Cosmetic surgery and neoliberalisms: Managing risk and responsibility

Risk and responsibility in neoliberalism

The context that is of special interest in this article is that of a healthcare system shaped by neoliberalism in which individuals are encouraged, even expected, to make ‘lifestyle’ choices to maximize their life chances and simultaneously held responsible for managing and minimizing the risks associated with these decisions (Rose, 2000). Neoliberalism is a political-economic ideology and practice that promotes individualism, consumerism and transferring state power and responsibility to the individual (Galvin, 2002; McGregor, 2001; Newman et al., 2007). Proponents of neoliberalism argue for decreased government funding and power over social services, through deregulation and privatization, in the pursuit of a free market (Kelly, 2001). Further, with government reconfigured in this way, neoliberal citizens are situated as autonomous individuals, independent from society, whose success is measured through continuous work and consumption (McGregor, 2001). This neoliberal paradigm has begun to dramatically (re)shape health‘care’ in the USA (McGregor, 2001); however, neoliberalism permeates many other Anglo/western healthcare systems.

In relation to the body and health, Peterson explains, ‘neoliberalism calls upon the individual to enter into the process of his or her own self-governance through processes of endless self-examination, self-care and self-improvement’ (1997: 194). Constructed currently as a form of bodily self-care (Raisborough, 2007), aesthetic surgery is thus a practice befitting the neoliberal ethos; which is perhaps in part why it has proliferated within this healthcare context. Neoliberal citizens are expected to ‘be empowered to take control of their lives’ (Galvin, 2002: 117), and their unruly bodies, with such empowerment usually expressed through consumptive practices. It follows that within this healthcare context, choice, in particular consumer choice, is emphasized (Braun, 2009; Ericson et al., 2000).

Concerning choices such as cosmetic surgery, Braun (2009: 117) for instance argues, ‘choice has been a central mechanism by which consumption, actions or representation otherwise cast as conforming to patriarchal, heterosexist gender relations are reframed as positive and empowered individual choices’. Moreover, neoliberal citizens are expected to be knowledgeable, educated and reflexive in their risk-benefit calculations and healthcare decisions (Ericson et al., 2000). Underscoring this sort of risk management is the notion that citizens should accept individual responsibility for their health (Newman et al., 2007) and healthcare choices (Galvin, 2002), as the ideology of neoliberalism increasingly shifts responsibility for consumer protection from the state to the individual. Rose (2000: 337) has referred to this moment in ‘advanced liberalism’ as containing an:

emphasis upon creating active individuals who will take responsibility for their own fates through the exercise of choice, and the organization of sociopolitical concerns around the management and minimization of risks to lifestyles of contentment and consumption.

Thus, in this study, we explore how ideologies of neoliberalism shape women’s decisions about cosmetic surgery as a lifestyle choice, their experience of risk and their strategies of risk management.

Feminist perspectives, cosmetic surgery, and risk

As mentioned, earlier feminist perspectives on cosmetic surgery (e.g. Bartky, 1990; Blum, 2003; Bordo, 2003; Morgan, 1991) have been critiqued for prioritizing either individual’s narratives of cosmetic surgery or the sociocultural contexts that contribute to, and perpetuate, the practice of cosmetic surgery (see Pitts-Taylor, 2007 for a comprehensive review). These theoretical frameworks have been termed respectively ‘agency’ and ‘structure’ perspectives (Pitts-Taylor, 2007). More recent feminist scholarship goes beyond a singular focus on either the cosmetic surgery patient or the culture surrounding surgery. One of these analytic shifts examines the increasing normalization of these practices, positioning both print media (Brooks, 2004) and reality make-over television shows (Banet-Weiser and Portwood-Stacer, 2006; Tait, 2007) as perpetuating American’s increasing comfort with cosmetic surgery. With regard to the former, American women’s magazines situate cosmetic surgery as a new technology that is ‘accessible and healthful, forward-looking and medically legitimate, [which] may become increasingly appealing – even difficult to refuse’ (Brooks, 2004: 215). Reality make-over television shows, on the other hand, are considered to contribute to the domestication of cosmetic surgery and to a limited number of subject positions, including the patient as ‘expert’ (Tait, 2007).

