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The biological subject of aesthetic medicine

Alexander Edmonds
Feminist Theory 2013 14: 65
DOI: 10.1177/1464700112468571
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Article

The biological subject

of aesthetic medicine
Alexander Edmonds

Feminist Theory
14(1) 6582
! The Author(s) 2013
Reprints and permissions:
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DOI: 10.1177/1464700112468571
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University of Amsterdam, The Netherlands

Abstract
This article explores how race, sexual attractiveness and female nature are biologised
in plastic surgery. I situate this analysis in relation to recent debates over the limits of
social constructionism and calls for more engagement with biology in feminist theory
and science studies. I analyse not only how the biological is represented by biomedicine,
but also how it is experienced by patients and, most problematically, how it is entangled
with social constructions of beauty, race and female reproduction. Drawing on ethnographic fieldwork conducted in Brazil, I focus on plastic surgery, but also analyse how
this specialty is linked to Ob-Gyn and endocrinology. I argue that medical procedures
instantiate a biologised model of beauty I call bare sex (Edmonds, 2010) that is defined
in terms of racial traits, anatomy, reproductive processes, hormones and secondary
sexual traits. While this is a historically specific model, it is also one that is inscribed on
patients, altering anatomy and physiological processes. It thus has the potential to create
a biological self-awareness that cannot fully be accounted for by a social constructionist
analysis.
Keywords
Biological agency, female reproduction, plastic surgery, race, social constructionism

While conducting ethnographic eldwork on plastic surgery in Brazil, I visited

hospitals and clinics, hung out with patients and surgeons, and investigated a
mass media steeped in images of sexual allure.1 In my initial analysis of this material, I stressed the historical, cultural and economic forces that shape beauty practices. But, as I reected further, I experienced a growing sense of unease with the
social constructionist approach I was taking. Patients and surgeons often saw
plastic surgery as a means to manage a reproductive, sexual, ageing body. The
biological body that is an object of clinical techniques and knowledge is partly

Corresponding author:
Alexander Edmonds, Department of Anthropology and Sociology, University of Amsterdam, Oudezijds
Achterburgwal 185, Amsterdam 1012 DK, The Netherlands.
Email: a.b.edmonds@uva.nl

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constructed by gendered ideologies about female nature; but should it be viewed

only as a social construction? What eects did surgery have once patients entered
the long therapeutic process of self-tinkering that targets tissues, anatomy, and the
skin both a sexual organ and the outer edge of the psyche (Pitanguy, 1992: 269)?
I also began to question my initial reading of the disturbing relationship between
race and beauty. Brazil has a cultural aesthetic ideal of the female body that prizes
ample hips and buttocks, round, full thighs, and not white, but as one can say in
Portuguese, whitish facial features (though not necessarily pale skin). This ideal is
a social construction reecting current colour hierarchy, as well as a long history of
fetishising racial mixture. On the other hand, as I observed clinical practices I was
confronted with a spectacular kaleidoscopic variation in phenotype, a product of
ve centuries of interracial union. The race that appears in surgeons and patients
words does not refer to a natural kind or stable biological referent. Yet to treat race
only as a construction would miss the opportunity to analyse how the biological
and the social are entangled within plastic surgery.
Another problem with a purely constructionist account of beauty is that it seems
to explain away what is particular about this domain of life. There is certainly a
connection between cosmetic practices and inequalities structured around gender,
race and class. Yet nearly every aspect of social life reects some kind of power
relationship. Moreover, aesthetic hierarchies do not mechanically mirror other
social hierarchies. The whiter the better, says a Brazilian proverb. However,
some comparatively lighter people are judged ugly by their peers and some comparatively darker people beautiful. The social capital whiteness gives is not reducible to the sexual or physical capital that attractiveness and youth confer.
Moreover, an encounter with a beautiful person can be a powerful bio-psychological event, as Elaine Scarry (2001) points out, with symptoms ranging from trembling to surging anxiety. Viewing beauty as only a social construction potentially
misses something important, and may ultimately hinder the eort to understand
the dramatic growth of demand for cosmetic surgery.
In this article, I explore how an engagement with the biological can illuminate
the ways sex and beauty are done in plastic surgery. Building on an earlier eort
to explore the limits of a social constructionist approach to beauty (Edmonds,
2010), I analyse not only how the biological is represented by biomedicine, but
also how it is experienced and internalised by patients, and, most problematically,
how it is entangled with social constructions of beauty, race and female reproduction. I focus on plastic surgery, but also analyse how it is linked clinically to other
medical specialties, including obstetrics-gynaecology (Ob-Gyn) and endocrinology.
I situate this analysis in relation to recent debates over the limits of social constructionism and calls for more engagement with nature, biology and matter in
feminist theory and science studies. Several scholars in these elds have critiqued a
paradigm of social constructionism for its lack of engagement with biological
matter (e.g. Alaimo and Hekman, 2008; Grosz, 2008; Hird and Roberts, 2011;
Wilson, 2004, 2008). Responding to this work, I explore how race and the
female reproductive body are materialised in plastic surgery. I argue that medical

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procedures biologise race, sex and beauty as they dene and operationalise them
in terms of anatomy, reproductive processes, hormones and secondary sexual
traits. Adapting Giorgio Agambens (1998) use of the term bare life, I propose
the term bare sex (Edmonds, 2010) to describe a model of beauty and sexual
attractiveness that is radically reduced to a biological organism. While this is a
historically specic model, it is also one that is inscribed on patients, altering tissues
and physiological processes. It thus has the potential to create a biological subject,
or biological self-awareness, that cannot fully be accounted for by a social
constructionist analysis.

