how cosmetic surgery
might be the best possible course of action for a particular woman,
while, at the same time, problematizing the situational constraints
which make cosmetic surgery an option.

I HE NETHERLANDS: A SPECIAL CASE

It seems almost self-evident that any book about cosmetic surgery
should begin in the U.S., where the cosmetic surgery craze emerged
(Wolf 1991). Cosmetic surgery tends to be regarded as a typically
American phenom enon, conjuring up visions o f Beverly Hills sur­
geons, celebrity “scalpel slaves,” and the Oprah Winfrey show. I have
situated my inquiry, however, in a country which is rarely mentioned
in conjunction with such surgery— The Netherlands. The Netherlands
is a special case and it is precisely for this reason that it offers a partic­
ularly good place to begin a feminist analysis o f the phenomenon.
Like the U.S. and most o f Europe, The Netherlands has experi­
enced a general upsurge in cosmetic surgery, both in terms of the
number o f operations and the number of procedures and technologies
available. It is estimated that more than twenty thousand cosmetic
operations are performed here every year— more per capita than in the
U.S.1A multi-million-dollar beauty industry, a history of medicalizing

5
R E S H AP I NG THE F E MA L E BODY

w om ens bodies, and an Anglo-European cultural norm o f feminine

beauty ensure that women are the main recipients o f cosmetic surgery.
In this respect, cosmetic surgery in The Netherlands is not an isolated
phenomenon, but is part o f the same cultural landscape which makes
it endemic to most highly industrialized nations.
The Netherlands is, however, also an exception, having until recently
the somewhat dubious distinction of being the only country in the
world to have included cosmetic surgery in its basic health care pack­
age. For many years it has been available to women who would not
have been able to afford it if not for national health insurance. Cosmetic
surgery is often expensive. In the U.S., with its fee-for-service medical
system, or in European welfare states where cosmetic surgery is not
covered by national health insurance, such surgery is limited to people
who can afford it. In The Netherlands, however, women from all social
backgrounds were potentially able to obtain surgery, provided their
appearance was classified as falling “outside the realm o f the normal.”
Despite its availability, cosmetic surgery in The Netherlands was, para­
doxically, something o f a taboo. In a culture with a Calvinist tradition
which cautions against frivolity and excess, cosmetic surgery tends to be
problematic, requiring some explanation on the part of the would be
recipient. This situation makes it possible to explore wom ens reasons
for having surgery, as well as their difficulties in justifying their deci­
sions, without financial considerations being an issue. While women in
the U.S. will presumably have similar experiences and struggles, eco­
nomic forces and a media-constructed image o f cosmetic surgery as
acceptable and unproblematic may obscure our view o f them .2 The
contrasting Dutch context allows the cultural dimension o f wom ens
involvement with the surgery to come to the fore— both in terms of
what makes it desirable and of what makes it problematic.
The advantages o f the Dutch case for the researcher are not limited
to understanding the motives o f the recipients, however. In a market
system of medicine like that o f the U.S., the medical profession is not
accountable in the same way that it is in a welfare system. In the U.S.,
cosmetic surgery is performed at the individual surgeon’s discretion.
Plastic surgeons seem to have little com punction about plying their
trade, providing the technology is available and the patient can pay
for it. In a system o f socialized medicine, however, health care ser­
vices have to be justified in terms o f medical necessity. As it became
increasingly difficult in the context o f economic recession for
the D utch welfare system to meet even basic health care needs, cos­
metic surgery became the object o f heated debate, among the medical

6
 C O S M E T I C S U R G E R Y AS F E M I N I S T D I L E M M A

profession, the welfare bureaucracy, and the national health insurance

system. The need to cut costs made cosmetic surgery increasingly
problematic, even for surgeons. An attempt was made to get the
problem under control by developing “scientific” criteria to decide
which bodies were normal and which were not and a heated public
debate ensued, primarily between plastic surgeons and the national
health insurance system, concerning the conditions under which cos­
metic surgery should or should not be performed.
As any medical sociologist will attest, such public accountability on
the part of the medical profession is unusual. It makes The Netherlands
an ideal site for exploring how the profession draws upon ideologies o f
femininity as it defines which bodies are deficient enough to require
surgical alteration. Thus, by virtue o f its being an exception, The
Netherlands provides a good place to explore the cultural and ideo­
logical dynamics of decisions concerning cosmetic surgery— dynamics
which may be obscured in the U.S., where such decisions are affected
both by unrestrained individual choice (possessed by both patients and
practitioners), on the one hand, and by the uncontrolled expansion o f
the beauty industry, on the other.

