Creating Beauty to Cure the Soul: Race and Psychology in the Shaping of Aesthetic Surgery by Sander L. Gilman

From the Publisher

In his exploration of the striking parallels between the development of cosmetic surgery and the field of psychiatry, Gilman entertains an array of philosophical and psychological questions that underlie the more practical decisions routinely made by doctors and potential patients considering these types of surgery. While surveying and incorporating the relevant theories of Sigmund Freud, Alfred Adler, Karl Menninger, Paul Schilder, contemporary feminist critics, and others, Gilman considers the highly unstable nature of cultural notions of health, happiness, and beauty. He reveals how ideas of race and gender structured early understandings of aesthetic surgery, discussing both the "abnormality" of the Jewish nose and the historical requirement that healthy and virtuous females look "normal" thereby enabling them to achieve invisibility. Reflecting on historically widespread prejudices, Gilman describes the persections, harassment, attacks, and even murders that continue to result from bodily difference, and he encourages readers to question the cultural assumptions that underlie the increasing acceptability of this surgical form of psychotherapy.

Journal of the American Medical Association

This book raises many interesting ideas that could explain the current rage for cosmetic surgery. The book is complex, and this brief review cannot discuss all the issues addressed. The focus on the nose and psychoanalysis is unique, as far as I am aware. Those interested in the phenomenon of cosmetic surgery will want to read this book.

Publishers Weekly

Arguing that pseudoscientific theories of race from the 19th and early 20th centuries still impact our current standards of beauty and 'unhappiness' with our own bodies, prolific critic Gilman explores plastic surgery as an extension of psychotherapy. He traces the history of aesthetic surgery from its initial function of hiding disease (most particularly syphilis) to is later incarnation as a means of erasing ethnic identity (specifically Jewish identifications by nose shape and size) and creating a more 'normal' appearance.

Times Literary Supplement

The development of aesthetic surgery required not only the discovery of anesthesia and antisepsis but also the emergence in society of a common perception of what constituted acceptable appearance. In Creating Beauty to Cure the Soul, Gilman shows how such ideas emerged during the Enlightenment with, among others, Kant and Karl Rosenkrantz, who saw the body in affective and then moral terms; what looked beautiful was pleasing and was a sign of virtue, health, and happiness. Certain visible differences-'ugliness'-were then categorized as unhealthy and stigmatized. If the 'ugly' were either ill, or predisposed to become ill, and destined to pass on these characteristics to their offspring, then no amount of surgery or cosmetics could alter this. . . . [Gilman] deserves great credit for uncovering the relationship between the complex and occasionally contradictory ideas of psychoanalysis and the more prosaic world of surgery, showing how psychoanalysis influenced and under pinned theories on the efficacy of aesthetic surgery.

Psychoanalytic Books

As a psychoanalytically informed and sophisticated cultural historian, Gilman critiques not only the profession of aesthetic surgery but also those persons who subject themselves to surgical intervention in order to overcome what must be seen as a psychological problem. He critically explores the ethical issues involved in surgically operating on a 'healthy' body to fit the patient's desire or wishes, an the rationalizations offered by cosmetic surgeons to justify their 'specialization. . . . ' [T]he book is an enjoyable venture into cultural history, well written and thus worthwhile. . .

What People Are Saying

George L. Mosse
"Gilman's undisputed mastery in explaining and analyzing human stereotyes receive a new and fascinating dimension through the role which aesthetic surgery plays in connecting ideas of physical change and human happiness." -- Author of The Image of Man and The Image Crisis of German Ideology

Product Details

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Table of Contents

Read a Sample Chapter

Chapter One

Reconstructing What?