Another analytic shift has converged around the complicated, and often conflictual, expectations of the patient-role in cosmetic surgery, with a particular focus on the ‘surgery junkie/addict’ (Blum, 2003; Fraser, 2003; Heyes, 2009; Pitts-Taylor, 2007, 2009). Blum (2003: 274) maintains that you ‘become surgical’ when ‘surgery enters your world as a remedy for the body’s flaws’. The ‘addict’, she contends, can be recognized by minimization of one’s surgical experience through a comparison with more ‘serious’ procedures and/or ‘someone who is addicted’ (Blum, 2003: 280). Yet herein lies the paradox within cosmetic surgery subjectivity: patients must be sufficiently dissatisfied with their appearance to seek cosmetic surgery, although excessive dissatisfaction may be deemed pathological and a contra-indication (Heyes, 2009; Pitts Taylor, 2007). Although the aforementioned research gives insight into the nuanced classification of surgical candidates, a question remains: how do cosmetic surgery patients manage, and experience, the risks of self-presentation to gain access to surgery?

Typically, risk in modern western cultures, deemed the ‘risk-society’ (Beck, 1992), is situated as something to be managed, minimized and generally avoided. The body in the risk-society is located in a position of endless safeguarding from external risks such as accidents and infection (Lupton and Tulloch, 1998). One could argue that electing to undergo cosmetic surgery – where risks such as bacterial infections are inevitable for some patients – is in direct conflict to this tendency towards risk-aversion. Raisborough (2007) complicates this taken-for-granted view of risk-avoidance and recontextualizes cosmetic surgery in the risk-society. She presents these procedures as a Foucauldian ‘practice of the self’, where individuals enhance and manage their bodies to create a self that is in alignment with current notions of morality.

Cosmetic surgery patients, for Raisborough (2007), are an example of Lupton and Tulloch’s (2001) ‘voluntary risk-takers’, who recognize and confront known risks for the purpose of self-development. However, what is experienced as ‘voluntary’ is shaped by gendered sociopolitical contexts (Chan and Rigakos, 2002). Raisborough explores the everyday ‘conditions of choosing’ that women negotiate when electing to have surgery. She suggests that cosmetic surgery is currently located, and marketed, on a continuum of women’s beauty practices, ranging from make-up and waxing, high-heeled shoes, to corset-wearing. By virtue of joining this continuum of bodily alterations, cosmetic surgery is normalized as yet another practice of ‘doing respectable femininity in the everyday’ (Raisborough, 2007: 28).

In the current climate of ‘self-help’ rhetoric, where the body is situated as a reflection of a moral self, what then becomes a ‘risk’ to women’s identity and worth is the ‘unattractive body’, which signifies ‘moral failure’ (Raisborough, 2007). Moreover, through ‘facing’ the known risks of cosmetic surgery, individuals can show their dedication to self-work in the moral economy of neoliberalism that values bodily work for self-transformation. Raisborough (2007: 37) suggests:

For Raisborough, then, cosmetic surgery is as much a normalized, understandable, and intelligible ‘risk-choice’ for women as a legitimate ‘practice of the self’ in neo-liberalism. The risks to self lie in the decision not to utilize cosmetic surgery as a ‘normalized vehicle for self-transformation’ (Raisborough, 2007: 30).