GETTING STARTED
My inquiry spanned a period o f several years and entailed three empir­
ical studies: an exploratory study, a clinical study, and field work. In the
first study, I looked for women who had already had or were planning
to have some kind of cosmetic surgery. I used what is often called the
“snow-ball m ethod” and involves talking to just about anyone who is
willing, in order to get acquainted with the phenom enon at hand
(Schwartz and Jacobs 1979). This proved surprisingly easy. In fact,
every time I went to a party or a social gathering and m entioned my
new research project, people would tell me that they knew someone
who had had cosmetic surgery and suggest that I talk to them. Some
told me that they had had surgery themselves, which was how I dis­
covered that my feminist friend was by no means an exception. After
harboring their experience as a slightly shameful secret, many women
explained that I was the first person they were really able to talk to
about their reasons for having it.
I spoke with women who had undergone everything from a rela­
tively simple ear correction or breast augmentation to— in the most
extreme case— having the whole face reconstructed. My only criteria
for these conversations was that the surgery be done purely for looks.

7
R E S H A P I NG THE F E MA L E ROBY

I did not talk to wom en who had had reconstructive surgery as a

result o f trauma, illness, or a congenital birth defect. The majority
were professional women— academics, social workers, teachers— and
most lived in Amsterdam. Some were m arried, some single; some
were heterosexual, others lesbian. Many were feminists. In addition to
many informal conversations w ith wom en (and men), I conducted
ten extensive biographical interviews w ith women who had had
cosmetic surgery.3
These conversations and interviews enabled me to become familiar
with the kinds of accounts women give of their experiences with their
bodies and how they explain their decisions to be altered surgically.
Since many of my respondents were professional or academic women
who had had cosmetic surgery several years prior to the interviews, I
became interested in expanding the scope o f the inquiry to include a
more representative group o f recipients. I also wanted to know more
about how women actually decide to have cosmetic surgery, and about
the process they go through in order to obtain it.

BEFORE AND AFTER

To this end, I embarked upon a second study. This was a clinical study
in the plastic surgery department o f a small teaching hospital. It was
conducted in collaboration with a psychologist who was developing a
therapy program for individuals who were dissatisfied with their
appearance. This study gave me access to cosmetic surgery recipients
from a diversity o f socio-economic backgrounds and allowed me to
interview them both before and after their operations.
Originally, I had anticipated some resistance from the surgeons
there. It is notoriously difficult for social scientists to gain entrance into
medical settings, particularly to do research on practices which are as
contested as cosmetic surgery. To my amazement, however, we were
welcomed with open arms and were immediately given permission to
contact patients currently on the waiting list for surgery, as well as to
conduct research in the clinic.
After talking to the surgeons, I realized that they were faced with
some difficulty in legitimating operations performed for strictly aes­
thetic reasons on otherwise healthy bodies. They explained how
difficult it was to develop scientific criteria for determining which
patients were candidates for cosmetic surgery. They seemed skeptical,
in particular, about their female patients’ motives, citing the misguided
middle-aged woman who hopes to hold on to her errant husband by