From the beginning of the profession, reconstructive surgery, in restoring function, seems to lie at one end of a spectrum and aesthetic surgery, in improving appearance, at the other. Even today, these two historically closely related forms of "plastic surgery" are perceived by many patients and physicians alike as antitheses, one being "serious" medicine, the other "frivolous" and, indeed, not really medicine at all. This distinction between "serious" reconstructive and "frivolous" aesthetic surgery is as old as the profession itself. One of the most knowledgeable aesthetic surgeons before World War I, Frederick Strange Kolle (1871-1929), was already puzzled by this distinction. He distinguished between the surgery of the nose applied to "deformities when caused by traumatism, the excision of neoplasms or destructive disease" and "such corrections [as] are made purely with the object of improving the nasal form when the deformity is either hereditary or the result of remote accident." He continued, however: "For some unaccountable reason [aesthetic surgery] has not met with the general favor the profession should grant it, yet the results obtained by such specialists as have undertaken this artistic branch of surgery have been all that could be desired, and have consequently added much to the comfort and happiness of the patient." Kolle's distinction between reconstructive and aesthetic surgery is continued in a widely quoted aphorism by the New Zealand-born surgeon Harold Delf Gillies (1882-1960), who understood reconstructive surgery as "an attempt toreturn to normal; aesthetic surgery as an attempt to surpass the normal." Gillies needed to provide a meaningful continuity between his reconstructive work during World War I and the postwar interest in aesthetic surgery. In doing so he stressed the continuity between two concepts of the "normal." The first is a reconstructive model, restoring function and a somewhat human visage that can "pass" as normal if the range and meaning of the trauma are understood. The second, that of aesthetic surgery, seeks to transcend the given and the normal. The arbitrariness of such a set of juxtapositions is clear: One culture's "normal" is another culture's ugly "deformity." What is visible in one culture as unaesthetic is (in)visible in another as a sign of "beauty." (In)visibility is the goal of all aesthetic procedures. Aesthetic procedures are intended to move an individual from being visible in one cohort to being a member of another cohort or collective, which is so visible that its visibility becomes defined as the "normal." The "normal" defines itself as invisible. A correlation to this is that not only is it important for the patient to become invisible, but (in his or her own estimation) the surgeon strives always to appear healthy and (in)visible.

    The status of aesthetic surgery in the latter half of the nineteenth century and the early twentieth century was undermined because its stated goal was not to correct physical pathologies (such as a cleft palate) but to deal "with purely external characters for which the only guidance is the patient's whims," as Gustavo Sanvenero-Rosselli (1897-1974) claims in the major Italian textbook of rhino-plastic surgery, published in 1931. The whims of the patient are the basis for the autonomy of the aesthetic surgical patient, who defines himself or herself as in need of surgery. Such negative views of patient autonomy seem to exist even today. One contemporary commentator on aesthetic surgery and ethics observes:

Some plastic surgery, though, neither affirms nor conflicts with full human personhood. Such operations, not designed to repair a defect, seek to enhance already normal appearance. This "beauty surgery" ... cannot be justified on medical grounds although it is morally unproblematic. "Non-medical" plastic surgery must be differentiated from the majority of procedures which are properly considered "medical." ... Distinguishing medical from non-medical plastic surgery has ethical import: medical procedures, I maintain, provide preconditions for full personhood; non-medical procedures on the other hand may enhance physical beauty, fashionable appearance, etc. While the moral legitimacy of plastic surgery is judged by its impact on the patient as person, the relative worth of these procedures is ascertained by considering the priority of the medical or non-medical values justifying them.

Such views permeate some of the contemporary feminist discussions of aesthetic surgery as well. They relegate it not to the non-medical because it is based on the "false consciousness" of the individual patient and is therefore exploitative and destructive. For these feminist critics, socialization of women into a "beauty" culture makes women believe themselves to be less than perfect. Aesthetic surgery becomes the means that the medical profession offers to achieve this false sense of belonging to the "normal" world of commodified beauty.

    The premise of this book is that despite the firm conviction of the critics of aesthetic surgery, both from within and without the profession, what many see as the absolute border between "good" reconstructive and "bad" aesthetic surgery seems all too often to waver. In a recent overview of the psychological literature on aesthetic surgery, Hans-Peter Wengle defined aesthetic (cosmetic) surgery as dealing with the defects caused by "aging and developmental disproportions, plastic (reconstructive) surgery as that dealing with the deformities caused by disease, accident, malformation OR surgical interventions for aesthetic and functional reasons." It is ironic that even errors in aesthetic surgery come within the purview of the reconstructive surgeon. The "official definition" of the American Society of Plastic and Reconstructive Surgeons (from 1987) does not evoke iatrogenic causes for aesthetic surgery: "Cosmetic surgery is performed to reshape normal structures of the body in order to improve the patient's appearance and self-esteem. Reconstructive surgery is performed on abnormal structures of the body, caused by congenital defects, developmental abnormalities, trauma, infection, tumors or disease. It is generally performed to improve function, but may also be done to approximate a normal appearance." This definition was accepted by the American Medical Association in June 1989. According to such definitions, all procedures can be "aesthetic" even if they are "reconstructive," as they reconstruct or construct a Platonic ideal of the body. Most important, they postulate that the prime location for this "reconstruction" is the psyche.