Theoretical context: Engaging with the biological

In recent years there have been rumblings of discontent in many elds with the
paradigm of social constructionism. Some critics have blamed the linguistic turn
of postmodernism for a singular focus on representations and discourses that
ultimately enervates social theory. For example, Sedgwick and Frank (1995: 16)
lament the absolutist and highly moralistic tendencies of a reexive antibiologism. They argue that specications that any given x in social life is constructed are
confused with a theory of x: Theory has become almost simply coextensive with
the claim (you cant say it often enough), its not natural (Sedgwick and Frank,
1995: 16). If everything is not natural, then it is dicult to make critical distinctions. Thus, they point out that constructionist accounts of aect often have no
feelings (Sedgwick and Frank, 1995: 17), i.e. they fail to distinguish between disgust, rage, shame, etc. This lack of specicity in discussing aect points to the weak
explanatory power of a theoretical approach that views all aspects of social existence as constructed.
Some scholars advocating a new materialism or feminist materialism have
called for more engagement with nature, biology and matter (e.g. Hird and
Roberts, 2011; Wilson, 2004, 2008). While they acknowledge that critiquing the
equation of women with nature was politically important, they argue that bracketing nature from analysis can reproduce materialist/discursive dichotomies
(Alaimo and Hekman, 2008: 6). This argument has generated considerable controversy. Sara Ahmed rebuked new materialists for using an inationary logic (2008:
31) that unfairly characterises the work of others. Noela Davis (2009) responded to
Ahmed, arguing that new materialists do, in fact, do something new with biology.
She maintains that earlier feminist analysis depicted biology as a rigid and passive
system that could not possibly account for the variability we see in society, and
argues that the newer work is distinguished by its theorisation of the entanglement
of materiality and sociality (Davis, 2009: 73). Alaimo and Hekman (2008: 7) similarly argue that for material feminists nature is more than a passive social construction but is, rather, an agentic force. . .for these theorists, nature punches
back at humans and the machines they construct to explore it in ways we
cannot predict.

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The notions of biological agency or biological ontology are problematic for a

few reasons, which I return to below, but rst I want to briey discuss two examples of how they have been used in this literature. Rereading Darwin, Elizabeth
Grosz (2008: 24) asks how biology facilitate[s] and make[s] possible cultural existence and social change? She argues that both scientists and non-scientists have
often misinterpreted Darwins theory of evolution, ignoring how it oers a subtle
and complex critique of both essentialism and teleology (p. 28). She argues that
Darwins work, however, has not only been falsely used to justify conservative
politics. More controversially, she proposes several ways that it can serve as a
resource for feminism, for example, by challenging nature/culture dichotomies or
teleological thinking that lends itself to conservative justications of the status quo
(Grosz, 2008: 45). Her work might be said to move from an engagement with the
epistemology to the ontology of biology in that it aims not just to correct false
interpretations of science, but also to reect on how biology can itself (positively)
shape social thought and political action.
Elizabeth Wilson (2004, 2008) argues similarly that close attention to biological
detail can invigorate political-ethical projects. Writing about SSRI antidepressants,
she argues that constructionist critiques have focused exclusively on the normalising, disciplinary power of pharmaceuticals. She argues, however, that examining
the biological substrata of depressive states can procure more dynamic (and more
politically vibrant) accounts of depression (Wilson, 2008: 379). Stressing the role
of braingut circuits in the pharmacokinetics of antidepressants can challenge a
reductionist account of depression as (exclusively) a brain disease. Moreover, viewing transference in talk therapies as simultaneously a symbolic and organic process
sidesteps the mindbody dualism that characterises constructionist accounts of
depression. Wilson concludes that engaging with biology is a vibrant source of
political agency and energy (2008: 390).
Such analyses of biological agency or ontology draw attention to the problematic status of the biological in much social theory, but they also raise several problems. First of all, one might object that agency is a human concept and only applies
to us, or perhaps to some animals. We might dene agency in such a way that it
does not require consciousness, yet such terms may still imply that biological forces
act autonomously in human social life. Annemarie Mol in fact argues that the turn
to ontology in new materialism has ignored that matter never is itself all by
itself and ironically rearms a stable and singular ontology that much work in
science studies had previously deconstructed (2012: 2). Another question concerns
what a social theorist can actually know about biological ontology. After all, it is
the natural sciences that have the tools and methods to produce new knowledge
about biology. What social theorists do is interpret, and such interpretations are
simply a new form of social construction.
These examples of engaging with biology also raise the question of whether and
how biology can be used for critique. Many advocating a new materialism have
argued that they do not aim, as earlier scholars have done, to simply correct politically conservative misinterpretations of science, and replace them with neutral