As a theoretical piece, Raisborough’s analysis does not include the voices of actual cosmetic surgery patients. Thus, the question of how this risk-choice is taken up, and managed, by real women remains unexplored. In this article we build on Raisborough’s work – incorporating qualitative data from cosmetic surgery patients – to explore the contention that cosmetic surgery is a ‘risky-but-rewarding activity’ (Larkin and Griffiths, 2004: 215). We suggest that by acknowledging that both agency and choice operate within the neoliberal epistemology, rather than outside it (Nahman, 2008), and situating an analysis within this reality, feminists can further resolve the aforementioned tensions between voice-centered and culture-centered approaches. Thus, following Raisborough, throughout our analysis we locate individual experiences of choice and agency in the conditions of choosing in which they are enmeshed. We hope that by examining both women’s personal accounts of surgical risk and the context of neoliberalism in which their surgical stories are embedded, we will begin to understand some of the complexities between the social/political, individual ‘choice’, and risk.

Managing risk as a consumer

In the neoliberal healthcare context of the USA, and particularly in the context of elective surgery, the cosmetic surgery patient is repositioned from patient to consumer (Jones, 2008). This emphasis on the patient as consumer was seen repeatedly in participants’ narratives on doctor selection, which was discussed by participants as a consumer experience or, as Jan referred to it, ‘doctor shopping:’ ‘I mean, you can shop around for doctors, like you can shoe stores or anything else.’ The notion of selecting a doctor is thus positioned as akin to other consumer choices. Moreover, embedded in the participants’ narratives was the repertoire of ‘caveat emptor’ – let the buyer beware – where the onus is on the patient/consumer. Although the means through which the participants found their doctor differed, as ‘responsible’ patients they managed their risk through careful consumer research. Conversely, those who suffered negative outcomes were depicted as generally having only themselves to blame. This sentiment is expressed explicitly by Maria:

Surgery is never easy but you know it's something that has to be done. Here this is something that you’ve made a choice and if it doesn't work out then you have only yourself to blame.

Catherine’s words underscore the expectation of neoliberal citizens to be ‘“enterprising individuals,” who make [consumer] “choices” and who, consequently, are responsible for the outcome of these choices’ (Galvin, 2002: 117). In contrast, those who refuse such consumption risk being deemed outmoded, or irrelevant.

Part of the management of consumer risk was depicted when participants repeatedly stated that it is the patient’s/client’s responsibility to find a ‘good doctor.’ One of the purposes of finding a good doctor was to minimize the chance of surgical mishaps and/or negative surgical outcomes. The relationship between selecting a good doctor and preventing negative surgical outcomes was seen in Jan’s discussion of how she finds good doctors:

And usually with doctors, I only go to doctors that are – I – that are referred to me. … Because I just like to – I, I don’t want to be one of these people that has, uh, whether its whatever the problem is I don’t want to have to worry about, um, having a – doctor and have something terribly go, something terribly medically go wrong with me.

The ways in which the participants selected good doctors varied from a single visit with a recommended doctor, visiting multiple doctors (sometimes traveling to do so), and researching doctors on the internet and in articles in beauty magazines. For example, when asked how she found the surgeon who performed her blepharoplasty, Maria explained at length the steps she took to find a good doctor:

What I did is I started with what I didn't want. My mother-in-law had her eyes done and it was a cheap job. It was horrible; she has one eye that looks higher than the other. I don't know what the hell she had done. She said it cost $2,500 and it was just garbage. The second thing was I started looking around. I guess I've been planning this for ten years because I just started ripping out articles and whatever magazines I saw that had these stories, Allure, Vogue or something. So I just started ripping out articles and I put them away. Then when I decided I was really going to do it, I pulled out the articles and I started researching the doctors and one of them was Dr. X.

In an attempt to avoid a negative surgical outcome like her mother-in-law experienced (which was seen as a result of going to a bad and cheap doctor), Maria undertook thorough research to find Dr X. However, despite doing so, she ultimately contracted a post-operative infection at the surgical site. She states:

A week after I got an eye infection. They did everything they could, set me up, made several appointments and stuff with doctors to try and clear it up. We finally hit the jackpot with the second doctor who diagnosed the problem. And the eye infection's cleared up. So I was really taken care of every step of the way.