10
 C O S M E T I C S U R G E R Y AS F E M I N I S T D I L E M M A

having her breasts augmented as a case in point. The twin spectre o f

the surgical junkie and the dissatisfied patient loomed large. Symptom
displacement was the underlying fear, implying as it did that the sur­
geon had not tackled the problem at its root. Thus, whereas other
medical specialists might be reticent about allowing critics a peek into
their kitchen, we were treated by the surgeons as potential helpmeets
who might be able to provide them with some additional psychologi­
cal criteria for the vague and subjective process o f determining which
patients were suitable for cosmetic surgery.
The clinical study focussed on breast augmentation as a paradigm
case for investigating w om ens decisions to have cosmetic surgery.
Breasts are irrevocably linked with cultural notions about femininity.
Particularly in Western culture, femininity and voluptuous breasts go
together, making breast augmentation a way to enhance femininity
(Ayalah & Weinstock 1979; Young 1990b). This is a form of cosmetic
surgery which is only performed on women— or transsexual men who
want to become women— and, unlike breast reduction, it is done
strictly for looks. Moreover, breast augmentations are the single most
frequently performed cosmetic surgery in The Netherlands (and in the
U.S., second only to liposuction).
In addition to contacting thirty women who had had breast aug­
mentations in the hospital within the previous five years, twelve women
who were currently waiting for operations were interviewed prior to
the surgery, immediately after it, and one year later. The respondents
came from a variety of backgrounds, ranging from a seventeen-year-old
woman living with her parents to a forty-three-year-old woman, mar­
ried, with teenage children. All were white and most came from
working-class or lower-middle-class backgrounds. Some had outside
employment as, for example, cashiers, saleswomen, or home helps; oth­
ers were full-time housewives. W ith one exception, their operations
were covered by national health insurance.
This clinical study allowed me to expand my initial explorative
study in several important ways. It enabled me to explore the motives
o f women from working-class as well as professional or middle-class
backgrounds. Moreover, because I could talk to these women prior to
the surgery, I could compare their reasons for wanting surgery with
how they felt about it after the fact. I was able to follow them through
the ordeal o f the surgery itself, which provided me with considerable
insight into what wom en have to go through in order to have their
bodies altered. Although I conducted several informal interviews with
plastic surgeons in the course o f the project, I was not permitted to sit

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R E S H A P I NG THE F E MA L E BODY

in on their consultations. As they explained— quite truthfully, as was

later confirmed by the patients— the time spent in consultation was
“too short to make it w orth my while.” In order to understand the
actual process o f determ ining which bodies are suitable for cosmetic
surgery, I had to turn to another medical setting— the national health
insurance system.

"NORMAL" BODIES
During a period of a year and a half, I did a third study which involved
participant observations in consultations where the decision was made
whether cosmetic surgery would be covered by national health insur­
ance. These consultations took place between a medical inspector and
various applicants for cosmetic surgery. The requests might involve
anything from the removal o f unwanted body hair or tattoos to nose or
ear corrections, face lifts, tummy tucks, breast surgery (augmentations,
reductions, or lifts), or corrective surgery to repair the results of previ­
ous cosmetic operations which had not been successful. The applicants
were primarily women and they came from a wide range of socio-eco­
nomic, educational, and ethnic backgrounds.
This field work allowed me to observe firsthand how patients pre­
sent their cases as well as how representatives of the medical profession
determine which bodies are “abnormal” enough to warrant surgical
intervention. It also enabled me to gain insight into how such deci­
sions are later justified. The medical inspector was under some
constraint to cut back expenditure for cosmetic surgery. He had,
together with plastic surgeons, developed criteria for sorting out the
illegitimate from the legitimate candidates— criteria which he would
explain to me as he went along. I was able to observe some of the dif­
ficulties he had in making the actual decision. His criteria proved
notoriously vague. Even when the patient’s appearance did not meet
the criteria required for coverage, her account o f her suffering often
made it difficult for the inspector to refuse. This often resulted in a
kind o f tug o f war between the patient and the inspector. In the
course o f my field work, he often asked me what I thought about an
assessment or whether I would have made it differently, indicating that
the guidelines did not automatically enable him to make decisions. It
also showed that he was compelled to explain and, in some cases,
defend his actions against potential criticism. The consultations, along
with informal conversations with the medical inspector, enabled me
to observe how decisions concerning w hich bodies require surgical

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 C O S M E T I C S U R G E R Y AS F E M I N I S T D I L E M M A

alteration are negotiated, as well as how practitioners defend and, in

some cases, struggle with these decisions.