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ones (Grosz, 2008: 25). For Grosz, this stance misses the opportunity to gain
insights, methods and questions from science that could be of some use in understanding and transforming the prevailing structures of (patriarchal) power (Grosz,
2008: 27). Wilson is even more explicit in advocating that biology can be recaptured for feminism (Wilson, 2008: 390). Other scholars also aim to progressively
use biology, in this more political sense, in work that aims to naturalise homosexuality or create a new ethics of humanenvironment and humananimal relationships (e.g. Alaimo, 2008; Hird, 2009).
Such uses of biology, I think, are a signicant development in social theory.
However, more openness (a recurring metaphor in this literature) to biological
agency should include openness to how it shapes, and also limits or constrains,
agency conceptualised in purely cultural terms. In fact, one of the major limitations
of social constructionist theory is arguably the conceptualisation of human agency
as limited by institutional and discursive power, but not by our species life as
biosocial beings. Engagement with the biological runs the risk of reproducing the
alleged anthropocentrism of social construction if it only uses biology in ways that
resonate with particular political values.
This point is germane to my own case study because biological accounts of
human beauty are particularly controversial. They have mostly been shaped by
disciplines with highly contested scientic status, such as evolutionary psychology
and sociobiology, or even by debunked medical science, such as eugenics. In fact,
some of the most destructive forms of scientic racism had a strange emphasis on
beauty, using an ethnocentric aesthetic hierarchy to ground assumptions about
evolutionary progress. Engaging with biological science thus may not directly
feed into progressive politics, though it is of course possible to reinterpret biological accounts of beauty.
My response to these dilemmas in what follows below is to take the notion of
biological agency as a provocation to explore the limits of a social constructionist
account of beauty and race. This is not to abdicate critique. On the contrary,
analysing the entanglement of biological and symbolic existence can help shed
light on how medical practices become appealing to the patient, which is also
important for critiquing them. I argue that race and beauty are not just constructed
in a particular medical and historical context in Brazil, they are also materialised in
clinical practices. Plastic surgery and linked medical specialties also can be said to
biologise beauty in that they create a subjectivity centred on physiological processes and structures that can be clinically managed. I use the terms materialise and
biologise to emphasise processes: the interplay between social and discursive forces
and a biology that cannot be known in itself.

The racialisation of beauty

Brazil is currently the worlds second biggest cosmetic surgery market (after the
United States). A reputation for quality and relatively low prices also attracts
considerable numbers of medical tourists (Edmonds, 2011). Surgeons from Latin

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America, Europe and elsewhere come to train in Brazils well-regarded residency

programmes, some of them run out of public hospitals that oer free cosmetic
operations to a population of needy patients (see Edmonds, 2007, 2009, 2010).
In the private sector, expanded access to consumer credit made cosmetic surgery
more available to a growing middle class, as well as to those aspiring to enter it.
During eldwork, I found that consumers and doctors openly evaluated the
body, and frankly, and often publicly, discussed beauty and ugliness. These conversations often made explicit references to the aesthetics of race and racial mixture. Race is, of course, a central category in plastic surgery, perhaps more so than
in any other contemporary medical specialty, with the exception of some areas of
genetics. Historically, early European experiments in plastic surgery aimed to correct racial traits, such as Jewish and Irish noses. Much public anxiety and fascination with the nascent specialty in the late nineteenth and early twentieth
centuries concerned this purported ability to mask race (Gilman, 1999). The current specialty which is increasingly available to non-white populations as demand
grows in the developing world is still centrally concerned with what a surgeon
terms anthropologic and physiologic considerations (Rogers, 1998: 31).
In Brazil, plastic surgery operationalises race makes it an operable trait and
object of clinical knowledge in specic ways. Common forms of rhinoplasty aim
to narrow the nose and increase its projection, sometimes through the insertion of a
piece of cartilage removed from the patients ear. They are often performed on
patients of some indigenous or African ancestry, and surgeons term one type of
procedure correction of the Negroid nose. More rarely, surgeons perform eyelid
surgeries, which they call Westernisation, on Brazilians of Japanese ancestry.
These clinical practices partly reect a specic folk taxonomy of appearance that
diverges from North American taxonomies that emphasise stronger racial boundaries between groups. Many Brazilians prefer to describe themselves and others
with dozens of colour terms that describe slight variations in appearance, but which
may not directly refer to ancestry. One of the most popular colour terms, moreno
(brown but also brunette), is used to describe people with a wide range of ancestry, including brancos (whites) as well as people of some African descent (Sansone,
2004). These colour terms are eroticised and aestheticised in many contexts
(Goldstein, 2003). A branco or moreno appearance is often valued more than a
negro (black) one. Some patients seek surgery on a black nose they believe they
have inherited, though they do not identify as black. Because colour terms are
relatively uid, a change in appearance can potentially nudge the patient in the
direction of a more socially and aesthetically valued colour category, without
changing race (which patients and surgeons agree would be an inappropriate
use of cosmetic surgery). Operations on racial traits thus reect strong social
hierarchies in Brazil as well as a specic cultural system of perceiving and classifying appearance.
Not only cultural, but also medical knowledge about race in Brazilian plastic
surgery diers from that found elsewhere. For example, the US plastic surgery
textbook, Ethnic Considerations in Facial Aesthetic Surgery, is lled with precise