Here we see how Maria’s ‘doctor shopping,’ and her decision to choose a recognized surgeon, shapes her attributions about her own complications. In contrast to her mother-in-law, neither she nor her surgeon is responsible. Rather, both Maria and her doctors’ successful management of the infection underscore her sense of agency, and her successful risk management. Since participants repeatedly placed the responsibility of going to a good doctor on themselves, attributing a negative outcome to the doctor would thereby imply that the patient had done a poor job of managing risk.

Thus, as noted, reflected in the participants’ narratives was a conflation of patient and consumer roles. This hybridized subject position echoes rhetoric of the ‘postfeminist consumer citizen’: a supposedly acultural subject who is empowered by the ability to choose when, how and where she engages with beauty practices (Gill, 2007: 74). At the individual level, the participants expressed feelings of accomplishment through making the decision to elect surgery and shop for a good doctor. However, consumer fulfillment from this choice at the micro-societal level reflects constrained choice(s) at the macro-societal level – choices made within a specific, regulated sociocultural system. As Braun (2009) argues, the choice of electing to have cosmetic surgery has become more of a mandate within neoliberalism where choosing to not alter one’s appearance in accordance with dominant beauty standards means choosing ugliness (or choosing a cumbersome, antiquated CD player over a sleek iPod). The doctor-shopping stories perhaps then indicate feelings of agency, where participants gain a sense of empowerment within a neoliberal healthcare milieu by doing exactly what sustains the system: assuming responsibility for a consumer choice. In this way, managing consumer risk has a somewhat paradoxical effect: the participants experienced feelings of agency through their research skills and their ability to select a good doctor, yet these experiences are simultaneously indicative of a neoliberal ethos that promotes empowerment through consumer choice and responsibility for self-care. Their individual agency, therefore, is embedded in the context in which it is enacted.

Managing medical risk(s)

As noted, risk in cosmetic surgery is typically associated with medical risks such as surgical blunders or botched procedures by untrained doctors (Raisborough, 2007). Although medical risks were not the only forms of risk that the participants attempted to manage, interactions with medical risks did appear repeatedly throughout the participants’ narratives. The participants emphasized or described their attempts to manage risks such as pain, bruising, swelling or scarring through various forms of self-care. The participants followed medically recommended strategies of care and also created their own care regimes in efforts to prevent negative physical outcomes such as severe bruising, scarring or infection. Medically endorsed forms of post-operative self-care included but were not limited to: icing the surgical site, sleeping upright, taking or not taking certain vitamins, taking antibiotics and private nurses. The participants explained that by following these recommendations they were able to ‘help’ the recovery process and avoid potential negative outcomes.

Additionally, some of the women had created their own self-care regimes, which they experienced as aiding in the recovery process. Kelly developed her own form of self-care using herbs and vitamins to manage bruising and bleeding:

The parsley really works. It takes the bruising away … Yeah. Just put parsley all over your face. That and, um, you just have to not take vitamin E and your omegas and – 'cause it makes you bleed worse.

We postulate that the participants’ emphasis on medically and self-created forms of post-operative self-care reflects both their feelings of electing cosmetic surgery as an agentic decision (Davis, 1995) and the expectation that they act as a good patient/consumer within a neoliberal healthcare milieu, that emphasizes hyper-responsible selves (Braun, 2009) who are liable for the consequences of actions taken on the body. As noted by Galvin (2002: 120), managing risks in health behavior ‘has become simultaneously a source of personal power and a tool for blaming those who fail in the face of choice’.

Participants spoke about managing post-operative pain in one of two ways – either as an expected, but necessarily silenced, part of the post-operative recovery process, or by negating and/or minimizing it. This is depicted in the following extract from Kelly:

Yeah. I mean, the first couple of days – you know what I learned as a woman undergoing surgery? You should keep your mouth shut. You know, I don’t think it serves anyone to complain about elective surgery. Be a big girl.

