Back in June, I wrote about the Beauty Demands seminar we hosted here at the Nuffield Council that looked at the role played by health professionals in both creating and meeting the increasing demand for invasive cosmetic procedures. In the next seminar of the series, held in Birmingham (also see Kate Harvey’s previous blog), we turned our attention to the globalisation of beauty, debunking the myth that the rising interest in surgical 'fixes' is a trend emerging only in the wealthy western world. In exploring the very different ways in which the demands of beauty play out in diverse societies around the world, some common and thought-provoking themes emerged.

Almost all speakers strongly challenged the idea that the growing use of surgery (and/or invasive non-surgical techniques such as fillers and botox) as a means to achieve beauty ideals is simply an example of 'westernisation' or 'Americanisation'. Of course the US is a major source of cultural exports – of media, fashion, and celebrity culture to name but a few – but these influences exist alongside, and often in relationship to, local cultural and beauty norms (which are not, necessarily, either more or less benign than the imported variety). In Japan, we were told, there are competing beauty ideals of 'American' larger breasts and 'Japanese' smaller ones, while in Brazil, breast reductions in response to the traditional preference for smaller breasts are one of the most common surgeries performed, despite the parallel popularity of implants. The US, moreover, is far from the only exporter of culture, technology or aesthetics: South Korea and Brazil were cited as examples of countries with their own pop and celebrity cultures whose influence extend well beyond their national borders.

In order to understand how, and why, interest in cosmetic procedures is likely to manifest itself differently in different societies, we were urged to think about how local ideas of skin colour, ‘race’, and notions of beauty first 'enter the clinic' – in other words, to take into account the critical role of political economy ('westernisation' often going alongside modernisation, industrialisation, neo-liberalism and urbanisation) and politics (particularly ‘race’ and gender politics), in rendering particular procedures desirable at a particular time in different cosmetic procedure markets.

The 'slim ideal' is a case in point. Female beauty has been associated, at different historical moments, with a full-figure, symbolising female fecundity and indicative of access to valued resources. Today's obsession with slimness in many parts of the world is a feature of economically secure societies: the International Body Project has found that in societies where sufficient food cannot be taken for granted, larger body size is still rated in preference to slim (while study participants from societies with secure access to food showed an alarming preference for clinically underweight body shapes). A fascinating study in the UK invited groups of people to rate body shapes when they were either sated or hungry: the sated groups preferred the underweight figures, while the hungry ones selected a range from underweight to overweight. The link between perceptions of ideal body shape and one's own access to food is not far to seek.

Less obviously, national politics, however apparently disconnected from concerns about appearance, can also play a critical role in influencing both beauty ideals and the means deemed acceptable to achieve them. China now embraces cosmetic surgery in powerful and visible reaction to the ideals of the earlier era of the Cultural Revolution, when high heels (bourgeois and decadent!) would be broken in the street by Party apparatchiks, and cosmetic surgeons represented an endangered species. In early 20th century Brazil, the notion of racial and cultural 'mixture' through its conceptualisation of itself as a ‘racial democracy’ was held up as a form of racial equality, in explicit contrast to US segregation, with kaleidoscopic beauty ideals promoted in celebration of this 'mixture'. Yet, this political ideal of 'mixture' did not necessarily lead to simple acceptance of a diversity of looks, but has rather manifested itself in a whole set of co-existing and competing beauty norms: the erotic ideal of curves and small waist leading to the high popularity of 'body-contouring' (procedures to move fat from one area of the body to another); the Black social movement promoting an emphasis on the importance of a distinct Black identity; and a competing emphasis on 'whitening' through skin bleaching. 'Mixture' can create disharmonies that 'need correction': we were told that medical notes might simply cite 'Negroid nose' as the reason for surgery.

Similar complexity is found in Jamaica as it emerges from its history of the colonial beauty ideal of the English rose (and note that the English rose herself used harmful bleaching products to achieve her desired paleness!). The post-colonial political idea of 'Out of many, one people' led to the apparent celebration of 'mixing'. But again, as in Brazil, 'mixing' has manifested itself in the development of distinct and contrasting beauty ideals: the darker skinned, black Nationalist 'look', for example, versus preference for lighter skin with straighter hair. Women representing these ideals are even chosen in two distinct beauty pageants: women with lighter skin and straighter hair compete to be Miss Jamaica World (leading on to the Miss World contest), while in Miss Jamaica Universe, darker skin is desirable (as long as she is also tall and slim ...).

In reaction to a long history of racist rejection of the possibility of Black beauty (ugly terminology of 'rubber lips' and 'cotton wool hair', for example, categorising Black girls and women in the UK as 'other'), more recently the notion of 'browning' has taken hold in Jamaica and the Jamaican diaspora. We were told that this is not so much the ideal of 'being brown' as a phenotype, but rather a celebration of women's agency and their freedom to shape and change how they look, for example, choosing if they wish to use skin lightening procedures and hair straighteners. Exercising such agency is a powerful way of talking back to imposed 'Black beauty shame' - and yet is still far from straightforward: research with Jamaican women in the UK reveals how those who are naturally lighter skinned with straight hair may be criticised and ostracised because they lack ‘true’ Black beauty. Thus the power to change one's appearance may be seen as a cause for celebration, yet without recognition or appreciation of those whose natural looks conform to a particular norm.

How these various ideals of beauty, shaped by social, economic and political history, then influence actual beauty 'practice' is a further, and separate, question. We heard that, in Brazil, cosmetic surgery has become routine for middle class and aspirational for working class women: seen as a 'necessary' procedure whether in order to boost one's self-esteem, look like an 'artista' (celebrity), or to get a better job. Just one plastic surgeon has been credited with playing a major part in this 'routinisation' – elaborating a 'right to be beautiful' by the poor as well as the rich, spearheading the provision of cosmetic procedures in public hospitals (alongside acquiring a strong reputation for reconstructive surgery), and initiating major residency programmes training plastic surgeons of the future. Value is placed on 'harmonising oneself' with society, so that cosmetic procedures are just as much a form of healing as therapeutic procedures, with no dividing line perceived between reconstructive and cosmetic surgery. This normalisation of plastic surgery in Brazil correlates closely with the medicalisation of other aspects of women's bodies and healthcare: it was reported, for example, that some Brazilian hospitals have Caesarean section rates as high as 90%, and that it is routine to be referred for cosmetic procedures after childbirth, for example to improve the appearance of the scar.

In Lebanon, cosmetic procedures can be understood as a form of care for oneself, closely tied in with the care one should take for others, and for social relationships of all kinds, including family, work and community. Procedures that are described as making you 'neat and tidy' are a way of taking care of yourself, and in so doing, being respectful of oneself as well as exemplifying one’s social duty to others. Advice may be offered frequently and benevolently, as to what procedures might help you meet these personal and social requirements. Such an understanding of the social role of cosmetic procedures highlights a final theme of the seminar presentations: the extent to which both the perceptions and the demands of beauty are relational. There was little sympathy among those present for the old argument that beauty ideals are broadly fixed and derive from objective elements such as the degree of facial symmetry. Rather, who is 'gazing' at us, and the meanings they ascribe to the way we look, is critical both in setting beauty norms, and in conditioning our responses to those norms. The fundamental and unanswered question is: how should we respond to that gaze, whether individually or collectively?

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