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anatomical descriptions of the ideal characteristics of beauty within each major

ethnic category (Matory, 1998: xix). This text uses racial groupings that correspond to current North American folk taxonomies of race (e.g. blacks, Caucasians
and Asians) or to older colonial taxonomies (e.g. Melanesians) (Rogers, 1998).
Some descriptions use pejorative language. For example, the Asian nose is
described as having poor lobular denition and decient anterior projection of
both pyramid and lobule (McCurdy, 1998: 263). This description constructs aesthetic defects (such as decient projection) in relation to a white norm (Kaw,
1993). The text also classies race in accordance with a North American one drop
of blood rule that tends to put mixed race people in a non-white category. In
Brazilian practice, racial boundaries are not as strongly dened and patients
with some African ancestry may, or may not, be dened as black. Thus, while it
is true that plastic surgery is a global medical specialty and techniques cross
national boundaries, the medical visualisation of race is not the same everywhere,
and reects to some degree specic social constructions of the body.
Not only the face, but also the female body is subtly racialised in clinical
practice as well as in popular culture. I have argued that beauty has, in highly
gendered ways, been a central trope in Brazilian twentieth century nation building (Edmonds, 2007, 2010). Beginning in the 1930s, nationalist scholars and artists countered elite assumptions about the negative eects of racial mixture by
arming what historian Gilberto Freyre (1986: 63) termed a magnicent miscegenation. An important ingredient in the discourse on mixture was physical
beauty, especially female beauty. Brazilian modernist art, scholarship and historiography celebrated phenotypic variation in the population and eroticised in particular the mulata, the Afro-Brazilian woman. This celebration of mixture
diverged sharply from contemporaneous eugenic thinking in Europe that equated
beauty with racial purity. Yet it also preserved elements of the eugenic emphasis
on racial improvement in its descriptions of the aesthetic eects of biological
inheritance.
Plastic surgeons echo eugenic thought in discussing how the biology of race
shapes beauty and ageing. For example, they claim that owing to the properties
of their skin pure whites age worse than people with some mixture. On the other
hand, they say that patients with African ancestry have a tendency to gain weight
more easily. Surgeons also say that there are better and worse mixtures. One surgeon told me that mixtures between Indian (indigenous) and European peoples
resulted in an ugly body dened by short legs, thin and at. This surgeon contrasted this product of miscegenation with African-European mixture, which he
said produced a very attractive bottom, a breast and a waist. Another surgeon
argued that some techniques, such as liposculpture, can be used to emulate (good)
African-European racial mixing, which blessed women with small waists. This
semiotics of racial mixture an interpretive art and science of reading how race
manifests itself in aesthetically prized or denigrated features is also present in
patient accounts. Some women spoke of particular bodily features, principally the
bunda (bottom), as being inherited from brown or black ancestors or relatives.

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Other patients viewed thin legs as ugly, contrasting them with the rounded black
thighs fetishised in popular culture (Edmonds, 2007, 2010).
I have up to this point analysed a biologising discourse about race as well as
Brazilian cultural aesthetic ideals. Surgeons describe their patients in racialised
terms, where ugly and beautiful body parts are linked to particular kinds of
racial mixture. While body contouring surgeries often aim at a national aesthetic
ideal of the female body, some nasal surgeries testify to the persistence of a whitening ideal, reecting contradictions in Brazilian racial ideologies. The operation
surgeons term correction of the Negroid nose cannot be understood apart from
a historical context where whitening was for decades a government policy and
marriage strategy in everyday life. My analysis of the disturbing nexus of beauty
and race has so far stayed within a social constructionist analytic frame. That is,
I have mostly described race and beauty in relation to representations, discourses
and institutions, without exploring how these entities are entangled with biology.
I now take up this more provocative question.