Kelly’s comment gives insight into why other interviewees may negate the experience of pain. We don’t necessarily know how Kelly learned this, but she makes it clear that she learned, perhaps through experience, it is not acceptable to express pain associated with aesthetic surgery. This discomfort with telling others about her bodily suffering could perhaps be explained by Bendelow and Williams’s (1995) argument that experiences and expressions of pain are mediated by the sociocultural context. More specifically, Jones (2008:18) argues, ‘cultural silences around the actual process of cosmetic surgery mirror the logic of before/after, meaning that the substantial emotional and physical pain, risk and suffering involved in the transformative methods are disavowed’. However, among those who insisted that ‘there was no pain’, suffering was expressed through various expressions or euphemisms. For example Jan states:

I was surprised because I was given painkillers and I didn’t need them … But for the, for the, for this, for the, facelift and the eyelid or – there was no pain. There was just, like, fire, discomfort, which was like, no big deal.

Jan’s narrative highlights how post-operative physical suffering was indeed experienced by some of the participants. However, what is of analytic interest here is why the participants denied and minimized ‘pain’ – situating these bodily experiences as ‘no big deal.’ We would like to suggest that these minimizing narratives are a product of the increasing normalization of cosmetic surgery. Articles in women’s magazines highlight cosmetic surgery as casual, unthreatening and accessible – likened to hairdressing or dental work – which contributes to the normalization of this practice (Brooks, 2004). Moreover, cosmetic surgery is located and advertised as a continuation of women’s everyday beauty practices, further normalizing surgery as part of a regime of normative femininity (Jeffereys, 2005; Raisborough, 2007). This minimizing ‘makes cosmetic surgery seem to be a “natural” part of women’s everyday worlds, making it an often unquestioned practice by those engaging in it’ (Ancheta, 2002: 148). The expression of post-operative bodily suffering as ‘no big deal’, like the experience of doctor shopping, illuminates ‘the economic and cultural normalization of cosmetic surgery in the United States over the past decade’ (Banet-Weiser and Portwood-Stacer, 2006: 269). Thus, it could be argued that cosmetic surgery as ‘no big deal’ reflects how in the last 30 years surgery has become just another form of make-up (Haiken, 1997; Jeffreys, 2005).

A ‘good patient’ not a surgery junkie

According to Pitts-Taylor (2009: 125), ‘the sorting of patients into good and bad candidates is now a significant part of the cosmetic surgery process.’ For instance, as part of her participant-observation in a cosmetic surgery clinic in the USA, Gimlin (2002) interviewed a surgeon who discussed the process by which patients are screened and selected. This surgeon had created a typology of potential patients, which included the ‘self-motivated and realistic patient’ and those who are ‘flighty’ and want surgery for ‘bizarre’ reasons, for whom access will likely be denied (Gimlin, 2002). Somewhat similarly, when describing the context of female genital cosmetic surgery, Braun (2009) notes that the ‘ideal’ patient is ‘rational’, ‘reasonable’, and has ‘realistic’ expectations regarding the outcome of surgery. Thus, women interested in cosmetic surgery walk a tightrope, having to maintain sufficient hope, and even fantasy, of how cosmetic surgery will transform their life to make it worthwhile to endure its relative high cost and physical demands, while simultaneously demonstrating to their surgeon their rationality and reasonability in order to gain access to it.

The participants also situated their surgical experience through comparisons with worse, excessive or extreme surgical consumers. Anne for example contrasted her experience as a ‘good patient’ with surgery ‘junkies’ or ‘addicts.’ As the following extract from Maria portrays, a surgery addict or junkie was depicted as someone who radically alters their exterior, while participants’ individual experiences were depicted as rational, common, or normal:

I know certain things there might be limitations. Unless you're Michael Jackson you're not really going to be able to change your entire face or the cat lady, what’s her name, Weinstein or whatever her name was. Yeah because this was something that's very common. It’s a very common procedure so this was something that could be done.