    Such a desire to place all surgery—reconstructive and aesthetic—into the same category is rooted in the social and professional stigma associated with being an aesthetic surgeon. (Here the corollary is also true: the desire to separate them is a sign of the stigma associated with the practice of aesthetic surgery.) In the popular imagination, one can see this operative in the 1991 Warner Bros.' film directed by Michael Caton-Jones, Doc Hollywood (based on a novel by Neil B. Schulman, MD), in which Ben Stone (played by Michael J. Fox) is a brash, newly minted aesthetic surgeon whose trip West to open a lucrative practice in Beverly Hills takes a small-town detour. He ends up in the fictional town of Grady, South Carolina, Squash Capital of the South, where he "discovers" that "real" medical service can be more morally satisfying as a general practitioner than in his imagined role as an aesthetic surgeon to the stars. The stigma of doing elective beauty procedures such as those ridiculed in Doc Hollywood is countered from the very beginning of this specialty by the views that the procedures have psychological effectiveness. Thus the physician's attitudes toward theories of the mind come to provide the rationale for aesthetic surgery.

    Ronald E. Iverson commented that "the tremendous increase in the number of plastic surgery procedures shows both the need for reconstructive surgery and the desire for cosmetic surgery. It is interesting that the increase reflects the versatility of board-certified plastic surgeons who are trained to perform both complex microsurgery and the most current cosmetic procedures." Here too the link between "reconstructive" and "aesthetic" procedures rehabilitates the aesthetic surgeon from the charge of pandering to the vanity of the patient.

    Reconstructive surgeons need to make distinctions between "malformation," "deformation," and "disruptions." Such distinctions come to play an important categorizing (nosological) role in the modern treatment of "undesirable" forms of the body (dysmorphology). Deformations are seen as "anomalies that represent the normal response of tissue to unusual mechanical forces," while malformations "denote a primary problem in the morphogensis of a tissue"; disruptions are the "breakdown of a previously normal tissue." These distinctions are ones that are clearly paralleled within aesthetic surgery. "Malformations" are aspects of the body with which the patient is born (such as the shape of the eyes or that of the nose), "deformations" come about during life (such as pendulous breasts), and "disruptions" can be represented in the breakdown of "normal" tissue or other features in the aging process. And yet this set of distinctions is rarely carried over into the debates about aesthetic surgery. To counter the stigma of "merely" pandering to the patient's vanity, aesthetic surgery has rooted itself not so much in an understanding of its role in "curing" the body as in the "curing" of the spirit.

    It has been argued that reconstructive surgery prior to the nineteenth century and the introduction of antisepsis (no infection) and anesthesia (no pain) was undertaken only when it was a functional necessity. Surgeons operated only in cases such as in the rebuilding of birth defects or deformative injuries of the face. During the course of the nineteenth century, the idea that one could cure the illness of the character or of the psyche through the altering of the body is introduced within specific ideas of what is beautiful or ugly. This was seen as a natural extension of the role of the reconstructive surgeons, who repaired the psyche through the rebuilding of the body. They postulated a Platonic "normal" and "intact" body and read their ability to reconstruct that imagined intactness as simultaneously reconstituting "psychic health": "Facial deformities, detrimental to the person's looks, are the hardest to bear because they are fully exposed to the `ruthless' scrutiny of all fellow men and make social contact hurtful, and often—unbearable ... the earlier in life the appearance—or awareness—of a facial deformity, the deeper its impact on the mind of the afflicted. One only has to watch the behavior of children marked by a cleft palate or hare-lip." As will become clear, such arguments are the core of the psychological theory of aesthetic surgery, but they are simultaneously part of the argument for reconstructive surgery. Curing the physically anomalous is curing the psychologically unhappy—this view provides the key to any understanding of the power of all surgery to alter the psyche. The "beautiful" becomes the "happy."

    It is also evident that the aesthetic has a place in general surgery. Scarring has always been seen as an undesirable result of the surgical intervention in the body. As early as the Edwin Smith Surgical Papyrus (3,000 B.C.E.) surgeons in Pharaonic Egypt were concerned about the aesthetic results of their interventions. The Egyptians were careful to suture the edges of facial wounds. Even fractures of the nose bone were dealt with by forcing them into normal positions by means of "two plugs of linen, saturated with grease," that were inserted into the nostrils. The Roman encyclopedist Aulus Cornelius Celsus (25 B.C.E.-50 C.E.) stressed the importance of the "beautiful" suture. This approach can be traced through to the surgery of the late nineteenth and early twentieth centuries with plastic surgeons such as Erich Lexer (1867-1938) stressing the aesthetic ends of an operation as "an always more appreciated requirement of modern surgery." Such a stress on the neatness and beauty of the closure was part of the image of the return to function following the operation. For the beautiful was a sign of the healthy, and in modernity the healthy becomes a sign of the happy. Central to this sense of happiness within the culture of medicine is the hope that the restoration of the body will not reveal any medical intervention. The scar reveals that the body has been ill or damaged, that the present body is not intact but "merely" restored. The scar shows the body not to be "natural" but inauthentic and constructed. It is intimation of mortality that vitiates any happiness as it indicates eventual dissolution and death.