Materialising race
A large body of scholarship in the twentieth century deconstructed the category of
race. Earlier scientic descriptions of race, which were so important for medical
and social institutions, have been largely debunked. We might reasonably ask: does
race have a biological reality at all or is it only social construction? Yet as Amade
Mcharek (2005, 2008) has shown race has hardly disappeared from science and
medicine, and may even be gaining strength in recent years in elds such as genetics
and forensic anthropology.
Cosmetic surgerys description of race is disturbing because it openly reects
social and racial prejudice and constructs racial or ethnic dierence in relation to a
white norm. As such it may seem preferable to simply bracket the biological.
I suggest that it is important, however, to analyse how the biology of race is
materialised in clinical practices. It may be helpful to consider rst the case of
reconstructive surgery, which is less controversial than cosmetic surgery.
Research in plastic surgery has created empirical knowledge about anatomical
variations in socially-dened ethnic groups. These studies are used not only in
cosmetic surgeries, but also in reconstructive surgeries performed on patients
with congenital defects. For example, Rogers (1998: 3132) describes how preauricular appendages are more common in blacks than in whites, how isolated
cleft lip occurs less commonly in blacks than in other ethnic groups, and how
protruding ears are more common in Celtic than in other white groups. This
understanding of race as a group with a higher susceptibility to certain genetically-based diseases, including congenital deformities mirrors a re-emergence of
race as a biological category in other branches of clinical medicine not explicitly
concerned with beauty or enhancement, such as genetics (Mcharek, 2005, 2008).
This medical knowledge of race may or may not stand up to further

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scientic scrutiny. But it is not necessarily racist, and reconstructive surgery does
not usually raise the same political and ethical concerns for social critics that cosmetic surgery does.
Cosmetic surgery is dierent from reconstructive surgery in that it constructs the
racial trait as a deformity, rather than studying dierent frequencies in congenital
deformities between dierent ethnic groups. Yet the boundary between aesthetic
and reconstructive surgery is blurred, as is the boundary between the aesthetic and
the congenital defect. Both types of procedures have aesthetic aims and empirically describe anatomical variations between populations. Taken as a whole, the
medical specialty thus constitutes race as a complex hybrid, a natureculture in
Donna Haraways (2003) terms. Put dierently, cosmetic surgery not only naturalises social constructions of a racialised body (for example, the aesthetic norm that
says whiter is better), it also materialises race.
One example of how race is materialised in clinical practice is the keloid scar.
Surgeons say that patients who have some African ancestry have a greater chance
of developing thick keloid scars after surgery. The issue is less relevant with
surgeries with a clear health indication since the scarring is justied by expected
benets of the surgery. But with aesthetic surgeries, particularly those that leave
large scars (like breast reductions), the probability of a keloid scar is important for
riskbenet calculations, because such a scar can interfere with aesthetic improvement. The problem, surgeons say, is that they do not know who is black just by
looking at patients because they are so miscegenated. The surgeons solution is to
make a very small, test incision to see how the patient will scar before deciding
whether to perform the operation.
In discussing this routine aspect of clinical practice one surgeon working at a
large private clinic told me that patients descended from slaves from Bantu (as
opposed to Angolan) regions scar better, because they have a good biology:
When miscegenation [i.e. the origin of the patient] is from a tribe which scarred
well in Africa, he scars well here, and vice versa. This surgeons comment clearly
reects a colonial discourse of race, but it is also entangled with a biology of race
that is observed in the patients healing response to a surgical incision. Race, then,
is best viewed not exclusively as a social construction, but as a complex biosocial
hybrid that is materialised in medical practices, which in turn naturalise cultural
aesthetic norms.
Engaging with the biology of race is important for critique because it can show
how cosmetic surgery becomes accepted as a form of healing and improvement. As
individuals recognise themselves in medical descriptions of ethnic anatomy which
appear in the pages of consumer magazines they absorb them into their body
image, creating a racialised body image and awareness of genetic determinants of
appearance. The widespread description of aesthetics in racial terms also has the
eect of biologising beauty. That is, it uses medical knowledge of human anatomy
and physiology to describe aesthetic norms and the appropriate techniques for
approximating them. It also highlights the role of genetics in determining attractiveness, and in this sense can be seen as a kind of legitimation work for plastic

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surgery since such hard wired defects may not be amenable to change with other,
less invasive, cosmetic techniques. I further analyse the biologisation of beauty, but
rst I want to discuss a second major object of cosmetic surgery: the female reproductive body.