Thus, surgery junkies from popular American culture were positioned by these participants as ‘Other’ to their ‘normal’ surgical experience. By the Other we refer to a non-self who deviates from social norms (Brooker, 2003), creating anxiety for the self particularly if the boundary between self and Other is blurred (Lupton, 1999). Notions of Otherness are predominant in risk interactions that involve the body (Lupton, 1999). According to Lupton, the body of the ‘risky Other’ is seen as unregulated and out of control and is frequently positioned as risky to oneself. The narratives in this study illustrate how the participants located their surgical experience within normal boundaries whereas the surgery junkie was positioned as deviating from socially sanctioned surgical experiences. Given that most of the participants compared their decision to elect cosmetic surgery to addicts or junkies from popular culture, we posit that the participants were concerned with what Lupton has called the ‘fear of contamination’, which occurs in members of the dominant group who have positioned a marginalized group as Other. Extending this concept to the cosmetic surgery patient and the surgery junkie, we postulate that this fear is present in the participants’ narratives because gaining access to cosmetic surgery is partially dependent on not being identified as a junkie/addict (Heyes, 2009; Pitts-Taylor, 2007).

Another distinction the participants made was between the procedure(s) the individual elected to have and other cosmetic surgeries. The participants experienced their cosmetic surgery as a necessary surgical fix whereas other procedures were situated as too vain, painful or harmful. When asked if she had ever tried any injectables such as Botox or Restylane, Rebecca explains:

I didn't. That's interesting that you said that, because I don't know why I'm against it. Um, and I think because when I see people – when they have it done, they look so – they can't move their face, they can't move their mouth. They look so artificial. And, um, I mean, it's a poison that you’re putting into your body.

For some participants, other procedures including fillers/injectables, cheek implants and other forms of face-lifts were discussed as crossing a boundary from reasonable surgical fix to harmful or unnecessary beauty practice. The variety of comparisons between surgeries lead us to postulate that it is not the procedure per se that the participants opposed. Rather, it is the act of drawing a line, demarcating a boundary between one’s own cosmetic procedure and Other forms of cosmetic surgery that serves to validate the participants’ decisions to elect to have (certain) cosmetic surgery, and to underscore these decisions as bounded and conservative. Larkin and Griffiths (2004) have referred to this form of risk comparison as ‘measured risk-taking’. Measured risk-taking involves discursively positioning one’s own risk choice as rational and balanced through downward comparisons with other users and activities. Extending this idea to cosmetic surgery, we speculate that the combined comparisons with addicts, extreme surgical aesthetics and other cosmetic procedures is a form of individual risk management that enables the participants to frame and experience their decision to elect to have cosmetic surgery as rational, reasonable and necessary as opposed to surgery that ‘Others’ have elected to have, which is seen as irrational, unreasonable and unnecessary.

Such downward comparisons and minimizations of the participant’s own practices have both individual and sociocultural functions and consequences. A surgical candidate must present herself as a normal patient, as opposed to a surgery junkie, in order to become a cosmetic surgery patient (Blum, 2003; Gimlin, 2002). If one requests too great a change or has had too many prior procedures then there is a risk of not being allowed to have surgery (Blum, 2003). However, what is considered ‘too much’ depends on the subjective decision of a given surgeon. In her interviews with cosmetic surgeons, Pitts-Taylor (2007) found that there was great variability amongst surgeons regarding what constitutes an addict; between five and 25 prior surgeries were cited as indicative of pathology. Thus, what constitutes an addict in interviews with doctors (Pitts-Taylor, 2007), medical texts (Fraser, 2003), and in the participants’ narratives, remains vague. Nonetheless, these comparisons with addicts do have a function, they enable those interested in surgery to distinguish themselves as rational, reasonable, good patients who are distinct from the surgery junkie/addicts, and thus these comparisons work as an entry point to a surgical experience where doctors seek good patients. Further, these downward comparisons also reflect the normalization of cosmetic surgery in a larger social context (Blum, 2003). Through discursively positioning their surgical narratives as distinct from surgery junkies, extreme surgical aesthetics and ‘unnecessary’ cosmetic surgeries the participants located their surgical experiences as normal, which enabled their personal surgical engagement, while simultaneously contributing to the normalization of cosmetic surgery as a practice.