ABOUT THE BOOK

The book has been organized around three themes which are the
threads running through each o f the chapters, serving to tie them
together and helping to make sense o f w om en’s involvement in cos­
metic surgery. The first theme is identity. It concerns the problem of
ordinariness and of how a person’s subjective sense of self is negotiated
in the face of what is perceived as a bodily deficiency. The second
theme is agency. It concerns both the problem o f giving shape to one’s
life under circumstances o f social constraint and the degree to which
cosmetic surgery may be a resource for empowerment for an individ­
ual woman. The third theme is morality. It concerns the problem o f
suffering and o f whether there are circumstances under which cos­
metic surgery might be regarded as a legitimate solution for emotional
pain which has gone beyond an acceptable limit.
Chapter One sets the stage with a brief historical sketch o f the
recent expansion o f the surgical fix. Cosmetic surgery has not only
become the fastest growing medical specialty, it is one o f the most
risky. This has necessitated its increasing legitimation on the part of the
medical profession and the welfare state. The forms this legitimation
takes depend on the way the health care system is organized. The
Dutch case will be drawn upon here as the exception which proves the
rule; namely, that even socialized medicine with its discourse o f need
cannot solve the problem o f w hether and under what circumstances
the surgical alteration o f the body for aesthetic reasons can be justified.
Chapter Two deals with explanations for wom en’s involvement in
beauty and their practices of body improvement. Social psychology, psy­
choanalysis, and sociology have looked to wom en’s propensity toward
conformity, low self-esteem, and narcissism, or to their position as brain­
washed consumers in late capitalist society for such explanations. What
is missing from these accounts is an analysis of gender and the cultural
constraints of the feminine beauty system. I locate this analysis in several
traditions of contemporary feminist theory on femininity and the body,
which treat women’s preoccupation with beauty as a cultural phenome­
non, linking the constraints of beauty practices to the reproduction of
femininity and to power asymmetries between the sexes and among
women. I draw upon this work to develop a theoretical perspective for
explaining women’s involvement in cosmetic surgery without relegating

11
R E S H AP I NG THE F E MA L E BODY

them to the position o f cultural dope— a perspective which highlights

womens agency and their active and knowledgeable struggles within the
cultural and structural constraints o f femininity and the beauty system.
The next four chapters form the heart of the book. Starting from
the three empirical studies described above, the trajectory which a
woman follows in order to have her body altered by surgical means is
explored. The three themes— identity, agency, and morality— will
serve as heuristic devices for understanding w om en’s biographical
reconstructions of their suffering over appearance, of their decision to
undergo cosmetic surgery, o f the surgery, and o f its aftermath.
In Chapter Three, the problem of “normal” appearance is explored.
Medical attempts to develop scientific criteria are contrasted with
wom en’s accounts o f why they decided to have their bodies altered
surgically. Prerequisite to these wom en’s decisions is a long history of
suffering with bodies which are experienced as unacceptable, different,
or abnormal. Their accounts dispel the notion that those who have
such surgery are simply the duped victims of the beauty system. Cos­
metic surgery is, first and foremost, about identity; about wanting to
be ordinary rather than beautiful.
In Chapter Four, cosmetic surgery is explored as a strategy for inter­
rupting the downward spiral o f suffering which can accompany a
woman’s problematic relationship to her body. Based on the narrative
analysis of one wom an’s experiences with surgery, I show how the
intervention enables her to renegotiate her relationship to her body
and through her body to herself, becoming, paradoxically, an embod­
ied subject rather than “just a body.”
In Chapter Five, w om en’s decision-making processes are explored
in more detail. W hile suffering precipitates the decision to undergo
cosmetic surgery, it is by no means seen as a sufficient reason for it.
I show how women struggle with their own anxieties and persuade
often reluctant family members and medical professionals that their
problems are serious enough to merit surgical intervention. The deci­
sion process is central and I explore it in terms o f agency; that is, of
how cosmetic surgery can be a way, if a problematic one, for women
to take their lives in hand.
Chapter Six describes surgery and its aftermath. Drawing upon
interviews with wom en a year after their operations, I continue to
examine how such operations change (or do not change) their rela­
tionship to their bodies, themselves, and the world around them. In
some cases, this change entails coming to terms with results which are
bitterly disappointing. In a discussion based on w om en’s attempts to

12
 C O S M E T I C S U R G E R Y AS F E M I N I S T D I L E M M A

make sense o f both decisions and outcomes, the issues o f choice and
informed consent are considered.
I argue that while decisions to have cosmetic surgery are rarely
taken with complete knowledge or absolute freedom, they are, never­
theless, choices. Cosmetic surgery can be an informed choice, but it is
always made in a context o f limited options and circumstances which
are not of the individuals own making.
Chapter Seven returns to the question raised at the outset of the
book, namely, how can wom ens involvement with cosmetic surgery
be critically situated in the cultural context of femininity and the
beauty system, without attacking women for having it? While the pre­
sent inquiry shows how this might be done, I conclude with a
discussion o f some o f the methodological, theoretical, and ethical
dimensions of the undertaking. A case is made for resisting a politically
correct feminist response to cosmetic surgery in favor of an approach
which takes ambivalence, empathy, and unease as its starting point.

13
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