Managing reproduction, ageing and sex

Notions of female nature (natureza) gure prominently in Brazilian clinical practice. Many operations including liposuction, breast surgery and abdominoplasty
are said to correct changes to the body that surgeons and patients blame on
pregnancy and breastfeeding. Patients often describe and plan cosmetic surgeries
in relation to their reproductive history. Some mothers postpone surgery until after
having a tubal ligation because they worry that a new pregnancy will estraga
(ruin) the results of the operation. Others see plastica as a kind of compensation
for the suering and sacrice of motherhood, or for the aesthetic and sexual
damage caused by other surgical interventions (including C-sections and hysterectomies). Plastic surgery is used not just to correct defects blamed on pregnancy,
but also to correct scars and accidity resulting from C-sections (Edmonds, 2010:
part III).
Notions of female physiology, ageing and nature also gure more generally in
discussions of plastic surgery. Surgeons, for example, debate what is the lowest
acceptable patient age (which varies from 13 to 16 years in most accounts) at which
cosmetic procedures may be performed. While some surgeons are concerned about
the emotional maturity of the adolescent patient, others believe that eligibility for
surgery should be determined by biological age, measured by years elapsed since
the onset of menstruation. Some women also discussed their operations in relation
to ageing and life-cycle events. One patient said, When I entered menopause three
years ago, everything fell, fell very fast. Women age quickly. Menopause, hormones, breast feeding, birth all deform your belly, your body. Some women
view plastic surgery as a form of technological progress that enables them to
manage the biological predations of a female nature. Another patient told me
during an interview that plastic surgery allowed women to breastfeed without
worrying about its negative aesthetic eects.
But while some women believe plastic surgery is a liberation from biological
constraints, clinical practices may also paradoxically heighten consciousness of a
awed, though malleable, biological body. Plastic surgery often has a pedagogical
and experimental aspect. Some patients begin to see aws they did not perceive
before speaking with a surgeon, such as small asymmetries in the face. Many have
multiple surgeries, either combined to take advantage of the anaesthesia, or
sequentially, timed to important biosocial events such as initiation into womanhood, childbearing, or menopause. Having one operation often makes a second or
third easier, but also more necessary. Some patients have a series of minor corrections, often described in the Portuguese diminutive form, e.g. coisinha, puxadinha (little things, little pulls), in order to heal their body image (Edmonds, 2010).

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A sometimes lifelong therapeutic process can make patients more conscious of the
reproductive, ageing and sexual body as a biological entity and object of surgical
improvement.
Patients also internalise an objectied understanding of aesthetics through their
clinical interactions. Clinical knowledge of beauty is communicated to patients in
various technical ways: through palpation techniques that produce the defect, such
as picking up and dropping accid tissue to demonstrate the loss of elasticity
(Mirivel, 2008); the careful documentation of defects through photography; the
quantication of defects through measurements with surgical instruments like callipers and scales; and the use of technical language.
I have so far analysed how a reproductive and ageing body is made an object of
aesthetic intervention. While cosmetic surgery is often justied as a health practice
by the notion that it performs psychological healing, clinical judgements about
sexual attractiveness are used to determine patient need and to document
improvement. Plastic surgery could be described, then, as another illustration of
how social constructions of gender shape clinical practices. In what follows, I
explore some of the limitations of a constructionist approach by examining
how beauty and sex are biologised in the interlinked specialties of plastic surgery,
Ob-Gyn and endocrinology.

The biological subject in cosmetic surgery and hormonal

therapy
A biological description of beauty and the risks posed to it by motherhood is
reinforced by links between plastic surgery and other medical specialties. Some
obstetricians refer patients to plastic surgeons for defects they say are the unavoidable eects of childbirth and breastfeeding. Ob-Gyns also instruct women on how
to aesthetically manage pregnancy through diets that avoid unnecessary weight
gain. Obstetrical practices reect a social construction of childbirth as posing a
manageable aesthetic and sexual risk to the mother (Diniz and Chacham, 2004).
Emilia Sanabria (2011) found that post-partum vaginal plastic surgery was often
performed on patients in public hospitals who had reduced access to C-sections
(which are performed at very high rates in private hospitals). She argues Ob-Gyns
oer vaginal cosmetic surgeries in public hospitals partly as a kind of proxy for the
Caesarean sections that are so common among middle- and upper-class women
(Sanabria, 2011: 109). There has also been a growth in the marketing of genital
cosmetic surgery in the private sector. The growing availability of corrective vaginal plastic surgery, particularly in a public health system, reinforces a view of
childbirth as causing sexual and aesthetic damage.
Plastic surgery is also combined with hormonal therapy. Despite new evidence
weakening the grounds for a health indication for hormonal therapy, sexual rationales for the treatment remain popular (Brody, 2009). Some plastic surgeons
are introducing hormonal therapy into their practice as part of an integrated
anti-ageing medicine (Kinney, 1998: 392; Garcia, 2007). There is even an emerging