    If medicine is seen as the space to construct a healthy body unblemished by signs of mortality, aesthetic surgery becomes the exemplary site for this desire. Thom Jones, one of the brightest of the young American writers, powerfully evokes this theme in his tale of death and the aesthetic surgeon, "Ooh Baby Bay" (1995). The Jaguar-driving Dr. Moses Galen (nomen est omen: Moses, the "divine hygienist," according to nineteenth-century texts, and Galen, the Roman surgeon) lives as a very successful aesthetic surgeon in Los Angeles. He had been a reconstructive surgeon in Africa, running "a cleft palate restoration clinic in Mogadishu in the early 70s" (121). Now he is being paged by the "hair transplant" he had done that morning because "the pressure bandages on his head were driving him nuts" (126). Galen's physician-girl friend in Los Angeles had been completely reconstructed by him: "her nose was too damn big, she asked if he could fix that. She was so pleased with the results that she had him do a little of this and that. Her beautifully high cheekbones had formerly been a little too shallow, the firm chin had been slightly recessive, but Moses fixed that. There had been crow's-feet and wrinkles and breasts far too small, but Galen took care of that, too" (129). He operates not so much to alter her body as to cure her anxiety.

    Linda's anxiety is "What happened to my body? Where has all the time goner?" (129). Galen's own diabetic body also shows the passage and decay of time. His very role as an aesthetic surgeon is based on his own anxiety about decay and death: "There was no easy death. Human organisms were tough and it was hard for them to die. That's why Moses went into cosmetic surgery—so he didn't have to look at death, even though he had seen his share just the same. In and out of hospitals every day, you just couldn't escape the problem of your own mortality. Dead wasn't so bad; it was the damn dying" (144-45). The tale ends with Galen collapsing with a heart attack, hoping that Linda does not hear his cries so that he can die alone. Jones's story exemplifies one model of representing aesthetic surgery, as the means of denying death to insure happiness. This utopian hope is recognized as both desirable and impossible by the patients and the physicians alike, and yet it is part of the hidden desire that shapes all aesthetic surgery.

    The image of an intact, healthy body is part of all surgery. And yet that sphere of surgery—aesthetic surgery—that expressly devotes itself to the reconstitution of the "happy psyche" through the constitution of an "intact," "ageless," "(in)visible," "beautiful" body has been highly stigmatized over the past century. Are such bodies real bodies or mere simulacra? The stigma of aesthetic surgery was felt not only on the part of the surgeon. The social response, in many cultures such as Brazil, was for "these patients to keep their surgery a secret, ashamed to confess their vanity to their friends and family." Such secretiveness has multiple readings. Breast reduction can be read as a reconstructive or an aesthetic procedure. This was clear in the desire of the U.S. Food and Drug Administration in 1992 to ban as frivolous silicone implants for women who had not had mastectomies. Such surgery is only "shameful" when it is understood as "aesthetic," camouflaging the body and enabling it to be understood as something that is "essentially" different from what it "is." The very boundary between reconstructive and aesthetic surgery is drawn differently in different cultures at different times, but it follows this guideline of the difference between the authentic and the inauthentic. It is clear in the histories of cosmetic surgery that aesthetic surgery was a "poor relation" (so Goumain and Izquierdo in 1957) of reconstructive surgery because it was seen as providing an "inauthentic" body.

    It is precisely this arena—the aesthetic rebuilding of the body—that is the most highly impacted by cultural definitions of authenticity. The explosion of the number of aesthetic procedures in the United States of (North) America and the United States of Brazil and the increase in aesthetic surgery in France, Germany, and the United Kingdom over the past decades are clear indicators that the border between an authentic and an inauthentic body is always changing. Aesthetic surgery is meeting with greater acceptance on the part of patients and physicians alike because the idea of the surgically altered body as inauthentic is becoming less and less compelling.