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subeld that calls itself aesthetic endocrinology (Gruber et al., 2002). The term
refers mainly to the use of topical (as opposed to oral) hormones to produce a
broad spectrum of eects on what a group of Austrian endocrinologists call
the aesthetic well-being of women (Gruber et al., 2002: 431). However, not
only topical hormones, but also oral hormone use can be said to be aesthetic in
a looser sense of the term. Both oral and topical treatments are marketed as a
means of enhancing an inchoate sense of well-being that includes body image,
sexual satisfaction and lifestyle. While synthetic hormones have been critiqued
by advocates of alternative medicine, bioidentical hormones have ironically been
marketed as more natural. Demand for hormonal therapy, then, is also aesthetic
in that it reects a broader social movement embracing holistic healing and an
art of health.
Enhancement rationales for hormonal use have been particularly prevalent in
Brazil, for men and for women. National news media have aggressively promoted
hormonal replacement therapy (HRT) as a key weapon in an arsenal of techniques for improving what Veja magazine named sex after 40 (Veiga, 2000).
Among men there has been widespread use of anabolic steroids to mould the
sarado (hard or literally forged) body. Brazilian travestis (transvestites) are
known internationally for their dramatic transformations achieved through medical plastic surgery, illegal self-injected liquid silicone, and ingestion of female birth
control pills, often available at the local pharmacy (Kulick, 1998). Womens use of
oral contraceptives also sometimes has an enhancement rationale, which Sanabria
(2010) shows is split along class lines. A logic of controlling fertility is more often
present when hormones are prescribed to poorer women, while among middle class
women particular doses and combinations are promoted as a means of sexual selfregulation. Compounding pharmacies prepare individually-tailored doses and
combinations including testosterone that are believed to boost libido.
The combination of cosmetic surgery with other specialties, including Ob-Gyn
and endocrinology, eectively locates the aesthetic defect or sexual dysfunction in
the patients endocrine system, anatomy, or reproductive or ageing processes. Such
biologically-dened defects in a sense call for interventions that address their root
cause. By acting on the physiological processes that it constructs as pathological,
medicine can create a biological self-awareness. Patients undergoing enhancement
therapies sometimes describe inner states in relation to clinically objectied changes
to their physiology. For example, drawing on ethnographic research she conducted
in Bahia, Sanabria (2010, 2012) describes how women using a female contraceptive
containing testosterone consider it to have worked when a cluster of dark hair
appears on the spot on the buttocks where it was implanted. Cosmetic surgery also
has the potential to profoundly aect body image and sexuality. In his medical
writing, Brazils leading surgeon, Ivo Pitanguy, claims that the skin is not only a
principal component of the personality, but also a sexual organ (Pitanguy, 1992:
269). Cosmetic surgery can initiate a process of self-tinkering where repeat surgeries are a means to improve knowledge of ones anatomical defects, but also
to experience libido rising to the head, as one patient I interviewed put it.

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These elective medical treatments could be said to interpellate consumers on a

biological stratum, producing a biological subject of aesthetic medicine.
I have suggested the term bare sex (Edmonds, 2010) to describe such a biologisation of sex and beauty. Giorgio Agamben (1998) draws on the Greek distinction between zoe, bare life and bios, qualied life, which diers from pure
biological existence by being lived within the public world of the city. A similar
distinction could be made between qualied sex sex as constituted within symbolic and moral realms and bare sex dened biologically in relation to a
physiological organism. The visual culture of plastica illustrates such a notion of
bare sex. Body parts are often portrayed in isolation, in either a awed or perfect
state, and quantied in clinical measurements. Unlike fashions embrace of playful
dissimulation and masquerade, this beauty practice instead insists on the honest
correction of defects. Despite its association with the enormous sexual charisma of
celebrities, plastic surgery may, ironically, contribute to a view of sex where pleasure and fantasy count less than the anatomical structure of the bare body.
Plastic surgery could also be said to biologise beauty in that it relentlessly links it
to youth and, to a certain extent, secondary sex characteristics. Although many
operations reect culturally-specic aesthetic ideals, much plastic surgery aims to
rejuvenate the body and remove any marks of childbearing. Liposculpture and
abdominoplasty atten the stomach and narrow the waist. Many facial surgeries
and peels homogenise the skin. Both face and body surgeries enhance symmetry.
And while breast surgeries partly reect cultural diversity in aesthetic norms, both
augmentations and reductions often lift and project the breasts. In many ways, this
way of doing sex and beauty mimics the aesthetic ideals that sociobiology claims
are rooted in evolutionary processes (Etco, 2000). Sociobiologists argue that
sexual selection has made the protruding female breast absent in other primate
species into a secondary sex characteristic, an inherently erotic trait. The at
stomachs and narrow waists, which are much promoted in plastic surgery marketing, are in their view signals of a nulliparous status (never having given birth).
Claims about the universality of aesthetic ideals made by sociobiologists and
evolutionary psychologists have been sharply critiqued (e.g. Lancaster, 2003).
Many of these cross-cultural studies seem to employ imsy methods. And the
portrait of love and sex among ancestral humans bears a suspicious resemblance
to contemporary, or rather, mid-twentieth century, western gender ideologies. But
one problem with these critiques of sociobiology is that they have generally not
come up with an alternative account of beauty and sex as biosocial phenomena.
Simply bracketing biology, as Wilson and Grosz have argued, in eect cedes it to
other, socially-authorised scientic accounts. It is unlikely that societies and historical epochs are completely free of biological constraints in constructing their
aesthetic ideals. And to argue that sexual selection has not shaped the human form,
or sexual responses to it, posits a radical discontinuity between us and other animal
species.
Of course, humans can never experience biology in itself. Or as Judith Butler
(1990: 17) argues, materialities are only formed in certain normative conditions.

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The meaning and aect attached to the erotic body cannot be separated and
puried from social context, reduced to some genetically predetermined essence.
To some extent sex will always be experienced and represented in symbolic terms.
Yet it is also possible that as self-aware animals we can become more or less conscious of our dual status as cultural and biological beings. Sex is always materialdiscursive, biosocial, or some other compound. Yet our awareness of the
biological, and its relative role in our experience, desires, moods and life possibilities, can change. Sex may never be bare completely, but it may become relatively
more so in particular historical and social conditions. I have argued that the historically particular form of plastic surgery as practised in Brazil reects and contributes to such conditions of bare sex.
The radical constructionist might reply that notions such as sex and nature, just
as much as gender, are cultural products. Yet while this argument is logically
impeccable, it is also true that diverse peoples have problematised natureculture
relationships and been troubled by their own status as self-aware animals (Viveiros
de Castro, 1998, 2004). There is no rewall around the human that insulates us
from awareness of a biological stratum to our existence. And there are likely historical circumstances in which symbolic constructions of sex recede in importance
and where humans are forced into a biological living. Moments of extreme brutalisation and social isolation are examples often given. Plastic surgerys radical
reduction of beauty to the naked organism is a more limited illustration of this
biological living.

Beyond social constructionism?

In this article, I rst analysed the historical and medical forces that construct a
racialised notion of beauty. I then argued, however, that race in plastic surgery is
not only a social construction, but is also materialised in statistical variations in
congenital deformities between dierent ethnic groups, or in the keloid scar that
surgeons say is more common among some ethnic groups. In the second part of the
article I discussed how female nature is made an object of medicine. I argued that
plastic surgery and other specialties in an emerging aesthetic medicine relentlessly
interpellate the patient on a biological stratum. This development in medicine is
certainly a discourse, but because these therapies also alter physiological processes
and structures they create a biologised self-awareness.
I would like to end by considering some of the implications of this analysis
for critique. Some of the work in feminist materialism I discussed earlier argues
that biological ontology can be reinterpreted in ways that invigorate political
and ethical projects. I suggest that openness to biological ontology should also
consider cases where it may limit or constrain human agency, or not necessarily support political aims. Biological accounts of race and beauty have been
among some of the most controversial and politically oensive in science and
medicine. These accounts may not resonate politically, methodologically or

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79

otherwise with social theory. However, engaging with the biological is still
useful for critique, and can complement or deepen a purely constructionist
analysis.
For one, openness to biological agency can help explain the social dynamics of
beauty. During eldwork I tried to understand class dierences in views of sexual
attractiveness and plastic surgery. Working class women sometimes saw beauty as
a kind of democratic equaliser because it is not distributed according to social
rank, and because sexual attraction can cross class barriers. And many poorer
patients expected cosmetic surgery to provide social mobility or improve their
position in labour markets or a dating market a view that does not conform
to ocial justications of surgery and often disturbed surgeons and psychologists
working at clinics. While such expectations were not always met, I argue that these
patients had insights into the social signicance of beauty. Youth, sexual desirability, and other physical attributes of masculinity and femininity are a kind of biosocial power. This power is partly inherited, partly independent from social
distinctions, and partly available to the poor in ways that cultural capital is not.
It can also disrupt or interfere with social hierarchies, though in very limited ways
(Edmonds, 2007, 2010). Plastic surgery does not always provide the benets it
promises, of course. Yet seeing beauty as a form of biosocial capital can help
explain the enthusiastic embrace of this technology, and shed light on the meaning
and value of beauty in dierent class contexts.
Constructionist analysis of gender, sex, beauty, race, reproduction and virtually
every aspect of the body has been a major critical impulse in the interpretive social
sciences and humanities. This theoretical paradigm has provided useful tools for
critiquing the normalising power of biomedicine. Yet it also raises some problems
for critique by bracketing the physiological eects of medical treatments, leaving
out a crucial aspect of the patients experience. Simply insisting that the category of
race is a ction may seem to patients to contradict their social experience, as well as
the self-evident eects of surgeries. Of course, such eects cannot be understood
apart from the social and medical contexts that give them meaning. But to reduce
them to discourse can paradoxically reinforce mindbody dualism and ignore biological limits on social life.
Engaging with biology can also help explain how medical practices like cosmetic
surgery become therapeutically compelling, despite their obvious health risks. In
this article, I have argued that one way they do so is by addressing patients at a
biological stratum of experience. Plastic surgery not only inscribes culturally variable aesthetic norms, but also clinically describes a biologically ageing, reproductive and sexual body. It reduces sexuality and beauty to physiological structures and
processes, and has the potential to create biologically self-aware subjects who select
medical technologies to calibrate the feedback relationships between body image,
sexual health and psychological well-being. To understand how these treatments
gain traction with users, it is thus important to consider not just the regulatory
ctions that naturalise constructions of gender and sex, but also the capacity of
medical treatments to materialise a biological body.

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Note
1. I conducted this fieldwork in Brazil, mainly in Rio de Janeiro, for approximately two
years intermittently between 1999 and 2007. Research methods included participant
observation fieldwork and semi-structured interviews with plastic surgeons and patients
from diverse social backgrounds, hospital ethnography at both public and private plastic
surgery clinics, and fieldwork at media production facilities. See Edmonds (2010) for a
more in-depth discussion of this research. I would like to thank Princeton University, the
Social Science Research Council, and a Woodrow Wilson postdoctoral fellowship for
funding this research.

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